Kubang Pasu District

First session

Date: 12th July 2009

Time: 9.00am

Location: Kubang Pasu District Health Office, Jitra

Topic: Tagging System,Immunisation,Pap Smear, Maternal & Child Health, Geriatrics (Family Health and Development Department)

Person in charge: Sister Zurida bt Abd Hamid

We assembled in the DHO meeting room to attend a talk by Sister Zurida bt Abd Hamid. There are 8 klinik kesihatan (Klinik Ibu &Anak) and 21 Klinik Desa in Kubang Pasu district. This unit provides services such as antenatal care, postnatal care, child care (for child age between 0-6 years old), School Health, Geriatrics care, Public Health, Prostar, Mental Health, Food and Diabetic care, Home Care Nursing (for geriatrics and chronic case only), Rehabilitation clinic, and also Dental care. We were briefly explained about the operation policy of Klinik Kesihatan (which includes all types of clinic available) in Kubang Pasu according to BUKU B.

The objective of Klinik Kesihatan is to provide comprehensive and quality service to the community to enhance the status of public health and to improve the accessibility to the health services. The organization chart of Kubang Pasu DHO and the function of various departments under this unit such as pharmacy, laboratory, clinical, imaging and administrative function was explained.
Klinik kesihatan provides its services:
• to walk-in patients,
• patient referred from various types of health care center
• they handles minor surgeries
• Non CD cases such as diabetes, high BP, Asthmatic, psychiatric patient, heart patient, and occupation related diseases.
• Ambulatory Medical Emergency treatment
• Simple fractures, minor orthopedic cases
• Besides that, this unit also responsible to prepare medical report, reten HMIS and carry out health promotion to their patient who visits their clinic.
• Screening test
• Last but not least, the aim in this clinic in this district is to give importance to antenatal care, including from beginning until the end of this period (more focus in this area).

SAFE MOTHERHOOD INITIATIVE 2 - SIK

Color Strings System on antenatal booklet for high risk pregnancy. (only in klinik kesihatan SIK)

It is one of the innovation project done by the Maternal and Child health clinic in Sik, under the program of Safe Motherhood Initiative. Strings with different color are tie on the right upper corner of both the antenatal booklets (Antenatal record KIK/1(a)/96 and KIK/1(b)/96) , according to the problem the antenatal mother is having. However, only
Antenatal Record KIK/1(a)/96 is kept in the clinic while the KIK/1(b)/96 is another copy for the mother. There are five colors of strings represent different antenatal problems:

1. red – hypertension in pregnancy
2. black – history of birth before arrival
3. yellow – anemia in pregnancy
4. blue – heart diseases in pregnancy
5. green – diabetes in pregnancy

If there are two or more strings of different color are tied on the antenatal booklet, that means the mother has more than one antenatal problem, for example black and red strings are tied on the booklet means the mother is having hypertension and she had history of birth before arrival (BBA).

All antenatal booklets will be kept in the shelf, those color strings tie on the booklet will be easily notice and so as the antenatal problems. The clinic staffs can find the case with different antenatal problem according the string’s color faster and easier. Management of the antenatal mother can focus more on the high risk cases with strings tied, especially those tied with more than one strings will be given priority first.

The color string system strengthens the original Color Coding System (stickers of different color on the front page of antenatal booklet) because the strings system makes the searching of booklets easier and faster on the shelf.

Benefits gain after this innovation:

1. management of antenatal cases become more effective and faster.
2. priority is given accurately for high risk mother
3. antenatal case with problem can be search from the shelf easier and faster
4. more attention is given for those with multiple problem (i.e multiple strings)
5. antenatal mother will be more alert as they know what problem they are facing
6. substandard maternal care is decreased

by Teoh Jia Qing 0500038

Reference:

1. Inovasi Keibua Selamat 1998 “Sistem tali berwarna pada kad antenatal kes berisiko”, pejabat kesihatan Sik Kedah Darulaman.

