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Gender Based Violence (GBV)

Gender based violence is any act that results in physical, sexual or psychological harm or suffering to women, men and children

Key terms related to Gender-based Violence

1. Gender;

This refers to the social and cultural construct of the roles, responsibilities, characteristics, opportunities, privileges, status and access to and control over resources and benefits between men and women, boys and girls in a given society.

• Men and female are sex categories while masculine feminine are gender Aspect of sex will not vary substantially between different human societies while aspect of gender will vary greatly.

Example of gender characteristics

• In developed countries women earn significantly less money than men for similar work.
• In many society, many more men smoke tobacco than women as female smoking has not traditionally been considered appropriate.
• In some countries, men are allowed to drive while women don’t.

2.     Gender-based violence;

This is any act that results in physical, sexual or psychological harm or suffering to women, men and children. It also includes threats of such acts; coercion and deprivations of liberty whether occurring in public or in private life.

3.     Violence against women;

Refers to any act of gender-based violence that results in or is likely in physical, sexual and psychological harm to women and girls whether occurring in private or in public. Violence against women is a form of gender-based violence and includes sexual violence.

4.     Sexual violence, exploitation and abuse.

This refers to any act, attempt or threat of sexual nature.

5.     Gender equality

This is the state or condition that awards men and women equal engagement of human rights, socially valued goods, opportunities and resources.

6.     Gender blind

Refers to a policy or plan that is silent on relevant gender issues

7.     Gender responsiveness

This is a policy or plan with actionable strategy that seeks to reduce inequality and ensures equal distribution of the benefits associated with a particular service.

8. Sexual and gender-based violence is a serious form of discrimination, particularly against women and children and as such contravenes the principle of no It is both a public health problem and a human right issue.

9.     Sex

It’s defined as biological characteristics of male and females. The characteristics are congenital and their differences are limited to physiological reproductive functions.

10.     Violence

This is any act that causes injury, harm, intimidation, fear, damage or humiliation to s person. It is a mean of control and oppression that can include emotional, social and economic force or pressure as physical harms. Examples like; threatening someone with a weapon, intimidation, physical assaults etc. The person targeted by this kind of violence is to behave as expected or act against his/her will out of fear.

11.     Sex typing

This refers to the differential treatment for people according to their biological sex.

12.     Gender equity

This is when women and men, boys and girls have equal opportunities of receiving services which are equally accessible to all.

13.     Gender sensitive

This refers to being aware that women and men perform different roles and have different needs which must be planed for accordingly.

14.     Gender neutrality

This refers to planning for men and women as if they are homogenous i.e. without taking consideration of their different needs and roles. Such programs are usually not effective because they fail to response to gender specific needs of individual. Treatment care and services do not favor women and men e.g. women to be examined by male and vice versa.

15.  Gender roles

These are the different task and responsibilities that society, defines and allocates to women and men, girls and boys. They are not necessarily determined by their biological make up and therefore change according to situation, time and society.

16.     Coercion;

This is forcing or attempting to force another person to engage in behavior against this/her will by using threats, verbal insistence, manipulation, deception, cultural expectations or economic power.

17.     Sexual preference/orientation

This refers to a person’s preference for the same or opposite partner e.g. homosexual, heterosexual.

18.     Gender role stereotype

This is socially determining model which contain the cultural beliefs about what gender role should be.

Examples

–     Girls should be obedience and cute, and allow to cry while boys are expected to be brave. However, women are better house keeper and boys strong, good at machinery similarly, boys are better at mathematics and girls are good at language differs from gender role in that it tends to be the way people fill adult others should behave.

Forms of violence in Uganda

1. Domestic violence such as wife battering, oppression, intimidation
2. Sexual abuse g. Rape, defilement and incest.
3. Harmful cultural practices like female genital mutilation and widow
4. Forced marriages: Girl children are married off early for economic purposes in form of bride Others are married off early because the girl child culturally is destined for marriage instead of advancing in education.
5. Others;
   • Sexual harassment and intimidation at work places, religious institutions and schools
   • Coercion or arbitrary deprivation of
   • Belief in large families
   • Men having forced sex with
   • Violence perpetrated or condoned by the

Setting where Gender-based violence can occur 

• Family; i.e. battering of women, sexual abuse of children and incest
• Community; sexual abuse, sexual harassment and intimidation, trafficking and forced prostitution
• State; poorly drafted or unenforceable laws, presence of law enforcement agents who violate people, lack of facilities and education for prevention and treatment of people exposed to violence.

Predisposing factors of sexual and gender violence

1. Low socio- economic status (topical) in the Women‘s low status in the community and their dependence on men to make decisions increase inequality and vulnerability to violence.
2. Infertility leading to the husbands and relatives blaming, battering or abandoning wife for this inability.
3. Fear of reporting because the perpetuators are not reprimanded and can easily come back to revenge.
4. Cultural definitions of gender roles e.g. Girls are made to fetch water, fire wood, cultivate and cook for the family. It is through execution of these duties that they meet men who defile them or boys grow up not knowing that they can help in performing some of the activities like cooking, washing utensils, clothes etc.
5. Some cultural practices like female genital mutilation, promoting early marriages of the girl child so as to earn bride pride for financial gains.
6. Physical and mental disabilities leading to rejection, discrimination and stigmatization. For instance people with blindness, deafness,
7. Ill health especially from HIV/AIDS.
8. Poverty making parents to force their daughters to be defiled or married so as to get some money as compensation.
9. Idleness and redundancy leading to over consumption of alcohol, drug abuse e.t.c.
10. Abduction of children exposing them to rape, defilement and assaults.
11. Land wrangles especially after a loss of a husband; the wife is denied ownership of property.
12. Conflict and camp environment resulting in congestion and loss of good morals.
13. Poor role modeling for boys and girls

Risk groups for Sexual Gender-based Violence

1. All children and women
2. Adolescents
3. Displaced persons including refugees
4. People with disabilities
5. Prisoners
6. Men in particular as they fear reporting acts of violence because they fear being embarrassed.
7. Pregnant mothers

Reasons for staying in an abusive relationship

1. Hope for change
2. Total love to the partner
3. Fear of losing the marriage
4. Purpose of the children
5. Shame
6. Poverty- fear of returning the bride price
7. Security purpose

Characteristics of those who are abused

1. They believe that violence give them immediate result
2. They are insecure, extremely jealous and possessive
3. They are emotionally dependent on other partner
4. They deny that their action are violence
5. They have poor impulse control

Impacts of Sexual Gender-based Violence

 These may be physical and or psychological

1. Various forms of injury, physical, mental and psychosocial to the body of the victim/survivor.
2. Reduced quality of life and low self esteem
3. Sexually transmitted infections including HIV/AIDS
4. Unwanted pregnancies resulting into unsafe abortion which can result in the lifelong health effects and death/suicide
5. Poverty and loss of means of livelihood
6. School dropout and unknown paternity of children
7. Psychological and behavioral problems in children
8. Rejection of survivors by society/stigmatization
9. Divorce
10. Child neglect
11. Loss of friends
12. Spiritual shame
13. Prostitution
14. Alcoholism
15. Early marriage
16. Suicidal attempt and ideation

8Ways through which Sexual Gender-based Violence can be reduced in Uganda

Sexual and gender-based violence should be recognized as an important public health matter. Therefore, everyone in the community can contribute tremendously to reducing the acts of sexual gender-based violence by actively doing the following:

1. Leaders should spearhead sensitization of communities on the impacts of sexual gender-based violence throughout the country.
2. Reporting all acts of violence to the health centers, police, and other relevant authorities.
3. Ensuring that those who commit these acts are punished appropriately.
4. Some of the current measures to punish the perpetrators should be revised and made stronger to deter people from committing acts of violence.
5. Communities should be encouraged to stop the culture of silence which hampers victims from reporting fearing the repercussions e.g. imprisonment and stigmatization.
6. Advocacy to reduce sexual and gender-based violence must be intensified at all levels.
7. Review the legal systems to improve the court relationship between the legal officers and the victims.
8. Improve the relationship between the legal and other practitioners during court session.
9. Health workers should be supported to undertake their roles to manage and care for survivors of Sexual Gender-based Violence.

Roles of leaders on SGBV in their community

The following ways can be used by leaders to fight Sexual Gender-based Violence by:

1. Speaking out against Sexual Gender-based Violence at every opportunity for instance during community meetings, campaigns, fundraising, funerals, drinking places.
2. Leaders should strive to act as role models by avoiding being perpetrators of SGBV.
3. Assisting victims to get help and to see that the culprits such as defilers, rapists, men who batter their wives are reported to the police and punished appropriately.
4. Leaders can form counseling groups to help men, children and women who are perpetrators of Sexual Gender-based Violence.

Control and prevention of Sexual Gender-based Violence

1. Improve girl child education at all level.
2. Reducing the high level of poor socio-economic status will in long run reduce women vulnerability to violence.
3. Increasing awareness of women‘s rights and responsibilities related to owning property and assets.
4. Reviewing and amending laws that safeguard women‘s rights.
5. Strengthening nationwide/community wide efforts to challenge the widespread tolerance and acceptance of violence against women.
6. Encouraging parents to bring up children who respect the rights of individuals as men or women, boys or girls
7. Supporting parents to bring up their boys and girls as equal partners

Reasons why the community and leaders be concerned about SGBV

1. Damages social bonds if women and girl who are sexually abused isolate themselves or are isolated by their families and communities.
2. Places a substantial health burden on the health care Example, victims often present with vague complaints that are difficult to diagnose and to treat.
3. Brings economic loss to households and communities when victims of Sexual Gender-based Violence due to physical injury or emotional stress are unable to undertake their roles in the households and the workplace (in many Uganda villages, women are among the key bread winners in their homes).
4. Bring a legacy of bitterness especially in conflict situation towards the group from which the perpetrators came. This will have a negative long term impacts on reconciliation and community reconstruction.

Roles of health workers in managing victims and addressing gender-based violence

This is important to note that health workers play instrumental roles in ensuring that families and victims of gender-based violence are professionally attended and see that the victims get justice. Therefore, the following cited are some of roles of health worker in gender-based violence management;

1. Offering psychosocial support and counseling services to the affected families and individuals.
2. Liaising with people and other stakeholders to see that the perpetrator (culprits) is brought to book to prevent possibility of reoccurrences.
3. Collecting victim‘s medical information and performing required medical examination to promote continuity of care.
4. Creating a friendly and confidential environment (shelter) where victims needs are addressed.
5. Offering timely and appropriate referral services as needed.
6. Establishing and promoting strict reporting of all gender-based violence related cases to responsible authority and ensure victims get fair justice.
7. Ensuring and maintaining constant follow-up care of all affected families or victims.

Sources of help for victims of SGBV

• Police
• Probation officers
• Child and family protection unit.
• Local leaders/elders
• Trusted person or family members
• Counselors etc

Note: In some African cultures, beating a woman or girls is part of the disciplining process; in fact some women even willingly accept to be beaten

Hormonal Methods of Family Planning

Hormonal family planning refers to the use of hormonal methods to prevent pregnancy. These methods involve the use of hormones, typically synthetic versions of those naturally produced by the body, to regulate a woman\’s menstrual cycle and prevent ovulation (the release of an egg from the ovaries). By preventing ovulation, hormonal methods make it difficult for sperm to fertilize an egg and thus prevent pregnancy.

These include;

1. Oral contraceptive pills
2. Implants
3. Injectable contraceptive
4. Emergency contraceptive pills

Oral Contraceptive Pills

i)      Progesterone Only Pills (POP)

Examples

• Ovrette
• microval

• They contain progesterone hormone
• They are recommended for breastfeeding mothers because they do not affect/suppress milk

Modes of action

• It acts mainly by making cervical mucus thick and viscous, thereby preventing sperm penetration
• Endometrium becomes atrophic so blastocyst implantation is also
• In about 2% ovulation is inhibited and 50% of women ovulate normally

Advantages

1. Highly effective
2. Limited related side effects
3. Protects against unwanted pregnancy
4. Do not affect breastfeeding
5. May decrease menstrual cramps
6. May improve anemia
7. Protects against ectopic pregnancy

Contraindications

1. Pregnancy
2. Unexplained vaginal bleeding
3. Recent history of breast cancer
4. Arterial diseases
5. Thromboembolic diseases
6. Active hepatic diseases
7. Hypertension

Side effects

1. Amenorrhea
2. Spotting
3. Prolonged or heavy bleeding
4. Lower abdominal pain
5. Weight gain or lose
6. Jaundice
7. Nausea and vomiting
8. Headache with blurred vision
9. Excessive hair growth
10. Breast fullness or tenderness
11. High blood pressure

i)      Combined Oral Contraceptive Pills (COC)

• This contains both oestrogen and It achieves effects of both hormones
• Oestrogen suppresses ovulation and progesterone creates unfavorable conditions for egg transport and thickening of the cervical mucus to impair sperm entrance into the canal.

