SY 2011-201

Subject: Obstetrics Topic: OB in Broad Perspective Lecturer: Dr. Crisostomo Date of Lecture: November 22, 2011 Transcriptionist: Dreaming of a White Christmas Editor: Muttley Pages: 17 Outline Reproductive health and the MDG The science of Obstetrics Definition of terms used in Obstetrics Health Vital Statistics Program to improve Maternal Health Reproductive health Within the framework of WHOs definition of health as a state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions, and system at all stages of life. Reproductive health, therefore, implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. Reproductive Health (WHO) Regional situation (Western Pacific) Every year, 30,000 50,000 women in the region die from complications related to pregnancy and childbirth More than 1M infants die before their first birthday and more than 30,000 babies die during the 1st week of their birth (the neonatal period). More than 35,000 new cases of sexually transmitted infections occur yearly in the Region. Regional objective: To support countries and areas to develop evidence based strategies and policies on maternal and newborn mortality reduction, particularly in the priority countries of Cambodia the Lao Peoples Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam. Comprehensive Reproductive Health Care Includes 1. Counseling, information, education, communication and clinical services in family planning 2. Safe motherhood, including antenatal care, safe delivery care and postnatal care, breastfeeding and infant and womens health care 3. Gynecologic care, including prevention of abortion, treatment of complications of abortion and safe termination of pregnancy as allowed by law (but in the Philippines, abortion is illegal, so this will not be discussed). 4. Prevention and treatment of sexually transmitted diseases (including HIV/AIDS), including condom distribution and universal precautions against transmission of blood-borne infections, voluntary testing and counseling 5. Prevention and management of sexual violence 6. Active discouragement of harmful traditional practices such as female genital mutilation (not so important in the Philippine setting)

7. Reproductive health programs for specific groups such as adolescents, including information, education, communication and services The Scope of reproductive health work in the WHO Western Pacific Region (Cairo, Egypt) However, due to limited resources and capacity, it is important to prioritize issues to address reproductive health according to the specific situation of each country and area. Making pregnancy safer and family planning are the priority issues that need to be addressed. 5 areas 1. Improving antenatal, perinatal, postpartum and newborn care 2. Providing, high quality service for family planning, including infertility 3. Eliminate unsafe abortion 4. Combating sexual transmitted infections including HIV, reproductive tract infections, cervical cancer, and other gynecological morbidity. 5. Promoting sexual health. UN: Millennium Development Goals At the Millennium Summit in September 2000 the largest gathering of world leaders in history adopted the UN Millennium Declaration, committing their nations to a new global partnership 1. Eradication of extreme hunger and poverty 2. Universal primary education for all 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS malaria and other diseases 7. Ensure environmental sustainability 8. Global partnership for development Strategies (4)Reduce child mortality (5)Improve maternal health Expected outcomes Reduce by 2/3 between 1990 and 2015 the under 5 mortality rate Reduce by between 1990 and 2015, the maternal mortality ratio

Above: Obstetricians are most concerned with objectives 4 and 5. Above are the goals that are hoped to be met.
Obstetrics Obstetrix: means midwife Connected with the verb obstare meaning to stand by or in front of The art and science that deals with delivery, its antecedents and sequelae, or pregnancy, labor and puerperium (puerperium: period of confinement during and just after birth; includes the 6 subsequent weeks during which normal pregnancy involution occurs) Concerned with reproduction of the human species Aims to promote health and well-being as a branch of Medicine that is concerned with pregnancy, labor and puerperium of both normal and abnormal conditions Used as early as 15th century worldwide The Evolution of the Science of Obstetrics Humans have larger brains and smaller pelvic dimensions making the fetus negotiate a series of turns to accommodate along the widest diameter of the human pelvis resulting in the fetus being delivered in the occiput anterior position. Human parturients need assistance because: Big brains of the neonate Maternal pelvis designed for walking upright diminishing its dimensions Rotational delivery in which the fetus is delivered facing downwards

