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:
1UNDERSTANDING THE CONCEPT OF PREVENTIVE AND COMMUNITY MEDICINE IN OBSTETRICS AND IMPLEMENTING IT IN ANC OPDDR. ASHA JAINMBBS, MS Gynecology and ObstetricsSENIOIR GYNECOLOGISTNEHRU HOMOEOPATHIC MEDICAL COLLEGE AND HOSPITAL
2Obstetrics is largely a preventive medicine 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.
3SOCIAL OBSTETRICSThis 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.
4SOCIAL AND ENVIRONMENTAL FACTORS 1. AGE OF MARRIAGE2. AGE OF CHILD BEARING3. CHILD SPACING4. FAMILY SIZE5. LEVEL OF EDUCATION6. ECONOMIC STATUS7. CUSTOMS AND BELIEFS8. ROLE OF WOMEN IN SOCIETY
5contd.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.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.MONSTERS OF OUR SOCIETY ARE IGNORANCE, POVERTY, ILLITERACY AND GENDER DISCRIMINATION.
6CONTD…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.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.
7Contd…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:Physiology and anatomy of reproductive sysemGenital hygiene and care during menstrual cycleHarmful effects of premarital and unsafe sexShould be taught about STD, HIV and contraception
8Contd…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.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.
9MATERNAL 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.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.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.6. Mother is first teacher of child.
10Contd…MCH care refers to promotive, preventive and rehabilitative health care for mother and child. It includes:Maternal healthChild healthFamily planningSchool healthHealth care of special cases like adolescent girls, handicapped children and care of children in special settings like daycare centers
11Antenatal careCare 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.Apart from other factors proper antenatal care has bought about remarkable results.
12Objectives of antenatal care Promote, protect and maintain helath of mother during pregnancyDetect high risk casesForesee complications and prevent themTo remove anxiety and dread related to pregnancy and deliveryTo reduce MMR and IMR related to deliveryTeach mother the elements of childcare, nutrition, hygiene, environmental sanitation etc.Sensitize mother about family planningTo attend under five children accompanying the mother
13MCH PROBLEMSMain health problems affecting the health of mother and child revolves around:1. Malnutrition2. Infections3. Consequences of unregulated fertility4. Scarcity of health and other services with poor socioeconomic conditions.
14ANTENATAL CARE General history Family history regarding history of TB, HT, DM, congenital anomalies, hereditary diseases.Personal history: H/O medical and surgical problems and H/O deficiencyMestrual history: LMP, EDDObstetric history:Previous pregnancies- abortions induced or spontaneousNormal deliveriesOperative deliveries- instrumental or CSAny complication during pregnancyComplications of laborThird stage complicationsPuerperiumCondition of child
15General and medical examination Height and weightStature and nutritional statusGaitMedical examination: Respiratory, cardiac, endocrinal and abdominal examinationExamination of oral cavityExamination of breastBP, edema feet, cyanosis, clubbing etc.
16Obstetric examination Height of uterusPresentation, lie and positionFetal heart rate
17Vaginal examination EARLY PREGNANCY To confirm diagnosis of pregnancy To rule out extra uterine pregnancyAny adenexal pathologyLATE PREGNANCYTo rule out CPDAt the time of labor andAny other obstetric indication
18Laboratory examination Hb, ABO Rh, blood sugar, urine analysis, HIV, VDRL, HbsAgICT in Rh –ve if husband is positive
19AdviceImpress upon her need for regular attendance at the clinic and assure her that pregnancy and labor would be smooth and safe.Ideal number of visits:First visit in 1st 3 monthsOnce a month till 28 weeksTwice a month till 36 weeksWeekly till deliveryAs it is difficult for the mother coming from low socio economic group minimum 3 visits during entire pregnancy is a must.1st visit earliest < 20 weeks2nd visit at 32 weeks3rd visit at 36 weeksFurther visits justified by the condition of the mother.Home visits are also paid by the health worker.All records are propely maintained in the ANC card.
