Rttigjiehiefhefepfkdrpe; Submitted on: INTRODUCTION- Obstetrics is largely preventive medicine , the age old concept that obstetrics is only

antenatal, intranatal , and postnatal care, and is thus concerned mainly the technical skill, is now considered as a very narrow concept , and is being replace by the concept of community obstetrics which combines obstetrical concerns with concept of primary health care. India accounts for over 20% of the worlds maternal death an incredibly high MMR which is unacceptable when compared to current indices elsewhere in Asia. Reduction in MMR by three quarters between 1990 and 2015 is one of the millennium development goals of United Nation . PREVENTIVE OBSTETRICS* PREVENTIVE - Preventive is the term used to prevention or slowing the course of an illness or diseases. * OBSTETRICS The branch of medicine that deals with the care of women during pregnancy, child birth and puerperium period following delivery is known as obstetrics. * PRENTIVE OBSTETRICS - Preventive obstetrics is the term for prevention of the complication that may arise during antenatal, intranatal and postnatal period. OR Preventive obstetrics is a art and science of preventing or managing the complications of pregnancy, labor and the puerperium. AIMS... [continues]

Impact of Technology Change

Industrialization: Technology has contributed to the growth of industries or to the process of industrialization. Industrialization is a term covering in agrarian of modern industry with all its circumstances and problems, economic and social. It describes in general term the gr manufacturing industry. The industry is characterized by heavy, fixed capital investment in plant and building by the application of scale standardized production. The Industrial Revolution of 18th century led to the unprecedented growth of industries. Indu production. The family has lost its economic importance. The factories have brought down the prices of commodities, improved process of production is mechanized. Consequently the traditional skills have declined and good number of artisans has lost t opportunities to thousands of people. Hence men have become workers in a very large number. The process of industrialization economy. It has contributed to the growth of cities or to

Urbanization: In many countries the growth of industries has contributed to the growth of cities. Urbanization denotes a diffusion of the influenc can be described as a process of becoming urban moving to cities changing from agriculture to other pursuits common to citi Hence only when a large proportion of inhabitants in an area come to cities urbanization is said to occur. Urbanization has bec growth has taken place not only in the number of great cities but also in their size. As a result of industrialization people have sta employment. Due to this the industrial areas developed

Modernization: Modernization is a process which indicates the adoption of the modern ways of life and values. It refers to an attempt on the part o to adapt themselves to the present-time, conditions, needs, styles and ways in general. It indicates a change in people's food h preferences, ideas, values, recreational activities and so on. People in the process of getting themselves modernized give more and technological inventions have modernized societies in various countries. They have brought about remarkable changes in the ideologies in the place of Development of the means of transport

Development of transport and communication has led to the national and international trade on a large scale. The road transport, eased the movement of men and material goods. Post and telegraph, radio and television, newspapers and magazines, telepho deal. The space research and the launching of the satellites for communication purposes have further added to these develo different corners of the nation or the world to

Transformation in the economy and the evolution of The introduction of the factory system of production has turned the agricultural economy into industrial economy. The indust organization into two predominant classes-the capitalist class and the working class. These two classes are always at conflict due intermediary class called the middle cl

Unemployment: The problem of unemployment is a concomitant feature of the rapid technological advancement. Machines not only provide empl the jobs of men through laborsaving devices. This results

Technology and The dangerous effect of technology is evident through the modern mode of warfare. The weaponry has brought fears and anxieti human race reveal how technology could be misused. Thus greater the technological advance

Changes in social Technology has profoundly altered our modes of life. Technology has not spared the social institutions of its effects. The ins property have been altered. Modern technology in taking away industry from the household has radically changed the family organ away by other agencies. Marriage is losing its sanctity. It is treated as a civil contract than a sacred bond. Marriages a re beco desertion and separation are increasing. Technology has elevated the status of women but it has also contributed to the stresses at home. Religion is losing hold over the members. People are becoming more secular, rational and scientific but less religious i have shaken the foundations of religion. The function of the state or the field of state activity has been widened. Modern technolo -the protection of the aged, the weaker section and the minorities making provision for education, health care etc.Transportation a functions from local government to the central government of the whole state. The modern inventions have also strengthened nati the bureaucracy have further impersonalized t

Cultural To provide a law of social change comparable to the laws of physics and biology that William F. Ogburn in 1922 advanced hi changes always originate in the invention by some individual of a new way of doing something new to do. So far he was follow Ogburn then began to wander in the tracks of Marx, Historically, he argued, inventions occur most often in the field of materi improvement in technology are self-evident. With each development in technology there comes, however, some disturbance to the or stress is set up between the new technique and various organizational aspects of the social system, changes in which come technology and old social organization, is social lag. The core of Ogburn's theory is the idea that cha

Social Social Movement is one of the major forms of collective behaviour.We hear of various kinds of social movements launched for o defined as collectively acing with some continuity to promote or resist change in the society or group of which it is a part. Hor promote or resist change.Smelser defines it as organized group effort to generate or resist social change. According to M.S.A

Collective Social Movement involves collective action. However it takes the form of a movement only when it is sustained for a long time. But it should be able to create an interest and awakening in re

