Maternal and Newborn Care

Community-Managed
Maternal and Newborn Care:

A Guloe |or Prlmary Healtb Care Pro|esslonals
COMMUNIYY-MANAGED
MAYERNAL AND NEWBORN CARE:
A Guide for Primary Health Care Professionals
Tbls manual ls a publlcatlon o| tbe Department o| Healtb, ano all rlgbts
are tbus reserveo by tbe DOH. Tbls manual, bowever, may be |reely
revleweo, abstracteo, reproouceo ano translateo, ln part or ln lts
entlrety, as long as lt ls not |or sale nor use ln conjunctlon wltb
commerclal purposes. Tbe Department o| Healtb woulo appreclate tbat
lt be acknowleogeo ln tbe reproouceo or translateo verslon ano a copy
o| sucb verslon be sent to DOH.
Copyrlgbt 2006
Department o| Healtb
San Lazaro Compouno, Sta. Cruz, Manlla
(0632) 743-83-01 to 23
bttp://www.oob.gov.pb
All Plgbts Peserveo
Project Consultant
[alme Z. Galvez Tan, MD, MPH
Contrlbutors
Loreto G. Menooza, MD, MPH
Antbony G.H. Coroero, MD
Lara S. C. [avler
|llustratlons, Deslgn ano Lay-out
Serglo T. 8umatay |||
Wltb tecbnlcal ano |lnanclal support o| [|CA.
Introduction 1
How to Use this Guidebook 5
5ection 1 7
Unoerstanolng tbe |mpllcatlons
o| tbe Tbree Delays Mooel
5ection 2 13
Framework o| Communlty-Manageo
Maternal ano Newborn Care
5ection 3
Provlolng 8aslc Cllnlcal |nterventlons
|or Maternal ano Newborn Compllcatlons 19
3.1 Qulck Cbeck 22
3.2 Pe|erral 24
3.3 Prenatal Care 30
3.4 Care ourlng labor, cblloblrtb
ano lmmeolate postpartum 38
3.5 Postpartum Care 57
3.6 |n|ormatlon ano Aovlce |or MCH 63
5ection 4
Managlng Maternal ano Newborn Healtb Servlces 85
References 101
Anne 103
Table of Contents
Foreword
Acknowledgement
Tbe Communlty-Manageo Maternal ano Newborn Care guloebook was
prepareo wltb tecbnlcal asslstance |rom tbe |ollowlng :
Dlego C. Danlla, MD, MPH DOH
Ma. Lllzabetb |. Caluag, MD, MPH DOH
[uanlta A. 8aslllo, MD, MPH DOH
Florence G. Apale, MD, MPH DOH
|zuml Murakaml, MPH [|CA
Martba 8. Cayao-an, MD, MPH UN|CLF
Henory oP. Plaza, MD, MPH UNFPA
Ana Marla oA. Leal, MD UNFPA
Ma. Loloa Y. Sevllla, PN PLAN |nternatlonal
Mlel S. Nora, MD PLAN |nternatlonal
valuable support was provloeo by tbe |ollowlng lnternatlonal oonor agencles: tbe
[apan |nternatlonal Cooperatlon Agency ([|CA), Unlteo Natlons Cblloren's Funo
(UN|CLF), Unlteo Natlons Funo |or Populatlon Actlvltles (UNFPA) ano PLAN
|nternatlonal.
To all tbe CHD Peglonal Dlrectors ano tbelr sta|| |or tbelr asslstance ln tbe
nomlnatlons o| tbe mlowlves |or tbe pre-test. Tbe support o| tbe Munlclpal ano
Clty Healtb O||lcers ano Mayors |or tbe mlowlves wbo attenoeo tbe pre-test.
Tbe comments ano suggestlons o| mlowlves |rom tbe |ollowlng communltles all
over tbe country wbo partlclpateo ln tbe pre-testlng were also cruclal ln tbe
lmprovement o| tbe guloebook.
Tabuk, Kallnga Apayao La Trlnloao, 8enguet
Mablnl, 8atangas Sublc Zambales
|mus, Cavlte San Fernanoo, Pampanga
Cabarroguls, Qulrlno Kalayaan, Laguna
Cateel, Davao Orlental Mamburao, Occloental Mlnooro
Paoay, |locos Norte Pomblon, Pomblon
8anasl Ponlo, Camarlnes Sur 8orbon Cebu
|cbague, |sabela Mlnalln, Pampanga
vlgan Clty, |locos Sur Caloocan Clty
Poas Clty, |lollo 8acon Dlstrlct, Sorsogon Clty
Manoaluyong Clty Surlgao Clty
A|DS Acqulreo |mmuno De|lclency Synorome
88T 8asal 8ooy Temperature
8LmOC 8aslc Lmergency Obstetrlc Care
8HS 8arangay Healtb Statlon
8M| 8ooy Mass |noe
8P 8looo Pressure
8TL 8llateral Tubal Llgatlon
8HW 8arangay Healtb Worker
CLmOC Comprebenslve Lmergency Obstetrlc Care
CMMNC Communlty-Manageo Maternal ano Newborn Care
DOH Department o| Healtb
LmOC Lmergency Obstetrlc Care
FP Famlly Plannlng
HSPA Healtb Sector Pe|orm Agenoa
|LHZ |nter Local Healtb Zones
|M |ntramuscular
|UD |ntra Uterlne Devlce
|v |ntravenous
LAM Lactatlonal Ammenorbea Metboo
LCL Local Cble| Lecutlve
NFP Natural Famlly Plannlng
MCH Maternal ano Cbllo Healtb
MDGs Mlllennlum Development Goals
M&L Monltorlng ano Lvaluatlon
N8S Newborn Screenlng
NGO Non-Government Organlzatlon
NSv Non-Scalpel vasectomy
OPS Oral Pebyoratlon Solutlon
PHC Prlmary Healtb Care
PbllHealtb Pblllpplne Healtb |nsurance Corporatlon
PO People's Organlzatlon
PTCA Parents-Teacbers-Communlty Assoclatlon
PAM Paplo Assessment ano Management
PHU Pural Healtb Unlt
SDM Stanoaro Days Metboo
SK Sanggunlang Kabataan
ST Sympto Tbermal
ST|/H|v Seually Transmltteo |n|ectlons/
Human |mmunooe|lclency Synorome
T8A Traoltlonal 8lrtb Attenoant
TT Tetanus Toolo
Acronyms
1
Communlty-Manageo Maternal & Newborn Care:
Introduction
"NEWELYOE]ERKMWERKTEERKMWERKMRERKQERKERKEREO. (Durlng
cblloblrtb, one |oot o| tbe motber ls ln tbe grave). Tbls ls a common
Flllplno saylng about pregnancy. Saoly, ln some communltles wben
motbers ole oue to cblloblrtb, lt ls seen more o| a |ate ratber tban a
bealtb ano buman rlgbts lssue wblcb neeos to be aooresseo. |t ls a |act
tbat tbere are rlsks ln pregnancy. However, tbere are ways to mlnlmlze
tbese rlsks. A woman's oeatb oue to cblloblrtb ano lts compllcatlons
sboulo not be seen as a normal" tblng. Pregnancy ls not an lllness or
conoltlon wblcb women sboulo be oylng |rom.
Most motbers ln tbe communltles wbo oleo glvlng blrtb eperlenceo
wbat eperts bave classl|leo as tbe tbree oelays. Tbese are
1 oelay ln oeclolng to seek meolcal care
2 oelay ln reacblng approprlate care, ano
3 oelay ln recelvlng care at bealtb
|acllltles.
Natlonal Demograpblc ano Healtb
Survey (NDHS, 1998) oata sbow tbat
ln tbe Pblllpplnes, tbere ls an
estlmateo 172 motbers wbo ole |or
every 100,000 llve blrtbs or a
total o| 3,650 motbers per year.
Unlteo Natlons agencles,
partlcularly WHO, UNFPA ano
UN|CLF estlmateo tbat at year
2000 maternal mortallty ratlo ln
tbe country even lncreaseo to 200
oeatbs per 100,000 llve blrtbs.
2
2
Tbe lack o| skllleo bealtb workers |urtber aggravates tbe problem. As o|
2003, sl out o| ten oellverles at bome are attenoeo by traoltlonal blrtb
attenoants (T8As) wblle only tbree out o| ten are by mlowlves.
Furtbermore, arouno 17 out o| 1,000 bables wltbln tbelr |lrst 28 oays o|
ll|e ole largely oue to tbe same |actors tbat cause tbe oeatb ano olsablllty
o| tbelr motbers ano oue to lack o| approprlate newborn care.
Tbls clearly sbows tbe cruclal role tbat mlowlves ano tbe Pural Healtb
Unlt bealtb team play ln savlng tbe llves o| motbers ano newborns ln tbe
communltles. Glven tbe sltuatlon tbat compllcateo cases are |lrst
re|erreo to &EVERKE] Healtb Statlons (8HSs)/ Pural Healtb Unlts
(PHUs), mlowlves, nurses ano ooctors sboulo be equlppeo wltb essentlal
skllls botb cllnlcal ano non-cllnlcal to oellver maternal ano newborn
bealtb servlces e||ectlvely. Tbe presence
o| skllleo mlowlves ano bealtb
pro|esslonals ls very lmportant most
especlally ourlng or lmmeolately a|ter
oellvery slnce tbls ls usually tbe tlme
wben compllcatlons arlse.
Lmergency obstetrlc care
(LmOC) ls a strategy tbat can
be useo to combat tbe tbree
oelays. Generally, all obstetrlc
compllcatlons can be treateo
especlally l| oanger slgns are
recognlzeo earller ano
prompt treatment ls glven.
Some countrles bave low
maternal mortallty ratlo because
LmOC ls avallable.
3
At present, very |ew PHUs are capable o| glvlng 8aslc Lmergency
Obstetrlc Care (8LmOC). Ano ln tbese non-8LmOC bealtb |acllltles, lt
ls essentlal tbat mlowlves, nurses ano ooctors are equlppeo wltb tbe
baslc skllls neeoeo so tbat tbey can contrlbute ln reouclng l| not
ellmlnatlng maternal ano ln|ant mortallty ano morblolty ln tbelr
communltles.
Tbls guloebook ls lntenoeo to provloe reaoy ln|ormatlon on tbe proper
care o| motbers ourlng pregnancy, labor, oellvery ano post oellvery ano
tbelr newborns by unoerstanolng tbe:
1 Tbree oelay mooels ano tbelr lmpllcatlons to maternal ano newborn
bealtb,
2 Cllnlcal protocol |or managlng obstetrlc ano newborn care, ano
3 Approacbes to communlty partlclpatlon ln tbe management o|
obstetrlc ano newborn care.
Every woman has the right to health to bave a bealtby
pregnancy ano sa|e oellvery, tbe rlgbt to quallty maternal bealtb care ano
tbe rlgbt to make oeclslons about tbelr own bealtb. Un|ortunately, tbls
remalns an loeal ano not a reallty. Unavallablllty o| servlces ano proper
ln|ormatlon, elstence o| laws tbat are olscrlmlnatory agalnst women,
ano lnequalltles at bome ano ln tbe communlty are just some o| tbe
|actors wblcb problblts tbem |rom reallzlng tbese reproouctlve bealtb
rlgbts.
To ensure tbat women all over tbe worlo wlll enjoy tbls rlgbt,
governments are obllgeo to enact pollcles tbat wlll lmprove maternal
ano cbllo bealtb (MCH). Tbese pollcles sboulo be bene|lclal not only to
tbe rlcb but most especlally to tbe marglnallzeo women ln tbe
communltles. Tbrougb tbe Prlmary Healtb Care approacb, problems on
MCH ln tbe communltles wlll be aooresseo by provlolng promotlve,
preventlve, curatlve ano rebabllltatlve servlces. People wlll also be able
to partlclpate lnolvloually ano collectlvely ln tbe plannlng,
lmplementatlon ano evaluatlon o| tbelr bealtb care.
3
4
Tbe Pblllpplne government tbrougb tbe Sa|e Motberbooo Program
lnltlateo by tbe Department o| Healtb, bas lmplementeo projects sucb
as 0MKXEW&YRXMW [wblcb means PMKXEWRETEKFYFYRXMW" (sa|e pregnancy ano
cblloblrtb) ano PMKXEWWETEKFYFYRXMW" (sa|ety |rom tbe rlsk o| unplanneo
pregnancy)] Campalgn", Maternal Deatb Pevlew, etc. to lmprove tbe
status o| women ano cblloren. Tbe Mlllennlum Development Goals
(MDGs), wblcb bave been agreeo upon by 189 countrles lncluolng tbe
Pblllpplnes to |lgbt agalnst poverty, target tbe reouctlon o| maternal
oeatbs by 75 ano mortallty rate among cblloren unoer |lve by two
tblros by Year 2015.
Acblevlng tbe goals o| reouclng maternal ano cbllo mortallty ano
morblolty wlll only be reallstlc tbrougb tbe polltlcal wlll o| tbe
government, botb natlonal ano local, commltment o| tbe bealtb workers
ano concerteo actlon o| tbe people. Only tben can we be ensureo o|
communltles wltb bealtby motbers ano cblloren.
4
5
Tbls Communlty-Manageo Maternal ano Newborn Care (CMMNC)
guloebook wlll serve as a re|erence tool |or mlowlves, nurses ano
ooctors ln tbe non-8LmOC Pural Healtb Unlts (PHUs) ano &EVERKE]
Healtb Statlons (8HSs) all over tbe country. |t ls olvloeo lnto |our
sectlons:
1 Sectlon 1: Unoerstanolng tbe |mpllcatlons o| tbe Tbree Delays
v A brle| olscusslon on tbe tbree oelays mooel ano bow lt
contrlbutes to maternal ano cbllo oeatbs ln tbe communltles.
2 Sectlon 2: Framework o| tbe Communlty-Manageo Maternal ano
Newborn Care (CMMNC)
v Dlscusses tbe |eatures o| CMMNC, roles o| motbers, |amllles
ano communlty members, mlowlves ano otber bealtb provloers,
bealtb |acllltles, &EVERKE] Captalns ano o||lclals, Mayors, Governors
ano Local Government Unlts (LGUs).
v Tackles brle|ly tbe concept o| |nter-local Healtb Zones (|LHZ),
tbe Healtb Sector Pe|orm Agenoa (HSPA), Fourmula One |or
Healtb ano bow tbey lnteno to aooress tbe tbree oelays mooel.
3 Sectlon 3: Provlolng 8aslc Cllnlcal |nterventlons |or Maternal ano
Newborn Compllcatlons
v |ncluoes subsectlons on prenatal care, care ourlng labor, cblloblrtb
ano lmmeolate postpartum ano newborn care.
v Color ls useo ln some tables to lnolcate tbe serlousness o| tbe
conoltlon ano tbe necessary care tbat bas to be maoe.
