Under the Guidance of Dept.

of Preventive And Social Medicine

Guided by

Special thanks to

Dr. G.P. Soni, HOD Dr. Nirmal Verma ,

Dr. N.K. Gandhi mam Dr. Meeta Jain, Dr. Divya Sahu, Dr. Shubhra Agarwal Gupta.

Compiled & Presented by

After having a glance at it you will come to know about

What is INC &Why arose its concept? What are its Types? How Government tries to provide INC? Being a Doctor, What to do? Why is institutional delivery not so popular & ways to overcome the hurdles? Results of our efforts.

Index
Introduction

Types of INC
Domiciliary care Institutional care

Infrastructure, staff & facilities at each level Management of a female with labour pains at a

PHC Causes of low institutional delivery & our strategies Effect of our efforts

What is INC &Why arose its concept?

Presented By Ankit Gupta

Introduction
Antenatal period

Period from Conception to beginning of labour. Its duration is about 40 weeks.

Intranatal period

Period from beginning of labour to birth of child.

Postnatal period

Period from birth of child to 6 weeks after it.

Definitions
Normal Labour or Eutocia

Process of expulsion per vaginum of a mature live fetus presented by vertex followed by placenta & membranes spontaneously without any complications or delay.
Dystocia

Any deviation from normal labour. Source:- Park, 21st edition

 Intranatal Care
It is the care of mother during labour.

Source:- Park, 21st edition

Types
Essential

Comprehensive

Contents of
Essential INC
It includes i.v. antibiotics i.v. oxytocic drugs i.v. anticonvulsants Manual removal of

Comprehensive INC
It includes Anesthetic services Surgical

retained products Assisted vaginal delivery

services(caesarean section) Safe B.T. services

Source- J. Kishore

IMR in India after independence

IMR(/1000)
160 140 120 100 IMR 80 60 40 20 0 IMR(/1000)

1951 146

1981 110

1991 80

2003 58

Current(2009) 47

Source-www.mohfw.nic.in

MMR in India after independence

MMR(/100000)

450 400 350 300 MMR 250 200 150 100 50 0 MMR(/100000) 1991 437 2003 301 Current(2009) 212

Source-www.mohfw.nic.in

Comparison of India & USA

Chart Title

USA

India

0 Early neonatal death rate(2009) Per 1000 live births MMR(2009) Per 100000 live births

50 India 44 212

100

150

200 USA 4.54 12.7

250

Source Office of Registrar General, India & U.S. National Center for

Health Statistics, Health, United States, 2009. See also

Intranatal Causes of Maternal Mortality

Contribution

Others 34%

Hemorrhage 37%

Abortion 8% Hypertensive disorders 5% Obstructed labour 5%

Sepsis 11%

Source Office of Registrar General, India

Major Causes Of Infant Mortality

Contribution

Birth injury 3% Cord infection 2% Diarrhoea 4% Congenital Malformation 5%

others 18%

Prematurity 51%

ARI 17%

Source Office of Registrar General, India

Need of promoting Institutional Delivery

States Institutional delivery(%) Rank

Kerala
Chhattisgarh Nagaland Indias average

100
16 12 41

1
27 28 -

This information was gathered from National Family Health

Objective
To reduce morbidity and mortality of mother as well as

child by adopting measures to avoid and reduce complications during child birth.

Aims
Thorough asepsis

Delivery with minimum injury to infant and mother

Readiness to deal with complications Care of the baby at delivery

Types of Intranatal Care on basis of Place of Delivery

1. DOMICILLARY CARE

2. INSTITUTIONAL CARE

Presented By Akash S. Rana

 Delivery conducted at home by

1. Domiciliary Care

Health Worker Female or Trained Dai.

Health Worker Female or Trained Dai

In the Domiciliary care system

deliveries are conducted by Health Worker Female or trained dai. This is known as domiciliary midwifery service.
They should be properly trained

so that they can recognize the danger signals and respond to them appropriately.

Advantages
Familiar surroundings

Decreased chances of cross infection

Mother is able to look after her children and

domestic affairs

Disadvantages
Less medical and nursing supervision

Asepsis may not be adequate

Mother may not have adequate rest Her diet may be neglected

She may resume her duties too soon

Aseptic Precautions
Universal Precautions

7 Cleans Clean hands Clean surface Clean blade Clean cord tie Clean cord stump Clean water Clean towel Source:-http://www.medicalgeek.com/viva/7889what-3-5-7-cleans-safe-delivery.html

Danger Signals
Sluggish pain or no pains after rupture of

membranes. No proper progress of pain Prolapse of the cord or hand Meconium-stained liquor or a slow irregular or excessively fast fetal heart rate. Excessive show or bleeding during labour.

Contd..
Collapse during labour

Placenta not separated within half an hour after

delivery Post-partum hemorrhage or collapse A temperature of 38 degree C or over during labour.

