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Maternity Care. By Prof. Drs. Asmaa Abdel Aziz Dr. Alaa Hassan. The basic principles that make the women health requires special care: Women constitute a large group of the population. They are vulnerable due to their physiological constituents

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maternity care

Maternity Care

By

Prof. Drs.

Asmaa Abdel Aziz Dr. Alaa Hassan

slide2
The basic principles that make the women health requires special care:
  • Women constitute a large group of the population.
  • They are vulnerable due to their physiological constituents
  • High frequency of Pregnancy related morbidity and mortality that can be prevented by simple and cost effective interventions.
  • Certain problems of the mother during pregnancy e.g. malnutrition, HIV, HB, Syphilis, German measles, drug intake and smoking have their adverse effects on the fetus.
slide3
Factors related to maternal mortality & morbidity

1- Factors related to the consumers ( Women):

2- Factors related to Health Care

slide4
Factors related to the consumers ( Women):
  • High burden of health problems among women.
  • Young age at conception, short interbirth interval, high parity
  • Lack of awareness about health problems & factors

behind them which leads to

-lack of personal hygiene

- Inadequate nutrition.

          • -Inability to recognize dangerous signs
          • &symptoms
          • -Delay in seeking health care
          • -Low utilization of preventive services
          • (Antenatal care).
slide5
II. Factors related to Health Care
      • Inaccessible Health services: Lack of transportation or long distance
      • Poor &inadequate referral system.
      • Low outreach for all services except for postnatal check up.
      • Shortage of drugs, equipment, transportation

Facilities.

      • Lack of experience & training of health personnel that lead to Failure of early diagnosis , inadequate management and time of referral.
slide6
Maternal mortality

The World Health Organization define maternal mortality as: Death of women while pregnant or within 42 days after termination of pregnancy (i.e. during pregnancy, delivery and puerperium), form any reasons related to / or aggravated by the pregnancy or its management, but not as a result of unrelated accidental or incidental causes.

slide7
World wide, around half a million women die yearly from maternal causes. Almost 99% of these deaths occur in developing countries
      • 60% of all maternal deaths occur after delivery,
      • 24% during pregnancy
      • 16% during delivery.
causes of maternal death
A) Direct causes:

1- Hemorrhage.

2- Eclampsia

3- Puerperal sepsis.

4- Obstructed labor.

5- Induced abortion.

B)Indirect causes:

Death from chronic diseases that are aggravated by pregnancy

e.g. heart, liver & kidney diseases, anemia, diabetes & hypertension

Causes of maternal death
slide10
1-Hemorrhage
  • Identification:
  • Antepartum hemorrhage is hemorrhage from the genital tract occurring after 22 weeks of gestation till before delivery of the baby.
  • Postpartum hemorrhage is the loss of 500 ml or more of blood from the genital tract after delivery of the baby.
slide11
Complications:
  • 1- Maternal :
        • shock
        • cardiac failure
        • infection.
  • 2- Fetus /newborn baby :
        • low birth weight,
        • asphyxia,
        • still birth
slide12
Early detection and management
  • 1- Antepartum hemorrhage
        • No vaginal examination should be carried out at the health center
        • Give IV fluids if mother is shocked
        • Refer to hospital.
  • 2-In postpartum hemorrhage
        • if placenta is still retained perform manual separation of placenta.
        • If removal is impossible refer to hospital.
  • 3-All women with bleeding should have iron therapy in post partum period.
slide13
2-Hypertensive disorders of pregnancy
  • Hypertension in pregnancy
        • The blood pressure is more than 140/90 Hg
  • Pre-eclampsia:
        • Hypertension + proteinuria
  • Eclampsia :
        • Hypertension + proteinuria +convulsion & coma.
slide14
Complications:
      • For Mothers :Maternal death & cerebrovascular strokes.
      • For Newborns: Low birth weight ,asphyxia
      • &still birth
slide15
Early detection of hypertensive disorders during pregnancy:
    • Raise the family awareness of signs and symptoms of hypertensive disorders of pregnancy.
    • pregnant woman should seek care if she suffers severe headache, generalized edema, blurred vision and /or convulsion.
    • During the antenatal care check out for edema, perform frequent blood pressure & weight measurement and urine analysis for proteinuria.
slide16
Management:
  • If B/P (diastolic) is100 mm Hg and no proteinuria
          • Management is at the health center
          • Bed rest & check B/P twice weekly.
  • If B/P rises and / or oedema or proteinuria develop
          • Refer to hospital
slide17
3-Puerperal sepsis
  • Identification:
  • It is infection of the genital tract occurring at any time between the onset of labor and within the 42 days post partum in which fever (38.5oC) and one or more of the following is present:
        • 1- Pelvic pain.
        • 2- Abnormal vaginal discharge (e.g. pus or abnormal smell ).
        • 3- Delay in the reduction of the size of the uterus
slide18
Predisposing factors for puerperal sepsis :
  • 1 -Low resistance:
  • General
          • a-Malnutrition (anemia)
          • b-Infections (respiratory, urinary, or genital)
          • c-Hemorrhage.
          • d- Preeclampsia or eclampsia.
  • Local:
          • a- Premature rupture of the membrane.
          • b- Prolonged labor.( Forceps)
          • c- Presence of perineal tears.
  • 2-Unclean practices during delivery (manual or operative intervention)
slide19
Complications:

Maternal complication:-septicemia, shock, death.

slide20
Prevention, early detection and management of puerperal sepsis:

During pregnancy:

1- Correction of predisposing factors

Malnutrition (anemia) infections (respiratory,

urinary, or genital) Preeclampsia or

eclampsia

2- Treatment of any septic focus

3- Health education on personal hygiene

slide21
During labor and puerperium:

1- Birth attendants

should be aware of the requirement for a clean delivery: strict aseptic techniques, avoidance of repeated manipulation and transmission of infection from attendants and visitors.

2- Prophylactic use of antibiotic.

3- Health care providers

should be trained to recognize puerperal sepsis, give antibiotics and refer to hospital if there is no improvement

4- Women

should be aware of the early signs and symptoms of infection and be encouraged to seek treatment.

slide22
4-Anemia in pregnancy
  • Identification:
  • Anemia in pregnancy is defined as a hemoglobin concentration of less than 11 gm % (11 gm/ 100 ml blood).
  • It is a risk factor to many complications during pregnancy.
  • Causes of iron deficiency anaemia:
        • 1-Repeated pregnancy & delivery within short intervals
        • 2-Parasitic Infections
        • 3- Deficient Iron Intake
complications of severe anemia
Maternal complications:

a-Cardiac failure.

b- Increase fatality from

Ant or postpartum hemorrhage.

c- Increase complications due to anesthesia or operation

d- Puerperal sepsis

Fetus/new born complications:

a- Low birth weight

b-Asphyxia.

c-Still birth

d-Perinatal mortality.

Complications of severe anemia:
slide24
Prevention, early detection of iron deficiency anaemia
        • All pregnant women should be given a standard dose of Iron /Folate during pregnancy
        • 2. Nutritional education
        • 3. Treatment of parasitic infections.
        • 4. Early detection by assessment for pallor & routine hemoglobin estimation
slide25
Management:
    • If moderate anemia:
          • - Give standard oral dose of
          • iron / Folate.
    • If severe anemia,
        • - Treat for a month with higher
        • dose or
        • - Give IM iron.
        • -If Hb level not raised after
        • treatment, refer to hospital
slide27
Maternity Care Program :
  • It includes:
        • Premarital Care
        • Antenatal Care
        • Natal care
        • Postnatal care
slide28
Aims of the program:

1- Detect any potential risk to pregnancy. : Biological obstetric, medical ,social

3- Save the off springs from the heath hazards of parental origin.

4- Guide and educate partners for a healthy family

slide30
Components of the Premarital Care:
  • a) History taking: A personal, family & medical history for diseases (diabetes, hypertension, Mental retardation, Sickle cell anaemia)
  • b) Medical examination.
  • c) Investigations:
      • Chest x-ray to exclude T.B.
      • Blood examination: ABO, Rh, blood sugar, Hb ,serological tests for Syphilis
      • Urine analysis for albuminuria, glycosuria & renal infection
      • Stool analysis for parasites.
  • Detected cases should be referred for management
slide31
d)-Parenthood and family life education:
  • Education on: infant care, child development & STDs
  • e) Genetic Counseling: For those with family history of genetic disorders
  • f) Immunization against
          • German measles
          • Tetanus (tetanus toxoid)
slide33
1- Antenatal care
  • Components:
          • I- Initial visit.
          • II- Return visit.
          • III- Home visit.
          • IV- Registration of data and maintenance of records.
slide34
I- Initial Visit:

1- History

a-Personal history:

Name, age and residence.

b-Social history:

education and occupation of pregnant women and husbands, smoking.

