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NATIONAL CHILD SURVIVAL
AND SAFE MOTHERHOOD PROGRAMME
PROGRAMME
INTERVENTIONS
£
Ministry of Health and Family Welfare
Government of India
New Delhi
1992
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GOALS AND COMPONENTS OF
NATIONAL CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAMME
GOALS
o
o
o
o
o
o
o
o
Infant mortality rate reduced from 81 to 75 by 1995 and 50 by 2000.
Child (1-4 years) mortality rate reduced from 41.2 to < 10 by 2000.
Maternal mortality rate reduced from 400 to 200/100,000 by 2000.
Polio eradication by 2000.
Neonatal tetanus elimination by 1995.
Measles - prevention of 95% deaths and 90% cases by 1995.
Diarrhoea - prevention of 70% deaths and 25% cases by 2000.
Acute respiratory infections - prevention of 40% deaths by 2000.
Components of this package would be:
Children
Newborn care at home - warmth and feeding.
Primary immunization by 12 months - 100% coverage
Vitamin A prophylaxis (9 months to 3 years) - 100% coverage
Pneumonia - Correct case management at home/health facilities.
Diarrhoea - Correct case management at home/health facility; ORS in every village
Pregnant Women
Immunization against tetanus - 100% coverage
Anaemia prophylaxis and oral therapy - 100% coverage
Ante-natal check-up - at least 3 check-ups in 100%
Referral of those with complications
Care at birth - promotion of clean delivery
Birth timing and spacing
■
/
PROGRAMME INTERVENTIONS
A.
CHILD SURVIVAL
B.
SAFE MOTHERHOOD
Published by
Ministry of Health and Family Welfare
Government of India
Nirman Bhavan
New Delhi
First Edition 1992
This publication is available in English only
PROGRAMME INTERVENTIONS
A.
CHILD SURVIVAL
B.
SAKE MOTHERHOOD
COMMUNITY HEALTH CELL
326. V Main. | 2lock
Koramcng ’>
/
Bangalore-bo JU34
India
CONTENTS
1.0
INTRODUCTION
1.1
1.2
1.3
1.4
2.0
NEW BORN CARE
8
Care of all new born babies
Assessment of bith weight
New born babies AT RISK
Referral of low birth weight babies
Service delivery at various levels
IMMUNIZATION
8
9
10
12
13
14
Sustaining immunization services
Polio eradication
Elimination of neonatal tetanus
Reduction of measles
Service delivery at various levels
14
16
19
20
21
CONTROL OF VITAMIN A DEFICIENCY
22
Prophylaxis
Diagnostic criteria
Treatment
Service delivery at various levels
22
22
23
24
3.2
3.3
3.4
3.5
4.1
4.2
4.3
4.4
5.0
1
2
3
6
7
3.1
4.0
The Programtne package
Integrating preventive care
Policy and programme issues
Statement of purpose
1
PART A - CHILD SURVIVAL INTERVENTIONS
2.1
2.2
2.3
2.4
2.5
3.0
I
CONTROL OF ACUTE RESPIRATORY INFECTIONS
5.1
5.2
5.3
5.4
5.5
5.6
Criteria for diagnosis
Classification of illness using
assessment charts
Dose schedule - Cotrimoxazole
Medical Officer’s role
Referral
EXERCISE A
EXERCISE B
Service delivery at various levels
25
26
27
30
30
31
28
32
33
6.0
CONTROL OF DIARRHOEAL DISEASES
34
6.1
6.2
6.3
Assess child with diarrhoea
Manage child with acute diarrhoea
Service delivery at various levels
EXERCISE C
36
40
50
38
CASE STUDIES ON MATERNAL MORTALITY
51
GROUP WORK TO ANALYZE CASE STUDIES
52
Case Study-I
Case Study-II
Case Study-Ill
Case Study-IV
Case Study-V
53
56
59
62 .
65
8.0
REDUCING MATERNAL DEATHS
69
9.0
ESSENTIAL CARE FOR ALL
71
9.1 Antenatal care
9.2 Management of Anaemia
9.3 Prevent deaths due to Tetanus
9.4 Care at Birth
9.5 Birth spacing and timing
71
73
74
75
76
EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS
78
10.1 Haemorrhage
10.2 Obstructed labour
10.3 Ruptured Uterus
10.4 Eclampsia/Toxaemia (preeclampsia)
10.5 Sepsis (Following Abortion or Delivery)
10.6 Severe Anaemia
79
81
81
82
83
84
EMERGENCY CARE FOR THOSE WITH OBSTETRIC COMPLICATIONS
85
11.1 Ante-partum Haemorrhage (PPH)
11.2 Post Partum Haemorrhage (PPH)
11.3 Obstructed labour and rupture of uterus
11.4 Pre-eclampsia and eclampsia
11.5 Puerperal Sepsis
11.6 Abortion - Bleeding and Sepsis
85
87
90
95
97
99
7.0
10.0
11.0
Annexure - INTERVENTIONS FOR SAFE MOTHERHOOD
1.0
INTRODUCTION
1.1
THE PROGRAMME PACKAGE
As part of an overall strategy to achieve reduction in infant mortality rate to below 50 per
thousand livebirths and child mortality rate to 10 per thousand by the year 2000 the
following programmes were intensified during the 7th Plan :
o
Immunization against preventable childhood diseases
o
Prophylaxis against anaemia as well as blindness due to Vitamin A deficiency, and
o
Oral rehydration therapy for control of deaths due to diarrhoeal diseases.
o
A pilot programme for the control of acute respiratory infections among children.
i-
The strategy in the Eighth Plan is to use the opportunity created by the Universal
Immunization Programme in terms of continued contact with mothers and young children
for implementing a "UIP Plus" package of services combining immunization with other basic
MCH interventions progressively with a view to universalizing this "package" by 1995. The
components of this package are :
For children
Newborn care,
Primary immunization by 12 months,
Administration of Vitamin A till 3 years of age,
Pneumonia therapy; in children below 5 years and
Control of diarrhoeal diseases in children below 5 years.
For mothers
(pregnant women)
Immunization against tetanus,
Anaemia prophylaxis, diagnosis of anaemia clinically and therapy,
Ante-natal check-ups - at least 3 check-ups in 100%
Identification and timely referral of complicattions,
Care at birth - promotion of Clean delivery; and
Promotion of spacing and timing of births.
1
1.2
INTEGRATING PREVENTIVE CARE
The basic strategy of this component is to use the delivery system and opportunities created
by the immunization programme for effective delivery of additional interventions that will
benefit the young child and mother significantly, without disrupting the pace of immunization
programme, or losing any of the strategic gains. For example, the immunization programme
focuses on the most vulnerable group of children under 5 years, that is, the infants. Infants
are the most difficult group to reach, and we will continue to address this most vulnerable
segment of the population. Similarly, the pregnant woman who is reached by tetanus toxoid
injections under the immunization programme, will receive priority attention so that we
concentrate our efforts on her needs.
The effort, therefore, is to build around the concept of converting the "immunization
sessions" into "Mother-Child protection sessions".
It is important to integrate in operational terms, prophylactic interventions against Vitamin
A deficiency and anaemia (distribution of iron and folic acid tablets) with immunization
efforts.
In operational terms, this strategy implies:o
Unified training for all levels of functionaries.
o
Unified logistics. (See manage cold chain and other supplies module)
o
Unified monitoring and supervision at state and district levels.
o
Integrated management information system. A set of beneficiary cards and sub
centre registers already developed under UIP make it possible to integrate reporting
of ante-natal care, care at birth, prophylaxis for Vitamin A and iron deficiencies with
immunization, complications of pregnancy and labour etc. (See modules on ‘Evaluate
service coverage’ and ‘Conduct disease surveillance’.
o
Integrated communication. In the immunization programme, a communication
strategy, which addressed "protection" of infants was developed positioning
immunization as one of the important interventions for protecting babies. This
umbrella concept will be enlarged to include protection against other diseases, death
and disability of children as well as mothers.
2
1.3
POLICY AND PROGRAMME ISSUES
1.
The National Child Survival and Safe Motherhood programme has the following
features :
o
It universalises a package of services for pregnant women and children - i.e. all
pregnant women and all children below five years will be reached through the
package of services.
o
It rationalises activities so that only those activities that have specific outcome and
use are undertaken. There will be no increase in workload from this programme.
In fact, the work will be streamlined and time optimised.
o
It specifies action at all levels so that health functionaries are aware of exactly what
they are expected to do. It is very important to ensure that a minimum quality of
services is provided and that technical standards are maintained.
2.
Safe Motherhood
HEALTH
NOW
Nutrition
Income
Education
Statue of
Woman
Equity
Immediate (5-10 years)
ENABLING
Medium term (10-20years)
FUNDAMENTAL
Long term (20-50 years)
Safe Motherhood and maternal death is influenced by several factors o
health action that can reduce maternal mortality by half in a five to ten year period.
This package attempts to implement activities to reduce maternal deaths in India by
2000 A.D.
o
several enabling factors such as income, nutrition and education are even more
important for longer term benefits. Action needs to start today in these areas such
that over the next 10 to 20 years, these services are improved.
3
o
there are fundamental issues related to women that impinge upon their health in a
significant manner - issues related to women’s status and equity. These need to be
addressed, and action initiated now so that over the next 50 years, improvements can
be seen.
However, the health sector needs to do what can be done NOW.
3.
Much discussion has gone into the formulation of a ’risk approach’, for maternal and
child care. Epidemiologically, a risk approach implies that there are criteria to screen
potential danger, identify those in danger and provide special care. In the context
of maternity, this would imply that certain conditions have a higher probability of
death. Some researchers have identified these as anaemia, short stature, bad
obstetric history. If these factors are taken into account, over 90% of India’s
pregnant women are at risk. Therefore, this approach does not help focus action,
and all women should get ante-natal care.
Maternal deaths
50 %
50 %
1 or > risk
No risk
factors
factors
present
present
Recent studies related to women who died due to pregnancy and child-birth revealed
that 50 % of them had one or more risk factors; and 50 % of them had no risk
factors. This clearly shows that pregnancy itself is the major risk factor, and that
prevention of pregnancy will reduce maternal mortality. This also underlines the
need to provide essential ante-natal care for all. This will include check-ups for early
detection of complications.
4
4.
Safe Motherhood services will include the following 3 major components:
E - Essential Obstretic Care for all
E - Early Detection of Complications
E - Emergency Services for those who need it
5.
Briefly, the above may be defined as follows:
E - Essential Obstetric Care for all
♦
Early registration - between 12 and 16 weeks
*
Check-up - minimum 3 times
*
Anaemia
*
Immunization - TT
♦
CARE AT BIRTH
prophylaxis
clinical diagnosis
treatment
deworm those with history of passing worms
clean hands
clean surface
clean razor blade
clean cord tie
clean cord stump (no cord applicant)
E - Early Detection of Complications
Clinical examination to detect anaemia
Bleeding -
APR
PPH
Blood Pressure rise }
}
Weight gain in excess}
Fever
Toxaemia
- Sepsis
5
E - Emergency Services for those who need it
Emergency care at first referral level
6.
For child survival, the following policy and programme guidelines need to be
underlined:
*
Immunization
sustain coverage at near 100% levels; implement catch-up rounds when
necessary; continue to implement the "fixed day" as the major strategy
for continuing services on a regular basis and having contact with the
community;
eradicate polio by 2000 AD. through improved surveillance;
investigating and taking action for every outbreak; instituting mop-up
rounds to replace the wild virus by vaccine virus;
eliminate neo-natal tetanus by 1995; immunise all pregnant women
with two doses of tetanus toxoid and promote clean delivery, both at
home and in hospitals.
*
Vitamin A Prophylaxis
Every child by the age of three years will receive at least five doses of
Vitamin A concentrated solution at six monthly intervals. Children
with Vitamin A deficiency will receive 2 megadoses of Vitamin A.
*
Control of Diarrhoeal Diseases
improve ORT use rates upto 60% widely and set up ORS depots with
the help of Anganwadi workers of ICDS and other village level
functionaries of other sectors wherever possible.
7.
Please be ready to view a film titled "Dying for Life’ which focuses on the problems
of safe motherhood in India.
1.4
STATEMENT OF PURPOSE
In this module, you will learn about various components of the Child Survival and Safe
Motherhood package, its rationale, strategy of implementation and your role in the service
delivery.
6
PART A
CHILD SURVIVAL INTERVENTIONS
7
2.0
NEWBORN CARE
Nearly 50% of all infant deaths occur in the neo-natal period. Half of these occur in the first
seven days. Common causes of death are prematurity or low birth weight, birth asphyxia,
neonatal tetanus and sepsis. You can prevent many of these deaths by proper and timely
care of the newborn. Supportive care regardless of birth weight and condition of the just
born prevents mortality.
Goals
Improved survival of newborns and infants
Institute timely and simple care of low birth weight newborns at home level.
Examine every new born and record body measurements (length, weight), reflexes, look for
congenital malformations, respiratory distress, cyanosisjaundice (if any) to detect ’AT RISK’
new born.
2.1
CARE OF ALL NEWBORN BABIES
You should ensure the following for all newborn babies :
*
Clear respiratory passages immediately after birth by sucking mucus with a clean
rubber catheter. Baby should cry immediately after birth and breathe normally.
*
Clean eyes with soft clean cloth, cotton swab, using one swab for each eye, moving
from medial to lateral side.
*
Blood, mucus and meconium should be gently cleaned and skin dried with a clean
cloth. In summer, baby may be bathed with soap and water soon after birth. Baby
must be wrapped with a clean cloth and put close to the mother, for warmth.
*
Tie cord with a clean cord tie at 2.5 cm (i.e. four finger breadth) from umbilicus, cut
with a new razor blade and separate baby from placenta. The cord should be
inspected later for bleeding. If there is bleeding, another cord tie must be used. Do
not apply any medication on the cut end of the cord.
*
Weigh the baby and record birth weight.
*
Initiate breast-feeding immediately after birth. Early breast milk, colostrum is
beneficial to the baby. Putting the baby to breast also helps in early establishment of
successful lactation and involution of uterus after delivery.
*
The following may occur in a baby but require no intervention :
8
transitional loose stools, regurgitation of feeds, oozing breast nodul
bleeding, sub-conjunctival haemorrhage, swelling of the head etc.
vaginal
Cephalhaematoma: Swelling of the head due to subperiosteal collection of blood dur
to injury during delivery. It is a fluctuant swelling and does not cross the suture line.
It resolves spontaneously after a few days or weeks. No need for incision or
aspiration.
Caput Succedaneum : diffuse swelling of the head due to collection of fluid around
the area which presses against the mouth of birth canal during delivery. It is present
at birth and disappears within 24 hours. It is not limited by suture lines.
2.2
ASSESSMENT OF BIRTHWEIGHT
Weight should be recorded as soon after the birth as feasible, but not later than 2 days.
Prepare a hammock (sling) by making four folds of a soft clean cloth and tie knots which
can be engaged into the hook of spring balance. Place baby in the hammock and weigh baby
as shown in the picture.
v
i
i
*
Record weight by exact measurement or thorough recognition of colour range. Grade birth
weight to decide about the care to be provided. Provide normal care at home to babies who
weigh more than 2500 grams at birth or are in green colour range (2500 to 4000 grams).
Special care at home is required for babies who weigh between 2000 and 2500 grams i.e.
those who are in yellow colour range. They are "at risk". Consultation or referral is advised
for babies who are less than 2000 grams at birth (red colour range which signifies danger)
since they are in danger of death or disease.
9
2.3
Newborn babies ’AT RISK’
All babies with following characteristics are at higher risk of dying in the neo-natal period.
i)
Low birth weight (less than 2500 gms) or pre-term babies (gestation period less than
37 weeks).
ii)
Birth Asphyxia
iii)
Jaundice in newborn
iv)
Convulsions
V)
Congenital malformation
vi)
Birth injuries
vii)
Inability to suck
You will be able to take specific action at your level for babies included in i) and ii) above
and other babies will have to be referred to the next level i.e. where child specialists are
available.
2.3.1
Care at Home/Sub Centre/PHC
Newborn babies ‘at risk’ will require additional care and management. The following babies
will require such additional care by attendants, health workers - female, health supervisors
and Medical Officers:
o
o
o
Birth weight between 2000 and 2500 grams
Gestation period between 37 and 40 weeks
Moderate birth asphyxia - i.e. a feeble cry or laboured breathing which can be due
to blocked passages.
I
Low Birth Weight Babies : If the birth weight is between 2000 and 2500 gm, you can
manage the baby at home by providing warmth, and ensuring adequate feeding.
Encourage normal growth in a low birth weight baby
Low birth weight babies must be weighed every month regularly. Plot the weight on
growth chart. If the weight increases from the previous record, growth is satisfactory.
If it does not increase, she may need additional feed. A low birth weight baby who
loses weight may be sick - consultation is necessary. Breast milk alone is adequate
during the first four months. After four months of age, supplement breast feeding
10
with soft fruits like banana, mashed vegetable or dal. If the low birth weight baby is
too weak to suck, express breast milk drop by drop directly into his mouth.
Prevent infections - in low birth weight babies.
A low birth weight baby requires gentle handlind. The persons handling baby should
observe proper cleanliness and wash their hands with soap and water before taking
care of the baby. The number of persons handling the baby should be kept at the
barest minimum to prevent infections. The baby should be roomed-in with the
mother in a clean, airy room.
II
Birth asphyxia : If the baby does not cry soon after birth and respiration is not
established satisfactorily.
clear airway with a clean rubber catheter or mucus extractor. You will have to, if
necessary, do oropharyngeal or nasopharyngeal suction with the help of a catheter
by sucking from the other end. If breathing is still not established, give controlled
mouth tcrmouth breathing with puffed cheek and with a gauze put over the nose and
mouth of the baby.
2.3.2
Care at Hospitals
The following categories of ’at risk’ newborns would be managed by Paediatrician and
trained nursing staff in CHC/District hospital:
*
*
*
*
*
*
♦
*
*
Low birth weight below 2000 gms, if possible.
Pre-term babies with gestation age of 33 to 36 weeks
Cases of severe birth asphyxia.
Neo-natal Jaundice
Sepsis
Metabolic disorders
Birth Injuries
Infected umbilicus and other septic cases.
congenital malformations
It is estimated that 15-20% of newborns would require care at hospitals.
Jaundice in newborn : Some babies develop jaundice after birth. This is a physiological
process and does not require treatment in majority of cases. If the jaundice keeps increasing
or does not subside, please refer the baby to a child specialist.