20AdviceAt this time the mother is more receptive to the advice concerning herself and the baby. She must be advised for:DietPersonal hygieneDrugsWarning signsRadiationChildcare
21Dietary adviceA daily intake of about calories meet the total energy needs of the average pregnant woman.Wt gain is directly related to healthy and adequate dietBalanced 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.1G for grains e.g. chapati2G for gram e.g. dal3G for green leafy vegetables and fruits.Milk requirement 110 ml/dayWater intake 2-3 lt/day, clean or boiled waterPictorial diet chart in regional language
22Care of minor symptoms during pregnancy Morning sickness and vomitingVaginal dischargeHeartburnEdemaLeg crampsHeadachePilesCarpel tunnel syndrome
23General advicePersonal hygiene: personal cleanliness, daily bath, rest and sleep for 8 hrs at night and 2 hrs at middayBowels: constipation should be avoidedExercises: light house work and regular walking, ANC exercises as advisedSmoking and alcohol should be avoidedProper dental careSexual intercourse should be avoided in last 3 monthsDrugs not essential should not be consumedAvoid radiationWarning 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 heldEducation on labor and child birth
24Contd…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.
25supplementation Iron and folic acid 1 cap 60 mg elemental iron 500 mg of folic acidCa mg with vitamin DImmunizationTwo doses of TT 4-6 weeks apart after 16 weeks of pregnancy
26Identify high risk cases Elderly primigravida > 30 yearsShort strature < 140 cmMalpresentation, breech etc.APH, threatened abortion, repeated abortionPET, eclampsiaAnaemiaTwins, hydramnios,Previous IUD, MRP, CSElderly grand multiparaPost dated pregnancyPregnancy and medical problems e.g. DM, HT, TB etc.
27Warning signs Vaginal bleeding Swelling of face and fingers Continuous headachesDimness of visionAbdominal painPersistent vomitingHigh feverDysuriaPassage of fluid per vaginumMarked changes in fetal movement or no movement
28INTRANATAL CARE Aim of good intranatal care is achieved by: High asepsisDelivery with minimum trauma to the mother and childReadiness to deal with impending complication like PET, prolonged labor, PPHCare of newborn at birth like resuscitation, care of cord, care of eyes etc.
29INTRANATAL CAREEvery pregnant woman is educated to have child birth by trained birth attendant85% pregnancies terminate into normal delivery though incidence varies from place to placeIn 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
30Management of first stage of labor Admission- MCH recordExaminationPreparation of the patientEnemaFrequent urinationProper postureFood during laborPain relief in labor
31Monitoring of 1st stage of labor Vital signsProgress of laborGraphic recording of labor can be doneBP, Pulse, uterine contraction, descent of presenting part, fetal heart rate, leaking PVPV examination whenever indicatedTotal duration of 1st stage is hrs I primigravida and 5-6 hrs in multigravida
32Monitoring of 2nd stage of labor High asepsisDelivery with minimum trauma to the mother and childReadiness to deal with impending complication like PET, prolonged labor, PPHCare of newborn at birth like resuscitation, care of cord, care of eyes etc.
33DOMICILIARY DELIVERY Home conditions should be satisfactory Delivery conducted by trained dai or LHVAdvantages include: familiar surroundings, less cross infection, mother can take care of other childrenDisadvantages include: less nursing supervision, inadequate rest, place may be unsuitable for the deliveryLHV of ANM should know when to refer the case to the hospital
34CARE OF BABY Cleaning airway APGAR score Care of cord Care of eyes Breast feedingMaintenance of body temperature 36.5 – 37.5˚c
35CARE OF MOTHER Objectives is to prevent postnatal complication Adequate breast feeding, child immunizationProvide family planning
36BREAST FEEDING Should be initiated in ½ hour of normal delivery 4-6 hours of CSHelps to establish bond between mother and childColostrumRich in proteins and other nutrientsAntibodies which provide protection to the newborn to various diseases and diarrheaDemand feedingNo feeding bottlesExclusive breast feeding for 6 months
37ADVANTAGES OF BREAST FEEDING Safe clean, cheap and readily availableFully meets nutritional requirement of infantContains antimicrobial factor e.g. macrophages, lymphocytes, secretory IgA etc. prevents against various infectionsEasily digested by normal premature infantsPromotes bonding between mother and childSuckling helps in development of jaw and teethPrevents malnutrition and infant mortalityHelps in spacing of child birthHelps in involution of uterus
38ARTIFICIAL FEEDINGArtificial feeding and weaning started at 4-5 month. Supplementary food like cow’s milk, cooked rice, dal, vegetables etc. should be given.
39IMMUNIZATION PROGRAM At birth – BCG, OPV 0dose 6 weeks – 1 DPT, OPV 9 months – measles16 – 24 weeks – DPT, OPV5 – 6 years – DT10 – 16 years - TTHepatitis B – 0 week, 6 weeks, 6 monthsMMR – 15 monthsOPTIONALTyphoidHepatitsMeningitis etc.
