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.