Examples

• Lo-femenal
• Pillplan (duofen)
• Microgynon

Advantages

1. Highly effective (99%)
2. Protects against unwanted pregnancy
3. It is convenient, simple to take and does not interfere with sexual intercourse
4. Helps to correct menstrual irregularities
5. Reduces risks of ovarian and endometrial cancers by 50%
6. Decreased menstrual cramps
7. Pelvic examination is not required before use
8. Limited related side effects
9. Quicker return of infertility

Disadvantages

• Refer to pop Side effects

Side effects

1. Chest pain
2. Amenorrhea
3. Spotting
4. High blood pressure
5. Nausea, dizziness & nervousness
6. Acne
7. Breast fullness & tenderness
8. Depression
9. Jaundice
10. Headache

Implants

Types

• Implanon ( 1 rod capsule for effective 3 years)
• Jadelle (2 rod capsules for 5 years)
• Norplant ( 6 rod capsules labeled for 5-7 years)

Modes of action

1. Thickens the cervical mucus 24 hours making it difficult for the sperm to enter the uterus.
2. It inhibits ovulation from taking place.

Advantages

1. Very effective within 24 hours after insertion
2. Easily reversible
3. No delay to return to fertility after removal
4. Make sickle cell crisis less frequent & less painful
5. Highly effective for long term
6. Others same as with Depo Provera

Common side effects and disadvantages

1. Changes in menstruations
   • Spotting
   • Heavy bleeding (rare)
   • Amenorrhea
2. Does not protect against STIs including HIV/AIDs
3. Discomfort in the hand after insertion
4. Overweight or weight loss
5. Minor surgical procedure required for insertion and removal.

Indications

1. Breast feeding post-partum mothers
2. Adolescents
3. Post abortion
4. Women with SCD
5. Women waiting surgical contraception
6. Women on treatment e. ARVs

Contraindications

1. Serious problems with heart or blood vessels
2. Breast cancer
3. Liver diseases- jaundice
4. Pregnancy

Signs and problems that need medical attention

• Soreness at the site of insertion
• Capsules come out
• Severe headache
• Heavy bleeding twice as much and twice as long she usually bleeds
• Pregnancy
• Missed period after several regular period or cycles.

Injectable contraceptives

Examples

• Depo provera 150mg
• Injecta plan
• Sayana press 104mg, 65ml subcutaneously
• Noristrat 200mg intramuscularly
• Norigynon 5mg intramuscularly

They both contain only one type of hormones, progestin

Depo Provera

Mode of action 

• Inhibits ovulation
• Thickens the cervical mucus making it difficult for the sperm to enter the uterus
• It also makes the lining of the womb thinner. This makes it unlikely that a fertilized egg will be able to implant in the womb.

Indications/who can use it?

• Breastfeeding mothers 6 weeks after delivery or immediately if not breastfeeding
• Women requiring long term contraception
• Known/suspected HIV positive women who need an effective FP method
• Women with sickle cell disease
• Women who cannot use COC due to estrogen content
• Women awaiting surgical method of contraception

Contraindications

• As for POP
• Women without proven fertility unless they have HIV/AIDs
• Pregnancy (known or suspected)
• Liver disease (jaundice)
• Unexplained vaginal bleeding that has not be investigated
• Hypertension 140/90mmg and above
• Serious problem with the heart or blood loss
• Breast or genital malignancy (known or suspected)
• Women with bone thinning/osteoporosis (known or suspected)

Advantages and non-contraceptive benefits

• Very effective
• Does not suppress lactation
• Clients only has to remember the return dates for subsequent injection
• Private-no one can know that the woman is on it
• No estrogen side effects
• Make sickle cell crisis less frequent
• If you want to stop using it you don\’t have to go back to your doctor or nurse to have it removed; you just have to wait for it to wear off.
• It does not interfere with sex

Disadvantages and common side effects

• Changes in menstrual bleeding
  • Spotting (common in the first 3 months)
  • Amenorrhea (often after 1^st injection and after 9-12months of use)
  • Prolonged heavy vaginal bleeding during 1^st 1-2 months after injection
• Weight gain or loss
• The injection cannot be removed once given. Any side-effects will last for more than 2-3 months, until the progesterone goes from your body.
• Delayed return of fertility
• Loss of lido
• Does not protect against STI/HIV/AIDs
• Alopecia
• Milk headache

Signs and problems that need medical attention

• Repeated severe headaches
• Excessive weight gain
• Depression
• Prolonged abdominal pain and pain at injection site
• Heavy bleeding per vagina twice as much and twice as long as she usually bleeds

Management

• Medroxyprogesterone acetate depot (Depo provera) Injection 150mg deep IM into deltoid or buttock muscle
  • Do not rub the area as this increases absorption and shortens depot effect

If given after day 1-7 of menstrual cycle

• Advise client
  • To abstain from sex or use a back-up FP method, e.g. condoms, for the first 7 days after injection
  • To return for the next dose  on a specific date 12 weeks after the injection (if the client returns more 2-4 weeks later than the date advised, rule out pregnancy before giving the next dose)
  • On likely side effects
  • To return promptly if there are any warning signs

Sayana Press

• Sayana press ® is a single-dose container with 104mg Medroxyprogesterone acetate (MPA) in 0.65ml suspension (104mg) formulated for subcutaneous
• It is administered subcutaneously into the anterior thigh or abdomen or arm
• The efficacy of Sayana press depends on adherence to the recommended dosage schedule of administration.

Mechanism of actions

• Its‘ main mechanism of action is to suppress ovulation
• It makes the endometrium unsuitable for implantation if fertilization occurs
• It also increases the viscosity of cervical mucus making the mucus less easily penetrable to sperm.

Indications

Nearly all women can use it safely & effectively including women:-

• Women whose partners have undergone vasectomy until vasectomy is effective
• Have or have not had children
• Any age including adolescents & women over 40 years old
• Have just had an abortion/miscarriage
• Breastfeeding women 6 weeks postpartum
• HIV infected whether or not on ART

Advantages & non- contraceptive benefits

• New formulation for S/C injection
• 30% low side effects compared to Depo-Provera
• Do not interfere with sex
• Private & no one else can tell that a woman is using it
• May help women gain weight
• Do not require daily action
• Prevents pregnancy
• Protects against endometrial cancer, uterine fibroids
• Reduces sickle cell crisis among women with sickle cell anemia
• Protects against symptomatic PID & iron deficiency aneamia

Contraindications

Sayana press is contraindicated in the following:-

• Clients with a known hypersensitivity to MPA
• Pregnancy (known or suspected)
• women with known or suspected malignancy of the breast or genital organs
• clients with undiagnosed vaginal bleeding
• patients with severe hepatic impairment
• patients with metabolic bone disease
• patients with thromboembolic disease
• patients with current or past history of cerebro-vascular disease

Disadvantages & Side effects

• Weight gain or loss
• Does not protect against STI/HIV/AIDs
• Delayed fertility return
• Hypersensitivity reactions
• Decreased/increased appetite
• Loss of libido & irritability
• Dizziness, headache & migraine
• Thromboembolic disorders
• Nausea & vomiting
• Jaundice
• Alopecia & urticaria
• Loss of bone mineral density
• Back & leg pains
• Mood changes
• Abdominal bloating & discomfort

Problems that may need medical attention

• Loss of bone mineral density
• Menstrual irregularities
• Thromboembolic disorders
• Anaphylaxis & anaphylactoid reactions
• Sudden partial or complete loss of vision

Permanent Method/Voluntary Surgical Contraceptives

 Because male and female sterilization are permanent methods of contraception, thorough counseling procedures must be followed to ensure that the client fully understands his or her choice and to minimize chances of regret. Clients younger than 30 years old or with fewer than three children require particularly careful counseling and exploration of other long-term method options.

1. Tubal ligation/tubectomy

• This is a voluntary surgical procedure for permanent termination of fertility in women.
• It can be done by a mini-operation (laparatomy/laparoscopy)

Mode of Action

• Blocking fallopian tube by cutting, cautery, rings or clips
• Prevent sperms from reaching the ovum

Indications

 In general, the majority of women who want tubal ligation can have a safe and effective procedure in a routine in a health facility equipped to provide the service, provided they have been counseled. They should also be able to give informed consent. Women who may consider tubal ligation include:

1. Those who are certain that they have achieved their desired family size
2. Women who want a highly effective permanent method of contraception
3. Women for whom pregnancy presents unacceptable risk Family planning should be delayed in case of:
   1. Pregnancy
   2. Immediately/early postpartum if woman had severe pre-eclampsia/eclampsia, early rupture of membrane (EROM), sepsis etc.
   3. Complicated abortion (infection, hemorrhage)
   4. Current DVT
   5. Unexplained vaginal bleeding (before evaluation)
   6. Malignant trophoblastic disease
   7. Current PID or purulent cervicitis
   8. Current gall bladder disease
   9. Severe anemia
   10. Acute respiratory disease
   11. Acute systemic infection or gastroenteritis
   12. Abdominal skin infection –      peritonitis

Timing of the tubal ligation

1. Immediately after childbirth or within first seven days (if she made voluntary choice in advance)
2. Six weeks or more after childbirth
3. Immediately after abortion (if she made voluntary choice in advance)
4. any time provided pregnancy is ruled out (but between seven days and six weeks postpartum)
5. during caesarean section

Benefits

• Highly effective
• Effective immediately
• It is permanent
• It is a simple surgery, usually done under local anesthesia
• No exposure or worries about contraception
• No further expense or worries about conception
• No long term side effects
• Does not interfere with sexual intercourse

Disadvantage

• Does not protect against STIs/AIDs
• It is irreversible

Side effects

• Wound infection
• Post-operative fever
• Bladder and intestinal injuries(rare)
• Hematoma
• Pain at the incision (post operatively)
• Superficial bleeding

Challenges associated with tubal ligation

• Desire for more children after when the operation is done
• Excessive desire in reversal
• Disagrees to sign the informed consent form
• Pressure from the someone else
• Depression
• Marital problems
• Single women
• Women with no children

General complications of tubal ligation

1. Obesity
2. Psychological upset
3. Chronic pelvic pain
4. Congestive dysmenorrheal
5. Menstrual abnormalities like menorrhagia, hypomenorrhea
6. Alteration in libido.

2.     Vasectomy

• This is a voluntary surgical procedure for permanently terminating fertility in men

Mode of action

Blocking the vas deferens (ejaculatory duct) so that sperms are not present in the ejaculate.

Indications

• Those who are certain that they have achieved their desired family size
• Men who want a highly effective permanent method
• Men whose wives face unacceptable risk in pregnancy

Contraindications

Vasectomy should be delayed in case of:

• Local infections (scrotal skin infections, orchitis etc)
• Current STI
• Systemic infections

Benefits

• Highly effective
• It is permanent
• It is a simple surgery done under local anesthesia
• No further expense or worries about conception
• No long term side effects
• Does not interfere with sexual intercourse

Side effects

• Wound infection
• Scrotal hematoma
• Granuloma
• Excessive swelling
• Pain at incision sites

Explain the following to the clients

• When to come back for follow up visits
• Common side effects of the method offered
• What to do if there are changes in the menstrual periods
• How soon the method is effective
• How to protect against STIs
• How to care for the wound in case of implants, vasectomy and tubal ligation

General instruction to the clients using permanent methods of family planning

1. Inform him or her when to come back for follow up visits
2. Explain the common side effects of the method in a simple language
3. Tell the client the warning signs or possible problems that may require medical attention
4. Tell the client what to do if there are changes in the menstrual periods
5. Inform the client how soon the method is effective
6. Let the client know that the method does not protect against HIV/AIDs and STIs and emphasize on the use of backup methods like condoms
7. Guide the client on how to care for the wound post operatively

Emergency /Post Coital Contraceptives

Emergency contraception (EC) refers to methods of contraception used by women to prevent unintended pregnancy following unprotected sexual intercourse. It should not be used as a routine contraceptive method. EC not a method for termination of pregnancy

Indications

1. Any woman who has had unprotected sexual intercourse
2. Women who have been raped
3. Any woman whose contraceptive method has failed (e.g. condom broke or slipped)
4. Any woman who has forgotten to take her COC pills for more than two days or who has forgotten to take her POP at the regular time
5. Missed injection for more than two weeks
6. Delay in taking pills more than 3 hours
7. Sexual assault or rape and the first time intercourse

Contraindications

1. Pregnancy
2. After 120 hours or 5 days of unprotected sex

Types

1. Emergency contraceptive pills (ECP)
2. Progesterone only pills regimen.

They are the preferred ECP regimen as they are more effective and have fewer side effects than COC pills

When to start?

 This should be started or taken within 5 days or 120 hours but the sooner the better following unprotected sexual intercourse.

What to use and the dose

1. Lofemenal or microgynon 4BD for 1 day (low dose COC)
2. Eugynon (high dose COC) 2BD for 1day
3. Regular POP such as Ovrette or microval can be used in recommended dose
4. Levonogestrel 2stat
5. Postinar 2 BD for 1day
6. vikela orlevonelle-2 or Norlevo plan B may be used

Side effects

1. Nausea & vomiting

a)            Intrauterine contraceptive devices (IUCDs)

Introduction of copper IUCDs with a maximum period of 5days can prevent conception following accidental unprotected sexual exposure.

Mechanism of action

• Prevents implantation
• Failure rate is about 1%
• Effectiveness is over 99% in preventing pregnancy

Notes

Post coital contraception is only employed as emergency measure and is not effective if used as regular method of contraception with the exception of the copper IUCDs

Women who need emergency contraception should be counseled about regular contraceptive options and encouraged to use regular methods consistently and correctly. Referral:

• Women should be referred for other relevant services such as HIV counseling and testing, post exposure prophylaxis (PEP) and treatment for STIs
• Women should be referred to specialized services such as for sexual and gender based violence.