C- Medical history:

Familial hereditary diseases, diabetes,

hypertension, Sickle cell anaemia

slide35
d) Obstetric history:
        • Previous obstetric history:
        • Parity ,gravidity, birth interval, pregnancy outcome, abortion, still birth and early neonatal deaths , cesarean section, complication during pregnancy , delivery or puerperium.
        • Present pregnancy:
        • Date of last menstrual period to estimate date of delivery, dangerous symptoms.
slide36
2- Physical examination
      • -Measurement of weight, height, blood pressure,
      • pulse and temperature.
      • -Checking pallor, edema, and lower limb
      • deformities.
      • -Examination of heart, chest, kidneys and breast.
      • -Abdominal or obstetric examination: fundal level,
      • fetal movement & fetal heart sounds.
      • -Dental examination to search for (septic focus).
slide37
3- Laboratory investigations:
    • Blood examination for :
    • 1-Hemoglobin concentration: done periodically or at
    • least once every trimester for detection of anemia.
    • 2- Determination of blood group.
    • 3- Serologic test for syphilis
    • 4-Rh factor.
slide38
Detection of RH Of the pregnant women

RH +

RH -

Nothing

Investigate the

husband for Rh

There is possibility of erythroblastosis

foetalis of the 2nd or the subsequent newborn

Investigate the pregnant women for

RH antibodies between 32-34 weeks of pregnancy

RH +

RH -

Nothing

RH

antibodies

+

RH

antibodies

-

Give the women RH IG

to neutralize her RH

antibodies within 48 Hs

after delivery

slide39
Urine examination for:
    • - Pregnancy test to verify pregnancy.
    • Albumin ( to detect Preeclampsia) and sugar ( to detect diabetes)
slide40
4-Management of minor conditions
  • Management of minor conditions detected like anemia ,Symptoms & signs of Physiological changes during pregnancy ,dental problems.
  • Major illness or complicated cases are referred to the specialists.
slide41
5- Risk assessment during pregnancy
  • A) Biological risk:
  • 1- Maternal age:
  • The optimal age for childbearing is between 20 and 30 years
  • i) Maternal age < 16 &> 35 years increases the risk for:
      • Abortion
      • Preterm delivery.
      • Eclampsia.
      • Uterine dysfunction.
      • Difficult labor
      • Intrauterine fetal death
      • Down’s syndrome.
      • Maternal and perinatal death.
      • Hypertension &diabetes.
slide42
2- Parity & Birth order:

Maternal risk is slightly greater with the first pregnancy and fifth pregnancy & more.

2- Paternal age:

There is an increased risk of Down syndrome with paternal age (over 55).

3- Inter-birth interval:

More than 10 years or less than one year is considered a risk pregnancy.

4- Maternal height:

Short stature of the mother (less than 152 cm) increases the prenatal morbidity & mortality.

6- Maternal weight

Both underweight and obesity are considered risk factors.

slide43
B) Medical risk:

Pregnancy with general disease e.g. cardiovascular, renal & liver diseases diabetes, anemia, …etc increase the maternal mortality

slide44
C) Obstetric risk:
  • Risk increases when there is
        • Obstetric history of abortion , still birth , neonatal mortality, cesarean section or instrumental delivery.
        • Mal-presentation , twins, hemorrhage eclampsia placenta previa……
slide45
D) Social risk:

Poor social condition , unsanitary home, heavy smoking …… all affect maternal health.

The identified risk groups may be in need

of specific treatment , frequent visits

for monitoring or referral to a higher level of

care for assessment & delivery.

slide46
Reasons for considering risk assessment

is of little value

1- High risk Women may

not develop complications.

2- Some life threatening complications,

develop suddenly,

can’t be predicted by risk assessment

e.g. postpartum hemorrhage.

