SGD 10 – Obstetrics & Gynecology and Community Health

Areas of Community Health in Obstetrics

• Safe motherhood & Childhood = Safe Pregnancy/Delivery/Puerperium
• Mortality (Mortality/Morbidity Statistics)
- Maternal and Perinatal

1. What is the aim of General Obstetrics practice Antenatal, Intrapartum & Postnatal?
• Reduce the maternal mortality/morbidity and perinatal mortality/morbidity and near miss cases

Maternal
1. Definition
Maternal Mortality
World Health Organization (WHO)
Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration
and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but
not from accidental or incidental causes

International Federal of Gynecology & Obstetrics (FIGO)

Maternal death occurring in association with pregnancy, childbirth or during the 6 weeks of the termination of
pregnancy
Maternal Mortality Rate
Number of maternal deaths during a given time period per 100,000 women of reproductive age (15-49 by UN)
during the same time period
Maternal Mortality Ratio
Number of maternal deaths during a given time period per 100,000 livebirths during the same time period
In Malaysia 40/100,000 (2016)

2. Classification
Direct deaths Death resulting from obstetric complications of the pregnant state (e.g., major PPH),
labour and puerperium, interventions, omissions or incorrect treatment
Indirect deaths Death resulting from previous existing disease or from disease that developed during
pregnancy and which was not due to direct obstetric causes, but was aggravated by
physiologic effects of pregnancy
Late deaths Deaths occurring 42 days to 1 year after delivery or miscarriage due to direct or indirect
cause (e.g., Thromboembolism, Sepsis, TB)
Coincidental deaths Death from unrelated causes not related to or influenced by the pregnancy or
puerperium

3. Causes
• Haemorrhage
- APH: Placenta previa, Placenta abruptio
- PPH
• Amniotic fluid embolism
• Infection
• Unsafe abortion (e.g. septic abortion)
• Hypertension
• Obstructed labour
- Uterine rupture
• Other direct causes
- Ectopic pregnancy
- Embolism
- Anesthesia-related causes
• Other indirect causes
- Anemia
- Malaria
- Heart disease
 SGD 10 – Obstetrics & Gynecology and Community Health
4. Aims to reduce death due to cause
Haemorrhage • Placenta Previa
- Early diagnosis by USG à Appropriate and timely management
• Placenta abruption
- Predict risk factors: PE, Uncontrolled ARM in poly, Previous abruption, Smoking,
Amnio reduction, Trauma, Cocaine
- CVP for monitoring
- Blood products: Blood transfusion for hypovolemia, Fresh Frozen Plasma (FFP),
Cryoprecipitate & Platelets (DIVC) regimen for coagulopathy and surgical intervention
• Post-Partum Haemorrhage
- Predict Risk Factors: Grand multipara, Multiple Pregnancy, Polyhydramnios, Fibroid
- Prophylactic use of Oxytocin & Ergometrine if not contraindicated (e.g. Cardiac, PIH)
- Availability of blood transfusion
- Proper management as in APH
Amniotic • Associated with coagulation disorders (DIVC) – 50%
Fluid • Soon after ROM, especially when uterine contraction is strong
Embolism • Early recognition and prompt treatment
Infection • Puerperal sepsis
o Prevention à Aseptic measure, Antibiotics
Unsafe o Avoid unplanned pregnancy
abortion o Enforce TOP guidelines
Hypertension o Efficient ANC
o Proper treatment of Pre-Eclampsia
o Prevent Eclampsia by Early recognition
Obstructed • Uterine rupture
labour - Early recognition and prompt intervention
Other Direct • Ectopic pregnancy
causes - High index of suspicion (PID, Previous ectopic)
- Optimal clinical diagnostic (TVS, βhCG)
- Timely intervention
• Pulmonary embolism
- Be aware of VTE prophylaxis
• Anesthesia-Related causes
- Multi-Disciplinary Team
Other • Anemia, Malaria, Heart disease
indirect o Efficient ANC
causes Anemia Anemia workup
Malaria Screening in endemic areas
Cardiac Cardiac ECHO
o Early diagnosis
o Proper management

