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Definition:
Embryo:
Fetus:
Gravidity
Parity
Abortion:
Immature infant:
Preterm/premature infant:
Term:
Post term
Date/Post date
Birth rate
Fertility rate
Neonatal period:
I, II & III
Perinatal period:
Perinatal mortality rate:
Maternal mortality rate:
3. Sign & symptoms of PRESUMPTIVE /PROBABLE manifestations
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Pregnancy test:
Biological
Immunological
Radioimmunoassay for HCG
Serum vs urine
4. “”Antenatal care is the clinical assessment of mother and fetus
during pregnancy, for the purpose of obtaining the best possible
outcome for both the mother and the fetus”
The aims of antenatal care:
Assessment and management of maternal risk and symptoms
Assessment and management of fetal risk
Prenatal diagnosis and management of fetal abnormalities
Diagnosis and management of perinatal complications
Decision regarding timing and mode of delivery
Education regarding pregnancy and childbirth
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5. Frequency of antenatal visits
12 weeks –booking + viability uss
16 weeks-blood screening (MW)
18 weeks-dating &detailed uss
24 weeks-
28 weeks- FBS, auto ab
30 weeks
32 weeks- growth uss
34 weeks
36 weeks –
38 weeks
40 weeks
41 weeks -
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6. 13/12/200
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booking visit (first visit):
The aim:
obtain a comprehensive history and physical examination
establish the gestational age
identify the maternal and foetal risk factors
History:
A FULL obstetric history particularly:
LMP (last menstrual period)
EDD (estimated delivery date)
Past obstetric, gynaecological, medical and surgical history
Family history
Social history ( inquire about smoking, alcohol, drugs)
Identify factors and categories which make patient high or low risk.
7. Assessment of gestational age:
Nagel’s rule (EDD) :
Subtract 3 months from the date of the last menstrual period and add
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7 days( 14 days in Arabic months).
If the cycle was longer than 28 days, the number of additional days
are added to the days used in the rule
Do the opposite if the cycle is shorter
Biparietal diameter: accurate +/- 3 weeks ( useful between wks 7-12)
Crown rump length: accurate +/- 1 week (useful between wks 7-12)
Fundal height: correspond to gestational age in weeks
.
9. Measurement Symphyseal
Fundal height
Evidence supports either palpation or S- F measurement
at every AN visit to monitor fetal growth
measurement should start at the variable point (F) and
continue to the fixed point (S)
SF measurement should be recorded in a consistent
manner (therefore cms at RWH)
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10. Fetal Presentation and
Descent
Check presenting part beginning around 30 weeks
Descent of presenting part is important as term
approaches
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11. Auscultation of fetal heart
Listening to fetal heart is of no known clinical benefit,
but may be of psychological benefit to mother
(Consensus opinion)
Should be offered at each visit after about 20 weeks
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12. Routine BP measurement
HT is defined when systolic BP is 140mmHg +/or DBP is
90 mmHg or there is an incremental rise of 30 systolic
or 15 diastolic
Automated devices & ambulatory devices should not be
used (Mercury devises seem best)
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13. Urinalysis by dipstick for
proteinuria - evidence
high incidence of false +ve and - ve using dipsticks cf 24
hr urine collection
reliable in detecting highly variable elevations in
protein in pre-eclampsia
Gribble et al AJOG 1995; 173: 214-7
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14. Urinalysis by dipstick forn
proteinuria - evidence
no statistical differences in rates of PAH, fetal distress,
abruptio placentae, neonatal outcome in those with
absent, mild or marked proteinuria by dipstick
US and Canadian Guidelines recommend screening for
pre-eclampsia by BP measurement rather than dipstick
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15. Urinalysis by dipstick for
proteinuria - guidelines
Routine screening for proteinuria in low risk pregnant
women not recommended IV
assessment hypertensive pregnancies requires
estimation of total protein in 24-hr collection IV
If detect hypertension then use dipstick for testing
proteinuria
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16. Routine weighing at A/N
visits - evidence
weighing at every antenatal visit
routine practice for many years
No conclusive evidence for weighing at
each visit. Maternal weight not
clinically useful screening tool for
detection of IUGR, macrosomia or pre-eclampsia
IV
Weighing at booking or other times
may be indicated eg anaesthetic risk
assessment (done BIV at RWH) or
