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Ms. Subhashini. G. Mrs. Santoshi Shrestha
HOD OBG Department I year M.Sc Nursing
Bangalore Bangalore
















Definition and Meaning of Maternal and Child Health

Definition and concepts of Maternal Health/ Reproductive Health
Objectives of Maternal and Child Health
Goals of Maternal and Child Health Services

A. Maternal Health Problems

I. Nutritional Problems

b) Malnutrition
c) Nutritional Anemia

II. Infection Problems

a) Reproductive Tract Infections ( RTIs)/ Sexually Transmitted Infection (STI)

b) Infection in general
c) Puerperal Sepsis

III. Disturbances and Menstruation

IV. Mature Gravidas
V. Adolescent Gravida
VI. Adolescent Parents Problems
VII. Unregulated Fertility
VIII. Abortions
IX. Complications of Deliveries
X. Infertility
XI. Uterine Prolapse
XII. Cancer of the Service
B. Child Health Problems

I. Nutritional deficiency Problems

a) Malnutrition
b) Vitamin Deficiency
c) Iron Deficiency
d) Low Birth Weight

II. Infectious Diseases

a) Tuberculosis
b) Diphtheria
c) Pertussis (Whooping Cough)
d) Tetanus
e) Poliomyelitis
f) Measles
g) Acute Respiratory Infection (ARI)
h) Diarrhoeal Diseases

III. Problems of Neonates

a) Hyper bilirubinemia
b) Hypothermia
c) Neo-natal tetanus
d) Birth asphyxia
e) Oral thrush
f) sepsis
g) The infected New Born


 Maternal Age
 Sexuality Factor
 Nutrition
 Environmental Factor
 Psychological Factor
 Ethnic and Socio Cultural Factor
 Lifestyle Factor
 Gender





Maternal and Child Health

Maternal and child health is recognized as one of the significant components of Family
Welfare. Health of both mother and children is a matter of Public Health concern. It is
also being observed that the deaths of mothers and children are the major contributors
to mortality in any community in India. In India 125,000 (460 per 100,000 live births)
women die due to pregnancy and child birth related causes. About 1.8 million (74 per
1000 live births) infants and 2.65 million (109 per 1000 live births) under five children
die every year.

Health of mothers and children is very important for acceptance and practice of family
norms to stabilize population.Materal and Child Health care services are essential and
specialized services because mothers and children have special health needs which are
not catered to by general health care services.

Moreover, children are the asset for the family, community and nation. They are their
future. Whereas mothers have an important role in their growth and development.
Mother’s health status during pregnancy and after delivery determines health status of
child. Therefore health care of mothers and children occupies an important place in our
health care delivery system and is integrated part of Primary Health Care.

The problems of maternal and child mortality are complex, involving women’s status,
education, employment opportunities and the availability to women of basic rights and

The maternal health status differs tremendously from place to place and in the same
place. It is assessed in terms of maternal health problems (maternal morbidity) and
maternal mortality. The factors which are responsible for maternal health problems i.e.
maternal morbidity and maternal mortality include poverty, ignorance, illiteracy,
malnutrition, age at marriage and pregnancy, the number and frequency of child
bearing and the number of unwanted pregnancies and abortions, lower status and worth
of women in society, lack of access to quality maternal health/ reproductive health
services, gender discrimination.

 Magnitude : Largeness, Importance

 Mortality : Quality or state of being subject to death,

number of deaths in relation to a specific
population, incidence.
 Morbidity : Condition of being diseased, Number of
causes of disease or sick person in
relationship to a specific population,
 Infant : A child who is under 1 year of age

 Sexuality : The part of life that has to do with being male

or female
 Sexually Transmitted Disease : Disease acquired as a result of sexual activity
with an infected individual.

 Delivery : Expulsion of a child with the placenta and

membranes from the mother at birth

 Fertility : Quality of being able to reproduce.

 Neonatal Mortality : Statistical rate of infant death during the first

28 days after live birth, expressed as the
number of such deaths per 1000 live births
in a specific geographic area or institution in
a given period of time.
 Puerperal Sepsis : Infection of the genital tract following
childbirth, still a major cause of maternal
death where is undetected and untreated.
 Abortions : The termination of pregnancy before the
fetus reaches the stage of viability (20 to
24 weeks)
 Miscarriage : Spontaneous abortion, lay term usually
referring specially to the loss of the
fetus between the fourth month and
 Premature Infant : Infant born before completing week 37
of gestation, irrespective of birth
weight, preterm infant.
 Low Birth Weight : Infant weighing 2500g or less at birth

 Eclampsia : Coma and convulsive seizures between

the 20th week of pregnancy and the end
of the first week postpartum

 Pregnancy Induced Hypertension: Hypertensive disorders of pregnancy

including preeclampsia, eclampsia,
transient hypertension.
 Pelvic Inflammatory Disease : Infection of internal reproductive
structures and adjacent tissues
usually secondary to STD infections.
 Ectopic : Out of normal place

 Infertility : Decreased capacity to conceive

 Nephritic : Related to the kidney

 Cystitis : Inflammation of the bladder usually

occurring secondary to ascending
urinary tract infections
 Amenorrhea : Absence or suppression of menstruation.

 Primary Dysmenorrhoea : Painful menstruation beginning 2 to 6

months after menarche, related to
 Uterine Bleeding) : Falling, sinking, or sliding of the
uterus from its normal location in the
 Metrorrhagia : Abnormal bleeding from the uterus,
particularly when it occurs at any time
other than the menstrual period.
 Menorrhagia : Abnormally profuse or excessive
Menstrual flow.
 Foetal Distress : Evidence such as a change in the fetal
heartbeat pattern or activity indicating
that the fetus is in jeopardy.

 Hypothermia : The state in which an individual’s body

temperature reduced below normal range.

 Thrush : Fungal infection of the mouth or throat

characterized by the formation of white
patches on a red, moist, inflamed mucous
membrane and is caused by Candida albicans.

 Apathy : Lack of emotion

 Dermatosis : Any disease of the skin in which

inflammation is not necessarily a feature
 Stomatitis : An inflammation of the mouth
 Keratomalacia : Softening of the cornea seen in early childhood owing
deficiencies of vitamin A

 Hemoptysis : The expectoration of blood arising from the oral cavity,

larynx, trachea, bronchi, lungs characterized by a
sudden attack of coughing with production of salty
sputum containing frothy bright red blood.
 Modesty : The quality of being modest

 Modest : Having or expressing a humble.

 Emphysema : A chronic pulmonary disease marked by an abnormal

increase in the size of air spaces distal to the terminal
bronchiole with destructive changes in their walls.



Maternal and Child Health (MCH) refers to a package of comprehensive health care
services which are developed to meet promotive, preventive, curative, rehabilitative
health care of mothers and children. It includes the sub areas of maternal health, child
health, family planning, school health and health aspects of the adolescents,
handicapped children and care for children in special settings.



Maternal Health is now referred as “Reproductive Health” (RH). According to WHO

it is defined as a state of complete physical, mental and social wellbeing and not merely
the absence of disease or infirmity in all matters relating to the reproductive system and
its functions and processes. It implies that people are able to have a satisfying and safe
sex life, are informed about to have access to safe, effective, affordable and acceptable
methods of family planning as well as other methods of their choice for regulation of
fertility which are not against the law, are able to have access to appropriate health care
services that will enable women to go safely through pregnancy and child birth and
provide couples with the best chance of having healthy babies.

Reproductive Health is defined as “People have the ability to reproduce and regulate
their fertility, women are able to go through pregnancy and child birth safely, the
outcome of pregnancies is successful in terms of maternal and infant survival and well
being and couples are able to have sexual relations free of fear of pregnancy and of
contracting diseases.”


 To reduce maternal, infant and childhood mortality and morbidity.

 To reduce perinatal and neonatal mortality and morbidity.
 Promoting satisfying and safe sex life.
 Regulate fertility so as to have wanted and healthy children when desired.
 Provide basic maternal and child Health Care to all mothers and children.
 Promote and protect health of mothers.
 To promote reproductive health.
 To promote physical and psychological development of children and adolescents
with in the family.


The main goal of maternal and child health services is the birth of a healthy infant into
the family and prevention of diseases in mothers and children. The goals which are
included are as follows:-

 To ensure the birth of a healthy infant to every expectant mother.

 To provide services to promote the healthy growth and development of children up
to the age of under- five- years.
 To identify health problems in mother and children at an early stage and initiate
proper treatment.
 To prevent malnutrition in mothers and children.
 To promote family planning services to improve the health of mothers and children.
 To prevent communicable and non- communicable diseases in mothers and
 To educate the mothers on improvement of their own and their children’s health.


The Maternal Health Problems are as follows:-

I. Nutritional Problems

a) Malnutrition
b) Nutritional Anemia

II. Infection Problems

a) Reproductive Tract Infections ( RTIs)/ Sexually Transmitted Infection (STI)

b) Infection in general
c) Puerperal Sepsis

III. Disturbances and Menstruation

IV. Mature Gravidas
V. Adolescent Gravida
VI. Adolescent Parents Problems
VII. Unregulated Fertility
VIII. Abortions
IX. Complications of Deliveries
X. Infertility
XI. Uterine Prolapse
XII. Cancer of the Service

I. Nutritional Problems

a) Malnutrition

Malnutrition is a very common problem among women who are discriminated and
underprivileged. Pregnant and nursing mothers are especially prone to the effects of
malnutrition. Malnutrition can cause poor resistance, abortion, anemia, miscarriage or
premature delivery, low birth weight baby (<2.5kg), eclampsia, postpartum hemorrhage
etc. These conditions can cause fatal effects on mothers, unborn and new born babies.

Malnutrition in women needs to be prevented and treated by some of the direct

measures such as 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.
Other measures which can help prevent mal-nutrition include prevention and control of
infections by improvement of environmental sanitation, safe water supply, food and
personal hygiene, immunization treatment of minor ailments, regulation of fertility and
practice of small family norm, and health education.

b) Nutritional Anemia

Anemia in pregnancy is defined as a hemoglobin concentration of less than 11g%.

Anemia is a condition in which concentration of hemoglobin in the red blood cell is

reduced. Hemoglobin is essential for life. It carries oxygen to all parts of the body for
its development and day to day function. It also maintains the immune system which
provides resistance to infection. Therefore, an anemia person acquires infection easily.
Brain also gets less oxygen if a person is anaemic.The brain requires a large quantity of
oxygen and therefore the child is anemic, its brain development suffers. It is also a
serious public health problem in India. Although it is wide spread in the country, it
especially affects woman in reproductive age, young children and adolescent girls.

Magnitude of the Problem

 More than half of the pregnant women during pregnancy suffer from anemia.13%
are severely anemic. Hemoglobin is less than 7 gm/ deciliter.
 1/5 of all maternal deaths are attributed to anemia during pregnancy.
 More than half of the adolescent girls are anemic.

Anaemia during pregnancy leads to

 20% of all maternal deaths.
 3 times greater risk of premature delivery and LBW babies.
 9 times higher risk of perinatal mortality.
 Higher risk of irrecoverable brain damage in infants born to severely anaemic

Adverse Effects

 Maternal depletion
 Low Birth Weight
 Postpartum Haemorrhage ( PPH)
 Anaemia
 Pregnancy induced Hypertension ( PIH)

Prevention of Nutritional Anaemia

Nutritional Anaemia can be easily prevented by the following ways:-

 Promoting consumption of iron rich food.

• Regular consumption of iron rich food, especially by pregnant and lactating

women, adolescents’ girls and boys and children under 5 years of age.
• Vitamin C promotes absorption of iron. Vitamin C rich foods are lemon, orange
and guava.
• Tea and Coffee inhibits absorption of iron in the stomach. It is advisable to
reduce intake of tea and coffee during pregnancy. It should otherwise be
avoided within the one hour of taking food or iron tablets.

 Promoting growth of iron rich at home will increase the availability of iron in food,
like spinach, lemon, amala, etc.
 Promoting consumption of iron and folic acid supplements. Supplementary iron in
form of tablets is the most common strategy for control of iron deficiency anemia.

II. Infection Problems

a) Reproductive Tract Infections (RTIs)/ Sexually Transmitted


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. A high incidence of infertility, tubal pregnancy, and poor
reproductive outcome is an indirect reflection of high prevalence of RTIs/ STIs in
Vaginal discharge is amongst the first 25% reasons to consult a doctor. 40 %
gynecological OPD attendance is because of RTIs and 16 % of gynecological
admissions and due to pelvic inflammatory disease (PID).

