Department of Making Pregnancy Safer

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Integrated Management of Pregnancy and Childbirth
Pregnancy, Childbirth, Postpartum and Newborn Care:
A guide for essential practice
World Health Organization
Geneva
2006
WHO Library Cataloguing-in-Publication Data
Pregnancy, childbirth, postpartum and newborn care : a guide for essential practice.
At head of title: Integrated Management of Pregnancy and Childbirth.

1.Labor, Obstetric 2.Delivery, Obstetric 3.Prenatal care 4.Perinatal care —
methods 5.Postnatal care - methods 6.Pregnancy complications - diagnosis
7.Pregnancy complications - therapy 8.Manuals I.World Health Organization.
ISBN 92 4 159084 X (NLM classification: WQ 175)
First edition 2003
Second edition 2006
© World Health Organization 2006
All rights reserved. Publications of the World Health Organization can be obtained from
Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27,
Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int).
Requests for permission to reproduce or translate WHO publications — whether for sale or
for noncommercial distribution — should be addressed to Publications, at the above address
(fax: +41 22 791 4806; email: permissions@who.int).
The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on
maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply
that they are endorsed or recommended by the World Health Organization in preference
to others of a similar nature that are not mentioned. Errors and omissions excepted, the
names of proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in this
publication is complete and correct and shall not be liable for any damages incurred as
a result of its use.
Printed in Singapore
Foreword
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In modern times, improvements in knowledge and technological advances have greatly improved the
health of mother and children. However, the past decade was marked by limited progress in reducing
maternal mortality and a slow-down in the steady decline of childhood mortality observed since the
mid 1950s in many countries, the latter being largely due to a failure to reduce neonatal mortality.
Every year, over four million babies less than one month of age die, most of them during the critical
first week of life; and for every newborn who dies, another is stillborn. Most of these deaths are a
consequence of the poor health and nutritional status of the mother coupled with inadequate care
before, during, and after delivery. Unfortunately, the problem remains unrecognized or- worse- accepted
as inevitable in many societies, in large part because it is so common.
Recognizing the large burden of maternal and neonatal ill-health on the development capacity of
individuals, communities and societies, world leaders reaffirmed their commitment to invest in mothers
and children by adopting specific goals and targets to reduce maternal and childhood-infant mortality
as part of the Millennium Declaration.
There is a widely shared but mistaken idea that improvements in newborn health require sophisticated
and expensive technologies and highly specialized staff. The reality is that many conditions that result
in perinatal death can be prevented or treated without sophisticated and expensive technology. What
is required is essential care during pregnancy, the assistance of a person with midwifery skills during
childbirth and the immediate postpartum period, and a few critical interventions for the newborn
during the first days of life.
It is against this background that we are proud to present the document Pregnancy, Childbirth,
Postpartum and Newborn Care: A guide for essential practice, as new additions to the Integrated
Management of Pregnancy and Childbirth tool kit. The guide provides a full range of updated,
evidence-based norms and standards that will enable health care providers to give high quality care
during pregnancy, delivery and in the postpartum period, considering the needs of the mother and her
newborn baby.
We hope that the guide will be helpful for decision-makers, programme managers and health care
providers in charting out their roadmap towards meeting the health needs of all mothers and children.
We have the knowledge, our major challenge now is to translate this into action and to reach those
women and children who are most in need.
dr. Tomris Türmen
Executive director
Family and Community Health (FCH)
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The Guide was prepared by a team of the World Health Organization, Department of Reproductive
Health and Research (RHR), led by Jerker Liljestrand and Jelka Zupan.
The concept and first drafts were developed by Sandra Gove and Patricia Whitesell/ACT International,
Atlanta, Jerker Liljestrand, Denise Roth, Betty Sweet, Anne Thompson, and Jelka Zupan.
Revisions were subsequently carried out by Annie Portela, Luc de Bernis, Ornella Lincetto, Rita Kabra,
Maggie Usher, Agostino Borra, Rick Guidotti, Elisabeth Hoff, Mathews Matthai, Monir Islam,
Felicity Savage, Adepeyu Olukoya, Aafje Rietveld, TinTin Sint, Ekpini, Ehounu, Suman Mehta.
Valuable inputs were provided by WHO Regional Offices and WHO departments:
■ Reproductive Health and Research
■ Child and Adolescent Health and Development
■ HIV/AIDS
■ Communicable Diseases
■ Nutrition for Health and Development
■ Essential Drugs and Medicines Policy
■ Vaccines and Biologicals
■ Mental Health and Substance Dependence
■ Gender and Women’s Health
■ Blindness and Deafness
editing: Nina Mattock, Richard Casna
layout: rsdesigns.com sàrl
cover design: Maíre Ní Mhearáin
WHO acknowledges with gratitude the generous contribution of over 100 individuals and organizations
in the field of maternal and newborn health, who took time to review this document at different stages
of its development. They came from over 35 countries and brought their expertise and wide experience
to the final text.
This guide represents a common understanding between WHO, UNFPA, UNICEF, and the World Bank
of key elements of an approach to reducing maternal and perinatal mortality and morbidity. These
agencies co-operate closely in efforts to reduce maternal and perinatal mortality and morbidity.
The principles and policies of each agency are governed by the relevant decisions of each agency’s
governing body and each agency implements the interventions described in this document in
accordance with these principles and policies and within the scope of its mandate.
The guide has also been reviewed and endorsed by the International Confederation of Midwives, the
International Federation of Gynecology and Obstetrics and International Pediatric Association.
The financial support towards the preparation and production of this document provided by UNFPA and
the Governments of Australia, Japan and the United States of America is gratefully acknowledged,
as is financial support received from The World Bank. In addition, WHO’s Making Pregnancy Safer
initiative is grateful to the programme support received from the Governments of the Netherlands,
Norway, Sweden and the United Kingdom of Great Britain and Northern Ireland.
Acknowledgements
AcknOWledgemenTs
International
Pediatric Association
International
Confederation of Midwives
International Federation of
Gynecology and Obstetrics
Table of contents
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TAble OF cOnTenTs
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InTrOducTIOn
Introduction
How to read the guide
Acronyms
Content
Structure and presentation
Assumptions underlying the guide
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PrIncIPles OF gOOd cAre
A2 Communication
A3 Workplace and administrative procedures
A4 Standard precautions and cleanliness
A5 Organising a visit
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QuIck cHeck, rAPId AssessmenT And mAnAgemenT OF WOmen OF cHIldbeArIng Age
b2 Quick check
b3-b7 Rapid assessment and management
b3 Airway and breathing
b3 Circulation (shock)
b4-b5 Vaginal bleeding
b6 Convulsions or unconscious
b6 Severe abdominal pain
b6 Dangerous fever
b7 Labour
b7 Other danger signs or symptoms
b7 If no emergency or priority signs, non urgent
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emergency TreATmenTs FOr THe WOmAn
b9 Airway, breathing and circulation
b9 Manage the airway and breathing
b9 Insert IV line and give fluids
b9 If intravenous access not possible
b10-b12 Bleeding
b10 Massage uterus and expel clots
b10 Apply bimanual uterine compression
b10 Apply aortic compression
b10 Give oxytocin
b10 Give ergometrine
b11 Remove placenta and fragments manually
b11 After manual removal of placenta
b12 Repair the tear and empty bladder
b12 Repair the tear or episiotomy
b13-b14 Important considerations in caring for a woman with eclampsia or pre-eclampsia
b13 Give magnesium sulphate
b13 Important considerations in caring for a woman with eclampsia
b14 Give diazepam
b14 Give appropriate antihypertensive drug
b15 Infection
b15 Give appropriate IV/IM antibiotics
b16 Malaria
b16 Give arthemether or quinine IM
b16 Give glucose IV
b17 Refer the woman urgently to the hospital
b17 Essential emergency drugs and supplies for transport and home delivery
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bleedIng In eArly PregnAncy And POsT-AbOrTIOn cAre
b19 Examination of the woman with bleeding in early pregnancy and post-abortion care
b20 Give preventive measures
b21 Advise and counsel on post-abortion care
b21 Advise on self-care
b21 Advise and counsel on family planning
b21 Provide information and support after abortion
b21 Advise and counsel during follow-up visits
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AnTenATAl cAre
c2 Assess the pregnant woman: pregnancy status, birth and emergency plan
c3 Check for pre-eclampsia
c4 Check for anaemia
c5 Check for syphilis
c6 Check for HIV status
c7 Respond to observed signs or volunteered problems
c7 If no fetal movement
c7 If ruptured membranes and no labour
c8 If fever or burning on urination
c9 If vaginal discharge
c10 If signs suggesting HIV infection
c10 If smoking, alcohol or drug abuse, or history of violence
c11 If cough or breathing difficulty
c11 If taking antituberculosis drugs
c12 Give preventive measures
c13 Advise and counsel on nutrition and self-care
c14-c15 Develop a birth and emergency plan
c14 Facility delivery
c14 Home delivery with a skilled attendant
c15 Advise on labour signs
c15 Advise on danger signs
c15 Discuss how to prepare for an emergency in pregnancy
c16 Advise and counsel on family planning
c16 Counsel on the importance of family planning
c16 Special consideration for family planning counselling during pregnancy
c17 Advise on routine and follow-up visits
c18 Home delivery without a skilled attendant
c19 Assess eligibility of ARV for HIV-positive pregnant woman
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cHIldbIrTH – lAbOur, delIvery And ImmedIATe POsTPArTum cAre
d2 Examine the woman in labour or with ruptured membranes
d3 Decide stage of labour
d4-d5 Respond to obstetrical problems on admission
d6-d7 Give supportive care throughout labour
d6 Communication
d6 Cleanliness
d6 Mobility
d6 Urination
d6 Eating, drinking
d6 Breathing technique
d6 Pain and discomfort relief
d7 Birth companion
d8-d9 First stage of labour
d8 Not in active labour
d9 In active labour
d10-d11 Second stage of labour: deliver the baby and give immediate newborn care
d12-d13 Third stage of labour: deliver the placenta
d14-d18 Respond to problems during labour and delivery
d14 If fetal heart rate <120 or >160 beats per minute
d15 If prolapsed cord
d16 If breech presentation
d17 If stuck shoulders (Shoulder dystocia)
d18 If multiple births
d19 Care of the mother and newborn within first hour of delivery of placenta
d20 Care of the mother one hour after delivery of placenta
d21 Assess the mother after delivery
d22-d25 Respond to problems immediately postpartum
d22 If vaginal bleeding
d22 If fever (temperature >38°C)
d22 If perineal tear or episiotomy (done for lifesaving circumstances)
d23 If elevated diastolic blood pressure
d24 If pallor on screening, check for anaemia
d24 If mother severely ill or separated from the child
d24 If baby stillborn or dead
d25 Give preventive measures
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cHIldbIrTH – lAbOur, delIvery And ImmedIATe POsTPArTum cAre (cOnTInued)
d26 Advise on postpartum care
d26 Advise on postpartum care and hygiene
d26 Counsel on nutrition
d27 Counsel on birth spacing and family planning
d27 Counsel on the importance of family planning
d27 Lactation amenorrhea method (LAM)
d28 Advise on when to return
d28 Routine postpartum visits
d28 Follow-up visits for problems
d28 Advise on danger signs
d28 Discuss how to prepare for an emergency in postpartum
d29 Home delivery by skilled attendant
d29 Preparation for home delivery
d29 Delivery care
d29 Immediate postpartum care of mother
d29 Postpartum care of newborn
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POsTPArTum cAre
e2 Postpartum examination of the mother (up to 6 weeks)
e3-e10 Respond to observed signs or volunteered problems
e3 If elevated diastolic blood pressure
e4 If pallor, check for anaemia
e5 Check for HIV status
e6 If heavy vaginal bleeding
e6 If fever or foul-smelling lochia
e7 If dribbling urine
e7 If pus or perineal pain
e7 If feeling unhappy or crying easily
e8 If vaginal discharge 4 weeks after delivery
e8 If breast problem
e9 If cough or breathing difficulty
e9 If taking anti-tuberculosis drugs
e10 If signs suggesting HIV infection
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PrevenTIve meAsures And AddITIOnAl TreATmenTs FOr THe WOmAn
F2–F4 Preventive measures
F2 Give tetanus toxoid
F2 Give vitamin A postpartum
F3 Give iron and folic acid
F3 Give mebendazole
F3 Motivate on compliance with iron treatment
F4 Give preventive intermittent treatment for falciparum malaria
F4 Advise to use insecticide-treated bednet
F4 Give appropriate oral antimalarial treatment
F4 Give paracetamol
F5–F6 Additional treatments for the woman
F5 Give appropriate oral antibiotics
F6 Give benzathine penicillin IM
F6 Observe for signs of allergy
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InFOrm And cOunsel On HIv
G2 Provide key information on HIV

G2
What is HIV and how is HIV transmitted?
G2 Advantage of knowing the HIV status in pregnancy
G2 Counsel on safer sex including use of condoms
G3 HIV testing and counselling
G3 HIV testing and counselling
G3 Discuss confidentiality of HIV infection
G3 Counsel on implications of the HIV test result
G3 Benefits of disclosure (involving) and testing the male partner(s)
G4 Care and counselling for the HIV -positive woman
G4 Additional care for the HIV -positive woman
G4 Counsel the HIV -positive woman on family planning
G5 Support to the HIV-positive woman
G5 Provide emotional support to the woman
G5 How to provide support
G6 Give antiretroviral (ARV) medicine(s) to treat HIV infection
G6 Support the initiation of ARV
G6 Support adherence to ARV
G7 Counsel on infant feeding options
G7 Explain the risks of HIV transmission through breastfeeding and not breastfeeding
G7 If a woman does not know her HIV status
G7 If a woman knows that she is HIV positive
G8 Support the mothers choice of newborn feeding
G8 If mother chooses replacement feeding : teach her replacement feeding
G8 Explain the risks of replacement feeding
G8 Follow-up for replacement feeding
G8 Give special counselling to the mother who is HIV-positive and chooses breastfeeding
G9 Give appropriate antiretroviral to HIV- positive woman and the newborn
G10 Respond to observed signs and volunteered problems
G10 If a woman is taking Antiretroviral medicines and develop new signs/symptoms, respond to
her problems
G11 Prevent HIV infection in health care workers after accidental exposure with body fluids (post
exposure prophylaxis)
G11 If a health care worker is exposed to body fluids by cuts/pricks/ splashes, give him
appropriate care.
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THe WOmAn WITH sPecIAl needs
H2 Emotional support for the woman with special needs
H2 Sources of support
H2 Emotional support
H3 Special considerations in managing the pregnant adolescent
H3 When interacting with the adolescent
H3 Help the girl consider her options and to make decisions which best suit her needs
H4 Special considerations for supporting the woman living with violence
H4 Support the woman living with violence
H4 Support the health service response to needs of women living with violence
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cOmmunITy suPPOrT FOr mATernAl And neWbOrn HeAlTH
I2 Establish links
I2 Coordinate with other health care providers and community groups
I2 Establish links with traditional birth attendants and traditional healers
I3 Involve the community in quality of services

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neWbOrn cAre
J2 Examine the newborn
J3 If preterm, birth weight <2500 g or twin
J4 Assess breastfeeding
J5 Check for special treatment needs
J6 Look for signs of jaundice and local infection
J7 If danger signs
J8 If swelling, bruises or malformation
J9 Assess the mother’s breasts if complaining of nipple or breast pain
J10 Care of the newborn
J11 Additional care of a small baby (or twin)
J12 Assess replacement feeding
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breAsTFeedIng, cAre, PrevenTIve meAsures And TreATmenT FOr THe neWbOrn
K2 Counsel on breastfeeding
K2 Counsel on importance of exclusive breastfeeding
K2 Help the mother to initiate breastfeeding
K3 Support exclusive breastfeeding
K3 Teach correct positioning and attachment for breastfeeding
K4 Give special support to breastfeed the small baby (preterm and/or low birth weight)
K4 Give special support to breastfeed twins
K5 Alternative feeding methods
K5 Express breast milk
K5 Hand express breast milk directly into the baby’s mouth
K6 Cup feeding expressed breast milk
K6 Quantity to feed by cup
K6 Signs that baby is receiving adequate amount of milk
K7 Weigh and assess weight gain
K7 Weigh baby in the first month of life
K7 Assess weight gain
K7 Scale maintenance
K8 Other breastfeeding support
K8 Give special support to the mother who is not yet breastfeeding
K8 If the baby does not have a mother
K8 Advise the mother who is not breastfeeding at all on how to relieve engorgement
K9 Ensure warmth for the baby
K9 Keep the baby warm
K9 Keep a small baby warm
K9 Rewarm the baby skin-to-skin
K10 Other baby care
K10 Cord care
K10 Sleeping
K10 Hygiene
K11 Newborn resuscitation
K11 Keep the baby warm
K11 Open the airway
K11 If still not breathing, ventilate
K11 If breathing less than 30 breaths per minute or severe chest in-drawing, stop ventilating
K11 If not breathing or gasping at all after 20 minutes of ventilation
K12 Treat and immunize the baby
K12 Treat the baby
K12 Give 2 IM antibiotics (first week of life)
K12 Give IM benzathine penicillin to baby (single dose) if mother tested RPR-positive
K12 Give IM antibiotic for possible gonococcal eye infection (single dose)
K13 Treat local infection
K13 Give isoniazid (INH) prophylaxis to newborn
K13 Immunize the newborn

K13 Give antiretroviral (ARV) medicine to newborn

K14 Advise when to return with the baby
K14 Routine visits
K14 Follow-up visits
K14 Advise the mother to seek care for the baby
K14 Refer baby urgently to hospital
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eQuIPmenT, suPPlIes, drugs And lAbOrATOry TesTs
L2 Equipment, supplies, drugs and tests for pregnancy and postpartum care
L3 Equipment, supplies and drugs for childbirth care
L4 Laboratory tests
L4 Check urine for protein
L4 Check haemoglobin
L5 Perform rapid plamareagin (RPR) test for syphilis
L5 Interpreting results
L6 Perform rapid test for HIV
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InFOrmATIOn And cOunsellIng sHeeTs
M2 Care during pregnancy
M3 Preparing a birth and emergency plan
M4 Care for the mother after birth
M5 Care after an abortion
M6 Care for the baby after birth
M7 Breastfeeding
M8-M9 Clean home delivery
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recOrds And FOrms
N2 Referral record
N3 Feedback record
N4 Labour record
N5 Partograph
N6 Postpartum record
N7 International form of medical certificate of cause of death
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glOssAry And AcrOnyms
The aim of Pregnancy, childbirth, postpartum and newborn care guide for essential practice (PCPNC) is
to provide evidence-based recommendations to guide health care professionals in the management of
women during pregnancy, childbirth and postpartum, and post abortion, and newborns during their first
week of life, including management of endemic diseases like malaria, HIV/AIDS, TB and anaemia.
All recommendations are for skilled attendants working at the primary level of health care, either at the
facility or in the community. They apply to all women attending antenatal care, in delivery, postpartum
or post abortion care, or who come for emergency care, and to all newborns at birth and during the first
week of life (or later) for routine and emergency care.
The PCPNC is a guide for clinical decision-making. It facilitates the collection, analysis, classification and
use of relevant information by suggesting key questions, essential observations and/or examinations,
and recommending appropriate research-based interventions. It promotes the early detection of
complications and the initiation of early and appropriate treatment, including timely referral, if
necessary.
Correct use of this guide should help reduce the high maternal and perinatal mortality and morbidity
rates prevalent in many parts of the developing world, thereby making pregnancy and childbirth safer.
The guide is not designed for immediate use. It is a generic guide and should first be adapted to
local needs and resources. It should cover the most serious endemic conditions that the skilled birth
attendant must be able to treat, and be made consistent with national treatment guidelines and other
policies. It is accompanied by an adaptation guide to help countries prepare their own national guides
and training and other supporting materials.
The first section, How to use the guide, describes how the guide is organized, the overall content and
presentation. Each chapter begins with a short description of how to read and use it, to help the
reader use the guide correctly.
The Guide has been developed by the Department of Reproductive Health and Research with
contributions from the following WHO programmes:
■ Child and Adolesscent Health and Development
■ HIV/AIDS
■ Nutrition for Health and Development
■ Essential drugs and Medicines Policy
■ Vaccines and Biologicals
■ Communicable Diseases Control, Prevention and Eradication (tuberculosis, malaria, helminthiasis)
■ Gender and Women’s Health
■ Mental Health and Substance Dependence
■ Blindness and Deafness
InTrOducTIOn
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Introduction
How to read the guide
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Content
The Guide includes routine and emergency care
for women and newborns during pregnancy,
labour and delivery, postpartum and post
abortion, as well as key preventive measures
required to reduce the incidence of endemic and
other diseases like malaria, anaemia, HIV/AIDS
and TB, which add to maternal and perinatal
morbidity and mortality.
Most women and newborns using the services
described in the Guide are not ill and/or do not
have complications. They are able to wait in line
when they come for a scheduled visit. However,
the small proportion of women/newborns who
are ill, have complications or are in labour, need
urgent attention and care.
The clinical content is divided into six sections
which are as follows:
■ Quick check (triage), emergency management
(called Rapid Assessment and Management
or RAM) and referral, followed by a chapter on
emergency treatments for the woman.
■ Post-abortion care.
■ Antenatal care.
■ Labour and delivery.
■ Postpartum care.
■ Newborn care.
In each of the six clinical sections listed
above there is a series of flow, treatment and
information charts which include:
■ Guidance on routine care, including
monitoring the well-being of the mother and/
or baby.
■ Early detection and management of
complications.
■ Preventive measures.
■ Advice and counselling.
In addition to the clinical care outlined above,
other sections in the guide include:
■ Advice on HIV, prevention and treatment.
■ Support for women with special needs.
■ Links with the community.
■ Drugs, supplies, equipment, universal
precautions and laboratory tests.
■ Examples of clinical records.
■ Counselling and key messages for women and
families.
There is an important section at the beginning
of the Guide entitled Principles of good care
A1-A5 . This includes principles of good care
for all women, including those with special
needs. It explains the organization of each
visit to a healthcare facility, which applies to
overall care. The principles are not repeated
for each visit.
Recommendations for the management of
complications at secondary (referral)
health care level can be found in the following
guides for midwives and doctors:
■ Managing complications of pregnancy and
childbirth (WHO/RHR/00.7)
■ Managing newborn problems.
Documents referred to in this Guide can be
obtained from the Department of Making
Pregnancy Safer, Family and Community Health,
World Health Organization, Geneva, Switzerland.
e-mail: mpspublications@who.int.
Other related WHO documents can be
downloaded from the following links:
■ Medical Eligibility Criteria 3rd edition:
http://www.who.int/reproductive-health/
publications/mec/mec.pdf.
■ Selected Practice Recommendations 2nd
edition: http://www.who.int/reproductive-
health/publications/spr/spr.pdf.
■ Guidelines for the Management of Sexually
Transmitted Infections: http://www.who.
int/reproductive-health/publications/rhr_01_
10_mngt_stis/guidelines_mngt_stis.pdf
■ Sexually Transmitted and other Reproductive
Tract Infections: A Guide to Essential Practice:
http://www.who.int/reproductive-health/
publications/rtis_gep/rtis_gep.pdf
■ Antiretroviral treatment of HIV infection in
infants and children in resource-limited
settings, towards universal access:
Recommendations for a public health
approach Web-based public review,
3–12 November 2005
http://www.who.int/hiv/pub/prev_care/en
■ WHO consultation on technical and
operational recommendations for scale-up
of laboratory services and monitoring HIV
antiretroviral therapy in resource-limited
settings. http://www.who.int/hiv/pub/prev_
care/en ISBN 92 4 159368 7
■ Malaria and HIV Interactions and their
Implications for Public Health Policy.
http://www.who.int/hiv/pub/prev_care/en:
ISNB 92 4 159335 0
■ Interim WHO clinical staging of HIV/AIDS and
HIV/AIDS case definitions for surveillance
African Region. http://www.who.int/hiv/pub/
prev_care/en Ref no:: WHO/HIV/2005.02
■ HIV and Infant Feeding. Guidelines for
decision-makers http://www.who.int/child-
adolescent-health/publications/NUTRITION/
ISBN_92_4_159122_6.htm
■ HIV and Infant Feeding. A guide for health-care
managers and supervisors http://www.who.
int/child-adolescent-health/publications/
NUTRITION/ISBN_92_4_159123_4.htm
■ Integrated Management of Adolescent and
adult illness
http://www.who.int/3by5/publications/
documents/imai/en/index.html
HOW TO reAd THe guIde
Structure and presentation
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ASK, CHECK RECORD LOOK, LISTEN FEEL SIGNS TREAT AND ADVISE CLASSIFY
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This Guide is a tool for clinical decision-making.
The content is presented in a frame work of
coloured flow charts supported by information
and treatment charts which give further details
of care.
The framework is based on a syndromic
approach whereby the skilled attendant
identifies a limited number of key clinical signs
and symptoms, enabling her/him to classify
the condition according to severity and give
appropriate treatment. Severity is marked in
colour: red for emergencies, yellow for less
urgent conditions which nevertheless need
attention, and green for normal care.
Flow charts
The flow charts include the following information:
1. Key questions to be asked.
2. Important observations and examinations to
be made.
3. Possible findings (signs) based on information
elicited from the questions, observations and,
where appropriate, examinations.
4. Classification of the findings.
5. Treatment and advice related to the signs and
classification.
“Treat, advise” means giving the treatment indicated
(performing a procedure, prescribing drugs or other
treatments, advising on possible side-effects and how to
overcome them) and giving advice on other important
practices. The treat and advise column is often cross-
referenced to other treatment and/or information charts.
Turn to these charts for more information.
Use of colour
Colour is used in the flow charts to indicate the
severity of a condition.
6. Green usually indicates no abnormal
condition and therefore normal care is given,
as outlined in the guide, with appropriate
advice for home care and follow up.
7. Yellow indicates that there is a problem that
can be treated without referral.
8. Red highlights an emergency which requires
immediate treatment and, in most cases,
urgent referral to a higher level health facility.
Key sequential steps
The charts for normal and abnormal deliveries
are presented in a framework of key sequential
steps for a clean safe delivery. The key sequential
steps for delivery are in a column on the left side
of the page, while the column on the right has
interventions which may be required if problems
arise during delivery. Interventions may be linked
to relevant treatment and/or information pages,
and are cross-referenced to other parts of the
Guide.
Treatment and information pages
The flow charts are linked (cross-referenced) to
relevant treatment and/or information pages in other
parts of the Guide. These pages include information
which is too detailed to include in the flow charts:
■ Treatments.
■ Advice and counselling.
■ Preventive measures.
■ Relevant procedures.
Information and counselling
sheets
These contain appropriate advice and
counselling messages to provide to the woman,
her partner and family. In addition, a section is
included at the back of the Guide to support the
skilled attendant in this effort. Individual sheets
are provided with simplified versions of the
messages on care during pregnancy (preparing a
birth and emergency plan, clean home delivery,
care for the mother and baby after delivery,
breastfeeding and care after an abortion) to be
given to the mother, her partner and family at the
appropriate stage of pregnancy and childbirth.
These sheets are presented in a generic format.
They will require adaptation to local conditions
and language, and the addition of illustrations
to enhance understanding, acceptability and
attractiveness. Different programmes may prefer
a different format such as a booklet or flip chart.
sTrucTure And PresenTATIOn
Assumptions underlying the Guide
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Recommendations in the Guide are generic,
made on many assumptions about the health
characteristics of the population and the
health care system (the setting, capacity and
organization of services, resources and staffing).
Population and
endemic conditions
■ High maternal and perinatal mortality
■ Many adolescent pregnancies
■ High prevalence of endemic conditions:
→ Anaemia
→ Stable transmission of falciparum malaria
→ Hookworms (Necator americanus and
Ancylostoma duodenale)
→ Sexually transmitted infections, including
HIV/AIDS
→ Vitamin A and iron/folate deficiencies.
Health care system
The Guide assumes that:
■ Routine and emergency pregnancy, delivery and
postpartum care are provided at the primary
level of the health care, e.g. at the facility near
where the woman lives. This facility could be a
health post, health centre or maternity clinic.
It could also be a hospital with a delivery ward
and outpatient clinic providing routine care to
women from the neighbourhood.
■ A single skilled attendant is providing care.
She may work at the health care centre, a
maternity unit of a hospital or she may go
to the woman's home, if necessary. However
there may be other health workers who receive
the woman or support the skilled attendant
when emergency complications occur.
■ Human resources, infrastructure, equipment,
supplies and drugs are limited. However,
essential drugs, IV fluids, supplies, gloves and
essential equipment are available.
■ If a health worker with higher levels of skill (at
the facility or a referral hospital) is providing
pregnancy, childbirth and postpartum care to
women other than those referred, she follows
the recommendations described in this Guide.
■ Routine visits and follow-up visits are
“scheduled” during office hours.
■ Emergency services (“unscheduled” visits) for
labour and delivery, complications, or severe
illness or deterioration are provided 24/24
hours, 7 days a week.
■ Women and babies with complications or
expected complications are referred for further
care to the secondary level of care, a referral
hospital.
■ Referral and transportation are appropriate for
the distance and other circumstances. They
must be safe for the mother and the baby.
■ Some deliveries are conducted at home,
attended by traditional birth attendants (TBAs)
or relatives, or the woman delivers alone (but
home delivery without a skilled attendant is
not recommended).
■ Links with the community and traditional
providers are established. Primary health care
services and the community are involved in
maternal and newborn health issues.
■ Other programme activities, such as
management of malaria, tuberculosis and
other lung diseases, treatment for HIV, and
infant feeding counselling, that require
specific training, are delivered by a different
provider, at the same facility or at the referral
hospital. Detection, initial treatment and
referral are done by the skilled attendant.
■ All pregnant woman are routinely offered HIV
testing and counselling at the first contact
with the health worker, which could be during
the antenatal visits, in early labour or in the
postpartum period.
Women who are first seen by the health worker
in late labour are offered the test after the
childbirth.
Health workers are trained to provide HIV
testing and counselling.
HIV testing kits and ARV medicines are
available at the Primary health-care
Knowledge and
skills of care providers
This Guide assumes that professionals using
it have the knowledge and skills in providing
the care it describes. Other training materials
must be used to bring the skills up to the level
assumed by the Guide.
Adaptation of the Guide
It is essential that this generic Guide is adapted
to national and local situations, not only within
the context of existing health priorities and
resources, but also within the context of respect
and sensitivity to the needs of women, newborns
and the communities to which they belong.
An adaptation guide is available to assist
national experts in modifying the Guide
according to national needs, for different
demographic and epidemiological conditions,
resources and settings. The adaptation guide
offers some alternatives. It includes guidance on
developing information and counselling tools so
that each programme manager can develop a
format which is most comfortable for her/him.

AssumPTIOns underlyIng THe guIde
A
Principles of good care
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PrinciPles of good cAre
Communication
PrinciPles of good cAre
A2
Communicating with the woman
(and her companion)
■ Make the woman (and her companion) feel welcome. ■ Be friendly, respectful and non-judgmental at all times. ■ Use simple and clear language. ■ Encourage her to ask questions. ■ Ask and provide information related to her needs. ■ Support her in understanding her options and making decisions. ■ At any examination or before any procedure: →seek her permission and →inform her of what you are doing. ■ Summarize the most important information, including the information on routine laboratory tests and treatments.
Verify that she understands emergency signs, treatment instructions, and when and where to return. Check for understanding by asking her to explain or demonstrate treatment instructions.
Privacy and confidentiality
In all contacts with the woman and her partner: ■ Ensure a private place for the examination and counselling. ■ Ensure, when discussing sensitive subjects, that you cannot be overheard. ■ Make sure you have the woman’s consent before discussing with her partner or family. ■ Never discuss confidential information about clients with other providers, or outside the health facility. ■ Organize the examination area so that, during examination, the woman is protected from the view of other people (curtain, screen, wall). ■ Ensure all records are confidential and kept locked away. ■ Limit access to logbooks and registers to responsible providers only.
Prescribing and recommending
treatments and preventive
measures for the woman
and/or her baby
When giving a treatment (drug, vaccine, bednet, condom) at the clinic, or prescribing measures to be followed at home: ■ Explain to the woman what the treatment is and why it should be given. ■ Explain to her that the treatment will not harm her or her baby, and that not taking it may be more dangerous. ■ Give clear and helpful advice on how to take the drug regularly: →for example: take 2 tablets 3 times a day, thus every 8 hours, in the morning, afternoon and evening with some water and after a meal, for 5 days.
■ Demonstrate the procedure. ■ Explain how the treatment is given to the baby. Watch her as she does the first treatment in the clinic. ■ Explain the side-effects to her. Explain that they are not serious, and tell her how to manage them. ■ Advise her to return if she has any problems or concerns about taking the drugs. ■ Explore any barriers she or her family may have, or have heard from others, about using the treatment, where possible: →Has she or anyone she knows used the treatment or preventive measure before? →Were there problems? →Reinforce the correct information that she has, and try to clarify the incorrect information. ■ Discuss with her the importance of buying and taking the prescribed amount. Help her to think about how she will be able to purchase this.
communicAtion
A3 Workplace and administrative procedures
PrinciPles of good cAre
Workplace
■ Service hours should be clearly posted. ■ Be on time with appointments or inform the woman/women if she/they need to wait. ■ Before beginning the services, check that equipment is clean and functioning and that supplies and drugs are in place. ■ Keep the facility clean by regular cleaning. ■ At the end of the service: →discard litter and sharps safely →prepare for disinfection; clean and disinfect equipment and supplies →replace linen, prepare for washing →replenish supplies and drugs →ensure routine cleaning of all areas. ■ Hand over essential information to the colleague who follows on duty.
Daily and occasional
administrative activities
■ Keep records of equipment, supplies, drugs and vaccines. ■ Check availability and functioning of essential equipment (order stocks of supplies, drugs, vaccines and contraceptives before they run out). ■ Establish staffing lists and schedules. ■ Complete periodic reports on births, deaths and other indicators as required, according to instructions.
Record keeping
■ Always record findings on a clinical record and home-based record. Record treatments, reasons for referral, and follow-up recommendations at the time the observation is made. ■ Do not record confidential information on the home-based record if the woman is unwilling. ■ Maintain and file appropriately: →all clinical records →all other documentation.
International conventions
The health facility should not allow distribution of free or low-cost suplies or products within the scope of the International Code of Marketing of Breast Milk Substitutes. It should also be tobacco free and support a tobacco-free environment.
WorkPlAce And AdministrAtive Procedures
Standard precautions and cleanliness
PrinciPles of good cAre
A4
observe these precautions to protect the woman and her baby, and you as the health provider, from infections with bacteria and viruses, including Hiv.
Wash hands
■ Wash hands with soap and water: →Before and after caring for a woman or newborn, and before any treatment procedure →Whenever the hands (or any other skin area) are contaminated with blood or other body fluids →After removing the gloves, because they may have holes →After changing soiled bedsheets or clothing. ■ Keep nails short.
Wear gloves
■ Wear sterile or highly disinfected gloves when performing vaginal examination, delivery, cord cutting, repair of episiotomy or tear, blood drawing. ■ Wear long sterile or highly disinfected gloves for manual removal of placenta. ■ Wear clean gloves when: →Handling and cleaning instruments →Handling contaminated waste →Cleaning blood and body fluid spills ■ Drawing blood.
Protect yourself from blood and
other body fluids during deliveries
→Wear gloves; cover any cuts, abrasions or broken skin with a waterproof bandage; take care when handling any sharp instruments (use good light); and practice safe sharps disposal. →Wear a long apron made from plastic or other fluid resistant material, and shoes. →If possible, protect your eyes from splashes of blood.
Practice safe sharps disposal
■ Keep a puncture resistant container nearby. ■ Use each needle and syringe only once. ■ Do not recap, bend or break needles after giving an injection. ■ Drop all used (disposable) needles, plastic syringes and blades directly into this container, without recapping, and without passing to another person. ■ Empty or send for incineration when the container is three-quarters full.
Practice safe waste disposal
■ Dispose of placenta or blood, or body fluid contaminated items, in leak-proof containers. ■ Burn or bury contaminated solid waste. ■ Wash hands, gloves and containers after disposal of infectious waste. ■ Pour liquid waste down a drain or flushable toilet. ■ Wash hands after disposal of infectious waste.
Deal with contaminated
laundry
■ Collect clothing or sheets stained with blood or body fluids and keep them separately from other laundry, wearing gloves or use a plastic bag. do not touch them directly. ■ Rinse off blood or other body fluids before washing with soap.
Sterilize and clean contaminated
equipment
■ Make sure that instruments which penetrate the skin (such as needles) are adequately sterilized, or that single-use instruments are disposed of after one use. ■ Thoroughly clean or disinfect any equipment which comes into contact with intact skin (according to instructions). ■ Use bleach for cleaning bowls and buckets, and for blood or body fluid spills.
Clean and
disinfect gloves
■ Wash the gloves in soap and water. ■ Check for damage: Blow gloves full of air, twist the cuff closed, then hold under clean water and look for air leaks. Discard if damaged. ■ Soak overnight in bleach solution with 0.5% available chlorine (made by adding 90 ml water to 10 ml bleach containing 5% available chlorine). ■ Dry away from direct sunlight. ■ Dust inside with talcum powder or starch.
This produces disinfected gloves.They are not sterile.
Good quality latex gloves can be disinfected 5 or more times.
Sterilize gloves
■ Sterilize by autoclaving or highly disinfect by steaming or boiling.
universAl PrecAutions And cleAnliness
A5 Organizing a visit
PrinciPles of good cAre
Receive and
respond immediately
receive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). ■ PerformQuick Check on all new incoming women and babies and those in the waiting room, especially if no-one is receiving them B2 . ■ At the first emergency sign on Quick Check, begin emergency assessment and management (RAM) B-B7 for the woman, or examine the newborn J-J . ■ If she is in labour, accompany her to an appropriate place and follow the steps as in Childbirth: labour, delivery and immediate postpartumcare d-d29. ■ If she has priority signs, examine her immediately using Antenatal care, Postpartum or Post-abortion care charts c-c8 e-e0 B8-B22. ■ If no emergency or priority sign on RAM or not in labour, invite her to wait in the waiting room. ■ If baby is newly born, looks small, examine immediately. Do not let the mother wait in the queue.
Begin each emergency care visit
■ Introduce yourself. ■ Ask the name of the woman. ■ Encourage the companion to stay with the woman. ■ Explain all procedures, ask permission, and keep the woman informed as much as
you can about what you are doing. If she is unconscious, talk to the companion. ■ Ensure and respect privacy during examination and discussion. ■ If she came with a baby and the baby is well, ask the companion to take care of the baby during the maternal examination and treatment.
Care of woman or baby referred for
special care to secondary level facility
■ When a woman or baby is referred to a secondary level care facility because of a specific problem or complications, the underlying assumption of the Guide is that, at referral level, the woman/baby will be assessed, treated, counselled and advised on follow-up for that particular condition/ complication. ■ Follow-up for that specific condition will be either: →organized by the referral facility or →written instructions will be given to the woman/baby for the skilled attendant at the primary level who referred the woman/ baby. →the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition. ■ Routine care continues at the primary care level where it was initiated.
Begin each routine visit
(for the woman and/or the baby)
■ Greet the woman and offer her a seat. ■ Introduce yourself. ■ Ask her name (and the name of the baby). ■ Ask her: →Why did you come? For yourself or for your baby? →For a scheduled (routine) visit? →For specific complaints about you or your baby? →First or follow-up visit? →Do you want to include your companion or other family member (parent if adolescent) in the examination and discussion? ■ If the woman is recently delivered, assess the baby or ask to see the baby if not with the mother. ■ If antenatal care, always revise the birth plan at the end of the visit after completing the chart. ■ For a postpartum visit, if she came with the baby, also examine the baby: →Follow the appropriate charts according to pregnancy status/age of the baby and purpose of visit. →Follow all steps on the chart and in relevant boxes. ■ Unless the condition of the woman or the baby requires urgent referral to hospital, give preventive measures if due even if the woman has a condition "in yellow" that requires special treatment.
■ If follow-up visit is within a week, and if no other complaints: →Assess the woman for the specific condition requiring follow-up only →Compare with earlier assessment and re- classify. ■ If a follow-up visit is more than a week after the initial examination (but not the next scheduled visit): →Repeat the whole assessment as required for an antenatal, post-abortion, postpartum or newborn visit according to the schedule →If antenatal visit, revise the birth plan.
During the visit
■ Explain all procedures, ■ Ask permission before undertaking an examination or test. ■ Keep the woman informed throughout. Discuss findings with her (and her partner). ■ Ensure privacy during the examination and discussion.
At the end of the visit
■ Ask the woman if she has any questions. ■ Summarize the most important messages with her. ■ Encourage her to return for a routine visit (tell her when) and if she has any concerns. ■ Fill the Home-Based Maternal Record (HBMR) and give her the appropriate information sheet. ■ Ask her if there are any points which need to be discussed and would she like support for this.
orgAnizingA visit
A2 communicAtion
A3 WorkPlAce And AdministrAtive
Procedures
A4 stAndArd PrecAutions And
cleAnliness
A5 orgAnizing A visit
These principles of good care apply to all contacts between the skilled attendant and all women and their babies; they are not repeated in
each section. Care-givers should therefore familiarize themselves with the following principles before using the Guide. The principles concern:
■ Communication A2 .
■ Workplace and administrative procedures A3 .
■ Standard precautions and cleanliness A4 .
■ Organizing a visit A5 .
Communication
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A2
Communicating with the woman
(and her companion)
■ Make the woman (and her companion) feel
welcome.
■ Be friendly, respectful and non-judgmental at
all times.
■ Use simple and clear language.
■ Encourage her to ask questions.
■ Ask and provide information related to her
needs.
■ Support her in understanding her options and
making decisions.
■ At any examination or before any procedure:
→ seek her permission and
→ inform her of what you are doing.
■ Summarize the most important information,
including the information on routine
laboratory tests and treatments.
Verify that she understands emergency signs,
treatment instructions, and when
and where to return. Check for understanding by
asking her to explain or demonstrate treatment
instructions.
Privacy and confidentiality
In all contacts with the woman and her partner:
■ Ensure a private place for the examination
and counselling.
■ Ensure, when discussing sensitive subjects,
that you cannot be overheard.
■ Make sure you have the woman’s consent
before discussing with her partner or family.
■ Never discuss confidential information about
clients with other providers, or outside the
health facility.
■ Organize the examination area so that, during
examination, the woman is protected from the
view of other people (curtain, screen, wall).
■ Ensure all records are confidential and kept
locked away.
■ Limit access to logbooks and registers to
responsible providers only.
Prescribing and recommending
treatments and preventive
measures for the woman
and/or her baby
When giving a treatment (drug, vaccine, bednet,
condom) at the clinic, or prescribing measures to
be followed at home:
■ Explain to the woman what the treatment is
and why it should be given.
■ Explain to her that the treatment will not harm
her or her baby, and that not taking it may be
more dangerous.
■ Give clear and helpful advice on how to take
the drug regularly:
→ for example: take 2 tablets 3 times a
day, thus every 8 hours, in the morning,
afternoon and evening with some water and
after a meal, for 5 days.
■ Demonstrate the procedure.
■ Explain how the treatment is given to the baby.
Watch her as she does the first treatment in
the clinic.
■ Explain the side-effects to her. Explain that
they are not serious, and tell her how to
manage them.
■ Advise her to return if she has any problems or
concerns about taking the drugs.
■ Explore any barriers she or her family may
have, or have heard from others, about using
the treatment, where possible:
→ Has she or anyone she knows used the
treatment or preventive measure before?
→ Were there problems?
→ Reinforce the correct information that
she has, and try to clarify the incorrect
information.
■ Discuss with her the importance of buying and
taking the prescribed amount. Help her to think
about how she will be able to purchase this.
communicAtion
A3
Workplace and administrative procedures
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Workplace
■ Service hours should be clearly posted.
■ Be on time with appointments or inform the
woman/women if she/they need to wait.
■ Before beginning the services, check that
equipment is clean and functioning and that
supplies and drugs are in place.
■ Keep the facility clean by regular cleaning.
■ At the end of the service:
→ discard litter and sharps safely
→ prepare for disinfection; clean and disinfect
equipment and supplies
→ replace linen, prepare for washing
→ replenish supplies and drugs
→ ensure routine cleaning of all areas.
■ Hand over essential information to the
colleague who follows on duty.
Daily and occasional
administrative activities
■ Keep records of equipment, supplies, drugs
and vaccines.
■ Check availability and functioning of essential
equipment (order stocks of supplies, drugs,
vaccines and contraceptives before they run out).
■ Establish staffing lists and schedules.
■ Complete periodic reports on births, deaths
and other indicators as required, according to
instructions.
Record keeping
■ Always record findings on a clinical
record and home-based record. Record
treatments, reasons for referral, and follow-up
recommendations at the time the observation
is made.
■ Do not record confidential information on the
home-based record if the woman is unwilling.
■ Maintain and file appropriately:
→ all clinical records
→ all other documentation.
International conventions
The health facility should not allow distribution
of free or low-cost suplies or products within the
scope of the International Code of Marketing
of Breast Milk Substitutes. It should also be
tobacco free and support a tobacco-free
environment.
WorkPlAce And AdministrAtive Procedures
Standard precautions and cleanliness
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observe these precautions to protect the
woman and her baby, and you as the health
provider, from infections with bacteria and
viruses, including Hiv.
Wash hands
■ Wash hands with soap and water:
→ Before and after caring for a woman
or newborn, and before any treatment
procedure
→ Whenever the hands (or any other skin
area) are contaminated with blood or other
body fluids
→ After removing the gloves, because they
may have holes
→ After changing soiled bedsheets or clothing.
■ Keep nails short.
Wear gloves
■ Wear sterile or highly disinfected gloves when
performing vaginal examination, delivery, cord
cutting, repair of episiotomy or tear, blood
drawing.
■ Wear long sterile or highly disinfected gloves for
manual removal of placenta.
■ Wear clean gloves when:
→ Handling and cleaning instruments
→ Handling contaminated waste
→ Cleaning blood and body fluid spills
■ Drawing blood.
Protect yourself from blood and
other body fluids during deliveries
→ Wear gloves; cover any cuts, abrasions or
broken skin with a waterproof bandage;
take care when handling any sharp
instruments (use good light); and practice
safe sharps disposal.
→ Wear a long apron made from plastic or
other fluid resistant material, and shoes.
→ If possible, protect your eyes from splashes
of blood.
Practice safe sharps disposal
■ Keep a puncture resistant container nearby.
■ Use each needle and syringe only once.
■ Do not recap, bend or break needles after
giving an injection.
■ Drop all used (disposable) needles, plastic
syringes and blades directly into this
container, without recapping, and without
passing to another person.
■ Empty or send for incineration when the
container is three-quarters full.
Practice safe waste disposal
■ Dispose of placenta or blood, or body fluid
contaminated items, in leak-proof containers.
■ Burn or bury contaminated solid waste.
■ Wash hands, gloves and containers after
disposal of infectious waste.
■ Pour liquid waste down a drain or flushable toilet.
■ Wash hands after disposal of infectious waste.
Deal with contaminated
laundry
■ Collect clothing or sheets stained with blood
or body fluids and keep them separately from
other laundry, wearing gloves or use a plastic
bag. do not touch them directly.
■ Rinse off blood or other body fluids before
washing with soap.
Sterilize and clean contaminated
equipment
■ Make sure that instruments which penetrate
the skin (such as needles) are adequately
sterilized, or that single-use instruments are
disposed of after one use.
■ Thoroughly clean or disinfect any equipment
which comes into contact with intact skin
(according to instructions).
■ Use bleach for cleaning bowls and buckets,
and for blood or body fluid spills.
Clean and
disinfect gloves
■ Wash the gloves in soap and water.
■ Check for damage: Blow gloves full of air, twist
the cuff closed, then hold under clean water
and look for air leaks. Discard if damaged.
■ Soak overnight in bleach solution with 0.5%
available chlorine (made by adding 90 ml
water to 10 ml bleach containing 5% available
chlorine).
■ Dry away from direct sunlight.
■ Dust inside with talcum powder or starch.
This produces disinfected gloves. They are not
sterile.
Good quality latex gloves can be disinfected 5 or
more times.

