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UNDERSTANDING THE CONCEPT OF PREVENTIVE AND COMMUNITY MEDICINE IN OBSTETRICS AND IMPLEMENTING IT IN ANC OPD DR. ASHA JAIN MBBS, MS Gynecology and Obstetrics.

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Presentation on theme: "UNDERSTANDING THE CONCEPT OF PREVENTIVE AND COMMUNITY MEDICINE IN OBSTETRICS AND IMPLEMENTING IT IN ANC OPD DR. ASHA JAIN MBBS, MS Gynecology and Obstetrics."— Presentation transcript:

1 UNDERSTANDING THE CONCEPT OF PREVENTIVE AND COMMUNITY MEDICINE IN OBSTETRICS AND IMPLEMENTING IT IN ANC OPD DR. ASHA JAIN MBBS, MS Gynecology and Obstetrics SENIOIR GYNECOLOGIST NEHRU HOMOEOPATHIC MEDICAL COLLEGE AND HOSPITAL

2 Obstetrics is largely a preventive medicine. the aim of both is the same which is to ensure the good health of mother through out pregnancy and puerperium so that every pregnancy may culminate in a healthy mother with a healthy baby.

3 SOCIAL OBSTETRICS This concept has recently gained popularity which is defined as the study of interplay of social and environmental factors and human reproduction going back to preconceptional and even pre marital period. This concept has recently gained popularity which is defined as the study of interplay of social and environmental factors and human reproduction going back to preconceptional and even pre marital period.

4 SOCIAL AND ENVIRONMENTAL FACTORS 1. AGE OF MARRIAGE 1. AGE OF MARRIAGE 2. AGE OF CHILD BEARING 2. AGE OF CHILD BEARING 3. CHILD SPACING 3. CHILD SPACING 4. FAMILY SIZE 4. FAMILY SIZE 5. LEVEL OF EDUCATION 5. LEVEL OF EDUCATION 6. ECONOMIC STATUS 6. ECONOMIC STATUS 7. CUSTOMS AND BELIEFS 7. CUSTOMS AND BELIEFS 8. ROLE OF WOMEN IN SOCIETY 8. ROLE OF WOMEN IN SOCIETY

5 contd. All socia and environmental factors are interrelated like early marriage is a social custom in third world countries especially in Indian BIMARU states. All socia and environmental factors are interrelated like early marriage is a social custom in third world countries especially in Indian BIMARU states. Mean age of marriages Is 17.4 years, it is even lower in above states. Mean age of marriages Is 17.4 years, it is even lower in above states. 20% of all pregnancies are teenage pregnancy forced by families and society. 20% of all pregnancies are teenage pregnancy forced by families and society. Pregnancy below 16 years leads to high precentage of risks like PIH, anaemia, small pelvis, immature perineum with injuries, preterm births and high perinantal and maternal morbidity. Pregnancy below 16 years leads to high precentage of risks like PIH, anaemia, small pelvis, immature perineum with injuries, preterm births and high perinantal and maternal morbidity. MONSTERS OF OUR SOCIETY ARE IGNORANCE, POVERTY, ILLITERACY AND GENDER DISCRIMINATION. MONSTERS OF OUR SOCIETY ARE IGNORANCE, POVERTY, ILLITERACY AND GENDER DISCRIMINATION.

6 CONTD… Gender discrimination is quite prevalent in Indian families. Best and good food goes to the father and the sons. Gender discrimination is quite prevalent in Indian families. Best and good food goes to the father and the sons. Very few realize that nutrition and health of adolescent girl forms most important step for the health of future pregnant woman. Very few realize that nutrition and health of adolescent girl forms most important step for the health of future pregnant woman. It is not wrong to say that nutrition and health care of the pregnant woman starts at the age of 10 and not when she becomes pregnant. It is not wrong to say that nutrition and health care of the pregnant woman starts at the age of 10 and not when she becomes pregnant.