Causes of Reproductive Tract Infection

 Infections caused by overgrowth of organism normally found in the vaginal tract

are known as endogenous infection. These infections are associated with inadequate
personal, sexual and menstrual hygienic practices.
 Sexually Transmitted Diseases (STDs) are a specific group of communicable
diseases that are transmitted through sexual contact.
 Infections which are due to inadequate medical procedures such as unsafe abortion,
unsafe delivery or unhygienic IUD insertion are known as iatrogenic infections.

Signs and Symptoms Associated with RTIs

In women

 Increased discharge from the vagina that looks and smells different from ( change
in amount, colour and smell)
 Pain or burning while urinating.
 Painful or painless sores, blisters or warts on or near the genitals.
 Pain on one or both sides of lower abdomen.
 Irregular menstrual periods.
 Pain or bleeding during intercourse.
 Rash on the entire body or just on the palms and soles.
 Swelling on one or both sides of the groins.

In Men

Symptoms usually appear within 2-3 days or a couple of weeks or even months after
having sex with an infected partner are:

 Pus or discharge from the penis.

 Burning or pain while urinating.
 Painful or painless sores, blisters or warts on or near the penis.
 Pain in one or both the testicles.

Prevention of RTIs and STI

 Identify the women with RTIs/STI

 Refer the women to medical officer of PHC promptly for examination and
 Identify sexual partners and ensure their treatment.
 Advice correct use of condom during every sexual act.
 Provide counseling/health education to individuals, family and community.
 Observe infection prevention measures amongst the health personnel.
A comprehensive RTI/STI control programme requires three levels of action.

 Primary Prevention

Avoiding acquisition of infection through infected sexual partners. Strategy of primary

prevention includes education and counseling about safe sex practices, sexual hygiene
and promotion of condom use. Use of condom prevents transmission of RTIs/STIs.

 Secondary prevention

Secondary prevention aims at early detection of signs and symptoms and early referral
of RTIs/STIs so that spread of infection to others decreased, in the peripheral healthcare
setting currently treatment is based on syndromic management.Counselling and
education to motivate health seeking behaviour in community by reducing the number
of sexual partners. Use of most appropriate antibiotics, practicing proper aspects during
reproductive interventions and educations of sex partners.

 Tertiary Prevention

Tertiary Prevention includes controlling complications of RTIs.Strategies for tertiary

prevention includes active screening for presence of infection in high risk groups and
appropriate management.
 Clinical management of septic abortion
 Transport for ectopic pregnancy
 Management for infertility
 Cervical cancer screening

b) Infection in general

The women during pregnancy, especially in underdeveloped areas and developing

countries are at risk of contracting infection.
Many women get infected with herpes simplex virus, cytomegalovirus, protozoon
which causes toxoplasmosis, E Coli causing nephritis or cystitis. Infection during
pregnancy can cause various harmful effects e.g. retardation of fetal growth, abortion,
low birth weight baby and puerperal sepsis.

It is very important that women during pregnancy need to alert and careful regarding
prevention and control of infection. They need to seek antenatal care right from the
beginning of inception of pregnancy so that mothers get proper antenatal care and get
well informed about these infections and participate in prevention and control of these

C) Puerperal 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 a time leucorrhoea
may persist for years. Some times secondary sterility may follow after acute or chronic
salpingities. Chronic infections of cervix may predispose to cancer of the cervix. It
requires proper preparations for confinement by the mother, conduct of deliveries by
trained and skillful dais, midwives etc.and availability of equipments and supplies etc.

III. Disturbances and Menstruation

Amenorrhoea, absence of menstrual flow, dysmenorrhoea, painful menstruation,

abnormal uterine bleeding, hypermenorrhoea/ menorrhagia, excessive bleeding
(amount and duration), metrorrhagia, bleeding between menstrual periods.

Menstruation is perceived as a particular problem for women. Intervention programmes

for various menstrual problems are as follows:-

Nursing Intervention for disturbed menstruation

S.N Nursing Diagnosis Nursing Intervention

1. Amenorrhea • Acknowledge patient’s feeling

Ineffective individual • Provide emotional support
coping related to lack of • Refer to counseling as necessary
menstrual flow • Explain diagnostic procedures
• Provide information, privacy, or consultation as
indicated sexual concern
2. Dysmenorrhoea • Provide information on orientation to hospital
a. Knowledge deficit setting, disease process procedures to be performed,
related to the lack of medication and treatment.
education concerning • Prepare for information, question and answer
disease process and sessions according to patient needs
treatment • Teach procedure to the patients
• Obtain feedback
• Be that certain learning has taken place
• Develop a trusting relationship
• Involve patient in care
b. Pain related to biological • Assess the nature of pain
agent • Observe non- verbal cues
• Encourage pain reduction technique as appropriate
• Explore best method for controlling (medication,
positioning comfort measure such as backrub, or
use of heat or cold etc.)
• Monitor vital signs
• Provide quiet environment , calm activities
• Promote wellness, discuss other significant ways
which can assist the patient
3. Menorrhagia • Assess for bleeding, pain, vaginal secretions and
psycho- social concern
• Encourage the woman to express her feelings
• Explain the importance of recording dates, type of
flow and number of sanitary pads or tampons used
• Teach the patient pain- relieving technique.
• Explain the importance of sharing concerns with
her partner.
Certain measures that have to be taken to reduce this problem are as

S.N Reasons of Anxiety Nursing Intervention

1. Irritability,Lethargy, • Encourage verbalization of feelings

fatigue,depression,headache, • Acknowledge existence of the syndrome
vertigo,backache,ache, and its symptoms
paresthesia(burning, tingling) of • Encourage the patient to keep a menstrual
hands and feet symptom calendar to document the cycle
and nature of symptoms
• Encourage the patient to plan activities
during symptom free part of her cycle
• Administer supplements of vitamin B6,
calcium, and magnesium as prescribed
• Encourage daily exercises and relaxation
• Encourage self – help groups and the
reading of self help literature
• Provide emotional support with non
judgemental and caring manner
• Assist in identifying possible source of
• Assist in identifying coping mechanism

Health Teaching for Menstruation

 Knowledge of the physiological process.

 Factors that may alter the menstrual cycle, stress, fatigue, exercise, acute or chronic
illness, changes in climate, or working hours and pregnancy.
 Personal hygiene
 Wear pads during early period of heavy flow.
 Change tampons frequently to decrease risk of toxic shock syndrome ( TSS)
 Consult physicians if tampons cause discomfort.
 Take daily shower for comfort (warm baths may relieve slight pelvic
 Keep perineal area clean and dry, clean from anterior to posterior.
 Cotton underwear preferred. Nylon panty hose and tight fitting slacks cause
retention of moisture and should not be used for extended periods of time.
 Feminine hygiene products such as vaginal sprays and suppositories may
contribute to a feeling of cleanliness.
 Exercise
 Exercise is not contracted and may help prevent discomfort.
 Modifies exercises if fatigue occurs.
 Diet
 Restrict salt intake if fluid retention is present.
 Consult physician if fluid retention persist after menstruation.
 Discomfort
 For mild discomfort take aspirin or apply warmth and rest.
 For prolonged, severe discomfort, consult physician.
 Sex during menstruation
There is no physiological reason for a woman to abstain from sexual activity during
menstruation. The uterine contractions that occur during orgasm may even ease the
discomfort of pelvic congestion and cramping. During excessive menstrual flow, or
physical discomfort, discourage the sexual activities.

IV. Mature Gravidas

The pregnant woman over 35 years faces unique problems. The primigravida in this age
category has generally decided to postphone child bearing until her career is well
established. Although the child may be wanted and anticipated, she will often have
much ambivalence and concern about how motherhood will affect her lifestyles and
how it will affect her relationship with the father of the baby. She might be the single
woman deciding to have a child on her own, perhaps even by artificial insemination or
in vitro fertilization. She might be having a child later in her child bearing years
because of remarriage or by accident.

It may seem that these women are the best prepared psychologically for the demands of
pregnancy and parenthood because their lives are stable. This readiness intensifies their
need for nursing care. They are heavily invested in these pregnancies because of the
need to have the first, the only, or the last child or because they have decided to carry
and deliver and unplanned pregnancy because it may be their last chance. When
something goes wrong or threatens to go wrong, there may be guilt and sorrow.

Issues particularly important in mature gravidas are control and past coping
behaviours.Many women have been successful in their careers by manipulating
situations to their advantages. When faced within a situation in which they are not in
control and must trust others, severe anxiety develops. Their past coping behaviours
will not be effective, and this will intensify their anxiety. They feel unable to take care
of themselves and often have little experience in relying on others during times of need.
The educational level of of the client must be considered when recommending
For woman having first pregnancy later in life, fear about the infant’s health and
survival often becomes the dominant feeling. This may be the last egg in the basket and
this is very much valued. As a result, cesarean birth is chosen more often by
obstetricians, and indicates an overcautious approach to birth problems.

V. Adolescent Gravida

The adolescent mother and her family create a particularly difficult problem. The needs
can be so extensive that care will be fragmented and ineffective unless and
interdisciplinary team approach coordinates the school, social and health care services.

The scope of adolescent pregnancy is enormous. The mean age of menarche is around
12 years. Forty two percent of girls and 64 percent of young boys are sexually active by
age 18.

A family’s reaction to teen age pregnancy varies considerably. In certain ethnic and
cultural groups, teenage parenting is common. Indeed the girl’s mother may have been
a teenage parent herself. In these cases, the situation is not a crisis. In other families,
major problems result.Sex education and family planning help to adolescent gravida.

 Sex Education

Adolescents lack of knowledge about their bodies and bodily changes. Many parents
find it difficult to talk with their children about maturation’s, birth control and
parenting. Parents may not understanding that this information is vital and that it must
be given early.Furstenbert ( 1980) found that although 59 percent of mothers frequently
talked to their daughters about sex, most of the messages were not get mixed up with
boys and not to do anything she would be sorry for later. This is hardly the information
teenagers require. On the other hand, 50 percent of birth control used contraception at
least occasionally.

 Family Planning

The pregnancy rate among teenagers is so high because only one in three sexually
active teens always uses contraceptives. Only about half of these use the most effective
method. The most common reasons given by teenagers for not using contraceptives
• They don’t feel they will get pregnant
• They did not anticipate having intercourse

While the national debate continues over where and by whom sex education
programmes should be taught, research is clear, we must began early and be specific.
Teenagers are at risk not only for pregnancy but also for STD including HIV infection.
It is unlikely that the Government will soon develop policies to encourage early sex
education programmes even though the urgency of the rates of HIV infection and of
teenage pregnancy demands it.
As nurses, role is two fold; nurse must care for adolescent parents and support their
parents and teachers in efforts to communicate about responsible sexual behaviour
before pregnancy occurs and after its termination either by abortion or delivery. Parents
and teachers need education also.

VI. Adolescent Parents Problems

The adolescent father is often neglected in these situations. Some families are angry
and upset and will ostracize him. As other times both families pool their financial,
physical and emotional resources to support the young parents as they care for their
infant. Some young men are not involved by their own choice, but others may distance
themselves because they assume that they don’t have a role to play or they are not
needed by their partner for support. They may fear that they will be forced to marry and
provide financial support before they are capable of doing so. These young men are in
the same developmental stage as the young women. Teenagers fathers have many
problems. They are young, are capable of sexual reproduction, but not considered
adults, are cognitively and psychologically immature possess few legal rights and are
out of life cycle synchrony with their peers.

Fathering a child as an adolescent is associated with reduced levels of education in

general. Lower educational levers limit career choices and earning potential. Adequate
wages for male employment have been found to be important in determining the
success of early marriage.

Adolescent parents are rarely able to support themselves and their children. Optimally,
the family should be involved early. Detailed arrangements must be worked out, and
allowing enough time before delivery makes the crisis less overwhelming. Building on
supplementing family resources and only substituting for families when absolutely
necessary is belived to be the most effective way to help adolescents and their infants.

Women who become parents as teenagers are less likely to complete their education or
to be employed, especially if they are younger than 17 years. Availability of child care,
especially by family members, is crucial factor in the mothers returning to school.

Today, a pregnant woman has three choices, to abort, to have the child place it for
foster care or adoption, or to have the child and raise it. Adolescents parents have the
same choices, but may need to guided through the decision making process.

