Community medicine (3) MCH (part 1) Dr. Huda Adnan
2014-2015Health: the state of complete physical, mental and social (and spiritual) wellbeing and not merely the absence of disease or infirmity and the ability to lead a socially and economically productive life.
Health care: Is the prevention, treatment, and management of illness and the preservation of mental and physical well being through the services offered by the HYPERLINK "http://en.wikipedia.org/wiki/Medicine" medical, HYPERLINK "http://en.wikipedia.org/wiki/Nursing" nursing, and HYPERLINK "http://en.wikipedia.org/wiki/Allied_health" health professions.
Primary health care (PHC): Is a term used for the activity of a HYPERLINK "http://en.wikipedia.org/wiki/Health_care_provider" health care provider who acts as a first point of consultation for all patients. Continuity of care is also a key characteristic of primary care.
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The main elements of the PHC:
Education concerning prevailing (common) health problems and the methods of preventing or controlling them .
Promotion of food supply and proper nutrition .
An adequate supply of safe water and basic sanitation .
Maternal and child health care (MCH) , including family planning .
Immunization against the major infectious diseases .
Prevention and control of locally endemic diseases ..
Appropriate treatment of common diseases and injuries .
Provision of essential drugs .
Training of health guides, health workers and health assistants.
Referral services.
Mental health.
Physical handicaps care.
Health and social care of the elderly.
Maternal &Child Heath (MCH) (including family planning):
Mothers and children are both vulnerable groups of the community.
Women in the childbearing period (15-49 years) constitute about 25% of the population. Children on the other hand constitute about 40% to 45% of the population in developing countries. This group is characterized by relative high mortality and morbidity rates.
MCH Definition:
It is that aspect of health which is concerned with the special needs & problems of mother & child, (problems that arise from the process of human reproduction growth and development),
It includes care for pregnant women and family planning, growth monitoring and development of infant and children.
MCH services are designed for the care of the mothers from time of conception to ensure that they have normal pregnancy, normal delivery and proper care in the postnatal period.
They also include protection and supervision of health of children from time of conception to the time they enter the school.
MCH includes:
1- Maternal care.
2- Child care
3- Family planning
General Objective of MCH:
To improve the health status of the largest and most vulnerable sector of the population by providing the best health care availableز
The objectives of MCH services:
To ensure desired pregnancy.
To achieve the best possible outcome for the baby and the mother i.e. the services are unique in that they simultaneously provide care for two important clients, the mother and the fetus, balancing the needs of both.
To prevent child health problems and to reduce the risk of adult health problems i.e. (Healthy child means healthy future adult).
Prevention and control of health hazards to children and females in child bearing age and to minimize morbidity and mortality.
Treatment of common problem and diseases arising in this period.
To optimize the normal developmental process to allow the child to achieve his fullest potential.
Rehabilitation of handicapped children.
Ensure secure relationship between parents themselves and parents with their children.
Importance of MCH services
Most of the problems of MCH are preventable.
Provide services to about two third of population.
Improve socioeconomic development.
Mother and children are high risk group ; they are delicate and vulnerable group with special needs.
Good site for training and health education.
Important for future of the nations, since mothers are responsible for health promotion and culture of children and family welfare , and so must be healthy and aware of requirements of health
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Phases of maternal care:I. Preconceptional care :
It is continued care for female, through all stages of growth and development, and until the time of conception (It is care of mother before pregnancy).
Components of Preconceptional Care:
Health promotion and attention to health related behavior before conception such as smoking , alcohol consumption , drug abuse .
2.Regular health assessment for early case detection and management, and prevention of its complications: e.g.:
sexually transmitted diseases .
diabetes mellitus & impaired glucose tolerance
pulmonary T.B
urinary tract infection
nutritional problems
rheumatic heart diseases
Endocrinological problems (e.g. thyroid problem.
3. Health education of young girls e.g. determinants and requirement of health, family health, family planning..
4. Premarital care (for both partners).
II. Premarital Care:
Health care given to girls and boys before they get married and is an essential part of adolescent health care. It include :
- Health education concerning : Proper nutrition
Healthy lifestyle, Safe sex,Sexually transmitted diseases .