Preparations for anticipated home delivery

Arrange money Mode of transport available for 24 hrs TBA Hygienic place for delivery Precautions for asepsis during delivery

Institutional Care
It consists of deliveries conducted in institutions like

PHCs, Hospitals, etc. It is the specialist care provided by the doctors which is basically required for High Risk cases and cases where unsuitable home conditions are Prevalent. Conducted by- medical professionals

Presented By Amit Kumar

Advantages
Aseptic delivery can be ensured.
Any complication arising in midst of labour

and child birth can be managed efficiently. Mother can be provided adequate rest. Prompt Emergency services are life-saving to mother & child.

Disadvantages
Chances of nosocomial infections to mother &

child. Anxiety in mother due to unfamiliar surroundings & being away from relatives. High cost. In context of magnitude of risks associated with home deliveries, it is always preferable to have institutional deliveries.

Terms
Rooming in

Keeping the babys crib by the side of the mothers bed.

Bedding in

Keeping the mother & baby on same bed side by side.

Source:- Park, 21st

edition

Domiciliary verses Institutional Care

Features Domiciliary care Institutional care

Complications Aseptic Condition Expert management Care of neonate Care of maternal health

More Poor Poor Poor Poor

Less Good Good Good Good

How we provide INC?

Infrastructure
Medical colleges

Staff

Facilities

All specialists as well as Entire range of facilities few Super specialists available with entire team Obstetrician, Anesthetist, Pathologist, Pediatrician, General doctors, nurses, paramedicals 4 Specialists, 21 paramedicals 1 MO,14 paramedicals Obstetric care & specialist consultations with better facilities & management

District hospital

CHC

Obstetric care & specialist consultations Can conduct normal delivery Drug kits

PHC

Sub Centre

1 ANM, 1MPW(M)
Source-www.mohfw.nic.in

Number of Health Centers in Chhattisgarh

Sub Centers PHCs

4776 715

CHCs
Source-www.mohfw.nic.in

144

First Referral Unit (F.R.U)

An existing Facility (District hospital, Sub-

divisional hospital, Community Health Centre, etc.) can be declared a fully operational First referral Unit (F.R.U.) only if it is equipped to provide round the clock services for emergency obstetric and new born care, in addition to the emergencies that a hospital is required to provide. Three critical determinants of a facility being declared as an F.R.U. Emergency Obstetric care including the surgical interventions like C-Section. New born care Blood storage facility on a 24 hour basis.

PACKAGES OF SERVICES AT FRU

VACCUM EXTRACTIONS ADMINISTRATION OF ANAESTHESIA BLOOD TRANSFUSION CASEAREAN SECTION MANUAL REMOVAL OF PLACENTA CARRY OUT SUCTION CURETTAGE FOR INCOMPLETE ABORTION INSERTION OF INTRAUTERINE DEVICES STERILIZATION OPERATION

TYPES OF KIT for FRU

Kit-E Laparotomy set Kit-F - Mini Laparotomy set Kit-G IUD insertion set Kit-H Vasectomy set Kit- I Normal delivery set Kit- J Vacuum extraction set Kit- k Embryotomy set Kit- L Uterine evacuation set Kit-M Equipment for anesthesia Kit-N- Neonatal resuscitation set Kit-O- Equipment and reagent for blood test Kit-P Donor blood transfusion set

Being a Doctor, what would I do?

Presented By

Ankush Verma

Management of a Full Term Female with Labour Pain

Take full obstetric and medical history to

rule out any high risk factor Examine the immunization status and IFA prophylaxis Check records General examination Local examination
Abdominal Vaginal

Signs of True Labour

Painful uterine contractions coming at

regular intervals, progressively increasing in duration and intensity. Progressive cervical dilation and effacement. Formation of bag of forewaters. Presence of show or bleeding.

Partogram
It is a graphical tool which is used to record all

observations made on a woman in labour. Information recorded

Cervix dilation in cm with time Fetal head descent Frequency and duration of uterine contraction

Fetal heart rate

Conditions of membrane Moulding of fetal head Maternal B.P , T.P.R., urine output, medications

Stages of Labour
1st stage Primigravi da Multigravid a 12 hrs
6 hrs

2nd stage 2 hrs

1 hr

3rd stage 10 min

5 min

1st Stage of Labour

Extends from onset of labour pain to the full dilation of

cervix

Monitoring
Helps to prevent prolonged and obstructed

labour. Makes it easy to detect other anomalies. A Partogram is started only when we have checked that there is no complication of pregnancy requiring immediate action.

Sequence of Recording
Cervical dilation

Descent of head
Uterine contractions:- Frequency & Duration Fetal condition Maternal condition

Cervical Dilation
In satisfactory progress plotting remains on or left of

danger line.

Descent of Head

Uterine Contractio ns
Observe
Frequency Duration

Fetal Condition
Fetal heart rate
> 160/min or <120/min indicates fetal distress <100/min indicates severe fetal distress

Membranes & Liquor- 4 observations on color

of liquor
I Membranes intact C- Liquor clear M- Meconium stained liquor A- Liquor absent

 Moulding of Fetal Skull Bones

KEY 0 +

Bones are separated and sutures can be easily felt Bones are just touching each other

++
+++

Bones are overlapping but can be easily separated from each other
Bones are overlapping severely and cannot be separated by pressure

Maternal Condition
Temperature, Pulse,

B.P. Urine Volume, Protein, Acetone Drugs and I.V. Fluid Oxytocin regime

2nd Stage of Labour

From dilation of cervix to expulsion of fetus
Diagnosis- suspect this stage when Patient vomits or reports that she feels a need

to defecate Membrane ruptures spontaneously Patient has intense urge to bear down during contractions PV examination cervix fully dilated and not palpable

Conduct of Delivery
Shift patient to the delivery room when fetal head is seen at vulva
Monitor F.H.R. every 5 min Bring patient to the edge of the table

Make decision as to requirement of Episiotomy or otherwise

Wash perineal area with antiseptic solution and use sterile drapes

Episiotomy

3rd Stage of Labour

Delivery of placenta Management

to deliver the placenta we look for signs of placental separation

Uterus becomes hard and globular.

Uterus rises just above umbilicus.

Extra vulval lengthening of umbilical cord. A gush of blood suddenly appears. On pushing the uterus, cord does not recede.

 Placental delivery- by

controlled cord traction 0.2mg i.v./i.m. methergine after delivery of placenta if not given at delivery of anterior shoulder inspect vagina for tears & repair, if any & of Episiotomy

 All women whose cervicograph moves to the right of

Guidelines

alert line must be transferred & managed in an institution with adequate facilities for obstetric interventions, unless delivery is near. You must refer her to FRU before she reaches action line. At the action line woman must be carefully re-assessed for reason of lack of progress & a decision made on further management.

Reasons for Low Institutional delivery rates and Strategies to overcome them.
Presented By Abhijeet

Need of promoting Institutional Delivery

States Institutional delivery(%) Rank

Kerala
Chhattisgarh Nagaland Indias average

100
16 12 41

1
27 28 -

This information was gathered from National Family Health

Money

To overcome this problem government of India launched a cash assistance program under Janani Shuraksha Yojna (JSY) with following provisions

Urban area Rural area (In Rs) (In Rs)

Mothers Package ASHAs package 1000 200 1400 600

Source- Mission Directorate, NRHM , Govt. Total 1200 2000

Contd..
Moreover Government of India also launched

a new program named Janani Shishu Shuraksha Yojana on 1st June 2011. Under this scheme following benefits are provided to the pregnant women Free Delivery and C-section. Free drugs and consumables before, during and till 6 months after delivery. Free diagnosis. Free diet during stay. Free transport. Exemptions from all kinds of user charges.

Transport

 For this again the emergency free

transportation is provided by the Government under the scheme JSY and other facilities like Sanjeevni Express (108 service), etc.

 In Chhattisgarh an emergency 24 hour ambulance service has been started in May 2009, The Mahatari Express which is aimed at facilitating transport of women for institutional delivery.

Lack of Awareness
To improve this ministry of Information and Broadcasting is carrying out certain measures to promote awareness regarding Intranatal care. Television & radio advertisements are being made.

 Role of ASHA is also important in promoting awareness among the people through regular counseling on birth preparedness, importance of safe delivery, government schemes , etc.

Lack of trained personnel

 Government of India partnership with professional bodies like

has

developed

Federation of Obstetric and Gynecological Societies of India (FOGSI)

The Indian Academy of Pediatrics (IAP) for training professionals under Navjaat Shishu Suraksha Karyakram (NSSK).

Contd..
Accreditation of Private Health Facilities for

conducting institutional delivery under Demand Promotion Scheme i.e. Janani Suraksha Yojana (JSY).
To involve private partners in providing RCH

services, GOI has developed Accreditation Guidelines for Private Health Facilities for providing RCH Services.

Contd..
States are also implementing different schemes under Public Private Partnership for providing RCH services to the people like Cheeranjeevi Yojna in Gujarat, Janani Sahyogi in Madhya Pradesh, Aayushmati Scheme in West Bengal, Mahatari Express in Chhattisgarh, etc.

Effects of our

Rates of institutional delivery in Chhattisgarh

NFHS2
Urban Rural Total 32% 10% 14%

NFHS3
58% 8% 16%

Recent status of Institutional Deliveries

All Data in MILLIONS

State \Year 2007-08 2008-09

200910 2.04 158.18

Chhattisgarh

1.49

1.79 145.80

Total in India 143.71

Source: NRHM State Data Sheet * HMIS Portal Note: Figures are provisional This information was given by Minister of for Health and Family Welfare Shri Ghulam Nabi Azad in written reply to a question raised in Lok Sabha