Nursing management

 Nursing diagnosis

• Ineffective individual coping related to developmental level, situation in which

pregnancy occurs.
• Coping, family potential for growth related to responses to adolescent or mature
pregnant woman.

 Planning ( objectives)
• Recognizes potential for growth in the situation.
• Chooses to obtain pre- natal care.
• Follows through on referrals.
• Seeks support for expressed needs.
• Recognizes fetal needs for a healthy start.

 Nursing interventions

 Nurse must first gain an understanding of the teenager’s situation when she comes
in for the visit. She has chosen to come in, which reflects a big decision for her. She
may be afraid to tell her parents, and the dynamics between them will reveal much
about the situation. She and her family may need a variety of assistance
programmes such as public assistance, or general social service. Unless you learn
this at the First counter, the young woman may be lost to follow – up. Do not wait
for her to volunteer information. It is important to engage her trust, a difficult talk
because an adolescent may not trust easily and may have difficulty, relating to
authority figures. The adolescents fears of confidentiality. A climate of strict
confidentiality is vital in all nursing situations, but is crucial for adolescents. For
these reasons, care is best given in a setting that has providers who specialize in
adolescent health care.

 Respond to the adolescent’s needs rather than to her behaviour. For example when
asked how her mother feels about the pregnancy, a teenager may state “Fine”.
When probed further, she may get angry and respond, “ why do you care perhaps
she is afraid to tell you that she has not hold her mother or that her mother is
insisting that she has an abortion. Respond to the need, do not react. For example
state, lots of pregnant girls of your age have real problems when they tell their
parents or are even afraid to tell them. Let us talk about that. “In this way, she is
given the opportunity to talk to a provider who shows care and understanding.
Because she may not want her parents to know where she is going and is concerned
that you will call them, a teenager may not give correct information. She may not
able to secure the insurance information on her own. Ability to pay or provide
insurance information should also become a barrier to provision of care of

 Identifies the girl’s readiness to use referrals. Ask her to write down sequence of
what has planned together, because tension will prevent her remembering what to
do. Follow through with telephone contact is she skips appointments – if her family
is aware of her condition. If she still doesn’t tell them early in the pregnancy, ask
her for a way to establish contact. Keep gently urging full disclosure of the family,
because it will become evidence in a very short time that she is pregnant. Help her
identify other sources of support in her extended family circle.

 Peer support groups in schools for pregnant adolescents or in clinics are helpful in
preparing teens to cope with the demands and scarifies of parenting. Educational
programmes and literature should be geared to teens. Providers must like working
with the teens and understand their unique problems and responses. The teen’s
father needs to be involved as much as possible. He should be invited to clinic visits
and parenting classes and assisted to see his role in providing physical and
emotional support for his partner and his child.

 Evaluation

The results of comprehensive care for a teenage mother would show some of the
 Stated she learned a great deal about herself and problem solving.
 Followed through on referrals and obtaining assistance.
 Involved father of child in planning and in care of infant.
 Followed guidelines for nutrition and self care during the pregnancy.
 Attended school and parenting classes.

VII. Unregulated Fertility

Unregulated fertility has been recognized to cause many maternal health hazards. These
include abortions, miscarriage, premature deliveries, low birth weight babies,
antepartum haemorrhages etc. All these health hazards are responsible for high
maternal and perinatal mortality. It is being recognized to regulate fertility by
integrated and comprehensive approach in family welfare services which include
effective measures related to reproductive health, child health and family planning.
These services should be accessible and acceptable to all and utilized by all the women,
children and couples throughout the countries.

VIII. Abortions

Twenty percent of maternal mortality is directly related to abortion related causes. The
number of abortions is on the increase because of unwanted pregnancies. Medical
Termination of Pregnancy (MTP) has been legalized under the MTP Act of 1971, under
certain conditions.

By and large abortions are still done by quacks and unauthorized persons in the rural
areas. This is mainly due to lack of access to safe abortion clinics, non- availability of
such clinics, poor financial resources to reach to clinics in urban areas, lack of
information about the availability of safe abortions clinics, lack of privacy and
impersonal atmosphere in the Government run clinics and reluctance of unmarried or
widowed. It is therefore very important to improve the accessibility of MTP services in
primary health centers and create awareness among the people about the availability of
such services.

IX. Complications of Deliveries

In India most of the deliveries take place at home under unhygienical environment and
mostly by untrained dais lacking obstetric skill. Often various health hazards results in
such as perineal tears, cervical damage, prolapse and displacement of uterus, fetal
distress, postpartum hemorrhage etc. Thus it is very important to have properly trained,
skilful and qualified health workers, adequate facilities and well linked referral units
where skillful and efficient emergency care can be given to save mother and baby.

X. Infertility

Infertility is both medical and social problem Even if the fault/defect is in the male
partner, usually it is the woman who is labeled as “Banjh” or “Barren” and is socially
not treated properly by the family and the society. Therefore this problem is to be
considered medically as well as socially. There is need to have empathetic attitude
towards childlessness of woman by society.

XI. Uterine Prolapse

Uterine prolapse is the major problem in women of hilly region. Women working at
construction sites, climbing heights, or digging and ground or climbing 2-3 storey with
heavy weights are predisposed to prolapse uterus. Certain child birth practices such as
pressing hard on the abdomen during labour, pulling the baby etc.lead to prolapse of the
uterus, especially when the mother is weak and malnourished. Uterine prolapse may
cause lot of inconvenience to mother and predispose her to infection. Hence the need
for trained and skillful dais and midwives, improvement of working conditions and
education of women.

XII. Cancer of the Cervix

Cancer of the cervix is very common among Indian women. There are various factors
which contribute to the prevalence of cancer of cervix. These are early marriage and
early pregnancy, multiple child birth, poor hygiene by the male partner, multiple
partners, and repeated infections. Most of these factors are pertaining to sociocultural
aspects of a community and families are imply involving attitudinal change in these
practices to prevent the occurrence of cancer of the cervix.


I. Nutritional deficiency Problems

a) Malnutrition
b) Vitamin Deficiency
c) Iron Deficiency
d) Low Birth Weight
III. Infectious Diseases

a) Tuberculosis
b) Diphtheria
c) Pertussis (Whooping Cough)
d) Tetanus
e) Poliomyelitis
f) Measles
g) Acute Respiratory Infection (ARI)
h) Diarrhoeal Diseases

IV. Problems of Neonates

a) Hyper bilirubinemia
b) Hypothermia
c) Neo-natal tetanus
d) Birth asphyxia
e) Oral thrush
f) sepsis
g) The infected New Born

I. Nutritional deficiency Problems

a) Malnutrition

The primary cause of malnutrition is inadequate and faulty diet. Apart from poverty and
other socio economic factors, environmental factors also play an important role in
aggravating the dietary deficiency diseases. These precipitating factors are the
widespread chronic infections among the poor living under conditions of poor
environmental sanitation and personal hygiene.

Malnutrition continues to be a major health problem in the world today, particularly in

children younger than 5 years of age. Lack of food; however is not always the primary
cause for malnutrition. In many developing and underdeveloped nations, diarrhea is a
major factor. Additional factors are bottle feeding (in poor sanitary conditions),
inadequate knowledge of proper child care practices, parental illiteracy, economic and
political factors, and simply the lack of adequate food for children.

Levels of Malnutrition

India has among the highest levels of child malnutrition in the world, and the
persistence of the problem has led to the formulator of the National Nutrition policy by
the government of India. UNICEF reports auch programmes through strategies promote
BF and to timely introduction of complementary foods, encouraging clean environment
with portable water, and tackling diarrhoeal and other infections.

Reasons for the problems of Malnutrition in India

 Food availability and Related Problems
• Low per capita food availability
• Low purchasing capacity of the masses
• Mal distribution of the available food
• Limited choice of food articles.

 Poverty and Malnutrition

• Ramification of poverty
• Low income of the masses
• Poverty – malnutrition – interaction

 Population Problem and Malnutrition

• Population explosion
• Effects on food availability
• Effects of uncontrolled fertility on nutrition.

 Social Factors Affecting Nutritional Status

• Customs, superstitions and taboos.
• Diet during illness
• Caste and false social status.
• Food tastes and faulty cooking methods.
• Food combinations.
• Influence of industrialization and urbanization and modernization.
• Ignorance and lack of education.
• Alcohol and malnutrition.

Protein Energy Malnutrition

Protein Energy Malnutrition is defined as a range of pathological conditions arising

from coincident lack of varying proportions of protein and calorie, occurring most
frequently in infants and young children and often associated with infection.

-WHO 1973

PEM has been identified since long as a major nutritional problem in India.
Insufficiency of food the so called “food gap” appears to be the chief cause of PEM,
which is a major health problem particularly in the first years of life. Various studies on
dietary intake reveal that the gap intake among children on habitual cereal – pulse
based diet is primarily due to inadequate intake of such diets and not the quality of
protein. Severe form of malnutrition (PEM) leads to two clinical forms of disorders.
They are as follows:-

• Kwashiorkor

Kwashiorkor is the condition of deficiency of protein with an adequate supply of

calories. A diet consisting mainly of starch grains or tubers provides adequate calories
in the form of carbohydrates but an inadequate amount of high quality proteins. The
child with kwashiorkor has thin, wasted extremities and a prominent abdomen from
edema (ascites). The edema often masks the severe muscular atrophy, making the child
appear less debilitated than he or she actually is. The skin is scaly and dry and has areas
of depigmentation.

Diarrhoea commonly occurs from lowered resistance to infection and produces

electrolyte imbalance. Protein deficiency increases the child’s susceptibility to
infection, which eventually results in death.

• Marasmus

Marasmus results from general malnutrition of both calories and protein. It is common
occurrence in underdeveloped countries during the times of the drought, especially in
cultures where adults eat first, the remaining food is often in sufficient in quality and
quantity for the children.

Marasmus is usually a syndrome of physical and emotional deprivation and is not

confined to geographic areas where food supplies are inadequate. Marasmus is
characterized by gradual wasting and atrophy of body tissues, especially of
subcutaneous fat. The child appears to be very old, with flabby and wrinkled skin. The
child is fretful, apathetic, withdrawn and so lethargic

Causes of Protein Energy Malnutrition

a) Nutritional Factors

 Poor caring practices include

 Not feeding the sick children.
 Not providing the adequate complementary feeding.
 Not supporting mothers to breast- feed adequately.
 Non – breastfed.
 Late weaning.
 Inadequate supplementation.
 Failure to feed during illness.
 Failure to increase to caloric intake immediately after the illness.

b) Non – Nutritional Factors

 Due to poverty, mother is not able to provide sufficient food to the child resulting in
under nutrition.
 Non- immunization
 Improper growth monitoring.
 Poor weight gain during adolescence
 Poor environmental and personal hygiene
 Illiteracy
 Large family
 False beliefs
 Failure to utilize Health/Hospital care.
 Low agricultural inputs, marketing, distribution of food and income.
 Poor and inadequate water and sanitation facilities.
 Political Problems
 Inadequate resources include money, material and manpower refers to the poor
quality, expensive and non convenience.
 Lack of health care services and information regarding maternal and child care
practices on basis of inadequate time and resources for taking care of health
diet, emotional and psychological needs of women and children.
 Poor caring practices include
 Poor antenatal care.
 Food taboos during and after pregnancy.
 Inadequate management of sick and malnourished.
 Infestation like ascariasis particularly giardiasis may lead to anorexia.

Signs and Symptoms of different types of PEM

 Kwashiorkor
 Oedema of the face and lower limbs
 Failure to thrive
 Anorexia
 Diarrhoea
 Apathy
 Dermatosis ( hypo and hyper- pigmentation)
 Sparce
 Soft and thin hair
 Angular stomatitis
 Cheilosis
 Anemia

 Marasmus

 Failure to thrive
 Irritability
 Fretfulness and apathy are common
 Diarrhoea is frequent
 Many are hungry but some may be anorexic
 The child is shrunk and there is little or no subcutaneous fat.
 There is often dehydration
 Temperature is subnormal
 Watery diarrhea and acid stools may be present.
 Muscles are weak and atrophic
 Limbs appear as skin and bones

 Marasmic Kwashiorkor
 These children exhibit a mixture of some of the features of both marasmus and

Management of PEM

 Therapeutic Management

 Adequate nutritious diet either by breastfeeding or a proper weaning diet.