Sterilize gloves
■ Sterilize by autoclaving or highly disinfect by
steaming or boiling.
stAndArd PrecAutions And cleAnliness
A5
Organizing a visit
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Receive and
respond immediately
receive every woman and newborn baby
seeking care immediately after arrival (or
organize reception by another provider).
■ Perform Quick Check on all new incoming
women and babies and those in the waiting
room, especially if no-one is receiving them B2 .
■ At the first emergency sign on Quick
Check, begin emergency assessment and
management (RAM) B-B7 for the woman, or
examine the newborn J-J .
■ If she is in labour, accompany her to an
appropriate place and follow the steps as in
Childbirth: labour, delivery and immediate
postpartum care d-d29.
■ If she has priority signs, examine her
immediately using Antenatal care,
Postpartum or Post-abortion care charts
c-c9 e-e0 B8-B22.
■ If no emergency or priority sign on RAM or not
in labour, invite her to wait in the waiting room.
■ If baby is newly born, looks small, examine
immediately. Do not let the mother wait in the
queue.
Begin each emergency care visit
■ Introduce yourself.
■ Ask the name of the woman.
■ Encourage the companion to stay with the woman.
■ Explain all procedures, ask permission,
and keep the woman informed as much as
you can about what you are doing. If she is
unconscious, talk to the companion.
■ Ensure and respect privacy during
examination and discussion.
■ If she came with a baby and the baby is
well, ask the companion to take care of the
baby during the maternal examination and
treatment.
Care of woman or baby referred for
special care to secondary level facility
■ When a woman or baby is referred to a
secondary level care facility because of
a specific problem or complications, the
underlying assumption of the Guide is that,
at referral level, the woman/baby will be
assessed, treated, counselled and advised
on follow-up for that particular condition/
complication.
■ Follow-up for that specific condition will be
either:
→ organized by the referral facility or
→ written instructions will be given to the
woman/baby for the skilled attendant at
the primary level who referred the woman/
baby.
→ the woman/baby will be advised to go for a
follow-up visit within 2 weeks according to
severity of the condition.
■ Routine care continues at the primary care
level where it was initiated.
Begin each routine visit
(for the woman and/or the baby)
■ Greet the woman and offer her a seat.
■ Introduce yourself.
■ Ask her name (and the name of the baby).
■ Ask her:
→ Why did you come? For yourself or for your
baby?
→ For a scheduled (routine) visit?
→ For specific complaints about you or your
baby?
→ First or follow-up visit?
→ Do you want to include your companion or
other family member (parent if adolescent)
in the examination and discussion?
■ If the woman is recently delivered, assess the
baby or ask to see the baby if not with the mother.
■ If antenatal care, always revise the birth plan at
the end of the visit after completing the chart.
■ For a postpartum visit, if she came with the
baby, also examine the baby:
→ Follow the appropriate charts according
to pregnancy status/age of the baby and
purpose of visit.
→ Follow all steps on the chart and in relevant
boxes.
■ Unless the condition of the woman or the
baby requires urgent referral to hospital, give
preventive measures if due even if the woman
has a condition "in yellow" that requires
special treatment.
■ If follow-up visit is within a week, and if no
other complaints:
→ Assess the woman for the specific condition
requiring follow-up only
→ Compare with earlier assessment and re-
classify.
■ If a follow-up visit is more than a week after
the initial examination (but not the next
scheduled visit):
→ Repeat the whole assessment as required
for an antenatal, post-abortion, postpartum
or newborn visit according to the schedule
→ If antenatal visit, revise the birth plan.
During the visit
■ Explain all procedures,
■ Ask permission before undertaking an
examination or test.
■ Keep the woman informed throughout.
Discuss findings with her (and her partner).
■ Ensure privacy during the examination and
discussion.
At the end of the visit
■ Ask the woman if she has any questions.
■ Summarize the most important messages with her.
■ Encourage her to return for a routine visit (tell
her when) and if she has any concerns.
■ Fill the Home-Based Maternal Record (HBMR)
and give her the appropriate information sheet.
■ Ask her if there are any points which need to be
discussed and would she like support for this.
orgAnizing A visit
Quick check, rapid assessment and management of women of childbearing age
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Quick check, rapid assessment and management of women of childbearing age
Quick check
Quick check, rapid assessment and management of women of childbearing age
ASK, CHECK RECORD
■ Why did you come? → for yourself? → for the baby? ■ How old is the baby? ■ What is the concern?
LOOK, LISTEN, FEEL
is the woman being wheeled or carried in or: ■ bleeding vaginally ■ convulsing ■ looking very ill ■ unconscious ■ in severe pain ■ in labour ■ delivery is imminent
check if baby is or has: ■ very small ■ convulsing ■ breathing difficulty
SIGNS
If the woman is or has: ■ unconscious (does not answer) ■ convulsing ■ bleeding ■ severe abdominal pain or looks very ill ■ headache and visual disturbance ■ severe difficulty breathing ■ fever ■ severe vomiting.
■ Imminent delivery or ■ Labour
If the baby is or has: ■ very small ■ convulsions ■ difficult breathing ■ just born ■ any maternal concern.
■ Pregnant woman, or after delivery, with no danger signs ■ A newborn with no danger signs or maternal complaints.
TREAT
■ Transfer woman to a treatment room for Rapid assessment and management b3-b7 . ■ Call for help if needed. ■ Reassure the woman that she will be taken care of immediately. ■ Ask her companion to stay.
■ Transfer the woman to the labour ward. ■ Call for immediate assessment.
■ Transfer the baby to the treatment room for immediate Newborn care J-J . ■ Ask the mother to stay.
■ Keep the woman and baby in the waiting room for routine care.
CLASSIFY
emergency for woman
labour
emergency for baby
routine care
if emergency for woman or baby or labour, go to b3 . if no emergency, go to relevant section
Quick check
a person responsible for initial reception of women of childbearing age and newborns seeking care should:
■ assess the general condition of the careseeker(s) immediately on arrival
■ periodically repeat this procedure if the line is long.
if a woman is very sick, talk to her companion.
b2

Rapid assessment and management (RAM) Airway and breathing, circulation (shock)
next: Vaginal bleeding Quick check, rapid assessment and management of women of childbearing age
b3

This may be pneumonia, severe anaemia with heart failure, obstructed breathing, asthma.
This may be haemorrhagic shock, septic shock.
TREATMENT

■ Manage airway and breathing b9 . ■ refer woman urgently to hospital* b7 .
Measure blood pressure. If systolic BP < 90 mmHg or pulse >110 per minute: ■ Position the woman on her left side with legs higher than chest. ■ Insert an IV line b9 . ■ Give fluids rapidly b9 . ■ If not able to insert peripheral IV, use alternative b9 . ■ Keep her warm (cover her). ■ refer her urgently to hospital* b7 .
* But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on d-d28.
rapid assessment and management (ram)
use this chart for rapid assessment and management (ram) of all women of childbearing age, and also for women in labour, on first arrival and periodically throughout
labour, delivery and the postpartum period. assess for all emergency and priority signs and give appropriate treatments, then refer the woman to hospital.-
first assess
EMERGENCY SIGNS
do all emergency steps before referral
airway and breathing
■ Very difficult breathing or ■ Central cyanosis
circulation (shock)
■ Cold moist skin or ■ Weak and fast pulse
MEASuRE
■ Measure blood pressure ■ Count pulse

Rapid assessment and management (RAM) Vaginal bleeding
Quick check, rapid assessment and management of women of childbearing age
b4
PREGNANCY STATuS
early pregnancy not aware of pregnancy, or not pregnant (uterus NOT above umbilicus)
late pregnancy (uterus above umbilicus)
during labour before delivery of baby
BLEEDING
heavy bleeding Pad or cloth soaked in < 5 minutes.
light bleeding
any bleeding is dangerous
bleeding more than 00 ml since labour began
This may be abortion, menorrhagia, ectopic pregnancy.
This may be placenta previa, abruptio placentae, ruptured uterus.
This may be placenta previa, abruptio placenta, ruptured uterus.
TREATMENT
■ Insert an IV line b9 . ■ Give fluids rapidly b9 . ■ Give 0.2 mg ergometrine IM b0 . ■ Repeat 0.2 mg ergometrine IM/IV if bleeding continues. ■ If suspect possible complicated abortion, give appropriate IM/IV antibiotics b5 . ■ refer woman urgently to hospital b7 .
■ Examine woman as on b9 . ■ If pregnancy not likely, refer to other clinical guidelines.
do not do vaginal examination, but: ■ Insert an IV line b9 . ■ Give fluids rapidly if heavy bleeding or shock b3 . ■ refer woman urgently to hospital* b7 .
do not do vaginal examination, but: ■ Insert an IV line b9 . ■ Give fluids rapidly if heavy bleeding or shock b3 . ■ refer woman urgently to hospital* b7 .
* But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on d-d28.
vaginal bleeding
■ assess pregnancy status
■ assess amount of bleeding
next: Vaginal bleeding in postpartum �
Rapid assessment and management (RAM) Vaginal bleeding: postpartum
next: Convulsions or unconscious Quick check, rapid assessment and management of women of childbearing age
b5
PREGNANCY STATuS
postpartum (baby is born)
check and ask if placenta is delivered
check for perineal and lower vaginal tears
check if still bleeding
BLEEDING
heavy bleeding ■ Pad or cloth soaked in < 5 minutes ■ Constant trickling of blood ■ Bleeding>250ml or delivered outsidehealthcentreandstill bleeding
placenta not delivered
placenta delivered
check placenta b
if present
heavy bleeding
controlled bleeding
This may be uterine atony, retained placenta, ruptured uterus, vaginal or cervical tear.
TREATMENT
■ Call for extra help. ■ Massage uterus until it is hard and give oxytocin 10 Iu IM b0 . ■ Insert an IV line b9 and give IV fluids with 20 Iu oxytocin at 60 drops/minute. ■ Empty bladder. Catheterize if necessary b2 . ■ Check and record BP and pulse every 15 minutes and treat as on b3 .
■ When uterus is hard, deliver placenta by controlled cord traction d2 . ■ If unsuccessful and bleeding continues, remove placenta manually and check placenta b . ■ Give appropriate IM/IV antibiotics b5 . ■ If unable to remove placenta, refer woman urgently to hospital b7 . During transfer, continue IV fluids with 20 Iu of oxytocin at 30 drops/minute.
if placenta is complete: ■ Massage uterus to express any clots b0 . ■ If uterus remains soft, give ergometrine 0.2 mg IV b0 . do not give ergometrine to women with eclampsia, pre-eclampsia or known hypertension. ■ Continue IV fluids with 20 Iu oxytocin/litre at 30 drops/minute. ■ Continue massaging uterus till it is hard. if placenta is incomplete (or not available for inspection): ■ Remove placental fragments b . ■ Give appropriate IM/IV antibiotics b5 . ■ If unable to remove, refer woman urgently to hospital b7 .
■ Examine the tear and determine the degree b2 . If third degree tear (involving rectum or anus), refer woman urgently to hospital b7 . ■ For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. Do not cross ankles. ■ Check after 5 minutes, if bleeding persists repair the tear b2 .
■ Continue IV fluids with 20 units of oxytocin at 30 drops/minute. Insert second IV line. ■ Apply bimanual uterine or aortic compression b0 . ■ Give appropriate IM/IV antibiotics b5 . ■ refer woman urgently to hospital b7 .
■ Continue oxytocininfusionwith20Iu/litre of IVfluids at 20drops/minfor at least one hour after bleeding stops b0 . ■ Observe closely (every 30 minutes) for 4 hours. Keep nearby for 24 hours. If severe pallor, refer to health centre. ■ Examine the woman using Assess the mother after delivery d2 .

Rapid assessment and management (RAM) Emergency signs
Quick check, rapid assessment and management of women of childbearing age
b6
EMERGENCY SIGNS
■ Convulsing (now or recently), or ■ unconscious If unconscious, ask relative “has there been a recent convulsion?”
■ Severe abdominal pain (not normal labour)
Fever (temperature more than 38ºC) and any of: ■ Very fast breathing ■ Stiff neck ■ Lethargy ■ Very weak/not able to stand
This may be eclampsia.
This may be ruptured uterus, obstructed labour, abruptio placenta, puerperal or post- abortion sepsis, ectopic pregnancy.
This may be malaria, meningitis, pneumonia, septicemia.
convulsions or unconscious
severe abdominal pain
dangerous fever
TREATMENT
■ Protect woman from fall and injury. Get help. ■ Manage airway b9 . ■ After convulsion ends, help woman onto her left side. ■ Insert an IV line and give fluids slowly (30 drops/min) b9 . ■ Give magnesium sulphate b3 . ■ If early pregnancy, give diazepam IV or rectally b4 . ■ If diastolic BP >110mm of Hg, give antihypertensive b4 . ■ If temperature >38ºC, or history of fever, also give treatment for dangerous fever (below). ■ refer woman urgently to hospital* b7 .
measure bp and temperature ■ If diastolic BP >110mm of Hg, give antihypertensive b4 . ■ If temperature >38ºC, or history of fever, also give treatment for dangerous fever (below). ■ refer woman urgently to hospital* b7 .
■ Insert an IV line and give fluids b9 . ■ If temperature more than 38ºC, give first dose of appropriate IM/IV antiobiotics b5 . ■ refer woman urgently to hospital* b7 . ■ If systolic BP <90 mm Hg see b3 .
■ Insert an IV line b9 . ■ Give fluids slowly b9 . ■ Give first dose of appropriate IM/IV antibiotics b5 . ■ Give artemether IM (if not available, give quinine IM) and glucose b6 . ■ refer woman urgently to hospital* b7 .
* But if birth is imminent (bulging, thin perineum during contractions, visible fetal head), transfer woman to labour room and proceed as on d-d28.
MEASuRE
■ Measure blood pressure ■ Measure temperature ■ Assess pregnancy status
■ Measure blood pressure ■ Measure temperature
■ Measure temperature
next: Priority signs �
Rapid assessment and management (RAM) Priority signs
Quick check, rapid assessment and management of women of childbearing age
b7
PRIORITY SIGNS
■ Labour pains or ■ Ruptured membranes
If any of: ■ Severe pallor ■ Epigastric or abdominal pain ■ Severe headache ■ Blurred vision ■ Fever (temperature more than 38ºC) ■ Breathing difficulty
■ No emergency signs or ■ No priority signs
TREATMENT
■ Manage as for Childbirth d-d28.
■ If pregnant (and not in labour), provide antenatal care c-c8. ■ If recently given birth, provide postpartum care d2 . and e-e0 . ■ If recent abortion, provide post-abortion care b20-b2. ■ If early pregnancy, or not aware of pregnancy, check for ectopic pregnancy b9 .
■ If pregnant (and not in labour), provide antenatal care c-c8. ■ If recently given birth, provide postpartum care e-e0 .
labour
other danger signs or symptoms
if no emergency or priority signs, non urgent
MEASuRE
■ Measure blood pressure ■ Measure temperature
B2

Quick check
B3 rapid assessment and
management (ram) ()
Airwayandbreathing
Circulationandshock
B4 rapid assessment and
management (ram) (2)
Vaginalbleeding
B5 rapid assessment and
management (ram) (3)
Vaginalbleeding:postpartum
B6 rapid assessment and
management (ram) (4)
Convulsions
Severeabdominalpain
Dangerousfever
B7 rapid assessment and
management (ram) (5)
prioritysigns
Labour
Otherdangersignsorsymptoms
Non-urgent
■ PerformQuickcheckimmediatelyafterthewomanarrives b2 .
Ifanydangersignisseen,helpthewomanandsendherquicklytotheemergencyroom.
■ AlwaysbeginaclinicalvisitwithRapidassessmentandmanagement(RAM) b3-b7 :
→Checkforemergencysignsfirst b3-b6 .
Ifpresent,provideemergencytreatmentandreferthewomanurgentlytohospital.
Completethereferralform n2 .
→Checkforprioritysigns.Ifpresent,manageaccordingtocharts b7 .
→Ifnoemergencyorprioritysigns,allowthewomantowaitinlineforroutinecare,accordingtopregnancystatus.
Quick check
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ASK,CHECKRECORD
■ Whydidyoucome?
→foryourself?
→ forthebaby?
■ Howoldisthebaby?
■ Whatistheconcern?
LOOK,LISTEN,FEEL
is the woman being wheeled or
carried in or:
■ bleedingvaginally
■ convulsing
■ lookingveryill
■ unconscious
■ inseverepain
■ inlabour
■ deliveryisimminent
check if baby is or has:
■ verysmall
■ convulsing
■ breathingdifficulty
SIGNS
Ifthewomanisorhas:
■ unconscious(doesnotanswer)
■ convulsing
■ bleeding
■ severeabdominalpainorlooksveryill
■ headacheandvisualdisturbance
■ severedifficultybreathing
■ fever
■ severevomiting.
■ Imminentdeliveryor
■ Labour
Ifthebabyisorhas:
■ verysmall
■ convulsions
■ difficultbreathing
■ justborn
■ anymaternalconcern.
■ Pregnantwoman,orafterdelivery,
withnodangersigns
■ Anewbornwithnodangersignsor
maternalcomplaints.
TREAT
■ TransferwomantoatreatmentroomforRapid
assessmentandmanagement b3-b7 .
■ Callforhelpifneeded.
■ Reassurethewomanthatshewillbetakencareof
immediately.
■ Askhercompaniontostay.
■ Transferthewomantothelabourward.
■ Callforimmediateassessment.
■ Transferthebabytothetreatmentroomfor
immediateNewborncare J-J .
■ Askthemothertostay.
■ Keepthewomanandbabyinthewaitingroomfor
routinecare.
CLASSIFY
emergency
for woman
labour
emergency
for baby
routine care
ifemergencyforwomanorbabyorlabour,goto b3 .
ifnoemergency,gotorelevantsection
Quick check
a person responsible for initial reception of women of childbearing age and newborns seeking care should:
■ assessthegeneralconditionofthecareseeker(s)immediatelyonarrival
■ periodicallyrepeatthisprocedureifthelineislong.
if a woman is very sick, talk to her companion.
b2
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Rapid assessment and management (RAM) Airway and breathing, circulation (shock)
next:Vaginalbleeding
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b3

This may be pneumonia, severe
anaemia with heart failure,
obstructed breathing, asthma.
This may be haemorrhagic shock,
septic shock.
TREATMENT

■ Manageairwayandbreathing b9 .
■ refer woman urgently to hospital* b7 .
Measurebloodpressure.IfsystolicBP<90mmHgorpulse>110perminute:
■ Positionthewomanonherleftsidewithlegshigherthanchest.
■ InsertanIVline b9 .
■ Givefluidsrapidly b9 .
■ IfnotabletoinsertperipheralIV,usealternative b9 .
■ Keepherwarm(coverher).
■ refer her urgently to hospital* b7 .
*Butifbirthisimminent(bulging,thinperineumduringcontractions,visible
fetalhead),transferwomantolabourroomandproceedason d-d28.
rapid assessment and management (ram)
use this chart for rapid assessment and management (ram) of all women of childbearing age, and also for women in labour, on first arrival and periodically throughout
labour, delivery and the postpartum period. assess for all emergency and priority signs and give appropriate treatments, then refer the woman to hospital.-
first assess
EMERGENCYSIGNS
do all emergency steps before referral
airway and breathing
■ Verydifficultbreathingor
■ Centralcyanosis

circulation (shock)
■ Coldmoistskinor
■ Weakandfastpulse
MEASuRE
■ Measurebloodpressure
■ Countpulse
t
Rapid assessment and management (RAM) Vaginal bleeding
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b4
PREGNANCYSTATuS
early pregnancy
notawareofpregnancy,ornotpregnant
(uterusNOTaboveumbilicus)
late pregnancy
(uterusaboveumbilicus)
during labour
beforedeliveryofbaby
BLEEDING
heavy bleeding
Padorclothsoakedin<5minutes.
light bleeding
any bleeding is dangerous
bleeding
more than 00 ml
since labour began
This may be abortion,
menorrhagia, ectopic pregnancy.
This may be placenta previa,
abruptio placentae, ruptured
uterus.
This may be
placenta previa, abruptio
placenta, ruptured uterus.
TREATMENT
■ InsertanIVline b9 .
■ Givefluidsrapidly b9 .
■ Give0.2mgergometrineIM b0 .
■ Repeat0.2mgergometrineIM/IVifbleedingcontinues.
■ Ifsuspectpossiblecomplicatedabortion,giveappropriateIM/IVantibiotics b5 .
■ refer woman urgently to hospital b7 .
■ Examinewomanason b9 .
■ Ifpregnancynotlikely,refertootherclinicalguidelines.
do not do vaginal examination, but:
■ InsertanIVline b9 .
■ Givefluidsrapidlyifheavybleedingorshock b3 .
■ refer woman urgently to hospital* b7 .
do not do vaginal examination, but:
■ InsertanIVline b9 .
■ Givefluidsrapidlyifheavybleedingorshock b3 .
■ refer woman urgently to hospital* b7 .
*Butifbirthisimminent(bulging,thinperineumduringcontractions,visible
fetalhead),transferwomantolabourroomandproceedason d-d28.
vaginal bleeding
■ assess pregnancy status
■ assess amount of bleeding
next:Vaginalbleedinginpostpartum
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Rapid assessment and management (RAM) Vaginal bleeding: postpartum
next:Convulsionsorunconscious
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b5
PREGNANCYSTATuS
postpartum
(babyisborn)

check and ask if placenta is delivered

check for perineal and lower
vaginal tears

check if still bleeding
BLEEDING
heavy bleeding
■ Padorclothsoakedin<5minutes
■ Constanttricklingofblood
■ Bleeding>250mlordeliveredoutside
healthcentreandstillbleeding
placenta not delivered
placenta delivered

check placenta b
if present
heavy bleeding
controlled bleeding
This may be uterine atony,
retained placenta, ruptured
uterus, vaginal or cervical tear.
TREATMENT
■ Callforextrahelp.
■ Massageuterusuntilitishardandgiveoxytocin10IuIM b0 .
■ InsertanIVline b9 andgiveIVfluidswith20Iuoxytocinat60drops/minute.
■ Emptybladder.Catheterizeifnecessary b2 .
■ CheckandrecordBPandpulseevery15minutesandtreatason b3 .
■ Whenuterusishard,deliverplacentabycontrolledcordtraction d2 .
■ Ifunsuccessfulandbleedingcontinues,removeplacentamanuallyandcheckplacenta b .
■ GiveappropriateIM/IVantibiotics b5 .
■ Ifunabletoremoveplacenta,referwomanurgentlytohospital b7 .
Duringtransfer,continueIVfluidswith20Iuofoxytocinat30drops/minute.
if placenta is complete:
■ Massageuterustoexpressanyclots b0 .
■ Ifuterusremainssoft,giveergometrine0.2mgIV b0 .
do notgiveergometrinetowomenwitheclampsia,pre-eclampsiaorknownhypertension.
■ ContinueIVfluidswith20Iuoxytocin/litreat30drops/minute.
■ Continuemassaginguterustillitishard.
if placenta is incomplete (or not available for inspection):
■ Removeplacentalfragments b .
■ GiveappropriateIM/IVantibiotics b5 .
■ Ifunabletoremove,referwomanurgentlytohospital b7 .
■Examinethetearanddeterminethedegree b2 .
Ifthirddegreetear(involvingrectumoranus),referwomanurgentlytohospital b7 .
■ Forothertears:applypressureoverthetearwithasterilepadorgauzeandputlegstogether.Donotcrossankles.
■ Checkafter5minutes,ifbleedingpersistsrepairthetear b2 .
■ ContinueIVfluidswith20unitsofoxytocinat30drops/minute.InsertsecondIVline.
■ Applybimanualuterineoraorticcompression b0 .
■ GiveappropriateIM/IVantibiotics b5 .
■ refer woman urgently to hospital b7 .
■ Continueoxytocininfusionwith20Iu/litreofIVfluidsat20drops/minforatleastonehourafterbleedingstops b0 .
■ Observeclosely(every30minutes)for4hours.Keepnearbyfor24hours.Ifseverepallor,refertohealthcentre.
■ ExaminethewomanusingAssess the mother after delivery d2 .
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Rapid assessment and management (RAM) Emergency signs
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b6
EMERGENCYSIGNS
■ Convulsing(noworrecently),or
■ unconscious
Ifunconscious,askrelative
“hastherebeenarecentconvulsion?”
■ Severeabdominalpain(notnormallabour)
Fever(temperaturemorethan38ºC)
andanyof:
■ Veryfastbreathing
■ Stiffneck
■ Lethargy
■ Veryweak/notabletostand
This may be eclampsia.
This may be ruptured uterus,
obstructed labour, abruptio
placenta, puerperal or post-
abortion sepsis, ectopic
pregnancy.
This may be malaria,
meningitis, pneumonia,
septicemia.
convulsions or unconscious
severe abdominal pain
dangerous fever
TREATMENT
■ Protectwomanfromfallandinjury.Gethelp.
■ Manageairway b9 .
■ Afterconvulsionends,helpwomanontoherleftside.
■ InsertanIVlineandgivefluidsslowly(30drops/min) b9 .
■ Givemagnesiumsulphate b3 .
■ Ifearlypregnancy,givediazepamIVorrectally b4 .
■ IfdiastolicBP>110mmofHg,giveantihypertensive b4 .
■ Iftemperature>38ºC,orhistoryoffever,alsogivetreatmentfordangerous
fever(below).
■ refer woman urgently to hospital* b7 .
measure bp and temperature
■ IfdiastolicBP>110mmofHg,giveantihypertensive b4 .
■ Iftemperature>38ºC,orhistoryoffever,alsogivetreatmentfordangerous
fever(below).
■ refer woman urgently to hospital* b7 .
■ InsertanIVlineandgivefluids b9 .
■ Iftemperaturemorethan38ºC,givefirstdoseofappropriateIM/IV
antiobiotics b5 .
■ refer woman urgently to hospital* b7 .
■ IfsystolicBP<90mmHgsee b3 .
■ InsertanIVline b9 .
■ Givefluidsslowly b9 .
■ GivefirstdoseofappropriateIM/IVantibiotics b5 .
■ GiveartemetherIM(ifnotavailable,givequinineIM)andglucose b6 .
■ refer woman urgently to hospital* b7 .
*Butifbirthisimminent(bulging,thinperineumduringcontractions,visible
fetalhead),transferwomantolabourroomandproceedason d-d28.
MEASuRE
■ Measurebloodpressure
■ Measuretemperature
■ Assesspregnancystatus
■ Measurebloodpressure
■ Measuretemperature
■ Measuretemperature
next:Prioritysigns
t
Rapid assessment and management (RAM) Priority signs
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b7
PRIORITYSIGNS
■ Labourpainsor
■ Rupturedmembranes
Ifanyof:
■ Severepallor
■ Epigastricorabdominalpain
■ Severeheadache
■ Blurredvision
■ Fever(temperaturemorethan38ºC)
■ Breathingdifficulty
■ Noemergencysignsor
■ Noprioritysigns
TREATMENT
■ ManageasforChildbirth d-d28.
■ Ifpregnant(andnotinlabour),provideantenatalcare c-c9.
■ Ifrecentlygivenbirth,providepostpartumcare d2 .and e-e0 .
■ Ifrecentabortion,providepost-abortioncareb20-b2.
■ Ifearlypregnancy,ornotawareofpregnancy,checkforectopicpregnancy b9 .
■ Ifpregnant(andnotinlabour),provideantenatalcare c-c9.
■ Ifrecentlygivenbirth,providepostpartumcare e-e0 .
labour
other danger signs or symptoms
if no emergency or priority signs, non urgent
MEASuRE
■ Measurebloodpressure
■ Measuretemperature
Emergency treatments for the woman
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EmErgEncy trEatmEnts for thE woman
airway, BrEathingand circulation
Airway, breathing and circulation
Em
ErgEncy trEatm
Ents for thE w
om
an
B
Manage the airway and breathing
If the woman has great difficulty breathing and:
■ If you suspect obstruction:
→Try to clear the airway and dislodge obstruction
→Help the woman to find the best position for breathing
→urgently refer the woman to hospital.
■ If the woman is unconscious:
→Keep her on her back, arms at the side
→Tilt her head backwards (unless trauma is suspected)
→Lift her chin to open airway
→Inspect her mouth for foreign body; remove if found
→Clear secretions from throat.
■ If the woman is not breathing:
→Ventilate with bag and mask until she starts breathing spontaneously
■ If woman still has great difficulty breathing, keep her propped up, and
■ refer the woman urgently to hospital.
Insert IV line and give fluids
■ Wash hands with soap and water and put on gloves.
■ Clean woman’s skin with spirit at site for IV line.
■ Insert an intravenous line (IV line) using a 16-18 gauge needle.
■ Attach Ringer’s lactate or normal saline. Ensure infusion is running well.
Give fluids at rapid rate if shock, systolic BP<90 mmHg, pulse>110/minute, or heavy vaginal bleeding:
■ Infuse 1 litre in 15-20 minutes (as rapid as possible).
■ Infuse 1 litre in 30 minutes at 30 ml/minute. Repeat if necessary.
■ Monitor every 15 minutes for:
→blood pressure (BP) and pulse
→shortness of breath or puffiness.
■ Reduce the infusion rate to 3 ml/minute (1 litre in 6-8 hours) when pulse slows to less than 100/
minute, systolic BP increases to 100 mmHg or higher.
■ Reduce the infusion rate to 0.5 ml/minute if breathing difficulty or puffiness develops.
■ Monitor urine output.
■ Record time and amount of fluids given.
Give fluids at moderate rate if severe abdominal pain, obstructed labour, ectopic pregnancy, dangerous
fever or dehydration:
■ Infuse 1 litre in 2-3 hours.
Give fluids at slow rate if severe anaemia/severe pre-eclampsia or eclampsia:
■ Infuse 1 litre in 6-8 hours.
If intravenous access not possible
■ Give oral rehydration solution (ORS) by mouth if able to drink, or by nasogastric (NG) tube.
■ Quantity of ORS: 300 to 500 ml in 1 hour.
do not give ORS to a woman who is unconscious or has convulsions.
BlEEding
Bleeding (1)
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B10
Massage uterus and expel clots
If heavy postpartumbleeding persists after placenta is delivered, or uterus is not well contracted (is soft):
■ Place cupped palm on uterine fundus and feel for state of contraction.
■ Massage fundus in a circular motion with cupped palm until uterus is well contracted.
■ When well contracted, place fingers behind fundus and push down in one swift action to expel clots.
■ Collect blood in a container placed close to the vulva. Measure or estimate blood loss, and record.
Apply bimanual uterine compression
If heavy postpartum bleeding persists despite uterine massage, oxytocin/ergometrine treatment and
removal of placenta:
■ Wear sterile or clean gloves.
■ Introduce the right hand into the vagina, clenched fist, with the back of the hand directed posteriorly
and the knuckles in the anterior fornix.
■ Place the other hand on the abdomen behind the uterus and squeeze the uterus firmly between the
two hands.
■ Continue compression until bleeding stops (no bleeding if the compression is released).
■ If bleeding persists, apply aortic compression and transport woman to hospital.
Apply aortic compression
If heavy postpartum bleeding persists despite uterine massage, oxytocin/ergometrine treatment and
removal of placenta:
■ Feel for femoral pulse.
■ Apply pressure above the umbilicus to stop bleeding. Apply sufficient pressure until femoral pulse is not felt.
■ After finding correct site, show assistant or relative how to apply pressure, if necessary.
■ Continue pressure until bleeding stops. If bleeding persists, keep applying pressure while transporting
woman to hospital.
Give oxytocin
If heavy postpartum bleeding
initial dose continuing dose maximum dose
IM/IV: 10 IU IM/IV: repeat 10 IU
after 20 minutes Not more than 3 litres
if heavy bleeding persists of IV fluids containing
IV infusion: IV infusion: oxytocin
20 IU in 1 litre 10 IU in 1 litre
at 60 drops/min at 30 drops/min