If a baby has convulsions, congenital malformations, birth injuries or is unable to suck you
should refer the baby to a child specialist.
11
LI3RARY ""X 0^
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DOCUMENTATION
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At
y
A
2.4
REFERRAL OF LOW BIRTH WEIGHT BABIES
REFER low birth weight baby, if the baby :
*
*
*
*
*
*
does not suck breast milk
is too sleepy or restless
feels too cold or too warm
has breathing problems
appears blue or pale
has red umbilicus or there is discharge of pus/blood/bad odour
Protect low birth weight babies from illness
Minimal handling and restrict different people handling the baby. Immunize low
birth weight babies in time. They need timely protection even more than normal birth
weight babies. Use recommended schedule of immunization to protect low birth
weight infants.
'
12
2.5
SERVICE DELIVERY AT VARIOUS LEVELS
Village
Mothers
TEA
*
*
*
*
*
*
*
*
Early feeding.
Keep baby warm.
Special care of low birth weight baby.
Manage asphyxia immediately after birth.
Care of normal / low birth weight newborn.
Weigh children at birth.
Teach mother, care of low birth weight babies at home.
Refer if child is unable to suckle, not breathing normally or if
birth weight is below 2000g
Sub-Centre
Health Worker *
*
Female
*
(HW-F)
All the above plus
Assess risk
Priority visiting of homes with low birth weight babies (below
2500 g).
PHC / Urban Centres
Medical
Officer
*
*
*
All the above plus
Treat neonatal sepsis.
Refer babies with complications which cannot be managed at
this level.
*
*
*
All mentioned for lower levels, plus
Observation and treatment of high risk neo-nates
Care of neo-nates referred with complications like birth
asphyxia, birth injuries, haemolytic disease, neonatal sepsis etc.
by paediatrician and trained
paediatric nursing staff.
CHC / District
Hospital /
First Level
Referral Centre
Specialist
13
3.0
IMMUNIZATION
In 1985-86, the Universal Immunization Programme was launched to extend immunization
coverage among the eligible children and to improve quality of services. We aim at
consolidating the gains of the UIP programme by strengthening implementation for
sustaining high immunization coverage in districts which have already achieved 80 per cent
coverage and increase the coverage in the remaining districts. In addition, the programme
will focus intensively on polio eradication, elimination of neo-natal tetanus and reduction of
measles.
3.1
SUSTAINING IMMUNIZATION SERVICES
Goals
to eliminate neo-natal tetanus and eradicate poliomyeitis
to reduce deaths due to diptheria and measles
to reduce incidence of whooping cough and childhood tuberculosis.
Coverage
Coverage of all pregnant women with two doses of tetanus toxoid and all infants with one
dose each of BCG and Measles and three doses each of OPV and DPT.
Immunization Sessions (fixed or outreach centres)
Shall continue to be implemented as a part of PHC activities. The immunization session will
now become immunization/MCH sessions in the villages. The "fixed day" day sessions will
be organized as per following norms :
Hospitals
Every working day
PHC
Once a week
Sub-centre village
Once a month
Villages that can be reached
within one hour or those with
easy access by private or
public conveyance and having
a population of 1000 or more
Villages with difficult
accessibility or pockets
with population less than
1000
Once a month
Once a month along with neighbouring
outreach sessions.
THE DAY AND TIME OF VACCINATION SESSION SHOULD BE FIXED AND
SHOULD BE PROMINENTLY DISPLAYED AND KNOW TO THE PEOPLE
14
(
Complete enumeration of all infants and pregnant women should be ensured. Enumeration
at village level will be done annually and updated continuously.
Catchup sessions will be organized every year in all PHCs/sub-centre areas where the
immunization coverage is low (i.e. every district where the immunization coverage from April
to September is less than 25 per cent of the annual target. These rounds should preferably
be organized over October, November and December months.
PHC-wise and sub centre-wise immunization coverage should be monitored so that
organizational and managerial support can be provided with high priority to those areas with
low coverage.
Private practitioners should be involved systematically, specifically in urban areas for the
delivery of immunization on ’Fixed Days’ as part of the immunization services system.
Wherever possible, these ’Fixed Centres’ will be made widely known to people indicating the
date and time of the immunization session. Vaccines and immunization cards should be
made available from the government health system to private practitioners who can maintain
an efficient cold chain system. A report of immunizations given by the private practitioners
should be obtained on a monthly basis.
The Immunization Card, which includes items on ante-natal care, iron and folic acid and
Vitamin A will remain the major tools for communication and information to the family. The
counter-foil will be kept by the health workers and private practitioners and linked to the
record system.
The Immunizations should not be denied unless absolutely contraindicated. Only criticaly ill
children with high fever (38 degree C, 100.4 degree F or more) and children requiring
hospitalization may be denied vaccination. But ensure vaccination as soon as the child
recovers.
Due to increased publicity and other mobilization efforts it is, however, likely that older
children may also be brought for immunization. These children may be given vaccines "ON
DEMAND" only and recorded separately.
REMEMBER : MALNUTRITION, LOW GRADE FEVER, MILD
RESPIRATORY INFECTIONS, DIARRHOEA AND OTHER MINOR
ILLNESSES ARE NOT CONTRA-INDICATION TO IMMUNIZATION
15
3.2
POLIO ERADICATION
Goal
Eradication of Poliomyelitis throughout the country by the year 2000.
Coverage
100% coverage of all infants with 3 doses of OPV and of under-twos with booster dose and
‘O’ dose of OPV at birth for institutional deliveries.
Strategy
The district or an urban unit above 1.000,000 population will be considered as the
geographic sub-unit for declaring an area free of polio.
*
You will give three doses of oral polio vaccine during infancy; For institutionlised
deliveries ’0’ dose of OPV will be given at birth. In addition, one booster dose of
OPV will be given between 16 to 24 months.
*
The plan for polio eradication is based on two categories of districts, those with
OPV3 coverage (a) 80% or greater and (b) those with less than 80% coverage (actual
coverage).
For districts with 80% or greater coverage
Surveillance
*
Immediate implementation of increased surveillance for suspected polio (Case
definition - suspected polio is. any case of acute flaccid paralysis including Guillan
Barre syndrome in a child less than 15 years of age).
*
Even the occurrence of one case of polio in these districts is defined as an outbreak
of poliomyelitis.
Case investigation
*
*
*
*
Physical examination by a medical officer.
Stool specimens for viral culture.
Follow-up examination at 60 days.
Increased local surveillance for other polio cases.
Outbreak control fcontainment immunization) - if there is a case meeting case definition
*
To be initiated and completed within one week of onset of paralysis in the case.
*
A dose of OPV to all children less than 3 vears regardless of immunization status to
2000 to 3000 children in urban areas or to all children within 5 kms in low density
rural areas.
16
*
One month later a second round of immunization is carried out.
*
If more than one month has elapsed after the onset of paralysis of last case no
outbreak immunization is carried out.
Mop -up operations
*
Mop up rounds should be implemented in those geographic areas where coverage is
relatively high and yet acute poliomyelitis cases occur.
*
Immunizations done in blocks or PHCs with polio cases reported in last year. May
be expanded to 2 or 3 years interval as polio cases decrease. Totally about 10,000
children are immunized.
*
Areas where number of polio cases have been reported or are likely to occur, all
children up to three years of age regardless of immunization status, must receive 2
doses of OPV one month apart, prior to transmission season (e.g. before rainy
season).
For districts with less than 80 per cent coverage:
o
o
o
increased routine immunization efforts to achieve 80 per cent coverage.
special immunization activities (such as catch-up rounds) needed to increase
coverage.
outbreak control as appropriate based on epidemiological investigation.
Select operational aspects:
1.
Catch-up rounds:
This needs to complement the routine immunization services being provided at the
village, sub-centre and PHC. As the fixed day strategy becomes institutionalised, the
catch-up rounds should be implemented in progressively in fewer areas and districts.
These rounds are necessary where coverage levels are low especially in areas that
remain cut off due to floods and other natural calamities.
2.
Mop-up rounds:
Mop-up rounds needs to be implemented to replace the wild polio virus with the
vaccine virus. They should be implemented before the epidemic season (generally
June to August in our country, and some times in May), when transmission is lowest.
Therefore, two mop-up rounds should be organised ideally during March and April.
Mop-up rounds should not interrupt regular service delivery. Therefore, every effort
should be made to implement mop-up rounds on the day immunization sessions are
held. That means, the health workers will complete the primary immunization of all
infants first. Thereafter, children below three years of age would be immunized with
OPV.
17
The OPV given during mop-up rounds should not be entered in the immunisation
card, unless it is part of the primary immunisation that is due for an infant on that
day. The worker is expected to submit a statement on the total number of children
below 3 years of age who have been given OPV (as a proportion of estimated
number of children below 3-years in that area) and does not need to identify these
children by name or address.
Mop-up rounds are not implemented for enhancing individual protection - they are
implemented to replace the wild virus. Therefore, it does not matter if a few children
are left out, or few children over 3 years of age are included. Much House-to-house
listing of children below 3 for mop-up rounds is not recommended since this is not
the best use of the health workers time who has to perform numerous activities.
Instead, it is advisable that all children below 3 years be brought to the immunization
session through a village based social mobilisation and communication initiative.
3.
Improving surveillance
Presently, data on disease trends are being collected through sentinel sites located at
state and district hospitals. The information from villages, sub-centres, primary health
centres and community health centres, reflecting the situation in communities are very
important. Timely response is a priority. In the programme, all out-break
containment measures will be taken for every case of poliomyelitis within one week
Therefore, every effort should be made to improve the surveillance system through
the routine monthly reports from both sentinel centres as well as the primary health
care system).
The village level functionaries as well as communities are expected to report all cases
of suspected poliomyelitis to the health worker within 24 hours. After the health
worker at sub-centre level is informed, information on suspected poliomyelitis cases
must reach the medical officers at the primary health centres within the next 24
hours. The health worker is not expected to leave the sub-centre headquarters and
go to the primary health centre, because this will disrupt the provision of regular
services in the community. A nodal person(s) should be identified and briefed from
the community, so that people are fully involved in this process.
The Medical Officer at primary health centre must respond to the information within
48 hours, and investigate the reported poliomyelitis case(s). If required, containment
measures must be taken within one week of the first report.
Information on the timeliness of the reporting will be maintained along with the line
listing of cases.
18
3.3
ELIMINATION OF NEONATAL TETANUS
Goal
Elimination of neo-natal tetanus from the country by the year 1995.
Strategy
A district approach will be adopted for elimination of neo-natal tetanus.
The four major interventions include:
*
*
*
*
100% coverage of pregnant women with 2 doses of tetanus toxoid.
Extensive information, education and communication efforts to promote clean
delivery at home level as well as correct medical practice in institutions
Community based surveillance of neo-natal deaths.
Promotion of clean delivery by a massive communication strategy for :
o
o
o
o
o
clean hands
clean surface
clean razor blade
clean cord tie
clean cord stump - no applicant
In addition, if your areas have high domiciliary delivery rates they will require the following
additional interventions :
*
*
TBA s will require to be trained, supported by female health workers through a
process of at least 10 contacts for continuing education every year. As the medical
officer with training responsibilities, you will identify at least 10 topics related to
maternal and child care for carrying out continuing education activities. The main
purpose is to promote clean delivery, improved ante-natal care as well as post-natal
care with the primary aim of reducing maternal mortality.
The need to provide facilities for clean and safe normal deliveries in sub-centres and
PHC’s where buildings are available is very important. You will have to encourage
and help your health workers carry out greater number of deliveries in the PHCs and
sub-centres.
19
3.4
REDUCTION OF MEASLES
Goal
Measles deaths reduced by 95% and cases reduced by 90% by the year 1995.
Coverage
100% coverage of all infants with measles vaccine.
II.
Strategy
The major strategy you will adopt for reducing measles cases and deaths will be as follows:
o
100% coverage of infants between 9-12 months with measles vaccine.
o
Good case management at home level, and educating mothers about complications
that may arise, especially pneumonia and diarrhoea. Health Workers and medical
practitioners need to be conscious of the post-measles complications that are the
major causes of deaths in babies.
o
Community based surveillance for early recording of cases.
o
During epidemics, you will conduct an investigation primarily to study the deficiencies
in the implementation of the immunization programme in your area and train your
health workers for adopting practices which will result in potent vaccine being used
for immunization activities. No containment measures are necessary.
20
3.5
SERVICE DELIVERY AT VARIOUS LEVELS
Village
*
*
*
*
Getting registered for immunization
Ensuring timely completion of immunization schedule
Maintenance of immunization cards
Motivate other eligibles
*
Education of mother on :
Need for immunization.
Completion of all doses of immunization as per schedule.
Maintenance of Mother/Infant immunization card.
Motivating other families.
Mother
with
assistance of
VHG/AWW/TBA
*
*
♦
*
*
*
*
Motivation of target group
Help enumeration of eligibles.
Help provision of immunization services at fixed intervals.
Maintaining records.
Referral of cases of adverse events.
Tracking drop outs and non-participants.
Help surveillance of neonatal deaths and outbreak of measles,
poliomyelitis
*
*
*
*
*
Provide immunization services once every month
Maintain records.
— Track drop outs and monitor coverage.
Education of mothers.
Referrals.
PHC/Urban Centre *
*
Medical
*
Officer
Provide immunization services once every week.
Maintain records.
Monitor programme coverage.
Storage and distribution of vaccine.
Training of staff.
Surveillance.
Education of mothers.
Sub Centre Level
HW - F
*
*
*
♦
CHC/Dist Hospital ♦
First level referral ♦
*
facility
Specialist
CMO/DHO/DIO
Supdt. Hospital
*
*
*
*
*
Provide immunization services daily or more than once a week.
Maintain records.
Monitor programmes.
Storage and distribution of vaccine.
Surveillance.
Investigate and manage adverse reactions.
Education of mothers.
Training of staff.
21
4.0
CONTROL OF VITAMIN A DEFICIENCY
Goals
Elimination of blindness and other consequences of Vitamin A deficiency.
100% coverage of children 9 months to 3 years with 5 mega doses of Vitamin A.
Strategy
4.1
PROPHYLAXIS
o
Prevalence of Vitamin A deficiency is maximum between 6 months and 3 years. It has
therefore been decided to focus attention on this priority age group.
o
Five mega doses of Vitamin A will be provided to every child between 9 months and
3 years. The first dose of 100,000 IU will be given at 9 months along with measles
immunization and the second dose of 200,000 IU will be given at 16 months with
booster dose of DPT/OPV. Three more doses will be given at 6 monthly intervals.
o
Dietary management will be integrated in all training and communication as a long
term strategy for control of Vitamin A deficiency.
o
The health worker (F) and other functionaries working in the Primary Health Centres
are responsible for administering Vitamin A concentrates to children under three
years and for advice on dietary management. Services of Integrated Child
Development Services (ICDS) functionaries will be utilized for the distribution of
Vitamin A to children in the ICDS Blocks and for the education of mothers on
prevention of Vitamin A deficiency.
4.2
DIAGNOSTIC CRITERIA
o
Children with symptoms of Vitamin A deficiency (night blindness, conjunctival
changes and corneal xerosis/ulceration) will be detected and treated as early as
possible.
Although Vitamin A deficiency affects many tissues in the body, its effect on the eye are
most damaging and can result in blindness. The surface of cornea becomes dry and rough,
and may ultimately break down partially or completely. This may lead to ulceration, and
permanent scarring or irreversible damage and loss of sight.
The ocular signs considered most reliable for identifying Vitamin A deficiency are:
Night blindness -
An early symptom - A child cannot see clearly after dark or in a dark room.
22
Xerophthalmia
Bitot’s spots - They are accumulation of foamy cheesy material on the conjunctiva, often
in association with other signs of xerophthalmia such as night blindness.
Corneal xerosis/ulceration - The cornea becomes dry (xerosis) and wrinkled, devoid of the
shine or gloss.
Keratomalacia - If the disease is not treated, a corneal ulcer can lead to ’’melting" or
"washing" of the cornea (keratomalacia).
Corneal scar - Keratomalacia can lead to perforation of cornea resulting in a scar. The
sooner the disease is treated, the smaller the ulcer and smaller the scar. If treated early,
corneal scars and blindness can be prevented.
4.3
TREATMENT
*
Treatment schedule is to administer 200,000 IU of Vitamin A immediately after
diagnosis. This must be followed by another dose of 200,000 IU four weeks later.
*
Children with eye lesions must be treated immediately with Vitamin A even if they
are being referred for special care.
*
Infants and young children suffering from diarrhoea, measles or acute respiratory
infections must be monitored closely and encouraged to consume Vitamin A rich
food. In case, early signs of Vitamin A deficiency are observed, the above treatment
schedule must be followed.
REMEMBER
Vitamin A concentrate solution is available in the PHC and sub-centres in the
form of a flavoured syrup at a concentration of 100,000 lU/ml or capsules
* Vitamin A syrup should be administered using the 2ml spoon provided with every
bottle. A marked level full of the 2 ml spoon contains 200,000 IU of Vitamin A
♦
23
4.4
SERVICE DELIVERY AT VARIOUS LEVELS
Village
*
*
*
*
*
*
Feeding colostrum to newborn
Early and exclusive breastfeeding for four to six months
Grow and consume green leafy vegetables and other
Vitamin A rich food.
Ensure Vitamin A prophylaxis at six monthly intervals of all
children.
Administer Vitamin A doses to under 3
years old children as per schedule.
Recording Vitamin A doses given on Immunization cards/registers.
Educate mothers on prevention of Vitamin A deficiency.
Advice on exclusive breastfeeding (including colostrum consumption).
Promote consumption of Vitamin A rich foods.
Sub-Centre
HW (F)
*
*
*
*
All the above plus
Give additional dose of Vitamin A during measles.
Detect deficiency cases and give full therapy.
Refer cases with eye signs to Medical Officer (MO), PHC.
PHC/Urban
Centres
Medical
Officer
*
*
*
*
All above plus
Receive referrals, assess and give therapy and prophylactic
care.
When indicated refer to district hospital.
Monitor and report coverage.
*
*
All above plus
Treat referred cases
Home
Mother
♦
*
AWW
♦
CHC/Dist.
Hospital
24
5.0
CONTROL OF ACUTE RESPIRATORY INFECTIONS (ARI) - Pneumonia Control
Acute respiratory infections (ARI) are one of the commonest causes of death in children in
developing countries. They are responsible for four out of the estimated 15 million deaths
that occur in children under 5 years of age even-’ year; two-thirds of these deaths are in
infants (especially young infants). A majority of these deaths are due to pneumonia. Under
the programme, the emphasis is on early diagnosis and treatment to prevent mortality due
to pneumonia.
