MCH Care

Prof. Dr. Farzana Zafreen, MBBS, MPH

Professor & Head
Department of Community Medicine
Medical College for Women & Hospital
 Introduction to MCH Care
MCH: Maternal & Child Health refers to promotion of preventive, curative
and rehabilitative health care for mothers & children.
• Specific Objectives of MCH:
1. Reduction of maternal, perinatal, infant and childhood mortality &
morbidity
2. Promotion of reproductive health
3. Promotion of physical & psychological development of child
Ultimate objective of MCH service is life long health.
• Maternity Cycle: The stages are-
1. Fertilization
2. Antenatal/prenatal period
3. Intra natal period
4. Postnatal period
5. Inter-conceptional period
 Introduction to MCH Care cont..
Common MCH Problems:
• Malnutrition
• Infection
• Uncontrolled reproduction / unregulated fertility
• Effects Malnutrition:
LBW, Anaemia, Toxemia of pregnancy, PPH
All leading to high mortality & morbidity.
• Effects of infection:
IUGR, LBW, Abortion, Puerperal sepsis
• Effects of uncontrolled reproduction:
LBW, APH, Abortion, Perinatal mortality, Maternal mortality
 Antenatal Care (ANC)
ANC: Care of women during pregnancy.
• Primary aim of ANC is to achieve at the end of pregnancy a healthy
mother and healthy baby.
Objectives of ANC:
1. To promote, protect and maintain the health of the mother during pregnancy
2. To detect high risk cases and give attention
3. To foresee complications and prevent them
4. To remove anxiety associated with delivery
5. To reduce mortality (MMR & IMR) and morbidity
6. To teach mother about elements of child care, nutrition, hygiene, sanitation
7. To sensitize the mother about the needs for FP (family planning)
8. To attend under five children accompanying the mother
 Antenatal Care cont..
• Antenatal Visits: Ideally a mother should attend ANC services
(14 times) as follows-
• Once a month during first seven months (7 times) then
• Twice a month for the next month (2 times) then
• Once in week till delivery (5 times)

