WHO Strategy 2017-2022: Saving Lives & Well-being

• The WHO Country Cooperation Strategy outlines strategic priorities
• The Strategy Agenda covers the period from 2017-2022

Strategic Priority 1

• Focuses on saving lives
• Aims to ensure full access to immediate-impact interventions
• Main focus areas includes accelerating progress towards targeted elimination of tropical diseases
• Address the high burden of viral hepatitis
• Intensify control and treatment of dengue, Zika, and Chikungunya
• Strengthen the implementation of maternal, neonatal, and child health policies, focusing on vulnerable groups
• Expand population coverage under the national vaccination program

Strategic Priority 2

• Promotes well-being
• Empowers people to lead healthy lives
• Enjoys responsive health services
• Maximize opportunities for healthy lifestyles
• Accelerate the introduction of tobacco-free societies
• Increase the responsiveness of health services to people's needs
• Enable reproductive choices for all women and men
• Optimize the health sector's contribution to preventing and addressing gender-based violence
• Support the implementation of a comprehensive nutrition program

Strategic Priority 3

• Focuses on protecting health
• Works to anticipate and mitigate disasters and environmental and emerging health threats
• Main focus includes supporting the implementation of the Asia Pacific Strategy for Emerging Diseases and Public Health
• Addresses emergencies and disaster risk management for health
• Co-lead the national Health Cluster response in emergency situations
• Improve access to clean air, safe water, and safe food
• Advocate for "green" healthcare facilities and the reduction of carbon emissions
• Support the implementation of the Philippine Action Plan to Combat Antimicrobial Resistance through a One Health Approach

Strategic Priority 4

• Centers on optimizing the health architecture
• To overcome fragmentation to achieve universal health coverage
• Works to improve the efficiency of health actors in an evolving, federalized governance structure
• Support the rollout of functionally defined service delivery networks, improving local stewardship for health
• Support efficient and effective regulatory capacity, procurement, and management of supplies and logistics
• Ensure protection from catastrophic health expenditures
• Ensure equitable health workforce distribution and capacity
• Promote evidence-informed policymaking and planning in support of achieving national and global targets

Strategic Priority 5

• Centers on the use of platforms for health
• Support health in all settings, policies, and sectors
• Work with government departments, legislators, and organizations on health-related legislation and regulations
• Support the educational sector and youth organizations through the Department of Education and the Commission on Higher Education
• Enable cities and islands to act as drivers for population health
• Enhance the Philippines' standing in regional and global health
• Address the issue of road and traffic injuries as a major public health concern
• Increase health synergies between public and private sectors

Maternal Mortality Ratio

• The Philippines faces unique challenges in aligning its health system with the needs of its inhabitants
• Challenges mainly arise from the country's geography and income distribution
• Many communities are in isolated mountain regions or coastal areas that are hard to reach
• There are wide disparities in health services across income levels
• A recent study found that 94% of women in the richest quintile delivered with a skilled birth attendant, versus only 25% in the poorest
• 84% of women in the richest quintile had an MMR of 1.9, compared to 5.2 in the poorest quintile
• The MDG target for MMR is 52 deaths per 100,000 live births
• The Philippines' official country-estimated MMR is 162, which is equivalent to seven women dying every 24 hours from pregnancy-related causes
• The Maternal Mortality Ratio in the Philippines is higher than in other middle-income countries in the region, such as Vietnam

Pregnancy

• Pregnancy can be a stressful time, women generally experience overall good health
• Women may experience good health due to extra care and concern in keeping healthy for two
• Extra motivation encourages a woman with a high-risk pregnancy to follow a therapeutic regimen for herself and fetus
• Both the woman and fetus can be at risk for complications

Complications

• Pregnancy can complicate a disease
• A disease can complicate a pregnancy
• Complications can affect the fetus or leave the woman less equipped to function in the future or undergo future pregnancies
• Nursing care needs to include close observation of both maternal and fetal well-being
• Education for the woman and her family about special danger signs is needed
• Actions to minimize complications are important whenever possible

Nursing actions

• Preventing disorders from affecting the health of the fetus
• Helping a woman regain her health to continue a healthy pregnancy and prepare for labor, birth, and newborn care
• Helping a woman learn more about her illness to safeguard her health during her childbearing years

National Health Goals

• Include reducing the rate of fetal deaths, maternal deaths, and maternal illness and complications
• Nurses can help the nation reach these goals by educating women about the importance of entering pregnancy in the best state of health possible

High-Risk Pregnancy

• A high-risk pregnancy threatens the health or life of the mother or fetus
• It often requires specialized care from specially trained providers
• Some pregnancies become high risk as they progress, while some women are at increased risk for complications before they get pregnant
• Early and regular prenatal care helps many women have healthy pregnancies and deliveries without complications

