preventive obstetrics

Obsterics and Gynaecology-
introduction-Preventive obstetrics is the concept of  prevention or early detection of particular health deviations through routine periodic examinations and screening .
The concept of preventive obstetrics concerns with the concepts of the health & wellbeing of the mother her baby during the antenatal,intranatal & postnatal period.
The goal of the preventive obstetrics is the delivery of a healthy infant by a healthy mother at the end of a healthy pregnancy.

Pregnancy & child birth normal physiological
process that change from conception to 
delivery.
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

1. SUBMITTED BY PRANATI PATRA M.SC NURSING 1ST YR PREVENTIVE OBSTETRIC

2. INTRODUCTION Preventive obstetrics is the concept of  prevention or early detection of particular health deviations through routine periodic examinations and screening . The concept of preventive obstetrics concerns with the concepts of the health & wellbeing of the mother her baby during the  antenatal,intranatal & postnatal period.

3. The goal of the preventive obstetrics is the delivery of a healthy infant by a healthy mother at the end of a healthy pregnancy . Pregnancy & child birth normal physiological process that change from conception to  delivery .

4. Preventive Preventive is the term used to prevention or slowing the  course of an illness or disease. It  isintended  or used to  prevent or hinder acting an obstacle. Obstetric The branch of medicine that deals with the care of  women during  pregnancy,childbirth  and recuperative  period following delivery is known as obstetrics. DEFINITION

5. Preventive Obstetric Preventive obstetric is the term for prevention of the complication that may arise during antenatal,  intra natal and postnatal period. Preventive Obstetric measure can be categorized  into three main stages. They are as follows:- A. Antenatal Nursing B.Intranatal  Nursing C.P ostnatal  Nursing

6. Antenatal care is the during pregnancy.  Antenatal care is essential. Even for a normal & healthy, pregnant women for her own wellbeing's that of the baby to be born . Ideally the care should start immediately after conceptionbut  practically as early as possible  during the first trimester and should continue  through the second and third trimesters . ANTENATAL NURSING

7. 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 Objectives

8. To reduce maternal and infant mortality and  morbidity. To teach the mother elements of child care , nutrition, personal hygiene & environmental sanitation. To sensitize the mother to the need for family  planning, including advice  tocases  seeking  medical termination of pregnancy. To detect and treat any abnormality found in  pregnancy as early as possible.

9. The essential components of services during  pregnancy include are:- Registration of Pregnant Women. Antenatal Visits and Antenatal Care. Immunization Against Tetanus. Iron and Folic Acid and Vitamin A and D  Supplementation. Health education / prenatal advise during pregnancy. Essential   Antenatal   Care   Services

10. Registration of Pregnant Women Care during pregnancy should be started  as early as  possible.  -The mother must be registered within 20 weeks of  pregnancy either at health centre/ antenatal clinic or at home by a nurse/health visitor/ female health worker  (ANM) or trained person. Through physical and obstetrical check up should be done to screen for risk factors,  make assessment & give appropriate care for  prevention and Control of various health Problems & complications.

11. Antenatal Visits and Antenatal Care Ideally a woman should be seen and given care during pregnancy once a month during the first trimester or till seven  months,once  in   fortnight,during  the second trimester or till the  eighth month and thereafter every week till  confinement. But often these  manyvisits  are not  feasible, neither for the mother nor for the health  infrastructure available.

12. The first visit should be done around 16 weeks or early as the mother is registered. The second visit between 24-28 weeks of pregnancy. The third visit at 32 weeks of pregnancy. The fourth visit at 36 weeks. Further visits may be made if justified by the condition of the mother.

13. The preventive services for mothers in the prenatal period are as follows: The first visit irrespective of when it occurs should  include:- Taking Health History- it includes recording history of menstruation, medical history ,obstetrical history, socioeconomic history. Physical Examination-It includes recording of height, weight, blood pressure ,temperature, pulse etc. general observation from head to toe. Obstetrical  Examination- It includes general observation, examination of breasts ,abdominal measurement, palpation & inspection , vaginal examination if necessary .

14. Specialized Investigations- U ltrasonography – Amniocentesis & amniotic fluids studies- is the aspiration of amniotic fluid by a way of a needle passed transabdominally in to the amniotic sac. early in pregnancy amniotic fluid is light yellow or straw in colored with slight turbidity. It then becomes colorless & clear.the colour of fluid thus may indicate condition or diseases - opaque with green brown discoloration. -yellow with slight turbidity. -opaque with some degree of dark red -opaque yellow brown fluids.

