1. Introduction to Maternaland Child health

2.  70% of the population of developing countries  In India women of child bearing age (15- 44 Yrs) are 19%  Children under 15 years 40%  Together 59%  They are vulnerable or special –risk group  Risk –connected with childbearing for women  Growth development and survival -children

3.  50% of deaths are above 70 yrs of age  Same among under-five children  Maternal mortality rates vary from 13- 440 per 100000 live births  Sickness and deaths among mothers and children are largely preventable  This have led to the formation of special health services for mother and children all over the world  The present strategy is to provide maternal and child as an integrated package of “Essential health care” also known as “Primary health care”

4. Mother and child as one unit- because 1. During the antenatal period , the fetus is part of the mother – development – 280 days, during this period fetus receives nutrition and oxygen from the mother 2. Child health is closely related to maternal health; a healthy mother brings forth a healthy baby; there is less chances of premature, still birth or abortion

5. 1. Certain diseases and conditions of the mother during pregnancy ( eg. Syphilis, German measles, drug intake) are likely to have their effects on the fetus 2. After birth, the child is dependant on the mother. Up to 6 - 9 months completely for feeding. The mental and social development is also dependant on the mother, if the mother dies the child's growth and development are affected (maternal deprivation syndrome)

6. 1. In the care cycle of women, there are few occasions when the service of the child is simultaneously called for . For instance post partum care is inseparable from neonatal care and family planning advice 2. The mother is also the first teacher of the child

7. Obstetrics, Pediatrics and PSM  In the past , maternal and child health services were rather fragmented and provided piecemeal “ personal health services” by different agencies, in different ways and separate clinics the current trend in many countries is to provide integrated MCH and family planning services as compact family welfare service

8.  This implies a close relationship of maternity health to child health, of maternal and child health to the health of the family; and of family to the general health of the community  In providing these services , specialists in obstetrics and child health have joined hands , and are now looking beyond the four walls of hospitals into community to meet health needs of mothers and children aimed at positive health

9.  In the process they have linked to community medicine( preventive and social medicine ) and as a result , terms such as “social obstetrics” , “preventive pediatrics” and “social pediatrics” have come into vogue

10. Obstetrics  Obstetrics is largely preventive medicine  The aims are same, to ensure that throughout pregnancy and puerperium, the mother will have good health and that every pregnancy may culminate in a healthy mother and healthy baby  The age old concept that obstetrics is now considered as a very narrow concept, and is being replaced by the concept of community obstetrics which combines obstetrical concerns with the concepts of primary health care

11. Social obstetrics  Gained usage in recent years  Defined as the study of the interplay of social and environmental factors and human reproduction going back to the preconceptional or even premarital period

12.  The social and environmental factors which influence human reproduction are a legion viz. age at marriage , childbearing, child spacing , family size , fertility patterns, level of education, economic status , level of education, economic status , customs and beliefs, role of women in society , etc.  The social and obstetric problem in India differs from other developed countries

13.  While accepting the influence of environmental and social factors on human reproduction, social obstetrics has yet another dimension, that is influence of these factors on the organization, delivery of comprehensive MCH services including family planning so that they could be brought within the reach of the total community

14. Preventive pediatrics  Like obstetrics pediatrics has a large component of Preventive and Social Medicine  There is no other discipline that teaches the value of preventive medicine  Recent years have witnessed further specialization within the broad field of pediatricsviz preventive pediatrics, social pediatrics, neonatology, perinatology, developmental pediatricspediatric surgery, pediatric neurology

15.  Preventive pediatrics comprises efforts to avert rather than cure disease and disabilities  It has been broadly divided into antenatal pediatrics and postnatal pediatrics  The aims of preventive pediatrics and preventive medicine are the same – prevention of disease and promotion physical , mental and social well being of children so that each child may achieve genetic potential with which he is born

16.  To achieve these aims , hospitals for children have adopted the strategy of “primary health care “ to improve child health care through such activities as growth monitoring, oral rehydration, nutritional surveillance, promotion of breast feeding, immunization, community feeding, regular health check ups etc.  Primary health care with its potential for vastly increased coverage through an integrated system of service delivery is increasedly looked upon as the best solution to reach millions of children