The pelvic inlet, where the fetus begins is transit, is widest from side to side. Midway through the pelvis, however, the orientation shifts 90 degrees and the widest dimension of the pelvis is from anterior to posterior. This change in pelvic dimensions means that the fetus must negotiate a series of turns as it passes through the birth canal so that its largest dimensions, which are the head and the shoulders, are always aligned with the widest dimension of the birth canal. As a consequence of this rotation, human fetuses predominantly assume the occiput anterior position at delivery. The human birth canal is a complicated passageway, there are series of turns: directed downward and then forward, so the baby needs to rotate in order for him/her to accommodate through the birth canal; the baby has to be in occiput anterior position to the mother for him/her to be delivered facing down)

Related Specialties Affecting Obstetrics (multifaceted) OB: has surgical management and intervention 1. Gynecology: study of the diseases in women; deals with human physiology of ovulation, menstruation, and reproduction 2. Pediatrics: deals with the newborn. Neonatologists handle high-risk cases such as premature deliveries 3. Endocrinology 4. Genetics 5. Immunology 6. Microbiology 7. Biochemistry 8. Physiology 9. Pharmacology 10. Psychology 11. Nutrition 12. Cardiology, Pulmonology 13. Gastroenterology, Nephrology Importance of Obstetrics Maternal and neonatal outcomes are universally used as index of the quality of health and life in the human society. Obstetrics in the Philippines The Beginning of Obstetrics in the Philippines Unknown period when the traditional or untrained birth attendants (Hilots) attended to deliveries By physicians, dates back to the establishment of San Juan de Dios Hospital before 1908 Followed by St. Pauls Hospital, Civil Hospital and Mary Johnston Hospital (92 OB cases from 1908 to 1909 were recorded) Vital Health Statistics National records are important which state the situation of important health indicators in the country Help in establishing trends in health status nationally and internationally. Based on standard definition terms and formulae Terminology Birth Complete expulsion or extraction of a fetus from the mother Weight > 500 grams Crown to heel length >25cm. Considered to be more accurate than weight, since dehydration may occur. 20 weeks AOG by LNMP (last normal menstrual period)

If any of the above values are too law, it is considered an abortus. Whether umbilical cord is cut or the placenta is attached

Live birth Complete expulsion or extraction of a fetus from the mother, regardless of the AOG (>20 weeks), which after separation, shows evidence of life like breathing, beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscle. Whether umbilical cord is cut or the placenta is attached Birthweight The first weight of the newborn obtained after birth Measured within the first hour of life before significant postnatal weight loss has occurred within the first few weeks of life. Low birthweight (LBW) <2500 grams Very low birthweight (VLBW) <1500 grams Extremely low birthweight (ELBW) <1000 grams Macrosomia , or large for gestational age (LGA) >4000 grams Normal: 2500 4000 grams The above values are for term babies. Doc did mention if a 28 week AOG baby were born weighing 1000 grams, it would be deemed AGA (appropriate for gestational age). Total births The total number of deliveries (>20 weeks AOG) including live births plus fetal deaths. Birth Rate Refers to number of live births per 1000 population, usually also referred to as the crude birth rate. Fertility rate Number of live births per 1000 female population age 15 to 44 (some say 49) years Women of reproductive age Women aged 15 to 44 (some say 49) years Fetal Death/Stillbirth Death prior to the complete expulsion or extraction from the mother, irrespective of the duration of pregnancy (>20 weeks). If <20 weeks, this is considered an abortus. Death as evidenced by the absence of breathing, beating of the heart, pulsation of the cord, definite movement of voluntary muscles Neonate A live born infant up to 28 days of life Neonatal death Early: death of a liveborn neonate during the first seven days after birth Late: death after 7 days but before 29 days Perinatal Period From 20 completed weeks to 28 completed days after birth Perinatal Death All fetal deaths/stillbirths of 20 or more weeks AOG plus neonatal deaths up to 1 week of age. Perinatal Mortality Rate Number of fetal deaths or stillbirths (beyond 20 weeks AOG) plus number of early neonatal deaths per 1000 total births Gestational Age

Refers to the number of completed weeks that have elapsed between the first day of the LNMP and the date of delivery, irrespective of whether the gestation results in a live birth or a fetal death When LNMP is unreliable, the AOG is based on best clinical estimates Expressed in weeks and days Based on the LNMP Eg, Patients LNMP = 08/05/2011. This lecture was 11/22/2011. 26 remaining days in August + 30 days in September + 31 days in October + 22 days in November = 109 days 15 weeks + 4 days Completed days or completed weeks 280 days or 40 weeks Preterm < 36 6/7 weeks (259 days) Term 37 completed weeks to 41 6/7 weeks (259 293 days) Post term > 42 completed weeks (294 days)