History taking: regarding hereditary diseases.-
-Physical examination : for evaluation of health status and nutritional status, and screening of suspected cases .
-Investigation includes:
Blood for: ABO group &RH , Hb% level , VDRL, HIV test, test for hepatitis
chest X ray : to exclude pulmonary T.B.
-preventive services (immunization) : Rubella vaccine is important before the female become pregnant ( pregnancy should be avoided for the next three months after vaccination) .
-Counseling : Genetic counseling, family planning counseling (if requested by couples).
III. Antenatal Care ( prenatal care ) ANC:
ANC : is complete health supervision of the pregnant women in order to maintain , promote and protect health & wellbeing of the mother , fetus and the newborn infant.
General objectives of antenatal care:
The general objective of ANC is to prepare the mother both physically and psychologically to give birth to a healthy newborn and to be able to care for it.
objectives of antenatal care:
Help to ensure best possible health status for mother & fetus
Early detection & timely referral of high risk pregnancy .
Education of the mother about :
- physiology of pregnancy .
- adequate nutrition.
- Alarming symptoms & signs .
- Infant care .
- breast feeding.
- Child care .
Registration: During the booking visit, and record keeping.
Medical examination and investigations; for both the booking visit and continuing visits.
Health education.
Immunization.
Supplementations.
Clinical services.
Social services (outreach services).
When the Antenatal care started?
Antenatal care started as soon as pregnancy is confirmed
Confirmation of pregnancy:
*History of missed period in otherwise normal cycle
Symptoms of pregnancy: nausea, vomiting heartburn, hyperacidity.
physical examination :*
breast changes
pelvic changes
abdominal changes
investigation: *
1-urine examination ; pregnancy test : for detection of human chorionic gonadotropin ( hCG ), which is more accurate on first morning specimen & to be done after 7-10 days from last missed menstrual period .
2-serum β – hCG which is accurate within 10 – 14 days of conception or approximately within the date of menstrual cycle
.
Standards of ANC: (initial visit and subsequent visits)
The initial visit (first visit) :
The first antenatal visit should take place as early as possible during the first trimester , as soon as the pregnancy is confirmed.
The initial visit should include:
Booking procedures (registration).
Physical examination.
Investigation.
Health education.
Instructions: including frequency of visits
Registration (Booking):
When primigravida visits MCH center for the first time a health record [ file with serial number ] is initiated to register all events concerning present pregnancy & it`s outcome .
Importance of record - keeping :
To be used as reference data in next pregnancies .
For collection of statistical data used as health indicator for assessment & evaluation of MCH services.
Booking procedures:
1. History: (personal, family, medical, drug , allergy, blood transfusion., surgical, menstrual, obstetrical )
- personal history
name , age, occupation, level of education (of both parent)
address, duration of marriage,
Consanguinity.
Potentially harmful habits ( e.g smoking , alcohol )
- family history : D.M , Hypertension , multiple pregnancy , congenital anomalies , mental retardation
medical history : -
Diseases: diabetes mellitus, Hypertension, Urinary tract infection, Heart diseases, Infectious disease
Drugs or allergy
History of blood transfusion, Rh incompatibility
- surgical history : history of previous operation
- Menstrual history : age of menarche, regularity , length of cycle, usual duration of each period , amount of blood loss , last menstrual period LMP , & expected day of delivery EDD is calculated accordingly , use of contraception , if she is lactating now
- Obstetrical history: history of all previous pregnancies in chronological order including :
Number of pregnancies
Date of birth or termination of each pregnancy
Duration of each pregnancy
Outcome of each pregnancy ( abortion or stillbirth or live birth)
Type of delivery : normal , assisted , or caesarian section (C\S)
Presentation
Complications during: pregnancy , labour , and postnatal.
Weight of newborn
Place of delivery : home , or hospital
Birth attendant : doctor , nurse, midwife , or traditional birth attendant ( TBA )
.Physical examination :2
- General ( systemic )
Vital signs : pulse , temperature , blood pressure (Bp ) which is best measured with the client sitting or in recumbent. position ( not lying ).
Weight ( with indoor clothing).