17. Social pediatrics  Defined as the application of the principles of social medicine to pediatrics to obtain a more complete understanding of the problems of children in order to prevent and treat disease and promote their adequate growth and development, through an organized health structure

18.  To study child health in relation to community, to social values and to social policy  This has given rise to concept of social pediatrics it is concerned not only with the social factors which influence child health but also with the influence of these factors on the organization, delivery and utilization of child health care services

19.  In other words , social pediatrics is concerned with the delivery of comprehensive and continuous child health care services and to bring these services within the reach of the local community.  Social pediatrics also covers various social welfare measures – local , national, international – aimed to meet the total health needs of the child

20. Contribution of Preventive and Social Medicineto Social Obstetrics and Pediatrics 1. Collection and interpretation of community statistics, delineating groups “at risk” for special care 2. Correlation of vital statistics ( eg., maternal and infant morbidity and mortality rates, perinatal and child mortality rates )with social and biological characteristics such as birth weight , parity, age, stature, employment etc., in the elucidation of etiological relationships

21. 1. Study of cultural patterns, beliefs and practices relating to childbearing and childrearing, knowledge of which might be useful in promoting acceptance and utilization of obstetric and pediatric services by the community 2. To determine priorities and contribute to the planning of MCH services and programmes 3. For evaluating whether MCH services and programmes are accomplishing their objectives

22. Maternity cycle - stages 1. Fertilization 2. Antenatal or prenatal period 3. Intranatal period 4. Postnatal period 5. Inter - conceptional period

23.  Fertilization takes place in the outer part of the fallopian tube.  Segmentation of the fertilized ovum begins at once and proceeds at a rapid rate  The fertilized ovum reaches the uterus in 8- 10 days.  Cell division proceeds at a rapid rate  By a process of cell division and differentiation, all the organs and tissues of the body are formed

24. Period of growth 1. Prenatal period 1. Ovum – 0-14 days 2. Embryo - 14 days to 9 weeks 3. Fetus – 9th week to birth 2. Premature – 28 to 37 weeks 3. Birth, full term – average 280 days

25. Antenatal care

26. Objectives  To promote, protect and maintain the health of the mother during pregnancy  To detect “high risk” cases and give them special attention  To foresee complications and prevent them  To remove anxiety and dread associated with delivery

27.  To reduce maternal and infant mortality and morbidity  To teach the mother elements of child care, nutrition, personal hygiene and environmental sanitation  To sensitize the mother to the need for family planning, including advice to cases seeking medical termination of pregnancy  To attend to the under fives accompanying the mother

28. Antenatal visits  Mother should attend AN clinics  Once a month during first 7 months  Twice a month during the next month  Thereafter once a week in the ninth month If everything is normal

29. Minimum 3 antenatal visits 1. At 20 weeks or as soon as pregnancy is known 2. At 32 weeks 3. At 36 weeks 4. At least 1 home visit by health worker

30. Preventive services for the mothers  Prenatal services ( before delivery)  First visit should include following  Health history  Physical examination  Laboratory examination

31. Lab tests 1. Complete urine analysis 2. Stool examination 3. Complete blood count, including Hb estimation 4. Serological examination 5. Blood grouping and Rh determination 6. Chest x- ray if needed, pap tests, Gonorrhea culture (Optional)

32. On subsequent visits  Physical examination( weight gain, Blood pressure)  Laboratory tests should include 1. Urine examination 2. Hemoglobin estimate

33.  Iron and folic acid supplementation  Tetanus Immunization  Group or individual instruction on nutrition, family planning, self care, delivery and parenthood  Home visiting by female health worker / trained dai  Referral services , where necessary

34. Risk approach  Identify high risk cases from a large group of antenatal mothers and arrange them for skilled care, while continuing to provide appropriate care for all mothers

35. At risk mothers 1. Elderly primi (30 years and over) 2. Short statured primi ( 140 cms and over) 3. Mal-presentations( breech, transverse lie) 4. Ante-partum hemorrhage, threatened abortion 5. Pre – eclampsia and eclampsia 6. Anemia