5. Community health in gynecology

• STI screening (Antenatal, Multi-partners, Sex workers)
• PID (proper diagnosis & proper management)
• Screening for gynecological cancer (Cervical cancer screening – Early detection)
Pap smear Done through
Gynecology clinics, Hospital women well-being campaign, Interior Medical campaign
Colposcopy Clinics
o HPV vaccination National Program (13 years old)
- Cervarix 16-18, Gardasil 6-11-16-18, Gardasil 9 Nonovalent vaccine 6,11,16,18,31,33,45,52,58)
1st dose Now
2nd dose 1 – 2 months from 1st dose
3rd dose 6 months from 1st dose
 SGD 10 – Obstetrics & Gynecology and Community Health
6. Risk Management
• Identify the risk – Analyze, Evaluate & Assess the risk
• Risk treatment
• Register the risk by documentation
• Antenatal screening
Malaysia Infection screening, Thalassemia screening, Malaria screening in endemic areas
UK Rubella, Tay-Sachs disease (Autosomal recessive genetic disorder progressive nerve destruction)

Perinatal
1. Definition
Perinatal mortality The number of perinatal deaths per 1000 total births
Perinatal death Fetal death (stillbirth) or an early neonatal death
Early Perinatal death Within first 7 days of life
Late Perinatal death 7 – 28 days of life

2. Perinatal mortality rate

[Perinatal deaths/Total births (Stillbirths + Live births)] x 1000

3. Causes of Fetal Death

• Maternal causes
Antenatal Intrapartum
• Smoking • Acute & Chronic placental insufficiency
• Substance abuse • Fetal distress
• Medical diseases - Prolonged labour
- Pre-eclampsia, DM, Anemia, - Obstructed labour
Heart disease, Renal disease - Ruptures uterus

4. Causes of Intrapartum death

Fetal Umbilical cord Placenta
• Abnormal lie à prolonged labour • Cord knot (True knot) • Placenta previa
• FGR • Cord prolapse • Placenta abruption
• Prematurity • Cord accident • Vasa previa
• Post maturity
• Congenital abnormalities

5. Causes of Early neonatal death

• Prematurity & low birth weight
• FGR
• Birth asphyxia (Hypoxic Ischemic Encephalopathy)
• Birth trauma (Cranial haemorrhage)
• Lethal congenital abnormalities
• Respiratory distress syndrome (not fully developed lungs)
• Pulmonary haemorrhage
• Infection (Prolonged ROM)
• Pneumonia
• Necrotizing enterocolitis (tissue of small/large intestine is injured or inflamed)

6. Fetal Screening
Antenatal Screening Down’s Syndrome, Fetal anomalies
Postnatal Screening Congenital hypothyroidism, G6PD deficiency, Hepatitis B
Other Screening Cystic fibrosis, Hearing, Phenyl ketonuria (metabolic disorder of amino acid)***,
Medium chain Acyl Co-A Dehydrogenase (FA metabolic disorder à Hypoglycemia)
***Phenylalanine à Mental disorder, Seizure, Behaviour problems
 SGD 10 – Obstetrics & Gynecology and Community Health
7. Prevention of perinatal death
Perinatal Death Stillbirth/IUFD
• Antenatally
- Identify risk factors (PIH, DM, Thalassemia, Previous eventful pregnancy –
Anomaly, IUD, Neonatal death)
- Hospitalization + Fetal surveillance
- Timely delivery (Appropriate time of delivery)
- Optimum mode of delivery

Fetal Surveillance
• Antepartum
- Asses the risk of fetal death om pregnancies complicated by pre-existing
maternal complications (e.g. DM, PIH) and fetal complications have
developed (e.g. FGR, Fetal anomaly)
Intrapartum Death • Maternal + Fetal monitoring by Partogram, Cardiotocography, Fetal Heart Sound
• Prompt delivery if Fetal Distress (Instrumental/Caesarean section)
• Avoid traumatic delivery
• Hospital delivery for risk cases
Early Neonatal Death • Neonatal resuscitation (NRP Neonatal Resuscitation Program)
• Avoid birth asphyxia
• Avoid fetal trauma (Vacuum head trauma)
• Joint care with Pediatrician, Orthopedician & Physiotherapy (Brachial Plexus
Injury)

8. How to reduce Maternal & Neonatal Mortality/Morbidity

• Multi-Disciplinary Team Plan for highly complicated cases
• Patient and relative counselling
• Continuous Medical education
• Formulation of Hospital Policies & Protocol
• Following International Guidelines (RCOG, NICE)
• Following National Guidelines (Malaysian CPG)
• Red alert & Blue alert system and conducting red and conducting red and blue alert drill (during office
hours)
• Conducting educational courses (OLSSC, Partogram, CTG) for obstetric emergencies
• Auditing (Caesarean section, Fresh Stillbith)
• Vaccination for Measles, Mumps, Rubella (MMR) à District, State, National
• Perinatal Mortality Rate à District, State, National