Maternal Health

Services
Professor Dr. Hisham Mohamed
Mahaba, M.D Public Health, M.D
Obstetrics and Gynecology
Maternal and Child health services
 Services provided to women in childbearing
period 15-45 y and preschool children.
 Maternal and Child Health Care is the most
important activity provided by Primary Health
Care , WHY?
 Vulnerable group
 Large sector of population
MCH care package

 Mother and her child must be considered as one

unit because:
 -A healthy mother will bring a healthy baby.
 -Up to age of five years the child is dependant on
his mother
 Separation of a child from his mother even during
hospitalization has been reported to be harmful.
 Preparing a women for childbearing should start
early in childhood
Objectives of MCH

 General objectives:
 -Promotion of reproductive health
 -Promotion of physical and psychological
development of children
 Reduction of mortality and morbidity
 -Reduction of costs of health services
Components of Maternal Care

 Preconception care (Premarital care)

 Antenatal care
 Natal care
 Postnatal care
 Inter- pregnancy care
Preconception care ( premarital care)
Goal : prevention and early detection of health
hazards or diseases that may affect the
normal child bearing in the future.
Objectives:
 Early detection of sexually transmitted
diseases
 Early detection of Genetic diseases
 Early detection of chronic maternal disease
affected by pregnancy
 Prevention of fetal infections e.g. rubella,
toxoplasmosis, syphilis, tetanus neonatorum
 Health education
 Pre Conceptional Care
Examination Pre Marital
It is one of the components of maternal health care
Family History

-Blood diseases
-Mental Retardation
-CVS Diseases
-Genetic Defects
-Recurrent Abortion
-Physical Deformity
-Schizophrenia
-Diabetes
-Cancer
 Immunization
Td
MMR Booster
dose

The adult unconjugated 23

Hepatitis B Valent pneumococcal
vaccine Polysaccharide vaccine
Once every 7 years
(in chronic lung disease)
Varicella-
Zoster
vaccine
Health Education
Nutrition :
Multivitamins (calcium, iron, folate)
Stop caffeine (coffee, tea)
Good exercise program

Habits :
Stop smoking, alcohol, street drug

Sexuality :
Counseling tests for HIV / AIDS , hepatitis or
other sexually transmitted diseases
 Investigations :
- Tuberculosis skin test
-Thyroid stimulating hormone
- Urine analysis &stool culture to exclude
parasitic diseases
- Hepatitis B , AIDS, RH , Blood grouping, Hb%

Physical Examination :
A yearly check of height, weight, blood pressure ,
breasts, skin , abdomen, pelvis, good physical &
dental health.
Ante Natal Care
Definition :

 Systematic medical
supervision of woman
during pregnancy.
Objectives of ANC
 Promote and maintain the physical, mental
and social health of mother and baby by
providing education on nutrition, personal
hygiene and birthing process
 Detect and manage complications during
pregnancy, whether medical, surgical or
obstetrical
 Develop birth preparedness and complication
readiness plan
 Help prepare mother to breastfeed
successfully, experience normal puerperium,
and take good care of the child physically,
psychologically and socially
Ante Natal Visit :
 Schedule of visits :
1) Once a month in 1st., 28 weeks.
2) Every 2 weeks till 36 weeks.
3) Every week thereafter if everything is
normal.
 The following minimum visit should
be implemented :

1) 1st. contact : before 12 weeks of pregnancy.

2) 2nd. contact 20 to 22 weeks of pregnancy.
3) 3rd. contact 28 to 32 weeks of pregnancy.
4) 4th. contact 34 to 36 weeks of pregnancy.
5) 5th. contact 38 to 22 week to full term.
In 1st., Ante Natal Visit :

1) Pregnancy Test : to confirm diagnosis.

2) B-History: Personal, family, obstetric and past
histories. Careful history taking is very important to
identify pregnant women with risk factors who
need special care.
3) Examination
 -General examination
 -Weight and Height
 -Teeth inspection
 -blood pressure measurement
 examination of leg for edema
 -Auscultation of heart and lung
 -Examination of breast and nipples
 -Examination of abdomen and assessment of the size of the uterus.
 -Inspection of vagina and cervix
 -Examination of pelvis.
 D- Investigations :
 -Urine examination
 -Blood sample for hemoglobin level, blood group , Rh, serological
test for syphilis.
Counseling
 is an approach which aims at voluntary
change of unhealthy behavior, attitude,
thoughts & knowledge of the people by
providing them correct & precise information
 Success of counseling depends largely
upon the personality, knowledge, attitudes &
skills of the counselor.
 Physicians, nurses, social workers &/or midwives
can do counseling as long as they have the
appropriate personality, attitude, knowledge, skills &
training.

 Counseling could be applied in :

 High risk pregnancy
 Family planning
 Breast Feeding
 Genetic counseling
Counseling and Health
Promotion
 Counseling for women and partners/
supporters on:
 Nutrition and micronutrients
 Rest and avoidance of heavy physical work
 Danger signals of complications and
disease/illness
 Family planning
 Breastfeeding
 Malaria prophylaxis
 Tobacco and alcohol use
4) Health Education :
 Proper diet during pregnancy and lactation.
 Personal hygiene.
 Dental Care.
 Sexual Intercourse during pregnancy.
 Drugs intake during pregnancy.
 Warning signs during pregnancy.
 Care of breast during pregnancy.
 Breast feeding.
 Proper weaning.
 Child care.
 Immunization.
5) Vaccination by 1st., dose of tetanus
toxoid.
Immunization by tetanus toxoid during pregnancy WHO
Schedule :
Duration
Dose Time Protection