 Five grams of protein/ kg body weight/day should be given for the existing weight.
 Rehydration with an oral rehydration solution that also replaces electrolytes.
 Treatment of infections. Medications such as antibiotics and antidiarrheals.
 Health education
 Fats: Forty percent of total calories can be from fat which can be tolerated by
children. Saturated fats such as butter, milk and coconut oil are preferred because
unsaturated fatty acids worsen diarrhea.
 Energy: It is important that there should be enough calories in the diet; otherwise
proteins will be utilized for energy purposes and not for building the tissues.
 Vitamin A should be supplied immediately.
 Anemia: Folic acid should be given

 Nursing Care Management

 Provision of essential physiologic needs, such as protection from infection,

adequate hydration, skin care and restoration of physiologic integrity because
children usually weak and withdrawn, they depend on others for feeding.
 Oral rehydration with an approved oral rehydration solution is commonly used in
cases of PEM where diarrhea and infection are not immediately life threatening.
 Health education concerning the importance of proper nutrition, whether
breastfeeding or bottle feeding, when being weaned to semisolid foods.
 Children with marasmus may suffer from emotional starvation as well; care should
be consistent with care of the child with failure to thrive.

b) Vitamin Deficiency

Vitamin A deficiency

Vitamin A deficiency is a major nutritional problem affecting young children leading to


In India about 5 – 7 percent children suffer annually from eye damage caused by
vitamin A Deficiency, Recent evidence suggests that mild vitamin A deficiency
probably increases morbidity and mortality in children, highlighting the public health
importance of this disorder.

Surveys show, that 1-5 percent of children have clinical signs of vitamin A deficiency.
The prevalence rates are higher in school age children than in younger age groups, but
severe forms of the deficiency resulting in blindness are confined to children below 3

The causes of severe form of vitamin A deficiency like Xerophthalmia arises when the
diet contains practically no whole milk and butter and very limited amounts of fresh
vegetables and fruit so lacks both retinol and carotenes.Xerophthalmia and
keratomalacia both occur in the first year of life amongst artificially fed infants but rare
amongst the breast fed. If the mother’s diet during pregnancy is low in vitamin A, the
child is born with low stores of vitamin A. Protein energy Malnutrition further
aggravates the partial deficiency because absorption and plasma transport of vitamin A
are impaired.Diarrhoea is known to be a precipitating factor in keratomalacia. The
major factors contributing to low availability of vitamin A are lack of awareness of the
importance of consuming vitamin A rich food and poverty leading to limited
accessibility to vitamin A rich food.

The Clinical Forms of the Deficiency will include:-

 Vitamin A Deficiency: - Vitamin A deficiency is seen more commonly in

younger children i.e. between 6 months and 3 years. Vitamin A is indispensable for
normal functioning of the eyes. It helps in the production of retinal pigments which
are required for vision in dim light.

 Conjunctival Xerosis:-.The conjunctiva becomes dry, appears muddy and

wrinkled due to failure to shed the epithelial cells and consequent keratinisation.
The pigmentation gives the conjunctiva a peculiar ‘smoky’ appearance. This
symptom in children under 5 years is more likely to be due to dietary deficiency.

 Night blindness: - This is the first sign of Xerophthalmia. The child is not able
to see in darkness in a dark room or when it gets dark in the late evening. This is
due to lack of retinal pigments.

 Bitot’s spots: - Although Bitot’s spots differ somewhat in size, location and
shape, they have similar appearance. They are accumulations of fomy cheesy
material on the conjunctiva on either side of the cornea, often in association with
other signs of Xerophthalmia, such as blindness. In children under 5 years of age
they are usually due to vitamin A deficiency.
 Corneal Xerosis/ ulceration: - The cornea becomes dry (xerosis). If the
disease is not treated, the xerosis can progress within hours to an ulcer of the
cornea. Corneal Xerosis may progress suddenly and rapidly to keratomalacia.

 Keratomalacia: - In this softening and dissolution of the cornea occurs. If the

process is not stopped by treatment, perforation of the corneal leads to prolapsed of
the iris, extrusion of the lens and infection of the whole eyeball which almost
invariably occurs. The chance of saving any useful vision are slight. Heating results
in scarring of the whole eye and frequently in total blindness.

 Xerophthalmia fundus:-In school children or young adults with prolonged

vitamin A deficiency ophthalmoscopic examination may show lesions appearing as
spots, either white or yellow scattered along the sides of the blood vessels. The
spots may fuse and the lesions are most numerous on the periphery of the fundus
( boral portion) and never appear on the macula (the yellow spot on the retina.

 Corneal scars: - These are white, opaque patches on the cornea as a result of
healing of an older ulcer. Vision may be affected seriously, depending on the size of
the scars.

Management of Vitamin A Deficiency

 Immediately on diagnosis, water soluble 1, 00,000 IU of vitamin A

intramuscularly can be given for corneal xerosis, ulcer, keratomalcia,
xerophthalmia, severe infection and malnutrition.
 Immediately on diagnosis for less severe forms like night blindness, conjunctival
xerosis, Bitot’s spot, oil solutions as palmitate 2, 00,000 IU can be given orally.
 On second day oil solution of 2, 00, 000 IU orally should be given prior to the
discharge from the hospital.

Preventive Measures

 Nutrition and health education should be given to the mothers.

 Pregnant and lactating mothers should be encouraged to consume dark green
leafy vegetables and yellow or orange fruits so that there is sufficient storage in
vitamin A in the liver of new born.
 Mothers should be motivated to feed their children as vitamin A present in the
milk is adequate for 3 to 6 months of infant’s life.
 The weaning diet should be consist of dark green leafy vegetables, yellow or
orange fruits, whole milk, butter, fish and egg.
 National Vitamin A supplementation programme is a more effective alternate
 Other measures:-
 Medical paramedical personnel should be trained to detect and treat
 They should know the importance of giving vitamin A oily solution once in 6
months at the door steps of the beneficiaries as community approach but not at
hospital as clinical approach.
 They should monitor periodically National Vitamin A prophylaxis
 Medical and paramedical personnel should be given nutrition education.
 To prevent vitamin A deficiency intake of green leafy vegetables, yellow
fruits its and vegetables like papaya, mango, pumpkin and carrots should be
promoted for long term measures kitchen garden should be encouraged.

Vitamin D Deficiency

Deficiency of vitamin D causes rickets in young children in the age group of 6 months
to 2 years. It reduces calcifications of bones which affects growth of bones and cause
deformity of bones such as curved legs, pigeon chest, rickety rosary, deformed pelvis.
There is delayed teething, standing and walking. It is no more a serious problem
because of improvement in child health care services, socio-cultural practices, plenty of
available sunshine.

Rickets is preventable by simple methods like exposure of children to sunshine

regularly and administration of vitamin D as prophylaxis periodically. It requires
education of mothers and family members about the importance of exposure of children
to sunshine regularly and to give food rich in vitamin D such as butter, cheese, egg
yolk, liver, fortified food such as milk, vanaspati oil etc. Fish liver oil is very good
source of vitamin D and is available in the form of capsule which can be given under
the direction of medical officer.

Excessive intake of vitamin D is harmful. It may cause loss of appetite, nausea,

vomiting, excessive thirst and drowsiness. There may be renal failure, cardiac
arrythemias and unconsciousness. All this is due to increased level of calcium in the
blood due to increased absorption of calcium. It is very important to recognize the signs
of rickets and refer the child to PHC/ Hospital etc. for therapeutic treatment as early as
possible. The mothers and family members need to be educated about the observations
of signs and reporting in the health center to treat and vitamin d deficiency in children.

c) Iron Deficiency

The iron deficiency causes nutritional anaemia in children. About 50 percent of

children have anaemia. It is due to malnutrition. It usually leads to various others
problems such as general weakness affecting work performance, reduced immunity and
resistance to infections resulting in increased morbidity and mortality. It affects
physical and psychological behaviour of the children. There is decrease in the
concentration of hemoglobin and it is lower than the normal cut off point set up by
WHO, which is 11 g/dl in children 6 months to 6 years. Anaemia is aggravated by
worm infestation and malarial parasites. It may also be caused because of these
infections. Another factor which causes anaemia is folic acid (folate) deficiency.

Anaemia in children can be prevented by preventing and controlling of anaemia in

pregnant and nursing mother’s by improvement in diet and prophylactic treatment by
iron folic acid, and nursing mother’s by improvement of diet of children emphasizing
on breast feeding, proper weaning and supplementation etc, iron folic acid drops/
tablets as prophylaxis, prevention and treatment of worm infestation and malaria.
Fortified salt with iron has been tried out by National Institute of Nutrition to control
anemia in regions with high prevalence of anaemia and is accepted by the government
as a public health approach to prevent anaemia.
Commercially Iron fortified salt is available in the market. The mothers and family
members and community people need to be educated by health workers about all these
preventive measures.

Monitoring of growth and development and anaemia is very important to make an

assessment of malnutrition and anaemia and accordingly take corrective measures.

Role of Nurse

The nurse and the team of health workers can play a very important role in prevention
and control of nutritional problems in children. She needs to:-

 Encourage mothers and family members to monitor growth and development of

their children and to bring them to health centers for regular check up and record
weight, height etc.
 Ensure 100% coverage of administration of vitamin A mega doses to children.
 Help and guide health workers and mothers detect early cases of malnutrition and
other nutritional deficiencies such as vitamin A, iron and vitamin D and refer them
to health centres as the need to be.
 Guide and supervise health workers to participate in nutrition programmes like
Integrated Child Development Scheme, Nutritional Anaemia prophylaxis
programme, midday meal programme and other nutrition supplementary

d) Low Birth Weight

It is major nutritional public health problem in many developing countries. Low birth
weight is a major public health problem in many developing countries. About 30
percent of babies born in India are low birth weight as compared to 4 percent in some
developed countries. In countries when the proportion of low birth weight is high the
majority are suffering from fetal growth retardation.

In countries where the proportion of low birth weight infants is low, most of them are
preterm. Although we don’t know all the causes of low birth weight, maternal
malnutrition and anaemia appear to be significant risk factors in its occurrence. Among
the other causes are of low birth weight are hard physical labour during pregnancy and
illnesses especially are due to infections. Short maternal stature, very young age, high
parity, smoking, class birth intervals are all associated factors. All these factors are

Since the problem is multifactorial, there is no universal solution.

Classification of Low Birth Weight

 Pre- term babies

These are babies born too early before 37 weeks of gestation (less than 259
days).Approximately, 2/3rd of all babies of low birth weight in developed countries are
estimated to be pre-term.

 Small for date ( SFD) Babies

Any infant whose birth weight is below the 10th percentile for the gestational age is
called small for date.SFD babies have a high risk of dying not only during the neonatal
period but during their infancy. Most of them become victims of PEM and infection.
Thus they contribute significantly to poor child survival and raise the rates of infants
and perinatal mortality and pose immediate and long term problems such as mental


 Maternal malnutrition and anaemia

 Physical labour during pregnancy
 Infection
 Short stature
 Very young age
 High parity
 Smoking
 Close birth intervals


The epidemiology is not well understood. In 30 to 505 of cases the cause is unknown.
In the developing countries adverse pre and postnatal development of the child is
associated with 3 interrelated conditions.

 Maternal Malnutrition
 Infections
 Unregulated fertility

The above conditions are due to poor socio economic conditions and environmental
conditions, including scarcity of health and social welfare services.

Besides the above several other risk factors during pregnancy have been identified.
These include:-

 Hard physical labour

 Smoking
 Poor maternal weight gain (less than 8 kg.)
 Maternal height less than 145cm.
 Maternal weight below 40 kg.
 Young maternal age below 20.
 Shorter birth intervals less than 2 years.
 Lack of antenatal care
 Medical conditions such as anemia, high blood pressure and toxaemias.

Management of Low Birth Weight Newborn

One third of all newborns are low birth weight. These new borns are at a higher risk
hypothermia, infections and death. It is possible to save most of these babies with
simple intervention.

 Provide warmth
 Exclusive breast feeding
 Prevent infections
 Teach mother to recognize danger signs seeking help.
• Refusal of feeds
• Increased drowsiness
• Difficult breathing
• Apnoea
• Cold to touch
• Yellow staining of skin
• Convulsions

Prevention of Low Birth Weight Babies

 Increasing Food Intake

• Even during the last trimester, small dietary improvement can result in a
significant improvement in the weight of the infant. It includes wide range of
• Supplementary feeding
• Distribution of iron and folic acids tablets.
• Fortification and enrichment of foods.