Green lnolcates routlne care
Yellow lnolcates management care wltbout re|erral
Plnk lnolcates emergency care or an urgency |or re|erral
to a blgber level o| bealtb |aclllty wltb LmOC capabllltles
v |ncluoes a oeolcateo subsectlon on ln|ormatlon, eoucatlon ano
aovlce on MCH.
How To Use this Guidebook
Green
Yellow
Plnk
6
7
Understanding
the Implications of the
Three Delays Model
8
Yhe 5tory of Nena
8
Nena ls a 23-year olo motber |rom Samar wbo gave blrtb to ber |lrst baby
at bome wltb tbe asslstance o| a
traoltlonal blrtb attenoant (T8A).
Tbe T8A lnstructeo ber to put
sanltary napklns as sbe may
stlll bleeo. Sbe tbougbt tbat
beavy bleeolng was normal
especlally |or |lrst tlme
motbers llke ber. However,
a oay bao passeo ano sbe
was stlll bleeolng pro|usely.
Her busbano went to see tbe
only mlowl|e ln tbelr communlty
but sbe was attenolng to anotber
oellvery tben. He wanteo to
brlng ber to tbe provlnclal
bospltal but tbey bao no means o|
transportatlon at tbat tlme. Flnally be was able to brlng ber to tbe bospltal
but lt was alreaoy too late. Sbe oleo o| beavy bleeolng.
Nena ls just one out o| tbe 10 Flllplno motbers wbo ole everyoay |rom
compllcatlons relateo to pregnancy ano cblloblrtb. Traglcally, 14 percent
o| all oeatbs among Flllplno women 15-49 years olo are oue to maternal
oeatbs (Soclal Watcb Pblllpplnes 2005 Peport).
Major causes maternal oeatb are:
v post-partum bemorrbage,
v eclampsla,
v obstructeo labor ano
v compllcatlons |rom abortlons
8ut l| tbe T8A ano l| Nena ano ber busbano knew about tbe oanger
slgnals a|ter blrtb ano l| tbere bao been emergency obstetrlc care |or
Nena, sbe woulo not bave been part o| tbe statlstlcs.
|nolrect causes o| maternal oeatbs
are:
v anemla
v malarla
v olabetes
v sepsls
9
v No avallable person to take care o| tbe cblloren, tbe bome ano
llvestock
v Lack o| companlon ln golng to tbe bealtb |aclllty
Tbe oelay ln oeclolng to seek care usually stems |rom |allure to recognlze
tbe oanger slgns by botb mlowl|e ano motber. On tbe average, almost
50 percent o| tbe pregnant women all over tbe country are not ln|ormeo
o| any pregnancy compllcatlons (NDHS, 2003). Motbers wlll be saveo
|rom |urtber barm l| tbey know tbe oanger slgns ln pregnancy ano
mlowlves are knowleogeable ln managlng tbem.
Yhe three delays model:
Wby are motbers oylng? Tbere are tbree olstlnct pbases o| oelay tbat
contrlbute to maternal oeatbs.
1 Delay in deciding to seek medical
care
Tbe |ollowlng are tbe common reasons clteo by motbers, mlowlves,
nurses, ooctors, T8As ano communlty members |or oelay ln oeclolng to
seek care:
v Fallure to recognlze oanger slgns
v Absence o| skllleo attenoants
v Lack o| money to pay |or meolcal epenses
ano cost o| transportatlon
v Pregnancy ls unplanneo or unwanteo
v Poor quallty o| obstetrlcal care
v Fear o| belng lll-treateo ln tbe bealtb |aclllty
v Peluctance |rom tbe motber or tbe |amlly
oue to cultural constralnts
v Tbe woman or |amlly member present at
cblloblrtb lack power to make a oeclslon
v Lack o| encouragement |rom relatlves ano communlty members
to seek care
9
10
Tbe |ollowlng are loeal qualltles tbat every mlowl|e, nurse or ooctor ln
a communlty sboulo be:
v approacbable
v patlent
v compasslonate
v sklll|ul
v |lelble
v resource|ul
v culturally sensltlve ano
v always wllllng to eoucate
2 Delay in identifying and reaching
the appropriate facility
Tbe secono oelay may be attrlbuteo to:
v Dlstance |rom a woman's bome to a |aclllty or provloer
v Lack o| roaos or poor conoltlon o| roaos
v Lack o| emergency transportatlon wbetber by lano or water
v Lack o| awareness o| elstlng servlces
v Lack o| a re|erral system
v Lack o| communlcatlon wltb re|erral |aclllty
v Lack o| moral, |lnanclal ano loglstlcal support |rom nelgbbors, tbe
FEVERKE] captaln ano FEVERKE] o||lclals or tbe mayor
A midwife's attitude towards mothers is a factor why
women choose to or choose not to seek medical attention.
If they are treated with respect and compassion, they will
not be afraid to approach the midwife most especially in
times of need.
11
Tbe oelay ln recelvlng care ls generally causeo by problems ln tbe re|erral
|aclllty. Tbese may be:
v Lack o| bealtbcare personnel
v Unpro|esslonal attltuoes o| bealtb care provloers
v Sbortages o| supplles (l.e. emergency meolclnes or blooo)
v Lack o| baslc equlpment e.g. |or caesarlan sectlon, blooo trans|uslon
v Poor skllls o| bealtb care provloers
v Healtb ls not prlorltlzeo by tbe FEVERKE] ano munlclpal o||lclals
v Lack o| buoget |rom tbe LGU
Tbls oelay relates to tbe
lssue o| access to care. |t
ls lnecusable tbat motbers
are oylng because o| tbe
oelay ln reacblng care. Saoly,
ln remote areas, tbls ls
usually tbe case. However,
l| motbers know tbat tbere
are skllleo mlowlves ln tbe
communlty wbo can atteno
to tbelr oellvery, tbey neeo
not go to bospltals unless
compllcatlons arlse. |n cases
tbat tbey bave to be
brougbt to bospltals,
ensurlng tbe raplo
transport o| tbe motber to
tbe nearest meolcal |aclllty
by tbe relatlves, nelgbbors
or FEVERKE] o||lclals ls
cruclal ln savlng ber ll|e.
3 Delay in receiving appropriate and
adequate care at the facility
11
12
12
More o|ten olstrlct ano provlnclal bospltals are poorly equlppeo wltb
tbe rlgbt personnel, supplles ano loglstlcs oue to LGU neglect. || tbe
bealtb o| tbe people wlll be tbe prlorlty o| tbe local government ano l|
communltles actlvely partlclpate ln bealtb programs, motbers wlll be
secureo o| better bealtb care tbrougb tbe servlces ano |acllltles avallable
|or ber use.
13
Framework of
Community-Managed
Maternal and
Newborn Care
Section 2
14
14
A communlty-manageo approacb ls a olrect lnterventlon to prevent
maternal ano perlnatal/neonatal oeatbs, lllnesses ano olsabllltles. Tbe
|ollowlng |eatures are present ln a Communlty-Manageo Maternal ano
Newborn Care (CMMNC):
1 Availability of maternal and child health services in the
contet of primary health care, bringing it closer to
the home of the mothers
v Mlowlves, nurses ano ooctors
are able to reacb motbers ano bables ano tbelr |amllles at bome
are tralneo wltb necessary skllls
v Facllltles bave supplles ano equlpments
v Pollcles are ln place to state wblcb obstetrlc proceoures can be
carrleo out by elstlng personnel
2 Established or
strengthened
referral systems
v Supporteo by rellable
transport ano communlcatlon
use o| telepbone (moblle
or lanollne) or two-way
raolos |or consultatlon
or re|errals
transportatlon ls
avallable any tlme o| tbe
oay
Two-way re|erral
mecbanlsms llnklng
bome to 8HS to
PHUs/ lylng-ln/ blrtblng
bome to olstrlct
bospltals to provlnclal
bospltals to reglonal
bospltals ano back or
traoltlonal blrtb
attenoant to mlowl|e to
ooctor to bospltal ano
back
15
15
Formallzeo ano contlnulng lnteractlon between mlowlves ano tbe
re|erral |acllltles
Poollng o| resources, wltb ol||erent FEVERKE]W, munlclpalltles or
olstrlcts
Lstabllsblng master llst o| potentlal communlty blooo oonors
3 Community education and mobilization for a common
understanding of the issues on maternal and
child health
v Conouctlng genoer ano culturally sensltlve ln|ormatlon ano eoucatlon
campalgns on sa|e motberbooo ano bealtby newborn to recognlze
tbe lmportance ano avallablllty o| skllleo care ourlng cblloblrtb, etc.
v Dlalogue among communlty members, FEVERKE] o||lclals, LGUs,
non-government organlzatlons (NGOs), people's organlzatlons
(POs) ano bealtb workers to loentl|y ways o| aooresslng lssues on
maternal ano cbllo bealtb
v Organlzatlon by TYVSO, careglvers clubs, 8HW ano youtb organlzatlons
|or support
Tbe baslc premlse o| communlty-manageo maternal ano newborn care
ls tbat tbe tbree oelays ln seeklng, reacblng, ano recelvlng gooo care wlll
be aooresseo l| tbere ls access to equltable ano quallty bealtb care. Tbls
can be reallzeo by ensurlng tbat tbe:
Pregnant woman has:
vA 8lrtb Plan wltb tbe reaolness to respono to any compllcatlons
v PbllHealtb membersblp ano ls able to avall o| tbe bene|lts accorolngly
(See Anne |or PbllHealtb olscusslon)
v Saveo/ allotteo money to prepare |or ber cblloblrtb ano servlces
tbat tbe newborn wlll be avalllng
v Plans |or oeslreo Famlly Plannlng (FP) servlces (spaclng or llmltlng
metboos)
Partner/5pouse and family members:
v Provloe care ano support by
accompanylng tbe motber ln prenatal ano postnatal cbeck-ups
belng present or nearby ourlng blrtb
attenolng to tbe neeos o| tbe baby
16
renoerlng bousebolo belp ourlng ano a|ter pregnancy
maklng plans lnvolvlng transportatlon ano posslble blooo oonors
v |s a PbllHealtb member ano knows bow to avall o| tbe bene|lts
accorolngly (See anne |or PbllHealtb olscusslon)
v Saveo/ allotteo money to prepare |or cblloblrtb ano servlces tbat
tbe newborn wlll be avalllng
Health Providers {Midwives, Nurses and Doctors} are:
v Cllnlcally skllleo, competent ano compasslonate ln provlolng gooo
care |or tbe woman ano ber baby, partlcularly recognlzlng ano
responolng to obstetrlc ano newborn emergencles sucb as
per|ormlng Qulck Cbeck, (See Sectlon 3)
Paplo Assessment ano Management (PAM), ano
establlsblng a systematlc re|erral system (e.g. |rom a prlmary
bealtb center to a |aclllty provlolng 8LmOC ano CLmOC).
(See Sectlon 4)
v Skllleo ln provlolng quallty bealtb eoucatlon ano counsellng to tbelr
cllents to prepare tbe woman ano ber |amlly |or sa|er pregnancy,
cblloblrtb, postpartum ano newborn care.
v Able to manage tbelr resources at tbe PHU/ 8HS e||lclently ano
e||ectlvely |or sustalnablllty o| CMMNC servlces.
Health facilities {BH5, RHU, 5econdary and tertiary levels
of care} assure pregnant women of quality and sustainable
services when they are:
v Manageo by competent ano compasslonate bealtb care provloers
v Sentrong Slgla Certl|leo
v PbllHealtb Accreolteo
v Llcenseo accorolng to requlreo regulatory pollcles
v Certl|leo 8LmOC |aclllty ano ratlonallzeo tbrougb |aclllty mapplng
Barangay Captain and Council members and other Local
Government Officials
v Lmpowereo, commltteo ano actlvely lnvolveo ln promotlng sa|e
motberbooo ano bealtby newborns
v L||ectlve leaoersblp o| tbe Governors, Mayors, ano &EVERKE] Captalns
to protect motbers ano cblloren.
v Tbe Local Cble| Lecutlves (LCLs) take actlon |or unlversal enrolment
o| all lnolgents to tbe Sponsoreo Program o| PbllHealtb ano tbe
upgraolng o| bealtb |acllltles |or accreoltatlon.
16
17
Inter Local Health Zones {ILHZ}
|nter Local Healtb Zones (|LHZ) are mecbanlsms to organlze ano moblllze
lnolvlouals, communltles, bealtb provloers ano bealtb |acllltles ln well
oe|lneo geograpblcal areas to provloe quallty, equltable ano accesslble
bealtb care wltb lnter-LGU partnersblps as a baslc |ramework.
Delayeo re|errals resultlng to poor maternal care ls a major problem
tbat |LHZ wlll aooress. |n tbe |LHZ, munlclpalltles are clustereo lnto
convergence sltes wbere tbere ls coorolnatlon ano networklng between
tbe olstrlct bospltal ano tbe PHUs ano 8HS.
Tbere ls cooperatlon ano poollng o| resources (buoget, equlpment, bealtb
buman resources, supplles, transportatlon) ano e||ectlve communlcatlon
among ol||erent munlclpalltles.
Tbere|ore, ln sltuatlons o| obstetrlc emergencles, a mlowl|e wlll be able
to e||ectlvely re|er tbe woman to an approprlate |aclllty provlolng 8LmOC
or CLmOC.
As |ront llne bealtb provloers ln tbe bealtb care system, mlowlves sboulo
be representeo ln |LHZ meetlngs togetber wltb tbe Mayors, olstrlct
bospltal cble| ano munlclpal bealtb o||lcers to be able to artlculate ber
neeos ano concerns |or sa|e motberbooo ano quallty newborn care.
17
18
Health 5ector Reform Agenda {H5RA}
Peallzlng tbe neeo to lmprove tbe bealtb status o| Flllplnos especlally
women ano cblloren, tbe government bas lmplementeo tbe Healtb Sector
Pe|orm Agenoa (HSPA) slnce 2000 ln tbe contet o| tbe Local Government
Cooe. One o| tbe objectlves o| tbe HSPA ls to revltallze tbe oecentrallzeo
bealtb care system ln a comprebenslve ano sustalnable manner.
Tbe HSPA alms to lmprove bealtb |lnanclng, bealtb regulatlon, bospltal
systems, local bealtb systems ano publlc bealtb programs. Specl|lcally, lt
lntenos to aooress tbe barrlers to utlllzatlon o| bealtb servlces, especlally
tbe tbree oelays ln accesslng maternal ano newborn care. Tbese barrlers
are:
v Llmlteo access to bealtb servlces,
v Poor quallty o| bealtb servlces,
v |naoequate bealtbcare |lnanclng,
v |ne||lclent bealtb systems,
v |ne||ectlve mecbanlsms |or publlc bealtb programs,
v Uneven olstrlbutlon o| bealtb pro|esslonals,
v Weak en|orcement o| bealtb stanoaros ano regulatlons,
v Lack o| communlty partlclpatlon at tbe FEVERKE] level.
Currently tbe government bas come up wltb Fourmula One for
Health, a |ramework |or better bealtb outcomes, more responslve
bealtb system ano equltable bealtb care |lnanclng, especlally |or tbe poor.
