Rotp+Dr+Asha+Jain

7/31/2019 Rotp+Dr+Asha+Jain

1/59

UNDERSTANDING THE CONCEPT

OF PREVENTIVE AND COMMUNITYMEDICINE IN OBSTETRICS ANDIMPLEMENTING IT IN ANC OPD

DR. ASHA JAIN

MBBS, MS Gynecology and Obstetrics

SENIOIR GYNECOLOGIST

NEHRU HOMOEOPATHIC MEDICAL COLLEGE ANDHOSPITAL


2/59

Obstetrics is largely a preventivemedicine. the aim of both is the

same which is to ensure the good

health of mother through outpregnancy and puerperium so thatevery pregnancy may culminate in a

healthy mother with a healthy baby.


3/59

SOCIAL OBSTETRICS

This concept has recently gainedpopularity which is defined as the study ofinterplay of social and environmental

factors and human reproduction goingback to preconceptional and even premarital period.


4/59

SOCIAL AND ENVIRONMENTALFACTORS

1. AGE OF MARRIAGE

2. AGE OF CHILD BEARING

3. CHILD SPACING

4. FAMILY SIZE

5. LEVEL OF EDUCATION

6. ECONOMIC STATUS

7. CUSTOMS AND BELIEFS

8. ROLE OF WOMEN IN SOCIETY


5/59

contd.

All socia and environmental factors are

interrelated like early marriage is a social customin third world countries especially in IndianBIMARU states.

Mean age of marriages Is 17.4 years, it is evenlower in above states.

20% of all pregnancies are teenage pregnancyforced by families and society.

Pregnancy below 16 years leads to highprecentage of risks like PIH, anaemia, small

pelvis, immature perineum with injuries, pretermbirths and high perinantal and maternalmorbidity.

MONSTERS OF OUR SOCIETY ARE IGNORANCE,

POVERTY, ILLITERACY AND GENDERDISCRIMINATION.


6/59

CONTD

Gender discrimination is quite prevalent inIndian families. Best and good food goes to thefather and the sons.

Very few realize that nutrition and health ofadolescent girl forms most important step forthe health of future pregnant woman.

It is not wrong to say that nutrition and healthcare of the pregnant woman starts at the age of10 and not when she becomes pregnant.


7/59

Contd

Ignorance, poverty and illiteracy results intounplanned sexual activity and pregnancies.

Though society is divided on the issue of sexeducation, it must be started at the school level

which should consist of: Physiology and anatomy of reproductive

sysem

Genital hygiene and care during menstrualcycle

Harmful effects of premarital and unsafe sex

Should be taught about STD, HIV and

contraception


8/59

Contd Best way to educate and influence people in

villages and town is to involve religious leaderswho can during their discourse point out theimportance of sex education, family planningand 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 ofabove factors.

Various NGOs and medical societies can alsohelp in changing the attitude of people towardssize of family, care of adolescent girl andpregnant mother and use of family planning

devises.


9/59

MATERNAL AND CHILD HEALTH

Mother and child must be considered a single unit because:

1. During antenatal period fetus is a part of mother andobtains all the building material and oxygen from mothersblood.

2. Childs health is closely related to maternal health, ahealthy mother brings forth a healthy baby.

3. Certain conditions and diseases are likely to have theireffect 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. Postpartum period care which is inseparable from neonatal care.

6. Mother is first teacher of child.


10/59


11/59

Antenatal care

Care of woman during pregnancy iscalled antennal care. The aim is toachieve 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.


12/59

Objectives of antenatal care

1. Promote, protect and maintain helath ofmother during pregnancy

2. Detect high risk cases3. Foresee complications and prevent them

4. To remove anxiety and dread related topregnancy and delivery

5. To reduce MMR and IMR related to delivery6. Teach mother the elements of childcare,

nutrition, hygiene, environmental sanitationetc.7. Sensitize mother about family planning8. To attend under five children accompanying

the mother


13/59

MCH PROBLEMS

Main health problems affecting the healthof mother and child revolves around:

1. Malnutrition

2. Infections

3. Consequences of unregulated fertility

4. Scarcity of health and other serviceswith poor socioeconomic conditions.


14/59

ANTENATAL CARE

1. General history2. 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, EDD5. Obstetric history:

1. Previous pregnancies- abortions induced or spontaneous2. Normal deliveries3. Operative deliveries- instrumental or CS4. Any complication during pregnancy5. Complications of labor6. Third stage complications7. Puerperium8. Condition of child


15/59

General and medical examination

1. Height and weight2. Stature and nutritional status

3. Gait

4. Medical examination: Respiratory,cardiac, endocrinal and abdominalexamination

5. Examination of oral cavity

6. Examination of breast

7. BP, edema feet, cyanosis, clubbing etc.


16/59

Obstetric examination

1. Height of uterus

2. Presentation, lie and position

3. Fetal heart rate


17/59

Vaginal examination

EARLY PREGNANCY

1. To confirm diagnosis of pregnancy

2. To rule out extra uterine pregnancy

3. Any adenexal pathology

LATE PREGNANCY

1. To rule out CPD

2. At the time of labor and

3. Any other obstetric indication


18/59

Laboratory examination

Hb, ABO Rh, blood sugar, urine analysis,HIV, VDRL, HbsAg

ICT in Rhve if husband is positive


19/59

Advice1. 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 1st 3 months Once a month till 28 weeks Twice a month till 36 weeks Weekly till delivery

As it is difficult for the mother coming from lowsocio economic group minimum 3 visits duringentire pregnancy is a must.