Oriented towards social A social movement is generally oriented towards bringing social change. This change could either be partial or total. Though the values, norms, ideologies of the existing system, efforts are also made by some other forces to resist the changes and to maint defensive and restorative rather than innovative and initiating change. They are normally the organized efforts of According to Yogendra Singh social movement is a collective mobilization of people in a society in an organized manner under a an ideologically defined social purpose. Social movements are characterized by a specific goal which has a collective significance of committed worker and strong leadership.Social movements have a life-cycle of their own origin, maturity and culmination.T. implies a study of social structure as movements originate from the contradictions which in turn emanate from social structure. He factors- Locality, Issues and social categories. Anthony Wallace view social movement as an attempt by local population to chang operates. An important component of social movement that distinguishes it from the general category of collective mobilization is the presen

mobilization and is oriented towards change. But in the absence of an ideology a student strike becomes an isolated event a minimum of organizational framework to achieve success or at least to maintain the tempo of the movement. To make the distinc clear the purposes of the movement to persuade people to take part in it or to support it, to adopt different techniques to achi amount of organizational frame-work. A social movement may adopt its own technique or method to achieve its goal. It may compulsive or persuasive, democratic or undemocratic means or methods to reach its goal. 2013 Sociology Guide.Com

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ardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest. Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early appropriate resuscitationinvolving early defibrillationand appropriate implementation of postcardiac arrest care lead to improved survival and neurologic outcomes.

Essential update: A drug combination to improve CPR outcome

In a randomized trial involving 268 patients with in-hospital cardiac arrest, treatment with a combination of vasopressin, steroids, and epinephrine (VSE) during CPR followed by treatment of survivors with daily steroids was associated with a greater likelihood of being discharged with a neurologically favorable outcome compared with standard care with epinephrine alone. VSE patients also had improved hemodynamics and central venous oxygen saturation, as well as less organ dysfunction.[1, 2] Patients were randomly assigned to combination treatment with vasopressin (20 IU/CPR cycle) plus epinephrine (VSE group) or saline placebo plus epinephrine (control group) for the first 5 CPR cycles after randomization. During the first CPR cycle, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. VSE patients who were successfully resuscitated but still hemodynamically unstable were treated with an intravenous infusion of hydrocortisone (300 mg daily for 7 days), while control patients were given saline placebo. Patients in the VSE group had a significantly higher probability of return of spontaneous circulation of 20 minutes or longer after CPR (83.9% of patients vs 65.9% in the control group) and a higher chance of survival to hospital discharge with a neurologically favorable outcome (13.9% vs. 5.1%). Among patients surviving after CPR but with post-resuscitation shock, those in the VSE group had a higher probability of survival to hospital discharge with a favorable neurologic outcome.

Indications and contraindications

CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid rhythm strip recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options. Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following:

Ventricular fibrillation (VF) Pulseless ventricular tachycardia (VT) Pulseless electrical activity (PEA) Asystole Pulseless bradycardia CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established.

Contraindications
The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a persons desire to not be resuscitated in the event of cardiac arrest. A relative contraindication to performing CPR is if a clinician justifiably feels that the intervention would be medically futile.

Equipment
CPR, in its most basic form, can be performed anywhere without the need for specialized equipment. Universal precautions (ie, gloves, mask, gown) should be taken. However, CPR is delivered without such protections in the vast majority of patients who are resuscitated in the out-of-hospital setting, and no cases of disease transmission via CPR delivery have been reported. Some hospitals and EMS systems employ devices to provide mechanical chest compressions. A cardiac defibrillator provides an electrical shock to the heart via 2 electrodes placed on the patients torso and may restore the heart into a normal perfu sing rhythm.

Technique
In its full, standard form, CPR comprises the following 3 steps, performed in order:

Chest compressions Airway Breathing For lay rescuers, compression-only CPR (COCPR) is recommended. Positioning for CPR is as follows:

CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum Delivery of CPR on a mattress or other soft material is generally less effective The person giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest For an unconscious adult, CPR is initiated as follows: Give 30 chest compressions Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing Before beginning ventilations, look in the patients mouth for a foreign body blocking the airway Chest compression The provider should do the following:

Place the heel of one hand on the patients sternum and the other hand on top of the first, fingers interlaced Extend the elbows and the provider leans directly over the patient (see the image below) Press down, compressing the chest at least 2 in Release the chest and allow it to recoil completely The compression depth for adults should be at least 2 inches (instead of up to 2 inches, as in the past) The compression rate should be at least 100/min The key phrase for chest compression is, Push hard and fast Untrained bystanders should perform chest compressiononly CPR (COCPR) After 30 compressions, 2 breaths are given; however, an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute This entire process is repeated until a pulse returns or the patient is transferred to definitive care To prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR Ventilation If the patient is not breathing, 2 ventilations are given via the providers mouth or abag-valve-mask (BVM). If available, a barrier device (pocket mask or face shield) should be used. To perform the BVM or invasive airway technique, the provider does the following:

Ensure a tight seal between the mask and the patients face Squeeze the bag with one hand for approximately 1 second, forcing at least 500 mL of air into the patients lungs To perform the mouth-to-mouth technique, the provider does the following: Pinch the patients nostrils closed to assist with an airtight seal Put the mouth completely over the patients mouth After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR) Give each breath for approximately 1 second with enough force to make the patients chest rise Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion After giving the 2 breaths, resume the CPR cycle

Complications
Complications of CPR include the following:

Fractures of ribs or the sternum from chest compression (widely considered uncommon) Gastric insufflation from artificial respiration using noninvasive ventilation methods (eg, mouth-to-mouth, BVM); this can lead to vomiting, with further airway compromise or aspiration; insertion of an invasive airway prevents this problem

ACLS
In the in-hospital setting or when a paramedic or other advanced provider is present, ACLS guidelines call for a more robust approach to treatment of cardiac arrest, including the following:

Drug interventions ECG monitoring Defibrillation Invasive airway procedures Emergency cardiac treatments no longer recommended include the following: Routine atropine for pulseless electrical activity (PEA)/asystole Cricoid pressure (with CPR) Airway suctioning for all newborns (except those with obvious obstruction)

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In ancient Greece and Rome, birth was usually an all-female event which affirmed the parturient's status as mother of the patriarchal family, especially when she produced a male child. Labouring women prayed to Asclepias and Artemis for support. Midwives came from a range of socioeconomic backgrounds, and they enjoyed varying amounts of prestige according to their training. In Greece, male and some female healers who were trained in empirically based knowledge derived from Hippocratic medicine enjoyed high social status, attended births, and sometimes worked together during both normal and problem deliveries. A midwife untrained in Hippocratic medicine relied on a variety of folk nostrums as well as on charms and amulets. In situations where a baby's abnormal birth position slowed its delivery, the birth attendant turned the infant inutero or shook the bed to attempt to reposition the fetus externally. A dead baby who failed to be delivered would be dismembered in the womb with sharp instruments and removed with a "squeezer." A retained placenta was delivered by means of counterweights, which pulled it out by force. Pain relievers and sedatives were employed only for excessive maternal suffering due to birth complications; pain associated with normal labor was seen as productive and as a part of the birthing process.

Birth was a rite of passage for the woman that affirmed her fertility and new status as a mother. In spite of the biblical injunction that "in sorrow thou shalt bring forth children" (Genesis 3:16) midwives administered narcotic or painrelieving herbs and wine. Catholic mothers also sought solace in praying to St. Margaret, the patron saint of pregnant women, while Protestant women prayed directly to their Lord without the intercession of saints Bloodletting at an ankle vein also might be administered. Popular and learned images of the midwife ranged from ignorant and unskilled to skilled and respectable. The modern notion of the midwife as witch had very little basis in reality. Court records document that midwives were rarely accused of witchcraft. In fact, ecclesiastical and municipal authorities entrusted midwives with a variety of medical and legal responsibilities. With increasing frequency, the midwife was called upon to testify as an expert witness in cases of contested pregnancy, infanticide, virginity, and rape; to mediate domestic squabbles; and to attest to religious conformity, illegitimate birth, or infanticide. moreover, husbands and moralists expressed concerns that a male presence during labor could easily compromise a woman's virtue. By the end of the eighteenth century, however, men attended 50 percent of all deliveries in many parts of England. The tendency was similar in France, and it became increasingly true in the United States as well. . Hospitals provided an endless supply of patients on which males could practice birthing techniques for normal and abnormal deliveries. In addition, famous surgeon accoucheurs and physicians set up private lecture courses for an all-male clientele on obstetrics, surgery, and dissection. A "hands-on" learning approach improved the students' skill and confidence. Some midwives clung to their traditional ways. Others embraced the new science and sought retraining. National policies also shaped the contours of midwifery practice. In France, for example, the fear of depopulation induced King Louis XV in 1759 to sponsor Madame du Coudray to educate rural midwives. Utilizing obstetrical mannequins and an illustrated manual, she trained an estimated ten thousand peasant women to deliver babies using advanced life-saving methods.

The potential danger that accompanied the use of anesthesia required a physician in attendance in a hospital setting. Women's erratic behavior under the anesthesia compelled their attendants to tether them to the hospital bed. Moreover, the mothers' delirious state made them totally unaware of the birth process. Consequently, Loudon reports in his 1997 book that the risk of dying in childbirth in 1863 and 1934 were virtually identical. The high death rate was the result of lax antiseptic practices and poorly trained birth attendants who engaged in unnecessary and dangerous obstetrical interventions, especially forceps deliveries. This fact became evident when national differences were taken into account The rationale for birth by cesarean section initially was religious. The operation was performed when the mother appeared to be dying in order to ensure that the fetus could be baptized. . In 1994 the rate fell to 21 percent from a high of 23 percent in 1992. The reduction has been attributed to a reduced number of same-patient cesarean sections after repeated challenges to the statement "once a cesarean section always a cesarean section." Due to the lack of universal health care in the United States, however, the availability and usage of prenatal clinics vary tremendously. Healthy, educated, middle-class women who have planned pregnancies are more apt to visit their physicians or midwives and to follow their advice. Women who are disadvantaged and lack access to prenatal care and/or are ambivalent about having children tend to have a higher rate of preterm deliveries and other health-related problems. Cultural and social reasons inhibit such women from taking advantage of prenatal services even when they are free and accessible. African-American women deliver low-birth-weight babies at a rate twice as high as white women. Some studies on prenatal care in the United States reinforce the advisability and efficacy of the European model for prenatal care: lowincome, high-risk, and/or African-American women who have access to nurse-midwifery care at prenatal clinics as opposed to standard prenatal care from obstetricians have better birth outcomes. . Midwives responded in a variety of ways. Swedish midwives acquired the training and right to use forceps, while midwives in other European countries acquired new medical skills to help them compete with physicians. By contrast, during the same period, American midwives'

