Maternal and

Child Health Nursing

Prepared by:

Ruby Shelah P. Dunque

Introduction Maternal and Child Health refer to philo-mother

and child relationship to one another and consideration of the entire family as well as the culture and socio-economic environment as framework of the patient.

It involves the care of the woman and family throughout pregnancy and childbirth and the health promotion and illness care for the children and families.

Goal of MCH

To ensure that every expectant and nursing mother maintains good health, learns the art of child care, has normal delivery and bears healthy child.

That every child, wherever possible lives and grows up in a family unit with love and security, in healthy surroundings, receives adequate nourishment, health supervision and efficient medical attention, and is taught the elements of healthy living (Reyala, 2000).

Promotion and maintenance of optimum health of the women and newborn.

Philosophy of MCN

Is community-centeredIs research-centeredIs based on nursing theoryProtects the rights of all family membersUses a high degree of independent

functioningPlaces importance on promotion of health

Is based on the belief that pregnancies or childhood illness are stressful because they are crises.

Is a challenging role for the nurse and is a major factor in promoting high level wellness in families.

Pregnancy, labor and delivery and the puerperium are part of the continuum of the total life cycle.

Personal, cultural and religious attitudes and beliefs influence the meaning of pregnancy for individuals and make each experience unique.

Maternal-child nursing is family centered. The father of the child is as important as the mother.

 Strategic thrusts (2005-2010)

Launch and implement the Basic Emergency Obstetric Care strategy in coordination with the DOH. It entails the establishments of facilities that provide emergency obstetric care for every 125,000 population and which are located strategically.

Improves the quality of prenatal and postnatal care.

Reduce women’s exposure to health risks through the institutionalization of responsible parenthood and provision of appropriate health care package to all women of reproductive age especially those who are less than 18 years old and over 35 years of age, women with low education and financial resources, women with unmanaged chronic illness and women who had just given birth in the last 18 months.

LGUs and NGOs and other stakeholders must advocate for health through resource generation and allocation for health services to be provided for the mother and the unborn.

Maternal Neonatal and Child Health and Nutrition Strategy

(MNCHN)

It applies specific policies and actions for local health systems to systematically address health risks that lead to maternal and especially neonatal deaths which comprise half of the reported infant mortalities.

BeMONC- Basic Emergency Obstetrics and Newborn Care

It refers to lifesaving services for emergency maternal and newborn conditions/complications being provided by a health facility or professional to include the following services:

Administration of parenteral oxytocic drugs.

Administration of dose of parenteral anticonvulsants

Administration of parenteral antibiotics

Administration of maternal steroids for preterm labor

Performance of assisted vaginal deliveries

Removal of retained placental products

Manual removal of retained placenta

It also includes neonatal interventions which include at the minimum:

Newborn resuscitation

Provision of warmth

Referral

Blood transfusion

BeMONC facility shall consist of the core district hospital.

For geographically isolated/disadvantaged areas/ densely populated areas, the designated BeMONC facilities are the following: Rural Health Unit, Barangay Health Station, Lying-in Clinics and Birthing Homes.

Accessibility within 1 hour from residence or referring facility within the ILHZ (Inter-local Health Zones)

Shall operate within 24 hours with 6 signal obstetric function.

Shall have access to communication and transportation facilities to mobilize referrals.

Staff composition: (1) Medical Doctor, (1) Registered Nurse, (1) Registered Midwife.

CeMONC- Comprehensive Emergency Obstetrics and Newborn Care facility

- Refers to lifesaving services for emergency maternal and newborn conditions/complications as in Basic Emergency Obstetric and Newborn Care plus the provision of surgical delivery and blood bank services and other specialized obstetric interventions.

Essential Health Services available in the Health Care Facilities

A. Antenatal Registration/ Prenatal Care

OBJECTIVE: to reach all pregnant women, to give sufficient care to ensure a healthy pregnancy and the birth of a full term healthy baby.

Normal Patients- following the initial evaluation they will be given healthy instructions and counseling. This will include advice for prompt prenatal care examination.

Patients with mild complications- a thorough evaluation of the needs of patients with mild complications will determine the frequency of follow-up of these cases by the rural health unit, city health clinic or puericulture center

Patients with potentially serious complications- these patients shall be referred to the most skilled source of medical and hospital care. As a first choice they will be referred if at all possible for continuing care or consultation. Second choice will be followed carefully by the rural health unit, city health clinic or puericulture center.

All RHUs and BHS should have a masterlist of pregnant women in their respective catchment center.