Goal
To reduce deaths due to pneumonia
Coverage
Prevention of pneumonia cases through measles and BCG immunization and Vitamin A
prophylaxis. Identification of pneumonia in children, promotion and education at home
remedies and early referral for proper treatment and preventing death.
Strategy
o
Reduce deaths due to pneumonia by standard case management by workers as well
as medical practitioners at all service facilities.
o
Equip mothers in early recognition of fast and difficult breathing and seeking referral.
o
Promote correct home care for ordinary cough and cold through education of
mothers.
o
Reduce inappropriate use of antibiotics in treating ARIs other than pneumonia in
children.
o
Sustain high coverage with immunization especially measles, DPT and BCG.
o
ARI control programme will be implemented as an integral part of the primary
health care system, closely linked with immunization outreach services, promotion of
breast-feeding, and use of ORT for diarrhoea management.
o
Surveillance of pneumonia cases and deaths.
o
As the medical officer, you should ensure that your health workers are trained to
assess children with cough and cold and are in a position to initiate correct case
management or give advice to parents for home care. In case of severe disease, they
should be able to refer to a health facility equipped to handle such emergencies.
25
5.1
CRITERIA FOR DIAGNOSIS
Health care providers - all levels
*
The basic criteria for diagnosis of pneumonia is based on the counting of respiratory
rate. A breathing rate of 60 per minute or more in an infant less than 2 months of
age, 50 or more in an infant 2-12 months of age and 40 or more in the children 1
year to 5 years of age suggests pneumonia. In each case respiratory rate should becarefully counted in a resting child for a full minute. In a child whose respiratory rate
exceeds these limits, a second count should be done before a diagnosis is made.
*
Children breathing at rates lower than mentioned above are considered to have no
pneumonia. Home treatment alone will be recommended in such cases. In this case,
for treatment of cough the worker will advise locally accepted remedies made from
household ingredients (honey, ginger, tulsi, hot water) or a suitable bulk cough
mixture made in the dispensary. You will ensure fever control with paracetamol,
continued feeding, adequate fluids and give instructions on when to return (if
breathing becomes rapid or laboured).
*
In the event that respiratory rates are above the indicated levels, the following action
will be taken:
Case Management
Infant aged 0-2 months, respiratory rate 60 per minute or more will be referred
immediately to a health care facility with a doctor for further evaluation and
treatment. No treatment will be offered by paramedical workers for these young
children in view of the high danger of respiratory disease in this age group. The dose
of cotrimoxazole (paediatric) in this age group is 1 tablet twice a day for five days.
Children 2-12 months of age, respiratory rate 50 per minute or faster, with no signs
of respiratory distress (e.g. chest indrawing) will be treated with cotrimoxazole
(paediatric), 2 tablets twice a day for five days.
Children 1-5 years of age with respiratory rate of 40 per minute or greater, and no
signs of respiratory distress would be treated with cotrimoxazole (paediatric), 3 tablets
twice daily for five days.
*
26
Each tablet of cotrimoxazole (paediatric) contains 20 mg trimethoprim and 100 mg
sulphamethoxazole. Oral cotrimoxazole (paediatric) tablets are recommended for
treatment of children (2 months - 5 years) with pneumonia at sub-centres and OPD
of hospitals or health centres and can be given by paramedical functionaries such as
the health worker.
*
Control of fever and advice on fluids, feeding and home based remedies will be given
for every child. All mothers will be told to return for further evaluation if the rate of
breathing increases, if the child is unable to drink or feed, or a child appears to
become sicker. Under such conditions, the child will be re-evaluated by the health
worker and sent for referral, if necessary.
The process of classification of illness for children below 2 months and those from 2 months
to 5 years for determining the treatment schedule is given in the charts that follow :
5.2
CLASSIFICATION OF ILLNESS USING ASSESSMENT CHARTS
CHILD (AGE 2 MONTHS UP TO 5 YEARS)
SIGNS
* Not able to drink
* Convulsions
* Abnormally sleepy or difficult to wake
* Stridor in calm child
* Wheezing in calm child
* Severe Undernutrition
SIGNIFY AS
VERY SEVERE DISEASE
TREATMENT
* Refer URGENTLY to hospital
* Give first dose antibiotic
* Treat fever, if present
SIGNS
* Chest indrawing
IDENTIFY AS :
TREATMENT :
* No chest indrawing and
* Fast breathing (50 per
minute or more if child
2 months up to 12 months
40 per minute or more if
child 12 months ip to
5 years)
* No chest indrawing and
* No fast breathing
(Less than 50 per minute
if child 2 months up to
12 months; less than
40 per minute if child
12 months up to 5 years)
SEVERE PNEUMONIA
PNEUMONIA
NO PNEUMONIA: COUGH OR COLD
* Refer URGENTLY to
Hospital
* Give first dose anti
biotic
* Treat fever, if present
(If referral is not
feasible, treat with
antibiotic and follow
closely)
* Advise mother to give
home care
* Give antibiotic
* Treat fever, if present
* Advise mother to return
with child in 2 days for
reassessment, or earlier
if the child is getting
worse.
* If coughing more than
30 days, refer for
assessment
* Assess and treat other
problems
* Advise mother to give
home care
* Treat fever, if present
Reassess in 2 days a child who is taking an ant biotic for pneunonia :
SIGNS :
WORSE
* Not able to drink
* Has chest indrawing
* Has other danger signs
TREATMENT :
* Refer URGENTLY to
Hospital
THE SAME
* Review antibiotic or
Refer
IMPROVING
* Breathing slower
* Less fever
* Eating better
* Finish 5 days of
antibiotic
27
THE YOUNG INFANT (AGE LESS THAN 2 MONTHS)
SIGNS
* Stopped feeding well
* Convulsions
* Abnormally sleepy or difficult to wake
* Stridor in calm infant
* Wheezing in calm infant
* Fever or Low body temperature
CLASSIFY AS :
VERY SEVERE DISEASE
TREATMENT
* Refer URGENTLY to hospital
Give first dose antibiotic
SIGNS :
* Fast breathing (60 per minute or MORE)
and or
* Severe chest indrawing
CLASSIFY AS :
SEVERE PNEUMONIA
* Refer URGENTLY to hospital for antibiotic
by injection
* Give first dose of antibiotic (if
referral is not feasible treat with
antibiotic and follow closely)
* Keep the young infant warm during
transfer
* Breast-feed frequently yocrig infant
during transfer.
TREATMENT
* No fast breathing (less than 60 per
minute)
* No severe chest indrawing
NO PNEUMONIA
* 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
EXERCISE A
1.
28
Mark the following statements about chest indrawing as true or false :
(a)
If chest indrawing is seen only some of the time, it is considered to be present
(b)
If chest indrawing may appear to be present in a child who is upset or trying
to feed
(c)
Any chest indrawing in a young infant indicates pneumonia
(d)
The position of the child is not improtant in the assessment of chest indrawing
(e)
Chest indrawing can be assessed during any phase of breathing i.e. inspiration
or expiration
2.
Amongst the following statements about assessment, identify what is true and what
is false
(a)
A young infant has pneumonia if he is breathing 50 times or more per minute
(b)
Central cyanosis indicates severe hypoxia
(c)
Cyanosis is a reliable sign in cases of severe anaemia
(d)
For assessment of an ear problem or sore throat, the child must have cough
or difficult breathing
(e)
Peripheral cyanosis does not always indicate hypoxia
29
5.3
DOSE SCHEDULE
COTRIMOXAZOLE(*) IN A SUSPECTED CASE OF PNEUMONIA
Amount per dose (in tablets,
capsules or ml) according to
Dose/Frequency (for each dose)
4 mg of Trimethoprim per kg
every 12 hours
do -
- do -
F
o
r
m
body weight in Kg
3-5 Kg
6-9 Kg
10-19 kg
Adult single strength tablet
containing 80 mg IMP + 400 mg of
SMX
0.25 **
0.5
1
Paediatric tablet containing 20 mg
of IMP + 100 mg of SMX
1
★★
2
3
Syrup containing 40 mg of IMP +
200 mg of SMX
2.5 **
5
7.5
*
**
Cotrimoxazole = Trimethoprim (TMP) + Sulfamethoxazole (SMX)
If the child is less than 1 month old, give 1/2 pediatic tablet or 1.25 ml syrup twice
daily. Avoid cotrimoxazole in neonates who are premature or jaundiced.
5.4
MEDICAL OFFICERS’ ROLE
Traditionally, medical officers like you have used auscultation of the chest, laboratory
investigations and chest X-ray to diagnose pneumonia. It has now been shown that rapid
respiratory rate, chest indrawing and inability to drink are, in most cases, more reliable and
practical in making a diagnosis of pneumonia. The pathognomonic value to these selected
signs has been well established. You must get yourself trained to assess these signs correctly
to classify illness for judging severity and for deciding about treatment instructions.
Danger signs which signify very severe disease or severe pneumonia are :
a)
Child stopped feeding well.
b)
Child too sleepy or difficult to wake.
c)
Stridor even when the child is calm.
d)
Wheezing.
e)
Convulsions.
f)
Severe undernutrition, and
g)
a very young infant who has fever or is cold to the touch.
Children with these signs will be referred for evaluation by you and generally for admission
in a hospital.
30
It is important that you train the health worker that in a child with severe pneumonia the
respiratory rate may actually slow down as a result of exhaustion and advanced disease.
Therefore, the presence of chest indrawing and other dangerous signs should take
precedence over respiratory rate as diagnostic criterion and reason to refer the child to you.
At the PHC, further evaluation will be conducted by you and parenteral antibiotic started.
You may choose to keep the child under direct observation in the PHC, or if the case is very
severe, may initiate parenteral antibiotic and send the child onward to another hospital
facility where round the clock nursing, oxygen, intravenous drugs and laboratory/radiological
investigations are available. In the referral hospital, a paediatrician will examine, assess and
provide appropriate medical treatment for all children, referred with a diagnosis of very
severe disease or severe pneumonia. Such patients should be treated as inpatients with
careful medical and nursing care until their disease remits.
Routine use of antimicrobials, cough syrups containing ephedrine, codeine, atropine or
alcohol, medicated nasal or ear drops are discouraged in the treatment of the child with
uncomplicated acute upper respiratory infections. Health centres and hospitals will stop
purchase of commercial cough syrups.
Private practitioners will be encouraged to use simple safe cough remedies and curtail the
use of cough medicines containing atropine, alcohol, codeine or antihistaminics in treatment
of children with cough.
Only saline nasal drops are recommended for running or blocked nose.
5.5
REFERRAL
A child coming from village to the Primary Health Centre managed and referred by a health
worker must be given priority attention over others in out patients’ que. This is because the
condition may be serious and such a child should not wait.
Ask for referral note and get an idea of the management given there. Assess the patient
quickly and start treatment immediately.
Do not point out any inadequaciis in the management by health worker in front of the
relations of the child. We must appreciate what she has done within the limitations of the
facilities she had. If there are serious flaws she can be corrected at a personal level later at
the sub centre or when she comes for monthly meetings.
A health worker has to take over your role of case management just in case a child with
pneumonia cannot be referred to a PHC. Please refer to the "Manual for Health Workers"
for the details of management at her level. If she has risen to the occasion compliment her
in your reply note when the child is discharged. Also write about the case management and
diagnosis and any follow up care by the health worker required for the child.
31
EXERCISE B
Sundari is a 16 month old girl. Her mother tells you that she had cough for 7 days but then
Sundari suddenly became ill. She did not feed well and was drinking poorly. There was no
fever and no history of convulsions. She was breathing 62/minute. She had chest indrawing
and appeared to be having breathing difficulty. Sundari had great effort breathing out and
her expiratory phase of breathing was prolonged. There was no wheezing or stridor. Her
tongue was blue, she was very restless and perspiring. Temperature was 38.4°C. She was
not undernourished.
(a)
List all of Sundari’s signs and symptoms of illness in the space below.
(b)
Record how you would classify Sundari’s illness by writing the classification in the
space below. Also list the signs you used to classify her illness.
How would you treat Sundari and name of each medicine you will prescribe and its
dose.
32
5.6
SERVICE DELIVERY AT VARIOUS LEVELS
Village
o
Mothers
o
o
o
o
o
AWW/VHG
PHO/
Urban centres
o
o
o
HW (F)
o
PHC/Urban Centres
Medical Officer
CIIC7
District Hospital/
First level referral centres
Specialist
Gel children Vitalnin A prophylaxis and immunization as per
schedule
Avoid exposure wf babies to cold, dust and smoke
Learn home-level care and when to seek help for cough and cold
Ensure immunization (DPT, Measles and BCG) and Vitamin A
prophylaxis
Educate on dust and smoke free environment
Teach/advicc on home remedies/carc for cough and cold
Assess and treat on the basis of standard case management
Refer when required
Educate on home remedies for cough, prevention and home care for
ARI \
Ensure immunization (DPT, measles and BCG) and Vitamin A
prophylaxis.
o
o
o
o
All above plus
Receive referrals, assess, manage and give feed back
Refer to district hospitals/first level referral centres when required
Record and follow surveillance procedures
o
Receive referrals and provide appropriate treatment especially for
severe and persistent pneumonia
Educate health functionaries regarding home remedies and early
referral, standard case management etc.
Compile surveillance data, analyze, send reports and provide
feedback.
o
o
33
"A
--te
t:'
6.0
CONTROL OF DIARRHOEAL DISEASES
Diarrhoea] diseases are a major cause of morbidity and mortality among
years (0-5 years). It has been estimated that diarrhoea accounts for 28
age group i.e. 1 million deaths every year. Most of the deaths in diar ■
re .
dehydration (loss of water and electrolytes) caused due to frequent passug c.
motions. A child on an average suffers from 2-3 attacks of diarrhoea eacr veu heveTiuur
of diarrhoea itself is not an easy task and remains a long term goal to n
National Oral Rehydration Therapy (Control of Diarrhoeal Diseases) Pro.
presently aims at reducing deaths due to diarrhoeal diseases among the (•
Goal
To reduce deaths due to dehydration caused by diarrhoeal diseases thr
Oral Rehydration Therapy (ORT) by 30 % in 1995 and by 70 % in 200
Coverage
Improved ORT use rate by 60 %
What is diarrhoea ?
Diarrhoea is defined as passage of liquid or watery stools. These liquifieci s
passed more than three times in a day; however, it is the recent change r.
character of the stools rather than the number of stools that is the more :
Passage of even one large watery motion among children may constitute
stools contain mucus or blood it is known as dysentery.
What is not diarrhoea ?
o
o
o
o
passage of frequent formed stools
passage of pasty stools in a breast-fed child
passage of stools during or immediately after feeding
passage of frequent loose greenish yellow stool in the 3rd and 4th day
diarrhoea)
In most situations, mothers know better what is an abnormal stool of he
THREE TYPES OF DIARRHOEA
1. Acute watery diarrhoea starts suddenly and mav continue for a nuna^x
more than 14 days. Most of these are self limiting and will last for 3 :
-i./- b< .:
2. Dysentery is diarrhoea with visible blood in stools.
Persistent diarrhoea begins acutely but is of unusually long duration
than 14 days.
34
iu.-—............
WHY IS DIARRHOEA DANGEROUS ?
o
two main dangers of diarrhoea are death and malnutrition.
o
diarrhoea leads to loss of water and electrolytes (sodium, chloride, pottassium and
bicarbonates) from the body through diarrhoea stool. Dehydration occus when these
losses are not replaced adequately and body develops a deficit of water and electrolytes.
If untreated, dehydration leads to death.
o
undernutrition in diarrhoea occurs because - nutrients are lost from the body, a child
with diarrhoea may be anorexis, and mothers often reduce food for some more days
even after diarrhoea is treated or has stopped.
Strategy
o
correct case management at all levels enabling mothers at home to use Home available
fluids (HAF) for diarrhoea without dehydration followed by Oral Rehydration Salts
(ORS) solution whenever a child gets dehydration. Mothers should be able to recognise
dehydration so that she can start Oral Rehydration Therapy and can seek help when the
condition of the child worsens. In addition, correct and improved management of cases
depending on degree of dehydration at all health facilities will have to be ensured.
o
ensure availability of ORS packets through government outlets and in villages through
village level functionaries including Anganwadi worker (AWW) wherever possible
o
eliminate irrational use of drugs in the management of diarrhoeal diseases.
The strategy is based on the following observations :
1.
Ninety percent of all diarrhoea episodes do not develop dehydration. These can be
managed at home by mothers with the use of home available fluids (HAF) and
continued feeding.
2.
Nine percent of all episodes will develop some dehydration. These need to be managed
at health facilities with the use of Oral Rehydration Salts (ORS) solution.
3.
One percent of episodes will develop severe dehydration needing intravenous infusion
therapy. These need to be referred to the nearest facility where intravenous infusion
could be given.
35
6.1 ASSESS CHILD WITH DIARRHOEA
A child with diarrhoea should be assessed to determine the nature and pattern of diarrhoea,
the degree of dehydration (no signs, some or severe dehydration) and the presence of any
other problems (i.e. blood in stool or severe undernutrition) so that appropriate treatment
can be started without delay.
History should be taken from the patient or a family member. ASK questions to obtain
information on : duration of diarrhoea, consistency of stool, presence of blood in stool,
presence of fever, convulsions or other problems, pre-illness feeding practices, type and
quantity of fluids (including breast milk), food consumed during illenss and drugs or other
remedies taken. However answers to many of these questions will not decide the degree of
dehydration. Please note that degree of dehydration will be determined by the signs as
described in the table that follows.
DETERMINE DEGREE OF DEHYDRATION USING THE TABLE BELOW
A
B
C
1. LOOK :CONDITION
Well, alert
♦Restless, Irritable*
EYES
Normal
Sunken
♦Lethargic or unconscious;
Hoppy*
Very sunken and dry
TEARS
Present
Absent
absent
MOUTH & TONGUE
Moist
Dry
Very dry
THIRST
Drinks
normally,
not thirsty
♦Thirsty, drinks
eagerly*
♦Drinks poorly or not able to
drink*
2. FEEL: SKIN PINCH
Goes back
quickly
♦Goes back slowly*
♦Goes back very slowly*
3. DECIDE:
The patient
has NO
SIGNS OF
DEHYDRA
TION
If the patient has two or
more signs, including at
least one *sign*, there
is SOME
DEHYDRATION
If the patient has two or more
signs, including at least one
♦sign*, there is SEVERE
DEHYDRATION
4. TREAT
Use
Treatment
Plan A
Weigh the patient, if
possible, and use
treatment Plan B
Weigh the patient and use
Treatment Plan C
URGENTLY
Physical examination
LOOK at the patient. General condition: alert; restless or irritable; floppy, lethargic or
unconscious; severely undernourished? Are the eyes: sunken or very sunken and dry?