Basic steps of client care for ECP

• Greet client, introduce yourself, and ask what he/she
• Show a respectful attitude
• Explain that your discussion with the client will be kept
• Explain the different ECP
• Screen the client for ECP use.
• Tell client about ECPs; give clear information about use, side effects, and needs for referral or follow-up.
• Encourage her to ask questions
• Discuss options for regular contraception with client

Counseling ECP clients

When counseling a client about ECP, the provider should:

• Actively involve the client in the counseling process
• Reassure the client that all information she gives you is kept confidential
• Provide a private and supportive environment
• Do not make judgmental comments or indicate disapproval through body language (such as such as crossing your arms over your chest)
• Be responsive to the client‘s needs
• Be supportive of the clients choices
• Be respectful

Artificial Methods of Family Planning

Artificial methods of family planning refer to the use of various techniques and devices to prevent pregnancy. These methods rely on the use of physical barriers, chemicals, or surgical interventions to either prevent sperm from reaching the egg or to interfere with the fertilization process.

FAMILY PLANNING CARD

 Criteria to follow before a client is put on a family planning methods

History taking

1. 1. Personal Age, sex, address, next of kin
   2. Social Marital status, education, any habits that may affect choices of some family planning methods e.g. smoking
   3. Medical To identify the presence of medical diseases, problems, sickle cell, medications.
   4. Reproductive /obstetric history:
      • Find out when clients started her period
      • How many children/pregnancies she had
   5. Gynecological To identify any diseases affecting a woman‘s reproductive organs e.g. bleeding, cancer of the cervix, PIDs, breast cancer etc.
   6. Family planning To find out about previous use of family planning methods.

General examination

Should be done from the head to toes;

• Anemia, edema, jaundice, lymphadenopathy
• Breast for colour changes, masses
• Per abdominal examination to check for masses
• Per vaginal examination to check for abnormal discharges

Note: Weight, blood pressure should be recorded when starting one on family planning especially the hormonal ones.

Artificial methods of family planning

 Barrier methods

1. Spermicides
2. Condoms
3. IUCDs
4. Diaphragm
5. Intra-vaginal contraceptive sponge
6. Cervical caps

Condoms (male and female)

• This is the most popular and oldest method
• This is a rubber sheath that is worn by a woman or man during sexual intercourse
• It is the only family planning method that prevents both pregnancy and STIs including HIV/AIDs if used consistently and correctly.

Indications

Condoms can be used by any man or woman regardless of his/her health status. People in particular need of condoms include:

• Men wishing to participate more actively in family planning
• Sexually active adolescents
• Couples who have sexual intercourse infrequently
• People in casual sexual relationships where pregnancy is not desired
• Couples needing a back-up method while waiting for another contraceptive methods to become effective.
• Couples who need a temporary method while waiting to receive another contraceptive method.
• Those who are at increased risk of STIs, (e.g. when one or both partners have other partners)
• Couples where one or both partners are HIV positive

Male Condoms

Male condoms are sheaths or coverings that fit over a man‘s erect penis. Most are made from thin latex rubber; some are polyurethane (plastic).

Primary mechanism of action

• Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy
• Also keep infectious agents in semen, on the penis, or in the vagina from infecting the other partner

Effectiveness

• Protection against pregnancy:
• As commonly used, about 18pregnancies per 100 women whose partners use male condoms over the first year
• When used correctly with every act of sex, about 2 pregnancies per 100 women whose partners use male condoms over the first year

Protection against HIV and other STIs:

• Male condoms significantly reduce the risk of becoming infected with HIV when used correctly with every act of sex.
• When used consistently and correctly, condom use prevents 80% to 95% of HIV transmission that would have occurred without condoms.
• Condoms reduce the risk of becoming infected,
  • Protect best against STIs spread by discharge, such as HIV, gonorrhea, and Chlamydia
  • Also protect against STIs spread by skin to skin contact, such as herpes and human papilloma virus (if condom covers lesions)

Any client concerns or questions

• Reinforcing correct condom use and reminding clients that condoms should not be reused
• Allergy to latex

Dispelling myths regarding condoms

Male condoms:

• Do not make men sterile, impotent, or weak
• Do not decrease men’s sex drive
• Do not promote promiscuity
• Cannot get lost in the woman\’s body
• Do not have holes that HIV can pass through
• Are not laced with HIV
• Do not cause illness in a woman because they prevent semen or sperm from entering her body
• Do not cause illness in men because sperm may move back up
• Are used by married couples; they are not only for use outside marriage

Who should not use condoms?

Individuals allergic to latex should consider other contraceptive options. However, for those at risks of STIs/HIV, condom use is still appropriate as there are no other methods that offer STI/HIV protection.

How to use male condoms

1. Use a new condom for each act of sex. Check package for damage and check the expiration Tear open carefully without using any sharp objects.
2. Before any physical contact, put condom on the tip of the erect penis with the rolled side out.
3. Unroll condom all the way to the base of the erect penis.
4. Immediately after ejaculation, hold rim in place and withdraw penis while it is still Slide the condom off, avoiding spilling semen.
5. Dispose of the used condom safely.

Practices to avoid when using condoms

• Unrolling condom before putting it on
• Using oil-based lubricants with latex condoms
• Using condoms that may be old or damaged (e.g. dried out, brittle, sticky)
• Reusing condoms

Practicing dry sex as it increases possibility of condom breakages due to friction

Female Condoms

• Female condoms are sheaths, or linings, that fit loosely inside a woman‘s vagina
• Most common type is Female Condom Two (FC2) made of thin, soft, synthetic rubber film, with flexible rings at both ends
• Latex female condoms are available in some countries Primary mechanism of action
• Work by forming a barrier that keeps sperm out of the vagina, preventing pregnancy
• Also keep infectious agents in semen, on the penis, or in the vagina from infecting the other partner

Effectiveness

Protection against pregnancy:

• When used correctly with every act of sex, about 5 pregnancies per 100 women using female condoms over the first year
• As commonly used, about 21 pregnancies per 100 women using female condoms over the first year.
• Protection against HIV and other sexually transmitted infections (STIs):
• Female condoms reduce the risk of infection with STIs, including HIV, when used correctly with every act of sex.

Characteristics of female condoms

• Safe
• Women can initiate their use
• Have a soft texture that quickly conducts body heat during sex
• Provide dual protection (against STIs/HIV and pregnancy)
• Outer ring provides added sexual stimulation for some women
• Do not require provider‘s help
• Can be inserted ahead of time so do not interrupt sex
• Are not tight or constricting like male condoms
• Do not dull the sensation of sex like male condoms
• Do not have to be removed immediately after ejaculation
• No side effects
• Can be used as a temporary backup method of contraception
• Protect women from conditions caused by STIs (pelvic inflammatory disease, cervical cancer, infertility)
• As typically used, less effective than many other FP methods
• Require partner communication and cooperation
• May be difficult to insert
• Can make noise during sex

Side effects of female condoms:

• None
• Allergic reactions to latex

Who can use female condom?

• All men and women can safely use synthetic rubber female
• All men and women can safely use natural latex female condoms, except those with a severe allergy to latex (extremely rare).

How to use female condoms

1. Use a new condom for each act of sex.
   • Check the condom
   • Do not use if torn, damaged or past the expiration
   • Open the package
2. Before any physical contact, insert the condom into the vagina. It can be inserted up to eight hours before sex. Find a comfortable position for insertion—squat; raise one leg, sit, or lie down. Grasp the ring at the closed end, and squeeze it so it becomes long and With the other hand, separate the outer lips and locate the opening of the vagina. Gently insert the inner ring into the vagina as far up as it will go. Insert a finger into the condom to push it into place. (The inner ring should be pushed up just past the pubic bone.)
3. Ensure that the penis enters the condom and stays inside the
4. To remove the condom, hold and twist outer ring to seal in fluids, and gently pull condom out of the vagina. The female condom does not need to be removed immediately after sex, but any time before standing up, to avoid spilling semen.
5. Dispose of the used condom safely.

Tips for new users

• Suggest to a new user that she practice putting in and taking out the condom before the next time she has sex. Reassure her that correct use becomes easier with practice. A woman may need to use the female condom several times before she is comfortable with it. 
• Suggest she try different positions to see which way insertion is easiest for her.
• The female condom is Some women find insertion easier if they put it in slowly, especially the first few times.
• If a client is switching from another method to the female condom, suggest that she continue with the previous method until she can use the female condom with confidence.

Provide follow up and counseling for

• Any client concerns or questions
• Correct condom use 

Dispelling myths regarding female condoms

Female condoms:

• Cannot get lost in the woman‘s body
• Are not difficult to use, but correct use needs to be learned
• Do not have holes that HIV can pass through
• Are used by married couples; they are not only for use outside marriage
• Do not cause illness in a woman because they prevent semen or sperm from entering her body

General Advantages

1. Effective when used correctly
2. No medical supervision required
3. Convenient to carry
4. Prevents both pregnancy and STIs including HIV/AIDs
5. Easy to use
6. Reduce risk of systemic side effects and reaction
7. Fairly cheap and available in almost every places

General Disadvantages

1. There is loss of spontaneity
2. May rupture or lose position during intercourse
3. It is often associated with extra marital sex and STIs
4. It is not suitable for poorly motivated persons
5. There is lack of privacy while purchasing condoms
6. It cannot be used by a man who cannot maintain erection
7. Requires male responsibility
8. It is considered unclean to some people

Spermicides

This involves application of chemicals into the vagina to prevent pregnancy.

Mode of action

• Aims at killing or inactivating sperms

Forms of Spermicides

• Jellies
• Creams
• Foams
• Tablets
• Lubricants in condoms
• Ingredient in vaginal sponge

Advantages

1. Available without prescription
2. Fairly effective if used correctly
3. Can be used as backups
4. Used only if required
5. Control is in the hand of a woman
6. Provide extra-vaginal lubrication
7. Protects against some STIs and PIDs

Disadvantages

1. Not effective when used alone
2. Some couple find the method messy i.e. too fluidic
3. Associated to some allergic reaction
4. Interrupts sexual intercourse

   Intra-Uterine Contraceptive Device (IUCDs)

These are devices inserted into the woman uterus to prevent implantation of the fertilized ovum by local inflammation.

Types of IUCDs

• Copper T 380A effective for 10-12 years
• Multi-load 375 for 5 years
• Mirena R hormonal IUCD

Advantages

1. It is very effective since it starts working right way
2. She does not need to keep coming for refill
3. Can offer protection up to 10 years and above
4. Fertility returns is immediate
5. Limited side effects reported as compared to other methods
6. Does not interfere with sexual intercourse
7. Has no effects on breastfeeding
8. Only one follow up is needed unless there are problems

Side effects

1. Increases menstrual bleeding
2. Spotting
3. Abnormal vaginal discharge
4. Menstrual cramps
5. PID

Indications

1. Breastfeeding
2. Women of any age
3. As for POP

Contraindications

1. Irregular vaginal bleeding of unknown origin g. cancer of cervix
2. Pregnancy
3. Heavy and painful menstruation
4. Cancer of the uterus
5. Current PIDs
6. Multiple sexual partners
7. Pregnancy

IUCDs users who develop PID should be treated with the IUCD in place if they want to continue using it. If no improvement within 72 hours, remove it.

 Insertion of IUCD Timing of IUCD insertion

• Any time provided pregnancy is ruled out
• The first seven days of the menstrual cycle
• Immediately following delivery or any time within 46 hours after childbirth
• Any time beyond four to six weeks after childbirth
• Immediately or within seven days after an uncomplicated abortion
• During caesarean section

Procedure

1. Consider aseptic technique like hand washing, wearing sterile gloves.
2. The device is put in an introducer and plunger.
3. It straightens inside the introducer.
4. Insert a Cusco ‘s vaginal speculum and clearly visualize the cervix.
5. Clean the cervix and vaginal vault with sterile swabs.
6. Measure the length of the uterus with a uterine sound.
7. Insert the introducer into the uterus through the cervix.
8. The plunger is gently pushed to force device out of the introducer into the uterus.
9. In the uterus, the device resumes its original shape and lodges against the uterine walls.
10. The two small strings attached to the device hang down through the cervical opening.
11. Cut the string with a pair of scissors to reduce the size approximately 3cm hanging out of the cervix.
12. After the insertion, the client She can remain on the procedure table until she feels ready to get dressed.
13. The woman usually feels the strings in the vagina to ensure that the device is in position.

Post insertion instructions

1. To use back up for a minimum of 3 days.
2. There may be some slight pain which does not require medication.
3. To check the string during menstruation to ensure that it is in place or come back if it is removed or dislodged.
4. To return to the facility immediately in case of any discomfort.

Removing the IUDs

1. In case a client is finding side effects difficult to tolerate, first discuss the complaints the client has. Weigh if she would rather try to manage the problem or to have the IUD removed.
2. Removing IUD is usually It can be done any time of the month.
3. Removing may also be easier during monthly bleeding, when the cervix is naturally In cases of uterine perforation or if removal is not easy, please refer the client to an experienced service provider to employ appropriate removal technique.