Give ergometrine
If heavy bleeding in early pregnancy or postpartum bleeding (after oxytocin) but
do not give if eclampsia, pre-eclampsia, or hypertension
initial dose continuing dose maximum dose
IM/IV:0.2 mg IM: repeat 0.2 mg Not more than
slowly IM after 15 minutes if heavy 5 doses (total 1.0 mg)
bleeding persists
Bleeding (2)
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B11
Remove placenta and fragments manually
■ If placenta not delivered 1 hour after delivery of the baby, OR
■ If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered
by controlled cord traction, or if placenta is incomplete and bleeding continues.
preparation
■ Explain to the woman the need for manual removal of the placenta and obtain her consent.
■ Insert an IV line. If bleeding, give fluids rapidly. If not bleeding, give fluids slowly B .
■ Assist woman to get onto her back.
■ Give diazepam (10-mg IM/IV).
■ Clean vulva and perineal area.
■ Ensure the bladder is empty. Catheterize if necessary B12 .
■ Wash hands and forearms well and put on long sterile gloves (and an apron or gown if available).
technique
■ With the left hand, hold the umbilical cord with the clamp. Then pull the cord gently until it is
horizontal.
■ Insert right hand into the vagina and up into the uterus.
■ Leave the cord and hold the fundus with the left hand in order to support the fundus of the uterus
and to provide counter-traction during removal.
■ Move the fingers of the right hand sideways until edge of the placenta is located.
■ Detach the placenta from the implantation site by keeping the fingers tightly together and using the
edge of the hand to gradually make a space between the placenta and the uterine wall.
■ Proceed gradually all around the placental bed until the whole placenta is detached fromthe uterine
wall.
■ Withdraw the right hand from the uterus gradually, bringing the placenta with it.
■ Explore the inside of the uterine cavity to ensure all placental tissue has been removed.
■ With the left hand, provide counter-traction to the fundus through the abdomen by pushing it in the
opposite direction of the hand that is being withdrawn. This prevents inversion of the uterus.
■ Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. If
any placental lobe or tissue fragments are missing, explore again the uterine cavity to remove them.
if hours or days have passed since delivery, or if the placenta is retained due to constriction ring
or closed cervix, it may not be possible to put the hand into the uterus. do not persist. refer
urgently to hospital B17 .
if the placenta does not separate from the uterine surface by gentle sideways movement of the
fingertips at the line of cleavage, suspect placenta accreta. do not persist in efforts to remove
placenta. refer urgently to hospital B17 .
After manual removal of the placenta
■ Repeat oxytocin 10-IU IM/IV.
■ Massage the fundus of the uterus to encourage a tonic uterine contraction.
■ Give ampicillin 2 g IV/IM B15 .
■ If fever >38.5°C, foul-smelling lochia or history of rupture of membranes for 18 or more hours, also
give gentamicin 80 mg IM B15 .
■ If bleeding stops:
→give fluids slowly for at least 1 hour after removal of placenta.
■ If heavy bleeding continues:
→give ergometrine 0.2 mg IM
→give 20 IU oxytocin in each litre of IV fluids and infuse rapidly
→refer urgently to hospital B17 .
■ During transportation, feel continuously whether uterus is well contracted (hard and round). If not,
massage and repeat oxytocin 10 IU IM/IV.
■ Provide bimanual or aortic compression if severe bleeding before and during transportation B10 .
rEpair thE tEar and Empty BladdEr
Bleeding (3)
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Repair the tear or episiotomy
■ Examine the tear and determine the degree:
→The tear is small and involved only vaginal mucosa and connective tissues and underlying
muscles (first or second degree tear). If the tear is not bleeding, leave the wound open.
→The tear is long and deep through the perineumand involves the anal sphincter and rectal mucosa
(third and fourth degree tear). Cover it with a clean pad and refer the woman urgently to hospital B17 .
■ If first or second degree tear and heavy bleeding persists after applying pressure over the wound:
→Suture the tear or refer for suturing if no one is available with suturing skills.
→Suture the tear using universal precautions, aseptic technique and sterile equipment.
→Use a needle holder and a 21 gauge, 4 cm, curved needle.
→Use absorbable polyglycon suture material.
→Make sure that the apex of the tear is reached before you begin suturing.
→Ensure that edges of the tear match up well.
do not suture if more than 12 hours since delivery. refer woman to hospital.
Empty bladder
If bladder is distended and the woman is unable to pass urine:
■ Encourage the woman to urinate.
■ If she is unable to urinate, catheterize the bladder:
→Wash hands
→Clean urethral area with antiseptic
→Put on clean gloves
→Spread labia. Clean area again
→Insert catheter up to 4 cm
→Measure urine and record amount
→Remove catheter.
Eclampsia and prE-Eclampsia (1)
Eclampsia and pre-eclampsia (1)
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B13
Give magnesium sulphate
If severe pre-eclampsia and eclampsia
iV/imcombined dose (loading dose)
■ Insert IV line and give fluids slowly (normal saline or Ringer’s lactate) —
1 litre in 6-8 hours (3-ml/minute) B .
■ Give 4-g of magnesium sulphate (20 ml of 20% solution) IV slowly over 20 minutes
(woman may feel warm during injection).
and:
■ Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% solution) IM deep in upper outer
quadrant of each buttock with 1 ml of 2% lignocaine in the same syringe.
if unable to give iV, give imonly (loading dose)
■ Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% solution) IM deep in upper outer
quadrant of each buttock with 1 ml of 2% lignocaine in the same syringe.
if convulsions recur
■ After 15 minutes, give an additional 2 g of magnesium sulphate (10 ml of 20% solution) IV
over 20 minutes. If convulsions still continue, give diazepam B14 .
if referral delayed for long, or the woman is in late labour, continue treatment:
■ Give 5 g of 50% magnesium sulphate solution IM with 1 ml of 2% lignocaine every 4 hours in
alternate buttocks until 24 hours after birth or after last convulsion (whichever is later).
■ Monitor urine output: collect urine and measure the quantity.
■ Before giving the next dose of magnesium sulphate, ensure:
→knee jerk is present
→urine output >100 ml/4 hrs
→respiratory rate >16/min.
■ do not give the next dose if any of these signs:
→knee jerk absent
→urine output <100 ml/4 hrs
→respiratory rate <16/min.
■ Record findings and drugs given.
Important considerations in caring for
a woman with eclampsia or pre-eclampsia
■ Do not leave the woman on her own.
→Help her into the left side position and protect her from fall and injury
→Place padded tongue blades between her teeth to prevent a tongue bite, and secure it to prevent
aspiration (do not attempt this during a convulsion).
■ Give IV 20% magnesium sulphate slowly over 20 minutes. Rapid injection can cause respiratory
failure or death.
→If respiratory depression (breathing less than 16/minute) occurs after magnesium sulphate, do
not give any more magnesium sulphate. Give the antidote: calcium gluconate 1 g IV (10 ml of
10% solution) over 10 minutes.
■ do not give intravenous fluids rapidly.
■ do not give intravenously 50% magnesium sulphate without dilluting it to 20%.
■ refer urgently to hospital unless delivery is imminent.
→If delivery imminent, manage as in Childbirth d1-d2and accompany the woman during
transport
→Keep her in the left side position
→If a convulsion occurs during the journey, give magnesiumsulphate and protect her fromfall and
injury.
formulation of magnesium sulphate
50% solution: 20% solution: to make 10 ml of 20% solution, vial containing 5 g in 10 ml (1g/2ml) add 4 ml of 50% solution to 6 ml sterile water
im 5 g 10 ml and 1 ml 2% lignocaine Not applicable
iV 4 g 8 ml 20 ml
2 g 4 ml 10 ml
After receiving magnesium sulphate a woman feel flushing, thirst, headache, nausea or may vomit.
B9

airway, BrEathing and
circulation
Managetheairwayandbreathing
InsertIVlineandgivefluids
B10 BlEEding (1)
Massageuterusandexpelclots
Applybimanualuterinecompression
Applyaorticcompression
Giveoxytocin
Giveergometrine
B11 BlEEding (2)
Removeplacentaandfragmentsmanually
Aftermanualremovaloftheplacenta
B12 BlEEding (3)
Repairthetear
Emptybladder
B13 Eclampsia and
prE-Eclampsia (1)
Importantconsiderationsincaringfora
womanwitheclampsiaandpre-eclampsia
Givemagnesiumsulphate
Eclampsia and prE-Eclampsia (2)
Eclampsia and pre-eclampsia (2)
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B14
Give diazepam
If convulsions occur in early pregnancy or
If magnesium sulphate toxicity occurs or magnesium sulphate is not available.
loading dose iV
■ Give diazepam 10 mg IV slowly over 2 minutes.
■ If convulsions recur, repeat 10 mg.
maintenance dose
■ Give diazepam 40 mg in 500 ml IV fluids (normal saline or Ringer’s lactate) titrated over 6-8 hours
to keep the woman sedated but rousable.
■ Stop the maintenance dose if breathing <16 breaths/minute.
■ Assist ventilation if necessary with mask and bag.
■ Do not give more than 100 mg in 24 hours.
■ If IV access is not possible (e.g. during convulsion), give diazepam rectally.
loading dose rectally
■ Give 20 mg (4 ml) in a 10 ml syringe (or urinary catheter):
→Remove the needle, lubricate the barrel and insert the syringe into the rectum to half its length.
→Discharge the contents and leave the syringe in place, holding the buttocks together for 10
minutes to prevent expulsion of the drug.
■ If convulsions recur, repeat 10 mg.
maintenance dose
■ Give additional 10 mg (2 ml) every hour during transport.
diazepam: vial containing 10 mg in 2 ml
iV rectally
initial dose 10 mg = 2 ml 20 mg = 4 ml
second dose 10 mg = 2 ml 10 mg = 2 ml
Give appropriate antihypertensive drug
If diastolic blood pressure is > 110-mmHg:
■ Give hydralazine 5 mg IV slowly (3-4 minutes). If IV not possible give IM.
■ If diastolic blood pressure remains > 90 mmHg, repeat the dose at 30 minute intervals until
diastolic BP is around 90 mmHg.
■ Do not give more than 20 mg in total.
infEction
Infection
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B15
Give appropriate IV/IM antibiotics
■ Give the first dose of antibiotic(s) before referral. If referral is delayed or not possible, continue
antibiotics IM/IV for 48 hours after woman is fever free. Then give amoxicillin orally 500 mg 3 times
daily until 7 days of treatment completed.
■ If signs persist or mother becomes weak or has abdominal pain postpartum, refer urgently to hospital B17 .
condition antiBiotics
■ Severe abdominal pain 3 antibiotics
■ Dangerous fever/very severe febrile disease ■Ampicillin
■ Complicated abortion ■ Gentamicin
■ Uterine and fetal infection ■ Metronidazole
■ Postpartum bleeding 2 antibiotics:
→lasting > 24 hours ■Ampicillin
→occurring > 24 hours after delivery ■ Gentamicin
■ Upper urinary tract infection
■ Pneumonia
■ Manual removal of placenta/fragments 1 antibiotic:
■ Risk of uterine and fetal infection ■Ampicillin
■ In labour > 24 hours
antibiotic preparation dosage/route frequency
ampicillin Vial containing 500 mg as powder: First 2 g IV/IM then 1 g every 6 hours
to be mixed with 2.5 ml sterile water
gentamicin Vial containing 40 mg/ml in 2 ml 80 mg IM every 8 hours
metronidazole Vial containing 500 mg in 100 ml 500 mg or 100 ml IV infusion every 8 hours do not giVE im
Erythromycin Vial containing 500 mg as powder 500 mg IV/IM every 6 hours (if allergy to ampicillin)
malaria
Malaria
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Give arthemeter or quinine IM
If dangerous fever or very severe febrile disease
arthemeter Quinine*
1ml vial containing 80 mg/ml 2 ml vial containing 300 mg/ml
leading dose for 3.2 mg/kg 20 mg/kg
assumed weight 50-60 kg 2 ml 4 ml
continue treatment 1.6 mg/kg 10 mg/kg
if unable to refer 1 ml once daily for 3 days** 2 ml/8 hours for a total of 7 days**
■ Give the loading dose of the most effective drug, according to the national policy.
■ If quinine:
→divide the required dose equally into 2 injections and give 1 in each anterior thigh
→always give glucose with quinine.
■ Refer urgently to hospital B17 .
■ If delivery imminent or unable to refer immediately, continue treatment as above and refer after
delivery.
* These dosages are for quinine dihydrochloride. If quinine base, give 8.2 mg/kg every 8 hours.
** Discontinue parenteral treatment as soon as woman is conscious and able to swallow. Begin oral
treatment according to national guidelines.
Give glucose IV
If dangerous fever or very severe febrile disease treated with quinine
50% glucose solution* 25% glucose solution 10% glucose solution (5 ml/kg)
25-50 ml 50-100 ml 125-250 ml
■ Make sure IV drip is running well. Give glucose by slow IV push.
■ If no IV glucose is available, give sugar water by mouth or nasogastric tube.
■ To make sugar water, dissolve 4 level teaspoons of sugar (20 g) in a 200 ml cup of clean water.
* 50% glucose solution is the same as 50% dextrose solution or D50. This solution is irritating to
veins. Dilute it with an equal quantity of sterile water or saline to produce 25% glucose solution.
rEfEr thE woman urgEntly to thE hospital
Refer the woman urgently to hospital
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B17
Refer the woman urgently to hospital
■ After emergency management, discuss decision with woman and relatives.
■ Quickly organize transport and possible financial aid.
■ Inform the referral centre if possible by radio or phone.
■ Accompany the woman if at all possible, or send:
→ a health worker trained in delivery care
→ a relative who can donate blood
→ baby with the mother, if possible
→ essential emergency drugs and supplies B17 .
→ referral note n2 .
■ During journey:
→ watch IV infusion
→ if journey is long, give appropriate treatment on the way
→ keep record of all IV fluids, medications given, time of administration and the woman’s condition.
Essential emergency drugs and supplies
for transport and home delivery
Emergency drugs strength and form Quantity for carry
Oxytocin 10 IU vial 6
Ergometrine 0.2 mg vial 2
Magnesium sulphate 5 g vials (20 g) 4
Diazepam (parenteral) 10 mg vial 3
Calcium gluconate 1 g vial 1
Ampicillin 500 mg vial 4
Gentamicin 80 mg vial 3
Metronidazole 500 mg vial 2
Ringer’s lactate 1 litre bottle 4 (if distant referral)
Emergency supplies
IV catheters and tubing 2 sets
Gloves 2 pairs, at least, one pair sterile
Sterile syringes and needles 5 sets
Urinary catheter 1
Antiseptic solution 1 small bottle
Container for sharps 1
Bag for trash 1
Torch and extra battery 1
if delivery is anticipated on the way
Soap, towels 2 sets
Disposable delivery kit (blade, 3 ties) 2 sets
Clean cloths (3) for receiving, drying and wrapping the baby 1 set
Clean clothes for the baby 1 set
Plastic bag for placenta 1 set
Resuscitation bag and mask for the baby 1set
B14 Eclampsia and
prE-Eclampsia (2)
Givediazepam
Giveappropriateantihypertensive

B15 infEction
GiveappropriateIV/IMantibiotics
B16 malaria
GiveartemetherorquinineIM
GiveglucoseIV
B17 rEfEr thE woman urgEntly
to thE hospital
Referthewomanurgentlytothehospital
Essentialemergencydrugsandsupplies
fortransportandhomedelivery

■ Thissectionhasdetailsonemergencytreatmentsidentified
duringRapidassessmentandmanagement(RAM)

B3-B6

tobe
givenbeforereferral.
■ Givethetreatmentandreferthewomanurgentlytohospital

B17.
■ Ifdrugtreatment,givethefirstdoseofthedrugsbeforereferral.
Donotdelayreferralbygivingnon-urgenttreatments.
airway, BrEathing and circulation
Airway, breathing and circulation
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Managetheairwayandbreathing
Ifthewomanhasgreatdifficultybreathingand:
■ Ifyoususpectobstruction:
→Trytocleartheairwayanddislodgeobstruction
→Helpthewomantofindthebestpositionforbreathing
→urgently refer the woman to hospital.
■ Ifthewomanisunconscious:
→Keepheronherback,armsattheside
→Tiltherheadbackwards(unlesstraumaissuspected)
→Liftherchintoopenairway
→Inspecthermouthforforeignbody;removeiffound
→Clearsecretionsfromthroat.
■ Ifthewomanisnotbreathing:
→Ventilatewithbagandmaskuntilshestartsbreathingspontaneously
■ Ifwomanstillhasgreatdifficultybreathing,keepherproppedup,and
■ refer the woman urgently to hospital.
InsertIVlineandgivefluids
■ Washhandswithsoapandwaterandputongloves.
■ Cleanwoman’sskinwithspiritatsiteforIVline.
■ Insertanintravenousline(IVline)usinga16-18gaugeneedle.
■ AttachRinger’slactateornormalsaline.Ensureinfusionisrunningwell.
Givefluidsatrapid rateifshock,systolicBP<90mmHg,pulse>110/minute,orheavyvaginalbleeding:
■ Infuse1litrein15-20minutes(asrapidaspossible).
■ Infuse1litrein30minutesat30ml/minute.Repeatifnecessary.
■ Monitorevery15minutesfor:
→bloodpressure(BP)andpulse
→shortnessofbreathorpuffiness.
■ Reducetheinfusionrateto3ml/minute(1litrein6-8hours)whenpulseslowstolessthan100/
minute,systolicBPincreasesto100mmHgorhigher.
■ Reducetheinfusionrateto0.5ml/minuteifbreathingdifficultyorpuffinessdevelops.
■ Monitorurineoutput.
■ Recordtimeandamountoffluidsgiven.
Givefluidsatmoderate rateifsevereabdominalpain,obstructedlabour,ectopicpregnancy,dangerous
feverordehydration:
■ Infuse1litrein2-3hours.
Givefluidsatslow rateifsevereanaemia/severepre-eclampsiaoreclampsia:
■ Infuse1litrein6-8hours.
Ifintravenousaccessnotpossible
■ Giveoralrehydrationsolution(ORS)bymouthifabletodrink,orbynasogastric(NG)tube.
■ QuantityofORS:300to500mlin1hour.
do notgiveORStoawomanwhoisunconsciousorhasconvulsions.
BlEEding
Bleeding (1)
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Massageuterusandexpelclots
Ifheavypostpartumbleedingpersistsafterplacentaisdelivered,oruterusisnotwellcontracted(issoft):
■ Placecuppedpalmonuterinefundusandfeelforstateofcontraction.
■ Massagefundusinacircularmotionwithcuppedpalmuntiluterusiswellcontracted.
■ Whenwellcontracted,placefingersbehindfundusandpushdowninoneswiftactiontoexpelclots.
■ Collectbloodinacontainerplacedclosetothevulva.Measureorestimatebloodloss,andrecord.
Applybimanualuterinecompression
Ifheavypostpartumbleedingpersistsdespiteuterinemassage,oxytocin/ergometrinetreatmentand
removalofplacenta:
■ Wearsterileorcleangloves.
■ Introducetherighthandintothevagina,clenchedfist,withthebackofthehanddirectedposteriorly
andtheknucklesintheanteriorfornix.
■ Placetheotherhandontheabdomenbehindtheuterusandsqueezetheuterusfirmlybetweenthe
twohands.
■ Continuecompressionuntilbleedingstops(nobleedingifthecompressionisreleased).
■ Ifbleedingpersists,applyaorticcompressionandtransportwomantohospital.
Applyaorticcompression
Ifheavypostpartumbleedingpersistsdespiteuterinemassage,oxytocin/ergometrinetreatmentand
removalofplacenta:
■ Feelforfemoralpulse.
■ Applypressureabovetheumbilicustostopbleeding.Applysufficientpressureuntilfemoralpulseisnotfelt.
■ Afterfindingcorrectsite,showassistantorrelativehowtoapplypressure,ifnecessary.
■ Continuepressureuntilbleedingstops.Ifbleedingpersists,keepapplyingpressurewhiletransporting
womantohospital.
Giveoxytocin
Ifheavypostpartumbleeding
initial dose continuing dose maximum dose
IM/IV:10IU IM/IV:repeat10IU
after20minutes Notmorethan3litres
ifheavybleedingpersists ofIVfluidscontaining
IVinfusion: IVinfusion: oxytocin
20IUin1litre 10IUin1litre
at60drops/min at30drops/min

Giveergometrine
Ifheavybleedinginearlypregnancyor postpartumbleeding(afteroxytocin)but
do not give if eclampsia, pre-eclampsia, or hypertension
initial dose continuing dose maximum dose
IM/IV:0.2mg IM:repeat0.2mg Notmorethan
slowly IMafter15minutesifheavy 5doses(total1.0mg)
bleedingpersists
Bleeding (2)
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Removeplacentaandfragmentsmanually
■ Ifplacentanotdelivered1hourafterdeliveryofthebaby,OR
■ Ifheavyvaginalbleedingcontinuesdespitemassageandoxytocinandplacentacannotbedelivered
bycontrolledcordtraction,orifplacentaisincompleteandbleedingcontinues.
preparation
■ Explaintothewomantheneedformanualremovaloftheplacentaandobtainherconsent.
■ InsertanIVline.Ifbleeding,givefluidsrapidly.Ifnotbleeding,givefluidsslowly B .
■ Assistwomantogetontoherback.
■ Givediazepam(10-mgIM/IV).
■ Cleanvulvaandperinealarea.
■ Ensurethebladderisempty.Catheterizeifnecessary B12 .
■ Washhandsandforearmswellandputonlongsterilegloves(andanapronorgownifavailable).
technique
■ Withthelefthand,holdtheumbilicalcordwiththeclamp.Thenpullthecordgentlyuntilitis
horizontal.
■ Insertrighthandintothevaginaandupintotheuterus.
■ Leavethecordandholdthefunduswiththelefthandinordertosupportthefundusoftheuterus
andtoprovidecounter-tractionduringremoval.
■ Movethefingersoftherighthandsidewaysuntiledgeoftheplacentaislocated.
■ Detachtheplacentafromtheimplantationsitebykeepingthefingerstightlytogetherandusingthe
edgeofthehandtograduallymakeaspacebetweentheplacentaandtheuterinewall.
■ Proceedgraduallyallaroundtheplacentalbeduntilthewholeplacentaisdetachedfromtheuterine
wall.
■ Withdrawtherighthandfromtheuterusgradually,bringingtheplacentawithit.
■ Exploretheinsideoftheuterinecavitytoensureallplacentaltissuehasbeenremoved.
■ Withthelefthand,providecounter-tractiontothefundusthroughtheabdomenbypushingitinthe
oppositedirectionofthehandthatisbeingwithdrawn.Thispreventsinversionoftheuterus.
■ Examinetheuterinesurfaceoftheplacentatoensurethatlobesandmembranesarecomplete.If
anyplacentallobeortissuefragmentsaremissing,exploreagaintheuterinecavitytoremovethem.
if hours or days have passed since delivery, or if the placenta is retained due to constriction ring
or closed cervix, it may not be possible to put the hand into the uterus. do not persist. refer
urgently to hospital B17 .
if the placenta does not separate from the uterine surface by gentle sideways movement of the
fingertips at the line of cleavage, suspect placenta accreta. do not persist in efforts to remove
placenta. refer urgently to hospital B17 .
Aftermanualremovaloftheplacenta
■ Repeatoxytocin10-IUIM/IV.
■ Massagethefundusoftheuterustoencourageatonicuterinecontraction.
■ Giveampicillin2gIV/IM B15 .
■ Iffever>38.5°C,foul-smellinglochiaorhistoryofruptureofmembranesfor18ormorehours,also
givegentamicin80mgIM B15 .
■ Ifbleedingstops:
→givefluidsslowlyforatleast1hourafterremovalofplacenta.
■ Ifheavybleedingcontinues:
→giveergometrine0.2 mgIM
→give20IUoxytocinineachlitreofIVfluidsandinfuserapidly
→refer urgently to hospital B17 .
■ Duringtransportation,feelcontinuouslywhetheruterusiswellcontracted(hardandround).Ifnot,
massageandrepeatoxytocin10IUIM/IV.
■ Providebimanualoraorticcompressionifseverebleedingbeforeandduringtransportation B10 .
rEpair thE tEar and Empty BladdEr
Bleeding (3)
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Repairthetearorepisiotomy
■ Examinethetearanddeterminethedegree:
→Thetearissmallandinvolvedonlyvaginalmucosaandconnectivetissuesandunderlying
muscles(firstorseconddegreetear).Ifthetearisnotbleeding,leavethewoundopen.
→Thetearislonganddeepthroughtheperineumandinvolvestheanalsphincterandrectalmucosa
(thirdandfourthdegreetear).Coveritwithacleanpadandrefer the woman urgently to hospital B17 .
■ Iffirstorseconddegreetearandheavybleedingpersistsafterapplyingpressureoverthewound:
→Suturethetearorreferforsuturingifnooneisavailablewithsuturingskills.
→Suturethetearusinguniversalprecautions,aseptictechniqueandsterileequipment.
→Useaneedleholderanda21gauge,4cm,curvedneedle.
→Useabsorbablepolyglyconsuturematerial.
→Makesurethattheapexofthetearisreachedbeforeyoubeginsuturing.
→Ensurethatedgesofthetearmatchupwell.
do notsutureifmorethan12hourssincedelivery.refer woman to hospital.
Emptybladder
Ifbladderisdistendedandthewomanisunabletopassurine:
■ Encouragethewomantourinate.
■ Ifsheisunabletourinate,catheterizethebladder:
→Washhands
→Cleanurethralareawithantiseptic
→Putoncleangloves
→Spreadlabia.Cleanareaagain
→Insertcatheterupto4cm
→Measureurineandrecordamount
→Removecatheter.
Eclampsia and prE-Eclampsia (1)
Eclampsia and pre-eclampsia (1)
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Givemagnesiumsulphate
Ifseverepre-eclampsiaandeclampsia
iV/im combined dose (loading dose)
■ InsertIVlineandgivefluidsslowly(normalsalineorRinger’slactate)—
1litrein6-8hours(3-ml/minute) B .
■ Give4-gofmagnesiumsulphate(20mlof20%solution)IVslowlyover20minutes
(womanmayfeelwarmduringinjection).
and:
■ Give10gofmagnesiumsulphateIM:give5g(10mlof50%solution)IMdeepinupperouter
quadrantofeachbuttockwith1mlof2%lignocaineinthesamesyringe.
if unable to give iV, give im only (loading dose)
■ Give10gofmagnesiumsulphateIM:give5g(10mlof50%solution)IMdeepinupperouter
quadrantofeachbuttockwith1mlof2%lignocaineinthesamesyringe.
if convulsions recur
■ After15minutes,giveanadditional2gofmagnesiumsulphate(10mlof20%solution)IV
over20minutes.Ifconvulsionsstillcontinue,givediazepam B14 .
if referral delayed for long, or the woman is in late labour, continue treatment:
■ Give5gof50%magnesiumsulphatesolutionIMwith1mlof2%lignocaineevery4hoursin
alternatebuttocksuntil24hoursafterbirthorafterlastconvulsion(whicheverislater).
■ Monitorurineoutput:collecturineandmeasurethequantity.
■ Beforegivingthenextdoseofmagnesiumsulphate,ensure:
→kneejerkispresent
→urineoutput>100ml/4hrs
→respiratoryrate>16/min.
■ do notgivethenextdoseifanyofthesesigns:
→kneejerkabsent
→urineoutput<100ml/4hrs
→respiratoryrate<16/min.
■ Recordfindingsanddrugsgiven.
Importantconsiderationsincaringfor
awomanwitheclampsiaorpre-eclampsia
■ Donotleavethewomanonherown.
→Helpherintotheleftsidepositionandprotectherfromfallandinjury
→Placepaddedtonguebladesbetweenherteethtopreventatonguebite,andsecureittoprevent
aspiration(do notattemptthisduringaconvulsion).
■ GiveIV20%magnesiumsulphateslowlyover20minutes.Rapidinjectioncancauserespiratory
failureordeath.
→Ifrespiratorydepression(breathinglessthan16/minute)occursaftermagnesiumsulphate,do
notgiveanymoremagnesiumsulphate.Givetheantidote:calciumgluconate1gIV(10mlof
10%solution)over10minutes.
■ do notgiveintravenousfluidsrapidly.
■ do notgiveintravenously50%magnesiumsulphatewithoutdillutingitto20%.
■ refer urgently to hospitalunlessdeliveryisimminent.
→Ifdeliveryimminent,manageasinChildbirth d1-d2andaccompanythewomanduring
transport
→Keepherintheleftsideposition
→Ifaconvulsionoccursduringthejourney,givemagnesiumsulphateandprotectherfromfalland
injury.
formulation of magnesium sulphate
50% solution: 20% solution:tomake10mlof20%solution,
vialcontaining5gin10ml(1g/2ml) add4mlof50%solutionto6mlsterilewater
im 5g 10mland1ml2%lignocaine Notapplicable
iV 4g 8ml 20ml
2g 4ml 10ml
Afterreceivingmagnesiumsulphateawomanfeelflushing,thirst,headache,nauseaormayvomit.
Eclampsia and prE-Eclampsia (2)
Eclampsia and pre-eclampsia (2)
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Givediazepam
Ifconvulsionsoccurinearlypregnancyor
Ifmagnesiumsulphatetoxicityoccursormagnesiumsulphateisnotavailable.
loading dose iV
■ Givediazepam10mgIVslowlyover2minutes.
■ Ifconvulsionsrecur,repeat10mg.
maintenance dose
■ Givediazepam40mgin500mlIVfluids(normalsalineorRinger’slactate)titratedover6-8hours
tokeepthewomansedatedbutrousable.
■ Stopthemaintenancedoseifbreathing<16breaths/minute.
■ Assistventilationifnecessarywithmaskandbag.
■ Donotgivemorethan100mgin24hours.
■ IfIVaccessisnotpossible(e.g.duringconvulsion),givediazepamrectally.
loading dose rectally
■ Give20mg(4ml)ina10mlsyringe(orurinarycatheter):
→Removetheneedle,lubricatethebarrelandinsertthesyringeintotherectumtohalfitslength.
→Dischargethecontentsandleavethesyringeinplace,holdingthebuttockstogetherfor10
minutestopreventexpulsionofthedrug.
■ Ifconvulsionsrecur,repeat10mg.
maintenance dose
■ Giveadditional10mg(2ml)everyhourduringtransport.
diazepam:vialcontaining10mgin2ml
iV rectally
initial dose 10mg=2ml 20mg=4ml
second dose 10mg=2ml 10mg=2ml
Giveappropriateantihypertensivedrug
Ifdiastolicbloodpressureis>110-mmHg:
■ Givehydralazine5mgIVslowly(3-4minutes).IfIVnotpossiblegiveIM.
■ Ifdiastolicbloodpressureremains>90mmHg,repeatthedoseat30minuteintervalsuntil
diastolicBPisaround90mmHg.
■ Donotgivemorethan20mgintotal.
infEction
Infection
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GiveappropriateIV/IMantibiotics
■ Givethefirstdoseofantibiotic(s)beforereferral.Ifreferralisdelayedornotpossible,continue
antibioticsIM/IVfor48hoursafterwomanisfeverfree.Thengiveamoxicillinorally500mg3times
dailyuntil7daysoftreatmentcompleted.
■ Ifsignspersistormotherbecomesweakorhasabdominalpainpostpartum,refer urgently to hospital B17 .
condition antiBiotics
■ Severeabdominalpain 3 antibiotics
■ Dangerousfever/veryseverefebriledisease ■Ampicillin
■ Complicatedabortion ■Gentamicin
■ Uterineandfetalinfection ■Metronidazole
■ Postpartumbleeding 2 antibiotics:
→lasting>24hours ■Ampicillin
→occurring>24hoursafterdelivery ■Gentamicin
■ Upperurinarytractinfection
■ Pneumonia
■ Manualremovalofplacenta/fragments 1 antibiotic:
■ Riskofuterineandfetalinfection ■Ampicillin
■ Inlabour>24hours
antibiotic preparation dosage/route frequency
ampicillin Vialcontaining500mgaspowder: First2gIV/IMthen1g every6hours
tobemixedwith2.5mlsterilewater
gentamicin Vialcontaining40mg/mlin2ml 80mgIM every8hours
metronidazole Vialcontaining500mgin100ml 500mgor100mlIVinfusion every8hours
do not giVE im
Erythromycin Vialcontaining500mgaspowder 500mgIV/IM every6hours
(ifallergytoampicillin)
malaria
Malaria
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GivearthemeterorquinineIM
Ifdangerousfeverorveryseverefebriledisease
arthemeter Quinine*
1mlvialcontaining80mg/ml 2mlvialcontaining300mg/ml
leading dose for 3.2mg/kg 20mg/kg
assumed weight 50-60 kg 2ml 4ml
continue treatment 1.6mg/kg 10mg/kg
if unable to refer 1mloncedailyfor3days** 2ml/8hoursforatotalof7days**
■ Givetheloadingdoseofthemosteffectivedrug,accordingtothenationalpolicy.
■ Ifquinine:
→dividetherequireddoseequallyinto2injectionsandgive1ineachanteriorthigh
→alwaysgiveglucosewithquinine.
■ Referurgentlytohospital B17 .
■ Ifdeliveryimminentorunabletoreferimmediately,continuetreatmentasaboveandreferafter
delivery.
* Thesedosagesareforquininedihydrochloride.Ifquininebase,give8.2mg/kgevery8hours.
**Discontinueparenteraltreatmentassoonaswomanisconsciousandabletoswallow.Beginoral
treatmentaccordingtonationalguidelines.
GiveglucoseIV
Ifdangerousfeverorveryseverefebrilediseasetreatedwithquinine
50% glucose solution* 25% glucose solution 10% glucose solution (5 ml/kg)
25-50ml 50-100ml 125-250ml
■ MakesureIVdripisrunningwell.GiveglucosebyslowIVpush.
■ IfnoIVglucoseisavailable,givesugarwaterbymouthornasogastrictube.
■ Tomakesugarwater,dissolve4levelteaspoonsofsugar(20g)ina200mlcupofcleanwater.
* 50%glucosesolutionisthesameas50%dextrosesolutionorD50.Thissolutionisirritatingto
veins.Diluteitwithanequalquantityofsterilewaterorsalinetoproduce25%glucosesolution.
rEfEr thE woman urgEntly to thE hospital
Refer the woman urgently to hospital
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Referthewomanurgentlytohospital
■ Afteremergencymanagement,discussdecisionwithwomanandrelatives.
■ Quicklyorganizetransportandpossiblefinancialaid.
■ Informthereferralcentreifpossiblebyradioorphone.
■ Accompanythewomanifatallpossible,orsend:
→ahealthworkertrainedindeliverycare
→arelativewhocandonateblood
→babywiththemother,ifpossible
→essentialemergencydrugsandsupplies B17 .
→referralnote n2 .
■ Duringjourney:
→watchIVinfusion
→ifjourneyislong,giveappropriatetreatmentontheway
→keeprecordofallIVfluids,medicationsgiven,timeofadministrationandthewoman’scondition.
Essentialemergencydrugsandsupplies
fortransportandhomedelivery
Emergency drugs strength and form Quantity for carry
Oxytocin 10IUvial 6
Ergometrine 0.2mgvial 2
Magnesiumsulphate 5gvials(20g) 4
Diazepam(parenteral) 10mgvial 3
Calciumgluconate 1gvial 1
Ampicillin 500mgvial 4
Gentamicin 80mgvial 3
Metronidazole 500mgvial 2
Ringer’slactate 1litrebottle 4(ifdistantreferral)
Emergency supplies
IVcathetersandtubing 2sets
Gloves 2pairs,atleast,onepairsterile
Sterilesyringesandneedles 5sets
Urinarycatheter 1
Antisepticsolution 1smallbottle
Containerforsharps 1
Bagfortrash 1
Torchandextrabattery 1
if delivery is anticipated on the way
Soap,towels 2sets
Disposabledeliverykit(blade,3ties) 2sets
Cleancloths(3)forreceiving,dryingandwrappingthebaby 1set
Cleanclothesforthebaby 1set
Plasticbagforplacenta 1set
Resuscitationbagandmaskforthebaby 1set
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Bleeding in early pregnancy and post-aBortion care
Bleeding in early pregnancy and post-abortion care
Bleeding in early pregnancy and post-aBortion care
B19
ASK, CHECK RECORD
■ When did bleeding start?
■ How much blood have you lost?
■ Are you still bleeding?
■ Is the bleeding increasing or
decreasing?
■ Could you be pregnant?
■ When was your last period?
■ Have you had a recent abortion?
■ Did you or anyone else do anything
to induce an abortion?
■ Have you fainted recently?
■ Do you have abdominal pain?
■ Do you have any other concerns to
discuss?
LOOK, LISTEN, FEEL
■ Look at amount of bleeding.
■ Note if there is foul-smelling vaginal
discharge.
■ Feel for lower abdominal pain.
■ Feel for fever. If hot, measure
temperature.
■ Look for pallor.
SIGNS
■ Vaginal bleeding and any of:
→Foul-smelling vaginal discharge
→Abortion with uterine
manipulation
→Abdominal pain/tenderness
→Temperature >38°C.
■ Light vaginal bleeding
■ History of heavy bleeding but:
→now decreasing, or
→no bleeding at present.
■ Two or more of the following signs:
→abdominal pain
→fainting
→pale
→very weak
TREAT ANDADVISE
■ Insert an IV line and give fluids B9 .
■ Give paracetamol for pain f4 .
■ Give appropriate IM/IV antibiotics B15 .
■ refer urgently to hospital B17 .
■ Observe bleeding for 4-6 hours:
→If no decrease, refer to hospital.
→If decrease, let the woman go home.
→Advise the woman to return immediately if
bleeding increases.
■ Follow up in 2 days B21 .
■ Check preventive measures B20 .
■ Advise on self-care B21 .
■ Advise and counsel on family planning B21 .
■ Advise to return if bleeding does not stop within
2 days.
■ Insert an IV line and give fluids B9 .
■ refer urgently to hospital B17 .
CLASSIFY
complicated aBortion
threatened
aBortion
complete aBortion
ectopic pregnancy
next: Give preventive measures
examination of the woman with Bleeding in early pregnancy, and post-aBortion care
use this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods

give preventive measures
Give preventive measures
Bleeding in early pregnancy and post-aBortion care
B20
ASSESS, CHECK RECORDS
■ Check tetanus toxoid (TT) immunization status.
■ Check woman’s supply of the prescribed dose of iron/folate.
■ Check HIV status c6 .
■ Check RPR status in records c5 .
■ If no RPR results, do the RPR test l5 .
TREAT ANDADVISE
■ Give tetanus toxoid if due f2 .
■ Give 3 month’s supply of iron and counsel on compliance f3 .
■ If HIV status is unknown, counsel on HIV testing g3 .
■ If known HIV-positive:
→refer to HIV services for further assessment and treatment.
→give support g4 .
→advise on opportunistic infection and need to seek medical help c10 .
→counsel on safer sex including use of condoms g2 .
■ If HIV-negative, counsel on correct and consistent use of condoms g4 .
If Rapid plasma reagin (RPR) positive:
■ Treat the woman for syphilis with benzathine penicillin f6 .
■ Advise on treating her partner.
■ Encourage HIV testing and counselling g3 .
■ Reinforce use of condoms g2 .
advise and counsel on post-aBortion care
Advise and counsel on post-abortion care
Bleeding in early pregnancy and post-aBortion care
B21
Advise on self-care
■ Rest for a few days, especially if feeling tired.
■ Advise on hygiene
→change pads every 4 to 6 hours
→wash the perineum daily
→avoid sexual relations until bleeding stops.
■ Advise woman to return immediately if she has any of the following danger signs:
→increased bleeding
→continued bleeding for 2 days
→foul-smelling vaginal discharge
→abdominal pain
→fever, feeling ill, weakness
→dizziness or fainting.
■ Advise woman to return in if delay (6 weeks or more) in resuming menstrual periods.
Advise and counsel on family planning
■ Explain to the woman that she can become pregnant soon after the abortion - as soon as she has
sexual intercourse — if she does not use a contraceptive:
→Any family planning method can be used immediately after an uncomplicated first trimester
abortion.
→If the woman has an infection or injury: delay IUD insertion or female sterilization until healed. For
information on options, see Methods for non-breastfeeding women on d27 .
■ Make arrangements for her to see a family planning counsellor as soon as possible, or counsel her
directly. (see The decision-making tool for family planning clients and providers for information on
methods and on the counselling process).
■ Advise on safer sex including use of condom if she or her partner are at risk of sexually transmitted
infection (STI) or HIV g2 .
Provide information and support after abortion
A woman may experience different emotions after an abortion, and may benefit from support:
■ Allow the woman to talk about her worries, feelings, health and personal situation. Ask if she has
any questions or concerns.
■ Facilitate family and community support, if she is interested (depending on the circumstances, she
may not wish to involve others).
→Speak to them about how they can best support her, by sharing or reducing her workload, helping
out with children, or simply being available to listen.
→Inform them that post-abortion complications can have grave consequences for the woman’s
health. Inform them of the danger signs and the importance of the woman returning to the health
worker if she experiences any.
→Inform them about the importance of family planning if another pregnancy is not desired.
■ If the woman is interested, link her to a peer support group or other women’s groups or community
services which can provide her with additional support.
■ If the woman discloses violence or you see unexplained bruises and other injuries which make you
suspect she may be suffering abuse, see h4 .
■ Advise on safer sex including use of condoms if she or her partner are at risk for STI or HIV g2 .
Advise and counsel during follow-up visits
If threatened abortion and bleeding stops:
■ Reassure the woman that it is safe to continue pregnancy.
■ Provide antenatal care c1-c18.
If bleeding continues:
■ Assess and manage as in Bleeding in early pregnancy/post-abortion care B18-B22.
→If fever, foul-smelling vaginal discharge, or abdominal pain, give first dose of appropriate IV/IM
antibiotics B15 .
→Refer woman to hospital.
B19

examination of the woman
with Bleeding in early
pregnancy and
post-aBortion care
B20 give preventive measures
B21 advise and counsel on
post-aBortion care
Adviseonself-care
Adviseandcounselonfamilyplanning
Provideinformationandsupportafter
abortion
Adviseandcounselduringfollow-upvisits
■ AlwaysbeginwithRapidassessmentandmanagement(RAM) B3-B7 .
■ NextusetheBleedinginearlypregnancy/postabortioncare B19

toassessthewomanwithlightvaginal
bleedingorahistoryofmissedperiods.
■ UsechartonPreventivemeasures B20

toprovidepreventivemeasuresduetoallwomen.
■ UseAdviseandCounselonpost-abortioncare B21 toadviseonselfcare,dangersigns,follow-up
visit,familyplanning.
■ Recordalltreatmentgiven,positivefindings,andtheschedulednextvisitinthehome-basedand
clinicrecordingforms.
■ IfthewomanisHIVpositive,adolescentorhasspecialneeds,useg1-g11 h1-h4 .
.
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ASK,CHECKRECORD
■ Whendidbleedingstart?
■ Howmuchbloodhaveyoulost?
■ Areyoustillbleeding?
■ Isthebleedingincreasingor
decreasing?
■ Couldyoubepregnant?
■ Whenwasyourlastperiod?
■ Haveyouhadarecentabortion?
■ Didyouoranyoneelsedoanything
toinduceanabortion?
■ Haveyoufaintedrecently?
■ Doyouhaveabdominalpain?
■ Doyouhaveanyotherconcernsto
discuss?
LOOK,LISTEN,FEEL
■ Lookatamountofbleeding.
■ Noteifthereisfoul-smellingvaginal
discharge.
■ Feelforlowerabdominalpain.
■ Feelforfever.Ifhot,measure
temperature.
■ Lookforpallor.
SIGNS
■ Vaginalbleedingandanyof:
→Foul-smellingvaginaldischarge
→Abortionwithuterine
manipulation
→Abdominalpain/tenderness
→Temperature>38°C.
■ Lightvaginalbleeding
■ Historyofheavybleedingbut:
→nowdecreasing,or
→nobleedingatpresent.
■ Twoormoreofthefollowingsigns:
→abdominalpain
→fainting
→pale
→veryweak
TREATANDADVISE
■ InsertanIVlineandgivefluids B9 .
■ Giveparacetamolforpain f4 .
■ GiveappropriateIM/IVantibiotics B15 .
■ refer urgently to hospital B17 .
■ Observebleedingfor4-6hours:
→Ifnodecrease,refer to hospital.
→Ifdecrease,letthewomangohome.
→Advisethewomantoreturnimmediatelyif
bleedingincreases.
■ Followupin2days B21 .
■ Checkpreventivemeasures B20 .
■ Adviseonself-care B21 .
■ Adviseandcounselonfamilyplanning B21 .
■ Advisetoreturnifbleedingdoesnotstopwithin
2days.
■ InsertanIVlineandgivefluids B9 .
■ refer urgentlyto hospital B17 .
CLASSIFY
complicated aBortion
threatened
aBortion
complete aBortion
ectopic pregnancy
next:Givepreventivemeasures
examination of the woman with Bleeding in early pregnancy, and post-aBortion care
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Give preventive measures
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ASSESS,CHECKRECORDS
■ Checktetanustoxoid(TT)immunizationstatus.
■ Checkwoman’ssupplyoftheprescribeddoseofiron/folate.
■ CheckHIVstatus c6 .
■ CheckRPRstatusinrecords c5 .
■ IfnoRPRresults,dotheRPRtest l5 .
TREATANDADVISE
■ Givetetanustoxoidifdue f2 .
■ Give3month’ssupplyofironandcounseloncompliance f3 .
■ IfHIVstatusisunknown,counselonHIVtesting g3 .
■ IfHIV-positive:
→refertoHIVservicesforfurtherassessmentandtreatment.
→givesupport g4 .
→adviseonopportunisticinfectionandneedtoseekmedicalhelp c10 .
→counselonsafersexincludinguseofcondoms g2 .
■ IfHIV-negative,counselonsafersexincludinguseofcondoms g4 .
IfRapidplasmareagin(RPR)positive:
■ Treatthewomanforsyphiliswithbenzathinepenicillin f6 .
■ Adviseontreatingherpartner.
■ EncourageHIVtestingandcounselling g3 .
■ Reinforceuseofcondoms g2 .
advise and counsel on post-aBortion care
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Adviseonself-care
■ Restforafewdays,especiallyiffeelingtired.
■ Adviseonhygiene
→changepadsevery4to6hours
→washtheperineumdaily
→avoidsexualrelationsuntilbleedingstops.
■ Advisewomantoreturnimmediatelyifshehasanyofthefollowingdangersigns:
→increasedbleeding
→continuedbleedingfor2days
→foul-smellingvaginaldischarge
→abdominalpain
→fever,feelingill,weakness
→dizzinessorfainting.
■ Advisewomantoreturninifdelay(6weeksormore)inresumingmenstrualperiods.
Adviseandcounselonfamilyplanning
■ Explaintothewomanthatshecanbecomepregnantsoonaftertheabortion-assoonasshehas
sexualintercourse—ifshedoesnotuseacontraceptive:
→Anyfamilyplanningmethodcanbeusedimmediatelyafteranuncomplicatedfirsttrimester
abortion.
→Ifthewomanhasaninfectionorinjury:delayIUDinsertionorfemalesterilizationuntilhealed.For
informationonoptions,seeMethodsfornon-breastfeedingwomenon d27 .
■ Makearrangementsforhertoseeafamilyplanningcounsellorassoonaspossible,orcounselher
directly.(seeThedecision-makingtoolforfamilyplanningclientsandprovidersforinformationon
methodsandonthecounsellingprocess).
■ Counselonsafersexincludinguseofcondomifsheorherpartnerareatriskofsexuallytransmitted
infection(STI)orHIV g2 .
Provideinformationandsupportafterabortion
Awomanmayexperiencedifferentemotionsafteranabortion,andmaybenefitfromsupport:
■ Allowthewomantotalkaboutherworries,feelings,healthandpersonalsituation.Askifshehas
anyquestionsorconcerns.
■ Facilitatefamilyandcommunitysupport,ifsheisinterested(dependingonthecircumstances,she
maynotwishtoinvolveothers).
→Speaktothemabouthowtheycanbestsupporther,bysharingorreducingherworkload,helping
outwithchildren,orsimplybeingavailabletolisten.
→Informthemthatpost-abortioncomplicationscanhavegraveconsequencesforthewoman’s
health.Informthemofthedangersignsandtheimportanceofthewomanreturningtothehealth
workerifsheexperiencesany.
→Informthemabouttheimportanceoffamilyplanningifanotherpregnancyisnotdesired.
■ Ifthewomanisinterested,linkhertoapeersupportgrouporotherwomen’sgroupsorcommunity
serviceswhichcanprovideherwithadditionalsupport.
■ Ifthewomandisclosesviolenceoryouseeunexplainedbruisesandotherinjurieswhichmakeyou
suspectshemaybesufferingabuse,see h4 .
■ CounselonsafersexincludinguseofcondomsifsheorherpartnerareatriskforSTIorHIV g2 .
Adviseandcounselduringfollow-upvisits
Ifthreatenedabortionandbleedingstops:
■ Reassurethewomanthatitissafetocontinuepregnancy.
■ Provideantenatalcare c1-c18.
Ifbleedingcontinues:
■ AssessandmanageasinBleedinginearlypregnancy/post-abortioncareB18-B22.
→Iffever,foul-smellingvaginaldischarge,orabdominalpain,givefirstdoseofappropriateIV/IM
antibiotics B15 .
→Referwomantohospital.
Antenatal care
A
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c
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■ Alwaysbeginwithrapid assessment and management (rAM) B3-B7 .Ifthewomanhasno
emergencyorprioritysignsandhascomeforantenatalcare,usethissectionforfurthercare.
■ NextusethePregnancy status and birth plan chart C2 toaskthewomanaboutherpresent
pregnancystatus,historyofpreviouspregancies,andcheckherforgeneraldangersigns.Decideon
anappropriateplaceofbirthforthewomanusingthischartandpreparethebirthandemergency
plan.Thebirthplanshouldbereviewedduringeveryfollow-upvisit.
■ Checkallwomenforpre-eclampsia,anaemia,syphilisandHIVstatusaccordingtothecharts c3-c6 .
■ Incaseswhereanabnormalsignisidentified(volunteeredorobserved),usethechartsrespond to
observed signs or volunteered problems c7-c11 toclassifytheconditionandidentifyappropriate
treatment(s).
■ Givepreventive measuresdue c12 .
■ Developabirth and emergency plan c14-c15 .
■ Adviseandcounselonnutrition c13 ,familyplanning c16 ,laboursigns,dangersigns c15 ,routine
andfollow-upvisits c17 usingInformation and counselling sheets M1-M19.
■ Recordallpositivefindings,birthplan,treatmentsgivenandthenextscheduledvisitinthehome-
basedmaternalcard/clinicrecordingform.
■ AssesseligibilityofARVforHIV-positivewoman c19 .
■ IfthewomanisHIVpositive,adolescentorhasspecialneeds,seeG1-G11 H1-H4 .
AntenAtAl cAre
Antenatal care
A
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c
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c1
Assess the pregnant woman Pregancy status, birth and emergency plan
AntenAtAl cAre
ASk, CHeCk, ReCoRD
All vIsIts ■ Check duration of pregnancy. ■ Where do you plan to deliver? ■ Any vaginal bleeding since last visit? ■ Is the baby moving? (after 4 months) ■ Check record for previous complications and treatments received during this pregnancy. ■ Do you have any concerns?
fIrst vIsIt ■ How many months pregnant are you? ■ When was your last period? ■ When do you expect to deliver? ■ How old are you? ■ Have you had a baby before? If yes: ■ Check record for prior pregnancies or if there is no record ask about: →Number of prior pregnancies/deliveries →Prior caesarean section, forceps, or vacuum →Prior third degree tear →Heavy bleeding during or after delivery →Convulsions →Stillbirth or death in first day. →Do you smoke, drink alcohol or use any drugs?
tHIrd trIMester Has she been counselled on family planning? If yes, does she want tubal ligation or IUD A15 .
Look, LISTeN, FeeL
■ Feel for trimester of pregnancy.
■ Look for caesarean scar
■ Feel for obvious multiple pregnancy. ■ Feel for transverse lie. ■ Listen to fetal heart.
INDICATIoNS
■ Prior delivery by caesarean. ■ Age less than 14 years. ■ Transverse lie or other obvious malpresentation within one month of expected delivery. ■ obvious multiple pregnancy. ■ Tubal ligation or IUD desired immediately after delivery. ■ Documented third degree tear. ■ History of or current vaginal bleeding or other complication during this pregnancy.
■ First birth. ■ Last baby born dead or died in first day. ■ Age less than 16 years. ■ More than six previous births. ■ Prior delivery with heavy bleeding. ■ Prior delivery with convulsions. ■ Prior delivery by forceps or vacuum. ■ HIV-positive woman.
■ None of the above.
ADVISe
■ explain why delivery needs to be at referral level c14 . ■ Develop the birth and emergency plan c14 .
■ explain why delivery needs to be at primary health care level c14 . ■ Develop the birth and emergency plan c14 .
■ explain why delivery needs to be with a skilled birth attendant, preferably at a facility. ■ Develop the birth and emergency plan c14 .
PLACe oF DeLIVeRY
referrAl level
PrIMAry HeAltH cAre level
AccordInGto woMAn’s Preference
next: Check for pre-eclampsia
Assess tHe PreGnAnt woMAn: PreGnAncy stAtus, BIrtHAnd eMerGency PlAn
use this chart to assess the pregnant woman at each of the four antenatal care visits. during first antenatal visit, prepare a birth and emergency plan using this chart
and review them during following visits. Modify the birth plan if any complications arise.
c2