7 Contd… Ignorance, poverty and illiteracy results into unplanned sexual activity and pregnancies. Ignorance, poverty and illiteracy results into unplanned sexual activity and pregnancies. Though society is divided on the issue of sex education, it must be started at the school level which should consist of: Though society is divided on the issue of sex education, it must be started at the school level which should consist of: Physiology and anatomy of reproductive sysem Physiology and anatomy of reproductive sysem Genital hygiene and care during menstrual cycle Genital hygiene and care during menstrual cycle Harmful effects of premarital and unsafe sex Harmful effects of premarital and unsafe sex Should be taught about STD, HIV and contraception Should be taught about STD, HIV and contraception

8 Contd… Best way to educate and influence people in villages and town is to involve religious leaders who can during their discourse point out the importance of sex education, family planning and care of girl child. Best way to educate and influence people in villages and town is to involve religious leaders who can during their discourse point out the importance of sex education, family planning and care of girl child. School teachers can also be educated. School teachers can also be educated. Posters and mass media like radio and TV can also propagate the idea and importance of above factors. Posters and mass media like radio and TV can also propagate the idea and importance of above factors. Various NGO’s and medical societies can also help in changing the attitude of people towards size of family, care of adolescent girl and pregnant mother and use of family planning devises. Various NGO’s and medical societies can also help in changing the attitude of people towards size of family, care of adolescent girl and pregnant mother and use of family planning devises.

9 MATERNAL AND CHILD HEALTH Mother and child must be considered a single unit because: 1. During antenatal period fetus is a part of mother and obtains all the building material and oxygen from mother’s blood. 1. During antenatal period fetus is a part of mother and obtains all the building material and oxygen from mother’s blood. 2. Child’s health is closely related to maternal health, a healthy mother brings forth a healthy baby. 2. Child’s health is closely related to maternal health, a healthy mother brings forth a healthy baby. 3. Certain conditions and diseases are likely to have their effect on fetus e.g.. DM, infections etc. 3. Certain conditions and diseases are likely to have their effect on fetus e.g.. DM, infections etc. 4. After birth child is dependent on mother. 4. After birth child is dependent on mother. 5. In the care cycle of women there are few occasions where service to the child is simultaneously called for eg. Post partum period care which is inseparable from neonatal care. 5. In the care cycle of women there are few occasions where service to the child is simultaneously called for eg. Post partum period care which is inseparable from neonatal care. 6. Mother is first teacher of child. 6. Mother is first teacher of child.

10 Contd… MCH care refers to promotive, preventive and rehabilitative health care for mother and child. It includes: MCH care refers to promotive, preventive and rehabilitative health care for mother and child. It includes: Maternal health Maternal health Child health Child health Family planning Family planning School health School health Health care of special cases like adolescent girls, handicapped children and care of children in special settings like daycare centers Health care of special cases like adolescent girls, handicapped children and care of children in special settings like daycare centers

11 Antenatal care Care of woman during pregnancy is called antennal care. The aim is to achieve healthy mother and a healthy baby at the end of pregnancy. Care of woman during pregnancy is called antennal care. The aim is to achieve healthy mother and a healthy baby at the end of pregnancy. In recent years there has been a mass reduction in maternal and perinatal morbidity and mortality. In recent years there has been a mass reduction in maternal and perinatal morbidity and mortality. Apart from other factors proper antenatal care has bought about remarkable results. Apart from other factors proper antenatal care has bought about remarkable results.

12 Objectives of antenatal care 1. Promote, protect and maintain helath of mother during pregnancy 2. Detect high risk cases 3. Foresee complications and prevent them 4. To remove anxiety and dread related to pregnancy and delivery 5. To reduce MMR and IMR related to delivery 6. Teach mother the elements of childcare, nutrition, hygiene, environmental sanitation etc. 7. Sensitize mother about family planning 8. To attend under five children accompanying the mother

13 MCH PROBLEMS Main health problems affecting the health of mother and child revolves around: Main health problems affecting the health of mother and child revolves around: 1. Malnutrition 1. Malnutrition 2. Infections 2. Infections 3. Consequences of unregulated fertility 3. Consequences of unregulated fertility 4. Scarcity of health and other services with poor socioeconomic conditions. 4. Scarcity of health and other services with poor socioeconomic conditions.