SAFE MOTHERHOOD INITIATIVE- SIK

TITLE: REDUCE INCIDENCE OF UNSAFE DELIVERY

The Safe Motherhood Initiative is a global effort that aims to reduce deaths and illnesses among women and infants, especially in developing countries. Partners in the Initiative support and implement safe motherhood interventions, in the context of broader reproductive health programmes.

Definition of safe delivery is any delivery that is conducted by a trained person.

Unsafe delivery is defined as all delivery that are not conducted by formally trained personnel. Classification:

1. Birth before arrival of any trained person such as nurse or doctor (mother delivers the baby alone).
2. delivery by TBA
3. delivery by untrained people or non-medical staff such as husband or mother-in-law.

The total number of unsafe deliveries in Sik in 1994,1995 and 1996 are 8.0%,5% and 11.8% respectively, which is consider very high.

Health indicator

1. % of unsafe deliveries

Number of unsafe deliveries among home deliveries x 100

Total of home deliveries

2. % of perineal tears (2^nd and 3^rd degree)

3. % of puerperal sepsis

Number ofpueperal sepsis among unsafe deliveries x 100

Total of unsafe deliveries

4. % of neonatal tetanus

Service indicator

1. % of Antenatal mother given advice on safe delivery

Number of antenatal mother given advice on safe delivery x 100

Total antenatal mother

2. % of antenatal mother at term who defaulted and were traced within 24 hours

Number of antenatal mother at term who defaulted and were traced within 24 hours x 100

Total antenatal mother at term

3. % of clinic staff given training on service of safe delivery

Number of clinic staff given training on service of safe delivery x 100

Total number of clinic staffs

4. % of staff who attended motivation courses

Number of staff who attended motivation courses x 100

Total number of staff

5. % of TBA who attended dialog session on safe delivery at least once a year.

Number of TBA who attended dialog session on safe delivery at least once a year

Total number of TBA

6. % of unsafe delivery among high risk mothers.

Number of unsafe deliveries among high risk mother x 100

Total number of deliveries among high risk mother

Difficulty indicator

1. % of unsafe deliveries due to non-availability of district nurses.

Number of unsafe deliveries due to non-availability of district nurses x 100

Total number of unsafe deliveries

Solution description

Issue of concern problem area	Interventions
1. Non-compliance of the mother	1. Health education about safe delivery - for mothers during every antenatal visit. - to mother at inaccessible area during home visit - give printed text about safe delivery for Iman to read during Friday prayers -Focal group discussion who had experience of unsafe deliveries and complications. - activate Panel Penasihat and community leaders to advice/ assist in social problem of the mothers -distribution of pamphlets to all mothers. orientation and visit to maternity ward in hospital. Defaulted tracing system between health clinics and hospital. Dialogue session for traditional birth attendants.
2. Inadequate knowledge of staff about complication of unsafe delivery.	1. organize talks by visiting specialist 2. increase frequency and quality of supervision/visit by supervisory 3. training programmes.
3. lack of motivation in hospital/ health clinics staff.	1. organize motivation talks 2. Islamic value by public service learn motivation counseling skill from counselor.
4. Unavailability of district nurses	1. Advertise date of leaves 2.cooperation from TBA
5. Ineffective supervision	1. increase frequency of supervison. 2. Appoint Staff with problems 3. give more attention to staff’s concern.

Implementations:

1. Hospital labor rooms visit by groups of antenatal mother who had no experience of delivering in hospital.
2. special marking and black string tie on the antenatal check up booklet for those who had experience of unsafe delivery.
3. nurses who have no experience of conducting a labor is sent to hospital for courses on conducting a labor.
4. those antenatal mother who have risk of unsafe delivery are invited to a focal group discussion on the importance of safe delivery in health clinic.
5. special arrangement is made for unwed mothers, they can have their antenatal check up at the day other than the antenatal day and if required, can be sent to other clinic to avoid public attention on them.
6. talks is given in villages which are located far from health clinic about the problems of unsafe delivery.
7. make sure all the antenatal mothers who are high risk for unsafe delivery have the chance to visit the hospital labor room.
8. increase number of Alternative birth centers especially in inaccessible villages for away from the hospital. Eg. Health clinics in Both Jeniang and Bulau have their ABCs operated at year 2001.