Assess the pregnant woman Check for pre-eclampsia
ASk, CHeCk ReCoRD
■ Blood pressure at the last visit?
Look, LISTeN, FeeL
■ Measure blood pressure in sitting position. ■ If diastolic blood pressure is ≥90 mmHg, repeat after 1 hour rest. ■ If diastolic blood pressure is still ≥90 mmHg, ask the woman if she has: →severe headache →blurred vision →epigastric pain and →check protein in urine.
SIGNS
■ Diastolic blood pressure ≥110 mmHg and 3+ proteinuria, or ■ Diastolic blood pressure ≥90-mmHg on two readings and 2+ proteinuria, and any of: →severe headache →blurred vision →epigastric pain.
■ Diastolic blood pressure 90-110-mmHg on two readings and 2+ proteinuria.
■ Diastolic blood pressure ≥90 mmHg on 2 readings.
■ None of the above.
TReAT ANDADVISe
■ Give magnesium sulphate B13 . ■ Give appropriate anti-hypertensives B14 . ■ Revise the birth plan c2 . ■ refer urgently to hospital B17 .
■ Revise the birth plan c2 . ■ Refer to hospital.
■ Advise to reduce workload and to rest. ■ Advise on danger signs c15 . ■ Reassess at the next antenatal visit or in 1 week if >8 months pregnant. ■ If hypertension persists after 1 week or at next visit, refer to hospital or discuss case with the doctor or midwife, if available.
No treatment required.
CLASSIFY
severe Pre-eclAMPsIA
Pre-eclAMPsIA
HyPertensIon
no HyPertensIon
next: Check for anaemia
cHeck for Pre-eclAMPsIA
screen all pregnant women at every visit.
AntenAtAl cAre
c3

Assess the pregnant woman Check for anaemia
AntenAtAl cAre
ASk, CHeCk ReCoRD
■ Do you tire easily? ■ Are you breathless (short of breath) during routine household work?
Look, LISTeN, FeeL
on first visit: ■ Measure haemoglobin
on subsequent visits: ■ Look for conjunctival pallor. ■ Look for palmar pallor. If pallor: →Is it severe pallor? →Some pallor? →Count number of breaths in 1 minute.
SIGNS
■ Haemoglobin <7-g/dl. And/or ■ Severe palmar and conjunctival pallor or
■ Any pallor with any of →>30 breaths per minute →tires easily →breathlessness at rest
■ Haemoglobin 7-11-g/dl. or ■ Palmar or conjunctival pallor.
■ Haemoglobin >11-g/dl. ■ No pallor.
TReAT ANDADVISe
■ Revise birth plan so as to deliver in a facility with blood transfusion services c2 . ■ Give double dose of iron (1 tablet twice daily) for 3 months f3 . ■ Counsel on compliance with treatment f3 . ■ Give appropriate oral antimalarial f4 . ■ Follow up in 2 weeks to check clinical progress, test results, and compliance with treatment. ■ refer urgently to hospital B17 .
■ Give double dose of iron (1 tablet twice daily) for 3 months f3 . ■ Counsel on compliance with treatment f3 . ■ Give appropriate oral antimalarial if not given in the past month f4 . ■ Reassess at next antenatal visit (4-6 weeks). If anaemia persists, refer to hospital.
■ Give iron 1 tablet once daily for 3 months f3 . ■ Counsel on compliance with treatment f4 .
CLASSIFY
severe AnAeMIA
ModerAte AnAeMIA
no clInIcAl AnAeMIA
next: Check for syphilis
cHeck for AnAeMIA
screen all pregnant women at every visit.
c4

Assess the pregnant woman Check for syphilis
ASk, CHeCk ReCoRD
■ Have you been tested for syphilis during this pregnancy? →If not, perform the rapid plasma reagin (RPR) test l5 . ■ If test was positive, have you and your partner been treated for syphilis? →If not, and test is positive, ask “Are you allergic to penicillin?”
Look, LISTeN, FeeL TeST ReSULT
■ RPR test positive.
■ RPR test negative.
TReAT ANDADVISe
■ Give benzathine benzylpenicillin IM. If allergy, give erythromycin f6 . ■ Plan to treat the newborn k12 . ■ encourage woman to bring her sexual partner for treatment. ■ Counsel on safer sex including use of condoms to prevent new infection G2 .
■ Counsel on safer sex including use of condoms to prevent infection G2 .
CLASSIFY
PossIBle syPHIlIs
no syPHIlIs
next: Check for HIV status
cHeck for syPHIlIs
test all pregnant women at first visit. check status at every visit.
AntenAtAl cAre
c5

Assess the pregnant woman Check for HIV status
AntenAtAl cAre
ASk, CHeCk ReCoRD
Provide key information on HIv G2 . ■What is HIV and how is HIV transmit- ted G2 ? ■ Advantage of knowing the HIV status in pregnancy G2 . ■ explain about HIV testing and counselling including confidentiality of the result G3 .
Ask the woman: ■ Have you been tested for HIV? →If not: tell her that she will be tested for HIV, unless she refuses. →Ifyes:Checkresult. (explainto herthatshehasarightnotto disclose the result.) →Are you taking any ARV? →Check ARV treatment plan. ■ Has the partner been tested?
Look, LISTeN, FeeL
■ Perform the Rapid HIV test if not performed in this pregnancy l6 .
SIGNS
■ Positive HIV-positive.
■ Negative HIV test.
■ She refuses the test or is not willing to disclose the result of previous test or no test results available.
TReAT ANDADVISe
■ Counsel on implications of a positive test G3 . If HIv services available: ■ Refer the woman to HIV ser vices for further assessment. ■ Ask her to return in 2 weeks with her documents. If HIv services are not available: ■ Determinetheseverityofthediseaseandassess eligibility for ARVs c19 . ■ Give her appropriate ARV G6 , G9 . for all women: ■ Support adherence to ARV G6 . ■ Counsel on infant feeding options G7 . ■ Provide additional care for HIV-positive woman G4 . ■ Counsel on family planning G4 . ■ Counsel on safer sex including use of condoms G2 . ■ Counselonbenefitsofdisclosure(involving)and testing her partner G3 . ■ Provide support to the HIV-positive woman G5 .
counsel on implications of a negative test G3 . ■ Counselontheimportanceofstayingnegativeby practising safer sex, including use of condoms G2 . ■ Counselonbenefitsofinvolvingandtestingthe partner G3 .
■ Counsel on safer sex including use of condoms G2 . ■ Counsel on benefits of involving and testing the partner G3 .
CLASSIFY
HIv-PosItIve
HIv-neGAtIve
unknown HIv stAtus
next: Respond to observed signs or volunteered problems
If no problem, go to page c12 .
cHeck for HIv stAtus
test and counsel all pregnant women for HIv at the first antenatal visit. check status at every visit.
Inform the women that HIV test will be done routinely and that she may refuse the HIV test.
c6

If ruPtured MeMBrAnes And no lABour
Respond to observed signs or volunteered problems (1)
ASk, CHeCk ReCoRD
■ When did the baby last move? ■ If no movement felt, ask woman to move around for some time, reassess fetal movement.
■ When did the membranes rupture? ■ When is your baby due?
Look, LISTeN, FeeL
■ Feel for fetal movements. ■ Listen for fetal heart after 6 months of pregnancy d2 . ■ If no heart beat, repeat after 1 hour.
■ Look at pad or underwear for evidence of: →amniotic fluid →foul-smelling vaginal discharge ■ If no evidence, ask her to wear a pad. Check again in 1 hour. ■ Measure temperature.
SIGNS
■ No fetal movement. ■ No fetal heart beat.
■ No fetal movement but fetal heart beat present.
■ Fever 38ºC. ■ Foul-smelling vaginal discharge.
■ Rupture of membranes at <8 months of pregnancy.
■ Rupture of membranes at >8 months of pregnancy.
TReAT ANDADVISe
■ Inform the woman and partner about the possibility of dead baby. ■ Refer to hospital.
■ Inform the woman that baby is fine and likely to be well but to return if problem persists.
■ Give appropriate IM/IV antibiotics B15 . ■ refer urgently to hospital B17 .
■ Give appropriate IM/IV antibiotic B15 . ■ refer urgently to hospital B17 .
■ Manage as Woman in childbirth d1-d28.
CLASSIFY
ProBABly deAd BABy
well BABy
uterIne And fetAl InfectIon
rIsk of uterIne And fetAl InfectIon
ruPture of MeMBrAnes
next: If fever or burning on urination
resPond to oBserved sIGns or volunteered ProBleMs
AntenAtAl cAre
c7
If no fetAl MoveMent

C2 Assess tHe PreGnAnt woMAn:
PreGnAncy stAtus, BIrtH And
eMerGency PlAn

C3 cHeck for Pre-eclAMPsIA
C4 cHeck for AnAeMIA
C5 cHeck for syPHIlIs
C6 cHeck for HIv stAtus
C7 resPond to oBserved sIGns or
volunteered ProBleMs (1)
Ifnofetalmovement
Ifrupturedmembraneandnolabour
Respond to observed signs or volunteered problems (2)
AntenAtAl cAre
ASk, CHeCk ReCoRD
■ Have you had fever? ■ Do you have burning on urination?
Look, LISTeN, FeeL
■ If history of fever or feels hot: →Measure axillary temperature. →Look or feel for stiff neck. →Look for lethargy. ■ Percuss flanks for tenderness.
SIGNS
■ Fever >38°C and any of: →very fast breathing or →stiff neck →lethargy →very weak/not able to stand.
■ Fever >38°C and any of: →Flank pain →Burning on urination.
■ Fever >38°C or history of fever (in last 48 hours).
■ Burning on urination.
TReAT ANDADVISe
■ Insert IV line and give fluids slowly B9 . ■ Give appropriate IM/IV antibiotics B15 . ■ Give artemether/quinine IM B16 . ■ Give glucose B16 . ■ refer urgently to hospital B17 .
■ Give appropriate IM/IV antibiotics B15 . ■ Give appropriate oral antimalarial f4 . ■ refer urgently to hospital B17 .
■ Give appropriate oral antimalarial f4 . ■ If no improvement in 2 days or condition is worse, refer to hospital.
■ Give appropriate oral antibiotics f5 . ■ encourage her to drink more fluids. ■ If no improvement in 2 days or condition is worse, refer to hospital.
CLASSIFY
very severe feBrIle dIseAse
uPPer urInAry trAct InfectIon
MAlArIA
lower urInAry trAct InfectIon
next: If vaginal discharge
If fever or BurnInG on urInAtIon
c8

Respond to observed signs or volunteered problems (3)
ASk, CHeCk ReCoRD
■ Have you noticed changes in your vaginal discharge? ■ Do you have itching at the vulva? ■ Has your partner had a urinary problem?
If partner is present in the clinic, ask the woman if she feels comfortable if you ask him similar questions. If yes, ask him if he has: ■ urethral discharge or pus. ■ burning on passing urine.
If partner could not be approached, explain importance of partner assessment and treatment to avoid reinfection. Schedule follow-up appointment for woman and partner (if possible).
Look, LISTeN, FeeL
■ Separate the labia and look for abnormal vaginal discharge: →amount →colour →odour/smell. ■ If no discharge is seen, examine with a gloved finger and look at the discharge on the glove.
SIGNS
■ Abnormal vaginal discharge. ■ Partner has urethral discharge or burning on passing urine.
■ Curd like vaginal discharge. ■ Intense vulval itching.
■ Abnormal vaginal discharge
TReAT ANDADVISe
■ Give appropriate oral antibiotics to woman f5 . ■ Treat partner with appropriate oral antibiotics f5 . ■ Counsel on safer sex including use of condoms G2 .
■ Give clotrimazole f5 . ■ Counsel on safer sex including use of condoms G2 .
■ Give metronidazole to woman f5 . ■ Counsel on safer sex including use of condoms G2 .
CLASSIFY
PossIBle GonorrHoeA or cHlAMydIA InfectIon
PossIBle cAndIdA InfectIon
PossIBle BActerIAl or trIcHoMonAs InfectIon
next: If signs suggesting HIV infection
If vAGInAl dIscHArGe
AntenAtAl cAre
c9

Respond to observed signs or volunteered problems (4)
AntenAtAl cAre
ASk, CHeCk ReCoRD
■ Have you lost weight? ■ Do you have fever? How long (>1 month)? ■ Have you got diarrhoea (continuous or intermittent)? How long, >1 month? ■ Have you had cough? How long, >1 month?
Assess if in high risk group: ■ occupational exposure? ■ Multiple sexual partner? ■ Intravenous drug abuse? ■ History of blood transfusion? ■ Illness or death fromAIDS in a sexual partner? ■ History of forced sex?
Look, LISTeN, FeeL
■ Look for visible wasting. ■ Look for ulcers and white patches in the mouth (thrush). ■ Look at the skin: →Is there a rash? →Are there blisters along the ribs on one side of the body?
SIGNS
■ Two of these signs: →weight loss →fever >1 month →diarrhoea >1month. or ■ one of the above signs and →one or more other signs or →from a risk group.
TReAT ANDADVISe
■ Reinforce the need to know HIV status and advise on HIV testing and counselling G2-G3 . ■ Counsel on the benefits of testing the partner G3 . ■ Counsel on safer sex including use of condoms G2 . ■ Refer to TB centre if cough.
■ Counsel on stopping smoking ■ For alcohol/drug abuse, refer to specialized care providers. ■ For counselling on violence, see H4 .
CLASSIFY
stronG lIkelIHood of HIv InfectIon
next: If cough or breathing difficulty
If sIGns suGGestInG HIv InfectIon
(HIv status unknown)
c10
If sMokInG, AlcoHol or druGABuse, or HIstory of vIolence

If tAkInGAntI-tuBerculosIs druGs
Respond to observed signs or volunteered problems (5)
ASk, CHeCk ReCoRD
■ How long have you been coughing? ■ How long have you had difficulty in breathing? ■ Do you have chest pain? ■ Do you have any blood in sputum? ■ Do you smoke?
■ Are you taking anti-tuberculosis drugs? If yes, since when? ■ Does the treatment include injection (streptomycin)?
Look, LISTeN, FeeL
■ Look for breathlessness. ■ Listen for wheezing. ■ Measure temperature.
SIGNS
At least 2 of the following signs: ■ Fever >38ºC. ■ Breathlessness. ■ Chest pain.
At least 1 of the following signs: ■ Cough or breathing difficulty for >3 weeks ■ Blood in sputum ■ Wheezing
■ Fever <38ºC, and ■ Cough <3 weeks.
■ Taking anti-tuberculosis drugs. ■ Receiving injectable anti- tuberculosis drugs.
TReAT ANDADVISe
■ Give first dose of appropriate IM/IV antibiotics B15 . ■ refer urgently to hospital B17 .
■ Refer to hospital for assessment. ■ If severe wheezing, refer urgently to hospital.
■ Advise safe, soothing remedy. ■ If smoking, counsel to stop smoking.
■ If anti-tubercular treatment includes streptomycin (injection), refer the woman to district hospital for revision of treatment as streptomycin is ototoxic to the fetus. ■ If treatment does not include streptomycin, assure the woman that the drugs are not harmful to her baby, and urge her to continue treatment for a successful outcome of pregnancy. ■ If her sputumis TB positive within 2 months of delivery, plan to give INH prophylaxis to the newborn k13 . ■ Reinforce advice on HIV testing and counselling G2-G3 . ■ If smoking, counsel to stop smoking. ■ Advise to screen immediate family members and close contacts for tuberculosis.
CLASSIFY
PossIBle PneuMonIA
PossIBle cHronIc lunG dIseAse
uPPer resPIrAtory trAct InfectIon
tuBerculosIs
next: Give preventive measures
If couGH or BreAtHInG dIffIculty
AntenAtAl cAre
c11

Antenatal care
AntenAtAl cAre
c12 Give preventive measures
AntenAtAl cAre
c12
GIve PreventIve MeAsures
Advise and counsel all pregnant women at every antenatal care visit.
ASSeSS, CHeCk ReCoRD
■ Check tetanus toxoid (TT) immunization status.
■ Check woman’s supply of the prescribed dose of iron/folate
■ Check when last dose of mebendazole given.
■ Check when last dose of an antimalarial given. ■ Ask if she (and children) are sleeping under insecticide treated bednets.
■ Record all visits and treatments given.
TReAT ANDADVISe
■ Give tetanus toxoid if due f2 . ■ If TT1, plan to give TT2 at next visit.
■ Give 3 month’s supply of iron and counsel on compliance and safety f3 .
■ Give mebendazole once in second or third trimester f3 .
■ Give intermittent preventive treatment in second and third trimesters f4 . ■ encourage sleeping under insecticide treated bednets.
first visit ■ Develop a birth and emergency plan c14 . ■ Counsel on nutrition c13 . ■ Counsel on importance of exclusive breastfeeding k2 . ■ Counsel on stopping smoking and alcohol and drug abuse. ■ Counsel on safer sex including use of condoms.
All visits ■ Review and update the birth and emergency plan according to new findings c14-c15. ■ Advise on when to seek care: c17 →routine visits →follow-up visits →danger signs.
third trimester ■ Counsel on family planning c16 .
Advise and counsel on nutrition and self-care
AntenAtAl cAre
c13
AdvIse And counsel on nutrItIon And self-cAre
use the information and counselling sheet to support your interaction with the woman, her partner and family.
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, milk, to help her feel well and strong (give examples of types of food and how much to eat). ■ Spend more time on nutrition counselling with very thin, adolescent and HIV-positive woman. ■ Determine if there are important taboos about foods which are nutritionally important for good health. 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.
Advise on self-care during pregnancy
Advise the woman to: ■ Take iron tablets (p.T3). ■ Rest and avoid lifting heavy objects. ■ Sleep under an insecticide impregnated bednet. ■ Counsel on safer sex including use of condoms, if at risk for STI or HIV G2 . ■ Avoid alcohol and smoking during pregnancy. ■ NoT to take medication unless prescribed at the health centre/hospital.
C8 resPond to oBserved sIGns or
volunteered ProBleMs (2)
Iffeverorburningonurination
C9 resPond to oBserved sIGns or
volunteered ProBleMs (3)
Ifvaginaldischarge
C10 resPond to oBserved sIGns or
volunteered ProBleMs (4)
IfsignssuggestingHIVinfection
Ifsmoking,alcoholordrugabuse,
orhistoryofviolence
C11 resPond to oBserved sIGns or
volunteered ProBleMs (5)
Ifcoughorbreathingdifficulty
Iftakinganti-tuberculosisdrugs
C12 GIve PreventIve MeAsures

C13 AdvIse And counsel on
nutrItIon And self-cAre
Counselonnutrition
Adviseonself-careduringpregnancy
Develop a birth and emergency plan (1)
AntenAtAl cAre
c14
develoP A BIrtHAnd eMerGency PlAn
use the information and counselling sheet to support your interaction with the woman, her partner and family.
Facility delivery
explain why birth in a facility is recommended ■ Any complication can develop during delivery - they are not always predictable. ■ A facility has staff, equipment, supplies and drugs available to provide best care if needed, and a referral system. ■ AIf HIV-positive she will need appropriate ARV treatment for herself and her baby during childbirth. ■ Complications are more common in HIV-positive women and her newborns. Women should deliver in a facility.
Advise how to prepare Review the arrangements for delivery: ■ How will she get there? Will she have to pay for transport? ■ How much will it cost to deliver at the facility? How will she pay? ■ Can she start saving straight away? ■ Who will go with her for support during labour and delivery? ■ Who will help while she is away to care for her home and other children?
Advise when to go ■ If the woman lives near the facility, she should go at the first signs of labour. ■ If living far from the facility, she should go 2-3 weeks before baby due date and stay either at the maternity waiting home or with family or friends near the facility. ■ Advise to ask for help from the community, if needed I2 .
Advise what to bring ■ Home-based maternal record. ■ Clean cloths for washing, drying and wrapping the baby. ■ Additional clean cloths to use as sanitary pads after birth. ■ Clothes for mother and baby. ■ Food and water for woman and support person.
Home delivery with a skilled attendant
Advise how to prepare Review the following with her: ■ Who will be the companion during labour and delivery? ■ Who will be close by for at least 24 hours after delivery? ■ Who will help to care for her home and other children? ■ Advise to call the skilled attendant at the first signs of labour. ■ Advise to have her home-based maternal record ready. ■ Advise to ask for help from the community, if needed I2 .
explain supplies needed for home delivery ■ Warm spot for the birth with a clean surface or a clean cloth. ■ Clean cloths of different sizes: for the bed, for drying and wrapping the baby, for cleaning the baby’s eyes, for the birth attendant to wash and dry her hands, for use as sanitary pads. ■ Blankets. ■ Buckets of clean water and some way to heat this water. ■ Soap. ■ Bowls: 2 for washing and 1 for the placenta. ■ Plastic for wrapping the placenta.
Advise on labour signs
Advise to go to the facility or contact the skilled birth attendant if any of the following signs: ■ a bloody sticky discharge. ■ painful contractions every 20 minutes or less. ■ waters have broken.
Advise on danger signs
Advise to go to the hospital/health centre immediately, day or night, wItHout waiting if any of the following signs: ■ vaginal bleeding. ■ convulsions. ■ severe headaches with blurred vision. ■ fever and too weak to get out of bed. ■ severe abdominal pain. ■ fast or difficult breathing.
She should go to the health centre as soon as possible if any of the following signs: ■ fever. ■ abdominal pain. ■ feels ill. ■ swelling of fingers, face, legs.
Discuss how to prepare for an emergency in pregnancy
■ Discuss emergency issues with the woman and her partner/family: →where will she go? →how will they get there? →how much it will cost for services and transport? →can she start saving straight away? →who will go with her for support during labour and delivery? →who will care for her home and other children? ■ Advise the woman to ask for help from the community, if needed I1–I3 . ■ Advise her to bring her home-based maternal record to the health centre, even for an emergency visit.
Develop a birth and emergency plan (2)
AntenAtAl cAre
c15
Advise and counsel on family planning
AntenAtAl cAre
c16
AdvIse And counsel on fAMIly PlAnnInG
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 counselling 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 on about what family planning method they will use. →Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. →Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not. →Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). ■ Counsel on safer sex including use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. Promote especially if at risk for STI or HIV G4 . ■ For HIV-positive women, see G5 for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time.
Method options for the non-breastfeeding woman can be used immediately postpartum 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) delay 3 weeks Combined oral contraceptives Combined injectables Diaphragm Fertility awareness methods
Special considerations for
family planning counselling during pregnancy
counselling should be given during the third trimester of pregnancy. ■ If the woman chooses female sterilization: →can be performed immediately postpartum if no sign of infection (ideally within 7 days, or delay for 6 weeks). →plan for delivery in hospital or health centre where they are trained to carry out the procedure. →ensure counselling and informed consent prior to labour and delivery. ■ If the woman chooses an intrauterine device (IUD): →can be inserted immediately postpartum if no sign of infection (up to 48 hours, or delay 4 weeks) →plan for delivery in hospital or health centre where they are trained to insert the IUD.
Method options for the breastfeeding woman can be used immediately postpartum Lactational amenorrhoea method (LAM) Condoms Spermicide Female sterilization (within 7 days or delay 6 weeks) Copper IUD (within 48 hours or delay 4 weeks) delay 6 weeks Progestogen-only oral contraceptives Progestogen-only injectables Implants Diaphragm delay 6 months Combined oral contraceptives Combined injectables Fertility awareness methods
AdvIse on routIne And follow-uP vIsIts
encourage the woman to bring her partner or family member to at least 1 visit.
Antenatal care
AntenAtAl cAre
c17 Advise on routine and follow-up visits
AntenAtAl cAre
c17
Routine antenatal care visits
1st visit Before 4 months 12-16 weeks 2nd visit 6 months 24-28 weeks 3rd visit 8 months 30-32 weeks 4th visit 9 months 36-38 weeks
■ All pregnant women should have 4 routine antenatal visits. ■ First antenatal contact should be as early in pregnancy as possible. ■ During the last visit, inform the woman to return if she does not deliver within 2 weeks after the expected date of delivery. ■ More frequent visits or different schedules may be required according to national malaria or HIV policies. ■ If women are HIV-positive ensure a visit between 26-28 weeks.
Follow-up visits
If the problem was: return in: Hypertension 1 week if >8 months pregnant Severe anaemia 2 weeks HIV-positive 2 weeks after HIV testing
Antenatal care
AntenAtAl cAre
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HoMe delIvery wItHout A skIlled AttendAnt
reinforce the importance of delivery with a skilled birth attendant
Instruct mother and family on
clean and safer delivery at home
If the woman has chosen to deliver at home without a skilled attendant, review these simple instructions with the woman and family members. ■ Give them a disposable delivery kit and explain how to use it.
tell her/them: ■ To ensure a clean delivery surface for the birth. ■ To ensure that the attendant should wash her hands with clean water and soap before/after touching mother/baby. She should also keep her nails clean. ■ To, after delivery, place the baby on the mother’s chest with skin-to-skin contact and wipe the baby’s eyes using a clean cloth for each eye. ■ To cover the mother and the baby. ■ To use the ties and razor blade from the disposable delivery kit to tie and cut the cord. The cord is cut when it stops pulsating. ■ To dry the baby after cutting the cord. To wipe clean but not bathe the baby until after 6 hours. ■ To wait for the placenta to deliver on its own. ■ To start breastfeeding when the baby shows signs of readiness, within the first hour after birth. ■ To NoT leave the mother alone for the first 24 hours. ■ To keep the mother and baby warm. To dress or wrap the baby, including the baby’s head. ■ To dispose of the placenta in a correct, safe and culturally appropriate manner (burn or burry).
Advise to avoid harmful practices
For example: not to use local medications to hasten labour. not to wait for waters to stop before going to health facility. not to insert any substances into the vagina during labour or after delivery. not to push on the abdomen during labour or delivery. not to pull on the cord to deliver the placenta. not to put ashes, cow dung or other substance on umbilical cord/stump.
encourage helpful traditional practices:
✎____________________________________________________________________
✎____________________________________________________________________
Advise on danger signs
If the mother or baby has any of these signs, she/they must go to the health centre immediately, day or night, wItHout waiting
Mother ■ Waters break and not in labour after 6 hours. ■ Labour pains/contractions continue for more than 12 hours. ■ Heavy bleeding after delivery (pad/cloth soaked in less than 5 minutes). ■ Bleeding increases. ■ Placenta not expelled 1 hour after birth of the baby.
Baby ■ Very small. ■ Difficulty in breathing. ■ Fits. ■ Fever. ■ Feels cold. ■ Bleeding. ■ Not able to feed.
Assesses eligibility of ARV for HIV-positive pregnant woman
AntenAtAl cAre
c19
ASk, CHeCk ReCoRD
■ Have you lost weight? ■ Have you got diarrhoea (continuous or intermittent)? ■ Do you have fever? How long (>1 month)? ■ Have you had cough? How long (> 1 month)? ■ Have you any difficulty in breathing? How long (> 1 month)? ■ Have you noticed any change in vaginal discharge?
Look, LISTeN, FeeL
■ Look for ulcers and white patches in the mouth (thrush). ■ Look at the skin: →Is there a rash? →Are there blisters along the ribs on one side of the body? ■ Look for visible wasting. ■ Feel the head, neck, and underarm for enlarged lymph nodes. ■ Look for any abnormal vaginal discharge c9 .
SIGNS
HIV-positive and any of the following: ■ Weight loss or no weight gain ■ Visible wasting ■ Diarrhoea > 1 month ■ Fever > 1 month ■ Cough > 1 month or difficult breathing ■ Cracks/ulcers around lips/mouth ■ Itching rash ■ Blisters along the ribs on one side of the body ■ enlarged lymph nodes ■ Abnormal vaginal discharge
HIV-positive and none of the above signs
TReAT ANDADVISe
■ Refer to hospital for further assessment.
■ Give appropriate ARVs G9 . ■ Support initiation of ARV G6 . ■ Revise ANC visit accordingly.
CLASSIFY
HIv-PosItIve wItH HIv-relAted sIGns And syMPtoMs
HIv-PosItIve wItHout HIv-relAted sIGns And syMPtoMs
Assess elIGIBIlIty of Arv for HIv-PosItIve PreGnAnt woMAn
use this chart to assess HIv-related signs and symptoms and to determine Arv needs for HIv-positive woman and her baby when appropriate HIv services and cd4 count
are not available.
C14 develoP A BIrtH And
eMerGency PlAn
Facilitydelivery
Homedeliverywithaskilledattendant
C15 Adviseonlaboursigns
Adviseondangersigns
Discusshowtoprepareforanemergencyin
pregnancy

