Maternal and Child Health

Dr. Smita .K. Panda

Associate Professor
Dept. of Community Medicine
 Why this topic is important ??

Every day we hear about the dangers of cancer,

heart disease and AIDS. But how many of us realize

that, in much of the world, the act of giving life to a

child is still the biggest killer of women of

childbearing age?”
 Mother and children are priority

• Mother and child component constitute 71.4% of the

population in developing countries.

• In India women of reproductive age group (15-49 yrs)

constitute 24% and children under 15 yrs 35.3%.
Together they constitute 59.3% of the population.

• They are the most VULNERABLE or SPECIAL RISK

group.
 WHY vulnerable.... ??
• 50% of all the deaths occurring in country are among
under fives, but not true for developed countries
where it is among old populations.

• According to WHO 303,000 maternal death occur

every year globally, 99% of these deaths occur in
developing countries and 1% maternal deaths in
developed countries.
• In India there is a steady decline of maternal mortality
ratio from 437/lakh live birth in 1990 to 130/lakh live
birth in 2014-2016.

• Maternal mortality is just the tip of iceberg; there are

20-30 cases of acute or chronic maternal morbidity for
every maternal death.

• Main causes of maternal deaths reported globally are

hemorrhage, hypertensive disorders, sepsis,
obstructed labour and abortion.
 A significant number of maternal deaths occur due to
three delays
a) Delay in deciding to seek care at family level due to
lack of knowledge
b) Delay in reaching the appropriate health facility
c) Delay in receiving quality care on reaching the
facility.
Majority of the deaths are preventable, but
how??
• Follow the principle of equity, intersectoral
coordination and community involvement

• Same is followed in providing PRIMARY HEAILTH

CARE

• It provides integrated package of health services to

mother and child considering them as ONE UNIT.
MOTHER and CHILD –One Unit
 Reasons….

• During antenatal period child is part of mother’s body.

• All the nutritional requirements of the foetus are met through

mother....so mother needs to be well nourished to have healthy
baby.

• Many diseases occurring during pregnancy also affect the foetus. Ex-
Syphilis, german measles

• After birth also exclusive breast feeding and child care are again
mother’s responsibility. Atleast upto the age of 6-9 months ,the
child is completely dependant on mother for feeding.
• Postpartum care including advice regarding family
planning also affect the health of new born

• This period of care makes mother the first teacher of

the child.
 Linking Obstetrics, Paediatrics and
Preventive and Social Medicine

Though mother care is with obstetricians and child

care is with paediatricians but the principle of
prevention has led to various other terms
 Social Obstetrics
 Preventive Pediatrics
 Social Pediatrics
 Social Obstetrics
• Study of interplay of social and environmental factors
and their effect on human reproduction.
• Not only conception phase is important but also
preconception and even premarital period is equally
important.
• Socio- environmental factors include: age at
marriage, age at child bearing, child spacing, family
size, fertility pattern, level of education, customs and
beliefs and role of women in society.
 Preventive Paediatrics
• Aims at providing efforts to avoid rather than curing
disease and disabilities among newborn and
children.
• So, divided into 2 parts- antenatal paediatrics and
postnatal paediatrics.
• Important activities include growth monitoring, oral
rehydration therapy, nutritional surveillance,
promotion of breast feeding, immunization,
community feeding, regular health check ups.
 Social Paediatrics
• Study the effect of social values and social policy on
child health.

• It is the “application of principles of social medicine

to paediatrics 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
organised health structure.”

• Examples include giving prelacteal feeds, preference

of male child, restricting diet during illness etc.
 Stages in Maternity Cycle
• Fertilization
• Antenatal/Prenatal period
• Intranatal period
• Postnatal period
• Inter- conceptional period
 Maternal Health Problems
I. Nutritional Problems
a)Malnutrition
b)Nutritional Anaemia

II. Infection Problems

a)Reproductive Tract Infections ( RTIs)/ Sexually Transmitted
Infection (STI)
b)Infection in general
c)Puerperal Sepsis

III. Disturbances of Menstruation

IV Adolescent Parents Problems
V. Unregulated Fertility
VI. Abortions
VII. Complications of Deliveries
VIII. Infertility
IX. Uterine Prolapse
X. Cancer of cervix
 MALNUTRITION

• Malnutrition can cause poor resistance, abortion, anaemia, miscarriage

or premature delivery, low birth weight baby (<2.5kg), eclampsia,
postpartum haemorrhage.

• These conditions can cause fatal effects on mothers, unborn and new
born babies.

• Malnutrition in women needs to be prevented by nutrition education,

modification and improvement of dietary intake before, during and after
pregnancy, supplementation of diet, distribution of iron and folic acids
tablets, subsidizing of food items and their fortification and enrichment.
 NUTRITIONAL ANAEMIA

• Anaemia in pregnancy is defined as a haemoglobin

concentration of less than 11g%.
• Prevention- Promoting consumption of iron rich food
like spinach, lemon, amala , etc.
• Promoting consumption of iron and folic acid
supplements.
WHO Cut off points for diagnosis of Anaemia

Adult males 13 gm/dl

Adult females, non pregnant 12 gm/dl

Adult females, pregnant 11gm/dl

Children 1 yr to 6 yrs 11gm/dl

Children, 6months to 1yrs 12gm/dl

 INFECTION PROBLEMS
A.REPRODUCTIVE TRACT INFECTIONS/STD

• RTIs include a variety of bacterial, viral and protozoal

infections of the lower and upper reproductive tract of both
sexes.
• RTIs pose a threat to women’s lives and well being
throughout the world.
• Vaginal discharge is amongst the first 25% reasons to consult
a doctor. 40% gynaecological OPD attendance is because of
RTIs and 16 % of gynaecological admissions and due to pelvic
inflammatory disease (PID)
PUEPERAL SEPSIS
• It is mainly due to infection during labour and after delivery because of
lack of personal hygiene, insanitary conditions, septic procedures, etc.

• This may lead to inflammation of ovaries, fallopian tubes,

endometrium, cervix and vagina. Many time leucorrhoea may persist
for years. Some times secondary sterility may follow after acute or
chronic salpingitis.