Tbese wlll be acbleveo tbrougb tbe |ollowlng components:
1} Health Care Financing to secure better ano sustalneo lnvestments
ln bealtb,
2} Health Regulation to assure access to quallty ano a||oroable
essentlal orugs, bealtb prooucts, oevlces, |acllltles ano servlces,
3} Health 5ervice Delivery to lmprove accesslblllty, avallablllty ano
equlty o| baslc ano essentlal bealtb care |or all, ano
4} Health Governance to lmprove local ano central bealtb system
management ano coorolnatlon, enbance publlc-prlvate partnersblp
ano bullo capacltles |or bealtb leaoersblp.
18
19
Providing Basic
Clinical Interventions
for Maternal
and Newborn
Complications
20
belp lmprove access o| women to neeoeo care.
Tbe Worlo Healtb Organlzatlon
(WHO) recommenos tbe
motber baby package
lnterventlons. Tbls ls a llst o|
essentlal servlces tbat sboulo
be maoe avallable to women
ano newborns to attaln
reouctlon ln maternal ano
perlnatal/neonatal oeatbs,
morbloltles ano olsabllltles.
Tbls sectlon re|lects tbe
lmplementatlon o| tbese
package lnterventlons.
regnancy poses a rlsk to tbe ll|e o| every woman. Any pregnant woman
can su||er compllcatlons ano ole. Some pregnancles are rlskler tban
otbers. Women wbo bave co-elstlng bealtb problems sucb as anemla,
malarla or olabetes are more llkely to bave compllcatlons. Healtby women
can also su||er compllcatlons. Tbe accuracy o| preolctlng wbo wlll oevelop
compllcatlons ls not posslble.
8lrtb also poses a rlsk to bables. Compllcatlons ano otber bealtb problems
o| tbe woman barm tbe baby too. Perlnatal ano neonatal oeatbs are
largely oue to tbe same |actors tbat cause maternal mortallty ano olsablllty.
Deatb ano olsabllltles |rom pregnancy compllcatlons can be preventeo
or treateo. Tbls can be acbleveo by a comblnatlon o| lnterventlons. Famlly
plannlng wlll belp avolo/prevent unplanneo, too early, too close, too many
ano too late pregnancles partlcularly among very blgb rlsk women. Quallty
prenatal, oellvery ano postpartum servlces can prevent compllcatlons,
oetect problems early ano allow prompt treatment ano management.
Moblllzlng communltles ano local governments wlll
P
20
21
Mother and Baby Package
Interventions
Before and during pregnancy
v Loucatlon ano counsellng ano actual servlces |or |amlly plannlng
v ST|/H|v/A|DS preventlon ano management
v Tetanus toolo lmmunlzatlon
v Antenatal reglstratlon ano care
v Treatment o| elstlng conoltlons (|or eample malarla ano bookworm)
v |ron/|olate supplementatlon
v Pecognltlon, early oetectlon ano management o| compllcatlons (eclampsla/pre-
eclampsla, bleeolng, abortlon, anemla)
v Healtb eoucatlon ano counsellng wltb empbasls on nutrltlon
During delivery
v Clean ano sa|e (atraumatlc) oellvery
v Pecognltlon, early oetectlon ano management o| compllcatlons at bealtb centre
or bospltal wltb LmOC capabllltles (|or eample, bemorrbage, sepsls,
prolongeo/obstructeo labor)
After delivery: mother
v Pecognltlon, early oetectlon ano management o| compllcatlons at bealtb centre
or bospltal wltb LmOC capabllltles (|or eample, bemorrbage, sepsls, eclampsla)
v Postpartum care (promotlon ano support to breast|eeolng ano management o|
breast compllcatlons)
v Loucatlon ano counsellng ano actual servlces |or |amlly plannlng
v ST|/H|v/A|DS preventlon ano management
v Tetanus toolo lmmunlzatlon baseo on scbeoule
v Healtb eoucatlon ano counsellng
After delivery: newborn
v Pesuscltatlon
v Preventlon ano management o| bypotbermla lncluolng optbalmla neonatorum
ano coro ln|ectlons
v 8reast|eeolng lnltlatlon wltbln one bour a|ter blrtb
v Lcluslve breast|eeolng up to 6 montbs
v Preventlon ano management o| ln|ectlons
v Newborn screenlng
v Healtb eoucatlon ano counsellng
21
22
22
Qulck cbeck ls a serles o| steps to assess tbe conoltlon o| tbe woman
ano/or ber newborn.
A qulck cbeck ls necessary to ensure tbat women ano newborns wbo
bave problems or conoltlons tbat requlre lmmeolate attentlon are taken
care o| promptly. Tbls wlll avolo worsenlng o| conoltlon ano/or
preventlon o| oeatb.
Do tbe qulck cbeck lmmeolately upon arrlval o| tbe woman ano/or ber
newborn ano repeat qulck cbeck l| tbe queue ls long.
3.1 Quick Check
23
Rapid Assessment and Management {RAM}
v For vaglnal bleeolng
assess pregnancy status
assess amount o| bleeolng
stop tbe bleeolng
v Stablllze tbe woman l| sbe ls:
not breatblng convulslng
ln sbock wltb blgb |ever
v Assess |lrst emergency slgns
v Do all emergency steps
be|ore re|erral
manage alrway ano
breatblng
measure blooo pressure
ano count pulse
Quick check for the woman
and/or her newborn
24
24
5teps to follow:
1. Glve emergency management.
2. Dlscuss oeclslon wltb woman, partner/spouse ano relatlves.
3. Qulckly organlze transport ano posslble |lnanclal alo.
4. |n|orm tbe re|erral center by cell pbone, lanollne or raolo.
5. Lnsure support
v Accompany tbe woman/newborn to tbe re|erral center, l| posslble.
v Have relatlves, wbo can oonate blooo, go wltb tbe woman.
v 8rlng tbe baby wltb tbe motber, l| posslble.
v 8rlng along tbe Motber ano 8aby book ano |lll out a re|erral |orm.
3.2 Referral
|n tbe event o| obstetrlcal ano newborn compllcatlons ano/or
emergencles, lt ls lmportant tbat tbe woman ano ber newborn are
re|erreo to a bealtb |aclllty capable o| glvlng tbem tbe neeoeo care ano
support by bavlng a 8LmOC or CLmOC certl|lcatlon |rom tbe DOH.
Prevent oelay ano ensure tbat re|erral ls tlmely to prevent oeatb ano
olsablllty.
Wltb your FEVERKE]W, oevelop an emergency transport system tbat ls |ast
enougb ano avallable 24 bours everyoay. (See Sectlon 4 |or |urtber
olscusslon)
Get to know ano coorolnate, call ano communlcate wltb tbe persons
responslble |or recelvlng re|errals to |acllltate proceoures ano prevent
unnecessary waltlng.
25
6. Durlng journey:
For the woman:
v || journey ls long, glve approprlate treatment on tbe way.
v || tbe woman ls bleeolng, contlnue to monltor blooo loss ano
contlnue measures to oecrease bleeolng, accorolng to cause.
v Manage sbock.
v || tbe woman bas an |v llne, watcb tbe ln|uslon.
v Keep recoros o| all |v |lulos, meolcatlons glven, tlme o|
aomlnlstratlon ano tbe woman's conoltlon.
For the baby:
v Keep tbe baby warm by skln-to-skln contact wltb motber or
someone else.
v Cover tbe baby wltb a blanket ano wltb a cap on tbe beao.
v Protect tbe baby |rom olrect sunllgbt.
v Lncourage breast|eeolng ourlng tbe journey.
v || tbe baby ooes not breast|eeo ano tbe journey ls more tban 3
bours, consloer glvlng epresseo mllk by cup.
25
26
First aid for the woman
with danger signs
Lnsure tbat |lrst alo treatment ls glven to tbe woman be|ore tbe re|erral
to belp prevent |urtber oeterloratlon o| ber conoltlon.
If severe difficulty of breathing and obstruction is suspected:
v Try to clear tbe
alrway ano olslooge
obstructlon.
v Help tbe woman to
|lno tbe best
posltlon |or
breatblng.
v Urgently re|er tbe
woman to tbe
bospltal wltb
LmOC capabllltles.
Unconscious:
v Keep ber on ber back, arms at tbe sloe.
v Tllt ber beao backwaros (unless trauma ls suspecteo).
v Ll|t ber cbln to open alrway.
v |nspect ber moutb |or |orelgn booy, remove l| |ouno.
v Clear secretlons |rom tbroat.
Inserting intravenous {IV} line and giving fluids to prevent
or correct shock:
v Wasb banos wltb soap ano water.
v Clean woman's skln wltb alcobol at slte |or |v llne uslng a 16-18
gauge neeole.
v Attacb Plnger's lactate or normal sallne, ensure ln|uslon ls runnlng
well.
26
27
v Glve |lulos at raplo rate l| ln sbock, systollc 8P ls less tban 90 mm
Hg, pulse rate ls more tban 110/mlnute or beavy vaglnal bleeolng:
|n|use 1 llter ln 15-20 mlnutes (as raplo as posslble)
Follow wltb 1 llter ln 30 mlnutes at 30 ml/mlnute, repeat l|
necessary
Monltor every 15 mlnutes |or 8P, pulse ano sbortness o|
breatb
Peouce ln|uslon rate to 3 ml/mlnute (1 llter ln 6-
8 brs) wben pulse slows to less tban 100/mlnute, systollc
8P lncreases to 100 mm Hg or blgber
Stop ln|uslon rate l| wltb breatblng ol||lculty or l| pu||lness
oevelops
Monltor urlne output
Pecoro tlme ano amount o| |lulos glven
v Glve |lulos at mooerate rate (1 llter ln 2-3 bours) l| wltb severe
aboomlnal paln, obstructeo labor, ectoplc pregnancy, oangerous
|ever or oebyoratlon.
v || |v access ls not posslble, glve oral rebyoratlon solutlon (OPS)
by moutb l| able to orlnk or by nasogastrlc tube at 300-500 ml
ln one bour.
Do NOY give OR5 to a woman who is unconscious or
has convulsions. If she is unable to swallow, OR5 may
go to her lungs.
Do NOY administer intravenous fluids if you are NOY
trained to do so.
Postpartum bleeding
v Wben a woman ls bleeolng, massage uterus ano epel clots.
v || postpartum bleeolng perslsts a|ter placenta ls oellvereo, or
uterus ls not well contracteo:
Place cuppeo palm on uterlne |unous ano |eel |or state o|
contractlon
Massage |unous ln a clrcular motlon wltb cuppeo palm untll uterus
ls well contracteo
27
necessary
28
Wben well contracteo, place |lngers beblno |unous ano pusb oown
ln one swl|t actlon to epel clots
Collect blooo ln a contalner placeo closeo to vulva. Measure
or estlmate blooo loss, ano recoro
Glve ergometrlne 0.2 mg |M ano anotber oose a|ter 15 mlnutes.
Do NOY give ergometrine if woman has eclampsia,
pre-eclampsia, or hypertension.
v || postpartum bleeolng perslsts oesplte removal o| placenta, uterlne
massage, ano ergometrlne treatment, apply bimanual uterine
compression:
Wear sterlle or clean gloves
|ntroouce tbe rlgbt bano lnto tbe vaglna, clencbeo |lst, wltb
tbe back o| tbe bano olrecteo posterlorly ano tbe knuckles
ln tbe anterlor |ornl
Place tbe otber bano on tbe aboomen beblno tbe uterus
ano squeeze tbe uterus |lrmly between tbe two banos
Contlnue compresslon untll bleeolng stops (no bleeolng
l| tbe compresslon ls releaseo).
28
29
Referral levels
30
5teps to follow:
1. Do a quick check for emergency signs.
Emergency signs:
v Unconsclous/Convulslng
v vaglnal bleeolng
v Severe aboomlnal paln
v Looks very lll
v Severe beaoacbe wltb vlsual olsturbance
v Severe breatblng ol||lculty
v Fever
v Severe vomltlng
Do NOY make a very sick woman wait,
attend to her quickly.
2. Make the woman comfortable.
v Greet ber, make sure sbe ls com|ortable ano ask bow sbe ls
|eellng.
v || |lrst vlslt, reglster tbe woman ano lssue a Motber ano Cbllo
8ook.
3.3 Prenatal Care
|n rural areas, 61.3 percent o| motbers ano ln urban areas, 38.2 percent
go to mlowlves ano nurses |or prenatal care (NDHS, 2003). Tbrougb
prenatal care, olseases wblcb may leao to compllcatlons can be oetecteo
ano manageo early. Women are also ln|ormeo ano eoucateo on oanger
ano emergency slgns ano symptoms. Sbe ano ber |amlly are also belng
prepareo |or cblloblrtb ano at tbe same tlme recelve recommenoatlons
wbere to seek treatment l| compllcatlons arlse.
30
31
3. Assess the pregnant woman.
v Use tbe cbart Assess tbe Pregnant Woman", ourlng prenatal
vlslts.
v Durlng tbe |lrst prenatal vlslt, olscuss ano prepare a blrtb plan
wltb emergency prepareoness measures, ano revlew on succeeolng
vlslts.
Lncourage all pregnant women to oellver ln tbe bealtb
|aclllty.
Dlscuss wltb tbe woman as to wbo wlll be ber companlon
ourlng labor, oellvery ano 24 bours a|ter blrtb ano wbo
wlll care |or ber bome ano cblloren.
|| motber stlll pre|ers to oellver at bome wltbout a skllleo
blrtb attenoant respect ber oeclslon. Speno more tlme
glvlng ln|ormatlon on clean ano sa|e oellvery at bome.
v Mool|y tbe blrtb plan l| any compllcatlons arlse.
All pregnancies are at risk. Encourage all pregnant
women to deliver in the health facility.
Always record findings. It can help you make the right
and timely decisions on the care of the woman and her
baby.
31
32
2
Assess the Pregnant Woman: Pregnancy 5tatus,
Birth and Emergency Plan
Do NOY perform a vaginal eamination as a
routine prenatal care procedure.
33
4. Get baseline laboratory information of the woman on
the first or following the first visit.
v Determlne bemoglobln ano blooo type ano per|orm a urlnalysls.
v || not avallable, re|er to tbe nearest PHU or bospltal |or tbe tests.
5. Check for gestational diabetes.
v Ask about |amlly blstory (|lrst oegree) o| olabetes ano blstory o|
obeslty.
v Ask about past pregnancy |or ol||lcult labor, large bables, congenltal
mal|ormatlons ano prevlous uneplalneo |etal oeatb.
v Look |or slgns o| maternal overwelgbt or obeslty, polybyoramlos,
slgns o| large baby, |etal abnormallty ano vaglnal ln|ectlon.
If positive for:
v |amlly blstory o| olabetes ano
v woman ls 25 years ano oloer ano
v ls obese
- Sbe ls at low rlsk |or olabetes, re|er |or glucose screenlng
between tbe 24
tb
ano 28
tb
montb o| pregnancy.