C16 AdvIse And counsel on
fAMIly PlAnnInG
Counselontheimportanceoffamilyplanning
Specialconsiderationsforfamilyplanning
counsellingduringpregnancy
C17 AdvIse on routIne And
follow-uP vIsIts
C18 HoMe delIvery wItHout A
skIlled AttendAnt
Instructmotherandfamilyoncleanandsafer
deliveryathome
Advisetoavoidharmfulpractices
Adviseondangersigns
C19 Assess elIGIBIlIty of Arv for
HIv-PosItIve woMAn
Assess the pregnant woman Pregnancy status, birth and emergency plan
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All vIsIts
■ Checkdurationofpregnancy.
■ Wheredoyouplantodeliver?
■ Anyvaginalbleedingsincelastvisit?
■ Isthebabymoving?(after4months)
■ Checkrecordforpreviouscomplicationsand
treatmentsreceivedduringthispregnancy.
■ Doyouhaveanyconcerns?
fIrst vIsIt
■ Howmanymonthspregnantareyou?
■ Whenwasyourlastperiod?
■ Whendoyouexpecttodeliver?
■ Howoldareyou?
■ Haveyouhadababybefore?Ifyes:
■ Checkrecordforpriorpregnanciesorif
thereisnorecordaskabout:
→Numberofpriorpregnancies/deliveries
→Priorcaesareansection,forceps,orvacuum
→Priorthirddegreetear
→Heavybleedingduringorafterdelivery
→Convulsions
→Stillbirthordeathinfirstday.
→Doyousmoke,drinkalcoholor
useanydrugs?
tHIrd trIMester
Hasshebeencounselledonfamily
planning?Ifyes,doesshewant
tuballigationorIUD A15 .
Look,LISTeN,FeeL
■ Feelfortrimesterofpregnancy.
■ Lookforcaesareanscar
■ Feelforobviousmultiple
pregnancy.
■ Feelfortransverselie.
■ Listentofetalheart.
INDICATIoNS
■ Priordeliverybycaesarean.
■ Agelessthan14years.
■ Transverselieorotherobvious
malpresentationwithinonemonth
ofexpecteddelivery.
■ obviousmultiplepregnancy.
■ TuballigationorIUDdesired
immediatelyafterdelivery.
■ Documentedthirddegreetear.
■ Historyoforcurrentvaginal
bleedingorothercomplication
duringthispregnancy.
■ Firstbirth.
■ Lastbabyborndeadordiedinfirst
day.
■ Agelessthan16years.
■ Morethansixpreviousbirths.
■ Priordeliverywithheavybleeding.
■ Priordeliverywithconvulsions.
■ Priordeliverybyforcepsorvacuum.
■ HIV-positivewoman.
■ Noneoftheabove.
ADVISe
■ explainwhydeliveryneedstobeatreferrallevel c14 .
■ Developthebirthandemergencyplan c14 .
■ explainwhydeliveryneedstobeatprimaryhealth
carelevel c14 .
■ Developthebirthandemergencyplan c14 .
■ explainwhydeliveryneedstobewithaskilledbirth
attendant,preferablyatafacility.
■ Developthebirthandemergencyplan c14 .
PLACeoFDeLIVeRY
referrAl level
PrIMAry
HeAltH cAre level
AccordInG to
woMAn’s Preference
next:Checkforpre-eclampsia
Assess tHe PreGnAnt woMAn: PreGnAncy stAtus, BIrtH And eMerGency PlAn
use this chart to assess the pregnant woman at each of the four antenatal care visits. during first antenatal visit, prepare a birth and emergency plan using this chart
and review them during following visits. Modify the birth plan if any complications arise.
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Assess the pregnant woman Check for pre-eclampsia
ASk,CHeCkReCoRD
■ Bloodpressureatthelastvisit?
Look,LISTeN,FeeL
■ Measurebloodpressureinsitting
position.
■ Ifdiastolicbloodpressureis≥90
mmHg,repeatafter1hourrest.
■ Ifdiastolicbloodpressureisstill≥90
mmHg,askthewomanifshehas:
→severeheadache
→blurredvision
→epigastricpainand
→checkproteininurine.
SIGNS
■ Diastolicbloodpressure
≥110 mmHgand3+proteinuria,or
■ Diastolicbloodpressure
≥90-mmHgontworeadingsand2+
proteinuria,andanyof:
→severeheadache
→blurredvision
→epigastricpain.
■ Diastolicbloodpressure
90-110-mmHgontworeadingsand
2+proteinuria.
■ Diastolicbloodpressure
≥90mmHgon2readings.
■ Noneoftheabove.
TReATANDADVISe
■ Givemagnesiumsulphate B13 .
■ Giveappropriateanti-hypertensives B14 .
■ Revisethebirthplan c2 .
■ refer urgently to hospital B17 .
■ Revisethebirthplan c2 .
■ Refertohospital.
■ Advisetoreduceworkloadandtorest.
■ Adviseondangersigns c15 .
■ Reassessatthenextantenatalvisitorin1weekif
>8monthspregnant.
■ Ifhypertensionpersistsafter1weekoratnextvisit,
refertohospitalordiscusscasewiththedoctoror
midwife,ifavailable.
Notreatmentrequired.
CLASSIFY
severe
Pre-eclAMPsIA
Pre-eclAMPsIA
HyPertensIon
no HyPertensIon
next:Checkforanaemia
cHeck for Pre-eclAMPsIA
screen all pregnant women at every visit.
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Assess the pregnant woman Check for anaemia
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■ Doyoutireeasily?
■ Areyoubreathless(shortofbreath)
duringroutinehouseholdwork?
Look,LISTeN,FeeL
on first visit:
■ Measurehaemoglobin
on subsequent visits:
■ Lookforconjunctivalpallor.
■ Lookforpalmarpallor.Ifpallor:
→Isitseverepallor?
→Somepallor?
→Countnumberofbreathsin1
minute.
SIGNS
■ Haemoglobin<7-g/dl.
And/or
■ Severepalmarandconjunctival
palloror
■ Anypallorwithanyof
→>30breathsperminute
→tireseasily
→breathlessnessatrest
■ Haemoglobin7-11-g/dl.
or
■ Palmarorconjunctivalpallor.
■ Haemoglobin>11-g/dl.
■ Nopallor.
TReATANDADVISe
■ Revisebirthplansoastodeliverinafacilitywith
bloodtransfusionservices c2 .
■ Givedoubledoseofiron(1tablettwicedaily)
for3months f3 .
■ Counseloncompliancewithtreatment f3 .
■ Giveappropriateoralantimalarial f4 .
■ Followupin2weekstocheckclinicalprogress,test
results,andcompliancewithtreatment.
■ refer urgently to hospital B17 .
■ Givedoubledoseofiron(1tablettwicedaily)
for3months f3 .
■ Counseloncompliancewithtreatment f3 .
■ Giveappropriateoralantimalarialifnotgiveninthe
pastmonth f4 .
■ Reassessatnextantenatalvisit(4-6weeks).If
anaemiapersists,refertohospital.
■ Giveiron1tabletoncedailyfor3months f3 .
■ Counseloncompliancewithtreatment f4 .
CLASSIFY
severe
AnAeMIA
ModerAte AnAeMIA
no clInIcAl
AnAeMIA
next:Checkforsyphilis
cHeck for AnAeMIA
screen all pregnant women at every visit.
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Assess the pregnant woman Check for syphilis
ASk,CHeCkReCoRD
■ Haveyoubeentestedforsyphilis
duringthispregnancy?
→Ifnot,performtherapidplasma
reagin(RPR)test l5 .
■ Iftestwaspositive,haveyouand
yourpartnerbeentreatedfor
syphilis?
→Ifnot,andtestispositive,ask
“Areyouallergictopenicillin?”
Look,LISTeN,FeeL TeSTReSULT
■ RPRtestpositive.
■ RPRtestnegative.
TReATANDADVISe
■ GivebenzathinebenzylpenicillinIM.Ifallergy,give
erythromycin f6 .
■ Plantotreatthenewborn k12 .
■ encouragewomantobringhersexualpartnerfor
treatment.
■ Counselonsafersexincludinguseofcondomsto
preventnewinfection G2 .
■ Counselonsafersexincludinguseofcondomsto
preventinfection G2 .
CLASSIFY
PossIBle syPHIlIs
no syPHIlIs
next:CheckforHIVstatus
cHeck for syPHIlIs
test all pregnant women at first visit. check status at every visit.
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Assess the pregnant woman Check for HIV status
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Provide key information on HIv G2 .
■WhatisHIVandhowisHIVtransmit-
ted G2 ?
■ AdvantageofknowingtheHIVstatus
inpregnancy G2 .
■ explainaboutHIVtestingand
counsellingincludingconfidentiality
oftheresult G3 .
Ask the woman:
■ HaveyoubeentestedforHIV?
→If not: tell her that she will be
testedforHIV,unlesssherefuses.
→Ifyes:Checkresult.(explainto
herthat she hasa rightnot to
disclosetheresult.)
→AreyoutakinganyARV?
→CheckARVtreatmentplan.
■ Hasthepartnerbeentested?
Look,LISTeN,FeeL
■ PerformtheRapidHIVtestifnot
performedinthispregnancy l6 .
SIGNS
■ PositiveHIVtest.
■ NegativeHIVtest.
■ Sherefusesthetestorisnotwilling
todisclosetheresultofprevious
testornotestresultsavailable.
TReATANDADVISe
■ Counselonimplicationsofapositivetest G3 .
If HIv services available:
■ ReferthewomantoHIVservicesforfurtherasses-
sment.
■ Askhertoreturnin2weekswithherdocuments.
If HIv services are not available:
■ Determinetheseverityofthediseaseandassess
eligibilityforARVs c19 .
■ GiveherappropriateARV G6 , G9 .
for all women:
■ SupportadherencetoARV G6 .
■ Counseloninfantfeedingoptions G7 .
■ ProvideadditionalcareforHIV-positivewoman G4 .
■ Counselonfamilyplanning G4 .
■ Counselonsafersexincludinguseofcondoms G2 .
■ Counselonbenefitsofdisclosure(involving)and
testingherpartner G3 .
■ ProvidesupporttotheHIV-positivewoman G5 .
■ Counselonimplicationsofanegativetest G3 .
■ Counselontheimportanceofstayingnegativeby
practisingsafersex,includinguseofcondoms G2 .
■ Counselonbenefitsofinvolvingandtestingthe
partner G3 .
■ Counselonsafersexincludinguseofcondoms G2 .
■ Counselonbenefitsofinvolvingandtestingthe
partner G3 .
CLASSIFY
HIv-PosItIve
HIv-neGAtIve
unknown HIv stAtus
next: Respondtoobservedsignsorvolunteeredproblems
Ifnoproblem,gotopage c12 .
cHeck for HIv stAtus
test and counsel all pregnant women for HIv at the first antenatal visit. check status at every visit.
Inform the women that HIV test will be done routinely and that she may refuse the HIV test.
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If ruPtured MeMBrAnes And no lABour
Respond to observed signs or volunteered problems (1)
ASk,CHeCkReCoRD
■ Whendidthebabylastmove?
■ Ifnomovementfelt,askwoman
tomovearoundforsometime,
reassessfetalmovement.
■ Whendidthemembranesrupture?
■ Whenisyourbabydue?
Look,LISTeN,FeeL
■ Feelforfetalmovements.
■ Listenforfetalheartafter6months
ofpregnancy d2 .
■ Ifnoheartbeat,repeatafter1hour.
■ Lookatpadorunderwearfor
evidenceof:
→amnioticfluid
→foul-smellingvaginaldischarge
■ Ifnoevidence,askhertoweara
pad.Checkagainin1hour.
■ Measuretemperature.
SIGNS
■ Nofetalmovement.
■ Nofetalheartbeat.
■ Nofetalmovementbutfetalheart
beatpresent.
■ Fever38ºC.
■ Foul-smellingvaginaldischarge.
■ Ruptureofmembranesat<8
monthsofpregnancy.
■ Ruptureofmembranesat>8
monthsofpregnancy.
TReATANDADVISe
■ Informthewomanandpartneraboutthepossibility
ofdeadbaby.
■ Refertohospital.
■ Informthewomanthatbabyisfineandlikelytobe
wellbuttoreturnifproblempersists.
■ GiveappropriateIM/IVantibiotics B15 .
■ refer urgently to hospital B17 .
■ GiveappropriateIM/IVantibiotic B15 .
■ refer urgently to hospital B17 .
■ ManageasWomaninchildbirth d1-d28.
CLASSIFY
ProBABly deAd BABy
well BABy
uterIne And fetAl
InfectIon
rIsk of uterIne
And fetAl InfectIon
ruPture of
MeMBrAnes
next:Iffeverorburningonurination
resPond to oBserved sIGns or volunteered ProBleMs
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Respond to observed signs or volunteered problems (2)
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■ Haveyouhadfever?
■ Doyouhaveburningonurination?
Look,LISTeN,FeeL
■ Ifhistoryoffeverorfeelshot:
→Measureaxillary
temperature.
→Lookorfeelforstiffneck.
→Lookforlethargy.
■ Percussflanksfor
tenderness.
SIGNS
■ Fever>38°Candanyof:
→veryfastbreathingor
→stiffneck
→lethargy
→veryweak/notabletostand.
■ Fever>38°Candanyof:
→Flankpain
→Burningonurination.
■ Fever>38°Corhistoryoffever
(inlast48hours).
■ Burningonurination.
TReATANDADVISe
■ InsertIVlineandgivefluidsslowly B9 .
■ GiveappropriateIM/IVantibiotics B15 .
■ Giveartemether/quinineIM B16 .
■ Giveglucose B16 .
■ refer urgently to hospital B17 .
■ GiveappropriateIM/IVantibiotics B15 .
■ Giveappropriateoralantimalarial f4 .
■ refer urgently to hospital B17 .
■ Giveappropriateoralantimalarial f4 .
■ Ifnoimprovementin2daysorconditionisworse,
refertohospital.
■ Giveappropriateoralantibiotics f5 .
■ encouragehertodrinkmorefluids.
■ Ifnoimprovementin2daysorconditionisworse,
refertohospital.
CLASSIFY
very severe feBrIle
dIseAse
uPPer urInAry trAct
InfectIon
MAlArIA
lower urInAry trAct
InfectIon
next:Ifvaginaldischarge
If fever or BurnInG on urInAtIon
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Respond to observed signs or volunteered problems (3)
ASk,CHeCkReCoRD
■ Haveyounoticedchangesinyour
vaginaldischarge?
■ Doyouhaveitchingatthevulva?
■ Hasyourpartnerhadaurinary
problem?
Ifpartnerispresentintheclinic,ask
thewomanifshefeelscomfortableif
youaskhimsimilarquestions.
Ifyes,askhimifhehas:
■ urethraldischargeorpus.
■ burningonpassingurine.
Ifpartnercouldnotbeapproached,
explainimportanceofpartner
assessmentandtreatmenttoavoid
reinfection.
Schedulefollow-upappointmentfor
womanandpartner(ifpossible).
Look,LISTeN,FeeL
■ Separatethelabiaandlookfor
abnormalvaginaldischarge:
→amount
→colour
→odour/smell.
■ Ifnodischargeisseen,examine
withaglovedfingerandlookatthe
dischargeontheglove.
SIGNS
■ Abnormalvaginaldischarge.
■ Partnerhasurethraldischargeor
burningonpassingurine.
■ Curdlikevaginaldischarge.
■ Intensevulvalitching.
■ Abnormalvaginaldischarge
TReATANDADVISe
■ Giveappropriateoralantibioticstowoman f5 .
■ Treatpartnerwithappropriateoralantibiotics f5 .
■ Counselonsafersexincludinguseofcondoms G2 .
■ Giveclotrimazole f5 .
■ Counselonsafersexincludinguseofcondoms G2 .
■ Givemetronidazoletowoman f5 .
■ Counselonsafersexincludinguseofcondoms G2 .
CLASSIFY
PossIBle
GonorrHoeA or
cHlAMydIA
InfectIon
PossIBle
cAndIdA InfectIon
PossIBle
BActerIAl or
trIcHoMonAs
InfectIon
next:IfsignssuggestingHIVinfection
If vAGInAl dIscHArGe
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Respond to observed signs or volunteered problems (4)
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■ Haveyoulostweight?
■ Doyouhavefever?
Howlong(>1month)?
■ Haveyougotdiarrhoea(continuous
orintermittent)?
Howlong,>1month?
■ Haveyouhadcough?
Howlong,>1month?
Assess if in high risk group:
■ occupationalexposure?
■ Multiplesexualpartner?
■ Intravenousdrugabuse?
■ Historyofbloodtransfusion?
■ IllnessordeathfromAIDSina
sexualpartner?
■ Historyofforcedsex?
Look,LISTeN,FeeL
■ Lookforvisiblewasting.
■ Lookforulcersandwhitepatchesin
themouth(thrush).
■ Lookattheskin:
→Istherearash?
→Arethereblistersalongtheribs
ononesideofthebody?
SIGNS
■ Twoofthesesigns:
→weightloss
→fever>1month
→diarrhoea>1month.
or
■ oneoftheabovesignsand
→oneormoreothersignsor
→fromariskgroup.
TReATANDADVISe
■ ReinforcetheneedtoknowHIVstatusandadviseon
HIVtestingandcounselling G2-G3 .
■ Counselonthebenefitsoftestingthepartner G3 .
■ Counselonsafersexincludinguseofcondoms G2 .
■ RefertoTBcentreifcough.
■ Counselonstoppingsmoking
■ Foralcohol/drugabuse,refertospecializedcare
providers.
■ Forcounsellingonviolence,see H4 .
CLASSIFY
stronG lIkelIHood of
HIv InfectIon
next:Ifcoughorbreathingdifficulty
If sIGns suGGestInG HIv InfectIon
(HIv status unknown)
c10
If sMokInG, AlcoHol or druG ABuse, or HIstory of vIolence
t
If tAkInG AntI-tuBerculosIs druGs
Respond to observed signs or volunteered problems (5)
ASk,CHeCkReCoRD
■ Howlonghaveyoubeencoughing?
■ Howlonghaveyouhaddifficultyin
breathing?
■ Doyouhavechestpain?
■ Doyouhaveanybloodinsputum?
■ Doyousmoke?
■ Areyoutakinganti-tuberculosis
drugs?Ifyes,sincewhen?
■ Doesthetreatmentincludeinjection
(streptomycin)?
Look,LISTeN,FeeL
■ Lookforbreathlessness.
■ Listenforwheezing.
■ Measuretemperature.
SIGNS
At least 2 of the following signs:
■ Fever>38ºC.
■ Breathlessness.
■ Chestpain.
At least 1 of the following signs:
■ Coughorbreathingdifficulty
for>3weeks
■ Bloodinsputum
■ Wheezing
■ Fever<38ºC,and
■ Cough<3weeks.
■ Takinganti-tuberculosisdrugs.
■ Receivinginjectableanti-
tuberculosisdrugs.
TReATANDADVISe
■ GivefirstdoseofappropriateIM/IVantibiotics B15 .
■ refer urgently to hospital B17 .
■ Refertohospitalforassessment.
■ Ifseverewheezing,referurgentlytohospital.
■ Advisesafe,soothingremedy.
■ Ifsmoking,counseltostopsmoking.
■ Ifanti-tuberculartreatmentincludesstreptomycin
(injection),referthewomantodistricthospitalfor
revisionoftreatmentasstreptomycinisototoxicto
thefetus.
■ Iftreatmentdoesnotincludestreptomycin,assure
thewomanthatthedrugsarenotharmfultoher
baby,andurgehertocontinuetreatmentfora
successfuloutcomeofpregnancy.
■ IfhersputumisTBpositivewithin2monthsofdelivery,
plantogiveINHprophylaxistothenewborn k13 .
■ ReinforceadviceonHIVtestingandcounselling
G2-G3 .
■ Ifsmoking,counseltostopsmoking.
■ Advisetoscreenimmediatefamilymembersand
closecontactsfortuberculosis.
CLASSIFY
PossIBle PneuMonIA
PossIBle cHronIc
lunG dIseAse
uPPer
resPIrAtory trAct
InfectIon
tuBerculosIs
next:Givepreventivemeasures
If couGH or BreAtHInG dIffIculty
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Give preventive measures
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GIve PreventIve MeAsures
Advise and counsel all pregnant women at every antenatal care visit.
ASSeSS,CHeCkReCoRD
■ Checktetanustoxoid(TT)immunizationstatus.
■ Checkwoman’ssupplyoftheprescribeddoseofiron/folate
■ Checkwhenlastdoseofmebendazolegiven.
■ Checkwhenlastdoseofanantimalarialgiven.
■ Askifshe(andchildren)aresleepingunderinsecticidetreatedbednets.
■ Recordallvisitsandtreatmentsgiven.
TReATANDADVISe
■ Givetetanustoxoidifdue f2 .
■ IfTT1,plantogiveTT2atnextvisit.
■ Give3month’ssupplyofironandcounseloncomplianceandsafety f3 .
■ Givemebendazoleonceinsecondorthirdtrimester f3 .
■ Giveintermittentpreventivetreatmentinsecondandthirdtrimesters f4 .
■ encouragesleepingunderinsecticidetreatedbednets.
first visit
■ Developabirthandemergencyplan c14 .
■ Counselonnutrition c13 .
■ Counselonimportanceofexclusivebreastfeeding k2 .
■ Counselonstoppingsmokingandalcoholanddrugabuse.
■ Counselonsafersexincludinguseofcondoms.
All visits
■ Reviewandupdatethebirthandemergencyplanaccordingtonewfindingsc14-c15.
■ Adviseonwhentoseekcare: c17
→routinevisits
→follow-upvisits
→dangersigns.
third trimester
■ Counselonfamilyplanning c16 .
Advise and counsel on nutrition and self-care
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AdvIse And counsel on nutrItIon And self-cAre
use the information and counselling sheet to support your interaction with the woman, her partner and family.
Counselonnutrition
■ Advisethewomantoeatagreateramountandvarietyofhealthyfoods,suchasmeat,fish,oils,nuts,
seeds,cereals,beans,vegetables,cheese,milk,tohelpherfeelwellandstrong(giveexamplesof
typesoffoodandhowmuchtoeat).
■ Spendmoretimeonnutritioncounsellingwithverythin,adolescentandHIV-positivewoman.
■ Determineifthereareimportanttaboosaboutfoodswhicharenutritionallyimportantforgood
health.Advisethewomanagainstthesetaboos.
■ Talktofamilymemberssuchasthepartnerandmother-in-law,toencouragethemtohelpensurethe
womaneatsenoughandavoidshardphysicalwork.
Adviseonself-careduringpregnancy
Advise the woman to:
■ Takeirontablets(p.T3).
■ Restandavoidliftingheavyobjects.
■ Sleepunderaninsecticideimpregnatedbednet.
■ Counselonsafersexincludinguseofcondoms,ifatriskforSTIorHIV G2 .
■ Avoidalcoholandsmokingduringpregnancy.
■ NoTtotakemedicationunlessprescribedatthehealthcentre/hospital.
Develop a birth and emergency plan (1)
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develoP A BIrtH And eMerGency PlAn
use the information and counselling sheet to support your interaction with the woman, her partner and family.
Facilitydelivery
explain why birth in a facility is recommended
■ Anycomplicationcandevelopduringdelivery-theyarenotalwayspredictable.
■ Afacilityhasstaff,equipment,suppliesanddrugsavailabletoprovidebestcareifneeded,anda
referralsystem.
■ IfHIV-positiveshewillneedappropriateARVtreatmentforherselfandherbabyduringchildbirth.
■ ComplicationsaremorecommoninHIV-positivewomenandhernewborns.HIV-positivewomen
shoulddeliverinafacility.
Advise how to prepare
Reviewthearrangementsfordelivery:
■ Howwillshegetthere?Willshehavetopayfortransport?
■ Howmuchwillitcosttodeliveratthefacility?Howwillshepay?
■ Canshestartsavingstraightaway?
■ Whowillgowithherforsupportduringlabouranddelivery?
■ Whowillhelpwhilesheisawaytocareforherhomeandotherchildren?
Advise when to go
■ Ifthewomanlivesnearthefacility,sheshouldgoatthefirstsignsoflabour.
■ Iflivingfarfromthefacility,sheshouldgo2-3weeksbeforebabyduedateandstayeitheratthe
maternitywaitinghomeorwithfamilyorfriendsnearthefacility.
■ Advisetoaskforhelpfromthecommunity,ifneeded I2 .
Advise what to bring
■ Home-basedmaternalrecord.
■ Cleanclothsforwashing,dryingandwrappingthebaby.
■ Additionalcleanclothstouseassanitarypadsafterbirth.
■ Clothesformotherandbaby.
■ Foodandwaterforwomanandsupportperson.
Homedeliverywithaskilledattendant
Advise how to prepare
Reviewthefollowingwithher:
■ Whowillbethecompanionduringlabouranddelivery?
■ Whowillbeclosebyforatleast24hoursafterdelivery?
■ Whowillhelptocareforherhomeandotherchildren?
■ Advisetocalltheskilledattendantatthefirstsignsoflabour.
■ Advisetohaveherhome-basedmaternalrecordready.
■ Advisetoaskforhelpfromthecommunity,ifneeded I2 .
explain supplies needed for home delivery
■ Warmspotforthebirthwithacleansurfaceoracleancloth.
■ Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,forcleaningthebaby’s
eyes,forthebirthattendanttowashanddryherhands,foruseassanitarypads.
■ Blankets.
■ Bucketsofcleanwaterandsomewaytoheatthiswater.
■ Soap.
■ Bowls:2forwashingand1fortheplacenta.
■ Plasticforwrappingtheplacenta.
Adviseonlaboursigns
Advisetogotothefacilityorcontacttheskilledbirthattendantifanyofthefollowingsigns:
■ abloodystickydischarge.
■ painfulcontractionsevery20minutesorless.
■ watershavebroken.
Adviseondangersigns
Advisetogotothehospital/healthcentreimmediately, day or night, wItHout waiting
ifanyofthefollowingsigns:
■ vaginalbleeding.
■ convulsions.
■ severeheadacheswithblurredvision.
■ feverandtooweaktogetoutofbed.
■ severeabdominalpain.
■ fastordifficultbreathing.
Sheshouldgotothehealthcentreas soon as possibleifanyofthefollowingsigns:
■ fever.
■ abdominalpain.
■ feelsill.
■ swellingoffingers,face,legs.
Discusshowtoprepareforanemergencyinpregnancy
■ Discussemergencyissueswiththewomanandherpartner/family:
→wherewillshego?
→howwilltheygetthere?
→howmuchitwillcostforservicesandtransport?
→canshestartsavingstraightaway?
→whowillgowithherforsupportduringlabouranddelivery?
→whowillcareforherhomeandotherchildren?
■ Advisethewomantoaskforhelpfromthecommunity,ifneeded I1–I3 .
■ Advisehertobringherhome-basedmaternalrecordtothehealthcentre,evenforanemergencyvisit.
Develop a birth and emergency plan (2)
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Advise and counsel on family planning
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AdvIse And counsel on fAMIly PlAnnInG
Counselontheimportanceoffamilyplanning
■ Ifappropriate,askthewomanifshewouldlikeherpartneroranotherfamilymembertobeincluded
inthecounsellingsession.
■ explainthatafterbirth,ifshehassexandisnotexclusivelybreastfeeding,shecanbecomepregnant
assoonasfourweeksafterdelivery.Thereforeitisimportanttostartthinkingearlyonaboutwhat
familyplanningmethodtheywilluse.
→Askaboutplansforhavingmorechildren.Ifshe(andherpartner)wantmorechildren,advisethat
waitingatleast2-3yearsbetweenpregnanciesishealthierforthemotherandchild.
→Informationonwhentostartamethodafterdeliverywillvarydependingwhetherawomanis
breastfeedingornot.
→Makearrangementsforthewomantoseeafamilyplanningcounsellor,orcounselherdirectly
(seetheDecision-makingtoolforfamilyplanningprovidersandclientsforinformationon
methodsandonthecounsellingprocess).
■ Counselonsafersexincludinguseofcondomsfordualprotectionfromsexuallytransmitted
infections(STI)orHIVandpregnancy.PromoteespeciallyifatriskforSTIorHIV G4 .
■ ForHIV-positivewomen,see G5 forfamilyplanningconsiderations
■ Herpartnercandecidetohaveavasectomy(malesterilization)atanytime.
Method options for the non-breastfeeding woman
can be used immediately postpartum Condoms
Progestogen-onlyoralcontraceptives
Progestogen-onlyinjectables
Implant
Spermicide
Femalesterilization(within7daysordelay6weeks)
CopperIUD(immediatelyfollowingexpulsionof
placentaorwithin48hours)
delay 3 weeks Combinedoralcontraceptives
Combinedinjectables
Diaphragm
Fertilityawarenessmethods
Specialconsiderationsfor
familyplanningcounsellingduringpregnancy
counselling should be given during the third trimester of pregnancy.
■ Ifthewomanchoosesfemalesterilization:
→canbeperformedimmediatelypostpartumifnosignofinfection
(ideallywithin7days,ordelayfor6weeks).
→planfordeliveryinhospitalorhealthcentrewheretheyaretrainedtocarryouttheprocedure.
→ensurecounsellingandinformedconsentpriortolabouranddelivery.
■ Ifthewomanchoosesanintrauterinedevice(IUD):
→canbeinsertedimmediatelypostpartumifnosignofinfection(upto48hours,ordelay4weeks)
→planfordeliveryinhospitalorhealthcentrewheretheyaretrainedtoinserttheIUD.
Method options for the breastfeeding woman
can be used immediately postpartum Lactationalamenorrhoeamethod(LAM)
Condoms
Spermicide
Femalesterilization(within7daysor
delay6weeks)
CopperIUD(within48hoursordelay4weeks)
delay 6 weeks Progestogen-onlyoralcontraceptives
Progestogen-onlyinjectables
Implants
Diaphragm
delay 6 months Combinedoralcontraceptives
Combinedinjectables
Fertilityawarenessmethods
AdvIse on routIne And follow-uP vIsIts
encourage the woman to bring her partner or family member to at least 1 visit.
Antenatal care
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Advise on routine and follow-up visits
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Routineantenatalcarevisits
1st visit Before4months Before16weeks
2nd visit 6months 24-28weeks
3rd visit 8months 30-32weeks
4th visit 9months 36-38weeks
■ Allpregnantwomenshouldhave4routineantenatalvisits.
■ Firstantenatalcontactshouldbeasearlyinpregnancyaspossible.
■ Duringthelastvisit,informthewomantoreturnifshedoesnotdeliverwithin2weeksafterthe
expecteddateofdelivery.
■ MorefrequentvisitsordifferentschedulesmayberequiredaccordingtonationalmalariaorHIV
policies.
■ IfwomenisHIV-positiveensureavisitbetween26-28weeks.
Follow-upvisits
If the problem was: return in:
Hypertension 1weekif>8monthspregnant
Severeanaemia 2weeks
HIV-positive 2weeksafterHIVtesting
Antenatal care
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HoMe delIvery wItHout A skIlled AttendAnt
reinforce the importance of delivery with a skilled birth attendant
Instructmotherandfamilyon
cleanandsaferdeliveryathome
Ifthewomanhaschosentodeliverathomewithoutaskilledattendant,reviewthesesimple
instructionswiththewomanandfamilymembers.
■ Givethemadisposabledeliverykitandexplainhowtouseit.
tell her/them:
■ Toensureacleandeliverysurfaceforthebirth.
■ Toensurethattheattendantshouldwashherhandswithcleanwaterandsoapbefore/after
touchingmother/baby.Sheshouldalsokeephernailsclean.
■ To,afterdelivery,placethebabyonthemother’schestwithskin-to-skincontactandwipethebaby’s
eyesusingacleanclothforeacheye.
■ Tocoverthemotherandthebaby.
■ Tousethetiesandrazorbladefromthedisposabledeliverykittotieandcutthecord.Thecordiscut
whenitstopspulsating.
■ Todrythebabyaftercuttingthecord.Towipecleanbutnotbathethebabyuntilafter6hours.
■ Towaitfortheplacentatodeliveronitsown.
■ Tostartbreastfeedingwhenthebabyshowssignsofreadiness,withinthefirsthourafterbirth.
■ ToNoTleavethemotheraloneforthefirst24hours.
■ Tokeepthemotherandbabywarm.Todressorwrapthebaby,includingthebaby’shead.
■ Todisposeoftheplacentainacorrect,safeandculturallyappropriatemanner(burnorburry).
Advisetoavoidharmfulpractices
Forexample:
nottouselocalmedicationstohastenlabour.
nottowaitforwaterstostopbeforegoingtohealthfacility.
nottoinsertanysubstancesintothevaginaduringlabourorafterdelivery.
nottopushontheabdomenduringlabourordelivery.
nottopullonthecordtodelivertheplacenta.
nottoputashes,cowdungorothersubstanceonumbilicalcord/stump.
encouragehelpfultraditionalpractices:
✎____________________________________________________________________
✎____________________________________________________________________
Adviseondangersigns
Ifthemotherorbabyhasanyofthesesigns,she/theymustgotothehealthcentre
immediately, day or night, wItHout waiting
Mother
■ Watersbreakandnotinlabourafter6hours.
■ Labourpains/contractionscontinueformorethan12hours.
■ Heavybleedingafterdelivery(pad/clothsoakedinlessthan5minutes).
■ Bleedingincreases.
■ Placentanotexpelled1hourafterbirthofthebaby.
Baby
■ Verysmall.
■ Difficultyinbreathing.
■ Fits.
■ Fever.
■ Feelscold.
■ Bleeding.
■ Notabletofeed.
Assesses eligibility of ARV for HIV-positive pregnant woman
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ASk,CHeCkReCoRD
■ Haveyoulostweight?
■ Haveyougotdiarrhoea
(continuousorintermittent)?
■ Doyouhavefever?
Howlong(>1month)?
■ Haveyouhadcough?
Howlong(>1month)?
■ Haveyouanydifficultyinbreathing?
Howlong(>1month)?
■ Have you noticed any change in
vaginaldischarge?
Look,LISTeN,FeeL
■ Lookforulcersandwhitepatchesin
themouth(thrush).
■ Lookattheskin:
→Istherearash?
→Arethereblistersalongtheribs
ononesideofthebody?
■ Lookforvisiblewasting.
■ Feelthehead,neck,andunderarm
forenlargedlymphnodes.
■ Lookforanyabnormalvaginal
discharge c9 .
SIGNS
HIV-positiveandanyofthefollowing:
■ Weightlossornoweightgain
■ Visiblewasting
■ Diarrhoea>1month
■ Fever>1month
■ Cough>1monthordifficult
breathing
■ Cracks/ulcersaroundlips/mouth
■ Itchingrash
■ Blistersalongtheribsononeside
ofthebody
■ enlargedlymphnodes
■ Abnormalvaginaldischarge
HIV-positiveandnoneoftheabove
signs
TReATANDADVISe
■ Refertohospitalforfurtherassessment.
■ GiveappropriateARVs G9 .
■ SupportinitiationofARV G6 .
■ ReviseANCvisitaccordingly c17 .
CLASSIFY
HIv-PosItIve wItH
HIv-relAted sIGns
And syMPtoMs
HIv-PosItIve wItHout
HIv-relAted sIGns
And syMPtoMs
Assess elIGIBIlIty of Arv for HIv-PosItIve PreGnAnt woMAn
use this chart to determine Arv needs for HIv-positive woman and her baby when appropriate HIv services and cd4 count are not available.
Childbirth: labour, delivery and immediate postpartum care
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Childbirth: labour, delivery and immediate postpartum Care
Examine the woman in labour or with ruptured membranes
Childbirth: labour, delivery and im
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Care
ASK, CHECK RECORD
history of this labour: ■ When did contractions begin? ■ How frequent are contractions? How strong? ■ Have your waters broken? If yes, when? Were they clear or green? ■ Have you had any bleeding? If yes, when? How much? ■ Is the baby moving? ■ Do you have any concern? Check record, or if no record: ■ Ask when the delivery is expected. ■ Determine if preterm (less than 8 months pregnant). ■ Review the birth plan. if prior pregnancies: ■ Number of prior pregnancies/ deliveries. ■ Any prior caesarean section, forceps, or vacuum, or other complication such as postpartum haemorhage? ■ Any prior third degree tear? Current pregnancy: ■ RPR status C5 . ■ Hb results C4 . ■ Tetanus immunization status f2 . ■ HIV status C6 . ■ Infant feeding plan g7-g8 .
LOOK , LISTEN, FEEL
■ Observe the woman’s response to contractions: →Is she coping well or is she distressed? →Is she pushing or grunting? ■ Check abdomen for: →caesarean section scar. →horizontal ridge across lower abdomen (if present, empty bladder b12 and observe again). ■ Feel abdomen for: →contractions frequency, duration, any continuous contractions? →fetal lie—longitudinal or transverse? →fetal presentation—head, breech, other? →more than one fetus? →fetal movement. ■ Listen to the fetal heart beat: →Count number of beats in 1 minute. →If less than 100 beats per minute, or more than 180, turn woman on her left side and count again. ■ Measure blood pressure. ■ Measure temperature. ■ Look for pallor. ■ Look for sunken eyes, dry mouth. ■ Pinch the skin of the forearm: does it go back quickly?
next: Perform vaginal examination and decide stage of labour
examine the woman in labour or with ruptured membranes
first do rapid assessment and management b3-b7 . then use this chart to assess the woman’s and fetal status and decide stage of labour.
d2

Decide stage of labour
ASK, CHECK RECORD
■ Explain to the woman that you will give her a vaginal examination and ask for her consent.
LOOK, LISTEN, FEEL
■ Look at vulva for: → bulging perineum → any visible fetal parts → vaginal bleeding → leaking amniotic fluid; if yes, is it meconium stained, foul-smelling? → warts, keloid tissue or scars that may interfere with delivery.
perform vaginal examination ■ do not shave the perineal area. ■ Prepare: → clean gloves → swabs, pads. ■ Wash hands with soap before and after each examination. ■ Wash vulva and perineal areas. ■ Put on gloves. ■ Position the woman with legs flexed and apart.
do not perform vaginal examination if bleeding now or at any time after 7 months of pregnancy.
■ Perform gentle vaginal examination (do not start during a contraction): → Determine cervical dilatation in centimetres. → Feel for presenting part. Is it hard, round and smooth (the head)? If not, identify the presenting part. → Feel for membranes – are they intact? → Feel for cord – is it felt? Is it pulsating? If so, act immediately as on d15 .
next: Respond to obstetrical problems on admission. Childbirth: labour, delivery and im
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Care
d3
deCide stage of labour
SIGNS
■ Bulging thin perineum, vagina gaping and head visible, full cervical dilatation.
■ Cervical dilatation: →multigravida ≥5 cm →primigravida ≥6 cm
■ Cervical dilatation ≥4 cm.
■ Cervical dilatation: 0-3 cm; contractions weak and <2 in 10 minutes.
MANAGE
■ See second stage of labour d10-d11. ■ Record in partograph n5 .
■ See first stage of labour – active labour d9 . ■ Start plotting partograph n5 . ■ Record in labour record n5 .
■ See first stage of labour — not active labour d8 . ■ Record in labour record n4 .
CLASSIFY
imminent delivery
late aCtive labour
early aCtive labour
not yet in aCtive labour

Respond to obstetrical problems on admission
Childbirth: labour, delivery and im
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Care
SIGNS
■ Transverse lie. ■ Continuous contractions. ■ Constant pain between contractions. ■ Sudden and severe abdominal pain. ■ Horizontal ridge across lower abdomen. ■ Labour >24 hours.
■ Rupture of membranes and any of: →Fever >38˚C →Foul-smelling vaginal discharge.
■ Rupture of membranes at <8-months of pregnancy.
■ Diastolic blood pressure >90 mmHg.
■ Severe palmar and conjunctival pallor and/or haemoglobin <7-g/dl.
■ Breech or other malpresentation d16 . ■ Multiple pregnancy d18 . ■ Fetal distress d14 . ■ Prolapsed cord d15 .
TREAT ANDADVISE
■ If distressed, insert an IV line and give fluids b9 . ■ If in labour >24 hours, give appropriate IM/IV antibiotics b15 . ■ refer urgently to hospital b17 .
■ Give appropriate IM/IV antibiotics b15 . ■ If late labour, deliver and refer to hospital after delivery b17 . ■ Plan to treat newborn J5 .
■ Give appropriate IM/IV antibiotics b15 . ■ If late labour, deliver d10-d28. ■ Discontinue antibiotic for mother after delivery if no signs of infection. ■ Plan to treat newborn J5 .
■ Assess further and manage as on d23 .
■ Manage as on d24 .
■ Follow specific instructions (see page numbers in left column).
CLASSIFY
obstruCted labour
uterine and fetal infeCtion
risk of uterine and fetal infeCtion
pre-eClampsia
severe anaemia
obstetriCal CompliCation
respond to obstetriCal problems on admission
use this chart if abnormal findings on assessing pregnancy and fetal status d2-d3 .
FORALL SITUATIONS INREDBELOW, refer urgentlyto hospital if in early labour, MANAGE ONLY IF INLATE LABOUR
d4
Respond to obstetrical problems on admission
SIGNS
■ Warts, keloid tissue that may interfere with delivery. ■ Prior third degree tear.
■ Bleeding any time in third trimester. ■ Prior delivery by: →caesarean section →forceps or vacuum delivery. ■ Age less than 14 years .
■ Labour before 8 completed months of pregnancy (more than one month before estimated date of delivery).
■ Fetal heart rate <120 or >160 beats per minute.
■ Rupture of membranes at term and before labour.
■ If two or more of the following signs: →thirsty →sunken eyes →dry mouth →skin pinch goes back slowly.
■ HIV test positive. ■ Taking ARV treatment or prophylaxis and infant feeding.
■ No fetal movement, and ■ No fetal heart beat on repeated examination
TREAT ANDADVISE
■ Do a generous episiotomy and carefully control delivery of the head d10-d11 .
■ If late labour, deliver d10-d28 . ■ Have help available during delivery.
■ Reassess fetal presentation (breech more common). ■ If woman is lying, encourage her to lie on her left side. ■ Call for help during delivery. ■ Conduct delivery very carefully as small baby may pop out suddenly. In particular, control delivery of the head. ■ Prepare equipment for resuscitation of newborn k11 .
■ Manage as on d14 .
■ Give appropriate IM/IV antibiotics if rupture of membrane >18 hours b15 . ■ Plan to treat the newborn J5 .
■ Give oral fluids. ■ If not able to drink, give 1 litre IV fluids over 3 hours b9 .
■ Ensure that the woman takes ARV drugs prescribed g9 . ■ Support her choice of infant feeding g7-g8 .
■ Explain to the parents that the baby is not doing well.
CLASSIFY
risk of obstetriCal CompliCation
preterm labour
possible fetal distress
rupture of membranes
dehydration
hiv-positive
possible fetal death
next: Give supportive care throughout labour Childbirth: labour, delivery and im
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Care
d5

d6
Communication
■ Explain all procedures, seek permission, and discuss findings with the woman. ■ Keep her informed about the progress of labour. ■ Praise her, encourage and reassure her that things are going well. ■ Ensure and respect privacy during examinations and discussions. ■ If known HIV positive, find out what she has told the companion. Respect her wishes.
Cleanliness
■ Encourage the woman to bathe or shower or wash herself and genitals at the onset of labour. ■ Wash the vulva and perineal areas before each examination. ■ Wash your hands with soap before and after each examination. Use clean gloves for vaginal examination. ■ Ensure cleanliness of labour and birthing area(s). ■ Clean up spills immediately. ■ do not give enema.
Mobility
■ Encourage the woman to walk around freely during the first stage of labour. ■ Support the woman’s choice of position (left lateral, squating, kneeling, standing supported by the companion) for each stage of labour and delivery.
Urination
■ Encourage the woman to empty her bladder frequently. Remind her every 2 hours.
Eating, drinking
■ Encourage the woman to eat and drink as she wishes throughout labour. ■ Nutritious liquid drinks are important, even in late labour. ■ If the woman has visible severe wasting or tires during labour, make sure she eats and drinks.
Breathing technique
■ Teach her to notice her normal breathing. ■ Encourage her to breathe out more slowly, making a sighing noise, and to relax with each breath. ■ If she feels dizzy, unwell, is feeling pins-and-needles (tingling) in her face, hands and feet, encourage her to breathe more slowly. ■ To prevent pushing at the end of first stage of labour, teach her to pant, to breathe with an open mouth, to take in 2 short breaths followed by a long breath out. ■ During delivery of the head, ask her not to push but to breathe steadily or to pant.
Pain and discomfort relief
■ Suggest change of position. ■ Encourage mobility, as comfortable for her. ■ Encourage companion to: →massage the woman’s back if she finds this helpful. →hold the woman’s hand and sponge her face between contractions. ■ Encourage her to use the breathing technique. ■ Encourage warm bath or shower, if available.
■ if woman is distressed or anxious, investigate the cause d2-d3 . ■ if pain is constant (persisting between contractions) and very severe or sudden in onset d4 .
give supportive Care throughout labour
use this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman’s wishes.
Give supportive care throughout labour
Childbirth: labour, delivery and im
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Care
Birth companion
Childbirth: labour, delivery and im
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Care
d7
Birth companion
■ Encourage support from the chosen birth companion throughout labour. ■ Describe to the birth companion what she or he should do: →Always be with the woman. →Encourage her. →Help her to breathe and relax. →Rub her back, wipe her brow with a wet cloth, do other supportive actions. →Give support using local practices which do not disturb labour or delivery. →Encourage woman to move around freely as she wishes and to adopt the position of her choice. →Encourage her to drink fluids and eat as she wishes. →Assist her to the toilet when needed.
■ Ask the birth companion to call for help if: →The woman is bearing down with contractions. →There is vaginal bleeding. →She is suddenly in much more pain. →She loses consciousness or has fits. →There is any other concern.
■ Tell the birth companion what she or he should not do and explain why: do not encourage woman to push. do not give advice other than that given by the health worker. do not keep woman in bed if she wants to move around.
D2 examine the woman in labour or
with ruptured membres
D3 deCide stage of labour
D4 respond to obstetriCal
problems on admission (1)
D5 respond to obstetriCal
problems on admission (2)
D6 give supportive Care
throughout labour
D7 birth Companion
d8
MONITOR EVERY HOUR:
■ For emergency signs, using rapid assessment (RAM) b3-b7 . ■ Frequency, intensity and duration of contractions. ■ Fetal heart rate d14. ■ Mood and behaviour (distressed, anxious) d6 .
■ Record findings regularly in Labour record and Partograph n4-n6 . ■ Record time of rupture of membranes and colour of amniotic fluid. ■ Give Supportive care d6-d7 . ■ never leave the woman alone.
ASSESS PROGRESS OF LABOUR
■ After 8 hours if: →Contractions stronger and more frequent but →No progress in cervical dilatation with or without membranes ruptured.
■ After 8 hours if: →no increase in contractions, and →membranes are not ruptured, and →no progress in cervical dilatation.
■ Cervical dilatation 4 cm or greater.
MONITOR EVERY 4 HOURS:
■ Cervical dilatation d3 d15. Unless indicated, do not do vaginal examination more frequently than every 4 hours. ■ Temperature. ■ Pulse b3 . ■ Blood pressure d23.
TREAT ANDADVISE, IF REqUIRED
■ refer the woman urgently to hospital b17.
■ Discharge the woman and advise her to return if: →pain/discomfort increases →vaginal bleeding →membranes rupture.
■ Begin plotting the partograph n5 and manage the woman as in Active labour d9 .
first stage of labour: not in aCtive labour
use this chart for care of the woman when not in aCtive labour, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes.
First stage of labour (1): when the woman is not in active labour
Childbirth: labour, delivery and im
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Care
d9
MONITOR EVERY 30 MINUTES:
■ For emergency signs, using rapid assessment (RAM) b3-b7 . ■ Frequency, intensity and duration of contractions. ■ Fetal heart rate d14. ■ Mood and behaviour (distressed, anxious) d6 .
■ Record findings regularly in Labour record and Partograph n4-n6 . ■ Record time of rupture of membranes and colour of amniotic fluid. ■ Give Supportive care d6-d7 . ■ never leave the woman alone.
ASSESS PROGRESS OF LABOUR
■ Partograph passes to the right of ALERT LINE.
■ Partograph passes to the right of ACTION LINE.
■ Cervix dilated 10 cm or bulging perineum.
MONITOR EVERY 4 HOURS:
■ Cervical dilatation d3 d15. Unless indicated, do not do vaginal examination more frequently than every 4 hours. ■ Temperature. ■ Pulse b3 . ■ Blood pressure d23.
TREAT ANDADVISE, IF REqUIRED
■ Reassess woman and consider criteria for referral. ■ Call senior person if available. Alert emergency transport services. ■ Encourage woman to empty bladder. ■ Ensure adequate hydration but omit solid foods. ■ Encourage upright position and walking if woman wishes. ■ Monitor intensively. Reassess in 2 hours and refer if no progress. If referral takes a long time, refer immediately (DO NOT wait to cross action line).
■ refer urgently to hospital b17 unless birth is imminent.
■ Manage as in Second stage of labour d10-d11.
first stage of labour: in aCtive labour
use this chart when the woman is in aCtive labour, when cervix dilated 4 cm or more.
First stage of labour (2): when the woman is in active labour
Childbirth: labour, delivery and im
m
ediate postpartum
Care
d10
MONITOR EVERY 5 MINUTES:
■ For emergency signs, using rapid assessment (RAM) b3-b7 . ■ Frequency, intensity and duration of contractions. ■ Fetal heart rate d14. ■ Perineum thinning and bulging. ■ Visible descent of fetal head or during contraction. ■ Mood and behaviour (distressed, anxious) d6 . ■ Record findings regularly in Labour record and Partograph (pp.N4-N6). ■ Give Supportive care d6-d7 . ■ Never leave the woman alone.
DELIVER THE BABY
■ Ensure all delivery equipment and supplies, including newborn resuscitation equipment, are available, and place of delivery is clean and warm (25°C) l3 .
■ Ensure bladder is empty. ■ Assist the woman into a comfortable position of her choice, as upright as possible. ■ Stay with her and offer her emotional and physical support d10-d11.
■ Allow her to push as she wishes with contractions.
■ Wait until head visible and perineum distending. ■ Wash hands with clean water and soap. Put on gloves just before delivery. ■ See Universal precautions during labour and delivery a4 .
TREAT ANDADVISE IF REqUIRED
■ If unable to pass urine and bladder is full, empty bladder b12 . ■ do not let her lie flat (horizontally) on her back. ■ If the woman is distressed, encourage pain discomfort relief d6 .
do not urge her to push. ■ If, after 30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin and stretch with contractions, do a vaginal examination to confirm full dilatation of cervix. ■ If cervix is not fully dilated, await second stage. Place woman on her left side and discourage pushing. Encourage breathing technique d6 .
■ If second stage lasts for 2 hours or more without visible steady descent of the head, call for staff trained to use vacuum extractor or refer urgently to hospital b17 . ■ If obvious obstruction to progress (warts/scarring/keloid tissue/previous third degree tear), do a generous episiotomy. do not perform episiotomy routinely. ■ If breech or other malpresentation, manage as on d16 .
seCond stage of labour: deliver the baby and give immediate newborn Care
use this chart when cervix dilated 10 cm or bulging thin perineum and head visible.
Second stage of labour: deliver the baby and give immediate newborn care (1)
Childbirth: labour, delivery and im
m
ediate postpartum
Care
Second stage of labour: deliver the baby and give immediate newborn care (2)
Childbirth: labour, delivery and im
m
ediate postpartum
Care
d11
DELIVER THE BABY
■ Ensure controlled delivery of the head: →Keep one hand gently on the head as it advances with contractions. →Support perineumwith other hand and cover anus with pad held in position by side of hand during delivery. →Leave the perineum visible (between thumb and first finger). →Ask the mother to breathe steadily and not to push during delivery of the head. →Encourage rapid breathing with mouth open.
■ Feel gently around baby’s neck for the cord. ■ Check if the face is clear of mucus and membranes.
■ Await spontaneous rotation of shoulders and delivery (within 1-2 minutes). ■ Apply gentle downward pressure to deliver top shoulder. ■ Then lift baby up, towards the mother’s abdomen to deliver lower shoulder. ■ Place baby on abdomen or in mother’s arms. ■ Note time of delivery.
■ Thoroughly dry the baby immediately. Wipe eyes. Discard wet cloth. ■ Assess baby’s breathing while drying. ■ If the baby is not crying, observe breathing: →breathing well (chest rising)? →not breathing or gasping?
■ Exclude second baby. ■ Palpate mother’s abdomen. ■ Give 10 IU oxytocin IM to the mother. ■ Watch for vaginal bleeding.
■ Change gloves. If not possible, wash gloved hands. ■ Clamp and cut the cord. →put ties tightly around the cord at 2 cm and 5 cm from baby’s abdomen. →cut between ties with sterile instrument. →observe for oozing blood.
■ Leave baby on the mother’s chest in skin-to-skin contact. Place identification label. ■ Cover the baby, cover the head with a hat.
■ Encourage initiation of breastfeeding k2 .
TREAT ANDADVISE, IF REqUIRED
■ If potentially damaging expulsive efforts, exert more pressure on perineum. ■ Discard soiled pad to prevent infection.
■ If cord present and loose, deliver the baby through the loop of cord or slip the cord over the baby’s head; if cord is tight, clamp and cut cord, then unwind. ■ Gently wipe face clean with gauze or cloth, if necessary.
■ If delay in delivery of shoulders: →do not panic but call for help and ask companion to assist →Manage as in Stuck shoulders d17 . ■ If placing newborn on abdomen is not acceptable, or the mother cannot hold the baby, place the baby in a clean, warm, safe place close to the mother.
do not leave the baby wet - she/he will become cold. ■ If the baby is not breathing or gasping (unless baby is dead, macerated, severely malformed): →Cut cord quickly: transfer to a firm, warm surface; start Newborn resuscitation k11 . ■ CALL FOR HELP - one person should care for the mother.
■ If second baby, do not give oxytocin now. get help. ■ Deliver the second baby. Manage as in Multiple pregnancy d18 . ■ If heavy bleeding, repeat oxytocin 10-IU-IM.
■ If blood oozing, place a second tie between the skin and the first tie.
do not apply any substance to the stump. do not bandage or bind the stump.
■ If room cool (less than 25°C), use additional blanket to cover the mother and baby.
■ If HIV-positive mother has chosen replacement feeding, feed accordingly. ■ Check ARV treatment needed g9 .
d12
MONITOR MOTHER EVERY 5 MINUTES:
■ For emergency signs, using rapid assessment (RAM) b3-b7 . ■ Feel if uterus is well contracted. ■ Mood and behaviour (distressed, anxious) d6 . ■ Time since third stage began (time since birth).
■ Record findings, treatments and procedures in Labour record and Partograph (pp.N4-N6). ■ Give Supportive care d6-d7 . ■ never leave the woman alone.
DELIVER THE PLACENTA
■ Ensure 10-IU oxytocin IM is given d11 . ■ Awaitstronguterinecontraction (2-3 minutes) and deliver placenta by controlled cord traction: →Place side of one hand (usually left) above symphysis pubis with palm facing towards the mother’s umbilicus. This applies counter traction to the uterus during controlled cord traction. At the same time, apply steady, sustained controlled cord traction. →If placenta does not descend during 30-40 seconds of controlled cord traction, release both cord traction and counter traction on the abdomen and wait until the uterus is well contracted again. Then repeat controlled cord traction with counter traction. →As the placenta is coming out, catch in both hands to prevent tearing of the membranes. →If the membranes do not slip out spontaneously, gently twist them into a rope and move them up and down to assist separation without tearing them.
■ Check that placenta and membranes are complete.
MONITOR BABY EVERY 15 MINUTES:
■ Breathing: listen for grunting, look for chest in-drawing and fast breathing J2 . ■ Warmth: check to see if feet are cold to touch J2 .
TREAT ANDADVISE IF REqUIRED
■ If, after 30 minutes of giving oxytocin, the placenta is not delivered and the woman is NOT bleeding: →Empty bladder b12 →Encourage breastfeeding →Repeat controlled cord traction. ■ If woman is bleeding, manage as on b5 ■ If placenta is not delivered in another 30 minutes (1 hour after delivery): →Remove placenta manually b11 →Give appropriate IM/IV antibiotic b15 . ■ If in 1 hour unable to remove placenta: →Refer the woman to hospital b17 →Insert an IV line and give fluids with 20 IU of oxytocin at 30 drops per minute during transfer b9 . do not exert excessive traction on the cord. do not squeeze or push the uterus to deliver the placenta.
■ If placenta is incomplete: → Remove placental fragments manually b11 . → Give appropriate IM/IV antibiotic b15 .
third stage of labour: deliver the plaCenta
use this chart for care of the woman between birth of the baby and delivery of placenta.
Third stage of labour: deliver the placenta
Childbirth: labour, delivery and im
m
ediate postpartum
Care
Third stage of labour: deliver the placenta
Childbirth: labour, delivery and im
m
ediate postpartum
Care
d13
DELIVER THE PLACENTA
■ Check that uterus is well contracted and there is no heavy bleeding. ■ Repeat check every 5 minutes.
■ Examine perineum, lower vagina and vulva for tears.
■ Collect, estimate and record blood loss throughout third stage and immediately afterwards.
■ Clean the woman and the area beneath her. Put sanitary pad or folded clean cloth under her buttocks to collect blood. Help her to change clothes if necessary.
■ Keep the mother and baby in delivery room for a minimum of one hour after delivery of placenta.
■ Dispose of placenta in the correct, safe and culturally appropriate manner.
TREAT ANDADVISE, IF REqUIRED
■ If heavy bleeding: → Massage uterus to expel clots if any, until it is hard b10 . → Give oxytocin 10 IU IM b10 . → Call for help. → Start an IV line b9 , add 20 IU of oxytocin to IV fluids and give at 60 drops per minute n9 . → Empty the bladder b12 . ■ If bleeding persists and uterus is soft: → Continue massaging uterus until it is hard. → Apply bimanual or aortic compression b10 . → Continue IV fluids with 20 IU of oxytocin at 30 drops per minute. → refer woman urgently to hospital b17 .
■ If third degree tear (involving rectum or anus), refer urgently to hospital b17 . ■ For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. do not cross ankles. ■ Check after 5 minutes. If bleeding persists, repair the tear b12 .
■ If blood loss ≈ 250-ml, but bleeding has stopped: →Plan to keep the woman in the facility for 24 hours. →Monitor intensively (every 30 minutes) for 4 hours: →BP, pulse →vaginal bleeding →uterus, to make sure it is well contracted. →Assist the woman when she first walks after resting and recovering. →If not possible to observe at the facility, refer to hospital b17 .
■ If disposing placenta: →Use gloves when handling placenta. →Put placenta into a bag and place it into a leak-proof container. →Always carry placenta in a leak-proof container. →Incinerate the placenta or bury it at least 10 m away from a water source, in a 2 m deep pit.
D8 first stage of labour (1): when
the woman is not in aCtive
labour
D9 first stage of labour (2):
in aCtive labour
D10 seCond stage of labour: deliver
the baby and give immediate
newborn Care (1)
D11 seCond stage of labour: deliver
the baby and give immediate
newborn Care (2)
D12 third stage of labour:
deliver the plaCenta (1)
D13 third stage of labour:
deliver the plaCenta (2)
next: If prolapsed cord
respond to problems during labour and delivery
d14 Respond to problems during labour and delivery (1) If FHR <120 or >160 bpm
Childbirth: labour, delivery and im
m
ediate postpartum
Care
ASK, CHECK RECORD LOOK, LISTEN, FEEL
■ Position the woman on her left side. ■ If membranes have ruptured, look at vulva for prolapsed cord. ■ See if liquor was meconium stained. ■ Repeat FHR count after 15 minutes.
SIGNS
■ Cord seen at vulva.
■ FHR remains >160 or <120 after 30 minutes observation.
■ FHR returns to normal.
TREAT ANDADVISE
■ Manage urgently as on d15 .
■ If early labour: →refer the woman urgently to hospital b17 →Keep her lying on her left side. ■ If late labour: →Call for help during delivery →Monitor after every contraction. If FHR does not return to normal in 15 minutes explain to the woman (and her companion) that the baby may not be well. →Prepare for newborn resuscitation k11 .
■ Monitor FHR every 15 minutes.
CLASSIFY
prolapsed Cord
baby not well
baby well
if fetal heart rate (fhr) <120 or >160 beats per minute