 Controlling Infection

Maternal infection should be diagnosed and treated.Malaria, filiria infections, rubella

and syphilitic infection should be prevented.
 Early Detection of Conditions or Problems and treatment for

• Family planning
• Prenatal advice
• Improvement in socio- economic conditions and environmental conditions.
• Availability of health and social services.

II. Infectious Diseases

a) Tuberculosis

It is a communicable disease suffered by all ages. It is a problem in community. It is an

infectious disease caused by mycobacterium tuberculosis. The major source of
infection is infected sputum of persons having tuberculosis who are either not being
treated or not being fully treated. They are source of infection to environment and
people around them. The other source of infection is infected milk of affected animals
e.g. cattles i.e. bovine source. In India. This source of infection is uncommon because
of the practice of boiling of milk before use. The tubercle bacilli primarily affects lungs
and cause pulmonary tuberculosis, but can also affect other organs like intestines,
meninges, bones and joints, hymph glands etc.

Tuberculosis affects all age group. The incidence of infections increases sharply from
infancy to adolescence. One percent of children in the age group under five are infected
with tubercle bacilli as evidenced by tuberculin test. The incidence of infection is more
in male children than in female children. The risk of developing tuberculosis disease is
high in preschool years. The child is not born with immunity. It is acquired as a result
of natural infection or BCG vaccination. Children who are malnourished and living in
dark and dying and over crowed places have poor resistance and have increased
chances of developing tuberculosis.

The disease is transmitted mainly by infected droplets exchaled out by sputum positive
patients especially by coughing, sneezing etc.Tuberculosis is not transmitted by simple
coming in contact with articles used by infected patients. The infection also can enter
by ingestion of unboiled milk and may initiate intestinal tuberculosis.

The incubation period of tuberculosis disease ranges from few weeks to months or
years depending upon the virulence and dose of the tuberculosis bacilli. The disease is
characterized by:
 Toxemic symptoms such as low grade fever especially in the evening, loss of
weight, lethargy.
 Localized symptoms depending upon the site of infection and symptoms can be
persient coughing with or without sputum, hemoptysis if the infection is in the
lungs, pain in chest and dyspnoea if the infection is of pleura, hoarseness of voice if
the infection is in larynx, diarrhea if infection is of intestine. The most common site
of infection is lungs.
The pulmonary tuberculosis diagnosis is conformed by X-ray examination, examination
of sputum and tuberculin test.

Magnitude of the problem

Not a single country succeeded in reaching a point of control i.e. less than 1 percent
tuberculin positive among children of age group 0 to 14. In the world there are about:-

 15 million cases of infectious tuberculosis at present

 2-3 million cases are added every year
 1-2 million people die every year.
 The problem is acute in developing countries. More than ¾ of total cases of
tuberculosis and more than ¾ of total tuberculosis deaths occur in developing

• Prevalence of infections: - It is evinced by tuberculin that testing on an average

50 percent of population are infected at any time.
• Mortality: - One million each year.
• Morbidity survey:-
- Prevalence rate of active cases, 1.8 percent population out 0.4 percent.
- Prevalence rate in towns, cities and villages are same.
- Prevalence rate showed increase with age.

Prevention and Control of Tuberculosis

Tuberculosis is preventable by health promotion and specific protection of children

under five. These measures include:-
 Improving general health and resistance of children by improving living conditions
i.e. clean, well ventilated and open houses, good nutrition, healthful habits, good
environmental sanitation etc.
 Specific protection by BCG.
 Immunization of children as discussed earlier, health education of parents and other
family members regarding health promotion and specific protection of children and
other members in the family.
 In order to control further spread of infection it is very important to find out cases,
conform diagnosis and initiate and complete the course of treatment not only to
break the chain of transmission of disease but also to cure the disease.
 It is therefore necessary for all health workers to help identify tuberculosis cases on
the basis of presumptive clinical symptoms.
 Anyone having low grade temperature especially in the evening, loss of weight,
general debility, cough or without sputum for a month or more should be referred to
PHC/CHC/Chest clinic.
 They should follow up cases to continue regular treatment when put on anti-
tuberculosis treatment.
 They should also educate the parents, family members and community at large
regarding recognition of signs and symptoms and availing of medical facilities
available for early diagnosis and treatment, regular and uninterrupted treatment
which is prescribed.
 Health supervisor/ Community health nurse must supervise and guide health
workers in carrying these responsibilities.

b) Diphtheria

Diphtheria is very serious disease because if it is not treated immediately it leads to

high mortality. It is caused by corynebacterium diphtheriae.The source of infection are
mild and missed cases and convalescent and healthy carriers. The persons remain
ineffective usually for two weeks to four weeks if no treatment is given. The rare cases
become chronic carriers. They may remain ineffective for 6 months or more.

Diphtheria is transmitted by direct droplet and direct airborne. It is also transmitted by

indirectly by inhaling contamitted dust particles. Transmission can also be transmitted
by using contamitted articles used by the patient but only for a short period.

The incidences of diphtheria are highest in the age group of 1-3 years. The incidences
are very low in infants below six months of age because of immunity obtained from
mother. By 3-5 years of age, most of the children (70-99%) acquire active immunity
because of in apparent infection. Therefore incidences are low from 3-5 years of age
and thereafter very rare. The incidence of diphtheria occurs throughout the year but
more during winter season. The average incubation period of disease is 3-4 days; it
ranges from 2-6 days.

Magnitude of the problem

Diphtheria is a worldwide problem in most developed countries owing to routine

children vaccination. In developed countries like England and Wales there were only 5
cases of diphtheria in 1980 as against 46,281 cases, seen among nonimmunised
children. In India, it is an endemic disease. The available data indicate a declining trend
of diphtheria in the ID Hospitals, Mubai, Chenni, Delhi and Bangalore. This may be
due to increasing coverage of the child population by immunization. Fatality rate on an
average is about 10 percent which has changed little in the past 50 years in untreated
cases and about 5 percent in treated cases.

Prevention and Control

 Diphtheria is preventable by specific protection by immunization of all children

with diphtheria toxoid.
 The children should be immunized as early as possible so as to protect them before
they lose their natural immunity.
 The immunization of diphtheria is done by combined or mixed vaccines which
include diphtheria, pertusis and tetanus vaccine (DPT).
 It is very important that health workers put in all the efforts to immunize all the
children. They educate parents and family members about the same.
 In order to control the infection it is necessary to recognize the cases clinically and
refer them immediately to CHC/ hospital without loss of time to be able to start
treatment immediately.
 The treatment is started without waiting for laboratory conformation. The usual
treatment is the administration of antidiphtheric serum. The dosage varies from
20000 to 100,000 units depending upon the severity of disease. Sensitivity is done
before administering. in addition to antitoxin, antibiotics either procain penicillin or
erythromycin are also given for 10 to 12 days.
 These children are must be isolated from other children in the family till they are
transferred to CHC/ hospital. These affected children should be kept under
 If they have already been immunized completely within two years time, no further
immunization is necessary. Only throat swab culture should be taken for which
necessary action should be taken.
 If complete immunization was done within more than two years time, only a
booster dose of diphtheria toxoid need to be given. A throat swab for culture also
needs to be taken and necessary action must be taken for the same.
 Those children who are not immunized are put on prophylactic treatment and are
placed under medical supervision. They must be referred to CHC/PHC. Repeated
culture of throat swabs for these children is necessary to conform their infective
 Proper disinfection of clothes, formities and sputum should be done.
 The community health nurses and health supervisors must see that these actions are
properly implemented by health workers and family members. They need to
educated, trained and supervised to ensure effective prevention and control of
diphtheria in children.

c) Pertussis (Whooping Cough)

Whooping cough is an acute infectious disease causing complications and high

mortality in many parts of the world. It is caused by Bordetella Pertussis.The source of
infection is infected human being. These may be typical, mild or missed cases. The
infection is present in nasopharyngeal and bronchial secretions. The disease is most
communicable during the later part of incubation period and inflammatory stage
(catarrhal stage). The period of infectivity usually extends from one week after
exposure to infection to about 3 weeks after the onset of typical whooping cough.

The infection is transmitted directly by droplets of infected persons. It can also be

transmitted by use of freshly contamitted articles. The period of incubation usually
ranges from 7 – 14 days, but in any case not more than 21 days.

The prevalence of disease is in all the countries. But the incidence of whooping cough
is on the decline. Disease is more common in tempo rate climate and during winter and
spring seasons. The incidence of whooping cough is highest in under five children.
Infants are susceptible to infection from birth because they do not get any immunity
from birth. Incidence is more in female children than in male children. Prevalence is
more in children living in overcrowded homes and slums. The disease affects trachea,
bronchi and bronchioles.

Magnitude of the problem

Whooping cough occurs in all countries since the beginning of this century. There has
been a marked and continuous drop in details from whooping cough. Pertussis is still a
clinically serious illness, with high mortality and complication rates. Whooping cough
occurs endemically and epidemically in tropical countries. Since the reporting of
whooping cough is inadequate, reliable information about the incidence of this disease
is lacking in most countries. About 10 percent of all whooping cough cases and about
half of the death occur in children under one year.

Prevention and Control

 The occurrences of pertussis can be prevented by immunization of children which is

done in combinations with diphtheria and tetanus.
 Control of pertussis can be done by early recognition of disease which can be done
by microscopic examination of secretions from nose and throat during catarrhal and
early paroxysms stage provided this facility is available.
 The child either having or suspected having whooping cough should be isolated as
far as possible. The infants and young children should be kept away from cases.
These children must be referred to PHC/ CHC so that medical care is given and
treatment is started as soon as possible.
 The usual treatment is administration of antibiotic to control secondary infections.
Usually erythromycin is given for ten days, adjusted according to child’s weight
(30-40 mg/kg in 4 divided doses). Erythromycin is also given to contacts for 10
days as a prophylactic measure to prevent settling of infection in them
 Clothes, fomities should be disinfected and discarded properly to prevent spread of
 Health workers must be trained to implement these measures. Health workers must
educate parents and family members for immunization of their children, early
recognition of disease, treatment and care of their children, prevention of spread of
infection to other children and their care etc.
 Community health nurse must provide adequate supervision, guidance for the same.
She must educate and train health workers for prevention and control of whooping
cough in children.

d) Tetanus

Tetanus is an acute and highly fatal disease. It is caused by clostridium tetani which is a
spore forming bacteria. The spores are highly resistant and can survive for years in the
soil and dust. They can be best destroyed by steam under pressure at 120 degree for 20
minutes. The organisms are found in the intestine of herbivorous animals such as cattle,
horses, goats and sheep and are excreted in the faeces of these animals. The organisms
form spores which get mixed up with soil and dust. The spores get blown up to distant
places anywhere.
Infections enter the body through injury which gets contaminated. The injury may be
small like pin prick, abrasion or big and punctured wound. The injury may be attained
by a fall, animal bite, surgery etc. Infections can take place by many other ways for
example during delivery and after delivery, while cutting the cord and thereafter by
improper care of the cord, extraction of teeth, injections, tattooing, gangrenous foot,
otitis media etc.
Tissue damage, dirty and anaerobic conditions predispose to tetanus. Tetanus can occur
at all ages. But the incidence is high in childhood. The new born baby can get tetanus
when the umbilical is cut with unclean blade and when the cord is not cared properly.
The tetanus occurring in the new born baby is known as “Neo-natal” tetanus. The
incidence occurs more in males than in females and also more in rural areas than in
urban areas mainly due to use of cowdung on muddy floors and walls and use of
compost. The incidence of tetanus is associated with unhygienic environmental
conditions and unfavorable sociocultural practices. The spores of bacilli are
continuously discharged with faeces of animals in the soil; manure is used in the
gardens and for agriculture. Cuts and injuries do happen every now and then.
Unhealthy and aseptic practices are carried by many people. All these conditions
predispose to infection.

The usual average incubation period ranges from 6-10 days. But it can be very short (1
days) or very long (several months) depending upon the germination of spores and
production of exotoxin.The mortality rate is very high (40-80%). It is highest in
neonatal tetanus (80-90%).

Magnitude of the problem

It is one of the leading causes of infant mortality. 5 to 10 percent of neonatal deaths in

Calcutta were due to tetanus. Geographical variation in incidence has been related to
climate, organic content of soil, amount of agricultural activity and prevalence of local
customs tending to promote infection. The incidence of the disease in Calcutta during
1971 was 24/ 100,000 population.