36
t
f
Are there tears when the child cries? Are the mouth and tongue: moist, dry or very dry?
(Confirm by feeling the child’s tongue and the inside of the mouth with a clean dry finger).
When water is offered to drink: is it taken normally or is the patient unable to drink?
FEEL skin pinch. Skin turgor. When the skin over the abdomen or the thigh is pinched
and released, does it flatten : quickly, slowly or very slowly?
Take temperature. Does the child have a high fever (Axillary temperature more than 38.5°C
or 101°F).
37
I
EXERCISE C
Look at the table given below. For the first part of the exercise try to recapitulate the signs
you should look and feel. Fill column 1 only. Against others you should enlist the serious
problems ( other than dehydration) one could identify in a case of diarrhoea.
This part is nothing but recapitulation so check yourself how many blanks you can fill up
without looking at the previous pages. IN CASE YOU HAVE MISSED ANY, FEEL
FREE TO CONSULT. DO NOT LEAVE ANY SPACE BLANK IN COLUMN 1,
BEFORE YOU PROCEED.
Col.No.I
1.
LOOK AT
2.
FEEL FOR
3.
OTHERS
Col.No.II
A
B
C
D
Since you could write up all the items in column 1, we assume you looked at and felt the
items for a diarrhoea child whose case history is given below:
Read out the following case history and enteR the observations in column 2 of the table on
the facing page against respective item.
Case history : The 18 months old child Panu is having diarrhoea since last 3 days. You
learn that Panu has been drinking a lot of water. He has vomited 2 times and has had 11
watery stools today. You note that Panu’s eyes are somewhat sunken and his mouth and
tongue are dry. When you pinch the skin in his abdomen the skin goes back slowly. His
temperature is 39°C. Panu is restless and irritable and cries during examination. There are
tears when he cries.
BEFORE YOU PROCEED FURTHER ENSURE THAT YOU HAVE ENTERED ALL
THE OBSERVATIONS IN COLUMN NO. II. >'
38
Based on your entry on Column I and Column II, you will find some symptoms/signs
belonging to category A (no dehydration), some in category B (some dehydration) and some
in category (severe dehydration) in the table ‘how to assess your patient’.
Can you interpret each item separately putting a tick mark against each of them under
column ‘A’, ‘B’ & ‘C’ to signify degree of dehydration or any other serious problem they
indicate in column ‘D’.
Finally look at the whole table you have filled up. Now you get a total picture of status of
dehydration of Panu. So please answer:
1.
What is the Oxgree of dehydration shown by Panu (Check one)
( ) no dehydration;
2.
( ) some dehydration,
( ) severe dehydration
Which treatment plan do you select for Panu for dehydration if any?
Plan
3.
Are there any other serious problem shown by Panu that require treatment?
If yes, how would you treat the problem?
39
6.2 MANAGE CHILD WITH ACUTE DIARRHOEA
Once assessment of degree of dehydration is performed - the appropriate treatment plan
has to be selected.
For no dehydration
Treatment Plan A
(Prevention of dehydration)
For some dehydration
Treatment Plan B
(Rehydration with ORS Solution)
For severe dehydration
Treatment Plan C
(Rehydration with I/V infusion)
Feeding during and after diarrhoea, to prevent nutritional damage is extremely important.
6.2.1 WHEN THERE ARE NO SIGNS OF DEHYDRATION (TREATMENT PLAN A)
This aims at preventing dehydration in early diarrhoea. Mothers should be taught how to
prevent dehydration at home by giving the child increased amount of fluids, how to continue
to feed the child and why these actions are important. There are three rules for treating
diarrhoea at home. See Treatment Plan A on page 41.
Rule 1
Give the child more fluids than usual to prevent dehydration
Home made or Home available fluids which are traditionally acceptable can be used for
home therapy of diarrhoea. Traditional fluids may vary from place to place. Home
available fluids (HAF) such as rice water, dal water, sikanji. buttermilk, etc. can be promoted
depending on suitability, availability and acceptability at local levels.
Ru 1 e 2 Continue feeding the child
Food should never be withheld during diarrhoea. This is important as it prevents
undernutrition of the child. Breast feeding should continue without interruption. The aim
is to give as much nutrient rich food as the child will accept. Child should be given
additional meals after the episode of diarrhoea is over for some days to prevent
undernutrition.
Rule 3
Watch for signs of dehydration
Explain the mother that she should take her child to a health worker if the child does not
get better in two days or child starts passing many stools, has repeated vomitting, is eating
and drinking poorly, develops excessive thirst, develops fever or has blood in stools. When
a parent brings a child with diarrhoea but no dehydration give one ORS packet.
40
TREATMENT PLAN A
TO TREAT DIARRHOEA AT HOME
USE THIS PLAN TO TEACH THE MOTHER TO:
•
•
Continue to treat at home her child's current episode of diarrhoea.
Give early treatment for future episodes of diarrhoea.
EXPLAIN THE THREE RULES FOR TREATING DIARRHOEA AT HOME:
1.
GIVE THE CHILD MORE FLUIDS THAN USUAL TO PREVENT DEHYDRATION:
• Use a recommended home fluid, such as a cereal gruel. If this is not possible, give
plain water. Use ORS solution for children described in the box below.
• Give as much of these fluids as the child will take. Use the amounts shown below for
ORS as a guide.
• Continue giving these fluids until the diarrhoea stops.
2. GIVE THE CHILD PLENTY OF FOOD TO PREVENT UNDERNUTRITION:
• Continue to breast-feed frequently.
• If the child is not breast-fed. give the usual milk. If the child is less than Smooths old
and not yet taking solid food, dilute milk or formula with an equal amount ot water for
2 days.
• If the child is 6 months or older, or already taking solic food:
- Aso give cereal or another starchy food mixed, if possible, with pulses,
vegetables, and meat or fish. Add 1 or 2 teaspoonfuls of vegetable oil to each
serving.
- Give fresh fruit juice or mashed banana to provide potassium.
- Give freshly prepared foods. Cook and mash or grind food well.
- Encourage the child to eat; offer food at least 6 times a day.
• Give the same foods after diarrhoea stops, and give an extra meal each day for
two weeks.
3. TAKE THE CHILD TO THE HEALTH WORKER IF THE CHILD DOES NOT GET
BETTER IN 3 DAYS OR DEVELOPS ANY OF THE FOLLOWING:
• Many watery stools
’ • Eating or drinking poorly
Repeated vomiting
• Fever
• Marked thirst
• Blood m the stool
CHILDREN SHOULD BE GIVEN ORS SOLUTION AT HOME, IF:
• They have been on Treatment Plan B ot C.
• They cannot return to me heann Morker it the Oarrhoea gets worse
• n ts national policy to grve OPS to al children
see a heann worker tor
diarrhoea.
IF THE CHILD WILL BE GIVEN ORS SOLUTION AT HOME, SHOW THE MOTHER
HOW MUCH ORS TO GIVE AFTER EACH LOOSE STOOL AND GIVE HER
ENOUGH PACKETS FOR 2 DAYS:
Age
Amount of ORS to give
after each loose stool
Amount of ORS to provide
for use at home
Less than 24 months
50-100 ml
500 ml/day
2 up to 10 years
100-200 ml
1000 ml/day
10 years or more
As much as wanted
2000 ml/day
• Describe and show the amount to be given after each stool using a local measure.
SHOW THE MOTHER HOW TO MIX ORS.
SHOW HER HOW TO GIVE ORS:
• Give a teaspoonful every 1-2 minutes for a child under 2 years.
• Give frequent sips from a cup lor an older child.
• II the child vomits, wait 10 minutes. Then give the solution more slowly (for example,
a spoonful every 2-3 minutes).
• II diarrhoea continues after the ORS packets are used up. tell the mother to give other
fluids as described in the first rule above or return tor more ORS.
..
41
6.2.2 WHEN THERE IS SOME DEHYDRATION (TREATMENT PLAN B)
Oral Rehydration Solution (ORS) must be used in cases with some dehydration. Treatment
with ORS aims at:
Correction of water and electrolyte deficit as indicated by degree of dehydration
(Rehydration); replacement of on going losses due to continuing diarrhoea (maintenance)
and provision of normal daily fluid requirement.
The detailed composition of ORS (WHO formulation) is :
INGREDIENTS
AMOUNT
Glucose (a form of sugar)
Sodium chloride (ordinary salt)
Sodium Citrate1
Potassium chloride
20.0 gms
3.5 gms
2.9 gms
1.5 gms
It is very important that the ORS solution is mixed properly, in exactly one litre of water.
The method of preparation of ORS solution is : Packets that contain the ingredients as
stated above are made for mixing in one litre of drinking water. This mixture is called ORS
SOLUTION. Preparation of ORS solution is a skill that all health workers should have.
They must always try to supply ORS solution as mothers can commit serious mistakes in
preparing the solution.
To prepare ORS solution, i) Wash your hands, ii) Measure 1 litre of clean drinking water
using the measuring container supplied and iii) Pour all the powder from one packet into
the wate and mix well until powder is completely dissolved.
Fresh ORS solution should be mixed each day in a clean container. The container should
be kept covered. Any solution remaining from the day before should be thrown away then
and there.
For determining the approximate volume of ORS Solution to be given, atdifferent ages
(when it is not possible to weigh the child) - the table given on the top of the chart on the
facing page may be used as a guideline. The exact quantity of ORS Solution to be given will
however, depend upon the child’s dehydration status. Patients with many or more marked
signs of dehydration will require more solution than those with fewer or less marked signs.
If the patient wants more ORS solution than the volume shown on the chart and there are
no signs of overhydration give more.
1 Trisodium citrate dihydrate - 2.9 grams soda bicarbonate 2.5.gms can also be used
as an alternative to sodium citrate.
42
TREATMENT PLAN B
TO TREAT DEHYDRATION
APPROXIMATE AMOUNT OF ORS SOLUTION TO GIVE IN THE FIRST 4 HOURS:
Age: •
Less than 4
months
4-11
months
12 - 23
months
2 -4
years
5 - 14
years
15 years or
older
Weight:
Less than 5 kg
5 - 7.9 kg
8 - 10.9 kg
11 - 15.9 kg
16- 29.9 kg
30 kg or more
in ml
200-400
400-600
600-800
800-1200
1200-2200
2200-4000
in local
measure_____________ _______________________ __]________________________ ____________ _
• Use the patient’s age only when you do not know the weight The approximate amount of ORS required
(in ml) can also be calculated by multiplying the patients weight (in grams) times 0.075.
• If the child wants more ORS than shown, give more.
• Encourage the mother to continue breast-feeding.
• For infants under 6 months who are not breast-fed, also give 100-200 ml clean
water during this period.
OBSERVE THE CHILD CAREFULLY AND HELP THE MOTHER GIVE ORS SOLUTION:
• Show her how much solution to give her child.
• Show her how to give it - a teaspoonful every 1 -2 minutes for a child under 2 years,
frequent sips from a cup for an older child.
• Check from time to time to see if there are problems.
• If the child vomits, wait 10 minutes and then continue giving ORS, but more slowly,
for example, a spoonful every 2-3 minutes.
• If the child's eyelids become puffy, stop ORS and give plain water or breast milk.
Give ORS according to Plan A when the puffiness is gone.
AFTER 4 HOURS, REASSESS THE CHILD USING THE ASSESSMENT CHART. THEN
SELECT PLAN A, B, OR C TO CONTINUE TREATMENT.
. |f there are no signs of dehydration, shift to Plan A. When dehydration has been
corrected, the child usually passes urine and may also be tired and fall asleep.
• If signs indicating some dehydration are still present, repeat Plan B, but start to
offer food, milk and juice as described in Plan A.
• If signs indicating severe dehydration have appeared, shift to Plan C.
IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT PLAN B:
• Show her how much ORS to give to finish the 4-hour treatment at home.
• Give her enough ORS packets to complete rehydration, and for 2 more days as
shown in Plan A.
•
Show her how to prepare ORS solution.
• Explain to her the three rules in Plan A for treating her child at home:
- to give ORS or other fluids until diarrhoea stops
- to feed the child
- to bring the child back to the health worker, if necessary.
43
6.23 WHEN THERE IS SEVERE DEHYDRATION (TREATMENT PLAN C)
Treatment Plan C deals with treatment of severe dehydration. Community based health
stafi should be advised not to attempt I.V. treatment in these cases. They should, however,
start immediate treatment with ORS as per Treatment Plan B and at once refer the case to
the nearby facility for I.V. treatment. If ORS packet is not available treatment with ‘Home
Available Fluids’ should be started.
Intravenous therapy for servere dehydration
Solutions for intravenous infusion - A number of solutions are available for IV infusion;
however, some do not contain appropriate or adequate amounts of the electrolytes required
to correct the deficits found in dehydration associated with acute diarrhoea.
Preferred solution is - Ringer s Lactate Solution which supplies adequate concentration of
sodium and potassium and the lactate yields bicarbonate for correction of acidosis, and
Acceptable solution is - Normal Saline which is readily available. It will not correct the
acidosis and will not replace potassium losses. If used, this solution should be accompanied
by ORS solution orally.
Providing IV Therapy for severe dehydration - The purpose is to give the patient a large
quantity of fluids quickly to replace the very large fluid loss which has resulted in severe
dehydration.
Plain Glucose and Dextrose Solutions should not be used as they provide only water and
sugar. They do not contain electrolytes and thus they do not correct the electrolyte losses
causing the acidosis.
Begin intravenous therapy quickly in the amount specified on Treatment Plan C
o
Start IV Fluids immediately if the patient can drink, give ORS by mouth while the drip
is set up. Give 100 ml/kg Ringer’s Lactate solution (or. if not available, Dextrose saline)
divided as given in the table on the top of the chart (facing page).
o
Repeat once if radial pulse is still very weak or not detectable
o
Reassess the child even' 1-2 hours if hydration is not improving, give the IV drip more
rapidly.
o
Also give ORS (about 5 ml/kg/hour) as soon as the patient can drink: usually after 3-4
hours (infants) of 1-2 hours (older patients)
o
After 6 hours (infants) or 3 hours (older patients), evaluate the patient using the
assessment chart. Then choose the appropriate Plan (A,B or C) to continue treatment
44
TREATMENT PLAN C
TO TREAT SEVERE DEHYDRATION QUICKLY
FOLLOW THE ARROWS. IF ANSWER IS “YES', GO ACROSS. IF‘NO", GO DOWN
START HERE
• Stan IV fluids immediately If the patient can drink, give
ORS by mouth while the dnp is set up Give 100 ml/kg
Ringer s Lactate Solution (or. if not available, normal
saime). divided as follows:
Can you give
intravenous (IV)
fluids immediately-’
Age
Infants
(under 12 months)
Older
First give
30 ml/kg m
Then give
70 ml/kg in
1 hour •
5 hours
30 minutes ’
2 1/2 hours
* Repeal once if radial pulse is still very weak or not detectable.
• Reassess lhe patient every 1 -2 hours. If hydration <s not
improving, give the IV dnp more rapidly.
• Also give ORS (about 5 ml/kg/hour) as soon as the patient
can drink: usually after 3-4 hours (infants) or 1 -2 hours
(older patients).
• After 6 hours (infants) or 3 hours (older patients), evaluate
the patient using the assessment chart. Then choose me
appropriate Plan (A. 8 or C) to continue treatment.
NO
• Send the patient immediately for IV treatment.
Is IV treatment
available nearby,
(within 30 minutes)'’
• If the patient can drink, provide the mother with ORS
solution and show her how to give it during the trip.
I
NO
Are you trained to
use a naso gastric
(NG) tube for
rehydration?
I
♦
Can the patient
dunk?
I
I
IfESI
• Start rehydration by tube with ORS solution: Give 20 ml/
kg/hour for 6 hours (total of 120 ml/kg).
• Reassess the patient every 1 -2 hours:
- If there is repeated vomiting or increasing abdominal
distension, give the fluid more slowly.
- If hydration is not improving after 3 hours, send the
patient for IV therapy
• After 6 hours, reassess the patient and choose the
appropriate Treatment Plan.
• Start rehydration by mouth with ORS solution, giving 20
ml/kg/hour for 6 hours (total of 120 ml/kg).
• Reassess the patient every 1 -2 hours.
- If there is repealed vomiting, give the fluid more
slowly
- If hydration is not improving after 3 hours, send the
patient for IV therapy.
• After 6 hours, reassess the patient and choose the
appropriate Treatment Plan.
URGENT Send
lhe patient tor IV or
NG treatment
NOTES;
• If possible, observe the patient at least 6 hours after rehydration to be sure the
mother can maintain hydration giving ORS solution by mouth.
• If the patient is above 2 years and there is cholera in your area, give an
appropriate oral antibiotic after the patient is alert.
45
6.2.4 WHEN THERE IS DYSENTERY
Diarrhoea with blood in stool
t
Treat with cotrimoxazole
t
+
Give ORS and early feeding
+
Treat fever with paracetamol
Observe daily for 2 days
+
Child weel or definitely improving
_______ ±________
Yes*
Continue therapy
Monitor weight response
No
Treat with Nalidixic Acid*
I
Monitor weight response
* As indicated by disappearance of fever and of blood in stools
** If not applicable, or not available refer to a pediatrician
6.2.5 WHEN THERE IS PERSISTENT DIARRHOEA
o
Persistent diarrhoea begins as acute diarrhoea and continues for more than 14 days
o
Malnutrition in such children is common due to a combination of unresolved infection
and malnutrition
/
o
A vicious cycle between malnutrition and diarrhoea each precipitating the other leads
to chronic illness in the child
o
Refer to child specialist if : the child is under 6 months old, dehydration is present
(Refer the child after treatment of dehydration),
o
Otherwise, teach the mother to feed her child as in Plan A, except:
dilute any animal milk with an equal volume of water or replace it with a fermented
milk product, such as curd and butter milk.
assure full energy intake by giving 6 meals a day of thick cereal and added oil, mixed
with vegetables, pulses, meat or fish.
o
Tell the mother to bring the child back after 5 days:
if diarrhoea has not stopped, refer to hospital
if diarrhoea has stopped, tell the mother tof,
use the same food for the child’s regular diet
after 1 more week, gradually resume the usual animal milk
give an extra meal each day for at least 1 month.