lack of organization, political power, and economic resources made it extremely difficult for them to defend themselves against the medical profession. Physicians labeled them as incompetent and ignorant in spite of many contemporary studies that contradicted these charges. A few notable exceptions included the continued practice of some immigrant midwives in the North and the founding of the Maternity Center Association in New York (1918) and the Frontier Nursing Service in Kentucky (1925) which trained nurses to become midwives for the poor. The safety and cost-effectiveness of national health care insurance combined with support of a home-birth tradition has allowed the Dutch midwife to enjoy greater autonomy vis--vis the medical profession than midwives in almost any country. American midwives made a comeback in the late twentieth century after their earlier decline. A consumer and feminist revolt against overmedicalized birthing led to a resurgence of interest in self-taught or apprentice-trained midwives for home births, called "lay" or "direct-entry" midwives. Despite gaining legal recognition in some states, direct-entry midwives remain on the medical fringe. Certified nurse-midwives who also are registered nurses with postgraduate training in midwifery have enjoyed greater acceptance. Middle-class and feminist women who demanded a more natural birth experience in a "safe" but "homey" hospital environment created the alternative birth movement, in which nurse-midwives played an important role. Shortages of physicians in the 1970s also encouraged the federal government to support nurse practitioners and nursemidwives to staff the newly-funded family planning centers for the poor. At the beginning of the third millennium, certified nurse-midwives enjoyed almost universal legal recognition throughout the United States. Data demonstrate that their expertise results in equal or better outcomes for low-risk pregnancies.
History Of CPR
Modern CPR developed in the late 1950s and early 1960s. The discoverers of mouth-to-mouth ventilation were Drs. James Elam and Peter Safar. Though mouth-to-mouth resuscitation was described in the Bible (mostly performed by midwives to resuscitate newborns) it fell out of practice until it was rediscovered in the 1950s.

In early 1960 Drs. Kouwenhoven, Knickerbocker, and Jude discovered the benefit of chest compression to achieve a small amount of artifical circulation. Later in 1960, mouth-to-mouth and chest compression were combined to form CPR similar to the way it is practiced today.

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Immunization Against Tetanus A p r e g n a n t wo ma n mu s t g e t t wo i n j e c t i o n s o f T e t a n u s To x o i d d u r i n g t h e p e r i o d between 16 36 weeks, at one month interval. These protect the mother and baby bothf r o m t h e r i s k o f t e t a n u s . Th e 2 n d

injection should preferably be given at least at onemonth before delivery. If a woman is registered late then in that case even one injectionwill do. If the woman is immunized earlier within three years of the pregnancy, thenone booster dose will be enough.

Iron and Folic Acid and Vitamin A and D Supplementation I t i s b e i n g f o u n d t h a t 5 0 - 6 0 p e r c e n t o f p r e g n a n t wo me n a r e a n a e mi c d u e t o i r o n deficiencies. Anaemia is also aggravated in pregnancy. It is therefore important to takeone tablet containing 60 mg.of elemental iron and 500 mg of folic acid three times dailya f t e r t h i r d mo n t h o f p r e g n a n c y t i l l 3 mo n t h s a f t e r c h i l d b i r t h i f t h e mo t h e r i s f o u nd having anaemia.During pregnancy, the mother requires extra iron and folic acid due to changes taking place in the body and growth of fetus in the womb. Therefore each mother is given onet a b l e t o f i r o n a nd f o l i c a c i d t wi c e a d a y f o r a t l e a s t 1 0 0 d a ys t o p r e v e n t a n a e mi a i n mother and to promote proper growth of fetus.An e mi a i s c o mmo n i n p r e g n a n c y a n d l o w i n c o me g r o u p . I t i s a m a jo r c a u s e o f maternal and fetal mortality. Prevention of Anemia

Avoidance of frequent of child birth:

A t l e a s t t wo ye a r s a n i n t e r v a l b e tw e e n pregnancies is most necessary to replace the lost iron during childbirth process andlactation. This can be achieved by proper family planning guidance.

Supplementary iron Therapy: Iron supplementary should be a routine after the patient becomes free from nausea and vomiting. Daily 60mg iron with 1mg folicacid is a quite effective prophylactic procedure.

Dietary Prescription: Well balanced diet rich in iron and protein should b e advised. The food rich in iron are liver, meat, egg, green vegetables, green pea bean,whole wheat etc.

A d e q u a t e t r e a t me n t s h o u l d b e i n s t i t u t e d t o e r a d i c a t e t h e i l l n e s s l i k e l y t o c a u s e anemia. These are hookworm infestation, dysentery, and malaria, bleeding piles,urinary tract infection etc.

Early detection of falling hemoglobin level is to be made. Hemoglobin level should be estimated at the first antenatal visit at the 28 th and finally at 36 th weeks.

Avoid excessive blood loss during the 2 nd stage of labour.

Puerperal sepsis This is infection of the genital tract within 3 weeks after delivery. This is accompanied by rise in temperature and pulse rate, foul smelling lochia, pain and tenderness in lower abdomen, etc. Puerperal sepsis can be prevented by attention to
asepsis, before and after delivery. This is particularly important in domiciliary midwifery service.