For those who can’t do that should make at least 3 visits

• 1st visit at 20 weeks of pregnancy
• 2nd visit at 32 weeks of pregnancy
• 3rd visit at 36 weeks of pregnancy
 Antenatal Care cont..
• Prenatal Services:
1. At 1st visit:
• Registration of pregnant women and preparing an antenatal card*
• History in details
• Physical examination (Pulse, BP, Anemia, Oedema, Heart & Lungs, Height & Weight
etc.)
• Laboratory investigations- Urine & Stool for R/E, Blood for CBC, Hb%, Grouping,
Serological tests, PAP smear test and X-ray chest etc.
2. At subsequent visits:
• Physical examination- (Pulse, BP, Anemia, Oedema, Heart & Lungs, Height & Weight and
search for toxemia of pregnancy)
• Laboratory investigations- Hb% and Urine R/E.
• USG- Ideally two; one at first trimester and the other at 18-22 weeks
3. Iron & Folic acid supplementation and other medication if needed
4. Immunization against tetanus
5. Instruction on: nutrition, delivery, self care, family planning etc.
6. Home Visit
7. Referral services
 Antenatal Care cont..
Antenatal Card:
• Prepared for the mother during the first antenatal visit
• Contains-
• Name and address of the mother
• Registration number
• Previous health history
• Date of LMP and
• Other main health events
 Antenatal Care cont..
Prenatal Advices during Antenatal Care:
• Diet: Need balanced diet with extra calorie and nutrient
• Personal cleanliness: Neat and clean clothing and every day bathing
• Rest and sleep: Two hours rest after mid-day meal and 8 hours sleep
• Bowel: Constipation should be avoided
• Exercise: Avoid hard physical care
• Smoking: Avoid smoking
• Drugs: Should be taken only on prescription from a recognized doctor
• Avoid Radiation
• Advice on warning signal on pregnancy*
• Immunization (TT Vaccine): is to be advised to prevent neonatal tetanus
• Place of delivery: Advised for hospital delivery in case of high risk mother
• Child rearing: Basic education regarding child care and breast feeding
 Antenatal Care cont..
Specific Health Protection during Antenatal Care:
• Anemia
• Nutritional deficiencies
• Toxemia of pregnancy
• Tetanus
• Syphilis
• German measles
• Rh status
• HIV infection
• Prenatal genetic screening
 Antenatal Care cont..
Risk Approach: The central purpose of ANC is to identify “High Risk Cases” as early as
possible. Following are the high risk mothers-
• High Risk Mothers:
1. Elderly primi ( ≥ 30 years)
2. Short statured primi (height ≤140 cm)
3. Mal presentation (breech presentation, transverse lie etc.)
4. APH, Threatened abortion, PET, Eclampsia
5. Severe anaemia
6. Twins, hydroamnios
7. Previous still birth, IUD, manual removal of placenta etc.
8. Elderly grand multipara
9. Prolonged pregnancy (14 days after EDD)
10. H/O previous C/S, instrumental delivery
11. Pregnancy associated with general diseases like- CVD, CKD, DM,TB etc.
The purpose of MCH care is to provide better services for all but special attention to
those who need them most.
 Warning Signal of Pregnancy
Warning Signals of High Risk Pregnancy:
• Swelling of feet
• Fits or Convulsion
• Headache
• Blurring of vision
• Per-vaginal bleeding or discharge
 Intra natal Care (INC)
Childbirth is a normal physiological process but complications may arise.
Septicemia may result from septic manipulation
• The aim of good intra natal care:
1. Thorough asepsis
2. Delivery with minimum injury to baby and mother
3. Readiness to deal with complications such as- prolonged labour,
APH, Convulsion, Mal-presentation, Cord prolapse etc.
4. Care of the baby at delivery (Resuscitation, care of cord, eyes etc.)
Place of Intra-natal care
• At home(Domiciliary care)*
• At hospital (Institutional care): is recommended for all high risk
cases and also for situations where home conditions are unsuitable
 Domiciliary Care
• Domiciliary care: Mother with normal obstetric history may have their
delivery at home provided the home conditions are satisfactory and
delivery maybe conducted by a female health worker or trained Dai or
TBA. This is known as “Domiciliary Midwifery Services”.
• Advantages of Domiciliary Midwifery Services:
1. The mother deliveries in familiar surrounding at home
2. The chances of cross infection are few
3. The mother can keep an eye on her children and domestic affairs
• Disadvantages of Domiciliary Midwifery Services:
1. The mother may have less medical supervision
2. She may start to work too soon
3. Her diet may be neglected
 Domiciliary Care
• Danger Signal of Domiciliary Delivery:
1. Sluggish or no pain after rupture of membrane
2. Good pain after rupture of membrane but no progress
3. Prolapse of cord or hand
4. Meconium stained liquor
5. Slow irregular or excessively fast foetal heart sound
6. Excessive show or bleeding during labour
7. Placenta not separated within half hour after delivery
8. PPH(post partum hemorrhage) or collapse
9. Temperature 38 c or more during labour
 Postnatal Care (PNC)
Care of the mother and newborn after delivery is known as postnatal or
post-partal care. It is the combined responsibility of the Obstetrician and
Pediatrician. It is also known as Perinatology.
The Objective of postnatal care: (Care of the mother)
1. To prevent complications of post-partal period
2. To provide care for rapid restoration of mother to optimum health
3. To check adequacy of breast feeding
4. To provide family planning services
5. To provide basic health education to mother/family
 Postnatal Care (PNC)
Complication Post Natal Period:
1. Puerperal sepsis- infection of genital tract within 3 weeks
2. Thrombo-phlebitis (infection of veins)
3. Secondary PPH - after 6 hours to the 6 weeks
4. Others: UTI, Mastitis etc.
 Postnatal Care (PNC)
Restoration of Mother to Optimum Health: The broad areas are-
• Physical:
• Postnatal examination of the mother for temperature, pulse, anemia,
respiration, lochia, urine, bowel, breast, involution of uterus etc.
• Providing the mother adequate diet for proper nutrition
• Advice for regular physical exercise
• Psychological
• Social
• Family Planning: (for spacing and family size)
• Basic Health Education*: Provide idea about- hygiene, feeding of
infants, spacing of pregnancy, birth registration etc.
 Postnatal Care (PNC)
Postnatal Basic Health Education to Mother
• Personal and environmental hygiene
• Feeding for mother and infant
• Pregnancy spacing
• Importance of health check up
• Birth registration
• Family planning services
 Postnatal Care (PNC)
Family Planning Methods in Postnatal Period:
• Breast feeding provides some protection against conception but cannot
be depended upon
• Contraceptive method used in postnatal period:
• Barriers method
• IUCDS these method don’t suppress lactation
• Miniphills
• DMPA
• Postpartum sterilization is also possible and is recommended on the
2nd day after delivery.
 Neonatal Care
Objectives of Neonatal Care:
1. Establishment and maintenance of cardio-respiratory functions
2. Maintenance of body temperature
3. Avoidance of infection
4. Establishment of satisfactory feeding regimen
5. Early detection and treatment of congenital and acquired
disorders, especially infection
 Neonatal Care
Flow Chart of Neonatal Care:
Delivery
Normal infant High Risk Infant