The Home Based Mother’s Record (HBMR) shall be used when rendering prenatal care as a guide in in the identification of risk factors, danger signs and to be able to do appropriate measures.

There should be atleast 3 prenatal visits following the prescribed timing:

First prenatal visits should be made as early in pregnancy as possible, during the first trimester.

Second during the second trimester

Third and subsequent visits during the third trimester.

More frequent visits should be done for those at risk or with complications.

Tetanus Toxoid Immunization

Neonatal tetanus is one of the public health concerns, that is why it is important for pregnant women and child bearing age women to get a tetanus toxoid immunization in order to protect them from this deadly disease.

A series of 2 doses of TT vaccination must be received by woman one month before delivery to protect baby from neonatal tetanus.

And the three booster dose shots to complete the five doses following the recommended schedule provides full protection. The mother is then called as a “Fully Immunized Mother” (FIM).

Micronutrient Supplementation

It is necessary to prevent anemia, vitamin A deficiency and other nutritional disorders.

Vitamin A

Dose: 10,000 IU

Given a week starting on the 4th month of pregnancy.

Do not give it before the 4th month of pregnancy because it might cause congenital problems in the baby. 

Iron

Dose: 60mg/400 ug tablet

Schedule: Daily

Clean and Safe Delivery

A. Check for Emergency signs

Unconsciousness

Vaginal bleeding

Severe abdominal bleeding

Looks very ill

Severe headache with visual disturbance

Severe breathing difficulty

Fever

Severe vomiting

B. Made woman comfortable

C. Assess the woman in laborLMPNumber of pregnancyStart of labor painsAge/heightDanger signs of pregnancy

D. Determine the stage of labor

E. Decide of the woman can safely deliver

F. Give supportive care throughout labor

G. Monitor and manage labor

H. Monitor closely after delivery

I. Continue care for at least two hours postpartum

G. Inform, counsel and teach womanBirth registrationImportance of breastfeedingNewborn screeningSchedule of postpartum visits. (1st

visit: 1st week postpartum preferably 3-5 days and 2nd visit: 6 weeks postpartum)

Home Delivery

It is for normal pregnancies attended by licensed health personnel. Trained hilots may be allowed to attend home deliveries only in the following circumstances:

Areas where there are no health personnel on maternal care.

When, at the time of delivery, such personnel is not available.

Actively practicing but untrained birth attendants (hilots) should be identified, trained and supervised by a personnel of the nearest BHS/RHU trained on Maternal Care.

The following are qualified for home delivery:

Full term

Less than 5 pregnancies

Cephalic position

Without existing diseases such as diabetes, bronchial asthma, heart disease, hypertension, goiter, tuberculosis, severe anemia.

No history of complications like hemorrhage during previous deliveries.

No history of difficult delivery and prolonged labor (more than 24 hours for primi and more than 12 hours for multigravida)

No previous cesarean section

Imminent deliveries (those who are about to deliver and can no longer reach the nearest facility in time for delivery)

No premature rupture of membranes

Adequate pelvis

Abdominal enlargement is appropriate for age of gestation.

Home delivery kit must atleast contain two pairs of clamps, a pair of scissors, antiseptic (may use 70% Povidone/Iodine) soap and hand brush, clean towel/piece of cloth, flashlight, sphygmomanometer, stethoscope.

Clean hands, clean surface and clean cord must be strictly followed to prevent infection.

Guide for home delivery:

For registered patient: time when regular pains started, whether bag of water ruptured or not, presence of absence of vaginal discharges, bleeding, etc., whether mother moved her bowels and has urinated, fetal movement felt by the mother or not, unusual symptoms such as bleeding, headache, spots before eyes.

For unregistered patients: get same information as for those registered patients and get medical and obstetric history.

Delivery in Healthy Facility

At lying-in clinics, Birthing Homes or within the BHSs/RHUs.

Normal pregnancies and with labor progressing normally must be encourage to deliver in this facility.

Delivery in Hospitals

Risk pregnancies should be advised to deliver in the hospital are the following:

Pregnancy more the 4

Previous CS

History of postpartum hemorrhage

History of medical illness such as heart disease, goiter, tuberculosis, diabetes, severe anemia, hypertension, bronchial asthma

Antepartum hemorrhage

Hypertensive disorders of pregnancy and Eclampsia

Cephalo-pelvic disproportionPlacenta previa and abruption placentaMultifetal pregnancyPost term and preterm pregnanciesPrevious uterine surgery such as

myomectomy.

