Community medicine (4) MCH (part 2) Dr. Huda Adnan
2014-2015At- Risk approach (in ANC):
This approach provides care for those who need it in a flexible and more rational distribution of existing resources according to the level of risk , so that some care will be provided for all but more skilled care is given to those at higher risk .
Objectives of At risk approach in antenatal care :
1- Early detection of risk factors during pregnancy .
2- Scoring of detected risks and hazards to classify At Risk cases ( high - risk groups ) that need either :
Just more care and follow up observation , for progress and early interference when necessary .
Referral for specialized investigations and or management .
In patient care , and hospital delivery .
High risk pregnancy
The term "high-risk pregnancy" describes a case where a pregnant woman has one or more factors that could put her or the fetus at risk for health problems.
The following are five risk categories associated with a high risk pregnancy :
1- Personal & menstrual history .
2- Obstetrical history .
3- Past history ( medical & or surgical )
4- Family history .
5- Current conditions .
The term "high-risk pregnancy" describes a case where a pregnant woman has one or more factors that could put her or the fetus at risk for health problems.
In general, a pregnancy may be considered high risk if the pregnant woman:
(35 years old or older, 15 years old or younger, underweight or overweight prior to becoming pregnant, pregnant with more than one fetus, has gestational diabetes, gone into premature labor, had a premature baby, had a baby with a birth defect, especially heart or genetic problems, has high blood pressure, heart disease, diabetes, lupus, asthma, a seizure disorder, or another longstanding medical problem).
Major Risk Factors with High- Risk pregnancy :-
1. personal & menstrual history
Age less than 18 years (15years).
Age more than 35 years.
Lives far from hospital facility.
Positive consanguinity.
Smoking.
Long duration of marriage with infertility & use of ovulation induction.
Unknown LMP.
2.Obstetrical history:
Parity ≥ 5.
No spacing.
Previous IUFD or neonatal death.
Previous small for gestational age(SGA).
Previous large for gestational age(LGA).
Previous congenital anomalies.
Recurrent first trimester abortion.
Previous hypertensive disorders.
Previous circulage.
Previous C/S delivery
gone into premature labor
has had a premature baby
has had a baby with a birth defect, especially heart or genetic problems.
3. Past history
- Hypertension, Heart disease, diabetes, lupus, asthma, a seizure disorder, or another longstanding medical problem - Previous blood transfusion - Previous Rh iso immunization or hydrops fetalis
4. family history
- Twin or multiple pregnancy of mother & sister. - Diabetes mellitus ( D.M )
5. current condition:
Maternal weight ˃ 90 kg ( excessive obesity ).
Maternal weight ˂ 45 kg .
Maternal stature ≤ 150 cm.
Excessive weight gain: > 2 kg first trimester.
> 7 kg second trimester.
> 4 kg third trimester .
Color : pallor, Jaundice.
Blood pressure ≥ 140 / 90 mm Hg.
Excessive amniotic fluid.
Heamoglobin < 11 gm / dI.
Rh negative.
Vaginal bleeding in early pregnancy.
Third trimester vaginal bleeding.
Rubella exposure.
IV. Natal Care
Normal delivery is defined as a process of delivery of a single fetus and other products of conception within 24 hours, through the normal birth canal and without complications.
Labor is a special care situation , any laboring women however healthy she may be , is potentially at risk from unpredictable acute emergencies .Any one of these emergencies can convert a potential patient into a real patient with serious , even , lethal complication. Natal Care: is the care provided to pregnant women during labor.
Objective of natal care : - Helping the pregnant women to have normal delivery . - Providing emergency service when needed . - Care of baby at birth.
Place of delivery:
Home PHC center (if with delivery room). Hospital .
Home delivery: if deliveries expected to be normal , can be carried at home by birth attendant who is either trained qualified nurse midwife of MCH center or traditional birth attendant ( TBA ) who is still popular in traditional communities and performs a good percent of deliveries .
Any birth attendant must be licensed from the health authorities and being :
Efficient and also trained for first aid and emergency service .
Free of infection ( usually streptococcal or staphylococcal ) of throat , nose & hands .
Uses sterile mask , gown , & gloves and have sterile articles .
Hospital delivery:
Developed countries prefer hospital delivery of all pregnant , in developing countries , it is limited to :
Pregnant who desire it .
When high risk labor is expected
- When difficulty arises during home delivery .
V. Postnatal Care
Care of mother after delivery. it is for 6weeks after delivery (puerperium period).
Usually done at the health center or home visit
First examination :2-3weeks after delivery.
Second examination: 4-6weeks after delivery.
Aim: to detect &cure minor problems result from birth.
Its components are:
Postpartum examination
Medical care
Follow up
Health education
Family planning services
Psychological and social support
For home delivery : home visits usually three within one week after delivery, by the health worker of MCH center .
Home visit also provided for those discharged early;(Patient stay at hospital 5 days in normal delivery,7 days in forceps delivery & 10 days in caesarean section).
each visit the mother is examined for :
General condition.
Body Temperature , any rise of body Temp. by 1C or more should be investigated whether it is due to puerperal sepsis or other causes.
Breast & nipple and whether lactation is practiced
Abdomen for involution of uterus.
Bleeding or discharge .
Any other complaint.
Follow up : mother is examined on periodic visits to MCH center :
At the end of 3rd week to check:
- General condition: if anemic ferrous sulfate is given.
-Supplementation of Vit A ( 200,000 IUs ).
- If she had puerperal infection and if she had managed properly.
Six weeks after delivery to check :
- Measurement of weight & Bp. - abdominal & pelvic examination is performed to check for the involution of uterus and repair of tears if any. -Assessment of the women's mental health is performed .
Health education : - Adequate nutrition for lactating mother . - Child feeding , ensuring breast feeding , and practices of weaning . - Dietary supplementation . - Child care in health & disease. - Physical exercise and it`s value (pelvic floor exercise(. - Postpartum birth control .