• It requires proper preparations for confinement by the mother,

conduct of deliveries by trained and skillful dais, midwives etc. And
availability of equipment's and supplies etc.
UNREGULATED FERTILITY
• Unregulated fertility has been recognized to cause
many maternal health hazards like abortions,
miscarriage, severe anaemia, premature deliveries,
low birth weight babies,APH etc
• All these health hazards are responsible for high
maternal and perinatal mortality.
• It is being recognized to regulate fertility by effective
measures related to reproductive health, child health
and family planning
 Maternal and Child Health
Maternal and child health (MCH) refers to a package of
comprehensive health care services which are
developed to meet promotive, preventive, curative,
rehabilitative needs of pregnant women before,
during and after delivery and of infants and pre-
school children from birth to five years.
 Objectives of MCH services
• Reduction of maternal ,perinatal, infant, and
childhood mortality and morbidity
• Regulate fertility so as to have wanted and healthy
children when desired.
• Provide basic maternal and child health care to all
mother and children.
• Promote and protect health of mothers.
• Promote and protect physical growth and psycho-
social development of child and adolescent in family.
 Components of Maternal Care
• Antenatal Care
• Intranatal Care
• Postnatal Care
 Antenatal Care
Pregnancy Detection-Urine Examination. Kits are
available with the health workers under the name
NISHCHAY pregnancy test kits. Other test kits also
available in market.
• Antenatal visits- ideally pregnant female should visit
health care provider once a month till 7th month of
pregnancy, then twice a month during 8th and
weekly thereafter. But if not feasible at least 4 visits
are minimally required.
 Antenatal visits
• 1st visit- within 12 wks (as soon as the pregnancy
suspected and to be registered if confirmed)
• 2nd visit- between 14 and 26 weeks
• 3rd visit- between 28 and 34 weeks
• 4th visit- between 36 weeks and term
ANTENATAL CARE
 What is Antenatal care?
Systemic supervision (examination and advice)
of a women during pregnancy is called
Antenatal care (ANC).
 Aims and objectives
1. To screen the high risk cases.
2. To prevent or to detect and treat at the earliest any
complications.
3. To ensure continued risk assessment and to provide
ongoing primary preventive health care.
4. To educate the mother about the physiology of
pregnancy and labour by demonstration, charts and
diagrams so that fear is removed and psychology is
improved.
 Aims and objectives
5. To discuss with the couple about the place, time and
mode of delivery, provisionally and care of the
newborn.
6. To motivate the couple about the need of family
planning and also appropriate advice to couple
seeking medical termination of pregnancy.
7. To reduce maternal & infant mortality & morbidity.
8. To teach the mother elements of child care,
nutrition, personal hygiene and environmental
sanitation.
 Aims and Objectives
• To ensure a normal pregnancy with delivery of
a healthy baby from a healthy mother.
• Health status of the mother can be assessed
by enquiring presence of any medical illness.
• Record of baseline information on blood
pressure, weight, haemoglobin etc.
 Aims and Objectives
• Timely detection of complications and its
management by appropriate referral.
• Confirmation unwanted pregnancy and its referral
to 24 hr PHC or FRU for safe abortion services.
• Sex selective abortion is illegal.
• To facilitate good interpersonal relationship
between the care giver and the pregnant woman,
early pregnancy detection and provision of care.
 Pregnancy tracking
( Estimation of annual expected pregnancies)

• For complete pregnancy registration ANM

should know estimated number of
pregnancies to be registered annually in her
area  judge the accuracy of the process 
missed pregnancy can be tracked by ASHAs
and AWWs.
• Use : Adequacy of stocks( Td Inj, IFA tab,
calcium tab, MCP cards, etc.)
 Calculation Formula
• Expected no. of live = 1000
births (Y) per year
= 25 x 5000 = 125
1000
annual expected
• 10% of LB to be pregnancies =
added for Pregnancy 125 + 13 = 138
wastage i.e= 125x
10%= 13
BR X Subcenter pop
 Calculations
• So, annual expected pregnancy in the above example is
138.
• In any month, the ANM should have 69 registered
pregnancies. (Half of the estimated pregnancies)
• ASHA, AWW have House-to-house visit to confirm
missed pregnancies.(Abortions, Late reporting, private
sector ANCs, unregistered)
• MCTS (Mother and Child Tracking System)-
Pregnant women and children are tracked for ANC,
PNC and immunization.
Tasks to be carried out during antenatal visits

1. Antenatal examination
2. Prenatal advice
3. Specific protection
4. Mental preparation
5. Family Planning
6. Paediatric component
 1. ANTENATAL VISITS
Ideally – ANC visits
• First 28 weeks – once a month
• Up to 36 weeks – twice a month
Thereafter weekly till delivery

Minimum – 4 ANC visits

1st visit- within 12 wks (as soon as the pregnancy suspected
and to be registered if confirmed)
2nd visit- between 14 and 26 weeks
3rd visit- between 28 and 34 weeks
4th visit- between 36 weeks and term
 Antenatal Care

• Antenatal care comprises of-

1.Registration of pregnancy
2. History taking
3. Antenatal examinations [general and obstetrical]
4. Laboratory investigations
5. Health education
 The First visit

• History taking
• Examination
• Investigation
 History taking
• 1. Particulars of the patient –after confirmation of pregnancy
• 2. Chief complaints with duration –Medical/Surgical/Obstetric
• 3. Past history
• 4. Obstetric history –Bad Obs H/O
• 5. Menstrual history (LMP and EDD-9months and 7days)
• 6. Family history – DM, HTN, TB, Thalassemia,
Twins/Congenital Malformation
• 7. Drug History
• 8. History of immunization
• 9. Socio-economic history
• 10. Contraceptive history
• 11. History of allergy
• 12. Symptoms indicating complications- Fever,
Persistant Vomiting, Abnormal Vaginal
discharge/bleeding, palpitation, easy fatiguebality,
breathlessness at rest/ mild exertion, generalised
swelling, sever headache, blurring of vision, burning
urination, decreased or absent fetal movements.
• 13. Any current systemic illness- Hypertension, DM,
TB, Renal disease, Epilepsy, Asthma, Jaundice,
Malaria, RTI, STD, HIV-AIDS, Sickle cell anaemia,
Thalassemia
Physical examination
 Examination
 Pallor – Examine palpebral conjunctiva, nails, tongue,
oral mucosa, palms in each visit and correlate with
Hb estimation.
 Pulse – 60-90 / min. (To be monitored high/Low)
 R.R. – 18-20 breaths / min. (Relevant in case of
breathlessness)
 Edema-Evening appearance and morning
disappearance is normal. Any edema of face, hands,
abdominal wall and vulva is abnormal.
( Edema with HTN/Heart disease/Anaemia/Protenuria
to be reffered).
 B.P. – Two consecutive readings – systolic > 140
mmHg and / or diastolic > 90 mmHg---two
consecutive readings four hours/more apart –(PIH)
 Check urine for the presence of albumin
 Pre eclampsia – Hypertension + albuminuria(+2)
 Imminent eclampsia – D.B.P. > 110 mmHg.—refered
to MO at 24x7 PHC
 If with albuminuria—refered toFRU immediately
 Eclampsia – Hypertension+ albuminuria +Convulsions
 Referral needed. (24x7 PHC /FRU)
 Regular weight monitoring each visit
• 9-11 kg. wt. gain entire pregnancy
. After first trimester, wt. gain 2 Kg. / month.

