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Ensuring safe motherhood
Safe motherhood means ensuring that all women have access to the
information and services they need to go safely through pregnancy and
childbirth. It includes
- Education on safe motherhood
- Prenatal care (care during pregnancy) and counseling with focus on
high risk pregnancies
- Promotion of maternal nutrition
- Adequate delivery assistance in all cases
- Provisions for obstetric emergencies including referral services
for pregnancy, childbirth and abortion complications
- Postnatal care(care after the child birth)
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The main causes of maternal mortality may be divided into 3
categories-social, medical and availability of health care
facilities.
| Social causes |
Medical causes(pregnancy related complications)
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Availability of health Care facilities
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- Early marriage and Pregnancy
- Repeated child birth
- Preference for sons
- Anemia
- Lack of information about danger signs and symptoms
- Delay in referral
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- Obstructed labour
- Hemorrhage(antenatal during labour and postnatal)
- Toxemia
- Infection or sepsis
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- Lack of essential supplies and trained health personnel at the
centers
- Non sympathetic attitude of health personnel.
- Deficient medical treatment of complications
- Inadequate action taken by medical personnel
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Antenatal care refers to health
education and regular medical check -ups given to a pregnant woman in
order to make the outcome of pregnancy safer, reduce cases of maternal
morbidity and mortality through early detection and treatment. ANC is
also necessary to screen high risk pregnancy and high risk labor signs.
The important components of antenatal care are discussed below:
Early registration: The
first visit of registration of a pregnant woman for Antenatal clinic
(ANC) should take place as soon as the pregnancy is suspected. Every
married woman in the reproductive age group should be encouraged to
visit her health provider or inform if he believes herself to be
pregnant. Ideally the first visit should take place in the first
trimester (first three months of pregnancy), before or at the 12th week
of pregnancy .However, if a woman comes late in her pregnancy for
registration, she should be registered, and care given to her according
to the gestational age(duration pregnancy).
Some pregnant woman will come by themselves to the antenatal
clinics that are organized. However many may not come. The health care
provider with the help of various community based functionaries such as
Anganwadi worker (AWW), the Traditional Birth Attendant (TBA)/Dai,
members of Mahila Mandals, self-help groups, the panchayat and
the village health committees who are likely to be aware of
pregnant woman in the village should update the list and provide
services .
Importance of early
registration
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Assesses the health of the mother and
to obtain baseline information on blood pressure(BP),weight
etc
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Screen for complications early and
manage them appropriately by referral and where required
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Help the woman recall the date of her
menstrual period
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Give the woman first dose of
tetanus toxoid injection (TT),well within time.(after 12 weeks of
pregnancy)
Pregnant women
Early
pregnancy
inj: TT1or Booster
After 4
weeks
TT2
Help the woman access facilities for an early and safe abortion if she
does not want to continue with her pregnancy
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Build a rapport between the pregnant
woman and the heath worker.
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Weight:
A pregnant woman’s weight should be checked at each visit. Normally a
woman should gain 9-11kg during her pregnancy. After the first
trimester, a pregnant woman gains around 2 kg every month or 0.5 kg per
week. If the diet is not enough, with less than the required amount of
calories, the woman might gain only 5-6 kg during her pregnancy. An
inadequate dietary intake can be suspected if the woman has gained less
than 2 kg per month. She needs to be put on food supplementation. A low
weight gain usually points, towards intrauterine growth retardation and
results in a low birth-weight baby. Excess weight gain (>3 kg in a
month) should arouse the suspicion of pre-eclampsia/twins. She should
be referred to medical officer.
Height:
There is an association between maternal
height and delivery outcome, at least in part due to increased risk due
to small pelvis in a very short woman. Nulliparous women below 145cms
of height have an increased risk of disproportion at delivery an there
fore considered high-risk mothers for whom hospital delivery is
recommended.
Blood pressure:
Measuring BP of pregnant woman is
important to rule out hypertensive disorders of pregnancy. if the BP is
high (More than 140/90mmHg;or diastolic more than 90mmHg) and albumin
(protein) is present in the urine, then the woman can be categorized as
having pre-eclampsia. If the diastolic BP is above 110mm Hg, it is a
danger sign pointing towards imminent eclampsia. Such woman must be
referred to the CHC/FRU immediately. a woman with pregnancy –induced
hypertension (PIH) /pre-eclampsia requires hospitalization.
Pallor:
If the lower palpebral conjuctiva(inner
part of lower eyelid), palms and nails, the oral mucosa and tongue of
the woman are pale, it is an indication that the woman is anemic.