3- Some complications can be caused by

medical intervention , e.g. infection.

slide47
- According to the mentioned reasons , the health system should focus on improving the quality and expanding the services for the prevention, early detection and treatment of pregnancy related complications among all pregnant women not only high risk groups.
slide48
6- Immunization

Determination of the immune status of the mother by asking her about the number of previous doses of tetanus toxoid and the date of last one

slide50
7- Maternal nutrition
  • Nutritional disorders among pregnant women:
  • Anemia (iron deficiency anemia with or without folic acid deficiency),
  • Osteomalacia,
  • Underweight or obesity,
  • IDD (goiter).
slide51
8-Health education:

1- During the first trimester:

a) Let the family accept the pregnancy.

b) Advise the mother to deal with nausea and vomiting during early pregnancy, traveling, clothes, bathing, douching& breast care.

c) Modal changes during pregnancy.

c) Warn mothers about harmful drugs, radiation& infection(German measles).

d) The importance of attending the center periodically

slide52
Frequency of the visits to the MCH Center

During the first six months One visit per month

During the 7th and 8th month Twice per month

During the 9th month of pregnancy Four visits per

months

  • At least four visits (at least 20 minutes duration each) at
  • 16th week
  • 24th -28th week
  • 32nd week
  • 36th week.
slide53
2-During the second & the third trimester:
  • -Immediately seek medical care if any of the following dangerous signs occurred: Persistent vomiting, vaginal bleeding, vaginal secretions, severe or continuous headache , blurring of vision, swelling of the face or fingers, fever, or marked changes in the frequency or intensity of fetal movements.
    • Motivate mothers for better diet.
    • Alleviate the mother’s fear about labor.
    • Emphasize on the importance of rest, sleep & exercise.
    • Motivate mothers for the proper place of delivery.
    • Give guidance about baby rearing and breast feeding.
slide54
II- Return visit

includes the followings:

1- History

2-Examination:

a) Measurements of weight

The normal weight gain in pregnancy is about Two kg per month

( from the 4th to the 9th months) .The total weight gain should not exceed 12 kg.

Weight gain of

-more than 50% of what is expected indicates:

obesity, accumulation of fluid, or pre-eclampsia.

-less than 50% of what is expected may indicate:

inadequate diet, excessive activity , or low birth weight.

slide55
b-Check blood pressure
  • C-Look for oedema and pallor
  • d-Examine the heart , chest, kidneys, lower limbs…
  • e-Abdominal or obstetric examination:- Measure fundal level, check fetal heart sounds and fetal movements.
  • 3-I investigations
  • Blood for hemoglobin concentration, urine for albumin and sugar.
  • 4- Early detection of complicated pregnancy for management or referral to specialist in case of:
          • Pre-eclampsia.
          • Diabetes.
          • Sever Anemia.
          • Antepartum hemorrhage.
slide56
III- Home visits:

Aims:-

1- In case of home delivery, to Observe the home environment if it is suitable for delivery.

2- Motivate pregnant women who failed to attend regularly for antenatal visit (Defaulters).

3- Follow up of pregnant women in out reach areas.

slide57
IV- Registration and maintenance of records.

The data related to initial & return visit are registered in the Family Health Records and in the home based maternal cards that are kept with the women.

-The advantages of home based maternal cards:

1-Availability of information even if the women move to another health center.

2-Continuity of care during pregnancy, delivery and puerperium.

3-It allows comprehensive view of woman’s reproduction & general health.

`

slide59
Natal care

Childbirth is a normal physiological process but complications may arise due to unhygienic conditions or improper intervention at delivery.

Aims:

1- Ensure a clean, safe and normal delivery.

2- Provide emotional support for the mother.

3- Monitor maternal and fetal well being throughout the delivery.

4- Early detection, management, or referral of complicated cases.( Women & neonates)

5- Provide good care for the new born.

place of delivery
Situations for Home deliveries:

Uncomplicated pregnancy & delivery

Suitable home conditions

Available trained personnel

(midwives or traditional birth attendants i.e. TBAs).

Referral of the cases in emergencies should be ensured.

Situations for MCH or hospital delivery

For all risk pregnancies &

complicated home deliveries..

In developing countries half of

maternal mortality occurring

during delivery is attributed to (3 Ds)

Delay in deciding to seek care.

Delay in reaching appropriate care.

Delay in receiving care at health facility.

Place of delivery
preventive natal care
Care of the newborn

Clearance of respiratory passages.

Aseptic cut of umbilical cord and use sterile dressing.( WHY)

Apply silver nitrate or sulfa eye drops. .( WHY)

Care of the mother

Administration of chemoprophylaxis.

Application of external clean lavage and sterile dressing.

Preventive natal care
slide62
Rooming in: i.e.

keeping the new born beside the mother immediately after delivery to ensure early initiation and successful breast feeding and to decrease the chance for spread of nosocomial infections.

slide64
Post natal Care

It is the care for the mother and the neonate that starts after delivery of the placenta by about an hour and continues till the end of six weeks( Period of Puerperium)

Aims of Postnatal care:

1- Check the normal physiological changes of the mother.

