Manual Reference Pediatric

HEALTH PROGRAMMING FOR INTEGRATED MATERNAL AND REBUILDING STATES NEWBORN CARE A BASIC BRIEFING PAPER SKILLS COURSE
2009 REFERENCE MANUAL
INTEGRATED MATERNAL AND NEWBORN CARE

BASIC SKILLS COURSE 2009 REFERENCE MANUAL
September 2009 This publication was produced for review by the United States Agency for International Development. It was prepared by USAID/BASICS and POPPHI. The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Reference Manual
U.S. Agency for International Development Bureau for Global Health Office of Health, Infectious Diseases and Nutrition Ronald Reagan Building 1300 Pennsylvania Ave., NW Washington, D.C. 20523 Tel: (202) 712-0000 Email: globalhealth@phnip.com www.usaid.gov/our_work/global_health
Deborah Armbruster, Project Director -orSusheela M. Engelbrecht, Sr. Program Officer POPPHI PATH 1800 K St., NW, Suite 800 Washington, DC 20006 Tel: (202) 822.0033 www.pphprevention.org
Indira Narayanan, Sr. Technical Advisor, Newborn Health -orGladys Mazia, Technical Officer, Newborn Health USAID/BASICS 4245 N. Fairfax Dr., Suite 850 Arlington, VA 22203 Tel: (703) 312-6800 Fax: (703) 312-6900 Email: basics@basics.org www.basics.org
Support for this publication was provided by the USAID Bureau for Global Health. USAID/BASICS (Basic Support for Institutionalizing Child Survival) is a global project to assist developing countries in reducing infant and child mortality through the implementation of proven health interventions. BASICS is funded by the U.S. Agency for International Development (contract no. GHA-I-00-04-0000200) and implemented by the Partnership for Child Health Care, Inc., comprised of the Academy for Educational Development, John Snow, Inc., and Management Sciences for Health. Subcontractors include the Manoff Group, Inc., the Program for Appropriate Technology in Health, and Save the Children Federation, Inc. The Prevention of Postpartum Hemorrhage Initiative (POPPHI) is a USAID-funded, five-year project focusing on the reduction of postpartum hemorrhage, the single most important cause of maternal deaths worldwide. The POPPHI project is led by PATH and includes four partners: RTI International, EngenderHealth, the International Federation of Gynaecology and Obstetrics (FIGO), and the International Confederation of Midwives (ICM).
Integrated maternal and newborn care Basic skills course
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Recommended Citation Basic Support for Institutionalizing Child Survival (BASICS) and the Prevention of Postpartum Hemorrhage Initiative (POPPHI). 2009. Integrated Maternal and Newborn Care Basics Skills Course: Reference Manual. Arlington, Va., USA: for the United States Agency for International Development (USAID). This publication is one in a series that make up the USAID/BASICS Newborn Health tool kit. The tool kit comprises: Facility Level Tools: Reference Manual Technical Presentations Facilitators Guide Participants Notebook Clinical Logbook with Learning and Evaluation Checklists
Community Level Tools: Guide for Training Community Health Workers/Volunteers to Provide Maternal and Newborn Health Messages Set of Counseling Cards
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ACKNOWLEDGEMENTS
Main Authors Indira Narayanan Sr. Technical Advisor, Newborn Health USAID/BASICS, USA Susheela Engelbrecht Sr. Program Officer USAID/POPPHI, PATH, USA Additional Contributing Authors USAID/BASICS Project Goldy Mazia Technical Officer, Newborn Health USAID/BASICS, USA Gloria Ekpo Technical Officer, Pediatric HIV/AIDS USAID/BASICS, USA USAID/POPPHI Project Deborah Armbruster Director USAID/POPPHI, PATH, USA Madagascar Jean Pierre Rakotovao Team Leader USAID/BASICS, Madagascar Julia Rasoaharimalala Physician, Department of Pediatrics Central Hospital for Mothers and Children Antananarivo Os Andrianarivony Physician, Dept of Obstetrics Maternity Hospital, Befelatanana Antananarivo Senegal Haby Signate Sy Professor of Pediatrics Albert Royer Central University Hospital Dakar Saliou Diouf Professeur of Pediatrics Institute of Social Pediatrics University C.A. Diop Dakar Aboubacry Thiam Regional Advisor, Africa Region USAID/BASICS, Senegal Democratic Republic of Congo (DRC) Celestin N. Nsibu Pediatrician University of Kinshasa Delphin I. Muyila Pediatrician General Hospital, Kinshasa Lucie M. Zikudieka Coordinator, Newborn Health USAID/BASICS, DRC Kanza NSIMBA Team Leader USAID/BASICS, DRC Marie Claude Mbuyi Coordinator, Reproductive Health USAID/AXxes, DRC Michel Mpunga Focal Person, Newborn Health USAID/AXxes, DRC Editing and Formatting Charlotte Storti Consultant USAID/BASICS, USA Paul Crystal Communications Manager USAID/BASICS, USA Christa Peccianti Program Coordinator USAID/BASICS, USA
NOTE: Content on definitions, newborn resuscitation, and minor and major infections was adapted from Le Manuel de RfrenceSante du Nouveau-n. Ministre de Sante et USAID/BASICS, 2005. All unidentified black and white illustrations were taken from: Engelbrecht, SM. Guide de la Matrone: Tome 2La consultation postnatale. Editions Nanondiral: Dakar, Sngal, 1998.
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TABLE OF CONTENTS
INTRODUCTION ....................................................................................................................... 1 Four Million Neonatal Deaths: Where do they occur?................................................................. 1 Four Million Neonatal Deaths: What do babies die of? ............................................................... 2 Four Million Neonatal Deaths: When do they occur?.................................................................. 2 CHAPTER 1: PREVENTING INFECTION ................................................................................. 4 Principles of Infection Prevention ............................................................................................... 4 Equipment and Supplies Related to Resuscitation ....................................................................22 CHAPTER 2: CLINICAL DECISION-MAKING ........................................................................ 23 The Problem-Solving Method....................................................................................................23 Documentation of Care .............................................................................................................26 CHAPTER 3: MATERNAL CARE TO IMPROVE MATERNAL AND NEWBORN SURVIVAL..29 Every Pregnancy is At Risk.....................................................................................................29 Maternal Conditions Affecting Fetal and Newborn Survival .......................................................30 Antenatal Care..........................................................................................................................33 Delays Resulting in Maternal and Newborn Deaths ..................................................................40 Birth-Preparedness Plan ...........................................................................................................40 Complication-Readiness Plan ...................................................................................................42 CHAPTER 4: PREVENTING POSTPARTUM HEMORRHAGE ............................................... 44 Causes of Postpartum Hemorrhage ..........................................................................................44 PPH Prevention and Early Detection.........................................................................................45 CHAPTER 5: ROUTINE CARE DURING THE THIRD STAGE OF LABOR .......................... ..48 Preparation for the Birth ............................................................................................................48 Essential Newborn Care ...........................................................................................................55 Care During the Third Stage of Labor .......................................................................................62 CHAPTER 6: MONITORING THE WOMAN AND NEWBORN DURING THE FIRST SIX HOURS POSTPARTUM .77 Monitoring the Woman ..............................................................................................................77 Monitoring the Newborn ............................................................................................................80 CHAPTER 7: ROUTINE POSTPARTUM CARE FOR THE WOMAN ...................................... 83 Male Involvement......................................................................................................................83 Postpartum Care.......................................................................................................................84 CHAPTER 8: RESUSCITATION FOR BIRTH ASPHYXIA ...................................................... 93 Causes of Birth Asphyxia ..........................................................................................................94 Preparation for Resuscitation ....................................................................................................94 Steps in Newborn Resuscitation ...............................................................................................99 Post-Resuscitation Care .........................................................................................................104
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CHAPTER 9: BASIC SYSTEMATIC EXAMINATION OF A NEWBORN AT PERIPHERAL CENTERS. . 109 Preparing for the Examination.................................................................................................109 Carrying out the Exam ............................................................................................................110 CHAPTER 10: POSTNATAL CARE OF THE NEWBORN, AT THE FACILITY AND DURING POSTNATAL VISITS .. 116 Timing of Most Neonatal Deaths .............................................................................................116 Components of Postnatal Care ...............................................................................................116 CHAPTER 11: DIAGNOSING AND TREATING BREASTFEEDING PROBLEMS................ 126 Common problems..................................................................................................................126 Prevention and Treatment.......................................................................................................126 Expressing and Feeding Breast Milk .......................................................................................132 CHAPTER 12: CARE OF THE LOW BIRTH WEIGHT BABY, INCLUDING KANGAROO MOTHER CARE ............................................................................................................... ..137 Factors Associated with Low Birth Weight...............................................................................137 Preventing Low Birth Weight ...................................................................................................137 Care of Low Birth Weight Babies ............................................................................................141 Discharge of the Low Birth Weight Baby .................................................................................147 CHAPTER 13: TREATMENT OF INFECTIONS IN THE NEWBORN .................................... 149 The Timing of Infections..........................................................................................................149 Types of Neonatal Infection.....................................................................................................150 Identifying and Treating Major Infections.................................................................................151 Identifying and Treating Minor Infections.................................................................................154 APPENDIX A: Selection and Storage of Uterotonic Drugs.................................................158 APPENDIX B: Alternative Assessment/Physical Examination of the Newborn at More Established Peripheral Centers ...........................................................................................163 APPENDIX C: Glossary.........................................................................................................168 REFERENCES .......................................................................................................................171
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List of Figures Intro. 1 Intro. 2 Intro. 3 1.1 1.2 1.3 1.4 1.5 1.6 1.7 2.1 3.1 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 5.24 7.1 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 Where do newborns die? What do newborns die of? When do newborns die? Hand washing Hand rubbing Putting gloves on Taking gloves off One-hand technique for needle recapping Sharps containers 0.5% chlorine solution Clinical decision making algorithm Signs of iron-deficiency anemia Positions that a woman may adopt during labor The modified WHO partograph Positions that a woman may adopt during childbirth Initial steps in the care of the baby at birth Two measures to prevent thermal loss at the time of birth Use of a pre-sterilized disposable cord clamp Signs of proper attachment at the breast Preparing oxytocin injection Put the baby on the mothers abdomen Rule out the presence of a second baby Give a uterotonic drug Pulsating and nonpulsating umbilical cord Keep the baby in skin-to-skin contact Clamping the umbilical cord near the perineum Palpate the next contraction Applying CCT with countertraction to support the uterus Supporting the placenta with both hands Delivering the placenta with a turning and up-and-down motion Massaging the uterus immediately after the placenta delivers Teach the woman how to massage her own uterus Examining the maternal side of the placenta Checking the membranes Gently inspect the lower vagina and perineum for lacerations Encourage breastfeeding within the first hour after birth Routine postpartum physical, obstetrical, and gynecological exam A warming table De Lee mucous aspirator Self-inflating bag and mask for ventilation of babies Sample list of equipment for newborn resuscitation Correct positioning Methods for stimulating the baby Correct positioning of the mask and formation of a good seal Giving supplemental oxygen Algorithm for resuscitation for birth asphyxia Algorithm for integration of AMTSL, ENC and resuscitation for birth asphyxia
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p. 1 p. 2 p. 3 p. 6 p. 8 p. 10 p. 10 p. 12 p. 13 p. 17 p. 28 p. 30 p. 51 p. 52 p. 53 p. 55 p. 56 p. 57 p. 59 p. 66 p. 66 p. 67 p. 67 p. 67 p. 68 p. 69 p. 69 p. 70 p. 70 p. 71 p. 71 p. 72 p. 72 p. 73 p. 73 p. 74 p. 84 p. 95 p. 96 p. 97 p. 98 p. 100 p. 101 p. 102 p. 103 p. 107 p. 108
List of Figures (cont.) 11.1 11.2 11.3 11.4 11.5 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 Appendix C.1 Two positions for breastfeeding Preparing and using a syringe for treatment of inverted nipples Anatomy of the breast How to express breast milk Three methods of feeding Basic evaluation of LBW babies to determine need for referral The kangaroo with the baby in the pouch Kangaroo mother care How to dress the baby for kangaroo care Photo example of kangaroo mother care The mother, father, or another family member may keep the baby on the chest Key components of care of the LBW infant Algorithm for care of the LBW baby Newborn periods p. 127 p. 132 p. 133 p. 134 p. 135 p. 140 p. 142 p. 143 p. 144 p. 144 p. 146 p. 147 p. 148 p. 169
List of Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Table 14 Table 15 Table 16 Table 17 Table A1 Table A2 Table A3 Mixing a 0.5% chlorine decontamination solution Steps in the problem-solving method Timing of SP dose Schedule for giving tetanus toxoid Key steps for immediate care of the newborn Comparison of physiologic and active management of the third stage of labor Bristol and Hinchingbrooke study results comparing active and physiologic management of the third stage of labor Monitoring of the baby in the first six hours after birth Schedule for routine postpartum visits Guidelines for identifying danger signs at peripheral centers Key steps in examining the newborn at a peripheral center Suggested timings of postnatal visits Care of the newborn during the 4-6 weeks after birth Summary of Postnatal Evaluation and Care of the Baby Complications in low birth weight and preterm babies Practical guidelines for identifying and treating major infections at peripheral centers Summary of treatment of minor infections Uterotonic drugs for AMTSL Change in effectiveness of injectable uterotonic drugs after one year of controlled storage Recommended guidelines for transport and storage of uterotonic drugs p. 19 p. 23 p. 34 p. 36 p. 61 p. 64 p. 65 p. 81 p. 84 p. 112 p. 115 p. 123 p. 124 p. 125 p. 139 p. 152 p. 157 p. 159 p. 160 p. 161
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About the Learning Materials

This learning package for integrated maternal and newborn care consists of a reference manual, a series of technical presentations, a participants notebook, a facilitators guide, and a clinical logbook. This learning package was developed for use by nurses, midwives, and doctors providing childbirth and immediate postpartum care for the woman and newborn in peripheral health care facilities. These documents comprise a set and should be used together. Facility Level Tools

The Reference Manual contains the theoretical content for the training course. It is intended to serve as the textbook or reference for participants and facilitators. The series of Technical Presentations contains PowerPoint slides of the different sessions. This will help in having more uniform training sessions and, along with the checklists, provide the key elements of each topic for easier learning. The Facilitators Guide includes lesson plans, knowledge evaluation tests (pre-test, mid-course test, and post-test) and their suggested answers, answers for learning exercises, and guidelines for conducting a clinical training program. The Participants Notebook assists participants throughout the training program. The notebook has the following components: overview of and agenda for the training program, learning objectives, learning exercises, and additional printed materials. The Clinical Logbook contains learning/practice guides or checklists and checklists for evaluating competencies, a logbook for clinical experiences, and a guide for the clinical practicum. Note: The checklists for evaluating competencies are also available as a separate document to be used after training during follow-up supervision.
Community Level Tools

Guide for Training Community Health Workers/Volunteers to Provide Maternal and Newborn Health Messages. A set of counseling cards
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The above resources are distinguished within the series by an identifying icon located on the top of the odd-numbered pages:
Reference Manual
Technical Presentations
Facilitators Guide
Participants Notebook
Clinical Logbook
Guide for Training Community Health Workers/Volunteers to Provide Maternal and Newborn Health Messages
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List of Abbreviations
AFASS AMTSL ANC ARV BP CCT CHW CMV CPT DIC EBM ENC FH FP FIGO Hb HLD HIV ICM IM IMCI IPTp IPTI ITN IU IUD IUGR IV LAM LBW MNH MTCT PMTCT POPPHI PPC acceptable, feasible, affordable, sustainable, and safe active management of the third stage of labor antenatal care antiretroviral blood pressure controlled cord traction community health worker cytomegalovirus cotrimoxazole prophylaxis therapy disseminated intravascular coagulopathy expressed breast milk essential newborn care fundal height family planning International Federation of Gynecology and Obstetrics hemoglobin high-level disinfection human immunodeficiency virus International Confederation of Midwives intramuscular integrated management of childhood illnesses intermittent preventive treatment in pregnancy intermittent preventive treatment in infants Insecticide-treated bednets international unit intrauterine device intrauterine growth retardation intravenous lactational amenorrhea method (for family planning) low birth weight maternal neonatal health mother-to-child transmission of HIV/AIDS prevention of mother-to-child transmission of HIV/AIDS postpartum hemorrhage prevention initiative postpartum care
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PPH PPPH PROM RAM RPR SP STI TSL TT USAID UTI VDRL VVM WHO
postpartum hemorrhage prevention of postpartum hemorrhage premature rupture of membranes rapid assessment and management Reactive Plasma Reagin sulfadoxine-pyrimethamine sexually transmitted infections third stage of labor tetanus toxoid United States Agency for International Development urinary tract infection Venereal Disease Research Laboratory vaccine vial monitor World Health Organization
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INTRODUCTION
While there has been a significant decrease in the mortality of children over the years, it has occurred mostly among infants and in children from one to five years of age. The mortality in the short but critical neonatal period (the first four weeks) still remains high and has not followed the same declining trend. Globally, an estimated four million deaths occur in these four weeks, with a similar number of stillbirths. During the past decade, a considerable amount of interest has been focused on newborns, with increased advocacy in this area leading to a number of operational research projects and programs.
FOUR MILLION NEONATAL DEATHS: WHERE DO THEY OCCUR?
4 Million Deaths: Where do newborn babies die?

1.5 million (38% of all newborn deaths) occur in 4 countries of South Asia
1.1 million (28% of all newborn deaths) occur in Sub Saharan Africa
Lancet series, 2005
99% of newborn deaths are in low/middle income countries 4 66% in Sub Saharan Africa and South Asia
Figure Intro. 1. Where do newborns die? Reprinted with permission from Elsevier (The Lancet, 2005, Vol 365, pg. 13)
FOUR MILLION NEONATAL DEATHS: WHAT DO BABIES DIE OF?

The major causes of death in the neonatal period are shown in Figure Intro. 2 and include infections, birth asphyxia, and prematurity.
Causes of Neonatal Mortality

Others 9% Congenital malformations 7% Diarrhea 3% Neonatal tetanus 3%
Prematurity 31%
Neonatal Infections 25% Birth asphyxia/trauma 23%

Source: WHO. The Global Burden of Disease: 2004 update. WHO, Geneva, 2008
Figure Intro. 2. What do newborns die of?
Among premature newborns, many die of complications of prematurity rather than of prematurity itself. In low-resource developing countries, infections are the most common complication and cause of death. Preventing infections, therefore, is a key strategy to reducing neonatal mortality in these countries.
FOUR MILLION NEONATAL DEATHS: WHEN DO THEY OCCUR?

As short as the neonatal period is, covering only the first four weeks of life, it is the most critical; indeed, 75 percent of all neonatal deaths take place in the first week and 50 percent within 24 hours after birth. The postpartum/postnatal period, especially the early phase, is also the most neglected part of the pregnancy, delivery, and postpartum continuum of care. In short, newborns are least likely to receive care during the period when they are at the greatest risk of dying.
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4 Million Newborn Deaths: When do newborn babies die?

Up to 50% of neonatal deaths are in the first 24 hours
75% of neonatal deaths are in the first week 3 million deaths
Time when most babies die is when coverage of quality care is lowest
Figure Intro. 3. When do newborns die? Adapted with permission from Elsevier (The Lancet, 2005, Vol 365, pg. 13)
Strategies to improve newborn health need to address policy issues, the supply side of health system strengthening, and the demand side at home and in the community to improve family behaviors. Current pre-service training for doctors, nurses, and midwives in essential newborn care has often been inadequate and at times inappropriate, so that health workers upon completion of their undergraduate course often lack basic skills in this area, including prevention and treatment of infections and birth asphyxia. Continuing education programs in newborn care are therefore essential to improving health worker skills. Still other support is needed to improve supervision and to provide and maintain basic equipment and supplies. Since the health and survival of the newborn are closely tied to that of the mother, it is important to integrate maternal and newborn health care into training programs wherever possible. Although it is not feasible to integrate all aspects of maternal and newborn care, this set of materials links selected aspects, including active management of the third stage of labor with care of the baby at birth, resuscitation for birth asphyxia, postnatal care of the mother and the baby, basic examination of the baby, care of the low birth weight infant, and prevention and treatment of major and minor infections.
CHAPTER 1: Preventing Infection1

PRINCIPLES OF INFECTION PREVENTION
Infection prevention practices are based on the following five principles/actions: Every person (client or staff) is considered potentially infectious. Hand washing is the single most important practice for preventing crosscontamination. Wear gloves before touching: o o anything wet: broken skin, mucous membranes, blood, or other body fluids. when there is a special risk of transmitting infection to or from the client.
Use protective gear (aprons, face masks, eye goggles, and caps) when splashes or spills of body fluids are expected. Use safe work practices (e.g., do not recap or bend needles), following guidelines for handling and cleaning instruments and disposal of sharps and medical waste. Hand Washing Hand washing significantly reduces the number of potentially infection-causing organisms on health workers hands and decreases the incidence of client sickness and death due to clinicacquired infections. It also protects the health worker from contact with blood and other body fluids. Wash hands on the following occasions: Immediately when you arrive at work. Before examining each client (mother or baby). After examining each client (mother or baby). Before putting on gloves for clinical procedures (such as a pelvic exam or an IUD insertion). After touching any instrument or object that might be contaminated with blood or other body fluids, or after touching mucous membranes. After removing any kind of gloves (hands can become contaminated if gloves contain tiny holes or tears). After using the toilet or latrine. Before leaving work.
This section provides guidelines on infection prevention practices to use when providing maternal and newborn services and is mainly adapted from materials developed by JHPIEGO, EngenderHealth, and WHO.
Reference Manual
Materials required for hand washing include: clean running water liquid soap (preferably in a receptacle fixed to the wall) or small pieces of soap, ideally used only once. Where feasible, liquid antiseptic soap would be better for places such as the delivery room and operation theater. sink or bowls veronica bucket (bucket with a tap) individual towels
The steps in hand washing are: 1. 2. 3. 4. 5. 6. 7. 8. Remove watches, bracelets, and rings. Nails should be short and without nail polish; artificial nails should not be worn. Wet hands with running water. Rub hands together with soap and lather well up to the elbows, covering all surfaces for 15-30 seconds. When attending deliveries, carrying out procedures, and where the hands are visibly soiled, wash longer, for about two minutes. Weave fingers and thumbs together and slide them back and forth, taking care to rub well between the fingers and the back of the hand. Rinse hands under a stream of clean, running water until all soap is gone. If there is no running water, hands should not be dipped inside the bowl of water; instead, the water should be poured over the hands from another container. Blot hands dry with a clean, dry towel or air-dry them; air-drying is the best, especially when sterile gloves have to be worn.
These steps are illustrated in Figure 1.1.
Figure 1.1. Hand washing. (WHO Guidelines on Hand Hygiene, 2006).

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The Hand Rub When hand washing is not possible, use of the hand rub is recommended. But so long as running water is available, the hand rub should not be used as a substitute for attending deliveries or when the hands are visibly soiled. The materials required are alcohol and a glycerine solution. The steps in hand rubbing are: 1. 2. 3. 4. Add 2 mL of glycerine, propylene glycol, or sorbitol to 100 mL of 60-90% alcohol. Pour about 1 teaspoon of the rub in the palm of the hand. Rub hands together, including in between the fingers and under the nails, until dry. Wash hands with soap and water after using the hand rub 5 times.
The technique using the alcohol-based formulation is shown in Figure 1.2.
Figure 1.2. Use of alcohol-based rub for hand hygiene. (WHO Guidelines on Hand Hygiene, 2006.)
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Use of Gloves Gloves protect the client from contact with micro-organisms on the health workers hands and the health worker from contact with blood and other body fluids. Three types of gloves are commonly used: Examination gloves (for contact with skin and intact mucous membranes and wherever there is risk of exposure for the health worker) Sterile/disposable surgical gloves (for contact with tissues under the skin or with the bloodstream, and preferably for conducting deliveries) Utility or heavy-duty household gloves, reusable after cleaning (for handling dirty linen, instruments, and waste, for housekeeping and cleaning contaminated surfaces) performing a procedure. there will be contact with intact mucous membranes. there will be contact with the tissues under the skin or with the bloodstream. handling soiled items (e.g., instruments and gloves). disposing of contaminated waste.
Wear gloves when:
When gloves are required, a separate pair of gloves must be used with each woman or baby to avoid cross-contamination. Disposable gloves are preferred, but when resources are limited, surgical gloves can be reused if they are: decontaminated by soaking in 0.5% chlorine for 10 minutes. washed and rinsed. sterilized by autoclaving or high-level disinfected by boiling or steaming.
Single-use or disposable surgical gloves should not be reused more than three times, even after the above steps, because invisible tears may occur. Note: Do not use gloves that are cracked, peeling, visibly torn, or that contain holes.
Putting gloves on Follow the steps below in putting gloves on. Step 1. Preparation for putting on surgical gloves. Gloves are cuffed to make it easier to put them on without contaminating them. When putting on sterile gloves, remember that the first glove should be picked up by the cuff only (see drawing below). The second glove should then be touched only by the other sterile glove. Follow steps 2-6 as illustrated below.
Figure 1.3. Putting gloves on. (EngenderHealth, online course: http://www.engenderhealth.org/ip/surgical/sum4.html)
Step 7. Adjust the glove fingers until the glove fits comfortably. Taking gloves off
Figure 1.4. Taking gloves off. (EngenderHealth, online course: http://www.engenderhealth.org/ip/surgical/sum4.htm)
Additional Protective Clothing Other kinds of protective clothing are listed and discussed below:
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coats/gowns waterproof aprons masks caps eye covers/face shields boots/slippers
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Gowns and waterproof aprons protect clients against micro-organisms and protect the providers skin and clothes from contact with blood and other fluids. Always wear a clean, preferably sterile gown during delivery. If the gown has long sleeves, place gloves over the gown sleeve to avoid contaminating the gloves. Ensure that gloved hands are held high above the level of the waist and do not come into contact with the gown. Masks protect clients against micro-organisms expelled during talking, coughing, and breathing, provided they are worn and used correctly, covering the mouth and nose. They also protect the providers nose and mouth from splashes of blood and other fluids. Caps protect clients against micro-organisms in hair and skin shed from the provider's head. No protection has been documented for providers. Eye covers/face shields protect the providers eyes from splashes of blood and other fluids. No protection has been documented for clients. Changing slippers at entry into the delivery room prevents bringing in the dirt from outside. Treatment of Soiled Linen Correct handling of linen prevents the spread of infections to hospital personnel who transport, sort, and clean the linen. It also prevents accidental injuries to hospital personnel who transport, sort, and clean the linen. Linen for delivery rooms, surgery, and neonatal units should be sterilized. The materials required to treat soiled linen include: utility gloves heavy duty plastic bags or buckets with covers detergent water a washing machine (ideal and far better than washing by hand)
No additional precautions (e.g., pre-rinsing, labelling, separating, or double bagging) are necessary, regardless of the patient diagnosis, if standard precautions are used in all situations. The guidelines for treating soiled linen are as follows: Housekeeping and laundry personnel should wear gloves and other personal protective equipment as indicated when collecting, handling, transporting, sorting, and washing soiled linen. When collecting and transporting soiled linen, handle it as little as possible and with minimum contact to avoid accidental injury and spreading of micro-organisms. Consider all cloth items (e.g., surgical drapes, gowns, wrappers) used during a procedure as infectious; even if there is no visible contamination, the item must be laundered.
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Carry soiled linen in covered containers or plastic bags to prevent spills and splashes, and confine the soiled linen to designated areas (an interim storage area) until transported to the laundry. Carefully sort all linen in the laundry area before washing. Do not presort or wash linen at the point of use. Pre-soak heavily soiled linen in soap, water, and bleach; wash separately from nonsoiled linen. Hand- or machine-wash (the latter is preferred). Air- or machine-dry completely (latter preferred). If air-drying, keep linen off the ground and away from animals and dirt. Sterilize linen for delivery rooms, operation theaters, and neonatal units by autoclaving that avoids burning. The linens should be in packs of not more than 5 kg; they may be in suitable drums. After autoclaving, store in a clean, dry, preferably closed storage area.
Handling Sharp Instruments Careful handling of sharps protects the client, health worker, and housekeeping staff from accidental injuries and exposure to blood and body fluids. Guidelines: Do not leave sharp instruments or needles (sharps) in places other than safe zones. Use a tray or basin to carry and pass sharp items. Pass instruments with the handle (not the sharp end) pointing toward the receiver. Warn others before passing sharps.
Needles and syringes Follow these guidelines to ensure safe handling of needles and syringes: Use each needle and syringe only once. Do not take the needle and syringe apart after use. Do not recap, bend, or break needles before disposal. Dispose of needles and syringes in a puncture-proof container. It is not recommended to recap needles. Where it is unavoidable, as in a situation where the needle cannot be placed in an appropriate, safe receptacle for sharps, then recap the needle, using the one-hand technique for recapping (Figure 1.5). Step 1: Place the cap on a hard, flat surface. Step 2: Hold the syringe with one hand and use the needle to scoop up the cap. Step 3: When the cap covers the needle completely, hold the base of the needle and use the other hand to make sure the cap is firmly in place.
Figure 1.5. One-hand technique for needle recapping. (WHO and CDC, 2007)
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Dispose of hypodermic needles and other sharps properly in a puncture-proof (heavy cardboard, glass, metal, or thick plastic) container (sharps container shown below).
Figure 1.6. Sharps containers
Make hypodermic needles unusable by burning them or, when the above container is full, seal the opening and burn the container or fill the container with decontaminating solution, seal the opening, and bury the container. Preventing Splashes Wear appropriate protective goggles, gloves, and gown during delivery. Preventing splashes protects the client, health worker, and housekeeping staff from accidental injuries and exposure to blood and body fluids. Prevent splashes from blood or amniotic fluid by following these guidelines: Avoid snapping the gloves when removing them, as this may cause contaminants to splash into the eyes, mouth, or onto the skin or on others. Hold instruments and other items under the surface of the water while scrubbing and cleaning to avoid splashing. Place items gently into the decontamination bucket to avoid splashes. Avoid rupturing membranes during a uterine contraction. Stand to the side when rupturing membranes to avoid splashes from amniotic fluid. Cut the cord, using sterile scissors or a scalpel blade, under cover of a gauze swab to prevent blood spurting. Always wear gloves when handling the placenta and handle it carefully. Keep it in a leakproof plastic bag or other container until it can be disposed of by burning or burying. The placenta should not be disposed of in a river or open garbage pit. Note: If blood or body fluids get in the mouth or on the skin, wash liberally with soap and water as soon as it is safe for the woman and baby. If blood or body fluids splash in your eyes, wash out well with water. The Steps of Processing Instruments Proper processing involves several steps that reduce the risk of transmitting infections from used instruments and other items to health care workers and clients. These steps are: 1) decontamination, 2) cleaning, 3) either sterilization or high-level disinfection (HLD), and 4) storage. For proper processing, it is essential to perform the steps in the correct order. 1. Decontamination kills viruses (hepatitis B and C, HCV, HIV) and many other germs. It makes items safer to handle during cleaning and easier to clean (hence, decontamination should always be done before cleaning).
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The materials needed for decontamination are: clean water chlorine solution/chlorine tablets/chlorine powder buckets with covers measuring cups a clock or timer
The four steps of decontamination are: 1) Fully immerse instruments and reusable gloves in 0.5% chlorine solution after use. (Details of preparation of this solution are noted below.) 2) Soak for 10 minutes and rinse immediately. 3) Change the solution every day or earlier if it is dirty or cloudy. 4) Wipe surfaces (exam tables) and spills with chlorine solution. 2. Cleaning removes blood, other body fluids, tissue, and dirt. It also reduces the number of germs and makes sterilization or HLD more effective. If a blood clot remains on an instrument, germs in the clot may not be completely killed by sterilization or HLD. The materials needed for cleaning are: detergent buckets or basins water toothbrush/brush utility gloves
The steps of cleaning are: 1) Wear utility gloves, a mask, and protective eyewear when cleaning instruments and other
items. 2) Using a soft brush, detergent, and water, scrub instruments and other items vigorously
to completely remove all blood, other body fluids, tissue, and other foreign matter. Hold instruments and other items under the surface of the water while scrubbing and cleaning to avoid splashing. Disassemble instruments and other items with multiple parts, and be sure to brush in the grooves, teeth, and joints of items where organic material can collect and stick. 3) Rinse items thoroughly with clean water to remove all detergent. Any detergent left on the items can reduce the effectiveness of further chemical processing. 4) Allow items to air-dry (or dry them with a clean towel). Note: Instruments that will be further processed with chemical solutions must dry completely to avoid diluting the chemicals; items that will be boiled or steamed do not need to be dried first. 3A. High-level disinfection (HLD) kills viruses (hepatitis B and C, HCV, HIV) and many other germs, but does not reliably kill all bacterial endospores. It is the only acceptable alternative when sterilization is not available.
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The materials needed for HLD include: a pot with a lid a clock or timer a steamer used for HLD disinfectant boiled water
Three methods of high-level disinfection are described below: Boiling: Immerse items fully in water, cover with a lid, and boil for 20 minutes (sufficient up to a height of 5500 meters/18,000 feet). Start timing when the water begins to boil. Do not add anything to the pot after timing begins. Drain off the water and keep covered before use or storage. Store for one week maximum. Steam instruments, gloves, and other items on the steaming tray for 20 minutes. Be sure there is enough water in the bottom pan for the entire steam cycle. Bring water to a rolling boil. Start timing when the steam begins to come out from under the lid. Do not add anything to the pan after timing starts. Drain off the water and store in covered steamer pans. Store for one week maximum. Sterilants used include 2.65% glutaraldehyde and hypochlorite/chlorine preparations noted below in this chapter. Cover all items completely with disinfectant. Soak for 20 minutes. Rinse with boiled water. Air-dry before use and storage.
Steaming:
Chemical HLD:
3B. Sterilization kills all germs, including endospores, but is not possible in all settings. The materials required are: an autoclave an oven chemical or mechanical indicators chemical products (e.g., glutaraldehyde) wraps/drums for autoclaving an autoclave tape sterile pickups a clock or timer
Sterilization can be done by dry (oven) or wet heat (autoclave), depending on the materials and supplies to be sterilized. For example, glass items can be kept in the hot air oven, but some items, such as those made of rubber and cloth, need to be autoclaved.
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Steam sterilization (autoclave): 121 C (250 F); 106 kPa (15 lbs/in2) pressure: 20 minutes for unwrapped items, 30 minutes for wrapped items. Decontaminate, clean, and dry items before sterilization. Allow the pressure to drop to zero before opening the autoclave. Allow items to dry before removing.
Dry-heat (oven): 170 C (340 F) for 1 hour or 160 C (320 F) for 2 hours. Chemical sterilization: Soak items in glutaraldehyde for 8 to10 hours or formaldehyde for 24 hours. Rinse with sterile water.
4. Storage/Usage. If items are stored properly they will not become contaminated after processing. Proper storage is as important as proper processing. Items processed through the first three steps can be stored up to one week in an HLD/sterilized container. Making a Chlorine Decontamination Solution The ability to decontaminate instruments is a critical step in preventing infection. The most common decontamination process is to soak instruments in a 0.5% chlorine solution for 10 minutes. Chlorine solutions made from sodium hypochlorite are usually the most inexpensive, fast-acting, and effective for decontamination. A chlorine solution can be made from: liquid household bleach (sodium hypochlorite) bleach powder or chlorine compounds available in powder form (calcium hypochlorite or chlorinated lime) chlorine-releasing tablets (sodium dichloroisocyanurate)
Chlorine-containing compounds contain a certain percentage of "active" (or available) chlorine. Active chlorine in these products kills microorganisms. The amount of active chlorine is usually stated as a percentage and differs among products, an important fact to ensure preparation of a chlorine solution with 0.5% "active" chlorine that can be used to decontaminate gloves and instruments. With regard to chlorine products, note the following: Different products may contain different concentrations of available chlorine, and the concentration should be checked before use. In countries where French products are available, the amount of active chlorine is usually expressed in "degrees chlorum." One degree chlorum is equivalent to 0.3% active chlorine. Household bleach preparations can lose some of their chlorine over time. Use newly manufactured bleach if possible. If the bleach does not smell strongly of chlorine, it may not be satisfactory for the purpose and should not be used. Thick bleach solutions should never be used for disinfection purposes (other than in toilet bowls), as they contain potentially poisonous additives.
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When preparing chlorine solutions for use note that: Because of their low cost and wide availability, chlorine solutions prepared from liquid or powdered bleach are recommended. Organic matter destroys chlorine, and freshly diluted solutions must therefore be prepared whenever the solution looks as though it needs to be changed (such as when it becomes cloudy or heavily contaminated with blood or other body fluids). Chlorine solutions gradually lose strength, and freshly diluted solutions must therefore be prepared daily. Calculate the ratio of water to liquid bleach, bleach powder, or chlorine-releasing tablets (see the calculations below). Clean, clear water should be used to make the solution because organic matter destroys chlorine. Use plastic containers for mixing and storing bleach solutions, as metal containers are corroded rapidly and also affect the bleach. Prepare bleach solutions in a well-ventilated area because they give off chlorine. Label the container with the percentage of the diluted decontamination solution prepared and note the day and time prepared. A 0.5% bleach solution is caustic. Avoid direct contact with skin and eyes.
Calculating the water-to-liquid-household-bleach ratio to make a 0.5% chlorine solution Chlorine content in liquid bleach is available in different concentrations. You can use any concentration to make a 0.5% chlorine solution by using the following formula: [% chlorine in liquid bleach divided by 0.5%] minus 1 = parts of water for each part bleach Note: "Parts" can be used for any unit of measure (e.g., ounce, liter, or gallon) and do not have to represent a defined unit of measure (e.g., a pitcher or container). For example: To make a 0.5% chlorine solution from a 3.5% chlorine concentrate, use one part chlorine and six parts water:
+ [3.5% divided by 0.5%] minus 1 = [7] minus 1 = 6 parts water for each part chlorine
Figure 1.7. 0.5% chlorine solution
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Calculating the water-to-bleach-powder ratio to make a 0.5% chlorine solution When using bleach powder to make a decontamination solution, calculate the ratio of bleach to water using the following formula: [% chlorine desired divided by % chlorine in bleach powder] times 1,000 = grams of powder for each liter of water. Note: When bleach powder is used, the chlorine solution will likely appear cloudy or milky. For example: To make a 0.5% chlorine solution from calcium hypochlorite powder containing 35% available chlorine, use the following formula: [0.5% divided by 35%] times 1,000 = [0.0143] times 1,000 = 14.3 Therefore, dissolve 14.3 grams of calcium hypochlorite powder in one liter of water in order to get a 0.5% chlorine solution. Calculating the water-to-chlorine-releasing-tablet ratio to make a 0.5% chlorine solution Follow the manufacturer's instructions when using chlorine-releasing tablets because the percentage of active chlorine in these products varies. If instructions are not available with the tablets, ask for the product instruction sheet or contact the manufacturer. Table 1 provides details on how to mix a decontamination solution with chlorine.
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Table 1. Mixing A 0.5% Chlorine Decontamination Solution
Liquid bleach (sodium hypochlorite solution) Type or brand (by country) 8 Chlorum* JIK (Kenya, Zambia), Robin Bleach (Nepal) 12 Chlorum Household Bleach (Indonesia, USA), ACE (Turkey), Eau de Javel (France) 15 Chlorum, Lejia (Peru), Blanquedor, Cloro (Mexico) Lavandina (Bolivia) Chloros (United Kingdom) Chloros (United Kingdom), Extrait de Javel (France), 48 Chlorum Dry powders Type or brand (by country) Calcium hypochlorite Calcium hypochlorite Sodium dichloroisocyanurate (NaDCC) Tablets Type or brand (by country) Chloramine tablets* Sodium dichloroisocyanurate (NaDCC-based tablets) % or grams active chlorine 1 gram chlorine per tablet 1.5 grams chlorine per tablet Water-to-chlorine = 0.5% solution 20 grams per liter (20 tablets per liter) 4 tablets per liter % or grams active chlorine 70% 35% 60% Water-to-chlorine = 0.5% solution 7.1 grams per liter 14.2 grams per liter 8.3 grams per liter % or grams active chlorine 2.4% 3.5% 3.6% 5% 6% 8% 10% 15% Water-to-chlorine = 0.5% solution 10 mL bleach in 40 mL water 1 part bleach to 4 parts water 10 mL bleach in 60 mL water 1 part bleach to 6 parts water 10 mL bleach in 90 mL water 1 part bleach to 9 parts water 10 mL bleach in 110 mL water 1 part bleach to 11 parts water 10 mL bleach in 150 mL water 1 part bleach to 15 parts water 10 mL bleach in 190 mL water 1 part bleach to 19 parts water 10 mL bleach in 290 mL water 1 part bleach to 29 parts water
*Chloramine releases chlorine slower than hypochlorite. Before using the solution, be sure the tablet is completely dissolved.
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Waste Disposal Proper waste disposal: minimizes the spread of infections and reduces the risk of accidental injury to staff who handle the waste. prevents the spread of infection to clients, visitors, and the local community. helps provide an aesthetically pleasing atmosphere. reduces odors. attracts fewer insects and does not attract animals. reduces the likelihood of contamination of the soil or ground water with chemicals or micro-organisms.
There is no risk from uncontaminated waste such as office paper, boxes, packages, plastic containers, and food-related trash which can be disposed of according to local guidelines. Materials needed to dispose of waste include: Separate waste containers for medical and nonmedical waste Sharps containers An interim storage area An incinerator, an on-site burial pit Protective gear, including utility gloves
Proper handling of contaminated waste, such as items with blood or body fluid, is required to minimize the spread of infection to other staff and the community. Proper handling includes: Wearing heavy-duty gloves. Transporting solid contaminated waste to the disposal site in covered containers Disposing of all sharp items in puncture-resistant containers Carefully pouring liquid waste down a drain or flushable toilet Burning or burying contaminated solid waste Washing hands, gloves, and containers after disposal of infectious waste
Housekeeping Good housekeeping reduces micro-organisms, reduces the risk of accidents, and provides an appealing work and service-delivery space. Materials required for good housekeeping include: Detergent and water (for cleaning of walls, windows, ceilings, doors, floors, and equipment such as stethoscopes and weighing scales) Disinfectant solution (0.5% chlorine solution for decontamination of soiled area before cleaning with detergent and water) Disinfectant cleaning solution (0.5% chlorine solution with detergent): o o Add detergent until the solution is slightly foamy. Use for cleaning contaminated areas (examination and delivery rooms, operation theaters, floors, sinks, toilets/latrines, waste containers, beds, mattresses, etc.). Do not mix chlorine solution with cleaning solutions such as ammonia or phosphoric acid.
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Recommended cleaning procedures are as follows: Cleaning procedures will depend upon the potential risk of contamination. Low-risk areas include waiting rooms and administrative areas. High-risk areas are toilets, latrines, and sluice rooms, and client-care areas such as operating theaters, procedure rooms, laboratories, areas where instruments are cleaned and processed. Develop and post cleaning schedules where all housekeeping staff can see them. Make sure that cleaning schedules are closely maintained. Clean immediately: after spills, procedures, and deliveries. Clean daily (at each shift if work load is excessive): delivery, operation, and examination/procedure rooms; floors, furniture, toilets/latrines, waste containers; and wipe incubators and radiant warmers with disinfectant solutions. Always wear gloves (preferably thick utility gloves) when cleaning. Use a damp or wet mop or cloth for walls, floors, and surfaces, instead of dry-dusting or sweeping, to reduce the spread of dust and micro-organisms. Scrubbing is the most effective way to remove dirt and micro-organisms. Scrubbing should be a part of every cleaning procedure. Wash surfaces from top to bottom so that debris falls to the floor and is cleaned up last. Clean the highest fixtures first and work downward; for example, clean ceiling lamps, then shelves, then tables, and then the floor. Change cleaning solutions whenever they appear to be dirty. A solution is less likely to kill infectious micro-organisms if it is heavily soiled. Clean up spills of potentially infectious fluids immediately. When cleaning up spills: o o o Always wear gloves. If the spill is small, wipe it with a cloth that has been saturated with a disinfectant (0.5% chlorine) solution. If the spill is large, cover (flood) the area with a disinfectant (0.5% chlorine) solution, mop up the solution, and then clean the area with a disinfectant cleaning solution.
CLEAN DELIVERY CARE