Prevention and Control

 Tetanus can be prevented by active immunization by tetanus toxoid of all antenatal

mothers and children according to national immunization schedule.
 The immunization is done by combined vaccine in case of children for the first
three doses and first booster dose as DPT and for 2nd booster dose as Dt.The
immunization of mothers and 3rd booster dose to children is done by monovalent
vaccine i.e. T.T Active Immunization of mothers during pregnancy also helps in
preventing neonatal tetanus as immunity gets transferred to baby.
 T.T immunization is done soon after road injury especially if T.T immunizations
are not done with in 5 years.
 In addition, all wounds and injuries should be thoroughly cleaned and covered with
sterilized dressing aseptically.
 Active immunization is done by 5ml of TT injection simultaneously which is
repeated after six weeks followed by a booster dose after one year to get long
lasting effects.
 It is essential for health workers to encourage and motivate parents, family
members and community at large for immunization of all pregnant women and
children against tetanus, to educate them regarding proper care of any kind of
 They must supervise and guide TBAs to conduct safe deliveries using “five cleans”
and ensure support for the same. They must educate community people about the
seriousness, mode of transmission and prevention of tetanus. The community health
nurse needs to help, guide and support health workers in carrying these functions.

e) Poliomyelitis

Poliomyelitis is a crippling disease as it causes lameness. It is caused by virus. The

virus is found only in human beings. The source of infections is human faeces and or
pharyngeal secretions of an infected person. The disease is most communicable 7 to 10
each before and after the onset of symptoms. The organisms from the infected persons
are excreted with faeces usually for 2-3 weeks but the period may prolong for 3 to 4

The main channel for spread of infection is fecal- oral channel. The infection is spread
directly by contaminated hands and indirectly by using contaminated water, milk, food
and by using contaminated articles. The infection is also spread by infected droplets
which are exhaled out by coughing, sneezing, talking when the virus is present in the
throat during acute phase of the disease.

The poliomyelitis was wide spread in the world. But by 1990s it has virtually
disappeared in the developed countries. In India there has been number of epidemics of
poliomyelitis in different states. At present there is almost eradication status of disease
by high level of routine immunization, by pulse polio immunization and by effective

The disease occurs in children under five years of age, but mostly between 6 months
and 3 years. It occurs three times more in male children than in female children. Over
crowding and poor sanitation provide increased opportunities for infection.

The incubation period ranges from 3 to 35 days but usually the clinical signs appear 7
to 14 days after the infections.

Most of the cases (90-94%) who are exposed to infection and get infection do not show
clinical signs and symptoms. They are sub clinical or said to have in apparent infection.
They can be recognized only by laboratory investigations.

Prevention and Control

 Poliomyelitis is prevented and eradicated by immunization of all infants by 6

months of age. There are two types of vaccines which are used. These are
inactivated polio vaccine (IPV) and Oral Polio Vaccine (OPV). Three doses of OPV
at an interval of one month each are recommended by WHO programme of
immunization and the National Programme of Immunization in India. The first dose
is to be given at the age of six weeks.
 The immunization must be completed by six months; one booster dose is to be
given at 12-18 months later. This will help prevent occurrence of polio between the
ages of 6 months and 3 years.
 The vaccine is administered by dropper by gently squeezing the cheeks or by
pinching the nose of the child to open the mouth and let the vaccine drop on the
 The health worker must educate parents and family members about the importance
of polio immunization and motivate them for the same.
 Paralytic polio can be recognized on the basis of clinical manifestation. The parents
and family members need to know so that they can avail medical, nursing and
physiotherapy services as early as possible to minimize or prevent crippling. Health
workers must be educated and trained for recognition of polio cases so that they can
help in early treatment and care of children with paralytic poliomyelitis.
 It is very important to do active surveillance of acute flaccid paralysis, including
causes other than poliomyelitis. Each and every case of acute flaccid paralysis must
be reported immediately to the chief medical officer with the following details:-
• Name, age and sex of the patient.
• Father’s name and complete address.
• Vaccination status
• Date of onset of paralysis and date of reporting.
• Clinical diagnosis
• Doctor’s name, address and phone number.

 Arrangement for stool examination should be done for isolation of poliovirus for
suspected cases of polio for rapid case investigation.
 The nurse/ health supervisor must help and guide health workers in prevention and
control of poliomyelitis in children in the community.

f) Measles

Measles is a worldwide endemic disease. It occurs more in the winter months from
December to April in the form of endemic in 2-3 years time. It is an acute and very
infectious disease. The disease is caused by virus. Secretions from nose, throat and
respiratory tract of children with measles are the source of infection. These secretions
are infective 4 days before appearance and 5 days after the appearance of rashes. The
disease is highly infectious during this period. It can be transmitted to other children by
direct contact by droplet infection. The children under 7 years are susceptible to
measles infection. But children in the age group of 6 months to 3 years are the most
susceptible. It is rare in under five months old infants because of antibodies received
from mother during pregnancy. Both male and female children are equally susceptible
to measles infection. An attack of measles gives life lasting immunity to the child in
general. Second attack occurs rarely. The severity of the disease causing high mortality
is more in malnourished children than in healthy and well nourished children.

The average incubation period 10 days but it ranges from 8 to 16 days. The common
complications which can occur during measles include broncho-pneumonia, diarrhea,
otitis media, encephalitis etc.depending upon the nutritional status and general body
resistance of the child. Mortality is very high in malnourished children. Mortality can
occur during acute phase and after the attack within nine months.

Prevention and Control

 The occurrence of measles can be prevented completely by achieving an
immunization level of 95 percent and by continuing immunization of children of
successive generation.
 As per National Immunization Programme, immunization must be done at the age
of 9 months by giving a single dose of 0.5ml of live attenuated vaccine
 Immunity develops after 11 to 12 days of vaccination and gives 95 percent
 During the season when measles occurs children suspected of having measles
should be isolated as far as possible before the appearance of rashes, and 7 days
after the appearance of rashes.
 Other children should not be allowed to come in contact with children having
 Prompt immunization of children from the age of 5 months onward at the beginning
of an endemic is essential to limit the spread.
 Health education of people at large to educate about prevention and control of
 The child with measles must be under the medical supervision, given good nursing
care, given good nourishing diet to prevent complications and promote quick
 The health workers must immunize all children following all precautions, to
maintain cold chain, safety of vaccine and aseptic techniques.
 They must educate and motivate parents and family members and community at
large about the immunization for measles.
 They must also help family in taking care of the child with measles, in preventing
infection to other children and in taking the child to PHC/CHC to avail medical and
nursing service. They must follow the children in post measles stage to help
mothers to take care of the children’s nutrition and monitor their growth and
development and refer in case there is any problem for timely actions.
 The community health nurse/ health supervisor must help and guide health workers
in prevention and control of measles in children in their community.
 They must actively participate in prevention and control of measles when required
and felt necessary. They must educate and train health workers and community
people for the same.

g) Acute Respiratory Infection (ARI)

Acute respiratory infection causes inflammation of respiratory tract from nose to deep
down in the lungs. Most of the time infection is mild characterized by cough and cold
but 10-25 percent of children in the developing countries have pneumonia which
frequently causes death. Death rates are higher in young infants and malnourished
children. On an average a child gets 5-8 episodes of ARIs per annum.In India ARIs is
one of the leading causes of death.
Acute respiratory infections are caused by variety of bacterias and viruses. At a time
there can be more than one infection. In developing countries measles and whooping
cough are the important causes of ARIs. The risk factors which predispose for ARIs
infections include climatic conditions, poor nutrition, low birth weight, crowding,
environment pollution etc.Infection is air-born and it is transmitted by direct (person to
person) contact. The clinical signs and symptoms includes running nose, sore throat,
cough, fast breathing, difficulty in breathing, fever, noisy breathing, wheeze chest.

Classification of ARIs

According to National Child survival and safe motherhood programme ARIs is

classified under:-

 The young infants ( age less than 2 months)

• Very severe disease
• Severe pneumonia
• No pneumonia
 Child aged 2 months up to 5 years
• Very severe disease
• Severe pneumonia
• Pneumonia
• No pneumonia but cough and cold

Management of ARIs

 First and foremost, it is very important to prevent the occurrence of ARIs.This can
be done by complete immunization of children according to the immunization
schedule. Also vitamin A should be administered to children under 3 years of age.
 Mother and family members should be educated and motivated for immunization of
their children, avoidance of children’s exposure to chills, providing dust free and
smoke free environment and ensuring adequate and nutritious diet.
 The mothers and family members must trained to recognize early signs of
pneumonia and to report about the signs immediately.
 Once the child with cough and cold visits the health center, through assessment of
the child’s condition is done by asking questions, making observations and
examination of the child. The question should be asked to find out whether the child
has cough and for how long, whether the child is able to drink or not, if the baby is
a young infant whether the baby has stopped feeding well, whether the child has
fever and for how long, whether the child had any convulsions, short periods of not
breathing or turning blue.

After taking history, observation and examination of the following signs should be

 Breathing
It is very important to count respiratory rate of the child. The child should be resting
while counting respiratory rate. The lower half of the chest or back should be exposed
well to watch the respiratory movements. The counting should be done for one minute.
Fast breathing is considered when a child of:

• Less than two months has 60 or more breaths per minute.

• 2 months – 12 months has 50 or more breaths per minute.
• 1 year- 5 years has 40 or more breaths per minute.

 Chest in drawing

For young infants, the mild chest indrawing is normal because their chest wall is soft.
However, severe chest indrawing (very deep and easy to see) may be a sign of
pneumonia. When in doubt, reposition the child so that he is lying flat on mother’s lap.
If the chest indrawning is still not clearly visible, it is assumed that the child does not
have chest indrawing. Chest in – drawing is significant only when it is present all the
time and definitely visible.

 Noisy breathing ( Stridor)

Look and listen for harsh noise when the child breaths in.
Wheeze chest: - Look for any sign of difficulty in breathing and listen to whistling
sound which might be there while breathing out.
Abnormally sleep or difficult to wake: - See if the child is drowsy for most of the
time and does not wake up.

From practical point of view fast breathing, chest indrawing and inability to drink are
considered reliable signs. Other signs which signify very severe disease or severe
pneumonia are:-
• Child stopped feeding.
• Child is too sleepy (drowsy) or difficult to wake.
• Stridor when the child is calm.
• Wheezing chest.
• Convulsions
• Severe under nutrition
• A very young infant who has fever or feels cold to touch.

Classification and Management of ARI

Child age < 2 months (Young Infants)

Check for the following signs

Stopped feeding well, convulsions, abnormally sleepy or difficult to wake, stridor in calm infant,
wheezing in calm infant, fever or low body temperature
Identify it as: Severe Pneumonia, if: No Pneumonia If

Very severe disease, if most • Fast breathing. • No fast breathing. ( less than
of these signs are present. (60 per minute or more) 60/min)
• Severe chest indrawing. • No severe chest indrawing.
Take the following actions: • Refer urgently to hospital Advise mother to give home
• Refer urgently to • Give first dose of care.
Hospital. antibiotic. • Keep baby warm
• Give first dose of • Keep the baby warm • Breast feed frequently
Antibiotic. during transfer. • Clear nose, if it interferes
• Keep the baby warm • Breast feed frequently with feeding.
during transfer. during transfer. Advise the mother to return if:
• Breast feed frequently • If referral is not possible • Illness worsens
during transfer. treat with antibiotic and • Breathing is difficult
follow closely. • Feeding becomes a problem.

Child age 2 months up to 5 years

Check for the following signs

Drowsiness Chest in drawing
Difficulty in waking up Stridor in calm child
Convulsion Wheezing in calm child
Inability to drink Severe under nutrition
Fast breathing
Identify it as : Severe Pneumonia, Pneumonia if there No pneumonia if there
if there is chest is fast breathing is no fast breathing, no
Very severe disease indrawing. chest in drawing.
if most of the signs • Advise mother to
presents • Refer to hospital give home care. • If cough persists for
immediately. • Give more than 30 days,
Take the following • Give one dose of cotrimoxazole. refer for assessment.
actions cotrimoxazole • Treat fever, if • Assess and treat other
• Refer to the • Treat fever if any. present. problems.
hospital • If referral is not • Advice mother to • Advice mother to
immediately. possible, treat return with child give care.
• Give one dose of with in 2 days or early • Treat fever, if
cotrimoxazole. cotrimoxazole condition if gets present.
• Treat fevere if and follow worse for
any. closely. assessment.