Apgar ScoringIt provides a valuable index for evaluation

of the infant’s at birth. It is based on five signs ranked in order of importance as follows: Heart Rate, Respiratory Effort, Muscle Tone, Reflex Irritability and Color. In general, they made 1 minute of life and 5 minutes. Each signs is evaluated according to the degree to which it is present and is given a score of 0, 1 and 2. The scores of each sign is added together to give a total scores (10 is the maximum).

Newborn Screening

It is a public health program aimed at the early identification of infants who are affected by certain genetic/metabolic/infectious conditions. Early identification and intervention can lead to significant reduction of morbidity, mortality and associated disabilities in affected infant

Significance:

Most babies with metabolic disorders look “normal” at birth. By doing NBS, metabolic disorders may be detected even before clinical signs and symptoms are present. And as a result of this, treatment can be given early to prevent consequences of untreated conditions.

Timing:

It is ideally done on the 48th-72nd hours of life. However, it may also be done after 24 hours from birth.

Procedure:

A few drops are taken from the baby’s heel, blotted on a special absorbent filter card and then sent to the Newborn Screening Center (NSC). The blood samples for Newborn Screening (NBS) may be collected by any of the following: physician, nurse, medical technologies or trained midwife. The procedure costs P550. The DOH advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for the collection of the sample. Newborn Screening is now included in the Philhealth Newborn Care Package. It is widely available in hospitals, Lying-ins, Rural Health Unit, Health Centers, and some private clinics. If babies are delivered at home, babies may be brought to the nearest institution offering newborn screening.

Results can be claimed from the health facility where NBS was availed. Normal NBS results are available by 7-14 working days from the time samples are received at the NSC. Positive NBS results are relayed to the parents immediately by the health facility. A NEGATIVE SCREEN MEANS THAT THE NBS IS NORMAL.

A positive screen means that the newborn must be brought back to his/her health practitioner for further testing. Babies with positive results maybe referred at once to a specialist for confirmatory testing and further management.

Disorders detected in Newborn Screening

Phenylketonuria

it is the inability to metabolize the amino acid phenylaline, which is a common component such a milk. Excessive accumulation of phenylalanine in the blood causes brain damage. The babies may look like “albino” with musty odor of the skin, hair, sweat and urine. PKU is treated with a special low-phenylalanine diet which the amount of amino acid is carefully regulated.

Congenital Hypothyroidismmost common causes of mental

retardation. Most affected infants may look normal at birth, however, they may have large fontanels and tongues, big tummies and prolonged yellowish discoloration of the skin and eyes. Infants are treated with thyroid hormones and it continues throughout life. If the disorder is not detected and hormone replacement is not initiated within two weeks, the baby with CH may suffer fro mental and growth retardation

Galactosemiait is the absence of enzymes necessary

for conversion of the milk sugar galactose to glucose. Affected infants present with difficulty in feeding, vomiting and diarrhea, yellowish skin and eyes, weakness, white eyes (cat’s eyes) and bleeding after blood extraction. Accumulation of excessive galactose in the body may cause liver damage, brain damage and cataracts. Treatment may include elimination of milk from the diet and use of milk substitute.

Glucose 6 phosphate dehydrogenase deficiency (G6PD deficiency)the body lacks the enzyme called G6PD

that may cause hemolytic anemia, when the body exposed to oxidative substances found in certain drugs, foods and chemicals. Children become pale, with yellow skin and eye, tea colored urine and fast breathing. It may lead to heart failure.

Congenital Adrenal Hyperplasiarefers to a group of disorders with an

enzyme defect that prevents adequate adrenal corticosteroid and aldosterone production an increases production of androgens. It manifested by poor feeding, vomiting and diarrhea and weak cry. It also causes short stature, early puberty excessive hair growth and infertility. Treatment of corticosteroids for the rest of child’s life.

Support to Breastfeeding Motivate ,mothers to practice breastfeeding

 

A. The Rooming-in and Breastfeeding Act of 1992

To encourage, protect and support the practice of breastfeeding. It shall create an environment where the basic physical, emotional and psychological needs of mothers and infants are fulfilled.

B. Milk Code of 1986

The aim of this code is to contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breast milk substitutes and breastmilk supplements when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Family Planning Counseling

Proper counseling of couples on the importance of family planning will help them inform on the right choices of family planning methods, proper spacing of birth and addressing the right number of children. Birth spacing of three to five years interval will help completely develop the health of a mother from previous pregnancy and childbirth. The risk of complications increases after the second birth.

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