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MAGNITUDE OF MATERNAL AND CHILD HEALTH PROBLEMS AND FACTORS INFLUENCING MATERNAL AND CHILD HEALTH
SUBMITTED TO Ms. Subhashini. G. HOD OBG Department Bangalore
SUBMITTED BY Mrs. Santoshi Shrestha I year M.Sc Nursing Bangalore
PADMASHREE INSTITUTE OF NURSING BANGALORE SEPTEMBER, 2009
: OBSTETRIC AND GYNAECOLOGICAL NURSING
: MAGNITUDE OF MATERNAL AND CHILD HEALTH PROBLEMS AND FACTORS INFLUENCING MATERNAL AND CHILD HEALTH :
NAME OF THE STUDENT : MRS. SANTOSHI SHRESTHA
NAME OF THE SUPERVISOR : MS. SUBHASHINI G.
1 2 3 INTRODUCTION TERMMINOLOGIES CONTENT
1. MAGNITUDE OF MATERNAL AND CHILD HEALTH PROBLEMS
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) b) c) d) Malnutrition Vitamin Deficiency Iron Deficiency Low Birth Weight
II. Infectious Diseases a) b) c) d) e) f) g) h) Tuberculosis Diphtheria Pertussis (Whooping Cough) Tetanus Poliomyelitis Measles Acute Respiratory Infection (ARI) Diarrhoeal Diseases
III. Problems of Neonates a) b) c) d) e) f) g) Hyper bilirubinemia Hypothermia Neo-natal tetanus Birth asphyxia Oral thrush sepsis The infected New Born
2. FACTORS INFLUENCING MATERNAL AND CHILD HEALTH
Maternal Age Sexuality Factor Nutrition Environmental Factor Psychological Factor Ethnic and Socio Cultural Factor Lifestyle Factor Gender
4 5 6
CONCLUSION JOURNAL ABSTRACT BIBLIOGRAPHY
MAGNITUDE OF MATERNAL AND CHILD HEALTH PROBLEMS AND FACTORS INFLUENCING MATERNAL AND CHILD HEALTH
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 freedom. 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 Mortality Morbidity
: Largeness, Importance : Quality or state of being subject to death, number of deaths in relation to a specific population, incidence. : Condition of being diseased, Number of causes of disease or sick person in relationship to a specific population, incidence. : A child who is under 1 year of age
: 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 Fertility Neonatal Mortality : Expulsion of a child with the placenta and membranes from the mother at birth : Quality of being able to reproduce. : 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. : Infection of the genital tract following childbirth, still a major cause of maternal death where is undetected and untreated. : The termination of pregnancy before the fetus reaches the stage of viability (20 to 24 weeks) : Spontaneous abortion, lay term usually referring specially to the loss of the fetus between the fourth month and viability. : Infant born before completing week 37 of gestation, irrespective of birth weight, preterm infant. : Infant weighing 2500g or less at birth : Coma and convulsive seizures between the 20th week of pregnancy and the end
Puerperal Sepsis Abortions Miscarriage
Premature Infant Low Birth Weight Eclampsia
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 Nephritic Cystitis Amenorrhea Primary Dysmenorrhoea Uterine Bleeding) Metrorrhagia Menorrhagia Foetal Distress : Decreased capacity to conceive : Related to the kidney : Inflammation of the bladder usually occurring secondary to ascending urinary tract infections : Absence or suppression of menstruation. : Painful menstruation beginning 2 to 6 months after menarche, related to ovulation : Falling, sinking, or sliding of the uterus from its normal location in the body. : Abnormal bleeding from the uterus, particularly when it occurs at any time other than the menstrual period. : Abnormally profuse or excessive Menstrual flow. : Evidence such as a change in the fetal heartbeat pattern or activity indicating that the fetus is in jeopardy. : The state in which an individual’s body temperature reduced below normal range. : 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. : Lack of emotion : Any disease of the skin in which inflammation is not necessarily a feature : An inflammation of the mouth
Apathy Dermatosis Stomatitis
Keratomalacia to Hemoptysis
: Softening of the cornea seen in early childhood owing deficiencies of vitamin A : 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. : The quality of being modest : Having or expressing a humble. : 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.
Modesty Modest Emphysema
1. MAGNITUDE OF MATERNAL AND CHILD HEALTH PROBLEMS
DEFINITION AND MEANING OF MATERNAL AND CHILD HEALTH
Maternal and Child Health (MCH) refers to a package of comprehensive health care services which are developed to meet promotive, preventive, curative, rehabilitative 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.
DEFINITION AND CONCEPTS OF MATERNAL HEALTH/ REPRODUCTIVE HEALTH
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.”
OBJECTIVES OF MATERNAL AND CHILD HEALTH
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.
GOALS OF MATERNAL AND CHILD HEALTH SERVICES
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 children. To educate the mothers on improvement of their own and their children’s health.
A. MATERNAL HEALTH PROBLEMS
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 mothers.
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
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 India.
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.
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 treatment. 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.
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 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 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 infections.
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
Amenorrhea Ineffective individual coping related to lack of menstrual flow • • • • • • • • • • • • • • • •
Acknowledge patient’s feeling Provide emotional support Refer to counseling as necessary Explain diagnostic procedures Provide information, privacy, or consultation as indicated sexual concern Provide information on orientation to hospital setting, disease process procedures to be performed, medication and treatment. Prepare for information, question and answer sessions according to patient needs Teach procedure to the patients Obtain feedback Be that certain learning has taken place Develop a trusting relationship Involve patient in care Assess the nature of pain 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.)