• 0, 0, 1kg, 1kg, 2kg ,2kg, 2kg, 2kg, 2kg.(around 10-12kg)

• Excessive weight gain > 3kg in a month- Twins, pre-eclampsia,

Gestational diabetes.

 Breast examination

 Abdominal Examination
Abdominal examination
 Measurement of fundal height
 Fetal heart sounds
 Fetal movements
 Fetal parts
 Multiple pregnancy
 Fetal lie and presentation
 Inspection of abdominal scar or any other relevant
findings
 Measurement of fundal height
• 12 weeks- uterine fundus just palpable
• 20 weeks- fundus flat at lower border of
umblicus
• 36 weeks- Fundus felt at the level of
xiphisternum.
 Foetal findings
• Foetal heart sounds - heard after 6 months, 120-130/min.
• Heard in midline and after 28 weeks can change its
location.
• Foetal movement can be felt around 18-22wks on
palpation of abdomen
• Foetal parts felt around 22nd weeks and after 28th week
distinguished head, back and limbs.
• Multiple pregnancy large uterus or palpation of multiple
fetal parts.
• Foetal lie and presentation relevant after 32 weeks of
pregnancy
 Assessment of gestational age
• The gold standard for assessment is routine early
ultrasound along with foetal measurements
ideally in first trimester.
• Initially LMP was the most widespread method.
• Now “Best Obstetric Estimate” combining
ultrasound and LMP.
• Poor resource setting- fundal height, LMP and
newborn clinical assessment, birth weight are
used for gestational age assessment.
 Laboratory investigations
• Hb estimation
• Blood grouping & Rh typing
• Urine R/M/Proteinuria
• Urine protein
• VDRL
• RBS
• HBs Ag test
• USG for Pregnancy profile.
 Risk approach
• Elderly primi (30 yr. and above)
• Short statured primi (140 cm and below)
• Mal presentations (breech, transverse lie)
• APH
• Threatened abortion
• Pre – eclampsia, eclampsia
 Risk approach
• Anaemia
• Twins,
• Hydramnios
• IUFD
• Previous still birth
• Manual removal of placenta
• Elderly grandmultipara
• Multipara
• Prolonged pregnancy (14 days after EDD)
• H/o past caesarean or instrumental delivery
 Risk approch
• Pregnancy associated with general diseases –
cardiovascular ,kindney, diabetes, TB, Liver,
malaria,convulsion,asthma, HIV, RTI and STI
• Treatment for infertility
• Three or more spontaneous consecutive
abortion.
“Risk approach”- a managerial tool for
improved MCH care.
 In subsequent visit
• Patient complains
• General examination
• Gestational age to be calculated
• Identification of problem
• Foetal movement
• SFH measurement (Symphysis Fundal Height )
• Health education
• Prophylaxis & treatment of anemia
• Developing individualized birth plan
Second visit (14-26 weeks)
• SFH measurement (Symphysis Fundal Height
measurement practised to detect foetal IUGR)
• To detect Multiple pregnancy
Third visit (28-34 weeks)
Screen for
1. Preeclampsia
2. Multiple pregnancy
3. Anemia
4. IUGR
Fourth visit (36 weeks)
Identification of foetal
1. Lie
2. Presentation
3. Position
4. Birth plan
 Maintainence of records
• MCP card should be duly filled and maintained for
every registered pregnant women.
(MCTS, identification proof, previous health history
and recent health events.)
• This card is joint venture of MOHFW and MOWCD.
• MCP card data to be included in HMIS format.
• Home visits – mother must be paid atleast one
home visit during antenatal period by ANM/HWF
for social and environmental monitoring.
 2. Prenatal advice (diet)
Sedentary- 1900kcal/day, Mod- 2230kcal/day,
Heavy- 2850kcal/day
Entire pregnancy – +350 Kcal/day (extra)
Lactation – First 6 months 600 Kcal/day and next
6 months 520kcal/day.
 Iron and Calcium supplemntation)
Under NIPI (Iron supplemtation)
Pregnant female- 100mg/60mg elemental iron and 500
microgram folic acid (one tablet for 180 days after first
trimester and 360 tablets for anaemic women in 6
months)
 Post partum- 100mg/60mg elemental iron and 500
microgram folic acid for 180 days
 Calcium supplementation
500mg calcium+ 250 IU Vit D twice daily with meals from
14 weeks of gestation till 6 months post partum.
 Hygiene
• Daily bath is recommended, as it stimulation
refreshing and relaxing.
• Avoid hot water bath.
• Bowel care: As there is increase chance of
constipation, regular bowel movement may be
facilitated by regulation of diet taking plenty
of fluids, vegetables and milk.
 Breast Care - Wash the breast with clean tap
water.
 Exercise - Walk in moderation.
Avoid lifting heavy things.
Avoid long time standing.
Avoid sitting with crossed legs as this may
impede circulation.
 Dressing
• Tight clothes and belts are avoided The patient
should wear loose but comfortable dresses. High
heel shoes are better avoided.