36. 1. Twins, hydramnios 2. Previous still birth, intrauterine death, manual removal of placenta 3. Elderly grand multiparas 4. Prolonged pregnancy( 14 days after expected date of delivery) 5. History of previous cesarean or instrumental delivery 6. Pregnancy associated with general diseases – cardiovascular disease, kidney disease, diabetes, tuberculosis, liver disease

37. Risk approach is a managerial tool  Services for all but with special attention to those who need them the most  Maximum utilization of all resources including some which are not involved in in such care – traditional birth attendants, community health workers, women groups  Improvements in coverage & quality of health care

38. Maintenance of records  Antenatal card- in first examination, thick paper to facilitate filing  Registration number. Identifying data, previous health history, main health events  Record is kept at MCH/FP center  A link is maintained between the antenatal card, postnatal card and under-fives card  Essential for evaluation and further improvement

39. Home visits  Home visiting is the backbone of all MCH services  Even if the expectant mother is attending the ante natal clinic regularly, she must be paid one home visit by the health worker female or public health nurse  More visits are required if the delivery is planned at home

40. Prenatal advice  Mother s more receptive to the advice concerning herself and her baby at this time than at other times  The talking points should cover not only the specific problems of pregnancy and childbirth but also about family and child health care

41. Prenatal advice - diet  Reproduction costs energy  Pregnancy in total duration consumes about 60000 k cal over and above normal metabolic requirements  Lactation demands about 550 kcal / day  Child survival is correlated with birth weight  Birth weight is correlated to the weight gain of the mothewrww .dsimuilimar.ciomng pregnancy

42.  On an average . A normal healthy women gains about 12 kg of weight during pregnancy  Average poor Indian women gains 6.5 Kgs  Thus pregnancy imposes extra calorie and nutritional requirements  If maternal stores of iron are poor (as may happen after repeated pregnancies) and if enough iron is not available to the mother during pregnancy, it is possible that fetus may lay down insufficient iron stores

43.  Such a baby may show a normal Hb. at birth but will lack the stores of iron necessary for rapid growth and increase in blood volume and muscle mass in the first year of life  Stresses in the form of malaria and other childhood infections will make the deficiency more acute, and many infants become severely anemic during the early months of life  Therefore a balanced diet is necessary

44. Personal hygiene  Personal cleanliness – bathe, clean clothes, hair  Rest and sleep – 8 hrs sleep, 2 hrs rest after midday meals  Bowels – constipation should be avoided by taking green leafy vegetables, fruits and extra fluids purgatives like castor oils should be avoided

45.  Exercise – light household work is advised but manual physical labour during late pregnancy may adversely affect the foetus Smoking – should be cut down, causes Intrauterine growth retardation, low birth weight babies.  Vasoconstrictor action produces placental insufficiency.  Mothers who smoke heavily produces on an average 170 g less weight babies at term.  The perinatal mortality amongst babies whose mother smoked during pregnancy is 10-40% higher

46.  Alcohol :alcohol causes fertility problems in mothers, pregnancy loss, various physical and mental problems in the child, causes fetal alcohol syndrome in the child – includes IUGR, developmental delay  Dental care – oral hygiene  Sexual intercourse – should be restricted especially in the last trimester

47. Drugs  Drugs which are not absolutely essential should be discouraged  Can cause fetal malformations – like thalidomide – more serious when taken 4-8 weeks of pregnancy  LSD produces chromosomal damage, streptomycin causing deafness, iodide causing congenital goitre

48.  Corticosteroids may impair growth  Sex hormones – virilism  Tetracyclines- growth of bones and enamel formation  Anesthetics – pethidine administered during labour- can have depressant effect and delay the onset of respiration  Certain drugs are excreted in breast milk

49. Radiation  Exposure to radiation, X ray during pregnancy - mortality from leukemia and other neoplasms are significantly higher  Congenital malformations such as microcephaly  X rays should be avoided in the last 2 weeks preceding menstrual cycle

50. Warning signs  Report immediately 1. Swelling of the feet 2. Fits 3. Headache 4. Blurring of vision 5. Bleeding or discharge per vagina 6. Any other unusual symptoms

51. Child care  The art of child care should be learnt  Special classes to be conducted  Mother craft includes – nutrition education, advice on hygiene and childrearing, cooking demonstrations, family planning education, family budgeting etc.