15. 3] Alpha-fetoprotein [AFP]testing- AFP is done to identify women at risk for having a baby with a neural tube defect or a number of other congenital defects. 4] Amnioscopy & fetoscopy - both involves direct visualization through the fetal membranes. 5] Biochemical – biochemical test are mainly done for assessment of pulmonary marurity . 6] Biophysical – biophysical profile is measures the health of a baby during prgnancy .

16. Laboratory Investigations complete urine analysis Stool examination Complete blood count including Hbg estimation Serological examination Blood grouping & Rh determination Chest X-ray , if needed Gonorrhoea test , if needed.

17. On subsequent visits Physical examination including weight and blood pressure. Laboratory tests including urine examination and haemoglobin  estimation Iron and folic acid supplementation and medications as  needed. Immunization against tetanus Group or individual teaching on nutrition, self care, family planning,  delivery and parenthood Home visiting by a female health worker or trained person  ( trained traditional birth attendant) Referral services, when necessary.

18. Risk Approach While continuing to provide appropriate care for all  mothers, ‘high risk’ cases must  beidentified  as early as  possible and arrangements to be made for skilled care.  These cases comprise the following:- Women below 18 years of age or over 35 years in   primigravida Women who have had four or more pregnancies and  deliveries. Those with  cephalopelvic  disproportion (CPD),  genital  prolapse.Malpresentations , e.g. breech,  transverse lie etc.

19. Antepartum   hemorrhage , threatened abortion Preeclampsia and  eclampsia Anemia Twins,  hydramnios Previous stillbirth, intrauterine death, manual removal of placenta Elderly  grandmultipara Those mother with blood  Rh  negative. Those with obesity and malnutrition. Prolonged pregnancy ( 14 days beyond expected date of delivery) Previous caesarean or instrumental delivery

20. Prevention Administration of folic acid 5mg daily months before conception . By improving pre- pregnancy health of woman. Providing quality antenatal care. Screening all pregnancies for high risk. Provide appropriate clinical and technological care by specialist on time. Prevent all kinds of infection. Early diagnosis of  malformation and termination of pregnancy .

21. Home Visit Home visits are paid by the Female Health Worker or Public Health Nurse.  If  thedelivery  is planned at home, several visits  are required. The home visit will provide opportunities to study the environmental and  social conditions at home and to provide  prenatal advice. In the home environment, the  woman will have more confidence  tomake  an  informed decision about home birth.

22. Immunization Against Tetanus A pregnant woman must get two injections of Tetanus  Toxoid  during the period between 16: 36 weeks, at  one month  interval.These  protect the mother from the risk of tetanus.The2ndinjection should  preferably be given at least at one month before delivery. If a woman is registered late then in that case even one injection will do.  If the woman is immunized earlier within three  years of the  pregnancy,theone  booster dose will be enough

23. Iron and Folic Acid and Vitamin A  and  D  Supplementation It is being found that 50to60 percent of pregnant women are anaemic due to  irondeficiencies . Anaemia is also aggravated in pregnancy. It is therefore important to take one tablet containing 60  mg.of  elemental iron & 500 mg  offolic  acid three times  dailyafter  third month of  pregnancy till 3 months after child  birth if the mother is  found having anaemia. During pregnancy, the mother requires extra iron and  folic acid due to changes taking place in the body and  growth of  fetus  in the womb. Therefore each mother is given  onetablet  of iron and folic acid twice a day for at  least 100 days to prevent anaemia  inmother  and to  promote proper growth of fetus .

24. Prevention of Anemia Avoidance of frequent of child birth: At  least two years an interval between pregnancies is most necessary to replace the lost in Iron during childbirth process & lactation.This   canbe  achieved   family planning guidance . Diet during pregnancy Well balanced diet rich in iron and protein should  beadvised.The  food rich in iron are liver, meat, egg, green vegetables, green pea  bean,whole  wheat etc.

25. Personal hygie ne - Advice regarding personalhygiene is equally important. about eight mid day meals should beadvised.constipation should be avoided by regular intake of green leafy vegetables,friuts ,& extra fluids.purgative such as caster oil to relieve constipation should be avoided.light household work should be encouraged but manual physical labour during pregnancy may be adversely affect the fetus .

26. Rest and sleep-: A pregnant women needs sufficient rest. she should do less & lighter work. she must have 8-10 hrs of sleep every night. Exercise -: exercise in pregnancy should be encouraged .exercise can improve cardiovascular function, lower blood pressure & improve self-esteem & confidence. Follow up visits-: it is important that mother must be educated about the need for regular visits & proper care during pregnancy. They follow the instructions regarding diet , personal hygiene ,rest, physical work ,exercise, smoking ,drinking, protect from infection. So as to promote health of both mother & the growing fetus

27. Preparing for confinement-: the preparation for safe delivery is very important.it should be done well in advance to avoid any type of difficulty or emergency which might occur at the time delivery.the health personnel discuss with the couple &may be other family members about the alternative suitable place for confinement which includes home,health center or hospital. The delivery room should be clean,ventilated & well lighted.it should be kept ready before head.