2- Ensure prevention, early detection and management of complications of mother and infant.

3- Provide advice on breast feeding, maternal nutrition and infant immunization

slide65
Postnatal care visit:
  • The least number of visits is 3 visits :
        • After 6 hours
        • In the 6th day
        • In the 6th week.
  • Personnel:
  • The assistant midwife and midwife
  • They carry-out the home visits and refer
  • complicated cases to the health center.
slide66
The components of post natal care are history, physical examination , health education & treatment if needed as well as referral of complicated cases.
  • Areas that should be covered during postnatal care are:
  • For Mothers:
    • - Sign & symptoms of puerperal sepsis
    • - Breast feeding
    • - Diet
    • - Physical exercise & rest
    • - Vitamin A & iron supplements
    • For the newborn:
  • vital signs, umbilical stump, suckling
  • power, respiratory distress (cyanosis), anuria.
  • convulsion, jaundice, vomiting, constipation
slide67
Postnatal Immunization

The Rh -ve woman is given 300 mg of Rh-immune globulin within 24-48 hours of labour.

slide68
Indicators Used for evaluation Maternity Care

1- Maternal mortality indicators

2- Perinatal mortality rate.

3- Maternal morbidity indicators.

4- Process indicators

slide69
Indicators of Maternal Mortality:
  • Maternal mortality ratio
  • Maternal mortality rate

Maternal mortality ratio:

The number of maternal deaths per 100,000 live births. Sometimes 10.000 or 1.000 live births are used instead.

The number of mothers died during pregnancy ,delivery or puerperium in

a year & locality X 1000

The number of live birth in the same year & locality

slide70
Maternal mortality rate: (MMR)

The number of maternal deaths per100,000 women aged 15- 49 . Sometimes 10.000 or 1.000 are used instead

The number of mothers died during pregnancy ,delivery or puerperium in

a year & locality X 1000

The number of women aged 15-49 years in the same year & locality

slide71
Maternal mortality is the death of women while pregnant or within 42 days of termination of pregnancy (i.e. during pregnancy, delivery and puerperium), for any reasons related to / or aggravated by the pregnancy or its management, but not as a result of unrelated accidental or incidental causes.
  • This dramatic reduction of maternal mortality is due to:
          • 1- Improvement of the quality of maternity
          • care ( health personnel, blood banks……)
          • 2- Discovery of antibiotics
          • 3- Increase health awareness of women
slide72
Perinatal Mortality Rate:

It is expressed as the sum number of still births and early neonatal deaths (less than 7 days of life) per 1000 total births.

The number of deaths in early neonatal period+ still birth in a locality & yearX1000

The total number of births ( live birth & still birth) in the same year & locality

slide73
Still Births

Definition

The complete expulsion of a product to conception after the age of fetal viability (20 or 28 weeks of gestation) showing no signs of life (Breathing, Pulsation of the umbilical cord, Heart beats, Movement of voluntary muscles).

Stillbirth Ratio=

The number of still birth in certain year & locality X 1000

The number of live births in the same year & locality

slide74
Causes of Perinatal Mortality:
  • 1- Antenatal Causes:
  • - Cardiovascular diseases, hypertension, diabetes
  • - Maternal malnutrition.
  • - Eclampsia of pregnancy
  • Ante-partum hemorrhage.
  • 2 – Natal Causes:
  • Birth injuries.
  • - Asphyxia.
  • 3- Postnatal Causes:
  • - Prematurity and low birth weight.
  • - Asphyxia ,Birth injuries,Respiratory distress syndrome.
  • - Infections (tetanus neonatorum).
  • Congenital anomalies.
slide75
The best indicators to assess the Quality of Maternity care are:
        • Maternal mortality rate & ratio
        • Perinatal mortality rate
  • because they reflect antenatal, natal & post natal care
slide76
3- Maternal morbidity Indicators
      • Attack rates of:

- Hemorrhage,

- Eclampsia

        • Puerperal sepsis
      • The prevalence rate of iron

deficiency anaemia

slide77
4- Process indicators:

The use of process indicators becomes a necessary alternative because of the difficulties of measuring maternal mortality & morbidity.

The commonly used process indicators are:

1- % of birth with skilled attendants.

2- % of pregnant women attending antenatal care at least once.

3- % of women immunized with tetanus toxoid

4- % of women receiving postnatal care.

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