Related to clean delivery practices, some promote the concept of the three "cleans"clean hands, clean surface, and clean cord careor the five "cleans": clean hands, clean surface, clean instrument for cutting the cord, clean ligatures for tying the cord, and then keeping the cord clean and dry. There is also the seven cleans: the five cleans plus clean perineum and keeping the vagina clean without introducing anything unclean inside it. The main supplies needed for the cleans include: A waterproof plastic cover (to provide a clean surface) Soap An unused razor blade kept in its cover for cutting the cord Clean cord ties (both the razor blade and the cord ties should preferably be boiled for at least 10 minutes before use) Clean, washed, and sun-dried towels kept in a clean container for drying and wrapping the baby A clean perineum A clean vagina without introducing anything unclean inside
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While the above may be acceptable at the community level, it is essential to take even greater care at the facility level where with some advocacy and planning it will eventually be possible to have as many sterile or disposable items as possible, especially those that come in direct contact with the perineum or the baby. These precautions will help prevent hospital-acquired infections which are particularly resistant to antibiotics and, hence, all the more dangerous. While it may be initially difficult to achieve these goals, it is necessary to keep aiming high, to be persistent on this important matter, and not be satisfied in just achieving cleanliness.
EQUIPMENT AND SUPPLIES RELATED TO RESUSCITATION

Equipment must be cleaned and disinfected after each use, and consumable supplies must be replaced. Manufacturers provide specific information on how to clean and disinfect/sterilize various pieces of equipment. Their guidelines should be carefully observed; failure to respect the guidelines may result in severe and/or lethal neonatal infection. Resuscitator Bag and Mask2 The mask and the patient valve should both be disinfected after each use since they are exposed to the newborn and to expiratory gases. The bag and the inlet valve should be disinfected after use with an infected newborn, and otherwise occasionally. The valve and the mask must first be disassembled, inspected for cracks and tears, washed with water and detergent, and rinsed. Selection of the decontamination method will depend on the material. Silicone and rubber bags and patient valves can be boiled for 10 minutes, autoclaved at 136 C, or disinfected by soaking in a disinfectant. Dilution of disinfectant and exposure time should be in accordance with the instructions of the manufacturer. All parts must be rinsed with clean water after chemical disinfection and air-dried before assembling. After re-assembling, the bag must be tested to check that it works correctly. Most manufacturers give step-by-step instructions for this procedure. If instructions are not available, use the following test: Block the valve outlet by making an airtight seal with the palm of the hand; squeeze the bag and feel the pressure against the hand; observe if the bag re-inflates when the seal is released; if the bag is not functioning correctly, it should be repaired before use. Repeat the test with the mask attached to the bag. The steps noted above relate to ideal conditions. Frequently, there is only one bag with no possibility of fixing or replacing it in case of damage. Many health workers have difficulty in reassembling the parts. If this is the case, it might be more feasible to clean the different parts with a damp cloth. The mask can be easily separated and cleaned with at least soap and water, dried, and fixed back on the front outlet of the bag. Aspiration Catheters and Suction Devices Disposable catheters and suction devices must be discarded; they are not recommended for reuse even after thorough cleaning. If these devices are not available on site, mothers should be asked to bring a suction bulb when they come for the delivery since a new bulb can be washed, sterilized, and used for the baby if required, and then discarded.
The text under this heading is reproduced from the WHO/Safe Motherhood Basic Neonatal Resuscitation A Practical Guide.
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CHAPTER 2: Clinical Decision-Making

THE PROBLEM-SOLVING METHOD
Clinical decision-making is the systematic process by which skilled providers make judgments regarding a patient's condition, diagnosis, and treatment. Skilled providers possess the skills and knowledge to perform procedures correctly. It is not enough to just perform procedures correctly, however. You must also choose the correct procedure to meet the woman or infants needs. In addition, you must be able to choose the right time to use a particular clinical skill. The problem-solving method guides you in giving care that is safe and effective, provides an organized way to approach and manage care, and uses skills and processes that are common in everyday life. Why Is It Important to Use the Problem-Solving Method? Using a methodical approach to solve problems has three advantages: It helps you gather information in an organized manner. It helps you gather complete information so that a problem can be correctly identified. It helps you avoid using interventions that are not needed.
Steps in Resolving a Problem The key steps in problem-solving are noted in Table 2.
Table 2. Steps in the Problem-Solving Method Step 1: History Step 2: Physical examination Step 3: Identification of problems/needs Step 4: Care plan Take a targeted history. Perform a targeted physical examination. Identify needs and problems. Make a plan of care based on identified needs and problems. Follow up with the client to evaluate the care that has been provided. This step repeats all the steps of the problem-solving method, starting with step 1.
Step 5: Follow-up
Step 1: Take a targeted history In this step providers will ask specific questions (what, how, where, when, who, why) about a problem to help make a diagnosis or determine the cause of the problem. Ask the client why she has come. The reason for seeking care is called the chief complaint. The provider asks the client about the problem (signs, symptoms, etc.) or stated need (vaccination, antenatal care
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visit, etc.). Listen carefully to all the answers; the clients answers are important and will help you identify the problems. Write down the important points in the answers. There are two types of histories: A routine history: This type of history is taken for every woman coming in for routine antenatal, postnatal, family planning, services, etc. Everyone who comes in for care will be asked the same questions, and the information will be documented on a standard form. A targeted history: This type of history is taken when a client comes in with a complaint. You will tailor the questions you ask around the complaint that the client has and will get information from the client that will help you identify problems or make a diagnosis. Make sure the woman feels welcome. Help the woman feel comfortable with your actions. Provide a private area to talk and assure the woman of confidentiality. Encourage the woman to talk and ask questions. Ask questions in a kind and interested way. Listen carefully to all the answers.
The following skills are important for taking a complete history:
Ask specific questions about signs and symptoms to help identify the problem(s). The clients answers about her problems are the findings of this first step. The results from this first step will guide the provider through step 2. Note: If the woman comes with an emergency, you will ask very few questions, as immediate action may be required. You may have to ask questions of the family who accompanies the woman. Step 2: Perform a targeted physical examination After explaining to the woman what you are planning to do, examine the areas of the clients body that relate to the information you gathered in step 1. A physical examination includes observation, palpation, percussion, auscultation, and smell. There are two types of physical examinations: A routine physical examination: Sometimes you will need to do a general or full examination of the body. In the case of a woman registering (booking) for antenatal care, you will need to know about the condition of her entire body. A general examination of the body may also help you to find problems that the woman herself has not recognized. This also applies to a baby who may be just brought in for a routine service such as immunization. A targeted physical examination: This type of physical examination is performed when a client comes in or a baby is brought in with a problem. You will tailor the physical examination around the complaint that the client has and will get information that will help you identify problems or make a diagnosis.
Results from the physical examination are the findings of this step. Order laboratory or other diagnostic tests as needed. Examination of the baby has some other components that are described in chapter 9 and in Appendix B.
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Step 3: Identify needs and problems This is the third step of the problem-solving method. Using the information from steps 1 and 2, the provider will identify problems the client is experiencing. Identification of needs or problems is done by thinking about findings, what the client has said (history), and what was found in the physical examination. The provider will compare the findings with what is known about normal findings to determine if the condition is normal or if there is a problem. If the findings are all normal, the provider will proceed to identify the clients needs. These are the things the client needs to remain healthy, such as immunizations, birth preparedness in the antenatal period, or counseling on nutrition and basic care of the woman and her baby. If the findings indicate there is a problem, the provider will compare the abnormal findings with what she/he remembers or finds in references about complications. If the findings match those for a complication, the provider will determine the diagnosis. Sometimes, it is difficult to determine an exact diagnosis. In this case, either eliminate some diagnoses and use a differential diagnosis or describe the problem and refer the woman/baby for further evaluation and care. It is important that all the clients problems and needs are treated, not just the problem that caused her to come to you. A pregnant woman may need information on family planning methods, good nutrition during pregnancy, how to relieve hemorrhoid pain, and where to go for immunizations for her small childrenall in one visit. She may have come with only one complaint, problem, or question. Make certain that you write all the problems or needs on her record/antenatal form. Step 4: Make a plan of care This is the fourth step of the problem-solving method. The provider will decide what should be done to solve each problem or meet each need. Ideally, the provider will develop the care plan with the client, the clients mother, or the clients family members. The following actions should be considered for each problem or need, and the provider must decide which to do first, second, and so on. Sometimes medical treatment will be needed first. For example, when a woman has a retained placenta and is bleeding heavily, you must stop the bleeding by manually removing the placenta before laboratory tests can be done. You may then give her more treatment, education or counseling, or refer her. Or, when a woman who is six months pregnant comes to you and is feeling very tired, you will test her hemoglobin (Hb) before giving her treatment, education and counseling, or referring her. A baby brought with a danger sign needs referral to an appropriate center after giving the first dose of antibiotics, whereas a newborn infant with a minor infection may be managed locally along with routine basic care, such as giving immunizations. Here are some appropriate actions a provider might write in the plan of care developed for the client: Medical treatment. Choose the correct medication, procedure, or treatment by following the clinical protocols. Education. Help the woman learn to care for herself well. Always teach women the danger signs they should be aware of in themselves and their babies and where to go if any of these signs or symptoms appear. Counseling. Help the client understand the problem or needs. Work with her to develop a way to treat the problem or meet the needs.
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Laboratory tests or other investigations. These include laboratory tests, ultrasound or x-ray examination as required and as feasible. Follow the clinical protocol guidelines for the appropriate use of these methods to obtain more information about the problem. Referrals. Use other resources in the area, such as doctors, hospitals, education programs, womens groups, or charity groups to help the woman meet her needs. Plan for follow-up. After you take appropriate action, you will see the woman/baby again and repeat the process.
This is how the problem-solving method is used, over and over again until the problem is resolved. Thank her for coming to see you and schedule an appointment for her return. Explain why you want her to return. Make sure she knows the danger signs and emphasize that she needs to come back immediately if she sees a danger sign in herself or her baby. When you are scheduling a return visit, the time she should return will depend upon how severe her problem is and how long it should take to improve. You may need to see her in 24 hours, 2-3 days, 2 weeks, or later. If she could develop a serious complication from her problem, she should be seen frequently until she is out of danger. Newborn babies with minor problems are often asked to be brought back after 48 hours. Low birth weight babies may be followed up on weekly until they are gaining weight and doing well. Step 5: Follow-up to evaluate the care provided Repeat the problem-solving method when you see the client at her next visit, which could be when she returns for a routine care appointment or for a check-up after treatment for a problem. By repeating the problem-solving method, the provider will find out if the problem is solved, is staying the same, or is getting worse. In some cases, the provider may need to develop a new plan for treating the patient. The mother may need to have information repeated to be sure she understands. She may need a different medication or treatment. She may need to be referred to a doctor or hospital. The provider will also find out if there are other new problems or different needs. Care needs to be taken to record all findings and actions taken. A clear report in the clients record helps others to give continued quality care. Somewhat similar plans apply to the newborn. However, since staff competence and facility resources and supplies may be more limited related to the care of the sick newborn at peripheral centers, babies with danger signs will frequently need to be referred to a suitable higher center or hospital for appropriate care.
Documentation of Care
The problem-solving method provides a clear and organized way to record the information about a womans problem and how it was managed. Along with the date and time record: all symptoms, based on what the woman tells you findings from the physical examination and laboratory information problems and needs identified
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When writing the plan of care, make sure it is tailored to respond to the problems and needs identified in the mother and her baby. For each problem/need, write the following information: treatments prescribed prophylaxis prescribed laboratory or other examinations ordered counseling and education given referrals made date to return for care and evaluation.
All items should be clearly and carefully written in the records or cards of the mother/baby and in the delivery room and clinic registers. When the recording is good and complete, the care is usually good and complete.
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Clinical Decision-Making
Receive the client and respond immediately.
Perform a quick check on each patient to evaluate for danger signs.
Yes Danger signs? No Gather information: Take a history and perform a physical examination.
Begin emergency assessment and management, including plans for referral where required.
B1
Identify problems/ make a diagnosis.
Evaluate the plan of care (begin the steps all over again).
Make a plan of care.
Implement the plan of care.
Figure 2.1. Clinical decision making algorithm
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CHAPTER 3: Maternal Care to Improve Maternal and Newborn Survival

The fetus growth and development depend on the health of the mother. The mothers body provides nutrition, rest, oxygen, and protection to the fetus. A healthy woman, who receives good antenatal care, has a much greater chance of giving birth to a healthy, term baby and of surviving pregnancy and childbirth. The goals of antenatal care are as follows: To promote and maintain the physical, mental, and social health of the mother and baby by providing education on nutrition, personal hygiene, and the birthing process. To detect and manage complications during pregnancy, whether medical, surgical, or obstetrical. To develop a birth-preparedness and complication-readiness plan. To help prepare the mother to breastfeed successfully, experience normal puerperium (the period from 4-6 weeks after delivery), and take good care of the child physically, psychologically, and socially.
EVERY PREGNANCY IS AT RISK

In the past, health services used a risk system to identify high risk pregnancies so that these women could be referred to specialized care centers. A risk factor is anything that increases a person's chances of developing a disease or a complication. Risk factors may be associated with but do not necessarily cause a particular disease or complication. In addition, persons without the risk factor can also develop the disease or complication. More than 10 years of experience with the risk factor approach have shown us that it has many limitations, including: So-called risk factors cannot predict complications because they are usually not the direct cause of the complication; for example, although young age can be associated with eclampsia, it does not always cause eclampsia. Women in older age groups can also develop eclampsia. Because maternal mortality is a relatively rare event in the population at risk, i.e., all women of reproductive age, and because the so-called risk factors are relatively common in the same population, these risk factors are not good indicators to identify women who actually do experience complications. The majority of women who actually did experience a complication were considered low risk, while the majority of the women (90 percent) considered to be high risk gave birth without experiencing a complication.
What can be done, then? The literature strongly suggests that: All health care providers and families understand that normal pregnancy and normal birth are retrospective diagnoses and can only be made at the end of pregnancy and childbirth. All pregnancies be regarded as potentially at risk and managed with the utmost care.
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All pregnant women receive at least four focused (quality) antenatal visits. Detection of risk factors should be modified to put the emphasis on educating the women, men, and family members about danger signs and the actions necessary to get timely access to maternal health services if the woman experiences a complication. The so-called risk factors, instead of being considered as markers or indicators of complications, should be regarded as factors associated with complications, and their importance for each pregnancy and childbirth should be considered on a case-by-case basis. The presence of risk factors implies a need for more careful monitoring, not because they are necessarily predictive of complications. For many of them (e.g., age), nothing can be done to alter the risk factor. However, additional care and watchfulness may prevent a complication from arising or enable its early detection and management.
MATERNAL CONDITIONS AFFECTING FETAL AND NEWBORN SURVIVAL

This section will discuss maternal conditions, pregnancy-related complications, and maternal infections that have an impact on fetal and newborn health and survival. Iron-deficiency Anemia An anemic pregnant woman has a high risk of getting ill (because of lowered resistance to infection), of having a low birth weight (LBW) infant with a birth weight of less than 2500 grams, of giving birth prematurely before 37 completed weeks of gestation, of suffering from postpartum hemorrhage and heart failure, and of dying. Many women are already anemic when they become pregnant; closely spaced pregnancies, malaria, hookworm, sickle cell anemia, and frequent and chronic infections are some of the causes of anemia.
Figure 3.1. Signs of iron-deficiency anemia
Iodine Deficiency Iodine needs increase greatly during pregnancy because iodine is essential for the development and maturation of the fetal nervous system. Iodine deficiency in the pregnant woman has been associated with: 1) in the fetus: abortion, stillbirth, retardation of cerebral development, and congenital anomalies; 2) in the newborn: low birth weight, goiter, and neonatal hypothyroidism; and 3) in the adult: goiter and complications from goiters. Malnutrition Maternal undernutrition during pregnancy is associated with low birth weight. Low birth weight, in turn, has been shown to correlate with an increased incidence of the following: neonatal, infant, and child morbidity and mortality, small head circumference, mental retardation, cerebral palsy, learning problems/disabilities, visual and hearing defects, neurologic defects, and poor infant growth and development.
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Malaria Susceptibility to malaria parasitemia is increased during pregnancy, particularly in the primigravida or women in their first malaria-exposed pregnancy. Malaria in pregnancy can cause severe anemia, provoke an abortion, premature birth, or the birth of a stillborn. Because placental sequestration of malarial parasites can occur, newborns of women who have suffered from malaria during pregnancy tend to be smaller, weaker, and more vulnerable to infections. Urinary Tract Infections Urinary tract infections (UTI) during pregnancy increase the risk of low birth weight infants and prematurity . Neonatal problems that are associated with UTI include sepsis and pneumonia. The risk of urinary tract infection on adverse perinatal outcomes is greatest among those with the most severe infection of the kidney, known as pyelonephritis. Syphilis Untreated maternal syphilis increases the risk of spontaneous abortion, stillbirth, congenital infection in the newborn, and neonatal mortality. Early detection and treatment is necessary to halt the devastating effects of progressive syphilis in the woman and to prevent transmission to her baby and her partner. The test for syphilis should be repeated in the third trimester if the woman or her partner engages in risky sexual behavior. HIV Infection with HIV affects many aspects of antenatal care. A woman infected with HIV requires additional care to keep her as healthy as possible, to prevent transmission to her baby and her partner, to treat her HIV infection, and to link her to appropriate support and help her make decisions about the future, including avoiding unintended pregnancies. The risk of mother-tochild transmission (MTCT) of HIV is 15-45 percent; more than 90 percent of pediatric AIDS cases are due to MTCT. Untreated maternal HIV can also result in increased incidence of stillbirths and newborn deaths, low birth weight, intrauterine growth retardation, and possibly spontaneous abortion and preterm birth. Diabetes Uncontrolled diabetes during pregnancy can result in maternal morbidity and mortality and is associated with an increase in perinatal/neonatal mortality. In addition, certain fetal anomalies are more common in babies of diabetic mothers, and the larger size of babies born to diabetic mothers may contribute to cephalopelvic disproportion, obstructed labor, and increased occurrence of birth asphyxia and birth trauma. Finally, the baby of a diabetic mother is also at increased risk for hypoglycemia, which may occur in the immediate postpartum period, and for jaundice, which may develop during the early neonatal period.
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Preeclampsia and Eclampsia Women who develop preeclampsia during pregnancy are all at increased risk of complications in the antenatal period, during labor and childbirth, and in the postpartum period. The increased risk applies to the mother as well to the fetus. In cases of severe preeclampsia, delivery should occur within 24 hours of the onset of symptoms. In cases of eclampsia, delivery should occur within 12 hours of the onset of convulsions. Delivery should take place as soon as the womans condition has stabilized, regardless of gestational age. Delaying delivery to increase fetal maturity will risk the lives of both the woman and the fetus and may result in the birth of a pre-term baby.
Perinatal outcome is strongly influenced by gestational age and the severity of hypertension. Severe preeclampsia is associated with different degrees of fetal complications. The main impact on the fetus is undernutrition as a result of utero-placental vascular insufficiency, which leads to growth retardation. There are short and long-term effects; the immediate impact observed is fetal growth retardation, resulting in greater fetal liability. Fetal health as well as the fetus weight are highly compromised, leading to various degrees of fetal morbidity, and fetal damage may be such as to cause fetal death. Pre-Labor Rupture of Membranes Pre-labor rupture of membranes (PROM) may pose immediate risks such as cord prolapse, cord compression, and placental abruption. PROM is believed to have an association with maternal and fetal infection, with the risk considered to increase proportionally to the time between membrane rupture and birth, the risk being greater when the duration exceeds 18 hours. PROM also increases the risk of Caesarean operation and extends the duration of the hospital stay. If PROM occurs before 37 weeks, there is an additional risk of giving birth to a premature infant. Vaginal Bleeding in Later Pregnancy and Labor Any amount of bleeding during pregnancy and labor can put the life of the woman and fetus in danger. Preterm delivery and low birth weight are associated with second trimester hemorrhage. Abruptio placentae, placenta praevia, and uterine rupture are all associated with fetal distress and death. If the woman is Rh-negative, there is a risk of maternal iso-immunization if maternal and fetal blood mix when hemorrhage occurs. This may have an impact on the baby and will certainly have consequences for future pregnancies.
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ANTENATAL CARE
Antenatal care (ANC) should begin as early as possible in the pregnancy. Appropriate scheduling depends on the gestational age of the pregnancy and also the womans individual needs. For women whose pregnancies are progressing normally, the following schedule for a minimum of four ANC visits may be sufficient: 1st Visit: 16 weeks (by the end of 4 months) or as soon as the woman thinks she is pregnant nd 2 Visit: 24-28 weeks (6-7 months) 3rd Visit: 32 weeks (8 months) 4th Visit: 36 weeks (9 months) for a total of 2 visits during the 3rd trimester Elements of a Routine Antenatal Visit During a routine antenatal visit, a skilled provider should: Perform a systematic examination including a rapid assessment to recognize danger signs and features of advanced labor and respond immediately and appropriately. Detect pregnancy-related complications, fetal complications, medical conditions, and infections. Take a detailed history to identify abnormalities and problems/potential problems that may affect the pregnancy: social problems, medical problems, history of obstetrical complications with previous pregnancies or births, and reported symptoms/problems. Perform a physical, obstetrical, and gynecological exam. Perform the following laboratory tests to evaluate the womans health and her pregnancy and screen for selected medical conditions and infections. Where essential tests are not feasible at the peripheral center, the woman must be referred to an appropriate facility. o Hemoglobin levels (first visit/as needed). o RPR (Reactive Plasma Reagin) or VDRL (Venereal Disease Research Laboratory) at first visit or as needed: The test should be repeated in the 3rd trimester if the woman or her partner engages in risky sexual behavior. o HIV (first visit/repeat in 3rd trimester/as needed): If the woman volunteers for testing or if the testing is initiated by the health care provider, a test should be conducted as early as possible during the pregnancy. A positive HIV status affects many aspects of ANC. Therefore, steps should be taken to prevent transmission of the virus to the baby and for appropriate treatment of the mother. o Urine for glucose: This test is used to screen for diabetes, which is a condition beyond the scope of basic care. Although many women with normal glucosetolerance tests spill sugar in their urine without any associated problems for mother or child, this test can help identify women who actually do have high blood glucose levels. o Urine for protein: This test is used to screen for preeclampsia, which is a condition beyond the scope of basic care. Although proteinuria is most commonly associated with preeclampsia or eclampsia, a woman's urine can test positive for protein if she is severely anemic, has kidney disease, or has a urinary tract infection, or if the urine
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o o
has been contaminated by blood (or if she has schistosomiasis), vaginal discharge, or amniotic fluid. Grouping and Rhesus factor: All pregnant women should have their blood grouped for ABO and Rhesus (Rh) types. Knowing the womans blood type can facilitate transfusion in the case of an emergency. Knowing her Rhesus type will allow timely administration of Rhesus antibodies (anti-D immunoglobulin) to prevent maternal iso-immunization. Women with Rh-negative blood group are screened for Rhesus antibodies with an indirect Coombs test. If there are no antibodies, the blood will be retested at 28 and 34 weeks of pregnancy. If antibodies are found at any stage, referral to a specialist will be required to decide on management of the pregnancy and the newborn. Urine test for bacteriuria (as needed): This test is used to diagnose urinary tract infections, which are conditions beyond the scope of basic care. Other tests as needed based on findings in history and physical examination.
Provide prophylaxis for health promotion and disease prevention: TT, intermittent preventive treatment (IPTp) of malaria, insecticide-treated bednets, iron/folate tablets, broad-spectrum anti-helminthics, and other nutritional supplements as needed. Provide treatment for any medical conditions, illnesses, and infections detected. Manage any pregnancy-related complications. Provide client-centered and gestational-age-specific counseling for women and partners/ supporters. Help the woman and her partner/support person develop a birth-preparedness and complication-readiness plan. Begin discussing the plan at the first visit and bring it up to date at each subsequent visit. Ideally, during the antenatal visits, the mother should be counseled on basic preventive care of herself and her baby after delivery, identification of danger signs, and the required care-seeking. A number of women may end up delivering at home even after having visited the antenatal clinic. Refer all women who need specialized care for any reason to an appropriate hospital.
Health Promotion and Disease Prevention Certain medications or simple health care measures can prevent or reduce the risk of suffering from specific health problems. The following measures should be explained and offered to all pregnant women. Preventing malaria Intermittent preventive treatment (IPTp) of malaria with sulfadoxine-pyrimethamine (SP) 500 mg + 25 mg. Do not give SP during the first trimester of pregnancy or during the 9th month of pregnancy. Table 3. Timing of SP dose SP Dose 1st dose Timing From 18 weeks (after quickening). Not before 16 weeks gestation. At 28 weeks or 1 month After the 1st dose.
Provide SP to all pregnant women: give 2 doses to women who are not infected with 2nd dose HIV; check national protocols for dose recommendations for women infected with HIV (if the woman is on cotrimoxazole prophylaxis, use another anti-malarial drug for IPTp).
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Have the woman take the dose in front of the provider. Do not give the dose on an empty stomach; ask the woman to eat something before taking the tablets. There should be at least one month between doses. Note: Studies are looking for evidence of an interaction between folic acid and SP when these drugs have been used together in the management of acute malaria. Refer to national protocols for the latest recommendations.
An insecticide-treated bednet is another way to protect the pregnant woman against malaria, reducing cases of malaria and subsequent risks of maternal anemia and death. Advise the mother to use an insecticide-treated bednet (see also the chapter on postpartum care of the mother).
Prevent iodine deficiency In areas where iodine deficiency is high, consult country protocols for pregnant women. Advise women to use iodized salt. Prevent iron-deficiency anemia Iron is essential to compensate for the increased blood volume that occurs during pregnancy and to ensure adequate fetal growth and development. Iron needs increase during the pregnancy as the fetus grows. The pregnant woman can help meet these increased needs for iron by taking iron and folic acid tablets and by ensuring that she has an adequate and balanced diet. Iron-rich foods include meat, especially liver and giblets, apricots, prunes, eggs, dry legumes, peanuts, other nuts, and green leafy vegetables. Iron/folate supplementation to prevent anemia is administered as follows: If the womans hemoglobin is between 8-11 g/dL, give ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic acid 400 mcg by mouth once daily. If the womans hemoglobin is 7 g/dL, treat for anemia: give ferrous sulfate or ferrous fumarate 120 mg by mouth plus folic acid 400 mcg by mouth once daily for 3 months/follow national protocols. Continue to give ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic acid 400 mcg by mouth once daily for at least 3 months after childbirth.
Intermittent preventive treatment of hookworm to prevent anemia Hookworm is a major cause of iron deficiency anemia and should be treated with a dose of mebendazole or albendazole every 6 months. A pregnant woman can safely take mebendazole or albendazole during the second and third trimesters of her pregnancy. Hookworm can also be prevented by always wearing shoes when walking outside.
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In areas endemic for hookworm (prevalence of 20 percent or more), give one of the following treatments starting after 16 weeks gestation and repeating every 6 months: albendazole 400 mg by mouth once; or mebendazole 500 mg by mouth once or 100 mg twice a day for 3 days
In highly endemic areas (prevalence of 50 percent or more), repeat the antihelminthic treatment 12 weeks after the first dose. Prevent newborn tetanus with tetanus toxoid Tetanus continues to kill many newborns and women in countries all over the world, in spite of the fact that neonatal tetanus can be prevented by immunizing women of childbearing age with tetanus toxoid (TT), either during pregnancy or outside of pregnancy. All women need to be informed about the series of five tetanus shots and should have a permanent card. A woman also needs to know that the risk of tetanus infection is much decreased if she is assisted by a skilled attendant at birth. Guidelines for giving tetanus toxoid: Table 4. Schedule for giving tetanus toxoid Dose Schedule At first contact with woman of childbearing age or 0.5 mL at first antenatal care visit, as early as possible. 0.5 mL 0.5 mL 0.5 mL 0.5 mL At least 4 weeks after TT1. At least 6 months after TT2. At least 1 year after TT3. At least 1 year after TT4.
TT 1 TT 2 TT 3 TT 4 TT 5
Note: A woman has lifetime protection against tetanus after she has received five doses of TT.
Health Education During Pregnancy Birth spacing Healthy timing and spacing of pregnancy through family planning is one of the most critical and essential preventive ways of improving the health of women and children, with additional benefits to the family and community. It is a key intervention associated with reduced risk of low birth weight, prematurity, and deaths in newborns and infants, as well as decreased health risks to mothers after abortions and births. Parents should use their family planning method of choice and wait before conceiving again for a period of two years following a birth and for at least six months after an abortion.
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Informing the pregnant woman about options for family planning gives her the time to reflect, talk with friends, talk with her husband/partner, and become educated about what choices she has. Contrary to popular practice, talking about family planning is very important during the pregnancy, although it may be taboo in some cultures. If the woman is not ready to talk about all the methods, you can plant the seed and provide future opportunities for discussion. Nutrition during pregnancy All pregnant women need particularly nutritious meals throughout their pregnancy. A pregnant woman needs the nutritious foods available to the family: milk, fruit, vegetables, meat, fish, eggs, grains, peas, and beans. All these foods are safe to eat during pregnancy. Women will feel stronger and be healthier during pregnancy if they eat foods that are rich in iron, vitamin A, and folic acid. These foods include meat, fish, eggs, green leafy vegetables, and orange or yellow fruits and vegetables. Growing adolescent girls may have higher nutritional requirements in order to support their own growth. Health care providers can provide pregnant women with iron tablets to prevent or treat anemia and, in vitamin-A-deficient areas, an adequate dosage of vitamin A to help prevent infection. Pregnant women should not take more than 10,000 international units (IU) of vitamin A per day or 25,000 IU per week. Advise mothers to take iodized salt. Women who do not have enough iodine in their diet are more likely to have miscarriages and risk having an infant who is mentally or physically disabled. Goiter is a clear sign that a woman is not getting enough iodine. Rest A pregnant woman needs additional rest during pregnancy. In early pregnancy, the woman will feel tired as her body becomes accustomed to being pregnant. As the pregnancy advances, the larger fetus makes greater demands and causes greater strains on her body, and she will need more and more rest. During pregnancy, in addition to whatever amount of sleep she normally needs, she should have additional periodic rest periods during the day, preferably lying down with her feet elevated. In addition, she should avoid sitting or standing for long periods during the day. In most cultures women do not get permission to rest during pregnancy. Many families feel that if the woman works hard through pregnancy the delivery will be easier. It may be the providers role to play advocate for the woman and help her find creative ways to reduce her workload and find more time for rest. Safer sex To assure good relations between the woman and her partner, it is important to address the issue of sexual intercourse. Sometimes the pregnant woman may not feel the desire to have sex, and she needs to feel empowered enough to refuse. If she does desire having intercourse, she needs to know that the only time that intercourse is discouraged is if there is suspected premature rupture of membranes, bleeding, bleeding and cramps in the first trimester, or infection of the partner; and that having sex will not harm the fetus. In addition, it may be necessary to make changes in position to accommodate the enlarged abdomen or find alternative methods of satisfying both male and female sexual needs.
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It is important to discuss issues of safer sex because infidelity by the male partner can be highest during the third trimester of pregnancy. The risk of getting HIV through sex can be reduced if: 1) people don't have sex, 2) if they reduce the number of sex partners, 3) if uninfected partners have sex only with each other, or 4) if people have safer sex, i.e., sex without penetration or while using a condom. Correct and consistent use of condoms can save lives by preventing the spread of HIV. Hygiene Due to hormonal changes brought about by the pregnancy, pregnant women sweat more and have more vaginal discharge than women who are not pregnant. The pregnant woman needs, therefore, to be vigilant about her personal hygiene to prevent infections and disease. Gentle reminders about needs for bathing and wearing clean clothes are never misplaced. When the woman comes in for antenatal care, the provider can remind her about other simple hygiene rules that can help her prevent diseases: hand washing, treatment and care of drinking water, avoiding raw meats, reheating leftovers well, and being careful about coming into contact with people who are ill. Dental care is also important during pregnancy because estrogen can make gum tissues edematous. Using a dental stick or using a toothbrush and toothpaste are equally appropriate. Breastfeeding Provide advice on breastfeeding, especially on early initiation without pre-lacteal feeds and on continuing exclusive breastfeeding on demand. Further details on normal breastfeeding are noted in chapter 5 under care of the baby at birth. Prevention of mother-to-child transmission (PMTCT) of HIV Offer HIV testing and counseling to all pregnant women and their sexual partners. The following are the standard HIV pre-test session messages in all PMTCT settings: Help the client understand basic information on HIV transmission and prevention. Explain in simple terms how HIV infection can be transmitted from mother to child. Explain how transmission of the infection from mother to child can be prevented. Explain the importance of HIV testing. Explain HIV testing processes and procedures, including issues of confidentiality. Discuss implications of positive and negative test results. Explain the importance of partner testing: o o discordance disclosure and partner referral prevention of sexual transmission of HIV PMTCT interventions, including ARV prophylaxis and safer infant feeding referral for prevention, care, treatment, and support
Explain risk-reduction and available services: o o o
Discuss with HIV-positive clients the mode of delivery and feeding options. Assist them in identifying HIV support services. Provide information on health timing and spacing of pregnancy and family planning. Encourage continuous healthcare attendance and delivery care.
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Provide post-test counseling to HIV-positive and negative women based on national guidelines. Counseling for those whose HIV test results are negative should include the following minimum information: Provide the HIV test result. Explain the test result, the window period, and a recommendation to retest in case of a recent exposure. Assess understanding of the result. Identify and address client questions. Discuss: o o o o o o partner HIV testing and disclosure safer sex and risk reduction (negative prevention) exclusive breastfeeding antenatal care, post-delivery care importance of delivering in a healthcare facility infant care
Provide referrals and take-home information.
In the case of individuals whose HIV test results are positive, the health care provider should: Provide the HIV test result and support. Assess understanding of the result. Identify and address client questions. Discuss: o o o o o o o o o ARV therapy or prophylaxis other relevant preventive health measures, such as good nutrition, use of cotrimoxazole and, in malaria areas, use of insecticide-treated bednets infant feeding options treatment and support services for the client and family partner HIV testing and disclosure safer sex and risk reduction (positive prevention) antenatal care, post-delivery care importance of delivering in a healthcare facility infant care and diagnosis
Discuss infant feeding options and support the woman to carry out her choice. Encourage and offer referral for testing and counseling of partners and children, HIV testing for the infant, and the follow-up that will be necessary. Provide take-home information.
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DELAYS RESULTING IN MATERNAL AND NEWBORN DEATHS