46
THEN, FOR OTHER PROBLEMS
ASK ABOUT BLOOD IN
THE STOOL
IF BLOOD IS PRESENT:
Treat for 5 days with an oral antibiotic recommended for
Shigella in your area.
f. e . c©r r i Asoxato'e
Teach the mother to feed the child as described in Plan A.
•
•
ASK WHEN THIS EPISODE OF
DIARRHOEA BEGAN
LOOK FOR SEVERE
UNDERNUTRITION
ASK ABOUT FEVER AND
TAKE TEMPERATURE
•
See the child again after 2 days if:
- under 1 year of age
- initially dehydrated
- there is still blood in the stool
- not getting better
•
If the stool is still bloody after 2 days, change to a second
oral antibiotic recommended for Shigella in your area.
Give it for 5 days. - Nandi xic Acid
IF DIARRHOEA HAS LASTED AT LEAST 14 DAYS:
•
Refer to hospital if:
- the child is under 6 months old
- dehydration is present. (Refer the child after
treatment of dehydration.)
•
Otherwise, teach the mother to feed her child as in Plan A,
except:
dilute any animal milk with an equal volume of water
or replace it with a fermented milk product, such as
yoghurt, (curd)
Assure full energy intake by giving 6 meals a day of
thick cereal and added oil, mixed with vegetables,
pulses, meat, or fish.
•
Tell the mother to bring the child back after 5 days:
- if diarrhoea has not stopped, refer to hospital.
- if diarrhoea has stopped, tell the mother to:
- use the same foods for the child's regular diet.
- after 1 more week, gradually resume the usual
animal milk.
- give an extra meal each day for at least 1 month.
i
IF THE CHILD HAS SEVERE UNDERNUTRITION:
•
Do not attempt rehydration; refer to hospital for management.
.
Provide the mother with ORS solution and show her how to
give 5 ml/kg/hr during the trip.
IF TEMPERATURE IS 39’ C OR GREATER:
•
Give paracetamol.
IF THERE IS FALCIPARUM MALARIA IN THE AREA,
and the child has any fever (38°or above) or history of fever in
the past 5 days:
• Give an antimalarial (or manage according to your malaria
programme recommendation).
47
Ensuring ORS availability through setting up of ORS Depots
You will attempt setting up of ORS depots in every village. The same functionaries who
normally may be acting as depot holders for contraceptives/chloroquine tablets for malaria
may also function as ORS Depot holders. The idea of such a strategy is to ensure ORS
availability in the village for 24 hours a day.
Wherever possible, you will identify Anganwadi workers (in ICDS blocks) village health
guides or trained birth attendants as ORS depot holders. Once they are identified as depot
holders, the supply line of ORS packets from several sources including government (health
and other departments), and non-government budgets will have to be ensured.
Remember a ORS depot holder in the villages covered by your health worker increases the
access to ORS packets and can prevent dehydration and death at village level.
Setting up ORT corners in Health Centre/Hospital
During summer season or when there is a big case load of diarrhoeas during other seasons,
it is very advantageous to set up an ORT corner. A portion of the out patient facility is
converted for the purpose.
What is the aim of an ORT comer?
The aim is to manage cases with some dehydration without admission and send home the
child before the end of the day. This will reduce the cost and inconvenience caused to the
family due to an avoidable hospitalisation of a child with diarrhoea. ORT corner not only
teaches the mother how to give oral rehydration solution but also convinces her how well
it works. This makes her confident to manage a child with diarrhoea next time in her own
home or in the neighbourhood.
What is done in an ORT Comer?
o
The child is assessed after taking history and examination.
o
Depending on the level of dehydration determine the amount of fluid to be given in 4-6
hours.
o
Demonstrate mixing and administering ORS to the mother.
o
Deal with difficulties in administering ORS (such as vomitting).
o
Treat other problems (e.g. giving paracetamol for fever - tepid sponging giving
antispasmodics for colic etc.).
48
o
Encourage the mother to begin feeding the child (Provision of food to children who
remain in ORT Corner more than 6 hours must be made).
o
Assess the patient every 2 hours till rehydrated and record the progress.
o
Determine the amount of ORS to be given for maintenance at home and provide the
same.
o
Teach the mother home level care and when to bring back the child.
o
Impress upon her how to prevent diarrhoea in future.
What do you need for the ORT Comer?
o
Enough place with good ventilation with access to toilet as well as washing facilities.
o
A few benches, mats, rubber sheets, ORS packets, large containers with taps at bottom
for easy distribution, cups, glasses, spoons, etc.
49
6.3 SERVICE DELIVERY AT VARIOUS LEVELS
Village level
*
*
VHG/AWW/TBA*
*
Assess diarrhoeal cases and provide Correct Case Management
Provide ORS through atieast one depot holder
Educate on Correct Home Management of diarrhoea.
Educate mothers on when to seek referrals.
*
*
*
All the above plus
Maintain records and report
Supply ORS packets to depot holders (wherever possible)
Medical officer
*
*
*
*
*
*
*
*
All the above plus
Have ORT Corners for outpatient care during seasonal peaks
Receive referrals and provide appropriate treatment.
Referrals to next level.
Maintain, analyse records and report,
Epidemic Control.
Surveillance.
Training of staff in diarrhoea management.
First level
referral centre
*
*
*
All the above plus
Diarrhoea Training Unit ORT Corners
Training for correct case management.
Sub-centre level
HW (F)
PHC/Urban
centre
50
CASE STUDIES ON
MATERNAL MORTALITY
(To be carried out in individual groups - one case study analysis per group
followed by presentation by groups in a plenary session)
0
CHIoi
COMMUNITY HEZITH CELL
326, V Ms in, | Block
Korarrh.ngiHa
Bangalore-66UQ34
India
7.0 GROUP WORK TO ANALYSE CASE STUDIES
Objectives
*
After this session you will be able to :
list 6 principal medical causes of maternal mortality;
able to associate common signs and symptoms with these causes of maternal
mortality; and
state at least 10 social causes of maternal mortality.
*
be aware of, and mention, the routine non-emergency health actions required during the
ante-natal, intranatal and post-natal periods.
*
spell out
what families can do at home, what families cannot do
what trained TBAs can do, and should not attempt to do
what health workers can do to prevent maternal deaths
*
identify which medical conditions can be effectively dealt with only at first level referral
with essential obstetric emergency services.
Design: There are five case studies specially included for this programme from the case
histores of unfortunate women admitted in leading hospitals of the country. Each
one of these cases are typical and represent several other such women who meet
similar ends at homes, in the sub-centre headquarters, PHCs and district hospitals.
You will be given forty-five minutes to analyse the case studies and answer the
questions that follow. Each group will be expected to analyse at least one case
study. Your facilitator will indicate the Case study you will be analysing in your
group. After answering the questions your group may identify one of you to
present the answers in the plenary session which will be for forty-five minutes.
52
<v
Case Study I
Taiji Bai came for her first ante-natal visit during the 7th month of pregnancy. On
enquiry it was found that Taiji was 29 years old, having had five full-term normal
deliveries, and the last delivery was eighteen months back. This time she said she
was feeling tired for the last two months, feeling breathless and could not perform
routine household work which she could before. She had developed swelling of the
feet during the last one month. The ANM found her pale and she asked her to get
admitted. Taiji did not get admitted because her husband did not take her as there
was nobody at home to look after the children. Taiji also said that she had five
normal deliveries at home, there was no checkup that was done, and everything was
fine in the past.
Three days later, the ANM visited her - she had gone into labour and was delivered
at home by an untrained dai. After the delivery of the baby, there was severe
bleeding and part of the placenta was still inside. So the dai told her to go to
hopsital. Before any transportation was organized Taiji died at home.
Taiji went to visit Dr. Matwankar, a private practitioner in the village at the seventh
month. Dr. Matwankar was interviewed by the Health Staff later. He said she was
anaemic when he saw Taiji and so Dr. Matwankar prescribed iron tablets and BComplex. But her brother said he did not purchase that medicine. Dr. Matwankar
also said that after the delivery of the baby he saw that part of the placenta inside
and so advised Taiji’s family to take her to the primary health centre. Due to lack
of transport he said the patient died at home. He also commented that no blood
or urine test was done, nor her blood pressure examined because these facilities
were not available.
53
1.
What was the direct cause of death?
2.
What were/was the underlying medical cause(s) of death?
3.
What were/was the associated social and other factor(s) that lead to death?
4.
What were the common signs and symptoms that Taiji suffered?
5.
What could have been done by the family to prevent this emergency?
6.
What could have been done by the family to save Taiji once the emergency occured?
7.
What were the ’’missed opportunities" for saving Taiji’s life? What were they?
8.
What action could have been taken at the village level?
54
9.
What action could have been taken at the Sub-centre or by health worker?
10. What action could have been taken at the Primary health Centre?
11. What action could have been taken at the first level referral services?
12. Who are the decision makers and influencers?
13. What could have been done by sectors other than health to prevent this death?
14.
What was the role of the private practitioner?’
15. What are the key programme interventions that would have saved Taiji?
55
Case Study II
Chanchai, 24 years old, residing at Bhirwadi, was admitted to the District Hospital,
Alibaug for two months amenhoerrea (no menstruation) with fever and bleeding
per vaginum. On enquiry, Chanchai had two full term normal deliveries - both
boys. She had a disturbed marital life. Her husband beat her up regularly after
being heavily drunk. Her mother-in-law always supported her husband to beat her
and abuse her. Chanchai left her in-laws’ house and went to her parents with both
her children. Occasionally, her husband would visit her. She became pregnant
after her husband’s last visit; she asked her husband what to do. Chanchai’s
husband refused to let her have an abortion (MTP) with or without sterilization.
Chanchai’s mother-in-law wanted her to deliver six children like herself.
Chanchai and her friend, Shobha, went to an ANM for medical termination of
pregnancy. The ANM gave her the District Hospital’s address. Chanchai’s mother
took her to a local dai who conducts delivery in the village. Maltibai (dai)
introduced a stick and paste into her uterus and asked her to go home. Chanchai
was bleeding and had fever with chills two days later. She started getting foul
smelling discharge. She went to maltibai who told her to wait and observe the
problem for a few days more. Meanwhile, Chanchai started having high
temperature, vomitting, distension of abdomen and breathlessness. The ANM was
called after three days; and advised them to go to the District Hospital.
The family went to primary health centre, and no doctor was there. They then
went to the district hospital. The Medical Officer examined the patient. Antibiotic
Ampicillin was started within 48 hours. Chanchai became more breathless, stopped
passing urine and died.
56
1.
What was the direct cause of death?
2.
What were/was the underlying medical cause(s) of death?
3.
What were/was the associated social and other factor(s) that lead to death?
4.
What were the first symptoms that Chanchai suffered?
5.
What could have been done by the family to prevent the emergency?
6.
What could have been done by family to save Chanchai once the emergency occured?
7.
Were there any opportunity to save the life of Chanchai? What were they?
8.
What action could have been taken at the village level?
.>*
57
9.
What action could have been taken at the Sub-centre or by health worker?
10. What action could have been taken at the Primary health Centre?
11. What action could have been taken at the first level referral services
12. Who are the decision makers and influencers?
13. What could have been done by sectors other than health to prevent this death?
14.
What made Chanchal’s mother decide to take her to the local dai instead of taking
her to the district hospital as advised by the ANM?
15. What are the key programme interventions that would have saved Chanchai.
58
Case Study III
Sulochana Gajanand Patel, 17 years old has been married for eight months. Since
her marriage, she did not menstruate.
She started developing swelling of feet since four months for which was advised to
go to Primary health centre for blood pressure, urine check, etc. Sulochana
contacted the ANM only after she got swelling of the feet.
Her mother-in-law refused to take Sulochana to any insitution, as she herself has
delivered 10 children and never seen a hospital. Two days later Sulochana had pain
in the abdomen, difficulty in vision and was irritable. The mother-in-law and
relatives thought it was due to evil spirits, so they sent for the person known for
removing evil spirits. He arrived after two hours and performed the rituals for
removing the evil spirits her. Suddenly the patient had fits. To stop the fit, they
put lime, shoes and other items in front of her nose. But the fits continued for
sometime. They went to call ANM who asked them to transfer her to a PHC. It
was night time so they did not get transport. Next day morning they took her in a
cloth stretcher to the primary health centre. She was found deeply unconscious,
with high blood pressure and no urine was passed. There was swelling of the face
and Sulochana’s leg. The PHC doctor referred Sulochana to the District Hospital.
At district hospital she was treated for five days before Sulochana died.
59
1.
What was the direct cause of death?
2.
What were/was the underlying medical cause(s) of death?
3.
What were/was the associated social and other factor(s) that lead to death?
4.
What were the Sulochana’s first symptoms?
5.
What could have been done by the family to prevent the emergency?
6.
What could have been done by the family to save Sulochana once the emergency
occured?
7.
Were there any opportunity to save the life of Sulochana? What were they?
8.
What action could have been taken at the village level?
60
9.
What action could have been taken at the Sub-centre or by health worker?
10. What action could have been taken at the Primary health Centre?
11. What action could have been taken at the first level referral services
12. Who are the decision makers and influencers ?
13. What could have been done by sectors other than health to prevent this death?
14. What are your comments on the present system of referral?
15. What are the key programme interventions that would have saved Sulochana?
61
Case Study IV
Sumati, aged 31, died in KEM Hospital, Bombay. She died after delivering a bady. She had
five children. Sumati never visited the sub-centre or primary health centre. Even though the
ANM visited Sumati’s village, she never contacted the ANM.
On 30 August 1989, Sumati delivered a baby. Within 24 hours she started bleeding heavily.
So Sumati’s relatives carried her to the primary health centre which was three kilometers
away on a cloth hammock on their shoulders. But in the primary health centre, Dr. Kama
was not present. So the relatives carried her to the next Primary health centre where they
reached at 11.00 p.m. at night. Dr. Tikkar examined Sumati and advised them to go
immediately to the district hospital as there was heavy bleeding and the primary health
centre had no blood transfusion facility. The relatives took Sumati to the District Hospital.
There was no blood available; nor were their any facilities to get the blood. So here again
she was referred to Bombay. The relatives took her to the Railway Station where she
delivered a dead baby. To save Sumati they went on KEM Hospital, Bombay. Sumati died
within six hours of admission.
62
1.
What was the direct cause of death?
2.
What were/was the underlying medical cause(s) of death?
3.
What were/was the associated social and other factor(s) that lead to death?
4.
What were the Sumati’s first symptoms?
5.
What could have been done by the family to prevent the emergency?
6.
What could have been done by the family to save Sumati once the emergency occured?
7.
Were there any opportunity to save the life of Sumati? What were they?
8.
What action could have been taken at the village level?
63
9.
What action could have been taken at the Sub-centre or by health worker?
10. What action could have been taken at the Primary health Centre?
11. What action could have been taken at the first level referral services
12. Who are the decision makers and influencers?
13. What could have been done by sectors other than health to prevent this death?
14.
What are the essential emergency services that are required at first level referral
for obstetric care?
15. What are the key programme interventions that would have saved Sumati?
64
Case Study V
Saku Tanagi Gadge, 35 years old had four full term normal deliveries. She was
admitted in the primary health centre as an emergency due to the inability of the
dai and relatives, as well as the local doctor, to deliver her.
*
Saku contacted the ANM during the eighth month of this pregnancy. She was given
iron folic acid tablet by ANM and asked to come for blood and urine examination.
According to ANM, Saku never felt the need in all five deliveries so she did not go
for investigation and ANC check up.
On 13 July 1990 she started labour pain at home. She was getting very strong pain
but could not deliver so the relative went and called the dai Shantabai. Shantabai
came and examined her by putting finger inside the birth canal without washing.
Shantibai went and called private doctor who gave Saku an injection. After the
injection Saku’s pain increased and she was screaming with pain but could not
deliver the baby. Then Shantibai told the relatives to take her to primary health
centre. There was no transport available in the village so they carried her on the
shoulder to primary health centre, walking for over four hours.
When she reached PHC Saku collapsed. The doctor incharge was not available in
the primary health centre because he had gone for a meeting. The other doctor
was on training leave. So the ANM, who accompanied the patient, asked them to
go to the doctor in the district hospital.
Relatives requested that the primary health centre vehicle be given for
transportation; but it was election time and the vehicle was not available.
Saku’s condition further deteriorated and she died in the PHC without treatment.
Post mortum revealed that the child was dead lying in the abdomen and uterus had
ruptured tearing unirary bladder.
65
1.
What was the direct cause of death?
2.
What were/was the underlying medical cause(s) of death?
3.
What were/was the associated social and other factor(s) that lead to death?
4.
What were the first symptoms that Saku suffered?
5.
What could have been done by the family to prevent the emergency?
6.
What could have been done by the family to save Saku once the emergency occured?
7.
Were there any opportunity to save the life of Saku? What were they?
8.
What action could have been taken at the village level?
66
9.
What action could have been taken at the Sub-centre or by health worker?
10. What action could have been taken at the Primary health Centre?
11. What action could have been taken at the first level referral services
12. Who are the decision makers and influencers?
13. What could have been done by sectors other than health to prevent this death?
14.
Please comment on the ANM’s role, and the support the system gave her.
15. What are the key programme interventions that would have saved Saku?
67
PART A
INTERVENTIONS FOR SAFE MOTHERHOOD
8.0 REDUCING MATERNAL DEATHS
Goal
Reduction of maternal mortality from the existing level of 400 per 100,000 live births to 300
in 1995 and 200 in 2000 AD.
Coverage
o
o
o
Essential ante-natal and obstetric services to all pregnant women and essential obstetric
care at village/sub-centre level ;
Early identification of all complicated pregnancies
Emergency obstetric care at first level referral centre to those with complications
Strategies
o
Enumeration, registration and check up of all pregnant women
o
Improving services at village, sub-centre and PHC
Diagnosis and management of all complicated cases will be conducted to the extend possible
at village, sub-centre and PHC level in addition to providing tetanus toxoid immunization,
giving prophylaxis and treatment of anaemia and services for birth spacing and timing.
o
Organization offirst level referral centres
A first level referral centre is defined as a district or sub district hospital or community
health centre, to which a woman identified prenatally as definitely having complications is
referred, or to which a woman is usually sent when she is in serious difficulty or emergency
in pregnancy, child birth or immediately after.
