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