1st

visit earliest < 20 weeks 2nd visit at 32 weeks 3rd 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.


20/59

Advice

At this time the mother is more receptive tothe advice concerning herself and the baby.She must be advised for:

1. Diet2. Personal hygiene

3. Drugs

4. Warning signs5. Radiation

6. Childcare


21/59

Dietary advice

A daily intake of about 2500-2800 calories meet thetotal 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. She is instructed to take such diet home resources

available in the budget. She may be provided a dietchart keeping in mind 3G formula.1. 1G for grains e.g. chapati

2. 2G for gram e.g. dal3. 3G for green leafy vegetables and fruits.

Milk requirement 110 ml/day Water intake 2-3 lt/day, clean or boiled water

Pictorial diet chart in regional language


22/59

Care of minor symptoms duringpregnancy

Morning sickness and vomiting

Vaginal discharge

Heartburn

Edema

Leg cramps

Headache

Piles

Carpel tunnel syndrome


23/59

General advice Personal hygiene: personal cleanliness, daily bath, rest

and sleep for 8 hrs at night and 2 hrs at midday Bowels: constipation should be avoided Exercises: light house work and regular walking, ANC

exercises as advised

Smoking and alcohol should be avoided Proper dental care Sexual intercourse should be avoided in last 3 months Drugs not essential should not be consumed Avoid radiation Warning signs: vaginal bleeding, swelling of feet,

headache, blurring of vision and fits, bleeding andleaking in last months of pregnancy and any otherunusual symptoms.

Childcare classes should be held Education on labor and child birth


24/59

Contd

Lack of proper communicationduring ANC and non complianceon the part of female and herrelatives leads to poor results.Therefore health worker has to

take pains to communicate healtheducation ot pregnanct womanand her attendants at each visits.


25/59

supplementation

Iron and folic acid 1 cap 60 mgelemental iron

500 mg of folic acid

Ca 500-1000 mg with vitamin D

Immunization

1. Two doses of TT 4-6 weeks apart after 16weeks of pregnancy


26/59

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.


27/59

Warning signs

Vaginal bleeding

Swelling of face and fingers

Continuous headaches

Dimness of visionAbdominal pain

Persistent vomiting

High fever

Dysuria

Passage of fluid per vaginum

Marked changes in fetal movement or no

movement


28/59

INTRANATAL CARE

Aim of good intranatal care is achieved by:1. High asepsis

2. Delivery with minimum trauma to the

mother and child3. Readiness to deal with impending

complication like PET, prolonged labor,

PPH4. Care of newborn at birth like

resuscitation, care of cord, care of eyes

etc.


29/59

INTRANATAL CARE Every pregnant woman is educated to have

child birth by trained birth attendant

85% pregnancies terminate into normaldelivery 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 is95%

Hospital delivery is safer and reducesmaternal and perinatal morbidity and

mortality


30/59

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


31/59

Monitoring of 1st stage of labor

1. Vital signs

2. Progress of labor

3. Graphic recording of labor can be done

4. BP, Pulse, uterine contraction, descent ofpresenting part, fetal heart rate, leakingPV

5. PV examination whenever indicated6. Total duration of 1st stage is 19-16 hrs I

primigravida and 5-6 hrs in multigravida


32/59

Monitoring of 2nd stage of labor

1. High asepsis

2. Delivery with minimum trauma to themother and child

3. Readiness to deal with impendingcomplication like PET, prolonged labor,PPH

4. Care of newborn at birth likeresuscitation, care of cord, care of eyesetc.


33/59

DOMICILIARY DELIVERY

Home conditions should be satisfactory Delivery conducted by trained dai or LHVAdvantages include: familiar surroundings,

less cross infection, mother can take careof other children 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


34/59

CARE OF BABY

1. Cleaning airway

2. APGAR score

3. Care of cord4. Care of eyes

5. Breast feeding

6. Maintenance of body temperature 36.537.5c


35/59

CARE OF MOTHER

Objectives is to prevent postnatalcomplication

Adequate breast feeding, childimmunization

Provide family planning


36/59


37/59

ADVANTAGES OF BREAST FEEDING

1. Safe clean, cheap and readily available2. Fully meets nutritional requirement of infant

3. Contains antimicrobial factor e.g.macrophages, lymphocytes, secretory IgA etc.

prevents against various infections4. Easily digested by normal premature infants

5. Promotes bonding between mother and child

6. Suckling helps in development of jaw andteeth

7. Prevents malnutrition and infant mortality

8. Helps in spacing of child birth

9. Helps in involution of uterus


38/59

ARTIFICIAL FEEDING

Artificial feeding and weaning started at 4-5month. Supplementary food like cowsmilk, cooked rice, dal, vegetables etc.

should be given.