Steps for IUD removal

• Explain what you are going to do to the client during removal
• Ensure privacy & confidentiality at all times
• Request the client to lie on her back
• The provider inserts a vaginal speculum to visualize the cervix & UID strings
• Carefully cleans the cervix & vagina with an antiseptic solution such as Savlon & do inspection
• The provider requests the client to take slow, deep breaths & to Inform the client to make you know in case she feels pain or any other discomfort during the procedure
• Using narrow forceps, the provider gently pulls the IUD strings & slowly until it comes completely out of the cervix
• Show the removed IUD to the client & let her handle with the hands. This helps to make the client understands that nothing has remain inside the uterus.
• Thank the client for cooperating throughout the procedure
• Clear away

Reasons for missed threads in IUDs

1. Coiled thread inside
2. Thread torn through
3. Device expelled outside unnoticed by the client
4. Device perforated the uterine wall and is lying in the peritoneal cavity
5. Device pulled by the growing uterus in pregnancy

Methods of identification

1. History taking i.e. exclude pregnancy
2. Ultrasonography
3. Hysterectomy
4. Hysteroscopy
5. Straight x-ray

Hormonal Methods of Family Planning (Click Here)

Family Planning

Family Planning is defined as a process through which individuals, couples make up an informed choice on how many children to have, when to have and how often to have so that each child born is expected and properly catered for in all ways. 

For instance, basic needs like good health, education, shelter, and all essential needs of humans are available.

This involves planning and proper birth spacing according to wishes rather than by chances. Birth spacing promotes the health of the mother, children and father.

Consent for family planning services

No verbal or written consent is required from parent, guardian or spouse before the client can be given family planning services except in cases of incapacitation (intellectual disability). Clients should give written consent to permanent family planning methods.

Setting of family planning clinics

Service delivery points where a health provider comes into contact with a potential or actual client

• Social mobilization events for any health services
• Youth clubs and schools through family life education activities
• Women and men organized clubs/groups
• Work places

Where to get family planning services

• • Facility based outlets such as hospitals, health centers and dispensaries
  • Outreach services including mobile clinics and workplaces
  • Community based outlets e.g. community based distribution, drug shops and dispensing machines
  • Social marketing
  • Private sector facility such as clinics, maternity and nursing homes, pharmacies and drug retail shops

Counseling

In order to promote informed choice, all clients seeking contraceptives are entitled, given accurate and adequate information about family planning methods available in the common settings. This is important for the initiation and continuation of family practice. Methods (of choice) of clients will be done individually and in a dignified manner. The discussion between the service provider and client must be private, confidential and should never include incentives or coercion for the adaptation of any method.

Initial counseling should include the following:

• Discussion of client’s reproductive goals, previous knowledge and/or experience with any method
• Showing the FP methods available
• Information on how each method prevents pregnancy
• How effective the method is and what conditions make I effective
• Method failure
• Common side effects
• The follow-up regarding each method
• Where the method can be obtained
• Importance of physical and pelvic examination
• Information on HIV/AIDs/STIs in relation to F/P
• HIV testing and screening of STIs
• Symptoms of breast and cervical cancer including available services for screening
• Clarification of misconceptions or rumors the client may have about each type of method

Subsequent counseling will aim at promoting and encouraging continued use of a method and should include:

• A review of the client ‘s satisfaction or problem with the method
• A review of the client ‘s understanding of user instructions
• Dispelling rumors and/or misconceptions, if any
• In indicated, a review of change of the client’s reproductive goal necessitating the need for a long term or permanent method
• Counseling on STIs and HIV/AIDs
• Possible method failure
• Information of common symptoms of breast and cervical cancer including available services for screening
• Counseling is also important:
• Where a contraceptive method has failed
• There is regret for having had a permanent method
• In cases of rape or defilement
• Where there are is need for referral for appropriate care

Screening

After a thorough counseling a client should then be ready to choose a contraceptive method. The next step is to screen for contraceptive use.

• Clients opting for hormonal method should have the relevant health, social history taken and physical assessment carried out on the first or subsequent visits. Where indicated, do a complete physical check up to rule out contra-indications to method use. Where is not possible or necessary to perform routine physical assessment, the client should be screened by a qualified staff or FP trained service provider using a standard checklist to initiate or resupply oral contraceptive or Depo Provera. After screening, the important findings should be communicated to the client including any issues she/he may want clarification on. The client will then be provided with the appropriate or preferred method and important findings should be recorded according to the guidelines.

Routine physical or pelvic examinations is not obligatory for initiating or re-supply of oral contraceptives or Depo Provera, an examination could be valuable for reproductive health and may help to rule out contra-indications to methods and/or establish the presence or absence of infections or cancer.

Where selected physical assessment or laboratory tests are indicated and is not possible to carry them out at a particular clinic, clients should be referred to a health unit equipped to provide the assessment test.

Importance of family planning

a)   To the mother

1. Allows mother to recover physically and mentally from the effects of previous pregnancy
2. Offers ample time for a woman to actively participate in productive activities like farming and business.
3. It increases social bondage between the mother and her baby
4. It helps to reduce on maternal mortality and morbidity the couples due to pregnancy related complications
5. It promotes a happy marital life and enjoyment between the couples without fear of getting unwanted pregnancy.

b)    To the child

1. Child receives adequate emotional and social support and as a result gets emotional maturity and stability
2. Allows adequate nutrition of the baby while in the womb and hence a healthy newborn
3. There is reduction of malnutrition as there is no early weaning and likely to have enough food for the child
4. The child gets fewer infections since immunity is

c)     To the father

1. Reduces domestic violence in a home
2. Ability to meet basic needs like foods, medical care
3. Reduces the cost of living in a home hence the father is able to invest in productive

d)    To the Community

1. Healthy and productive people who enhance community stability and harmony
2. Reduces overcrowding hence available land can be maximize for productivity
3. There will be increased socio-economic development
4. Presence of bad characters in the community like street kids, smokers and other bad group in the community since parents have adequate time to provide for their

e)     To the Nation

1. Reduces rapid population growth rate
2. Reduces the country‘s dependence on foreign aids
3. The government will be able to provide better social services and infrastructures like roads, health facilities
4. It is easy to budget for the people since the number of resources to the population is

Available family planning methods in Uganda

 The family planning methods can be broadly classified into: –

• Natural family methods.
• Hormonal /Artificial family planning.

1.     Natural /traditional methods

• Calendar/rhythm
• Basal body temperature
• Cervical mucus method
• Lactation amenorrhea methods
• Abstinence
• Withdrawal/coitus interrupters

2.     Artificial methods

1. Barrier methods

• Spermicides
• Condoms
• Intrauterine contraceptive devices (IUCDs)
• Diaphragm

b)    Hormonal methods

1. Oral pills
   • Combined oral contraceptives
   • Progesterone only pills
   • Emergency contraceptive pills

ii.          Implants

• Implanon (1 rod capsule)
• Jadelle (2 rod capsules)
• Norplant (6 rod capsules)

iii.          Injectable contraceptives

• Depo Provera
• Injector plan
• Sayana press
• Noristerat

c)     Permanent methods

• Tubal ligation (tubectomy) for women
• Vasectomy for men

Natural methods of family planning

These are also known as fertility awareness method. They are based on the following physiological conditions.

• The lifespan of a sperm is 24 hours
• The lifespan of an ovum is 48 hours
• Menstruation takes place between 1-16 days before the next period

General advantages

1. They are safe with no side effects
2. Cheap
3. They are acceptable to many groups and religious that opposes the modern methods
4. They teach women about their own menstruation cycle and fertility
5. Couples have control over their methods
6. Help in planning a pregnancy

General disadvantages

1. Some require substantial teaching before use
2. It is difficult as records on several cycles ought to be kept for proper references
3. Difficult to use if the period are irregular
4. Requires adjustment to sexual behaviors
5. Requires co-operation between the partners which in most cases is difficult
6. Do not protect against STIs/HIV/AIDs

 Fertility awareness method

 Fertility awareness methods of family planning involve identification of the fertile days of the menstrual cycle (when pregnancy is most likely to occur) and avoiding sexual intercourse (or using barrier methods) during these days. The fertile days of the menstrual cycle can be determined by one of the following methods:

• Basal body temperature (BBT)
• Cervical mucus
• Symptom- thermal (a combination of cervical mucus and BBT methods)
• Calendar (rhythm) or Standard Days method, including cycle

A woman or couples who are planning to use fertility awareness methods need special training from a trained counselor in family planning.

Indications

 Any woman or couple who is willing and motivated to observe, record and interpret fertility signs daily.

• • Women who find other contraceptive methods unacceptable for various reasons including religious beliefs
  • Women who are unable to use some other methods for health reasons
  • Couples who are willing to abstain from sexual intercourse (or use condoms) for more than one week during each days

Contraindications

There are no medical conditions that are worsened with the use of fertility awareness methods. However, there are some conditions that make their use more difficult. If these conditions are present, the method can either be delayed or the provider should offer special counseling to ensure the correct use.

These conditions include:

• Breast feeding (especially until menses return)
• Less than three postpartum menses
• Irregular vaginal bleeding
• Abnormal vaginal discharge
• Disease that evaluates body temperature

Calendar /rhythm method

• This is the only method approved o the Roman Catholic Church
• Before starting to use this method, one needs to have an accurate record of menstrual cycles for about 6-8 months
• The failure rate is between 20-30%
• The method is referred to as ―safe days‖ because it aims at identifying days with least chance of conception
• The woman should provide a record of her menstrual cycles to the health worker and then go into the calculation as shown below.

Calculating the fertile period

Fertile period is the time of the cycle when a woman has the ―highest ―chances of conception.

Procedure

1. Record the length of each Length of a cycle is the time between the first day of one menstruation period and the first day of the following period
2. Identify the shortest and longest cycle
3. Get the first fertile day (FFD) by subtracting 18 from the shortest cycle (16 + 2 days of sperm survival)
4. Get the last fertile day (LFD) by subtracting 11 from the longest cycle (12-1 day of ovum survival)

Examples

A woman with a regular cycle of 28 days duration report to the family planning clinic and has opted for calendar method. Demonstrate the ability to calculate this in order for her to start using the method.

1. Record the length of each menstrual cycle: This is the time between the first day of one menstruation period and the first day of the following period.
2. Identify the shortest and longest cycles: Determine the cycle with the fewest days as the shortest cycle, and the cycle with the most days as the longest cycle.
3. Calculate the first fertile day (FFD): Subtract 18 from the duration of the shortest cycle. This accounts for the fact that sperm can survive for about 2 days.
4. Calculate the last fertile day (LFD): Subtract 11 from the duration of the longest cycle. This considers the fact that the ovum (egg) can survive for about 1 day.

Here\’s an example to demonstrate how to apply this method:

Examples

1. A woman with a regular cycle of 28 days duration report to the family planning clinic and has opted for calendar method. Demonstrate the ability to calculate this in order for her to start using the method.

Given: Number of cycles: 28 days

To calculate:

Shortest cycle: 28 – 18 = 10th day

Longest cycle: 28 – 11 = 17th day

Interpretation:

The woman is highly fertile between the 10th and 17th days of her cycle.

Comments/Remarks:

• It is recommended to avoid sexual intercourse between the 10th and 17th day of her cycle.
• It\’s advisable to use condoms or another form of contraception as a backup method.

      2. A woman with irregular cycle whose shortest cycle is 25 days and the longest cycle is 32. Calculate and interpret he finding to the client

Solution

Given number; Shortest cycle =25 days Longest cycle=32 days

Therefore:

FFD=shortest cycle=shortest cycle-18          =25-18 =7^th day

LFD=longest cycle-11                =32-11                  =21^st day 

Interpretation

• A woman is very fertile between 7^th-21^st day of every cycle
• Avoid sexual intercourse between 10^th-17^th day of her cycle
• To always use condoms or any other family planning method as a dual or backup

Self-help assessment

Demonstrate your ability to calculate & interpret the following to the client:-

• A client with cycle of 29 regular
• A client with cycles of 24 & 30 days respectively (irregular cycles)
• A client with 27 day cycle (regular)

Advantages

1. No cost
2. No side effects
3. Refer to general advantages of natural methods of family planning

Disadvantages

1. Difficult to calculate the safe period reliably
2. Needs several months training to use these methods
3. Compulsory abstinence from sexual act during certain periods
4. Not applicable during lactation amenorrhea when the periods are irregular
5. Does not protect against STIs including HIV/AIDs

Lactation amenorrhea method

• Immediately after birth, there is a period of naturally decreased fertility which can be prolonged by regular breastfeeding. The hormone responsible for the suppression of fertility is prolactin that controls milk production.
• The effect of breast feeding on reducing fertility awareness is well known. However, LAM is a temporary 9 short- term) method of contraception. It is highly effective for the first six months after delivery, providing the woman breastfeed fully and remains amenorrhoeic.
• In non- lactating mothers, prolactin gradually decreases within weeks after child birth reaching normal levels in about 4 weeks post-partum.
• Regular nipple stimulation by sucking is necessary to maintain milk production and lactation amenorrhea method.
• LAM may last up to 24 months during a regular prolactin release which inhibits the ovarian functions
• When all three criteria of LAM are met, it is about 98%

Indications

1. Women who are fully breastfeeding and
2. Who are amenorrhoeic (no menses) and
3. Whose baby is not older than six months

Fully breastfeeding means:

• Breast feeding whenever the baby desires (at least every four hours)
• Night time feeding (at least every six hours)
• Not substituting other food or drink in place of breast milk

Who cannot use LAM/contraindications?