• Alcohol, smoking and drugs should be avoided as the

may affect the fetal wellbeing
 Rest and sleep
• 8 hour sleep at night
• At least 2 hour sleep after mid-day meal
• Hard strenuous work should be avoided in first
trimester and last 4 weeks
 Warning sign
1. Headache
2. Blurring of vision
3. Convulsion
4. Vaginal bleeding
5. Fever
 3. Specific health protection
• Anemia and other nutritional deficiencies
• Toxemia of pregnancy: Increased BP. Early detection is
indicated must be accordingly managed.
• Td: two doses one month apart, 1 booster dose if
female conceives within 3 years.
• Syphillis: Leading cause of pregnancy wastage. If timely
diagnosed can be treated by giving penicillin for 10 days.
• Rubella/ german measles: Timely vaccination should be
done otherwise major congenital malformations may
occur.
• Rh status: Rh negative mother with Rh positive fetus may lead to
immunogenic reaction leading to hemolysis and other complications. Timely
screening should be done preferably at 28 weeks and if required Rh anti D
immunoglobulin should be given to mother to prevent immune reactions. If
baby is Rh positive anti D Immunoglobulin – 72 hours.

• HIV infection: ART should be given to decrease MTCT of HIV.

• Hepatitis B infection: If mother is HBV positive, new born should

immediately receive HB Igs and Hepatitis B vaccine.

• Prenatal genetic screening: Screening for chromosomal aberrations esp

when there is positive history, so that timely abortion can be carried out if
required (screening for Hemoglobinopathies, trisomy 21, NTD). TIFA scan
used for prenatal screening.
• TORCH – Toxoplamsa, Rubella, Cytomegalovirus,
Herpes.
• Asymtomatic bacteuria
• Gestational diabetes- FBS 92-125mg/dl, 2 hr post
prandial 153-199mg/dl
 Hyperglycemia at any time during pregnancy. It
is more common in second trimester
Risk of developing type 2 diabetes increases in
future .
 4.Mental preparation

 Apprehension regarding change in body

appearance
 Alleviate fears regarding child birth and child
rearing
 Mothercraft
 5. Family Planning
Mother is more motivated to adopt family
planning measure and she should be advised
accordingly like spacing methods or terminal
methods
 6. Paediatric Component
It is suggested that a paediatrician should be in
attendance at all antenatal clinics to pay
attention to the underfives accompanying the
mothers.
 National Health Programs
• Mamata scheme
• JSY
• JSSK
• RMNCH+A (RMCHA+N)
• PMSMA
• NIPI
INTRANATAL CARE
 Learning Objectives
• Summary of previous lesson
• Delivery points/ MCH Level
• Intra natal care
• Partograph
• Active Management of 3rd stage of labour
 MCH: One Unit
• Size
• Vulnerability
• Child association with mother since
conception
• Dependency on mother
• Mother’s health status : a determinant of
health of child
Measures to improve nutrition in 1000 days
• Solutions to improve nutrition in the 1000 days window are readily available,
affordable and cost-effective.

• Good nutritional practices:

1. Receipt of appropriate macro and micro nutrients for women & mothers during

pregnancy

2. Good and balanced nutrition practice for young children and after birth until

2years’s of child’s age.

3. Early initiation of breastfeeding , timely complementary feeding and immunization

practices to be strengthened

4. Treating Malnourished Children with special therapeutic food.(NRC)

5. Feeding of children appropriately and adequately during illness.

• Maternal Mortality Ratio: According to WHO, a maternal death
is defined as “the death of a woman while pregnancy or within 42days of
termination of pregnancy, irrespective of the duration and site of
pregnancy, from any cause related to or aggravated by pregnancy or its
management but not from accidental or incidental causes.
Total no. of female deaths due to
• Maternal Mortality Ratio = complications of pregnancy, childbirth or
within 42days of delivery from “puerperal
causes” in an area during a given period
__________________________________ X 1,00,000
Total no. of live births in the same area
and year

• Maternal Mortality Rate = Number of maternal deaths in a given

period
__________________________________ X 1,00,000
Total no. of women in reproductive age
during that period
• Late Maternal Death: It is defined as “the death
of a woman from direct or indirect causes , more
than 42days but less than one year of termination of
pregnancy, irrespective of the cause of death”.
 Classification of Maternal Deaths (ICD-10)
DIRECT OBSTETRIC DEATHS INDIRECT OBSTTRIC DEATHS

Due to obstetric complications of the Due to previous existing disease or

pregnancy state (pregnancy, labour, disease that developed during pregnancy
puerperium)

Due to intervention, omissions, incorrect Not due to direct obstetric causes but
treatment aggravated by physiological effects of
pregnancy
Determinants of maternal mortality in
India
Medical Causes Social Factors
Obstetric Causes: Age t child birth
Toxaemia of pregnancy Parity
Haemorrhage Too close pregnancies
Infection Family size
Obstructed labour Malnutrition
Unsafe abortion Poverty
Illiteracy
Ignorance & Prejudices
Lack of maternity services
Shortage of health manpower
Non-obstetric causes: Delivery by untrained data
Anaemia Poor environmental sanitation
Associated diseases, e.g. Cardiac, renal Poor communictions and transport
hepatic metabolic and infectious facilities
Malignancy Social customs,etc
Accidents
 Approaches for measuring maternal
mortality
1. Civil registration systems- Routine registration of birth & death

2. Household surveys- alternative to Civil registration

3. Sisterhood methods- Interviewing a representative sample of respondents

about the survival of all there adult sisters.

4. Reproductive-age mortality studies (RAMOS)- investigating the causes of

Maternal death in a dfined area.

5. Verbal autopsy- interview with family or community members to know the cause

of death when medical certification is not advised.

6. Census- National level stimates of Maternal mortaity elimanates sampling

error detailed breakdown of result (time trend, geographical distribution,

Social srata)
Factors related to Health System contributing to
Maternal deaths

1. Weak administrative, technical and logistical capacity.

2. Inadequate financial investment
3. Lack of skilled health personnel
4. Inaccessible family planning practices.
5. Inadequate nutrition
6. Inadequate Water and sanitation facilities
7. Unaffordable basic health care protection from abuse,
violence, discrimination.
8. Lack of women empowerment.
9. Low female literacy.
 Approaches to control MMR
1. Early registration of pregnancy
2. At least four antenatal check-ups
3. Dietary supplementation, including correction of
anaemia
4. Prevention of infection and haemorrhage during
puerperium
5. Prevention of complication, e.g.,eclampsia,
malpresentation, ruptured uterus
6. Treatment of medical conditions, e.g., hypertension,
diabetes, tuberculosis
7. Anti-malaria and tetanus prophylaxis.
8. Clean delivery practice
9. Trained village level health worker
10. Institutional deliveries for women with bad
obstetric history and risk factors
11. Promotion of family planning – to control
the number of children to not more than two,
and spacing of births
12. Identification of every maternal deaths, and
searching for its cause
13. Safe abortion services
 Delivery Points
MCH Level/Delivery Facility Type of Care Features
Points