These centres are organized to deal with all obstetric emergencies specifically bleeding and
obstructed labour. Community health centres (corresponding to block PHCs) and
district/tehsil hospitals will be strengthened for first level referral. There are eight functions
for these centres :
1.
Surgical functions
Caesarean section
Laparotomy for repair of ruptured uterus
Repair of high vaginal and cervical tear
Surgical treatment of sepsis
Removal of ectopic pregnancy presenting as acute abdomen
Evacuation of uterus in uncomplicated abortion
Amniotomy with/without I.V. Oxytocin infusion
69
1.
Administer anaesthesia
3.
Medical treatment of complications in pregnancy
Treatment of shock and sepsis
Control of hypertensive disorders of pregnancy and eclampsia
Intravenous iron infusion etc.
Treatment of congestive heart failure due to various causes, including severe anaemia
4.
Blood replacement
Blood grouping, typing, cross matching and transfusion.
5.
Manual and/or assessment functions
Manual removal of placenta
Vacuum extraction
Partograph etc.
6.
Family Planning support functions
Vasectomy and Tubectomy (Laproscopic and abdominal)
Inserting IUD
Norplant and other contraceptives
7.
Management of complicated pregnancies / labour referred from other levels
8.
Newborn care
Resuscitation
Thermal control
Feeding
Treating neonatal sepsis
In addition there must be Laboratory support - radiological and other facilities
Maternity homes or Dharamsalas where such referral cases can wait and receive supervision
during last month of pregnancy.
Organization of Transport
If a woman develops an obstetric complication, her chances of survival and receiving
appropriate treatment are excellent if she reaches the appropriate institution in time. The
time gap often appears inadequate due to either lack of transportation (vehicle) or lack of
good roads in rural areas. This gets further worsened due to lack of clear instructions to the
community regarding where the patient should be taken. An advance community based
transport plan should be made in every sub-centre and PHC area to transport women
requiring emergency care.
70
9.0 ESSENTIAL CARE FOR ALL
A review of the association of "risk factors” with maternal mortality reveals that 50% of
maternal deaths had one or more risk factors associated while the other 50% had no risk
factors at all. "Risk factors" are therefore not the best criteria to give priority to a particular
group in ante-natal or obstetric care. Essential care for all is thus critical to safe
motherhood. In this section of the module, you will learn about various activities to be
carried out for all pregnant women regardless of their risk status.
9.1 ANTE NATAL CARE
o
Early registration
You will ensure enumeration and early registration of all pregnant women by 12-16
weeks of their pregnancy.
o
Ante-natai Check ups
You will ensure that a minimum of three ante-natal visits are made during pregnancy.
These will be at 20 weeks or as soon as pregnancy is known and registered,
32 weeks and
36 weeks or once during the last trimester preferably at least one month before delivery.
There are certain minimum activities you will have get your health workers to perform.
These are :
At the first ante-natal visit and/or contact
o
o
o
o
o
o
register and prepare a mother and infant immunization card
take history to rule out too old (> 30 years) or too young (<20 years) primigravida
and examine clinically to diagnose anaemia.
do an abdominal examination to detect lie, rule out associated general diseases,
record blood pressure, weight, give IFA tablets, take weight and motivate for first
dose of TT (can be done at sub-centre clinic)
give ante-natal advice on (i) diet, (ii) rest and (iii) danager signs (complications)
if there is history of passing worms, give mebendazole tablets (only in the
second/third trimester)
motivate pregnant women to attend ante-natal clinic at least three times.
At the second and third visit/contact
o
o
o
specifically look for anaemia give IFA tablets and give mebendazole tablets if there
is history of worn infestations (only in second/third trimester)
record blood pressure
motivate for 2nd dose of TT
71
o
record weight and determine if there is adequate weight gain
Weight gain of more than 5 Kg in any month is an early warning sign for toxaemia - can
be done at the sub-centre clinic
o
reinforce diet, rest and inform about warning signs such as bleeding, loss of foetal
movements, headaches, dizziness, blurred vision for which the pregnant woman
should seek immediate help from health worker/ medical officer.
During the third visit
o
o
o
o
72
your health worker will have to carry out all activities included above for the second
visit except TT (if given earlier) and deworming
enquire about the place of delivery and motivate for institutional delivery, remind
the mother about the need to have the delivery conducted under the five cleans
conditions.
give a disposable delivery kit if your district has these available
advise regarding preparation for labour including the five cleans during deliver,
early initiation of breast feeding i.e. within 2 hours of birth of the baby.
9.2 MANAGEMENT OF ANAEMIA
Anaemia is one of the major health problems affecting women of child bearing age and
children in the country. Anaemia in pregnant women is an important aggravating cause of
maternal mortality. Apart from affecting the health of pregnant women, it affects the new
born also. You will seek to prevent nutritional anaemia in mothers by giving them one
tablet of iron and folic acid daily for a period of 100 days. The beneficiaries of the scheme
are expectant and nursing mothers and women who have accepted family planning methods.
All cases of anaemia are however required to be given therapy with higher doses of iron.
Goal
Reduction of iron deficiency anaemia in pregnant women
Coverage
Universal coverage (near 100%) of pregnant women with iron and folic acid.
The major problems related to the National anaemia prophylaxis programme has been poor
reach and utilization of services and lack of a strategy that addresses additional needs of
moderate and severe anaemic cases. There are two aspects of administration of iron and
folic acid to pregnant women : prevention and control.
The anaemia control programme in this package will focus primarily on the pregnant women
to reduce anaemia and thereby maternal mortality as well as to improve birth weight of
babies. Every effort will be made to cover all pregnant women. The maximum impact of
iron and folic acid supplementation is seen if all pregnant women are reached.
Specifically, the interventions for pregnant women are :
o
o
o
o
o
o
All pregnant women will be given 1 tablet of iron and folic acid for 100 days.
All pregnant women will be clinically examined for anaemia at the time of
immunization/MCH session.
Those found to be anaemic will be given two tablets of iron and folic acid for 100 days.
Women diagnosed as severely anaemic by clinical assessment will be referred to medical
officers at primary health centres.
Women with a history of worm infestation will be dewormed during second and third
trimesters.
Dietary advice for consumption of adequate qtys. of iron-rich foods will be given.
Iron and folic acid (IFA) tablets will be given during the immunization session (mother-child
protection session). In ICDS blocks, IFA tablets may be provided through ICDS
functionaries with the coordination of the health worker.
There may be certain areas where IFA may not be effective due to heavy worm infestation.
In such cases, whenever there is history of worm infestation in mothers or children, IFA
tablets will be given after deworming.
73
93 PREVENT DEATHS DUE TO TETANUS
Goal
Maternal/Neonatal deaths due to tetanus will be prevented.
Coverage
Universal coverage of all pregnant women with 2 doses of tetanus toxoid; ante-natal care
for 75% of pregnant women and 80% of deliveries conducted by at least a trained birth
attendant.
Four major interventions for preventing maternal deaths due to tetanus are :
1.
100 percent coverage of pregnant women with 2 doses of tetanus toxoid.
2.
Extensive information, education and communication efforts to promote safe deliveries
at home level as well as correct obstetric practices in institutions i.e., 5 cleans.
clean hands
clean surface
clean razor blade
clean cord tie
clean cord stump (no applicant)
3.
Community based surveillance for maternal and neo-natal deaths.
4.
Involving trained traditional birth attendants(TTBAs) in districts with high maternal and
infant mortality for clean home delivery practices; reaching out to families for improved
care during birth wherever neighbours or relatives conduct deliveries.
A district approach will be adopted for preventing maternal deaths due to tetanus. Criteria
for selection of districts will have an epidemiological basis where neo-natal tetanus mortality
rates are high. Although, accurate district-wise information is not available, the review of
immunization programme has shown that neo-natal tetanus mortality rates are highest where
infant mortality rates are also high, infrastructure development is poor and the proportion
of deliveries by untrained workers is high. Therefore, districts which have high vacancy rates
of female health workers, along with a high proportion of deliveries will be selected for
specific interventions related to maternal/ neo-natal tetanus mortality.
74
9.4 CARE AT BIRTH
Goal
To ensure clean delivery for all pregnant women and to refer immediately if any
complication arises.
Coverage
From the existing level of 15%, all deliveries are to be attended by a trained birth attendant
by 2000 AD with 80% of deliveries attended by trained attendants by 1995.
Normal deliveries can be conducted at home even in the absence of health staff provided
it is conducted under full aseptic conditions. To ensure clean delivery the traditional birth
attendants must be trained on 5 cleans :
clean hands
clean surface
clean razor blade
clean cord tie
clean cord stump (no applicant)
These aspects must be emphasized in the messages for mothers and family members
anticipating a home delivery.
The TBAs require refresher courses and continued supervision for conducting safe and clean
delivery at home.
In order to help TEA follow the clean practices during delivery, she must be given
disposable delivery kits which contain soap, plastic sheet, cotton/gauze pads, thread/ligature,
new razor blade, and savlon or antiseptic solution.
While improving skills and quality of delivery care by TBA efforts must be made
simultaneously to promote institutional deliveries.
All TBAs must be trained properly to refer all complicated cases at the right time and to
the right place. It is crucial that a TBA must refer a case of bleeding prior to delivery or
obstructed labour (labour pain for more than 24 hours), to a CHC or a District Hospital and
not to a sub-centre or Primary Health Centre. It saves time and precious lives.
Post-natal care
After the delivery, mother must be given adequate rest, plenty of fluids to drink. She must
be watched for any increased bleeding and deteriorating general condition. It is again
important to reach within 2 hours a CHC or District Hospital where blood transfusion
facilities exist just in case bleeding after delivery crosses normal limits.
75
9.5 BIRTH-SPACING AND TIMING
Goal
To increase the proportion of births spaced three years apart from existing levels of 30%
by 1995 and 60% by 2000 AD; to decrease the proportion of births in women below 20 years
from the existing level to less than 10% in 1995 and 2% in 2000 AD.
Coverage
Access to all couples to information and services for spacing and timing births from the
existing level of 35% to 75% in 1995 and 100% by 2000 AD.
To increase the effective couple protection rate from the existing level of 46% in 1990 to
55% by 1995 and 65% by 2000 AD.
Birth spacing and timing of birth are amongst the most important determinants of maternal
and childhood morbidity and mortality. The crucial issues requiring immediate attention in
our country are :
Early marriage and first pregnancy before 20 years (teenage) ;
Birth interval less than three years ;
Fourth or later pregnancies;
Pregnancies after the age of 30 years ;
o
o
o
o
These issues can be addressed by educating the community and making spacing and other
family planning methods readily available to them. Various spacing methods have received
insufficient importance so far. Under the programme, birth timing and spacing of births will
be given attention to improve the health of the mother and the child and also to prevent
mortality amongst pregnant women and children.
BIRTH TIMING
Problem
Action required
Implementations for Health of
Mother
Baby
1.
Pregnancy before 18
years of age
Mother physically &
psychologically not ready for
child birth and care. Higher
maternal mortality due to
obstructed labour. Anaemia
Higher LBW incidence
Perinatal and infant
mortality
Delay marriage after 18
years for girls. If married
earlier, adopt spacing
method.
2.
Birth interval of less
than 3 years
Higher incidence of Anaemia and
infections
Higher IMR
Spacing method soon after
child birth (breastfeeding
not reliable for
contraception)
3.
Fourth or later
pregnancy
Higher incidence of Anaemia,
APH PPH
Higher IMR
Adopt terminal method as
soon as family completed
4.
Pregnancy after 35
years
Higher incidence of obstructed
labour, APH, PPH, Anaemia
Increase in cogenital
anomalies. Perinatal
mortality
As above
Greater care if pregnancy
occurs.
76
Following strategies will be used to increase information on timing of births and spacing :
o
You will organise a massive communication campaign to provide information on the
benefits of birth spacing and timing. Birth spacing will be positioned as a health
measure for welfare of people rather than a demographic measure.
o
Training of medical and para medical personnel will include technical aspects of
contraception as well as appropriate counselling to people required for the success of
the programme.
o
At various health facilities including sub-centres, a variety of contraceptives will have
to be offered. You will make special efforts to promote IUDs and oral contraceptives.
o
You will give emphasis on availability of contraceptives. You will ensure th^t supplies
are available in every immunization session as well as during home-visits of health
workers. In addition, all health facilities will have contraceptives available. Condoms
should be available in every village at all times.
o
Organise appropriate education sessions during mothers’ meetings and to adolescent
girls and boys in schools and colleges.
o
You will also highlight protection offered by the use of condoms against Sexually
transmitted diseases including AIDS.
o
Innovative ways for family life education will have to be designed for adolescents who
are not in school.
o
Functional literacy programmes as well as ICDS, UBS and DWCRA programmes will
include appropriate information. You will interact with block and district level
managers of these programmes to ensure success of your programmes.
o
Coverage evaluation surveys will include information on birth spacing and timing so as
to provide a system of tracking progress in this programme.
o
Education after secondary school and acquiring professional skills after school final to
increase earning capacity for girls are other means of delaying marriage and
motherhood as well as empowering women.
77
10.0 EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS
Seriousness of complications determine the pregnancy outcome. There are few complications
during pregnancy, delivery and during puerperium which if identified early can help prevent
maternal mortality. As a medical officer you have learnt that pregnancy and delivery require
minimal assistance and you only need to monitor that it is progressing well. You will have to
ensure that during the ante-natal visit and during the intra-natal period, the health worker or
the trained birth attendant look for these complications and take action as detailed below :
We get at least three opportunities to detect complications if any, during pregnancy. These
are the three ante-natal visits. Although one can look for complications in high risk
pregnancies, we also know that half of the complications arise in the so called "non-risk
pregnancies". Therefore, the strategy under this programme is to educate all pregnant women
and their family members during ante-natal contacts of the danger signs in pregnancy and
ensure that they seek early help when any of the danger signs start appearing.
Training of DAIs, village health guides and Anganwadi workers will also help you in identifying
the early danger signs in pregnant women during ante-natal visit or during labour. The health
worker or the birth attendant will have to be educated by you to ensure that once a pregnancy
with complication is identified, such a pregnant woman will have to be referred early to the
appropriate level for immediate care. Depending on the complication identified, there may
be only two hours to 7 days between life and death of the pregnant woman. Every minute is
critical to the life of the mother. The table on the next page gives the average time between
the onset of a complication and death in a pregnancy. The table also suggests the place or
health facility to which such a pregnancy should be referred.
78
COMPLICATIONS DURING
ANTE-NATAL, INTRA-NATAL AND POST-NATAL PERIOD
Complication
Average time from
onset to death
Where to refer
12 hours
2 hours
} First referral
} level*
1. Haemorrhage
o APH
o PPH
2. Rupture uterus
24 hours (1 day)
First referral
level*
3. Ecl ampsi a
2 days
PHC / CHC
4. Obstructed
3 days
First referral
level*
6 days
PHC / CHC
2 hours to 1 day**
PHC
labour
5.
Sepsis (after
abortion /
delivery)
6. Severe anaemia
(CHF in Labour)
*
First referral level facility is that which has the following :
o
o
o
A surgeon (Obstetrician & Gynaecologist)
An anaesthetist and anaesthesia equipment
Blood transfusion facilities
During severe anaemia even the slightest bleeding during the third stage of labour
or the exertion of second stage of labour can lead to mortality.
You will note from the above table that the sooner you diagnose a complication and send
the pregnant woman to the appropriate health facility, the better are the chances of averting
her death.
How will you or your worker or a birth attendant suspect any of these complications
10.1
HAEMORRHAGE
Ante-partum haemorrhage will be suspected when the pregnant woman starts bleeding from
the vagina any time after the 28th week of pregnancy and before the birth of the child.
The bleeding may be frank blood or mixed with liquor amnii. There may or may not be
pain or tenderness over the abdomen along with the bleeding. Sometimes, bleeding may not
be revealed and can occur within the uterus. In such cases, the pregnant woman starts
having pain of the abdomen and the abdominal girth increases.
79
No vaginal examination should be done at a health facility which does not have facilities for
emergency surgery. At the peripheral level, the pregnant woman will have to be transported
immediately to the first level referral centre. The patient may be transported in left lateral
position. In case intra-venous fluids are available, a slow intravenous infusion may be
started.
If it is a painful bleeding, give intramuscular injection Morphine 15 mg or Pethidine 100 mg
IM one dose.
&
Post-partum haemorrhage is excessive bleeding (more than 500 ml) from the genital tract
after the birth of the child. The haemorrhage may be immediate or primary, or if it occurs
more than 24 hours after delivery, it may be known as secondary. When post-partum
haemorrhage is seen every minute is very critical to the life of the patient. At the peripheral
level, the vagina must be packed with sterile or clean gauze/cloth after removing
products/membranes and ensuring that the uterus is not atonic. If it is an atonic uterus,
apply external bimanual compression and give Injection Ergometrine.
If the bleeding still continues, you will have to ensure that the patient is transported
immediately to a centre which has surgical and blood transfusion facilities. In case, such a
facility is more than 2 hours away, the patient may be taken to another facility en-route
where intra-venous fluids including plasma expanders (dextran) can be infused. Thereafter,
if the patient is still bleeding, her vagina should be packed once again and the patient should
be transported to the first level referral level with intravenous infusion on flow. The foot
end of .the patient should be raised during transport.
80
10.2
OBSTRUCTED LABOUR
Labour is said to be obstructed when there is no progress in spite of strong uterine
contractions. This will manifest with failure of cervix to dilate or failure of the presenting
part to descend in the birth canal. It is a serious condition and if untreated, can lead to
fatality of both mother and foetus.
The earliest sign of impending obstruction during labour is the deterioration of the condition
of the pregnant woman. She looks tired and anxious and behaves as if she is beginning to
lose the ability to deliver and will not co-operate. In between the pains, she is unable to
relax and her anxiety increases. The presenting part is often above or at the level of the
pelvic brim. The membranes rupture early in labour because the presenting part is badly
applied to the lower segment. The cervix may be not well applied to the presenting part.
The liquor drains away and there is retraction of the placental site leading to reduction in
the maternal blood flow to the placenta and eventually results in foetal death due to
hypoxia. The pulse rate and temperature rise and the quantity of urine secreted diminishes
and it becomes concentrated and deeply coloured.
In the first stage, dilatation of cervix should be progressive, although sometimes it is not
rapid even in normal cases. Descent of the presenting part should also be continuous,
especially in the second stage. Any failure of the progress of labour calls for careful
abdominal and vaginal examination to exclude any possible cause of obstruction.
