ANC- PRESENTATION OF ANC,PNC & DC.pptx

Dr. Adanwali Hassan Ahmed
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1. BY Adanwali Hassan Ahmed MWn , Bsc - Medical Doctor(MD), Health Officer(HO), Msc - Gyn / Obest . ANTENATAL CARE

2. ANTENATAL CARE

3. Definition Antenatal care refers to the care that is given to an expected mother from time of conception is confirmed until the beginning of labor. It is a preventative cost effective service

4. GOALS 1-Ensure mother health. 2- Ensure delivery of a healthy infant. 3-Anticipate problem. 4- Diagnose problem early.

5. Objectives: 1-Early detection and if possible, prevention of complications of pregnancy. 2-Educate women on danger and emergency signs & symptoms. 3-Prepare the woman and her family for childbirth. 4- Give education & counseling on family planning.

6. Cont--- To detect problems that might affect the woman's pregnancy and require additional care - routinely, screen for Anemia , Hypertension, HIV, Syphilis and Diabetes Mellitus. Recognize other problems that may complicate pregnancy: M alnutrition and Tuberculosis, Vaginal bleeding, Vaginal discharge, Fetal distress and Abnormal fetal position after 36 weeks

7. Danger and emergency signs: Fever, vaginal bleeding, headache and blurring of vision, severe abdominal pain, convulsion, severe difficulty of breathing Birth and emergency plan

8. Schedule of antenatal care : Medical check up: Every four weeks up to 28 weeks gestation Every 2 weeks until 36 weeks of gestation Every week until delivery An average 7-11 antenatal visits/pregnancy . More frequent visits may be required if complications arise.

9. On first antenatal visit 1-First : Confirm pregnancy by pregnancy test or US. 2-History 3-Physical examination 4-investigation

10. History Personal history Menstrual history Obstetrical history Family history Medical and surgical history History of present pregnancy.

11. IMMEDIATE ASSESSMENT for emergency signs . Vaginal bleeding Severe abdominal or pelvic pain Severe headache with visual disturbance Persistent vomiting Unconscious/Convulsion Severe difficulty in breathing High grade Fever Looks very ill

12. Weight measurement Maternal height and weight measurements to determine body mass index(BMI). Maternal weight should be measured at each antenatal Visit.

13. Check for pallor or anemia . 1-Look for palmar pallor. 2-Look for conjunctival pallor 3-Count respiratory rate in one minute.

14. Blood pressure measurement Measure BP in sitting position. If diastolic BP is 90 mm Hg or higher repeat measurement after 6 hour rest. If diastolic BP is still 90 mm Hg or higher ask the woman if she has : Severe headache Blurred vision Epigastric pain Check urine for protein.

15. Get baseline on the first or following the first visit. Hemoglobin, blood type Urine analysis VDRL or RPR to screen for syphilis Hepatitis B surface antigen To detect carrier status or active disease Investigations

16. At each visit 1-Questions about fetal movement 2-Ask for danger signs during this pregnancy 3-Ask patient if she has any other concerns

17. Symphysis Fundal hieght LMP plus 280 days Add 7 days, subtract 3 months MacDonald's Rule (cm = weeks)

18. At third trimester Do Leopold’s exam

19. Provide advice on Diet and weight gain Medication Avoid Radiation exposure Self-care during pregnancy Minor complaints. Family planning Breastfeeding Birth place preparation and anticipation of complication& Emergency situations.

20. Supplementation 1-Folic acid 0.4 mg tab daily 2- iron (ferrous sulphate or gluconate )300 mg/daily 3- Ca 1200mg /daily. - Those with a normal balanced diet probably don’t need extra vitamins

21. Weight gain in pregnancy: There is a slight loss of pounds during early pregnancy if the patient experiences much nausea and vomiting. Weight gain of 2 to 4 lbs(0,5-1 kg) by the end of the first trimester. Gain of 1 lb(0.5)/ per wk is expected during the second and third trimesters. Monitoring of weight gain should be done in conjunction with close monitoring of BP.

22. Medications During Pregnancy Antibiotics - some OK, some not Local anesthetics - OK Local with epinephrine - not OK Aspirin - not OK Immunizations - some are OK, some are not Antimalarial - some OK, some are not Narcotics - OK except for addiction issue

23. Which vaccines should I not get if I am pregnant? Human papillomavirus (HPV) vaccine. Measles, mumps, and rubella (MMR) vaccine. Live influenza vaccine (nasal flu vaccine) Varicella (chicken pox) vaccine. Certain travel vaccines: yellow fever, typhoid fever, and Japanese encephalitis.