1st., Natal Visit At the 1st Ante Zero -

At least 4 weeks after the 1st and
2nd., 80% 3 years
more than 2 weeks before term
At least 6 months after or during
3rd., 95% 5 years
the next pregnancy
At least one year after or during
4th., 99% 10 years
next pregnancy
At least one year after or during
5th., 99% Life long
next pregnancy
 6- The mother is then registered and
antenatal care time schedule is prepared in
two copies: one kept in her file in the health
center and the other should be kept with the
mother and she should be instructed to bring
it with her at every antenatal visit.
At Risk Pregnancy

-Definition:
 Risk factor: the presence of a condition
known to have poor outcome or prognosis
 At risk approach: managing health problems
through identification of at risk subjects or
groups and applying special care for such
subjects and the normal care is applied to
those free of risk factors.
 Risk factors Adverse outcomes
Perinatal Maternal

Biological Perinatal death and low ------

Age 18 years weight ------
Age 30 yrs, first birth order ------
Age 35 years *APH, PPH retained
Grand multipara birth order 4 > placenta
Birth interval less than 24 months

Nutritional status Perinatal death and low Prolonged labor

Height 150 cm birth weight -
Weight at delivery45 kg Perinatal death and high -
Weight gain < 7Kg birth weight Hypertension
Weight at delivery 95Kg ----- APH , PPH
Hemoglobin 10 gm

Medical complications Perinatal death and low Maternal Death

Diabetes Mellitus birth weight Maternal Death
Chronic hypertension Perinatal death and low
Heart diseases birth weight, birth asphyxia
Renal diseases
Chest diseases
Known exposure to specific drugs or infections
Known frequent exposure to X-Rays
Obstetric complications
Pre-eclampsia
Bleeding
Preterm
Post date
Small for date
Malpresentation
Weight gain less than 6 kg
Twins or multiple pregnancy
History of difficult labor
Previous Caeserian section
Previous history of large baby (>4kg)
Genital tract anomalies or tumours
History of complicated labour: Hemorrhage, birth
injuries, still birth
Health care utilization
NO antenatal care (Unbooked)
Advantage of High risk approach
 High risk approach achieves rapid, easy and
cheaper reduction in health problems
Disadvantages of at risk approach
 Health problems can still occur among those
classified as low risk e.g. Post partum
hemorrhage, puerperal sepsis and death can
occur among those identified as normal
pregnant cases.
 Goal directed
Antenatal Care

Antenatal Care: Overview 31

 Why Disease Detection and
Not Risk Assessment
 Risk approach is not an efficient or
effective strategy for maternal mortality
reduction:
 “Risk factors” cannot predict complications:
usually not direct cause of complication
 What do you do once you identify risks?
What about “low risk?”
 Maternal mortality is relatively rare in
population at risk

Fortney 1995; Yuster 1995.

Goal-Directed Interventions
Give a Framework for Effective
ANC
 Disease detection
 Counseling and health promotion
 Birth preparedness
 Complication readiness
Goal-Directed Components of
ANC: Disease Detection
 Look for problems requiring additional
care
Parameter Condition
Skin, general appearance, night Malnutrition
blindness, goiter
Temperature, dysuria Signs of infection
Blood pressure, edema, proteinuria, Signs of pre-eclampsia
reflexes
Hemoglobin, conjunctiva/palms/ Signs of anemia
tongue pallor
Breast exam Breast disease
Baby’s movements, fundal height, Fetal distress/demise
baby’s heart beat
Pelvic and speculum exam Sexually transmitted diseases
Goal-Directed Components of
ANC: Birth Preparedness
 Make plans for the birth:
 Prepare the necessary items for birth
 Identify a skilled attendant and arrange for
presence at birth
 Identify appropriate site for birth, and how to get
there
 Identify support people, including who will
accompany the woman and who will take care of
the family
 Establish a financing plan/scheme
Natal care
 Aims :
 -1 To conduct delivery under aseptic condition with
minimum injury to the infant and to the mother.
 The three cleans 3Cs :clean hands, clean surface
for delivery and clean cutting and dressing of
the umbilical cord..
 -2 To be ready to manage emergencies.
 3 -Care of baby at birth.
Site of delivery
A- Home delivery
 Home delivery is only allowed under the
following conditions
 - Normal pregnancy .
-If the home condition is satisfactory - .
Under medical supervision.
B- Institutional delivery

 At Health Centers: For only normal

pregnancy and low risk group. Well equipped
delivery room and trained team should be
available.
 At Hospital: All pregnancies including high
risk pregnancy. Obstetrician, operating room
and blood bank facilities should be available.
Post-natal Care -
 Aims:
 Prevent complications of postnatal period.
 Ensure success of breast feeding.
 Provide family planning services.
Post-natal visits

 Schedule :Twice a day during the first day, once a day

for three days, end of first week, and at the end of the
perperium(
 The following activities should be done :
 Women: Examination: Pulse, temperature, respiratory
rate, breast examination, uterine involution, inspection
of lochia (vaginal discharge) color and smell for any
signs of sepsis, episiotomy scar
 Child : Check breast feeding and care of umbilical
stump.
 Advice (see health education during perperium)
Health education during perperium

 Personal hygiene.
 Care of episiotomy scar and umbilical stump.
 Feeding of mother.
 Breast feeding
 Child spacing.
 Immunization.
 Importance of birth registration and visits to well
baby clinic (see child care).
 Importance of family planning.
V- Inter conception care
 It is care of the mother in- between
pregnancies for preparation of the mother for
the next pregnancy.
 -Health promotion for adequate nutrition and
healthy lifestyle.
 -Birth control: proper spacing to prevent
unfavorable outcomes.