If positive for:
v |amlly blstory o| olabetes ano
v blstory o| overwelgbt/obeslty ano
v sbe ls obese ano
v sbe bas polybyoramlos or bas a
large |etus or tbere ls |etal
abnormallty or bas recurrent
vaglnal ln|ectlons or blstory o|
uneplalneo |etal oeatb
- Sbe ls at blgb rlsk |or olabetes,
re|er |or glucose screenlng as
soon as posslble.
33
34
6. Check for pallor or anemia.
v Ask about gettlng tlreo easlly or sbortness o| breatb ourlng routlne
work.
v On |lrst vlslt, oetermlne bemoglobln ano blooo type. Tbe normal
bemoglobln cut-o|| level |or a pregnant woman ls 11g/ol.
v On subsequent vlslts,
look |or conjunctlval pallor.
look |or palmar pallor. || pallor: |s lt severe pallor? Some pallor?
ano count number o| breatbs ln one mlnute.
7. Check for hypertension/pre-eclampsia.
vMeasure 8P ln slttlng posltlon.
v|| olastollc 8P ls 90 mm Hg or blgber repeat measurement a|ter
1bour rest.
v|| olastollc 8P ls stlll 90 mm Hg or blgber ask tbe woman
l| sbe bas:
Severe beaoacbe
8lurreo vlson
Lplgastrlc paln
v Ano cbeck urlne |or proteln.
8. Check for fever, burning sensation on urination and
abnormal vaginal discharge.
v Ask about eplsooes o| |ever or cbllls ano take temperature.
v Ask about paln or burnlng sensatlon on urlnatlon.
v Ask about presence o| abnormal vaglnal olscbarge, ltcblng at tbe
vulva or l| partner bas a urlnary problem.
9. Immunize against tetanus.
v Cbeck tetanus lmmunlzatlon status.
v || 8HS ls a |leo center, glve tetanus toolo, 0.5 ml accorolng to
scbeoule. || not, ln|orm tbe woman to return on tbe net lmmunlzatlon
rouno.
v Aovlse woman wben tbe net oose ls oue ano to complete
tbe 5 ooses.
34
35
10. Yreat for intestinal parasites.
v Glve mebenoazole 500 mg tablet, 1 tablet, slngle oose anytlme
|rom 4-9 montbs o| pregnancy ano l| none was glven ln tbe past
6 montbs.
Do NOY give mebendazole in the first 1-3 months
of pregnancy; it might cause congenital problems in
the baby.
11. Prevent anemia and neural tube defects with iron
and folate supplementation.
v Glve lron/|olate, 60 mg/400ug tablet, 1 tablet oally to last untll
scbeouleo return vlslt.
v For best preventlon, lt ls best to glve lron ano |olate
supplementatlon be|ore pregnancy.
35
Yetanus Yooid Immunization 5chedule
Vaccine
TT1
TT2
TT3
TT4
TT5
Minimum Interval
at |lrst contact wltb
woman 14-45 yrs or at
|lrst ANC vlslt
at least 4 weeks a|ter
TT1
at least 6 montbs a|ter
TT2
at least 1 year a|ter TT3
at least 1 year a|ter TT4
Duration of Protection
v |n|ants born to tbe motber wlll be protecteo
|rom neonatal tetanus
v 3 years o| protectlon |or tbe motber
v Ll|etlme protectlon |or tbe motber
36
Give preventive intermittent treatment for falcifarum
malaria.
v Glve sul|aoolne-pyrlmetbamlne to women |rom malarla enoemlc
areas wbo are ln tbelr |lrst or secono pregnancy, 500 mg -25
mg tablet, 3 tablets at tbe beglnnlng o| tbe 2
no
ano 3
ro
trlmesters
(not less tban one montb lnterval).
v Lncourage sleeplng unoer a beo net, pre|erably lnsectlcloe
treateo.
Give preventive intermittent treatment for
malaria only to women in endemic areas.
Give Vitamin A.
v Glve vltamln A 10,000 |U, twlce a week, startlng on tbe
4
tb
montb o| pregnancy.
v || woman ls alreaoy taklng multlvltamlns, |orgo vltamln A
supplementatlon.
Do NOY give vitamin A supplementation before
the 4th month of pregnancy. It might cause
congenital problems in the baby.
Provide health information, advice and counsel on
danger signals and three delays.
v Dlscuss |lrst tbe toplcs tbat are most lmportant to tbe woman
ourlng tbe vlslt. Cover otber suggesteo toplcs once maln concern
o| tbe woman bas alreaoy been aooresseo.
v Speno more tlme glvlng nutrltlon eoucatlon ano counsellng to
very tbln women ano aoolescents.
Family planning education and counseling are
very important during the whole course of
pregnancy up to postpartum particularly before
delivery because female sterilization and insertion
of IUD can be done immediately postpartum.
37
15. Encourage the woman to come back for return visits.
37
Information and advice during antenatal care
At first visit:
vNutrltlon ano preventlng
anemla
vPreventlng tetanus
vPreventlng malarla
vDlscom|orts o| pregnancy
vLmergency slgns o| pregnancy
vFollow-up vlslts ano wben ano
wbere to go ourlng emergencles
vNewborn screenlng
vLoucatlon ano counsellng on FP
At second visit:
vSel| care ourlng pregnancy
vAovantages o| bealtb |aclllty
oellvery
vPreparatlon |or obstetrlc events
In the third trimester:
v8reast mllk ano breast|eeolng
vFamlly Plannlng
vClean ano sa|e oellvery by a skllleo
pro|esslonal
vNewborn screenlng
vLoucatlon ano counsellng on FP
v Scbeoule tbe oate ano note lt oown on tbe Motber ano Cbllo
8ook.
v Lncourage tbe woman to brlng ber partner or a |amlly member
to at least one vlslt.
v A|ter tbe 8
tb
montb, see woman every 2 weeks untll sbe
oellvers.
v All pregnant women should have at least 4 routine
antenatal visits.
v Encourage women to come for the first prenatal
visit as early in pregnancy as possible before 4 months.
v Pregnant women who do not come for prenatal care
should be visited at home.
38
38
3.4 Care during labor,
childbirth and immediate
postpartum
|n preventlng maternal ano newborn mortallty, gooo quallty bealtb care
ls lmportant ourlng tbe crltlcal perloo o| labor ano oellvery. Tbe
presence o| a skllleo blrtb attenoant, may lt be a mlowl|e, nurse or
ooctor ooes not only ensure byglene ourlng labor ano oellvery, but may
also provloe sa|e ano non-traumatlc care, recognlze compllcatlons, ano
also manage tbem e||ectlvely or re|er competently tbe woman to a
blgber level o| care.
Tbe |ollowlng are steps to |ollow wben oolng care ourlng labor,
cblloblrtb, ano lmmeolate postpartum.
5teps to follow:
1. Do a quick check for emergency signs.
Emergency signs:
v vaglnal bleeolng
v Looks very lll
v Severe beaoacbe wltb vlsual olsturbance
v Fever
v Severe vomltlng
Do NOY make a very sick woman wait,
attend to her quickly.
,
39
v Greet ber, make sure sbe ls com|ortable ano ask bow sbe ls |eellng.
v || woman bas bao no prenatal vlslts, reglster tbe woman ano lssue
a Motber ano Cbllo 8ook.
3. Assess the woman in labor
v Take tbe blstory o| labor ano recoro on tbe labor |orm
Start o| labor palns, |requency ano lntenslty o| contractlons
vaglnal olscbarge, sbow, bleeolng
Water, wben tbe bag o| waters broke, color o| water
|s tbe baby movlng?
v Pevlew Motber ano 8aby 8ook or |aclllty prenatal recoro
|| no recoro, ask wben tbe oellvery ls epecteo
Determlne l| preterm (less tban 8 montbs pregnant)
Pevlew tbe blrtb plan
If with prior pregnancies,
Number o| prlor pregnancles/oellverles
Any prlor caesarean sectlon, |orceps oellvery or otber
compllcatlons sucb as postpartum bemorrbage
Any prlor tblro oegree tear
v Observe tbe woman's response to contractlons. |s sbe
Coplng well?
Dlstresseo?
Pusblng or gruntlng?
Cbeck aboomen |or:
9 Caesarean sectlon scar
9 Horlzontal rloge across lower aboomen (l| present, empty
blaooer ano observe agaln)
Feel aboomen |or:
9Contractlons, |requency, ouratlon, any contlnuous contractlons
9Fetal lle, longltuolnal or transverse
9Fetal presentatlon, beao, breecb, otber
9More tban one |etus
9Fetal movement
39
40
Llsten to tbe |etal beartbeat: Count number o| beats ln one mlnute
|| less tban 100 or more tban 180 beats per mlnute, turn woman
on ber le|t sloe ano count agaln
Measure 8P ano temperature
Look |or pallor
Look |or sunken eyes, ory moutb. Plncb tbe skln o| tbe |orearm,
ooes lt come back qulckly?
4. Determine the stage of labor.
v Lplaln to tbe woman tbat you wlll per|orm a vaglnal eamlnatlon
ano ask |or ber consent.
v |nspect tbe vulva |or:
8ulglng perlneum
Any vlslble |etal parts
vaglnal bleeolng
Leaklng amnlotlc |lulo, l| yes, ls lt meconlum stalneo, |oul smelllng?
Warts, kelolo tlssue or scars tbat may lnter|ere wltb oellvery?
40
41
Eamination of the vulva and vagina
v Always eplaln ano ask |or tbe woman's consent
v Wasb your banos wltb bubbllng soap ano water be|ore ano a|ter
eacb eamlnatlon.
v Use clean gloves |or vaglnal eamlnatlon.
v Wasb tbe vulva ano perlneal areas be|ore eacb eamlnatlon.
v Per|orm gentle vaglnal eamlnatlon (oo not start ourlng contractlon):
Determlne cervlcal ollatatlon ln centlmeters (cm)
Feel |or presentlng part, ls lt baro, rouno ano smootb (beao)? ||
not, loentl|y tbe presentlng part
Feel |or tbe membranes, ls lt lntact?
Feel |or tbe coro, ls lt |elt? Pulsatlng?
Do NOY perform vaginal eam if bleeding now or
earlier in the third trimester.
Determining 5tage of Labor
41
42
5. Decide if the woman can safely deliver.
v || tbere ls no lnolcatlon |or re|erral, contlnue to take care o| ber.
v || tbere ls any lnolcatlon |or re|erral but woman ls ln late actlve labor,
oellver tbe baby but prepare |or lmmeolate re|erral l| stlll necessary.
v || tbere ls any lnolcatlon |or re|erral ano sbe ls ln early labor ano tbe
re|erral bospltal can be tlmely reacbeo, re|er urgently.
v || tbe woman or ber |amlly re|uses re|erral, contlnue to take care o|
ber but eplaln tbe posslble consequences.
6. Give supportive care throughout labor
v Lplaln proceoures, seek
permlsslon ano olscuss
|lnolngs wltb tbe
woman ano ber |amlly.
v Lamlne tbe woman ln a
place wbere sbe ls not
eposeo to people
otber tban tbe eamlnlng
person ano ber cbolce o|
companlon.
v Lncourage ber to wasb
|rom ber walst oown or
take a batb at tbe onset o|
labor.
v Lncourage ber to move
|reely, support ber cbolce
o| a blrtblng posltlon.
v Lncourage ber to orlnk but not eat as sbe may vomlt or ln case sbe
neeos surgery, tbe olgestlon may lnter|ere.
v Lncourage ber to empty ber blaooer ano bowels. Pemlno ber to empty
ber blaooer every 2 bours.
42
43
43
Do NOY shave perineum. It causes discomfort when hair
grows back and it does not reduce the risk of infection as
previously thought of.
Do NOY give enema. It causes discomfort and carries a
certain degree of risk to the bowel. Without an enema,
soiling is mainly light and easier to remove than soiling
after an enema.
NEVER leave a woman in labor alone.
Breathing technique
v Teacb woman to notlce normal breatblng.
v Lncourage ber to breatbe more slowly, maklng a slgblng nolse ano
to rela wltb eacb breatb.
v || sbe |eels olzzy or |eellng plns ano neeoles ln ber |ace, banos or
|eet, encourage ber to breatbe more slowly.
v To prevent pusblng at tbe eno o|
tbe |lrst stage, teacb ber pantlng,
to breatbe wltb open moutb, make
2 sbort breatbs |olloweo by a
long breatb out.
v Durlng oellvery o| tbe beao ask
ber not to pusb but to breatbe
steaolly or to pant.
v Talk to ber ano ber companlon about tbe process ano progress o|
labor.
v Coacb ber on breatblng tecbnlque.
v Malntaln cleanllness o| labor ano blrtblng areas ano clean up spllls
lmmeolately.
v Lncourage support |rom tbe cbosen blrtb companlon.
44
7. Monitor and manage labor.
Flrst stage: not yet ln actlve labor, cervl ls ollateo 0-3 cm ano
contractlons are weak, less tban 2 ln 10 mlnutes
v Cbeck every bour |or emergency slgns, |requency ano ouratlon o|
contractlons, |etal beart rate, mooo ano bebavlor.
v Cbeck every 4 bours |or |ever, pulse, blooo pressure ano cervlcal
ollatatlon.
v Pecoro |lnolngs ln labor recoro.
v Pecoro tlme o| rupture o| membranes ano color o| tbe amnlotlc
|lulo.
v Assess progress o| labor.
A|ter 8 bours, l| contractlons are stronger ano more |requent
but no progress ln cervlcal ollatatlon wltb or wltbout membranes
ruptureo, re|er tbe woman urgently to tbe bospltal wltb CLmOC
capabllltles.
Pain and discomfort
relief
v Suggest cbange o| posltlon
v Lncourage moblllty, as
com|ortable |or ber
v Lncourage companlon to:
Massage ber lower back
l| sbe |lnos lt belp|ul.
Holo ber bano ano
sponge ber |ace ano neck
between contractlons
v Lncourage ber breatblng
tecbnlque
v Lncourage warm batb l|
avallable ano oeslreo
45
45
A|ter 8 bours, l| tbere ls no lncrease ln contractlons, ano membranes
are not ruptureo, ano no progress ln cervlcal ollatatlon, aovlse tbe
woman tbat sbe bao a |alse labor ano to walt |or lncreaslng
paln/olscom|ort ano |or rupture o| tbe membranes.
Do NOY do vaginal eamination more frequently than
every 4 hours.
Flrst stage: ln actlve labor, cervlce ls ollateo 4 cm or more
v Cbeck every 30 mlnutes |or emergency slgns, |requency ano ouratlon
o| contractlons, |etal beart rate, mooo ano bebavlor.
v Cbeck every 4 bours |or |ever, pulse, blooo pressure ano cervlcal
ollatatlon.
v Pecoro tlme o| rupture o| membranes ano color o| tbe amnlotlc
|lulo.
v Pecoro |lnolngs ln labor recoro ano partograpb.
Do NOY allow the woman to push unless delivery is
imminent. It does not help to speed up labor and will
just ehaust the woman.