Beneficial experiences in Daerah Sik

Birth	1996	1997	1998	1999	2000
Total birth in District	1302	1232	1243	1275	1266
Total Home Delivery (safe)	427	289	196	165	115
Total unsafe delivery	45	48	33	19	16
% unsafe delivery of home deliveries	10.5	16.6	16.8	11.5	12.2
% general unsafe delivery	3.46	3.9	2.65	1.49	1.3

Result of antenatal visit to hospital Sik (year 2000)

Clinic	Total antenatal mother visit to hospital	Total visiting sessions to hospital	Total antenatal mother visit to hospital with partners	Total number of hospital delivery	Total number of delivery conducted by community nurses	Total number of unsafe delivery
Maternal and Child Health Clinic Sik	80	12	24	74	6	-
Health Clinic Jeniang	58	12	5	56	2	-
Health clinic Gulau	48	12	9	38	10	-
Total	186	36	38	168	18	-

By Teoh Jia Qing 0500038

REFERENCES

1. Yearly report of Safe motherhood initiative, district team problem solving, 1997.
2. Projek Kumpulan Meningkat Mutu Kerja KKM

Kubang Pasu District

First session (Morning session)

Date: 12th July 2009
Time: 9.00am
Location: Kubang Pasu District Health Office, Jitra
Topic: Tagging System,Immunisation,Pap Smear, Maternal & Child Health, Geriatrics (Family Health and Development Department)
Person in charge: Sister Zurida bt Abd Hamid

We assembled in the DHO meeting room to attend a talk by Sister Zurida bt Abd Hamid. There are 8 klinik kesihatan (Klinik Ibu &Anak) and 21 Klinik Desa in Kubang Pasu district. This unit provides services such as antenatal care, postnatal care, child care (for child age between 0-6 years old), School Health, Geriatrics care, Public Health, Prostar, Mental Health, Food and Diabetic care, Home Care Nursing (for geriatrics and chronic case only), Rehabilitation clinic, and also Dental care. We were briefly explained about the operation policy of Klinik Kesihatan (which includes all types of clinic available) in Kubang Pasu according to BUKU B.
The objective of Klinik Kesihatan is to provide comprehensive and quality service to the community to enhance the status of public health and to improve the accessibility to the health services. The organization chart of Kubang Pasu DHO and the function of various departments under this unit such as pharmacy, laboratory, clinical, imaging and administrative function was explained.
Klinik kesihatan provides its services:
• to walk-in patients,
• patient referred from various types of health care center
• they handles minor surgeries
• Non CD cases such as diabetes, high BP, Asthmatic, psychiatric patient, heart patient, and occupation related diseases.
• Ambulatory Medical Emergency treatment
• Simple fractures, minor orthopedic cases
• Besides that, this unit also responsible to prepare medical report, reten HMIS and carry out health promotion to their patient who visits their clinic.
• Screening test

Kuala Muda District - MCH Clinic

Kuala Muda DHO Posting
Seventh Day (13th July 2009)

First Session
Venue : Maternal & Child Health Clinic Bandar Sungai Petani
Time : 8.30 am
Topic : Maternal & Child Health Clinic (Klinik Ibu & Anak)
Persons in charge : Sister Maryam & Staff Nurse M Ponnu

Antenatal Care

All pregnancy cases will be recorded in log book KIB 101. At booking visit:
- Done below 12 weeks by the staff nurse or community nurse for dating and screening
- Urine Pregnancy Test done to confirm pregnancy
- Vital Signs, Weight, height, blood pressure, and general examination is done
- Rubella status, Tetanus toxoid dose status determined
- Routine Lab Investigations: Blood typing and rhesus, VDRL, HIV Rapid Test, Blood glucose and Hb levels, Urine glucose and protein

Next, palpation will be done by specialist nurse before being sent medical officer for routine examination. All complicated cases will be recorded in form KIB 102.