52. Specific health protection – 1.anemia  About 50% to 60% of mothers in India of low socio economic groups are anemic in the last trimester of pregnancy  Etiology is iron and folic acid deficiency  Associated with high incidence of premature births, postpartum hemorrhage, peuerperal sepsis and thromboembolic phenomena in the mother  IFA supplementation is done by Govt. of India

53. Other nutritional deficiencies  Protein, vitamin and minerals  Especially vit A and iodine  Milk should be supplemented, or skimmed milk should be given  Capsules of vitamin A and D also supplied free of cost

54. Toxemias of pregnancy  Presence of albumin in urine and increase in blood pressure  Their early detection and management

55. Tetanus  2 doses of adsorbed tetanus toxoid should be given  First dose 16 – 20 weeks and second 20-24 weeks of pregnancy  Minimum interval between 2 doses should be 1 month  Second dose should be given at least 1 month before the EDD

56.  However , no dose of TT should be denied to the mother even in late pregnancy  For a mother who have been immunized earlier, 1 booster dose will be sufficient  When such booster doses are given it will cover subsequent pregnancies in the next 5 years  It is advised not to immunize the mother in every pregnancy in order to prevent hyperimmunization

57. Syphilis  Important cause of pregnancy wastage in some countries  Pregnancies in primary and secondary syphilis end in spontaneous abortion, still birth, perinatal death or birth of a child with congenital syphilis  Syphilitic infection in pregnant women is transmissible to the foetus

58.  Neurological damage with mental retardation is one of the most serious consequences of congenital syphilis  Infection of the foetus does not occur in 4th month of pregnancy  it is most likely to occur after the 6th month of pregnancy by which time the Langhans cell layer has completely atrophied  Infection of the foetus most likely in primary and secondary stage of syphilis but rare in late syphilis

59. German measles  In a long-term prospective study done in Great Britain, when rubella is contracted to the mother in the first 16 weeks of pregnancy, foetal death or death during the first year of life occurred in 17% of offspring's  Among survivors who were followed up the age of 8 years, 15 % had major defects like cataract, deafness and congenital heart diseases

60.  Risk of malformations is about 20% up to 20 weeks of gestation  In some countries all school aged children are vaccinated  Before vaccinating the women of child bearing age should be made sure that they are not pregnant and they follow contraception for 8 weeks later to prevent risk of rubella to the fetus

61. Rh status  The fetal red cells may enter the maternal circulation in a number of difficult circumstances, during labor, caesarean section, therapeutic abortion, external cephalic version and apparently spontaneously in the late pregnancy

62.  The intrusion of these cells, if the mother is Rh –ve and the child is Rh +ve, provokes an immune response in her so that she forms antibodies to Rh which can cross placenta and produces fetal RBC hemolysis  The same response may be seen by the transfusion of Rh+ve blood  In a pregnant woman, iso-immunisation mainly occurs in labour, so that the first child although Rh+ve, is unaffected except where the mother is already www.similima.com sensitized.

63.  In the second or subsequent pregnancies, if the child is Rh +ve, the mother will react to the smallest intrusion of fetal cells, by producing antibodies to destroy fetal blood cells causing hemolytic disease in the fetus  Clinically hemolytic disease takes the form of Hydropsfetalis, icterus gravis neonatorum( of which Kernicterus is a common sequel) and congenital hemolytic anemia

64.  Routinely test the blood for rhesus type early in pregnancy  If the women is Rh-ve and the husband is +ve , she is kept under surveillance for Rh antibody levels during antenatal care  The blood should be further examined at 28 weeks and 34-36 weeks of gestation for antibodies  Rh anti D immunoglobulin should be given at 28 weeks of gestation so that sensitization during the first pregnancy can be prevented

65.  If the baby is Rh +ve, the Rh anti D immunoglobulin is given again within 72 hrs of delivery  It should also be given after abortion  Post maturity should be avoided  Whenever evidence of hemolysis in-utero is suspected mother should be shifted to special centers equipped to deal with such problems  Incidence of hemolysis due to Rh factor in India is 1 for every 400- 500 live births

66. HIV infection  HIV in child may occur through placenta, delivery, breast feeding  1/3 of the children get infected through above routes  Risk is higher if the mother is newly infected or she had already developed AIDS  Voluntary prenatal testing for HIV infection should be done as early in pregnancy for all wmww.simoilimtah.coemrs