The factors that often prevent women and newborns from getting the life-saving health care they need include: distance from health services cost (direct fees as well as the cost of transportation, drugs, and supplies) multiple demands on womens time womens lack of decision-making power within the family poor quality services, including poor treatment by health providers and discourteous behavior which makes women reluctant to use services
These have been described as the following delays: Delay in recognizing the problem: When a woman or newborn experiences a danger sign, someone must recognize that there is a problem. If pregnant women, their families, and women caring for them dont know the danger signs that indicate the woman or newborn is experiencing a complication, they will not know when they need to seek care. Delay in deciding to seek care: When a problem arises, the woman and her family have to decide to seek care. If the primary decision-maker is not present, it may mean that the woman is not allowed to seek care, or take her newborn for care, or that seeking care is delayed. Delay in arriving at the appropriate facility: Once a decision is made to seek care, the woman and her family must find a means of transport and the necessary funds to go to the appropriate facility. If there are no means of transport and/or the woman and her family do not have the necessary funds, the woman or newborn will not get to the appropriate health care facility in a timely fashion. Delay in receiving quality care: Once the woman or newborn has reached the appropriate facility, care providers must provide quality services for whatever emergency has transpired. If the care provided is not good quality or appropriate, then the woman or newborn will have reached the appropriate facility in vain.
When delays occur in recognizing problems and referring women or newborns to appropriate health care facilities, the result can lead to maternal and newborn deaths. One solution to combat these problems is to work with the pregnant woman and her family to develop two plans: a birth-preparedness plan and a complication-readiness plan.
BIRTH-PREPAREDNESS PLAN
Having a birth plan can reduce delayed decision-making and increase the probability of timely care. A birth-preparedness plan is an action plan made by the woman, her family members, and the health care provider. Often this plan is not a written document but an ongoing discussion between all concerned parties to ensure that the woman receives the best care in a timely manner. Each family should have the opportunity to make a plan for the birth. Health care providers can help the woman and her family develop birth-preparedness plans and discuss birth-related issues. Work with the woman to: 1. Make plans for the birth: Discuss the idea of a birth plan and what to include during the first visit. Inquire about the birth-preparedness plan during subsequent visits.
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Ask if arrangements are made for a skilled birth attendant and the birth setting during the antenatal visit in the eighth month. If the woman is planning a home delivery with a skilled birth attendant, discuss access to a safe delivery kit consisting of: 1) a piece of soap for cleaning the birth attendants hands and the womans perineum, 2) a plastic sheet about one square meter for use as a clean delivery surface, 3) a clean string for tying the umbilical cord (usually two pieces), and 4) a clean razor blade for cutting the cord. Advise the woman/family to boil the threads to be used as cord ties and the blade in water for 10 minutes before use. where to give birth who will be the skilled birth attendant how to contact the provider how to get to the place of birth who will be the birth companion who will take care of the family while the woman is absent how much money is needed for care and transport and how to access these funds what transport will be used and how to ensure its availability Discuss items needed for the birth (perineal pads/cloths, soap, clean bed sheets) on the third antenatal visit. Confirm necessary items are gathered near the due date. Note: In some cultures, superstition surrounds buying items for an unborn baby. If this is not the case, families can prepare for the birth by buying baby supplies such as blankets, diapers, and clothes.
2. Make birth-related decisions:
3. Prepare for the birth:
4. Save money: Discuss why and how to save money in preparation for the birth during the first visit. Discuss how to plan to make sure that any funds needed are available at birth. Check that the woman and her family have begun saving money or that they have ways to access necessary funds. Note: Encourage the family to save money so necessary funds are available for routine care during pregnancy and birth. Assess financial needs with the women as well as sources for accessing these funds so they are available before labor. If traditional beliefs do not permit getting clothes ready, advise the family to keep aside at least pieces of cloth/linen/blanket to dry and wrap the baby.
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COMPLICATION-READINESS PLAN
The complication-readiness plan is an action plan that outlines steps that can be discussed and determined prior to an emergency. Developing this plan helps the family to be prepared for and respond quickly when the woman or newborn has a complication and needs medical care. It is important that a complication-readiness plan is prepared with the woman and her chosen family members. Unless others are involved, the woman may have difficulties putting the plan into action should complications occur for her or her baby. Recognizing maternal danger signs Women, family members, and community caregivers must know the signs of life-threatening complications. Many hours can be lost from the time a complication is recognized until the time arrangements are made for the woman to reach help. For postpartum hemorrhage, the time from the start of bleeding to death can be as little as two hours. In too many cases, families of women who died in pregnancy, birth, or postpartum, did not recognize the problem in time. It is critical to reduce the time needed to recognize problems and make arrangements to receive care at the most appropriate level of care. Women, family members, and community caregivers must know the signs of life-threatening complications. Maternal danger signs include: vaginal bleeding (any vaginal bleeding during pregnancy, heavy vaginal bleeding or a sudden increase in vaginal bleeding during the postpartum period) pre-labor rupture of membranes (PROM) breathing difficulties fever severe abdominal pain severe headache/blurred vision convulsions or loss of consciousness pain during urination, bloody or scanty urine foul-smelling discharge from vagina, tears, and incisions calf pain, with or without swelling night blindness verbalization or behavior indicating the mother may hurt the baby or herself hallucinations Note: A pregnant woman should seek care immediately even if she is experiencing only one of the danger signs listed. Save money Similar to the birth-preparedness plan, the family should be encouraged to save money so necessary funds are available for emergencies. In many situations, women either do not seek or receive care because they lack funds to pay for services. Choose a decision-maker in case of emergency In many families, one person is the primary decision-maker. Too often other members of the family do not feel they can make decisions if that person is absent. This can result in death when an emergency occurs and the primary decision-maker is absent. It is important to discuss how the family can make emergency decisions without disrupting or offending cultural and
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family values. If possible, find out which family member can make a decision in the absence of the chief decision-maker. Have an emergency transportation plan Too many women and newborns die because they suffer serious complications and do not have access to transportation to the type of health care facility that can provide needed care. Each family should develop a transportation plan during the womans early pregnancy in case the woman experiences complications and urgently needs a higher level of care. This plan should be prepared during pregnancy and after giving birth, either before discharge from the health facility or immediately after returning home. The plan should address the following: where to go if complications arise how to get to the next level of care in case of an emergency who in the family will accompany the woman
Have an emergency blood donation plan Many health care facilities lack an adequate, safe blood supply for transfusions. After birth, women are more likely to need blood transfusions because the complications they experience from birth lead to blood loss. For these reasons, it is extremely important that the woman and her family determine blood donors that can be available if needed.
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CHAPTER 4: Preventing Postpartum Hemorrhage3

The loss of some blood during childbirth and postpartum is normal and cannot be avoided. However, losing any amount of blood beyond normal limits can cause serious problems even for women with normal hemoglobin levels. For many anemic women, even the normal amount of blood loss might be catastrophic. Fortunately, providers can take action to prevent unnecessary blood loss. Note: The importance of a given volume of blood loss varies with the womans health status. A woman with a normal hemoglobin level may tolerate blood loss that would be fatal for an anemic woman. (WHO, 2007) Postpartum hemorrhage (PPH) is defined as vaginal bleeding in excess of 500 mL occurring less than 24 hours after delivery; severe PPH is blood loss exceeding 1000 mL. Delayed PPH is excessive vaginal bleeding (vaginal bleeding increases rather than decreases after delivery), occurring more than 24 hours after childbirth. Because it is difficult to measure blood loss accurately, research shows that blood loss is frequently underestimated. For instance, nearly half of women who deliver vaginally often lose at least 500 mL of blood, and those who give birth by Caesarean delivery normally lose 1000 mL or more. For many women, this amount of blood loss does not lead to problems; however, outcomes are different for each woman. For severely anemic women, blood loss of as little as 200 to 250 mL can be fatal. This fact is especially important to keep in mind for women living in developing countries where significant numbers of women have severe anemia. For these reasons, a more accurate definition of PPH might be any amount of bleeding that causes a change for the worse in the womans condition (e.g., low systolic blood pressure, rapid pulse, signs of shock). Predicting who will have PPH based on risk factors is difficult because two-thirds of women who have PPH have no risk factors. Therefore, all women are considered at risk, and preventing hemorrhage must be incorporated into the care provided at every birth. Note: Every woman is at risk for postpartum hemorrhage.
CAUSES OF POSTPARTUM HEMORRHAGE

There are several possible reasons for severe bleeding during and after the third stage of labor. Uterine atony, or inadequate uterine contraction, is the most common cause of severe PPH in the first 24 hours after childbirth. Contractions of the uterine muscle fibers help to compress maternal blood vessels. Bleeding may continue from the placental site if contractions are not adequate. Many factors can contribute to the loss of uterine muscle tone, including: retained placenta or placental fragments partial placental separation overdistention of the uterus due to multiple gestation, excess amniotic fluid, large baby, or multiparity
Adapted from PATH. OUTLOOK Volume 19, Number 3, May 2002.

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prolonged labor induction or augmentation of labor precipitous labor (labor lasting less than 3 hours) a full bladder
Undetected or untreated lower genital tract lacerations, such as cervical, vaginal, or perineal lacerations and episiotomy, are the second most common cause of PPH. Episiotomy causes loss of blood and can lead to lacerations. Lacerations can also be caused by deliveries that are poorly controlled, difficult, or managed with instruments (e.g., large baby, twins, or non-cephalic presentation). When the woman has genital lacerations, it is still important to check for and treat uterine atony because these conditions may occur together. Other causes include: retained placenta or placental fragments. If the uterus is not empty, it cannot contract adequately. This can occur if even a small part of the placenta or membranes is retained. A partially separated placenta may also cause bleeding. uterine rupture and uterine inversion. Although rare, these conditions also cause PPH. disseminated intravascular coagulation (DIC). Although uncommon, this clotting disorderassociated with preeclampsia, eclampsia, prolonged labor, abruptio placentae, and infectionsis a significant and serious cause of PPH. (Coagulation means a defect in the body's mechanism for blood clotting. While there are several possible causes for coagulopathies, they generally result in excessive bleeding and a lack of clotting.) harmful traditional practices. Women with genital lacerations caused by traditional birth attendants and traditional healers for prolonged labor at home may be brought to the facility with PPH.
Preventing PPH and careful monitoring during the first hours after birth are critical for every woman at every birth. Despite the best strategies to prevent blood loss, approximately three percent of women will still lose blood in excess of 1000 mL. Preparing for early treatment of PPH (e.g., additional uterotonic drugs and arranging for blood where feasible) is critical to womens health.
PPH PREVENTION AND EARLY DETECTION

It is impossible to predict which women are more likely to have a PPH. Many factors may contribute to uterine atony or lacerations. Addressing these factors may help prevent PPH and reduce the amount of bleeding a woman may have. Taking a preventive approach can save womens lives. Despite the best efforts of health providers, women may still suffer from PPH. If PPH does occur, positive outcomes depend on how healthy the woman is when she has PPH (particularly her hemoglobin level), how soon a diagnosis is made, and how quickly effective treatment is provided after PPH begins. To prevent PPH and reduce the risk of death, routine preventive actions should be offered to all women from pregnancy through the immediate postpartum period.
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During Antenatal Care Health care providers should take the following steps during antenatal care: Develop a birth-preparedness plan. Women should plan to give birth with a skilled attendant who can provide interventions to prevent PPH (including AMTSL), and can identify and manage PPH, and refer the woman for additional treatment if needed. Develop a complication-readiness plan that includes recognition of danger signs and what to do if they occur, where to get help and how to get there, and how to save money for transport and emergency care. For more information, see chapter 3. Routinely screen to prevent and treat anemia during preconceptual, antenatal, and postpartum visits. Counsel women on nutrition, focusing on available iron and folic acidrich foods, and provide iron/folate supplementation during pregnancy. Help prevent anemia by addressing major causes, such as malaria and hookworm. For malaria, encourage use of insecticide-treated bednets, provide intermittent preventive treatment during pregnancy to prevent asymptomatic infections among pregnant women living in areas of moderate or high transmission of Plasmodium falciparum, and ensure effective case management for malaria illness and anemia. For hookworm, provide treatment at least once after the first trimester. Determine the womans blood group where feasible. In cases where the woman cannot give birth with a skilled attendant, prevent prolonged/obstructed labor by providing information about the signs of labor, when labor is too long, and when to come to the facility or contact the birth attendant. Avoid procedures such as external cephalic version to correct abnormal lie of the baby. Prevent harmful practices by helping women and their families recognize harmful customs practiced during labor (e.g., providing herbal remedies to increase contractions, health workers giving oxytocin by intramuscular injection during labor). Take culturally sensitive actions to involve men and encourage understanding about the urgency of labor and need for immediate assistance.
During the First and Second Stages of Labor Health care providers should take the following steps during the first and second stages of labor: Use a partograph to monitor and guide management of labor and quickly detect unsatisfactory progress. Ensure early referral when progress of labor is unsatisfactory. Encourage the woman to keep her bladder empty. Limit induction or augmentation use for medical and obstetric reasons. (Induction means stimulating uterine contractions to produce delivery before the onset of spontaneous labor; augmentation means stimulating the uterus during labor to increase the frequency, duration, and strength of contractions.) Limit induction or augmentation of labor to facilities equipped to perform a Caesarean delivery. Do not encourage pushing before the cervix is fully dilated. Do not use fundal pressure to assist the birth of the baby. Do not perform routine episiotomy. Consider episiotomy only with complicated vaginal delivery (e.g., breech, shoulder dystocia, forceps, vacuum, scarring from female genital cutting or poorly healed third- or fourth-degree tears, and fetal distress).
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Assist the woman in the controlled delivery of the babys head and shoulders to help prevent tears. Place the fingers of one hand against the babys head to keep it flexed (bent), support the perineum, and instruct the woman to use breathing techniques to push or stop pushing.
During the Third Stage of Labor Health care providers should take the following steps during the third stage: Provide active management of the third stage of labor (AMTSL)the single most effective way to prevent PPH. Do not use fundal pressure to assist the delivery of the placenta; instead, apply pressure on a woman's abdomen to help expel the placenta. Do not perform controlled cord traction (CCT) without administering a uterotonic drug. Do not perform CCT without providing countertraction to support the uterus.
After Delivery of the Placenta Health care providers should provide the following care during the immediate postpartum period (the first six hours after childbirth): Routinely inspect the vulva, vagina, perineum, and anus to identify genital lacerations. Cervical examination is only recommended when the cause of PPH has not been diagnosed and uterine atony, lower genital lacerations, and retained placenta are ruled out. Inspect the placenta and membranes for completeness. Evaluate if the uterus is well contracted and massage the uterus at regular intervals after placental delivery to keep the uterus well-contracted and firm (at least every 15 minutes for the first 2 hours after birth). Teach the woman to massage her own uterus to keep it firm. Instruct her on how to check her uterus and to call for assistance if her uterus is soft or if she experiences increased vaginal bleeding.
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CHAPTER 5: Routine Care during the Third Stage of Labor
PREPARATION FOR THE BIRTH

Developing a birth-preparedness plan during pregnancy will help ensure that the woman in labor arrives at the health care facility in a timely manner and can be assisted by a skilled birth attendant. Ideally there should be at least two qualified providers at each birth to ensure that both the woman and her newborn receive the quality care they need. Having two qualified providers is especially important if either the woman or her newborn require additional care. Preparing the Delivery Room The following guidelines will be helpful in preparing the delivery room. Ensure that the client care area is adequately prepared by: o o o o o placing waste products and contaminated objects (from the previous birth) into the appropriate containers. wiping down surfaces with 0.5% chlorine solution. tidying the area. checking that the injection safety box is accessible and does not require changing. making sure that buckets with 0.5% chlorine are available for decontamination and that the solution does not need to be changed.
Make sure that the womans bodily privacy is protected (curtains, doors that close, etc.); if permitted, ask the woman if she would like a companion with her during childbirth and facilitate that persons presence in the delivery room. Check that all needed equipment and instruments for delivery care, essential maternal and newborn care, newborn resuscitation, and adult resuscitation are available, clean, sterile/HLD, and in good working order and readily accessible. Make sure that the room is warm (at least 25-28 C/77.0-82.4 F) and free from drafts from open windows and doors or from fans. This is especially true for the area in the room where newborns receive special care, such as resuscitation. Make sure that all of the windows are closed. If the temperature of the room is less than optimal, a heater should be available to warm the room. In some circumstances, it might be easier to warm a small area of a room rather than the whole room. In hot weather, air conditioning or fans should be turned off or adjusted in the delivery room. Make sure that supplies needed to keep the newborn baby warm are prepared. The supplies should include as a minimum: two absorbent pieces of cloth/towels large enough to cover a newborn baby's whole body and head, a cap, a sheet or blanket for covering mother and baby, and suitable baby clothes if feasible/acceptable. In cool weather, a source of heat should be available to pre-warm the clothes and towels. Even though the care of a normal baby can be carried out while he/she is in skin-to-skin contact with the mothers chest, it is important to have a corner or area for the newborn in the delivery room where all the equipment and supplies can be collected and kept together. Ideally there should be a heater/source of warmth under or near which the
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linen and blanket for the baby can be kept for pre-warming before the delivery, and where resuscitation can be carried out. Make sure that all surfaces the woman and baby will come in contact with are clean, warm, and dry. Make sure the room is well-lit. Review and complete the womans medical records (if available): o the antenatal care card (take special care to check the womans HIV status, and if she is infected with HIV, ask about her antiretroviral (ARV) regimen and if she has brought ARV drugs for her baby) partograph any other records she may have with her Encourage the woman to wash herself or bathe or shower at the onset of labor. Put a clean, waterproof sheet under the womans bottom. Clean the vulval and perineal areas before each examination. Wash hands with soap before and after each examination. Ensure cleanliness of laboring and birthing area(s). Clean up all spills immediately.
o o
Maintain cleanliness of the woman and her environment: o o o o o o
Follow infection prevention practices to reduce exposure to blood and other body fluids during labor and delivery, and thereby help protect the woman and providers from infection: o Wash hands with soap and water and dry with a clean, dry cloth before examining each client; after examining each client; before putting on gloves for clinical procedures (such as a vaginal exam or examination of the placenta); after touching any instrument or object that might be contaminated with blood or other body fluids, or after touching mucous membranes; after handling blood, urine, or other specimens; after removing any kind of gloves; after using the toilet or latrine. Wear protective clothing: sterile/HLD gloves, masks, gowns, and waterproof aprons, caps, eye covers/face shields.
During the first stage of labor, preferably in between contractions and before contractions are very intense: o o o Explain and offer AMTSL to the woman and obtain her permission to apply it. Explain skin-to-skin contact and that the newborn will be placed first on her abdomen and then on her chest, and obtain her permission to do this. Explain that essential newborn care will be provided while the baby is in skin-to-skin contact with her and obtain her permission; care includes placing an identification bracelet on the baby, eye and cord care, vitamin K1 injection, and early initiation of breastfeeding .
Routine Care for the Woman in Labor Regardless of how the third stage of labor is managed, basic care for the woman and baby during labor and postpartum remains the same. The following actions represent the elements of essential care for the woman during labor.
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Supportive care during labor Encourage the woman to have personal support from a person of her choice throughout labor and birth: o o o Encourage support from the chosen birth companion. Arrange seating for the companion next to the woman. Encourage the companion to give adequate support to the woman during labor and childbirth (rub her back, wipe her brow with wet cloth, assist her to move about).
Ensure good communication and support by staff: o o o Explain all procedures, seek permission, and discuss findings with the woman. Provide a supportive, encouraging atmosphere for birth, respectful of the womans wishes. Ensure privacy and confidentiality. Encourage the woman to move about freely. Support the womans choice of position for birth.
Ensure mobility: o o
Encourage the woman to empty her bladder regularly. Note: Do not routinely give an enema to women in labor.
Encourage the woman to eat and drink as she wishes. If the woman has visible severe wasting or tires during labor, make sure she is fed. Nutritious liquid drinks are important, even in late labor. Teach breathing techniques for labor and delivery. Encourage the woman to breathe out more slowly than usual and relax with each expiration. Help the woman in labor who is anxious, fearful, or in pain: o o o Give her praise, encouragement, and reassurance. Give her information on the process and progress of her labor. Listen to the woman and be sensitive to her feelings.
If the woman is distressed by pain: Suggest changes of position (Figure 5.1). Encourage mobility. Encourage her companion to massage her back or hold her hand and sponge her face between contractions. Encourage breathing techniques. Encourage a warm bath or shower. If necessary, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM. Do not give Pethidine (to avoid respiratory depression and birth asphyxia in the baby) if you envisage that the baby is likely to be delivered within 2 hours of administering the drug, especially not in peripheral centers since Naloxone (0.1mg/kg) that can be used to reverse the respiratory depressant effect of Pethidine may not be available.
If the woman is infected with HIV, follow national protocols to prevent mother-to-child transmission of HIV/AIDS.
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Figure 5.1. Positions that a woman may adopt during labor. (WHO, 2003)
Monitor progress of the first stage of labor using the partograph Findings which suggest satisfactory progress in the first stage of labor are: regular contractions of progressively increasing frequency and duration. rate of cervical dilatation at least 1 cm per hour during the active phase of labor (cervical dilatation on or to the left of alert line). cervix well applied to the presenting part.
Findings which suggest unsatisfactory progress in first stage of labor are: irregular and infrequent contractions after the latent phase, or rate of cervical dilatation slower than 1 cm per hour during the active phase of labor (cervical dilatation to the right of alert line), or cervix poorly applied to the presenting part.
Use the partograph card (see Figure 5.2 below) to monitor progress of the first stage of labor. Unsatisfactory progress in labor can lead to prolonged labor (the woman has been experiencing labor pains for 12 hours or more without delivery). Be sure to transfer women immediately to a facility with operative facilities as soon as unsatisfactory progress has been identified. Other signs that indicate the woman is experiencing a complication include: There is vaginal bleeding in labor and delivery. The diastolic blood pressure is 90 mm Hg or more. The woman complains of severe headache or blurred vision. The woman is found unconscious or having convulsions. The fetal heart rate is less than 100 or more than 180 beats per minute after a contraction. Membranes have been ruptured for more than 12 hours before childbirth. The woman has a fever.
Follow national protocols for management and referral of complications.
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Figure 5.2. The modified WHO partograph. (WHO, 2003)
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Supportive care during childbirth Encourage the woman to have a companion with her who can provide support for her during childbirth. Encourage the woman to assume the position she prefers.
Figure 5.3. Positions that a woman may adopt during childbirth. (WHO, 2003)
Help the woman empty her bladder when the second stage is near. Inform the woman of her babys sex and health status and provide information about the care you are providing her baby. Make sure the woman is comfortable.
Preparation for Care of the Baby at Birth The mother and her baby must, as far as possible, remain together. It is only when special care is required for one of them, where it is not safe to have the two together, that the baby should be looked after in a separate place. As noted earlier, it is ideal to have two qualified persons attending the delivery so that both the mother and baby can receive adequate care. This is particularly useful if either or both develop problems needing care. However, this is usually not feasible, especially at peripheral centers. However, with some advance planning one can explore training another staff member, even a less qualified person, to assist the skilled birth attendant to facilitate the latter in dealing with the key problems. Preparation of the newborn corner in the delivery room Ideally all items necessary for the baby should be kept in a designated area, the newborn baby corner. This corner can also be used to resuscitate an asphyxiated baby or provide any special care as required. This area should have a table and ideally an overhead heater/warmer. For normal babies not requiring special care, most routine care can be carried out on the baby placed on the mothers chest. It is absolutely essential that the delivery room, including items for resuscitation (see chapter 8 on resuscitation for birth asphyxia), is ready at all times. In addition it is mandatory that the staff on duty verify that this is so at the beginning of each day, every shift, and when called to attend a delivery. Make sure that all equipment, including those for resuscitation, is available, in functioning order, and clean or sterile as needed.
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Checklist to prepare for the care of the baby at birth Display the checklist of all required items on the wall near the table at eye level, framed with a glass cover or within a display or notice board to protect the paper. More details related to the equipment for resuscitation are noted in chapter 8 on resuscitation for birth asphyxia. The checklist should contain the following items: A warm room with no drafts or open windows. A table with a firm mattress covered with a washable surface such as a plastic or rubber sheet. Over this a clean, preferably sterile cloth/linen should be placed just before delivery. The clean/sterile equipment and supplies can be placed on it, leaving enough room for special care for the baby, such as resuscitation. A source of heat. Ideally this should be an overhead heater (the heat source being a heating rod or a set of bulbs). A hot water bottle is not recommended as it may result in burns. If its use is unavoidable, make sure that the water is warm, not hot, and the bottle is wrapped in several layers of cloth. In addition, for extra safety check the skin of the baby in contact with the bottle frequently for excessive heat or redness. Three to five pieces of clean, preferably sterile cloths to dry and wrap the baby (cap where available) and blanket where required. A wall thermometer to monitor the room temperature. A clinical thermometer to measure the axillary temperature. Suction equipment (for details see chapter 8 on resuscitation): o o De Lee mucous extractor or Suction machine (electrical/foot operated) with simple suction catheters 8F and 10F. In the absence of a suction machine, a 10 mL syringe attached to the catheter can be used to remove the secretions. If a rubber bulb is used for suction, it should be sterilized. It is not recommended to use the same bulb for multiple infants due to the risk of the transmitting major infections.
Newborn resuscitator bag (240-500 mL) with two baby face masks (#1 for normal size babies, # 0 for LBW babies). In general, where resources are limited, the 500 mL bag is preferable as it can be used for the normal weight and the larger proportion of low birth weight infants. A supplemental oxygen source, if available. If cylinders are used, check that they have adequate oxygen. Note, however, that supplemental oxygen is not required for resuscitation in most cases. A wall clock with second hand for noting the time of birth and where necessary to count the respiratory and heart rate if there is no timer or watch. In case of an emergency situation such as asphyxia, it is easy to lose track of time. It is important to note the time of birth and the time spent in the procedure, since there is a time limit to active resuscitation. If no respiration is noted after twenty minutes, it is necessary to stop all action. A stethoscope where available. Miscellaneous: sterile gauze/pieces of sterile cloth and gloves, either sterile or high-level disinfected.
All equipment has to be disinfected and cleaned after use. The manufacturer gives specific instructions for cleaning, disinfection, and sterilization of equipment. Follow these instructions carefully.
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Advance preparation for skin-to-skin contact between baby and mother and early breastfeeding Close contact between the mother and baby after birth will promote temperature maintenance and breastfeeding. Hence, where the mother and baby are normal, it is good for the baby to be kept with the mother in skin-toskin contact. In fact, most of the care that a normal baby requires can be carried out while he/she is with the mother, initially on her abdomen and later, after the cord is cut, on her chest. Because some centers may not have been following this practice, mothers may not be aware of these steps or be prepared for them. To get the mothers acceptance and cooperation, it is essential that these plans are discussed with the mother before delivery so that she is prepared for them; otherwise, there may be some challenges in implementing these steps.
ESSENTIAL NEWBORN CARE

The initial steps in the care of the baby at birth, such as drying, wrapping, and evaluation of breathing, are similar for all babies. Subsequent care, however, may be different if there are problems such as birth asphyxia. Dry the Infant Place the infant on the abdomen of the mother. Wipe the face and dry the baby thoroughly immediately after birth and discard the wet cloth. Do not let the baby remain wet, as this will cool the body and make him/her hypothermic. Let the baby stay prone in skin-to-skin contact on the abdomen and cover the baby quickly, including the head, with a fresh dry cloth.
Figure 5.4. Initial steps in the care of the baby at birth.
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Evaluate Breathing Check if the baby is crying while drying him/her. If the baby does not cry, see if the baby is breathing properly. If the baby is not breathing and/or is gasping: o o o Call for help. The assistant can provide basic care for the mother while you provide the more specialized care for the baby who is not breathing. Cut the cord rapidly and start resuscitation as described in chapter 8 on resuscitation. If the baby breathes well, continue routine essential newborn care.
Do not do suction of the mouth and nose as a routine. Do it only if there is meconium, thick mucous, or blood. Announce the time of birth and the sex of the infant after you have made certain that the baby is breathing well.
Prevent Hypothermia Keep the baby warm by placing him/her in skin-to-skin contact on the mothers abdomen. Cover the babys body and head with a cloth. If the room is cool (<25 C), use a blanket to cover the baby over the mother.
Figure 5.5. Two measures to prevent thermal loss at the time of birth: breastfeeding and skin-to-skin contact.
Cord Care Good cord care consists of the following: Clamping the cord: If the baby does not need resuscitation, wait for cord pulsations to cease or approximately 2-3 minutes after birth of the baby, whichever comes first, and then place one metal clamp several centimeters from the babys abdomen so that there is at least 4-5 cm of the cord to apply the ligature or small disposable clamp. Cutting the cord soon after birth can decrease the amount of blood that is transfused to the baby from the placenta and, in preterm babies, it is likely to result in subsequent anemia and increased chances of needing a blood transfusion.
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Cutting the cord: Squeeze the cord at the site where it is to be cut to flatten it, but do not milk the cord, especially towards the baby. Cut the cord with sterile scissors or a scalpel blade, under a piece of gauze in order to avoid splashing of blood. At every delivery, a pair of scissors or a scalpel with blade should be designated for this purpose. If an episiotomy is performed, use a different pair of scissors for cutting the cord. Tying the cord: Tie the cord firmly with sterile ligatures after the mother and baby are stable and after implementation of AMTSL. In finally tying the cord, make sure that it is tied tightly with 2-3 knots, about two fingers (about 2-3 cm) from the babys abdomen and cut the cord 2 cm from the ligature. Check for bleeding/oozing and retie if necessary. The cord may be tied by using sterile cotton ties, elastic bands, or presterilized disposable cord clamps (see Figure 5.6). Advise the mother not to cover the cord with the diaper. Counsel the family not to apply harmful substances such as clay, herb mixtures, or butter on the cord. If recommended by the Ministry of Health, apply an antiseptic on the umbilical stump after washing hands with soap and water. In such cases, demonstrate to the mother before she leaves the facility how to apply the antiseptic on the cord, including the base.
Figure 5.6. Use of a pre-sterilized disposable cord clamp.
Eye Care Apply prophylactic eye drops as recommended by the Ministry of Health (tetracycline ophthalmic drops or ointment). Apply prophylactic drops or ointment as follows: o o o o Wash your hands with soap and water if not washed earlier. Place the infant on the back. Clean the babys eyes by swabbing each eye separately with a sterilized cotton swab or cloth (boiled for 10 minutes and then cooled). Hold one eye open or depress the lower eyelid, allow one drop of medication to fall into the eye. If using ointment, put a ribbon of ointment along the inside of the lower eyelid. Repeat the procedure on the other eye. Make sure the tip of the dropper or the tube does not touch the babys eyes or other objects.
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Assess for Major Defects The following defects may need special inputs at birth: cleft lip and palate. The mother will need additional support for feeding; she may need to give expressed breast milk with a small cup. esophageal atresia (usually associated with excessive secretion in the mouth) open spinal defects imperforate anus
The last three conditions need urgent referral to appropriate hospitals for surgery. Give Vitamin K1 Give vitamin K1 intramuscular (1 mg for term infant and 0.5 mg for the very low birth weight infant <1500 grams). The technique for giving an intramuscular injection in the newborn is as follows: Explain the procedure to the mother. Wash your hands thoroughly with soap and water, air-dry or dry with clean paper towels (use gloves in areas of HIV prevalence). Gather the necessary equipment: disposable syringe, needle, medication, alcohol/antiseptic solution, and clean, preferably sterile gauze/cotton. Examine carefully the medications label to verify the name, expiration date, instructions for dilution, if any, or any other special notes. Calculate the amount to be given where required. Draw out the medication: o o o o Clean the rubber stopper with alcohol swab/cut the ampoule at its neck. Push the needle into the bottle/ampoule. Draw the calculated amount and pull the needle out. Remove the air while holding the syringe with the needle pointing up and tapping on the syringe barrel.
Expose the babys thigh and gently hold the knee so the baby is unable to kick. Grasp the muscle of the antero-lateral part of the upper thigh, clean the skin with the alcohol/antiseptic, and let it dry for a few seconds. In one quick movement put the needle in the muscle straight in, pull back on the plunger a little bit to make sure that the tip of the needle is not in a blood vessel. If blood comes to the syringe, take the needle out and apply pressure at the site to prevent bleeding. Re-inject in a fresh spot. Inject the drug slowly, remove the needle, and apply gentle pressure for a short while and ensure that there is no oozing of blood upon removal of the swab. Discard the needle and syringe immediately in a sharps disposal container.
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Place an Identification Label on the Baby Place the identification tag /label on the wrist and ankle (as recommended by the Ministry of Health). If a ready-made disposable identification is not available, prepare one locally using sticking plaster and gauze strips. Note, at a minimum, the names of the mother and, if available, the father, and the date and time of birth. Early, Exclusive Breastfeeding Inform the mother about the importance of colostrum and encourage her to initiate breastfeeding early within one hour of birth, without giving the baby any other milks, fluids, or foods. Tell the mother to breastfeed the baby frequently and on demand, day and night (about 8-10 times in 24 hours). Advise the mother not to use pacifiers. Assist the mother to breastfeed the baby within the first hour after the birth/before transferring out of the delivery room. Help the mother to find as comfortable a position as feasible. Some of the steps noted below may need to be modified depending on the type of table available in the delivery room. Make sure that: o The babys whole body is fully supported and held close at the level of the breast and turned toward the mother. o The mother, if possible, holds the breast with thumb on top and other fingers at the bottom without touching the nipple. o When the baby opens his/her mouth widely, the nipple and most of the surrounding areola are introduced into the mouth. o The babys nose is not blocked by the breast tissue. o The mother does not feel pain in the nipple when the baby sucks. If she does, show her how to release the nipple from the babys mouth (by gently depressing the babys chin) and reintroduce the nipple after the pain subsides. o That attachment at the nipple is appropriate (see Figure 5.7 below). o Unrestricted time is allowed for the feeding.
Signs of a proper attachment: The babys chin is touching or nearly touching the breast. The mouth is wide open. The lower lip is everted (turned outward). Most of the areola is inside the mouth, especially the part below so that the areola is visible more above the mouth than below. The sucking is slow and deep and swallowing is audible.
Figure 5.7. Signs of proper attachment at the breast. (WHO, 2003)