Mothers ‘red book’ are separated based on the risk that the pregnancies carry and areas that the mothers live in. The risk is marked as:

a. White I (Option to deliver at hospital)
- Primigravida
- Age less than 18 yrs old or more than 40 yrs
- Gravida 6 and above
- Spacing less than 2 yrs or more than 5 yrs
- Height less than 145cms
- Single mother
- Unsuitable home condition

b. White II (Option to deliver at home or alternative birth centre)
- Gravida 2 to 5
- No history of obstetric or medical complications
- No pregnancy complications
- Height more than 145cms
- Age between 18 to 40 yrs
- Married mother with good family support
- Period of amenorrhea between 37 to 41 wks
- Estimated fetal weight between 2 to 3.5kgs

c. Green: Refer to medical officer
- Rhesus negative mother
- Current medical problems (psychiatric and physically handicapped) except diabetes and hypertension
- History of gynecological operations
- Addiction to drugs/cigarette/alcohol
- Unsuitable LNMP
- History of recurrent miscarriage (more than 3 times)
- Past obstetric history (cesarean section, PIH/Eclampsia/Diabetes, Perinatal death, etc)
- Blood pressure (140/90 mmHg) with urine albumin negative
- Hemoglobin less than 11 g/dL
- Glycosuria ++
- Urine albumin more than 1+
- Sudden increase in body weight (less than 2 kg in one week)
- Body weight more than 80 kg
- Loss of weight
- SFH less or more than 4 cm than date
- Abnormal lie with no sign of labor at more than 36 weeks (Primigravida)
- Head is not engaged at term (more than 37 weeks)

d. Yellow: Refer to Family Medicine Specialist
- HIV positive mother
- Hepatitis B positive mother
- BP more than 140/90 and less than 160/110 mmHg with urine albumin negative
- Diabetic mother
- Reduced fetal movement at more than 32 weeks
- +7 from EDD
- Multiple pregnancy

e. Red: Refer for immediate hospital admission (Consultant Obstetrician)
- Eclampsia
- Pre-eclampsia (High blood pressure with urine albumin 1+) or symptomatic or Blood pressure more or equal to 160/110
- Symptomatic heart disease during pregnancy (shortness of breath and palpitations)
- Shortness of breath when engaging light activities (i.e. sweeping the floor or doing the dishes)
- Uncontrolled diabetic mother (brick-red urine) with presence of urinary ketone (more or equal to 1+)
- Ante partum hemorrhage including miscarriage
- Abnormal fetal heart rate (less than 110 per minutes at and after 26 weeks) (less than 160 per minute after 34 weeks)
- Symptomatic anemia during pregnancy
- Premature uterine contraction (less than 37 weeks)
- Leaking liquor without contraction
- Severe asthma attack

Mother’s residence area will also be colour coded with the colour blue, green, yellow or red.

Routine Visits
a. General examination - Weight Gain, Blood Pressure,
b. Lab investigation - Urine Tests (protein and sugar) and Hb levels
c. Obstetrics examination- Gestational weeks , SFH , Presentation and lie of fetus
d. Fetal Kick Chart (At quickening/28 weeks)
e. Anti- Tetanus toxoid : usually given after quickening (20th week and 1 month after)
• For primigravida
i. 1st and 2nd dose.
• For multi
i. 1 dose only
ii. Gap > 5 years after previous pregnancy (2 doses)

f. Ultrasound monitoring on first visit around 12th week and to check for viabilty and for fetal growth monitoring

On average, this clinic refers around 100 deliveries every month to the hospital. Deliveries are recorded in the log book KIB 103. It is also worth noting that there is a ‘delivery bag’ available in the clinic in case of emergency labour takes place on the premise.

Antenatal check up (for an uncomplicated pregnancy) is done once in every month up to 28 week of gestation and 2 week once up to 36 week and weekly thereafter. If the pregnancy is considered high risk, then the antenatal visit will be scheduled at a more frequent interval.