Obstructed labour undiagnosed in time can lead to rupture of uterus. A patient with
obstructed labour should be referred immediately to the first level referral centre with
surgical and blood transfusion facilities.
Before transporting a patient to the hospital, an intravenous infusion may be started if
facilities are available.
10.3
RUPTURED UTERUS
Rupture of uterus usually occurs during prolonged labour. The causes of rupture of uterus
could be :
*
*
*
*
obstructed labour
injudicious induction of labour
intra-uterine manipulations
a weak scar of uterus after a previous caesarean section
Rupture of uterus will be suspected, when there is lower abdominal tenderness, patient is
in severe pain and at times in shock. Slight vaginal bleeding may also be associated. The
presenting part may not be felt and at times fetal parts may be palpable through the
abdomen very freely.
Such a patient requires immediate surgery and will be referred to the first referral centre
where surgical and blood transfusion facilities are available.
81
10.4
ECLAMPSIA / TOXAEMIA (PRE-ECLAMPSIA)
You will suspect toxaemia (pre-eclampsia) in a pregnant woman when either of the following
are observed :
*
*
Systolic blood pressure is 140 mm Hg or more ,
An increase in the weight more than 5 Kg. in a single month.
These two together are very good and early predictors of toxaemia in a patient. Such a
patient requires further management by a medical officer. In this module, we will not
discuss what management is to be given by the medical officer. This can be referred to in
any standard text book.
Eclampsia may be suspected in a patient who is already having toxaemia or not having
toxaemia if the following symptoms / signs are present :
*
*
*
*
Visual problem, Blurring of vision
Convulsions in a patient of toxaemia
Vomiting / severe headache
Severe epigastric pain
A patient of eclampsia will have to be referred to a first level referral centre and managed
as per standard treatment for patients of eclampsia.
Keep the patient away from external stimuli such as noise, bright light and painful
procedure.
During convulsions, there is considerable risk of hypoxia to the mother and foetus. The
mother needs adequate ventilation and care should be taken to insert a spoon and prevent
tongue falling behind and blocking airways.
Eclampsia cannot be treated at home or sub-centre. Patient of eclampsia will have to be taken to
a Primary health centre with intravenous fluids facility or a first level referral centre.
82
10.5
SEPSIS (FOLLOWING ABORTION OR DELIVERY)
You will suspect sepsis in a patient who is pregnant if there is fever tollowing abortion or
delivery.
Sepsis following abortion
Usually sepsis following abortion is found when illegal / illicit attempts to terminate
pregnancy have been made. There will be fever and increased pulse rate. Lower abdomen
tenderness and pain is often found. There could be in addition foul smelling or purulent
discharge from the vagina.
At home or at a village level, if there is fever more than 39° Celsius, the patient should be
referred to the Primary Health Centre or hospital for antibiotic therapy and further
management. Tablet paracetamol and cold sponges may be given to reduce temperature.
Sepsis following delivery (puerperal sepsis)
Puerperal sepsis is defined as rise of temperature to or above 38° C within 14 days of labour
or miscarriage irrespective of the cause. The causes of puerperal sepsis include :
*
*
*
*
*
*
*
retained piece of placenta/membrane
birth canal infection
urinary tract infection
breast infection
thrombophlebitis
respiratory tract infection
any other cause of pyrexia.
The earliest and most important sign of puerperal sepsis is fever. Fever may appear within
12 hours of delivery and only exceptionally later. The rise of temperature will be abrupt,
occasionally accompanied by a rigor or it may be step-like taking several days to reach its
maximum. Along with fever, the pulse rate increases and the patient feels hot with
headache and backache.
•
Spread to the pelvic peritoneum will .be suspected when lower abdominal pain and
tenderness on examination of uterus and neighbouring areas is found. The patient may be
very ill and would require immediate attention.
Management can be in the Primary Health centre. Antibiotic therapy with intravenous fluids
therapy will have to be instituted. Sometimes, there may be collection of pus in the uterus
or in the peritoneal cavity,, in which case uterus or the peritoneal abscess should be
evacuated surgically in a first level referral centre.
83
10.6
SEVERE ANAEMIA
Clinically severe anaemia is diagnosed when there is pallor and breathlessness on exertion.
During early part of pregnancy, the pregnant woman requires two tablets of IFA every day
for 100 days. In case, the pregnancy is already advanced, the patient will require intravenous
iron therapy at the Primary Health Centre, or blood transfusion in a hospital facility with
transfusion services.
During labour, pregnant women with severe anaemia may go into Congestive Heart Failure
leading to death. Such patients require assistance at the PHC to cut short second stage of
labour and decrease exertion during second stage of labour. Some patients may also require
blood transfusion in which case they will be referred to the First level referral centre.
Anaemic women when they develop APH or PPH have greater risk of dying.
84
11.0
EMERGENCY CARE FOR THOSE WITH OBSTETRIC COMPLICATIONS
IjL.l
ANTEPARTUM HAEMORRHAGE (APH)
APH is any bleeding rrom the vagina occurring at any time after the 28th week of pregnancy
and before the birth of the child
There are three varieties of APH based on the cause of bleeding :
o
o
o
Accidental Haemorrhage or Abruptio Placentae
Placenta Previa
Incidental haemorrhage
Accidental Haemorrhage
Accidental haemorrhage or Abruptio placentae is due to the partial separation of placenta
normally situated on the upper segment of the uterus. Maternal blood from the opened
sinuses escapes and track down between the membranes and the wall of the uterus. If the
blood escape at the cervix to vagina it is a "revealed accidental haemorrhage" and if it
remains inside the uterine cavity it is concealed accidental haemorrhage". Direct injury or
blow can separate placenta and lead to retro-peritoneal bleeding.
The exact cause is not established. Pre-eclampsia, essential hypertension and rarely chronic
nephritis are associated with 25% of the cases.
Management in the Peripheral level
All cases of APH should be referred without any delay to the "first level referral" centre.
No vaginal examination should be done till the patient is in a place equipped for caesarean
section if needed and facilities for blood transfusion exist. An intramuscular injection of
Morphine 15 mg or Injection Pethidine lOOmg IM may be given before moving the patient.
This part of the module is relevant for medical officers at primary health centres
and community health centres only. A more detailed description will be found
in standard text books of Obstetrics & Gynaecology
85
She is turned into Sim’s left lateral position in order to prevent aggravating the hypotension
caused by the weight of the gravid uterus on the inferior vena cava. Awaiting transport, a
patient in shock may be started on an IV and connected to a plasma expander. But what she
needs is liberal transfusion of blood. If already known matching blood group donor
volunteers are available the medical officer must encourage them to accompany the patient
till the first level referral centre. This is to avoid delay in blood transfusion just in case the
required group of blood is out of stock.
Placenta Previa
It is a condition where the placenta is wholly or partly attached to the lower uterine
segment.
The degree of encroachment onto the lower uterine segment is important because both
treatment and prognosis are determined by it. Based on the position of placenta in the lower
segment and its relation to the internal os there are four types. The actual determination of
the types can be made only in a facility which has surgical, blood and anaesthesia services
available.
Symptoms and signs
During the last trimester (occasionally earlier) patient notices slight bleeding from the vagina
without any pain. These occur without evident cause, perhaps during sleep, but they may
also follow hard exercise or coitus. Foetal heart sounds are usually normal. There are usually
repeated slight "warning haemorrhages" before the large bout. During labour severe
haemorrhage is inevitable as the cervix dilates. In the third stage of labour, there may be
PPH because the placental site is larger than normal and lies on the lower segment which
may not retract efficiently. Any cervical tear will bleed freely because of the increased
vascularity.
On abdominal examination the fetal head may be high and freely mobile. There may be a
breech presentation or oblique lie. All these are due to the placenta occupying the lower
segment and preventing the head from entering the pelvis. There is no uterine tenderness
unlike in accidental haemorrhage.
Hypertension and proteinuria are not found.
DO NOT DO A PER VAGINAL EXAMINATION till the patient has reached a place
where a caesarean section can be done immediately if needed. (Note: If no transport
facilities are available, per speculum examination may be performed to determine if
membranes are seen, in which case amniotomy can facilitate fixation of the presenting part
and arrest bleeding.)
86
Management - Transfer to first level referral centre
'
* • can be given before transfer of the patient.
Injection Morphine 15mg
intramuscular
Haemorrhage and shock are the chief causes of death in placenta previa. Blood transfusion
and caesarean section may be required to save the pregnant woman.
Incidental Haemorrhage - Transfer to first level referral centre
Haemorrhage due to a lesion of the cervix or vagina such as an erosion, a polyp or a
carcinoma are called incidental haemorrhage in pregnancy. On gently passing a Sim s
speculum and examining under good light, these causes can be established.
11.2 POST PARTUM HAEMORRHAGE (PPH)
It is the excessive bleeding (more than 500 ml) from the genital tract after the birth of the
child. The haemorrhage may be immediate or primary, or if it occurs more than 24 hours
after delivery, it is described as secondary.
Primary postpartum haemorrhage
There are two possible sources of primary post partum haemorrhage, the placental site and
lacerations of the genital tract.
Primary haemorrhage from the placental site
Some blood must escape (less than 200 ml) as the placenta separates. Further loss is
normally prevented by the retraction of the uterine muscle fibres which surround the vessels
in the wall of the uterus and compress them until intravascular thrombosis occurs.
Excessive bleeding occurs when o
Ineffective contraction of uterus in the third stage of labour result in failure of complete
separation and expulsion of placenta and adequate retraction of the placental site. (e.g.
in prolonged labour, multipara with atonic uterus, over distended uterus with twins or
hydramnios etc.)
o
Third stage of labour is mismanaged e.g. if ergometrine injection has not been given at
the end of the second stage or injudicious attempts to pull out placenta before complete
separation
o
Placenta is abnormally adherent (placenta accreta) or when placenta has a wider area
of attachment including the lower segment which may fail to retract.
o
Hypofibrinogenaemia is present associated with concealed accidental haemorrhage,
amniotic embolism or retention of dead foetus in the uterus for some weeks.
87
Primary post partum haemorrhage from lacerations
Commonest sites of lacerations occurring during labour are either cervix or vagina. It is
suspected when bleeding continues even after the expulsion of placenta and firm retraction
of the uterus.
Signs and symptoms of PPH
Bleeding more than 500 ml and early signs of shock must alert the Medical Officer. Increase
in pulse rate, fall in blood pressure, pallor and air hunger occurs early in a woman who is
already anaemic in pregnancy. Rarely bleeding occurs into the cavity of an atonic uterus and
it is detected by an abnormally high fundus of uterus on per abdominal palpation.
Management
Post partum haemorrhage is the fastest killer among all the causes of a woman undertaking
the risk of child birth. The obstetrician must be very alert in detecting it early to save a
precious life. A high index of suspicion is needed if normal events are delayed during second
and third stage of labour.
If a TBA or Health Worker (F) attending the delivery suspects a PPH then the lady must
be transported at the shortest interval to the first level referral centre for further
management. But in case the patient has landed up at the PHC the medical officer may
make an attempt to save her from death by the following quick steps of management.
o
o
o
o
Start an intravenous line with 5% dextrose normal saline.
Raise the foot end of bed
Keep the patient warm and adequately covered
Make her lie in the lithotomy position for assessment
If the placenta is undelivered :
Assess whether the placenta is separated or not. The fundus is rubbed gently, when it will
usually contract.
(i)
If placenta is separated :
Uterus will be felt as a firm rounded mass about 10 cm in diameter, at about the level of
the umbilicus and movable from side to side. If these signs of separation are present there
should be no difficulty in delivering the placenta by modified Brandt Andrews method.
(Rubbing up a contraction and elevation of uterus with left hand flat on the abdomen and
controlled cord traction with right hand after the separation of placenta). If the bleeding
does not stop an intravenous injection of Ergometrine 0.5 mg is given (irrespective of
whether she received the first dose of ergometrine after the delivery of the head of the baby
or not).
88
If the uterus does not contract well in spite of the ergometrine bimanual compression is
immediately performed. One gloved hand is inserted into the vagina and formed into a fist,
which is placed in the anterior fornix above the cervix. The other hand is placed on the
abdomen and pressed downwards onto the posterior wall of the uterus so that it is
compressed between the two hands. This is an effective but temporary method of controlling
uterine bleeding. Firm pressure must be maintained until the uterus is felt to contract.
(ii)
If placenta has not separated
as revealed by vaginal examination or if the placenta expelled are incomplete (on physical
examination) it has to be removed digitally under general anaesthesia. The patient has to
be rushed to the first level referral centre.
Repeated or violent attempt to express the placenta by squeezing the uterus or pressing on
it are unlikely to succeed and often produce shock.
If manual removal is to be performed it is best to withhold any further injection of
ergometrine until after the removal of the placenta.
If placenta is delivered and still bleeding :
If the patient was brought bleeding after the expulsion of placenta and the uterus is well
contracted examine the cervix with a speculum under good source of light. The blood in the
fornices are mopped to visualise the cervix. If there is a profuse haemorrhage from a
cervical tear involving a branch of the uterine artery, this can be temporarily controlled by
clamping the highest part of the tear with a sponge holder until the patient can be taken to
the operating theatre.
Bleeding from tears of the lower vagina, perineum or vulva should be controlled by pressure
until the tear is sutured under local anaesthesia.
If there are no tears and there is bleeding, give 5 units of Oxytocin and 0.2 mg of
Ergometrine intramuscular injection and transport the patient fast to the first level of
referral centre.
Secondary post partum Haemorrhage
This occurs more than 24 hours after delivery of the child, often starting between Sth and
10th days. Commonest cause is retention of a piece of placenta and it is frequently
complicated by intrauterine infection.
Other causes of secondary bleeding are separation of an infected slough in a cervical or
vaginal tear or in a lower segment caesarean wound.
Management is exploration and evacuation under general anaesthesia. This must be done
at the first level referral centre.
89
113
OBSTRUCTED LABOUR & RUPTURE OF THE UTERUS
Labour is said to be obstructed when there is no progress in spite of strong uterine
contractions. This may be shown by failure of the cervix to dilate or failure of descent the
presenting part to descent through the birth canal. It is a most dangerous condition if it is
untreated, and can then be fatal to both mother and fetus.
Causes of Obstructed labour
The space in the bony canal of the mother is either too small or too distorted to permit easy
passage of the head of the baby during labour.
If well fed, most women attain their genetically determined maximum stature at about 18
years with growth of bony pelvis ceasing by 21 years. With poor nutrition and recurrent
infections like, diarrhoea, measles, childhood tuberculosis, malaria etc. growth in stature will
be slow and often result in stunting.
Obstructed labour may arise from maternal or fetal conditions, or both.
Maternal conditions
o
o
o
o
o
Contraction or deformity of the bony pelvis
Pelvic tumours
Uterine fibromyomata
Ovarian tumours
Abnormalities of the uterus or vagina (Rare)
Fetal conditions
o
o
o
o
0
o
o
o
o
o
Large fetus.
Malposition or malpresentation
Persistent occipito-posterior or transverse position
Breech presentation
Mento-posterior position
Brow presentation
Shoulder presentation
Compound presentation and
Locked twins (Rare)
Congenital abnormalities of the fetus (rare)
Some of these causes can be detected during pregnancy so that early treatment is possible,
or a plan of action can be made before labour. The effects of obstructed labour if it is left
untreated is given below :
90
Symptoms and signs of obstructed labour
The early detection of possible obstruction in labour is important, for if labour is allowed
to progress to the point of absolute obstruction the death of the fetus is almost certain and
the life of the mother is endangered. In a primigravida complete obstruction leads within 2
or 3 days to a state of uterine exhaustion or secondary hypotonia; any relief which this gives
to the mother and fetus is only temporary. In a multigravida obstruction becomes established
much sooner and progressive thinning of the lower segment may lead to uterine rupture in
less than 24 hours.
The earliest sign of impending obstruction is a deterioration in the patient’s general
condition. She looks tired and anxious and behaves as though she is beginning to lose her
ability and will to cooperate. Between the pains she seems unable to relax and her anxiety
increases.
♦
The presenting part is often above or at the level of the pelvic brim. The membranes
rupture early in labour because the presenting part is badly applied to the lower segment
The cervix may not be well applied to the presenting part. The liquor drains away and there
is retraction of the placental site, which causes reduction in the maternal blood flow to the
placenta, and eventual fetal death from hypoxia.
In late obstruction the patient’s pulse rate and temperature rise. The quantity of urine
secreted diminishes and it is concentrated and deeply coloured. Ketone bodies are present
in the urine and acetone can also be smelt in the patient’s breath.
The possibility of obstructed labour should be suspected when labour fails to progress. In
the first stage dilatation of the cervix should be progressive, although sometimes it is not
rapid even in normal cases. Descent of the presenting part should also be continuous,
especially in the second stage. Any failure in the progress of labour calls for careful
abdominal and vaginal examination to exclude any possible cause of obstruction particularly
in the case of previously undiagnosed disproportion or malpresentation.
If the diagnosis of obstruction is missed for a time the dangerous condition of over-retraction
of the uterus (generalized tonic retraction) may occur. In normal labour some retraction of
the upper segment persists after each contraction, and the upper segment becomes slightly
shorter and thicker, while the lower segment becomes stretched and thinner. If the fetus is
unable to descend because of obstruction, the total length of the uterine cavity must remain
constant, so that as uterine contractions continue progressive retraction causes abnormal
stretching and thinning of the lower segment. The line of junction of the upper and lower
segments becomes very evident and is known as the retraction ring of Bandl. It may become
so high in the uterus that it can be seen or felt on abdominal examination. Eventually
rupture of the lower segment occurs.
91
»
I
In advanced obstructed labour the uterus is found on abdominal examination to be moulded
to the shape of the fetus. It feels hard all the time and does not relax. It is tender to
palpation and Bandl’s ring may be evident. Fetal parts are easily felt and the fetal heart
sounds are absent. The presenting part is fixed at the level of obstruction.
On vaginal examination the vagina is found to be oedematous and feels hot and dry. The
oedematous cervix is only loosely applied to the presenting part. If the head is presenting
there will be a large caput succedaneum and extreme moulding of the skull. The presenting
part is tightly fixed, and even under anaesthesia cannot be pushed upward without danger
of causing uterine rupture. If there is a shoulder presentation the oedematous arm of the
fetus will have prolapsed, with the hand projecting from the vulva.
Management
Excessive retraction of the uterus should never be allowed to develop. The cause of the
obstruction should have been discovered during pregnancy or in early labour, such women
should not be delivered at home. When tonic retraction is present the fetus is certainly dead
and the aim of treatment is to deliver the mother immediately by the safest possible method.
