Reproductive health

Reproductive health

Dr. Muslim N. SaeedFamily & Community Medicine Department
Feb. 3th ,2021 / online

Adolescence health

Objectives:
by the end of this lecture, you’ll be able to:
1.Define adolescence period & its stages.
2.Understand Adolescence preventive services: screening, lab tests, immunization.
3.Understand proper ANC guidelines.
4.Identify high risk pregnancy.
5.Know proper preventive measures for pregnancy complications.

Definition

-Adolescence is a time of a physical, emotional, mental & psychosocial changes.
*Stages of adolescence:
1- Early adolescence: 11-13 years of age &merges with mid adolescence at14-15 years. characterized by concrete thinking & body image disruption.
2- Mid adolescence: 14-15 years of age till 17 years, involves autonomy may lead to parental conflict.
3- Late adolescence: 17-21yr.the upper end is particularly variable & depends on cultural, economic,& educational factors. adolescents begin to think about the future & form stable intimate relationship.

Guideline of adolescence preventive services:

A series of recommendations regarding the delivery of health services ,promotion of well-being, screening for common conditions ,& provision of immunization for adolescents & young adults includes:
• Annual health visits: (3 complete physical examinations, one at each stage).
• Counseling for both parents & adolescent.
• Screening

Adolescence preventive services:

A) Routine screening:
• Hypertension (measuring Bp)
• Hearing ( conduct objective test at 12-15-18 yr.)
• Visual acuity (Snellen’s test)
• High risk or symptomatic adolescents( TB. ,anemia , cholesterol)
• eating disorder & obesity (BMI)
• Use of tobacco , alcohol & other abusable substances

B) Laboratory test:

In the asymptomatic teenager, screening lab. tests should be kept at a minimum.
• Hb or Hematocrit : anemia screening is recommended at the end of puberty.
• Lipid profile.
• Sexually active adolescents :
- Males: gonorrhea, Chlamydia, annual syphilis serology, HBV (homosexual).
- Female: Pap smear starting at age 21 in vulnerable groups.


C) Immunization:

• Diphtheria, tetanus: a booster of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) is recommended 10 years after the initial dose.
• Meningococcal conjugate vaccine: administer to unvaccinated adolescents at high school entry (15y).
• Influenza vaccine.
• Hepatitis A and B: if not received during childhood.
• Pneumococcal vaccine: for adolescents with chronic illnesses (HIV, B-cell immune deficiency) and those with cardiovascular and pulmonary disease.
• HPV vaccine: all females 11-12 years of age should receive the 3 dose series
• Rubella: unimmunized females.

Maternal & Child health servicesMCH services

Maternal & Child Heath (MCH) (including family planning):
MCH Definition:
It is that aspect of health which is concerned with the special needs & problems of mother & child.
-It includes care for pregnant women and family planning, growth monitoring and development of infant and children.
-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 includes: 1- Maternal care. 2- Child care 3- Family planning

Importance of MCH services:

• Most of the problems of MCH are preventable.
• Provide services to about two third of population.
• Improve socioeconomic development.
• Mother & children are high risk group; they are 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.

Maternal Health Care

Phases of maternal care:

• Pre-conception care: It is continued care for female, through all stages of growth and development, & until the time of conception (It is care of women before pregnancy).
• Premarital Care:
Health care given to men and women before they get married and is an essential part of adolescent health care. It include:
a) Health education concerning:
Proper nutrition, Healthy lifestyle, Safe sex, sexually transmitted diseases.
b) History taking: regarding hereditary diseases.
c) Physical examination: for evaluation of health status and nutritional status, and screening of suspected cases.


d) Investigation includes:
-Blood for: ABO group &RH, Hb% level, VDRL, HIV test, test for hepatitis.
-Chest X ray: to exclude pulmonary T.B.
e) Preventive services (immunization): Rubella vaccine is important before the female become pregnant (pregnancy should be avoided for the next 3 months after vaccination).
f) Counseling: Genetic counseling, family planning counseling (if requested by couples).

• III. Antenatal Care ( prenatal care ) ANC:

is complete health supervision of the pregnant women in order to maintain, promote & 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.”
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.
-pregnancy test.

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:
1. Booking procedures (registration).
2. Physical examination.
3. Investigation.
4. Health education.
Instructions: including frequency of visits


Registration (Booking):
When primi-gravida 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 .
o Importance of record - keeping:
1. To be used as reference data in next pregnancies
2. For collection of statistical data used as health indicator for assessment & evaluation of MCH services.
-History: (personal, family, medical, drug , allergy, blood transfusion., surgical, menstrual, obstetrical )
-EDD is calculated accordingly , use of contraception , if she is lactating now.

Obstetrical history: history of all previous pregnancies in chronological order.

2) Physical examination: general and systemic.
Abdominal (Obstetric) examination, pelvic exam.
3) Investigations:
1-Blood analysis: complete blood picture.
- ABO grouping & Rh.
- Screening for diabetes, RBS, 2HPP (2 hours post prandial), GTT if needed.
- VDRL
2-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 is five visits, including the booking visit, is acceptable.
-The quality of care is more important than the frequency of visits.