1. Women whose menses have returned.
2. Women whose babies have turned six months old.
3. Women who have introduced supplementary feedings.

Note: Women with HIV should be counseled about the infant feeding options to reduce risk of mother-to-child transmission and be supported in their choice. Women without reliable access to safe alternative feeding options should be encouraged to breast feed exclusively for six months

Standard Days Method (Moon beads/cycle beads)

The Standard Days Method® is a fertility awareness-based family planning method that identifies a fixed fertile window for women with cycles that are between 26 and 32 days long. For women with cycles in this range, the method identifies days 8 through 19 as potentially fertile days. A user simply tracks the start date of her period and the days of her cycle to know if she is on a day when pregnancy is possible or not.

What are moon beads?

• They are string of colored beads
• The colors of moon beads help you know the days when you can get pregnant
• They also help you know the days you are not likely to get pregnant
• To prevent a pregnancy do not have sex on the days you can get pregnant, or use a barrier method.

Note: Moon beads are based on a natural method of family planning that is 95% effective when used correctly. This means that only 5 out of 100 women may become pregnant when the method is used correctly.

Modes of action

If a woman wants to prevent pregnancy using this family planning method, then she should avoid intercourse or use a back-up birth control method such as condoms during her fertile days (days 8-19). The patented Cycle Beads tools help a woman use this method by tracking her cycle, identifying her fertile and non-fertile days based on when her period started, and confirming that her cycles are in range for effective use of this family planning method.

Moon beads and the menstrual cycle

• Moon beads represent a woman‘s menstrual cycle
• Each bead is a day of the

Note: The menstrual cycle is not the same as the woman‘s period. The period is when a woman has menstrual bleeding while cycle includes all days from the start of one period to the day before the next period.

Indications/Eligibility/who can use it

1. Couples who communicate well and agree not to have unprotected sex when the woman is likely to get pregnant
2. Women who have failed to use other modern methods
3. Women who have cycles that is between 26 and 32 days

Advantages

• Refer to natural methods
• More than 95% Effective
• Side-Effect Free
• Easy to Use
• Inexpensive
• Educational & Empowering

How to use moon beads

1. The day you get your period, move the ring to the RED bead.
2. Also mark that day on the calendar
3. Move the ring, one bead each day
4. Do not have unprotected sex when the ring is on any WHITE bead. You can get pregnant on those days
5. You can have sex when the ring is on any brown beads. You are not likely to get pregnant on those days
6. Move the ring to the RED bead again when your next period starts. Skip over any beads that are left.

When to contact the healthcare provider

1. Had unprotected sex on a WHITE bead If she thinks she might be pregnant because she has not gotten her period.
2. If she gets her period before she reaches the DARK BROWN beads, this means that her cycle is shorter than 26 days.
3. If her period does not start by the DAY AFTER she reaches the last brown bead, this mean that her cycle is longer than 32

 Antenatal Care in Reproductive Health

Antenatal care; antenatal care is a planned program of medical management of pregnant  women directed towards making pregnancy, labour a safe and satisfying experience.

The health of pregnant women would be improved if effective antenatal care (ANC) was  available to all. Antenatal care therefore, constitutes one of the cornerstones to safer motherhood.  It is suggested that more flexibility concerning the place of consultation and timing of visits  could lead to better attendance and consumer satisfaction. The ministry of health therefore  recommends integration of services, e.g. family planning, EMTCT focused antenatal care,  immunization etc. 

Aims/purposes of antenatal care 

1. To promote and maintain the physical, mental and social health during pregnancy. 
2. To detect and treat conditions pre-existing or arising during pregnancy whether medical,  surgical or obstetric. 
3. To prepare the mother for the safe birth of the child for emergencies, complications. 
4.  To achieve delivery of a full term healthy baby or babies with minimal morbidity to  mother. 
5. To help the mother to experience normal puerperium and in conjunction with the partner to  take good care of the Childs‘ physical, psychological and social needs. 
6. To recognize deviation from normal and provide management or treatment as required by  ensuring privacy at all times. 
7. To prepare the mother for successful breastfeeding and give advice about adequate  preparation for lactation. 
8. To offer nutritional advice to the mother. 
9. To offer advice on parenthood either in a planned program or an individual basis taking  into consideration the clients‘ concerns. 
10. To build up a trusting relationship between the family, the mother and health workers  which will encourage them/her to share their anxieties, fears about pregnancy and care  being given through adequate communication and counseling. 
11. During this time, the pregnant woman is provided with previous preventive and advisory  services. The health worker makes consultation with her regarding the most appropriate  place of delivery of the baby and the things she needs to prepare emphasizing the concept  of a clean safe delivery e.g. having maama kits. 

Goals of Focused/Oriented Antenatal Care 

Important:  

• – Goals are different depending on the timing of the visit. 4 visits are aimed for an  uncomplicated pregnancy. 
• – If a woman books later than in the first trimester, preceding goals should be combined and  attended to. At all visits, address any identified problems, check BP and measure the  symphysio-fundal height (SFH) 

To promote maternal and newborn health survival through: 

• ∙ Early detection and treatment of problems and complications. 
• ∙ Prevention of complications and disease.
• ∙ Birth preparedness & complication readiness. 

Scheduling and timing of goal/focused antenatal care visits 

• ∙ First visit: by 0-16 weeks or when a woman first thinks she is pregnant. 
• ∙ Second visit: at 16-28 weeks or at least once in the second trimester. 
• ∙ Third visit: at 28-32 weeks 
• ∙ Fourth visits: if complication occurs, follow-up or referral is needed, woman wants to  see a provider, or provide changes frequently based on findings (history, exam, testing) or  local policy. 
• ∙ Refer  

Risk factors during pregnancy 

The following conditions are considered to have adverse effect on the course and outcome of  pregnancy and therefore are considered risk factors: 

1. Conditions likely to recur and cause bleeding: 

• – Previous hemorrhage, APH, PPH, retained placenta 
• – Too many pregnancies of five (5) or more 
• – Aneamia 
• – Multiple pregnancy 
• – Uterine scar. 

1. Conditions that affect intrauterine fetal growth and may cause abortion or premature – Preeclampsia 

• – Aneamia 
• – Malnutrition 
• – HIV 
• – Malaria, smoking, maternal underweight due to malnutrition 
• – Birth less than 2 years apart 
• – Diabetes 
• – Multiple pregnancy 
• – Excessive alcohol 
• – Sickle cell disease 
• – Abortion in the last 3 months 

1. Conditions that pose risk of infections to mother and baby and may cause abortion – HIV infection 

• – STIs e.g. syphilis 
• – Early rupture of membranes 
• – Diabetic mellitus 
• – Malaria 

1. Conditions where delivery may have to be assisted by cesarean section or vacuum extraction.

• – Short stature below 150cms 
• – Young primigravida below 18 years 
• – Elderly primigravida above 35 years 
• – Previous uterine scar 
• – Cardiac disease 
• – Diabetes mellitus 
• – Injury or deformity of the pelvis and lower part of the spine. 5. Severe pre-eclampsia and eclampsia 

Other conditions which are likely to: 

1. a) Recur  

• – Abortion 
• – Stillbirth 
• – Premature delivery 
• – Eclampsia 

1. b) Worsen with pregnancy 

• – Renal disease 
• – Mental illness 
• – Epilepsy 
• – Pulmonary tuberculosis 
• – Heart disease 
• – AIDs 
• – Diabetes mellitus 

1. c) Cause social discomfort 

• – Lack of support from partner/family 
• – GBV 
• – Low socio-economic status 
• – Unwanted pregnancy 

1. Conditions likely to cause abnormalities or disease to the baby – Age of mothers above 35 years 

• – STDs such as syphilis, HIV infection etc. 
• – Some drugs used to treat other conditions in the mother e.g. Tetracycline 

1. Methotrexate 
2. Efavirenz 
3. Ciprofloxacin 

• – Alcohol consumption and smoking including passive smoking. – Some genetic diseases e.g. hemophilia, Sickle cell disease 

1. Common problems that may complicate pregnancy and its management 

• – Aneamia 
• – Malaria
• – STDs 
• ▪ HIV 
• ▪ Gonorrhea 
• ▪ Syphilis 
• ▪ Vaginal/vulvar warts 
• – Urinary tract infection 

Roles of health workers in reducing the dangers of risk factors facing pregnant women

1.  Health education targeted at the community and pregnant women , giving them  sufficient time to express their concerns and discuss them 
2. Identification of pregnant women at risk of recurrent conditions or developing  complications such as pre-eclampsia and eclampsia, cephalo-pelvic disproportion etc.  and refer them appropriately 
3. Discuss the birth plan and emergency preparedness with the mother and another person  of her choice. 
4. Prepare management of pregnancy 
5. Appropriate referral of women with risk factors. 

Services offered during antenatal care 

• ✔ Health education 
• ✔ Counseling  
• ✔ Screening and risk assessment through 

1. – History taking 
2. – General and abdominal examination 
3. – Investigations 
4. – Vaginal pelvic examination where applicable 
5. – STIs testing including HIV 

• ✔ Provision of hematinic 
• ✔ Deworming 
• ✔ Immunization against tetanus (TT) 
• ✔ Intermittent presumptive treatment of malaria (IPT) 
• ✔ Early recognition, management and referral of high risk mothers and those who  develop complications 
• ✔ Delivery and postpartum care plan for every woman. 
• ✔ Treatment of medical conditions e.g. malaria, hypertension, diabetes, STIs,  Pulmonary tuberculosis 
• ✔ PMTCT, EMTCT 

In order to offer the services at ANC, the clinic should have at least the following: 

1. Waiting room: space where mother assemble for antenatal education: – Reception table

• – Benches for clients to sit on 

1. An examination room with privacy 
2. A stable and firm examination couch 
3. Weighing scale, a height measure in centimeters, a tape measure, a clinical thermometer,  urine testing kits, BP machine, a stethoscope and a fetoscope. 
4. A small laboratory capable of screening for common problems such as aneamia,  hookworm infestations, syphilis, pre-eclampsia and diabetes. 
5. Essential drugs spelt out for health centre including vaccines such as TT, SP, hematinic,  elimination of mother to child transmission of HIV/AIDs (EMTCT) drugs. 

The following are also recommended 

1. Mothers should be advised to attend ANC as early as possible preferably to have the first attendance during the first sixteen (16) weeks of pregnancy 
2. ANC should be integrated in other family health services and offered on a daily basis 
3.  Outreach ANC services outside the established health facilities should be held on specified  and regular days of the week which should be known by the general public in the area.

Health Education 

Aims  

• To provide clients with information that will help a pregnant woman to ensure that she remains  healthy throughout pregnancy and delivery. 
• The information should be given at appropriate periods including during follow up visits.

Some  key messages include the following: 

1. – Services offered to pregnant women during ANC and benefits of ANC. – How to keep health during pregnancy 
2. – STIs and other effects on pregnancy and newborn 
3. – Malaria and its complications during pregnancy 
4. – Minor disorders of pregnancy and how to cope with them 
5. – Diet during pregnancy and lactation 
6. – Danger signs during pregnancy and labour 
7. – Pregnant women who must be attended to and delivered in hospital 
8. – Benefit of family planning and different options 
9. – Women who are likely to get problems if they become pregnant 
10. – What to prepare for delivery 
11. – Signs of labour 
12. – Benefits of delivery under a skilled provider in a health unit 
13. – Family planning methods of postpartum mothers 
14. – Postnatal care 
15. – Benefits of breastfeeding

Steps in planning maternal health client education session 

• ✔ Identify target group 
• ✔ Identify needs of target groups e.g. 

1. – Present knowledge and practices in R.H 
2. – The priority message related to problem 

• ✔ Best media approach and language 
• ✔ Identify resources such as: 

1. – Leaders in the community 
2. – Influential supporters of RHS for example, old acceptors of RHS 
3. – Materials/visual aids relevant to the topic 
4. – Venue/ that is conducive for effective RHS client education session 

Preparation 

1. ✔ Prepare venue, which is conducive for the session delivery 
2. ✔ Notify target group through their leaders in the community 
3. ✔ Prepare yourself 
4. ✔ Identify satisfied clients 
5. ✔ Prepare influential supporters of RHS 
6. ✔ Prepare materials/visual aids 
7. ✔ Prepare contents and channels for delivering it, e.g. a song or a talk 

Steps in conducting education session talks; 

1. Introduction of self and colleagues 
2. Acknowledge leaders and group present 
3. State purpose of the session in a stimulating way by use of a slogan, poster or small story 
4.  Deliver content allowing groups to participate and use visual aids where appropriate 
5.  Allow for questions and answers 
6. Evaluate the sessions, using simple methods e.g. observing group participation, asking a  few questions while referring to the contents, getting to know and understand their  feelings, learning and how they will use this knowledge 
7. Summarize key points 
8. Give follow on information e.g. where one can obtain individual attention 
9.  Allow them to select a topic among R.H topics 
10. Announce where the next session will be held 
11. Thank the group for participating 

Antenatal Risk Assessment 

This is an evaluation carried out on pregnant women during the antenatal period to screen them from  the probability of these women who are likely to develop poor pregnancy outcome during childbirth, detection and management of any illness or pregnancy complications as they arise.

First Antenatal Visits/Booking Visit 

The purpose of this visit is to obtain the baseline information against which subsequent findings  in a woman will be assessed. 