After 12 weeks of gestation, mothers are started on hematinics. Hematinics given include:
- Folic acid
- Ferrous Fumarate
- Vitamin B Complex
- Vitamin C

In the event positive result on HIV rapid test, further sample will be sent for Western block in Institute of Medical Research (IMR) in Kuala Lumpur.

Postnatal Care

For the first 10 days post-delivery, the community nurses will be visiting the mother and her baby every day. Attention will be given particularly at mother’s episiotomy wound, cesarean section wound, and baby’s jaundice if any.

After one month post delivery, the mother will bring her baby to the clinic for assessment. For the mother:
- weight
- urine analysis
- haemoglobin
- palpation to assess uterine involution
- advice on family planning methods

For the little one:
- Anthropometrics measurement
o Weight
o Length
o Head circumference
o Chest circumference
- Full physical examination

Child Vaccination

Below is the updated immunization schedule practiced in Klinik Ibu & Anak Bandar Kuala Muda. However, our staff nurse explained that Hepatitis B injection is no longer a part of the schedule.

*Picture of the immunization schedule will be posted later.

Cold chain

Besides the vaccine itself, the most important part in the vaccination process is storage of the vaccine. Vaccines need to be kept at a regulated small temperature range of 2 – 8 degrees Celsius in order to maintain its potency. There were 2 fridges and 2 cool boxes in the KIA Bandar for this purpose. The fridges were spaced out at certain distances from the wall and ceiling for regulation purposes.

1 fridge is mainly used for storage of vaccine stocks while another smaller fridge is for daily usage. The stock fridge contains ice packs in the freezer compartment and vaccines are stored in the chilled area. Bottles of water are kept in the vegetable compartment and bottle pockets. These water bottles act as buffers to maintain the temperature within the fridge in case of a cut in the electrical supply.

Vaccines are segregated according to types on the shelves. Live vaccines are kept at the top shelf right below the freezer while attenuated vaccines are kept in the lowest shelf. These vaccines are spaced out from each other for proper ventilation.
On the other hand, vaccines of daily use are kept in the smaller fridge. Vaccines in here are lesser and are compartmentalized and labelled in small baskets. Opened vials are also properly kept and dated so that they can be finished before the expiry date.
Both the fridges are equipped with ‘minimax’ thermometers to monitor the temperature accurately. Basically, these thermometers need to be reset every time the fridge is opened. The temperature monitoring is ensured by proper recording on a book by the nurse in charge. This recording is done twice daily, in the morning and in the afternoon.

Vaccines that are removed from the larger fridge 1, is kept in smaller fridge 2 for daily uses. Those opened vials that can be reused for more than one patient is maintained in two cool boxes. Cool boxes are used so that the fridge doesn’t need to be opened frequently. These cool boxes are filled with ice packs to maintain the temperature within. This temperature is monitored by a dial thermometer.

This process of vaccine transferring so that it remains within its optimum temperature range is called ‘cold chain’; a tedious process and strict monitoring by the clinic staff in order to deliver the best health care service to the public.

Family planning

For green, yellow and red labelled mothers, counselling and advice on methods of contraception must be given.

Types of contraceptive pills available in this clinic are:
- Marvelon
- Noriday
- Microgynon 30

Condoms are also available.

Women receiving contraceptive service from the clinic will be given a family planning card (kad perancang keluarga) which recorded the types of contraception received, the date the women received them and the TCA (to come again) date for the next appointment. The clinic also keeps track of these women in a booklet assigned for every patient (booklet PKW 1(a)/06). This booklet contains the full bio data details of the patient, past obstetric and gynaecological history, past history of family planning, together with the data of current contraception used.

Pap smear service

This clinic also offers pap smear service to local women. It is carried out by a trained staff nurse in a pap smear room. Samples are sent to lab in Hospital Universiti Kebangsaan Malaysia (HUKM) and results are expected to return in couple of weeks.