At- Risk approach in ANC
This approach provides care for those who need it in a flexible but more skilled care is given to those at higher risk .
 Objectives of At – risk approach in antenatal care :
1) Early detection of risk factors during pregnancy .
2) Scoring of detected risks and hazards to classify At – Risk cases (high – risk groups) that need either:
o Just more care and follow up observation, for progress and early interference when necessary .
o Referral for specialized investigations and or management .
o In – patient care , and hospital delivery .

High – risk pregnancy

The term "high-risk pregnancy" describes a case where a pregnant woman has one or more factors that could put her or the fetus at risk for health problems.
The following are five risk categories associated with a high risk pregnancy :
1- Personal & menstrual history .
2- Obstetrical history .
3- Past history ( medical & or surgical )
4- Family history .
5- Current conditions .

Major Risk Factors with High- Risk pregnancy:

1) Personal & menstrual history
 Age less than 18 years (15years).
 Age more than 35 years.
 Lives far from hospital facility.
 Positive consanguinity.
 Smoking.
 Long duration of marriage with infertility & use of ovulation induction.
 Unknown LMP.


2) Obstetrical history:

 Parity ≥ 5.

 No spacing.
 Previous IUFD or neonatal death.
 Previous small for gestational age(SGA) or (LGA).
 Previous congenital anomalies.
 Recurrent first trimester abortion.
 Previous hypertensive disorders.
 Previous circulage or C/S delivery
 gone into premature labor or had a premature baby
 has had a baby with a birth defect, especially heart or genetic problems.

3) Past history

 Hypertension, Heart disease, diabetes, lupus, asthma, a seizure disorder, or another longstanding medical problem.
 Previous blood transfusion
 Previous Rh iso immunization or hydrops-fetalis
4) Family history
Twin or multiple pregnancy of mother & sister.
Diabetes mellitus (D.M)


5) Current condition:

• Maternal weight ˃ 90 kg (obesity ) or ˂ 45 kg .

• Maternal stature ≤ 150 cm.
• Excessive weight gain: > 2 kg first trimester, > 7 kg second trimester, > 4 kg third trimester .
• Color : pallor, Jaundice.
• Blood pressure ≥ 140 / 90 mm Hg.
• Excessive amniotic fluid.
• Heamoglobin < 11 gm / dI.
• Rh negative.
• Vaginal bleeding in early pregnancy.
• Third trimester vaginal bleeding.
• Rubella exposure.

Periodic visits (subsequent visits):

-At each visit the following procedures & examination should be performed :
 History:
- Record new complaints
- Ask about alarming signs.
 Examination:
- General: (Weight, Blood pressure, Edema of lower limbs.)
- Abdominal: (Fundal height (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
 Immunization: tetanus toxoid (TT ) is needed to prevent tetanus neonatorum.
 Health education.


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 or discharge, Sever edema.
 Abnormal gain or loss of weight, Decrease or cessation of fetal movement .
 Severe, persistent or recurrent headache, Visual disturbance (blurred vision)
 Epigastric pain, Fever, Respiratory discomfort or dyspnea & Convulsion.

The following Schedule is used in Iraq:

Natal Care

Natal Care: is the care provided to pregnant women during labor.
Objective of natal care
 Helping the pregnant women to have normal delivery .
 Providing emergency service when needed .
 Care of baby at birth.
Place of delivery:
-Home delivery: if deliveries expected to be normal , can be carried at home by birth attendant.
-Hospital delivery: Developed countries prefer hospital delivery of all pregnant , in developing countries , it is limited to :
-Pregnant who desire it.
-When high risk labor is expected
-When difficulty arises during home delivery .


Postnatal Care
Care of mother after delivery. it is for 6weeks after delivery (puerperium period).
 Usually done at the health center or home visit
 First examination: 2-3weeks after delivery.
 Second examination: 4-6weeks after delivery.
Aim: to detect &cure minor problems result from birth.
- Its components are:
o Postpartum examination
o Medical care
o Follow up
o Health education
o Family planning services
o Psychological and social support

- In postpartum exam., the mother is examined for:

 General condition.
 Body Temperature , any rise of body Temp. by 1C° or more should be investigated.
 Breast & nipple and whether lactation is practiced
 Abdomen for involution of uterus.
 Bleeding or discharge .
 Any other complaint.


Follow up: mother is examined on periodic visits to MCH center :
 At the end of 3rd week maximum to check:
- General condition: if anemic ferrous sulfate is given.
- Supplementation of Vit A ( 200,000 IUs ).
- If she had puerperal infection and if she had managed properly.
 Six weeks after delivery to check :
- Measurement of weight & Bp.
- abdominal & pelvic examination is performed to check for the involution of uterus and repair of tears if any.
- Assessment of the women's mental health is performed .

Health education:

- Adequate nutrition for lactating mother .
- Child feeding , ensuring breast feeding , and practices of weaning .
- Dietary supplementation .
- Child care in health & disease.
- Physical exercise and it`s value (pelvic floor exercise).
- Postpartum birth control .

End