This baseline information is obtained through:- 

1. ✔ History taking 
2. ✔ Physical taking – General, systemic and abdominal examination 
3. ✔ Investigations 

1. History taking 

This is done in a proper and orderly manner to assess the health status of the mother and  fetus. 

History must include:- 

• ✔ Name and place of residence, noting accessibility to medical and maternity care 
• ✔ Age: noting the high risk age of below 18 and above 35 years 
• ✔ Parity: noting the young and elderly primigravida, those above Para 4 and closely  spaced pregnancies (>2 years in between) 
• ✔ Social history, inquire whether married, source of social and financial support,  education status, genital mutilation, where applicable, alcohol, smoking, health of  partner.  
• ✔ Medical history e.g. hypertension, renal disease, epilepsy, diabetes mellitus, sickle  cell disease, asthma, TB and HIV, surgical history, operation, blood transfusion,  skeletal deformity, fractures of pelvis, spine and femur. 
• ✔ Obstetric and gynecological history, inquire about previous pregnancy and their  outcomes such as previous cesarean section, previous retained placenta, PPH, still  birth, prolonged labour and early maternal death, ectopic pregnancies, D & C , APH,  pre-eclampsia etc. 
• ✔ Family e.g. history of hypertension, diabetes in her family, twins, sickle cell disease.
• ✔ Menstrual history:- 

1. – Information on the woman‘s‘ menstrual history is obtained and recorded  e.g. age at menarche, length and regularity of the cycle, duration and  amount of menstrual flow. 
2. – Contraceptive history e.g. use of modern contraceptive methods and dates  of discontinuation should be noted. 

• ✔ History of present pregnancy:- Information regarding the first day of LNMP is obtained and the expected  date of delivery (EDD) calculated. This will guide the provider during  examination to compare the weeks of amenorrhea with the height of fundus. If pregnancy is over 20 weeks, dates of quickening should be noted. Any problems encountered since she became pregnant should be probed into and noted e.g.  bleeding, vomiting, hospitalization, HIV sero-status and diseases like fever,  cough, and diarrhea. 

1. Physical examination 

General  

A physical examination from head to toe should be performed and note nutritional state and  illness which may not be related to pregnancy:- 

• ✔ Measure the weight, noting those that are underweight or over- weight (below 45  Kg and above 80 Kg) 
• ✔ Measure height and note those below 159Cms and check for skeletal deformities  or limping. 
• ✔ Take blood pressure- note those with BP 140/90 mmHg and above 
• ✔ Check for anemia and jaundice by examination of the conjunctiva, tongue, palm  of the hand and capillary refilling in the nail beds 
• ✔ Check for oedema of feet, hands, face and sacral area 
• ✔ Carry out a systematic examination of the respiratory and cardiovascular systems  to exclude abnormalities. 
• ✔ Examine breasts for possible masses and signs of breast malignancy, educate  women to care the nipples and teach herself breast examination 
• ✔ Assessment of physical abuse: 

1. – Drug abuse 
2. – Bruising 

• ✔ Assessment of any complaints 

1. Abdominal examination 

The abdomen should be adequately exposed to show important landmarks. 

1. ✔ Inspect the abdomen and note: 

• – size, shape of abdomen and presence of scar that may indicate a previous  uterine operation 
• – presence of fetal movements 

       2. ✔ Palpation of abdomen noting: 

• – presence of enlarged liver, spleen and tenderness of renal angles 
• – Height of fundus and compare it with the weeks of gestation. excessive  enlargement of abdomen, maybe an indication of multiple pregnancy or  presence of polyhydramnios 
• – The lie, presentation, position, any tenderness and the amount of liquor. 

        3. ✔ Auscultation. listen to fetal heart noting the rate, volume and rhythm

Inspection of the vulva 

This should be done to detect lesions of the vulva, vagina and abnormal discharge. Note any  scars at the perineum or vulva. If an abnormal discharge is detected and there are facilities for  gram stain, take of specimen for analysis. If there are no laboratory services, use the STI  ―syndromic approach to provide treatment to the mother. 

Laboratory Investigations during Antenatal Care 

Baseline investigations: 

• – Hb (normal 10.5-15gm) 
• – Blood group (ABO and Rhesus factor) 
• – Urinalysis (protein and sugar) 
• – VDRL, RPR for syphilis 

Special Investigations (Refer When Necessary) 

1. – Rhesus antibodies for RH-ve mothers 
2. – Random blood sugar where there is a history or presence of glycosma 
3. – Mid-stream urine for culture and sensitivity 
4. – High vaginal swab (HVS) 
5. – Elisa test for HIV 
6. – Sickling test 

Others 

• – Provide TT to complete the recommended schedule for immunization against tetanus. this  is routinely done to protect the mother and neonate from tetanus 
• – Explain to the mother the importance of tetanus immunization 

Recording, Assessing Findings and Planning For Management 

• ✔ After examination, all finding should be recorded on ANC clients‘ card and register 
• ✔ Review findings on history, examination and investigations 
• ✔ Share plans for next steps 
• ✔ If the woman has to be referred, a referral note should be filled, handed to the client and  she should be explained on where to go for further management 

The health worker should refer a client/patient to health facility that is able to handle the types of  obstetric condition identified to avoid wastages of time and transport costs encountered by the  patient/family. The health worker with assistance of relatives should organize quick means of  transport. A relative/health worker escorts the mother where applicable. 

Conducting Follow up Visits for Pregnant Women 

Purpose 

1. Monitor progress of pregnancy and the well-being of the mother and foetus
2. Identify and manage arising conditions such as STIs or HIV risk, pre-eclampsia, anemia,  syphilis 
3. Provide information on planning to delivery, preparing for the newborn, postpartum care  and family planning 
4. Get opportunity to deal with the woman‘s‘ concerns 

Frequency of Follow-Up Visits 

Routine 

1. More frequently if the mother has recurrent risk factor 
2. Every 4 weeks until 30 weeks 
3. Then every 2 weeks until 36 weeks 
4. And then every week until delivery 

More frequently if the client has risk factors (past or present such as: 

• – Vaginal bleeding during pregnancy late 
• – Unsure of dates and booked 
• – Past history pre-eclampsia, premature labour, small or large gestation 
• – Not gaining weight or fundal height not growing 
• – Gaining weight exclusively

DELAYS IN SAFE MOTHERHOOD

DELAYS IN SAFE MOTHERHOOD MEANS DEATH

Many women die due to delay at several levels while seeking medical help. The community and health workers must work hand in hand to prevent this delay and addressing  this problem will reduce maternal death and promote safe motherhood. 

Some causes of delay in acquiring medical care 

1. Delay in decision making. 

• ✔ Lack of information on health services available 
• ✔ Communication barrier in language or bad roads and physical barriers like lakes  or mountains 
• ✔ Lack of resources e.g. no money or husbands is away and transport cannot be got  to transport mother to the hospital 
• ✔ Inappropriate care e.g. mother taken to TBAs first  
• ✔ Lack of decision making by the mother since she is waiting for the husband to  come back to give her permission and money. 

1. Delay in reaching the health facility 

• ✔ Distance may delay the mother so that by the time she reaches the hospital is too  late 
• ✔ Transport may not be available to take mother quickly to hospital 
• ✔ Road may be bad and impossible taking a longer time to reach hospital 
• ✔ Cost of transport may be too high for the mother

1. Delay in receiving adequate care 

• ✔ Unskilled staffs who lack knowledge on what to do for the mothers and dealing  with high risk pregnancy 
• ✔ Drugs may not be available in the health units, this includes blood for transfusion,  antibiotics, analgesics, etc 
• ✔ Lack of equipment e.g. sterile supplies which may delay cesarean section or  syringes which may delay giving an oxytocic drugs 
• ✔ Few varieties of services offered at the health facilities.

Factors that affect delay to seek medical care 

1. Family – mother may be single or young and does not know whether she is pregnant or  fears to go to health unit – mothers may wait for a decision to be made by the husband who may be away – mother -in- law may delay as she tries to manage giving herbs for contraction 
2.  Husband – she may take time to decide or may be away looking for money 
3. Education level – if lowly educated, mother may not think of seeking the advice 
4. Socio-economic status – poverty may prevent quick action 
5. Natural barriers – like rivers, likes, mountains and floods 
6. Security; wars and insurgencies 

Maternal Mortality 

This is the death of a woman/mother while pregnant or within 42 days of the termination of  pregnancy irrespective of the duration and the sites of pregnancy from any cause related to or  aggravated by the pregnancy or its management but not from accidental or incidental causes. 

Maternal mortality rate 

This is the ratio of the total number of maternal deaths occurring in a period of time (usually a  year) to the total number of live births occurring in the same period expressed as a percentage (or  per 1,000 or 100,000).  

Incidence 

Worldwide, every year approximately 8 million women suffer from pregnancy related  complications. Over half a million of them die as a result. The problem of maternal mortality and  morbidity are greatest (99%) for the poor women in the developing countries. One woman of 11  may die of pregnancy related complications in developing countries compared to one in 5000 in  developed countries. It is further estimated that for 1 maternal death at least 16 more suffer from  severe morbidities. 

The maternal mortality rate in Uganda has been declining over the years, from 506/100,000 in  2004 to 435/100,000 in 2011. However, this is one of the highest in the world and demands for  more concerted efforts towards its reactions. The new report released by the World health  organization (WHO) has shown a remarkable decrease in maternal mortality by 44% worldwide due to fully implemented millennium development goals. However, there is not much difference  in the reduction in the developing countries like Uganda.

Factors contributing to the high maternal mortality in Uganda 

There is no single factor that can be counted on as responsible for the high maternal mortality in  Uganda. It is rather an interplay of factors. Any approach therefore, aimed at effectively addressing maternal mortality has to pay a close look at all those factors. The easily identifiable ones in  Uganda include the following: 

1. Poverty  

Several women are engaged in productive work at home and do not have means of  earnings. Such women cannot afford to meet even simple costs like transport in case any  emergencies develop. Poverty also means that the woman will not be able to afford basic human  needs like food which will predispose the woman to further complications during  pregnancy and/or labour. They are also likely to be less privileged in the fields of  nutrition, housing, education and antenatal care. 

1. Gender issue 

In Uganda, men are decision makers on all matters in the home including health care  seeking. This means that the woman may have to wait for the man to grant her  permission in order to seek medical care. Some women are even prevented from  attending antenatal care by their husbands. This predisposes the mother to developing  complications in the absence of a trained health worker who can offer help. 

1. Inadequate and inaccessible health services 

There are very few health facilities equipped to handle and manage conditions associated  with pregnancy and delivery. Despite government policy of bringing services close to the  people, some women need to travel long distances in order to access a health facility. This  usually keeps those who feel unwell away as they may not be in position to walk or have  the money for transport. 

1. Limited health workers 

The number of trained health workers in Uganda is still very low compared with the  skyrocketing population. This has resulted in long queues observed daily at the various  rural and urban health facilities as clients wait to be attended to. Unfortunately others go  back without attention. This discourages many and at the end, women prefer to be 

attended to by the village traditional healer or herbalist who may not have the necessary  skills to manage incase complications develop. 

1. Poor attitudes of health workers towards mothers. 

On many occasions, health workers have been reported of being rude, arrogant and  unfriendly while attending pregnant women and those in labour. This scares such  women away and finally ends up in the hands of untrained people for help. Health workers need to develop better attitudes and make the caring environment friendly so as to  motivate mothers to seek health services from them. 

1. Early marriages 

For a long, the girl child has been seen as a source of wealth for the family. Girls are forced  into marriages at a tender age for the family to acquire cattle and money. These girls get  pregnant before their bones and bodies are fully developed which predisposes them to  various complications during pregnancy and/or labour. 

1. Illiteracy 

Women, over the years, have comprised the highest number of those who cannot read and  write. This means that they cannot effectively influence policy on matters that affect them  like reproductive health. As such, they surrender all rights of decision making to the men  

including the number of children to have and sometimes the age of marriage. Education  keeps girls in school until they are old enough to marry and have children. It also  empowers them to stand out for their rights and freedom. 

1. Beliefs, customs and taboos(harmful traditional practices) 

Some traditional customs, beliefs and taboos predispose women to developing  complications during pregnancy or labour. Denying women some nutritious foods like  chicken, eggs etc. predispose them to malnutrition which in turn has a negative bearing to  reproductive life. Practices like female genital mutilation predispose the woman to  extensive perineal tears that may lead to excessive hemorrhage during child birth and yet  the use of some traditional herbs (Cytoxic herbs) may predispose to uterine rupture. Some  communities perceive women who deliver from health units as not strong being enough.  This is dangerous as it predisposes any woman to unnecessary complications during  labour. 

1. Poor transport and communication infrastructures 

Statistically, seventy five percent (75%) of the Ugandan population lives in rural areas  and yet most of the health facilities are located in urban centers. The road network linking  up these areas are very poor in most of the areas which delay transfer of women in case  complications develop during pregnancy or labour. This is more common in  geographically impassible areas like mountainous parts of Kigezi, areas encircled by water  bodies.

1. High child mortality 

Uganda‘s child mortality is still high though it has been declining over the years. Parents  are filled with uncertainties as to how many of their children will make it to adulthood.  As such, they prefer to produce many for a few to survive. For example, in post war  Northern Uganda, many people claim that they have lost their relatives more than  expected in the war and so the need to produce more children is valued currently. 