Equipments available in the pap smear room include:
- disposable Cusco’s speculum
- disposable pap smear kit
- fixative spray
- slides holder

Additional remarks:

Form KIB 101 – Booking
Form KIB 102 – Complications referral
Form KIB 103 – Delivery record (Case will only be recorded if booking was done in this clinic)
Form KIB 104 – Maternal deaths record
Form KKK 101 – Child health record
Form KPK 101 – Pap smear report

KOTA STAR District

KLINIK IBU DAN ANAK

We visited the klinik ibu dan anak (KIA) today. Although the Klinik is placed in PKDKS building, it is still actually part of KKBAS.

Staffs: 25

Doctor – 1 (Dr.Goi)

Sister – 1 (Sister Azizah)

Staff nurse – 9

Community nurse – 7

Lab assistant – 1

Lab head – 1

Medical assistant – 4

Driver – 1

The clinic is divided into 7 rooms, each with a different function. Summarized below:

Initially the patient gets their queue number. If a pregnant woman has come for her booking, her weight, height, BP, urine (sugar + albumin), blood (grouping, Rh, VDRL, HIV) is taken. After this she receives a ‘red card’ or ‘kad merah’ whereby one copy to be kept by the patient and one by the klinik. For subsequent antenatal visits, only the weight and BP are recorded.

For children, their weight and height are recorded by staff nurse in their ‘rekod kesihatan dan perkembangan kanak-kanak’ to detect derangements in their growth. In another section, the child’s development is assessed by a staff nurse.

1) Bilik suntikan (injection room) - this rooms deals with administering the vaccination for children, according to the MOH schedule. Some of the vaccines are:

- Tritanrix – HiB + HepB + DTP (2,3,5 months)

(Tetanus vaccine – 2yrs shelf life, every 0.5ml has potency of 40IU, one 0.5ml injection given every 10yrs)

(DTP vaccine – 2yrs shelf life, consists of purified diphtheria, tetanus toxoid & inactivated whooping cough organisms, every 0.5ml has potency of 30IU for diphtheria, 4IU for pertusis & 60IU for tetanus, 10 dose vials are available)

- MMR- Priorix (12months)

(2yrs shelf life, consists of attenuated measles, mumps and rubella, dose given is 0.5ml)

- OPV (still used) (2,3,5 booster at 18months)- 10 & 20 dose vials are available

(Polio vaccine – 2yr shelf life, 2drops = 0.1ml, S/E (rare) – paralysis 1 per million administrations)

NOTE : IPV is only used in hospitals and not at the district level. IPV is only given routinely for immunocompromised children here, but in hospitals they’re taking extra precautions to get all children covered with vaccine efficiently so that no cases of polio arise in the future.

- BCG (usually immediately after birth in the hospital, in the Klinik for LBW babies)

Storage of vaccine:

- Iced lined refrigerator – temperature monitoring chart to check the temp daily (done at 8am and 5pm daily) using the Minimax Thermometer. Red colour on the chart indicates the max temp, green for min temp, blue for current temp.

Temperature chart

Minimax Thermometer

- If the temperature of the refrigerator is noticed to be not within the acceptable range of 2 to 8 degrees, the vaccines are not thrown away but sent to the pharmacist. The pharmacist checks for the potency of the vaccines and if it is still good then the vaccines are administered again.

- 2 refrigerators both ice lined (one back-up)

- Vaccines in the refrigerator are not stored in any particular order.

Ice lined Refrigerator

Vaccines stored in no particular order

Records:

- Each time a vaccine is administered, it is recorded in the ‘rekod immunisasi di klinik kesihatan kanak-kanak’ (to record number of vaccines given each week)

- In addition it is also recorded in a separate card (white) KKK1/93A (for patient) (white) KKK1/93B (kept in Klinik) – each card has a different coloured string tied to it to indicate the area the patient comes from.

- Roughly 80-100 children are vaccinated each day. 1 community nurse administers the vaccines.

1) Blood collection room – tests available:

- Antenatal – Hb

- Children – FBC & serum bilirubin

- If the doctor requests for other investigations the sample is taken and sent to HSB lab and the results sent back. There is a delivery system everyday. FBP takes 1 month, Serum ferritin 2weeks, mGTT 3 days.

- Roughly 30-40 samples are taken each day.