14 ANTENATAL CARE 1. General history 2. Family history regarding history of TB, HT, DM, congenital anomalies, hereditary diseases. 3. Personal history: H/O medical and surgical problems and H/O deficiency 4. Mestrual history: LMP, EDD 5. Obstetric history: 1. Previous pregnancies- abortions induced or spontaneous 2. Normal deliveries 3. Operative deliveries- instrumental or CS 4. Any complication during pregnancy 5. Complications of labor 6. Third stage complications 7. Puerperium 8. Condition of child

15 General and medical examination 1. Height and weight 2. Stature and nutritional status 3. Gait 4. Medical examination: Respiratory, cardiac, endocrinal and abdominal examination 5. Examination of oral cavity 6. Examination of breast 7. BP, edema feet, cyanosis, clubbing etc.

16 Obstetric examination 1. Height of uterus 2. Presentation, lie and position 3. Fetal heart rate

17 Vaginal examination EARLY PREGNANCY EARLY PREGNANCY 1. To confirm diagnosis of pregnancy 2. To rule out extra uterine pregnancy 3. Any adenexal pathology LATE PREGNANCY LATE PREGNANCY 1. To rule out CPD 2. At the time of labor and 3. Any other obstetric indication

18 Laboratory examination Hb, ABO Rh, blood sugar, urine analysis, HIV, VDRL, HbsAg Hb, ABO Rh, blood sugar, urine analysis, HIV, VDRL, HbsAg ICT in Rh –ve if husband is positive ICT in Rh –ve if husband is positive

19 Advice 1. Impress upon her need for regular attendance at the clinic and assure her that pregnancy and labor would be smooth and safe. 2. Ideal number of visits: First visit in 1 st 3 months First visit in 1 st 3 months Once a month till 28 weeks Once a month till 28 weeks Twice a month till 36 weeks Twice a month till 36 weeks Weekly till delivery Weekly till delivery As it is difficult for the mother coming from low socio economic group minimum 3 visits during entire pregnancy is a must. 1 st visit earliest < 20 weeks 1 st visit earliest < 20 weeks 2 nd visit at 32 weeks 2 nd visit at 32 weeks 3 rd visit at 36 weeks 3 rd visit at 36 weeks 3. Further visits justified by the condition of the mother. 4. Home visits are also paid by the health worker. 5. All records are propely maintained in the ANC card.

20 Advice At this time the mother is more receptive to the advice concerning herself and the baby. She must be advised for: 1. Diet 2. Personal hygiene 3. Drugs 4. Warning signs 5. Radiation 6. Childcare

21 Dietary advice A daily intake of about calories meet the total energy needs of the average pregnant woman. Wt gain is directly related to healthy and adequate diet Balanced and nutritious diet required is as follows: high protein, high roughage and rich in iron content. Balanced and nutritious diet required is as follows: high protein, high roughage and rich in iron content. She is instructed to take such diet home resources available in the budget. She may be provided a diet chart keeping in mind 3G formula. She is instructed to take such diet home resources available in the budget. She may be provided a diet chart keeping in mind 3G formula. 1. 1G for grains e.g. chapati 2. 2G for gram e.g. dal 3. 3G for green leafy vegetables and fruits. Milk requirement 110 ml/day Milk requirement 110 ml/day Water intake 2-3 lt/day, clean or boiled water Water intake 2-3 lt/day, clean or boiled water Pictorial diet chart in regional language Pictorial diet chart in regional language

22 Care of minor symptoms during pregnancy Morning sickness and vomiting Morning sickness and vomiting Vaginal discharge Vaginal discharge Heartburn Heartburn Edema Edema Leg cramps Leg cramps Headache Headache Piles Piles Carpel tunnel syndrome Carpel tunnel syndrome