Risk Factors for a High-Risk Pregnancy

• Existing health conditions, like high blood pressure, diabetes, or being HIV-positive
• Overweight and obesity increases the risk for many complications, including high blood pressure and gestational diabetes
• Obesity can raise infants' risk of heart problems at birth by 15%
• Risk of complications are higher in women carrying more than one fetus
• Common complications include preeclampsia, premature labor, and preterm birth
• More than one-half of all twins and 93% of triplets are born at less than 37 weeks' gestation
• Pregnancy in teens and women age 35 or older increases the risk for preeclampsia and gestational high blood pressure
• Women with high-risk pregnancies should receive care from a special team of healthcare providers
• Pregnancies can be designated as high risk for any of several undesirable outcomes

Those at Risk for Uteroplacental Insufficiency (UPI)

• Gradual decline in delivery of needed substances by the placenta to the fetus
• This carries a serious threat for fetal growth restriction, intrauterine fetal death, intrapartum death, intrapartum fetal distress, and various types of neonatal morbidity
• Previously risk factors were evaluated only from a medical standpoint, adverse medical, obstetric, or physiologic conditions considered risk
• A more comprehensive approach is now used and factors are grouped into broad categories based on threats to health and pregnancy outcome
• Categories of risk are biophysical, psychosocial, sociodemographic, and environmental
• Risk factors are interrelated and cumulative in their effects

Biophysical Factors

• Genetic considerations: genetic factors may interfere with normal fetal or neonatal development, result in congenital anomalies, or create difficulties for the mother
• These factors include defective genes, transmissible inherited disorders and chromosomal anomalies, multiple pregnancy, large fetal size, and ABO incompatibility
• Medical and obstetric disorders: complications of current and past pregnancies, obstetric-related illnesses, and pregnancy losses put the patient at risk
• Nutritional status: adequate nutrition is essential for fetal growth and development
• Factors that influence nutritional status include young age, multiple pregnancies, tobacco, alcohol, or drug use, inadequate dietary intake, inadequate or excessive weight gain, and low hematocrit

Psychosocial Factors

• Smoking has been linked to reduced birth weight, higher neonatal mortality rates, increased miscarriages, and premature rupture of membranes
• These risks are increased with low socioeconomic status, poor nutrition, and concurrent use of alcohol
• Birth defects in humans have not been related to caffeine consumption
• Pregnant women who consume more than 200 mg of caffeine daily may be at increased risk for miscarriage or for giving birth to infants with IUGR
• Alcohol exerts adverse effects on the fetus, resulting in fetal alcohol syndrome, fetal alcohol effects, learning disabilities, and hyperactivity

Psychosocial cont

• Drugs: may be teratogenic, cause metabolic disturbances, produce chemical effects, or alter CNS function
• Includes medications prescribed by a health care provider or bought over the counter, as well as commonly abused drugs such as heroin, cocaine, and marijuana
• Psychologic status: Childbearing triggers profound and complex physiologic, psychologic, and social changes
• Conditions includes specific intrapsychic disturbances and addictive lifestyles, a history of child or spouse abuse, inadequate support systems, family disruption, noncompliance with cultural norms, unsafe cultural practices, and situational crises

Sociodemographic Factors

• Low income: poverty leads to inadequate resources for food and prenatal care, poor health, increased risk of medical complications and environmental influences
• Lack of prenatal care: is a risk factor due to financial barriers, lack of access, depersonalization of the system, lack of understanding of the need for early care, or cultural beliefs
• Age: women at both ends of the childbearing-age spectrum have an increased incidence of poor outcomes
• Adolescents: young mothers have a 60% higher mortality rate than older mothers
• More complications are seen in young mothers pregnancies occurring less than 6 years after menarche
• Complications include anemia, preeclampsia, prolonged labor, and contracted pelvis
• Mature mothers are at risk due to number and spacing of pregnancies, medical history, lifestyle, and prenatal care
• Medical conditions include hypertension and preeclampsia, diabetes, extended labor, cesarean birth, placenta previa, abruptio placentae, and death

Sociodemographic Factors cont

• Parity: the number of previous pregnancies is a risk factor
• Preeclampsia and dystocia is increased with a first birth
• Marital status: unmarried women have increased mortality and morbidity rates, often related to inadequate care and a young childbearing age
• Residence: the availability and quality of prenatal care varies with geographic residence
• Ethnicity: non-Caucasian women are more than three times as likely as Caucasian women to die of pregnancy-related causes
• African-American babies have the highest rates of prematurity and low birth weight, with the infant mortality rate being more than double that among Caucasians • Various environmental substances can affect fertility and fetal development • The chance of a live birth, and the child's subsequent mental and physical development
• Environmental factors include infections, and radiation
• Chemicals such as pesticides, therapeutic drugs, and illicit drugs
• Industrial pollutants, cigarette smoke, stress, and diet
• Paternal exposure to mutagenic agents in the workplace

Nursing Care in High-Risk Pregnancy

• Characterized by quality pre-natal and home care
• A plan for individualized care is organized by nurses and a multi-professional team
• Under family support and use of light technologies
• For care of a woman with a preexisting or newly acquired illness