Integrated maternal and newborn care Basic skills course 59
Weigh the Baby and Record the Weight Take the weight when the baby is stable and warm. Place a clean cloth or paper on the pan of the weighing scale. Adjust the weight so it reads zero with the paper/cloth on it. Place the baby over the pan. If a cloth was used, fold it to cover the body of the baby. Note the weight when the baby and pan are not moving. Never leave the baby unattended on the scale. Write down the weight of the baby in the partograph/maternal/baby charts and in the delivery room registers as recommended by the Ministry of Health. Return the baby to skin-to-skin contact with the mother.
Keep the Mother and Baby Together If no emergency care is required, keep the baby warm by putting her/him in skin-to-skin contact with the mother and covering both with a clean cloth/blanket as required. If the baby cannot be in skin-to-skin contact with the mother due to issues such as a Cesarean operation, an ill mother, or an ill baby, then wrap her/him with a clean dry cloth and/or blanket, taking care to cover the head, and keep the baby away from drafts. Note: Never leave the woman and newborn alone soon after delivery. Avoid separating the mother and the baby.
Counsel the Mother and Family Counsel the mother before she leaves the delivery room. However, if she is very tired after delivery, only talk to her about the key points noted below. Keep the baby warm. Continue breastfeeding frequently on demand day and night. Do not give any other fluids/food to the baby. Do not apply any harmful substances on the cord, such as ash or herbal preparations.
More detailed counseling can be done in the postnatal period in the facility before the mother is discharged and at subsequent postnatal visits. The major issues are noted in chapter 10 on postnatal care.
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If the mothers HIV status is positive: Take particular care not to suction the mouth and the nose unless it is absolutely necessary. Consider swabbing the whole body of the baby with chlorhexidine (0.25%) swabs/wipes as recommended by the Ministry of Health. Administer ARV prophylaxis (niverapine and AZT or others as recommended by the Ministry of Health). Infant feeding options for mothers whose HIV status is positive include the following: o exclusive breastfeeding, taking care to avoid problems such as engorged breasts and sore nipples, until six months, followed by rapid switch to formula feeds and complementary feeding with semi-solids. use of expressed breast milk (EBM) rendered safe by flash heating of the milk (see below), continued with complementary feeds with semisolids from the age of six months (see chapter 11 on breastfeeding). use of formula feeds with complementary feeds from birth with semi-solids from the age of six months. Formula feeds are applicable when replacement feeding is acceptable, feasible, affordable, sustainable, and safe (AFASS); avoidance of all breastfeeding by HIV-infected women is recommended. (WHO, 2009)
The actual type of feeding will depend on the mothers choice. You as the health care provider should ensure that she is given the counseling and support she needs. It is important to stress the dangers of mixed feeding (breast milk and formula).
Table 5. Key Steps for Immediate Care of the Newborn (The order may be changed according to the local needs, except for steps 1-3.) Step 1 Dry the baby and keep him/her warm by placing the baby on the mothers abdomen. Step 2 Assess breathing. Make sure the baby is breathing well. Step 3 If the baby does not breathe, clamp/tie and cut the cord immediately and start resuscitation. If the baby does cry/breathes well, clamp/tie and cut the cord after pulsations stop or after 2-3 minutes. Step 4 Place the infant in skin-to-skin contact on the mothers chest and cover both with clean linen and blanket as required. Carry out all the steps noted below up to #9, preferably with the baby on the mothers chest. Administer eye drops/eye ointment. Administer vitamin K1. Place the baby identification bands on the wrist and ankle. Initiate breastfeeding within the first hour. Select the appropriate method of feeding for the HIV-infected mother, based on informed choice. Weigh the infant when he/she is stable. Record observations and treatment provided in the registers/appropriate chart/cards. Defer the bath for at least six hours. Clean the newborn of an HIV-infected mother as recommended by the Ministry of Health.
Step 5 Step 6 Step 7 Step 8
Step 9 Step 10 Note
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CARE DURING THE THIRD STAGE OF LABOR

The third stage of labor is usually uneventful, with delivery of the placenta taking place without complications. During this stage of labor, however, the woman may encounter complications that could lead to maternal morbidity and mortality. The most common complication is postpartum hemorrhage or vaginal bleeding in excess of 500 mL that occurs less than 24 hours after childbirth. (See chapter 4 for more information on PPH.) PPH may cause or worsen anemia or deplete iron stores in women, causing weakness and fatigue. If severe, PPH may result in shock or maternal death. A blood transfusion may help improve anemia in women and shorten hospital stays, but transfusion carries risks of reaction and infection and is not universally available. Because many health facilities lack an adequate supply of safe blood, PPH can often strain the resources of the best blood banks. PPH may increase the likelihood of other issues: The need for emergency anesthetic services. Manual exploration or use of instruments inside the uterus (increasing the risk of sepsis). Prolonged hospitalization. New studies show that extended hospitalizations can cause significant and long-term financial hardships for the woman and her family. Delayed breastfeeding.
Additionally, women who have severe PPH and survive (near misses) are significantly more likely to die in the year following the PPH. Length of the Third Stage Considerable research has examined how active management affects the third stage of labor. Investigations found that 50 percent of placental deliveries occur within five minutes, and 90 percent are delivered within 15 minutes. Other large studies confirm the rapid delivery of the placenta; a WHO study found a mean delivery time of 8.3 minutes. A third stage of labor lasting longer than 18 minutes is associated with a significant risk of PPH. When the third stage of labor lasts longer than 30 minutes, PPH occurs 6 times more often than it does among women whose third stage lasted less than 30 minutes. Description of Active Management of the Third Stage of Labor (AMTSL) The majority of PPH occurs during the third stage of labor. During this stage, the muscles of the uterus contract, helping the placenta to separate from the uterine wall. The amount of blood lost depends on how quickly this happens, since the uterus can contract more effectively after the placenta is expelled. The third stage of labor lasts between 5 and 15 minutes. If the third stage lasts longer than 30 minutes, it is considered to be prolonged and is associated with complications. If the uterus does not contract normally (such as in uterine atony) after the placenta is delivered, the blood vessels at the placental site stay open and hemorrhage results. Because the estimated blood flow to the uterus is 500 to 800 mL/minute at term, most of which passes through the placenta, severe postpartum hemorrhage can happen within just a few minutes. Active management of the third stage of labor (AMTSL) is a combination of actions performed during the third stage to speed delivery of the placenta and prevent uterine atony by increasing uterine contractions. The components of AMTSL are: Administration of a uterotonic drug within one minute after the baby is born (oxytocin is the uterotonic of choice) and a second baby has been ruled out.
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Controlled cord traction (CCT) with simultaneous countertraction to the uterus. Uterine massage immediately after delivery of the placenta.
Current evidence indicates active management of the third stage of labor (administration of uterotonic drugs, controlled cord traction, and fundal massage after delivery of the placenta) can reduce the incidence of postpartum hemorrhage by up to 60 percent in situations where: National guidelines support the use of AMTSL (active management of the third stage of labor). Health workers receive training in using AMTSL and administering uterotonic drugs. Injection safety is ensured. Necessary resources (uterotonic drugs and cold chain for storage of uterotonic drugs; equipment, supplies, and consumables for infection prevention and injection safety) are available.
Skilled birth attendants all over the world can play an important role in preventing unnecessary maternal deaths by applying this simple, low cost, evidence-based intervention. Approaches for Managing the Third Stage There are two main approaches for managing the third stage of labor: the physiologic (or expectant) approach and the active approach. Table compares how the third stage is managed using each of these approaches.
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Table 6. Comparison of Physiologic and Active Management of the Third Stage of Labor (AMTSL)4 Physiologic (expectant) management Uterotonic Uterotonic is not given before the placenta is delivered. Wait for signs of separation: gush of blood lengthening of cord uterus becomes rounder and smaller as the placenta descends Placenta delivered by gravity assisted by maternal effort. Massage the uterus before the placenta is delivered. Advantages Does not interfere with normal labor process. Does not require special drugs/supplies. May be appropriate when immediate care is needed for the baby (such as resuscitation) and no trained assistant is available. May not require a birth attendant with injection skills. Active management Uterotonic is given within one minute of the babys birth (after ruling out the presence of a second baby). Do not wait for signs of placental separation. Instead: Palpate the uterus for a contraction. Wait for the uterus to contract. Apply CCT with countertraction. Placenta delivered by controlled cord traction (CCT) while supporting and stabilizing the uterus by applying countertraction. Massage the uterus after the placenta is delivered. Decreases the length of the third stage. Decreases the likelihood of prolonged third stage. Decreases average blood loss. Decreases the number of PPH cases. Decreases the need for blood transfusion. Requires uterotonic drugs and items needed for injection/injection safety. Requires a birth attendant with experience and skills giving injections and using CCT.
Signs of placental separation
Delivery of the placenta Uterine massage
Disadvantages
The length of the third stage is longer compared to AMTSL. o Blood loss is greater compared to AMTSL. o Increased risk of PPH.
(The definition of active management as described in this table differs from the original research protocol in the Bristol and Hinchingbrooke trials because the original protocols included immediate cord clamping and did not include massage of the uterus. In the Hinchingbrooke trial, midwives used either CCT or maternal effort to deliver the placenta.)
Rogers J, et al. 1998. Active versus expectant management of the third stage of labour: the Hinchingbrooke randomized controlled trial. Lancet 351:693699.
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Scientific evidence supporting AMTSL Giving a uterotonic drug to prevent PPH promotes strong uterine contractions and leads to faster retraction and placental separation and delivery. Several large, randomized controlled trials have investigated whether physiologic management or active management is more effective in preventing PPH. These trials have consistently shown that active management provides several benefits for the mother compared to physiologic management. Table 7 provides detailed results from two important studies comparing active and physiologic management of the third stage of labor. These results show that only 12 women need to receive AMTSL to prevent one case of PPH. This means that AMTSL is a very effective and cost-efficient public health intervention. These studies also confirm that AMTSL decreases: the incidence of PPH the length of the third stage of labor the percentage of third stages of labor lasting longer than 30 minutes the need for blood transfusion the need for uterotonic drugs to manage PPH Table 7. Bristol and Hinchingbrooke Study Results Comparing Active and Physiologic Management of the Third Stage of Labor Management Factors Study Active PPH Average length of the third stage of labor Third stage of labor longer than 30 minutes Blood transfusion needed Additional uterotonic drugs needed to manage PPH Bristol Hinchingbrooke Bristol Hinchingbrooke Bristol Hinchingbrooke Bristol Hinchingbrooke Bristol Hinchingbrooke
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Physiologic 17.9% 16.5% 15 minutes 15 minutes 26% 16.4% 5.6% 2.6% 29.7% 21.1%
5.9% 6.8% 5 minutes 8 minutes 2.9% 3.3% 2.1% 0.5% 6.4% 3.2%
Prendiville et al. 1988. The Bristol third stage trial: active versus physiological management of the third stage of labour. BMJ, 297: 12951300.
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Preparing for Active Management Before or during the second stage of labor: Prepare the injectable uterotonic (10 IU of oxytocin is the preferred injectable uterotonic) in a sterile syringe before second stage (Figure 5.8) or have oxytocin in Uniject or 600 mcg of misoprostol available. Prepare other essential equipment and supplies for birth, the third stage of labor, and the care of the baby, including resuscitation, before onset of the second stage of labor. Ask the woman to empty her bladder when the second stage is near. Assist the woman into her preferred position for giving birth (e.g., squatting, semi-sitting).
Figure 5.8. Preparing oxytocin injection. (Gomez et al., 2005)
Steps for AMTSL There are three main components or steps of AMTSadministering a uterotonic drug, CCT, and massaging the uteruswhich should be implemented along with the provision of immediate newborn care. Before reading this part of the Reference Manual, watch the DVD AMTSL: A demonstration. If you cant watch it at this time, continue with your reading but try to watch it at some other time before you begin practicing AMTSL. 1. Thoroughly dry the baby, assess the babys breathing and perform resuscitation if needed, and place the baby in skin-to-skin contact with the mother. After delivery, immediately dry the infant and assess the babys breathing. Then place the reactive infant, prone, on the mothers abdomen.* Remove the cloth used to dry the baby and keep the infant covered with a dry cloth or towel to prevent heat loss. *If the infant is pale, limp, or not breathing, it is best to keep the infant at the level of the perineum to allow optimal blood flow and oxygenation while resuscitative measures are performed. Early cord clamping may be necessary if immediate attention cannot be provided without clamping and cutting the cord.
Figure 5.9. Put the baby on the mothers abdomen. (POPPHI, 2007)
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2. Administer a uterotonic drug within one minute of the babys birth. Administering a uterotonic drug within one minute of the babys birth stimulates uterine contractions that will facilitate separation of the placenta from the uterine wall. Before giving the uterotonic drug, it is important to rule out the presence of another baby. If the uterotonic drug is administered when there is a second baby, there is a small risk that the second baby could be trapped in the uterus. The steps for administering a uterotonic drug include: 1. Before performing AMTSL, gently palpate the womans abdomen (Figure 5.10) to rule out the presence of another baby. At this point, do not massage the uterus.
Figure 5.10. Rule out the presence of a second baby. (POPPHI, 2007)
2. If there is not another baby, begin the procedure by giving the woman 10 IU of oxytocin IM in the upper thigh (Figure 5.11). This should be done within one minute of childbirth. If available, a qualified assistant should give the injection.
Figure 5.11. Give a uterotonic drug. (POPPHI, 2007)
3. Cut the umbilical cord. Clamp and cut the cord (Figure 5.12) following strict hygienic techniques after cord pulsations have ceased or approximately 2-3 minutes after the birth of the baby, whichever comes first.
Figure 5.12. Pulsating and nonpulsating umbilical cord. (POPPHI, 2007)

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4. Keep the baby warm.
Place the infant directly on the mothers chest, prone, with the newborns skin touching the mothers skin (Figure 5.13). While the mothers skin will help regulate the infants temperature, cover both the mother and infant with a dry, warm cloth or towel to prevent heat loss. Cover the babys head with a cap or cloth.
Figure 5.13. Keep the baby in skin-to-skin contact. (POPPHI, 2007) 5. Perform controlled cord traction. CCT helps the placenta descend into the vagina after it has separated from the uterine wall and facilitates its delivery. It is important that the placenta be removed quickly once it has separated from the uterine wall because the uterus cannot contract efficiently if the placenta is still inside. CCT includes supporting the uterus by applying pressure on the lower segment of the uterus in an upward direction towards the womans head, while at the same time pulling with a firm, steady tension on the cord in a downward direction during contractions. Supporting or guarding the uterus (sometimes called counter-pressure or countertraction) helps prevent uterine inversion during CCT. CCT should only be done during a contraction. Note: CCT is not designed to separate the placenta from the uterine wall but to facilitate its expulsion only. If the birth attendant keeps pulling on an unseparated placenta, inversion of the uterus may occur. The steps for CCT include: 1. Wait for cord pulsations to cease or approximately 2-3 minutes after birth of the baby, whichever comes first, and then place one clamp 4 cm from the babys abdomen. Note: Delaying cord clamping allows for transfer of red blood cells from the placenta to the baby that can decrease the incidence of anemia during infancy. 2. Gently milk the cord towards the womans perineum and place a second clamp on the cord approximately 2 cm from the first clamp. 3. Cut the cord using sterile scissors under cover of a gauze swab to prevent blood spatter. After the mother and baby are safely cared for, tie the cord.
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4. Place the clamp near the womans perineum to make CCT easier (Figure 5.14).
Figure 5.14. Clamping the umbilical cord near the perineum. (Gomez, et al, 2005)
5. Hold the cord close to the perineum using a clamp. (Figure 5.15) 6. Place the palm of the other hand on the lower abdomen just above the womans pubic bone to assess for uterine contractions (Figure 5.15). If a clamp is not available, controlled cord traction can be applied by encircling the cord around the hand.
Figure 5.15. Palpate the next contraction. (POPPHI, 2007)
7. Wait for a uterine contraction. Only do CCT when there is a contraction.
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8. With the hand just above the pubic bone, apply external pressure on the uterus in an upward direction (toward the womans head) (Figure 5.16).
9. At the same time with your other hand, pull with firm and steady tension on the cord in a downward direction (follow the direction of the birth canal). Avoid jerky or forceful pulling.
Figure 5.16. Applying CCT with countertraction to support the uterus. (POPPHI, 2007; Gomez, et al, 2005)
If the placenta does not descend during 30-40 seconds of controlled cord traction (i.e. there are no signs of placental separation), do not continue to pull on the cord: Gently hold the cord and wait until the uterus is well contracted again. If necessary, use a sponge forceps to clamp the cord closer to the perineum as it lengthens; With the next contraction, repeat controlled cord traction with countertraction.
10. Do not release support on the uterus until the placenta is visible at the vulva. Deliver the placenta slowly and support it with both hands (Figure 5.17).
Figure 5.17. Supporting the placenta with both hands. (POPPHI, 2007)
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11. As the placenta is delivered, hold and gently turn it with both hands until the membranes are twisted (Figure 5.18). 12. Slowly pull to complete the delivery. Gently move membranes up and down until delivered (Figure 5.18).
Figure 5.18. Delivering the placenta with a turning and up-and-down motion. (POPPHI, 2007; ANCM, 2008)
Note: If the membranes tear, gently examine the upper vagina and cervix wearing high-level disinfected or sterile gloves and use a sponge forceps to remove any pieces of remaining membrane. 6. Massage the uterus.
Massage the uterus immediately after delivery of the placenta and membranes until it is firm (Figure 5.19). Massaging the uterus stimulates uterine contractions and helps to prevent PPH. Sometimes blood and clots will be expelled during this process. After stopping massage, it is important that the uterus does not relax again.
Figure 5.19. Massaging the uterus immediately after the placenta delivers. (POPPHI, 2007)
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Instruct the woman how to massage her own uterus, and ask her to call if her uterus becomes soft (Figure 5.20).
Figure 5.20. Teach the woman how to massage her own uterus. (POPPHI, 2007)
Care after delivery of the placenta 7. Examine the placenta. Examine the fetal and maternal sides of the placenta and membranes to ensure they are complete. A small amount of placental tissue or membranes remaining in the woman can prevent uterine contractions and cause PPH. Note: Follow infection prevention guidelines when handling contaminated equipment, supplies, and sharps. 1. To examine the placenta for completeness hold the placenta in the palms of the hands with the maternal side facing upward and make sure that all lobules are present and fit together (Figure 5.21).
Figure 5.21. Examining the maternal side of the placenta. (Gomez, et al, 2005)
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2. Hold the cord with one hand, allowing the placenta and membranes to hang down. Place the other hand inside the membranes, spreading your fingers to ensure that membranes are complete (Figure 5.22). 3. Dispose of the placenta as appropriate.
Figure 5.22. Checking the membranes. (Gomez et al, 2005)
8. Examine the lower vagina and perineum.
1. Gently separate the labia and inspect the lower vagina and perineum for lacerations that may need to be repaired to prevent further blood loss (Figure 5.23). 2. Repair lacerations or episiotomy.
Figure 5.23. Gently inspect the lower vagina and perineum for lacerations. (POPPHI, 2007)
3. Gently cleanse the vulva, perineum, buttocks, and back with warm water and a clean compress. 4. Apply a clean pad or cloth to the vulva. 5. Evaluate blood loss. 6. Explain all examination findings to the woman and, if she desires, her family.
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9. Provide immediate care. After examining the placenta and external genitals, continue caring for the mother and newborn.
If the woman has chosen to breastfeed, the mother and baby may need assistance to breastfeed within the first hour after the birth and before transferring them out of the delivery room (Figure 5.24). Assess the readiness of the woman and newborn to breastfeed before initiating breastfeeding; do not force the mother and baby to breastfeed if they are not ready.
Figure 5.24. Encourage breastfeeding within the first hour after birth. (POPPHI, 2007)
Also ensure that: Infection prevention practices are strictly followed. The baby is kept warm. The mother and baby are kept together. The mother and baby are not left alone. The woman and baby stay in the delivery room for at least one hour after delivery of the placenta. PMTCT interventions are provided per national guidelines. AMTSL practices are recorded as required by local protocols (on the partograph, womans chart, or delivery log). The woman receives information about how she will be cared for during the next few hours. The woman is given a chance to ask questions and receive information about her queries and concerns.
10. Monitor the woman and newborn immediately after delivery of the placenta. During the first two hours after the delivery of the placenta, monitor the woman at least every 15 minutes (more often if needed). Perform a comprehensive examination of the woman and newborn one and six hours after childbirth. Continue with routine care for the woman and newborn, provide interventions to prevent/reduce the risk of MTCT of HIV according to national guidelines, and follow applicable requirements for recording information about the birth, monitoring of the woman and newborn, and any care provided.
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Managing the Third Stage When the Birth Attendant Is Alone and the Baby Needs Resuscitation There is a potential conflict of interest in caring for the mother and baby when the baby needs resuscitation. How the provider cares for each one will depend upon several factors: if the birth attendant is alone or has an assistant and what type of resuscitative efforts are required for the baby. If the birth attendant is alone and the baby is not breathing or is gasping at birth, the birth attendant will manage the third stage of labor as follows: If the baby begins breathing after stimulation, active management of the third stage of labor will most likely be possible. Place the baby in such a position that you can observe him/her during implementation of AMTSL: 1. Administer a uterotonic drug within one minute after the baby is born (oxytocin is the uterotonic of choice) and a second twin has been ruled out. 2. Apply controlled cord traction with simultaneous countertraction to the uterus. 3. Perform uterine massage immediately after delivery of the placenta. If the baby requires resuscitation with bag and mask, there are two possible scenarios: Scenario 1: The provider is alone but is able to administer a uterotonic drug within one minute after birth of the baby: 1. Administer a uterotonic drug within one minute after the baby is born (oxytocin 10 IU IM or misoprostol 600 mcg by mouth) and a second twin has been ruled out. 2. Deliver the placenta either by maternal effort or with assistance of the provider. 3. Perform uterine massage immediately after delivery of the placenta. Scenario 2: The provider is alone and is not able to administer a uterotonic drug within one minute after birth of the baby: 1. Perform physiologic management of the third stage of labor. 2. Perform uterine massage immediate after delivery of the placenta. Managing the Third Stage When the Woman Is Infected with HIV The practice of AMTSL is the same for all women regardless of their HIV status. However, women who are HIV-infected may choose not to breastfeed, so providers need to respect and support the womans choice for infant feeding. In addition, providers need to ensure that national guidelines for PMTCT are implemented for the woman and newborn in addition to routine care during labor, childbirth, and in the immediate postpartum. Recommendations for Selecting a Uterotonic Drug to Prevent PPH In the context of active management of the third stage of labor, if all injectable uterotonic drugs are available: Skilled attendants should offer oxytocin to all women for prevention of PPH in preference to ergometrine/methylergometrine. This recommendation places a high value on avoiding adverse effects of ergometrine and assumes similar benefit for oxytocin and ergometrine for preventing PPH. Skilled attendants should offer oxytocin for prevention of PPH in preference to oral misoprostol (600 mcg). This recommendation places a high value on the relative benefits of oxytocin in preventing blood loss compared to misoprostol, as well as the increased adverse effects of misoprostol compared to oxytocin.
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In the context of active management of the third stage of labor, if oxytocin is not available but other injectable uterotonics are available: Skilled attendants should offer ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine to women without hypertension or heart disease for prevention of PPH. Skilled attendants should offer 600 mcg misoprostol orally for prevention of PPH to women with hypertension or heart disease for prevention of PPH.
In the context of prevention of PPH, if oxytocin is not available or the birth attendants skills are limited, misoprostol should be administered soon after the birth of the baby. The usual components of giving misoprostol include: Administration of 600 mcg misoprostol orally after the birth of the baby. Controlled cord traction only when a skilled attendant is present at the birth. Uterine massage after the delivery of the placenta as appropriate.
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CHAPTER 6: Monitoring the Woman and Newborn during the First Six Hours Postpartum
The first six hours after childbirth is a critical period for maternal and newborn health and survival, and providers need to carefully monitor the woman and her newborn to detect and appropriately manage complications in a timely manner. Early recognition of danger signs by providers, women, and families and timely, appropriate management of complications could significantly reduce the incidence of maternal and newborn death and disability. The woman and her newborn should remain in the delivery room for at least one hour after delivery of the placenta, and for longer periods as necessary. After this, they should be transferred to an area where they can continue to be closely monitored for at least an additional five hours. If at all possible, women and newborns should not be discharged from the facility before 12 hours after delivery of the placenta.
MONITORING THE WOMAN

PPH is the most important single cause of maternal death in the world, and the majority of these deaths (88 percent) occur within four hours of delivery, indicating that they are a consequence of events in the third stage of labor. It is therefore imperative that the provider carefully monitor the woman to assess if the uterus is well contracted and how much the woman is bleeding during the hours following childbirth. During the first hour after delivery of the placenta, while the woman is still in the delivery room, the provider should monitor the following parameters at least every 15 minutes (more often if needed): Uterine contraction: o Palpate the uterus to check for firmness. o Massage the uterus until firm. (Ask the woman to call for help if bleeding increases or her uterus gets soft.) o Ensure the uterus does not become soft after massage is stopped. o Instruct the woman how the uterus should feel and how she can massage it herself. Vaginal bleeding Blood pressure and pulse Note: Action should be taken immediately to evaluate and treat PPH if excessive bleeding is detected. During this time the provider will also: ensure the woman has sanitary napkins or clean material to collect vaginal blood. encourage the woman to eat, drink, and rest.
Before beginning, explain what you will be doing to the woman. If all vital and other signs are normal, reassure the woman. If they are not normal, act immediately.
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facilitate breastfeeding. encourage the woman to empty her bladder and ensure that she has passed urine. ensure the room is warm (25 C). ask the womans companion to watch her and call for help if bleeding or pain increases, if the woman feels dizzy or has severe headaches, visual disturbance, or epigastric distress. keep the mother and baby together. never leave the woman and newborn alone. document all findings and care provided.
Just prior to transfer out of the delivery room or at least one hour after childbirth, ideally the provider should perform a comprehensive exam of the woman. Monitoring the Woman 1-6 Hours after Delivery of the Placenta During the next five hours the woman and newborn should be placed in an area where providers can easily continue to monitor their condition. During hours 1 to 5 after delivery of the placenta, the provider will monitor the woman as follows:
Danger Signs: BP, pulse, vaginal bleeding, and uterus
Uterine contraction, vaginal bleeding, blood pressure, and pulse: o o o every 15 minutes for 1 hour then every 30 minutes for the third hour then every hour for three hours
Diastolic BP 90 mmHg Systolic BP <60 mmHg Pulse >110 beats/minute Pad soaked in less than 5 minutes Constant trickle of blood Estimated blood loss of 250 mL or more or a woman who gave birth at home and presents with persistent vaginal bleeding Uterus is neither hard nor round Genital laceration extending to the anus or rectum
Danger Signs: Temperature and Respiration

Temperature >38 C Rapid breathing Palmar or conjunctival pallor associated with 30 respirations per minute or more (the woman is quickly fatigued or has rapid breathing at rest)
Temperature and respiration every 4 hours
Danger Signs: Bladder
Urinary bladder (assist the woman to empty her bladder, if distended/full, every hour)
The woman cannot void on her own and her bladder is distended and the woman is uncomfortable. Urinary incontinence
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Danger Signs: Breastfeeding
The baby is not taking the breast well. Breastfeeding has not yet been initiated.
Breastfeeding 2 to 3 times in the 6 hours
Danger Sign
Psychological reactions every hour
Negative feelings about herself or the baby
Counsel and care for the woman 1-6 hours after delivery of the placenta During this time, the provider should: Encourage the woman to eat, drink, and rest. Ensure the room is warm (25 C). Ask the womans companion to watch her and call for help if bleeding or pain increases, if the woman feels dizzy or has severe headaches, visual disturbance or epigastric distress. Keep the mother and baby together. Monitor the mother and baby frequently as noted. Document all findings and care provided. Perform a comprehensive exam of the woman six hours after childbirth.
Taking care to respect the familys culture and customs, congratulate the family and discuss how they can help the woman care for herself. Her body, clothing, bedding, and environment should be kept clean to prevent infection. She needs to eat well. Ask the family what foods they have available. Encourage them to offer her plenty of the foods she wants. Keep cultural beliefs and practices in mind. She needs to drink frequently because fluids help her body produce milk and replace lost fluids. A simple way to remember is to try and have something to drink at the babys feed times. She needs to get enough rest. She has just worked very hard so she needs to rest after this job. Getting enough rest is one of the most important things she can do to help herself and her baby. It will help her uterus stay hard and get smaller sooner, so she bleeds less. She can move around as much as she feels able. She shouldnt do any hard work or lift any heavy objects. Someone should help her with any heavy house work. If she experiences pain after delivery, she can take some paracetamol/acetaminophen to help relieve the discomfort.
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MONITORING THE NEWBORN

The mother and the baby should be kept together as far as possible and separation must be avoided. Evaluate the baby when the mother is examined. In these early hours the key elements to be monitored include breathing, color, temperature, the cord, and evaluation for danger signs. Before the evaluation, explain to the mother what will be done. Check the baby whenever the mother is evaluated: every 15 minutes during the first 2 hours after birth every 30 minutes during the third hour after delivery every hour during the next 3 hours
Monitoring of the baby in the first six hours is summarized in the chart below.
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Table 8. Monitoring of the baby in the first six hours after birth
Note: Wash hands with soap and water before touching the baby. Ensure when using items such as the thermometer that it is washed with soap and water and swabbed with alcohol before every use. Parameter Frequency of assessment Respiration Color Temperature (Record axillary temperature at least once in the first 6 hours. At other times, touch the babys hands and feet and check axillary temperature if they are cold.) Umbilical cord for bleeding Presence of other danger signs Ensure breastfeeding within one hour of birth and subsequent exclusive breastfeeding on demand Danger signs Rapid respirations (more than 60 respirations per minute) Slow respirations (less than 30 respirations per minute) Flaring of the nostrils Grunting Severe subcostal retractions Poor sucking/not sucking Cyanosis, especially of the lips and tongue. (Cyanosis of the hands and feet may also be due to hypothermia for which the baby needs to be warmed.) Hypothermia: body feeling cold (temperature <36.5 C.) Fever: usually later in the postnatal period; while the usual recommendation is >38 C, some feel that in the newborn its better to act when the temperature is even 37.5 C. Convulsions. Umbilical cord bleeding usually in the first day or two; needs retying of the cord; referral not required if that is the only sign.
Assess the baby in general when the mother is assessed in the AMTSL strategy:
immediately after birth then every 15 minutes for 2 hours, then every 30 minutes for 1 hour, then every hour for the next 3 hours
First voiding of urine (within 48 hours) First stool (within 24 hours)
Check anal opening after birth. Ask about urine and stools every day and before discharge from the health care facility.
Absence of stool or urine after the 24 hours and 48 hours, respectively
As part of newborn monitoring, the following guidelines are standard: Look first for the general status of the baby to see that he/she is active and has a good pink color in the lips, palms, and soles. Count the respiratory rate which is normally between 30-60/minute without flaring of the nostrils and severe subcostal retraction.
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Temperature: Take the axillary temperature of the baby with a clinical thermometer cleaned with an alcohol swab (normal = 36.5-37.5 C) at least once in the six hours. At other times, at least verify the body temperature by touching the abdomen, palms, and soles and ensure that they are all warm. If they are cold, recheck axillary temperature. If the palms and soles are cold or blue, it suggests that the baby is Danger Signs not warm enough. If the abdomen is cold, it Sucking poor or weak or not suggests an even more severe sucking at all hypothermia. Rewarm the baby, preferably Inactivity/lethargy/moving only on by placing in skin-to-skin contact with the stimulation mothers chest and covering the baby with Fever/body too hot or layers of clean cloth and a blanket. If, however, this does not warm the baby, it hypothermia/body too cold represents a serious danger sign that Rapid breathing/difficulty in necessitates urgent referral. breathing Monitoring for danger signs: These signs, Convulsions adapted from research studies, are noted in Persistent vomiting/abdominal the adjacent box and described in greater distension detail in the session on major neonatal Severe umbilical infections infections or sepsis. (redness/swelling surrounding the Assess for major defects that need special umbilicus and/or foul smell with or inputs. Asses for these defects if they have without pus) not been monitored soon after birth: The first five signs are the most important. o cleft lip and palate (needs additional Although all the danger signs have been support for feeding and may need listed for completeness, the last three feeding of expressed breast milk with a more often appear later in the postnatal cup/spoon) period. Related to the cord, on the first day o esophageal atresia (usually associated or two look particularly for oozing of blood/ with excessive secretion in the mouth) bleeding for which the cord must be retied o open spinal defects properly. o imperforate anus
If the baby is normal and no danger signs are noted, provide any routine care due and reassure the mother. If there are any problems/danger signs take the necessary steps promptly. In this period the baby continues to need basic care such as temperature maintenance, cord care, cleanliness, steps for prevention of infection, and exclusive, frequent breastfeeding on demand. Administer the first vaccines such as a dose of oral polio vaccine, BCG, and hepatitis B based on the recommendations of the Ministry of Health.
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CHAPTER 7: Routine Postpartum Care for the Woman

It is usually a joyful event when a woman gives birth to a baby she wants. Despite the pain and discomfort, birth is the long-awaited culmination of pregnancy and the start of a new life. However, birth is also a critical time for the health of the mother and her baby. Problems may arise that, if not treated promptly and effectively, can lead to ill health and even death for one or both of them. Nonetheless, the postpartum period is often neglected by maternity care. The lack of postpartum care ignores the fact that the majority of maternal deaths and disabilities occur during the postpartum period and that early neonatal mortality remains high. Postpartum care needs to be a collaborative effort between the woman, her family, community health workers, facility health care providers, health care managers, community groups, and policy makers. All members need to be informed of the components of quality postpartum care. In spite of the fact that so many deaths occur in the postpartum, very few women seek care and very few providers offer early postpartum services. Providers must offer quality services to ensure that women use these essential services that can substantially improve their chance of survival. This section covers various components of postpartum care. Individual Ministries of Health and implementing organizations can determine by consensus the priorities to be covered, especially in the early phases of implementation, depending on funds and time available for training, follow-up supervision, and monitoring and evaluation.
MALE INVOLVEMENT
In most communities, it is not traditional for men to be included in postpartum and newborn care, but where men have been encouraged to participate, they have shown that they are willing to do so. It may take several years before this becomes routine, but vaccination and homebased child health records also took several years to establish. Even small or busy clinics can be encouraged to identify a space (even the porch) where men can feel comfortable to wait and receive information from a trained male staff member about sex in the postpartum and the risk that unprotected sex outside the marriage holds for their baby, their wife, and themselves. Both men and women should be aware of the following facts: Sexual relations may be resumed as soon as it is comfortable for the woman and she is ready for it. The couple should use condoms when having sex, particularly if the woman still has lochia. The early weeks of breastfeeding are times when women are at particular risk of becoming infected with HIV for the following reasons: Men may have sex with partners other than their spouse(s) during the period of pregnancy and childbirth-related abstinence at home. o Women are more susceptible to HIV for a range of biological reasons at this time. The risk of MTCT is much higher when the woman is newly infected with a very high viral load. Mixed feeding carries particular risks for MTCT of HIV and other newborn infections. o
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POSTPARTUM CARE
Ideally a comprehensive examination of the woman should be performed at one hour and six hours after delivery and before discharge from the health care facility. For women who are not having any problems, the following schedule for routine postpartum visits may be sufficient: Table 9. Schedule for routine postpartum visits Visits Timing Within the first week postpartum, 1st Visit preferably within 2 or 3 days nd 2 Visit 4-6 weeks During a routine postpartum visit, a skilled provider will: perform a rapid assessment to recognize danger signs and signs/symptoms of complications or problems and respond immediately and appropriately. detect pregnancy-related complications, hemorrhage, medical conditions, and infections by: o taking a detailed history to identify any problems/potential problems; social problems, medical problems, problems during the most recent pregnancy and birth; and reported symptoms/problems. o performing a physical, obstetrical, and gynecological exam. o if the womans HIV status is positive, carrying out clinical staging and assessing for opportunistic infections.
Figure 7.1. Routine postpartum physical, obstetrical, and gynecological exam