23 General advice Personal hygiene: personal cleanliness, daily bath, rest and sleep for 8 hrs at night and 2 hrs at midday Personal hygiene: personal cleanliness, daily bath, rest and sleep for 8 hrs at night and 2 hrs at midday Bowels: constipation should be avoided Bowels: constipation should be avoided Exercises: light house work and regular walking, ANC exercises as advised Exercises: light house work and regular walking, ANC exercises as advised Smoking and alcohol should be avoided Smoking and alcohol should be avoided Proper dental care Proper dental care Sexual intercourse should be avoided in last 3 months Sexual intercourse should be avoided in last 3 months Drugs not essential should not be consumed Drugs not essential should not be consumed Avoid radiation Avoid radiation Warning signs: vaginal bleeding, swelling of feet, headache, blurring of vision and fits, bleeding and leaking in last months of pregnancy and any other unusual symptoms. Warning signs: vaginal bleeding, swelling of feet, headache, blurring of vision and fits, bleeding and leaking in last months of pregnancy and any other unusual symptoms. Childcare classes should be held Childcare classes should be held Education on labor and child birth Education on labor and child birth

24 Contd… Lack of proper communication during ANC and non compliance on the part of female and her relatives leads to poor results. Therefore health worker has to take pains to communicate health education ot pregnanct woman and her attendants at each visits.

25 supplementation Iron and folic acid 1 cap 60 mg elemental iron Iron and folic acid 1 cap 60 mg elemental iron 500 mg of folic acid 500 mg of folic acid Ca mg with vitamin D Ca mg with vitamin D Immunization Immunization 1. Two doses of TT 4-6 weeks apart after 16 weeks of pregnancy

26 Identify high risk cases 1. Elderly primigravida > 30 years 2. Short strature < 140 cm 3. Malpresentation, breech etc. 4. APH, threatened abortion, repeated abortion 5. PET, eclampsia 6. Anaemia 7. Twins, hydramnios, 8. Previous IUD, MRP, CS 9. Elderly grand multipara 10. Post dated pregnancy 11. Pregnancy and medical problems e.g. DM, HT, TB etc.

27 Warning signs Vaginal bleeding Vaginal bleeding Swelling of face and fingers Swelling of face and fingers Continuous headaches Continuous headaches Dimness of vision Dimness of vision Abdominal pain Abdominal pain Persistent vomiting Persistent vomiting High fever High fever Dysuria Dysuria Passage of fluid per vaginum Passage of fluid per vaginum Marked changes in fetal movement or no movement Marked changes in fetal movement or no movement

28 INTRANATAL CARE Aim of good intranatal care is achieved by: 1. High asepsis 2. Delivery with minimum trauma to the mother and child 3. Readiness to deal with impending complication like PET, prolonged labor, PPH 4. Care of newborn at birth like resuscitation, care of cord, care of eyes etc.

29 INTRANATAL CARE Every pregnant woman is educated to have child birth by trained birth attendant Every pregnant woman is educated to have child birth by trained birth attendant 85% pregnancies terminate into normal delivery though incidence varies from place to place 85% pregnancies terminate into normal delivery though incidence varies from place to place In India incidence of home delivery is 65% and 35% hospital delivery in comparison to western countries where hospital delivery is 95% In India incidence of home delivery is 65% and 35% hospital delivery in comparison to western countries where hospital delivery is 95% Hospital delivery is safer and reduces maternal and perinatal morbidity and mortality Hospital delivery is safer and reduces maternal and perinatal morbidity and mortality

30 Management of first stage of labor 1. Admission- MCH record 2. Examination 3. Preparation of the patient 4. Enema 5. Frequent urination 6. Proper posture 7. Food during labor 8. Pain relief in labor

31 Monitoring of 1 st stage of labor 1. Vital signs 2. Progress of labor 3. Graphic recording of labor can be done 4. BP, Pulse, uterine contraction, descent of presenting part, fetal heart rate, leaking PV 5. PV examination whenever indicated 6. Total duration of 1 st stage is hrs I primigravida and 5-6 hrs in multigravida

32 Monitoring of 2 nd stage of labor 1. High asepsis 2. Delivery with minimum trauma to the mother and child 3. Readiness to deal with impending complication like PET, prolonged labor, PPH 4. Care of newborn at birth like resuscitation, care of cord, care of eyes etc.