24. Postnatal Care Introduction: The postnatal period is the period when most maternal deaths occur compared to the antepartum and intrapartum periods. DEFINITION: PNC is the care provided to the woman and her baby during the six weeks period, following delivery in order to promote healthy behavior and early identification and management of complications. 24

25. It should include assessment, health promotion and care provision. WHO recommends a postpartum visit within 1-3 days , if possible through home visits by community health workers. The main life threatening complications of the postnatal period include Hemorrhage Anemia Genital trauma Hypertension sepsis, UTI and Mastitis. 25

26. POST NATAL CARE CONTEXTS: OBJECTIVES THE FIRST 24 HRS AFTER CHILD BIRTH INFORMATION OF THE NEW BABY DURING THE FIRST FEW WKS CONCERN ON FOR BREAST FEEDING CONCERN FOR THE NEW BORN BABY AT EVERY POST NATAL CONTACT BY 6-8 WKS CHALLENGES IN PNC SERVICES 26

27. 1. Objectives PNC Plan- Include relevant care according to the present condition and that during previous pregnancy, labor and child birth. Adequate rest, privacy, food and plenty of oral drinks Observation of any abnormalities in both mother and baby by examining both in the first 1 hr , 24 hrs and continuously. Advise on baby, self and future pregnancies 27

28. 2. In the first 24 hrs Measure BP every 6 hrs. Check if have passed urine within the first 6 hrs & observe the Lochia (for clots, offensive smell etc) Encourage moving around & gently (Ambulant) Offer you an opportunity to talk about the birth. Cleaning of the perinuem using non antiseptic lotions or soap, but saline water Perineal exercises After pains in the first 2-3 days caused by mild contractions of the uterus can be relieved by 500mg of paracetamol . 28

29. Cont.. Observe changes in the uterus. Daily palpation of the uterine fundus . Lochia should change gradually from bloody to watery until it clears completely. Be informed of the problems e.g , fever, breast engorgement, PV bleeding, smelly discharge, sores on the nipples, inverted nipples, baby blues , episiotomy site and how to clean it. If mother had a C/S, advise her on the care of the wound , eating habits, bowel and bladder care. She has to remain in the hospital until her condition and the baby stabilizes, or as per Drs advise. 29

30. Cont.. The first breast milk ( colostrum ) & is importance to be explained (rich in fats and proteins and protects the baby from infection- contains antibodies). Best position and holding the baby on the breast should be explained. The baby should be put on each breast interchangebly . Observe flattened nipples and use your fingers to roll the nipples continously . Breast feeding exclusively is important for the first 6 months unless contraindicated.

31. 3. Information on the baby Baby should pass thick, sticky, greenish stool ( meconium ) in the first 24 hrs Should able to breast feed. Inj Vit K is administered. Normal baby’s skin is (yellow colour ) in the first 24 hrs(physiological jaundice). Mothers are advised to put their children with such conditions under the sunrays in the morning for some days to enable the body manufacture Vit D, if it persists (Pathological Jaundice )this therefore needs attention of the Dr. The baby should be examined throughly in the first 72 hrs for any abnormalities. 31

32. 4. During the first few wks The following problems may occur and the mother should be advised accordingly; Urine retention Infection presented by fever – pueperal pyrexia Constipation Incontinence of urine Baby blues(Post natal depression or post partum psychosis). Haemorroids Faecal incontinance Anaemia PV bleeding Musculoskeletal problems 32

33. 5. Concern on breastfeeding Inverted nipples Painfull , tender breasts Cracked or painful nipples Mastitis (Red, tender and painful breasts) Sleepy baby Not enough milk Difficulties in positioning the baby for breastfeeding. 33

34. 6. Concern for the newly born baby Pale stool Jaundice in breastfeeding babies Persistent and painful nappy rash Thrush (fungal infection in the mouth) Failure to pass meconium in the first 24 hrs 34

35. 7. At every Post natal contact; - Advise on exercise, nutrition, family planning, hygiene, perineal muscle exercises, vulval swabbing (using for saline water.) Breast feeding exclusively Immunization Treatment of any infections Prevention of HIV and other STDs. Family planning options 35

36. Cont---; Examine the breast for the nipples and masses. Teach the mother self breast examination. Examine the size of the uterus, by 10 days it should have reduced but involution is not complete until 6 weeks following child birth. Take BP, Temperature Assess for any abnormal PV discharge Self care. 36

37. 8 . By 6-8 WKS The reproductive organs have returned to the non pregnant state. Lactation is fully established Other physiology changes have been reversed Baby has created relationship with the parents The mother has fully recovered from the stress of pregnancy and assumes fully responsibility to care for the infant. 37

38. 9. Challenges in PNC Services Distance form health units for continuity of care Lack of male involvement Poor economic status of the family HIV/AIDS and other diseases in the mother Too short periods of conception between pregnancies Preterm babies and babies born with congenital abnormalities which may need intensive care. Young mothers Deliveries done under surgical measures that require hospital confinement. Other illnesses aggravated by pregnancy, eg hypertension, diabetes, Sickle cell anaemia etc .. 38

39. Delivery Care Normal birth is defined as Spontaneous in onset, low risk at start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37-42 completed weeks of pregnancies. After birth, mother and baby (child) are in good condition.