Prevention Puerperal sepsis is to a great extent preventable. Certain measure should be taken under before, during and following labour. Antenatal

Detect and eradicate the septic focus especially located in the teeth, gums, tonsils,middle ears etc.

Maintain and improve the health of status of the patient especially to raise Hb level, prevent eclampsia, early treatment of any abnormalities.

Vaginal examination during pregnancy especially in the last months should be keptin a minimum and should be carried out with strict surgical asepsis.

Intercourse should be avoided during the last two months to prevent introduction of organisms like streptococcus.

The patient should avoid contact with persons suffering from infectious disease.

The patient should take care of personal hygiene. Intranatal

The nurse, doctor and other personnel entering into labour room should wear mask,gown and cap to prevent the infection of personnel spread to labour room.

The delivery should be conducted taking full surgical asepsis.

Members should be kept preserved as long as possible.

Well management on every step of labour which prevents possibility of infection.

Avoid prolonged labour and mother from exhaustion.

Traumatic vaginal delivery should preferable be avoided a n d i n t r a u t e r i n e manipulation if required should be done by maintaining strict surgical asepsis.

After placenta delivery, explore the vagina to determine if there are any pieces of membranes or blood clots retained in uterus.

Enema should be given in first stage of labour to prevent the contamination of stoolin 2 nd stage of labour.

Dust should be avoided in the labour room.

Laceration of the genital tract should be repaired promptly.

E x c e s s i v e b l o o d l o s s d u r i n g d e l i ve r y s h o u l d b e r e p l a c e d p r o mp t l y b y b l o od transfusion to improve the general body resistance. Postnatal Period

Aseptic precaution should be taken for at least one week following delivery untilthe open wound the uterus and the genital tract injury, if any, are healed up.

Nurse should take aseptic precaution and wear mask while giving perineal care.

Restrict too much visitors in ward.

Sterilized sanitary pad should be used and changed frequently to prevent lochiato decompose and become offensive on the pad.

Clean the vulval area with antiseptic solution after each u r i n a t i o n a n d defecation.

Isolation as well as barrier nursing measure for infected patient and infants isimperative.

Advise to avoid sexual intercourse for 4-6 weeks after delivery.

Thrombo phlebitis

This is an infection of the veins of the legs, frequently associated with varicose veins.The leg may become tender, pale and swollen. So the mother should be encouraged todo the leg exercise to increase the muscle tone.

Deep vein Thrombosis It is the thrombosis of deep vein of calf, thigh or pelvis, clot formation in the absence of infection. Prevention The three important factors i. e. trauma, sepsis and anemia should be prevented and to be treated effectively after detection. Dehydration during delivery should be promptlycorrected.L e g e x e r c i s e a n d e a r l y a mb u l a t i o n a r e e n c o u r a g e d e s p e c i a l l y f o l l o wi n g o p e r a t i v e delivery.

Postpartum Hemorrhage

Postpartum hemorrhage is the condition of excessive bleeding from the genital tract atany time following the babys birth up to 6 weeks after delivery . It may occur at anytime that is during third stage of labour, with in 24 hours or after 24 hours of labour. Preventive measures of PPHS L . N A n t e n a t a l P e r i o d I n t r a n a t a l P e r i o d P o s t n a t a l P e r i o d 1. E n s u r e r e g u l a r antenatal care

J u d i ci ou s l y a d mi n i s t er sedative, analgesic a n d oxytocin C o n t i n u e t o mo n i t o r vital signs2. Maintain Hb level asnear as normal Avoid hasty delivery of the baby. One should take at least 2-3 m i n u t e s t o d e l i v e r t h e trunk after the head is born. Baby should be pushed out by the retracted uterus andnot be pulled out. Observe the lochia,t y p e , a m o u n t C P r e v e n t t h e l a b o u r b e i n g prolonged C h e c k H b l e v e l i f needed4. Identify high risk m o t h e r s ( t w i n s , h y d r a m n i o s , A P H , g r a n d mu l t i p a r a e t c ) a n d d e l i v e r i n a we l l equipped hospital h e c k b l o o d grouping and typing a n d consistency.3.

A v o i d f i d d l i n g a n d kneading of the uterus o r pulling the cord before the placental separation Prevent infection5. Strict application of activemanagement of third stagee.g. Immediate
oxytocinControl Cord TractionUterine Massage

Observe the mother f o r t w o h o u r s a f t e r delivery and e n s u r e that the uterus is harda n d c o n t r a c t e d enough.6. In all cases of the inducedo r a u g m e n t e d l a b o u r b y oxytocin should be kept onc o n t i n u o u s o x y t o c i n i n f u s i o n f o r a t l e a s t o n e hour after delivery. Encourage the mother for breast feeding.7. E x a mi n e t h e p l a c e n t a a n d m e m b r a n e s c o r d carefully Encourage and assistt o e mp t y t h e b l a d d e r p e r i o d i c a l l y a n d f o r ambulation. a n d

Inversion of the uterus The uterus is said to be inverted if it rums inside out partially or completely duringdelivery of the placenta. Preventive measures

Dont employ any method to expel the placenta when the uterus is relaxed.

Avoid pulling cord simultaneously with fundal pressure.

Attempt proper technique to deliver the placenta and of manual removal of placenta.

Pay visilant observation for separation of placenta.