33 DOMICILIARY DELIVERY Home conditions should be satisfactory Home conditions should be satisfactory Delivery conducted by trained dai or LHV Delivery conducted by trained dai or LHV Advantages include: familiar surroundings, less cross infection, mother can take care of other children Advantages include: familiar surroundings, less cross infection, mother can take care of other children Disadvantages include: less nursing supervision, inadequate rest, place may be unsuitable for the delivery Disadvantages include: less nursing supervision, inadequate rest, place may be unsuitable for the delivery LHV of ANM should know when to refer the case to the hospital LHV of ANM should know when to refer the case to the hospital

34 CARE OF BABY 1. Cleaning airway 2. APGAR score 3. Care of cord 4. Care of eyes 5. Breast feeding 6. Maintenance of body temperature 36.5 – 37.5˚c

35 CARE OF MOTHER Objectives is to prevent postnatal complication Objectives is to prevent postnatal complication Adequate breast feeding, child immunization Adequate breast feeding, child immunization Provide family planning Provide family planning

36 BREAST FEEDING 1. Should be initiated in ½ hour of normal delivery hours of CS 3. Helps to establish bond between mother and child 4. Colostrum Rich in proteins and other nutrients Rich in proteins and other nutrients Antibodies which provide protection to the newborn to various diseases and diarrhea Antibodies which provide protection to the newborn to various diseases and diarrhea 5. Demand feeding 6. No feeding bottles Exclusive breast feeding for 6 months

37 ADVANTAGES OF BREAST FEEDING 1. Safe clean, cheap and readily available 2. Fully meets nutritional requirement of infant 3. Contains antimicrobial factor e.g. macrophages, lymphocytes, secretory IgA etc. prevents against various infections 4. Easily digested by normal premature infants 5. Promotes bonding between mother and child 6. Suckling helps in development of jaw and teeth 7. Prevents malnutrition and infant mortality 8. Helps in spacing of child birth 9. Helps in involution of uterus

38 ARTIFICIAL FEEDING Artificial feeding and weaning started at 4-5 month. Supplementary food like cow’s milk, cooked rice, dal, vegetables etc. should be given.

39 IMMUNIZATION PROGRAM At birth – BCG, OPV 0dose 6 weeks – 1 DPT, OPV 10 weeks – 2 DPT, OPV 14 weeks – 3 DPT, OPV 9 months – measles 16 – 24 weeks – DPT, OPV 5 – 6 years – DT 10 – 16 years - TT Hepatitis B – 0 week, 6 weeks, 6 months MMR – 15 months OPTIONALTyphoidHepatits Meningitis etc.

40 FAMILY PLANNING Family planning refers to practices that help individual or couples to attain certain objectives: 1. To avoid unwanted birth 2. To bring about wanted birth 3. To regulate interval between pregnancy 4. To determine number of children in family 5. To control the time at which birth occur in relation to age of the parents.

41 Indications for contraception 1. To restrict family and stabilize population 2. Medical disorders in females 3. Obstetric and gynecology indication 4. Eugenic and fetal condition

42 Commonly used contraceptives 1. Pills and injectables 2. IUCD’s 3. Condoms and vaginal contraceptives 4. Tubectomy (98.1%) and vasectomy (1.99%)

43 Preference of contraceptives After marriage or nulliparous After marriage or nulliparous 1. Pills or condom till pregnancy is planned After 1 st child birth After 1 st child birthIUCD 1. Condom with vaginal contraception 2. Pills after 6 months 3. injectables After 2 nd pregnancy After 2 nd pregnancy 1. IUCD 5 years after complete family 5 years after complete family 1. Tubectomy and vasectomy

44 ORAL PILLS combination of hormones estrogens and progesterone: mostly used from years of age combination of hormones estrogens and progesterone: mostly used from years of age Common names: MALA-D, MALA-N, OVRAL, TRIQUILAR Common names: MALA-D, MALA-N, OVRAL, TRIQUILAR 21 tabs are taken from 5 th -25 th day with 7 days of iron tabs 21 tabs are taken from 5 th -25 th day with 7 days of iron tabs If no side effects then taken for 3-5 years continuously If no side effects then taken for 3-5 years continuously Mini pills or only progesterone pills Mini pills or only progesterone pills