28. Preparation of the articles includes-: -washed & sun-dried sufficient old clothes - A new razor blade,clean cotton. - A plastic sheet - Enema -one kidney tray,torch,a pair of scissors,artery forceps,spong holder -Drugs & antiseptic like injection methergin,oxytocin & methylated spirit. - hand washing articles.

29. PSYCHOLOGICAL PREPARATION OF THE MOTHER Psychological preparation of the mother is important during pregnancy & delivery.the expectant mother,especially the primary para mother has fear & anxiety about childbirth,its outcome &complication etc. it is very important to discuss various aspects of pregnancy & delivery.this helps to overcomimg their fears & anxiets . FAMILY PLANNING Family planning is related to every phases of the maternity cycle.educational & motivational efforts must be initiated during the antenatal period.if the mother has had two or more children , she must be motivated for puerperal sterilization.

30. Childbirth is a normal physiological process, but complications may  arise.  Septicemiamay  result from unskilled and septic manipulations, and  tetanus  neonatorum  from the use of unsterilized  instruments.The need for effective  intranatal  care is therefore indispensable,even if the  delivery is going to be a normal one. The emphasis  is on the cleanliness. It entails clean hands and fingernails, a clean surface for  delivery,cleancutting  and care of  the cord, and keeping birth canal clean by avoiding  harmful practices INTRANATAL   NURSING

31. Objectives of  Intranatal  Care To delivery with minimum injury to the newborn and  mother. To be readiness to deal with complications such as  prolonged Prolong labour, haemorrhage,convulsion   malpresentations ,  prolapse  of the cord etc. To do care of the baby at delivery like resuscitation, care of the cord, care of the eyes etc. To prevent infection.

32. Domiciliary Care Mothers  with normal obstetric history may  be advised to have  their confinement in their own  homes, provided the home conditions  are  satisfactory. In such cases, the  deliverymay  be conducted by Health Worker  Female or  trained  Dai.This  is known  as“domiciliary   midwifery  service ”.

33. Advantages of the domiciliary midwifery  service The mother delivers in the familiar surroundings of her  home and this may tend  toremove  the fear associated  with delivery in a hospital, The chances for cross infection are generally fewer at home than in the nursery/ hospital,and The mother is able to keep an eye upon her children and domestic affairs; this  maytend  to ease her mental  tension. Most deliveries will have to take place in the home with  the aid of Female  HealthWorkers  or trained dais.  Domiciliary out reach  is a major component of  intranatalhealth  care.

34. The Female Health Worker, who is a pivot of domiciliary care, should  beadequately  trained to recognize the  ‘danger  signals’during  labour and seek immediate help in transferring the mother to the nearest Primary  Health Centre or  Hospital.the danger signs are- Meconium  stained liquor or a slow irregular or excessively  fastfetal   heart. Excessive ‘show’ or bleeding during labour  Collapse during labour  A placenta not separated within half an hour after  delivery. Postpartum haemorrhage or collapse.

35. POSTNATAL NURSING Care of the mother and newborn after delivery is known as postnatal or  postpartal  care. Following delivery, the mother and baby are visited daily for ten  days.During  each of these visits the midwife/  FHW  checks temperature, pulse  andrespirations  of  the  mother, examines her breasts,  checks the progress of  normalinvolution  of  uterus,examines   lochia  for any  abnormality.

36. Objectives of postnatal care To prevent complications of the post- partal  period. To restore, promote and maintain health of the mother and baby. To promote breast feeding. To establish good nutritious of the baby. To check the adequacy of breast feeding.

37. Complications of the postnatal period Certain complications may arise during the postnatal  period which is be  recognizesearly  and dealt with  promptly. These are as follows: Thrombo  – phlebitis This is an infection of the veins of the legs, frequently  associated with varicose  veins.The  leg may become  tender, pale and swollen. So the mother should be  encouraged  todo  the leg exercise to increase the muscle tone. Deep vein Thrombosis It is the thrombosis of deep vein of calf, thigh or pelvis, clot formation in the absence of infection.

38. Prevention The three important factors  i . e. trauma,  sepsis and  anemia  should be prevented  and to be treated effectively after  detectionDehydration  during delivery should be  promptlycorrected.Leg  exercise and early ambulation are encouraged especially  following  operativedelivery .