Intrauterine manipulations are very liable to cause rupture of the abnormally thin lower
segment. Internal version is particularly dangerous. Refer the case immediately for a
caesarean section.
Rupture of the uterus
It usually occurs during labour, although it occasionally also happens during the later weeks
of pregnancy.
Causes
During pregnancy the only common cause of rupture of the uterus is a weak scar after
previous operations on the uterus. The higher the scar is placed on the uterus the greater
is the risk The most dangerous scar is that of ’classical’ Caesarean section; this is more
dangerous than a hysterotomy scar. Rupture of a lower segment Caesarean scar is
uncommon during pregnancy, and rupture of a myomectomy scar or those following
perforation of the uterus with a curette or cannula are rare. Rupture of the uterus during
pregnancy has also followed a direct blow on the abdomen.
During labour rupture may be caused by :
o
The injudicious use of oxytocic drugs.
o
Obstructed labour. The rupture may be spontaneous especially in multi-gravida or
follow manipulations carried out for the relief of the obstruction.
92
j
o
A weak scar in the uterus after Caesarean section, or in rare instances after
hysterotomy, myomectomy or perforation of the uterus with a curette or cannula.
o
Intrauterine manipulations, such as internal version or manual removal of an
adherent placenta.
o
Forcible dilation of the cervix. Rarely, a cervical tear in a normal delivery may extend
up into the body of the uterus.
o
Degeneration of uterine muscle, which is most likely to occur in multigravida.
Symptoms and signs
Rupture through a uterine scar :
♦
o
History of the previous operation and the scar in the skin (a low transverse incision
may be hidden by pubic hair). Rupture during pregnancy may be so gradual that the
symptoms may be very slight at first, and the description ’silent rupture’ has been
applied to these cases.
o
Abdominal pain (which may be wrongly attributed to the onset of labour).
o
More severe pain and shock occur (if the rupture becomes complete and part of the
uterine contents are extrude into the peritoneal cavity.
Rupture of a scar more often occurs during labour, and the scar gives way more suddenly
than during pregnancy, so the symptoms are more dramatic, with severe pain and shock. The
possibility of rupture of the scar should always be considered if a patient who has had a
Caesarean section suddenly complains of severe pain during labour which is not synchronous
with the uterine contractions.
Spontaneous rupture during obstructed labour. Prolonged labour or violent uterine action
almost without intermission between the pains makes the patient exhausted before the
rupture occurs. There may be signs of disproportion or of a malpresentation such as a
transverse lie. At the moment of rupture the patient cries out and complains of a sharp pain
in the lower abdomen. Soon after the rupture she presents signs of shock, with pallor and
sweating. The pulse becomes thready and rapid and the blood pressure falls. With an
incomplete tear the signs of shock may not be so severe.
Slight vaginal haemorrhage is usually present. On abdominal examination there is marked
tenderness. The presenting part may not be felt unless the head is impacted in the pelvis.
If the fetus is completely extruded into the peritoneal cavity uterine contractions may cease,
but in other cases often continue. With complete extrusion the fetus may be felt in the
abdominal cavity with the retracted uterus beside it.
93
Extensive cervical lacerations. They are usually produced with the forceps at a difficult
delivery, especially if the cervix is not completely dilated, but they seldom extend far enough
to open the peritoneal cavity. Brisk external haemorrhage may occur. The uterus is empty
and firmly retracted and the tear can be confirmed by visual exarfiination. For this effective
retractors and the help of an assistant will be required.
Rupture caused by oxytocic drugs. Rupture of the uterus has followed the administration
of oxytocin before the delivery of the child particularly when there was some obstruction.
The risk is much greater in multipara and when oxytocin is given intramuscular.
Treatment
Prevention. Disproportion must be recognized early, and labour must not be allowed to
continue to the stage of obstruction. An oblique lie must be corrected early but if the
shoulder has become impacted, versions should not be attempted: Caesarean section is the
correct treatment.
The cervix must not be forcibly dilated and forceps must not be applied unless it is fully
dilated. Manual removal of the placenta must be carefully performed, with an external hand
guarding the fundus.
A patient who has had a Caesarean section, hysterotomy or extensive myomectomy must be
delivered in a hospital where all obstetric facilities are available.
Treatment after rupture has occurred.
A.
At Primary Health Centre (if the patient happens to arrive at PHC) :
o
o
o
Give Morphine injection
Start intravenous glucose solution
and TRANSFER THE PATIENT IMMEDIATELY to first level referral centre.
B.
At first level referral centre (for your information) :
Before operation the general condition of the patient must be improved as much as possible
by blood transfusion and intravenous glucose solution.
If the rupture is complete laparotomy is always necessary.
Many cases of uterine rupture during obstructed labour are best treated by hysterectomy,
as efficient suturing of bruised and ragged tissues may be impossible.
Wide spectrum antibiotics are given, and paralytic ileus is treated by giving only intravenous
fluids and maintaining gastric aspiration until bowel sounds reappear.
94
11.4
PRE-ECLAMPSIA & ECLAMPSIA
Weight gain
The weight gain during the first trimester is minimal. After 12th week there is an average
weight gain of about 0.5 kg per week. An increase of more than 1 kg weight gain per week
should arouse the suspicion of pre-eclampsia. At the workers’ level, a weight gain of more
than 5 Kg during one month is an early indicator suggesting pre-eclampsia.
Blood pressure
Ideally the blood pressure before pregnancy must be known to assess the changes due to
conception. Mostly 140/90 mm is the diagnostic level for pre-eclampsia and at 160/110 she
might develop eclampsia. When blood pressure rises abruptly the patient may complain of
severe and persistent frontal headache and may vomit. For diagnosing toxaemia, an increase
of more than 30 mm of Hg in systolic pressure or an increase of more than 10 mm. of Hg
in diastolic pressure will be treated as a danger sign requiring referral.
Management of Pre-eclampsia
A patient with weight gain of more than 5 Kg. in one month or an increase in systolic
pressure of more than 30 mm Hg or diastolic pressure increase of more than 10 mm. Hg.
or a single reading of blood pressure of more than 130/80 mm Hg may be managed at home
and reviewed after 1 week.
Home management
o
o
o
o
Complete bed rest for one week
No extra salt
No restriction on fluid intake
Tab Phenobarbitone 30 mg twice a day
BP above 140/90 mm Hg or a rise of 20 mm over the diastolic BP recorded at the first
-----------------------trimester visit needs admission and bed resL-
The aim of management of a patient with toxaemia is to obtain a live baby as mature as
possible while controlling BP so as to avoid eclampsia, cerebral haemorrhage and accidental
APH.
Diazepam should not be used for mild cases as it can have depressant effect on the baby if
born premature. However, it is useful sedative in post partum eclampsia and in control of
convulsions in severe eclamptics.
Though hypotensives act at the expense of placental blood flow and function, severe
95
- —-
preeclampsia or eclampsia may need potent anti hypertensive drugs. The health worker
female must visit daily and check BP.
Imminent eclampsia
If the situation is worsening i.e. diastolic BP remains above 100 mm Hg in spite of bed rest
or if proteinuria persists and the gestation has crossed 36 weeks labour should be induced.
Keep the patient away from external stimuli such as loud noise, bright lights and painful
procedures. These are liable to trigger off a fit.
Eclampsia
Characterized by the occurrence of major epileptiform convulsions :n a pre-eclamptic
patient. Post partum eclampsia is usually less severe tlian ante partum or intrapartum
eclampsia. The mortality varies with the number of fits and the quality of treatment and the
speed with which it is made available.
Eclamptic seizure has got four stages, the aura, the cry, the tonic and the clonic phase. Aura
is usually visual flashes of light and spots before the eyes.
During the convulsions there is considerable risk of hypoxia to the mother and foetus,
inhalation of vomitus, cerebral haemorrhage, accidental separation of placenta, disseminated
intravascular coagulation and renal necrosis.
Management at PHC - Sedate and refer to first level referral centre.
Sedation is by :
1.
2.
o
o
o
96
Inj. Pethidine 100 mg IM
or
Inj. Phenobarbitone 300 mg IM
Inj. Chlorpromazine 25 mg in 20ml of 5% Dextrose slow I.V.
and then
Inj. Chlorpromazine 50 mg IM
Inj. Promethazine 25mg IM
Put airway in the mouth to prevent injury during fit.
Suction with mucus catheter on the way.
Send Health Worker (F) with the patient and also give a referral note to the
obstetrician.
11.5
PUERPERAL SEPSIS
Puerperal pyrexia was defined as a rise of temperature to or above 38 °C (100.4OF) within
14 days of labour or miscarriage irrespective of the cause.
Aetiology
When the placenta separates from the uterine wall a raw area is left which may be regarded
as an extensive but superficial wound. As a result of delivery, the cervix is occasionally torn,
the fourchette is commonly torn in first confinements, and sometimes the perineum also.
These wounds may become infected. It is a common risk with
(a) Anaemia
(b) Traumatic delivery
(c) Intrauterine manipulation
(d) Prolonged labour
(e) Antepartum or post partum haemorrhage.
Patients and attendants suffering from colds and sore throats are liable to harbour
haemolytic streptococci or staphylococci in their noses and throats, but a small proportion
of healthy individuals are carriers.
The incidence of carriers of resistant strains of staphylococci among hospital staff has now
risen greatly, and these resistant strains are harboured in dust and bedding. Staphylococci
may colonize the umbilical stump of the newborn child, and organisms from this site may
spread to other infants in the nursery. Infection with penicillin-resistant strains of
staphylococci is not only of importance in puerperal sepsis, but also in breast infections, and
danger to the newborn.
Depending on the spread of infection three degrees of severity are recognized :
In the mildest cases the infection remains localized to the birth canal, in perineal, vaginal
or cervical lacerations or at the placental site.
Direct spread of infection may take place from the vagina or cervix into the pelvic cellular
tissue to cause pelvic cellulitis; infection may spread from the uterine cavity to involve the
Fallopian tubes and pelvic peritoneum, giving rise to acute salpingitis and pelvic peritonitis.
When the organisms are particularly virulent, as in the case of the haemolytic streptococcus
group A, the infection may involve the general peritoneal cavity to cause a general
peritonitis, or spread into the blood stream to produce septicaemia. The patient rapidly
becomes acutely ill from the effect of toxins formed by the organisms, but the local
inflammatory response at the site of entry of the organisms in the birth canal may be
minimal, and a perineal laceration, for example, may look quite clean.
97
Symptoms and signs. The earliest and most important sign of puerperal sepsis is fever. The
fever may appear within 12 hours of delivery, more often within 24 hours, and only
exceptionally later. The rise of temperature may be abrupt, occasionally accompanied by a
rigor, or it may be step-like, taking several days to reach its maximum. Coincidentally with
the fever the pulse rate is raised and the patient feels hot, with headache and backache.
Spread to the pelvic peritoneum is shown by lower abdominal pain and tenderness on
examination of the uterus and adnexa. Pelvic cellulitis causes persistent pyrexia and a mass
to one or both sides of the vagina and uterus which may take several weeks to resolve.
In cases of general peritonitis the patients are severely ill with a rapid thready pulse,
abdominal pain and distention, vomiting and diarrhoea. There is generalized tenderness and
few, if any, bowel sounds. The fever is usually persistently high, but in the very worst cases,
and terminally, it may be slight.
In septicaemia, however, rigors are common with continuous high fever. The patients are
very ill and there may be no localizing signs. A high vaginal swab and blood culture are of
paramount importance in diagnosing these cases.
Diagnostic examination.
In every case a general clinical examination should be made, including the throat, chest,
breasts, abdomen, renal angles and legs. Involution of the uterus may be delayed and it is
often tender on abdominal examination. The perineum should be examined to see if any
lacerations or an episiotomy are infected. The lochia may be purulent and foul-smelling,
when coliforms and anaerobic streptococci are commonly found. If the severity of the illness
or the type of fever leads to suspicion of septicaemia blood is taken for culture, preferably
when the temperature is at its height or during a rigor. Several blood cultures are sometimes
needed to establish a diagnosis.
Prevention
Aseptic precautions during delivery
Hand washing and cutting nails before conducting delivery
Avoiding too many superfluous vaginal examinations
Cleaning instruments with cold disinfectants and boiling before use
Prophylactic antibiotics for premature rupture of membranes (more than 24 hours duration)
Management
External vulval douches useful.
DO NOT give vaginal douches
Remove stitches of infected perineal wound
Give broad spectrum antibiotics like Cotrimoxazole, Ampicillin, Cephalexin, etc.
IV fluids for very ill patients
Close monitoring of pulse, blood pressure and temperature
Refer if uncontrolled or if infected pus has to be surgically drained and blood transfusion
has to be given or retained placental bits is to be removed by curetting.
98
11.6
ABORTION - BLEEDING AND SEPSIS
Deaths due to complications of illegal abortions have remained among the most intractable
causes of maternal mortality in many countries. Bleeding and sepsis are the major lethal
complications after abortion. This is more common in the hands of unqualified people who
conduct abortion secretly.
Traditions, culture and religious faiths do not support inducing abortions. But women do
have pregnancies that they refuse (for whatever reasons) to carry to term. Then they will
resort to illegal and secretive sources for an abortion with its consequent ill effects on the
mother.
Even access to modern contraceptives does not obviate the demand for induced abortion
though it can reduce it. This is because no method of contraception is perfect. Still, major
intervention of reducing abortion revolves around birth spacing and timing. Health
education, oral contraceptives IUCD and propagation of condom usage are the indirect
measures to reduce the number of illegal abortions.
Clinical assessment
History of missed periods and illicit attempts to terminate pregnancy.
Fever and increased pulse rate.
Per abdomen-tenderness, and a mass may be present
Speculum examination to rule out injury to fornices and cervix and presence of foreign body.
Gentle vaginal examination to note the size and position of uterus, condition of os, and to
check if there is any tender adnexal mass.
Management in PHC
Correct shock with IV fluids.
Start on antibiotics with broad spectrum coverage plus intravenous Metronidazole.
Inj. Pethidine 50 mg IM, if pain is severe.
Paracetamol for fever.
As soon as stabilized, transport the patient to first level referral centre.
99
TABLE I
INTERVENTIONS FOR SAFE MOTHERHOOD
Cause of Death
1. ABORTIONS
Interventions
List of Activities
Organise birth
spacing & timing
programme (using
pills, IUCD and
condoms)
Train personnel for:
Health information
- Distribution of pills
- Insertion of IUCD
- Promotion & guidance in condom usage
Sub
Vi I Lage Centre PHC
0
0
0
0
1st Level
ref.centre
Supply:
-
Pills
IUCD
-
Condoms
Communications
2. SEPSIS
1. Safe Delivery
2. Treatment of
puerperal
sepsis
0
Training and Service Delivery
- Home deliveries conducted by HW(F),
TTBA's with sterile delivery kits &
sterile techniques for low-risk
cases.
- Hospital deliveries - Forceps
- Vacuum
- Caesarean
CoCriMoxoto/e,
3. BLEEDING
1. Management of
anaemia in
pregnancy
* Prophylaxis
Nil
0
0
0
0
0
0
0
In prophylaxis of anaemia by
a) Distribution of iron & folic
tablets
b) Dietary advice
By a)
b)
c)
o
0
2 £z> x 3
3 dcx'/s
Service Delivery
c)
+ = Yes
0
0
0
Health Education
d)
- Diagnosis
0
0
0
Ampicillin 250 mg QID x 3 days
If still febrile after 3 days - refer
Laboratory diagnosis and appropriate
antibiotics and treatment.
3. Prevention of
i 11egaI
abortion
0
Advice on birth spacing
Deworming
Clinical Examination
Haemoglobin estimation by
haemogIobi nometer
Peripheral blood film
examination
Treatment
a) Treatment by oral iron and folic
acid for mild degree of anaemia
(e.g. above 10 gm)
b) Injectable iron
c) Blood transfusion
Treatment of
concomi tant
infection
Anti helminthics &
Antima larials when required
0
5.
Cause of Death
Interventions
List of Activities
2. Recognition of
cases at risk
of post-partum
haemorrhage
Training of health personnel to spot
risk cases
Referral of risk cases for hospital
delivery
Referral for sterilization in grand
multiparous women.
3. Injection
Ergometrine
As a first aid treatment for bleeding
4. Blood
Transfusion
Training and service delivery for
a) Grouping and cross matching blood '
b) Collecting donor's blood
c) Storage of blood
d) Transfusion
Sub
Village Centre
PHC
0
O
O
Screening donors for diseases transmissable by blood e.g. malaria, HBV
infection, HIV infection
O
O
O
©
0
o
0
0
o
o
o
o
0
o
o
Referral & transportation of cases with
bleeding to first level referral centre
o
5. Surgical inter Training and Service delivery for
vention when
surgical intervention.
requi red
4. HYPERTENSIVE Early Detection
DISORDERS OF
PREGNANCY
5. OBSTRUCTED
LABOUR
Anticipation and
referral
o
Training of health personnel for early
detection with
a) Abnormal weight gain with regular
weighing of mothers
b) BP measurements
c) Detection of proteinuria
d) Detection of pitting oedema
Referral to
- Health Education
hospital treatment - Advice on salt-restricted diet & rest
- Referral & transportation - Training
& service delivery of health
personnel
- Treatment of mild cases
- Treatment with careful maternal and
fetal monitoring
1st Level
ref.centre
o
©
o
o
o
o
.o
o
©
o
0
Training health personnel to recognize
cases at risk of obstructed labour e.g.
ma Ipresentations, abnormal lie.
O
Referral & transportation to hospital
Early diagnosis & Training and service delivery:
operative inter - Provision of resources and upgrading
vention with blood of facilities for operative inter
transfusion if
vention and expert care
needed
o
o
CH/OI
COMMUNITY HEALTH CELL
326, V Main, I Block
Koramongala
Bangalore-&6uC34
India
O
Education is empowerement. Every girl and boy must be helped to
complete at least primary education in school. This will facilitate
attainment of good health. In this endeavour all of us can contribute and
make a difference.
You can :
♦
ask every family you meet during your health work, whether their
children are in primary school;
♦
persuade them to send all their children including girls, to attend and
complete primary school, if they are not in school;
♦
identify the primary school teachers of the villages covered by you;
♦
facilitate communication between the family and the school teacher
whenever possible;
♦
encourage all functionaries working with you to actively promote
school attendance and completion of primary school; ask them
regularly, what they have done;
*
include a panel/discussion on primary education whenever you
organize a health exhibition/camp.
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