40FAMILY PLANNINGFamily planning refers to practices that help individual or couples to attain certain objectives:To avoid unwanted birthTo bring about wanted birthTo regulate interval between pregnancyTo determine number of children in familyTo control the time at which birth occur in relation to age of the parents.
41Indications for contraception To restrict family and stabilize populationMedical disorders in femalesObstetric and gynecology indicationEugenic and fetal condition
42Commonly used contraceptives Pills and injectablesIUCD’sCondoms and vaginal contraceptivesTubectomy (98.1%) and vasectomy (1.99%)
43Preference of contraceptives After marriage or nulliparousPills or condom till pregnancy is plannedAfter 1st child birthIUCDCondom with vaginal contraceptionPills after 6 monthsinjectablesAfter 2nd pregnancy5 years after complete familyTubectomy and vasectomy
44ORAL PILLScombination of hormones estrogens and progesterone: mostly used from years of ageCommon names: MALA-D, MALA-N, OVRAL, TRIQUILAR21 tabs are taken from 5th -25th day with 7 days of iron tabsIf no side effects then taken for 3-5 years continuouslyMini pills or only progesterone pills
45MECHANISMPrevents midcycle FSH and LH surge from anterior pitutary- no follicular development therefore no ovulationPeripheral- cervical mucus becomes less penetrableEndometrium becomes unreceptive
46ABSOLUTE CONTRAINDICATIONS Recent liver diseaseH/O any thromboembolic disorderEpilepsyCa breast, cervix or uterusUndiagnosed vaginal bleeding
47RELATIVE CONTRAINDICATIONS MigraineSevere allergyHTSmokingWoman > 35 years
48BENEFITS OF ORAL PILLS Pills are highly effective if taken regularly Pregnancy rate is as low as 0.1% per 100 woman yearApart from contraceptive effectsreduces chances of functional ovarian cystsCorrects of menorrhagia and prevents anemiaRegularizes mensesRelief of dysmenorrheaReduces chances of ectopis pregnancyDecrease chances of fibroids, fibroadenoma and fibrocystic diseases through reduction of estrogen receptors
49SIDE EFFECTS OF ORAL PILLS Nausea and vomitingBreakthrough bleedingPill amenorrheaLeucorrheaCandidiasisWeight gainHTAlters carbohydrate and lipid metabolism
50CENT CHROMAN (SAHELI) It is a non – steroidal low estrogenic compound 30 mg tab is taken twice a week for 3 months and then weeklyContraindication: same as pillsFailure rate is 4 per 100 woman yearSide effects: delayed cycle in 8% of cases otherwise quite safe
51LONG ACTING INJECTABLES Injection of progesterone DEPO PROVERA (medroxy progesterone acetate) taken every 3rd monthCan be taken continuously for 3 years if no side effectsMode of action is by suppression of ovulationMain side effect- menstrual irregularity
52HORMONE IMPLANTS Hormone laden implants: multiple rod and single rod Not easily available in India
53IUCD Have been in use since 1962 First generation: Lippe’s loop Second generation: Cu-T 200Third generation: multiload Cu devise, hormone bearing IUCD’s like progestasert and mirenaINDICATION: TO BE USED PAROUS WOMEN
54MECHANISM Causes foreign body tissue reaction in endometrium Copper interferes with uterine estrogen receptorsIncreased prostaglandin liberation in endometrium causes abnormal uterine activityPhagocytosis of sperms and blastocyte
55ABSOLUTE CONTRAINDICATIONS Carcinoma of genital organsInfection after child birth or abortionRecent history of STD or PIDUnexplained vaginal bleedingDistortion of uterine cavityGenital TB
56SIDE EFFECTS OF IUCD Abnormal uterine bleeding Pain and dyspareunia Infections
57COMPLICATION OF IUCD Uterine perforation Expulsion ectopic pregnancy FAILURE RATE OF IUCD IS 2 – 5 PER 100 WOMAN YEAR
58PERMANENT CONTRACEPTION Male sterilizationIt is safer, easier, less expensive with low failure rate 0.1-1%Female sterilizationpost partum within seven daysInterval anytime after mensesLate post partum when uterus is fully involutedAt the time of CSFAILURE RATE DEPENDS ON THE METHOD OF TUBAL LIGATION. LAP STRILIZATION, FAILURE RATE %