Respiratory Rate (RR):
It is important to check RR, especially
if the woman complains of breathlessness. if the RR is more than 30
breaths/minute and pallor is present ,it indicates that the woman has
severe anemia and needs immediate referral to the doctor
Generalized Oedema:
The presence of generalized oedema (swelling) as indicated by the
puffiness of face should arouse the suspicion of
pre-eclampsia.
Abdominal examination:
Abdominal examination should be done to
monitor the progress of pregnancy and foetal growth, and to check the
foetal lie (foetal position)and foetal presentation(whether head
or bottom first).
Iron-folic acid (IFA) supplementation:
Stress the need for increased requirements of iron during pregnancy
and the dangers of anemia to pregnant women. All pregnant women need to
be given one tablet of IFA (100mg of elemental iron and 0.5mg of folic
acid) every day for at least 100 days, starting after the first
trimester at 14-16 weeks of gestation. This is the dose of IFA given to
prevent anemia (prophylactic dose). If a woman is anemic (Hb<10g/dl)
or she has pallor, give her two IFA tablets per day for 3 months. This
means a woman with anemia in pregnancy needs to take at least 200
tablets of IFA during whole of pregnancy period. This is the dose of
IFA required to correct anemia (therapeutic dose). Women with
severe anemia (hb<7g/dl) or those who have breathlessness and
tachycardia (increased heart rate)due to anemia, should be started on
the therapeutic dose of IFA and also referred to the doctor for further
management.
Injection tetanus toxoid
administration:
Administration of 2 doses of inj.TT to a pregnant woman is an
important step on the prevention of neonatal tetanus (tetanus of the
newborn). The first dose of TT should be given just after the first
trimester, or as soon as the woman registers for ANC whichever is
later.TT injection is not to be given in the first trimester of
pregnancy. the second dose is to be given one month after the first
dose, but at least one month before the EDD.
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The pregnant woman’s diet should provide
for the needs of the growing foetus maintenance of the mother’s health,
physical strength required during labour and successful
lactation.
Protein foods are essential for the growth of the foetus . If
possible, the pregnant woman should take plenty of milk, eggs, fish
poultry and meat. If she is vegetarian, she will need to have different
cereals, a lot of pulses and nuts.
Iron is very important for making the
baby’s blood and to avoid or reduce incidence of anemia. She should
have jaggery instead of sugar; eat ragi or bajra preparations, sesame
seeds and plenty of dark green leafy vegetables. Liver and kidney are
also rich in iron.
Calcium is necessary for making the
baby’s bones and teeth. The best source of calcium is milk. Calcium is
also present in ragi and bajra , she should be encouraged to eat small
dried fish.
Vitamins are important for pregnant women. She should have plenty of
vegetables (especially dark green leafy vegetables) and fruits
including citrus kinds.
Modified diets
In the presence of pregnancy induced hypertension or preeclampsia low
salt diet is advised to prevent or reduce oedema. The woman may have a
normal diet but avoid salted foods, and use little or no salt in
cooking.
High protein diet for preeclampsia,
especially if there is albumin in the urine. The mother should be
advised to increase her intake of protein foods
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Too much physically demanding work
during pregnancy can contribute to problems with the pregnancy such as
miscarriage, premature labour or underweight infants, especially if a
woman is not eating enough.
Women should therefore be encouraged to avoid heavy physical labour
during pregnancy. If they cannot be given up completely, women should
make sure they rest as much as possible between tasks.
A pregnant woman should also get as much rest as possible. She should
lie down for an hour or so during the day, and sleep between six and
ten hours every night.
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The following symptoms cause some discomfort and indications of
complications.
Symptoms indicating discomfort |
Symptoms indicating that complications may be
arising
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- Nausea and vomiting
- Heart burn
- Constipation
- Increased frequency of urination
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- Fever
- Vaginal discharge
- Palpitations, easy fatigability and breathlessness at rest
- Generalized swelling of the body puffiness of the face
- Passing smaller amounts of urine
- Vaginal bleeding
- Decreased or absent foetal movements
- Leaking of watery fluid per vagina(P/V)
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Getting sick during pregnancy is
especially uncomfortable and unpleasant, partly because of the
pregnancy itself and partly because some medicines need to be avoided
during pregnancy. In addition some diseases such as malaria can cause
serious problems during pregnancy. For, these reasons women need to be
especially careful to avoid diseases and infections when they are
pregnant. For example, they should use mosquito nets when they
sleep and avoid drinking contaminated water.
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Bathing everyday is refreshing and also
reduces the chance of getting an infection or illness. It is especially
important to take care of the breasts and the genital area by washing
often with clean water; harsh chemicals or detergents are not necessary
and even can be harmful. Loose clothes made of light cotton are ideal.
Well fitting brassieres can help support the breasts as they get bigger
and tender.