Urinary tract infection and incontinence of urine It is one of the common causes of puerperal pyrexia, the incidence being 15 % of alld e l i v e r i e s . I t i s d u e t o f r e q u e n t c a t h e t e r i z a t i o n e i t h e r d u r i n g l a b o u r o r i n e a r l y puerperium to relieve retention of urine, recurrence of previous pyelitis, poor personalhygiene
and vaginal hygiene, trauma following instrumental delivery, poor fluid intake.It is extremely important to look for these complications in the postnatal period and prevent or treat them promptly.

Postnatal Blues Pregnancy and puerperium are highly stressful periods in a womans life. The person isthreatened by various changes such as physiological changes, and endocrine changes occurring in ones body, as she is in reorganization of psyche in accordance with thenew mother role especially in the first pregnancy. Body image changes and unconsciousi n t r a p s yc h i c c o n f l i c t s r e l a t e d t o p r e g n a n c y, c h i l d b i r t h , a n d mo t h e r h o o d b e c o me a c t i v a t e d . I t i s n o wo u n d e r t h a t 2 5 % t o %0 % o f t h e p r e g n a n t w o mr n d e v e l o p mi l d psyc h o l o g i c a l s ymp t o ms i n t h e p u e r p e r a l p e r i o d . Th e c o m mo n e s t t yp e i s t h e mi l d depression and irritability known as the postnatal blues.

- Hein Roth 2006 Prevention

Advice to the family and relatives to deal properly with the postnatal situation of the postnatal mother.

Help her to feed the baby and assist her in domestic duties.

Advice to provide sufficient rest, balance diet and to give love and care. 4. Respiratory Distress Syndrome and Neonatal Problems

Asphyxia Neonatorum Asphyxia neonatorm is defined as failure to initiate and m a i n t a i n s p o n t a n e o u s r e s p i r a t i o n wi t h i n o n e mi n u t e s o f b i r t h . I t ma y d u e t o t r a u ma t i c f o r c e p s o r v a c c u m delivery, maternal lack of oxygen due to anemia, pre- eclampsia, intra uterine hypoxiadue to placental
insufficiency APH, and premature separation of placenta.

Prevention Antenatal screening of high risk patients.

Complete fetal monitoring, particularly in high risk pregnancy group to ensure earlydetection of fetal distress Intrapartum fetal monitoring.

Respiratory Distress syndrome Respiratory distress syndrome almost always occurs in preterm babies. It may be due to p r e ma t u r e l y, ma t e r n a l a n e mi a , p r e - e c l a mp s i a , d i a b e t e s , A P H a f t e r 2 8 w e e k s o f gestation, intrauterine hyposia etc. Prevention Administration of dexamethasone in patients anticipating p r e t e r m d e l i v e r y especially before 34 weeks for lung maturity. Assessment of lung maturity before premature induction of labour and induction of labour and to delay the induction as much as possible without any risk to the fetus.

Prevent fetal hypoxia in diabetic mothers. A v o i d s mo k i n g , a n e mi a , p r e - e c l a mp s i a , A P H a n d o t h e r c o mp l i c a t i o n d u r i n g pregnancy. Suction immediately after birth to patent the airway. 5. Prevention of Birth Injuries

Intracranial injury and haemorrhage T h e i n t r a c r a n i a l i n ju r y a n d h a e mo r r h a g e i s d u e t o t r a u ma , r a p i d c o mp r e s s i o n a s i n breech delivery, face presentation, instrumental delivery. Prevention

Comprehensive intranatal and antenatal care is the key to success in the reduction of intracranial injuries. Prevent or detect intrauterine fetal asphyxia in earliest by intensive fetal monitoring. Episiotomy and use of forceps to deliver the premature b a b y m i n i m i z e t h e intracranial disturbance. Avoid traumatic vaginal delivery in preference to caesarean section. Difficult forceps should be avoided. In vaccum delivery, traction is made only after proper cephalic application. Avoid prolonged and difficult labour. Prevention of injuries in the new born babies Comprehensive antenatal and intranatal care is the key to success in reduction of birtht r a u m a a n d c o n s e q u e n t l y i n t h e r e d u c t i o n o f p e r i n a n t a l m o r t a l i t y a n d n e o n a t a l morbidity. Antenatal period

Screen out the risk babies.

Employ liberal use of C/S and episiotomy.

Contracted pelvis, CPD, malpresentation should be i n c l u d e d a n d m a n a g e accordingly. Intranatal periodDuring normal delivery

Continuous fetal monitoring to detect fetal distress, extract baby before he becomecompromised. This can prevent traumatic cerebral anoxia.

Episiotomy is to be done carefully after placing two fingers in between the head andthe stretched perineum- to prevent injury to the scalp.

The neck shouldnt be unduly stretched while delivering the shoulders to minimizeinjuries to the brachial plexus or steromastoid Special care in preterm delivery

Prevent anoxia

Avoid strong sedation.

Liberal episiotomy and use of forceps to minimize intracranial compression.

Administer vitamin k 1 mg intramuscularly to prevent or minimize haemorrhagefrom the traumatized area. Forceps Delivery

Difficult forceps are to be withheld in preference to the safer caesarean section.

Never apply traction unless the application is a correct one Ventouse Delivery

It is relatively less traumatic, but it should be avoided in preterm babies. Vaginal Breech Delivery To prevent intracranial injuries: The crucial period in breech delivery is duringdelivery of the aftercoming head.

Never be in haste during delivery of the head which find little time to mould.

