GROUP A: Group A2 : Day 2 @ DHO KUBANG PASU

MATERNAL AND CHILD HEALTH

It is our second day in the District Health Office of Kubang Pasu, which began at 9 am on Thursday, 5th January 2012. First and foremost, we were given a briefing about services provided by the Maternal and Child health department of KK Kubang Pasu by Sister Siti Aminah.

The objectives of maternal care services are to provide the best care and consultation to pregnant mothers, screening of pregnant mothers whom are at risk of having complications and to obtain the optimum health condition as well as educating them on the methods of family planning.

The staffs comprise of a medical officer, sister, staff nurses, community nurses and assistant health officers. They are responsible for the services offered in MCH clinic and home-visits, which include antenatal care, postnatal care and child health.

Organization Chart

1) Ante natal care

Flow Chart of How Ante Natal Cases Are Handled

To start off with, each pregnant mother will come to the Klinik Kesihatan for registration. It can either be a new registration or a re-registration for the multigravidas.

When a new case is registered, they would be given a Red Antenatal Book. This is called booking. There are two books, KIK/ 1(a) / 96 / Home-based card & KIK / 1(b) / 96, the former is for the mother and the latter is for the clinic.

Anthropometric measurements such as height and weight are measured and a battery of lab tests will be conducted such as below :

a) ABO and Rh grouping

b) VDRL +/- TPHA

c) Rapid test HIV ( compulsory, but optional for the partner)

d) Haemoglobin level

e) Urine FEME

f) Blood sugar level

g) Blood pressure

h) Hepatitis screening (optional)

Upon booking, examinations will be done by the medical officer and an ultrasound scanning will be performed to assess the viability of the pregnancy. Hence, an overall assessment will be made based on all these investigations and examinations.

Subsequently, colour coding will be done accordingly. Colour coding system is implemented in Malaysian Healthcare System for maternal health and it is of paramount importance in lowering the maternal morbidity and mortality rate. There are four different colour codes :

a) White 1 and 11 - normal pregnancy, which can either be delivered at home or hospital

b) Green - Refer to the medical officer or health officer

c) Yellow - Refer to the Family Medicine Specialist or O&G Specialist at the nearest hospital

d) Red - High risk pregnancy which requires immediate admission into the hospital

Red book - Colour coding at the top left corner indicates the area code and colour coding at the top right corner indicates the risk factors.

For an uncomplicated pregnancy, standard antenatal medications will be given such as folic acid, iron, vitamin C and vitamin B Complex. However, there are cases of pregnant mothers whom cannot tolerate the medications, hence, a different medication known as 'Soft Gel' will be given instead. They will also be given appointments for a subsequent follow up check-up.

Clinic visits : Up to 32 weeks - 4 weekly, 32 to 36 weeks - 2 weekly and 36 weeks onwards- weekly

*Frequents visits are denoted for those with high-risk pregnancies.

Iron tablets, Vitamin C, Vitamin B Complex, Folic acid

Soft Gel

Composition of Soft Gel

Explanation about the medications by the Sister and Staff Nurses

During the visits, they will be reviewed by the nurses and colour coding will be done once again. The colour coding may change accordingly in relation to the health condition of the mother and foetus, throughout the course of the pregnancy. Upgrading of a code can be done by the nurses, however, downgrading of a code can only be done by the specialist.

Routine lab investigations and examinations done will be the weight, Hb level, blood sugar level, blood pressure, urine test, palpation to assess the gestational weeks based on the symphisio-fundal height measurements as well as ultrasound scanning which is usually conducted by the doctor at booking and 32 weeks of gestation.

Besides, anti tetanus toxoid (ATT) vaccination will be given also. For primi, first dose is given at 16th weeks and followed by a second dose 6 weeks later, whereas, for multi, only one vaccination is given at 18th weeks.

2) Post natal care

Comprises of Pre-pregnancy care (PPC) for the mother, family planning services as well as to monitor neonatal jaundice of the child. At least 8 home-visits have to be done by the nurses for an uncomplicated patient, on the 1st, 2nd, 3rd, 4th, 5th, 6th, 10th and 20th day after the delivery of the baby, whereas, in a complicated case, daily home-visits up to the 10th day is required.

During the visits, the nurse will perform palpation to assess the size of uterus, examine the vagina / episiotomy scar, daily swabbing for perineal care, urine dip stick test for albumin and sugar as well as the vital signs such as blood pressure and temperature. Apart from that, they will also check the baby for any symptoms or signs of neonatal jaundice and weight of the baby on the 10th and 20th day. Sometimes, they will also teach the mother on how to bathe the baby, but it is rarely done now. Apart from that, mothers are also expected to continue all those medications taken prior to delivery such as iron tablets, vitamin C and vitamin B Complex tablets except folic acid for the next 4 weeks after delivery. Sometimes, they would have to continue taking the iron tablets if they are anaemic. Contraceptive methods will be dealt in family planning.

c) Child health care

It begins after the delivery. Each baby will be given a card, blue for the boys and pink for the girls. The nurses will be doing the home-visits during the neonatal phase to assess for neonatal jaundice and baby's physical appearance. If the child is suspected of having jaundice, the baby should be immediately referred to the KK to check the serum bilirubin count, and if found high, subjected to phototherapy. Apart from that, anthropometric measurements will be done on the 10th and 20th day and plotted on the card. After that, the mother will be asked to bring the baby to the clinic for subsequent assessments and immunization at the KK.

Immunization :

At birth - BCG and Hep B (1st dose)

1st month - Hep B (2nd dose)

2nd month- DTap + Hib + IPV (first dose)

3rd month-DTap + Hib + IPV (second dose)

5th month-DTap + Hib + IPV (third dose)

6th month- Hep B (3rd dose) and measles in Sabah only

12th month- MMR (1st dose)

18th month- DTap + Hib +IPV (fourth dose)
6 years - DTap + IPV (booster dose) , MMR (2nd dose) and BCG ( if there's no scar)

Objectives are to ensure optimum growth and development of the child and for complete immunization before school entry.

Prepared by,

S.V.ANITA RANI NAIDU

FAMILY PLANNING

Today, we were briefed by Sister Siti Aminah regarding family planning. There was no patient today and we could not really see how the procedures are done here. Hence, the Sister used this opportunity to just explain briefly about the topic mentioned above.

Flow Chart of Family Planning

According to her, usually, mothers who come in for their post natal visit here in MCH clinic 1 month after delivery, will be sent for family planning advice after the normal post natal routine investigations are done. The contraceptives available in MCH Kubang Pasu are in the form of pills, IUCD, injections(Depo) and condoms(for males).

CONDOM

Commonly prescribed contraceptive pills here are Regulon, Rigevidon, Noriday and Marvelon. Noriday is prescribed as a method of contraception for those mothers who are still lactating.

RIGEVIDON

REGULON

Pills are normally not recommended in hypertensive patients, instead they are advised to use other methods, such as injection.

DEPOCON INJECTION

Besides, according to Sister Siti, the IUCDs' available in whole Malaysia are without hormones, unlike our neighbouring country, Thailand, which is more advanced in family planning services, has IUCD with hormones.

IUCD

Bilateral tubal ligation is not done here due to some religious issue. Nonetheless, for those mothers who are found to have risks of endangering her life in the subsequent pregnancy, BTL is advised for them and they can do it in private hospitals.

Usually, the patient who comes for family planning will be registered under family planning clinic. Upon registration, normal routine investigations are done like measuring BP, height, weight, laboratory investigations, general examinations, and also Pap smear. Sister Siti Aminah told that pap smears are usually done 6 months once. Once it is over, if the patient is proven fit to take the contraceptives, they are given explanations regarding the various methods of contraception, side effects of each, ways to take it, and finally the nurses will suggest to the patient, which of the method of contraceptions suits them by looking into various criteria such as age and whether or not they want to get pregnant in future. If the patient is found to have some health problems after those examinations and investigations mentioned above, they are referred to family health specialists or hospital and they’ll decide the next step.