if prolapsed Cord
the cord is visible outside the vagina or can be felt in the vagina below the presenting part.
Childbirth: labour, delivery and im
m
ediate postpartum
Care
d15 Respond to problems during labour and delivery (2) If prolapsed cord
ASK, CHECK RECORD LOOK, LISTEN, FEEL
■ Look at or feel the cord gently for pulsations. ■ Feel for transverse lie. ■ Do vaginal examination to determine status of labour.
SIGNS
■ Transverse lie
■ Cord is pulsating
■ Cord is not pulsating
TREAT
■ refer urgently to hospital b17 .
if early labour: ■ Push the head or presenting part out of the pelvis and hold it above the brim/pelvis with your hand on the abdomen until caesarean section is performed. ■ Instruct assistant (family, staff) to position the woman’s buttocks higher than the shoulder. ■ refer urgently to hospital b17 . ■ If transfer not possible, allow labour to continue.
if late labour: ■ Call for additional help if possible (for mother and baby). ■ Prepare for Newborn resuscitation k11 . ■ Ask the woman to assume an upright or squatting position to help progress. ■ Expedite delivery by encouraging woman to push with contraction.
■ Explain to the parents that baby may not be well.
CLASSIFY
obstruCted labour
fetus alive
fetus probably dead
next: If breech presentation �
Respond to problems during labour and delivery (3) If breech presentation
Childbirth: labour, delivery and im
m
ediate postpartum
Care
SIGN
■ If early labour
■ If late labour
■ If the head does not deliver after several contractions
■ If trapped arms or shoulders
■ If trapped head (and baby is dead)
next: If stuck shoulders
if breeCh presentation
d16
TREAT
■ refer urgently to hospital b17 .
■ Call for additional help. ■ Confirm full dilatation of the cervix by vaginal examination d3 . ■ Ensure bladder is empty. If unable to empty bladder see Empty bladder b12 . ■ Prepare for newborn resuscitation k11 . ■ Deliver the baby: →Assist the woman into a position that will allow the baby to hang down during delivery, for example, propped up with buttocks at edge of bed or onto her hands and knees (all fours position). →When buttocks are distending, make an episiotomy. →Allow buttocks, trunk and shoulders to deliver spontaneously during contractions. →After delivery of the shoulders allow the baby to hang until next contraction.
■ Place the baby astride your left forearm with limbs hanging on each side. ■ Place the middle and index fingers of the left hand over the malar cheek bones on either side to apply gentle downwards pressure to aid flexion of head. ■ Keeping the left hand as described, place the index and ring fingers of the right hand over the baby’s shoulders and the middle finger on the baby’s head to gently aid flexion until the hairline is visible. ■ When the hairline is visible, raise the baby in upward and forward direction towards the mother’s abdomen until the nose and mouth are free. The assistant gives supra pubic pressure during the period to maintain flexion.
■ Feel the baby’s chest for arms. If not felt: ■ Hold the baby gently with hands around each thigh and thumbs on sacrum. ■ Gently guiding the baby down, turn the baby, keeping the back uppermost until the shoulder which was posterior (below) is now anterior (at the top) and the arm is released. ■ Then turn the baby back, again keeping the back uppermost to deliver the other arm. ■ Then proceed with delivery of head as described above.
■ Tie a 1 kg weight to the baby’s feet and await full dilatation. ■ Then proceed with delivery of head as described above. never pull on the breech do not allow the woman to push until the cervix is fully dilated. Pushing too soon may cause the head to be trapped.
LOOK, LISTEN, FEEL
■ On external examination fetal head felt in fundus. ■ Soft body part (leg or buttocks) felt on vaginal examination. ■ Legs or buttocks presenting at perineum.

Respond to problems during labour and delivery (4) If stuck shoulders
SIGN
■ Fetal head is delivered, but shoulders are stuck and cannot be delivered.
■ If the shoulders are still not delivered and surgical help is not available immediately.
TREAT
■ Call for additional help. ■ Prepare for newborn resuscitation. ■ Explain the problem to the woman and her companion. ■ Ask the woman to lie on her back while gripping her legs tightly flexed against her chest, with knees wide apart. Ask the companion or other helper to keep the legs in that position. ■ Perform an adequate episiotomy. ■ Ask an assistant to apply continuous pressure downwards, with the palm of the hand on the abdomen directly above the pubic area, while you maintain continuous downward traction on the fetal head.
■ Remain calm and explain to the woman that you need her cooperation to try another position. ■ Assist her to adopt a kneeling on “all fours” position and ask her companion to hold her steady - this simple change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery. ■ Introduce the right hand into the vagina along the posterior curve of the sacrum. ■ Attempt to deliver the posterior shoulder or arm using pressure from the finger of the right hand to hook the posterior shoulder and arm downwards and forwards through the vagina. ■ Complete the rest of delivery as normal. ■ If not successful, refer urgently to hospital b17 .
do not pull excessively on the head.
next: If multiple births
if stuCk shoulders (shoulder dystoCia)
Childbirth: labour, delivery and im
m
ediate postpartum
Care
d17

Respond to problems during labour and delivery (5) If multiple births
Childbirth: labour, delivery and im
m
ediate postpartum
Care
SIGN
■ Prepare for delivery
■ Second stage of labour
■ Third stage of labour
■ Immediate postpartum care
TREAT
■ Prepare delivery room and equipment for birth of 2 or more babies. Include: →more warm cloths →two sets of cord ties and razor blades →resuscitation equipment for 2 babies. ■ Arrange for a helper to assist you with the births and care of the babies.
■ Deliver the first baby following the usual procedure. Resuscitate if necessary. Label her/himTwin 1. ■ Ask helper to attend to the first baby. ■ Palpate uterus immediately to determine the lie of the second baby. If transverse or oblique lie, gently turn the baby by abdominal manipulation to head or breech presentation. ■ Check the presentation by vaginal examination. Check the fetal heart rate. ■ Await the return of strong contractions and spontaneous rupture of the second bag of membranes, usually within 1 hour of birth of first baby, but may be longer. ■ Stay with the woman and continue monitoring her and the fetal heart rate intensively. ■ Remove wet cloths from underneath her. If feeling chilled, cover her. ■ When the membranes rupture, perform vaginal examination d3 to check for prolapsed cord. If present, see Prolapsed cord d15 . ■ When strong contractions restart, ask the mother to bear down when she feels ready. ■ Deliver the second baby. Resuscitate if necessary. Label her/himTwin 2. ■ After cutting the cord, ask the helper to attend to the second baby. ■ Palpate the uterus for a third baby. If a third baby is felt, proceed as described above. If no third baby is felt, go to third stage of labour. do not attempt to deliver the placenta until all the babies are born. do not give the mother oxytocin until after the birth of all babies.
■ Give oxytocin 10 IU IM after making sure there is not another baby. ■ When the uterus is well contracted, deliver the placenta and membranes by controlled cord traction, applying traction to all cords together d12-d23. ■ Before and after delivery of the placenta and membranes, observe closely for vaginal bleeding because this woman is at greater risk of postpartum haemorrhage. If bleeding, see b5 . ■ Examine the placenta and membranes for completeness. There may be one large placenta with 2 umbilical cords, or a separate placenta with an umbilical cord for each baby.
■ Monitor intensively as risk of bleeding is increased. ■ Provide immediate Postpartum care d19-d20. ■ In addition: →Keep mother in health centre for longer observation →Plan to measure haemoglobin postpartum if possible →Give special support for care and feeding of babies J11 and k4 .
next: Care of the mother and newborn within first hour of delivery of placenta
if multiple births
d18

d19
MONITOR MOTHER EVERY 15 MINUTES:
■ For emergency signs, using rapid assessment (RAM) b3-b7 . ■ Feel if uterus is hard and round.
■ Record findings, treatments and procedures in Labour record and Partograph n4-n6 . ■ Keep mother and baby in delivery room - do not separate them. ■ never leave the woman and newborn alone.
CARE OF MOTHER AND NEWBORN
woman ■ Assess the amount of vaginal bleeding. ■ Encourage the woman to eat and drink. ■ Ask the companion to stay with the mother. ■ Encourage the woman to pass urine.
newborn ■ Wipe the eyes. ■ Apply an antimicrobial within 1 hour of birth. →either 1% silver nitrate drops or 2.5% povidone iodine drops or 1% tetracycline ointment. ■ DO NOT wash away the eye antimicrobial. ■ If blood or meconium, wipe off with wet cloth and dry. ■ DO NOT remove vernix or bathe the baby. ■ Continue keeping the baby warm and in skin-to-skin contact with the mother. ■ Encourage the mother to initiate breastfeeding when baby shows signs of readiness. Offer her help. ■ DO NOT give artificial teats or pre-lacteal feeds to the newborn: no water, sugar water, or local feeds. ■ Examine the mother and newborn one hour after delivery of placenta. Use Assess the mother after delivery d21 and Examine the newborn J2-J8 .
MONITOR BABY EVERY 15 MINUTES:
■ Breathing: listen for grunting, look for chest in-drawing and fast breathing J2 . ■ Warmth: check to see if feet are cold to touch J2 .
INTERVENTIONS, IF REqUIRED
■ If pad soaked in less than 5 minutes, or constant trickle of blood, manage as on d22 .. ■ If uterus soft, manage as on b10 . ■ If bleeding from a perineal tear, repair if required b12 or refer to hospital b17 .
■ If breathing with difficulty — grunting, chest in-drawing or fast breathing, examine the baby as on J2-J8 . ■ If feet are cold to touch or mother and baby are separated: →Ensure the room is warm. Cover mother and baby with a blanket →Reassess in 1 hour. If still cold, measure temperature. If less than 36.50C, manage as on k9 . ■ If unable to initiate breastfeeding (mother has complications): →Plan for alternative feeding method k5-k6 . →If mother HIV-positive: give treatment to the newborn g9 . →Support the mother's choice of newborn feeding g8 . ■If baby is stillborn or dead, give supportive care to mother and her family d24 .
■ refer to hospital now if woman had serious complications at admission or during delivery but was in late labour.
Care of the mother and newborn within first hour of delivery of plaCenta
use this chart for woman and newborn during the first hour after complete delivery of placenta.
Care of the mother within first hour of delivery of placenta
Childbirth: labour, delivery and im
m
ediate postpartum
Care
D14 respond to problems during
labour and delivery (1)
Iffetalheartrate<120or>160bpm
D15 respond to problems during
labour and delivery (2)
Ifprolapsedcord
D16 respond to problems during
labour and delivery (3)
Ifbreechpresentation
D17 respond to problems during
labour and delivery (4)
Ifstuckshoulders
D18 respond to problems during
labour and delivery (5)
Ifmultiplebirths
D19 Care of the mother and
newborn within first hour of
delivery of plaCenta
Childbirth: labour, delivery and immediate postpartum care
C
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l
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d1
d20
MONITOR MOTHER AT 2, 3 AND 4 HOURS,
THEN EVERY 4 HOURS:
■ For emergency signs, using rapid assessment (RAM). ■ Feel uterus if hard and round.
■ Record findings, treatments and procedures in Labour record and Partograph n4-n6 . ■ Keep the mother and baby together. ■ never leave the woman and newborn alone. ■ do not discharge before 12 hours.
CARE OF MOTHER
■ Accompany the mother and baby to ward. ■ Advise on Postpartumcare and hygiene d26 . ■ Ensure the mother has sanitary napkins or clean material to collect vaginal blood. ■ Encourage the mother to eat, drink and rest. ■ Ensure the room is warm (25°C).
■ Ask the mother’s companion to watch her and call for help if bleeding or pain increases, if mother feels dizzy or has severe headaches, visual disturbance or epigastric distress.
■ Encourage the mother to empty her bladder and ensure that she has passed urine.
■ Check record and give any treatment or prophylaxis which is due. ■ Advise the mother on postpartum care and nutrition d26 . ■ Advise when to seek care d28 . ■ Counsel on birth spacing and other family planning methods d27 . ■ Repeat examination of the mother before discharge using Assess the mother after delivery d21 . For baby, see J2-J8 .
INTERVENTIONS, IF REqUIRED
■ Make sure the woman has someone with her and they know when to call for help. ■ If HIV-positive: give her appropriate treatment g6 , g9 .
■ If heavy vaginal bleeding, palpate the uterus. → If uterus not firm, massage the fundus to make it contract and expel any clots b6 . → If pad is soaked in less than 5 minutes, manage as on b5 . → If bleeding is from perineal tear, repair or refer to hospital b17 .
■ If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is uncomfortable, help her by gently pouring water on vulva. do not catheterize unless you have to.
■ If tubal ligation or IUD desired, make plans before discharge. ■ If mother is on antibiotics because of rupture of membranes >18 hours but shows no signs of infection now, discontinue antibiotics.
Care of the mother one hour after delivery of plaCenta
use this chart for continuous care of the mother until discharge. see J10 for care of the baby.
Care of the mother one hour after delivery of placenta
Childbirth: labour, delivery and im
m
ediate postpartum
Care
assess the mother after delivery
use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge.
for examining the newborn use the chart on J2-J8 .
Childbirth: labour, delivery and im
m
ediate postpartum
Care
d21 Assess the mother after delivery
ASK, CHECK RECORD
■ Check record: →bleeding more than 250 ml? →completeness of placenta and membranes? →complications during delivery or postpartum? →special treatment needs? →needs tubal ligation or IUD? ■ How are you feeling? ■ Do you have any pains? ■ Do you have any concerns? ■ How is your baby? ■ How do your breasts feel?
LOOK, LISTEN, FEEL
■ Measure temperature. ■ Feel the uterus. Is it hard and round? ■ Look for vaginal bleeding ■ Look at perineum. →Is there a tear or cut? →Is it red, swollen or draining pus? ■ Look for conjunctival pallor. ■ Look for palmar pallor.
SIGNS
■ Uterus hard. ■ Little bleeding. ■ No perineal problem. ■ No pallor. ■ No fever. ■ Blood pressure normal. ■ Pulse normal.
TREAT ANDADVISE
■ Keep the mother at the facility for 12 hours after delivery. ■ Ensure preventive measures d25 . ■ Advise on postpartum care and hygiene d26 . ■ Counsel on nutrition d26 . ■ Counsel on birth spacing and family planning d27 . ■ Advise on when to seek care and next routine postpartum visit d28 . ■ Reassess for discharge d21 . ■ Continue any treatments initiated earlier. ■ If tubal ligation desired, refer to hospital within 7 days of delivery. If IUD desired, refer to appropriate services within 48 hours.
CLASSIFY
mother well
next: Respond to problems immediately postpartum If no problems, go to page d25 . �
Respond to problems immediately postpartum (1)
Childbirth: labour, delivery and im
m
ediate postpartum
Care ASK, CHECK RECORD
■ Time since rupture of membranes ■ Abdominal pain ■ Chills
LOOK, LISTEN, FEEL
■ A pad is soaked in less than 5 minutes.
■ Repeat temperature measurement after 2 hours ■ If temperature is still >38ºC →Look for abnormal vaginal discharge. →Listen to fetal heart rate →feel lower abdomen for tenderness
■ Is there bleeding from the tear or episiotomy ■ Does it extend to anus or rectum?
SIGNS
■ More than 1 pad soaked in 5 minutes ■ Uterus not hard and not round
■ Temperature still >380C and any of: →Chills →Foul-smelling vaginal discharge →Low abdomen tenderness →FHR remains >160 after 30 minutes of observation →rupture of membranes >18 hours
■ Temperature still >380C
■ Tear extending to anus or rectum.
■ Perineal tear ■ Episiotomy
TREAT ANDADVISE
■ See b5 for treatment. ■ refer urgently to hospital b17 .
■ Insert an IV line and give fluids rapidly b9 . ■ Give appropriate IM/IV antibiotics b15 . ■ If baby and placenta delivered: →Give oxytocin 10 IU IM b10 . ■ refer woman urgently to hospital b17 . ■ Assess the newborn J2-J8 . Treat if any sign of infection.
■ Encourage woman to drink plenty of fluids. ■ Measure temperature every 4 hours. ■ If temperature persists for >12 hours, is very high or rises rapidly, give appropriate antibiotic and refer to hospital b15 .
■ refer woman urgently to hospital b15 .
■ If bleeding persists, repair the tear or episiotomy b12 .
CLASSIFY
heavy bleeding
uterine and fetal infeCtion
risk of uterine and fetal infeCtion
third degree tear
small perineal tear
next: If elevated diastolic blood pressure
if vaginal bleeding
if fever (temperature >38ºC)
if perineal tear or episiotomy (done for lifesaving CirCumstanCes)
d22

if elevated diastoliC blood pressure
Childbirth: labour, delivery and im
m
ediate postpartum
Care
d23 Respond to problems immediately postpartum (2)
ASK, CHECK RECORD LOOK, LISTEN, FEEL
■ If diastolic blood pressure is ≥90 mmHg, repeat after 1 hour rest. ■ If diastolic blood pressure is still ≥90-mmHg, ask the woman if she has: →severe headache →blurred vision →epigastric pain and →check protein in urine.
SIGNS
■ Diastolic blood pressure ≥110 mmHg OR ■ Diastolic blood pressure ≥90 mmHg and 2+ proteinuria and any of: →severe headache →blurred vision →epigastric pain.
■ Diastolic blood pressure 90-110 mmHg on two readings. ■ 2+ proteinuria (on admission).
■ Diastolic blood pressure ≥90 mmHg on 2 readings.
TREAT ANDADVISE
■ Give magnesium sulphate b13 . ■ If in early labour or postpartum, refer urgently to hospital b17 . ■ if late labour: →continue magnesium sulphate treatment b13 →monitor blood pressure every hour. →do not give ergometrine after delivery. ■ refer urgently to hospital after delivery b17 .
■ If early labour, refer urgently to hospital e17 . ■ If late labour: →monitor blood pressure every hour →do not give ergometrine after delivery. ■ If BP remains elevated after delivery, refer to hospital e17 .
■ Monitor blood pressure every hour. ■ do not give ergometrine after delivery. ■ If blood pressure remains elevated after delivery, refer woman to hospital e17 .
CLASSIFY
severe pre-eClampsia
pre-eClampsia
hypertension
next: If pallor on screening, check for anaemia �
Respond to problems immediately postpartum (3)
Childbirth: labour, delivery and im
m
ediate postpartum
Care ASK, CHECK RECORD
■ Bleeding during labour, delivery or postpartum.
LOOK, LISTEN, FEEL
■ Measure haemoglobin, if possible. ■ Look for conjunctival pallor. ■ Look for palmar pallor. If pallor: →Is it severe pallor? →Some pallor? →Count number of breaths in 1-minute
SIGNS
■ Haemoglobin <7 g/dl. and/or ■ Severe palmar andconjunctival pallor or ■ Any pallor with >30 breaths per minute.
■ Any bleeding. ■ Haemoglobin 7-11-g/dl. ■ Palmar or conjunctival pallor.
■ Haemoglobin >11-g/dl ■ No pallor.
CLASSIFY
severe anaemia
moderate anaemia
no anaemia
next: Give preventive measures
if pallor on sCreening, CheCk for anaemia
if mother severely ill or separated fromthe baby
if baby stillborn or dead
d24
TREAT ANDADVISE
■ if early labour or postpartum, refer urgently to hospital b17 .
■ if late labour: →monitor intensively →minimize blood loss →refer urgently to hospital after delivery b17 .
■ do not discharge before 24 hours. ■ Check haemoglobin after 3 days. ■ Give double dose of iron for 3 months f3 . ■ Follow up in 4 weeks.
■ Give iron/folate for 3 months f3 .
■ Teach mother to express breast milk every 3 hours k5 . ■ Help her to express breast milk if necessary. Ensure baby receives mother’s milk k8 . ■ Help her to establish or re-establish breastfeeding as soon as possible. See k2-k3 .
■ Give supportive care: →Inform the parents as soon as possible after the baby’s death. →Show the baby to the mother, give the baby to the mother to hold, where culturally appropriate. →Offer the parents and family to be with the dead baby in privacy as long as they need. →Discuss with them the events before the death and the possible causes of death. ■ Advise the mother on breast care k8 . ■ Counsel on appropriate family planning method d27 . �
d25
ASSESS, CHECK RECORDS
■ Check RPR status in records. ■ If no RPR during this pregnancy, do the RPR test l5 .
■ Check tetanus toxoid (TT) immunization status. ■ Check when last dose of mebendazole was given.
■ Check woman’s supply of prescribed dose of iron/folate. ■ Check if vitamin A given.
■ Ask whether woman and baby are sleeping under insecticide treated bednet. ■ Counsel and advise all women.
■ Record all treatments given n6 .
■ Check HIV status in records.
TREAT ANDADVISE
■ If RPR positive: →Treat woman and the partner with benzathine penicillin f6 . →Treat the newborn k12 .
■ Give tetanus toxoid if due f2 . ■ Give mebendazole once in 6 months f3 .
■ Give 3 month’s supply of iron and counsel on compliance f3 . ■ Give vitamin A if due f2 .
■ Encourage sleeping under insecticide treated bednet f4 . ■ Advise on postpartum care d26 . ■ Counsel on nutrition d26 . ■ Counsel on birth spacing and family planning d27 . ■ Counsel on breastfeeding k2 . ■ Counsel on safer sex including use of condoms g2 . ■ Advise on routine and follow-up postpartum visits d28 . ■ Advise on danger signs d28 . ■ Discuss how to prepare for an emergency in postpartum d28 .
■ If HIV-positive: →Support adherence to ARV g6 . →Treat the newborn g9 . ■ If HIV test not done, offer her the test e5 .
give preventive measures
ensure that all are given before discharge.
Give preventive measures
Childbirth: labour, delivery and im
m
ediate postpartum
Care
D20 Care of the mother one hour
after delivery of plaCenta
D21 assess the mother after delivery
D22 respond to problems
immediately postpartum (1)
Ifvaginalbleeding
Iffever
Ifperinealtearorepisiotomy
D23 respond to problems
immediately postpartum (2)
Ifelevateddiastolicbloodpressure
D24 respond to problems
immediately postpartum (3)
Ifpalloronscreening,checkforanaemia
Ifmotherseverelyillorseparatedfrombaby
Ifbabystillbornordead
D25 give preventive measures
d26
Advise on postpartum care and hygiene
Advise and explain to 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 have enough rest and sleep. ■ The importance of washing to prevent infection of the mother and her baby: →wash hands before handling baby →wash perineum daily and after faecal excretion →change perineal pads every 4 to 6 hours, or more frequently if heavy lochia →wash used pads or dispose of them safely →wash the body daily. ■ To avoid sexual intercourse until the perineal wound heals.
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, 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 harmthe breastfeeding baby. ■ Spend more time on nutrition counselling 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 partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work.
advise on postpartumCare
Advise on postpartum care
Childbirth: labour, delivery and im
m
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Care
d27
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 counselling session. ■ Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as 4 weeks after delivery. Therefore it is important to start thinking early about what family planning method they will use. →Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. →Information on when to start a method after delivery will vary depending on whether a woman is breastfeeding or not. →Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). ■ Councel on safer sex including use of condoms for dual protection fromsexually transmitted infection (STI) or HIV and pregnancy. Promote their use, especially if at risk for sexually transmitted infection (STI) or HIV g2 . ■ For HIV-positive women, see g4 for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time.
method options for the non-breastfeeding woman Can be used immediately postpartum 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) delay 3 weeks Combined oral contraceptives Combined injectables Fertility awareness methods
Lactational amenorrhoea method (LAM)
■ A breastfeeding woman is 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.
method options for the breastfeeding woman Can be used immediately postpartum Lactational amenorrhoea method (LAM) Condoms Spermicide Female sterilisation (within 7 days or delay 6 weeks) copper IUD (within 48 hours or delay 4 weeks) delay 6 weeks Progestogen-only oral contraceptives Progestogen-only injectables Implants Diaphragm delay 6 months Combined oral contraceptives Combined injectables Fertility awareness methods
Counsel on birth spaCingand family planning
Counsel on birth spacing and family planning
Childbirth: labour, delivery and im
m
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Care
d28
Routine postpartum care visits
first visit d19 Within the first week, preferably within 2-3 days
seCond visit e2 4-6 weeks
Follow-up visits for problems
if the problem was: return in: Fever 2 days Lower urinary tract infection 2 days Perineal infection or pain 2 days Hypertension 1 week Urinary incontinence 1 week Severe anaemia 2 weeks Postpartum blues 2 weeks HIV-positive 2 weeks Moderate anaemia 4 weeks If treated in hospital According to hospital instructions or according to national for any complication guidelines, but no later than in 2 weeks.
Advise on danger signs
advise to go to a hospital or health centre immediately, day or night, without waiting, if any of the following signs: ■ vaginal bleeding: →more than 2 or 3 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. ■ severe abdominal pain.
Go to health centre as soon as possible if any of the following signs: ■ fever ■ abdominal pain ■ feels ill ■ breasts swollen, red or tender breasts, or sore nipple ■ urine dribbling or pain on micturition ■ pain in the perineum or draining pus ■ foul-smelling lochia
Discuss how to prepare for an emergency in postpartum
■ Advise to always have someone near for at least 24 hours after delivery to respond to any change in condition. ■ Discuss with woman and her partner and family about emergency issues: →where to go if danger signs →how to reach the hospital →costs involved →family and community support. ■ Advise the woman to ask for help from the community, if needed i1-i3. ■ Advise the woman to bring her home-based maternal record to the health centre, even for an emergency visit.
advise on when to return
use this chart for advising on postpartum care on d21 or e2 . for newborn babies see the schedule on k14 .
encourage woman to bring her partner or family member to at least one visit.
Advise on when to return
Childbirth: labour, delivery and im
m
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Care
d29
Preparation for home delivery
■ Check emergency arrangements. ■ Keep emergency transport arrangements up-to-date. ■ Carry with you all essential drugs b17 , records, and the delivery kit. ■ Ensure that the family prepares, as on C18 .
Delivery care
■ Follow the labour and delivery procedures d2-d28 k11 . ■ Observe universal precautions a4 . ■ Give supportive care. Involve the companion in care and support d6-d7 . ■ Maintain the partograph and labour record n4-n6 . ■ Provide newborn care J2-J8 . ■ refer to facility as soon as possible if any abnormal finding in mother or baby b17 k14 .
Immediate postpartum care of mother
■ Stay with the woman for first two hours after delivery of placenta C2 C13-C14. ■ Examine the mother before leaving her d21 . ■ Advise on postpartum care, nutrition and family planning d26-d27. ■ Ensure that someone will stay with the mother for the first 24 hours.
Postpartum care of newborn
■ Stay until baby has had the first breastfeed and help the mother good positioning and attachment b2 . ■ Advise on breastfeeding and breast care b3 . ■ Examine the baby before leaving n2-n8 . ■ Immunize the baby if possible b13 . ■ Advise on newborn care b9-b10 . ■ Advise the family about danger signs and when and where to seek care b14 . ■ If possible, return within a day to check the mother and baby. ■ Advise a postpartum visit for the mother and baby within the first week b14 .
home delivery by skilled attendant
use these instructions if you are attending delivery at home.
Home delivery by skilled attendant
Childbirth: labour, delivery and im
m
ediate postpartum
Care
D26 advise on postpartum Care
Adviseonpostpartumcareandhygiene
Counselonnutrition
D27 Counsel on birth spaCing and
family planning
Counselonimportanceoffamilyplanning
Lactationandamenorrhoeamethod(LAM)
D28 advise on when to return
Routinepostpartumvisits
Adviseondangersigns
Discusshowtoprepareforanemergency
postpartum
D29 home delivery by skilled
attendant
Preparationforhomedelivery
Deliverycare
Immediatepostpartumcareofthemother
Postpartumcareofthenewborn
■ Alwaysbeginwith rapid assessment and management (ram) b3-b7 .
■ Next,usethechartonexamine the woman in labour or with
ruptured membranes d2-d3 toassesstheclinicalsituationand
obstetricalhistory,anddecidethestageoflabour.
■ Ifanabnormalsignisidentified,usethechartsonrespond to
obstetrical problems onadmission d4-d5 .
■ Careforthewomanaccordingtothestageoflabour d8-d13and
respondtoproblemsduringlabouranddeliveryason d14-d18.
■ Usegive supportive care throughout labour d6-d7