I SC/ EOC 24 x 7
(3 NVD/month) PHC, SBA
NBCC

II PHC/ Non FRU CHC BEmOC NBCC

(10 NVD/month NBSU.
+mgmt. Of
complication)
III FRU-CHC/SDH/DH CEmOC NBCC
(20-50 and above NBSU.
deliveries/month SNCU
including C/S)
 Defined minimal 'Signal Functions'
BEmOC Services CEmOC Services
• Administer parental antibiotics • Perform signal functions 1-7
• 2. Administer parental oxytocin (BEmOC Services),
• 3. Administer parental
anticonvulsants :magnesium
• plus:
sulphate) • 8. Perform surgery (e.g,
• 4. Manual Removal of placenta Caesarean section)
• 5. MVA, D &C
• 9. Perform blood
• 6. assisted vaginal delivery (eg.
vacuum extraction, forceps delivery) transfusion
• 7. Performs basic neonatal
resuscitation (e.g. with bag and
mask)
 Importance of Intra partum care
• Ensuring a safe delivery
resulting in a healthy mother and child
• Early detection and management
of complications and
timely referral, if required
 Care during labour
• Assessment
• Supportive Care
• Vaginal examination
• Pelvic examination
 Stages of labour
First stage: From onset of labor till full dilatation of cervix
Second stage: From full dilatation of cervix
till delivery of baby
Third stage:
From delivery of baby to delivery of placenta

Fourth stage:
For 2 hrs after delivery of the baby

Care during labor and delivery 107

 Partograph
What is a partograph?
• Graphic recording of the progress of labor & condition of
mother and fetus
• Labor record , thus reduces paper work
• Tool to identify complications of labor and make timely
referrals

Care during labor and delivery 108

Care during labor and delivery 109
 REFERRAL
• If Alert line is crossed (the plotting moves to
the right of the alert line) it indicates
abnormal labour : prolonged/ obstructed
labour,Note the time, Refer to FRU
• By the time the action line is crossed the
woman should ideally have reached the FRU
for the appropriate intervention to take place
 Management of 3rd stage of
labour( AMTSL)
• Oxytocin 10 iu IM
• CCT once uterus is contracted & cord is cut
• Uterine massage to keep uterus contracted
• misoprostol (600 μg)if Oxytocin is unavailable
• Delayed Cord Clamping
 Prevention of PPH
Community Clinics
• Community awareness • Focussed ANC
• -BCC & IEC • Line listing & Treatment of
Anemia
• (BPCR) plan
• Use of Partograph
• Promotion of SBA at birth • Limiting episiotomy at normal
• Detection & treatment of birth
Anemia • AMTSL
• Misoprostol at Community • Routine inspection of placenta
level for completeness
• Routine immediate postpartum
care & monitoring
 Management of PPH
Community Clinics
• Facility or place of birth • Active triage of emergency cases
Skilled provider • Resuscitation
• Rapid assessment & diagnosis
• Early detection of danger
• Emergency protocol for PPH
signs management
• Designated decision • Basic emergency Obstetric care
maker(s) • IV fluid resuscitation
• Communication • Manual removal of Placenta
Parental
• Emergency transportation • Oxytocics & antibiotics
Emergency funds • Comprehensive EmOC:
• Blood donors • Blood transfusion Surgery
 Infection Prevention
• To prevent the occurrence of infections and to
minimize the risk of transmitting any
infections including hepatitis B, C and HIV to
clients, health care staff and community.
 Standard Precautions
1. Hand washing
2. Use of protective attire
3. Processing of used items
4. Proper handling and disposal of sharps
5. Maintaining a clean environment
6. Biomedical waste disposal

Infection Prevention 116

 “six cleans”
• clean surface,
• clean hands of attendant,
• clean cord,
• clean cord tie without dressing and
• clean and dry wrapping of the baby.
• Clean Perineum
 Rumination
• There are – stages of labour
• At least – no of antenatal visits are necessary
• HIV test for pregnant women can be conducted at MCH Level-.
• Calcium tablet is given to pregnant mothersto prevent -.
• During – stage of labour placenta is removed.
• Partograph has one active line and one inactive line. True/ False
• Dosage of misoprostol is 600 mg. True/False
• Calcium Tablet is given for 180 days during antenatal period.
True/ False
• Frequent vaginal examination helps assess progress of labour
Thanks
SBA - Presentation 5 (c)

Care after delivery:

Postpartum Care

Maternal Health Division

Ministry of Health & Family Welfare
Government of India
 Objectives
To learn
• Number and timing of postpartum visits for mother
and baby
• History-taking, examination, management and
counseling during postpartum visits
• Steps for referral and transfer of baby

Care after delivery: Postpartum Care 121

 Importance of Postpartum Care
• More than 60% of maternal deaths take
place during postpartum period
• First 48 hours are most crucial
• Most maternal and neonatal complications
occur during this period.

Care after delivery: Postpartum Care 122

 Postpartum visits by ANM/ASHA

Visits After delivery at home / sub After delivery at PHC/FRU

centre (woman discharged after 48
hrs)
First visit 1st day(within 24 hrs) Not applicable

Second visit 3rd day after delivery 3rd day after delivery

Third visit * 7th day after delivery 7th day after delivery

Fourth visit 6 weeks after delivery 6 weeks after delivery

* There should be three additional visits in case of babies with low birth weight, on days 14, 21 and 28
as per Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines.

Care after delivery: Postpartum Care 123

 First postpartum visit
Mother New born
• History • History
• Examination • Examination
• Management and Counseling • Newborn care
– Postpartum care and hygiene – Keeping baby
– Nutritional advice warm
– Rest – Hygiene
– IFA supplementation – Cord care
– Contraception – Breast feeding
– Breast feeding – Immunization
– Birth registration

Care after delivery: Postpartum Care 124

 First postpartum visit: Mother
History Examination
• Place of delivery • Pulse, BP, RR. Temp
• Initiation of breast feeding • Pallor
• Any complaints : • Abdomen : tender uterus, refer
Excessive bleeding to FRU
Abdominal pain • Vulva and perineum:
Convulsions tear, swelling or pus,
Loss of consciousness refer to FRU after initial
management
Pain in legs , fever
• Excessive bleeding P/V
Urinary retention refer to FRU after initial
Difficulty in breathing management
Foul smelling lochia • Breast : lump, tender
refer to FRU

Care after delivery: Postpartum Care 125

 First postpartum visit: Mother
Management / Counseling

1. Postpartum care and hygiene

Advise the mother to
• Wash perineum daily and after passing urine and stools
• Change perineal pads every 4 - 6 hours
• Wash hands frequently and take bath daily

Care after delivery: Postpartum Care 126

 First postpartum visit: Mother
Management / Counseling contd..

