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development goal.
This means a MMR of 112/100,000 live births in 2010 and 80/100,000 live births by 2015. Year 2010 2015 Expected MMR 112/100,000 live births 80/100,000 live births
The maternal mortality ratio (MMR) has declined from an estimated 209 per 100,000 live births in 1987-93 (NDHS 1993) to 172 in 1998. The Philippines found it hard to reduce morality. Similarly, perinatal mortality reduction has been minimal. It went down by 11% in 10 years from 27.1 to 24 per thousand live births. Year 1987-1993 1998 Actual MMR 209/100,000 live births 172/100,000 live births
The percentage of pregnant woman with at least four prenatal visits decreased from 77% in 1998 to 70.4 in 2003. In addition, pregnant women who received at least two doses of tetanus toxoid also decreased from 38% in 1998 to 37.3% in 2003. Only about 76.8% of pregnant women received iron supplementation during pregnancy. The Philippine Health Statistics revealed that maternal deaths are due to: Complication Hypertension Postpartum Hemorrhage Pregnancy with abortive outcomes Percentage of total maternal deaths 25% 20.3% 9%
However births attended by health professionals increased from 56% in 1998 to 59.8% in 2003. There was also a notable increase to 51% in 2003 from 43% in 1998 in the percentage of women with at least one prenatal visit. Only 44.6% of postpartum women received a dose of Vitamin A.
The underlying causes of maternal deaths are delays in taking critical actions:
delay in seeking care, delay in making referral and delay in providing of appropriate medical management.
closely spaced births, frequent pregnancies, poor detection and management of high-risk pregnancies, poor access to health facilities brought about by geographic distance and cost of transportation, and as well as health care and health staff who lack competence in handling obstetrical emergencies.
The overall goal of the program is to improve the survival, health and well being of mothers and unborn through a package of services all throughout the course of and before pregnancy.
less than 18 years old and over 35 years of age, women with low educational and financial resources, women with unmanaged chronic illness and women who had just given birth in the last 18 months.
Antenatal Registration
Pregnancy poses a risk to the life of every woman. Pregnant women may suffer complication and die. Every woman has to visit the nearest facility for antenatal registration and to avail prenatal care services. This is the only way to guide her in pregnancy care to make her prepare for child birth. The standard prenatal visits that women have to receive during pregnancy are as follows: Prental Visits 1 visit 2
nd rd st
Period of Pregnancy As early in pregnancy as possible before four months or during the first trimester During the 2
th nd rd
visit
trimester
Micronutrient Supplmentation
Micronutrient supplementation is vital for pregnant women. These are necessary to prevent anema, vitamin A deficieny and other nutritional disorders. They are: Nutrient Dose Vitamin 10,000 IU A Iron tablet Schedule Twice a week starting on the 4 month of pregnancy 60 mg/400 ug Daily
th
Remarks Do not give Vitamin A supplementation before the 4 month of pregnancy. It might cause congenital problems in the baby.
th
Clear airway Place in her best position Refer woman to hospital with EmOC capabilities Keep on her back arms at the side Tilt head backward (unless trauma is suspected) Lift chin to open airway
Post partum bleeding
Clear secretions from throat Give IVF to prevent or correct shock Monitor VS every 15 minutes Monitor fluid given. If difficulty of breathing and puffiness develops, stop infusion Monitor U.O. Do not give oral rehydration solution to a woman who is unconscious or has convulsions. Do not give IVF if you are not trained to do so Massage uterus and expel clots If bleeding persists:
Place cupped palm on uterine fundus and feel for state of contraction Massage fundus in a circular motion Apply bimanual uterine compression if ergometrine treatment done and p[ostpartum bleeding still persists Give ergometrine 0.2. IM and another dose after 15 minutes.
Do not give ergometrine if woman has eclampsia, preeclampsia or hypertension. Do not give mebendazole in the first 1-3 months of pregnancy. This might cause congential problems in baby.
Intestinal parasite infection Giver mebendazole 500mg tablet single dose anytime from 4-9 months of pregnancy if none was given in the past 6 months Malaria Give sulfadoxin-pyrimethamine to women from malaria endemic areas who are in 1 or 2 beginning of 2
nd rd st nd
Assessing the client is a reference guide for a health worker to determine its status during labor stage. This can be done by taking the history of the ff:
Last menstrual period (LMP) Number of pregnancy Start of labor pains Age/height Danger signs of pregnancy
Taking the history through interview will help determine the clients condition during delivery of a baby.
Encourage to take a bath at the onset of labor Encourage to drink but not to eat as this may interfere surgery in case needed. Encourage to empty bladder and bowels to facilitate delivery of the baby. Remind to empty bladder ever 2 hours Encourage to do breathing technique to help energy in pushing baby out the vagina. Panting can be done by breathing with open mouth with 2 short breaths followed by long breath. This prevent pushing at the end of the first stage.
Check every hour for emergency signs, frequency and duration of contractions, fetal heart rate, etc. Check every 4 hours for fever, pulse, BP and cervical dilatation Record time of rupture of membranes and color of amniotic fluid. Assess progress of labor
Refer woman immediately to hospital facility with comprehensive emergency obstetrical care capabilities if after 8 hours, contractions are stronger and more frequent but no progress in cervical dilatation, with or without membranes ruptured.
First Stage
Check every 4 hours for fever, pulse, BP and cervical dilation Record time of rupture of membranes and color of amniotic fluid Record findings in partograph/patient record. Do not allow woman to push unless delivery is imminent. It will just exhaust the woman. Do not give medications to speed up labor. It may endanger and cause trauma to mother and the baby. Check every 5 minutes for perineum thinning and bulging, visible descend of the head during contraction, emergency signs, fetal heart rate and mood and behavior.
Second Stage Cervic dilated 10 cm or bulging thin perineum and head visible
Third Stage Between birth of the baby and delivery of the placenta
Continued recording in the partograph. Do not apply fundal pressure to help delivery the baby. Deliver the placenta Check the completeness of placenta and membranes Do not squeeze or massage the abdomen to deliver the placenta
Others
Monitor closely within one hour after delivery and give supportive care Continue care after one hour postpartum. Keep watch closely for at least 2 hours. Educate and counsel on FP and provide FP method if available and decision was made by a woman. Birth registration Importance of BF Newborn Screening for babies delivered in RHU or at home within 48 hours up to 2 weeks after birth Schedule when to return for consultation for post partum visits
Conclusion
The DOH has be eager to decrease the maternal mortality rate of the country and this program is a good example to that effort. This was adapted from the DOH book. Image is from here.