Viva-voce Questions

CLINICOSOCIAL CASE STUDY

POST-NATAL CASE
Department of Community Medicine
MMR/IMR
Maternal Mortality Ratio
• Assam (215), Bihar (149), Madhya Pradesh (173), Chhattisgarh (159),
Odisha (150), Rajasthan (164), Uttar Pradesh (197) and Uttarakhand
(99).
• States with lower MMR — Andhra Pradesh (65), Telangana (63),
Karnataka (92), Kerala (43) and Tamil Nadu (60)

INFANT MORTALITY RATE: 32/1000LB

• MP- 48
• Nagaland- 4
Questions

• What is Social obstetrics?

• What are Mother craft clinics?
• What’s Rooming-in?
• Explain Kangaroo Mother care
• Exclusive breast feeding
• Breast feeding in Diseases
• Advantages of breast feeding
• Weaning, Complementary feeds, Colostrum
• Baby Friendly Hospital Initiative
• Uses of growth chart
Advantages of Breast Feeding
• Advantages of breastfeeding for the baby
• Superior nutrition
• Immunity
• Decreased risk of allergies and infections
• Fewer stomach upsets and constipation
• Promotes the proper development of baby’s jaw and teeth.
• Breastfed infants tend to have higher IQs
• Babies benefit emotionally, because they are held more
• Breastfeeding promotes mother-baby bonding
• In the long term, breastfed babies have a decreased risk of malnutrition,
obesity and heart disease compared to formula fed babies.
Advantages of Breast Feeding
• Advantages of breastfeeding for the mother
• The baby's sucking causes a mothers uterus to contract and reduces the flow of bood after
delivery
• During lactation, menstruation ceases, offering a form of contraception
• Mothers who breastfeed tend to lose weight and achieve their pre-pregnancy figure
• Mothers who breastfeed are less likely to develop breast cancer later in life
• Breastfeeding is more economical than formula feeding
• There are less trips to the doctor and less money is spent on medications
• Breastfeeding promotes mother-baby bonding
• Hormones released during breast-feeding create feelings of warmth and calm
Breastfeeding in HIV
• India - morbidity and mortality due to diarrhoea, pneumonia and
malnutrition are prevalent – exclusively breastfeed - 6 months,
• then introduce appropriate complementary foods and continue
breastfeeding up to at least the child’s first birthday
• HIV - mother to child - pregnancy, labour or delivery, breast-milk
• Giving antiretroviral treatment (ART) to mothers living with HIV
significantly reduces the risk of transmission through breastfeeding
and also improves her health.
Breastfeeding in COVID-19
• WHO recommends that mothers with suspected or confirmed COVID-
19 should be encouraged to initiate or continue to breastfeed.
• Mothers should be counselled that the benefits of breastfeeding
substantially outweigh the potential risks for transmission.
• Mother and infant should be enabled to remain together while
rooming-in throughout the day and night and to practice skin-to-skin
contact, including kangaroo mother care, especially immediately after
birth and during establishment of breastfeeding, whether they or
their infants have suspected or confirmed COVID-19.
• sIgA in Breastmilk, Viral particles rare
Newborn care:
• Kangaroo Mother Care: skin-to-skin contact between mother and baby
immediately after birth; Esp. in pre-term infants; life saving in low-resource
setting
• Initiation of breastfeeding within the first hour of life;
• Exclusive Breast Feeding- Only breastmilk upto 6 months of age; not giving
babies additional food or drink, even water, unless medically necessary
• Breastfeeding on demand (that is, as often as the child wants, day and
night);
• Rooming-in (allowing mothers and infants to remain together 24 hours a
day);
Weaning
• The child is EBF for first 6months
• As child grows nutitional requirements increase
• Around the age of 6 months, an infant’s need for energy and nutrients
starts to exceed what is provided by breast milk
• Thus, child is introduced complementary foods
• Weaning means transition from EBF to Breast Milk + Complementary
feeds which can then lead to solid foods.
Complementary Feeding
• 2–3 times a day between 6–8 months
• 3–4 times daily between 9–24
• +1–2 times per day Nutritious snacks for ages 12–24 months