1. Desire for more children 

Many people perceive children as a source of prestige in the community. A family with  many children was always looked at as being very strong and secure and as a result, many  people desire to have many children and yet more children mean more deliveries and  moiré risk for maternal mortality. 

1. Sex preferences in children 

Some women may keep on giving birth in an attempt to get a child of their preferred sex.  Parents tend to rate children of different children sex differently as a result may prefer a  particular sex. This is risky to the mother who carries and delivers the pregnancy and also  unhealthy to the father and children due to inadequate care that will be provided and  received. 

1. High fertility rate 

Uganda has a very high fertility rate estimated at about 7 children per woman per  reproductive life span. It is one of the highest in the world. This implies that women  are exposed to the risks many times. 

1. Underutilization of the existing services 
2. Inadequate drug supplies and other medical related equipment is most often interrelated and are  responsible for an increased number of avoidable deaths. Poor referral systems for handling  emergency 
3. Poor attitudes by the health workers 
4. Noninvolvement of the husbands 
5. Lack of awareness/ignorance 
6. Disrespect for human rights 
7. Gender stereotypes and inequalities 

Delays that can lead to maternal mortality 

In most instances, women who die in childbirth experienced at least one of the following delays: 

       1. Delays at the individual woman‘s levels 

• – Inability to make decision on life threatening health conditions in time for  appropriate response 
• – Late recognition that there is a problem,  
• – Fear of the hospital or of the costs that will be incurred there,

1. Delay at the level of the family and community levels in decision making to assist the  woman to more/husband‘s issues/ in laws‘ issues. 
2. Delay at the level of accessing services. Usually transport is a major problem and or lack  of resources. Many villages has very limited transportation options and poor roads.
3. Delay in the health units to institute the necessary interventions. 

• – Inadequate skills and poor staffing 
• – Failure to make appropriate decision 
• – Lack of drug supplies etc. 

Note: Not only mothers die, babies too die. 4000,000 newborn deaths occur globally yet  almost all are due to preventable conditions. 

Causes of maternal mortality 

There are several causes of maternal mortality broadly grouped into direct and indirect causes. In Uganda 506 per 100,000 women die of pregnancy and birth related and recent data shows that 16  women die every day during giving birth related complications in Uganda. 

A direct death is one resulting from obstetric complications of pregnancy, delivery or from  interventions, omissions or incorrect treatment or a chain of events resulting from the above. 

An indirect death is one resulting from a previously existing diseases (present before) or  developed during pregnancy and was not due to obstetric causes but aggravated by the  physiological effects of pregnancy. 

Direct Causes of Maternal Mortality 

i) Sepsis 

This is a common cause of maternal mortality. All women get infections when  membranes rupture early, delivered in dirty environments like gardens or following  operative procedures where the aseptic technique was compromised. All women  should be given prophylactic antibiotics following cesarean section. Women who had  prolonged labour or early rupture of membranes should be given antibiotics. If such a  woman develops fever, she should be carefully assessed, admitted and appropriate  treatment instituted as soon as possible. 

ii) Hemorrhage 

This is a serious condition especially in women with underlying anemia or bleeding  disorders. It may present as APH due to placental retention, uterine inertia etc.  women should be encouraged and given micronutrient supplements during  pregnancy, screened for anemia and always book some units of blood for mothers in  labour. 

iii) Early pregnancy deaths

This is death resulting from ectopic pregnancies and abortions. This is one of the  major causes of maternal mortality in Uganda. Criminal abortions account for the  highest number of deaths in this category. 

iv) Hypertensive conditions 

Severe pre-eclampsia and eclampsia are common causes of maternal mortality. If any  mother develops any of these complications should be managed effectively.  Magnesium sulphate is the drug of choice. Ensure proper fluid management. Always  identify any risk factors of developing pre-eclampsia in a mother during antenatal  care and manage them promptly and effectively whenever possible. 

v) Others 

• – Thrombosis and thrombo-embolism 
• – Genital trauma 

Indirect causes of maternal mortality 

i) Cardiovascular diseases 

• – Pulmonary hypertension 
• – Endocarditis 

ii) HIV/AIDs 

iii) Malnutrition 

iv) Diabetes 
v) Thyroid diseases 
vi) Anemia 

Predisposing factors to maternal mortality and morbidity 

• ∙ Early pregnancy (less than 20 years old); 
• ∙ Uncontrolled fertility; 
• ∙ Low socioeconomic status of women; 
• ∙ Poverty and lack of empowerment of women; 
• ∙ Lack of access to quality services; 
• ∙ Inadequate referral systems; 
• ∙ Lack of support from spouses. 

Prevention of maternal mortality 

Eighty percent (80%) of these deaths can be prevented through actions that are effective and  available in developing country‘s settings. This is a coordinated long term effort within the  families, countries and health systems, national legislation and policy. 

Primary prevention 

1. Girl child education

Education keeps girls at school until they are old enough to marry and have children.  This means that they get fewer pregnancies and produce fewer babies. Educated women will  also have more chances of getting employed and have money to look after themselves better.  Education also empowers them to stand out for their rights and freedom. 

1. Proper nutrition of the girl child 

Malnutrition during childhood and puberty has been closely related to the inadequate  development of the pelvis (contracted). This usually predisposes the woman to developing  obstetric complications like Cephalopelvic disproportion (CPD). Parents should be educated  that girl children need more to eat as much as boys and adolescent girls should be encouraged  to eat adequate food for proper body development and functioning. 

1. Family planning 

Maternal mortality is common in women who get pregnant while too young (below 20 years  of age). Most cases of criminal abortion that turns out with complications are as a result of  unwanted pregnancies. Family planning provides an absolute answer to all these questions by  enabling the mother (couple) to have children by chop ice and not by chance. 

1. Quality antenatal care 

All pregnant women should be encouraged to have timely attendance of at least 4 quality  antenatal visits, where the woman is fully assessed for presence of any risk factors that may  predispose her to developing complications. Once any risk factor has been identified, it  should be managed effectively and appropriately during antenatal care. 

1. Immunization 

All women in the reproductive age should be immunized against tetanus, HepB. This is  because; such women are at higher risk of developing the infections during any time in the  reproductive cycle. 

1. Provision of information, education and communication about maternal mortality.  Individuals and families should be given adequate information about the causes of maternal  mortality and how they can be prevented. It is important that such messages spell out the  roles of each individual in preventing maternal mortality. Individuals should be empowered  to take action and stop thinking that the sole role of government is to protect and care for  their lives. 

Secondary prevention 

1. A skilled attendant should be present at every birth. Functional referral systems is very  essential here 
2. Emergency obstetric care services are to be provided and made accessible to the people 
3.  Transport and communication networks need to be improved to gain access to all health  facilities. Transport means like ambulances should be made available and accessible.
4. Health facilities should be equipped with adequate equipment, operating theaters which  should be functional, blood storage facilities in case of any emergency, equipment in good  working conditions and drugs. The government should always ensure a steady supply of  essential drugs. 
5. Adequate referral systems for complications should be instituted. Clients should be in  position to get assistance from a higher level in the shortest time possible. Some clients  decline referrals because they are not sure of obtaining any better help at the next level. In  most cases, such clients either refuse and stay at the referring health units or go home and  wait for whatever may happen next. 
6. Proper evaluation and reporting of maternal deaths and timely intervention taken 
7.  Decentralization of services to make them available to all women 
8. Barriers to the access to health care facilities should be removed; policies should increase  women‘s decision making power as regards to their own health and reproduction.
9. Recruitment of skilled staffs to balance of the workload 
10. Improving the standard and quality of care by organizing refresher courses for the health  care personnel. 

Tertiary prevention 

1.  This involves the control and management of complications that may arise 
2.  Emergency obstetric care services should be provided.

 Maternal Morbidity 

Although considerable attention has been given to maternal mortality, very little concern has  been expressed for maternal morbidity. It is estimated that for one maternal death at least 15  more suffer from severe morbidities. As such about an optimistic 5-7 million suffer a severe  impaired quality of life as a result of short term or long term disability. 

Definitions 

Obstetric morbidity originates from any cause related to pregnancy or its management any time  during antepartum, intrapartum and postpartum period, usually up to 42 days ( weeks) after  confinement. 

Parameters of Maternal Morbidity 

• ✔ Fever more than 38 degree centigrade 
• ✔ Blood pressure greater than 140/90mmHg 
• ✔ Recurrent vaginal bleeding 
• ✔ Hb less than 10.5g/dl irrespective of gestational age 
• ✔ Asymptomatic bacteriuria of pregnancy

Classifications 

1. i) Direct obstetric morbidity 

• – Temporary 
• – Permanent 

1. ii) Indirect obstetric morbidity 

Direct  

∙ Temporary (mild) 

• – APH, PPH, eclampsia, obstructed labour 
• – Rupture uterus 
• – Sepsis 
• – Ectopic pregnancy 
• – Molar pregnancy etc. 

∙ Permanent (chronic) 

• – Vesico-vaginal fistula and rectovaginal fistula 
• – Dyspareunia 
• – Prolaps 
• – Secondary infertility 
• – Obstetric palsy 

Indirect  

These conditions are only expressions of aggravated previous existing diseases like malaria,  hepatitis, tuberculosis, anemia etc. by changes in the various systems during pregnancy.

Perinatal Mortality 

This is defined as deaths among fetuses weighing 1000 g or more at birth (greater than 28 weeks  gestation) that die before or during delivery or within the first 7 days of delivery. The Perinatal mortality rate is expressed in terms of such deaths per 1000 total births. The  Perinatal mortality rate closely reflects both the standards of medical care and effectiveness of  public and social health measures. According to WHO, the limit of viability is brought to a fetus  weighing 500g (22 weeks).  

Incidence 

• ∙ Worldwide nearly 4 million newborns die within the first week of life and another 3  million are born dead. 
• ∙ Perinatal deaths could be reduced by at least 50% worldwide if key interventions are  applied for the newborn. 
• ∙ Perinatal mortality is less than 10 per 1000 total births in the developed countries while in  the developing it is much higher. 
• ∙ The major health problem in the developing world arise from the synergistic effects of  malnutrition, infections and unregulated fertility combined with lack of adequate  obstetric care 
• ∙ Majority of feotal deaths (70-90%) occur before the onset of labour. The important  causes. 

Predisposing factors to perinatal mortality 

Many factors influence the perinatal mortality in Uganda and theses are briefly discussed below; 

Maternal factors 

1. a) Epidemiology 

• – Age over 35 years 
• – Teenage pregnancies
• – Multiparity 
• – Low socio economic condition(poverty) 
• – Poor maternal nutritional status 

Note. All the above adversely affect the pregnancy outcome 

1. b) Medical disorders 

• – Anemia (Hb less than 8g/dl) 
• – Hypertensive disorders 
• – Syphilis 
• – Diabetic mellitus 
• – Prematurity 
• – Congenital malformation (baby) 
• – Malaria 
• – Other infections 

1. c) Obstetric complications 

• – Antepartum hemorrhage (APH) particularly abruptio placentae is  
• responsible for about 10% of perinatal death due to severe hypoxia 
• – Pre-eclampsia, eclampsia is associated with high perinatal loss either due to  placental insufficiency of prematurity 
• – Rhesus Iso-immunization 
• – Cervical incompetence which may lead to premature effacement and  
• dilatation of cervix between 24-36 weeks 

1. d) Complications of Labour 

• – Dystocia from disproportion, mal-presentation and abnormal uterine action 
• – Premature rupture of membranes (PROM) may result in hypoxia, amnionitis  and birth injuries contributing to perinatal death 

Feto-placental factors (causes) 

• – Multiple pregnancy, most often leads to preterm delivery and usual complications 
• – Congenital malformation and chromosomal abnormalities are responsible for 15%  of perinatal death 
• – Intrauterine growth restriction and low birth weight babies 

Unexplained causes 

About 20% of stillbirths have no obvious fetal, placental, maternal or obstetric causes.

 4. Other causes/risk factors refer to maternal mortality 

Causes of perinatal mortality 

Infection 

• – Sepsis 
• – Meningitis 
• – Pneumonia
• – Neonatal tetanus, congenital 

Birth asphyxia and trauma 

 Hypothermia 

Prematurity and/ low birth weight 
Congenital malformation 

Control and prevention of perinatal mortality 

As every mother has a right to conclude her pregnancy safely, so also the baby has a right to be  born alive, safe and healthy. As such improvement of obstetric services will not minimize  perinatal death appreciably therefore simultaneously demographic and social changes help in the  reduction of perinatal mortality rate significantly. The following measures are helpful in  reducing perinatal mortality. 