Infant deaths Any death at anytime from birth up to the moment just before one year of age Infant Mortality Rate Number of infant deaths per 1000 live births Maternal Death Death of a woman while pregnant or within 42 days after termination of pregnancy irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Direct Obstetric Death Resulting from obstetric complications of the pregnant state (pregnancy, labor, puerperium) From interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect Obstetric Death Resulting from previous existing disease or disease that develops during pregnancy Not due to direct obstetric causes Can be aggravated by physiologic effects of pregnancy : Heart disease Pulmonary disease Cerebrovascular accident Cerebral aneurysm Infectious disease Breast cancer Meningitis Malaria Non obstetric Death Maternal deaths due to traumatic causes such as suicide, accident, gunshot wound, and similar conditions. Vehicular accidents Gunshot wounds Stab wounds Electrocution Drowning Food poisoning Burns Suicide Maternal Mortality Ratio

The number of maternal deaths that result from the reproductive process per 100,000 live births Used more commonly, but less accurately, are the terms maternal mortality rate or maternal death rate. The term ratio is more accurate because it includes in the numerator the number of deaths regardless of pregnancy outcome. % 38.2 26.9 18.1 9.1 7.7

Maternal Mortality by main cause, 1998 Cause No. Rate/ 1000 live births Complications related to 603 0.4 pregnancy Hypertension 425 0.3 Postpartum hemorrhage 286 0.2 Pregnancy with abortive 144 0.1 outcome Hemorrhage 121 0.1

Direct Causes of Maternal Deaths Cause Other complications related to pregnancy occurring in the course of labor, delivery, and puerperium Hypertension complicating pregnancy, childbirth, and puerperium Postpartum hemorrhage Pregnancy with abortive outcome Hemorrhage related to pregnancy * Percent share to total number of maternal deaths

N o. 77 9 53 3 32 7 16 1 1

Rat e 0.5 0.3 0.2 0.1 0.0

% 43. 3 29. 6 18. 2 8.9 0.1

Indirect Obstetric Deaths Cause Cardiac (RHD, CHD, HPNHD) Pulmonary (Pneumonia, TB, BA, CA) Metabolic (Thyroid storm, DM) Urinary tract (Hydronephrosis, ruptured renal artery, aneurysm) Hematologic (Aplastic anemia, leukemia) Vascular (Thrombosis/embolism, pre existing hypertension, aneurysm) Reproductive tract (Uterine anomalies) Gastrointestinal (AGE, malignancy, cholangitis) Others (Sepsis, CNS infection, MTX toxicity, typhoid fever, spinal cord compression, acute peritonitis, CVA intracranial bleed) Vital Statistics Fetal death rate Fetal deaths X 1000 Total births (LB + stillbirths) Fetal death ratio Fetal deaths x 1000 Live births Fetal death rate, weight specific (age specific) Fetal deaths weighing 1000g and above x 1000 Total births weighing 1000g and above Neonatal Mortality Rate Neonatal deaths x 1000

No. 30 25 10 7 5 4 4 3 15

% 5.50 4.59 1.83 1.83 0.92 0.73 0.73 0.55 2.75

Live births Neonatal Mortality Rate, weight specific

Neonatal deaths of infants weighing 1000g and above at birth x 1000 Live births weighing 1000g and above Perinatal Mortality Rate Fetal deaths and Early Neonatal deaths x 1000 Total births Perinatal Mortality Ratio Fetal deaths and Early Neonatal Deaths x 1000 Live births Perinatal Mortality Rate, weight specific Fetal deaths weighing 1000g and above, plus Early Neonatal deaths of infants weighing 1000g and above at birth x 1000 Total births weighing 1000g and above