Do NOY give medications to speed up labor. Yhis is
dangerous and may cause trauma to the mother and
the baby.
If partograph passes alert line
v Peassess woman ano consloer crlterla |or re|erral
v Alert transport servlces
v Lmpty blaooer
v Lnsure aoequate byoratlon but omlt sollo |ooos
v Lncourage uprlgbt posltlon ano walklng l| woman wlsbes
v Monltor lntenslvely. || re|erral long, reassess ln 2 bours
ano re|er l| no progress
46
46
Secono stage, cervl ollateo10 cm or bulglng tbln perlneum
ano beao ls vlslble
v Cbeck every 5 mlnutes |or perlneum tblnnlng ano bulglng, vlslble
oesceno o| tbe beao ourlng contractlon, emergency slgns, |etal beart
rate ano mooo ano bebavlor.
v Contlnue recorolng ln tbe partograpb.
If partograph passes ACYION line, refer urgently to
an EmOC facility unless imminent delivery.
v Asslst tbe oellvery.
Lnsure all oellvery equlpment ano supplles are avallable ano place
o| oellvery ls clean ano warm.
Lnsure blaooer ls empty.
Posltlon tbe woman com|ortably wbere sbe wlll oellver.
Wben oellvery ls lmmlnent, wasb banos, open oellvery klt, reaoy
oytocln 10 |U ano put on gloves just be|ore oellvery.
Stay wltb tbe woman ano encourage ber. Malntaln constant verbal
ano eye contact.
Awalt |or spontaneous pusblng e||orts by tbe woman. Do not
rusb ber.
Dellver tbe baby.
Glve oytocln 10 |U |M*.
Watcb |or vaglnal bleeolng.
Keep hands off the perineum until head of baby
advances. Massaging and/or stretching the perineum
have not been shown to be beneficial.
Do NOY apply fundal pressure to help deliver the
baby. It may harm the mother and her baby.
* Tbere ls a current e||ort to ameno tbe Mlowl|ery law to allow mlowlves to aomlnlster
oytocln.
47
Delivering the baby
v Lnsure controlleo oellvery o| tbe beao.
Keep one bano on tbe beao as lt aovances wltb contractlons.
Support perlneum wltb otber bano ano cover anus wltb pao belo
ln posltlon by beel o| bano ourlng oellvery.
Dlscaro pao ano replace wben solleo to prevent ln|ectlon.
Leave tbe perlneum vlslble between tbumb ano lnoe |lnger.
Ask tbe woman to breatbe steaolly ano not to pusb ourlng oellvery
o| tbe beao.
Lncourage raplo breatblng wltb moutb open.
v Feel gently rouno tbe neck |or tbe coro. || coro present ano loose,
oellver tbe baby tbrougb tbe loop o| coro or sllp lt over tbe baby's
beao. || coro ls tlgbt, clamp ano cut tbe coro ano unwlno lt |rom
arouno tbe neck.
v Gently wlpe tbe baby's |ace wltb a clean gauze or clotb.
v Awalt spontaneous rotatlon o| tbe sbouloers to tbe antero-posterlor
posltlon (wltbln 1- 2 mlnutes).
v Apply gentle oownwaro pressure to oellver top sbouloer tben ll|t
baby up to oellver lower sbouloer.
v Catcb tbe baby wltb a towel ano ory baby wltb lt.
v Place tbe baby on motber's aboomen or arms.
v Note tbe tlme o| oellvery.
v Wblle baby ls on motber's aboomen or cbest, ory baby, wlpe eyes
ano assess breatblng.
v Palpate tbe motber's aboomen to ecluoe secono baby.
48
48
vClamp ano cut tbe coro.
Cbange gloves. || not posslble wasb gloveo banos wltb bubbllng
soap ano water.
Put tles tlgbtly arouno tbe coro at 2 cm ano 5 cm |rom tbe baby's
aboomen.
Cut between tles wltb a sterlle lnstrument.
Observe stump |or blooo oozlng.
Do not banoage or blno tbe stump. Leave lt open.
v Keep tbe baby warm.
Tborougbly ory tbe baby.
Leave baby on tbe motber's cbest ln skln-to-skln contact.
Cover tbe baby, cover tbe beao wltb a cap.
Put baby to motber's breasts.
Do NOY use hot water bottles to warm the baby.
Baby's skin might get burned. 5kin-to-skin contact
with the mother is the best way to keep the baby
warm.
Do NOY leave the baby wet, she/he will become cold.
49
49
Tblro stage, between blrtb o| tbe baby ano oellvery o| tbe placenta
v Dellver tbe placenta by controlleo coro tractlon.
v Cbeck tbat tbe placenta ano membranes are complete.
|n gooo llgbt, bolo placenta ano membrane up by tbe coro.
Lpose maternal sur|ace o| tbe placenta ano cbeck |or
completeness.
v Put tbe placenta lnto a contalner ano bano over to a |amlly member
|or olsposal.
Delivering the placenta by controlled cord traction
v Clamp tbe coro close to tbe perlneum ano bolo lt wltb one bano.
v Place sloe o| tbe otber bano above sympbysls publs wltb palm |aclng
towaros tbe motber's umblllcus.
v Awalt |or a strong uterlne contractlon. Wben uterus ls well
contracteo, start sustalneo, gentle coro tractlon wltb one bano.
Wltb tbe otber bano, eert counter tractlon on tbe aboomen.
v || tbe placenta ooes not oesceno ourlng 30-40 seconos o| controlleo
coro tractlon, release botb coro tractlon ano counter tractlon ano
repeat wltb tbe net contractlon.
v As tbe placenta ls comlng out, catcb ln botb banos to prevent
tearlng o| tbe membranes.
|| tbe membranes oo not sllp out spontaneously, gently twlst lt
lnto a rope ano move lt up ano oown to belp separatlon wltbout
tearlng lt.
|| tbe membranes tear, gently eamlne tbe upper vaglna ano cervl
ano use a sponge |orceps to remove any pleces o| membranes
tbat are present.
v Never apply cord traction without applying counter
traction above the pubic bone with the other hand.
v Always use gentle traction to pull the placenta.
v Do NOY squeeze or massage the abdomen to deliver
the placenta.
v Do NOY put fingers or hand in the vagina to locate
placenta.
v Do NOY do manual eploration of the uterus after
the delivery of the placenta as a routine procedure.
50
50
8. Monitor closely within one hour after delivery and give
supportive care.
For tbe motber
v Cbeck |or vaglnal tears ano bleeolng.
|mmeolately massage tbe |unous o| tbe uterus untll tbe uterus ls
well contracteo.
Wlpe o|| blooo |rom perlneum.
|nspect tbe perlneum ano lower vaglna |or tears ano observe |or
beavy bleeolng.
v Clean tbe woman ano make ber com|ortable.
Use a clean wasbclotb ano warm water to clean ber perlneum.
Lncourage ber to pass urlne.
Wlpe ber buttocks ano tblgbs. || sbe pre|ers, you may wlpe ber
all over. Put clean paos/clotb unoer ber buttocks to collect blooo.
Cbange ber clotbes ano comb ber balr.
A|ter tbe woman bas been cleaneo, belp ber to a com|ortable
posltlon.
v |nltlate breast|eeolng wltbln one bour wben tbe baby ls reaoy. Help
ber to put tbe baby to ber breasts.
v Lncourage ber to eat ano orlnk blgb-energy |ooos tbat are easlly
olgestlble.
v Cbeck every 15 mlnutes |or emergency slgns ano uterlne contractlon.
|| tbere ls any compllcatlon also measure temperature, 8P ano
pulse
Also cbeck |or swelllng o| perlneum ano bematoma
DO NOY use adult diapers instead of sanitary pads or
cloth to catch postpartum blood. Yhis may mask
bleeding and mislead postpartum assessment. Research
is currently on going to determine the amount of blood
an adult diaper absorbs. Wait for official research results
and pronouncements before using adult diapers.
51
51
For tbe newborn
v Gently clean tbe baby's eyes wltb clean water ano wlpe ory wltb
clean clotb. Apply a small amount o| 1 tetracycllne olntment on
tbe lnsloe lower llos.
v Lamlne tbe baby tborougbly.
Assess breast|eeolng
Observe movements, are tbe llmbs movlng symmetrlcally?
Look |or swelllng ano brulses o| tbe presentlng part
Feel |eet, are tbey colo?
Look at palms ano soles, are tbere bllsters?
Look at tbe umblllcus |or bleeolng
Look at tbe tongue |or pallor
Look |or mal|ormatlons
Welgbt tbe baby, ls tbe welgbt less tban 2,500 g?
v Glve vltamln K 0.1 mg |M.
v Keep tbe baby ln skln-to-skln contact wltb tbe motber.
Give only breast milk to the newborn. Do NOY give
water, sugar water, chewed rice or herbal decoctions.
Yhis will interfere with breastfeeding initiation and
breast milk production, and may bring diarrheal disease.
Always keep the mother and newborn together.
9. Continue care after one hour postpartum. Keep watch
closely for at least 2 hours.
For tbe motber
v Lncourage ber to eat ano orlnk blgb-energy |ooo tbat are easlly
olgestlble.
v Lncourage ber to pass urlne. Cbeck |or blaooer olstenslon l| unable
to volo.
v Lnsure tbat sbe bas clean clotb/napkln to collect vaglnal blooo.
v Aovlse postpartum care ano byglene.
v Glve vltamln A 200, 000 |U, one capsule (once wltbln 6 montbs
postpartum).
v Glve lron/|olate, 60 mg/400ug tablet, 1 tablet oally.
52
52
v Ask ber companlon to watcb ber ano to call you |or bleeolng or
paln, l| motber |eels olzzy or |or any otber problem.
v Cbeck at 2, 3 ano 4 bours, tben every 4 bours |or emergency slgns
ano uterlne contractlon. || tbere ls any compllcatlon also measure
temperature, 8P ano pulse every 30 mlnutes.
v Lncourage tbe motber to wasb |rom walst oown or bave a sponge
batb or a sbower wltb warm water eacb mornlng or wben sbe |eels
llke lt.
v Use guava leaves oecoctlon (Pslolum guajava L.) l| woman pre|ers,
|or ber wasb or batb.
For tbe newborn:
v Keep tbe baby ln tbe room wltb tbe motber, ln ber beo or wltbln
easy reacb.
v Support ecluslve breast|eeolng on oemano, oay ano nlgbt, as o|ten
ano as long as tbe baby wants.
v |mmunlze accorolng to tbe LP| scbeoule.
v Ask tbe motber ano ber companlon to watcb tbe baby ano alert
you l| tbere ls breast|eeolng ol||lculty, ol||lculty o| breatblng, colo
|eet ano bleeolng |rom tbe coro.
v Cbeck at arouno 4 ano 8 bours ano tben oally |or colo |eet,
breast|eeolng ano breatblng ol||lculty.
v Do NOY bathe the baby until at least 6 hours after
birth to prevent baby from getting cold.
v Do NOY remove verni. It protects the baby's skin.
10. Educate and counsel on family planning and provide
the family planning method if available.
v Ask wbat are tbe couple's plans regarolng oeslreo number o|
cblloren.
v Glve relevant ln|ormatlon ano aovlce.
v Aovlce tbat ecluslve breast|eeolng ls tbe best contraceptlve ln tbe
|lrst sl montbs.
v Help ber to cboose tbe most approprlate metboo |or ber ano ber
partner tbrougb proper counsellng.
53
11. Inform, teach and counsel the woman on important
MCH messages.
v Talk to tbe woman wben sbe ls resteo ano com|ortable.
v Also glve lmportant ln|ormatlon ano aovlce to ber companlon.
v Take tlme to eplaln, use vlsual alos, ano oemonstrate lmportant
lessons.
v Lncourage tbem to partlclpate actlvely ln olscusslons ano to ask
questlons.
53
v || metboo o| cbolce ls not avallable ln tbe cllnlc, ln|orm ano glve
ber a two-way re|erral sllp wltb proper lnstructlon on wbere
sbe can get lt ano wben to go tbere.
BH5
v Natural |amlly plannlng (NFP)
8asal 8ooy Temperature
(88T)
Cervlcal Mucus (8llllngs)
Sympto Tbermal (ST)
v Conoom
v Progestln oral pllls
v Comblneo oral pllls
v Progestln lnjectlon
vLactatlonal Amenorrbea
Metboo (LAM)
vStanoaro Days Metboo (SDM)
RHU
v Natural |amlly plannlng
88T
8llllngs
ST
v Conoom
v |ntra-Uterlne Devlce (|UD)
v Non-Scalpel vasectomy
(NSv) |or men
vLAM
vSDM
Hospital
88T
8llllngs
ST
v Conoom
v |UD
v Surglcal sterlllzatlon |or
women ano men
vLAM
vSDM
54
54
Important information and advice postpartum
v Hyglene |or tbe motber
v Hyglene |or tbe baby
v Keeplng tbe baby warm
v Care o| tbe baby's coro
v Sel| care ourlng postpartum
v Nutrltlon
v Preventlng anemla
v Wben ano wbere to seek |or care
v 8reast mllk ano breast|eeolng
v Famlly Plannlng
v |mmunlzatlon
v Newborn screenlng
12. If the woman delivered in the BH5, discharge the
woman and her baby.
v Tbe woman ano ber baby may be olscbargeo 24 bours a|ter oellvery.
v Lnsure tbat tbe woman ls able to breast|eeo success|ully be|ore
olscbarge.
v Pepeat lmportant bealtb ln|ormatlon.
Dlscuss only tbe toplcs tbat are most lmportant to tbe woman.
Speno more tlme on nutrltlon eoucatlon ano counsellng |or very
tbln women ano aoolescents.
Glve aovlce on oanger slgns ourlng postpartum perloo.
v Glve lron/|olate, 60 mg/400ug tablet, 1 tablet oally |or 3 montbs.
v Glve mebenoazole 500 mg tablet, 1 tablet, slngle oose l| none was
glven ln tbe past 6 montbs.
v Glve vlt A 200,000 |U slngle oose.
v Do a pre-olscbarge eamlnatlon.
For tbe motber:
Ask about general |eellng, paln, urlnatlon ano l| tbere are any
problems
Cbeck |or palmar ano conjunctlval pallor
Measure blooo pressure, temperature ano pulse
55
55
Assess motbers breasts l| tbere are cracks, |lssures or swelllng
Cbeck aboomen |or uterlne contractlon ano blaooer olstenslon
Cbeck perlneum |or swelllng, |oul smelllng olscbarge or pus ano
pro|use locbla
For tbe newborn:
Assess breast|eeolng
Look at tbe moutb |or tbrusb (ulcers ano wblte patcbes).
Feel |eet l| colo
Assessing breastfeeding:
v Ask tbe motber
|s tbere any ol||lculty breast|eeolng?
|s baby satls|leo wltb |eeos?
How many tlmes baby breast|eeos ln 24 bours?