2. Nutritional Advice
• To increase intake of fluid and food especially iron and
protein rich foods like green leafy vegetables, jaggery, lentils,
eggs and meat
• Increase intake of milk and milk products like curd, cheese
etc

3. Advise adequate rest

Care after delivery: Postpartum Care 127

 First postpartum visit: Mother
Management / Counseling contd..

4. IFA Supplementation
• Women with normal Hb are advised to take 1 IFA tablet daily
for 3 months
• If Hb below 11 gm%, advise her to take 2 IFA tabs daily and
repeat Hb after 1 month

5. Contraception
• Counsel couple regarding contraception

Care after delivery: Postpartum Care 128

 First postpartum visit: Mother
Management / Counseling contd..

6. Breastfeeding
Advise the mother-
• For exclusive breast feeding on demand, at least 6 to 8 times
during day & 2-3 times during night

AVOID PRE- LACTEAL FEEDS

Care after delivery: Postpartum Care 129

 First postpartum visit: Mother
Breast feeding problems:

Cracked /sore nipples

Advise the mother:
• to apply hind milk for soothing effect
• ensure correct positioning and attachment of baby

Engorged breasts
Advise the mother:
• to continue breast feeding
• to put warm compresses

Care after delivery: Postpartum Care 130

 First postpartum visit: Mother
Registration of birth

Emphasize the importance of registration of birth

with local panchayat
• It is a legal document
• Required for many purposes

Care after delivery: Postpartum Care 131

 Postpartum period: danger signs
Woman should be counseled
to report to FRU if she has

• Fever
• Convulsions
• Excessive bleeding
• Severe abdominal pain
• Difficulty in breathing
• Foul smelling lochia

Care after delivery: Postpartum Care 132

 First postpartum visit for baby
History taking:
• Ask if breast feeding has been initiated
• Inquire whether the baby has passed urine and meconium
• Elicit h/o any problems in newborn

Refer to FRU if
• Not feeding well
• Cold to touch or fever
• Baby is lethargic or has had convulsions
• Difficulty in breathing

Care after delivery: Postpartum Care 133

 First postpartum visit for baby

Examination of newborn Refer to FRU

Cry and activity Poor cry
Lethargic / unconscious

Chest in drawing Severe chest in drawing is a sign of

pneumonia
Respiration If <30 or ≥ 60 breaths /min

Central Cyanosis Bluish discoloration of tongue and lips

Body temperature If temperature is <35.5oC or > 37.4o

C

Care after delivery: Postpartum Care 134

 First postpartum visit for baby

Examination of newborn Refer to FRU

Umbilical stump Any bleeding, redness or pus

Skin infection If ≥ 10 pustules or a big boil

Jaundice If appears in < 24 hrs of

birth
Eyes Redness, discharge or swelling

Congenital If present
malformation
and Birth injury

Care after delivery: Postpartum Care 135

 First postpartum visit for baby
Breast Feeding : Signs of good attachment
• Chin touching breast
• Mouth wide open
• Lower lip turned outward
• More areola visible above than below the mouth

A baby well attached to the breast A baby poorly attached to the breast

Care after delivery: Postpartum Care 136

 First postpartum visit for baby
Breast Feeding: Effects of poor attachment
• Pain and damage to nipples, leading to sore nipples
• Breast is not emptied completely, resulting in
breast engorgement
• Poor milk supply: baby not satisfied
• Poor weight gain of baby.

Care after delivery: Postpartum Care 137

 First postpartum visit for baby
Immunization of Newborn
Counsel mother on where and when
to take baby for immunization

Care after delivery: Postpartum Care 138

 2nd and 3rd visit for mother
On 3rd and 7th day following delivery

History taking:
As on first visit
In addition ask for history of
• Continued bleeding P/V, foul discharge P/V
• Swelling or tenderness of breast.
• Feeling unhappy or crying easily

Examination: Same as on 1st visit

Management and Counseling: Same as on 1st visit

Care after delivery: Postpartum Care 139

 2nd and 3rd visit for baby
History taking and Examination:
Same as in first visit

Management and Counseling:

In addition to counseling in first visit, advise the mother :
To exclusively breast feed for six months.
To wean at six months.

Care after delivery: Postpartum Care 140

 Fourth visit for mother
At 6 weeks following delivery

History taking:
Ask the mother for following:
• Has vaginal bleeding stopped?
• Has menstrual cycle returned?
• Is there any foul smelling vaginal discharge?
• Any problems regarding breast feeding?
• Any other complaints?
• Give relevant advice & refer to M.O. if needed

Care after delivery: Postpartum Care 141

 Fourth visit for mother
Examination:
Similar to examination during previous visit

Management and Counseling:

Diet and Rest:
Emphasize importance of nutrition as in second and third visit.

Contraception:
Emphasize importance of using contraceptive methods for
spacing and limiting family size

Care after delivery: Postpartum Care 142

 Fourth visit for baby
History taking:
Ask the mother about
• Vaccines received by baby so far
• Is baby taking breast feed well?
• Weight gain of baby
• Any other problem

Examination:
• Check weight of baby.
• General examination of baby

Care after delivery: Postpartum Care 143

 Fourth visit for baby
Management and Counseling:
Emphasize on exclusive breast feeding

Refer baby to F.R.U. if

• Not sucking well at breast
• Is lethargic / unconscious
• Has fever or is cold to touch
• Cord - swollen or discharge present
• Diarrhea, blood in stool
• Convulsions
• Difficulty in breathing

Care after delivery: Postpartum Care 144

 Key messages
Post partum care: Mother
• Make at least 4 postpartum visits for timely recognition
of complications like PPH, puerperal sepsis
• Advise mother on nutrition
• Advise mother on rest, hygiene, breast feeding and
contraception

Care after delivery: Postpartum Care 145

 Key messages
Post partum care: New born
Screen for danger signs in newborn

Advise the mother to

• Keep baby warm
• Take care of umbilicus, skin & eyes
• Give exclusive breast feeds
• Ensure correct positioning & attachment to breast
• Immunize the baby