Nursing process Overview

• Assessment
• Nursing diagnosis
• Outcome Identification and Planning
• Implementation
• Outcome Evaluation

Assessment

• Accurate prenatal assessment
• Through understanding of the signs/symptoms of the illness in addition to the understanding of the course of normal pregnancy
• Assessment techniques for objective measures baseline
• Subjective factors include extent of edema and level of exhaustion

Nursing Diagnosis

• Ineffective tissue perfusion (cardiopulmonary) related to poor heart function secondary to mitral valve prolapse during pregnancy
• Pain related to pyelonephritis secondary to uterine pressure on ureters
• Social isolation related to prescribed bed rest during pregnancy secondary to concurrent illness
• Ineffective role performance
• Knowledge deficit
• Fear
• Health seeking behavior
• Situational low self-esteem

Outcome Identification and Planning

• Expected outcomes should be realistic
• Base plans on the pattern of her life before pregnancy
• Give a woman available alternatives
• Allow her to choose among alternatives to participate in her own care
• Refer women and their families to online resources for further info when appropriate

Implementation

• Nursing interventions may focus on new or additional measures to maintain health during pregnancy
• Imaginative solutions to problems need to be created

Outcome Evaluation

• If an evaluation of outcomes at healthcare visits reveals that an expected outcome is not being met, a new assessment, analysis and planning needs to be done
• May need better psychological support to continue to follow a healthcare routine
• Have woman make evaluation ongoing throughout pregnancy to ensure success

Case Study: Angelina Gomez

• 22 years old, is a gravida 1, para 0 woman, 34 weeks pregnant, presented in the emergency room
• Known history of rheumatic fever with mitral valve stenosis
• Developed gestational diabetes during this pregnancy

Vital Statistics for Case Study

• Serum glucose at the moment is 207mg/dl
• Bp 90/40 mmHg
• Pulse 130 b/min
• Fetal heart rate 180 b/min
• A uterine monitor shows she is having moderate strength contraction 7 min apart

Pregnancy Complications

• May come from a preexisting or; newly acquired illness
• A high-risk pregnancy is defined as one that threatens the health or life of the mother or her fetus
• Factors categorizing a pregnancy as high risk

Psychological Factors

• Include pregnancy, loss of support person
• Illness of a family member, decrease in self-esteem and drug abuse include alcohol
• Cigarette smoking, poor acceptance of pregnancy
• History of drug dependence including alcohol or intimidate partner abuse
• History of mental illness

Social Factors

• Refusal of or neglected prenatal care
• Exposure to environmental teratogens, disruptive family incident, and decreased economic support
• Conception less than 1 year after last pregnancy Occupation handling of toxic substances including radiation and anesthesia gases
• Environmental contaminants at home or isolation

Physical Factors

• Multiple gestation
• A bleeding disruption
• Poor placental formation or position
• Gestational diabetes, a prior poor pregnancy
• Potential blood incompatibility from mother and baby
• Visual or hearing challenges and pelvic inadequacy

Cardiac Conditions During Pregnancy

• Increased blood volume and cardiac output due to increased workload on the heart
• Beginning in the first trimester, the mother's blood volume and cardiac output Increases to approximately 50 percent more than before pregnancy and high throughout the rest of gestation
• The heart must adjust to this increase blood volume by contracting harder and faster
• During labor and delivery, cardiac workload increases even more
• Systemic vascular resistance drops significantly 25% during pregnancy
• Excessive blood loss with delivery places more demands on the heart as the organ must work doubly hard to pump and recirculate a deficient blood volume
• Normal cardiac findings in pregnancy

Normal Cardiac Findings in Pregnancy: Symptoms

• Fatigue
• Dyspnea
• Light-headedness

Normal Cardiac Findings in Pregnancy: Physical

• Displaced apical impulse
• Prominent jugular venous pulsations
• Widely split first and second heart sounds
• Soft ejection systolic murmur

Normal Cardiac Findings in Pregnancy: ECG

• Sinus tachycardia
• Premature atrial or ventricular ectopic beats
• Right or left axis deviation
• ST-segment depression
• T-wave changes

Normal Cardiac Findings in Pregnancy: Echo Findings

• Mild increase in the left ventricular diastolic dimension with preservation of ejection fract
• Functional tricuspid and mitral regurgitation small pericardial effusion

New York Heart Association Functional Classifications of Heart Disease

• Class I: uncompromised
• Class II; slightly compromised
• Class III: marked limitation of physical activity
• Class IV; inability to perform any physical activity

Signs and Symptoms of Cardiac Conditions

• Difficulty of breathing, arrhythmia, and chest pain
• Hemoptysis and syncope with exertion
• Clubbing of fingers and neck vein distention
• Systolic and diastolic murmur, cardiomegaly, and persistent split second sound

Management

• Prenatal care is an important aspect of the process
• Requires assessment and promotion of rest
• Management depends on the functional capacity of the heart and the condition is determined through diagnostic tests
• Management also involves diet and medications