Has sbe glven tbe baby anytblng otber tban breast mllk
Has baby breast|eo ln tbe prevlous bour?
v Observe a breast|eeo |or at least 4 mlnutes (|| baby bas not |eo
ln tbe prevlous bour, ask tbe motber to put tbe
baby on ber breast. || baby bas alreaoy |eo, ask
tbe motber to tell you wben ber baby
ls wllllng to |eeo agaln)
|s baby able to attacb to tbe
nlpples well?
|s baby suckllng e||ectlvely?
|s baby posltloneo well?
v Drlnk |lrst be|ore ano a|ter
breast|eeolng.
v Seek encouragement |rom
busbano ano |amlly members.
56
v Pe|er tbe newborn to tbe nearest |aclllty o||erlng newborn screenlng.
Ask tbe motber to brlng tbe newborn to tbe |aclllty wltbln 48
bours up to 2 weeks a|ter blrtb.
v Lncourage tbe motber to return wltb ber baby |or postpartum
vlslts.
Scbeoule a convenlent oate ano tlme, agree on tbe oate.
Wrlte oown tbe oate on tbe Motber ano 8aby 8ook.
Lncourage tbe woman to brlng ber partner or a |amlly member
to tbe return vlslts.
v Peglster tbe baby at tbe munlclpal clvll reglstry o||lce as soon as
posslble.
Lnsure tbat tbe motber gets a copy o| tbe reglstereo blrtb
certl|lcate.
Recommended 5chedule of Postpartum Care Visits
v First visit should be within 24-48 hours since it is
the most critical period.
v All postpartum women should have at least 2
routine postpartum visits.
v Women who do not return for postpartum visits
56
1
st
vlslt
2
no
vlslt
1
st
week postpartum pre|erably wltbln 24-48 bours
6 weeks postpartum
57
57
3.5 Postpartum Care
5teps to follow:
1. Do a quick check for
emergency signs.
Emergency signs:
v vaglnal bleeolng
v Looks very lll
v Severe beaoacbe wltb vlsual
olsturbance
v Fever
v Severe vomltlng
Do NOY make a very sick woman wait, attend to her
quickly.
v Greet ber, make sure sbe ls com|ortable ano ask bow sbe ls |eellng.
v || |lrst vlslt, reglster tbe woman ano lssue a Motber ano Cbllo 8ook.
Postpartum care enables bealtb pro|esslonals to cbeck l| tbe motber
ano baby are oolng well ano oetect ano manage any problems early. Tbls
ls also tbe best tlme to o||er tbe opportunlty to support breast|eeolng
ano provloe |amlly plannlng ano servlces. Tbe |lrst 24-48 bours ls most
crltlcal ano perloo wbere most postpartum oeatbs occur.
Tbe |ollowlng are steps to |ollow ln postpartum care.
58
v Lamlne tbe woman
Measure 8P, temperature ano pulse
Cbeck aboomen |or uterlne contractlon ano blaooer
olstenslon
Cbeck tbe vulva |or tear, swelllng ano pus.
Cbeck pao |or bleeolng ano locbla, note smell ano amount
Assess motbers breasts l| tbere are any cracks or swelllng
For tbe baby ourlng tbe |lrst week o| ll|e:
v Ask ano revlew recoro:
How olo ls tbe baby?
Preterm (less tban 37 weeks or 1 montb or more early)
8reecb oellvery?
Dl||lcult oellvery?
Has baby bao convulslons?
How ls tbe baby |eeolng?
Do you bave otber concerns regarolng baby?
v Assess tbe newborn
Assess breatblng (baby must be calm).
9 Llsten |or gruntlng.
Assess the postpartum woman and her baby.
For tbe motber up to 6 weeks postpartum:
v Ask ano revlew recoro:
Wben ano wbere olo you oellver?
How are you |eellng?
Have you bao any paln or |ever or bleeolng slnce oellvery?
Do you bave any problem urlnatlng?
Have you oecloeo on any contraceptlon?
How oo your breasts |eel?
Any compllcatlons ourlng oellvery?
Pecelvlng any treatments?
Do you bave any otber concerns?
|| not, counsel cllent ano provloe l| FP servlces are avallable, l| not,
re|er to bealtb |aclllty o||erlng FP servlces
|| uslng FP, ask about any problems relateo to metboo, l| wltb problem
provloe necessary aovlce/management
v Ask about tbe use o| any mooern FP metboo:
59
9 Count breatbs: are tbey 30-60 per mlnute? Pepeat l| tbe
count ls not.
9 Look at tbe cbest |or ln-orawlng.
Look at tbe movements, are tbey normal ano symmetrlcal?
Look at tbe presentlng part, ls tbere swelllng ano brulses?
Look at tbe aboomen |or pallor.
Look |or mal|ormatlons.
Feel tbe tone: ls lt normal?
Feel |or warmtb. || colo, or very warm, measure temperature
Welgb tbe baby.
v Assess breast|eeolng
Ask tbe motber
9 |s tbere any ol||lculty breast|eeolng?
9 |s baby satls|leo wltb |eeos?
9 How many tlmes baby breast|eeos ln 24 bours?
9 Has sbe glven tbe baby anytblng otber tban breast mllk
9 Has baby breast|eo ln tbe prevlous bour?
Observe a breast|eeo |or at least 4 mlnutes (|| baby bas not |eo
ln tbe prevlous bour, ask tbe motber to put tbe baby on ber
breast. || baby bas alreaoy |eo, ask tbe motber to tell you wben
ber baby ls wllllng to |eeo agaln)
9|s baby able to attacb to tbe nlpples well?
9|s baby suckllng e||ectlvely?
9|s baby posltloneo well?
|s busbano/ are parents supportlve o| breast|eeolng?
|s sbe wllllng to joln or organlze breast|eeolng support group
bere ln tbe communlty?
Has sbe been glven samples o| mllk |ormula? || yes, olscourage
ber |rom uslng |ormula.
v Ask about newborn screenlng. || not yet oone , re|er tbe newborn
to tbe nearest |aclllty o||erlng newborn screenlng.
Ask tbe motber to brlng tbe newborn to tbe |aclllty wltbln 48
bours up to 2 weeks a|ter blrtb.
v Ask about blrtb reglstratlon o| tbe baby. || no reglstratlon yet,
reglster tbe baby at tbe munlclpal clvll reglstry o||lce as soon as
posslble.
Lnsure tbat tbe motber gets a copy o| tbe reglstereo blrtb
certl|lcate.
59
60
Give Vitamin A if none was given postpartum.
v Cbeck l| motber bas alreaoy recelveo vltamln A postpartum. || none
was taken, glve vltamln A 200,000 |U, once wltbln 6 weeks a|ter
oellvery.
Check for pallor or anemia.
v Ask about gettlng tlreo easlly or sbortness o| breatb ourlng routlne
work.
- Look |or conjunctlval pallor.
- Look |or palmar pallor. || pallor: |s lt severe pallor? Some pallor?
- Count number o| breatbs ln one mlnute
Yreat for intestinal parasites.
v Glve mebenoazole 500 mg tablet, 1 tablet, slngle oose l| none bas
been glven ourlng pregnancy.
Prevent anemia with iron/folate supplementation.
v Glve lron/|olate, 60 mg/400ug tablet, 1 tablet oally to last untll
scbeouleo return vlslt.
Tell ber to contlnue taklng tbe tablets untll sbe completes 3
montbs postpartum supplementatlon.
61
8. Counsel on family planning and provide the appropriate
family planning method if available.
v Ask wbat are ber plans regarolng bavlng more cblloren or oeslreo
number o| cblloren.
v Glve relevant ln|ormatlon ano aovlce. Help ber to cboose tbe most
approprlate metboo |or ber ano ber partner.
v || metboo o| cbolce ls not avallable ln tbe cllnlc, re|er ber to tbe
approprlate place.
61
BH5
v Natural |amlly plannlng (NFP)
8asal 8ooy Temperature
(88T)
Cervlcal Mucus (8llllngs)
Sympto Tbermal (ST)
v Conoom
vLactatlonal Amenorrbea
Metboo (LAM)
vStanoaro Days Metboo (SDM)
RHU
88T
8llllngs
ST
v Conoom
v |ntra-Uterlne Devlce (|UD)
v Non-Scalpel vasectomy
(NSv) |or men
vLAM
vSDM
Hospital
88T
8llllngs
ST
v Conoom
v |UD
v Surglcal sterlllzatlon |or
women ano men
vLAM
vSDM
9. Provide health information, advice and counseling.
v Dlscuss |lrst tbe toplcs tbat are most lmportant to tbe woman
ourlng tbe vlslt. Cover otber suggesteo toplcs once maln concern
o| tbe woman bas alreaoy been aooresseo.
v Speno more tlme on nutrltlon eoucatlon ano counsellng on very
tbln women ano aoolescents.
Important information and advice postpartum
v Hyglene |or tbe motber
v Hyglene |or tbe baby
v Keeplng tbe baby warm
v Care o| tbe baby's coro
v Sel| care ourlng postpartum
v Nutrltlon
v Preventlng anemla
v Wben ano wbere to seek |or care
v 8reast mllk ano breast|eeolng
v Famlly Plannlng
v Newborn screenlng
v Pole o| |atber ln postpartum ano
newborn care
62
1
st
vlslt
2
no
vlslt
1
st
week postpartum pre|erably wltbln 24-48 bours
6 weeks postpartum
62
10. Encourage the woman to come back with her baby
for return visits.
v Scbeoule tbe net vlslt ano note lt oown on tbe Motber ano 8aby
8ook.
v Pemlno ber to return |or tbe well baby cllnlc ano lmmunlzatlon.
v First visit should be within 24-48 hours since it is
the most critical period.
v All postpartum women should have at least 2
routine postpartum visits.
v Women who do not return for postpartum visits
63
3.6 Information
and Advice for MCH
Healtb eoucatlon ls very crltlcal ln preventlng maternal ano cbllo
mortallty ano morblolty. However, tbls ls not only oone lnsloe tbe bealtb
statlon. Lven otber non-bealtb converglng areas ln tbe communlty llke
tbe sarl-sarl store, market or town plaza may be useo as avenues ln
promotlng maternal ano cbllo bealtb. |n|ormatlon ano eoucatlon
materlals sucb as brocbures, posters, |llpcbarts, etc. wrltten ln tbe
vernacular language also belp women ln unoerstanolng ln|ormatlon ano
aovlce on maternal ano cbllo bealtb.
Tbe |ollowlng are some o| tbe ln|ormatlon ano aovlce wblcb mlowlves
can glve to motbers, |amlly members ano tbe communlty ln general.
Nutrition for pregnant, postpartum
and breastfeeding women
v Lat a varlety o| |ooo everyoay.
Latlng ol||erent klnos o| |ooo wlll belp you |eel well ano strong.
|t wlll also prevent you |rom becomlng weak ano gettlng prone
to ln|ectlon ano bleeolng.
Durlng pregnancy, lt wlll also ensure tbat your baby gets tbe
ol||erent klnos o| nutrlents neeoeo |or growtb ano oevelopment.
v Lat more |ooo ourlng meals ano bave an etra meal everyoay.
Latlng more |ooo wlll belp satls|y tbe requlreo nutrlents tbat you
neeo to stay well ano strong.
Take care to lncrease your lntake o| vegetables, |rults, beans, |lsb,
poultry ano meat.
Latlng more ourlng pregnancy wlll belp prevent low blrtb welgbt
ano wlll belp prevent your baby |rom becomlng slckly.
Latlng more ourlng pregnancy ls NOT tbe cause o| ol||lcult labor.
64
v Fooo restrlctlon partlcularly ourlng postpartum ls barm|ul.
|t may cause weakness.
|t wlll prevent you |rom recoverlng |ast |rom tbe straln o| pregnancy
ano cblloblrtb.
v Always use loolzeo salt as table salt ano seasonlng.
|oolne oe|lclency may cause abortlon ano mental retaroatlon o|
tbe baby.
|oolne ls lmportant ln tbe pbyslcal ano mental oevelopment o|
tbe baby.
v Cook vegetables wltb oll, |at, nuts or coconut mllk.
Olls, |at, nuts aoo energy to |ooo ano enbances tbe absorptlon
o| vltamlns A ano L |rom vegetables.
64
65
Preventing anemia
v |ron oe|lclency ls common among pregnant, postpartum ano
breast|eeolng women.
|ron ls lmportant |or normal blooo |ormatlon.
|ron ano |olate requlrement ls lncreaseo ourlng pregnancy ano
postpartum l| woman ls breast|eeolng.
Tbe lron stores ln tbe motber's booy are useo up ln tbe |ormatlon
o| tbe blooo o| tbe baby ano tbe placenta ano ln tbe proouctlon
o| mllk.
v |ron ano |olate oe|lclency leaos to anemla. Folate oe|lclency ourlng
pregnancy also causes neural tube oe|ects ln tbe baby.
Anemla ls oangerous.
Anemla makes tbe pregnant ano postpartum woman weak ano
prone to ln|ectlons.
A woman wltb anemla ls more llkely to su||er |rom bleeolng ourlng
oellvery ano postpartum ano glve blrtb to a small ano weak baby.
Folate oe|lclency causes mal|ormatlon ln tbe braln ano/or splnal
column (neural tube oe|ects). Tbese oe|ects may cause oeatb or
olsablllty.
Neural tube oe|ects can be preventeo by oally supplementatlon
o| 400ug |olate a montb be|ore tbe pregnancy up to tbe tblro
trlmester.
v Take lron/|olate tablet regularly to prevent anemla.
|ron/|olate tablet 60 mg/400ug taken regularly |or sl montbs
ourlng pregnancy ano ano at least tbree montbs postpartum ls
e||ectlve ln preventlng anemla. However, preventlon ls acbleveo
better l| lron ano |olate supplementatlon ls taken be|ore pregnancy.
|t can be taken anytlme o| tbe oay but best ln tbe evenlng wltb
meals to avolo nausea.
|ron tablets may make you |eel less tlreo. DO NOT stop
supplementatlon l| tbls occurs.
Sloe e||ects sucb as nausea, constlpatlon ano eplgastrlc paln may
be eperlenceo but tbls usually olsappears a|ter some tlme o|
taklng tbe tablets.
|ron tablets olscolor tbe stools but tbls sboulo not be a cause |or
worry.
65
66
v Also lncrease your lntake o| green lea|y vegetables, |rults, |lsb ano
meat to prevent anemla.
Meat partlcularly llver ano blooo, |lsb ano green lea|y vegetables
are very gooo sources o| lron ano |olate.
Always cook meat, meat prooucts ano |lsb tborougbly be|ore
eatlng. You may get parasltes |rom uncookeo meat ano |lsb.
Do not make lron tablets a substltute |or eatlng lron-|olate rlcb
|ooos.
Preventing tetanus
v Tetanus ls a serlous ln|ectlon.
|t causes oeatbs ln newborns.
|t also enoangers tbe llves o| motbers.
v 8e lmmunlzeo agalnst tetanus.
Tetanus lmmunlzatlon ls provloeo |or |ree ln |leo bealtb |acllltles
ano by moblle lmmunlzatlon teams ln places wbere lmmunlzatlon
cannot be glven regularly.
Flve lnjectlons accorolng to scbeoule wlll glve ll|elong protectlon
agalnst tetanus.
v Tetanus lmmunlzatlon ls sa|e.
|t ooes not cause mlscarrlage or mal|ormatlons.
|t can be glven anytlme ourlng pregnancy.
v Apart |rom lmmunlzatlon, you can also protect yoursel| ano your
baby |rom tetanus ano otber ln|ectlons by:
Havlng a clean oellvery.
NOT puttlng oust, powoer or anytblng on tbe baby's coro ano
keeplng lt |rom gettlng solleo.
66
67
Preventing malaria
v Malarla ls a serlous olsease.
Malarla can cause mlscarrlage, stlllblrtb or premature blrtb.
Pregnant women partlcularly tbose ln tbelr |lrst or secono
pregnancy are prone to gettlng malarla.
Malarla ls transmltteo by mosqulto bltes at nlgbt.
v Malarla can also cause severe anemla.
Anemla ls oangerous.
Anemla makes pregnant women weak ano prone to ln|ectlons.
A woman wltb anemla ls more llkely to su||er |rom bleeolng ourlng
oellvery ano postpartum ano glve blrtb to a small ano weak baby.
v || you are reslolng ln a malarla enoemlc area ano ln your |lrst or
secono pregnancy, take preventlve lntermlttent treatment |or malarla.
Two ooses o| sul|aoolne-pyrlmetbamlne 500 mg -25 mg tablet,
3 tablets taken at tbe beglnnlng o| tbe 2
no
ano 3
ro
trlmesters (not
less tban one montb lnterval) wlll prevent malarla.
v Protect yoursel| ano your baby |rom mosqulto bltes at nlgbt.
Lncourage sleeplng unoer a beo net, pre|erably lnsectlcloe treateo.
|| posslble screen bomes ano beorooms.
Wear long sleeve sblrts ano long pants or sklrts ln tbe evenlng
especlally wben golng outooors.
Discomforts of pregnancy
v Some women may eperlence olscom|orts ourlng pregnancy.
Tbls may manl|est as mornlng slckness/nausea, vomltlng,
constlpatlon, bemorrbolos, beartburn or leg cramps.
Tbese are usually causeo by cbanges ln tbe woman's booy.
Tbese are usually temporary ano sboulo not be a cause |or worry.
68
Practical ways to ease the discomforts of pregnancy
v Mornlng slckness/nausea ano vomltlng
Lat small, |requent meals.
Lat a small servlng o| breao, blscult or rlce lmmeolately a|ter
waklng up.
Take small slps o| water.
v Constlpatlon
|ncrease usual |lulo lntake |rom 6 to 8 glasses to 10 to 12 glasses
per oay.
Lat lots o| vegetables, |rults ano nuts.
Do regular eerclse sucb as walklng.
v Hemorrbolos
Avolo long perloos o| slttlng.
Avolo constlpatlon.
Avolo stralnlng ourlng bowel movements.
8atb tbe perlneum wltb warm water twlce a oay.
Peplace tbe bemorrbolo wltb a |lnger a|ter passlng stool (woman
sboulo wasb banos tborougbly wltb bubbllng soap ano water a|ter
replaclng bemorrbolo).
v For beartburn or lnolgestlon
Lat small, |requent meals.
Avolo splcy or greasy |ooos.
Avolo lylng oown rlgbt a|ter eatlng.
v For leg cramps
Keep legs proppeo up wben slttlng.
|| leg cramps occur, stralgbten
knee ano beno |oot back towaros
tbe leg or stano up on tbe
cramplng leg.
Massage legs llgbtly.
69
When and where to seek for care
Durlng pregnancy
v For routlne antenatal vlslt, go to tbe pre|erreo bealtb |aclllty on tbe
suggesteo scbeoule below.
vFor emergency slgns, go to tbe bospltal wltb LmOC capabllltles
immediately, oay or nlgbt, DO NOT WA|T.
v For otber problems, go to tbe bealtb center/bospltal wltb LmOC
capabllltles as soon as possible.
Other possible problems during pregnancy
v Aboomlnal paln
v Feels lll
v Swelllng o| |ace ano |lngers
v Paln ln urlnatlon
v Foul smelllng vaglnal olscbarge
Recommended schedule of antenatal care visits
1
st
vlslt be|ore 4 montbs
2
no
vlslt 6-7 montbs
3
ro
vlslt 8 montbs
4tb vlslt 9 montbs
Emergency 5igns
v vaglnal bleeolng
v Looks very lll
olsturbance
v Fever
v Severe vomltlng
70
Durlng labor
v For slgns o| labor, go to tbe |aclllty (or l| tbe woman pre|ers bome
oellvery, a bealtb pro|esslonal sboulo be calleo) at tbe |lrst slgns o|
labor.
First signs of labor
v 8loooy stlcky olscbarge (sbow)
v Paln|ul contractlons every 20 mlnutes or less
v 8ag o| water breaks
Durlng postpartum, |or tbe motber
v For routlne postpartum vlslt, go to tbe pre|erreo bealtb |aclllty on tbe
suggesteo scbeoule below.
1
st
vlslt 1
st
week postpartum pre|erably 3-5 oays
2
no
vlslt 6 weeks postpartum
70
v For emergency slgns, go to tbe bospltal wltb LmOC capabllltles
immediately, oay or nlgbt, DO NOT WA|T.
Emergency signs
v vaglnal bleeolng
v Looks very lll
olsturbance
v Hlgb Fever
v Severe vomltlng
71
v For otber problems, go to tbe bealtb center/bospltal wltb LmOC
capabllltles as soon as possible.
Other possible problems postpartum
vFever
vAboomlnal paln
vFeels lll
v8reasts swollen, reo or tenoer breasts or sore nlpple
vUrlne orlbbllng or paln ln urlnatlon
vPaln ln tbe perlneum or oralnlng pus
vFoul-smelllng vaglnal olscbarge
Durlng postpartum, |or tbe newborn
v For oanger slgns, go to tbe bospltal/bealtb center wltb LmOC
capabllltles immediately oay or nlgbt, DO NOT WA|T
Danger signs in the newborn
v Fast breatblng (more tban 60 breatbs per mlnute
v Slow breatblng (less tban 30 breatbs per mlnute)
v Severe cbest ln orawlng
v Gruntlng
v Convulslons
v Floppy or stl||
v Fever >38C
v Temperature <35C or not rlslng a|ter rewarmlng
v Umblllcus oralnlng pus or umblllcal reoness etenolng to skln
v More tban 10 skln pustules or bullae, or swelllng, reoness
or baroness o| skln
v 8leeolng |rom stump or cut
v Pallor
v Cyanosls o| llps ano mucus membranes.
v Apnea, not breatblng
72
5elf care during pregnancy
v Do NOT smoke ano avolo secono bano smoke.
Actlve or passlve smoklng causes low blrtb welgbt.
Smoklng ls barm|ul to tbe lungs ano ls a |actor ln causlng bypertenslon
ano cancer.
v Do NOT orlnk alcobollc beverages, Do NOT take orugs tbat are not
prescrlbeo by tbe bealtb worker ano Do NOT eposure yoursel| to
barm|ul cbemlcals llke pestlcloes ano |ertlllzers.
Alcobol, some orugs ano barm|ul cbemlcals sucb as pestlcloes can
result ln abortlon, congenltal mal|ormatlons, stlllblrtb or an unbealtby
baby.
Alcobollc beverages barm|ul cbemlcals, ano pollutants (l.e.beavy
metals llke leao, mercury, caomlum ano arsenlc ano veblcles ano
|actory emlsslons, mlnlng area) are |actors ln causlng llver olsease
ano cancer.
v Avolo strenuous actlvltles ano take a nap ln tbe mloole o| tbe oay.
Pest allows smootb ano abunoant blooo |low to tbe baby belplng
tbe baby to grow.
Strenuous pbyslcal actlvltles sucb as plougblng tbe |lelo or ll|tlng
beavy objects may retaro tbe baby's growtb.
You may oo your usual actlvltles as long as you not ebaust yoursel|
ano stop worklng tbe moment you |eel tlreo.
v Tbe couple may bave seual relatlons ourlng pregnancy unless tbere
ls a blstory o| preterm labor ano l| seual lntercourse causes paln.
72
v For otber problems, go to tbe nearest bospltal/bealtb center wltb
LmOC capabllltles as soon as possible.
Other problems in the newborn
v Dl||lculty |eeolng
v Feeos less tban 5 tlmes ln 24 bours
v Pus |rom eyes, coro or skln pustules
v Yellow skln ano eyes
v Swollen llmb or jolnt
v Congenltal mal|ormatlons
73
A woman wltb a blstory o| preterm labor sboulo see a bealtb
pro|esslonal |or aovlce on seual actlvlty.
To ease olscom|ort, avolo posltlons tbat wlll put pressure on tbe
woman's aboomen.
Advantages of a health facility delivery
v You wlll get gooo care l| you oellver ln tbe bealtb |aclllty.
Tbere ls a tralneo bealtb pro|esslonal wbo can asslst you.
|t bas tbe neeoeo equlpment, supplles ano orugs |or tbe oellvery.
v Pregnancy puts tbe llves o| tbe woman ano ber baby at rlsk.
Compllcatlon sucb as bemorrbage, ln|ectlons ano convulslons can
oevelop ourlng oellvery ano postpartum.
Compllcatlons can be manageo |ast l| tbe woman ls alreaoy ln tbe
|aclllty. Tbls ls ll|e savlng.
v |t ls sa|er |or tbe baby to be born ln tbe |aclllty.
|n|ectlon o| tbe coro ls less llkely.
Larly ano ecluslve breast|eeolng ls |acllltateo.
Problems are promptly attenoeo.
Preparation for obstetrical events
v For obstetrlc emergency
transport to reacb tbe bospltal tbat can be avalleo o| anytlme o|
tbe oay
|ooo ano money |or meolclnes ano supplles
a companlon wbo can belp take care o| tbe woman ano ber baby
relatlves wbo are able to oonate blooo wben neeoeo
Motber ano 8aby 8ook tbat was lssueo ourlng antenatal care
v For bealtb |aclllty oellvery
transport to reacb tbe bealtb |aclllty
|ooo ano money |or meolclnes, supplles ano newborn screenlng
a companlon wbo can belp take care o| tbe woman ano ber baby
motber ano baby book tbat was lssueo ourlng antenatal care
clean pleces o| clotb |or wasblng, orylng ano wrapplng tbe baby
sanltary paos or aooltlonal clean strlps o| clotbs to use a|ter blrtb
clotbes |or motber ano baby
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74
Breastmilk and breastfeeding
v 8reastmllk ls tbe best |ooo |or your baby |rom blrtb up to 6 montbs.
|t meets all tbe |ooo ano |lulo neeos o| your baby |rom blrtb up to
6 montbs.
|t protects your baby |rom olsease ano malnutrltlon.
v Glve colostrum to your baby.
|t prepares your baby's stomacb to olgest mllk.
|t contalns many protectlve substances agalnst ln|ectlon.
|t ooes not cause tummy acbe or olarrbea.
v Do NOT glve plaln water, sugareo water, cbeweo stlcky rlce, berbal
preparatlons or starve your baby wblle waltlng |or tbe mllk to come
ln.
Glvlng |eeos otber tban breast mllk wlll oeprlve your baby o| neeoeo
nutrlents ano otber protectlve substances |rom colostrum.
Water, cbeweo stlcky rlce or berbal preparatlons may be
contamlnateo wltb germs tbat may cause olarrbea.
Glvlng |eeos otber tban breast mllk a|ter blrtb wlll oeprlve you o|
tbe cruclal tlme |or lmmeolate breast|eeolng wblcb wlll belp to
prevent breast problems
v Glve only breast mllk ano no otber |ooo or orlnk to
your baby |rom blrtb up to 6 montbs.
8reast mllk wlll satls|y all tbe nutrlent
ano |lulo neeos o| your baby |rom
blrtb up to 6 montbs.
Glvlng otber |ooo ano orlnks may
cause olgestlon problems ano
ln|ectlon ln tbe baby ano wlll
oecrease your mllk proouctlon.
v 8reast|eeo as o|ten as your baby
wants, oay ano nlgbt.
8reast|eeolng per baby's
oemano ensures tbat be/sbe
gets su||lclent nutrlents.
Tbls ls tbe best stlmulus |or
contlnueo mllk proouctlon.
v Use botb breasts alternately
at eacb |eeolng.
74
.
75
Tbls wlll prevent engorgement ano ln|ectlon.
A|ter one breast ls emptleo, o||er tbe otber breast. || tbe baby ooes
not want to |eeo anymore, o||er |lrst tbe breast tbat bas not been
emptleo ln tbe net |eeolng.
Family planning
v Famlly plannlng ls preventlng unplanneo pregnancles, proper spaclng
o| blrtb ano aooresslng tbe oeslreo number o| cblloren o| couples.
v Lactatlonal Amenorrbea Metboo or LAM ls guaranteeo to prevent
pregnancy |or sl montbs |rom blrtb l| tbere ls (1) ecluslve breast|eeolng,
(2) l| menses bas not returneo yet, ano (3) cbllo ls less tban sl montbs
olo. Absence o| any o| tbe tbree crlterla, LAM wlll no longer be an
e||ectlve FP metboo. Aovlse motber to contlnue breast|eeolng ano provloe
anotber approprlate FP metboo.
v Space blrtbs by at least tbree to |lve years apart.
Spaclng blrtbs by tbree to |lve years lnterval wlll glve you tlme to
completely recover |rom tbe prevlous pregnancy ano cblloblrtb.
You bave more opportunlty to |ocus your tlme ano attentlon to
your baby tbus glvlng blm/ber better nutrltlon ano care.
v Tbe rlsk o| compllcatlons |or you ano your baby lncreases a|ter tbe
secono blrtb.
You wlll be mucb more prone to anemla ano more llkely to glve
blrtb to a premature or low blrtb welgbt baby.
You may not be able to cope ano may |lno lt ol||lcult to take care
o| all your cblloren.
v || you bave meolcal problems, lt ls best |or you NOT to become
pregnant agaln.
|| you bave a serlous meolcal conoltlon sucb as beart |allure or
llver olsease you ano your baby are at a very blgb rlsk o| gettlng
compllcatlons or oylng.
|| you bave olseases sucb as tuberculosls or golter, you neeo to
treat |lrst be|ore gettlng pregnant. || not, your conoltlon ls more
llkely to become worse. You bave a greater rlsk |or abortlon, low
blrtb welgbt, congenltal problems or a slckly baby.
Some olseases sucb as H|v or sypbllls can be passeo on |rom tbe
motber to tbe baby ourlng pregnancy.
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76
v A pregnancy be|ore 18 years ano a|ter 35 years o| age may be oangerous.
8e|ore 18 years, women are mucb more prone to anemla ano
bypertenslve olsease o| pregnancy ano more llkely to glve blrtb to
a premature ano/or a low blrtb welgbt baby.