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perform the following laboratory tests to evaluate the womans health and screen for selected medical conditions and infections: o o o hemoglobin levels (as needed). RPR (or VDRL): The test should be done if the womans status is not known. HIV (first visit/if last test >3 months ago/as needed): If the woman does not know her status and volunteers for testing, a test should be conducted. A positive HIV status affects many aspects of care for the woman and her newborn. check CD4 count according to national protocols if the womans HIV status is positive.
provide prophylaxis for health promotion and disease prevention: TT, intermittent insecticide-treated bednets (ITN), iron/folate tablets, vitamin A, broad-spectrum antihelminthics, and other nutritional supplements as needed. promote safer sexual practices. if the womans HIV status is positive, provide prophylaxis for opportunistic infections according to national guidelines. provide treatment for any medical conditions, illnesses, and infections detected. manage any pregnancy-related complications. provide PMTCT interventions according to national guidelines. If the woman is not already on ARV treatment, consider referring her for care with an HIV specialist. provide client-centered counseling for women and partners/supporters. help the woman and her partner/support person develop a complication-readiness plan. refer all women who need specialized care for any reason.
Importance of Routine Couple Visits A routine couple visit prior to discharge from the facility enables discussion with the partner/father about warning signs of complications in the woman and newborn and the need to make a plan for urgent transport and referral. He can also learn what he can do to protect his wife's and newborns health and understand the importance of exclusive breastfeeding. In these ways a couple discharge visit can contribute to maternal and perinatal health. The couple visit also provides an opportunity for both partners to be educated about treatment and prevention of sexually transmitted infections, the importance of family planning, and the availability of different family planning methods, including vasectomy. If the male partner has not yet been tested for HIV, the couple can be counseled and encouraged to be tested without the danger of blame being put on the woman because she has been tested first. Where appropriate, condoms can be demonstrated, promoted, and provided. A couple visit acknowledges the usual gender role of men in protecting their family and in making decisions. Health Promotion and Disease Prevention Certain medications or simple health care measures can prevent or reduce the risk of suffering from specific health problems. The following measures should be explained and offered to all women.
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Prevent malaria Ask whether the woman and newborn will be sleeping under a bednet. If yes: o o Ask if it has it been dipped in insecticide. Advise her to dip it every six months.
If not, advise her to use an insecticide-treated bednet, and provide information to help her do this. Note that WHO/GMP (Global Malaria Program) now recommends use of long lasting insecticidal nets (LLINs) that maintain efficacy for at least 3 years.6 Prevent vitamin A deficiency Give 200,000 IU vitamin A capsules after delivery or within six weeks of delivery. Explain to the woman that the capsule with vitamin A will help her to recover better and that the baby will receive the vitamin through her breast milk. Ask her to swallow the capsule in your presence. Explain to her that if she feels nauseated or has a headache, it should pass in a couple of days. Do not give capsules with high dose of vitamin A during pregnancy.
Prevent iron-deficiency anemia For intermittent preventive treatment of hookworm to prevent anemia, provide doses of a broad antihelminthic (to be taken every six months) to women living in hookworm endemic areas. Iron/folate supplementation to prevent anemia. If hemoglobin is between 811 g/dL, give ferrous sulfate or ferrous fumerate 60 mg by mouth plus folic acid 400 mcg by mouth once daily for at least three months after childbirth. If hemoglobin is 7 g/dL, treat for anemia according to national protocols. (Note: The ferrous sulfate or fumerate dose will depend upon the womans hemoglobin. Follow national guidelines on the specific treatment, as this may vary from country to country.)
Source: http://www.who.int/mediacentre/news/releases/2007/pr43/en/index.html; accessed on March 26, 2009
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Prevent tetanus
Tetanus toxoid (TT). Provide TT if a dose is due and remind women to keep the TT cards and vaccinations up to date.
Counsel on nutrition Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, and milk, to help her feel well and strong (give examples of types of food and how much to eat). Reassure the mother that she can eat any normal foods; these will not harm the breastfeeding baby. Spend more time on nutrition counseling with very thin women and adolescents. Determine if there are important taboos about foods which are nutritionally healthy. Advise the woman against these taboos. Talk to family members, such as the partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work. Remind the woman and her family that a breastfeeding woman needs to eat extra. In order to eat enough for herself and to produce enough milk, she should ideally eat five to seven times a day. If possible, she should try to eat smaller quantities of food at more frequent intervals during the day. In low-resource settings in developing countries where women eat less frequently, she should take at least one extra meal a day.
A breastfeeding woman needs to drink a lot. She should try to drink something after every time her baby breastfeeds.
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Advise on postpartum care and hygiene Advise the woman: To always have someone near her for the first 24 hours to respond to any change in her condition. Not to insert anything into the vagina. To avoid sexual intercourse until the perineal wound heals and it is comfortable for her. To have enough rest and sleep. About the importance of washing to prevent infection of the mother and her baby: o o Wash the perineum daily and after fecal excretion. Change perineal pads every 4 to 6 hours, or more frequently if there is heavy lochia. Wash used pads or dispose of them safely. Wash the body once daily during bathing with soap and water. Wash hands before handling the baby, at least after changing the diaper/napkin, after using the toilet herself, and after cleaning the house. Wash hands every time before handling a low birth weight baby.
o o
Advise on the need for rest and sleep during the postpartum Explain to the woman: That a breastfeeding woman needs additional time to rest. This is because she is recovering from pregnancy and childbirth, breastfeeding, and taking care of a little baby, which takes up a lot of her time. That she can try to negotiate with family members to help with household chores so that she can take more time to rest. That she can ask a health care provider to help her explain her needs in the postpartum to her partner and family members.
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Counsel on the importance of family planning If appropriate, ask the woman if she would like her partner or another family member to be included in the counseling session. Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as four weeks after delivery. Therefore it is important to start thinking early about what family planning method she and her partner will use. Her fertility can return even before she commences menstruation after childbirth. Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 3-5 years between pregnancies is healthier for the mother and child. After a live birth, couples should use an effective family planning (FP) method of their choice consistently for at least two years before trying to become pregnant again, and not more than five years after the last birth. After a miscarriage or abortion, couples should use an effective FP method of their choice consistently for at least six months before trying to become pregnant again. Counsel on safe sex, including use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. Promote their use, especially if there is a risk of sexually transmitted infections or HIV. For HIV-positive women, follow guidelines for family planning considerations. Her partner can decide to have a vasectomy (male sterilization) at any time.
Family planning methods Information on when to start family planning methods after delivery and the actual method to be used will vary depending on whether a woman is breastfeeding or not. Make arrangements for the woman to see a family planning counselor or counsel her directly. Family planning options for the non-breastfeeding woman that can be used immediately postpartum include: condoms, Progestogen-only oral contraceptives, Progestogen-only injectables, implant, spermicide, female sterilization (within 7 days or delay 6 weeks), copper IUD (immediately following expulsion of placenta or within 48 hours). Options for the nonbreastfeeding woman that should be delayed for 3 weeks include: combined oral contraceptives, combined injectables, and fertility awareness methods. A breastfeeding woman may choose the lactational amenorrhea method (LAM), but she will be protected from pregnancy only if she is no more than 6 months postpartum and she is breastfeeding exclusively (8 or more times a day, including at least once at night: no daytime feedings more than 4 hours apart; and no night feedings more than 6 hours apart; no complementary foods or fluids), and her menstrual cycle has not returned. A breastfeeding woman can also choose any other family planning method, either to use alone or together with LAM.
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Method options for the breastfeeding woman that can be used immediately postpartum include: lactational amenorrhea method, condoms, spermicide, female sterilization (within 7 days or delay 6 weeks), copper IUD (within 48 hours or delay 4 weeks). Method options for the breastfeeding woman that should be delayed for 6 weeks include: Progestogen-only oral contraceptives, Progestogen-only injectables, implants, diaphragm. Method options for the breastfeeding woman that should be delayed for 6 months include: combined oral contraceptives, combined injectables, fertility awareness methods.
Advise on sexual intercourse during the postpartum period Explain to the woman:

that she can have sex as soon as she is ready and it is comfortable, but she should use a condom if she still has lochia discharge. that unless partners have sex only with each other and are sure that they are both uninfected, they should practice safer sex. Safer sex means non-penetrative sex (where the penis does not enter the mouth, vagina, or rectum) or the use of a new latex condom for every act of intercourse. (Latex condoms are less likely to break or leak than animalskin condoms or the thinner more sensitive condoms.) Condoms should never be reused.
Advise on danger signs Advise the woman to go to a hospital or health center immediately, day or night without waiting, if she experiences any of the following signs: Vaginal bleeding: more than two or three pads soaked in 20-30 minutes after delivery or bleeding increases rather than decreases after delivery. Convulsions
Fast or difficult breathing Fever and too weak to get out of bed
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Severe abdominal pain
Feels ill
Swollen, red or tender breasts, or sore nipple (seek advise as soon as feasible)
Urine dribbling or pain on micturition
Pain in the perineum or draining pus Foul-smelling lochia
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Discuss how to prepare for an emergency in postpartum Advise the woman to always have someone near for at least 24 hours after delivery to respond to any change in her condition. Discuss with the woman and her partner and family about emergency issues: o o o o where to go if there are danger signs how to reach the hospital how to meet the costs involved options for family and community support
Advise the woman to ask for help from the community, if needed. I1Advise the woman to bring her home-based maternal record to the health center, even for an emergency visit.
Advise on when to return Encourage the woman to bring her partner or family member to at least one visit. Explain the timing of routine postpartum visits. When the mother and baby are normal: o o the first visit should be within the first week, preferably within 2-3 days. the second visit should be 4-6 weeks postpartum.
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CHAPTER 8: Resuscitation for Birth Asphyxia

Birth asphyxia is a major cause of death in the newborn period, accounting for about 23 percent of deaths in the first four weeks of life. From 3-5 percent of newborns do not start spontaneous breathing at birth. A great number of newborns do not receive appropriate care because many birth attendants do not have the knowledge, ability, or the appropriate equipment and supplies to perform the necessary steps of resuscitation in an optimal manner. It is extremely important to train healthcare personnel in this area to prevent neonatal deaths and disability. The term birth asphyxia indicates the babys inability to commence and maintain breathing. A normal baby at birth has a good cry; continues to breathe well; has a pink tongue, lips, palms and soles; and has adequate reactions and good muscle tone, with the limbs well flexed and moving well. The slight bluish tinge of the palms and soles commonly seen in babies at birth is due to vasoconstriction of the local blood vessels as a result of the chilling that takes place at birth. This chilling is due to the baby coming from a warm intrauterine environment to the colder exterior and to the evaporation of the amniotic fluid. The blue color changes rapidly to pink as the baby is dried, wrapped, and warmed. Basic resuscitation of the newborn is not the exclusive field of a specialist. Midwives, nurses, and doctors who attend deliveries at all levels should have the skills and resources to resuscitate babies with birth asphyxia in order to decrease neonatal mortality and morbidity. This training program of staff at the peripheral health centers will focus on: drying and stimulation and maintenance of temperature clearing of the airways ventilation with bag and mask
It will not deal with cardiac massage, intubation, or the use of drugs because: more than 80 percent of asphyxiated babies require only stimulation, clearing of airways, and ventilation for revival. health workers at peripheral centers (such as health centers and health posts) targeted in this training program are likely to deal with far fewer cases of birth asphyxia and are thus more likely to lose some of their skills unless there is constant supervision and opportunities to practice, at least on mannequins which, in practice, does not often happen. It is thus better to limit this discussion to the minimum actions required to deal with most cases. anticipation appropriate preparation timely recognition of the signs of asphyxia rapid implementation of treatment
Each of the following is a prerequisite to successful neonatal resuscitation:

It is best to have two persons to provide appropriate care at resuscitation, even if the two are not equally skilled. Hence, centers should plan in advance and train additional persons at the site who can assist the more skilled person carrying out the specialized tasks for resuscitation.
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CAUSES OF BIRTH ASPHYXIA

Some causes of birth asphyxia are noted below. It should be noted, however, that up to 50 percent of newborns who require resuscitation may have no identifiable risk factors before birth. Hence, persons attending any delivery should be prepared and ready to initiate resuscitation, if required. Maternal causes for birth asphyxia include:

eclampsia bleeding (e.g., placenta previa/abruption) fever maternal sedation/anesthesia abnormal presentations prolonged/difficult labor infections such as malaria, syphilis, tuberculosis, and HIV/AIDS
Causes in the newborn include:

cord prolapse/knot thick meconium in the amniotic fluid (may be due to fetal distress, but if aspirated into the lungs may perpetuate asphyxia after birth) prematurity/IUGR post-maturity multiple births selected congenital malformations
PREPARATION FOR RESUSCITATION

The cry of the baby at birth is generally considered to be the first sign of extrauterine life and good health. Most newborns cry and start breathing immediately after birth and adapt well to the extrauterine environment. All that is needed is to be surrounded by a clean and warm environment and to be carefully monitored. Breathing must be established before the baby is given to the mother to be kept warm. A suitable room and the necessary equipment should be ready, and health workers should be well prepared for resuscitation at every birth without delay. The life and brain of the infant are at stake. While routine essential care of the baby can be carried out while the baby is placed on the mothers abdomen or chest, it is convenient to designate a newborn baby corner or area where resuscitation and other special care for the baby can be carried out. It should have a table with a firm mattress covered with a clean rubber or plastic sheet and a clean, preferably sterile cloth, under a warmer where all necessary equipment and supplies can be placed and readily accessed. Equipment for Preventing Hypothermia The following equipment is recommended for preventing hypothermia:

A warm room. Make sure the room is warm, with no drafts or open windows. A source of heat. A clean treatment surface/table should be available, preferably with an overhead warmer. Where overhead heaters are very expensive, a warming table can be manufactured locally by fixing either a heating rod or 2-3 bulbs on a wooden frame (as shown in Figure 8.1), taking care that the wiring is well done in order to avoid inadvertent
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shocks. Where a heating rod is fixed, an additional lamp will be required to provide adequate lighting. Babies under the warmer should always be monitored to ensure that that they are maintaining their body temperature appropriately and are not too cold or hot. In general, water bottles are not recommended due to the risk of burns. If there is no alternative to a bottle, the water must be warm and the bag containing the bottle must be wrapped in a thick cloth or several layers of cloth. The baby must be frequently checked to ensure that the skin is not excessively hot or red.
Figure 8.1. A warming table. (USAID/BASICS Senegal Newborn Health Program)
Three to five pieces of clean, preferably sterile, cloth to dry and wrap the baby, a cap where available, and a washable blanket or several layers of cloth where required. A wall thermometer to monitor the room temperature. A thermometer to measure the axillary temperature of the baby.
Equipment for Aspiration of Secretions The following suction equipment is recommended: De Lee mucous aspirator. This is perhaps the simplest item to use (see Figure 8.2). It consists of two tubes attached to a transparent trap. One tube end is introduced into the babys mouth and throat, and the health worker applies suction with his mouth at the tip of the other tube; the trap is to prevent aspirated material from entering the health workers mouth. The item comes in individual pre-sterilized packs. Since cleaning and decontamination of the narrow tubes present challenges and due to the risk of infection, especially of HIV/AIDS, only a single use with careful application of suction is recommended to avoid any risk of the secretions entering the tube in the care providers mouth. In fact, for safety, it might be better to use a fresh aspirator. After use, the item should be discarded in a safe manner and not reused, even after cleaning and disinfection. Some practitioners do not recommend the use of this aspirator because of the potential risk of secretions entering the care providers mouth, despite the presence of the trap.
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Figure 8.2. De Lee mucous aspirator. (WHO: Safe Motherhood: Basic Newborn Resuscitation-A Practical Guide)
Suction machine (electrical/foot operated) used with single-use simple catheters 8F and 10F may be better than an aspirator, as there is no risk of secretions contaminating the oral mucosa of the care provider. Notes on use: o In newborn infants, the negative pressure used for the suction should not be more than 100 mm/Hg or 130 cm of water. Most suction machines may attain pressures often ranging from 400-600 mm/Hg and at times going up to 700 mm/Hg (when being used for adults). Suction at a high negative pressure may result in bradycardia and/or apnea in the baby due to vagal stimulation. Since the same aspirator may be used for the mother and the newborn, care should be taken to change the level of the negative pressure of the suction. A clearly visible sticker should be attached permanently to the equipment with the following message: Adjust the pressure to 100 mm/Hg or 130 cm of water for the newborn infant. The suction tubes/catheters used with the machine should also be the pre-sterilized single use variety and should not be reused. In the absence of a suction machine, a 10 mL syringe attached to the suction catheter can also be used to remove the secretions but may not be so effective. In many centers in advanced countries, a rubber bulb is used for suction, but it should be used only for one baby. The bulb is also readily available in many countries in Africa, but it is commonly used repeatedly on several babies. It is not possible to clean this properly or to even verify that it is clean, as the bulb is opaque. Hence, the rubber bulb is not recommended in developing countries. If no other item is available for suctioning, a new bulb may be washed, boiled, and used for only one baby and then discarded.
o o o
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Equipment for Ventilation Bag and mask: a newborn resuscitator bag (240-500 mL) with appropriate size face masks (#1 for normal size newborn babies, #0 for LBW babies). (See Figure 8.3.) In general, where resources are limited, the 500 mL bag is preferable as it can be used for the normal weight baby and for the larger low birth weight infants which constitute the biggest proportion of the high-risk group. Notes:
Figure 8.3. Self-inflating bag and mask for ventilation of babies.
o o o
The resuscitator bag should be the self-inflating kind that inflates automatically after it is squeezed and released. Bags that require a flow of air/oxygen mixes to inflate are, in general, not appropriate for resuscitation. In certain models the mask consists of one piece of silicone/siliconized rubber; in others, it consists of two parts, a plastic component to which a different transparent soft plastic/rubber/silicone piece is attached. Make sure that the pieces are appropriately attached so that the soft part is the one that comes in contact with the babys face and not the hard plastic part that can hurt the baby. Check that the mask fits properly with the bag. To check the functioning of the self-inflating bag, block the mask by making a seal with the palm of the hand. Then squeeze the bag. Make sure that you feel pressure against your hand that indicates that the seal is working well without leaks. When the pressure is raised, it can also force the pressure-release valve open. When the pressure is released, the balloon should reinflate. Squeeze the bag only to the extent necessary to expand the chest. Excessive pressure carries a risk of injury to the lungs.
A supplemental oxygen source, if available. If cylinders are used, check that they have adequate oxygen. Note that while it is good to have supplemental oxygen available, it is not required in most cases. A wall clock with a second hand. In dealing with emergency situations such as asphyxia, it is easy to lose track of time. It is important to note the time of birth and the time spent in resuscitation, since there is a time limit to active resuscitation. The clock can also be used to check the heart and respiratory rate in the delivery room.
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A stethoscope where available. Miscellaneous: sterile gauze/pieces of sterile cloth and sterile/HLD gloves.
Attempts should be made to procure as many sterile items as possible in order to avoid nosocomial infection which will increase morbidity and mortality. All equipment has to be cleaned and disinfected after use. The manufacturer gives specific instructions for cleaning, disinfecting, and sterilizing equipment. Follow these instructions carefully. To ensure that all the necessary items are kept ready for every delivery, attach a list on the wall near the table for resuscitation in the baby corner. To protect the list it can be laminated or framed with a glass cover or attached inside a locked notice board. Here is a sample: Equipment and Supplies for Newborn Resuscitation in the Baby Corner or Area of the Delivery Room It is mandatory to ascertain (a) every morning, (b) at the beginning of every shift, and (c) before each delivery that the equipment/supplies listed below are available, in working order, sterile/clean, and ready to be used. 1. A heat and light source 2. A table for resuscitation with a mattress with a clean washable surface covered with a clean, preferably sterile cloth. This could be part of the warming table. 3. Three to five pieces of clean, preferably sterile, cloth to dry and wrap the baby, including the head, a cap or bonnet, where available, and a washable blanket or several layers of cloth where required. 4. Sterile gauzes/pieces of cloth 5. Disposable sterile (preferable)/high-level disinfected gloves 6. Suction equipment with suction tubes/catheters 7. A self-inflating bag (500 mL) and masks (sizes 1 and 0) 8. A wall clock with a second hand 9. A wall thermometer 10. A clinical thermometer to record the axillary temperature of the baby 11. Disposable syringes (1 mL, 2 mL, 10 mL) 12. Vitamin K1 13. A weighing scale
Figure 8.4. Sample list of equipment for newborn resuscitation
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Identifying a Baby with Birth Asphyxia The baby may have the following features:

does not cry at birth is either not breathing or has very slow breathing (less than 20/minute) or is gasping is blue or pale is limp and not moving or not responding properly to stimulation
The Apgar score is used at hospitals to assess the status of the baby in relation to breathing, heart rate, color, muscle tone, and reflex response to stimulation at 1, 5, and 10 minutes after birth. Low scores at 5 and 10 minutes have also had some correlation with a poorer long-term outcome, but this correlation is not always consistent. However, in most peripheral centers the scoring is frequently carried out in a wrong/inappropriate manner. The score, in any case, is not required and must not be used to make decisions to carry out resuscitation. Hence, the Apgar score will not be covered in this training session.
STEPS IN NEWBORN RESUSCITATION

The initial actions for resuscitation are similar for all babies, irrespective of the status of the baby and presence or absence of asphyxia. After each step, an evaluation of the condition must be made to judge progress so that the appropriate next step can be implemented. Evaluation and action constitute a cycle that has to be repeated in a timely manner until the baby recovers or a decision is made to discontinue an unsuccessful resuscitation. Universal precautions for the safety of the baby and the staff and steps for prevention of infection are also mandatory. Preparation Switch on the heating source before the delivery to warm the table top/mattress for the baby. Place the linen for the baby on the table under the warmer so that it gets warmed up before the delivery. Wash your hands and wear sterile gloves. Immediate Care in the Case of Meconium in the Amniotic Fluid If the amniotic fluid is stained by meconium, and especially in case of thick meconium: Suction the mouth and nose as soon as the head is delivered on the perineum and before the delivery of the shoulders. Tell the mother not to push for a little while, giving time to suction the mouth and nose of the baby. Based on research results, this preliminary suction before full delivery is not carried out in centers in advanced countries; instead, early suction, including endotracheal suction, is carried out immediately after delivery if the baby is not crying. However, in low-resource settings, such as peripheral centers in developing countries where intubation is not feasible, suctioning of the mouth and nose before delivery of the shoulders is likely to decrease the risk of meconium inhalation into the lungs that could cause additional problems. After full delivery of the baby, if no breathing is observed, suction the mouth and nostrils before drying and stimulation. Do not suction a baby who is already crying.
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Drying the Baby and Keeping the Baby Warm (Initial Steps for All Babies) In general, the first step immediately after birth is to dry the baby well. Drying the baby well also serves to provide safe stimulation to a baby who is not breathing. While drying, verify if the baby is breathing/crying. If the baby is breathing well, follow the steps noted above in the section of care of the baby immediately after birth. If the baby is not breathing, discard the wet cloth. Wrap the babys body and head with a fresh dry cloth, keeping the baby on the mothers abdomen, and verify again if he/she is breathing. Where it is clean and feasible, placing the baby who is not breathing on the table between the mothers legs will allow a better flow of blood to the baby. If the baby is still not breathing, clamp and cut the cord. If you have an assistant who can deal with/observe the mother and a separate place for special care, take the baby there and place it under a warmer (if available) for commencing additional steps for resuscitation.
Position of the Baby Initially during the steps noted above, the baby can be turned on one side with the head slightly extended. However, if the baby is still not breathing, it is convenient to have the baby on its back on a warm, firm surface with the head towards you. The head should be slightly extended, which you can do either by extending the head slightly with your hand or by placing a roll of linen under the shoulders to raise them by 2-3 cm (see Figure 8.5).
Positioning during Resuscitation

Correct position
(Neck slightly extended)
Newborn with elevated shoulders 2 to 3 cm. with a small linen roll, placed below, to slightly extend the neck. The neck may be extended by positioning with the hand without the linen roll
Incorrect positions
Neck hyperextended Neck flexed
Figure 8.5. Correct positioning.
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Clearing of the Airways If the baby is still not breathing, clear the airways by suction. Make sure that: o The suction tube is introduced enough to suction effectively, but no more than 5 cm into the mouth or 3 cm into the nostrils. Suction the mouth before the nostrils because if the nose is suctioned first, it may stimulate the baby to breathe and if there is thick mucus in the mouth/throat, it may get inhaled or aspirated. o Suction should be carried out gently and only when pulling out the tube, not when introducing it. o Suction should not be applied for more than 20 seconds. Re-examine the baby. If the baby starts to cry or breathe well, proceed with routine essential care of the newborn. If the baby is still not breathing or is just gasping, carry out the steps noted below.
Tactile Stimulation Usually stimulation through proper drying and suctioning of the mouth and nose are adequate. At the most, if the baby is still not breathing, very brief additional stimulation by flicking or slapping the soles of the feet may be tried before commencing ventilation with the bag and mask. Perform these steps quickly. All the above steps should take approximately 30 seconds. Do not slap repeatedly; it is not only harmful but will also waste precious time which could be better used in ventilating the baby as noted below.
Figure 8.6. Methods for stimulating the baby.
Ventilating the Newborn with the Bag and Mask All the above steps should be carried out quickly to ensure that ventilation where required is started within one minute after birth. Verify that the babys neck is in slight extension, either held in position with a hand or by placing a small cloth roll (2.5 cm-3.0 cm) under the shoulders (whichever is more convenient for the care provider). Use the proper size mask: o o Use #1 for normal size babies and #0 for LBW babies. Make sure the mask covers the babys chin, mouth, and nose, but not the eyes (see Figure 8.7).
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Form a proper seal between the masks edge and the babys face so that air does not leak out during ventilation.
FORM A PROPER SEAL BETWEEN THE MASK AND FACE
CORRECT
INCORRECT
Figure 8.7: Correct positioning of the mask and formation of a good seal.
Commence ventilation at about 40 times a minute (the range for ventilation is 40-60 breaths/minute). A simple way is to count one two breathe and squeeze the bag at each breathe. Make sure the babys chest rises and the valve of the self-inflating bag moves with each inflation; this is an indication that ventilation is efficient. If this does not happen, adjust the position of the head of the infant and the bag, suction the mouth and nose again to remove secretions, and proceed with ventilation with a slightly higher pressure. You must see the chest rise.
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Reassess the babys breathing after one minute. o If the newborn cries and spontaneous breathing is established, stop ventilation and observe for at least 5 minutes. If the baby is breathing normally (30-60 respiratory movements/minute), proceed with routine essential newborn care. o If the baby is still not breathing or is gasping, assess the heart rate with a stethoscope if available, or by feeling the umbilical cord pulsations. Count the heart rate or the umbilical pulsations for 6 seconds and multiply by 10 to obtain the heart rate per minute. If the heart rate is more than 100/minute, continue ventilation. If the heart rate is less than 100/minute, clear the infants airways again, reposition the bag, and continue bagging until spontaneous breathing is established. o If the heart rate cannot be evaluated, continue ventilation as long as the chest is expanding well. If not, clear the infants airways again, reposition the bag, and continue bagging until spontaneous breathing is established.
If the baby is blue, especially in the mouth and tongue, give supplemental oxygen, if available. (Figure 8.8.) Remember, most babies do not require supplemental oxygen for resuscitation. If oxygen is administered, it can be carried out with the bag and mask. Attach the oxygen tube to the resuscitator bag at the oxygen inlet end. Remember: if the resuscitator bag is used, oxygen will reach the baby only if the bag is squeezed repeatedly as in ventilation. Oxygen can be given to a baby that is already breathing but is blue by holding the mask of the resuscitator bag above the face and squeezing the bag periodically. Other methods of giving oxygen to a baby who is breathing are indicated in the diagrams below. They include holding the oxygen tube with the flow of oxygen with or without a cupped hand or through a facemask. In general a flow of 1-2 L/minute of oxygen should be adequate.
Figure 8.8. Giving supplemental oxygen.
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When to Discontinue Resuscitation While it is essential to carry out the steps for resuscitation in a correct and timely manner, it is equally important to know when the process should be terminated. Conventionally, if a newborn does not breathe and does not cry for 20 minutes, resuscitation should be discontinued. A newborn who is not breathing 20 minutes after appropriately managed resuscitation has already suffered from significant hypoxia and merely continuing ventilation without ancillary support carries the risk of further brain damage and long-term disability. Intensive care is appropriate at this time. At a peripheral center, where it is not feasible to provide such care, a baby who is not breathing should be managed as best as feasible locally, unless facilities exist to transport the baby with effective ventilation to an appropriate higher referral center where intensive care is available. Otherwise, the baby is likely to die on the way or reach the center in a state from which it cannot be revived or that may be associated with severe disability. Dangerous/Inefficient Resuscitation Practices Avoid harmful practices such as: Vigorous aspiration of the mouth and nose of the baby. It may result in bradycardia or cardiac arrest due to vagal stimulation. Postural drainage with head down. Slapping of the babys back. Compression of the chest to eliminate secretions. This is dangerous since it may lead to rib fractures, pulmonary lesions, and even death. Strong stimulation of the newborn, such as slapping the buttock. Immersing the baby in cold water and then in hot water. Introducing a glass thermometer in the anus, as this may result in injury. Use of medication such as sodium bicarbonate administered without indication before breathing is established or rapidly in high concentrations.
POST-RESUSCITATION CARE
After resuscitating the asphyxiated baby, the health care worker has to provide routine essential care, monitor the infant for problems/complications, counsel the family, and document all events and actions. All equipment needs to be decontaminated/cleaned/sterilized before it can be used again (see chapter 1) and all disposable or consumable/single-use supplies need to be replenished. Care Following A Successful Resuscitation Prevent hypothermia; keep the baby warm and dry and if feasible in skin-to-skin contact with the mother, covering his/her body and head over the mothers chest, keeping the face exposed. Examine the baby and evaluate the respiratory rate: o If the infant has cyanosis, breathing problems such as rapid breathing with a rate of more than 60/minute, intercostal retractions, and/or expiratory grunting, administer supplemental oxygen as illustrated above. If these do not subside, refer the baby.
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Measure the axillary temperature: o If the temperature remains above or equal to 36.5 C, keep the baby on the mothers chest. o If the temperature is less than 36.5 C, warm the baby by skin-to-skin contact or by placing under a warmer as is most appropriate, based on available equipment and the status of the baby and mother. If the infant remains hypothermic, this represents a danger sign; refer the baby to the appropriate referral center. After resuscitation, reassess the baby periodically every 15 minutes for 2 hours and every 30 minutes for 6 hours for breathing, color, and activity. Continue assessment, including evaluation of feeding, every 3 hours for the next 48-72 hours. If the baby develops respiratory difficulty or any one of the danger signs noted in chapter 13 on major infections, refer him/her to the appropriate referral center following the guidelines for appropriate referral in the same chapter. If the baby improves, commence routine essential newborn care: o o o o o o o o Keep him/her warm and dry, if feasible in skin-to-skin contact with the mother. Administer vitamin K (1mg intramuscular for a normal weight baby) to the baby. As soon as the baby is stable, help the mother to start breastfeeding. A newborn that required resuscitation is at risk for hypoglycemia. If the baby does not suck well, transfer him/her to a hospital that cares for sick newborns. If the baby has a good suck, it is sign that he is improving. Defer the first bath preferably for at least 24 hours, until the baby is much more stable, warm, and continues to breathe and feed normally. Provide all the routine care and counseling noted in the chapter on care of the normal baby at birth. Record all the findings and treatment provided for birth asphyxia in the mother/baby records and in the delivery register. Make sure that all equipment is decontaminated, cleaned, and sterilized as appropriate and all disposable supplies are replenished and kept ready for the next delivery. What was done for the baby and why, in simple terms. Continuing breastfeeding on demand, and ask them to inform you if the baby does not demand to be fed or does not suck well. Keeping the baby warm, in skin-to-skin contact where required, and to verify that the baby remains warm. Identification of danger signs noted in chapter 9 on systematic examination of the baby. Even the presence of a single danger sign is important and requires referral to a higher center/hospital.
Counsel the mother and the family regarding: o o o o
Where the baby has to be referred, follow all the steps for referral outlined in chapter 13 on major infections.
Care Following an Unsuccessful Resuscitation When resuscitation attempts are not successful, it is extremely important to inform the parents and provide an explanation.
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Indicate that everything possible was done to save the baby. Respond to the questions the family may wish to ask and let them express their feelings. Show the baby to the parents and family members and, if culturally appropriate, provide them with an opportunity to hold the baby. Ensure that the family has privacy for holding the baby in these sad circumstances. Explain that the mother will need rest, good nutrition, and emotional support at home. With the babys death, the mother will face mammary engorgement 2-3 days after delivery. Advise the mother to: o o o o o support the breasts with a large cloth band or a bra. apply cold compresses on the breasts to decrease congestion and pain. avoid breast massage or exposure to heat. avoid stimulating the nipples. prescribe oral paracetamol when necessary for pain.
Make arrangements to follow the mother for at least three days to make sure she is improving. Discuss the options of family planning and explain that in this case there is a greater chance of the woman conceiving earlier and that for the health of the mother and future babies it is better to have an interval of three years before the birth of the next baby. Prepare the death certificate and follow the protocol to register the death.
Completing Medical Records All healthcare facilities must keep charts/documents that record each birth and information about the events surrounding the birth. The basic protocols must provide the necessary information, such as the condition of the infant at birth and if resuscitation or any other treatment was administered. This information must be copied into the health records of the baby where separate records exist for the baby. All problems detected at birth as well as procedures and treatment applied must be written legibly in the chart for future reference in case it is needed for healthcare or administrative reasons. The systematic collection of information is important to establish health statistics and to serve as educational material to improve the quality of care. Good documentation is also extremely important in case of medico-legal issues that may surface later. The following details should be present: date and time of birth condition of the baby at birth procedures used to initiate breathing where applicable time delay between birth and the first breath observations during and after resuscitation, if any result of resuscitation procedures in case of unsuccessful resuscitation, list the likely reason(s) for failure name of the healthcare worker(s) present at resuscitation
The key steps in resuscitation and for integrating with AMTSL are summarized in the algorithms given below (Figures 8.9 and 8.10).
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Figure 8.9 Algorithm for resuscitation for birth asphyxia
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Integration of AMTSL and ENC

Keep required items for the mother and baby close by, load oxytocin in syringe. Inform the woman what is being planned in a way she can understand.
Receive and dry the baby, discard wet linen.
Baby cries well
Cry not heard
Place the baby on the mot hers abdomen; cover with a dry cloth.
Place the baby on the mothers abdomen; c over the baby with a dry cloth.
Inform the mother about her baby and AMTSL; administer uterotonic after checking for a second baby.
Breathing well
Not breathing/ gasping

Cut the cord; resuscit at e the baby. If possible, administer uterotonic after checking for a second baby.
Clamp cord when pulsations stop/2-3 minut es after birth. Place the baby on the mothers chest and keep the baby warm.
Inform the mot her about her baby and AMTSL; administ er ut erotonic after checking for a second baby.
Clamp cord when puls at ions stop/2-3 mins. after birth. Place the baby on the mothers chest and keep warm.
Apply controlled cord traction + countertraction; perform uterine massage.
Apply cont rolled cord traction + countertraction; perform uteri ne massage.
Depending on the level of resuscitat ion efforts needed and whether an assistant is present, del iver placent a by maternal effort or controlled cord traction.
Monitor the woman and baby closely. Implement ENC at birth: eye prophylaxis; cord care; warmth (skin-to-ski n); breastfeeding. Continue rout ine c are for the woman and her baby.
Figure 8.10 Algorithm for integration of AMTSL, ENC and resuscitation for birth asphyxia
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CHAPTER 9: Basic Systematic Examination of a Newborn at Peripheral Centers