• 6 months: pureed, mashed and semi-solid foods

• 8 months: “finger foods” (self eating food)
• By 12 months: Family food; including animal-sourced foods like meat,
poultry, fish, eggs and dairy products.
• Avoid: hard, big food- grapes, raw carrots; low nutrient value drinks
such as tea, coffee and sugary soft drinks;
Colostrum
• Colostrumis ‘the first milk secreted at the time of parturition, differing
from the milk secreted later, by containing more lactalbumin and
lactoprotein, and also being rich in antibodies that confer passive
immunity to the newborn.
• Rich in protein, immunoglobulin, lactoferrin and growth factors.
• Culturally- sometimes discarded as it’s thick and yellow
• MUST be gven to the baby
• Telugu: Murrupaalu
BFHI
• WHO-UNICEF Ten Steps of the Baby-Friendly Hospital Initiative to promote successful
breastfeeding:
1. Have a written breastfeeding policy that is routinely communicated to all health-care staff.
2. Train all health-care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one half-hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated
from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming in: Allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teat or pacifiers (also called “dummies” or “soothers”) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge
from hospitals or clinics.
Social Obstetrics
• It may be defined as the study of the interplay of social and
environmental factors and human reproduction going back to the
preconceptional or even premarital period.

• Age at marriage, child bearing, child spacing, family size fertility

patterns, level of education, economic status, customs and beliefs, role
of women in society, etc.