toprovide
supportandcarethroughoutlabouranddelivery.
■ Recordfindingscontinuallyonlabourrecordandpartograph n4-n6 .
■ Keepmotherandbabyinlabourroomforonehourafterdelivery
andusechartsCare of the mother and newborn within first
hour of delivery placentaon d19 .
■ Nextuse Care of the mother after the first hour following
delivery of placenta d20 toprovidecareuntildischarge.Use
charton d25 toprovidepreventive measuresandadvise on
postpartum care d26-d28toadviseoncare,dangersigns,when
toseekroutineoremergencycare,andfamilyplanning.
■ Examinethemotherfordischargeusingcharton d21 .
■ do notdischargemotherfromthefacilitybefore12hours.
■ IfthemotherisHIV-positiveoradolescent,orhasspecialneeds,
seeg1-g11 h1-h4 .
■ Ifattendingadeliveryatthewoman’shome,see d29 .
Examine the woman in labour or with ruptured membranes
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ASK,CHECKRECORD
history of this labour:
■ Whendidcontractionsbegin?
■ Howfrequentarecontractions?
Howstrong?
■ Haveyourwatersbroken?Ifyes,
when?Weretheyclearorgreen?
■ Haveyouhadanybleeding?
Ifyes,when?Howmuch?
■ Isthebabymoving?
■ Doyouhaveanyconcern?
Check record, or if no record:
■ Askwhenthedeliveryisexpected.
■ Determineifpreterm
(lessthan8monthspregnant).
■ Reviewthebirthplan.
if prior pregnancies:
■ Numberofpriorpregnancies/
deliveries.
■ Anypriorcaesareansection,
forceps,orvacuum,orother
complicationsuchaspostpartum
haemorhage?
■ Anypriorthirddegreetear?
Current pregnancy:
■ RPRstatus C5 .
■ Hbresults C4 .
■ Tetanusimmunizationstatus f2 .
■ HIVstatus C6 .
■ Infantfeedingplan g7-g8 .
■ Receivinganymedicine.
LOOK,LISTEN,FEEL
■Observethewoman’sresponseto
contractions:
→Isshecopingwellorisshe
distressed?
→Isshepushingorgrunting?
■Checkabdomenfor:
→caesareansectionscar.
→horizontalridgeacrosslower
abdomen(ifpresent,emptybladder
b12 andobserveagain).
■ Feelabdomenfor:
→contractionsfrequency,duration,
anycontinuouscontractions?
→fetallie—longitudinalor
transverse?
→fetalpresentation—head,breech,
other?
→morethanonefetus?
→fetalmovement.
■Listentothefetalheartbeat:
→Countnumberofbeatsin1minute.
→Iflessthan100beatsper
minute,ormorethan180,turn
womanonherleftsideandcount
again.
■Measurebloodpressure.
■Measuretemperature.
■Lookforpallor.
■Lookforsunkeneyes,drymouth.
■Pinchtheskinoftheforearm:does
itgobackquickly?
next:Performvaginalexaminationanddecidestageoflabour
examine the woman in labour or with ruptured membranes
first do rapid assessment and management b3-b7 . then use this chart to assess the woman’s and fetal status and decide stage of labour.
d2
t
Decide stage of labour
ASK,CHECKRECORD
■ Explaintothewomanthat
youwillgiveheravaginal
examinationandaskforher
consent.
LOOK,LISTEN,FEEL
■ Lookat vulvafor:
→ bulgingperineum
→ anyvisiblefetalparts
→ vaginalbleeding
→ leakingamnioticfluid;ifyes,isit
meconiumstained,foul-smelling?
→ warts,keloidtissueorscarsthatmay
interferewithdelivery.
perform vaginal examination
■do notshavetheperinealarea.
■Prepare:
→ cleangloves
→ swabs,pads.
■Washhandswithsoapbeforeandaftereach
examination.
■Washvulvaandperinealareas.
■Putongloves.
■Positionthewomanwithlegsflexedandapart.
do notperformvaginalexaminationifbleeding
noworatanytimeafter7monthsofpregnancy.
■ Performgentlevaginalexamination(donotstart
duringacontraction):
→ Determinecervicaldilatationin
centimetres.
→ Feelforpresentingpart.Isithard,round
andsmooth(thehead)?Ifnot,identifythe
presentingpart.
→ Feelformembranes–aretheyintact?
→ Feelforcord–isitfelt?Isitpulsating?If
so,actimmediatelyason d15 .
next:Respondtoobstetricalproblemsonadmission.
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d3
deCide stage of labour
SIGNS
■Bulgingthinperineum,vagina
gapingandheadvisible,full
cervicaldilatation.
■Cervicaldilatation:
→multigravida≥5cm
→primigravida≥6cm
■Cervicaldilatation≥4cm.
■Cervicaldilatation:0-3cm;
contractionsweakand
<2in10minutes.
MANAGE
■Seesecondstageoflabourd10-d11.
■Recordinpartograph n5 .
■Seefirststageoflabour–activelabour d9 .
■Startplottingpartograph n5 .
■Recordinlabourrecord n5 .
■Seefirststageoflabour—notactivelabour d8 .
■Recordinlabourrecord n4 .
CLASSIFY
imminent delivery
late aCtive labour
early aCtive labour
not yet in aCtive
labour
t
Respond to obstetrical problems on admission
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SIGNS
■ Transverselie.
■ Continuouscontractions.
■ Constantpainbetweencontractions.
■ Suddenandsevereabdominalpain.
■ Horizontalridgeacrosslower
abdomen.
■ Labour>24hours.
■ Ruptureofmembranesandanyof:
→Fever>38˚C
→Foul-smellingvaginaldischarge.
■ Ruptureofmembranesat
<8-monthsofpregnancy.
■ Diastolicbloodpressure>90mmHg.
■ Severepalmarandconjunctival
pallorand/orhaemoglobin<7-g/dl.
■ Breechorothermalpresentation d16 .
■ Multiplepregnancy d18 .
■ Fetaldistress d14 .
■ Prolapsedcord d15 .
TREATANDADVISE
■ Ifdistressed,insertanIVlineandgivefluids b9 .
■ Ifinlabour>24hours,giveappropriateIM/IV
antibiotics b15 .
■ refer urgently to hospital b17 .
■ GiveappropriateIM/IVantibiotics b15 .
■ Iflatelabour,deliverandrefertohospital
afterdelivery b17 .
■ Plantotreatnewborn J5 .
■ GiveappropriateIM/IVantibiotics b15 .
■ Iflatelabour,deliverd10-d28.
■ Discontinueantibioticformotherafterdeliveryifno
signsofinfection.
■ Plantotreatnewborn J5 .
■ Assessfurtherandmanageason d23 .
■ Manageason d24 .
■ Followspecificinstructions
(seepagenumbersinleftcolumn).
CLASSIFY
obstruCted labour
uterine and
fetal infeCtion
risk of uterine and
fetal infeCtion
pre-eClampsia
severe anaemia
obstetriCal
CompliCation
respond to obstetriCal problems on admission
use this chart if abnormal findings on assessing pregnancy and fetal status d2-d3 .
FORALLSITUATIONSINREDBELOW,refer urgently to hospital if in early labour,MANAGEONLYIFINLATELABOUR
d4
Respond to obstetrical problems on admission
SIGNS
■ Warts,keloidtissuethatmay
interferewithdelivery.
■ Priorthirddegreetear.
■ Bleedinganytimeinthirdtrimester.
■ Priordeliveryby:
→caesareansection
→forcepsorvacuumdelivery.
■ Agelessthan14years.
■ Labourbefore8completedmonths
ofpregnancy(morethanonemonth
beforeestimateddateofdelivery).
■ Fetalheartrate
<120or>160beatsperminute.
■ Ruptureofmembranesattermand
beforelabour.
■ Iftwoormoreofthefollowingsigns:
→thirsty
→sunkeneyes
→drymouth
→skinpinchgoesbackslowly.
■ HIVtestpositive.
■ TakingARVtreatmentorprophylaxis.
■ Nofetalmovement,and
■ Nofetalheartbeaton
repeatedexamination
TREATANDADVISE
■ Doagenerousepisiotomyandcarefullycontrol
deliveryofthehead d10-d11 .
■ Iflatelabour,deliver d10-d28 .
■ Havehelpavailableduringdelivery.
■ Reassessfetalpresentation(breechmorecommon).
■ Ifwomanislying,encouragehertolieonherleftside.
■ Callforhelpduringdelivery.
■ Conductdeliveryverycarefullyassmallbabymaypop
outsuddenly.Inparticular,controldeliveryofthehead.
■ Prepareequipmentforresuscitationofnewborn k11 .
■ Manageason d14 .
■ GiveappropriateIM/IVantibioticsifruptureof
membrane>18hours b15 .
■ Plantotreatthenewborn J5 .
■ Giveoralfluids.
■ Ifnotabletodrink,give1litreIVfluidsover3hours b9 .
■ EnsurethatthewomantakesARVdrugsas
prescribed g6
, g9 .
■ Supportherchoiceofinfantfeeding g7-g8 .
■ Explaintotheparentsthatthebabyisnotdoing
well.
CLASSIFY
risk of obstetriCal
CompliCation
preterm
labour
possible fetal
distress
rupture of
membranes
dehydration
hiv-positive
possible fetal death
next:Givesupportivecarethroughoutlabour
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d5
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d6
Communication
■ Explainallprocedures,seekpermission,anddiscussfindingswiththewoman.
■ Keepherinformedabouttheprogressoflabour.
■ Praiseher,encourageandreassureherthatthingsaregoingwell.
■ Ensureandrespectprivacyduringexaminationsanddiscussions.
■ IfknownHIVpositive,findoutwhatshehastoldthecompanion.Respectherwishes.
Cleanliness
■ Encouragethewomantobatheorshowerorwashherselfandgenitalsattheonsetoflabour.
■ Washthevulvaandperinealareasbeforeeachexamination.
■ Washyourhandswithsoapbeforeandaftereachexamination.Usecleanglovesforvaginal
examination.
■ Ensurecleanlinessoflabourandbirthingarea(s).
■ Cleanupspillsimmediately.
■ do notgiveenema.
Mobility
■ Encouragethewomantowalkaroundfreelyduringthefirststageoflabour.
■ Supportthewoman’schoiceofposition(leftlateral,squating,kneeling,standingsupportedbythe
companion)foreachstageoflabouranddelivery.
Urination
■ Encouragethewomantoemptyherbladderfrequently.Remindherevery2hours.
Eating,drinking
■ Encouragethewomantoeatanddrinkasshewishesthroughoutlabour.
■ Nutritiousliquiddrinksareimportant,eveninlatelabour.
■ Ifthewomanhasvisibleseverewastingortiresduringlabour,makesuresheeatsanddrinks.
Breathingtechnique
■ Teachhertonoticehernormalbreathing.
■ Encouragehertobreatheoutmoreslowly,makingasighingnoise,andtorelaxwitheachbreath.
■ Ifshefeelsdizzy,unwell,isfeelingpins-and-needles(tingling)inherface,handsandfeet,
encouragehertobreathemoreslowly.
■ Topreventpushingattheendoffirststageoflabour,teachhertopant,tobreathewithanopen
mouth,totakein2shortbreathsfollowedbyalongbreathout.
■ Duringdeliveryofthehead,askhernottopushbuttobreathesteadilyortopant.
Painanddiscomfortrelief
■ Suggestchangeofposition.
■ Encouragemobility,ascomfortableforher.
■ Encouragecompanionto:
→massagethewoman’sbackifshefindsthishelpful.
→holdthewoman’shandandspongeherfacebetweencontractions.
■ Encouragehertousethebreathingtechnique.
■ Encouragewarmbathorshower,ifavailable.
■ if woman is distressed or anxious, investigate the cause d2-d3 .
■ if pain is constant (persisting between contractions) and very severe or sudden in onset d4 .
give supportive Care throughout labour
use this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman’s wishes.
Give supportive care throughout labour
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Birth companion
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d7
Birthcompanion
■ Encouragesupportfromthechosenbirthcompanionthroughoutlabour.
■ Describetothebirthcompanionwhatsheorheshoulddo:
→Alwaysbewiththewoman.
→Encourageher.
→Helphertobreatheandrelax.
→Rubherback,wipeherbrowwithawetcloth,doothersupportiveactions.
→Givesupportusinglocalpracticeswhichdonotdisturblabourordelivery.
→Encouragewomantomovearoundfreelyasshewishesandtoadoptthepositionofherchoice.
→Encouragehertodrinkfluidsandeatasshewishes.
→Assisthertothetoiletwhenneeded.
■ Askthebirthcompaniontocallforhelpif:
→Thewomanisbearingdownwithcontractions.
→Thereisvaginalbleeding.
→Sheissuddenlyinmuchmorepain.
→Shelosesconsciousnessorhasfits.
→Thereisanyotherconcern.
■ Tellthebirthcompanionwhatsheorheshouldnot doandexplainwhy:
do notencouragewomantopush.
do notgiveadviceotherthanthatgivenbythehealthworker.
do notkeepwomaninbedifshewantstomovearound.
d8
MONITOREVERYHOUR:
■ Foremergencysigns,usingrapidassessment(RAM) b3-b7 .
■ Frequency,intensityanddurationofcontractions.
■ Fetalheartrate d14.
■ Moodandbehaviour(distressed,anxious) d6 .
■ RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .
■ Recordtimeofruptureofmembranesandcolourofamnioticfluid.
■ GiveSupportivecare d6-d7 .
■ never leave the woman alone.
ASSESSPROGRESSOFLABOUR
■ After8hoursif:
→Contractionsstrongerandmorefrequentbut
→Noprogressincervicaldilatationwithorwithoutmembranesruptured.
■ After8hoursif:
→noincreaseincontractions,and
→membranesarenotruptured,and
→noprogressincervicaldilatation.
■ Cervicaldilatation4cmorgreater.
MONITOREVERY4HOURS:
■ Cervicaldilatation d3

d15.
Unlessindicated,do notdovaginalexaminationmorefrequentlythanevery4hours.
■ Temperature.
■ Pulse b3 .
■ Bloodpressure

d23.
TREATANDADVISE,IFREqUIRED
■ refer the woman urgently to hospital b17.
■ Dischargethewomanandadvisehertoreturnif:
→pain/discomfortincreases
→vaginalbleeding
→membranesrupture.
■ Beginplottingthepartograph n5 andmanagethewomanasinActivelabour d9 .
first stage of labour: not in aCtive labour
use this chart for care of the woman when not in aCtive labour, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes.
First stage of labour (1): when the woman is not in active labour
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d9
MONITOREVERY30MINUTES:
■ Foremergencysigns,usingrapidassessment(RAM) b3-b7 .
■ Frequency,intensityanddurationofcontractions.
■ Fetalheartrate d14.
■ Moodandbehaviour(distressed,anxious) d6 .
■ RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .
■ Recordtimeofruptureofmembranesandcolourofamnioticfluid.
■ GiveSupportivecare d6-d7 .
■ never leave the woman alone.
ASSESSPROGRESSOFLABOUR
■ PartographpassestotherightofALERTLINE.
■ PartographpassestotherightofACTIONLINE.
■ Cervixdilated10cmorbulgingperineum.
MONITOREVERY4HOURS:
■ Cervicaldilatation d3

d15.
Unlessindicated,do not dovaginalexaminationmorefrequentlythanevery4hours.
■ Temperature.
■ Pulse b3 .
■ Bloodpressure

d23.
TREATANDADVISE,IFREqUIRED
■ Reassesswomanandconsidercriteriaforreferral.
■ Callseniorpersonifavailable.Alertemergencytransportservices.
■ Encouragewomantoemptybladder.
■ Ensureadequatehydrationbutomitsolidfoods.
■ Encourageuprightpositionandwalkingifwomanwishes.
■ Monitorintensively.Reassessin2hoursandreferifnoprogress.Ifreferraltakesalongtime,refer
immediately(DONOTwaittocrossactionline).
■ refer urgently to hospital b17 unlessbirthisimminent.
■ ManageasinSecond stage of labourd10-d11.
first stage of labour: in aCtive labour
use this chart when the woman is in aCtive labour, when cervix dilated 4 cm or more.
First stage of labour (2): when the woman is in active labour
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d10
MONITOREVERY5MINUTES:
■ Foremergencysigns,usingrapidassessment(RAM) b3-b7 .
■ Frequency,intensityanddurationofcontractions.
■ Fetalheartrate d14.
■ Perineumthinningandbulging.
■ Visibledescentoffetalheadorduringcontraction.
■ Moodandbehaviour(distressed,anxious) d6 .
■ RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .
■ GiveSupportivecare d6-d7 .
■ Neverleavethewomanalone.
DELIVERTHEBABY
■ Ensurealldeliveryequipmentandsupplies,includingnewbornresuscitationequipment,are
available,andplaceofdeliveryiscleanandwarm(25°C) l3 .
■ Ensurebladderisempty.
■ Assistthewomanintoacomfortablepositionofherchoice,asuprightaspossible.
■ Staywithherandofferheremotionalandphysicalsupportd10-d11.
■ Allowhertopushasshewisheswithcontractions.
■ Waituntilheadvisibleandperineumdistending.
■ Washhandswithcleanwaterandsoap.Putonglovesjustbeforedelivery.
■ SeeUniversalprecautionsduringlabouranddelivery a4 .
TREATANDADVISEIFREqUIRED
■ Ifunabletopassurineandbladderisfull,emptybladder b12 .
■ do notletherlieflat(horizontally)onherback.
■ Ifthewomanisdistressed,encouragepaindiscomfortrelief d6 .
do not urgehertopush.
■ If,after30minutesofspontaneousexpulsiveefforts,theperineumdoesnotbegintothinand
stretchwithcontractions,doavaginalexaminationtoconfirmfulldilatationofcervix.
■ Ifcervixisnotfullydilated,awaitsecondstage.Placewomanonherleftsideanddiscourage
pushing.Encouragebreathingtechnique d6 .
■ Ifsecondstagelastsfor2hoursormorewithoutvisiblesteadydescentofthehead,callforstaff
trainedtousevacuumextractororrefer urgently to hospital b17 .
■ Ifobviousobstructiontoprogress(warts/scarring/keloidtissue/previousthirddegreetear),doa
generousepisiotomy.do notperformepisiotomyroutinely.
■ Ifbreechorothermalpresentation,manageason d16 .
seCond stage of labour: deliver the baby and give immediate newborn Care
use this chart when cervix dilated 10 cm or bulging thin perineum and head visible.
Second stage of labour: deliver the baby and give immediate newborn care (1)
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Second stage of labour: deliver the baby and give immediate newborn care (2)
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d11
DELIVERTHEBABY
■ Ensurecontrolleddeliveryofthehead:
→Keeponehandgentlyontheheadasitadvanceswithcontractions.
→Supportperineumwithotherhandandcoveranuswithpadheldinpositionbysideofhandduringdelivery.
→Leavetheperineumvisible(betweenthumbandfirstfinger).
→Askthemothertobreathesteadilyandnottopushduringdeliveryofthehead.
→Encouragerapidbreathingwithmouthopen.
■ Feelgentlyaroundbaby’sneckforthecord.
■ Checkifthefaceisclearofmucusandmembranes.
■ Awaitspontaneousrotationofshouldersanddelivery(within1-2minutes).
■ Applygentledownwardpressuretodelivertopshoulder.
■ Thenliftbabyup,towardsthemother’sabdomentodeliverlowershoulder.
■ Placebabyonabdomenorinmother’sarms.
■ Notetimeofdelivery.
■ Thoroughlydrythebabyimmediately.Wipeeyes.Discardwetcloth.
■ Assessbaby’sbreathingwhiledrying.
■ Ifthebabyisnotcrying,observebreathing:
→breathingwell(chestrising)?
→notbreathingorgasping?
■ Excludesecondbaby.
■ Palpatemother’sabdomen.
■ Give10IUoxytocinIMtothemother.
■ Watchforvaginalbleeding.
■ Changegloves.Ifnotpossible,washglovedhands.
■ Clampandcutthecord.
→puttiestightlyaroundthecordat2cmand5cmfrombaby’sabdomen.
→cutbetweentieswithsterileinstrument.
→observeforoozingblood.
■ Leavebabyonthemother’schestinskin-to-skincontact.Placeidentificationlabel.
■ Coverthebaby,covertheheadwithahat.
■ Encourageinitiationofbreastfeeding k2 .
TREATANDADVISE,IFREqUIRED
■ Ifpotentiallydamagingexpulsiveefforts, exertmorepressureonperineum.
■ Discardsoiledpadtopreventinfection.
■ Ifcordpresentandloose,deliverthebabythroughtheloopofcordorslipthecordoverthebaby’shead;
ifcordistight,clampandcutcord,thenunwind.
■ Gentlywipefacecleanwithgauzeorcloth,ifnecessary.
■ Ifdelayindeliveryofshoulders:
→do not panicbutcallforhelpandaskcompaniontoassist
→ManageasinStuck shoulders d17 .
■ Ifplacingnewbornonabdomenisnotacceptable,orthemothercannotholdthebaby,placethebabyin
aclean,warm,safeplaceclosetothemother.
do notleavethebabywet-she/hewillbecomecold.
■ Ifthebabyisnotbreathingorgasping (unlessbabyisdead,macerated,severelymalformed):
→Cutcordquickly:transfertoafirm,warmsurface;startNewbornresuscitation k11 .
■ CALLFORHELP-onepersonshouldcareforthemother.
■ Ifsecondbaby,do notgiveoxytocinnow.get help.
■ Deliverthesecondbaby.ManageasinMultiple pregnancy d18 .
■ Ifheavybleeding,repeatoxytocin10-IU-IM.
■ Ifbloodoozing,placeasecondtiebetweentheskinandthefirsttie.
do not applyanysubstancetothestump.
do notbandageorbindthestump.
■ Ifroomcool(lessthan25°C),useadditionalblankettocoverthemotherandbaby.
■ IfHIV-positivemotherhaschosenreplacementfeeding,feedaccordingly.
■ CheckARVtreatmentneeded g6
, g9 .
d12
MONITORMOTHEREVERY5MINUTES:
■ Foremergencysigns,usingrapidassessment(RAM) b3-b7 .
■ Feelifuterusiswellcontracted.
■ Moodandbehaviour(distressed,anxious) d6
.
■ Timesincethirdstagebegan(timesincebirth).
■ Recordfindings,treatmentsandproceduresinLabour record andPartograph (pp.N4-N6).
■ GiveSupportive care d6-d7 .
■ never leave the woman alone.
DELIVERTHEPLACENTA
■ Ensure10-IUoxytocinIMisgiven d11 .
■ Awaitstronguterinecontraction (2-3minutes)anddeliverplacenta bycontrolled cord
traction:
→Placesideofonehand(usuallyleft)abovesymphysispubiswithpalmfacingtowardsthe
mother’sumbilicus.Thisappliescountertractiontotheuterusduringcontrolledcordtraction.At
thesametime,applysteady,sustainedcontrolledcordtraction.
→Ifplacentadoesnotdescendduring30-40secondsofcontrolledcordtraction,releasebothcord
tractionandcountertractionontheabdomenandwaituntiltheuterusiswellcontractedagain.
Thenrepeatcontrolledcordtractionwithcountertraction.
→Astheplacentaiscomingout,catchinbothhandstopreventtearingofthemembranes.
→Ifthemembranesdonotslipoutspontaneously,gentlytwistthemintoaropeandmovethemup
anddowntoassistseparationwithouttearingthem.
■ Checkthatplacentaandmembranesarecomplete.
MONITORBABYEVERY15MINUTES:
■ Breathing:listenforgrunting,lookforchestin-drawingandfastbreathing

J2 .
■ Warmth:checktoseeiffeetarecoldtotouch

J2 .
TREATANDADVISEIFREqUIRED
■ If,after30minutesofgivingoxytocin,theplacentaisnotdeliveredandthewomanisNOTbleeding:
→Emptybladder b12
→Encouragebreastfeeding
→Repeatcontrolledcordtraction.
■ Ifwomanisbleeding,manageason b5
■ Ifplacentaisnotdeliveredinanother30minutes(1hourafterdelivery):
→Removeplacentamanually b11
→GiveappropriateIM/IVantibiotic b15 .
■ Ifin1hourunabletoremoveplacenta:
→Referthewomantohospital b17
→InsertanIVlineandgivefluidswith20IUofoxytocinat30dropsperminute
duringtransfer b9 .
do notexertexcessivetractiononthecord.
do notsqueezeorpushtheuterustodelivertheplacenta.
■ Ifplacentaisincomplete:
→Removeplacentalfragmentsmanually b11 .
→GiveappropriateIM/IVantibiotic b15 .
third stage of labour: deliver the plaCenta
use this chart for care of the woman between birth of the baby and delivery of placenta.
Third stage of labour: deliver the placenta
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Third stage of labour: deliver the placenta
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d13
DELIVERTHEPLACENTA
■ Checkthatuterusiswellcontractedandthereisnoheavybleeding.
■ Repeatcheckevery5minutes.
■ Examineperineum,lowervaginaandvulvafortears.
■ Collect,estimateandrecordbloodlossthroughoutthirdstageandimmediatelyafterwards.
■ Cleanthewomanandtheareabeneathher.Putsanitarypadorfoldedcleanclothunderher
buttockstocollectblood.Helphertochangeclothesifnecessary.
■ Keepthemotherandbabyindeliveryroomforaminimumofonehourafterdeliveryofplacenta.
■ Disposeofplacentainthecorrect,safeandculturallyappropriatemanner.
TREATANDADVISE,IFREqUIRED
■ Ifheavybleeding:
→Massageuterustoexpelclotsifany,untilitishard b10 .
→Giveoxytocin10IUIM b10 .
→Callforhelp.
→StartanIVline b9 ,add20IUofoxytocintoIVfluidsandgiveat60dropsperminute n9 .
→Emptythebladder b12 .
■ Ifbleedingpersistsanduterusissoft:
→Continuemassaginguterusuntilitishard.
→Applybimanualoraorticcompression b10 .
→ContinueIVfluidswith20IUofoxytocinat30dropsperminute.
→refer woman urgently to hospital b17 .
■ Ifthirddegreetear(involvingrectumoranus),refer urgently to hospital b17 .
■ Forothertears:applypressureoverthetearwithasterilepadorgauzeandputlegstogether.
do notcrossankles.
■ Checkafter5minutes.Ifbleedingpersists,repairthetear b12 .
■ Ifbloodloss≈250-ml,butbleedinghasstopped:
→Plantokeepthewomaninthefacilityfor24hours.
→Monitorintensively(every30minutes)for4hours:
→BP,pulse
→vaginalbleeding
→uterus,tomakesureitiswellcontracted.
→Assistthewomanwhenshefirstwalksafterrestingandrecovering.
→Ifnotpossibletoobserveatthefacility,refer to hospital b17 .
■ Ifdisposingplacenta:
→Usegloveswhenhandlingplacenta.
→Putplacentaintoabagandplaceitintoaleak-proofcontainer.
→Alwayscarryplacentainaleak-proofcontainer.
→Incineratetheplacentaorburyitatleast10mawayfromawatersource,ina2mdeeppit.
next:Ifprolapsedcord
respond to problems during labour and delivery
d14
Respond to problems during labour and delivery (1) If FHR <120 or >160 bpm
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ASK,CHECKRECORD LOOK,LISTEN,FEEL
■ Positionthewomanonherleftside.
■ Ifmembraneshaveruptured,lookat
vulvaforprolapsedcord.
■ Seeifliquorwasmeconiumstained.
■ RepeatFHRcountafter
15 minutes.
SIGNS
■ Cordseenatvulva.
■ FHRremains>160or<120after30
minutesobservation.
■ FHRreturnstonormal.
TREATANDADVISE
■ Manageurgentlyason d15 .
■ Ifearlylabour:
→refer the woman urgently to hospital b17
→Keepherlyingonherleftside.
■ Iflatelabour:
→Callforhelpduringdelivery
→Monitoraftereverycontraction.IfFHRdoesnot
returntonormalin15minutesexplaintothe
woman(andhercompanion)thatthebabymay
notbewell.
→Preparefornewbornresuscitation k11 .
■ MonitorFHRevery15minutes.
CLASSIFY
prolapsed Cord
baby not well
baby well
if fetal heart rate (fhr) <120 or >160 beats per minute
t
if prolapsed Cord
the cord is visible outside the vagina or can be felt in the vagina below the presenting part.
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d15
Respond to problems during labour and delivery (2) If prolapsed cord
ASK,CHECKRECORD LOOK,LISTEN,FEEL
■ Lookatorfeelthecordgentlyfor
pulsations.
■ Feelfortransverselie.
■ Dovaginalexaminationto
determinestatusoflabour.
SIGNS
■ Transverselie
■ Cordispulsating
■ Cordisnotpulsating
TREAT
■ refer urgently to hospital b17 .
if early labour:
■ Pushtheheadorpresentingpartoutofthepelvis
andholditabovethebrim/pelviswithyourhandon
theabdomenuntilcaesareansectionisperformed.
■ Instructassistant(family,staff)topositionthe
woman’sbuttockshigherthantheshoulder.
■ refer urgently to hospital b17 .
■ Iftransfernotpossible,allowlabourtocontinue.
if late labour:
■ Callforadditionalhelpifpossible(formotherandbaby).
■ PrepareforNewbornresuscitation k11 .
■ Askthewomantoassumeanuprightorsquatting
positiontohelpprogress.
■ Expeditedeliverybyencouragingwomantopush
withcontraction.
■ Explaintotheparentsthatbabymaynotbewell.
CLASSIFY
obstruCted labour
fetus alive
fetus
probably dead
next:Ifbreechpresentation
t
Respond to problems during labour and delivery (3) If breech presentation
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SIGN
■ Ifearlylabour
■ Iflatelabour
■ Iftheheaddoesnotdeliver
afterseveralcontractions
■ Iftrappedarmsorshoulders
■ Iftrappedhead(andbabyisdead)
next:Ifstuckshoulders
if breeCh presentation
d16
TREAT
■ refer urgently to hospital b17 .
■ Callforadditionalhelp.
■ Confirmfulldilatationofthecervixbyvaginalexamination d3 .
■ Ensurebladderisempty.IfunabletoemptybladderseeEmptybladder b12 .
■ Preparefornewbornresuscitation k11 .
■ Deliverthebaby:
→Assistthewomanintoapositionthatwillallowthebabytohangdownduringdelivery,forexample,
proppedupwithbuttocksatedgeofbedorontoherhandsandknees(allfoursposition).
→Whenbuttocksaredistending,makeanepisiotomy.
→Allowbuttocks,trunkandshoulderstodeliverspontaneouslyduringcontractions.
→Afterdeliveryoftheshouldersallowthebabytohanguntilnextcontraction.
■ Placethebabyastrideyourleftforearmwithlimbshangingoneachside.
■ Placethemiddleandindexfingersofthelefthandoverthemalarcheekbonesoneithersidetoapply
gentledownwardspressuretoaidflexionofhead.
■ Keepingthelefthandasdescribed,placetheindexandringfingersoftherighthandoverthebaby’s
shouldersandthemiddlefingeronthebaby’sheadtogentlyaidflexionuntilthehairlineisvisible.
■ Whenthehairlineisvisible,raisethebabyinupwardandforwarddirectiontowardsthemother’sabdomenuntil
thenoseandmoutharefree.Theassistantgivessuprapubicpressureduringtheperiodtomaintainflexion.
■ Feelthebaby’schestforarms.Ifnotfelt:
■ Holdthebabygentlywithhandsaroundeachthighandthumbsonsacrum.
■ Gentlyguidingthebabydown,turnthebaby,keepingthebackuppermostuntiltheshoulderwhichwas
posterior(below)isnowanterior(atthetop)andthearmisreleased.
■ Thenturnthebabyback,againkeepingthebackuppermosttodelivertheotherarm.
■ Thenproceedwithdeliveryofheadasdescribedabove.
■ Tiea1kgweighttothebaby’sfeetandawaitfulldilatation.
■ Thenproceedwithdeliveryofheadasdescribedabove.
neverpullonthebreech
do notallowthewomantopushuntilthecervixisfullydilated.Pushingtoosoonmaycausetheheadtobe
trapped.
LOOK,LISTEN,FEEL
■ Onexternalexaminationfetalheadfelt
infundus.
■ Softbodypart(legorbuttocks)
feltonvaginalexamination.
■ Legsorbuttockspresentingat
perineum.
t
Respond to problems during labour and delivery (4) If stuck shoulders
SIGN
■ Fetalheadisdelivered,but
shouldersarestuckandcannotbe
delivered.
■ Iftheshouldersarestillnot
deliveredandsurgicalhelpisnot
availableimmediately.
TREAT
■ Callforadditionalhelp.
■ Preparefornewbornresuscitation.
■ Explaintheproblemtothewomanandhercompanion.
■ Askthewomantolieonherbackwhilegrippingherlegstightlyflexedagainsther
chest,withkneeswideapart.Askthecompanionorotherhelpertokeepthelegsin
thatposition.
■ Performanadequateepisiotomy.
■ Askanassistanttoapplycontinuouspressuredownwards,withthepalmofthe
handontheabdomendirectlyabovethepubicarea,whileyoumaintaincontinuous
downwardtractiononthefetalhead.
■ Remaincalmandexplaintothewomanthatyouneedhercooperationtotry
anotherposition.
■ Assisthertoadoptakneelingon“allfours”positionandaskhercompanionto
holdhersteady-thissimplechangeofpositionissometimessufficienttodislodge
theimpactedshoulderandachievedelivery.
■ Introducetherighthandintothevaginaalongtheposteriorcurveofthesacrum.
■ Attempttodelivertheposteriorshoulderorarmusingpressurefromthefingerof
therighthandtohooktheposteriorshoulderandarmdownwardsandforwards
throughthevagina.
■ Completetherestofdeliveryasnormal.
■ Ifnotsuccessful,refer urgently to hospital b17 .
do notpullexcessivelyonthehead.
next:Ifmultiplebirths
if stuCk shoulders (shoulder dystoCia)
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d17
t
Respond to problems during labour and delivery (5) If multiple births
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SIGN
■ Preparefordelivery
■ Secondstageoflabour
■ Thirdstageoflabour
■ Immediatepostpartumcare
TREAT
■ Preparedeliveryroomandequipmentforbirthof2ormorebabies.Include:
→morewarmcloths
→twosetsofcordtiesandrazorblades
→resuscitationequipmentfor2babies.
■ Arrangeforahelpertoassistyouwiththebirthsandcareofthebabies.
■ Deliverthefirstbabyfollowingtheusualprocedure.Resuscitateifnecessary.Labelher/himTwin1.
■ Askhelpertoattendtothefirstbaby.
■ Palpateuterusimmediatelytodeterminethelieofthesecondbaby.Iftransverseorobliquelie,gentlyturnthebabybyabdominalmanipulationtoheadorbreechpresentation.
■ Checkthepresentationbyvaginalexamination.Checkthefetalheartrate.
■ Awaitthereturnofstrongcontractionsandspontaneousruptureofthesecondbagofmembranes,usuallywithin1hourofbirthoffirstbaby,butmaybelonger.
■ Staywiththewomanandcontinuemonitoringherandthefetalheartrateintensively.
■ Removewetclothsfromunderneathher.Iffeelingchilled,coverher.
■ Whenthemembranesrupture,performvaginalexamination d3

tocheckforprolapsedcord.Ifpresent,seeProlapsedcord d15 .
■ Whenstrongcontractionsrestart,askthemothertobeardownwhenshefeelsready.
■ Deliverthesecondbaby.Resuscitateifnecessary.Labelher/himTwin2.
■ Aftercuttingthecord,askthehelpertoattendtothesecondbaby.
■ Palpatetheuterusforathirdbaby.Ifathirdbabyisfelt,proceedasdescribedabove.Ifnothirdbabyisfelt,gotothirdstageoflabour.
do notattempttodelivertheplacentauntilallthebabiesareborn.
do notgivethemotheroxytocinuntilafterthebirthofallbabies.
■ Giveoxytocin10IUIMaftermakingsurethereisnotanotherbaby.
■ Whentheuterusiswellcontracted,delivertheplacentaandmembranesbycontrolledcordtraction,applyingtractiontoallcordstogether d12-d23.
■ Beforeandafterdeliveryoftheplacentaandmembranes,observecloselyforvaginalbleedingbecausethiswomanisatgreaterriskofpostpartumhaemorrhage.If
bleeding,see b5 .
■ Examinetheplacentaandmembranesforcompleteness.Theremaybeonelargeplacentawith2umbilicalcords,oraseparateplacentawithanumbilicalcordforeachbaby.
■ Monitorintensivelyasriskofbleedingisincreased.
■ ProvideimmediatePostpartumcare d19-d20.
■ Inaddition:
→Keepmotherinhealthcentreforlongerobservation
→Plantomeasurehaemoglobinpostpartumifpossible
→Givespecialsupportforcareandfeedingofbabies J11 and k4 .
next:Careofthemotherandnewbornwithinfirsthourofdeliveryofplacenta
if multiple births
d18
t
d19
MONITORMOTHEREVERY15MINUTES:
■ Foremergencysigns,usingrapidassessment(RAM) b3-b7 .
■ Feelifuterusishardandround.
■ Recordfindings,treatmentsandproceduresinLabour recordandPartograph n4-n6 .
■ Keepmotherandbabyindeliveryroom-do not separate them.
■ never leave the woman and newborn alone.
CAREOFMOTHERANDNEWBORN
woman
■ Assesstheamountofvaginalbleeding.
■ Encouragethewomantoeatanddrink.
■ Askthecompaniontostaywiththemother.
■ Encouragethewomantopassurine.
newborn
■ Wipetheeyes.
■ Applyanantimicrobialwithin1hourofbirth.
→either1%silvernitratedropsor2.5%povidoneiodinedropsor1%tetracyclineointment.
■ DONOTwashawaytheeyeantimicrobial.
■ Ifbloodormeconium,wipeoffwithwetclothanddry.
■ DONOTremovevernixorbathethebaby.
■ Continuekeepingthebabywarmandinskin-to-skincontactwiththemother.
■ Encouragethemothertoinitiatebreastfeedingwhenbabyshowssignsofreadiness.Offerherhelp.
■ DONOTgiveartificialteatsorpre-lactealfeedstothenewborn:nowater,sugarwater,orlocalfeeds.

■ Examinethemotherandnewbornonehourafterdeliveryofplacenta.
UseAssess the mother after delivery d21 andExaminethenewborn J2-J8 .
MONITORBABYEVERY15MINUTES:
■ Breathing:listenforgrunting,lookforchestin-drawingandfastbreathing

J2 .
■ Warmth:checktoseeiffeetarecoldtotouch

J2 .
INTERVENTIONS,IFREqUIRED
■ Ifpadsoakedinlessthan5minutes,orconstanttrickleofblood,manageason d22 ..
■ Ifuterussoft,manageason b10 .
■ Ifbleedingfromaperinealtear,repairifrequired b12 orrefer to hospital b17 .
■ Ifbreathingwithdifficulty—grunting,chestin-drawingorfastbreathing,examinethebabyason J2-J8 .
■ Iffeetarecoldtotouchormotherandbabyareseparated:
→Ensuretheroomiswarm.Covermotherandbabywithablanket
→Reassessin1hour.Ifstillcold,measuretemperature.Iflessthan36.5
0
C,manageason k9 .
■ Ifunabletoinitiatebreastfeeding(motherhascomplications):
→Planforalternativefeedingmethod k5-k6 .
→IfmotherHIV-positive:givetreatmenttothenewborn g9 .
→Supportthemother'schoiceofnewbornfeeding g8 .
■Ifbabyisstillbornordead,givesupportivecaretomotherandherfamily d24 .
■ refer to hospitalnowifwomanhadseriouscomplicationsatadmissionorduringdeliverybutwas
inlatelabour.
Care of the mother and newborn within first hour of delivery of plaCenta
use this chart for woman and newborn during the first hour after complete delivery of placenta.
Care of the mother and newborn within first hour of delivery of placenta
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d20
MONITORMOTHERAT2,3AND4HOURS,
THENEVERY4HOURS:
■ Foremergencysigns,usingrapidassessment(RAM).
■ Feeluterusifhardandround.
■ Recordfindings,treatmentsandproceduresinLabour record andPartograph n4-n6 .
■ Keepthemotherandbabytogether.
■ never leave the woman and newborn alone.
■ do not dischargebefore12hours.
CAREOFMOTHER
■ Accompanythemotherandbabytoward.
■ Adviseon Postpartum care and hygiene d26 .
■ Ensurethemotherhassanitarynapkinsorcleanmaterialtocollectvaginalblood.
■ Encouragethemothertoeat,drinkandrest.
■ Ensuretheroomiswarm(25°C).
■ Askthemother’scompaniontowatchherandcallforhelpifbleedingorpainincreases,ifmother
feelsdizzyorhassevereheadaches,visualdisturbanceorepigastricdistress.
■ Encouragethemothertoemptyherbladderandensurethatshehas
passedurine.
■ Checkrecordandgiveanytreatmentorprophylaxiswhichisdue.
■ Advisethemotheronpostpartumcareandnutrition d26 .
■ Advisewhentoseekcare d28 .
■ Counselonbirthspacingandotherfamilyplanningmethods d27 .
■ RepeatexaminationofthemotherbeforedischargeusingAssess the mother after delivery d21 .For
baby,see J2-J8 .
INTERVENTIONS,IFREqUIRED
■ Makesurethewomanhassomeonewithherandtheyknowwhentocallforhelp.
■ IfHIV-positive:giveherappropriatetreatment g6
, g9 .
■ Ifheavyvaginalbleeding,palpatetheuterus.
→Ifuterusnotfirm,massagethefundustomakeitcontractandexpelanyclots b6 .
→Ifpadissoakedinlessthan5minutes,manageason b5 .
→Ifbleedingisfromperinealtear,repairorrefertohospital b17 .
■ Ifthemothercannotpassurineorthebladderisfull(swellingoverlowerabdomen)andsheis
uncomfortable,helpherbygentlypouringwateronvulva.
do not catheterizeunlessyouhaveto.
■ IftuballigationorIUDdesired,makeplansbeforedischarge.
■ Ifmotherisonantibioticsbecauseofruptureofmembranes>18hoursbutshowsnosignsof
infectionnow,discontinueantibiotics.
Care of the mother one hour after delivery of plaCenta
use this chart for continuous care of the mother until discharge. see J10 for care of the baby.
Care of the mother one hour after delivery of placenta
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assess the mother after delivery
use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge.
for examining the newborn use the chart on J2-J8 .
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d21
Assess the mother after delivery
ASK,CHECKRECORD
■ Checkrecord:
→bleedingmorethan250ml?
→completenessofplacentaand
membranes?
→complicationsduringdeliveryor
postpartum?
→specialtreatmentneeds?
→needstuballigationorIUD?
■ Howareyoufeeling?
■ Doyouhaveanypains?
■ Doyouhaveanyconcerns?
■ Howisyourbaby?
■ Howdoyourbreastsfeel?
LOOK,LISTEN,FEEL
■ Measuretemperature.
■ Feeltheuterus.Isithardand
round?
■ Lookforvaginalbleeding
■ Lookatperineum.
→Isthereatearorcut?
→Isitred,swollenordrainingpus?
■ Lookforconjunctivalpallor.
■ Lookforpalmarpallor.
SIGNS
■ Uterushard.
■ Littlebleeding.
■ Noperinealproblem.
■ Nopallor.
■ Nofever.
■ Bloodpressurenormal.
■ Pulsenormal.
TREATANDADVISE
■ Keepthemotheratthefacilityfor12hoursafter
delivery.
■ Ensurepreventivemeasures d25 .
■ Adviseonpostpartumcareandhygiene d26 .
■ Counselonnutrition d26 .
■ Counselonbirthspacingandfamilyplanning d27 .
■ Adviseonwhentoseekcareandnextroutine
postpartumvisit d28 .
■ Reassessfordischarge d21 .
■ Continueanytreatmentsinitiatedearlier.
■ Iftuballigationdesired,refertohospitalwithin7
daysofdelivery.IfIUDdesired,refertoappropriate
serviceswithin48hours.
CLASSIFY
mother well
next:Respondtoproblemsimmediatelypostpartum
Ifnoproblems,gotopage d25 .
t
Respond to problems immediately postpartum (1)
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ASK,CHECKRECORD
■Timesinceruptureofmembranes
■Abdominalpain
■Chills
LOOK,LISTEN,FEEL
■Apadissoakedinlessthan5
minutes.
■Repeattemperaturemeasurement
after2hours
■Iftemperatureisstill>38ºC
→Lookforabnormalvaginal
discharge.
→Listentofetalheartrate
→feellowerabdomenfor
tenderness
■Istherebleedingfromthetearor
episiotomy
■Doesitextendtoanusorrectum?
SIGNS
■Morethan1padsoakedin
5minutes
■Uterusnothardandnotround
■Temperaturestill>38
0
Candanyof:
→Chills
→Foul-smellingvaginaldischarge
→Lowabdomentenderness
→FHRremains>160after30
minutesofobservation
→ruptureofmembranes>18hours
■Temperaturestill>38
0
C
■Tearextendingtoanusorrectum.
■Perinealtear
■Episiotomy
TREATANDADVISE
■See b5 fortreatment.
■refer urgently to hospital b17 .
■InsertanIVlineandgivefluidsrapidly b9 .
■GiveappropriateIM/IVantibiotics b15 .
■Ifbabyandplacentadelivered:
→Giveoxytocin10IUIM b10 .
■refer woman urgently to hospital b17 .
■Assessthenewborn J2-J8 .
Treatifanysignofinfection.
■Encouragewomantodrinkplentyoffluids.
■Measuretemperatureevery4hours.
■Iftemperaturepersistsfor>12hours,isveryhighor
risesrapidly,giveappropriateantibioticand
refer to hospital b15 .
■refer woman urgently to hospital b15 .
■Ifbleedingpersists,repairthetearorepisiotomy b12
.
CLASSIFY
heavy
bleeding
uterine and
fetal infeCtion
risk of uterine and
fetal infeCtion
third degree tear
small perineal tear
next:Ifelevateddiastolicbloodpressure
if vaginal bleeding
if fever (temperature >38ºC)
if perineal tear or episiotomy (done for lifesaving CirCumstanCes)
d22
t
if elevated diastoliC blood pressure
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d23
Respond to problems immediately postpartum (2)
ASK,CHECKRECORD LOOK,LISTEN,FEEL
■Ifdiastolicbloodpressureis
≥90mmHg,repeatafter1hourrest.
■Ifdiastolicbloodpressureisstill
≥90-mmHg,askthewomanifshe
has:
→severeheadache
→blurredvision
→epigastricpainand
→checkproteininurine.
SIGNS
■Diastolicbloodpressure
≥110 mmHgOR
■Diastolicbloodpressure
≥90 mmHgand2+proteinuriaand
anyof:
→severeheadache
→blurredvision
→epigastricpain.
■Diastolicbloodpressure90-110
mmHgontworeadings.
■2+proteinuria(onadmission).
■Diastolicbloodpressure
≥90 mmHgon2readings.
TREATANDADVISE
■Givemagnesiumsulphate b13 .
■Ifinearlylabourorpostpartum,
refer urgently to hospital b17 .
■if late labour:
→continuemagnesiumsulphatetreatment b13
→monitorbloodpressureeveryhour.
→do notgiveergometrineafterdelivery.
■refer urgently to hospital after delivery b17 .
■Ifearlylabour, refer urgently to hospital e17 .
■Iflatelabour:
→monitorbloodpressureeveryhour
→do notgiveergometrineafterdelivery.
■IfBPremainselevatedafterdelivery,
refer to hospital e17 .
■Monitorbloodpressureeveryhour.
■do notgiveergometrineafterdelivery.
■Ifbloodpressureremainselevatedafterdelivery,
refer woman to hospital e17 .
CLASSIFY
severe
pre-eClampsia
pre-eClampsia
hypertension
next:Ifpalloronscreening,checkforanaemia
t
Respond to problems immediately postpartum (3)
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ASK,CHECKRECORD
■ Bleedingduringlabour,deliveryor
postpartum.
LOOK,LISTEN,FEEL
■ Measurehaemoglobin,ifpossible.
■ Lookforconjunctivalpallor.
■ Lookforpalmarpallor.Ifpallor:
→Isitseverepallor?
→Somepallor?
→Countnumberofbreathsin
1-minute
SIGNS
■ Haemoglobin<7g/dl.
and/or
■ Severepalmarandconjunctivalpalloror
■ Anypallorwith>30breathsperminute.
■ Anybleeding.
■ Haemoglobin7-11-g/dl.
■ Palmarorconjunctivalpallor.
■ Haemoglobin>11-g/dl
■ Nopallor.
CLASSIFY
severe
anaemia
moderate
anaemia
no anaemia
next:Givepreventivemeasures
if pallor on sCreening, CheCk for anaemia
if mother severely ill or separated from the baby
if baby stillborn or dead
d24
TREATANDADVISE
■ if early labour orpostpartum,refer urgently to hospital b17 .
■ if late labour:
→monitorintensively
→minimizebloodloss
→refer urgently to hospital after delivery b17 .
■ do notdischargebefore24hours.
■ Checkhaemoglobinafter3days.
■ Givedoubledoseofironfor3months f3 .
■ Followupin4weeks.
■ Giveiron/folatefor3months f3 .
■ Teachmothertoexpressbreastmilkevery3hours k5 .
■ Helphertoexpressbreastmilkifnecessary.Ensurebaby
receivesmother’smilk k8 .
■ Helphertoestablishorre-establishbreastfeedingassoonas
possible.See k2-k3 .
■ Givesupportivecare:
→Informtheparentsassoonaspossibleafterthebaby’s
death.
→Showthebabytothemother,givethebabytothemotherto
hold,whereculturallyappropriate.
→Offertheparentsandfamilytobewiththedeadbabyin
privacyaslongastheyneed.
→Discusswiththemtheeventsbeforethedeathandthe
possiblecausesofdeath.
■ Advisethemotheronbreastcare k8 .
■ Counselonappropriatefamilyplanningmethod d27 .
t
d25
ASSESS,CHECKRECORDS
■CheckRPRstatusinrecords.
■IfnoRPRduringthispregnancy,dotheRPRtest l5 .
■Checktetanustoxoid(TT)immunizationstatus.
■Checkwhenlastdoseofmebendazolewasgiven.
■Checkwoman’ssupplyofprescribeddoseofiron/folate.
■CheckifvitaminAgiven.
■Askwhetherwomanandbabyaresleepingunderinsecticidetreatedbednet.
■Counselandadviseallwomen.
■Recordalltreatmentsgiven n6 .
■CheckHIVstatusinrecords.
TREATANDADVISE
■IfRPRpositive:
→Treatwomanandthepartnerwithbenzathinepenicillin f6 .
→Treatthenewborn k12 .
■Givetetanustoxoidifdue f2 .
■Givemebendazoleoncein6months f3 .
■Give3month’ssupplyofironandcounseloncompliance f3 .
■GivevitaminAifdue f2 .
■Encouragesleepingunderinsecticidetreatedbednet f4 .
■Adviseonpostpartumcare d26 .
■Counselonnutrition d26 .
■Counselonbirthspacingandfamilyplanning d27 .
■Counselonbreastfeeding k2 .
■Counselonsafersexincludinguseofcondoms g2 .
■Adviseonroutineandfollow-uppostpartumvisits d28 .
■Adviseondangersigns d28 .
■Discusshowtoprepareforanemergencyinpostpartum d28 .
■IfHIV-positive:
→SupportadherencetoARV g6 .
→Treatthenewborn g9 .
■IfHIVtestnotdone,offerherthetest e5 .
give preventive measures
ensure that all are given before discharge.
Give preventive measures
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d26
Adviseonpostpartumcareandhygiene
Adviseandexplaintothewoman:
■Toalwayshavesomeonenearherforthefirst24hourstorespondtoanychangeinhercondition.
■Nottoinsertanythingintothevagina.
■Tohaveenoughrestandsleep.
■Theimportanceofwashingtopreventinfectionofthemotherandherbaby:
→washhandsbeforehandlingbaby
→washperineumdailyandafterfaecalexcretion
→changeperinealpadsevery4to6hours,ormorefrequentlyifheavylochia
→washusedpadsordisposeofthemsafely
→washthebodydaily.
■Toavoidsexualintercourseuntiltheperinealwoundheals.
Counselonnutrition
■Advisethewomantoeatagreateramountandvarietyofhealthyfoods,suchasmeat,fish,oils,
nuts,seeds,cereals,beans,vegetables,cheese,milk,tohelpherfeelwellandstrong(giveexamples
oftypesoffoodandhowmuchtoeat).
■Reassurethemotherthatshecaneatanynormalfoods–thesewillnotharmthebreastfeedingbaby.
■Spendmoretimeonnutritioncounsellingwithverythinwomenandadolescents.
■Determineifthereareimportanttaboosaboutfoodswhicharenutritionallyhealthy.
Advisethewomanagainstthesetaboos.
■Talktofamilymemberssuchaspartnerandmother-in-law,toencouragethemtohelpensurethe
womaneatsenoughandavoidshardphysicalwork.
advise on postpartum Care
Advise on postpartum care
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d27
Counselontheimportanceoffamilyplanning
■Ifappropriate,askthewomanifshewouldlikeherpartneroranotherfamilymembertobeincluded
inthecounsellingsession.
■Explainthatafterbirth,ifshehassexandisnotexclusivelybreastfeeding,shecanbecomepregnant
assoonas4weeksafterdelivery.Thereforeitisimportanttostartthinkingearlyaboutwhatfamily
planningmethodtheywilluse.
→Askaboutplansforhavingmorechildren.Ifshe(andherpartner)wantmorechildren,advisethat
waitingatleast2-3yearsbetweenpregnanciesishealthierforthemotherandchild.
→Informationonwhentostartamethodafterdeliverywillvarydependingonwhetherawomanis
breastfeedingornot.
→Makearrangementsforthewomantoseeafamilyplanningcounsellor,orcounselherdirectly
(seetheDecision-making tool for family planning providers and clientsforinformationon
methodsandonthecounsellingprocess).
■Councelonsafersexincludinguseofcondomsfordualprotectionfromsexuallytransmittedinfection(STI)or
HIVandpregnancy.Promotetheiruse,especiallyifatriskforsexuallytransmittedinfection(STI)orHIV g2 .
■ForHIV-positivewomen,see g4 forfamilyplanningconsiderations
■Herpartnercandecidetohaveavasectomy(malesterilization)atanytime.
method options for the non-breastfeeding woman
Can be used immediately postpartum Condoms
Progestogen-onlyoralcontraceptives
Progestogen-onlyinjectables
Implant
Spermicide
Femalesterilization(within7daysordelay6weeks)
copperIUD(immediatelyfollowingexpulsionof
placentaorwithin48hours)
delay 3 weeks Combinedoralcontraceptives
Combinedinjectables
Fertilityawarenessmethods
Lactationalamenorrhoeamethod(LAM)
■Abreastfeedingwomanisprotectedfrompregnancyonlyif:
→sheisnomorethan6monthspostpartum,and
→sheisbreastfeedingexclusively(8ormoretimesaday,includingatleastonceatnight:no
daytimefeedingsmorethan4hoursapartandnonightfeedingsmorethan6hoursapart;no
complementaryfoodsorfluids),and
→hermenstrualcyclehasnotreturned.
■Abreastfeedingwomancanalsochooseanyotherfamilyplanningmethod,eithertousealoneor
togetherwithLAM.
method options for the breastfeeding woman
Can be used immediately postpartum Lactationalamenorrhoeamethod(LAM)
Condoms
Spermicide
Femalesterilisation(within7daysordelay6weeks)
copperIUD(within48hoursordelay4weeks)
delay 6 weeks Progestogen-onlyoralcontraceptives
Progestogen-onlyinjectables
Implants
Diaphragm
delay 6 months Combinedoralcontraceptives
Combinedinjectables
Fertilityawarenessmethods
Counsel on birth spaCing and family planning
Counsel on birth spacing and family planning
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d28
Routinepostpartumcarevisits
first visit d19 Withinthefirstweek,preferablywithin2-3days
seCond visit e2