39. Postpartum  Hemorrhage Postpartum  hemorrhage  is the condition of excessive bleeding from the genital tract  atany  time following  the baby’s birth  up to 6 weeks after  delivery.It  may  occur at anytime that is during third stage of  labour, with in 24 hours or after 24 hours of labour. Prevention Continue to monitor vital signs Observe the lochia type,amount &consistency. Check Hb levels if necessary. Prevent infection. Observe the mother for two hrs after delivery & ensure that uterus is hard &contracted enough. Encourge the mother for breast feeding.

40. Restoration of mother to optimum health The second objective of postnatal care is to provide  care  whereby,thewoman can recuperate physically and emotionally from her experience of delivery. POSTNATAL EXAMINATION Soon after delivery, the health  checksups  must be frequent, i.e., twice a day during the first 3 days & subsequently once a day till the umbilical cord drops off. At each of the examinations, the health personnel should checks temperature, pulse  andrespiration , examines the breasts, checks progress of normal involution of the uterus,examines   lochia  for any abnormality .

41. Nutrition Though a malnourished mother is able to secrete as  much breast milk as  well  nourishedone . The nutritional needs of the mother must be  adequately met. Often the family budget is limited, the mother should be shown   themeans  how she can eat better with less money. Postnatal Exercises Postnatal exercises are necessary to bring the stretched abdominal and pelvic muscles back to normal  as quickly as possible. Gradual resumption of  normal  house  holdduties  may be enough to restore  one’s figure.   .

42. Breast – feeding Postnatal care offers an excellent opportunity to find out how the mother  getttingalong  with her baby, particularly with regard to  feeding.Postnatal  care includes helping the mother to establish successful breastfeeding.  For  many babies breast milk provides the main source of nourishment in the  first year of life. It is therefore very  important to advise mothers to provide exclusive  breastfeeding .

43. Health Education to Mother and Family Health education during the postnatal  period should cover the following areas: •Hygiene- personal and environmental •Breast Care •Breast Feeding of infant. •Care of the Newborn baby •Care of the umbilical cord •Bathing the baby

44. Nutritious diet for the mother  •Postnatal Exercise •Rest, sleep and activity •Pregnancy spacing •Health check up for mother and baby •Prevention of infection in the baby •Birth registration

45. SUMMARY

46. CONCLUSION preventive obstetrics concerns with the  concepts of  the health and wellbeing of  themother  and her baby during the antenatal,  intranatal  and postnatal period. It aims  to  promote the well being of mothers and babies and to support sound parenting  and stable families.

47. JOURNAL ABSTRACT “ Postnatal Blues is an insidious vacuum that crawls into your brain and pushes your mind out of the way. It is the complete absence of rational thought. It is not possible  toroll  over in bed because blues steals away who ever  you were prevents you from seeing who you might someday be and replaces your life with black hole.”-

48. BIBLIOGRAPHY • Shirish  S  Sheth, “ Essential  of Obstetrics ” , 1stEdition, Chapter13, Antenatal  Care,Jaypee  Brothers Medical Publishers, New Delhi,2004, page no.: 102 - 107. Maya Devi  Subedi, “ Manual  of Midwifery A ” , 1stEdition, Chapter  11,  AntenatalAdvice , Books and Stationers, 2005, page no.: 157 - 165. •Kamala  Shova   Napit, “ Manual  of Midwifery B ” , 1stEdition, Chapter 4,Management of First Stage of  Labour,published  by Makalu Books and Stationers,2005, page no.: 41 to 64.

49. Maheswari   Jaikumar , “  Pocket Manual of  Community Health  Nursing ” , 1stEdition, Chapter13,14,15, Antenatal  Care,Intranatal   Care, Postnatal Care, published by  Jypee  Brothers Medical Publishers,2008, page no.: 120-159. •Krishna  Kumari   Gulani, “ Community  Health Nursing  (Principles  andPractices )”, 1stEdition , Chapter11, Maternal and Child Health,  published  byKumar  Publishing House, 2005, page no.:  354 – 366. •K  Park , “Park’s  Textbook of Preventive and Social  Medicine ” , 19thEdition,Chapter  9, Preventive Medicine in  Obstetrics,  Pediatrics  and Geriatrics, published by M/s  Banarsidas   Bhanot ,  2007, page no.: 415 – 422

50. JOURNALS •Dr. Christy Simpson,  M.Sc  (N),Janet Jones  M.Sc  (N),   Nirmala   Manoharan   M.Sc (N), Indian Journal of  Continuing Nursing Education, January June 2007,  volume 8, no. 1. •Mrs. S.  Rajamani  Victor, Mrs.  Chandrani  Samson, Dr.   Nalini   Jeyayantha   Santha , Nightingale “Nursing Times”, August 2008, Volume – 4, Issue