67. Prenatal genetic screening  Prenatal genetic screening includes screening for chromosomal abnormalities associated with serious birth defects, screening for direct evidence of congenital structural anomalies, screening for hemoglobinopathies and other inherited conditions detectable by biochemical assays  Universal genetic screening is generally not recommended www.similima.com 67

68.  Screening for chromosomal abnormalities and for direct evidence for structural anomalies is performed in pregnancy in order to take decisions regarding therapeutic abortions  Typical examples are Down’s syndrome and severe neural tube defects  Women aged above 35 years and those who are having afflicted child are at higher risk

69. Mental preparation  It is also important  A free and frank talks on all aspects of pregnancy and delivery  Removing the fears about confinement  The mother craft classes at the MCH centers

70. Family planning  Related to every phase of maternity cycle  Mothers are psychologically more receptive to the advice on family planning than at other times  Motivation and education should be done during the antenatal period  If the mother has had 2 or more children she should be motivated for puerperal sterilization  All India post partum programme services are available

71. Pediatric component  Pediatrician should be in attendance at all antenatal clinics to pay attention to the under fives accompanying the mother

72. Intranatal care

73.  Childbirth is a normal physiological process, but complications may arise  Septicemia may result from unskilled and septic manipulationsand tetanus neonatorum from the use of unsterile instruments  The need for effective in tranatal care is indispensable  The emphasis is on cleanliness  5 cleans - clean hands and fingernails,a clean surface for delivery, clean blade for cutting the cord, clean cord tie, clean cord stump and care of the cord

74.  Keep the birth canal clean by avoiding harmful practices  Hospital and health centers should be equipped for delivery with midwifery kits, a regular supply of sterile gloves and drapes, towels, cleaning materials, soap and antiseptic solution, as well as equipment for sterilizing instruments and supplies

75.  There are delivery kits available with the items needed for basic hygiene for delivery at home, where a midwife with a midwifery kit is not likely to be present

76. AIMS 1. Thorough asepsis 2. Delivery with minimum injury to the infant and mother 3. Readiness to deal with complications such as prolonged labour, antepartum haemorrhage, convulsions, malpresentations, prolapse of the cord 4. Care of the baby at delivery- resusitation, care of the cord, eyes etc.

77. Domiciliary care  Confinement can be in home if the conditions are satisfactory  In such cases delivery may be conducted by the health worker female or trained dai  This is called as domiciliary midwifery service

78. Advantages of domiciliary care 1. The mother delivers in the familiar surroundings of her home and this may tend to remove the fear associated with delivery in a hospital 2. The chances for cross infection are generally fewer at home than in nursery/hospital 3. The mother is able to keep an eye upon other children and domestic affairs; this may tend to ease her mental tension

79. Disadvantages of domiciliary care 1. The mother may have less medical and nursing supervision than in the hospital 2. The mother may have less rest 3. May resume her duties too soon 4. Her diet may be neglected 5. Many homes in India may be unsuitable for even a normal delivery

80.  Since 74% of India’s population live in rural areas, most deliveries will have to take place at home with the aid of female health workers and trained dai’s  Female health worker who is a pivot of domiciliary care should be adequately trained to recognize the ‘danger signals’ during labour and seek immidiate help in transferring the motherto the nearest Primary health center or hospital

81. Danger signals 1. Sluggish pains or no pains after rupture of membranes 2. Good pains for an hour after rupture off membranes but no progress 3. Prolapse of cord or hand 4. Meconium stained liquor or a slow irregular or excessively fast fetal heart rate

82. 1. Excessive ‘show’ or bleding during labour 2. Collapse during labour 3. A placenta not separated within half an hour after delivery 4. Post partum hemorrhage or collapse 5. A temperature of 38 deg C or over during labour There should be a close liaison between domiciliary and institutional delivery services

83. Institutional care  About 1% of deliveries tend to be abnormal and 4% difficult requiring the services of a doctor  Recommended for all high risk cases and where home conditions are unsuitable  The mother is allowed to rest in bed on the first day after delivery, next day to be up and about, discharge after 5 days of lying period

84. Rooming in  Keeping the baby’s crib by the side of the mother’s bed is called “rooming in”  This arrangement gives an opportunity for the mother to know her baby  Mothers interested in breast feeding usually find there is a better chance for success  It also allays the fear in the mother’s mind that the baby is not misplaced in the central nursery  It also builds up her self confidence www.