The Philippine Demographic Data and Health Vital Statistics Philippine Statistics
INDICATOR School Participation Rate Elementary Secondary Average Annual Family Income Average Annual Family Expenditures Poverty Threshold Poverty Incidence 88.84% SY 2007- 2008 61.91% SY 2007 2008 P173,000 (2006) P147,000 (2006) P15,057 (2006) 26.9% of total families 2006 School Participation Rate Elementary Secondary Average Annual Family Income Average Annual Family Expenditure Poverty Threshold Poverty Incidence 88.84% SY 2007 2008 61.91% SY 2007 2008 P173,000 (2006) P147,000 (2006) P15,057 (2006) 26.9% of total families 2006 Population Population density Projected population growth rate 88.57 million as of 08/01/07 255 persons per sq km as of 05/01/00 2.05% 2000 - 2005 83.22% SY 2006 2007 58.59% SY 2006 - 2007 P148,616 (2003) P124,377 (2003) P14,196 (2005) 24.4% of total families 2003 76.5 M as of 05/01/00 246 persons per sq km as of 09/01/95 2.3% 1990 - 2000 83.22% SY 2006 2007 58.59% SY 2006 2007 P148,616 (2003) P124,377 (2003) P14,196 (2005) 24.4% of total families 2003 LATEST PREVIOUS

Projected life expectancies at birth Males Females Infant Mortality Rate Simple Literacy Rate

66.1 yrs (2005) 71.6 yrs (2005) 30 per 1000 livebirths 2003 (official estimate) 93.4% (2003)

67.53 yrs (2004) 72.78 yrs (2004) 36 per 1000 livebirths 1998 (official estimate 92.3% (2000)

Demography: Projected Population

Projected Population, Philippines (Medium Assumption) 2006 Male Female Both Sexes 43,472,1 00 43,230,4 00 86,972,5 00 2007 44,608,3 00 44,098,0 00 88,706,3 00 2008 45,483,1 00 44,974,1 00 90,457,2 00 2009 46,368,9 00 45,857,7 00 92,226,6 00 2010 47,263,6 00 46,749,6 00 94,013,2 00 2011 48,157,5 60 47,646,0 60 95,803,6 20 2012 49,051,5 20 48,452,5 20 97,594,0 40

Frequency Distribution of Livebirths by Sex and Region, Philippines, 2006 AREA BOTH MALE FEMAL SEXES E NCR 270,619 141,179 129,4 4 CAR 32,335 16,820 15,51 5 Region I (Ilocos Region) 95,523 49,578 45,94 5 Region II (Cagayan Valley) 60,452 31,281 29,17 1 Region III (Central Luzon) 191,408 99,623 91,78 5 Region IV-A (CALABARZON) 226,862 117,666 109,1 96 Region IV-B (MIMAROPA) 43,332 22,734 20,59 8 Region V (Bicol Region) 110,769 57,323 53,44 6 Region VI (Western Visayas) 114,558 60,002 54,55 6 Region VII (Central Visayas) 148,921 77,346 71,57 5 Region VIII (Eastern Visayas) 59,700 30,970 28,73 0 Region IX (Zamboanga 51,606 26,877 24,72 Peninsula) 9 Region X (Northern 79,048 41,200 37,84 Mindanao) 8 Region XI (Davao) 75,850 39,419 36,43

Region XII (SOCCSKSARGEN) Region XIII (CARAGA) ARMM TOTAL

54,852 32,983 14,211 1,633,029

28,419 17,163 7,281 864,881

1 26,43 3 15,82 0 6,930 798,1 48

Livebirths by Gender and Weight: Region, 2008

Region Total livebirths By Sex Male 116,3 75 128,9 99 991,6 76 Femal e 104,0 38 121,9 46 925,5 75 Weight at Birth 2500 gms & greater 188,811 218,059 1,707,081 Less than 2500 gms 30,873 22,064 152,650 Not known 729 9,968 57,520

NCR REGION 4 (CALABARZON) TOTAL

220,413 250,091 1,917,251

Places of Delivery, Philippine Situation (2003) 60% at home attended by hilots and midwives 40% in a health facility attended by a trained birth attendant Need for training of hilots and midwives to diminish maternal morbidity and mortality. Midwives, though, are more trainable that hilots. Need for easy and immediate access to a facility with basic and comprehensive OB services.