Height (without shoes).
body mass index BMI is calculated = weight ( kg) \ height (m)2.
Pallor.
Jaundice .
-Head & neck including thyroid gland ( goiter ).
-Chest & heart examination.
Breast examination.-
-Lower limb edema .
-Skeletal or neurological abnormalities .
Abdominal ( obstetric ) examination -
Inspection :
Size & shape of abdomen.
Scars of previous operations.
Signs of pregnancy ( linea nigra , striae gravidarm ).
Fetal movement.
Dilated veins.
Edema.
Palpation:
Tenderness , rigidity or any palpable organs
Fundal level.
Auscultation : fetal heart , from 10 weeks fetal heart rate detector is used . from 20 weeks Pinard fetal stethoscope is used.
-Pelvic examination : vaginal examination is not recommended routinely unless in cases of vaginal discharge .
3.Investigation :
Blood analysis: complete blood picture .
-ABO grouping & Rh .
-Screening for diabetes , RBS , 2HPP( 2 hours post prandial ) , GTT if needed .
-VDRL
Urine analysis : GUE for albumin urea , microscopic examination for bacteriurea & pus cell . culture & sensitivity (C&S) if recommended
Arrange for pelvic ultrasound : if the women is not sure of gestational age or if her period is not reliable .
Schedule of antenatal care visits:
for low risk pregnancy the following schedule of visits should be followed :
up to 28 weeks gestation every 4 weeks
28 36 weeks gestation every 2 weeks
After 36 weeks gestation every one week
In a low risk pregnancy with no complication , a minimum number of antenatal visits ( recommended by the Royal College of Obstetricians & Gynecologists) is five visits, including the booking visit, is acceptable . The quality of care is more important than the frequency of visits.
Periodic visits (subsequent visits):
At each visit the following procedures & examination should be performed :
History :
Record new complaints
Ask about alarming signs & rate of fetal growth
Examination :
General: (Weight, Blood pressure, Edema of lower limbs.)
Abdominal: ( FL (fundal level ), Fetal lie ( longitudinal , transverse , oblique), Fetal presentation ( cephalic , breech ), FH (fetal heart)).
Laboratory investigation:
screening for diabetes at 28 week of pregnancy .
Urine examination for protein , glucose & ketones
Hb% & PCV
Health education:
Assessment of fetal well being in low risk pregnancy:
Fetal size assessment FL (Fundal level ) or the symphyseal fundal height .
Fetal kick count ( fetal movement ) at least 10 movements per 12 hours ( a change in the kick count is more important than the absolute number )
Fetal movement absence precedes intrauterine fetal death by 48 hours
Fetal heart sounds ( bradycardia & or tachycardia indicate possible fetal problem )
Assessment of fetal wellbeing in low risk pregnancy at 37 weeks :
Assessment of fetal size , lie , and presentation
Assessment of pelvic capacity if there is suspicion of pelvic inadequacy ( stature < 145 cm , pelvic fractures , or previous C\S for cephalopelvic disproportion )
The degree of engagement of the presenting part
Alarming Symptoms & Signs:
Pregnant women should be advised to seek immediate medical care if they experience any of the following symptoms or signs :
Vaginal bleeding .
Sever edema .
Passage of fluid from the vagina .
Abnormal gain or loss of weight .
Decrease or cessation of fetal movement .
Sever , persistent or recurrent headache.
Visual disturbance (blurred vision)
Epigastric pain
Fever
Lower abdominal pain
Respiratory discomfort or dyspnea.
Convulsion
Immunization:
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Nutrition of pregnant women :
The developing fetus is influenced mostly by diet between 17 & 56 days after conception, therefore diet should be optimal before pregnancy.
Ideal nutritional regimen for the pregnant women is by:
Increasing the caloric requirement by 200 kcal / day.
increasing protein intake by 20% , calcium by 50%
doubling her folic & iron intake .
Supplementation for pregnant women :
1. iron ( 30mg of ferrous iron / day )
drugs used are either : ferrous gluconat, ferrous fumarate, or ferrous sulfate
A dose of 30 mg elemental iron /day should be enough for most women.
women pregnant with twins , those who book for antenatal care late in pregnancy , or taken iron irregularly can take ( 60 100 mg/ day ) .
