Post on 24-Apr-2015
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Dr.Rajkumar PatilAsstt.Prof.,Dept. of Community Medicine
A V Medical College,Pondicherry
Antenatal Care
Care of the woman during pregnancy
Objectives of Antenatal care
To promote,protect and maintain the health of pregnant mother
To detect and manage “high risk”cases
To remove anxiety associated with delivery
To reduce maternal and infant mortality and morbidity
To educate mother about nutrition,hygiene,child care, sanitation and family planning (including MTP)
To attend to the other children (under 5) of pregnant mother
Antenatal Visits
Ideally 13 visits 7 in first 7 months 2 in 8th month 4 in 9th month
Minimum 4 visits
I : As soon as the pregnancy is suspected
(For registration & first check-up)
II : 26 weeks
III: 32 weeks
IV : 36 weeks
(At least one visit at home by health worker)
Why early registration is required?
To assess the health status
To identify and manage high risk cases
To estimate EDD more accurately
To give the first dose of TT (after 12 weeks)
To help the woman for an early and safe abortion (MTP)
if it is required by her
To start the regular dose of folic acid during the first trimester
Antenatal services for mothers
Health history Physical examination Laboratory Examination Urine/Stool/Blood(Count)/Hb/Serological/Blood group(Rh also) Pap test(if facilities)/ Chest X-Ray and Gonorrhoea test(if needed) High risk approach IFA and necessary medications TT Immunization Health education Home visit Referral(if needed)
Maintenance of records
Antenatal CardAntenatal register
Antenatal Checkup
History
(i) to diagnose pregnancy (ii) to identify any complications during previous pregnancies (iii) to identify any medical/obstetric condition(s) that may complicate this pregnancy
Calculation of EDD
Ask for the first day of the last menstrual cycle (LMP)Ask for the date when the foetal movements were first felt(quickening)Also assess the fundal height to estimate the gestational ageAsk for any test done to confirm pregnancy EDD= LMP + 9 months + 7 days
Age of the woman
Complications when <16 years/>40 years
Order of the pregnancy
Primigravidas and multiparas are at risk
Birth interval
Ideally should be >3 years
Symptoms during the present pregnancy
Symptoms indicating discomfort
nausea and vomiting
heartburn
constipation
frequency of urination
Symptoms indicating that a complication may be arising
fever
vaginal discharge/bleeding
palpitations
breathlessness at rest
generalized swelling of the body;puffiness of the face
oliguria
decreased or absent foetal movements
Previous pregnancies/Obstetric history
number of earlier pregnancies/abortions/deliveries
number of premature birth(s)/stillbirth(s)/neonatal deaths
hypertensive disorders of pregnancy (history of convulsions)
prolonged/obstructed labour
malpresentation
APH/PPH
modes of deliveries(normal/assisted/caesarean section)
birth weight of the previous baby
any surgery on the reproductive tract
iso-immunization (Rh-ve) in the previous pregnancy
(any costly inj. given to her within 72 hours of her previous delivery)
History of any systemic illness(es)
hypertension
diabetes
heart disease
tuberculosis
renal disease
convulsions
asthma
rashes
jaundice
Family history of systemic illness
above illnesses
thalassaemia
delivery of twins or delivery of an infant with congenital malformation
History of drug intake or allergies
History of intake of habit-forming substances (tobacco,alcohol)
Physical examination
General examination
1.Weight
At the time of registration-baseline weight
Normal weight gain in pregnancy: 9-11 kg
After the first trimester: 0.5 kg weight per week (gain)
Low weight gain >>>> IUGR
Excessive weight gain>>>> pre-eclampsia/twins
2.Blood pressure
High BP (>140/90 mmHg) indicates pre-eclampsia
3.Pallor
See the lower palpebral conjunctiva,tongue,oral mucosa,palms and nails
4.Respiratory rate (RR)
RR >30 breaths/minute and pallor indicates severe anaemia
5.Generalized oedema/puffiness of the face
Indicates pre-eclampsia
6.Abdominal examination
Progress of pregnancy /foetal growth/foetal lie and presentation
Fundal height
o If the height of the uterus is more than that expected,it may be due to:
wrong date of LMP/full bladder/multiple pregnancy
polyhydramnios/hydatidiform mole/pregnancy with a pelvic tumour
o If the height of the uterus is less than that expected,it may be due to:
wrong date of LMP/IUGR/missed abortion/IUD/transverse lie
Foetal lie and presentation
Longitudinal, transverse or obliquePresenting part is the vertex/breech/face/brow
Foetal heart sound (FHS) and rate(FHR)
120-160 beats per minuteFHS is usually heard after 20-24 weeks
Multiple pregnancy
An unexpectedly large uterus Multiple foetal parts are felt on abdominal palpation
Laboratory investigations in pregnancy
Haemoglobin (Hb)
< 7 to 11 g/dl as moderate anaemia,
< 7 g/dl as severe anaemia
Blood grouping
Urine albumin
Uristix
Urine sugar
Diastix
Interventions
Folic acid supplementation: 5 mg/day, till 12 weeks
Iron folic acid (IFA) supplementation
Prophylaxis:IFA tab (100 mg elemental iron+0.5 mg folic acid)-100 days
Treatment (if 7-11 g/dl Hb): 2 tablets of IFA per day
How to take IFA tablets?
• Early in the morning on an empty stomach or with meals or at night
• Side effect:black stools,constipation(drink more water)
• Avoid tea/coffee for 30-60 min.after food as well as after tablets
TT Immunization
2 doses or booster(0.5 ml/dose,deep IM,Deltoid) one month apart after 16 wk
Inform the woman about swelling, pain & redness at the inj. site for 1-2 days
Fundal Height Foetal palpation
Risk approach in pregnancy
Use of screening tools to identify individuals who are at more risk of suffering from severe morbidity or mortality
Use of all possible resources:TBAs,Health Workers,Women’s groups
1.Age: elderly primi >30 years,elderly grand multi-paras2.Height: <140 cm3.Mal-presentations4.Threatened Abortion5.Antepartum Haemorrhage6.Preeclampsia and eclampsia7.Anaemia8.Twins,Hydramnios9.Prolonged preganancy(>42 weeks)10.Medical conditions: cardiovascular disease,kidney disease,diabetes, tuberculosis,liver disease etc.11.History of: Stillbirth/IUD/manual removal of placenta/CS/instrumental delivery
Antenatal Advice
1.Diet 300 kcal extra per day
Avoid taking tobacco/tea/coffee especially within 1 hour of a meal
Fibres should be consumed to avoid constipation
Advise on food taboos
Avoid alcohol or smoking
2.Rest Night 8 hours ,Day 2 hours (Lt side)
Avoid heavy work (especially lifting heavy weights)
Avoid the supine position
(especially in late pregnancy,if it is necessary, a small pillow under
the lower back at the level of the pelvis should be used)
2.Personal Hygiene
3.Sex:Restricted in first and last trimester
4.Drugs:thalidomide,iodide containing preparations,
corticosteroids
5.Radiation:Avoid X-rays
6.Danger/warning signs
7.Health education:Education about breast feeding,
nutrition,family planning
Danger signs•High fever with/without abd.pain,feels too weak to get out of bed
•Fast/difficult breathing
•Decreased or absent foetal movements
•Excessive vomiting (woman is unable to take food/fluids)
•Any bleeding P/V during pregnancy
•Heavy (>500 ml) vaginal bleeding during and following delivery
•Severe headache with blurred vision
•Convulsions or loss of consciousness
•Labour lasting longer than 12 hours
•Failure of the placenta to come out within 30 minutes of delivery
•Preterm labour
•Premature or prelabour rupture of membranes (PROM)
•Continuous severe abdominal pain
Specific Health Protection
1.Nutritional disorders:Anaemia and others
2.Toxemias in pregnancy
3.Tetanus
4.Syphilis:Abortion,perinatal death,congenital syphilis
5.Rubella:Abortion,congenital defects
6.Haemolytic disease(Rh):Mother Rh –ve,foetus Rh +ve
7.HIV
8.Prenatal genetic screening
Intranatal Care Objectives of Intranatal Care
1.Thorough asepsisDelivery kit(DDK)
Five "cleans" HTSSC”(Hands,Tie,Surface,Stump,Cut)
2.Delivery with minimum injury to mother and child3.Ready to deal with complications4.Care of the newborn at the time of delivery
Signs of labourBleeding/sticky discharge P/V after 22 weeks
Painful abdominal contractions every 20 min or less
The bag of waters has broken,
and she has clear fluid coming out P/V (leaking)
Monitoring of progress of labour
Partograph-
Graphic record of progress of labour & conditions of mother and foetus.