39/59

IMMUNIZATION PROGRAM

At birth BCG, OPV0dose

6 weeks 1 DPT, OPV

10 weeks 2 DPT, OPV

14 weeks 3 DPT, OPV

9 months measles

16 24 weeks DPT,

OPV5 6 years DT

10 16 years - TT

Hepatitis B 0 week, 6weeks, 6 months

MMR 15 months

OPTIONAL

Typhoid

Hepatits

Meningitis etc.


40/59

FAMILY PLANNING

Family planning refers to practices that helpindividual or couples to attain certainobjectives:

1. To avoid unwanted birth2. To bring about wanted birth

3. To regulate interval between pregnancy

4. To determine number of children in family5. To control the time at which birth occur in

relation to age of the parents.


41/59

Indications for contraception

1. To restrict family and stabilizepopulation

2. Medical disorders in females3. Obstetric and gynecology indication

4. Eugenic and fetal condition


42/59

Commonly used contraceptives

1. Pills and injectables

2. IUCDs

3. Condoms and vaginal contraceptives4. Tubectomy (98.1%) and vasectomy

(1.99%)


43/59

Preference of contraceptives

After marriage or nulliparous1. Pills or condom till pregnancy is planned

After 1st child birthIUCD

1. Condom with vaginal contraception2. Pills after 6 months3. injectables

After 2nd pregnancy1. IUCD

5 years after complete family1. Tubectomy and vasectomy


44/59

ORAL PILLS

combination of hormones estrogens andprogesterone: mostly used from 25-35 years ofage

Common names: MALA-D, MALA-N, OVRAL,TRIQUILAR

21 tabs are taken from 5th -25th day with 7 daysof iron tabs

If no side effects then taken for 3-5 yearscontinuously

Mini pills or only progesterone pills


45/59

MECHANISM

Prevents midcycle FSH and LH surge fromanterior pitutary- no follicular developmenttherefore no ovulation

Peripheral- cervical mucus becomes lesspenetrable

Endometrium becomes unreceptive


46/59

ABSOLUTE CONTRAINDICATIONS

1. Recent liver disease

2. H/O any thromboembolic disorder

3. Epilepsy4. Ca breast, cervix or uterus

5. Undiagnosed vaginal bleeding


47/59

RELATIVE CONTRAINDICATIONS

1. Migraine

2. Severe allergy

3. HT

4. Smoking

5. Woman > 35 years


48/59

BENEFITS OF ORAL PILLS

Pills are highly effective if taken regularly Pregnancy rate is as low as 0.1% per 100

woman year Apart from contraceptive effects

1. reduces chances of functional ovarian cysts2. Corrects of menorrhagia and prevents anemia3. Regularizes menses4. Relief of dysmenorrhea

5. Reduces chances of ectopis pregnancy6. Decrease chances of fibroids, fibroadenoma and

fibrocystic diseases through reduction of estrogenreceptors


49/59

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


50/59

CENT CHROMAN (SAHELI)

It is a non steroidal low estrogeniccompound

30 mg tab is taken twice a week for 3

months and then weekly

Contraindication: same as pills

Failure rate is 4 per 100 woman year

Side effects: delayed cycle in 8% of casesotherwise quite safe


51/59

LONG ACTING INJECTABLES

1. Injection of progesterone DEPOPROVERA (medroxy progesteroneacetate) taken every 3rd month

2. Can be taken continuously for 3 years ifno side effects

3. Mode of action is by suppression of

ovulation

4. Main side effect- menstrual irregularity


52/59

HORMONE IMPLANTS

1. Hormone laden implants: multiple rodand single rod

2. Not easily available in India


53/59

IUCD

Have been in use since 1962

First generation: Lippes loop

Second generation: Cu-T 200

Third generation: multiload Cu devise, hormonebearing IUCDs like progestasert and mirena

INDICATION: TO BE USED PAROUS WOMEN


54/59

MECHANISM

1. Causes foreign body tissue reaction inendometrium

2. Copper interferes with uterine estrogen

receptors

3. Increased prostaglandin liberation inendometrium causes abnormal uterine

activity

4. Phagocytosis of sperms and blastocyte


55/59

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


56/59

SIDE EFFECTS OF IUCD

1. Abnormal uterine bleeding

2. Pain and dyspareunia

3. Infections


57/59

COMPLICATION OF IUCD

1. Uterine perforation

2. Expulsion

3. ectopic pregnancy

FAILURE RATE OF IUCD IS 2 5 PER

100 WOMAN YEAR


58/59

PERMANENT CONTRACEPTION

Male sterilization1. It is safer, easier, less expensive with low failure

rate 0.1-1%

Female sterilization1. 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 OFTUBAL LIGATION. LAP STRILIZATION,FAILURE RATE 0.2-1-3%


59/59

THANK YOU

Rotp+Dr+Asha+Jain

Documents

Transcript of Rotp+Dr+Asha+Jain