In major hospitals the pediatrician/neonatologist performs a systematic and complete examination of the newborn. This kind of evaluation is presently not feasible in the peripheral centers where such specialists are not available. The purpose of this manual is for peripheral healthcare workers to acquire competence in basic evaluation and care of the newborn infant, and the manual will therefore focus on basic components of care and evaluation. A somewhat more detailed systematic examination, noted in Appendix B, may be relevant at some of the larger, more established centers. While in general there is a systematic method of examination, it is important in some cases to adapt the steps to take into consideration certain situations that apply to very young babies such as newborns. The newborn infant is frequently asleep, for example, so it is advisable to take advantage of this to carry out those steps that require a quiet infant, such as counting the respiratory rate. On the other hand, if the baby is crying, it becomes easier to look into the mouth to identify the presence of problems such as a cleft lip or an infection such as thrush. If necessary, newborns can usually be calmed with breastfeeding, which provides an opportunity to evaluate sucking and attachment at the breast.
PREPARING FOR THE EXAMINATION

Timing of the Examination Examinations should be done at the following times: As soon as feasible after birth when the baby is stable and warm. At least once a day as long as the baby is in the facility. Before discharge. This is extremely important in order to detect any high risk factors or a danger sign in the early stages. The latter may necessitate a longer stay at the facility, beginning treatment/referral to the hospital, or recommending an earlier follow-up visit. The early postpartum period is very important as 75 percent of deaths in newborns take place in the first week following birth. At the first and subsequent follow-up visits in the postpartum period.
Equipment and Supplies Needed for the Examination a source of clean water, soap, alcohol/glycerine hand rub and clean towels a clean examination table/mothers bed (should be free of drafts and well-lit) a baby weighing scale a clean stethoscope a clinical thermometer for recording axillary temperature cotton swabs and alcohol a tape measure a watch or clock with a second hand or a timer to aid in measuring the respiratory rate a mother/baby card
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Preparation Promote cleanliness of the site where the baby is examined. Arrange to have adequate light. Welcome the mother and her family/companion, install them comfortably in a draft-free area, and explain what you are going to do. Wash hands with soap and water; if these are unavailable, use alcohol/glycerine hand rub. Prevent heat loss/hypothermia. Select a draft-free area, keep the baby warm during examination with a heat source, or, if not available, keep the baby covered, close to the mother, and expose only the part(s) to be examined.
CARRYING OUT THE EXAM

Main Steps of the Exam 1. Prepare a suitable place. 2. Plan to maintain the babys temperature during the examination. 3. Greet the mother and make her feel comfortable. 4. Review available records of the mother and baby. 5. Ask about danger signs and other problems. 6. Check for danger signs (and refer the baby if even one sign is present). 7. Check for jaundice. 8. Check for minor infections. 9. Evaluate breastfeeding. 10. Weigh the baby. 11. Document observations and care of the baby in appropriate charts/cards/registers. 12. Counsel the mother on basic newborn care. Detailed advice for some of these 12 steps is provided in the following sections. Review the mothers and babys records and ask about danger signs Look for information related to: Pregnancy: Note any care received by the mother and risk factors for infection. Regarding the delivery, note: o o o o condition at birth, when the baby cried after birth and if it was spontaneous; if not, note what actions were taken to initiate the cry birth weight care given at birth (eye and cord care, vitamin K1 injection) immunizations
Inquire about danger signs (see below). Ask about any other problems the newborn may have. Ask about the passage of stools and urine, specifically the approximate number per day (urine being passed more than six times a day is reasonable evidence of adequate breastfeeding).
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The following three adaptations may be necessary during an examination of a newborn:
Count the respiratory rate whenever the baby is quiet. If the baby cries, take advantage to examine the mouth to look for cleft palate or thrush. If feeding is necessary to calm the baby, take advantage to observe attachment at the breast and quality and adequacy of the sucking.
Check for danger signs Check for the following newborn danger signs: Difficulty in sucking. The danger signs related to sucking/feeding can be assessed by asking the mother and verified by direct observation. Lethargy, diminished activity, moving only when stimulated. Except in deep sleep, babies move frequently, both spontaneously and on stimulation. The arms and legs are flexed. If a limb is consistently kept straight, evaluate for paralysis. Note also if the limbs seem very limp or flaccid. Fever or hypothermia. Assess the body temperature by at least touching the babys abdomen, hands, and feet and ensuring that all are warm. Where possible, note the axillary temperature with a thermometer leaving it in place for four minutes or as recommended by the manufacturer for axillary temperature recording. The normal temperature is 36.5-37.5 C. The thermometer should be clean, preferably washed with soap and clean water, and wiped with an alcohol swab to prevent cross infection. Storing in liquid antiseptics should be done only if they are changed frequently. Otherwise there is risk of infections with Pseudomonas sps which may be highly resistant organisms. It is not recommended to take a rectal temperature as it is associated with a higher risk of infection and trauma. In the newborn infant, both fever and low body temperature outside the normal range of 36.5-37.5 C are danger signs, especially if they are not reversed rapidly with simple steps, such as warming through skin-to-skin contact, or through removal of excess clothes, or covering in the hot weather. Rapid breathing/difficulty in breathing. Assess respiration: the normal respiratory rate is 30-60 breaths/minute. There should be no flaring of the nostrils, grunting, or subcostal retractions. Although breathing can be somewhat irregular with short pauses, there should be no apnea, which is defined as cessation of breathing lasting for more than 20 seconds or of a shorter duration associated with cyanosis, pallor, or bradycardia with a heart rate less than 110/minute. The normal heart rate ranges between 110-160 beats/minute, with the lower rates when the baby is asleep and the higher rates when the baby is active or crying. Convulsions. Features of convulsions are often atypical in the newborn, such as a staring look, blinking of eyelids, chapping movements of the lips, and clonic/tonic movements of the limbs. Persistent vomiting and/or abdominal fullness . Vomiting is determined from the history taken from the mother. Occasional vomiting is normal, but persistent vomiting or green-colored vomitus are abnormal. Severe umbilical infection. Lift the cord to see the base; check for pus discharge, redness, swelling, and foul smell. In the first day or two also check the cord for bleeding or oozing of blood.
The danger signs are summarized in Table 10 below.
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Table 10. Guidelines for Identifying Danger Signs at Peripheral Centers DANGER SIGNS Sucking less or not sucking at all Lethargy/ inactivity Fever/ low body temperature IDENTIFICATION (Ask and look for) Not sucking at all; sucking less than usual; not opening the mouth when offered feeds; not demanding feeds. Not as active as usual, sleeping excessively, difficult to arouse, not waking up for feeds, lying limp, loose-limbed, excessively quiet or too good. Fever: Body hot to touch, history of the mouth feeling excessively hot during breastfeeding; temperature 38 C or more. (While the temperature is usually >38 C, some feel that in the newborn it is better to be on more watchful when the temperature is even 37.5 C.) Low body temperature/hypothermia: body feels colder than normal; temperature less than 36.5 C. Respirations more than 60/minute (count a second to verify), flaring of the nostrils, groaning or grunting, subcostal retraction.
Fast breathing/ respiratory difficulty Convulsions
Features of convulsions are often atypical in the newborn such as a staring look, blinking of eyelids, chapping movements of the lips, clonic/tonic movements of the limbs. Occasional vomiting is common, but persistent vomiting or green-colored vomitus are abnormal. Abdominal distension or fullness may be present.
Persistent vomiting and/or abdominal distension Severe umbilical infection
Lift the cord to see the base. Look for spreading redness or swelling around the umbilicus and/foul smell with or without pus discharge.
Earlier detection of problems such as major infections Babies with danger signs have to be taken long distances to the appropriate centers. Hence, ideally, infections need to be detected even earlier. Very early signs of infection are vague and difficult to recognize. They include the baby not looking well or having a sick look or facial grimace. They require careful daily observation. Mothers, family members, and health care providers (depending on whether the baby is at home or at a facility) should be encouraged to see the baby in adequate light at least once a day, especially in the first week.
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Check for jaundice Unlike in older infants, it is not easy to see jaundice in the early phase in the eyes of the newborn. It is best assessed in the skin. Jaundice starts in the face and spreads down to the hands and feet. Gently press the tip of the nose, release the pressure, and observe the blanched area for any yellow tinge/color. It can also be seen in the grooves of the skin when the baby frowns or cries. This is the only time in life that some jaundice is normal, and this used to be termed physiologic jaundice of the newborn. It starts after the first 24 hours on the face and does not spread to the palms and soles and disappears by two weeks. When the color reaches the palms or soles, it correlates with a serum bilirubin of about 15 mg/100mL (or 256.5mols/L). Such babies require referral for assessment and treatment, such as phototherapy. These guidelines apply only to full-term normal weight babies. Preterm and low birth weight babies require treatment at far lower levels of bilirubin. Hence, such babies with any jaundice need to be referred to a competent person/center for assessment and treatment. They should not be considered to have physiological jaundice. Here is a summary of referral criteria for jaundice: starting early, within 24 hours of birth present on the palms and soles associated with a danger sign occurring in a low preterm/birth weight baby persisting beyond the second week of life
Check for minor infections Conjunctivitis: Subconjunctival hemorrhage can be a normal finding following the delivery. Check for conjunctivitis, seen as redness and/or discharge. Thrush: Examine the tongue and the inner side of the mouth for oral thrush, seen as irregular, dirty, white patches on the tongue and inner sides of the cheeks. Thrush is different from the normal smooth white coating which may be seen over the middle of the tongue in some babies. It is best to look into the mouth when the baby cries or yawns. Avoid introducing a spatula or spoon into the mouth to open it. If doing this is unavoidable, then it must be done very gently, as vagal stimulation may result in bradycardia or even cardiac arrest. Skin infection including pustules on the skin: The lesions may be seen as yellowish pustules or as areas of peeling with underlying redness. Examine the skin from head to toe. Look particularly in the neck folds and elbow, behind the ears, in the axilla and groin. Turn the baby over and examine the back. Minor infections of the umbilicus: Look for pus discharge from the umbilicus or base of the cord (lift the cord to see the base) without redness or swelling over the surrounding skin and/or a foul smell.
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Evaluate feeding This can be done at any convenient time as noted above, especially after excluding danger signs, such as the inability to suck, that need immediate attention. If the baby can suck well, evaluate the latching or attachment of the babys mouth at the breast. Note that: The babys chin is touching or nearly touching the breast. The mouth is wide open. The lower lip is everted. Most of the areola is inside the mouth, especially the part below, so that the areola is visible more above the mouth than below. The sucking is slow and deep and swallowing is audible.
Weigh the baby Place a clean cloth or paper on the baby scale pan. Adjust the scale so it reads zero with the paper/cloth on it. Place the baby over the cloth or paper. If it is a cloth and of adequate size, fold it to cover the body of the baby. Note the weight when the baby and pan are not moving. Never leave the baby unattended on the scale. Write down the weight of the baby in the mother/baby and delivery room records, based on recommendations of the Ministry of Health. The normal weight range is 2.5-4 kg. Low birth weight is below 2500 grams.
Document key findings Record all key observations in writing in the babys health cards and chart/delivery register. Counsel the mother/family Advise the mother on the following: frequent breastfeeding on demand day and night keeping the baby appropriately warm cord care general cleanliness, including washing hands before handling the baby at least after using the toilet, after changing the napkin/diaper, and after cleaning the house having additional fluids and eating an extra meal the danger signs to look for in herself and in the baby
The key elements of the basic systematic examination of the newborn at peripheral centers are summarized in Table 11.
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Table 11. Key Steps in Examining the Newborn at a Peripheral Center Ask the mother for danger signs. Ask about other problems. Check/assess for danger signs that are features of major infections. (Even if there is only one danger sign, institute steps for transfer of the baby to an appropriate referral center). Check for jaundice. Check for minor infections. Evaluate feeding. Weigh the baby. Prescribe treatment of minor infections. Document the findings and care provided on cards/chart/record books. Take advantage of this contact to provide care such as the necessary vaccines. Counsel the mother/family members on basic care at home.
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CHAPTER 10: Postnatal Care of the Newborn, at the Facility and During Postnatal Visits
Some use the words postpartum and postnatal synonymously. Others use the word postpartum (after delivery) for the mother and the word postnatal (after birth) for the baby. In this session the word postpartum will be used for the mother and the word postnatal for the baby, for easy differentiation. The postnatal/postpartum period starts after the delivery of the placenta and extends to 6 weeks after birth. Guidelines for assessment and care may be followed during specific time intervals, as with the WHO classification: at birth, the first hour, around 6 hours, after 6 days, and after 6 weeks. However, the length of the stay in the delivery room and the postnatal ward and the day of discharge vary considerably in different countries and at different levels of facilities. Thus, these intervals, especially the hourly ones, may at times be difficult to identify and adhere to. An alternative classificationwith specific, easily identifiable times for specific activities rather than just the period of time that has elapsedmay be easier to use. This classification is as follows: at birth (in the delivery room) before the mother and baby leave the delivery room every day during the stay at the facility at discharge from the facility
at the postnatal visits
TIMING OF MOST NEONATAL DEATHS

As noted in the introduction, 50 percent of deaths in the newborn period take place within 24 hours of birth and 75 percent by the end of the first week of life. There are currently no specific recommendations based on evidence for the timing and numbers of contacts in the postnatal period at the facility and in the community. There is some evidence to suggest that home visits by community health workers on day two have been correlated with a decrease in neonatal mortality. However, in view of the high mortality during the first week, it is clear that these recommendations for the postnatal period need to focus on this period, especially the first 48-72 hours.
COMPONENTS OF POSTNATAL CARE

The postnatal period has been the most neglected period in the pregnancy/delivery/postnatal continuum of care. Both health workers and mothers/families are not, in general, aware of the potential dangers and high mortality in the early postnatal period. Mothers and babies tend to stay home after a delivery, and there is also a lack of motivation among families to bring mothers and babies for early and regular check-ups, especially if the babies or mothers seem
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normal. Skilled health workers do not generally carry out home visits in most countries; in some areas, it may be difficult to have community health workers make home visits at suitable times. Promotion of early postnatal visits is essential, but it is likely that strategies to deal with the different scenarios that exist and for covering the first week of life, including the first 2-3 days, are even more important. The possible scenarios for this critical period include the following. Deliveries may take place at home, and both the mother and the baby may remain there throughout the neonatal/postpartum period, bound frequently by strong cultural practices that, in general, prevent them from going outside their homes. Where deliveries take place at the facility level, the stay for a normal delivery may vary considerably, from a few hours to 2-3 days. Too early a discharge is frequently associated with inadequate time for evaluation, care, and counseling. Longer stays are associated with overcrowding, potential risk of nosocomial infections, increased costs, and poor compliance by families. Chances of an early first visit to the health center after a home delivery and return after discharge from a facility birth depend on the degree of motivation, constraints due to challenges in family finances and transport, resulting in poor access, quality, and the cost of the care provided.
Thus strategies for postnatal assessment and basic care need to include both facility and community components, involving trained skilled health workers and community health workers (CHWs), with links between the two. These may include home visits by CHWs and visits by mothers and babies at the facility, depending on the above scenarios. Through community mobilization and communication strategies, including interpersonal communication and traditional methods and use of mass media, families at home can learn about basic preventive care, identifying danger signs, and seeking appropriate care. Trained CHWs making home visits can also contribute to the latter components. It is far more difficult in most countries for skilled birth attendants to make home visits. Good links between community and facility level workers can help promote referrals to health centers as required. In facility deliveries, after birth, it is critical to ensure careful examinations of the mother and baby by the skilled birth attendant, with appropriate actions at three points: just before transferring them out of the delivery room to the rooming-in ward at least once a day during their stay at the facility just before discharge
These evaluations will help to identify special risk factors or problems in the early stages that may necessitate some treatment, a longer stay at the facility, special advice, and/or an earlier follow-up appointment. Proper counseling, especially at discharge, on preventive care at home, identifying danger signs, and appropriate care seeking are also extremely important. Content of the Postnatal Visit In addition to having an early visit/contact at the appropriate time, the content and quality of the visit need to be considered. Key components are noted below: courteous, supportive behavior towards the mother/family
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basic, systematic examination and care at appropriate times provision of essential newborn care (ENC) through health workers, mothers and families, including: o o o o o o cleanliness for prevention of infection maintaining body temperature continued cord care exclusive breastfeeding on demand additional care such as vaccines identification and treatment of problems and referral
recording key information treatment of any problems detected, locally or through referral counseling the mother/family on ENC and follow-up
Management Issues Proper management is required to ensure that postnatal care at the facility is implemented effectively. Key tasks include the following. Develop supportive strategies to implement basic postnatal care during a facility stay and at postnatal visits. Prepare the site (space, basic furniture, equipment, supplies and drugs). Develop a user-friendly follow-up clinic. Provide a client flow that aids the mother and baby to receive evaluation and care (routine MNH care, HIV/AIDS, PMTCT, family planning, and counseling) in a reasonable amount of time. Ensure recording of information, maintenance, local review, and central transmission of data.
Equipment and Supplies for Postnatal Visits a clean, draft-free, and well-lit environment water, soap, or alcohol-based hand scrub and clean towel/paper towel a clean examining table with a mattress with a surface that can be cleaned (during the hospital stay the baby may be examined on the mothers bed) a thermometer for recording axillary temperature a stethoscope a baby weighing scale a measuring tape sterile syringes, cotton swabs, and alcohol vitamin K1 antiseptic solutions vaccines (BCG, oral polio vaccine and hepatitis B, as recommended by the Ministry of Health) medication for the baby as recommended by the Ministry of Health, such as oral amoxicillin, cloxacillin, injectable ampicillin and gentamycin, tetracycline eye drops / ointment, mycostatin, gentian violet solution, Betadine solution
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Steps of Postnatal Care at the Facility Level The following are the key steps of quality postnatal care at the facility level: Step 1: Carry out all tasks at the appropriate time. Step 2: Carry out a basic systematic examination of the baby. Step 3: Provide relevant care. Step 4: Document findings and care in a baby card/register. Step 5: Promote continued follow-up and schedule the next appointment. Step 6: Counsel the mother and family. These steps are explained in more detail below. Step 1: Carry out all tasks at the appropriate time Arrange for proper assessment and care at the following times: at birth and during the first six hours at least once a day during any stay at the facility just before discharge during postnatal follow-up visits
Step 2: Carry out a basic systematic examination of the baby The examination should include the following steps: Prepare to maintain the babys temperature during the examination. Greet the mother and make her feel comfortable. Review available records of the mother and baby. Ask and asess for danger signs and other problems. Check for jaundice. Check for minor infections. Evaluate infant feeding. Weigh the baby. Document all findings and care.
Step 3: Provide relevant care If a danger sign exists (even just one), administer the first dose of antibiotics and refer the baby. Administer treatment for minor infections. Administer immunizations, OPV, BCG, hepatitis B, if not already done.
Step 4: Document findings and care in a baby card/register Step 5: Promote continued follow-up and schedule the next appointment For newborns with minor infection, schedule a visit after two days. For low birth weight babies follow up once a week until the baby is at least 2000 grams.
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Where feasible and available, place the mother/family in contact with a trained community health worker or volunteer.
Step 6: Counsel the mother and family. Counsel the mother and family in the following topics: Continue exclusive breastfeeding on demand, day and night, for six months. After that, start semisolid food but continue breastfeeding into the second year of life. Tell the mother that if breastfeeding is exclusive, frequent, and on demand, and if the woman has not resumed menstruation, it can also prevent pregnancy during the first six months. Keep the baby warm: o The room where the baby stays should be warm and free of drafts. In cold weather the baby should be wearing warm clothes with a hat/cloth covering the head. Wet diapers should be changed quickly. The baby should sleep with the mother in bed. o Check the babys temperature, touching feet, hands, and abdomen (if the abdomen is cold, moderate to severe hypothermia is present). o Skin-to-skin contact is the best way of keeping the baby warm at home if the newborn is hypothermic, especially for a LBW baby. (See kangaroo mother care in chapter 12.) o Teach the mother/family how to avoid chilling during a bath (the section below also includes a few additional points for promoting cleanliness during bathing): Wash hands with soap and water before handling the newborn. Delay the first bath for at least 6 hours, preferably 24 hours after delivery. Have everything ready before the bath. Bathe the baby in a warm room with no drafts. Make sure the water is warm (verify this by touching the water with a clean hand or elbow). Take care to expose and clean all skin folds. Wash the babys hair last; dry the baby fast with a cloth or towel. Place the baby in skin-to-skin contact with the mother after the bath (if necessary). Keep the cord and umbilicus clean: o o o o Keep the cord dry and clean. Fold the diaper below the cord so that it does not touch the cord. Dont apply harmful substances on the cord (e.g., ash, mud, clay, or herbs). If recommended by the Ministry of Health/health center, apply the appropriate antiseptic on the cord, taking care to apply it to the base.
Additional basic hygiene/cleanliness of the baby: o Wash hands with soap and water before handling the baby, especially after changing the diaper/napkin, after cleaning the house, and after using the toilet. Hands should be washed every time before handling a low birth weight baby. The baby should be cleaned/bathed daily, taking care to ensure that the folds of skin are exposed and cleaned.

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Birth spacing and family planning: see chapter 7 on maternal postpartum care. Prevention of malaria: see chapter 7 on maternal postpartum care.
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Identification of danger signs: o o o o o o o poor sucking or not sucking at all inactivity or lethargy fever (body too hot) or hypothermia (body too cold) difficulty in breathing/rapid breathing convulsions repeated or persistent vomiting and/or abdominal distention redness and/or swelling surrounding the base of the umbilicus, with our without pus discharge, and/or foul smell
The first five danger signs are the most important. Although these are standard danger signs, it is essential to inform mothers that they should look at their babies carefully at least once a day in adequate light. Even if they do not detect a specific danger sign, mothers should still seek care from an appropriate health worker if they feel their baby is not looking or doing well. In this way, sick newborns can be identified and treated early which is particularly important in the newborn period when the condition can deteriorate rapidly. Preparation for emergency issues in the mother or baby. Discuss with the woman and her partner and family about emergency issues: o o o o where to go if there are danger signs how to reach the hospital how to meet the costs involved options for family and community support
Advise the woman to ask for help from the community, if needed. Advise the woman to bring her home-based maternal record to the health center, even for an emergency visit.
Care for HIV-Positive Mothers and Their Exposed Infants For the baby, ask the following questions: Was ARV medication for prophylaxis administered to the baby (according to the recommendation of the Ministry of Health)? If possible verify from any available records. Is the baby currently on any ARV prophylaxis? Is the baby receiving cotrimoxazole prophylaxis? (If not, counsel for commencing cotrimoxazole prophylaxis according to national guidelines.) Has the baby been tested for HIV? o o If yes, note and record the test result. If not, refer the baby for HIV testing as early as six weeks after birth. Provide support for the infant feeding choice. If breastfeeding: Reinforce messages on care of the breast and prevention of problems. Address any questions, concerns, and problems related to breastfeeding. Warn about the risks of mixed feeding, giving both breast milk and formula.
Check infant feeding options: o o
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Check the infant for the following: o o o inadequate weight gain skin rashes oral thrush
For the mother, do the following: Refer the mother for clinical assessment and evaluation of the need for ARV treatment if eligible. Provide cotrimoxazole prophylaxis therapy (CPT) for the mother, according to national guidelines. Counsel the mother on: o The benefits of birth spacing if she is not already using a family planning method: Stress the special importance and benefits of birth spacing/family planning. Provide information on available methods. Support her in her choice of the method, including LAM. Arrange for follow-up counseling and support on her chosen method. o o o o Continued safer sex practices. Frequent occurrence in the baby of diarrhea, acute respiratory infections, acute otitis media, opportunistic infections such as thrush and failure to thrive. Symptoms of opportunistic infections in herself, such as fever, cough, night sweats, weight loss, diarrhea. When to bring the child for immunization, weight check-up/growth monitoring, and for supplements such as vitamin A.
If no clinical HIV services are immediately available for referral of the mother and infant, counsel the mother about HIV in infants and the need to get testing and treatment as soon as possible. Provide psychosocial support and link the mother to community support for HIV care and services. Make an appointment for the next visit for HIV care according to national guidelines. Place the family in contact with an available community health worker/volunteer where available and feasible.
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Table 12. Suggested Timings of Postnatal Visits

Ideally should be provided by a skilled attendant who is usually at the facility level, linked with a community health worker/volunteer (CHW). If access to the facility is extremely difficult, have the postnatal visit through the CHW. Scenario 1st postnatal visit 2d postnatal visit 3d postnatal visit 4-6 weeks
Facility delivery, normal baby, discharge within 24 hours Facility delivery, normal baby discharge day 2 or 3 Delivery by Cesarean section, normal baby and discharged after a week, in some cases earlier Home delivery
In the first 2-3 days, ideally 2 days after birth 4-7 days
5-7 days (may coincide with special events)
Second week
4-6 weeks
2 weeks
4-6 weeks
Ideally on day of birth and within day 48-72 hours; If not feasible, at least one visit within 48 hours.
5-7 days (may be adjusted to accommodate special family events)
4-6 weeks
LBW should ideally stay at least 3-7 days at facility. Refer very small babies and those with problems to higher center.
Visit every week until weight gain is adequate, e.g., 2000-2500 grams and the baby is doing well.
The number and timing of home visits by the CHW can vary based on feasibility and the recommendations of the program implementing agency/MOH and on existing problems, but advocacy should be carried out for coverage during the first week, especially during the first 2 3 days.
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Table 13. Care of the Newborn during the 4-6 Weeks after Birth
(Use with the learning checklist on the postnatal visit) From birth to six weeks Action At birth Before mother and baby leave the delivery room At least once a day during stay in postnatal ward At discharge First postnatal visit Second postnatal visit Third postnatal visit at 4-6 weeks
Provide care/ counseling Observe/look for Provide counseling
Essential Newborn Care Brief examination, look for danger signs Targeted counseling, i.e., breastfeeding, protection against hypothermia, danger signs. Eye care Cord care Vitamin K Identification band Breastfeeding Full basic systematic examination
Full counseling
Give specific care
BCG, OPV, and hepatitis B any time in the postpartum period according to the recommendations of the Ministry of Health. Care of the baby of the HIV positive mother including ARV.
DPT, oral polio, and BCG if not administered earlier and cotrimoxazole for babies of HIV positive mothers weight X
Weigh Document information in mother/baby card registers
weight
weight X
Weight
weight X
weight X
weight X
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Table 14. Summary of Postnatal Evaluation and Care of the Baby 1. Implement tasks at the appropriate time. After birth, evaluate and provide care:

before transfer out of the delivery room. at least once a day during the stay of the baby at the facility (more frequently for low birth weight babies and if a problem needing observation was noted). at discharge. during postnatal visits.
2. Carry out a basic systematic examination of the baby (see session 9 for details). 3. Provide appropriate care: If a danger sign exists (even if only one), give the first dose of antibiotics and refer the baby. Administer/prescribe treatment for minor infections. Give immunizations: OPV, BCG, hepatitis B (based on recommendations of the Ministry of Health) if this was not already done.
4. Document findings/care in mother/baby card/register. 5. Promote continued follow-up and schedule the next appointment. 6. Counsel the mother/family on basic preventive care at home, identifying danger signs and appropriate care seeking. 7. Where the mother is HIV-positive, ensure appropriate care for the mother and baby. 8. Where feasible and appropriate, put the family in contact with an available trained community health worker.
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CHAPTER 11: Diagnosing and Treating Breastfeeding Problems

COMMON PROBLEMS
Breastfeeding difficulties may be due to problems in breastfeeding techniques, problems with the baby, or breast conditions in the mother. Problems with the baby include but are not limited to: congenital anomalies such as cleft lip or palate prematurity small baby or twin inability to suck as with sepsis
Breast conditions which sometimes cause difficulties with breastfeeding include but are not limited to: sore nipples and nipple fissure engorgement mastitis breast abscess flat or inverted nipples
Diagnosis and management of these breast conditions are important both to relieve the mother and to enable breastfeeding to continue. Care for breast conditions will need to include both management of the condition and assistance with breastfeeding technique.
PREVENTION AND TREATMENT

Cracked or Sore Nipples Sore nipples and superficial breaks in the skin, sometimes called cracks, are usually caused by poor attachment or feeding techniques. Prevention Make sure the baby is properly attached to the breast. Counsel the mother to keep her breasts clean and dry and to only use soap once per day when taking her bath. If she uses soap more often than once daily, she may get cracked nipples. Help mothers find positions that are comfortable and help them feel relaxed; two common positions are the underarm position (holding the baby with the arm opposite the breast) and lying on the side.
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Underarm position
Side lying position
Figure 11.1. Two positions for breastfeeding. (WHO, 1993)
Management Build the mother's confidence. Improve attachment and continue breastfeeding. Reduce engorgement; suggest frequent feeding and express breast milk if needed. Treat for Candida if the skin is red, shiny, flaky; if there is itchiness or deep pain; or if soreness persists. Advise the mother: o Not to wash her breasts more than once a day and not to use soap or rub hard with a towel. Breasts do not need to be washed before or after feeds; normal washing as for the rest of the body is all that is necessary. Washing removes natural oils from the skin and makes soreness more likely. Not to use medicated lotions and ointments because these can irritate the skin, and there is no evidence that they are helpful. To rub a little expressed breast milk over the nipple and areola with her finger after breastfeeding; this promotes healing. To expose her breasts to the air for brief periods. To start the feed on the unaffected breast. This may help if the pain seems to be preventing the oxytocin reflex. Change to the affected breast after the reflex starts working. To breastfeed the baby in different positions at different feeds.
o o o o
If breastfeeding is difficult, help the mother to express the milk.
Breast Engorgement Breast engorgement is an exaggeration of the lymphatic and venous engorgement that occurs prior to lactation; it is not the result of over-distension of the breast with milk. Engorgement may occur between days 2 and 4, causing the breast to become hard and tense and the nipples to become taut, shiny, and hard; this usually resolves spontaneously in 24 to 48 hours. Symptoms of engorgement breast pain and tenderness symptoms occurring 3-5 days after delivery hard enlarged breasts both breasts affected
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Prevention It is normal for breasts to become larger, heavier, and a little tender when the milk becomes more plentiful on the second to sixth day following birth. This normal fullness usually decreases within the first few weeks after birth if the baby is feeding regularly and well. Breast fullness may develop into engorgement if the baby has not been feeding often or long enough. The key to preventing engorgement is to nurse frequently and unrestrictedly. Management If the baby is not able to suckle, encourage the woman to express milk by hand or with a clean pump. If the baby is able to suckle: o o o Encourage the woman to breastfeed more frequently, using both breasts at each feeding. Show the woman how to hold the baby and help him/her attach. Relief measures before feeding may include: applying warm compresses to the breasts just before breastfeeding, or encourage the woman to take a warm shower. massaging the womans neck and back. having the woman express some milk manually prior to breastfeeding and wet the nipple area to help the baby latch on properly and easily. o Relief measures after feeding may include: supporting breasts with a binder or brassiere. applying cold compress to the breasts between feedings to reduce swelling and pain. giving paracetamol 2 tablets or 1000 mg by mouth as needed, not to exceed 4 times or 8 tablets a day. Carefully examine the breast for signs of infection such as redness, inflammation, or pus. Check the womans temperature and ask if she has chills. Follow up three days after initiating management to ensure response.
Mastitis Mastitis is an infection of the breast associated with pain, redness, swelling, fever, and chills. Mastitis usually develops when bacteria enter the breast tissue through an injury to the breast. Injury to the breast may be caused by bruising from rough manipulation, breast over-distention, milk staying in the breast (stasis), or cracking or fissures of the nipple. Symptoms of mastitis breast pain and tenderness reddened, wedge-shaped area on breast symptoms occurring 3-4 weeks after delivery inflammation preceded by engorgement usually only one breast affected
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Management Treat with antibiotics: o Cloxacillin 500 mg by mouth 4 times per day for 10 days, or o Erythromycin 250 mg by mouth 3 times per day for 10 days Encourage the woman to: o Continue breastfeeding. o Support breasts with a binder or brassiere. o Apply cold compresses to the breasts between feedings to reduce swelling and pain. Give paracetamol 500 mg by mouth as needed. Follow up three days after initiating management to ensure response.
The most important part of treatment is to improve the drainage of milk from the affected part of the breast. Look for a cause of poor drainage and correct it: Look for poor attachment. Look for pressure from clothes, usually a tight bra, especially if worn at night, or pressure from lying on the breast. Notice what the mother does with her fingers as she breastfeeds. Does she hold the areola and possibly block milk flow? Notice if she has large, pendulous breasts, and if the blocked duct is in the lower part of her breast. If so, suggest that she lifts the breast more while she feeds the baby, to help the lower part of the breast to drain better. Breastfeed frequently. The best way is to rest with her baby, so that she can respond to him/her and feed him/her whenever the infant is willing. Gently massage the breast while her baby is suckling. Show her how to massage over the blocked area and over the duct which leads from the blocked area down to the nipple. This helps to remove the block from the duct. o She may notice that a plug of thickened milk comes out with her milk. (It is safe for the baby to swallow the plug.) Apply warm compresses to her breast between feeds. Start the feed on the unaffected breast. This may help if pain seems to be preventing the oxytocin reflex. Change to the affected breast after the reflex starts working. Breastfeed the baby in different positions at different feeds. This helps to remove milk from different parts of the breast more equally. Show the mother how to hold her baby in the underarm position or how to lie down to feed him/her, instead of holding him/her across the front at every feed. However, do not make her breastfeed in a position that is uncomfortable for her. If breastfeeding is difficult, help her to express the milk: o o o Sometimes a mother is unwilling to feed her baby from the affected breast, especially if it is very painful. Sometimes a baby refuses to feed from an infected breast, possibly because the taste of the milk changes. In these situations, it is necessary to express the milk (see below). If the milk stays in her breast, an abscess is more likely.
Whether or not you find a cause, advise the mother to do these things:
Sometimes it is helpful to do these things:
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Breast Abscess Breast abscesses occur when mastitis is not appropriately or adequately treated, or if it is not treated in a timely manner. Intervention at the first signs of mastitis may prevent the condition from worsening and developing into a breast abscess. Symptoms firmness very tender breast overlying erythema fluctuant swelling in the breast draining pus
Management Treat with antibiotics: o o
Cloxacillin 500 mg by mouth 4 times per day for 10 days, or Erythromycin 500 mg by mouth 3 times (in severe cases up to 4 times) per day for 10 days. General anesthesia is usually required. Hence, the mother may need to be referred to an appropriate center. Make the incision radially, extending from near the alveolar margin towards the periphery of the breast to avoid injury to the milk ducts. Wearing high-level disinfected gloves, use a finger or tissue forceps to break up the pockets of pus. Loosely pack the cavity with gauze. Remove the gauze pack after 24 hours and replace with a smaller gauze pack.
Drain the abscess: o o o o o
If there is still pus in the cavity, place a small gauze pack in the cavity and bring the edge out through the wound as a wick to facilitate drainage of any remaining pus. Encourage the woman to: o o o Continue breastfeeding on the normal side and express out milk from the affected side. Support her breasts with a binder or brassiere. Apply cold compresses to the breasts between feedings to reduce swelling and pain.
Give paracetamol 500 mg by mouth as needed. Follow up three days after initiating management to ensure response.
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Inverted Nipples Some women have flat or inverted nipples which may reduce their confidence in their ability to breastfeed and cause some babies frustration when they are starting to breastfeed. There is no reason why women with inverted nipples cannot breastfeed. Antenatal treatment may not always be helpful. Assisting women with inverted nipples is most important soon after birth, when the baby starts breastfeeding. Management of flat and inverted nipples Build the mother's confidence. o Explain that it may be difficult at the beginning, but with patience and persistence she can succeed. Explain that her breasts will improve and become softer in the week or two after delivery. Her baby's suckling will help to pull her nipples out. Explain that a baby suckles from the breast not from the nipple. Her baby needs to take a large mouthful of breast. Explain also that as her baby breastfeeds, he/she will pull the breast and nipple out.
o o
Encourage her to give plenty of skin-to-skin contact and to let her baby explore her breasts. Let him/her try to attach to the breast on his/her own, whenever he/she is interested. Some babies learn best by themselves. Help her to position her baby. o If a baby does not attach well by himself/herself, help the mother to position the baby so that he/she can attach better. Give her this help early, in the first day, before her breast milk comes in and her breasts are full. Help her to try different positions to hold her baby. Sometimes putting a baby to the breast in a different position makes it easier for him/her to attach. For example, some mothers find that the underarm position is helpful (see Figure 11.1).
Help her to make her nipple stand out more before a feed. Sometimes making the nipple stand out before a feed helps a baby to attach. Stimulating her nipple may be all that a mother needs to do. Or she can use a hand breast pump or a syringe to pull her nipple out (see Figure 11.2). Express her milk and feed it to her baby with a cup. Expressing milk helps to keep breasts soft so that it is easier for the baby to attach to the breast, and it helps to keep up the supply of breast milk. She should not use a bottle because that makes it more difficult for her baby to take her breast. Express a little milk directly into her baby's mouth; some mothers find that this is helpful. The baby gets some milk straight away so he/she is less frustrated, and he/she may be more willing to try to suckle.
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Figure 11.2. Preparing and using a syringe for treatment of inverted nipples. (WHO, 1993)
EXPRESSING AND FEEDING BREAST MILK