Care after delivery: Postpartum Care 146

 Steps for transfer and referral of baby

Preparation:
• Explain reason for transferring baby to higher facility
• If possible transfer the mother with baby so that she can feed
the baby
• A health care worker should accompany baby
• Ask relative to accompany baby and mother

Care after delivery: Postpartum Care 147

 Steps for referral of baby
Communication:
• Fill up a referral form with baby’s essential information and
send it with baby
• If possible contact health care facility in advance

Care after delivery: Postpartum Care 148

 Steps for transfer of baby
Care during transfer:
• Keep baby in skin to skin contact with mother, if not possible
keep baby dressed and covered
• Ensure that baby receives feeds
• If baby gasping or respiratory rate <30 breaths /minute,
resuscitate baby using bag and mask

Care after delivery: Postpartum Care 149

 LEARNING OBJECTIVES

• Describe the basic needs of the baby at birth

• Describe evidence-based routine care of a newborn

baby at the time of birth

• Enumerate the components of ‘Clean chain’

• Enlist the components of ‘Warm chain

 For every child, early moments matter.

• In the first 1,000 days,

• babies’ brains form new connections at an astounding
rate: up to 1,000 every single second – a pace never
repeated again.
• With every hug and every kiss,
• with every nutritious meal
• and game you play,
• you’re helping to build your baby’s brain.
• The first 1,000 days have a lasting effect on a child’s future.
• We have one chance to get it right.
 Essential Newborn Care(ENC)
• Care that every newborn baby needs for at
least the first 7 days after birth
 Four basic needs
• Warmth
• Normal breathing
• Mother’s milk
• Protection from infection
 Essential Newborn care
• Call out time of birth.
• ■ Deliver baby onto abdomen.
• ■ Thoroughly dry baby immediately and assess breathing.
• ■ Wipe eyes. Discard wet cloth.
• ■ Cover/wrap baby with dry cloth.
• ■ Clamp/tie and cut the cord.
• ■ Leave baby on mother’s chest in skin to skin contact.
• ■ Place identification labels on baby.
• ■ Cover mother and baby with blanket.
• ■ Cover baby’s head with a hat.
• ■ Wait for the baby to ‘crawl’ to the breast
• ■ The baby initiated breastfeeding
 The “warm chain”
1. Warm delivery room
2. Immediate drying
3. Skin-to-skin contact
4. Breastfeeding
5. Bathing and weighing postponed
6. Appropriate clothing and bedding
7. Mother and baby together
8. Warm transportation (skin-to-skin)
9. Warm resuscitation
10. Training and awareness
 ‘Warm chain’
• ‘1. At delivery:
• Ensure the delivery room is warm (25° C), with no
draughts.
• Dry the baby immediately; remove the wet cloth.
• Wrap the baby with clean dry cloth.
• Keep the baby close to the mother (ideally skin-
to-skin) to stimulate early breastfeeding.
• Postpone bathing/sponging for 24 hours.
 ‘Warm chain’
• 2. After delivery:

• Keep the baby clothed and wrapped with the head covered.

• Minimize bathing especially in cool weather or for small

babies.
• Keep the baby close to the mother.

• Use kangaroo care for stable LBW babies and for re-warming
stable bigger babies.
 Hypothermia
• Body temperature below the normal range
(36.5°C – 37.5°C)
• mild (36.0°C – 36 .5°C),
• moderate (32.0°C – 35.9°C),
• severe (<32.0°C) hypothermia
 Vulnerability of newborn to hypothermia

• Larger surface area

• Decreased thermal insulation due to lack of
subcutaneous fat
• Reduced amount of brown fat
 First signs of Hypothermia
• A cold baby
• is less active
• does not breastfeed well
• has a weak cry
• has respiratory distress
 ‘Clean chain’
1. Clean delivery (WHO six cleans):
• Clean attendant's hands (washed with soap).
• Clean delivery surface.
• Clean cord- cutting instrument (i.e. razor,
blade).
• Clean string to tie cord.
• Clean cloth to wrap the baby.
• Clean cloth to wrap the mother.
 ‘Clean chain’
2. After delivery:
• All caregivers should wash hands before handling
the baby.
• Feed only breast milk.
• Keep the cord clean and dry; do not apply
anything.
• Use a clean cloth as a diaper/napkin.
• Wash your hands after changing diaper/napkin.
Keep the baby clothed and
 PREVENTION OF INFECTION
• Basic requirements for asepsis in a baby care area:
• • Running water supply
• • Soap
• • Elbow or foot operated taps
• • Strict hand washing
• • Avoid overcrowding, optimal number of health
providers for care of more babies
• • Plenty of disposals
• • Strict adherence to good housekeeping and asepsis
routines
 Time Band 0 -3 mins: Immediate, Thorough Drying

• –Do not wipe off vernix

• –Do not bathe the newborn
• –Do not bathe the newborn
• –Do not do foot printing
• –No slapping
• –No hanging upside -down
• –No squeezing of chest
 Time Band: After 30 secs of drying Early Skin-to-Skin Contact

• If newborn is breathing or crying:

• –Position the newborn prone on the mother’s
abdomen or chest abdomen or chest
• –Cover the newborn’s back with a dry blanket
• –Cover the newborn’s head with a bonnet
 Avoid
• –any manipulation,
• e.g. routine suctioning
• –Place identification band on ankle (not wrist)
 Time Band: 1 -3 mins Properly -timed cord clamping

• Remove the first set of gloves

• After the umbilical pulsations have stopped,
clamp the cord using a sterile stopped, clamp
the cord using a sterile plastic clamp or tie at 2
cm from the umbilical base
• Clamp again at 5 cm from the base
• Cut the cord close to the plastic clamp
• Observe for oozing of blood
 Cord clamping

• Do not milk the cord towards the baby

• –After the 1st clamp, you may “strip” the cord
–After the 1st clamp, you may “strip” the cord
of blood before applying the 2nd clamp
• –Cut the cord close to the plastic clamp so
that there is no need for a 2nd “trim”
• –Do not apply any substance onto the cord
• Within 1 hour of birth
• A baby’s eyes should be wiped as soon as
possible after birth and an antimicrobial eye
medicine
• ■ It should not be washed away
• 1% silver nitrate eye drops
• ■ 2.5% povidine-iodine eye drops
• ■ 1% tetracycline ointment
 First feed