- Sterile syringes and needles used for each case, and disposed of in a sharps yellow bin, once full sent to HSB for incineration.

- 2 staff nurse take blood.

2) Antenatal room (divided into 2 parts) –

- 1^st visit- head to toe examination including; eyes (pallor, jaundice), dental carries (all women referred to dental klinik in KKB), thyroid (including fine tremors), breast examination, legs (oedema + varicose veins) after which Obs palpation. Done by staff nurse.

- Follow up visit, only Obs palpation unless otherwise indicated

- Chart is present in the room to guide the nurses on what to counsel in each trimester.

- We met a patient with GDM, whereby BSP done for her monthly and doctor refers the patient to HSB if the BSP is abnormal, to start insulin. Diet counseling is given by pegawai kesihatan makanan.

- Heamatinics (vit.B complex, Folic acid and ferrous fumarate) given from the 1^st week, dosage:

Normal HB – once daily

<11g/dl>

<10g/dl>

- If vomiting s/e prominent, then ‘softgel’ capsules are given, which have lower doses of ferrous fumarate.

- If under-nourished mothers, milk powder & iodized salt is given by the clinic free (no need to go to the welfare department).

- ATT given, primi 2 doses, multi 1 dose, given after quickening felt, and 2^nd dose 4 weeks later.

- Tagging / Colour coding is done to indicate if the mother faces any complications and who should deliver her child. If white tag, home visit done twice, if green, yellow or red tag, home visit done 4 times throughout pregnancy.

1. White: - mother can deliver in hospital without specialist, a nurse can attend to her

White 1 Cases :

• Primigravida.

• Young or old mother.

• Grand multi Para( 6 or more).

• Height of less than 145cm.

• Single mother.

• Unsuitable home environment.

White 2 Cases :

• Gravida 2-5

• No past obstetrics problem.

• No medical problem.

• No past antenatal complications.

• Height of more than 145cm.

• Child-bearing age.

• Appropriate fetal size and weight.

• POA is between 37 and 41 weeks.

• Proper family and social support

2. Green: - doctor has to attend, Cases :

• Rhesus negative.

• BMI <> 30

• Past Gynecological operation.

• Drug/cigarette/alcohol addiction.

• Unsure Last Normal Menstrual Period ( LMNP).

• Past History of continuous miscarriages ( > 3 times).

• Past history of obstetrics.

• Caesarean

• History of Pregnancy Induced Hypertension / Eclampsia / Diabetes/Premature Death

• History of Low birth weight of the new born –

• Third degree perineal tear.

• Sticked placenta.

• Post partum hemorrhage.

• Instrumental delivery.

• High blood pressure with urine albumin.

• Anemia.

3. Yellow: - seen by family health specialist, Cases :

• HIV positive mother

• Hepatitis B positive mother

• High blood pressure > 140/90 and <160/110

• Diabetic mother.

• Reduced fetal movement at > 32 weeks of gestation.

• Gestation is more than 7 days from the EDD

• Multiple pregnancy

4. Red: - referred to hospital immediately, Cases :

• Eclampsia

• Chest pain during pregnancy

• Breathing difficulty while doing mild work

• Uncontrolled diabetes during pregnancy

• Bleeding per vagina

• Abnormal heart beat of the fetus

• Anemic symptoms regardless the gestation week

• Premature contractions

• Leaking liquor without uterine contraction

• Severe Asthmatic attack

- Delivery, patient referred to HSB, but if emergency then delivered in the clinic (special area), as all staff nurses are trained in midwifery. Rarely mothers deliver at home, but if they insist on doing so then staff nurses will go over to deliver the child.

- Alternative Birthing Centre (ABC) which is place in Kuala Kedah, is where mothers with white tag can deliver their child without going to the hospital. This centre has a labour room and postnatal room set up for this purpose.

Equipment:

- 1 U/S (doctor’s room)

- 3 Daptone (2 working)

- 1 ECG

Non-compliant patients – who does not follow the scheduled visit, the clinic phones the patient, after which a nurse in charge of the area goes and visits her in her home.