There are many situations in which expressing breast milk is useful and important to enable a mother to initiate or continue breastfeeding. The most useful way for a mother to express milk is by hand. It needs no appliance, so she can do it anywhere and at any time. With a good technique, it can be very efficient. It is easy to hand express when the breasts are soft; it is more difficult when the breasts are engorged or tender. Many mothers are able to express plenty of breast milk using unusual techniques, but if a mother's technique works for her, let her do it that way. If a mother is having difficulty expressing enough milk, however, then teach her a more effective technique. How to Prepare a Container for Expressed Breast Milk Choose a cup, glass, jug, or jar with a wide mouth. Wash the cup in soap and water. (She can do this the day before.) Ideally, boil the cup for 10 minutes before use.
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How to Express Breast Milk by Hand Teach a mother to do this herself; do not express her milk for her. Touch her only to show her what to do. Be gentle. Teach her to: Wash her hands thoroughly. Sit or stand comfortably and hold the container near her breast. Put her thumb on her breast above the nipple and areola and her first finger on the breast below the nipple and areola, opposite the thumb. She supports the breast with her other fingers. Press her thumb and first finger slightly inwards towards the chest wall. She should avoid pressing too far because that can block the milk ducts. Press her breast behind the nipple and areola between her finger and thumb. She must press on the lactiferous sinuses beneath the areola.
Figure 11.3. Anatomy of the breast. (WHO, 1993)
Sometimes in a lactating breast it is possible to feel the sinuses; they are like pods or peanuts. If she can feel them, she can press on them. Press and release, press and release. o o o o o This should not hurt; if it hurts, the technique is wrong. At first no milk may come, but after pressing a few times, milk starts to drip out. It may flow in streams if the oxytocin reflex is active. Press the areola in the same way from the sides to make sure that milk is expressed from all segments of the breast. Avoid rubbing or sliding her fingers along the skin; the movement of the fingers should be more like rolling. Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the milk; this is the same as the baby sucking only the nipple.
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1) Place a finger and thumb on each side of the areola and press inwards towards the chest wall. 2) Press behind the nipple and areola between your finger and thumb. 3) Press from the sides to empty all segments. Figure 11.4. How to express breast milk. (WHO, 1993)
Express one breast for at least 3-5 minutes until the flow slows; then express the other side; and then repeat both sides. She can use either hand for either breast, and change when they tire. Explain that to express breast milk adequately takes 20-30 minutes, especially in the first few days when only a little milk may be produced. It is important not to try to express in a shorter time. The mother should express as much as she can as often as her baby would breastfeed.
How to Feed a Baby by Cup Teach the mother to:

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Hold the baby sitting upright or semi-upright on her lap. Hold the small cup of milk to the baby's lips. Rest the cup (or paladai or spoon) lightly on the babys lower lip and touch the outer part of the babys upper lip with the edge of the cup (see Figure 11.5). Tip the cup (or paladai or spoon) so the milk just reaches the babys lips. The baby becomes alert and opens his/her mouth and eyes.
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An LBW baby starts to take the milk into his/her mouth with the tongue. A full term or older baby sucks the milk, spilling some of it. Do not pour the milk into the baby's mouth. Just hold the cup to his/her lips and let the baby take it him/herself. When the baby has had enough, he/she closes the mouth and will not take any more. If he/she has not taken the calculated amount, he/she may take more next time, or you may need to feed the baby more often. Measure the babys intake over 24 hours, not just at each feed. Advise the mother to burp the baby after the feed by placing him/her on the shoulder and gently rubbing or patting the back. Encourage the mother to begin breastfeeding as soon as she is ready.
Figure 11.5. Three methods of feeding: A. by cup, B. paladai, or C. by a cup and spoon. (WHO/IMPAC, 2003)
Storing Expressed Milk Unheated expressed breast milk should be stored in as cool a place as possible. In general, unheated expressed breast milk may be stored: for 1-2 hours if the ambient temperature is higher than 26 C. for up to 6 hours if the ambient temperature is 26 C. for up to 10 hours if the ambient temperature is between 19 C and 22 C. for up to 24 hours in a refrigerator. for up to 2 weeks in the freezer section of a refrigerator. for up to 3 months in a stand-alone freezer.
Note: If the electricity is not stable, expressed breast milk should only be stored for short periods in the refrigerator. If the mother has stored the milk either at ambient temperature or in a refrigerator or freezer, she needs to warm the milk by placing the closed container in a bowl of really warm or hot water before giving it to the baby and make sure the baby drinks it immediately.
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Special Guidelines for Mothers Who Are HIV-Positive Feeding options for HIV-positive mothers include the following: Exclusive breastfeeding, taking care to avoid problems such as engorged breasts and sore nipples, until six months, followed by rapid switch to formula feeds and complementary feeding with semi-solids. Use of expressed breast milk rendered safe by flash heating of the milk (see below), along with complementary feeds with semi-solids from the age of six months. Use of formula feeds from birth, if AFASS conditions are met (when replacement feeding is acceptable, feasible, affordable, sustainable, and safe WHO 2009) with semi-solids from the age of six months.
Flash heating of expressed milk Flash heating of expressed breast milk is a method to destroy the HIV while still retaining the nutrients and much of the anti-infective factors unique to breast milk. This permits the HIVpositive mother to give breast milk to the baby and avoid formulas. Guidelines for the mother and family Items required: o o o cups and spoons for feeding jars with lids to collect and sterilize EBM a container to boil the milk
Wash all utensils with soap and water. Sterilize these by boiling in a container of water for 10 minutes. Express breast milk into the glass jar as noted above in this chapter. Remember to express the breasts as completely as possible so as to get the nutritious milk obtained at the end. The amount of milk to be collected in one jar is between 50-150 mL. If there is more milk, divide it into two jars. Place the jar in a pan/container of water, making sure that the level of water is two fingers above the level of milk. Heat the water on a very hot fire or, if on a stove top, turn the knob/dial to the highest setting until the water reaches a rolling boil (when it is boiling well with large bubbles). Stay close by because the process after this takes only a few minutes. Do not let the water boil too long as it will destroy the special nutrients in breast milk. Remove the jar from the container as soon as the water comes to a good boil. Place the jar in a container of cool water, cover it with its clean lid, and let it stand until it reaches room temperature. This milk can then be kept at room temperature for six hours and fed to the baby. Use a small cup, preferably directly to feed the baby. It is better than using a bottle which is more difficult to clean and carries the risk of causing diarrhea in the baby.
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CHAPTER 12: Care of the Low Birth Weight Baby, Including Kangaroo Mother Care
Low birth weight (LBW) babies weigh less than 2500 grams at birth. Babies may be low birth weight because they: are born too early, before 37 completed weeks of gestation (preterm or premature). have suffered intrauterine malnutrition or intrauterine growth retardation (IUGR), making them small for date or small for gestational age. Such babies may be term, preterm, or post-term (>42 completed weeks).
Although the basic aspects of essential newborn care for LBW newborns are similar to those for normal infants, LBW babies, being vulnerable, need additional support, especially for temperature maintenance, feeding, prevention of infection, and detection and management of problems and complications. They are also associated with a greater risk for complications and a higher neonatal mortality. In fact, 60-80 percent of deaths in the neonatal period are among low birth weight babies, and they continue to have a high mortality during infancy. Even though LBW babies need extra care, most of them are the larger ones, above 1500 grams. They can be managed with some extra care and with methods such as kangaroo mother care that are simple and low cost. The very small LBW babies needing more costly intensive care represent a much smaller proportion.
FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT

Mothers may have a history of: previously having had a LBW baby being young (less than 16 years) or older (more than 35 years) performing excessive physical work without appropriate rest belonging to a low socio-economic group having short intervals (less than two years) between pregnancies having multiple pregnancies malnutrition severe anemia preeclampsia/eclampsia infections during pregnancy such as urinary tract infection, malaria, syphilis, toxoplasmosis, herpes, CMV, Rubella, HIV/AIDS certain congenital malformations intrauterine acquired infection
Mothers may have problems during pregnancy such as:
The fetus may be abnormal with:
In 30-50 percent of cases of low birth weight, no obvious cause is found.
PREVENTING LOW BIRTH WEIGHT

Prevention of LBW presents challenges. Some interventions are noted below:
Ideally take preventive steps early with appropriate care and nourishment of the girl child. Counsel families/mothers to ensure that women in general: o o o o delay child bearing until they are at least 20 years old. have adequate nutrition. have sufficient rest and are not subjected to hard work during pregnancy. have basic care to detect and treat problems before pregnancy.
Ensure through care and counseling that pregnant women: o receive quality prenatal care, including taking iron and folic acid to manage anemia and preventing malaria through the intermittent preventive treatment of malaria and use of insecticide-treated bednets. recognize danger signs and seek appropriate care. follow birth spacing (2-3 years) through being encouraged to use contraception.
o o
Complications of Low Birth Weight Low birth weight babies have several handicaps that make them more susceptible to a number of problems, many of which can be life threatening, especially in smaller, more preterm infants. Some of the key issues are noted in Table 15, along with some strategies for treatment and management.
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1.
2.
Table 15. Complications in Low Birth Weight and Preterm Babies Handicap Problems Management Lung immaturity Respiratory distress Need referral to higher center syndrome Apnea less with KMC Apnea (pauses in respiration) Difficulty in Hypothermia very KMC very useful in maintaining body maintaining body common temperature temperature Hyperthermia in hot Use of appropriate clothing weather Immature sucking reflex and gastrointestinal system Immature immune systems and increased exposure, being dependent for care on others with frequent handling/procedures Difficulty in sucking, retaining, and assimilating feeds Increased infections associated with high mortality Frequent breast feeds Expressed breast milk fed with cup/spoon Prevention of infection (hygienic practices such as frequent hand washing, breastfeeding, use of EBM) Early identification and treatment of infections Avoidance of needless handling and procedures
3.
4.
5.
Bleeding due to immaturity of the liver and poor production of clotting factors Increased risk of jaundice
High risk for bleeding at various sites, including intracranial bleeding LBW babies can have more prolonged jaundice and can have brain damage at lower levels of bilirubin
Administration of vitamin K Prevention and treatment of problems such as asphyxia, infections and hypothermia LBW babies with any jaundice should be referred early to an appropriate center for evaluation and treatment
6.
Evaluation of Infants with Low Birth Weight Since this manual primarily relates to basic care at peripheral health facilities, it will not deal with how to differentiate between premature and growth-retarded babies. Rather, it will focus on how to identify babies that need to be transferred to a higher level of care and those that may be managed locally at the place of birth. It will also focus on a simple low-cost method of management of these vulnerable babies, namely, kangaroo mother care. In general, babies weighing more than 1800 grams at birth, without problems and danger signs, can fare well if managed appropriately. They may, thus, be cared for by trained personnel in a
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peripheral health center and later at home. Mothers and family members must be provided with appropriate counseling and support. Knowing the exact gestational age is not important in peripheral centers. In practical terms, what is more important is to determine the status of an individual baby to decide what actions need to be taken. Thus, the health worker should verify if the baby: Can maintain temperature with simple aids such as extra clothing or skin-to-skin contact (kangaroo mother care, see further details below). Can accept frequent breast feeds or expressed breast milk fed with alternate methods of feeding, such as the use of a cup, spoon, or an appropriate traditional feeding device (see chapter 11 on breastfeeding). Is free of problems or danger signs (see chapter 9 on physical examination).
Babies who fulfill the above criteria can be managed in peripheral centers and at home; ideally, however, if access to a suitable center is easy, they should be taken there for an assessment and counseling. Newborns not meeting the above criteria need to be referred to appropriate facilities that have the competence, equipment, and supplies to manage them.
Fig. 12.1. Basic evaluation of LBW babies to determine need for referral.
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CARE OF LOW BIRTH WEIGHT BABIES

Provide extra care for these vulnerable babies. While in general the same basic care should be followed as with normal newborn babies, the LBW baby will require extra attention in three areas: Temperature maintenance: They require extra clothing, covering, or prolonged skin-toskin contact (kangaroo mother care). Early initiation of and more frequent feeding: They need additional support for feeding, including the use of expressed breast milk fed with a cup, spoon, or a suitable traditional feeding device. Prevention of infection: As such babies are particularly prone to infection, great care should be taken to prevent infection, including: o o o washing of hands before handling the baby breastfeeding/use of breast milk and avoidance of other milks and fluids avoiding unnecessary visitors and needless handling
Other care is the same as that for all newborns: Weigh the baby at birth. Check breathing and temperature frequently: every 15 minutes for the first 2 hours, every 30 minutes in the third hour, then every hour until 6 hours, and then every 3 hours or at feed times. Very small babies tend to stop breathing periodically (apnea). Such babies need to be stimulated by rubbing the back or a limb and will need to be taken to the referral hospital in the kangaroo mother care position with stimulation as required. The mothers respiratory movements serve to stimulate the baby to breathe better with fewer apneic pauses. If the baby has no breathing problems and sucks well: o o o o Keep the baby in continuous skin-to-skin contact with the mother (see the section on kangaroo mother care below). Cover the babys head with a hat or scarf. If the LBW baby requires additional care, such as resuscitation, keep him/her under a warmer/heater. Delay the babys first bath for one week after birth. Clean the dirty areas such as the face, groin, and skin folds with a damp cloth, using soap as required. If necessary give a sponge bath, exposing small portions at a time. Dry quickly and maintain temperature as noted above.
At birth give a dose of 1 mg of vitamin K IM (0.5 mg if the baby weighs <1500grams). Refer babies <1800 grams and those with problems irrespective of weight to a higher level health facility using skin-to skin contact during transport. Make sure that if the baby is able to swallow, he/she is breastfed or receives breast milk by cup/spoon/ appropriate traditional feeding device (see section on transport of babies). Before transfer, take care to: o o Stabilize the baby. Provide the first dose of antibiotic if: there is a danger sign the mother had fever or other features of infection and/or
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there is premature rupture of membranes or leaking of the amniotic fluid for more than 18 hours o Follow the other guidelines for referral noted in chapter 13 on major infections.
Kangaroo Mother Care Kangaroo mother care (KMC) is a simple method that promotes the health and the well-being of the LBW/preterm baby by skin-to-skin contact with his/her mother or another person through maintaining the babys body temperature and encouraging exclusive breastfeeding. In some countries, mothers do not like being compared to an animal. If this is the case, describe this method of care as skinto-skin contact to protect the vulnerable low birth weight infant.
Figure 12.2. The kangaroo with the baby in the pouch.
Advantages of KMC For the baby: It is a low cost method that is a good alternative to conventional care of preterm/LBW babies in low resource countries. The outcome has been similar to use of an incubator, which is more expensive and more difficult to maintain. The baby is comfortable in this position and is quieter, crying less frequently than in incubators. The vertical position decreases the risk of aspiration, improves cardio-respiratory functions, and decreases apnea. Closeness to the breast favors frequent sucking that prolongs the duration of breastfeeding. The hospital stay is shorter.
For the mother: It helps to empower the mother as she plays the main role by providing warmth to her baby, protection against infections, and nutrition through breastfeeding. It promotes mother-infant bonding and decreased rejection of preterm babies. The method includes participation of the mother and family in the care of the baby. It allows the mother to return to activities at home while caring for the baby.
Preparation for Kangaroo Mother Care Start KMC as soon as possible after birth, when breathing has been well established and the baby does not require any medical treatment.
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Explain the reasons for and advantages of KMC to the mother and the family: o KMC replaces the warmth within the uterus. o The baby is very close to the breast, facilitating frequent feedings. o KMC favors the milk ejection reflex and successful feeding. o The newborn is protected from exposure to the external environment and infections. Requirements include: o a warm room without drafts o appropriate clothing for the mother, as needed and influenced by the weather o a square piece of clothing folded diagonally or a Lycra band to fix the baby to the mothers chest o a cap, socks, and diapers for the newborn o a chair with an inclined back or a bed that can be adjusted with pillows, for example, at a 15-30 degree angle for the mother
Selecting Babies for KMC: The common criteria for deciding whether to use KMC for an LBW baby include: weight less than 2500 grams, although KMC can be used for any weight group stable cardio-respiratory condition ability to suck and swallow maternal acceptance and family support
The KMC Technique Advise the mother to maintain good hygiene, including daily baths, change of clothes, frequent hand washing, and short and clean fingernails.
Figure 12.3. Kangaroo mother care. (WHO, 2003)
Place the baby in skin-to-skin contact between the mothers breasts with the babys feet below her breasts and the babys hands above; the babys hips should be in a frog position and the arms flexed (Figure 12.3). Extend the head slightly and turn it to one side. Avoid excessive flexion or hyperextension of the neck. Turn the head to alternate sides periodically. This position keeps the airway open and allows eye contact between the mother and her baby. Support the babys head by pulling the wrap under the babys ear.
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Place an additional cloth or a towel under the buttock of the baby to prevent dirtying the mothers chest and dress if cloth diapers are used. Change the diapers frequently. Some use a small baby vest to cover the back for extra thermal protection. Make sure in such cases that the front of the vest is open to allow the chest of the baby to be in direct contact with the chest of the mother (Figure 12.4). Fix the baby to the mothers chest by wrapping the clean cloth around the mother and the baby, leaving room to permit the babys abdominal breathing but being tight enough so that the baby does not slip out when the mother stands. Secure the cloth with a safe, secure knot and tuck the loose ends under the tied band. Alternatively, a circular Lycra band can be used to fix the baby. Practice with the mother and supervise her until she is totally comfortable with the method. Through advocacy and counseling encourage the other members of the family, including the father, to assist the mother in KMC.
Figure 12.4. How to dress the baby for Kangaroo Care. (WHO, 2003)
Figure 12.5. Photo of kangaroo mother care. (Source: Delphin Muyila, DRC)
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Breastfeeding the LBW Baby in KMC Explain to the mother the benefits of breast milk, especially for a LBW baby. The baby is ready to start breastfeeding when he/she starts moving the tongue and mouth and shows interest in sucking his/her fingers or the mothers skin. Start breastfeeding when the baby is awake. Promote frequent breastfeeding (about every 2-3 hours). Help the mother get in a comfortable position on an armless chair in a quiet place, if possible. Before starting to breastfeed, loosen the cloth wrap around the baby. With the baby in skin-to-skin contact, follow the same steps for attachment and positioning as for the normal baby. Being small, the baby will need more frequent breastfeeding, with several pauses during feeding. The baby needs to be allowed to feed while he/she still shows interest in sucking. If the baby gags, coughs, or spits up, teach the mother to take the baby off the breast and the cloth wrap, hold the baby covered against her chest until she/he quiets down and breathes normally before retrying again. If the ejection reflex is strong, express a little milk before restarting feeding. When the mothers breasts are engorged, express enough breast milk to make the areola soft enough to introduce into the babys mouth to facilitate his/her sucking. Some babies may need additional support: o o o o o o o o o Wait until the baby is awake. Loosen the wrap around the baby. Hold the baby with the mouth close to the nipple. Express a few drops of breast milk. Let the baby smell and lick the nipple and open the mouth. Express milk into the babys open mouth. Wait for the baby to swallow the milk. Repeat the procedure until the baby closes his/her mouth and will not take any more milk even after stimulation. Alternatively, milk can be expressed from the breast into a clean container that has been sterilized by boiling for 10 minutes, and feed the baby by cup, spoon, or a suitable traditional feeding device. Note: If the infant cannot suck/accept feeds, he/she needs referral for care at a higher level facility. Do not introduce milk into the mouth of the baby who cannot swallow. Counsel the Mother and Family about KMC Counsel the mother and the family: On the benefits of KMC. To use an extra cloth or towel beneath the babys bottom to avoid soiling of the mothers clothes, and change the cloth/diaper frequently. If a cloth is used, advise to always use a clean, dry cloth for the newborns diaper.
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To feed the baby by breastfeeding/use of expressed breast milk frequently. If the LBW baby does not suck well or tires easily while sucking, advise use of expressed breast milk with a cup, spoon, or a suitable traditional feeding device (clean with soap and water and, ideally, boiled for 10 minutes.). To remove the baby out of the skin-to-skin contact only for changing diapers, hygiene, and cord care. The low birth weight baby need not be bathed daily. The dirty parts, especially skin folds, can be sponged clean. When the baby is bathed, it is important to do so in a warm room with no draft, using warm water, finish as soon as possible, dry the body well, and recommence the skin-to-skin contact quickly. To have continuous 24-hour kangaroo care until the babys weight increases. Another family member may replace the mother for periods of time to relieve the mother.
Figure 12.6. The mother, the father, or another family member may keep the baby on the chest.
Practicing KMC after Discharge Advise the mother and family to: Continue kangaroo mother care at home. Seek care with an appropriate health worker/center as designated if the baby develops any of the following danger signs (the first five are most important): o o o o o o o difficulty in sucking or not sucking at all lethargy/inactivity fever/body too hot or hypothermia/body feeling too cold fast breathing/difficulty in breathing convulsions persistent vomiting, abdominal distension redness, swelling around the umbilicus and/or foul smell, with or without pus discharge and/or pus discharge
Come for regular follow-up care: o o Make the first follow-up appointment one week after discharge. While the exact intervals may vary in individual cases, in general, counsel for continued weekly follow-up of the LBW infant until the baby is doing well and preferably until the weight reaches 2000 grams.
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Follow-up checks by skilled health workers are ideal, but where the latter is not feasible at times, additional support through visits by trained community health workers should be instituted. Even in facility births try to link the family with a trained community health worker for additional follow-up.
DISCHARGE OF THE LOW BIRTH WEIGHT BABY

Babies are fit for discharge if: Their general health is good. There are no features of infection or danger signs. The baby is sucking well, and breastfeeding is well established. The baby is gaining weight or at least the weight is stabilized for three consecutive days (but some wait until the babys weight reaches 1800 grams). The baby is maintaining temperature well, with extra clothing or with kangaroo mother care, for at least three consecutive days. The baby has no obvious problems. The health personnel judges that the mother is able to take care of her baby, and the mother/family feels confident with caring for the baby.
Care for the LBW baby is summarized in the diagram and the algorithm below.
Figure 12.7: Key components of care of the LBW infant: KMC/well wrapped close to the mother, cleanliness including frequent hand washing, early exclusive breastfeeding without pre-lacteal feeds, monitoring of weight gain/growth (Source: Counseling cards from Senegal).
Care of the LBW baby (Birth weight less than 2500 gm; preterm - < 37 wks., intrauterine growth retardation, or both)
Wash hands before touching the baby Dry and wrap the baby including head/start skin-to-skin contact Practice early and frequent exclusive breastfeeding Keep the baby warm, ideally through practicing kangaroo mother care Delay bathing for one week or until baby is well stabilized When bathing, use warm water, dry, wrap well or place in skin-to skin contact Evaluate baby Sucking well Maintaining temperature Has no danger signs YES Manage at centre/home Counsel mother/family Advise mother to check baby at home at feed times until s/he is doing well. Weekly follow-up by health worker NO
At follow-up, if poor weight gain or baby has danger sign
Send to referral center
Figure 12.8. Algorithm for care of the LBW baby.
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CHAPTER 13: Treatment of Infections in the Newborn

Infections are the major cause of death during the neonatal period accounting for 35 percent of deaths in the first four weeks of life. Newborn infants, especially low birth weight infants, are at a particularly high risk for infection because of their underdeveloped immune processes and their increased exposure to germs since, being totally dependent on the mother, family members and other care providers, they come in frequent physical contact with a number of persons. Newborn babies are also susceptible to germs that do not readily cause major infections in normal older infants. Common organisms include E. coli, Klebsiella sps, Staphylococcus sps, and group B streptococci. Organisms vary by region, over time, and due to long-term use of antibiotics. In the newborn, minor/localized infections may spread easily. Rapid progression of disease is very common and it may become life threatening. This necessitates early identification and prompt treatment with antibiotics. In the later stages babies not only stop sucking but are also unable to accept and retain feeds, thereby necessitating intravenous fluids and antibiotics that are feasible only at higher level health centers. Hence, early identification and prompt treatment are essential. Socio-cultural factors also influence the impact of infections. Mothers and babies are confined to their homes, and even those who have facility births go home early and then continue to remain there. Danger signs, even if identified, are often attributed to nonmedical reasons, and appropriate care is not sought early so that when babies reach facilities, the disease has advanced considerably. Many families, moreover, do not have adequate faith in the care provided at facilities. Women are frequently not empowered, and major decisions in the family are made by the men. While paternal grandmothers may have some influence, mothers often have very little influence when medical decisions are being made. Some families are also handicapped by little or no access to services, either because of distance or due to lack of finances. Pre-service education of doctors, nurses, and midwives related to newborn care is often inadequate and inappropriate, so that basic health workers do not have the competence to manage newborn infants, especially sick babies. They also do not have the support of the necessary equipment, supplies, and drugs of appropriate sizes and strengths. Their interaction with families also presents challenges in some cases due to lack of courtesy. They often do not have the time nor the skills to establish rapport and to counsel mothers and families effectively.
THE TIMING OF INFECTIONS

Some infections are early onset and some are late onset. Early onset infections (from delivery through day 3) are usually acquired from maternal risk factors and during delivery. These factors include:
maternal infections, including urinary tract infection during the last months of pregnancy premature rupture of the membranes (>18 hours) unhygienic delivery practices, including poor cord care Babies with these maternal risk factors may appear normal at birth. The signs may appear after the baby has returned home. Identification of the maternal risk factors can lead to prophylactic antibiotic treatment that may be life saving. These babies need careful follow-up and should benefit from a longer stay at the health center. Even in the absence of laboratory tests in peripheral health centers, just taking a good maternal history may help identify these risk factors and enable suitable actions.
These risk factors are significant and have important practical implications:
Late-onset infections (day 4-28) are usually acquired from the environment in the home or facility. They are caused by several factors including: Unhygienic use of formulas, other milk, and fluids instead of exclusive breastfeeding. Poor newborn care practices, such as lack of proper hand washing, contact with unclean clothes and other items, infected persons, use of improperly cleaned/sterilized supplies/equipment (the last mentioned is particularly common at the facility level). Excessive, invasive hospital procedures with poor infection control practices.
TYPES OF NEONATAL INFECTION

Major Infections Specific entities such as pneumonia, diarrhea, septicemia, and meningitis are difficult to diagnose in the newborn, as the signs may be nonspecific and the disease spreads rapidly to involve several organs. Hence, the catch-all term neonatal sepsis is used in the public health area. Relevant to diarrheas in the newborn period, babies receiving breast milk pass loose stools with separate watery and curdy portions several times a day, being particularly frequent in days 3-5. These are termed transitional stools and may be wrongly diagnosed as diarrhea, and oral rehydration solution/therapy may be given. The latter is not only needless, but it may also carry a risk of causing real infection if given in an unhygienic manner. The risk of diarrheas and other major infections is particularly high if initiation of breastfeeding is delayed and the newborn and the infant under six months receive other milks and fluids. Thus, even when the mother is HIV-positive and opts to give formula feeds, the health workers should counsel and support the family adequately to ensure that the feeds are given in a clean manner. Otherwise there is a real risk of the baby developing diarrhea with spread of infection that can result in complications and even death. Where appropriate care is not taken, especially in illiterate, low socio-economic groups, there will actually be a greater chance of babies dying of such infections than from HIV/AIDS.
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Major infections in the newborn period are identified by the presence of one or more danger signs, as noted below in Table 16 (on practical guidelines for identifying and treating major infections at peripheral centers). Minor Infections The most common minor infections are: thrush conjunctivitis skin infections umbilical infection (localized)
While the focus in this manual will be on the most common major and minor infections listed above, other newborn infections include syphilis, HIV/AIDS, Hepatitis B, and tetanus.
IDENTIFYING AND TREATING MAJOR INFECTIONS

Very early signs of major infection/neonatal sepsis are vague and sometimes difficult to recognize, but early detection is needed as it takes time to effect referral to suitable centers. These early features include vague signs such as the baby just not looking well or appearing as if he/she is just not well, at times described as a facial grimace. However, these early features are more difficult to detect and require careful daily observation. Mothers, family members, and health care providers should be encouraged to view the baby in adequate light at least once a day, especially in the first week or two. More conventional clinical features labeled as danger signs used to identify newborn sepsis include the following (the first five are the most important): sucking less or poor/no sucking lethargy or diminished activity/inactivity fever (body too hot) or hypothermia (body feeling too cold) rapid breathing/difficulty in breathing convulsions repeated or persistent vomiting and/or abdominal fullness features of severe umbilical infection (peri-umbilical redness, swelling and/or foul smelling, with or without pus discharge and/or foul smell)
The first five danger signs are the most important. Although these are standard danger signs, it is essential that health workers should look at babies carefully at least once a day in adequate light while they remain in the facility. Even if they do not detect a specific danger sign, health workers should take care if they feel the baby is not looking or doing well. In this way, sick newborns can be identified and treated early which is particularly important in the newborn period when the condition can deteriorate rapidly. Mothers should also be counseled on these points to promote early careseeking. Training personnel in good follow-up supervision is necessary to identify these danger signs. Since they are difficult to remember, especially when health workers do not see very many
cases, it is very useful to have easily accessible job aids available (which could be adapted from Table 16 below). Use of Antibiotics Administer antibiotics using these guidelines: Ampicillin 50 mg/kg IM/IV every 12 hours in first 7 days and every 8 hours after day 8. Gentamycin IM/IV once daily 3 mg/kg for babies < 2500 grams. and 5 mg/kg in babies > 2500 grams. Duration of treatment: 10 days. At the peripheral health center, give the first doses IM prior to transfer to a higher level of care. Continue to provide additional support such as feeding where feasible, temperature maintenance and cleanliness/avoidance of superadded or secondary infection.
Danger Signs Table 16: Practical Guidelines for Identifying and Treating Major Infections at Peripheral Centers Note: The first five danger signs are the most important. Management of the newborn at risk for early infection: For a newborn with maternal infections and premature rupture of membranes of 18 hours or more, even in the absence of symptoms, give intramuscular antibiotic treatment (ampicillin and gentamycin), for at least 3 days and preferably for 5 days, as blood cultures are not feasible at peripheral centers. Observe the baby at the facility. If there are no danger signs, discharge the infant. If there are danger signs, transfer to a higher level of care. DANGER SIGNS Sucking less, or poorly, or not sucking at all Lethargy/ inactivity IDENTIFICATION (Ask and look for/verify) MANAGEMENT
Not sucking at all; sucking less than usual; not opening the mouth when offered feeds; not demanding feeds. Not as active as usual, sleeping excessively, difficult to arouse, moving only when stimulated, not waking up for feeds, lying limp, loose-limbed, excessively quiet or too good. Fever: Body hot to touch, history of the mouth feeling excessively hot during breastfeeding; temperature more than 37.5 C Hypothermia: Body colder than normal; temperature less than 36.5 C. Respiration more than 60/minute (verify by counting a second time),
Fever/low body temperature
Rapid breathing/
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Administer (a) First doses of the two antibiotics: ampicillin and gentamycin; (b) vitamin K 1 mg if it was not given at birth; (c) Diazepam if convulsions: 0.5 mL rectally, or IM (thigh) or slow IV . Send the baby to the referral hospital. Explain to the mother why the baby needs referral and advise her to go along with another attendant. Advise how to care for the baby during transport: o Keep the baby warm by skin-toskin contact (see chapter 12 on LBW and KMC). o To prevent hypoglycemia, if the baby can accept feeds give direct breastfeeding or expressed breast milk with cup.
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difficulty in breathing Convulsions
Persistent vomiting Abdominal distension Severe umbilical infection
flaring of the nostrils, groaning or grunting, severe sub-costal retraction. Features of convulsions are often atypical in the newborn, such as a staring look, blinking of eyelids, chapping movements of the lips, clonic/tonic movements of the limbs. Occasional vomiting is common but persistent vomiting is abnormal, as is green-colored vomitus. Distension or fullness of the abdomen. Spreading redness or swelling around the umbilicus and/or foul smell, with or without pus discharge.
Do not attempt to feed a baby that cannot swallow fluids. o Check the baby frequently to ensure that there is no additional problem. o If possible, contact the referral center to inform them. Send a referral note with the mother indicating: o name and address of the mother o date and time of birth o problems if any at birth o reasons for referral o treatment given o advice given
The first five danger signs are the most important. Although these are standard danger signs, it is essential that health workers should look at babies carefully at least once a day in adequate light while they remain in the facility. Even if they do not detect a specific danger sign, health workers should take care if they feel the baby is not looking or doing well. In this way, sick newborns can be identified and treated early which is particularly important in the newborn period when the condition can deteriorate rapidly. Mothers should also be counseled on these points to promote early careseeking.
Referral and Transport of Sick Newborns The condition of the sick newborn with sepsis may deteriorate rapidly. It is important to stabilize the baby prior to transfer. Some of the key tasks are noted below: Provide information and counseling to the mother and family. Explain to the mother and family members the problem and reason for the transfer. Answer their questions. Explain that even if the transport has its own risk, the required treatment cannot be provided at the peripheral health center or at home. Describe what to expect at the referral center. Explain care of the newborn during transport: o Keep the baby warm during the transport by placing him/her in skin-to-skin with the mother, covered with a cloth, with or without blanket, depending on the weather. This will also protect the baby from drafts and insects. To prevent hypoglycemia, offer breastfeeds. If the suck is weak or absent, try to feed the baby expressed breast milk with a clean cup. Do not feed an infant who cannot swallow. Check the babys condition frequently to detect other complications. Arrange for the fastest means of transportation.
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Prepare the baby for transport: o
o o o
Transfer the mother and baby along with a family member. If possible, have a health care worker accompany them. If possible, inform the referral center by telephone of the condition of the baby, including the maternal history. Prepare for the transfer by stabilizing the babys condition to the extent possible and giving the first dose of antibiotics.
Document the referral and its time in the record book of the peripheral center. The referral document of the baby to be sent with the family should contain the following: o o o o o o name and address of the mother date and time of birth reason for referral treatment initiated all available information on pregnancy, labor, delivery, postnatal period, and supplemental information on the baby advice given Continue the antibiotic treatment, breast feeding/feeding of expressed breast milk, and skin-to-skin contact. Continue family support.
If the transfer is delayed or not possible for any reason: o o
IDENTIFYING AND TREATING MINOR INFECTIONS