Dysmenorrhoea Knowledge deficit related to the lack of education concerning disease process and treatment
Pain related to biological agent
• • • 3. Menorrhagia • • • • •
Monitor vital signs Provide quiet environment , calm activities Promote wellness, discuss other significant ways which can assist the patient 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 follows:S.N 1. Reasons of Anxiety
Irritability,Lethargy, fatigue,depression,headache, vertigo,backache,ache, paresthesia(burning, tingling) of hands and feet • • • • • • • • • •
Encourage verbalization of feelings Acknowledge existence of the syndrome and its symptoms Encourage the patient to keep a menstrual 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 anxiety 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 discomfort.) 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 literature.
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.
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.
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 are:• 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.
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 adolescents. 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.
The results of comprehensive care for a teenage mother would show some of the following: 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.
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.
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.
B. CHILD HEALTH PROBLEMS
I. Nutritional deficiency Problems a) Malnutrition b) Vitamin Deficiency c) Iron Deficiency d) Low Birth Weight
III. Infectious Diseases a) b) c) d) e) f) g) h) Tuberculosis Diphtheria Pertussis (Whooping Cough) Tetanus Poliomyelitis Measles Acute Respiratory Infection (ARI) Diarrhoeal Diseases
IV. Problems of Neonates a) b) c) d) e) f) g) Hyper bilirubinemia Hypothermia Neo-natal tetanus Birth asphyxia Oral thrush sepsis 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 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 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
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
These children exhibit a mixture of some of the features of both marasmus and kwashiorkor.
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 blindness. 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 years. 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.
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 approach. Other measures: Medical paramedical personnel should be trained to detect and treat xerophthalmia.
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 programme. 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 programmes.
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 interrelated. 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 retardation.
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 activities. Supplementary feeding Distribution of iron and folic acids tablets. Fortification and enrichment of foods.
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 Disorders
• • • • 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 countries. • • • 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 antituberculosis 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.
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 surveillance. 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 status. 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 infections. 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.
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 injuries.
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.
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 months. 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 surveillance. 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 tongue. 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.
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 subcutaneously. Immunity develops after 11 to 12 days of vaccination and gives 95 percent protection. 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 measles. 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 measles. The child with measles must be under the medical supervision, given good nursing care, given good nourishing diet to prevent complications and promote quick recovery. 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 done:-
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: Fast breathing. (60 per minute or more) Severe chest indrawing. Refer urgently to hospital Give first dose of antibiotic. Keep the baby warm during transfer. Breast feed frequently during transfer. If referral is not possible treat with antibiotic and follow closely.
No Pneumonia If • No fast breathing. ( less than 60/min) • No severe chest indrawing. Advise mother to give home care. • Keep baby warm • Breast feed frequently • Clear nose, if it interferes with feeding. Advise the mother to return if: • Illness worsens • Breathing is difficult • Feeding becomes a problem.
Very severe disease, if most • of these signs are present. • Take the following actions: • • Refer urgently to • Hospital. • Give first dose of • Antibiotic. • Keep the baby warm • during transfer. • Breast feed frequently • during transfer.
Child age 2 months up to 5 years Check for the following signs
Drowsiness Difficulty in waking up Convulsion Inability to drink Fast breathing Identify it as : Severe Pneumonia, if there is chest Very severe disease indrawing. if most of the signs presents • Refer to hospital immediately. Take the following • Give one dose of actions cotrimoxazole • Refer to the • Treat fever if any. hospital • If referral is not immediately. possible, treat • Give one dose of with cotrimoxazole. cotrimoxazole • Treat fevere if and follow any. closely. Chest in drawing Stridor in calm child Wheezing in calm child Severe under nutrition Pneumonia if there No pneumonia if there is fast breathing is no fast breathing, no chest in drawing. • Advise mother to give home care. • If cough persists for more than 30 days, • Give refer for assessment. cotrimoxazole. • Assess and treat other • Treat fever, if problems. present. • Advice mother to • Advice mother to give care. return with child in 2 days or early • Treat fever, if condition if gets present. worse for assessment.
Reassess the Child in 2 Days Worse:
• Not able to drink. Has chest in drawing.
The same as above
• • Improved breathing. Less fever
Have other danger signs. Refer immediately to hospital
Eating better Finish 5 days of cotrimoxazale
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 year.
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.
It is transmitted through drinking water of contaminated water from the contaminated water sources, which have been in contact with human excreta.
Ingestion of contaminated food and drink has been associated with diarrhoeal diseases. Bottle feeding could be a significant risk factor for infants.
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
• Rapid,i.e Hyperpnoea
• • • Loose and fluid in consistency Greenish or yellow green in colour May contain mucus or blood.
• Mild and intermittent to severe vomiting
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.
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 community.
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 possible. 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.
2. FACTORS INFLUENCING MATERNAL AND CHILD HEALTH
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 entertainment. 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 development. 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 age. 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 membranes. 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 society.
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 newborn. 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 etc.
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 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.
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 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 months.
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.
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.
JOURNAL RESEARCH ABSTRACT “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.
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