Reassess the Child in 2 Days

Worse: The same as above Improving:

• Not able to drink. Has chest in • Improved breathing.

drawing. • Less fever
• Have other danger signs. • Eating better
• Refer immediately to hospital • Review antibiotic • Finish 5 days of

h) Diarrhoeal Disease

Diarrhoea is an acute or chronic intestinal disturbance characterized by increased

frequency, or volume of lower movement. It has been defined as passing of more than
three loose motions in a day or 24 hours. It has been further classified an acute diarrhea
i.e. lasting for less than 21 days, and chronic diarrhea, lasting beyond 21 days, while
chronic diarrhea is responsible for the serious problem of malnutrition, acute diarrhea is
responsible for death due to dehydration.

Diarrhoea is caused by variety of bacteria such as E.Coli, Shigella, vibrio cholera and
salmonella, Rotavirus, protozoans. The organisms are found in the intestines of both
human beings and animals. The infection is transmitted through fecal-oral route, either
water borne, food borne or by direct transmission through contamitted hands, fingers,
nails and formites.

Magnitude of Problem

According to certain small studies conducted in India it is assumed as 100 million

children (14.1 percent of the total population) suffer from 300 million episodes of
diarrhea per year. Ten percent or 30 million develop dehydration and one percent or 3
million may face death.Diarrhoea disease is a major cause of death and disease among
children under five years. A child on average suffers 2 to 3 attacks of diarrhea every

Mode of transmission

Most of the enteric pathogens are transmitted primarily by the fecal- oral route, which
may be water-borne, food borne or direct contact.

 Contaminated Water

It is transmitted through drinking water of contaminated water from the contaminated

water sources, which have been in contact with human excreta.

 Contaminated Food

Ingestion of contaminated food and drink has been associated with diarrhoeal diseases.
Bottle feeding could be a significant risk factor for infants.

 Direct Contact
Person to person transmission readily takes place through contaminated fingers while
carelessly handling excreta and vomit of patients and contaminated linen.

Clinical Manifestation

Clinical features of the diarrhea depend upon the severity of the disease.

 Dehydration
• Little to extreme loss of subcutaneous fat.
• Upto 50 percent total body weight loss.
• Urinary output decreases.
• Poor skin turgor dry skin and dry mouth.
• Sunken fontanelles and eyes.
• High pulse

 Behavioral Changes
• Irritability
• Restlessness
• Weakness
• Pallor
• Stupor and convulsions

 Respiration
• Rapid,i.e Hyperpnoea

 Stools
• Loose and fluid in consistency
• Greenish or yellow green in colour
• May contain mucus or blood.

 Vomiting
• Mild and intermittent to severe vomiting

 Anorexia

Preventive Measures of Diarrhoea

 Promotion of environmental sanitation which includes safe water supply, safe

disposal of excreta, having sanitary latrines, avoidance of defecations by children
here and there, protection of food from contamination.
 Washing of hands before handling and preparing food, before eating and feeding
the child, after defecation and cleaning the baby after defecation each time.
 Toilet training and training of health habits to children.
 Immunization of children against measles can prevent 25 percent of diarrhoeal
deaths due to measles.
 Promotion of exclusive breast feeding for 6 months, introduction of supplemental
food items after six months, full and nutritious diet by one year onwards.
 Prevention of low birth weights by improving prenatal and postnatal nutrition.
 Education and training of health workers.

III. Problems of Neonates

a) Hyper bilirubinemia

This condition refers to excessive presence of bilirubin in the blood. It is indicated as

pallor of the skin and eyes. It is either due to physiological jaundice, RH or ABO
incompatibility. Physiological jaundice usually disappears with in days with
phototherapy. Jaundice due to RH incompatibility occurs due to 24 hours and requires
blood transfusion.

b) Hypothermia

The new born baby may go into hypothermia within one hour of birth, with the
temperature (axillary) falling below 36.5 degree c (97.7 degree F). This happens if
proper precautions are not taken to prevent chilling of the baby. The woman in the
family and birth attendant should be made aware about drying the baby after birth,
providing skin to skin contact with the mother and initiating breast feeding within an
hour of birth. Hypothermia is harmful to the new born, increasing the risk of the
morbidity and mortality.

c) Neo-natal tetanus

Neo- Natal tetanus is the common problem. It is usually due to sepsis caused by
uncleaned delivery and cord care. It is still quite common in the developing world.
According to the WHO estimates there is considerable decline in the incidence of NNT
and mortality due to NNT in the world. The greast decline in NNT is observed in south
East Asian countries. According to surveillance report in India, there has been decline
in the reported cases from 31,844 in 1987 to 4811 in 1999 (decline by 84.9%). The
decline is the mainly due to significant increase in immunization coverage of antenatal
mothers in the world and in India. Considering the preventable nature of NNT, Who
has resolved to eliminate NNT by aiming to reduce the incidence to less than 1 case per
1000 live births. The same goal is accepted by the Indian Government. The following
actions are implemented.

 100 percent coverage of pregnant women with two doses of Tetanus Toxoid (T.T.)
 100 percent clean deliveries.
 Surveillance of neonatal deaths and investigations of tetanus cases and deaths in the
 Use of information, education and communication strategies to promote 5 cleans
i.e. clean, surface, clean hands, clean surroundings, clean blade/ scissors, clean tie
and clean cord.

d) Birth asphyxia

Birth asphyxia is characterized by absent or depressed breathing at birth. In developing

countries 3 percent of all new-born babies (3.6 million) develop moderate or severe
asphyxia. Of these, about 84000 die and approximately the same number of them
develop severe epilepsy and mental retardation. Difficulty in initial breathing is due to
variety of reasons such as prolonged or obstructed labour,prematurity, infection etc.
often it can be anticipated. The following actions should be taken to reduce neonatal
deaths due to birth asphyxia.

 To keep ready the necessary equipments for management of birth asphyxia.

 Clearing of air passage immediately as the child is born.
 Ventilating with mask or bag and mask.
 Cardiac massage when brady- cardia persists.
 Mouth to mouth breathing when necessary.
 Training of health workers including TBAs in the assessment and management of
birth asphyxia.

e) Oral thrush

Oral thrush is characterized by white patches in the mouth. It is caused by candida

albicans which is usually present in the vagina of some women. It is very important to
maintain personal hygiene to prevent this infection.

f) Sepsis

The new born baby is very susceptible to infection. Within few hours of birth,
staphylococcal may generate colonies on the baby’s skin and in the nasal passages and
may cause infection of the umbilical cord, skin fold such as axilla and groin, nostrils
etc. The baby should be protected from being exposed to infection. Any person having
any infection such as upper respiratory infection, diarrhea, skin infection shouldn’t be
allowed to come in contact with baby. Personal hygiene and general cleanliness need to
be maintained.

g) The infected New Born

The child may be born with infection present in the mother. The child may attain this
infection either through transplacental circulations or/ and during the course of
pregnancy and delivery. The various infections which the child can have include
tetanus, syphilis, gonorrhoea, hepatitis B and C virus, and HIV. Tetanus can be
prevented by two doses of T.T.immunization of all pregnant women and by observing
five cleans for all deliveries. Congenital syphilis and gonorrhoea can be prevented by
early recognition of these diseases among the couples and their treatment and by
observing clean and safe delivery practices during and after. But usually these diseases
are not reported and treated properly. It is also not possible to recognize the congenital
syphilis because clinical signs do not occur soon after birth. But treatment can be
started in doubtful babies and especially in those cases where monitoring is not

New born can be infected with hepatitis if the mother is chronic carrier of hepatitis B
virus. Transmissions occur through blood and genital secretions. Therefore the newborn
contract infection during the immediate perinatal period. If the child gets the infection,
he or she becomes carrier and develops chronic hepatitis, cirrhosis or primary cancer of
the liver during adulthood.Perinatal transmission of the hepatitis B can be prevented by
combined seroprophylaxis (2ml of anti HBs gamaglobin) combined with anti- hepatitis
B vaccination within 12 hours of birth. The vaccination must be repeated at 1 and 2
months and then at one year of age. Though it is found to be effective but practically it
has not been found feasible firstly because it is difficult to identify and detect mothers
who are carriers of this infection and secondly because of low cost involved.

New born may also be infected with HIV if the mother is HIV positive. About 30
percent of the babies born to HIV positive mothers get infected with HIV. Like in
hepatic B, transmission occurs through blood and genitals secretions. The risk
transmission depends upon the severity of infection in mother. The possibility of
transmission of infection through breast milk is also there. Therefore whether to breast
feed the baby or not, it is to be considered for the survival of child especially for
socioeconomic ally poor and underdeveloped people. BCG vaccination is contracted in
these children and shouldn’t be given unless confirmed otherwise. Unlike hepatitis B,
no preventative treatment so far is available for the new born.

 Maternal Age

As maternal age advances, so does the rate of aneuploidy. The result is increased rates
of pregnancy loss and birth of infants with chromosomal anomalies. Most women and
men are aware that advanced maternal age (older than 35 years) may affect a pregnancy
adversely. This awareness is the direct outcome of the adoption of practice standards
that obligate obstetricicians, gynecologists, and women’s health nurses to appropriately
disseminate this information and the considerable media exposure about this issue
through public service campaigns, news programs, and storylines in popular

Conversely, the general public health care providers are less aware that advanced
paternal age (older than 45 years at conception) unfavourably affects fetal growth and

People of advanced reproductive age require information about the possible outcomes
for a child conceived with their genetic gametes. The nurse should offer education and
counseling using incidence tables for chromosomes anomalies associated with
advanced maternal age and review characteristics of disorders that may occur through
paternal transmission of spontaneous new mutation as a result of advanced paternal

 Sexuality Factor

Both the client and her partner may express concerns about sexuality and intercourse
during pregnancy. Although there is no reason why the healthy woman need abstain
from intercourse or orgasm during pregnancy, some sources suggest that women should
avoid coitus and orgasm in the last 4 weeks of pregnancy. Regardless of suggestions
studies have found that the frequency of coitus decreases as pregnancy progresses.

Intercourse or orgasm is contraindicated in cases of known placenta previa, or ruptured


Nipple stimulation, vaginal penetration, or orgasm may cause uterine contractions

secondary to the release of prostaglanins and oxytocin. Therefore women who are
predisposed to preterm labour or threatened abortion may choose to avoid intercourse.

Development of sexuality is an important part of each person’s psychosocial identity,

integrated sense of self, reproductive capacity and ability to fulfill role functions in
 Nutrition

During pregnancy changes must occur to ensure that gestation progresses and both
mother and fetus remain healthy. These changes involve synthesis of new tissues and
hormonal variations to regulate essential processes. Nutrition has critical role in
pregnancy outcomes maternal nutritional status at conception and throughout gestation
greatly influences not only the mother’s health but also that of the fetus. Although solid
nutrition cannot guarantee a healthy pregnancy, it can certainly minimize problems.

Adequate folate status, which helps prevent neural tube defects, and control of blood
glucose level, which improves the abilities to conceive and to give birth to a healthy

Women require proper nutrition and normal endocrine function for normal fetal
development. Women specially require additional vitamins and minerals to support
fetal growth and development. Especially important is additional folic acid to reduce
the risk for neural tube defects.

 Environmental Factor

Environmental factor also influence on maternal and child health. So we have to know
about the environment in which the woman and partner reside and work.

Men exposed to toxic substances such as heat, radiation, viruses, bacteria, alcohol, and
prescription and recreational drugs are more likely to have decreased morphologically
and genetically normal sperm in a single ejaculate. This results in reproductive failure
preconception and post fertilization.

Women exposed to similar toxic agents experience diminished ovarian reserver, poor
endometrial lining development, and abnormal fetal development. Likewise, chronic
and acute diseses decrease fecundity and increase fetal wastage.

 Psychological Factor

Virtually all culture emphasizes the importance of maintaining a psychological and

agreeable environment for a pregnant woman. An absence of stress is important in
ensuring a successful outcome for the mother and baby. Harmony with other people
must be fostered, and visits from extended family members may be required to
demonstrate pleasant and no controversial relationships. If discord exists in a
relationship, it is usually dealt with in culturally prescribed ways.

Certain environmental factors such as emotional stress, anxiety, fears, frustrations,

broken homes, poverty and many others can lead to mental illness. The psychosocial
environment at home or school is an essential factor for health. Children exposed to
happy and healthy homes make them physically and mentally healthy. Other factors
affecting the health status of children include community and social support measures
Pregnancy is the gestational process. Comprising the growth and development with a
woman of a new individual from conception through the embryonic and fetal periods to
birthing environment. However, an increasing amount of social science and midwifery
research has explored the issue of social support for child bearing women and the role
that the maternity services might play in offering or facilitating rather than
undetermining such support to women.