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It is safe to have sex throughout the
pregnancy, as long as the pregnancy is normal. Sex should be avoided
during pregnancy if there is risk of abortion (history of previous
recurrent spontaneous abortions), or a risk of preterm delivery
(history of previous preterm labour). Some women experience a decreased
desire for sex during their pregnancy. The husband should be informed
that this is normal and the woman‘s consent should be sought before
engaging in sex. Some couples find engaging in sex uncomfortable during
pregnancy. The comfort of the woman should be ensured by her husband
during sexual relations.
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Four out of ten pregnant or postpartum
women will experience some complication related to their pregnancy; for
about 15% of these women, the complication can be potentially life
threatening and will require immediate obstetric care. Since most of
these complications cannot be predicted, every pregnancy necessitates
preparation for a possible emergency.
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All pregnant women must be encouraged to
opt for an institutional delivery. Any complication can develop during
delivery; complications are not always predictable; they can cost the
life of the mother and/or the baby.
A health facility has staff, equipment,
supplies and drugs available to provide the best care if needed. It
even has a referral system should the need to refer arise.
Identify support people: these
people are needed to help the woman care for her children and/or
household, arrange for transportation, and/or accompany the woman to
the health facility in an emergency. Seek help from either close
relatives or community –based health functionaries such as
AWW(anganwadi worker) and the TBA(trained birth attendent).
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The woman and her family should be given
an estimate of the expenses for the delivery and related
aspects (such as transport etc...) They should also be advised to keep
some emergency fund, or have a source for emergency funding, should a
complication arise and more money is required than initially
anticipated. They should also be made aware of the existing schemes
that provide funds for maternal health, and any other schemes that may
be launched from time to time.
Signs of labour: advise the woman
to go to the health facility or contact the TBA if she has any one of
the following signs which indicate the start of labour.
- A bloody sticky discharge per vaginum (her private part)
- Painful abdominal contractions every 20 minutes or less
- The bag of waters has broken, and she feels clear fluid coming out
of vagina.
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Danger signs: The woman and her
family/caretakers should be informed about potential danger signs
during pregnancy, delivery and the postpartum period. She must be told
that if she has any of the following during pregnancy, delivery or
postpartum/post-abortion, she should immediately visit a hospital or
health centre, without waiting, be it day or night.
The woman should visit an
FRU if she has any of the following conditions:
- Any bleeding P/V during pregnancy, and heavy(>500 ml) vaginal
bleeding during and following delivery
- Severe headache with blurred vision
- Convulsions or loss of consciousness
- Labour lasting longer than 12 hours.
- Failure of the placenta to come out within 30 minutes of
delivery
- Preterm labour (labour starting before 8 gestational months)
- Premature or prelabour rupture of membranes
- Continuous severe abdominal pain
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- High fever with or without abdominal pain, and feels too weak to
get out of bed
- Fast or difficult breathing
- Decreased or absent foetal movements
- Excessive vomiting, wherein the woman is unable to take anything
orally, leading to a decreased urinary output.
Location of the nearest PHC/FRU:
The woman and her family members should be aware of the nearest health
facility both the PHC where 24 hour functioning emergency obstetric
care services are available and the FRU, where facilities for a blood
transfusion and surgery are available.
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Delay in reaching a healthcare
facility is one of the major delays responsible for
maternal mortality. If the woman has decided to deliver at a health
facility, a vehicle should be identified which should be available
whenever the woman needs it, to take her to the health facility. Even
if the woman decides to deliver at home, a vehicle should be identified
and ideally be kept ready to transport her to the nearest health
facility or referral centre in case she develops some complications
that need immediate referral and care. The help of the
Panchayat Village Health Committee, Mahila Mandals .,
Youth groups, or any other such groups can be taken to decide on how to
obtain a vehicle in case of an emergency , if a vehicle is
not available in the village. The various schemes
which are presently available for assisting the woman with
transportation facilities should be kept in mind.
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Haemorrhage , both antepartum and
postpartum, is an important cause maternal mortality. Blood transfusion
can be life saving in such, cases. As blood cannot be bought one needs
a voluntary donor to replace the blood before it is issued for
transfusion. Such donors (2-3in number) must be ready, should the need
for transfusion arise.
Post natal care:
Research has shown that more than 50% of
maternal deaths take place during the postpartum period.
Conventionally, the first 42 days (6 weeks) after delivery
are taken as the postpartum period. Of this, it is the first 48 hours,
followed by the first one week, which is the most crucial period
for the health and survival of both the mother and
her new born, as most of the fatal and near-fatal maternal and neonatal
complications during this period.