1. Pre pregnancy health care and counseling 
2. Genetic counseling in high risk cases and prenatal diagnosis to detect genetic,  chromosomal or structural abnormalities are essential 
3. Regular antenatal care with advice regarding health, diet and rest 
4. Detection and early management of medical disorders in pregnancy such as anemia,  diabetes, hypertension 
5. Screening of high risk clients where mandatory hospital delivery is instituted like those  from poor socioeconomic status, high parity, extreme of age etc. 
6. Careful monitoring and management of Labour to detect hypoxia, early evidence of  traumatic vaginal delivery etc. 
7. Skilled birth attendance to minimize sepsis  
8. Provision of neonatal referral services especially to look after the preterm babies
9. Health education of the mothers about the care of a new born such as early exclusive  breastfeeding and prevention of hypothermia 
10. Educating the community to utilize family planning services and also to utilize the  available maternity and child health care services 
11. Increased resource allocation towards maternal and child health services 
12.  Regular review of perinatal death cases and ensuring effective supervision, monitoring  and evaluation to realize the missing gaps 
13. Improving on social infrastructures like health care, transport and communication  network  
14. Continuous decentralization of maternal and child health care services

Preconception Care

The outcome of pregnancy depends so much on the factors that operate during the period of  growth and development of the mother from childhood. Some of the factors which influence proper  growth and development of the mother are; 

• – type of birth and circumstances surrounding her birth 
• – her birth weight 
• – breast feeding and nutrition 
• – childhood infections 
• – formal education 
• – sexual and reproductive health education and services utilization 
• – Socio-cultural practices 

Therefore it is important that the girl child is given adequate care during this period of  development. 

Pre-conception refers to the care of women and men during their reproductive years, which are  the years they can have a child. It focuses on taking steps now to protect the health of a baby  they might have sometimes in the future. 

However all women and men can benefit from preconception care, whether or not they plan to  have a baby one day. This is because part of preconception health is about people getting and  staying healthy overall, throughout their lives. In addition, no one expects an unplanned  pregnancy. But it happens often. 

Preconception care is the medical care a woman or man receives from trained medical  professionals that focus on the parts of health that have been shown to increase the chance of  having a healthy baby. 

Preconception health is important for every woman, not just those planning pregnancy. It means  taking every woman, not just those choosing healthy habits. It means living well, being healthy and feeling good about your life. Preconception care is about making plans for the future and  taking the steps to get there. 

Preconception care is important for men too. It means choosing to get and stay as healthy as  possible and helping others to do the same as well. As a partner it means encouraging and  supporting the health of your partner. As a father, it means protecting your children. 

Healthy babies 

Preconception care is a precious gift to babies. For babies it means their parents took steps to get  healthy before pregnancy. Such babies are less likely to be born early (preterm) or have a low  birth weight; they are likely to be born without birth defects or other disturbing conditions.  Preconception care gives babies the best gift of all the best chance for a healthy start in life. 

Healthy families 

Ensuring preconception health is a great way to create a healthy family. The health of a family  relies on the health of the people in the family. Taking care of your health now will help to  ensure a better quality of life for yourself and your family in the coming year. 

Objective 

1. Assess clients‘ readiness for pregnancy by ensuring adequate mental, physical and socio economic readiness. 
2. Prevent, treat and manage medical conditions that affect pregnancy and the newborn. 3. Prepare for pregnancy and childbirth 
3. Promote safer and responsible sexual behaviors 
4. Promote delay of age at first pregnancy 
5. Prevention of HIV and sexually transmitted disease 

Services offered during Preconception Care 

1. Education and information on: 

• – Sexuality 
• – Growth and development of the coming child  
• – Pregnancy and child birth  
• – Responsible parenthood  
• – Family planning  
• – STI/HIV 
• – Malaria prevention  
• – Personal hygiene  
• – Nutrition 
• – Use of drug during pregnancy (drugs of abuse and medicine ) 
• – Previous health intervention – repair of Vesico-vaginal fistula, ruptured uterus, treatment for infertility etc. 
• – Diabetes mellitus  

1. Screening for and managing conditions which may complicate pregnancy, childbirth and  health of the mother and child thereafter e.g. 

• – HIV  
• – Syphilis  
• – Sickle cell diseases – Heart disease  
• – Hypertension  

1. Provision of services  

• – Congenital abnormalities – Aneamia 
• – Diabetes Mellitus 
• – Mental illness  
• – Folic acid supplementation 3 months for woman before pregnancy  
• – Immunization  
• – Deworming for women  
• – Management of STI/STDS and other identified diseases 
• – Provision of long other insecticide treated nets  
• – Routine screening for reproductive health cancers  
• – Family planning  
• – VCT for HIV  

1. Support channels. 

• – Identify and locate the organization that will support the groups and work with them.
• – Appropriate counseling of individuals and couples about their pregnancy needs 
• – Establishing the pre pregnancy health status/profile for the purpose of follow up. 
• – Identify special group women such as, disabilities, adolescence and HIV infection 
• – Develop appropriate intervention to address the needs of the different special groups 
• – Mobilize and sensitize the community to be supportive to the needs of the special groups. 

1. Responsible motherhood and fatherhood 
2. Contraception and family planning information and service. 

Where Can Preconception Care be done. 

• ∙ Health units 
• ∙ Community based group. 

Ways to reach out to special groups. 

• ∙ Health education in the community 
• ∙ Mass media  
• ∙ Church groups  
• ∙ Appropriate ITC materials 
• ∙ Opinion leaders. 

Obstetrical Emergencies

Obstetrical Emergency is the situation when the life of the mother or baby is in danger of death and something must  be done quickly to save lives.

There is a need for the midwife to take quick action in provision of  emergency treatment and consideration of proper referral systems. 

List of Obstetrical Emergency 

1. AntePartum Hemorrhage 
2. Postpartum hemorrhage 
3. Cord prolapse 
4. Ruptured uterus 
5. Fetal distress 
6. Vasa previa 
7. Intrapartum hemorrhage 
8. Obstructed labour 
9. Retained placenta 
10. Severe preeclampsia and eclampsia 
11. Pulmonary embolism 
12. Severe anemia 
13. Inversion of the uterus 
14. Impending rupture of uterus 
15. Obstetric shock. 

Roles of a Nurse/Midwife in Obstetrical Emergencies 

1. At The Community Level 

• ✔ Health education of the community about obstetrical emergencies and their roles in  management and prevention 
• ✔ Educate, supervise and evaluate the TBAs in management given to the mother during  pregnancy, labour and puerperium 
• ✔ To create awareness on the available health facility like dispensary, clinics, maternity  centre and hospitals
• ✔ To encourage them to attend antenatal clinics, intranatal clinics, postnatal clinics,  young child clinics and family planning clinics 
• ✔ Advice women to start self-help project to minimize over dependency on their  husbands 
• ✔ Help them realize the importance of taking a well-balanced diet 
• ✔ Discourage harmful traditional practices and beliefs which expose a girl child to early  sex marriages as a result of lack of education, boy preferences 
• ✔ Husband should take over tiring duties from their wives when pregnant to relieve them  psychologically and physically 
• ✔ Encourage the community to help to transport in case of obstetrical emergencies. 

2. During Pregnancy 

• ✔ Identify cases of high risk pregnancies which may end in obstetrical emergencies and  refer in time 
• ✔ Thorough history taking, examination and early investigations on every mothers during  pregnancy 
• ✔ Early preparation of mothers for labour and successful lactation 
• ✔ Prompt treatment of mothers with minor conditions like morning sickness etc 
• ✔ Early referral of mothers with serious conditions for further management 
• ✔ Proper referral systems. 

1. During Labour 

• ✔ Proper admission of mothers in labour inform of a warm welcome, reassurance and  counseling 
• ✔ Proper history taking, examination and investigation on every mother in labour ✔ Proper monitoring of mothers in labour by use of a partograph 
• ✔ Early detection of danger signs. the midwife should summon for help in time 
• ✔ Avoid prolonged and exhausting labour by administration of analgesics, reassurance  and avoid early pushing plus rehydration with IV fluids or per Os 
• ✔ Give assisted timely episiotomy in case of assisted delivers to prevent; extended tears,  hemorrhage; give episiotomy in mal-presentation and malposition 
• ✔ Use aseptic techniques throughout labour, infection prevention and control techniques 
• ✔ Ensure proper management of 3rd stage of labour to prevent PPH. 

1. After Delivery 

• ✔ Carryout proper observation to the mother and baby especially in the 1st 2 hours to  prevent 4th stage complications 
• ✔ Health education of the mothers about the need of; 

1. – Taking a well-balanced diet 
2. – Breastfeeding on demands 
3. – Carrying out postnatal exercise 
4. – Maintain personal and environmental hygiene
5. – Come back for review after 6 weeks to postnatal clinic 
6. – Attending family planning clinic 
7. – Bringing the baby in YCC for immunization 

General Management 

Principles applied in this management 

1. Readiness with everything used in management used in management of high risk  pregnancy this includes facilities such as:  

• ✔ Emergency tray containing the following; ▪ Drugs i.e. Ergometrine, hydrocortisone, diazepam, dexamethasone,  mannitol, digoxin, lasix, dextrose 5%, 50%, vitamin K, aminophylline,  atropine, pethidine, morphine, pitocin, magnesium sulphate, others are  adrenaline, oxygen cylinder, solutions like normal saline, needles and  syringes, adequate staffs, Umbu bags and any facility needed for  resuscitation 
• ✔ The midwife/nurse should be calm, quick and knowledgeable and should summon  for help 
• ✔ Start with the most urgent need first e.g. arresting hemorrhage, rehydration or  delivery of the baby 
• ✔ Quick general history taking, examination and investigations 
• ✔ Apply the essential care systematically according to the emergency such as  delivery, manual removal of the placenta, resuscitation etc (apply nursing process) ✔ Reassure the mother and the relatives 
• ✔ Some mothers with HRP are cared for in the maternity centre during pregnancy  and referred at full term for delivery in the hospital. others are referred on the first  contact 
• ✔ Early detection and referral are very important 
• ✔ Prepare for transport 
• ✔ Writing referral notes which includes the following:- 

1. ▪ Time of arrival  
2. ▪ Personal history of the mother 
3. ▪ General conditions on arrival 
4. ▪ All what has been found on examination and admission 
5. ▪ Treatment given plus obstetrical management 
6. ▪ Reasons for referral 
7. ▪ Conditions at referral

Complications 

To the mother 

Obstetrical emergency exposes the mothers and fetus to a higher chance of morbidity and  mortality. This becomes worsened in case the management is delayed or even wrongly applied.  There is lack of facilities or poor knowledge; however the mothers and fetus may face the  following; 

• ✔ Hemorrhage due to APH, PPH and intra-partum hemorrhage 
• ✔ Shock as a result of severe bleeding 
• ✔ Infections following delay in 2nd stage and in manual removal of the placenta 
• ✔ General ill health 
• ✔ Anemia 
• ✔ Puerperal psychosis 
• ✔ Venous thrombosis 
• ✔ Poor lactation 
• ✔ Sterility 
• ✔ Assisted deliveries 
• ✔ Premature labour 
• ✔ Low resistance to infections 
• ✔ ABO incompatibility 
• ✔ Amniotic fluid embolism 
• ✔ Infertility as a result of infections and damage to the reproductive system. 

To The Baby 

• ✔ High neonatal and infant morbidity and mortality 
• ✔ Failure to thrive 
• ✔ Cerebral damage leading to mental retardation 
• ✔ Premature deliveries with their complications 
• ✔ Abortions (pregnancy wastage) 
• ✔ Assisted deliveries and its complications 
• ✔ Intrauterine fetal growth retardation 
• ✔ Low resistance to infections. 

Prevention of Obstetric Emergencies 

• ✔ The role of a midwife in the obstetric emergencies 
• ✔ The nurse/midwife should be knowledgeable of how to deal with the obstetric  emergencies 
• ✔ Update herself in obstetrical conditions 
• ✔ Equip her maternity center and be able to deal with such emergencies efficiently 
• ✔ Make sure she can transfer the mother to the hospital immediately.

Pediatric Emergencies

Pediatric Emergencies are conditions where the life of the baby is in danger of death or complications.

They are  considered right from birth up to 5 years of age. 

List of pediatric emergencies 

• ✔ Asphyxia as seen in below conditions 
• ✔ Intrauterine anoxia due to cord prolapsed and APH 
• ✔ Cerebral damage 
• ✔ Hemorrhagic of a newborn 

As The Child Grows 

1. Swallowed objects and aspiration 
2. Poisons 
3. Insect bites 
4. Falling 
5. Burns 
6. Cuts 
7. Fractures and diseases. 

Causes of Neonatal Morbidity and Mortality 

1. Asphyxia neonatorum 
2. Birth injuries 
3. Low birth weights 
4. Hypothermia 
5. Congenital abnormalities 
6. Sepsis like neonatal sepsis, pneumonia, acute respiratory infection, diarrhea, tetanus,  meningitis and septicemia. 

Causes of infant mortality and morbidity in Uganda 

• ✔ Measles 
• ✔ Diarrhea 
• ✔ URTI 
• ✔ Malaria 
• ✔ Malnutrition

Management of pediatrics emergencies 

Depends on the causes BUT you have to consider the following; 

1. Resuscitation 
2. Induced emesis if the substances taken is not acidic 
3. Give milk to drink 
4. Give oxygen  
5. Put up a drip 

Complications of pediatric emergencies 

1. Depends on the type of pediatric emergencies 
2. Complications may happen permanently or temporarily at birth or later in life 

Prevention of Pediatric Emergencies 

1. Health education to the public of pediatric emergencies, their causes and prevention. Since  most of the maternal conditions leads to paediatric emergencies, neonatal/infant  morbidity and mortality. Therefore in preventing such emergencies, neonatal /infant  morbidity and mortality such as high risk pregnancies 
2. Knowledge of life saving skills in pediatric e.g. resuscitation is essential.