Regular Nursery Without Complication With Complication

Home Temporary Observation Unit Special Care Nursery

Special Procedure
 Neonatal Care
Immediate Care of Newborn:
1. Cleaning of the airway: mucus and other secretions are cleaned
by proper positioning and suction for establishing breathing
2. Care of the cord: cut by sterilized instrument and ties after it
stops pulsating
3. APGAR scoring*: at 1 min and 5 min
4. Care of the eyes: lid margins should cleaned with sterile wet
swabs.
5. Care of the skin: clean with warm water and soap to remove
vernix and meconium
6. Maintenance of body temperature: wrap in warm clothes
7. Breast feeding: start within one hour for colostrum and bonding
8. Birthweight: measuring birthweight of baby
 APGAR Score of Newborn
• APGAR Score: It is scoring system to get an immediate estimate of the
physical condition of a new born baby. (A = Appearance, P=Pulse,
G=Grimace (reflex response), A= Activity (Muscle tone), R=Respiration)
APGAR Score
Score
Sl Signs 0 1 2
1 Appearance Blue/pale Body pinks, Extremities blue Completely pink
2 Pulse Absent Less than 100 More than 100
3 Grimace No response Grimace Cry/cough
4 Activity Flaccid Dome flexion of extremities Active motion
5 Respiration Absent Slow and irregular Good
• Scoring: Total Score= 10; Minimum= 0 ; Maximum= 10;
≥7 Normal; 4-6 Moderately depressed; 0-3 Severely depressed
 Neonatal Care
Examination of Newborn:
First Examination:
a) Cyanosis of lips & skin
b) Breathing
c) Imperforated anus
d) Persistent vomiting
e) Sign of cerebral irritation
Second Examination:
a) Body size, weight and temperature
b) Skin
c) Cardio respiratory activity
d) Neuro behavioral activity
e) Body parts: Head & Face, Abdomen, limbs & Joints, Spine,
External Genitalia
 Neonatal Care
Measuring the Baby
a) Birth weight
b) Length
c) Head Circumference

Identification of Infants at Risk:

1. Birth weight < 2.5 kg
2. Twins
3. Birth order ≥ 5
4. Artificial feeding
5. Child with PEM
6. Working/ Single mother
7. Failure to gain weight during three successive months or loose
weight during two succesive months
 Neonatal Infection
Common Neonatal Infections:
• Neonatal tetanus
• Congenital syphilis
• Newborn with an HBV and HIV positive mother
• ToRCH Infection

Causes of Neonatal Infections:

• Traditional practice
• Poor hygiene
• Premature rupture of membrane
• Small for date
• Trans placental contamination
 Low Birth Weight (LBW)
LBW: has been defined a birthweight of baby less than 2.5 kg preferably
within the 1st hour of life.
Types of LBW: Preterm Baby and Small for Date Baby (IUGR)
Cause of Preterm Baby:
• Multiple births
• Acute infections
• Hard physical work
• Hypertensive disorder of pregnancy
Cause of Small for Date Baby:
• Maternal factor: Malnutrition, Severe anemia, Heavy physical work
during pregnancy, Hypertension, Malaria, Toxemia, Smoking, Low
economic status, Very young age, High parity, Close birth spacing, Low
education status
• Placental factors: Placental insufficiencies, Placental abnormality
• Foetal factors: Foetal abnormalities, Intrauterine infections,
Chromosomal abnormalities, Multiple gestations
 Low Birth Weight (LBW)
Risk factors of LBW:
1. Malnutrition
2. Infection
3. Unregulated fertility
Leading Causes of Death in LBW Babies are:
1. Atelectasis
2. Pulmonary hemorrhage
3. Malformation
4. Intra cranial bleeding or birth trauma
5. Pneumonia and other infection
6. Tetanus
 Low Birth Weight (LBW)
Importance of LBW: it is important because-
• LBW associated with high perinatal and infant mortality and
morbidity
• Many become victim of PEM and infections
• Very high cost of special care
• High chance of mental retardation
• Reflects malnutrition of mother
Prevention of LBW:
• Proper antenatal care
• Improvement of maternal nutrition
• Avoidance of too many, too close, too soon and too late pregnancies
• Decreasing heavy maternal work load
• Treatment of specific maternal disease
 Complications of LBW
Immediate complications:
• Hypoxemia, ischemia
• Intraventricular hemorrhage
• Sensory neural injury
• Respiratory failure
• Necrotizing enterocolitis
• Cholestatic liver diseases
Late Complications:
• Mental retardation, Microcephaly, Hydrocephalus,
• Spasticity, Seizures, Corpulmonary,
• Hearing & Visual impairment, Retinopathy,
• Bronchopulmonary dysplasia, Bronchospasm, Respiratory infection
• Malnutrition, Cirrhosis, Hepatic failure, Carcinoma, etc.
 Feeding of Infants
• Colostrum: The yellowish and sticky secretion from the breast in later part of
pregnancy and for first 5 days after delivery.
Characteristics of colostrum:
• More immunoglobulin, lactoferrin and white blood cells
• Higher level of vitamin A
• More sodium and zinc
• Protein rarely 10%
• Less fat and lactose
• It is laxative and helps the baby to pass meconium and thus helps to prevent
jaundice
• It is baby's first immunization against many bacteria and virus, it is high Ig A rich
• Transitional milk: During 6 to 10 days of postpartum period colostrum is replaced
by transitional milk.
• Mature breast milk: By the 3rd week (15 days to 15 months postpartum)
transitional milk gradually assumes the characteristics of mature breast milk
 Feeding of Infants
1. Breast feeding:
• Mothers secrete 450-600 ml milk daily
• Protein content of human milk: 1.1 gm / 100 ml
• Energy value of human milk: 70 kcal / 100 ml
2. Artificial feeding:
• Indication: Failure of breast milk / disease condition of mother
• Source: Dried milk or Cows milk

Anti-infective agents in human milk

• Immunoglobulin secretory IgA, Ig G and Ig M
• Cellular elements lymphoid cells, polymorphs macrophages
• Opsonic and chemotactiles activation C3 & C4
• Unsaturated lactoferrin and transferrin
• Lysozyme & Lactoperoxidase
 Feeding of Infants
Exclusive Breast Feeding: Under any circumstances breast milk is the
ideal food for the infant and no other food is required until six
months after birth.
Milk Injury: If a baby is fed only with milk over a long period of time
(say two years) without giving any supplementary food the baby
become flabby and edematous due to deficiency of protein and
anemic due to deficiency of iron then it called milk injury.
Weaning: weaning is a gradual process of withdrawing a baby from
breast feeding, starting at six months and adding supplementary
foods rich in protein and other nutrients such as fruits, soft cooked
rice cereals etc.
 Special Definitions
• Babies According to Gestational Age
Preterm: Babies born before the end of 37 weeks of gestation.
Term: Babies born from 37 weeks to < 42 weeks of gestation.
Post term: Babies born at 42 completed weeks of gestation or
anytime thereafter.

• Rooming in: Keeping the baby’s crib by the side of the mother’s bed is
called rooming in.
Advantage of Rooming in:
• It gives the mother an opportunity to know her baby
• Mother becomes confident that the baby is not misplaced
• It provides is a better success of breast feeding
 Indicators of MCH Care
1. Maternal Mortality Rate (MMR)
2. Mortality in Infancy and Childhood:
a) Perinatal Mortality Rate
b) Neonatal Mortality Rate
c) Postnatal Mortality Rate
d) Infant Mortality Rate (IMR)
e) 1-4 years Mortality Rate
f) Under 5 Mortality Rate
Total number of female death due to complication of Pregnancy, childbirth or
within 42 days of delivery or puerperal cause in an area during a given year
MMR =--------------------------------------------------------------------------------------- X 1000
Total number of live birth in the same area in that year

Number of Death of Infants in a year

IMR =---------------------------------------- X 1000
Number of live birth in the same year