Support must be individualized and tailored to the woman’s changing needs during
labour. Emotional support includes physical presence and words of affirmation
reassurance, encouragement and praise. Comfort measures are any hands on activity
aim at decreasing the physical discomfort (pain, hunger and thirst) of labour.
Information and advice ensure that the woman is aware of what is happening and of
techniques that may help her to cope.

 Ethnic and Socio Cultural Factor

Culture and family must be viewed simultaneously for, regardless of the family type, it
remains the basic unit of society and influences human development over the life span.
The older adults in these families often have significant roles in health and child care,
household maintenance, and decision making. Multiple care takers are available to help
with childrearing and discipline.

Socialization is an early family function. Socialization includes all the learning

experiences of early life. Home remedies and folk care practices for prevention of
illness, maintenance of health, and curative purposes remain primary sources for most
families, regardless of ethnic and cultural backgrounds.

Communication patterns are influenced by a family’s culture. Religious beliefs and

practices are part of cultural and familial heritage and influence health care
behaviours.Within the neighborhood and community, health families tend to associate
freely with community groups and institutions to identify resources and receive
services as needed by them. The ability of the healthy family to seek help through
contact with others appears related in part to the family’s perception of itself as a part
of a whole and to their successful dealings with the larger community in meeting
physical, psychologic, and social requirements.

The value of the children varies greatly, depending on the meaning each society
attaches to children. Health values and beliefs are also important in understanding
reactions and behaviour. If a culture views pregnancy as a sickness, certain behaviours
can be expected, whereas if pregnancy is viewed as a natural occurrence, other
behaviours may be expected. Prenatal care may not be a priority for women who view
pregnancy as a natural phenomenon.

Many cultural variations in prenatal care exist. Even if the prenatal care describes is
familiar to a woman, some practices may conflict with the beliefs and practices of a
subculture group to which she belongs. Because of these and other factors, such as lack
of transportation, and poor communication on the part of health care providers, women
from many such groups do not participate in the prenatal care system. Such behaviour
may be misinterpreted by nurses as uncaring, lazy or ignorant.
A concern for modesty is also a deterrent to the seeking of prenatal care for many
women. For some women exposing body parts, especially to a man is considered a
major violation of their modesty. For many women, invasive procedures, such as
vaginal examination, may be so threatening that they cannot be discussed, even with
their own husbands. Thus many women prefer a female to a male health care provider.

Although pregnancy is considered normal by many, certain practices are expected of

women of all culture to ensure a good outcome. Cultural prescriptions tell women what
to do, and prescriptions establish taboos. The purposes of these practices are to prevent
maternal illness resulting from a pregnancy – induced imbalanced state and to protect
the vulnerable fetus. Prescriptions regulate the women’s emotional response, clothing,
activity and rest, sexual activity, and dietary practices.

 Lifestyle Factors

The health of an individual has direct relationship to the lifestyle. It is nothing but just a
way of living. A person who has healthy practices of day to day living will remain
healthy. Those people who follow the healthy life styles are much healthier than those
who follow injurious life styles. The way of life of people in a community and their
individual life style also has a significant impact on health.

Health is related deeply to life- style which includes ways of living, personal hygiene,
habits and behaviour. A healthy lifestyle helps to promote health and poor lifestyle has
ill effects on health. Lifestyles are the most critical modifiable factor influencing the
health today. Life style refers to a person’s general way of living, including living
conditions and individual patterns of behaviour that are influenced by sociocultural
factors and personal characteristics.

Life styles choices may have positive or negative effects on health. Practices that have
potentially negative effects on health are often referred to as risk factors.
E.g. over eating
Getting insufficient exercise

Being over viewing are closely related to the incidence of heart disease, diabetes and
hypertension. Excessive use of tobacco is clearly implicated in lung cancer,
emphysema and cardiovascular diseases. These lifestyle risk factors have gained
increased attention because it is known that many of the leading causes of death. This
also represents a huge impact on the economics of the health care system. Therefore it
is important to understand the impact of lifestyle behaviours on health status. Nurses
can educate their clients and the public on wellness- promoting lifestyle behaviours.

Factors Influencing Maternal and Child Health Lifestyles

 Proper nutrition and exercise.

 Healthy sleep patterns.
 Adequate rest.
 Healthy coping with stress.
 Ability to use family and community support and resources.
 Health promotion progress in community
• Educating school children about the food guide.
• Encouraging the provision of healthy snacks.
• Well – balanced meals in the home.
• Fitness program for all ages.
• Promotion of community play grounds in the community.
• Establishing networks of support in the community.

 Life enhancing activities

• Meaningful work
• Creative outlet
• Interpersonal Relationship
• Recreational activities
• Opportunity for spiritual and intellectual growth

 Mental Health Promotion interventions

 Arts and crafts classes
 Encourage creative expression
 Community event sports events.
 Volunteer programs encourage community participants.
 Personal hygiene
• Washing hands with soap and water before eating.

 Avoidance of excess salt, fats, sweets and cholesterol containing items.

 Consumptions of fiber- rich foods.
 Avoiding of having tobacco, alcohol, drugs of addiction.
 Indulgence in safe sex practices
 Practicing relaxation techniques.
o E.g. yoga, Mediation
 Health education is an important aspect to change life style and practicing the
healthy ways of living.
 Daily routine work

• Bathing
• Washing of hair and clothes
• Care of teeth, ear, and eyes.
• Eating habits
• Exercise
• Sleep
• Rest
• Avoid smoking and drinking
• Care of posture

 The school children must be taught good health habits and include health topic
in curriculum.
 Health education is a basic element of all health activity.
• Changing views of people
• Changing behaviour of people
• Changing habits of people

Examples of Healthy Lifestyles Choices of Maternal and Child Health

 Regular exercise
 Weight control
 Avoidance of saturated fats
 Alcohol and tobacco avoidance
 Seat belt use
 Immunization updates
 Regular dental check up
 Regular health maintenance

 Regular exercise

Regular routine exercise is very important in human life. Regular exercise makes the
body healthy. Regular exercise helps in maintaining the muscle tone, preventing from
diseases. During the antenatal period the pregnant mother can do light exercise daily.

 Weight control

There is need to control the weight to maintain healthy life style .In obese people the
excess weight leads to happen different diseases like cardiac disease, hypertension,
diabetes etc.

 Avoidance of saturated fats

These saturated fats are not good for health. These fats will lead to accumulation in our
body which affects the healthy life. The mother and the children should be avoided of
taking saturated food.
Example of saturated food like burger, oil junk foods, noodles, deep fried food etc

 Alcohol and tobacco avoidance

Excessive use of alcohol and tobacco is clearly implicated in lung cancer, emphysema,
cardiovascular disease, pulmonary diseases, gastrointestinal disease, cirrhosis of liver,
hepatitis, reproductive disorders (infertility). Tobacco smoke contains different
chemical substances of which it produces cancer. Tobacco is the second major cause of
death in the world. Smoking produces peptic ulcer by increasing acid secretion. The
role of the nurse in avoidance of alcohol and tobacco through education, giving
information and cessation efforts etc.

 Seat belt use

Seat belt safety should be maintained to prevent from accident while driving car, bus
etc.Especially during pregnancy the mother should have seat belt.

 Immunization updates

Immunization is very necessary to protect from the six major killer diseases like
tuberculosis, tetanus, diphtheria, whooping cough, measles and poliomyelitis in the
children. After having immunization the update should be done appropriately. The
detail of immunization should be updated for not to miss any dose which may help to
maintain healthy life style.

 Regular dental check up

Regular dental check up should be done to know the condition of the teeth and to
prevent from dental carries. Regular dental check up should be done every interval of 6

 Regular health maintenance

Regular health check up which includes monitoring of Blood Pressure, blood sugar,
closterol level and follow up for the pre- existing problems.

 Gender

In some society there may be the discrimination between the male and female baby. If
the mother having a male baby the family will provide more care and attention towards
the mother and baby. And if the mother having a female babies the family members
will provide her less care and attention towards the mother and baby. So gender also
influences the maternal and child health.

Maternal and child health is recognized as one of the significant components of Family
Welfare. Health of both mother and children is a matter of Public Health concern. It is
also being observed that the deaths of mothers and children are the major contributors
to mortality in any community in India.

The maternal health status differs tremendously from place to place and in the same
place. It is assessed in terms of maternal health problems (maternal morbidity) and
maternal mortality. The factors which are responsible for maternal health problems i.e.
maternal morbidity and maternal mortality include poverty, ignorance, illiteracy,
malnutrition, age at marriage and pregnancy, the number and frequency of child
bearing and the number of unwanted pregnancies and abortions, lower status and worth
of women in society, lack of access to quality maternal health/ reproductive health
services, gender discrimination.

The different factors which influence the maternal and child health are age, gender,
sexuality, sociocultural factor, environment, nutrition etc.


“Assessment and Utilization of Maternal and Child Health and Family

Welfare Services among Rural Women.”

This study was conducted in selected primary health centers and its health sub
centres areas of Pondicherry health unit district. Out of 250 mothers selected, 208
mothers were delivered and given birth to a baby and 42 mothers who were pregnant. A
structured interview schedule was used for data collection and analysis was done, the
collected data were analyzed and found out the main out come, Association of
demographic variables, awareness of MCH and family welfare services and the extent
of utilization of services during perinatal period. The conceptual frame work adopted
for the study was based on systems model that influences the factors that intervene in
the utilization of maternal and child health services. The infant mortality was found to
be 33.5/1000 live births which was low, when compared to National average (62/1000
live births) and it was statistically significant (P< 0.000). The most causes of infant
mortality identified were prematurity, asphyxia, and low birth weight. The mother had
poor knowledge in purpose of immunization, Vaccine Preventable diseases, high risk
factors, antenatal diet, family welfare methods and warning signs of pregnancy. Though
the government has given top priority in implementation of MCH Programmes, the
women were not aware of many health programmes related to mother and child health
and had poor knowledge in existing programmes.

 BT Basavanthapa, “Community Health Nursing”, 2nd Edition, Chapter-11,

Maternal and Child Health, Published by Jaypee Brothers Medical publishers, 2008,
Page No.-355-560.
 Krishna Kumari Gulani, “Community Health Nursing (Principles and
Practices)”, 1st Edition, Chapter-11, Maternal and Child Health, Published by
Kumar Publishing House, 2005, Page No.: 339 – 366.
 Wong Hockenberry Wilson and Perry Lowdermilk, “ Maternal Nursing Care”, 3rd
Edition, Chapter- 11, Health Problems of Children, Published by Mosby
Elsevier,2006, Page No:1444-1448.
 S Kamalam, “Essentials in Community Health Nursing Practice”, 2nd Edition,
Chapter-15, Maternal and Child Health, Published by Jaypee Brothers Medical
Publishers, 2005, Page No.: 403-425.
 Potter Perry, “Fundamental Of Nursing” 6th Edition, Chapter – 9, caring for
Families, Page No.: 99.
 Judith Ann Allender Barbara Walton spradley, “Community Health Nursing
( Promoting and Protecting the Public’s Health)”, 6th Edition, Chapter- 35,
Clients with mental Health Issues and addictions, Lippincott Williams and Wilkins
Publishers, Page No.: 842.
 B. Sridhar Ras, “Community Health Nursing”, 1st Edition, 2006, Chapter-2,
Health care, Disease, Levels of prevention, AITBS Publishers, page No.: 20, 15.
 Sunita Patney, “Textbook of Community Health Nursing”, First Edition, 2005,
Chapter – 11, Concept of Health, Modern Publishers, Page No.: 138, 134.
 Berman, Snyder, Kozier, Erb, “Fundamentals of Nursing (Concepts, process and
practice)”, 8th edition, Chapter – 17, Health, wellness and Illness, Person Education
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 Sally B. Olds Marcia L. London Patricia A. ladewig, “ Maternal Newborn
Nursing ( A Family Centered Approach), 2nd Edition, Chapter- 3, Dynamics Of
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• Prof.Mrs.S.Kamalam, Principal, Kasturba Gandhi Nursing College, M.G.M.C and

R.I, Pillaiyarkuppam, “Pondicherry Journal of Nursing”, PJN Volume 1, Issue 2,
Sep- Nov 2008, Page No: 25.
• Mrs. S. Vijayalakshmi, “Nightingale Nursing Times”, volume 3, Issue 10, January
2008, Page No: 24.