Of all the components of maternal and
child health care delivery post natal care and early new born care are
most neglected components. Only one in six women receives care during
the postpartum period in India. The National Family Health Survey
(NFHS) data indicate that only 17%of the women delivering at home were
followed by a check-up within two months of delivery. Again of those
delivering at home, only 2% received postpartum care within two days of
delivery and a meager 5% within the first 7 days. Even out of this
minor fraction of women most of them were not provided the entire range
of information and services that should have been provided to a woman
during a postpartum visit.
After delivery a woman has to make both
physical and emotional adjustments and she needs support and
understanding. Some of the medical disorders during this period are,
puerperal sepsis or infection of the uterus and surrounding tissues,
urinary infection, acute prolapse of the cervix and puerperal
psychiatric illness. It is important to diagnose and treat these
conditions as early as possible. Some of these may lead to more serious
/life threatening complications.
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- She may feel sad or tearful after the stress of pregnancy and
labour
- Her internal organs especially the womb, return to normal
size.
- The blood and other fluids from the womb gradually change from red
to pale cream in colour, and stop altogether about four weeks after
delivery. This discharge is called lochia.
- Menstruation returns after 4 -6weeks if she is not breastfeeding ,
or several more months if she is breastfeeding
Possible complications;
There are three serious complications
that can develop in the period after delivery: eclampsia(within the
first two days or 48 hours after delivery),infection and
hemorrhage(heavy bleeding).
Infection is most often caused by prolonged labour or early rupture of
the membranes. It can also be due to poor hygiene during a delivery
(for example, if the birth attendant’s hands or instruments were not
clean), or it can happen after a Caesarian section. The signs of a
severe infection are fever, headaches, pain in the lower abdomen, bad-
smelling vaginal discharge and vomiting or diarrhea. These are
dangerous signs and a woman should go to a clinic or hospital
immediately if she has them.
Haemorrhage can happen as late as ten
days or more after delivery. If placenta did not come out completely
after delivery, bleeding may continue and become heavy.
Other complications that can develop after delivery are anemia and
fistulae. Fistulae are holes that can develop between the vagina and
the urinary tract or rectum.
Serious complications
Postpartum danger signs:
If a woman has any of the following danger signs after she has
delivered her baby, she should seek care immediately:
- Fainting , fits, or convulsions
- Bleeding that increases rather than decreases or has many large
clots or pieces of tissue.
- Fever
- Severe pain in the abdomen, or pain that keeps increasing
- Vomiting and diarrhea
- Bleeding or fluid from the vagina that has a bad smell
- Severe pain in the chest, or shortness of breath.
- Pain , swelling , and /or redness in the leg or breast
- Pain ,swelling , redness, and/or discharge at the site of an
incision (if a woman had an episiotomy or a caesarean section)
- Urine or faeces (stool from a bowel movement)leaking out of the
vagina
- Pain when urinating
- Paleness in the gums, eyelids, tongue, or palms.
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Ideally a new mother should visit a
health facility for her first postpartum visit, or be visited by a
health worker at home, within 7 -10 days of delivery. This is
especially true if she delivered at home. This first visit is important
to make sure that the woman and the infant are recovering from the
labour and delivery. If all is well, the next visit should be about six
weeks after the birth of the baby. Both the mother and infant should
have thorough physical examination and the infant should be
immunized. In addition this is an excellent opportunity to
answer any questions the woman may have about breastfeeding, sexual
relations, family planning, and immunization for the baby or other
topics.
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After child birth, women need to eat
well in order to regain their strength and recover from the labour and
delivery. They should continue to take iron tablets to prevent anemia,
especially since they lost blood during delivery. If a woman is
breastfeeding, her diet should include extra food and drink.
Breastfeeding mothers need to eat even more than they did while
pregnant, as breastfeeding places great demands on nutritional
reserves. Foods rich in calories, proteins, iron, vitamins and other
micronutrients should be taken. For example, cereals, milk and
milk products, green leafy vegetables and other vegetables,
fruits, poultry, meat, egg, and fish. Food taboos
immediately after delivery and during lactation are usually
stronger and more in number than during pregnancy. These should be
discouraged. They should also be certain to drink
plenty of liquids. The woman needs sufficient rest during postpartum
period to be able to regain her strength. She and her husband and other
family members should be advised that she should not be allowed to do
any heavy work except looking after her self and her baby.
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Advise and explain to the woman
not to insert anything into the vagina and to wash the perineum daily
and after passing faeces. Perineal pads should be changed more
frequently if there is heavy lochia or for every 4 -6hours.If
cloth pads are used, the pads should be washed with plenty of soap and
water and dried in the sun. She should be advised to take bath
regularly and to wash her hands before handling the baby.
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