On 2^nd day after delivery, a nurse will visit the mom and baby at their residence. Routinely the baby’s SBC is checked and the mother’s general health is observed. If the baby is normal, then the nurse visits the baby on the 3^rd, 4^th, 6^th, 8^th and 10^th day as well. If the baby is jaundiced or ill, the check ups are more frequent. If the baby suffers from severe neonatal jaundice, the baby is referred to HSB immediately.

3) Family planning clinic / pap smear / post-natal clinic –

- Post natal clinic – (at 42 days) Urine, BP and weight is taken, head to toe examination is done, vaginal examination done and family planning counseling is given. The mother is also encouraged to give exclusive breast feeding for their baby for atleast the first 6months.

- Family planning method is the patient’s choice, but all the options available are explained to them beforehand with the advantages and side effects of each. However, irrespective of which contraceptive is given, the women is asked to come for review and physical examination every 6 months once.

(a)IUD (Cu) – only inserted by the doctor, only started distributing last month

(b)COCP – 2 types available, Rigevidon (ethinylestradiol 0.03mg, levonogestrel 0.15mg) and Marvelon (ethinylestradiol 0.03mg, desogestrel 0.15mg)

(c)POP – Noriday (norethisterone 350microgram)

(d)Uni-depo injection – given once every 3months, but has many s/e like spotting, irregular menstruation in early stages and eventually the menstruation stops.

(e)Condoms – given 24 packets every month

OCPs and Uni-Depo

IUCD

- PAP smear is done for mothers postnatally, or for those who bring their children for vaccination. PAP smear programs are conducted often as they have a target of 1445 to reach annually. So far they have detected 2 abnormal PAP smear results when the samples were sent to HSB lab for analysis, ad have referred them to HSB for further check up.

1) Child health area - 3 staff nurses are in charge here – growth chart and developmental milestones are reviewed every 3 months, if below the 3^rd percentile, the child is referred to the pegawai zat makanan (nutritionist) and MO in clinic – if any medical problem is detected, the child is referred to the HSB. A routine medical examination (RME) is done for every child until the child is 1 month old.

If under nourished children, the ‘Food Basket’ is offered to the child, which consists of rice, milk powder, biscuits, sugar, oil, vitamins, peanuts and other protein-rich food. This basket costs RM75 and is given to the family twice a month until the child’s nutritional status is satisfactory. However, so far no one has qualified for this program as it specially allocated for those lying below the poverty line only.

From 1 year old onwards, the child is given deworming medication every 6months once until the child is 6 years old. The KIA does not cater to children who are ill; they would have to go to the OPD to get treatment. However, minor sickness like common cold and fever will be looked at by the doctor in KIA.

Non compliant patient – who does not follow the scheduled visit, the clinic phones the patient, after which a nurse in charge of the area goes over to visit the child at home.

2) Doctor’s room – 1 MO is present everyday (Dr. Goi), every Tuesday the family medicine specialist (FMS) visits. Per day 80-100 patients are seen. Common diseases seen are: (Any complicated cases, a referral letter is written to HSB)

- GDM

- HPT

- Jaundice

- PP

- Immunisation review

Dr.Goi will be the one doing an Ulatrasound for the pregnant mother if she requires one, and she also places the IUD in women who wish to have it.

3) Laboratory – only core biochemical tests performed, including:

- FBC

- Blood grouping, RH, VDRL, HIV

- Bilirubin

- Urine FEME

Equipment:

- 1 microscope

- 1 centrifuge machine

- 1 refrigerator to store reagents (temp checked 8am and 5pm)

- Auto – hematology analyzer

- Neo-bil plus machine ( bilirubin analyzer)

Centrifuge machine in the lab in the KIA Klinik

Auto-haemotology analyzer

Results:

- FBC result in 2-3 mins

- Bilirubin in 3 mins

Results recorded in a results book. The patient carries the sample to the lab, results given, after which they are reviewed by staff nurse at the respective rooms.

Klinik KIA, seven different rooms for different purposes described below.