45 MECHANISM Prevents midcycle FSH and LH surge from anterior pitutary- no follicular development therefore no ovulation Prevents midcycle FSH and LH surge from anterior pitutary- no follicular development therefore no ovulation Peripheral- cervical mucus becomes less penetrable Peripheral- cervical mucus becomes less penetrable Endometrium becomes unreceptive Endometrium becomes unreceptive

46 ABSOLUTE CONTRAINDICATIONS 1. Recent liver disease 2. H/O any thromboembolic disorder 3. Epilepsy 4. Ca breast, cervix or uterus 5. Undiagnosed vaginal bleeding

47 RELATIVE CONTRAINDICATIONS 1. Migraine 2. Severe allergy 3. HT 4. Smoking 5. Woman > 35 years

48 BENEFITS OF ORAL PILLS Pills are highly effective if taken regularly Pills are highly effective if taken regularly Pregnancy rate is as low as 0.1% per 100 woman year Pregnancy rate is as low as 0.1% per 100 woman year Apart from contraceptive effects Apart from contraceptive effects 1. reduces chances of functional ovarian cysts 2. Corrects of menorrhagia and prevents anemia 3. Regularizes menses 4. Relief of dysmenorrhea 5. Reduces chances of ectopis pregnancy 6. Decrease chances of fibroids, fibroadenoma and fibrocystic diseases through reduction of estrogen receptors

49 SIDE EFFECTS OF ORAL PILLS 1. Nausea and vomiting 2. Breakthrough bleeding 3. Pill amenorrhea 4. Leucorrhea 5. Candidiasis 6. Weight gain 7. HT 8. Alters carbohydrate and lipid metabolism

50 CENT CHROMAN (SAHELI) It is a non – steroidal low estrogenic compound It is a non – steroidal low estrogenic compound 30 mg tab is taken twice a week for 3 months and then weekly 30 mg tab is taken twice a week for 3 months and then weekly Contraindication: same as pills Contraindication: same as pills Failure rate is 4 per 100 woman year Failure rate is 4 per 100 woman year Side effects: delayed cycle in 8% of cases otherwise quite safe Side effects: delayed cycle in 8% of cases otherwise quite safe

51 LONG ACTING INJECTABLES 1. Injection of progesterone DEPO PROVERA (medroxy progesterone acetate) taken every 3 rd month 2. Can be taken continuously for 3 years if no side effects 3. Mode of action is by suppression of ovulation 4. Main side effect- menstrual irregularity

52 HORMONE IMPLANTS 1. Hormone laden implants: multiple rod and single rod 2. Not easily available in India

53 IUCD Have been in use since 1962 Have been in use since 1962 First generation: Lippe’s loop Second generation: Cu-T 200 Third generation: multiload Cu devise, hormone bearing IUCD’s like progestasert and mirena INDICATION: TO BE USED PAROUS WOMEN

54 MECHANISM 1. Causes foreign body tissue reaction in endometrium 2. Copper interferes with uterine estrogen receptors 3. Increased prostaglandin liberation in endometrium causes abnormal uterine activity 4. Phagocytosis of sperms and blastocyte

55 ABSOLUTE CONTRAINDICATIONS 1. Carcinoma of genital organs 2. Infection after child birth or abortion 3. Recent history of STD or PID 4. Unexplained vaginal bleeding 5. Distortion of uterine cavity 6. Genital TB

56 SIDE EFFECTS OF IUCD 1. Abnormal uterine bleeding 2. Pain and dyspareunia 3. Infections

57 COMPLICATION OF IUCD 1. Uterine perforation 2. Expulsion 3. ectopic pregnancy FAILURE RATE OF IUCD IS 2 – 5 PER 100 WOMAN YEAR FAILURE RATE OF IUCD IS 2 – 5 PER 100 WOMAN YEAR

58 PERMANENT CONTRACEPTION Male sterilization Male sterilization 1. It is safer, easier, less expensive with low failure rate 0.1-1% Female sterilization Female sterilization 1. post partum within seven days 2. Interval anytime after menses 3. Late post partum when uterus is fully involuted 4. At the time of CS FAILURE RATE DEPENDS ON THE METHOD OF TUBAL LIGATION. LAP STRILIZATION, FAILURE RATE %

59 THANK YOU


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