maternal weight concerns
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18. Initial recommended tests
FBE
MCHC/MCV (Thal screen. Ferritin and
Hb electrophoresis if low)
Blood group/Ab screen
HIV (level 1 evidence)
Hep B
Syphilis (ideally prior 16 weeks)
Rubella Abs
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19. Urine testing- either 2 step or
MSU+dipstick
PAP if due
Consider
Hep C
Ferritin
Vit D levels - common in patients at RWH
addit Thal screen
dating US
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20. Hepatitis C screening
Should be offered to all at increased risk
history of injecting drugs
partner who injected drugs
tattoo or piercing
been in prison
blood t/f later positive for Hep C
long-term dialysis or organ transplant before 7/92
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21. Prenatal testing
Down screening
Screening - : early US, 15-17 week MSST, Early
combined screening(first trimester MSST and early US)
diagnostic testing - CVS, amniocentesis
Other testing according to history eg for CF, Fragile X,
Thalassaemia, Huntington's disease
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22. Prenatal screening for Down’s
syndrome
All women should be offered screening irrespective of
age III/IV
counselling given by appropriately trained staff and
specific to age of each woman III/IV
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23. Down syndrome screening
Screening should
include accurate dating by 1st T u/s IV
either by 2nd T biochem, or nuchal translucency alone or
combination III
notify result irrespective of risk in understandable format
II
if increased risk should be offered further counselling and
diagnostic testing within 72 hrs or ASAP IV
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24. Down’s syndrome screening
Quality of counselling is of primary importance, non-directional,
if chooses screening, should be single-step
III
Nuchal translucency should be performed at 11-14
weeks by trained operators and risks derived in
conjunction with gestation and maternal age IV
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25. Other recommended tests
26 weeks (at hospital)
Gestational diabetes screening -
AB screen on all women
36 weeks
GBS screen
(Ab if RH -ve has been ceased)
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26. Screening for GDM
In absence of high level evidence to either support or
abandon screening reasonable to
not offer screening
selectively offer screening to all with risk factors
offer screening to all
if screening do so between 24-28 weeks
RWH screen all women at 26 weeks
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27. Prevention of Early Onset GBS
Swabs should be taken between 35-37 weeks’ III
Intrapartum antibiotics recommended if
<37 weeks’
ruptured membranes >18 before delivery
maternal temperature ³38 C
previous GBS colonisation, bacteruria or infant with GBS III
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28. Antenatal anti-D prophylaxis
Prophylactic Anti-D at 28 and 34
weeks’ gestation
No level I evidence
Level II and III evidence would suggest
that the 1.5 percent immunisation
rate could be reduced to 0.1-0.2%
through antenatal prophylaxis (Huchet
et al, 1987;Bowman and Pollock, 1978;
Hermann et al, 1974)
www.health.gov.au/nhmrc/publicatio
ns/pdf/wh27.pdf
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29. 13/12/200
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Investigation:
routine test:
Blood group and Rh type ( if positive, appropriate management)
CBC
Urine analysis- to prevent UTI affecting pregnancy)
MSU
HBs Ag ( if a mother has it, 70-90% chance of foetus getting it,
90% chance of being chronic carrier. Prevent by treating newborn
of HBs AG+ve mother with B immune globulin and hep B
vaccine)
Rubella
Syphilis
U/S:
Determine foetal crown rump length and thus gestational age
Identify multiple gestation
Identify gross abnormalities/ markers of genetic disease.
Cervical cytology
30. 2-Screening tests:
Anaemia
Gestational DM (best carried out between 24 and 28 weeks, observe 1 hr
after 50g glucose solution. A reading of 126 mg/dl or greater is abnormal,
according to the amended WHO recommendations 1999 regarding DM,
as is HbAlc of greater than 90%. In these cases proceed to glucose
tolerance test)
Antibodies
Triple test: Alpha feto protein in normal serum, oestriol, HGG
( to detect neural tube defect or chromosomal defect, 16-18 weeks)
Hb electrophoresis
Tuberculin skin testing
Urine culture- for glucose, ketones and protein, bacilli
Cervical culture: N gonorrhoea, group B streptococci,
Chlamydia trachomatis, Mycoplasma hominis
Toxoplasma antibody test
HIV
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31. HIV: Voluntary Counseling
and Testing
Voluntary HIV counseling and testing should be
available to every pregnant woman--for public health
reasons as well as for the benefit to the individual
woman.