85. Post natal care

86.  Care of the mother and the newborn after delivery is known as postnatal care or post partal care  Broadly this care falls into 2 areas - care of the mother ( primarily the responsibility of the obstetrician), care of the newborn( combined responsibility of the pediatrician and the obstetrician)  The combined area of responsibility is also called perinatology

87. Care of the mother The objectives of postpartal care are 1. To prevent the complications of postpartal period 2. To provide care for the rapid restoration of the mother to the optimum health 3. To check the adequacy of breast feeding 4. To provide family planning services 5. To provide basic health education to mother/ family

88. Complications of the post partumperiod Should be recognized early and dealt with promptly 1. Puerperal sepsis ; this is infection of the genital tract within 3 weeks after delivery 2. This is accompanied by rise in temperature and pulse rate, foul smelling lochia, pain and tenderness in lower abdomen Prevented by asepsis before, during and after delivery

89. 2. Thrombophlebitis: infection of the veins of the legs, frequently associated with varicose veins The leg may become tender, pale and swollen 3. Secondary hemorrhage : Bleeding from vagina anytime from 6hrs after delivery to the end of peurperium(6weeks ) is called secondary hemorrhage, and may be due to retained placenta or membranes 4. Others UTI, mastitis

90. Restoration of the mother to optimumhealth  Physical  Psychological  Social

91. Physical Postnatal examinations- health check ups must be frequent- twice a day during first 3 days and subsequently once a day till the umbilical cord drops off. At each of these examinations, the FHW checks temperature, pulse and respiration, examines the breasts, checks progress of normal involution of uterus, examines lochia for any abnormality, checks urine and bowels and adviseson perinatal toilet including care of the stitches, if any

92.  The immidiate postnatal complications, viz peurperal sepsis, thrombophlebitis secondary haemorrhage should be kept in mind  At the end of 6 weeks , an examination is necessary to check up involution of uterus which should be complete by then  Further visits should be done once a month during the first 6 months, and thereafter once in 2-3 months till the end of 1 year

93.  In rural areas only limited postnatal care is possible  Efforts should be made by the FHWs to give at least3-6 postnatal visits  The common conditions seen during the postnatal period are subinvolution of uterus, retroverted uterus, prolapse of uterus and cervicitis.

94. 1. Anemia – to be detected and treated 2. Nutrition – breast feeding mothers should be given nutritious diet 3. Postnatal exercises –are necessary to bring the stretched abdominal and pelvic muscles back to normal as quickly as possible

95. Psychological  Fear and insecurity which is generally born of ignorance – to be eliminated by prenatal instruction  Timidity and insecurity regarding the baby  To endure cheerfully the emotional stresses of childbirth, she requires the support and companionship of her husband  Postpartum psychosis - rare

96. Social  Women to have a baby – part of the truth  To nurture and raise the child in a wholesome family atmosphere  She with her husband should develop her own methods

97. Breastfeeding  Breast milk provides the main source of nourishment – first year of life and in India up to 18 months of life  Feeding bottle is nutritionally poor and bacteriologically dangerous  Indian mothers feed up to 2 years  They secrete 400- 600ml of milk /day during first year

98.  Exclusive breast feeding up to 6 months  Complementary or supplementary foods thereafter  weaning

99. Family planning  Related to every phase of maternity cycle  Motivate mothers when they attend maternity clinics  Spacing or terminal  Post partum sterilization generally recommended on the second day  Lactational amenorrhea cannot be relied on for contraception

100.  To ask the mother to come at first menstrual cycle may be too late  Contraceptive should not affect lactation  IUD and non hormonal are choice in first 6months  Oral pills to be avoided  DMPA- successful without suppressing lactation, but causes irregular bleeding and prolonged infertility- so not recommended for general use

101. Basic health education  Hygiene – personal and environmental  Feeding – mother and infant  pregnancy spacing  Importance of check –up  Birth registration