40. Cont--- Describes as the process by which the fetus, placenta with its membrane is expelled through birth canal. It is not always possible to anticipate which pregnancies end up with complications. Therefore, it is essential to extend delivery services to all pregnant women in order to provide timely help for complications of labour and delivery. Delivering women should be observed at least for 24 hours after delivery as most of the deaths post partum occur at this time.

41. Aims of delivery care are to achieve A healthy mother and child with the least possible level of intervention . Early detection and management of complications. Timely referral of obstetric emergencies (if any) to a level where it can be managed appropriately.

42. Cont--- More than three-quarters of all maternal deaths in developing countries take place during or soon after childbirth. Based on these aims, the single most critical intervention for safe motherhood is to ensure that a skilled attendant is present in every birth, and transportation is available in case of an emergency referral.

43. Who is a skilled attendant? In 1999, the WHO/UNFPA/UNICEF/World Bank statement recognized skilled attendants as health professionals such as midwives, doctors, or nurses with midwifery skills who have been educated and trained to proficiency in the skills necessary to manage normal pregnancies, C hildbirth and the immediate postnatal period, and the identification, management, and referral of complications in women and newborns.

44. Cont-- Skilled care during childbirth is important because millions of women and newborns develop hard-to predict complications during or immediately after delivery. Skilled attendants can also recognize these complications, and either treat them or refer women to health centers or hospitals immediately if more advanced care is needed. Skilled attendance depends on a partnership of skilled attendants, an enabling environment, and access to emergency obstetric care services.

45. Cont--- This means Skilled attendance can only be provided when health professionals operate within a functioning health system, or ‘enabling environment’, where drugs, equipment, supplies, and transport are all available. In 1996, skilled birth attendants were present at only 53 % of births in the developing world. In the developed world, skilled birth attendance is almost universal.

46. Cont--- The best person to care for women during delivery is a health professional with midwifery skills who lives in or near to the community he or she serves. However, most midwives work in hospitals and urban areas. In parts of Asia and Africa, there is only one midwife for every 15,000 births.

47. Cont-- Adequate equipment, drugs and supplies are also essential to enable skilled attendants to provide good quality care. In addition, skilled attendants need to be supported by appropriate supervision. When delivery is taking place at home or in a local health facility, an emergency transport system must be available to take women to facilities that can be provide more advanced care.

48. Cont--- In developing countries women commonly seek the help of traditional birth attendants. These attendants may have some training. However, without emergency backup support (including referral), training TBAs does not decrease a woman’s risk of dying during childbirth.

49. Cont-- As countries try to ensure that a qualified health professional is present at the birth of every child, they face a number of significant problems. Which are:- • Existing health workers often lack the skills they need to save the lives of women who suffer emergency complications • Curricula used to teach midwifery skills are often out of date and do not reflect new techniques and research.

50. Cont--- • In many places, especially in Africa and Asia, women give birth with the help of a relative, or alone Reproductive Health . •Refresher training in family planning and maternal health care are often inadequate. • Many midwives and physicians have no training in traditional belief systems, communication and community organizing.

51. Recommended ways to increase skilled birth attendance Increase the number of professionals with midwifery skills in underserved regions. ‰ Train, authorize and equip midwives, nurses and community physicians to provide all feasible obstetric services needed within communities, especially emergency interventions and to prescribe medications. ‰ Upgrade, establish and expand comprehensive midwifery training programs that include lifesaving skills for dealing with obstetric emergencies.

52. Cont--- Create clearly defined protocols for routine care and the management of complications. Establish systems for supervising and supporting skilled attendants, and for emergency referral and Rx. TBAs already exist in many developing country communities, it has been suggested that they could perform the role of the skilled attendant, where required with some training.

53. Cont--- However, it is recognized that for some women TBAs are the only source of care available during pregnancy. Some countries such as Malaysia has shown, TBAs can become an important element in a country’s safe motherhood strategy and can serve as key partners for increasing the number of births at which a skilled attendant is present.

54. Cont---- The impact of training TBAs on maternal mortality appears to be limited and the greatest benefit may be improved referral and linkages with the formal health system. Results from a meta-analysis suggest that TBA training may increase antenatal attendance rates.

55. Cont In practical terms, TBAs can help in the provision of skilled care to women and newborns by serving as advocates for skilled attendants and maternal and newborn health needs, disseminating health information through the community and families. In all countries, emphasis should be placed on training and deploying an adequate number of professional, skilled midwives to provide the majority of delivery care.

56. Where TBAs account for a significant portion of deliveries, safe motherhood programs should include activities aimed at providing adequate supervision and integrating them into the health system:- ‰Appropriate training (skilled trainers and appropriate teaching methodologies). Linkages to the health system that include proper supervision and referral for complicated cases. ‰Ongoing assessment of the impact of TBA programs.

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