Episiotomy should be done as a routine to minimize head compression.

Controlled delivery of the head by forceps is preferable. To prevent spinal injury: Acute bending at the neck is to be prevented while forcepsare being applied to the after coming head or delivery of the head. To prevent fracture: T h e l i mb s a r e d e l i v e r e d i n a ma n n e r d e s c r i b e d i n b r e e c h delivery. 6. Major Disorders of Newborn Baby

Ophthalmia Neonatorum Ophthalmia neonatrum is the inflammation of conjunctiva during first 3 weeks of lifewhich is characterized by purulent discharge, swelling and redness of affected eyes.

The broad areasof this care fall into three divisions:

Physical

It has been said that the most important thing a woman can do is to have a baby. This isonly part of the truth. The really important thing is to nurture and raise the child in awholesome family atmosphere. She, with her husband, must develop her own methods. Arrangements to burn or deep bury the placenta.Th e t r a i n e d D a i s h o u l d b e r e a d y wi t h h e r o wn k i t f o r d e l i v e r y. I t s h o u l d ha v e t h e following articles: a. Enema can two bowels and one kidney tray, torch, a pair of scissors. b. Clean gauze pieces, cord ligatures, mucus sucker and baby weighing spring balance.c.Drugs and antiseptic like injection methergin, methylated spirit.d . H a n d w a s h i n g a r t i c l e s . These equipments and articles must be kept ready by the mother and family so thatthere is no problem at the time of delivery. The instructions must be given to another regarding these. Similarly the trained dais and health workers should be ready with their delivery kit for conduct of delivery at home. First Trimester Antenatal care in the first trimester starts with a visit to the GP after a missed period andc o n f i r ma t i o n o f p r e g n a n c y. I t a l s o p r o v i d e s a n i d e a l o p p o r t u n i t y f o r t h e wo ma n t o discuss any anxieties she may have. 8 .H e m a t o l o g i c a l I n v e s t i g a t i o n s These include hemoglobin estimation and a complete blood picture if indicated. Bloodgroup determination and antibody screen is also performed to identify rhesus negativewomen who will need prophylaxis against rhesus isoimmunization.

Full blood count

T h i s i s t h e mo s t c o m mo n l y p e r f o r me d h e ma t o l o g i ca l i n v e s t i g a t i o n i n p r e g n a n c y. Pregnancy is associated with a physiological dilutional anemia due to greater increasein plasma volume than red cell mass and therefore the lower limit for a normal Hb is10.5 g/dl in pregnancy as opposed to 11.5g/dl in the non pregnant female. Many womene n t e r p r e g n a n c y w i t h a l o w i r o n r e s e r v e a n d t h e r e f o r e i f a n e m i a i s d e t e c t e d i n pregnancy it should be appropriately investigated by assessment of ferritin, total iron binding
capacity (TIBC), serum and red cell folate and B12 levels based on the blood picture. The most common cause of anemia in pregnancy is iron deficiency anemia.FBC estimation is performed 4 8 weekly in the second half of pregnancy and lowhemoglobin on admission in labour is an indication for sending a specimen to the labfor

group and save in case of intrapartum or

postpartum bleeding.

Blood grouping and screening for antibodies Blood grouping at booking, enables the determination women who are rhesus negativeand therefore may be at risk of rhesus isoimmunization. The incidence of rhesus diseaseh a s d r a m a t i c a l l y f a l l e n o v e r t h e l a s t t h i r t y y e a r s t h e i n t r o d u c t i o n o f a n t i D administration. Despite screening at 28 and 34 weeks or after any potential sensitizingevent and administration of prophylactic anti D at these times, a small number of RhDnegative women still develop anti-D antibodies because of
small silent hemorrhages predominantly in the third trimester or because of failure of timely administration of a n t i D i m m u n o g l o b u l i n . S c r e e n i n g f o r r e d c e l l a n t i b o d i e s s h o u l d b e r e p e a t e d i n a l l women in early pregnancy in subsequent pregnancies, even if rhesus positive, as theremay be other clinicall y

significant antibodies as a consequence of previous pregnancyo r b l o o d t r a n s f u s i o n . An a n t i b o d y s c r e e n i s p e r f o r me d t o d e t e c t t h e p r e s e n c e o f antibodies that may put the baby at risk of hemolytic disease or result in difficultieswith cross- matching blood for the mother if required at any age of pregnancy, labour or postnatally. If antibodies are detected, the titer is
determined and subsequent samplestaken for further estimation at appropriate time interval.

9 .S c r e e n i n g f o r U r i n a r y T r a c t i n f e c t i o n Urinary tract infections may be asymptomatic. Whether symptomatic or not, urinarytract infections present a risk to both mother and fetus. Prevention of these infections ise s s e n t i a l . Th e wo m a n s u n d e r s t a n d i n g

a n d u s e o f g e n e r a l h yg i e n e me a s u r e s a r e assessed. Before developing a plan of care, the nurse needs to elicit feelings or ideas concerning cultural, ethnic, religious, or other factors affecting health practices. Ther a t i o n a l e b e i n g t h a t s o me c a s e s a s ymp t o ma t i c b a c t e r i u r i a a n d a l o w e r u r i n a r y t r a c t infection may lead to complications of the advanced stages of the disease.The woman may need to learn that every woman should always wipe from
front to back after urinating or moving her bowels and use a clean piece of toilet paper for each wipe.W i p i n g f r o m b a c k t o f r o n t m a y c a r r y b a c t e r i a f r o m t h e r e c t a l a r e a t o t h e u r e t h r a l opening and increase risk of infection. Soft, absorbent toilet tissue, preferably white andunscented, should be used because harsh, scented or printed toilet paper may causeirritation. Women need to change panty shields or sanitary napkins often. Bacteria canmultiply on soiled napkins. Women need to wear underpants and pantyhose with acotton crotch. They should avoid wearing tight fitting slacks or jeans or panty shieldsfor long periods.Some women dont have an adequate fluid and food intake. After eliciting her food preferences, the nurse should advise the women to drink 2 to 3 quarts (8 to 12 glasses)of liquid a day.