Pre and post-test counseling is an essential part of
managing HIV in pregnancy.
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Source: WHO and UNAIDS 1999.
32. Benefits of Voluntary HIV
Counseling and Testing
1) If the HIV test is positive, the woman can
get early counseling and treatment
2)Allows appropriate follow-up and treatment
of child
3)Enables a woman to make decisions
regarding continuation of the pregnancy
and future fertility
4)May allow the institution of anti-retroviral
(ARV) therapy
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Source: WHO and UNAIDS 1999.
33. Benefits of Voluntary HIV Counseling and
Testing continued
5) Provides the opportunity to
implement strategies that attempt
to prevent transmission to the child
6) Can inform partner and enable him
to get counseling and testing
7) Women can take precautions to
prevent transmission to partners
8) If the HIV test is negative, the
woman can be guided in
appropriate HIV prevention
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Source: WHO and UNAIDS 1999.
34. Syphilis
Maternal-fetal transmission may
be as high as 80%.
Incidence of adverse effects on
the fetus/infant due to untreated
maternal syphilis reported in some
studies was:
Spontaneous abortion – 20%
Perinatal death – 30%
Congenital syphilis – 25%
Source: WHO 1991.
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35. Syphilis continued
A study in Zambia found syphilis to be the
single most common cause of fetal wastage.
The adverse outcomes of syphilis were
halved by a fairly incomplete program of
screening and treatment.
Sources: Hira et al 1990; Tinker and Koblinsky 1993.
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36. Syphilis continued
Even where prevalance is relatively low
(i.e., as in most industrialized countries) an
antenatal syphilis screening program is a
cost-effective intervention.
Initiation of treatment should occur at the
same visit as the screening.
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Source: Wang and Smaill 1989.
37. Tuberculosis
Infants born to women with tuberculosis (TB) have an increased risk
of morbidity and mortality in the neonatal period.
Source: Figueroa-Damian and Arredondo-Garcia 2001.
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38. Severe anemia
Mild or moderate anemia is not correlated with adverse
pregnancy outcomes
Severe anemia, however, (hgb <7 g/dL or hct <20%) is
associated with increased preterm delivery, inadequate
intrauterine growth, increased perinatal mortality and
increased maternal mortality.
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39. Severe anemia continued
Providers can screen for anemia by
1)Hemoglobin (hgb) by thin film/smear
2)Hematocrat (hct) test
3)Hemoglobin Color Scale, or
4) Clinical observation of the inferior conjunctiva
of the eye, the nail beds and the palm. If any of
these are pale, the woman is severely anemic.
Other symptoms include shortness of breath
and signs of heart failure.
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40. Tetanus Toxoid
Tetanus toxoid is
An effective, stable, cheap toxoid
which has been available for > 50 years
and is produced in many developing
countries.
Effective in preventing neonatal
tetanus (NNT), which causes
approximately half a million
deaths/year) and maternal tetanus,
which is estimated to cause 30,000
deaths annually.
Sources: Fauveau V et al 1993; Bennett JV 2000.
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41. Iron Deficiency
Globally among all populations, iron
deficiency (and its manifestation in anemia)
is the single most prevalent nutrient
deficiency condition. The World Health
Organization (WHO) estimates put anemia
prevalence at 52% among pregnant women.
Source: MotherCare, John Snow, Inc. 2000.
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42. Iron Folate Supplements
The International Nutritional Anemia Consultative
Group, WHO and UNICEF have endorsed the
following guidelines:
1) All women should consume daily iron folate
supplements for 6 months during pregnancy.
2) Where anemia prevalence is <40%, women should
receive supplements of 60 mg iron and 400
micrograms of folate
3) In areas where anemia prevalence is high among
pregnant women (³40%), women should continue
the same dosage for 3 months into postpartum.