• Give the baby to its mother for skin-to-skin contact

• Let the baby feed when it is ready.
• Check the position and attachment
• Let the baby feed for as long as it wants on both
breasts.
• Keep the mother and baby together for as long as
possible after delivery,
• Delay tasks, such as weighing, washing etc until
after the first feed.
 Early Breastfeeding

• Leave the newborn in skin-to-skin contact

•Observe for feeding cues, including tonguing,
•Observe for feeding cues, including tonguing,
licking, rooting
• •Point these out to the mother and encourage
her to nudge the newborn towards the breast
 Immediate care of the umbilical cord
• Steps:
• 1. Put the baby on mother’s abdomen or on a warm, clean and dry
surface close to the mother.
• 2. Change gloves; if not possible, wash gloved hands.
• 3. Put ties (using a sterile tie) tightly around cord at 2 cm and 5 cm
from the abdomen.
• 4. Cut between the ties with a sterile instrument (e.g. blade).
• 5. Observe for oozing blood. If blood oozes, place a second tie
between the skin and first tie.
• 6. DO NOT APPLY ANY SUBSTANCE TO THE STUMP.
• 7. DO NOT bind or bandage stump.
• 8. Leave stump uncovered.
 Eye care
Do’s:
• Clean eyes immediately after birth with swab
soaked in sterile water using separate swab for
each eye. Clean from medial to lateral side.
• Give prophylactic eye drops within 1 hour of
birth as per hospital policy*.
Don’ts:
• Putting anything else in baby's eyes can cause
infection.
 MONITORING THE BABY
• The health personnel should monitor all the
parameters every 15 minutes for the first hour
after birth of the baby.
KANGAROO MOTHER CARE
 KMC
Two components:
1. Skin to skin contact
2. Exclusive Breast feeding
Two prerequisites:
1. Support to the mother in hospital and at
home
2. Post-discharge follow up
Benefits

1. Temperature maintenance
with a reduced risk of
hypothermia
2. Increased breastfeeding
rates
3. Early discharge from the
health facility
4. Less morbidities
5. Less stress (for both baby
and mother)
 First 24 Hours
1st hour
• Essential newborn care
• Inj Vit K
• Breast feeding
• Next 23 Hours
• Birth Weight
• Immunization
• Monitoring
• MCP Card
Neonatal Health
 Learning Objective
1. Significance of child health
2. Burden
3. Neonatal Health
4. Burden
5. Causes of death
6. Preventive measures
 Child Health
• nation’s present and its future
• warrant special attention: Growth,
Development , Dependence
• Health,
• Safety,
• Well-Being

• Childhood Has a Long Reach

 Triple burden of malnutrition on under five
children
Sr no Nutrition problem Burden
1 Not growing well 1 in 3
2 hidden hunger 1 in 2
3 Stunting 1in 5
4 Wasting 1 in 14
5 Severe wasting 1 in 50
6 Overweight/Obese 1 in 18
676 million children globally are below
 Child Death Proprtion
Age Death in no( million) percentage
0-15 years 6.2
0-5years 5.3 85

0-1years 3.97 75 of under five death

0-1 Month 2.5 62 of infant deaths

 INDIA
Age Rate (per 1,000 live births)

0-5 36.6

0-1 29.9

0-1 month 22.7

 Neonatal deaths
• 2. 6 million neonatal death
• 2. 6 million stillbirth ( 50% after labour has
begun)
TOP CAUSES
1. Prematurity
2. Complications during birth
3. Severe Infection
Preventable with high quality care- 75 per cent
73
37
 India’s target by 2030
• U5 Death-25
• Neonatal death rate-12
1. A normal newborn should be breathing regularly at a rate of ___

to ___ breaths per minute.

2. Number one cause of neonatal death is -.

3. Vernix caseosa of newborn should not be wiped off. Why?

4. Wipe both the eyes from the medial side (inner canthus) to the

lateral side (outer canthus) with one sterile gauze. True/False.

5. Once the cord is cut, the baby should be placed between the

mother‟s breasts to initiate skin-to-skin care. Why?

6. The identity label should be placed on the ________ of the baby.
7. A newborn baby‟s head should be covered with a cap to prevent loss of
heat. Why?
8. Ensure the delivery room is warm (25° C), with enough draughts. True/
False
9. The key features of good hand washing technique include:
a. ___________________________ steps
b. ____________________________ minutes hand washing before entering
the newborn care area.
c. ____________________________ seconds hand washing in between and
after touching the baby.
10. Sterile gloves should be worn for the following procedures (Enumerate
any three).
1. Systematic screening for active TB should be considered for pregnant women as

part of antenatal care in settings where the tuberculosis prevalence in the general

population is -/100 000 population or higher.

2. Full blood count testing is the recommended method for diagnosing anaemia in

pregnancy. True/ False

3. Vitamin B6 (pyridoxine) supplementation is recommended for pregnant women

to improve maternal and perinatal outcomes. True/ False

4. Routine Doppler ultrasound examination is recommended for pregnant women to

improve maternal and perinatal outcomes. True/ False

5. Two ultrasound scan before 24 weeks of gestation (early ultrasound) is

recommended for pregnant women. True/ False

6. Full form of IPTp-SP in conext of recommendation for pregnant
women of In malaria-endemic areas in Africa, is ____.
7. Antenatal care models with a minimum of- contacts are
recommended to reduce perinatal mortality and improve women’s
experience of care.
8. In WHO ANC 2016 model the term visit is used in place of contact.
True/ False
10. When Universal children’s day is observed in India?
11. Article no. – of the constitution of India prevents child abuse.
12. One of the workplace related right of children is protecting
children in emergencies. True/ False
13. Good care for children is one of the underlying
determinants of children’s diet. True/ False
14. More adolescent from high income countries eat fast food
at least once a week. True /False
15. Lack of dietary diversity is a risk factor for children
between 6 months to 2 years age group. True /False
16. Innocenti declaration on IYCF was made during the year
_____.
17. In south east Asia 1 in 7 children under 5 is wasted. True
/False
18. Global target of reducing prevalence of LBW by 2025 is -
per cent.
19. The name of rod humanoid puppet, the global ambassador
is -.
20. - % of under five deaths occur during 0-1 year.
21. Children warrant special attention in terms of growth,
development and -.