Anaemic women should take 200 mg / day .
Iron requirements are increased only in the latter half of pregnancy .
[ Note : if iron and calcium are prescribed , they should be taken 6 -12 hours apart ]
2. Folic acid supplementation ( 400 μg/ day ):
Megaloblastic anemia from deficiency of folic acid may occur during pregnancy. To prevent megaloblastic anemia , it is recommended that women take 0.4 mg folic acid / day through out pregnancy .
It is recommended that women at high risk for neural tube defects ( who had offspring with neural tube defects , who has neural tube defects herself , or a strong family history of the disorder ) take a supplement of 4 to 5 mg of folic acid / day at least two months prior to conception and for the first 12 weeks.
Women on antiepileptic drugs, e.g. carbamazepine and especially valproate , may need higher doses of folic acid to combat folate deficiency .
Common problems associated with pregnancy affecting diet & nutrition of pregnant women and what can be done for it:
1.Heartburn
Eat earlier in the evening and avoid late night meals
Eat small, low fat meals & snacks , fruits ,and eat slowly.
Drink fluids mainly between meals.
Decrease or avoid spices , greasy and fried foods .
Avoid tobacco , caffeine , and carbonated beverages .
Avoid lying down for 1 -2 hours after eating or drinking .
Avoid bending after eating
2. constipation ;
Drink plenty of fluids preferably water .
Eat high fiber cereals &other grains , fruits , and vegetables.
Engage in physical activity such as walking .
3.pica : is the practice of eating non food substances, such as clay , freezer scrapings and dirt : could be prevented by
Going for a walk or reading a book when the urge hits .
Chewing sugarless gum .
Eating sour pickles .
Chewing on frozen fruit juice cubes instead of ice .
Weight gain:
Weight gained in pregnancy is a combination of maternal and fetal tissues and fluid as well as fat stores
Rate of weight gain is usually not constant , around 2 kg are gained in the first trimester , and the reminder through out second and third trimester at a rate of around 0.4 kg / per week
Weight gain during pregnancy has to be estimated according to the pre- pregnancy weight of the mother :
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Health education for pregnant women:
Pregnant women should be informed about the following:
1. Adequate nutrition : the daily requirement of macronutrient , micronutrient and caloric need
2. Exercise & work:
● Exercise should be mild , preferably walking● Housework , if not overtiring , is allowed .
● The following working situations have been associated with adverse
Pregnancy outcomes .:
- working more than 10 hours /day .
- standing more than 6 hours/ shift .
- lifting heavy items .
- exposure to excessive noise .
3. Travel
-Travel is allowed when comfortable .
-Car safety belts have to be adjusted to be comfortable for the women
-Those traveling more than three hours ( either by car or airplane ) must take a break every two hours and walk for about five minutes to decrease the risk of deep vein thrombosis
4. Dental care
Have teeth examined twice during pregnancy .
Brush teeth after meals .
Tooth extraction is allowed [ even for pregnant women with rheumatic heart disease if prophylactic antibiotic are given .
5.Breast care
Offer the following advice to pregnant women :
- wash breast daily to reduce cracking .
- massage breast to :
Express breast secretions .
Open lacteal ducts and sinuses
Nipples
If there is dry secretion treat with a mixture of glycerin & alcohol
If retracted , treat by pulling out gently & regularly .
6. Smoking:
Smoking has potential adverse effect on the current pregnancy :
Fetal anoxia .
Low birth weight neonates ( LBW ) .
Prematurity .
Pre- labor rupture of the membranes .
Abruption placentae .
7. clothing:
Clothing should be loose ,light and hanging from shoulders .
Avoid high heels , shoes , with thin soles , belts , or corsets .
8. Sexual activity
Sexual activity is allowed in moderate..
It is to be avoided in pregnant women with threatened abortion , preterm labor , or antepartum heamorrhage
9.Drugs
- Avoid all unnecessary drugs during pregnancy
- Taking drugs that are not known to affect the fetus does not guarantee safety of the fetus .
10.Timing of the subsequent visit (the next visit):
Supply the female with a card with full information to maternity hospital at the last visit.