Domicilliary Care
Advantages:Familiar,No chance of nosocomial infection,mental easeDisadvantages:Less medical/nursing supervision,less rest
Danger signals during labour
Less/no pains after rupture of membraneProlapse of the cord/handMeconium stained liquorAbnormal FHRExcessive “show” or bleeding during labourCollapse during labourPlacenta not separated within 30 minutesPPHFever
Institutional Care
For all high risk cases
Rooming In
Keeping the baby’s crib by the side of the mother’s bedEase for breast feedingMother and Child relation develops better
Postnatal Care
Care of the mother and child after delivery
Objectives
To prevent complicationsTo provide care for rapid restoration of mother’s healthTo facilitate breast feedingTo provide family planning servicesTo provide basic health education
Complications in postpartum period
Infection: Genital tract(Puerperal sepsis),UTI,Mastitis Thrombo-phlebitis of legsHaemorrahge
Restoration of mother’s health
1.Postnatal checkups: Minimum 2 visits(within 2 days & 7 days) Ideally:Twice a day during first 3 days Daily till the umbilical cord drops off After 6 weeks Once a month till 6 months
2.Anaemia:Check Hb
3.Nutrition: 550 kcal extra (first 6 months), 400 kcal extra(next 6 months)
4.Postnatal exercises: Gradual resumption of normal household duties
5.Mental health:Insecurity regarding baby
6.Contraception: Lactational Amenorrhoea
Registration of birth Within 21 days
Danger signs Excessive vaginal bleeding
i.e. soaking more than 2-3 pads in 20-30 minutes after delivery
Convulsions
Fast or difficult breathing
Fever and weakness so that she cannot get out of bed
Severe abdominal pain
Postnatal checkup
History-taking Place of delivery
Person who conducted the delivery
History of danger signs in mother and children
Any problem in the child
When did the child pass urine and/stools (meconium)?
Examination Pulse, BP and temperature
Pallor
Abdominal examination
Rule out any uterine tenderness
Examine the perineum for any tear
Postnatal Care
Care of the mother and child after delivery
Objectives
To prevent complicationsTo provide care for rapid restoration of mother’s healthTo facilitate breast feedingTo provide family planning servicesTo provide basic health education
Complications in postpartum period
Infection: Genital tract(Puerperal sepsis),UTI,Mastitis Thrombo-phlebitis of legsHaemorrahge
Restoration of mother’s health
1.Postnatal checkups: Minimum 2 visits(within 2 days & 7 days) Ideally:Twice a day during first 3 days Daily till the umbilical cord drops off After 6 weeks Once a month till 6 months
2.Anaemia:Check Hb
3.Nutrition: 550 kcal extra (first 6 months), 400 kcal extra(next 6 months)
4.Postnatal exercises: Gradual resumption of normal household duties
5.Mental health:Insecurity regarding baby
6.Contraception: Lactational Amenorrhoea