Morning Sickness ( Nausea and Vomiting) N a u s e a a n d v o mi t i n g e s p e c i a l l y i n t h e mo r n i n g , s o o n a f t e r getting out of bed, areu s u a l l y c o m m o n i n p r i m i g r a v i d a . I t may due to emotional factors, fatigue, andcarbohydrate metabolism. So it is important to prevent it from getting w o r s e a s hyperemesis gravidarum may occur. Prevention o Identify the particular odour of foods that are most upsetting and avoid the odour of certain foods, because women are very sensitive to smells. o Eat dry crackers or bread 15 minutes before getting up from the bed in the morning. o Advice to consume small frequent meal (every 2 hours if possible). o Avoiding spicy and greasy food and consuming protein snack at night

o Advice to take light and dry snacks instead of heavy meal. o Avoid brushing after eating. o Keep room well ventilated for fresh air.

Indigestion Indigestion often occurs after eating too much of heavy or greasy food or drinking toomuch of alcohol. It is characterized by discomfort or a burning feeling in the mid chest or stomach. Prevention

Avoid fatty, greasy and spicy foods

Eat small frequent meals instead of the usual three meals.

Avoid alcohol, coffee and cigarettes.

Eat boiled foods.

Varicose veins Varicose veins are enlarged superficial veins on the legs; vulva and anus varicose veinsa r e d i s o r d e r o f t h e s e c o n d a n d t h i r d t r i me s t e r s . I t i s d u e t o i n c r e a s e d ma t e r n a l a g e , excessive weight gain large foetus and multiple pregnancies etc.

Prevention

Exercise regularly and avoid tight clothes.

Avoid standing for long time and sitting with feet hanging down.

Lift the legs up with extra pillows while sitting, resting or sleeping.

Avoid crossing legs at the knees because it provides the pressure on her veins.

Backache This is common problem during pregnancy especially in the third trimesters. Slight backache may be due to faulty posture and is more common in multigravida.It may bedue to fatigue, by lifting heavy objectives and poor postures, fatigue. Prevention

Take adequate rest in proper position and posture.

Wear supportive shoes with low heels, avoid high heels shoes.

Do prenatal exercise and do not gain more weight.

A v o i d e x c e s s i v e t wi s t i n g , b e n d i n g , s t r e t c h i n g a n d a l s o e x c e s s i v e s t a n d i n g o r walking.

Fainting ( Syncope) It is the disorder common in second and third trimester. M a n y p r e g n a n t w o m e n occasionally fall to faint, especially in warm and crowed areas. It is due to anemia,sudden changes of position, standing for long periods in warm and crowd areas. Prevention

Avoid prolonged standing.

Rest in side lying position in left lateral to prevent supine hypotension.

Eat regularly iron containing food and plenty of liquid.

Advice to be alert for safety.

Heartburn Heartburn is a burning sensation in the mediastinal r e g i o n d u e t o b a c k f l o w (regurgitation) of acid contents into the oesophagus often accompanied by bad test inthe mouth. Prevention

Avoids foods known to cause gastric upset.

Avoid greasy, fried foods, coffee, alcohol and cigarettes.

Advice to take small frequent meal, but eat slowly.

Take adequate rest in sleeping with more pillows on propped position.

Explain that this is related to pregnancy and the problem disappears after pregnancy.

Constipation Constipation is a condition of infrequent, irregular and difficulty in passing stool or the p a s s i n g o f h a r d s t o o l . I t i s c o mmo n d u r i ng p r e g n a n c y. I t i s d u e t o l a c k o f p h ys i c a l activity or exercise, decrease fluids, oral iron supplement, pressure of enlarging uteruson intestine. Prevention

Encourage to maintain bowel habit, going to toilet at same time everyday and toiletwhen having the urge.

Encourage to drinking adequate liquid ( of least 200ml per day)

Advice to eat in regular schedule.

Encourage eating fruits, vegetables, gains and roughage in the diet.

Advice to do regular daily exercise.

Itching

Itching is an unpleasant cutaneous sensation that provokes a desire to scratch the skin. Itmay be due to poor personal hygiene, heat rash, minor skin disease. Prevention

Advice to take daily bath.

Advice to wear non- irritating clothes, cotton panty.

Leg Cramps Leg Cramps are painful muscle spasm in the muscles. They occur most frequently atnight but may occur at other times.Leg cramps are more common in the third trimester. Prevention

Advice to take enough calcium ( milk, greenleafy vegetables)

Advice to take warm bath to improve the circulation.

Advice to do exercise regularly.

Strengthen the legs, point or pull toes upward towards the knees.