Sources: Stoltzfus and Dreyfuss 1998; McDonagh 1996.
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43. 3-Specific nutritional advice:
0.4 mg Folic Acid per day ( it prevents tube defects)
30 mg ferrous iron
60 mg ferrous iron 2 times a day ( anaemic patients)
Supplement copper and zinc in anaemic patients
Avoid Vitamin A in huge amounts as it is teratogenic
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44. Nutrition Requirements
Good antenatal nutrition includes:
Meeting the caloric needs
Eating foods which supply specific micronutrients
Providing micronutrient supplementation
An underweight mother increases the
likelihood of a low birth weight (LBW) baby;
low iron intake contributes to anemia.
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45. Models of antenatal care
At each visit midwives and doctors should offer
information, consistent advice, clear explanations and
provide opportunity to ask questions III/IV
More likely to be satisfied with A/N care when perceive
care givers are kind, supportive, courteous, respectful,
recognise individual needs IV
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47. Complications Cannot Be
Reliably Predicted
No formula or scoring system can reliably distinguish those who will
develop complications from those who will not.
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48. Complication Readiness is
KNeepyal tStou dSyurvival
Less than 50% of families of women who died in
pregnancy, delivery or postpartum, recognized the
problem.
36% decided within 2 hours to seek care and get
transport.
15% decided in 2 to 23 hours to seek care and get
transport.
29% made the decision and arranged transport 1 to
8 or more days after recognition of a life-threatening
complication.
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Source: MOH, Nepal 1998.
49. Complication Readiness is
Key to Survival continued
The interval from onset to death for
antepartum hemorrhage can be
approximately 12 hours.
The interval from onset to death for
postpartum hemorrhage can be two hours.
The hours required for making
arrangements (which could have been
made prior to the emergency) may define
the line between survival and mortality.
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Sources: Maine 1991; MOH, Nepal 1998.
50. Danger Signals
Families of pregnant women need to know how to recognize the signs
of complications as well as what to do and where to get help
In Nepal, less than 50% of families of women who died recognized the
problem.
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Source: MOH, Nepal 1998.
51. On subsequent visits
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Check:
oBp 0 urine analysis 0 weight?
Ask for :
0 FM 0 Maternal complaints
Examine:
0 abdomen/obstetric 0 listen/see FH USS if required
Advice:
Treatment of complaint & health education
63. Assessment of gestational age and fetal growth:
menstrual history unreliable in up to 45% of women
serial fundal height measurement provides a guide to fetal growth
USS: crown-rump length before 14 weeks
USS: BPD serial measurement every 2 weeks for fetal growth.
Unreliable after 28 weeks for dating
USS: head/abd ratio, 2 weeks serial HC & AC for fetal growth .. IUGR
AC< but initially HC ~.
USS: femur length, more precise guide to gestational age than BPD
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64. 13/12/200
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Principles:
the ideal scheme to assess FWB should:
Take account of cycles of normal fetal behavior
detect impending harm accurately and in time to intervene to
prevent it
give reassurance preferably up to 7 days
avoid causing unnecessary anxiety
allow detection of specific causes e.g hypoxia, infection, malf’n
produce measurable benefits in reducing perinatal loss/injury
such system is likely to involve tests which assess several
fetal systems, CVS, NS,, RS and use >1 modality
66. BPP uses FHR monitor and real time USS to assess:
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fetal breathing movement
discrete body or limb movement
fetal tone
FHR
amniotic fluid volume
Amniotic fluid volume is most important
Fetal breathing movement is the first to disappear in asphyxia
7 days reassurance in low risk, only 24 hours in high risk preg
68. Clinical Indications for Doppler Studies
most useful in assessing IUGR
identify only the sub-group which is hypoxemic bec/of
inadequate placental function and may be abnormal for up to 18
weeks before any fetal problem is observed
no proven role in population screening for increased risk of
pre-eclampsia or IUGR
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Source: WHO and UNAIDS. 1999. HIV in Pregnancy: A Review, pp. 27-31. Geneva, Switzerland.
Source: WHO and UNAIDS. 1999. HIV in Pregnancy: A Review, pp. 27-31. Geneva, Switzerland.