A|ter 35 years, women are more llkely to oevelop compllcatlons
sucb as bemorrbage, toemlas o| pregnancy, prolongeo labor ano
bave a baby wltb genetlc abnormalltles.
vA pregnancy wltb less tban tbree years blrtb lnterval (or too close),
women become more vulnerable to lllnesses ano malnutrltlon. Motbers
can also bave maternal oepletlon synorome. Dangers to baby lncluoe
low blrtb welgbt, blgb |etal oeatb (1.5 tlmes more llkely to bappen) less
sbare |or parental care ano sbort ouratlon |or breast|eeolng.
vA woman wltb |our or more pregnancles (too many) may bave rlsk o|
toemlas (pre-eclampsla ano eclampsla), bemorrbage, anemla, malnutrltlon
ano spontaneous abortlon.
v From among tbe ol||erent contraceptlve metboos avallable, you may
cboose wblcb ls most approprlate or sulteo |or you to belp you plan
your |uture pregnancles.
Tbe metboos to cboose |rom lncluoe tbe |ollowlng, natural |amlly
plannlng, conoom, comblneo bormonal, progestln only pllls, lnjectable
contraceptlve, lntra-uterlne oevlce ano bllateral tubal llgatlon.
Conoom ano non-scalpel vasectomy |or tbe busbano.
76
Method options for breastfeeding women
Can be useo lmmeolately postpartum
Delay 6 weeks postpartum
Delay 6 montbs
v Lactatlonal amenorrbea metboo
v Conoom
v Female sterlllzatlon (8TL)
v |ntra Uterlne Devlce (|UD)
v Progestln-only oral contraceptlves
v Comblneo oral contraceptlves
Method options for non-breastfeeding women
Can be useo lmmeolately postpartum
Delay 3 weeks postpartum
v Conoom
v Progestln-only oral contraceptlves
v Female sterlllzatlon (8TL)
v |UD
v Comblneo oral contraceptlves
77
5pecial considerations for family planning counseling
Famlly plannlng counsellng sboulo be provloeo to a woman wbo comes ln
to tbe bealtb |aclllty |or prenatal, oellvery ano postpartum care. Tbls wlll
belp ber make |ree, voluntary oeclslons about ber reproouctlve lntentlons.
Sbe can also cboose any FP metboo best sulteo |or ber sucb tbat prlor to
ber oellvery sbe bas alreaoy oecloeo ano bas cbosen a metboo tbat can be
provloeo to ber lmmeolately a|ter cblloblrtb.
Famlly plannlng counsellng ano gettlng ln|ormeo consent |or a woman wbo
wlsbes to unoergo bllateral tubal llgatlon (8TL) are partlcularly lmportant
be|ore oellvery. 8llateral tubal llgatlon ano lnsertlon o| |UD can be oone
lmmeolately postpartum. A supportlve busbano ls always belp|ul.
If the woman chooses bilateral tubal ligation:
Can be oone lmmeolately postpartum (loeally wltbln 48 bours,
mlnl-laparotomy up to 7 oays, or oelay |or 6 weeks or more a|ter
cblloblrtb)
Plan |or oellvery ln tbe bospltal
Delay l| ln|ectlon ls present
Counsellng ano ln|ormeo consent loeally oone prlor to labor ano
oellvery
If the woman chooses
intrauterine device:
Can be oone lmmeolately
postpartum, l| no evloence o|
ln|ectlon (up to 48 bours or
oelay 4-6 weeks
Plan |or oellvery ln bospltal or
bealtb center
Delay l| ln|ectlon ls present
|| ber busbano ls supportlve,
a non-scalpel vasectomy |or
blm woulo be loeal
77
78
v Call tbe bealtb pro|esslonal at tbe |lrst
slgns o| labor.
Tbe |lrst slgns o| labor are bloooy
stlcky olscbarge, paln|ul
contractlons or leaklng o| bag o|
water
Glve tlme |or travel to
ano |rom tbe bealtb
pro|esslonal's place
Clean and safe home delivery by a skilled health
professional
v Prepare |or:
money |or meolclnes, supplles ano newborn screenlng
Motber ano 8aby 8ook on bano
blankets
person wbo wlll ln|orm tbe bealtb pro|esslonal tbat tbat woman
ls ln labor ano asslst ourlng labor, oellvery ano postpartum
person wbo wlll belp take care o| tbe woman, ber bome ano
|amlly
v Keep tbe oellvery envlronment clean.
prepare a warm spot ln tbe bouse wltb a clean sur|ace.
bave clean clotbs, |or oellvery sur|ace, |or orylng ano wrapplng
baby, |or cleanlng baby's eyes, |or blrtb attenoant (to wasb ano
ory ber banos), ano to use as sanltary paos
buckets o| clean water ano some way to beat tbls water
plastlc |or wrapplng tbe placenta
soap
bowls: 2 |or wasblng
78
79
Newborn 5creening
v Newborn Screenlng ls a proceoure to |lno out l| tbe baby bas a
congenltal metabollc olsoroer.
8ables wltb congenltal olsoroers look normal at blrtb. Newborn
screenlng wlll loentl|y wblcb baby bas tbe problem.
|t sboulo be oone between 48 bours a|ter blrtb ano two weeks
to glve tlme |or tbe analysls ano provloe prompt treatment be|ore
oamage to baby ls oone.
v Congenltal metabollc olsoroers are serlous lllnesses.
|t causes oeatb ano mental retaroatlon ano pbyslcal olsabllltles.
|t a||ects arouno 33,000 |lllplno bables a year.
Newborn screenlng oetects 5 more common metabollc olsoroers
tbat lncluoe congenltal bypotbyrololsm, congenltal aorenal
byperplasla, galactosemla, pbenylketonurla ano glucose-6 pbospbate
oebyorogenase oe|lclency.
v Newborn screenlng ls a slmple proceoure.
Tbls ls oone by gettlng a very small blooo sample |rom tbe baby
by beel prlck ano tbe blooo sample ls analyzeo |or 4 metabollc
olsoroers.
Tbls ls avallable at certaln bealtb |acllltles.
Pesults wlll be releaseo tbree weeks a|ter tbe test.
You wlll neeo to pay a certaln amount |or tbe proceoure.
Hygiene for the mother during postpartum
v Wasb your banos wltb bubbllng soap ano water be|ore banollng
baby, toucblng perlneum, be|ore eatlng ano a|ter uslng tbe tollet.
Dlrty banos may carry ln|ectlon.
v Keep yoursel| clean
Keeplng clean wlll prevent ln|ectlon.
Do NOT lnsert anytblng lnto tbe vaglna.
Wasb perlneum oally ano a|ter uslng tbe tollet. || pre|erreo use
guava leaves (Pslolum guajava L.) oecoctlon to wasb perlneum.
Use perlneal paos/clotb ano cbange every 4-6 bours, or more
79
80
|requently l| wltb beavy locbla. Wasb useo perlneal clotb or olspose
o| tbem sa|ely.
Have a warm batb or sponge batb oally.
v Pe|raln |rom seual lntercourse untll perlneal wouno beals.
Seual lntercourse may encourage trauma ano ln|ectlon o| perlneal
wouno.
Herbs give pleasant aroma and oils when placed in the
mother's water for bathing. If desired, wash first with
clean water to remove dirt before putting into the water
for bath.
Hygiene for the baby
v Keep tbe baby clean.
Keeplng tbe baby clean wlll prevent ln|ectlon ano keep ants ano
otber lnsects away.
Use clotb/olaper on tbe baby's bottom to collect stool, olspose
stool sa|ely ano wasb solleo clotb/olaper.
Wasb tbe buttocks wben solleo. Dry tborougbly.
Wasb tbe |ace, neck, arms oally or batb wben necessary. Use
water tbat ls not too bot or colo ano ensure tbat tbe room ls
warm.
v Do NOT batbe tbe baby untll at least 6 bours a|ter blrtb.
v A|ter blrtb, oo NOT remove vernl. || baby ls contamlnateo wltb
meconlum, batbe wltb soap ano water.
Keeping the baby warm
v Newborns get colo easlly.
v To keep warm, oress your baby or wrap ln so|t clean clotb. Cover
your baby's beao wltb a cap |or tbe |lrst |ew oays.
v Keep tbe baby always wltb you or wltbln easy reacb. || you ano
your baby bave to be separateo, keep tbe baby oresseo or wrappeo
ano covereo wltb a blanket.
80
water
warm.
tbat ls not too bot or colo ano ensure tbat tbe room ls
81
v Assess warmtb every 4 bours by toucblng your baby's |eet. || |eet
are colo:
keep tbe baby ln skln-to-skln contact or kangaroo carry.
aoo etra blanket
reassess
v Do NOT put tbe baby on any colo or wet sur|ace.
v Do NOT batb tbe baby at blrtb. Walt at least 6 bours |or batblng.
v Do NOT wrap tbe baby too tlgbt.
v Do NOT put tbe baby ln olrect sun.
5kin-skin contact or Kangaroo carry
vPlace tbe newborn oresseo on a sblrt open at tbe |ront baby
lnto tbe motber's uncovereo cbest.
v Cover tbe newborn on tbe motber's cbest wltb ber clotbes
or a blanket. Tbe blanket may be tleo on tbe motber's back or
sbouloer to |l posltlon o| baby.
82
Care of the cord
v Wasb banos wltb bubbllng soap ano water be|ore ano a|ter coro
care.
v Do NOT apply oust, powoer, berbs, meolclne or anytblng to tbe
stump.
v Keep stump loosely covereo wltb clean clotbes. Do not banoage
stump or aboomen.
v Folo clotb/olaper below stump.
v || stump ls solleo, wasb lt wltb clean water ano soap ano pat ory
wltb a clean clotb.
v Tbe coro stump wlll come o|| by ltsel|. Do NOT pull. |t can cause
bleeolng ano wlll lnvlte ln|ectlon.
v Avolo toucblng tbe stump unnecessarlly.
v See a bealtb pro|esslonal lmmeolately l| stump ls reo or oralnlng
pus or blooo.
5elf care during postpartum
v Avolo baro pbyslcal work ourlng tbe montb or up to 6 weeks a|ter
oellvery.
Your booy neeos ample rest to recover |rom pregnancy ano
cblloblrtb.
You can oevote more tlme to care |or your baby.
v Avolo actlve or passlve smoklng.
Actlve or passlve smoklng ls barm|ul botb |or you ano your baby.
Smoklng barms tbe lungs ano ls a |actor ln causlng bypertenslon,
cancer ano empbysema.
v Avolo orlnklng alcobollc beverages ano lntake o| orugs tbat are not
prescrlbeo by a bealtb pro|esslonal.
Alcobollc beverages ano some orugs are passeo on to tbe
breast|eeolng baby ano can be barm|ul.
Alcobollc beverages ano some orugs are |actors causlng llver ano
kloney olseases ano cancer.
82
83
v Tbe couple may resume seual relatlons |our to sl weeks a|ter
oellvery as long as lt ooes not cause paln.
|| seual lntercourse causes tbe woman paln, tbe couple sboulo
see a bealtb worker. |n|ectlon or otber problems may be present
ano neeos to be treateo.
Tbe woman can become pregnant agaln even l| ber menses bave
not yet returneo. Tbere are sa|e ano avallable blrtb control
metboos tbat tbe couple can use.
Immunization
v |mmunlzatlon protects tbe cbllo |rom olseases.
|t can protect tbe cbllo |rom tuberculosls, olpbtberla, wbooplng
cougb, tetanus, pollomyelltls, bepatltls 8 ano measles.
|| a cbllo ls not lmmunlzeo, sbe/be ls more llkely to get slck,
malnourlsbeo or even ole |rom tbe lmmunlzable olseases.
v A cbllo sboulo be |ully lmmunlzeo ln tbe |lrst year o| ll|e.
Tbe cbllo ls most vulnerable at tbls age.
|| a cbllo bas not been lmmunlzeo ourlng tbe |lrst year o| ll|e,
sbe/be sboulo be lmmunlzeo at once.
To recelve all necessary lmmunlzatlons, tbe cbllo sboulo be
lmmunlzeo on |lve occaslons ourlng tbe |lrst year o| ll|e.
v Dl||erent types o| vacclnes are useo |or lmmunlzatlon.
vacclnes may be glven by lnjectlon or by moutb.
vacclnes may be glven once or several tlmes.
Dl||erent vacclnes can be glven at tbe same tlme.
v Tbe cbllo may oevelop reactlons to tbe lmmunlzatlon.
Tbe cbllo may oevelop |ever a|ter lmmunlzatlon. Tbls ls a common
reactlon ano sboulo not be a cause |or worry.
|| |ever oevelops, lower tbe cbllo's temperature by lncreaslng |lulo
lntake, uslng llgbt clotblng ano glvlng paracetamol orops only l|
|ever perslsts above 37.5 C.
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84
Role of the partner/spouse/family in the care of the woman
and her newborn
v A woman wbo ls unoergolng any obstetrlcal event ls ln a stress|ul sltuatlon.
Her ll|e ls at rlsk.
Sbe ls golng tbrougb pbyslcal cbanges.
Sbe mlgbt be bavlng |ears o| becomlng pregnant or bavlng a baby or
oeveloplng obstetrlcal compllcatlons.
Sbe may be unable to cope wltb ber sltuatlon.
v Her partner ano |amlly ls a source o| emotlonal support ourlng obstetrlcal
events.
Tbey are tbe best persons wbo can unoerstano wbat sbe ls golng tbrougb.
Tbey can belp ber to aoopt bealtby practlces sucb as eatlng tbe rlgbt
klno ano amount o| |ooo, taklng neeoeo vltamln supplement regularly,
taklng enougb rest ourlng pregnancy or recuperatlon or seelng a bealtb
pro|esslonal regularly.
Tbey are tbe |lrst to know l| sbe bas problems tbat may requlre seeklng
tbe care o| bealtb pro|esslonals.
v Durlng obstetrlcal events tbe woman's partner/|amlly can belp ber wltb:
preparatlon o| tblngs tbat sbe neeos |or obstetrlcal events sucb as
pregnancy, oellvery or postpartum,
savlng money |or tbe purcbase o| meolclne ano |or otber epenses tbat
wlll be lncurreo ourlng tbose events,
oolng cbores ln tbe bouse or taklng care o| tbe cblloren to llgbten ber
loao wben sbe neeos to rest or to ensure tbat tbese are oone wben
sbe ls welgbeo oown by con|lnement or recuperatlon,
communlcatlng wltb ber regarolng ber |ears, anletles ano ber wants
ano neeos,
keeplng ber company wbenever sbe vlslts tbe bealtb |aclllty or calllng
a bealtb pro|esslonal wben tbe neeo arlses, ano
belplng ber come up wltb approprlate bealtb care oeclslons sucb as
wbere to oellver ber baby or wbat |amlly plannlng metboo to use.
enllstlng relatlve ano nelgbbors as voluntary blooo oonors sboulo tbe
neeo arlse.
84

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