Conjunctivitis/Eye Infections At peripheral health centers it is not possible to carry out cultures. Unfortunately, gonococcal infection is a serious problem and can lead to blindness. Assume and treat as gonococcal infection if there is frank pus discharge in endemic areas in babies within the first week, with or without swelling: Give ceftriaxone IM 50 mg/kg in a single dose. While wearing gloves, clean the eyelids using cotton swabs that have been sterilized by boiling in clean water for at least 10 minutes and then cooled down before putting in the eye drops/ointment, such as tetracycline, as recommended by the Ministry of Health. Teach the mother and ask her to repeat the treatment 4 times/day. If the mother and baby are near a health facility, there is no need to admit the mother and baby; otherwise they need to be admitted. Treat the mother and partner, if not already treated. Give ceftriaxone 250 mg IM as a single dose to the mother and give a ciprofloxacin, 500 mg orally as a single dose to the partner. Where the above drugs are not available, refer to an appropriate hospital. If you are in a non-endemic area and the eyes are red and sticky, without excess pus discharge: o o Continue cleaning the eyes and apply 1% tetracycline ointment to the affected eye(s) 3-4 times a day until symptoms disappear. If the problem persists after 2 days of general management and/or pus appears, start erythromycin by mouth 12.5 mg/kg every 8 hours for 14 days.
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As Chlamydia may be the cause, treat mother and partner, if not already treated, with erythromycin 500 mg orally 4 times a day for 7 days for the mother; tetracycline 500 mg orally 4 times a day for 7 days or doxycycline 100 mg orally twice a day for 7 days for her partner.
Thrush Thrush is a fungal infection due to Candida species which is usually localized in the mouth or in the diaper area. Treating thrush in the mouth: Oral thrush is seen as irregular, dirty white patches on the tongue and inner sides of the cheeks. It is different from the normal smooth white patch that may be seen coating the middle of the tongue in some babies. If in doubt treat as thrush. Apply mycostatin/nystatin oral solution or 0.5% gentian violet 4 times daily after feeds, continuing for 2 days after lesions have healed. Have the mother apply mycostatin/nystatin cream or 0.5% gentian violet on her breasts after breastfeeding for as long as the baby is being treated. Mothers should be advised to clean their breasts once a day with soap and water when bathing. Repeated washing with soap should not be done, as it will lead to drying and sore nipples. Apply nystatin cream or 0.5% gentian violet at every diaper change, continuing for 2-3 days after the lesions have healed. Ensure the diaper is changed as soon as possible when soiled or wet, taking care to clean and dry the skin well.
Treating thrush in the diaper area
Local Infection of the Umbilicus Local umbilical infection may be associated with stickiness or pus discharge from the base of the cord or from the umbilicus after the cord falls off. Redness and swelling of the skin around the umbilicus and a foul smell are features of a serious umbilical infection. Treat the infection as follows: While wearing gloves, clean the area with 60-90% alcohol or an antiseptic solution (2.5% polyvidone iodide, 4% chlorhexidine gluconate, triple dye, or gentian violet) 3-4 times a day. Take care to lift the cord and apply the antiseptic to the base of the cord or, if the cord has fallen off, to the depth of the umbilicus. Demonstrate the application to the mother. Ask the mother to return for follow-up after 2 days. Any worsening or signs of more serious infection noted above should be treated as sepsis and the baby should be referred to a higher center after giving the first doses of the antibiotics.
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Skin Infection The severity of skin infection is classified by the number and size of the lesions, and signs of sepsis as follows : Fewer than ten pustules/blisters, with no signs of sepsis: o o o o Wash the affected areas with an antiseptic. Swab the pustules/blisters with gentian violet 4 times a day until they are healed. Ask the mother to bring the baby for follow-up after 2 days. If the lesions dont clear but there are no danger signs, give erythromycin or cloxacillin by mouth for 5 days (50 mg/kg every 12 hours the first week of life; every 8 hours the 2nd week of life; and subsequently every 6 hours). If not available, try oral amoxicillin (every 12 hours the first week of life, older than 1 week, every 8 hours). Continue local treatment as noted above. Give cloxacillin orally. Ask the mother to come back for follow-up, ideally the next day or at least after 2 days. Assess the baby for signs of improvement (not spreading and drying): If there is improvement, continue treatment to complete 5-7 days. If there is no improvement, add gentamicin (Day 1-7): 4 mg/kg IM once daily for babies < 2 kg, 5 mg/kg once daily for babies 2 kg; day 8 and over: 7.5 mg/kg once daily for all weights and treat for 7-10 days. For cellulitis/abscess: o If there is fluctuant swelling, incise and drain the abscess. If this is not feasible in the peripheral center, refer to the referral center after giving the first dose of the antibiotic. If cloxacillin cannot be given IV, give oral cloxacillin with IM injection of gentamycin If admitted locally, assess the baby daily: If the baby improves, continue to complete 10 days of treatment. If there is no improvement, refer to the appropriate center.
Ten or more pustules/blisters with no danger signs of sepsis: o o o o
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Table 17: Summary of Treatment of Minor Infections IDENTIFICATION TREATMENT Pus discharge from Treat as gonococcal infection in endemic the eyes with or areas: (ceftrioxone 50 mg/kgIM) plus without redness eye toilet and tetracycline drops or ointment. Treat parents. Minor umbilical Pus discharge from Clean the cord base/depth of the umbilicus infection umbilicus or base of well with alcohol and apply antiseptic (such cord as chlorhexidine, Betadine, triple dye, or gentian violet). Thrush Dirty white patches Local application of nystatin or gentian on the tongue, inner violet: a drop or two in the mouth 4 times a cheeks, and palate day. Pustules, boils, Pustules or peeling Clean the skin with an antiseptic solution. If impetigo of skin not available, use soap and water. If less than 10 pustules, apply gentian violet paint twice a day. If more than 10, give oral antibiotics amoxicillin or erythromycin. If no improvement in 2 days change to oral cloxacillin for 7-10 days. PROBLEM Conjunctivitis
Source: WHO. 2003. Managing Newborn Problems: A Guide for Doctors, Nurses and Midwives.
PREVENTING INFECTIONS
During the prenatal period: Give tetanus immunization. Follow guidelines for preventing and treating sexually transmitted diseases, HIV/AIDS, and malaria. Follow clean delivery practices; at the facility, as many of the items as possible coming in contact with the baby and for the delivery should be sterile. Provide basic care of the newborn, including temperature maintenance, early and exclusive breastfeeding, eye care, cord and skin care, general hygiene, including hand washing.
During delivery:
During the postnatal period give preventive care for the mother and the newborn, including general hygiene, hand washing, and the other components noted above. Follow-up care: Ask the mother to bring back the baby after two days for follow-up. Counsel the mother on identification of danger signs and to return immediately should even one danger sign be present. Counsel the mother on basic preventive essential newborn care, including breastfeeding, cord care, and temperature maintenance. Make an appointment for when the next immunizations are due.
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APPENDIX A: Selection and Storage of Uterotonic Drugs

The information in this appendix comes from POPPHI. Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor (AMTSL): A Reference Manual for Health Care Providers. Seattle: PATH; 2007. Available at: http://www.pphprevention.org/AMTSLlearningmaterials.php. Accessed October 16, 2008. Uterotonics act directly on the smooth muscle of the uterus and increase the tone, rate, and strength of rhythmic contractions. The body produces a natural uterotonicthe hormone oxytocinthat acts to stimulate uterine contractions at the start of labor and throughout the birth process. Drugs such as oxytocin, ergometrine, and misoprostol have strong uterotonic properties and are used to treat uterine atony and reduce the amount of blood lost after childbirth. Oxytocin is widely used for induction and augmentation of labor. The use of a uterotonic drug immediately after the delivery of the newborn is one of the most important actions used to prevent postpartum hemorrhage.
UTEROTONIC DRUGS USED FOR AMTSL

Oxytocin is fast-acting, inexpensive, and in most cases has no side effects or contraindications for use during the third stage of labor. Oxytocin is also more stable than ergometrine in hot climates and light (when cold/dark storage is not possible). WHO recommends oxytocin as the drug of choice for AMTSL and advises that ergometrine, Syntometrine, or misoprostol be used only when oxytocin is not available. WHO recommends oxytocin as the drug of choice for AMTSL. Table A.1 compares dosage, route of administration, drug action and effectiveness, side effects, and cautions for the most common uterotonic drugs used for AMTSL.
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Table A.1. Uterotonic Drugs for AMTSL Name of drug/preparation Oxytocin Posterior pituitary extract. Commonly used brand names include Pitocin or Syntocinon. Misoprostol Synthetic prostaglandin E1 (PGE1) analogue. Commonly used brand names include Cytotec, Gymiso, Prostokos, Vagiprost, U-Miso Dosage and route Give 10 units IM injection.* Drug action and effectiveness Side effects and cautions
minutes. Effect lasts about 15-30 minutes.
Acts within 2-3
First choice. No known contraindications for postpartum use.** Minimal or no side effects.
Give 600 mcg (three 200 mcg tablets) orally.
Orally: Acts within 6 minutes. Peak serum concentration between 18 and 34 minutes. Effect lasts 75 minutes.
No known contraindications for postpartum use.** Common side effects: shivering and elevated temperature.
Ergometrine (methylergometrine), also known as ergonovine (methylergonovine) Preparation of ergot (usually comes in dark brown ampoule). Commonly used brand names include Methergine, Ergotrate, Ergotrate Maleate Syntometrine Combination of 5 IU oxytocin plus 0.5 mg ergometrine.
Give 0.2 mg IM injection.
Acts within 6-7 minutes IM. Effect lasts 24 hours.
Contraindicated in women with a history of hypertension, heart disease, retained placenta, preeclampsia, or eclampsia.*** Causes tonic contractions (may increase risk of retained placenta). Side effects: nausea, vomiting, headaches, and hypertension. Note: Do not use if the drug is cloudy; this means it has been exposed to excess heat or light and is no longer effective. Same cautions and contraindications as ergometrine. Side effects: nausea, vomiting, headaches, and hypertension.
Give 1 mL IM injection.
Combined rapid action of oxytocin and sustained action of ergometrine.
If a woman has an IV, an option may be to give her 5 IU of oxytocin by slow IV push. This is intended as a guide for using these uterotonic drugs during the third stage of labor. Different guidelines apply when using these uterotonic drugs at other times or for other reasons. *** Lists of contraindications are not meant to be complete; evaluate each client for sensitivities and appropriateness before using any uterotonic drug. Only some of the major postpartum contraindications are listed for the above drugs. IM = intramuscular; IV = intravenous
**
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DRUG EFFECTIVENESS
Effects of Heat and Light on Uterotonic Drugs Two factors can influence the effectiveness of uterotonic drugs: temperature and light. This is especially important in hot temperatures and in conditions where refrigeration is not always available or reliable. A WHO research program examined the effectiveness of different injectable uterotonic drugs at various temperatures and light conditions. Table A.2 shows one comparison from this study.
Table A.2. Change in Effectiveness of Injectable Uterotonic Drugs after One Year of Controlled Storage Uterotonic drug Oxytocin Dark 4-8 C 0% loss Dark 30 C 14% loss Light 21-25 C 7% loss Effects of heat and light/key findings Minimal effect from light, more stable for longer time at higher temperatures than ergometrine. Significantly more affected by heat and light, not stable at higher temperatures.
Ergometrine
5% loss
31% loss
90% loss
Keeping Uterotonic Drugs Effective The stability of a drug is defined by how well it maintains active ingredient potency (and other measures such as pH) when stored over time. Pharmaceutical companies conduct stability studies to determine the appropriate shelf-life, storage conditions, and expiration dating for safe storage of the oxytocin they produce. Manufacturers will recommend storage conditions based on the conditions under which they have performed stability studies, and will set the expiry date to be consistent with this. It is therefore important to read storage recommendations made by the manufacturer. Since ergometrine and Syntometrine are sensitive to heat and light, and oxytocin is sensitive to heat, following the storage guidelines is critical to ensure the optimal effectiveness of injectable uterotonic drugs. When drugs are inadequately stored, drug effectiveness can diminish, posing serious consequences for the postpartum woman. Storage practices in health care facilities vary widely and may not follow guidelines for correct storage. For example, vials of uterotonic drugs might be kept on open trays or containers in the labor ward, leaving them exposed to heat and light. Pharmacists, pharmacy managers, and birth attendants using oxytocin need to carefully read and follow recommended guidelines for transporting and storing uterotonic drugs. Recommended guidelines for transporting and storing specific uterotonic drugs are noted in Table A.3.
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Table A.3. Recommended Guidelines for Transport and Storage of Uterotonic Drugs Drug Transport Storage Check manufacturers recommendations; some manufacturers are producing oxytocin that is more heat stable than previously available. Temporary storage outside the refrigerator at a maximum of 30 C is acceptable for no more than 3 months. If possible, keep refrigerated at 2-8 C. Store at room temperature in closed container and protected from humidity. Store in the dark. Keep refrigerated at 2-8 C. Store in closed container. Protect from freezing.
Oxytocin
Unrefrigerated transport is possible if no more than one month at 30 C.
Misoprostol Protect from humidity. Unrefrigerated transport in the dark is possible if no more than one month at 30 C. Protect from freezing.
Ergometrine / Syntometrine
Tips To Increase Uterotonic Drug Effectiveness In the pharmacy: Make sure that there are adequate stocks of uterotonic drugs, syringes, and injection safety materials. Check the manufacturers label for storage recommendations. Make sure that there is a system in place to monitor the temperature of the refrigerator/cold box; record the temperature in the refrigerator on a regular basis, preferably at the hottest times of the day (put thermometers in different parts of the refrigerator). Make sure that there is a back-up system in place in case of frequent electricity cuts; for example, gas or solar refrigerators, placing ice packs in the refrigerator to keep it cool, etc. Follow the rule of first expired-first out (or first in-first out) and maintain a log to keep track of expiration dates to reduce wastage of uterotonic drugs. Store misoprostol at room temperature and away from excess heat and moisture. To ensure the longest life possible of injectable uterotonics, keep them refrigerated at 28 C. Protect ergometrine and Syntometrine from freezing and light. In the delivery room: Check the manufacturers label for recommendations on how to store injectable uterotonic drugs outside the refrigerator. In general:
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o o o
Oxytocin may be kept outside the refrigerator at a maximum of 30 C (warm, ambient climate) for up to three months and then discarded. Ergometrine and Syntometrine vials may be kept outside the refrigerator in closed boxes and protected from the light for up to one month at 30 C and then discarded. Misoprostol should be stored at room temperature away from excess heat and moisture.
Record the temperature in the delivery room on a regular basis, preferably at the hottest times of the day. Periodically remove ampoules from the refrigerator for use in the delivery room; carefully calculate the number removed from the refrigerator based on anticipated need. Only remove ampoules or vials from their box just before using them. Make sure that there are adequate stocks of syringes and injection safety materials. Avoid keeping injectable uterotonics in open kidney dishes, trays, or coat pockets.
Ergometrine loses 21-27 percent potency in one month of exposure to indirect sunlight. Oxytocin has no loss of potency after one month of exposure to indirect sunlight.
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APPENDIX B: Alternative Assessment/Physical Examination of the Newborn at More Established Peripheral Centers
TIMING OF ASSESSMENTS
As soon as feasible after birth. At least once a day as long as the baby is in the facility. Before discharge. This is extremely important to detect any high risk factor or a danger sign in the early stages. These may necessitate a longer stay at the facility, commencement of treatment/referral to the hospital, or the recommendation of an earlier follow-up visit. The early postpartum period is very important; 75 percent of deaths in babies take place in the first week following the birth. At first and follow-up visits in the postnatal period.
CONDUCTING THE ASSESSMENT

Preparation Wash your hands with soap and water. Greet the mother/attendant, make her and the baby comfortable in a warm place free of drafts, and explain what is going to be done.
Ask the Mother/Family about any problems noted by them in the baby how the baby is feeding about stools, and urination (number, quality, etc) about the presence of specific danger signs including: o o o o o o o difficulty in/poor feeding lethargy or diminished activity fever or body feeling too cold fast breathing/difficulty in breathing repeated vomiting and/or abdominal fullness convulsions signs related to severe umbilical infection (surrounding redness, swelling, foul smell with or without pus discharge)
Assess for Danger Signs Check for general alertness and activity. Except in deep sleep, babies move frequently, spontaneously, and on stimulation. The arms and legs are flexed. If a limb is consistently kept straight, evaluate for paralysis. Note also if the limbs seem very limp or flaccid. Assess temperature: o Assess the body temperature by at least touching the babys abdomen, hands, and feet and ensuring all are warm.
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Where possible note the axillary temperature with a thermometer leaving it in place for 4 minutes. The normal temperature is 36.5-37.5 C. (The thermometer should be clean and wiped with at least an alcohol swab to prevent cross infection. Storing in liquid antiseptics should be done only if they are changed frequently. Otherwise there is a risk of infections with Pseudomonas. It is not recommended to take rectal temperature as a routine as it is associated with a higher risk of infection and trauma.) In the newborn infant, both fever and low body temperature outside the normal range of 36.5-37.5 C are danger signs.
Assess respiration: Normal respiratory rate is 30-60 breaths/minute. Although breathing can be somewhat irregular with short pauses, there should be no apnea which is defined as cessation of breathing lasting for more than 20 seconds or of a shorter duration associated with cyanosis, pallor, or bradycardia, with heart rate less than 110/minute. The normal heart rate ranges between 110-160 beats/minute, with the lower rates when the baby is asleep and the higher rates when the baby is active or crying. There should be no: o o o o flaring of the nostrils grunting increased respiratory rate above 60/minutes severe subcostal retractions
Look for abdominal fullness. Examine the umbilical cord, taking care to lift it to see the base/umbilicus. Check for pus discharge, redness, swelling, foul smell.
Take the Babys Weight Place a clean cloth or paper on the baby scale pan. Adjust the weight so it reads zero with the paper/cloth on it. Place the baby over a paper or a cloth. If cloth, fold it to cover the body of the baby. Note the weight when the baby and pan are not moving. Never leave the baby unattended on the scale. Write down the weight of the baby in the mother/baby and ward records based on recommendations of the Ministry of Health. The normal weight range is 2.5-4 kg. Low birth weight is below 2.5 kg.
Examine the Newborn In general newborn babies are examined from head to toe and front to back. Head Note the general shape of the head and inspect the scalp for cuts or bruises from forceps or vacuum. Elongated or asymmetrical shape may be due to molding during birth. Palpate the anterior fontanel and check for any bulging. Caput succedaneum is a soft swelling over the part of the head that presented first. It disappears by 48 hours.
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Cephalhematoma is a subperiostial hemorrhage that is usually seen as a fluctuant swelling 48-72 hours after delivery. It never extends across the suture line. Most resolve within a few weeks and need no treatment. Subconjunctival hemorrhage can be a normal finding following the delivery. Check for conjunctivitis, seen as redness and/or discharge. The lips, mouth, tongue, palms, and soles should be pink. If the palms and soles are bluish, it suggests that the baby may be not warm enough and may actually be maintaining temperature in a stressful manner through vaso-constriction of the peripheral vessels. If blueness persists after warming, it may be due to problems such as shock or a congenital heart defect. The skin may also show other features that are normal for this age that disappear over varying periods of days or weeks, such as: o o o o tiny raised white/pale yellow dots on the face (milia) collections of tiny capillary vessels on the face over the forehead and upper lips (telangiectasia) bluish areas over the back and limbs (Mongolian spots/patches) reddish spots/patches on the skin (toxic erythema)
Eyes
Skin and mucous membranes
Check for jaundice Unlike in older infants, it is not easy to see jaundice in the early phase in the eyes of the newborn; it is best assessed in the skin. Jaundice starts in the face and spreads down to the hands and feet. Gently press the tip of the nose, release, and observe the blanched area for any yellow tinge/color. It can also be seen in the grooves of the skin when the baby frowns or cries. This is the only time in life that some jaundice in a full term baby does not require any treatment if it starts after the first 24 hours on the face and does not spread to the palms and soles, and disappears by two weeks. When the color reaches the palms or soles, it correlates with a serum bilirubin of about 15 mg/100 mL (or 256.5 mols/L). Such babies require referral for assessment and treatment. These guidelines apply only to full term normal weight babies. Preterm and low birth weight babies require treatment at far lower levels. Hence, such babies with any jaundice need to be referred to a competent person/center for assessment and treatment and should not be considered to have physiological jaundice.
Mouth Check for cleft lip and look inside the mouth for cleft palate. Examine the tongue and the inner side of the mouth for oral thrush, seen as irregular, dirty white patches on the tongue and inner sides of the cheeks. Thrush is different from the normal smooth white patch that may be seen over the middle of the tongue in some babies.
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Chest Look for symmetry and movement during breathing. The breasts in both boys and girls may be engorged and secrete a small amount of milk. Do not express the babys breasts, as it may lead to trauma and infection. Listen to the heart sounds with a stethoscope. The rate is faster in the newborn period, the range being 110-160/minute. Soft murmurs may be normal in the early newborn period. The abdomen should be rounded and soft. Check the umbilical cord for: o o o The presence of two arteries and one vein which is normal. The vein is seen as an elongated open slit and the arteries as thin cord-like structures. Oozing of blood. If present, tie the cord again. Signs of infection. In case of a pus discharge from umbilicus or the base of the cord, lift the cord to see the base. Redness or swelling over the surrounding skin and/or a foul smell are features of a major infection.
Abdomen
Anus
Later, after the umbilicus heals well, a small umbilical hernia may develop in some babies. It usually resolves spontaneously. Do not apply a coin or a pressure bandage over it. Gently palpate the abdomen for masses. The liver and spleen are normally palpable.
Note when the baby passes stools (usually at birth or within 24-48 hours of the delivery). At birth or when seen for the first time during the first few days after birth, check the position of the anus and ensure the patency of the anal opening. Where there is doubt, verify patency carefully and gently with a clean blunt rectal thermometer.
Male genitalia The urethra opens at the end of the penis. Do not try to retract the prepuce, as it is often adherent at this stage. One or both the testes are felt in the scrotum in a full term baby, but they may be undescended in a preterm infant. If the baby has been circumcised, check for any signs of bleeding or infection. Examine the groin and scrotal sac for hernias and hydroceles: o Hernias are reducible and are not trans-illuminated with a torch/flashlight. Although, usually it is not an emergency unless impacted or strangulated, such babies need to be referred to an appropriate hospital for assessment and planned management. Hydroceles which can be trans-illuminated with a torch/flashlight may also be noted. They usually disappear in a few months or by the first birthday.
Female genitalia Examine the labia and clitoris; make sure there is no fusion of the labia. The hymen is often prominent and may project out as the hymenal tag, which is normal.
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A white discharge from the vagina, with or without blood, is normal in the first week of life. Referral is required only if bleeding is excessive and should be done after administration of vitamin K1 (1 mg).
Check the back Turn the baby over gently, ensuring that the head is turned to one side, and examine the back for obvious defects such as a swelling or an open spina bifida along the vertebral column. Sometimes spina bifida occulta may be present without any obvious swelling or an opening but may manifest with a tuft of hair or a dimple. Although not urgent, such babies need referral to a higher center for x-rays of the spine.
Assess Feeding This can be done at any convenient time after excluding danger signs, such as the inability to suck, that need immediate attention. If the baby can suck well, assess attachment of the babys mouth. Note that: The babys chin is touching or nearly touching the breast. The mouth is wide open. The lower lip is everted. Most of the areola is inside the mouth, especially the part below, so that it is visible more above the mouth than below. The sucking is slow and deep and swallowing is often audible.
Counsel the Mother/Family Advise the mother on: frequent breastfeeding on demand day and night keeping the baby appropriately warm washing hands before handling the baby, at least after using the toilet and after changing the napkin/diaper having an extra meal and additional fluids the danger signs to look for in herself and in the baby when she has to come with the baby for follow-up and for immunization (make an appointment)
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APPENDIX C: Glossary
Active management of the third stage of labor (AMTSL): A combination of actions performed during the third stage of labor to prevent PPH. AMTSL speeds delivery of the placenta by increasing uterine contractions and prevents PPH by minimizing uterine atony. The components of AMTSL are: Administration of a uterotonic drug within one minute after the baby is born (oxytocin is the uterotonic of choice) after verifying that there is no second baby. Controlled cord traction (CCT). Uterine massage immediately after delivery of the placenta.
Controlled cord traction (CCT): Traction on the cord during a contraction combined with countertraction upward on the uterus with the providers hand placed immediately above the symphysis pubis. CCT facilitates expulsion of the placenta once it has separated from the uterine wall. Delayed cord clamping: Clamping the umbilical cord after cord pulsations have ceased. Studies show that delaying clamping and cutting of the umbilical cord is helpful to both full-term and preterm babies. In situations where cord clamping and cutting was delayed for preterm babies, these infants had higher hematocrit and hemoglobin levels and a lesser need for transfusions in the first 4 to 6 weeks of life than preterm babies whose cords were clamped and cut immediately after birth. Delayed PPH: Excessive vaginal bleeding (vaginal bleeding increases rather than decreases after delivery), occurring more than 24 hours after childbirth. Immediate PPH: Vaginal bleeding in excess of 500 mL, occurring less than 24 hours after childbirth. Immediate postpartum period: See fourth stage of labor. Infant mortality rate: Number of deaths during the first year of life, expressed per 1000 live births. Live birth: A baby who is born alive as indicated by the baby moving, crying, breathing, having heart beats, or showing cord pulsations. Low birth weight infant: A newborn weighing less than 2500 grams at birth. A low birth weight infant (LBW) may be preterm, with or without intrauterine growth retardation (IUGR), or full term, or post term with IUGR. Neonatal mortality rate: Number of newborn deaths during the first 28 days of life, expressed per 1000 live births. Neonatal period: This period commences at birth and ends at 28 completed days of life. The neonatal period is divided into two parts: the early neonatal period extends from day 1 to 7 completed days; the late neonatal period extends from day 8 to 28 completed days. Perinatal mortality rate: The number of stillbirths and deaths in the first week of life, expressed per 1000 live plus stillbirths. Perinatal period: This period extends from the 22d week of gestation to the end of the first week of life (7 completed days). In some developing countries, authorities feel that since
Reference Manual
survival of babies born before 28 weeks is in practice not feasible, the definition of the commencement of the perinatal period should only be from 28 weeks. However, it is better to have definitions uniform across countries so that data can be compared. As conditions ameliorate in countries, outcomes will improve.
Newborn - Definitions
Perinatal Period
Early neonatal period Late neonatal period
22 wk Pregnancy
Birth
1 wk Newborn period
4 wk
Figure C.1. Newborn periods.
Physiologic (expectant) management of the third stage of labor (PMTSL): Management of the third stage of labor that involves waiting for signs of placental separation and allowing for spontaneous delivery of the placenta aided by gravity and/or nipple stimulation. The components of PMTSL are:

Waiting for signs of separation of the placenta (cord lengthening, small blood loss, uterus firm and globular on palpation at the umbilicus). Encouraging maternal effort to bear down with contractions and, if necessary, to encourage an upright position. Uterine massage after the delivery of the placenta as appropriate.
Placenta accreta: A severe obstetric complication occurring when the placenta attaches itself too deeply and too firmly into the wall of the uterus, preventing separation of the placenta from the uterus. Post term infant: A baby who is born after 42 completed weeks of gestation. Preterm infant: A baby who is born before 37 completed weeks of gestation. Retraction: The act of the uterine muscle pulling back. Retraction is the ability of the uterine muscle to keep its shortened length after each contraction. Together with contractions, retraction helps the uterus become smaller after the delivery of the baby.
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Severe PPH: Vaginal bleeding in excess of 1000 mL, occurring less than 24 hours after childbirth. Stages of labor First stage of labor. The first stage of labor begins with the onset of contractions and ends when the cervix is fully dilated (10 cm). This stage is divided into two phases, known as the latent and active phases of labor. During the latent phase, the uterine cervix gradually effaces (thins out) and dilates (opens). This is followed by active labor, when the uterine cervix begins to dilate more rapidly and contractions are longer, stronger, and closer together. Second stage of labor. The second stage of labor begins when the uterine cervix is fully dilated and ends with the birth of the baby. This is sometimes referred to as the pushing stage. Third stage of labor. The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta and its attached membranes. Fourth stage of labor (also known as the immediate postpartum period). The fourth stage of labor begins with the delivery of the placenta and goes from one to six hours after delivery of the placenta, or until the uterus remains firm on its own. In this stabilization phase, the uterus makes its initial readjustment to the nonpregnant state. The primary goal is to prevent hemorrhage from uterine atony and cervical or vaginal lacerations.
Stillbirth: A baby who is born with no signs of life noted under live birth. Stillbirths are of two types: macerated stillbirth (when the body may be distorted, soft, often smaller than normal, and the skin is unhealthy with discoloration and peeling) and fresh stillbirth (when the body appears normal unless associated with a major congenital malformations and the skin appears normal in texture and consistency, although it may appear pale). Here the death has occurred fairly close to the time of birth. It may have been due to problems during labor. On some occasions a live birth with minimal signs of life, such as just a few cord pulsations or an occasional faint gasp, may mistakenly be passed off as a stillbirth. Improved care during labor and better recognition and reporting will result in a decrease in the number of fresh stillbirths. Hence, in maintaining records, it is worthwhile to try and differentiate between macerated and fresh stillbirths. Term infant: A baby who is born within 37-42 completed weeks of gestation. Uterine atony: Loss of tone in the uterine muscle. Normally, contraction of the uterine muscles compresses the uterine blood vessels and reduces blood flow, increasing the chance of coagulation and helping to prevent bleeding. The lack of uterine muscle contraction or tone can cause an acute hemorrhage. Clinically, 75 to 80 percent of PPH cases are due to uterine atony. Uterine massage: An action used after the delivery of the placenta in which the provider places one hand on top of the uterus to rub or knead the uterus until it is firm. Sometimes blood and clots are expelled during uterine massage. Uterotonic drugs: Substances that stimulate uterine contractions or increase uterine tone.
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REFERENCES
The following sources were consulted in preparing this manual. ACCESS Program. 2006. Kangaroo Mother Care Training Guide. Baltimore, MD: JHPIEGO. Bang AT, Bang RA, Baitulle SB, Reddy MH, Deshmukh MD. 1999. Effect of home-based neonatal care and management of sepsis on neonatal mortality: Field trial in rural India. Lancet 354: 1955-1961. Chaparro, C. 2007. Essential delivery care practices for maternal and newborn health and nutrition. Washington DC: Pan American Health Organization, Unit on Child and Adolescent Health. Dombrowski MP, Bottoms SF, Saleh AA, Hurd WW, Romero R. 1995. Third stage of labor: analysis of duration and clinical practice. American Journal of Obstetrics and Gynecology, 172:127984. EngenderHealth. Online course for Infection Prevention. Available at: www.engenderhealth.org/IP/instrum/in4a.html. Accessed April 2, 2007. Everett F, Magann EF, Evans S, Chauhan SP, Lanneau G, Fisk AD, Morrison JC. 2005. The Length of the Third Stage of Labor and the Risk of Postpartum Hemorrhage. Obstetrics & Gynecology, 105(2): 290293. Fortney J. 1995. Antenatal risk screening and scoring: a new look. Int J Gynecol Obstet 50 (Suppl 2): S53S58. Gomez P, Kinzie B, and Metcalfe G. 2005. Active Management of the Third Stage of Labor: A Demonstration [CD-ROM]. Baltimore, MD: JHPIEGO. Gulmezoglu AM, Villar J, Ngoc NN, Piaggio G, Carroli G, Adetoro L, et al. 2001. WHO Collaborative Group to Evaluate Misoprostol in the Management of the Third Stage of Labour. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet, 358:68995. Hayashi RH. 1986. Postpartum hemorrhage and puerperal sepsis. In: Hecker NF, Moore JG. Essentials of Obstetrics and Gynecology. Philadelphia, PA: WB Saunders Company. Hutton EK, Hassan ES. 2007. Late vs. early clamping of the umbilical cord in full term neonates: Systematic review and meta-analysis of controlled trials. JAMA, 297: 1241-1251. Impact International. 2007 February. Measuring and Addressing Outcomes After Pregnancy: A Holistic Approach to Maternal Health. Impact International: Aberdeen, United Kingdom. Available at: www.prb.org/pdf07/Outcomes.pdf. Accessed April 2, 2007. International Confederation of Midwives (ICM) and International Federation of Gynaecology and Obstetrics (FIGO). 2006. Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings Joint Statement. The Hague: ICM; London: FIGO. Available at: www.figo.org/docs/PPH%20Joint%20Statement%202%20English.pdf. Accessed April 2, 2007.
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JHPIEGO and Maternal and Neonatal Health (MNH). 2001. Birth Preparedness and Complication Readiness. Baltimore, MD: JHPIEGO/MNH. JHPIEGO. 2001 November. Preventing Postpartum Hemorrhage: Active Management of the Third Stage of LaborA Maternal And Neonatal Health Program Best Practice. JHPIEGO TrainerNews. Washington, DC: JHPIEGO. Available at: http://www.reproline.jhu.edu/english/6read/6issues/6jtn/v4/tn110hemor.htm. Accessed September 28, 2007. JHPIEGO. 2004. Infection Prevention Learning Resource Package [CD-ROM]. Baltimore, MD: JHPIEGO. Kane TT, El-Kady AA, Saleh S, Hage M, Stanback J, Potter L. 1992. Maternal mortality in Giza, Egypt: magnitude, causes, and prevention. Stud Fam Planning, 23: 45-57. Marshall M, Buffington ST, Beck D and Clark A. 2007. Life Saving Skills Manual for Midwives, Draft, 4th Edition. Washington DC: American College of Nurse-Midwives. OMS. 2002. Prise en charge des complications de la grossesse et de laccouchement: Guide destine la sage-femme et au mdecin. Genve: OMS. OMS. 2003. Management of Problems in the Newborn: Guide for the doctors, nurses and midwives. Genve: OMS. PATH. OUTLOOK Volume 19, Number 3, May 2002. POPPHI. 2007. Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage of Labor (AMTSL): A Reference Manual for Health Care Providers. Seattle: PATH. Available at: http://www.pphprevention.org/AMTSLlearningmaterials.php. Accessed October 16, 2008. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. 1988. The Bristol third stage trial: active versus physiological management of the third stage of labour. BMJ, 297: 12951300. Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D.1998. Active versus expectant management of the third stage of labour: the Hinchingbrooke randomized controlled trial. Lancet, 351:693699. UNICEF. 2005. Components of HIV-pre test and counseling sessions. HIV counseling and testing in PMTCT. New York: UNICEF. Retrieved from http://www.uniteforchildren.org/knowmore/files/Module_6PM.pdf Van Rheenan PF and Brabin BJ. 2006. A practical approach to timing cord clamping in resource poor settings. BMJ, 333:954-958. World Health Organization. 1993. Breastfeeding counseling: A training course. Geneva: WHO. World Health Organization. 1997. Safe Motherhood: Basic Newborn Resuscitation: A Practical Guide. Geneva:WHO. World Health Organization. 2000. Managing Complications in Pregnancy and Childbirth. Geneva: WHO. Available at: http://www.who.int/reproductivehealth/impac/Clinical_Principles/General_care_C17_C22.html. Accessed April 2, 2007. World Health Organization and the US Centers for Disease Control and Prevention in partnership with the Francois-Xavier Bagnoud Center at the University of Medicine & Dentistry of New Jersey (UMDNJ) and JHPIEGO. 2003. Infection Prevention Guidelines for Healthcare Facilities with Limited Resources. Baltimore, MD: JHPIEGO. Available at: www.womenchildrenhiv.org/wchiv?page=pi-60-00. Accessed April 2, 2007.
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World Health Organization. 2003. Kangaroo Mother Care A Practical Guide. Geneva: WHO Department of Reproductive Health and Research. World Health Organization. 2003. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Geneva: WHO. Available at: http://www.who.int/reproductivehealth/impac/Clinical_Principles/Normal_labour_C57_C76.html Accessed October 16, 2008. World Health Organization. 2003. Managing Newborn Problems: A Guide for Doctors, Nurses and Midwives. Geneva: WHO. World Health Organization. 2006 October. WHO HIV and Infant Feeding Technical Consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infections in Pregnant Women, Mothers and their Infants, Geneva, October 25-27. Consensus Statement. Geneva: WHO. World Health Organization. 2006. WHO Recommendations for the prevention of postpartum haemorrhage. Geneva: WHO Department of Making Pregnancy Safer. Available at: www.who.int/making_pregnancy_safer/publications/WHORecommendationsforPPHaemorrha ge.pdf. Accessed January 2, 2008. World Health Organization. 2007. Guidance for Provider-Initiated HIV Testing and Counseling in Health Facilities. Geneva: WHO. Retrieved from http://www.who.int/hiv/pub/guidelines/9789241595568_en.pdf. World Health Organization. 2007. Guideline on Global Scale-Up of Prevention of Mother-ToChild Transmission of HIV. Geneva: WHO. World Health Organization. 2007 October. Prevention of Postpartum Haemorrhage by Active Management of the Third Stage of Labour. MPS Technical Update. Geneva: WHO Department of Making Pregnancy Safer. Available at: http://www.who.int/making_pregnancy_safer/publications/PPH_TechUpdate2.pdf. Accessed April 2, 2007. World Health Organization. 2008 January. Young Infants Clinical Signs Study Group. The Lancet, 371(9607):135-42. World Health Organization. 2009. Infant and Young Child Feeding: Model Chapter for textbooks for medical students and allied health professionals. Geneva: WHO. Retrieved from: http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf Yuster EA. 1995. Rethinking the role of the risk approach and antenatal care in maternal mortality reduction. Int J Gynecol Obstet 50(Suppl 2): S59S61.
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HEALTH PROGRAMMING FOR INTEGRATED MATERNAL AND REBUILDING STATES NEWBORN CARE A BASIC BRIEFING PAPER SKILLS COURSE

2009 REFERENCE MANUAL

INTEGRATED MATERNAL AND NEWBORN CARE

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

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Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

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Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

FOUR MILLION NEONATAL DEATHS: WHERE DO THEY OCCUR?

4 Million Deaths: Where do newborn babies die?

Lancet series, 2005

Integrated maternal and newborn care Basic skills course

FOUR MILLION NEONATAL DEATHS: WHAT DO BABIES DIE OF?

Causes of Neonatal Mortality

Neonatal Infections 25% Birth asphyxia/trauma 23%

Figure Intro. 2. What do newborns die of?

FOUR MILLION NEONATAL DEATHS: WHEN DO THEY OCCUR?

Integrated maternal and newborn care Basic skills course

4 Million Newborn Deaths: When do newborn babies die?

75% of neonatal deaths are in the first week 3 million deaths

Integrated maternal and newborn care Basic skills course

CHAPTER 1: Preventing Infection1

These steps are illustrated in Figure 1.1.

Integrated maternal and newborn care Basic skills course

Figure 1.1. Hand washing. (WHO Guidelines on Hand Hygiene, 2006).

The technique using the alcohol-based formulation is shown in Figure 1.2.

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Wear gloves when:

Integrated maternal and newborn care Basic skills course

Figure 1.3. Putting gloves on. (EngenderHealth, online course: http://www.engenderhealth.org/ip/surgical/sum4.html)

Figure 1.4. Taking gloves off. (EngenderHealth, online course: http://www.engenderhealth.org/ip/surgical/sum4.htm)

coats/gowns waterproof aprons masks caps eye covers/face shields boots/slippers

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Figure 1.6. Sharps containers

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

Table 1. Mixing A 0.5% Chlorine Decontamination Solution

Integrated maternal and newborn care Basic skills course

Integrated maternal and newborn care Basic skills course

CLEAN DELIVERY CARE

Integrated maternal and newborn care Basic skills course

EQUIPMENT AND SUPPLIES RELATED TO RESUSCITATION

Integrated maternal and newborn care Basic skills course

CHAPTER 2: Clinical Decision-Making

Integrated maternal and newborn care Basic skills course

The following skills are important for taking a complete history: