Maternal pdf - د. بتول

By the end of this lecture you will be able to:



Define Maternal & Child Health & Services



Understand the impact of MCH on population

health & development.



List the phases of maternal health services;

Premarital, antenatal, natal and post natal care



Describe the important aspect of premarital

care.



Mentioned the detailed services provided to
the pregnant women during ANC.

MCH

; Is that aspect of health which is concerned

with the special needs and problems of mothers

and children and more precisely the needs and

problems arising from the process of human

reproduction, growth and development.

MCH Services

: Are the services concerned with

the well fare of mothers, infants and pre-school

children.

Why are MCH Services Needed?

In the developing countries



20 -25 % of the population are children below 5

years of age.



48 % of the population below 14 year of age.



Mothers represent 25 % of the population.



Annually,

200 million women become

pregnant all over the world.



At least 15% of all pregnant women

need

skilled

obstetric care some time during pregnancy,

delivery or puerperium



For 580,000 women,

complications of pregnancy,

child birth or the puerperium are fatal.



Of the infants born alive,

nearly 8.1 million die

during the first year of their lives.



One half of those (4 million)

die during the first

month of their lives.



Of those

2.8 million die during the first week of

their lives



An equal number to the above die in utero and

are stillborn.

Health promotion of children. (H. Education)

Prevention and control of health hazards to

children

Treatment of common childhood diseases

Rehabilitation of handicapped children

Ensuring a favourable outcome of pregnancy

and puerperium and dealing with factors

leading to unfavourable outcomes (risk factors).

Ensuring secure relationships between parents

themselves and parents and their children.

Is the health care given to girls and boys before they get married

and is an essential part of adolescent health care. it includes

promotive health services such as:

History

(past

medical

history,

hereditary

diseases)

Medical

examination &

investigations

(blood group

(ABO and Rh),

CXR for

excluding TB.

Testing for

Sexually

Transmitted

Infections

(STIs) , for

HIV/AIDS,

Syphilis

(VDRL, WR

or Kahn

test)

Education

regarding

proper

nutrition

& Life

style

It also

includes

preventive

services such

immunization

Counselling

on family

planning

(in some

countries)

It is defined as the complete health

supervision of the pregnant woman in order
to maintain, protect and promote the health
and well-being of the mother, the foetus and
the newborn infant.

Phases of Maternity Care

B) Prenatal Care or Antenatal (ANC):

Six (6) Important Reasons to Attend the
Antenatal Clinic

1. To build a trusting relationship between client and

health care provider.

2. To achieve the best possible health status for mother

and fetus.

3. To obtain baseline recording data.
4. To identify and manage high-risk pregnancies.
5. To provide basic health education in relevant topics.
6.To minimize maternal and fetal mortality and

morbidity rates

Phases of Maternity Care

B) Prenatal Care or Antenatal (ANC):



In order to make antenatal care (ANC) services

effective, they must be delivered adequately.



Adequacy should be in quantity & quality



Schedule of ANC Visits

First 28 weeks gestation

Every 4 weeks

28th - 36th week

Every 2 weeks

36th week to term

Every week



AND AT ANY TIME WHEN MEDICAL
CARE IS NEEDED

The first

visit

• The most important AN visit is the first visit
• During this visit confirmation of pregnancy should be done

Confirming

Pregnancy

• This can be done on a urine sample for the detection of Human

Chorionic Gonadotrophin (HCG) during the first 13 weeks

• The test becomes positive 2-3 weeks after the date of the first missed

period

Abdominal

examination

• If gestational age is beyond 13 weeks, the gravid uterus can be

felt by abdominal examination or visualized with a sonogram.

When the pregnancy is confirmed, a file is

opened for the pregnant mother in the AN clinic

Personal

History

• Name, age, address, occupation, educational level (both partners), duration of

marriage, consanguinity, potentially harmful habits.

Complaints

• Details and duration

Menstrual

History

• Onset ( age of menarche), length, duration, regularity, dysmenorrhoea, LMP (1st

day) which is important:

• To calculate the E.D.D. & To calculate the gestational age and compare it with the

size of the uterus. (Large for date= Mistaken date, twin, tumors, Small for date=

mistaken date, dead fetus).

Obstetric

History

• Gravidity, parity, abortions, stillbirths, Ante partum care, labor and puerperium of

previous pregnancies. (Mode of termination, Number/sex of living children, Birth

weights, Mode of infant feeding & Date of Last Labor and Last Abortion

Present

Obstetric

History

• Symptoms of pregnancy. * Symptoms of pre- eclampsia.
• * Symptoms of disease in other organ systems. * Fetal movements.
• * Bleeding, vaginal discharge, nausea, vomiting, dysurea, etc.

Family

History

• * DM * BP * Multiple pregnancies * Thalassaemia
• * Congenital anomalies.

Medical

History

• Diseases: DM, BP, UT troubles, heart diseases, viral infections, drugs, and/or

allergies
• Others: Blood transfusion, Rh incompatibility, X-ray exposure.

Surgical

History

• Previous operations:* Dilation and curettage, * Vaginal repair, * CS,

* Cerclage, *Non - gynecological operations

Others

• Family Planning History.
• Immunization History.
• Breastfeeding History

Examination

General

(Systemic)

Height ( if

< 145cm

risk of

contracted

pelvis)

Weight

(to be

monitored)

Physical

signs Chest

examination,

Breast

examination,

Skeletal or

neurological

abnormalities

Obstetrical

Inspection:

Contour and size

of abdomen,

Scars from

operations,

Signs of

pregnancy, Fetal

movements,

Varicose veins,

Edema.

Palpation:

Fundal

height,

Fundal

grip

Auscultatio

n * At 10

weeks

Sonicaid.

* At 20

weeks

Pinard’

Investigation

Stool

analysis

For ova &

Parasites

GUE

Pus

cells ;

UTI

Protein ;

eclampsia

(HT,

Protein urea

peripheral

odema).

Glycosuria ;

Could be

normal due

to the

lowered

renal

threshold

for

glucose, yet

if +ve

Blood

glucose is

indicated

Blood

Blood

analysis:

Complete

blood

count ,

ABO

grouping

and Rh

typing

Blood sugar

level;

(normal,

elevated =

GDM,

Borderline=

GTT)

Serology

especially for

syphilis to

prevent

Congenital

(Tertiary)

syphilis

First-level

ultrasound

Note: Supply the mother with a CARD containing full information
to be used by the maternity hospital during delivery

1. Vaginal bleeding



< 20 weeks



Threatened abortion.



>20 weeks



Antepartum hemorrhage.

2. Symptoms of pre-eclampsia



Severe persistent headache.



Blurring of vision.



Epigastric pain.



Generalized edema.

3. Abdominal pain (2nd half):

Placental abruption suspected if:



Trauma.



Pre-eclamptic toxemia (PET).



Fundal Level > period of amenorrhea.



Fetal parts difficult to feel.



Hard tender uterus.



F.H.S usually absent.

4.  Persistent vomiting.
5.  Dysuria.
6.  Chills or fever.
7.  Escape of fluid from vagina  (PROM).
8. Abdominal size too big or too small for gestational age.

1. Record any new complaints.
2. Perform examination at each visit

* General: Weight, Blood pressure , Lower Limbs

Local: Fundal level, Fetal lie , Fetal presentation & Fetal heart

sound

3. Investigation

* Some, not all the investigations should be repeated in the 2nd & 3rd

trimester: *GUE, * Hb level

* Determine Rh antibody titre for Rh negative mothers

4. Assess Fetal Well-Being

   * Maternal weight:   Little or no gain = fetal jeopardy.
   * Fetal size through assessment of fundal level.
        * Fetal kick count:   At least 10 movements / 12 hours.
   * Fetal movements: Absence precedes (IUFD) by 48 hours.
   * Fetal heart sounds.
   * Ultrasonography.

At 37 weeks;

Assessment of fetal size, lie, and presentation.

Assessment of pelvic capacity.

Calories 2500/ day

* Adequate Nutrition
* Excess - Fat and Obesity- Predispose to PE

Protein 85 gm/ day

* Animal (Meat, fish, cheese, milk, eggs), Plant ( Peas, beans, lentils)
* Low intake; Fetus – Premature, Mother- Anemia and edema

3. Calcium 1.5 gm/day

Milk, cheese, yogurt, calcium carbonate

* low Ca; Infant – Rickets, Mother - Osteomalacia

Iron 30 mg/day

     * Animal( Liver, red meat), Plant ( Green leafy vegetables)
     * Drug ( Ferrous gluconate, ferrous fumarate, Ferrous sulphate)
     * Iron deficiency; Mother -  Iron deficiency-anemia

5. Folic Acid 1mg/day

* Folic acid deficiency ; Mother- Megaloblastic anemia.

II. Breast Care
III. Dental Care



Examine twice during pregnancy.



Brush teeth after meals.



Tooth extraction is allowed even for pregnant women with rheumatic heart

disease( prophylactic antibiotics are given).

IV. Clothing
V. Exercise

VI. Weight Gain



Healthy pregnant woman gain a total of 10 - 12 kg.



Undernourished woman will gain less than 8 Kg, especially if performing

heavy physical work



Sources of weight gain:

1. Products of conception (foetus, placental, amniotic fluid and

membranes).

2. Enlargement of the organs of reproduction (uterus and breasts).

3.Increase in the fat stores.

4.Expansion of the extra-cellular fluid compartment.

VII. Smoking
VIII. Traveling
IX. Rest and Sleep



TT1

At first contact, or as soon as possible during pregnancy.



TT2

At least 4 weeks after TT1.



TT3

At least 6 months after TT2 or during subsequent

pregnancy.



TT4

At least 6 months after TT3 or during subsequent

pregnancy.



TT5

Minimum 1 year after TT4 or during subsequent

pregnancy.

Common Complaints of Pregnancy



Nausea and vomiting.



Heartburn and hyperacidity.



Ptyalism.



Constipation.



Hemorrhoids and varicose veins.



Edema.



Leg cramps.



Leukorrhea.



Backache.

This approach provides care for the community as well

as for individuals through a flexible and more rational
distribution of existing resources according to the level of risk,

so that some care will be provided for all, but more
skilled care is given to those at higher risk

High Risk Pregnancy

Is one in which the foetus and/or the mother has a

significantly increased chance of morbidity or mortality.

Pregnant women at such risk must be identified during

ANC, according to the presence of certain risk factors

The Risk Approach

High-risk Pregnancy

1. Less than 18 years old.

2. More than 35 years old.

3. Lives far from health facility.

4. Positive consanguinity.

5. Smoking habits.

6. Long duration of marriage with infertility

and use of ovulatory drugs.

Risk Factors for Evaluation

A. Personal Factors (already present)

Primigravida > 30 years.

2. Parity of > 5.

3. No spacing.

4. Previous intrauterine fetal death (IUFD) or

neonatal death.

5. Previously small for gestational age.

6. Previously large for gestational age.

7. Previous fetal malformation.

8. Previous spontaneous 2

trimester abortion or

premature labor.

B. Obstetrical History

9. Previous 1

trimester abortion.

10. Previous hypertensive disorders during

pregnancy.

11. Previous cesarean section delivery.

12. Prior retained placenta or post-partum

hemorrhage.

13. Previous Rh-isoimmunization or hydrops

fetalis.

14. Duration of labor < 4 hours.

15. Previous instrument delivery.

B. Obstetrical History (continue) :

1. Hypertension.

2. Heart disease or heart murmur.

3. Tuberculosis or anti-tuberculosis drugs.

4. Epilepsy or anti-epileptic drugs.

5. Chronic illness.

6. Uterine anomalies including uterine

fibroid or other pelvic masses.

C. Past History

7. Previous myomectomy.

8. Previous cerclage.

9. Previous successful classical repair.

10. Previous successful repair of fistula.

11. Previous blood transfusion.

C. Past History ( continue) :

1. Fetal abnormality.

2. Twin or multiple pregnancy of

mother and sister.

3. Hypertension.

4. Diabetes.

D. Family History

Unknown date of last menstrual period

(LMP).

2. Hyperemesis gravidarum.

3. Not immune against tetanus neonatorum.

4. Fetal movements absent.

5. Marked changes in frequency and/or

intensity of fetal movements.

6. Vaginal bleeding in early pregnancy.

E. Current Situations Affecting Obstetric

Outcome

History

7. Premature uterine contractions.

8. Third trimester vaginal bleeding.

9. Sudden gush of vaginal watery fluid.

10. Rubella exposure.

11. Herpes.

Examination

12. Gait:

“limping”

13. Color:

pallor

jaundice

E. Current Situations Affecting Obstetric

Outcome (continue):

14. Maternal weight > 90 kg=excessive obesity
15. Maternal weight < 45 kg.
16. Maternal height  < 150 cm.
17. Marked varicosities of lower limbs.
18. Excessive weight gain:
      > 2 kg         1

trimester

> 7 kg 2

trimester

> 4 kg 3

trimester

E. Current Situations Affecting Obstetric

Outcome ( continue) :

19. Poor weight gain < 8 kg.

20. Smaller uterine size than gestational age.

21. Larger uterine size than gestational age.

22. Blood pressure > 140/80.

23. Non-engagement of fetal head at 36-40
weeks gestation in primigravida.

24. Malpresentation.

E. Current Situations Affecting Obstetric

Outcome ( continue) :

25. Excess amniotic fluid.

26. Diminished amniotic fluid.

27. Hemoglobin < 11 g%.

28. Proteinuria > +1.

29. Glucosuria.

30. Bacteriuria.

Investigation

E. Current Situations Affecting Obstetric

Outcome ( continue) :

This phase is characterized not only by its short

duration (hours), but also by being a dangerous phase

for both mother and infant.



If not properly handled, it leads to morbidity or

mortality of either or both of them.



The mother might develop complications such as

* Bleeding
* May be exposed to surgical interventions,
* Risk of infections
* Risk of trauma.



The infant may be exposed to

* Asphyxia
* Birth trauma
* Hypothermia
* Infections.



Good natal care will reduce the number of

deaths and disabilities resulting from such

conditions.



Training of birth attendants (doctors and

midwives) is very important for the reduction of

these conditions.



Only 50 % of Deliveries occur in Hospitals or Health

institutes .



On discharge, a CARD containing full birth

information should be given to the mother to be used

by the PHCC for completing child care.

PHCC

Postnatal care for

mothers & infants

Child Care

PHCC

ANC

Maternity Hospital

Natal, Neonatal,

Postnatal & Mother Care



This period starts one hour after delivery of the

placenta and continues for six weeks.



During this period two medical examinations

with the aim of detecting and curing minor

ailments resulting from birth.



The first examination is carried out within two

weeks after delivery.



The second between 4 and 6 weeks after

delivery.



We must check the size and position of the

uterus, cervix and perineum, blood pressure.



The GUE and Hb testing should be repeated.



We must teach pelvic floor exercise and

promote breast feeding.



Home visits should be paid to women who are

discharged early by a home visitor or a public

health nurse.