Source: WHO and UNAIDS. 1999. HIV in Pregnancy: A Review, pp.27-31. Geneva, Switzerland.
Source: World Health Organization Programme of Maternal and Child Health and Family Planning Unit. 1991. WHO Consultation on Maternal and Perinatal Infections, 28 November – 2 December 1988 report. WHO/MCH/91.10. WHO: Geneva, Switzerland.
Sources: Hira SK et al. 1990. Syphilis intervention in pregnancy: Zambian demonstration project. Genitourinary Medicine 66(3): 159-164;Tinker A and MA Koblinsky. 1993. Making Motherhood Safe, pp. 99-100, World Bank: Washington, DC.
Source: Wang E and F Smaill. 1989. Infection in pregnancy, in Effective Care in Pregnancy and Childbirth. Chalmers I, MW Enkin and MJNC Keirse (eds), pp.534-564. Oxford University Press: Oxford, UK.
Source: Figueroa-Damian R and JL Arredondo-Garcia. 2001. Neonatal outcome of children born to women with tuberculosis. Archives of Medical Research 32(1): 66-69.
Sources: The LINKAGES Project. 2000. Maternal Nutrition: Issues and Interventions. A computer-based slide presentation for advancing maternal nutrition. Academy for Educational Development: Washington, DC; Stoltzfus RJ and ML Dreyfuss. 1998. Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia. INACG/WHO/UNICEF: Washington, DC.
Sources: Fauveau V et al. 1993. Maternal tetanus: Magnitude, epidemiology, and potential control measures. International Journal of Gynecology and Obstetrics 40(1): 3-12; Bennett JV. 2000. Memo from author, The role of topical antimicrobials, to persons interested/involved in control of neonatal tetanus (NNT), 14 February.
Source: MotherCare, John Snow, Inc. (JSI). September 2000. Issues in Programming for Maternal Anemia. MotherCare/JSI: Arlington, Virginia.
Sources: Stoltzfus RJ and ML Dreyfuss. 1998. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. INACG/WHO/UNICEF: Washington,DC; McDonagh M: 1996. Is antenatal care effective in reducing maternal morbidity and mortality? Health Policy and Planning 11(1): 1-15.
The source listed below discusses the difficulties in implementing an effective risk scoring system.
Source: Rooney C. 1992. Antenatal Care and Maternal Health: How effective is it? A review of the evidence, pp. 12-16. WHO: Geneva, Switzerland.
Note: Optional slides 24 and 25, if used, should always be used together.
In Nepal, a recent study showed that less than 50% of families of women who died in pregnancy, delivery or postpartum, recognized the problem. In rural situations in the developing world, as many as 12 to15 hours may elapse between the decision to seek treatment and the beginning to travel towards that treatment.
Source: Ministry of Health (MOH). His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, p. 29. MOH: Kathmandu, Nepal.
This same study in Nepal found that of those families who did decide to seek care, 36% decided within 2 hours to seek care and get transport; 15% decided in 2 to 23 hours to seek care and get transport; while 29% made the decision and arranged transport 1 to 8 or more days after recognition of a life-threatening complication.
Source: Ministry of Health (MOH). His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, p. 31. MOH: Kathmandu, Nepal.
Note: Optional slides 24 and 25, if used, should always be used together.
Life-depleting hours can be lost from the time a complication that needs treatment is recognized through the time arrangements have been made for all the elements that must be in place for the woman to reach help. Considering that the interval from onset to death for antepartum hemorrhage can be approximately 12 hours, while the interval from onset to death for postpartum hemorrhage can be two hours, the hours required for making arrangements (which could have been made prior to the emergency) may define the line between survival and mortality.
Sources: Maine D. 1991. Safe Motherhood Programs: Options and Issues. Center for Population and Family Health, p. 42. Columbia University: New York; Ministry of Health (MOH), His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, pp. 27-28. Kathmandu, Nepal.
Birth planning and complication readiness prior to the development of a complication is key to survival.
Source: Ministry of Health (MOH). His Majesty’s Government of Nepal. 1998. Maternal Mortality and Morbidity Study, p. 29. MOH: Kathmandu, Nepal.