Livebirths by Attendance by Region, 2008

Regi on Total deliveri es 220,413 250,091 1,920,0 98 Doctors No NCR Reg. 4A Total 124,9 11 76,29 7 601,4 72 % 56. 7 30. 5 31. 3 Nurses No 2,03 2 2,30 5 21,4 77 % 0. 9 0. 9 1. 1 Midwives No 72,84 3 113,7 94 797,9 08 % 33. 0 45. 5 41. 6 Trained hilot No 15,20 3 52,22 5 420,3 67 % 6.9 20. 9 21. 9 Untrained hilot No 5,02 5 4,87 1 55,3 62 % 2. 3 1. 9 2. 9 Others / unknown No 399 599 23,51 2 % 0. 2 0. 2 1. 2

Above: Note the percentage of births attended by hilots in NCR (6.9%) vs. Region 4A (20.9%). Also the percentage of doctor attended livebirths in NCR (56.7) vs. Region 4A (30.5%) Deliveries by Type and Place, 2006
Regi on # of Livebir ths Total numbe r of Deliver ies Total Home Hospital Others

No

No

No

No

NCR Regio n 4A TOTA L

220,41 3 250,09 1 1,917,2 51

220,41 3 250,09 1 1,920,0 98

220,41 3 250,09 1 1,907,3 48

10 0 10 0 99. 5

51,361 150,28 2 1,056,9 93

23. 3 60. 1 55. 4

128,9 11 77,64 8 720,1 25

58. 5 31. 0 37. 8

40,14 1 22,16 1 130,2 30

18. 2 8.9 6.8

Wanted Fertility Rate, Total Fertility Rate and Mean Number of Children Ever Born to Women Age 40-49 Years by Region Philippines, 2003
Region Wanted Fertility Rate 2.0 2.7 3.0 2.6 2.4 2.3 3.6 2.6 2.7 2.6 2.9 2.6 Total Fertility Rate 2.8 3.8 3.8 3.4 3.1 3.2 5.0 4.3 4.0 3.6 4.6 4.2 Mean Number of Children Ever Born to Age 40-49 Years 3.2 4.7 3.9 4.1 4.1 3.8 5.1 5.5 4.9 4.4 5.4 4.9

NCR CAR Ilocos Cagayan Valley Central Luzon CALABARZON MIMAROPA Bicol Western Visayas Central Visayas Eastern Visayas Zamboanga Peninsula Northern Mindanao Davao Region SOCCKSKARGEN Caraga ARMM Philippines

2.8

3.8

4.8

2.2 3.0 2.8 3.7 2.7

3.1 4.2 4.1 4.2 3.5

4.6 5.0 5.4 5.2 4.3

Fetal Deaths 2006

AREA NCR (Metro Manila) CAR (Cordillera) FETAL DEATHS 2,026 118

Region 1 (Ilocos) Region 2 (Cagayan Valley) Region 3 (Central Luzon) Region 4A (CALABARZON) Region 4B (MIMAROPA) Region 5 (Bicol) Region 6 (Western Visayas) Region 7 (Central Visayas) Region 8 (Eastern Visayas) Region 9 (Western Mindanao) Region 10 (Northern Mindanao) Region 11 (Southern Mindanao) Region 12 (Central Mindanao) CARAGA ARMM Foreign countries Residence not stated TOTAL

572 153 551 1,447 227 483 544 974 164 181 430 290 196 87 15 4 8458

Above: The areas with high fetal death rates are also urban centers with high pollutants.

Fetal Deaths 2005 AREA NCR (Metro Manila) Region 4A (CALABARZON) Foreign Countries Residence not stated TOTAL FETAL DEATHS 2,550 1,681 10,351

Infant Mortality: 10 Leading Causes 2006

Cause 1. Bacterial sepsis of newborn 2. Respiratory distress of newborn 3. Pneumonia 4. Disorders related to short gestation and low birth weight, not elsewhere classified 5. Congenital malformations of the heart 6. Congenital pneumonia 7. Neonatal aspiration syndromes 8. Other congenital malformation 9. Intrauterine hypoxia and birth asphyxia 10.Diarrhea and gastro-enterities of presumed infectious origin Above: Good prenatal care can improve fetal mortality.

Number 3,194 2,400 1,947 1,608 1,409 1,290 1,145 1,046 1,005 984

Ra te 1.9 1.4 1.2 1.0 0.8 0.8 0.7 0.6 0.6 0.6

Perce nt 14.7 11.0 8.9 7.4 6.5 5.9 5.3 4.8 4.6 4.5

Health Indicators Neonatal mortality

Rural Area

Urban Areas

Selected Health Indices in Urban and Rural Areas Philippines, 2003

21 per 1,000 livebirths

14 per 1,000 livebirths

Philippine Health Picture 1960 2006

TUBERCUL OSIS 5.1 6.1 5.2 5.4 5.6 5.6 DEATH RA TE 42.5 31.0 33.0 35.9 35.1

POPUL CRUDE 36 per 1,000 CRUDE Infant mortality ATION BIRTH DEATH livebirths R RATE ATE

INFANT 1,000 FETAL 24 per DEATH R DEATH R livebirths ATE ATE

Under-five 86,972,500 per 1,000 live 5.1 per 1,000 live 52 19.1 30 2006 13.1 mortality births births 2005 85,261,000 19.8 5.0 12.8 Total fertility 4.3 3.0 2004 83,558,700 20.5 4.8 13.2 rate 2003 81,081,457 Child births at 2002 79,503,670 home 2001 77,925,894 20.6 77% 21.0 22.0 4.9 5.0 4.9 13.7 45.5% 14.3 15.2

The Problem of Maternal Morbidity and Mortality Anything can happen: mothers are categorized as low-risk or high risk 40 % of women experience complications in any stage of pregnancy 15 % develop potentially life - threatening problems (be prepared and be recognized, and with diagnosis, may institute immediate management) Trends in Maternal Mortality Ratio, Philippines, 1993 2003

Above: There is a decline according to the above graph, but according to doc the figures mostly come from hospitals that are accredited and do not give an accurate picture for the Philippines.

Percentage Distribution of the Main Cause of Maternal Mortality, Philippines, 2003

Maternal Mortality: By Main Cause Number, rate/1000 livebirths and percent distribution, Philippines, 2006
CAUSE Number 1,721 732 Rate Percent* 1.0 0.4 TOTAL 100.0 42.5

1. Complications related to pregnancy occurring in

the course of labor, delivery and puerperium 2. Hypertension complicating pregnancy, childbirth and puerperium

565 261 163 0

0.3 0.2 0.1 0

32.8 15.2 9.5

3. Postpartum hemorrhage 4. Pregnancy with abortive outcome 5. Hemorrhage in early pregnancy

*Percent share to total number of maternal deaths Above: The majority of complications that lead to maternal mortality are preventable. Maternal Mortality by Cause 2005
CAUSE Number 1,721 Rate Percent* 1.0 0.5 TOT AL 100. 0 47.3

1. Complications related to pregnancy occuring

in the course of labor, delivery and puerperium

819

2. Hypertension complicating
pregnancy,childbirth and puerperium

510 263 138 2

0.3 0.2 0.1 0

29.4 15.2 8 0.1

3. Postpartum hemorrhage 4. Pregnancy with abortive outcome

5. Hemorrhage in early pregnancy

Above:

Working Definitions of Direct Obstetric Complications

Direct Obstetric Complications Hemorrhage Ante partum Postpartum *Definitions

Any bleeding before labor and during labor: placenta previa, abruptio placenta Retained placenta Severe bleeding from lacerations ( vaginal or cervical )

Prolonged / Obstructed Labor

This is dystocia ( abnormal labor ) and will include: Prolonged established, 1st stage of labor ( >12 hours). Prolonged 2nd stage of labor ( > 1 hour from active second stage ). CPD, transverse lie, brow / face presentation.

Postpartum sepsis

A woman with fever ( 38* C or >, with at least 2 readings), more than 24 hours, after delivery. Other S/S: lower abdominal pain, purulent, offensive vaginal discharge, tender, uterus.

Severe Preeclampsia

Eclampsia Ruptured Uterus

Diastolic blood pressure 110 mm Hg or more after 20 weeks AOG. Proteinuria +2 or > Various S/S: HA, hyperflexia, blurred vision, oliguria, epigastric pain, pulmonary edema. Convulsions Diastolic BP 90 mm Hg or more after 20 weeks AOG. Proteinuria +2 or more. Various S/S: Coma & other S/S of severe pre-eclampsia. Internal bleeding from a pregnancy outside the uterus. Lower abdominal pain and shock possible from internal bleeding. History of pregnancy. Uterine rupture with a history of prolonged / obstructed labor when uterine contractions suddenly stopped. Painful abdomen. Patient may be in shock from internal and / or vaginal bleeding.

Ectopic pregnancy

Note: The above graphs are meant to give a broad picture of what is happening with obstetrics in the Philippines and to point out those areas that need improvement. So that our class and others to follow may work on achieving these goals. UNICEF: Philippines ranks #48 in Maternal Mortality 230 maternal deaths per 100,000 live births. The United Nations established a high level commission to develop an accountability framework for the Global Strategy for Womens and Childrens Health. "Strengthening accountability is critical if we are to save the lives of more women and children," said UN Secretary-General Ban Ki-moon. UNICEF According to the 2009 UN Childrens Fund report, The State of the Worlds Children, the Philippines has an MMR average of 230 per 100,000 live births. Health officials predict the 2015 Millennium Development Goal of 5560 per 100,000 live births will not be met. Crucial to reducing maternal deaths is having a skilled attendant present during a delivery. Only 60 percent of the births in the Philippines are supervised by a skilled birth attendant, who can be a physician, a nurse or a midwife (18 months to two years of adequate training). What is not accepted in this definition is a traditional birth attendant, who have had no formal training. Some 230 women die here for every 100,000 live births, compared with 110 in Thailand, 62 in Malaysia and 14 in Singapore, according to United Nations figures. Causes of maternal deaths are hemorrhage, sepsis, obstructed labor, hypertensive disorders in pregnancy, and complications of unsafe abortion, most of which are preventable with proper diagnosis and intervention, health specialists said. The maternal mortality ratio in the Philippines is listed as the Millennium Development Goal least likely to be achieved by 2015, for the Philippines. The country has an adjusted maternal mortality ratio of 160 per 100,000 live births against a goal of 55-60 deaths per 100,000 livebirths.~ Vanessa Tobin, UNICEF country representative Empowering Midwives to Curb Maternal Deaths (MDG) Giving midwives access to further training in life-saving skills could prevent up to 80 percent of maternal deaths in the Philippines, says Rosalie Paje,

division chief of the Family Health Office under the Department of Health (DOH). Midwives can help prevent up to 90 percent of maternal deaths when they are supported to provide basic life-saving skills in functioning health systems, Patricia Mines Gomez, IMAP president, said. There is a need to increase of the number of skilled birth-attendants, including midwives, nurses and doctors, to improve maternal health. In the Philippine Framework for Maternal Mortality Reduction, health workers are identified as playing an integral part in achieving a lower MMR in the country. However the lack of professional health practitioners (such as doctors and nurses) in rural areas in the country is a major concern.

PH Reproductive Health (RH) Bill Still pending in Congress At least 6 versions Controversial due to issue of contraceptives as essential drugs yet are considered abortifacient. RH Bill Provisions: Summary Setting up more maternal healthcare facilities and services Building more modern and complete Nursery Health Care Facilities and Services Setting up blood bands in hospitals and other health facilities Establishing centers for education and information on Reproductive Health. Premarital counseling centers in churches and in government offices that conduct marriage licensure services. Ensuring that reproductive health services are delivered with a full range of supplies, facilities and equipment and that service providers are adequately trained for such reproductive health care delivery Expanding the coverage of the Philippine Health Insurance Corporation (PhilHealth), especially among poor and marginalized women, to include the full range of reproductive health services and supplies as health insurance benefits. Government to supply centers of family planning materials to help prevent unwanted pregnancies. Providing mobile clinics in congressional districts that render education and information on reproductive health and sex education. Humane and non discriminating healthcare to post abortive complication cases. Mandatory age appropriate reproductive health and sexuality education in schools by adequately trained teachers. Reproductive Health Improvement in RH Better survival and education of children Increased productivity of men, women, and children Reduced fertility increasing resources share for everyone Good maternal health services can strengthen the entire health system since many of the health requirements for the health of the female would provide already for more than half of the susceptible population.~Mario Festin, MD, WHO Family Planning Liason Maternal mortality can be reduced without first achieving economic development since many of the existing interventions and programs have been proven effective if utilized properly. ~Mario Festin, MD, WHO Family Planning Liason What is DOH doing? Barangay Based Womens Health Teams (WHTs) Composed of: Midwife as team leader

Barangay health workers (BHWs) and traditional birth attendants (TBAs) as members Municipal Health Officer (MHO) as overall supervisor of the WHTs