• Influence of these factors on the organization, delivery and utilization

of obstetric services by the community.
Mother-craft Clinics
• skill in or knowledge of looking after children as a mother
• pregnant women into homogenous groups according to period of
gestation, and explaining to them all aspects of pregnancy, labour and
child care in 5 to 6 antenatal sessions.
• Special stress on nutrition during pregnancy.
• Feeding techniques, clothing, bathing, exercise and sensory
stimulation, warmth, cleanliness, mothering, management, and rest
and sleep.
ANC Visits
• Ideal
• Upto 7 Months: Once a Month (1x7)
• 8th Month: Twice a Month (2x1)
• 9th Month onwards: Once a week (4x1)
• Total 13
• Minimum
• 1st:Within 12 weeks (Confirmation, Registration and ANC Checks)
• 2nd: between 14 and 26 weeks
• 3rd: between 28 and 34 weeks
• 4th: between 36 and term
Infections in Mother
• HIV
• Hepatitis B
• Toxoplasma
• Rubella
• Cytomegalovirus TORCH
• Herpes Simplex
• UTI
• Syphillis
• Tetanus
Growth Chart- Uses
• Monitoring Tool
• Diagnostic Tool-To identify high risk children.
• Planning and policy making
• Education tool- for educating mothers
• Tool for Action- helps in type of intervention that is needed
• Evaluation of Intervention
• Tool for teaching
• Complications of Postpartum Period
• Schedule of Postpartum examination
• What contraceptive advice will you give this lady?
• Antenatal Visits
• Calorie increase during pregnancy and lactation
• Protein intake during pregnancy and lactation
• High Risk Pregnancy
• Specific health protection in Pregnancy
• Objectives of ANC and PNC
• Babies Milestones
Postnatal Complications
• Immediate postnatal complications:
puerperal sepsis, thrombophlebitis, secondary haemorrhage
• Late postnatal complications:
subinvolution of uterus, retroverted uterus. prolapse of uterus and
cervicitis.
Postnatal Schedule of Visits
• 1st 3 days: Twice a day (Hospital)
• Once a day till Umbilical cord falls off (7-12days) (ANM Home visit)
• At 6 weeks (during immunization)
• Once every 2-3 months
• Check: temperature, pulse and respiration, progress of normal
involution of uterus, urine and bowels
• Examine: the breasts, lochia for any abnormality
• Advice: perineal toilet including care of the stitches
Nutrition
• Additional Calories
+ 350 Pregnancy
+ 600 Lactation
• Additional Proteins
+15g/Day Pregnancy
+25g/Day Lactation
High Risk
1. Elderly primi (30 years and over).
2. Short statured primi (140 cm and below).
3. Malpresentations, viz breech, transverse lie, etc.
4. Antepartum haemorrhage, threatened abortion.
5. Pre-eclampsia and eclampsia.
6. Anaemia.
7. Twins, hydramnios.
8. Previous still-birth, intrauterine death, manual removal of placenta.
9. Elderly grandmultiparas.
10. Prolonged pregnancy (14 days-after expected date of delivery).
11. History of previous caesarean or instrumental delivery.
12. Three or more spontaneous consecutive abortions.
13. Pregnancy associated. with general diseases, viz. cardiovascular disease, kidney disease, diabetes, tuberculosis, liver
disease, malaria, convulsions, asthma, HIV, RTI, STI, etc.
Specific Health Protection
• Infections:
• Toxaemia of Pregnancy
• Gestational Diabetes
• Nutritional Deficiency
• Anemia
Objectives of ANC
The objectives of Antepartum care are :
(1) To promote, protect and maintain the health of the mother during pregnancy;
(2) To detect "high-risk" cases and give them special attention;
(3) To foresee complications and prevent them;
(4) To remove anxiety and dread associated with delivery;
(5) To reduce maternal and infant mortality and morbidity;
(6) To teach the mother elements of child care, nutrition, personal hygiene, and
environmental sanitation;
(7) To sensitize the mother to the need for family planning, including advice to
cases seeking medical termination of pregnancy; and
(8) To attend to the under-fives accompanying the mother.
Objectives of PNC
The objectives of Postpartum care are :
(1) To prevent complications of the postpartal period
(2) To provide care for the rapid restoration of the mother to optimum health
(3) To check adequacy of breast-feeding
(4) To provide family planning services
(5) To provide basic health education to mother/family.
Baby Milestones
• Hold up head @ 3 months
• Sitting up @ 6 months
• Babbling @ 6 months
• Roll over @ 7 months
• Crawling @ 9 months
• Walking @ 12 months
• Talking @ 12 to 18 months
• One-two word sentences @ 18 months
• Full sentences @ 2 to 3 years
Pearls
• Nischay- Pregnancy Detection Kits from GoI (hCG in Urine)
• MCTS- Mother and Child Tracking System (Mobile no and Aadhar)
• eVIN- Electronic Vaccine Intelligence Network - digitizes the entire
vaccine stock management, their logistics and temperature tracking at
all levels of vaccine storage – from national to the sub-district.
• NCCMIS- National Cold Chain Management Information System -
track the cold chain equipment inventory, availability and
functionality
• AMB- Anemia Mukt Bharat- 180days 100mg Iron
Newer Vaccines
• Inactivated Polio Vaccine (IPV): IPV has been introduced in UIP as part of Global Polio end-game strategy, to
mitigate the risk associated with tOPV to bOPV switch. IPV was introduced in November 2015 initially in 6
states, which was expanded across the country by April 2016.
• Rotavirus vaccine (RVV): RVV has been introduced to reduce mortality and morbidity caused by Rotavirus
diarrhoea in March 2016. It has been introduced in 11 states (Andhra Pradesh, Haryana, Himachal Pradesh,
Jharkhand, Odisha, Assam, Tripura, Rajasthan, Tamil Nadu, Madhya Pradesh and Uttar Pradesh). The vaccine
will be expanded across the country in 2019-20.
• Measles Rubella (MR) vaccine: India is committed to the goal of measles elimination and rubella control and
to achieve the goal MR vaccine was introduced in the country through a campaign mode in a phased manner
in 2017. MR campaign target around 41 crore children in the age group of 9 months to 15 years (covering ⅓
of the total population of the country) followed by 2 doses in routine immunization at 9-12 months and 16-24
months. Rubella component is now under routine immunization as MR vaccine.
• Pneumococcal Conjugate Vaccine (PCV): PCV has been launched in May 2017 for reducing Infant mortality
and morbidity caused by pneumococcal pneumonia. It has been introduced in Bihar, Himachal Pradesh,
Madhya Pradesh, 19 districts of Uttar Pradesh and 18 districts of Rajasthan.
• Tetanus and adult diphtheria (Td) vaccine: TT vaccine has been replaced with Td vaccine in UIP to limit the
waning immunity against diphtheria in older age groups. Td vaccine to be administered to adolescents at 10
and 16 years of age and to pregnant women.
• What all drugs should a pregnant mother receive and for what duration?
• What are the causes of maternal mortality?
• What is Low birth weight? Low birth weight: causes, types, importance, prevention
• What is the schedule for immunization during pregnancy?
• What is the National Immunization Schedule in AP?
• Name some vaccine preventable diseases?
• IMNCI
• ICDS
• INAP
• JSY
• JSSK
• PMMVY
• PMSMA