DOH Programs WHTs An important task of the WHT is to track every pregnancy within its catchment area and report the outcome The WHTs base of operation in the community is the Barangay Health Station (BHS) The Functions of the WHT Include: To track every pregnancy occurring within the community using the Pregnancy Tracking Form. To assist the pregnant woman in accomplishing the Birth Plan. To provide quality maternal care, family planning, STI prevention and HIV control and adolescent and youth health services. To make accurate recordings. To provide good counseling services. To refer clients appropriately. To report maternal death. To discuss relevant womens issues with the community. EmOC A facility for emergency care of women with pregnancy related complications Guiding Principles in the Operation of BemOC Facility All pregnant women are at risk of life threatening obstetric complications. There is no such thing as a no risk pregnancy. The fetal outcome depends on the quality of care pregnant women receive during the pre pregnancy, antenatal, natal, and post natal periods. Quality, timely and affordable health and nutrition services should always be accessible at all times. Establishing linkages and developing collaboration to ensure sustainability and continuity of health care; Empowering and mobilizing families and communities to recognize and address emergency care for both mothers and newborn babies. Promotion of womens rights and gender sensitivity Reporting and reviewing all maternal and newborn deaths. Distribution of BemOC facility shall be 1 / 125,000 population and 1 for every isolated area ( the upland mountainous municipality or island towns; A BEmOC facility can be a birthing home, RHU with lying-in, primary, secondary or tertiary facility. Facility Based WHSMTs BemOC Team -A basic emergency obstetric care team is organized and trained to attend to normal births in BEmOC facilities designated to receive referrals from WHTs; CEmOC Team - A comprehensive emergency obstetric care team is likewise organized in CEmOC facilities and trained to attend to complicated cases referred by BEmOC facilities. BEmOC - A doctor who is either a specialist in obstetrics or is trained on emergency obstetric care service provision heads these teams. The team members include nurses, medical technologist and the midwife leader of the WHT. CEmOC - Team members include an obstetric-gynecology specialist or a general practitioner trained on CEmOC service provision, nurses, anesthesiologist, pathologist and fetologist (if available). Signal Functions

BEmOC 1. Administer Parenteral (intravenous or injection) Administer Parenteral Oxytocic Drugs. Administer Parenteral anticonvulsants. Perform manual removal of placenta. Perform removal of retained products of conception. Perform assisted vaginal delivery.

CEmOC 1. Administer Parenteral (intravenous or injection) 2. Administer Parenteral Oxytocic Drugs. 3. Administer Parenteral anticonvulsants. 4. Perform manual removal of placenta. 5. Perform removal of retained products of conception. 6. Perform assisted vaginal delivery. 7. Perform surgery (CS) 8. Perform Blood Transfusion

2.

3.
4. 5. 6.

Above: In a nutshell, CEmOC = BEmOC + perform surgery + perform blood transfusion. Facility Based WHSMTs CEmONC CEmOC plus Neonatal care Ideal of one CEmONC facility per 500,000 population Antenatal Care in the Philippines DOH recommends at least four ANC Complied by 70% (2003) First ANC must be during the first trimester 53% had first ANC between 4 to 5 mos AOG 10 % had their first prenatal check-ups between 6 to 7 mos AOG Health-Related Practices Affecting Maternal Health, Philippines, 1998 and 2003

Past Interventions Done Proper Antenatal Care not achieved and complications not diagnosed early Training of traditional birth attendants lead to delayed referrals and still lack proper skills Linkages with adequately manned and equipped Emergency facility is vital. Strategies for Reduction of Maternal Mortality Better training of health attendants, midwives, doctors, TBA? Improve quality and quantity of pre-natal, natal, and post natal care for all women (Safe Motherhood Program) Provide skilled obstetrical care for high risk and emergency cases Family planning Improvement of Maternal Care Role of midwives Role of GPs/Nurses Role of Obstetricians

Role of Government Role of community Paradigm shift: Implement strategies that employ a combination of financial incentives, advocacy and communication to change stakeholders behavior in the context of their particular roles in the fulfillment of a common goal.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~End of Transcription~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ For the spirit of searches everything, even the depths of the God. For who knows a persons thoughts except the spirit of that person, which is in him? So also no one comprehends the thoughts of God, except the spirit of God. 1 Corinthians 2:10