4-6weeks
Follow-upvisitsforproblems
if the problem was: return in:
Fever 2days
Lowerurinarytractinfection 2days
Perinealinfectionorpain 2days
Hypertension 1week
Urinaryincontinence 1week
Severeanaemia 2weeks
Postpartumblues 2weeks
HIV-positive 2weeks
Moderateanaemia 4weeks
Iftreatedinhospital Accordingtohospitalinstructionsoraccordingtonational
foranycomplication guidelines,butnolaterthanin2weeks.
Adviseondangersigns
advise to go to a hospital or health centre immediately, day or night, without waiting, if any of
the following signs:
■ vaginalbleeding:
→morethan2or3padssoakedin20-30minutesafterdeliveryor
→bleedingincreasesratherthandecreasesafterdelivery.
■convulsions.
■ fastordifficultbreathing.
■ feverandtooweaktogetoutofbed.
■ severeabdominalpain.
Gotohealthcentreas soon as possibleifanyofthefollowingsigns:
■ fever
■ abdominalpain
■ feelsill
■ breastsswollen,redortenderbreasts,orsorenipple
■ urinedribblingorpainonmicturition
■ painintheperineumordrainingpus
■ foul-smellinglochia
Discusshowtoprepareforanemergencyinpostpartum
■ Advisetoalwayshavesomeonenearforatleast24hoursafterdeliverytorespondtoanychangein
condition.
■ Discusswithwomanandherpartnerandfamilyaboutemergencyissues:
→wheretogoifdangersigns
→howtoreachthehospital
→costsinvolved
→familyandcommunitysupport.
■ Advisethewomantoaskforhelpfromthecommunity,ifneededi1-i3.
■ Advisethewomantobringherhome-basedmaternalrecordtothehealthcentre,evenforan
emergencyvisit.
advise on when to return
use this chart for advising on postpartum care on d21 or e2 . for newborn babies see the schedule on k14 .
encourage woman to bring her partner or family member to at least one visit.
Advise on when to return
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Preparationforhomedelivery
■ Checkemergencyarrangements.
■ Keepemergencytransportarrangementsup-to-date.
■ Carrywithyouallessentialdrugs b17 ,records,andthedeliverykit.
■ Ensurethatthefamilyprepares,ason C18 .
Deliverycare
■ Followthelabouranddeliveryprocedures d2-d28 k11 .
■ Observeuniversalprecautions a4 .
■ Givesupportive care.Involvethecompanionincareandsupport d6-d7
.
■ Maintainthepartographandlabourrecord n4-n6 .
■ Providenewborncare J2-J8 .
■ refer to facility as soon as possible if any abnormal finding in mother or baby b17 k14 .
Immediatepostpartumcareofmother
■ Staywiththewomanforfirsttwohoursafterdeliveryofplacenta C2 C13-C14.
■ Examinethemotherbeforeleavingher d21 .
■ Adviseonpostpartumcare,nutritionandfamilyplanningd26-d27.
■ Ensurethatsomeonewillstaywiththemotherforthefirst24hours.
Postpartumcareofnewborn
■ Stayuntilbabyhashadthefirstbreastfeedandhelpthemothergoodpositioningandattachment b2 .
■ Adviseonbreastfeedingandbreastcare b3 .
■ Examinethebabybeforeleaving n2-n8 .
■ Immunizethebabyifpossible b13 .
■ Adviseonnewborncare b9-b10 .
■ Advisethefamilyaboutdangersignsandwhenandwheretoseekcare b14 .
■ Ifpossible,returnwithinadaytocheckthemotherandbaby.
■ Adviseapostpartumvisitforthemotherandbabywithinthefirstweek b14 .
home delivery by skilled attendant
use these instructions if you are attending delivery at home.
Home delivery by skilled attendant
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Postpartum care
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postpartum Care
postpartum
Care
e2 Postpartum care
ASK, CHECK RECORD
■ When and where did you deliver? ■ How are you feeling? ■ Have you had any pain or fever or bleeding since delivery? ■ Do you have any problem with passing urine? ■ Have you decided on any contraception? ■ How do your breasts feel? ■ Do you have any other concerns? ■ Check records: →Any complications during delivery? →Receiving any treatments? →HIV status.
LOOK, LISTEN, FEEL
■ Measure blood pressure and temperature. ■ Feel uterus. Is it hard and round? ■ Look at vulva and perineum for: →tear →swelling →pus. ■ Look at pad for bleeding and lochia. →Does it smell? →Is it profuse? ■ Look for pallor.
SIGNS
■ Mother feeling well. ■ Did not bleed >250 ml. ■ Uterus well contracted and hard. ■ No perineal swelling. ■ Blood pressure, pulse and temperature normal. ■ No pallor. ■ No breast problem, is breastfeeding well. ■ No fever or pain or concern. ■ No problem with urination.
TREAT ANDADVISE
■ Make sure woman and family know what to watch for and when to seek care d28 . ■ Advise on Postpartum care and hygiene, and counsel on nutrition d26 . ■ Counsel on the importance of birth spacing and family planning d27 . Refer for family planning counselling. ■ Dispense 3 months iron supply and counsel on compliance F3 . ■ Give any treatment or prophylaxis due: →tetanus immunization if she has not had full course F2 . ■ Promote use of impregnated bednet for the mother and baby. ■ Record on the mother’s home-based maternal record. ■ Advise to return to health centre within 4-6 weeks.
CLASSIFY
normal postpartum
next: Respond to observed signs or volunteered problems
postpartumexamination oF the mother (up to 6 weeks)
use this chart for examining the mother after discharge from a facility or after home delivery
if she delivered less than a week ago without a skilled attendant, use the chart assess the mother after delivery d2 .
to examine the baby see J2-J8 .
if breast problem see J9 .

next: If pallor, check for anaemia
Respondto observedsigns or volunteered problems (1) If elevated diastolic bloodpressure
postpartum
Care
e3
ASK, CHECK RECORD
■ History of pre-eclampsia or eclampsia in pregnancy, delivery or after delivery?
LOOK, LISTEN, FEEL
■ If diastolic blood pressure is ≥90 mmHg , repeat after a 1 hour rest.
SIGNS
■ Diastolic blood pressure ≥110 mmHg.
■ Diastolic blood pressure ≥90 mmHg on 2 readings.
■ Diastolic blood pressure <90 mmHg after 2 readings.
TREAT ANDADVISE
■ Give appropriate antihypertensive b4 . ■ refer urgently to hospital b7 .
■ Reassess in 1 week. If hypertension persists, refer to hospital.
■ No additional treatment.
CLASSIFY
severe hypertension
moderate hypertension
blood pressure normal
respond to observed signs or volunteered problems
iF elevated diastoliC blood pressure

postpartum
Care
e4 Respond to observed signs or volunteered problems (2) If pallor, check for anaemia
ASK, CHECK RECORD
■ Check record for bleeding in pregnancy, delivery or postpartum. ■ Have you had heavy bleeding since delivery? ■ Do you tire easily? ■ Are you breathless (short of breath) during routine housework?
LOOK, LISTEN, FEEL
■ Measure haemoglobin if history of bleeding. ■ Look for conjunctival pallor. ■ Look for palmar pallor. If pallor: →is it severe pallor? →some pallor? ■ Count number of breaths in 1 minute.
SIGNS
■ Haemoglobin <7-g/dl and/or ■ Severe palmar and conjunctival pallor or ■ Any pallor and any of: →>30 breaths per minute →tires easily →breathlessness at rest.
■ Haemoglobin 7-11-g/dl or ■ Palmar or conjunctival pallor.
■ Haemoglobin >11-g/dl. ■ No pallor.
TREAT ANDADVISE
■ Give double dose of iron (1 tablet 60 mg twice daily for 3 months) F3 . ■ refer urgently to hospital b7 . ■ Follow up in 2 weeks to check clinical progress and compliance with treatment.
■ Give double dose of iron for 3 months F3 . ■ Reassess at next postnatal visit (in 4 weeks). If anaemia persists, refer to hospital.
■ Continue treatment with iron for 3 months altogether F3 .
CLASSIFY
severe anaemia
moderate anaemia
no anaemia
next: Check for HIV status
iF pallor, CheCk For anaemia

Respond to observed signs or volunteered problems (3) Check for HIV status
postpartum
Care
e5
ASK, CHECK RECORD
provide key information on hiv g2 . ■ What is HIV and how is HIV transmitted g2 ?
■ Advantage of knowing the HIV status g2 . ■ Explain about HIV testing and counselling including confidentiality of the result g3 . ask the woman: ■ Have you been tested for HIV? →If not: tell her that she will be tested for HIV, unless she refuses. →If yes: check result. (Explain to her that she has a right not to disclose the result.) →Are you taking any ARV treatment? →Check treatment plan. ■ Has the partner been tested?
LOOK, LISTEN, FEEL
■ Perform the Rapid HIV test if not performed in this pregnancy l6 .
SIGNS
■ Positive HIV test
■ Negative HIV test
■ She refuses the test or is not willing to disclose the result of previous test or no test results available
TREAT ANDADVISE
■ Counsel on implications of a positive test g3 . ■ Refer the woman to HIV services for further assessment. →Counsel on infant feeding options g7 . →Provide additional care for HIV-positive woman g4 . →Counsel on family planning g4 . →Counsel on safer sex including use of condoms g2 . →Counsel on benefits of disclosure (involving) and testing her partne g3 . →Provide support to the HIV-positive woman g5 . ■ Follow up in 2 weeks.
■ Counsel on implications of a negative test g3 . ■ Counsel on the importance of staying negative by practising safer sex, including use of condoms g2 . ■ Counsel on benefits of involving and testing the partner g3 .
■ Counsel on safer sex including use of condoms g2 . ■ Counsel on benefits of involving and testing the partner g3 .
CLASSIFY
hiv-positive
hiv-negative
unknown hiv status
next: If heavy vaginal bleeding
CheCk For hiv status
use this chart for hiv testing and counselling during postpartum visit if the woman is not previously tested. If the women has taken ARV during pregnancy or childbirth refer her to HIV services for further assessment.

iF heavy vaginal bleeding
Respond to observed signs or volunteered problems (4)
postpartum
Care
e6
ASK, CHECK RECORD
■ Have you had: →heavy bleeding? →foul-smelling lochia? →burning on urination?
LOOK, LISTEN, FEEL
■ Feel lower abdomen and flanks for tenderness. ■ Look for abnormal lochia. ■ Measure temperature. ■ Look or feel for stiff neck. ■ Look for lethargy.
SIGNS
■ More than 1 pad soaked in 5 minutes.
■ Temperature >38°C and any of: →very weak →abdominal tenderness →foul-smelling lochia →profuse lochia →uterus not well contracted →lower abdominal pain →history of heavy vaginal bleeding.
■ Fever >38ºC and any of: →burning on urination →flank pain.
■ Burning on urination.
■ Temperature >38°C and any of: →stiff neck →lethargy.
■ Fever >38°C.
TREAT ANDADVISE
■ Give 0.2 mg ergometrine IM b0 . ■ Give appropriate IM/IV antibiotics b5 . ■ Manage as in Rapid assessment and management b3-b7 . ■ refer urgently to hospital b7 .
■ Insert an IV line and give fluids rapidly b9 . ■ Give appropriate IM/IV antibiotics b5 . ■ refer urgently to hospital b7 .
■ Give appropriate IM/IV antibiotics b5 . ■ refer urgently to hospital b7 .
■ Give appropriate oral antibiotic F5 . ■ Encourage her to drink more fluids. ■ Follow up in 2 days. If no improvement, refer to hospital.
■ Insert an IV line b9 . ■ Give appropriate IM/IV antibiotics b5 . ■ Give artemether IM (or quinine IM if artemether not available) and glucose b6 . ■ refer urgently to hospital b7 .
■ Give oral antimalarial F4 . ■ Follow up in 2 days. If no improvement, refer to hospital.
CLASSIFY
postpartum bleeding
uterine inFeCtion
upper urinary traCt inFeCtion
lower urinary traCt inFeCtion
very severe Febrile disease
malaria
next: If dribbling urine
iF Fever or Foul-smelling loChia

Respond to observed signs or volunteered problems (5)
postpartum
Care
e7
ASK, CHECK RECORD
■ How have you been feeling recently? ■ Have you been in low spirits? ■ Have you been able to enjoy the things you usually enjoy? ■ Have you had your usual level of energy, or have you been feeling tired? ■ How has your sleep been? ■ Have you been able to concentrate (for example on newspaper articles or your favourite radio programmes)?
LOOK, LISTEN, FEEL SIGNS
■ Dribbling or leaking urine.
■ Excessive swelling of vulva or perineum.
■ Pus in perineum. ■ Pain in perineum.
Two or more of the following symptoms during the same 2 week period representing a change from normal: ■ Inappropriate guilt or negative feeling towards self. ■ Cries easily. ■ Decreased interest or pleasure. ■ Feels tired, agitated all the time. ■ Disturbed sleep (sleeping too much or too little, waking early). ■ Diminished ability to think or concentrate. ■ Marked loss of appetite.
■ Any of the above, for less than 2 weeks.
TREAT
■ Check perineal trauma. ■ Give appropriate oral antibiotics for lower urinary tract infection F5 . ■ If conditions persists more than 1 week, refer the woman to hospital.
■ Refer the woman to hospital.
■ Remove sutures, if present. ■ Clean wound. Counsel on care and hygiene d26 . ■ Give paracetamol for pain F4 . ■ Follow up in 2 days. If no improvement, refer to hospital.
■ Provide emotional support. ■ refer urgently the woman to hospital b7 .
■ Assure the woman that this is very common. ■ Listen to her concerns. Give emotional encouragement and support. ■ Counsel partner and family to provide assistance to the woman. ■ Follow up in 2 weeks, and refer if no improvement.
CLASSIFY
urinary inContinenCe
perineal trauma
perineal inFeCtion or pain
postpartum depression (usually aFter First week)
postpartumblues (usually in First week)
next: If vaginal discharge 4 weeks after delivery
iF dribbling urine
iF pus or perineal pain
iF Feeling unhappy or Crying easily

e2 postpartum examination oF
the mother (up to 6 weeks)
e3 respond to observed signs or
volunteered problems ()
Ifelevateddiastolicpressure
e4 respond to observed signs or
volunteered problems (2)
Ifpallor,checkforanaemia
e5 respond to observed signs or
volunteered problems (3)
CheckforHIVstatus
e6 respond to observed signs or
volunteered problems (4)
Ifheavyvaginalbleeding
Iffeverorfoul-smellinglochia
e7 respond to observed signs or
volunteered problems (5)
Ifdribblingurine
Ifpussorperinealpain
Iffeelingunhappyorcryingeasily
Respond to observed signs or volunteered problems (6)
postpartum
Care
e8
next: If cough or breathing difficulty
ASK, CHECK RECORD
■ Do you have itching at the vulva? ■ Has your partner had a urinary problem?
If partner is present in the clinic, ask the woman if she feels comfortable if you ask him similar questions. If yes, ask him if he has: ■ urethral discharge or pus ■ burning on passing urine.
If partner could not be approached, explain importance of partner assessment and treatment to avoid reinfection.
LOOK, LISTEN, FEEL
■ Separate the labia and look for abnormal vaginal discharge: →amount →colour →odour/smell. ■ If no discharge is seen, examine with a gloved finger and look at the discharge on the glove.
SIGNS
■ Abnormal vaginal discharge, and partner has urethral discharge or burning on passing urine.
■ Curd-like vaginal discharge and/or ■ Intense vulval itching.
■ Abnormal vaginal discharge.
TREAT ANDADVISE
■ Give appropriate oral antibiotics to woman F5 . ■ Treat partner with appropriate oral antibiotics F5 . ■ Counsel on safer sex including use of condoms g2 .
■ Give clotrimazole F5 . ■ Counsel on safer sex including use of condoms F4 . ■ If no improvement, refer the woman to hospital.
■ Give metronidazole to woman F5 . ■ Counsel on safer sex including use of condoms g2 .
CLASSIFY
possible gonorrhoea or Chlamydia inFeCtion
possible Candida inFeCtion
possible baCterial or triChomonas inFeCtion
iF vaginal disCharge 4 weeks aFter delivery
iF breast problem
see J9 .

Respond to observed signs or volunteered problems (7)
postpartum
Care
e9
next: If signs suggesting HIV infection
ASK, CHECK RECORD
■ How long have you been coughing? ■ How long have you had difficulty in breathing? ■ Do you have chest pain? ■ Do you have any blood in sputum? ■ Do you smoke?
■ Are you taking anti-tuberculosis drugs? If yes, since when?
LOOK, LISTEN, FEEL
■ Look for breathlessness. ■ Listen for wheezing. ■ Measure temperature.
SIGNS
At least 2 of the following: ■ Temperature >38ºC. ■ Breathlessness. ■ Chest pain.
At least 1 of the following: ■ Cough or breathing difficulty for >3 weeks. ■ Blood in sputum. ■ Wheezing.
■ Temperature <38ºC. ■ Cough for <3 weeks.
■ Taking anti-tuberculosis drugs.
TREAT ANDADVISE
■ Give first dose of appropriate IM/IV antibiotics b5 . ■ refer urgently to hospital b7 .
■ Refer to hospital for assessment. ■ If severe wheezing, refer urgently to hospital. ■ Use Practical Approach to Lung health guidelines (PAL) for further management.
■ Advise safe, soothing remedy. ■ If smoking, counsel to stop smoking.
■ Assure the woman that the drugs are not harmful to her baby, and of the need to continue treatment. ■ If her sputumis TB-positive within 2 months of delivery, plan to give INH prophylaxis to the newborn k3 . ■ Reinforce advice for HIV testing g3 . ■ If smoking, counsel to stop smoking. ■ Advise to screen immediate family members and close contacts for tuberculosis.
CLASSIFY
possible pneumonia
possible ChroniC lung disease
upper respiratory traCt inFeCtion
tuberCulosis
iF Cough or breathing diFFiCulty
iF takinganti-tuberCulosis drugs

Respond to observed signs or volunteered problems (8) If signs suggesting HIV infection
postpartum
Care
e0
ASK, CHECK RECORD
■ Have you lost weight? ■ Do you have fever? How long (>1 month)? ■ Have you got diarrhoea (continuous or intermittent)? How long (>1 month)? ■ Have you had cough? How long (>1 month)?
LOOK, LISTEN, FEEL
■ Look for visible wasting. ■ Look for ulcers and white patches in the mouth (thrush). ■ Look at the skin: →Is there a rash? →Are there blisters along the ribs on one side of the body?
SIGNS
■ Two of the following: →weight loss →fever >1 month →diarrhoea >1 month. or ■ One of the above signs and →one or more other sign or →from a high-risk group.
TREAT ANDADVISE
■ Reinforce the need to know HIV status and counsel for HIV testing g3 . ■ Counsel on the benefits of testing her partner g3 . ■ Counsel on safer sex including use of condoms g2 . ■ Examine further and manage according to national HIV guidelines or refer to appropriate HIV services. ■ Refer to TB centre if cough.
CLASSIFY
strong likelihood oF hiv inFeCtion
iF signs suggesting hiv inFeCtion
hiv status unknown or known hiv-positive.
e8 respond to observed signs or
volunteered problems (6)
Ifvaginaldischarge4weeksafterdelivery
Ifbreastproblem

J9
e9 respond to observed signs or
volunteered problems (7)
Ifcoughorbreathingdifficulty
Iftakinganti-tuberculosisdrugs
e0 respond to observed signs or
volunteered problems (8)
IfsignssuggestingHIVinfection
■ AlwaysbeginwithRapidassessmentandmanagement(RAM)

b2-b7 .
■ NextusethePostpartumexaminationofthemother

e2 .
■ Ifanabnormalsignisidentified(volunteeredorobserved),usethechartsRespondtoobservedsignsorvolunteeredproblems

e3-e0 .
■ Recordalltreatmentgiven,positivefindings,andtheschedulednextvisitinthehome-basedandclinicrecordingform.
■ Forthefirstorsecondpostpartumvisitduringthefirstweekafterdelivery,usethePostpartumexaminationchart

d2 andAdviseand
counsellingsection

d26 toexamineandadvisethemother.
■ IfthewomanisHIVpositive,adolescentorhasspecialneeds,use

g-g h-h4 .
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Postpartum care
ASK,CHECKRECORD
■ Whenandwheredidyoudeliver?
■ Howareyoufeeling?
■ Haveyouhadanypainorfeveror
bleedingsincedelivery?
■ Doyouhaveanyproblemwith
passingurine?
■ Haveyoudecidedonany
contraception?
■ Howdoyourbreastsfeel?
■ Doyouhaveanyotherconcerns?
■ Checkrecords:
→Anycomplicationsduring
delivery?
→Receivinganytreatments?
→HIVstatus.
LOOK,LISTEN,FEEL
■ Measurebloodpressureand
temperature.
■ Feeluterus.Isithardandround?
■ Lookatvulvaandperineumfor:
→tear
→swelling
→pus.
■ Lookatpadforbleedingandlochia.
→Doesitsmell?
→Isitprofuse?
■ Lookforpallor.
SIGNS
■ Motherfeelingwell.
■ Didnotbleed>250 ml.
■ Uteruswellcontractedandhard.
■ Noperinealswelling.
■ Bloodpressure,pulseand
temperaturenormal.
■ Nopallor.
■ Nobreastproblem,
isbreastfeedingwell.
■ Nofeverorpainorconcern.
■ Noproblemwithurination.
TREATANDADVISE
■ Makesurewomanandfamilyknowwhattowatch
forandwhentoseekcare d28 .
■ AdviseonPostpartumcareandhygiene,
andcounselonnutrition d26 .
■ Counselontheimportanceofbirthspacingand
familyplanning d27 .
Referforfamilyplanningcounselling.
■ Dispense3monthsironsupplyand
counseloncompliance F3 .
■ Giveanytreatmentorprophylaxisdue:
→tetanusimmunizationifshehasnothad
fullcourse F2 .
■ Promoteuseofimpregnated
bednetforthemotherandbaby.
■ Recordonthemother’shome-basedmaternal
record.
■ Advisetoreturntohealthcentrewithin4-6weeks.
CLASSIFY
normal postpartum
next:Respondtoobservedsignsorvolunteeredproblems
postpartum examination oF the mother (up to 6 weeks)
use this chart for examining the mother after discharge from a facility or after home delivery
if she delivered less than a week ago without a skilled attendant, use the chart assess the mother after delivery d2 .
to examine the baby see J2-J8 .
if breast problem see J9 .
t
next:Ifpallor,checkforanaemia
Respond to observed signs or volunteered problems (1) If elevated diastolic blood pressure
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e3
ASK,CHECKRECORD
■ Historyofpre-eclampsiaor
eclampsiainpregnancy,deliveryor
afterdelivery?
LOOK,LISTEN,FEEL
■ Ifdiastolicbloodpressureis
≥90mmHg,repeatafter
a1hourrest.
SIGNS
■ Diastolicbloodpressure
≥110 mmHg.
■ Diastolicbloodpressure
≥90 mmHgon2readings.
■ Diastolicbloodpressure
<90 mmHgafter2readings.
TREATANDADVISE
■ Giveappropriateantihypertensive b4 .
■ refer urgently to hospital b7 .
■ Reassessin1week.
Ifhypertensionpersists,refertohospital.
■ Noadditionaltreatment.
CLASSIFY
severe
hypertension
moderate
hypertension
blood pressure
normal
respond to observed signs or volunteered problems
iF elevated diastoliC blood pressure
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e4
Respond to observed signs or volunteered problems (2) If pallor, check for anaemia
ASK,CHECKRECORD
■ Checkrecordforbleedingin
pregnancy,deliveryorpostpartum.
■ Haveyouhadheavybleedingsince
delivery?
■ Doyoutireeasily?
■ Areyoubreathless(shortofbreath)
duringroutinehousework?
LOOK,LISTEN,FEEL
■ Measurehaemoglobinifhistoryof
bleeding.
■ Lookforconjunctivalpallor.
■ Lookforpalmarpallor.
Ifpallor:
→isitseverepallor?
→somepallor?
■ Countnumberofbreathsin1
minute.
SIGNS
■ Haemoglobin<7-g/dl
and/or
■ Severepalmarandconjunctival
palloror
■ Anypallorandanyof:
→>30breathsperminute
→tireseasily
→breathlessnessatrest.
■ Haemoglobin7-11-g/dl
or
■ Palmarorconjunctivalpallor.
■ Haemoglobin>11-g/dl.
■ Nopallor.
TREATANDADVISE
■ Givedoubledoseofiron
(1tablet60mgtwicedailyfor3months) F3 .
■ refer urgently to hospital b7 .
■ Followupin2weekstocheckclinicalprogressand
compliancewithtreatment.
■ Givedoubledoseofironfor3months F3 .
■ Reassessatnextpostnatalvisit(in4weeks).
Ifanaemiapersists,refertohospital.
■ Continuetreatmentwithironfor3months
altogether F3 .
CLASSIFY
severe
anaemia
moderate anaemia
no anaemia
next:CheckforHIVstatus
iF pallor, CheCk For anaemia
t
Respond to observed signs or volunteered problems (3) Check for HIV status
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e5
ASK,CHECKRECORD
provide key information on hiv g2 .
■ WhatisHIVandhowisHIV
transmitted g2 ?
■ AdvantageofknowingtheHIVstatus
g2 .
■ ExplainaboutHIVtestingand
counsellingincludingconfidentiality
oftheresult g3 .
ask the woman:
■ HaveyoubeentestedforHIV?
→Ifnot:tellherthatshewillbe
testedforHIV,unlesssherefuses.
→Ifyes:checkresult.(Explainto
herthatshehasarightnotto
disclosetheresult.)
→AreyoutakinganyARV
treatment?
→Checktreatmentplan.
■ Hasthepartnerbeentested?
LOOK,LISTEN,FEEL
■ PerformtheRapidHIVtestifnot
performedinthispregnancy l6 .
SIGNS
■ PositiveHIVtest
■ NegativeHIVtest
■ Sherefusesthetestorisnotwilling
todisclosetheresultofprevious
testornotestresultsavailable
TREATANDADVISE
■ Counselonimplicationsofapositivetest g3 .
■ ReferthewomantoHIVservicesforfurther
assessment.
→Counseloninfantfeedingoptions g7 .
→ProvideadditionalcareforHIV-positivewoman g4 .
→Counselonfamilyplanning g4 .
→Counselonsafersexincludinguseofcondoms g2 .
→Counselonbenefitsofdisclosure(involving)and
testingherpartne g3 .
→ProvidesupporttotheHIV-positivewoman g5 .
■ Followupin2weeks.
■ Counselonimplicationsofanegativetest g3 .
■ Counselontheimportanceofstayingnegativeby
practisingsafersex,includinguseofcondoms g2 .
■ Counselonbenefitsofinvolvingandtestingthe
partner g3 .
■ Counselonsafersexincludinguseofcondoms g2 .
■ Counselonbenefitsofinvolvingandtestingthe
partner g3 .
CLASSIFY
hiv-positive
hiv-negative
unknown
hiv status
next:Ifheavyvaginalbleeding
CheCk For hiv status
use this chart for hiv testing and counselling during postpartum visit if the woman is not previously tested.
IfthewomenhastakenARVduringpregnancyorchildbirthreferhertoHIVservicesforfurtherassessment.
t
iF heavy vaginal bleeding
Respond to observed signs or volunteered problems (4)
p
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a
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e6
ASK,CHECKRECORD
■ Haveyouhad:
→heavybleeding?
→foul-smellinglochia?
→burningonurination?
LOOK,LISTEN,FEEL
■ Feellowerabdomenandflanksfor
tenderness.
■ Lookforabnormallochia.
■ Measuretemperature.
■ Lookorfeelforstiffneck.
■ Lookforlethargy.
SIGNS
■ Morethan1padsoakedin5
minutes.
■ Temperature>38°Candanyof:
→veryweak
→abdominaltenderness
→foul-smellinglochia
→profuselochia
→uterusnotwellcontracted
→lowerabdominalpain
→historyofheavyvaginalbleeding.
■ Fever>38ºCandanyof:
→burningonurination
→flankpain.
■ Burningonurination.
■ Temperature>38°Candanyof:
→stiffneck
→lethargy.
■ Fever>38°C.
TREATANDADVISE
■ Give0.2mgergometrineIM b0 .
■ GiveappropriateIM/IVantibiotics b5 .
■ Manageasin
Rapid assessment and management b3-b7 .
■ refer urgently to hospital b7 .
■ InsertanIVlineandgivefluidsrapidly b9 .
■ GiveappropriateIM/IVantibiotics b5 .
■ refer urgently to hospital b7 .
■ GiveappropriateIM/IVantibiotics b5 .
■ refer urgently to hospital b7 .
■ Giveappropriateoralantibiotic F5 .
■ Encouragehertodrinkmorefluids.
■ Followupin2days.
Ifnoimprovement,refertohospital.
■ InsertanIVline b9 .
■ GiveappropriateIM/IVantibiotics b5 .
■ GiveartemetherIM(orquinineIMifartemethernot
available)andglucose b6 .
■ refer urgently to hospital b7 .
■ Giveoralantimalarial F4 .
■ Followupin2days.
Ifnoimprovement,refertohospital.
CLASSIFY
postpartum
bleeding
uterine
inFeCtion
upper urinary traCt
inFeCtion
lower
urinary traCt
inFeCtion
very severe Febrile
disease
malaria
next:Ifdribblingurine
iF Fever or Foul-smelling loChia
t
Respond to observed signs or volunteered problems (5)
p
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e7
ASK,CHECKRECORD
■ Howhaveyoubeenfeelingrecently?
■ Haveyoubeeninlowspirits?
■ Haveyoubeenabletoenjoythe
thingsyouusuallyenjoy?
■ Haveyouhadyourusuallevelof
energy,orhaveyoubeenfeelingtired?
■ Howhasyoursleepbeen?
■ Haveyoubeenabletoconcentrate
(forexampleonnewspaper
articlesoryourfavouriteradio
programmes)?
LOOK,LISTEN,FEEL SIGNS
■ Dribblingorleakingurine.
■ Excessiveswellingofvulvaor
perineum.
■ Pusinperineum.
■ Paininperineum.
Twoormoreofthefollowingsymptoms
duringthesame2weekperiod
representingachangefromnormal:
■ Inappropriateguiltornegative
feelingtowardsself.
■ Crieseasily.
■ Decreasedinterestorpleasure.
■ Feelstired,agitatedallthetime.
■ Disturbedsleep(sleepingtoomuch
ortoolittle,wakingearly).
■ Diminishedabilitytothinkor
concentrate.
■ Markedlossofappetite.
■ Anyoftheabove,
forlessthan2weeks.
TREAT
■ Checkperinealtrauma.
■ Giveappropriateoralantibioticsforlowerurinary
tractinfection F5 .
■ Ifconditionspersistsmorethan1week,referthe
womantohospital.
■ Referthewomantohospital.
■ Removesutures,ifpresent.
■ Cleanwound.Counseloncareandhygiene d26 .
■ Giveparacetamolforpain F4 .
■ Followupin2days.Ifnoimprovement,refertohospital.
■ Provideemotionalsupport.
■ refer urgently the woman to hospital b7 .
■ Assurethewomanthatthisisverycommon.
■ Listentoherconcerns.Giveemotional
encouragementandsupport.
■ Counselpartnerandfamilytoprovideassistanceto
thewoman.
■ Followupin2weeks,andreferifnoimprovement.
CLASSIFY
urinary
inContinenCe
perineal
trauma
perineal
inFeCtion or pain
postpartum
depression
(usually aFter
First week)
postpartum blues
(usually in First week)
next:Ifvaginaldischarge4weeksafterdelivery
iF dribbling urine
iF pus or perineal pain
iF Feeling unhappy or Crying easily
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next:Ifcoughorbreathingdifficulty
ASK,CHECKRECORD
■ Doyouhaveitchingatthevulva?
■ Hasyourpartnerhadaurinary
problem?
Ifpartnerispresentintheclinic,ask
thewomanifshefeelscomfortableif
youaskhimsimilarquestions.
Ifyes,askhimifhehas:
■ urethraldischargeorpus
■ burningonpassingurine.
Ifpartnercouldnotbeapproached,
explainimportanceofpartner
assessmentandtreatmenttoavoid
reinfection.
LOOK,LISTEN,FEEL
■ Separatethelabiaandlookfor
abnormalvaginaldischarge:
→amount
→colour
→odour/smell.
■ Ifnodischargeisseen,examine
withaglovedfingerandlookatthe
dischargeontheglove.
SIGNS
■ Abnormalvaginaldischarge,and
partnerhasurethraldischargeor
burningonpassingurine.
■ Curd-likevaginaldischargeand/or
■ Intensevulvalitching.
■ Abnormalvaginaldischarge.
TREATANDADVISE
■ Giveappropriateoralantibioticstowoman F5 .
■ Treatpartnerwithappropriateoralantibiotics F5 .
■ Counselonsafersexincludinguseofcondoms g2 .
■ Giveclotrimazole F5 .
■ Counselonsafersexincludinguseofcondoms g2 .
■ Ifnoimprovement,referthewomantohospital.
■ Givemetronidazoletowoman F5 .
■ Counselonsafersexincludinguseofcondoms g2 .
CLASSIFY
possible
gonorrhoea or
Chlamydia
inFeCtion
possible Candida
inFeCtion
possible
baCterial or
triChomonas
inFeCtion
iF vaginal disCharge 4 weeks aFter delivery
iF breast problem
see J9 .
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ASK,CHECKRECORD
■ Howlonghaveyoubeencoughing?
■ Howlonghaveyouhaddifficultyin
breathing?
■ Doyouhavechestpain?
■ Doyouhaveanybloodinsputum?
■ Doyousmoke?
■ Areyoutakinganti-tuberculosis
drugs?Ifyes,sincewhen?
LOOK,LISTEN,FEEL
■ Lookforbreathlessness.
■ Listenforwheezing.
■ Measuretemperature.
SIGNS
Atleast2ofthefollowing:
■ Temperature>38ºC.
■ Breathlessness.
■ Chestpain.
Atleast1ofthefollowing:
■ Coughorbreathingdifficultyfor
>3 weeks.
■ Bloodinsputum.
■ Wheezing.
■ Temperature<38ºC.
■ Coughfor<3weeks.
■ Takinganti-tuberculosisdrugs.
TREATANDADVISE
■ GivefirstdoseofappropriateIM/IVantibiotics b5 .
■ refer urgently to hospital b7 .
■ Refertohospitalforassessment.
■ Ifseverewheezing,referurgentlytohospital.
■ Advisesafe,soothingremedy.
■ Ifsmoking,counseltostopsmoking.
■ Assurethewomanthatthedrugsarenotharmfulto
herbaby,andoftheneedtocontinuetreatment.
■ IfhersputumisTB-positivewithin2monthsofdelivery,
plantogiveINHprophylaxistothenewborn k3 .
■ ReinforceadviceforHIVtesting g3 .
■ Ifsmoking,counseltostopsmoking.
■ Advisetoscreenimmediatefamilymembersand
closecontactsfortuberculosis.
CLASSIFY
possible pneumonia
possible ChroniC
lung disease
upper respiratory
traCt inFeCtion
tuberCulosis
iF Cough or breathing diFFiCulty
iF taking anti-tuberCulosis drugs
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Respond to observed signs or volunteered problems (8) If signs suggesting HIV infection
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ASK,CHECKRECORD
■ Haveyoulostweight?
■ Doyouhavefever?
Howlong(>1month)?
■ Haveyougotdiarrhoea
(continuousorintermittent)?
Howlong(>1month)?
■ Haveyouhadcough?
Howlong(>1month)?
LOOK,LISTEN,FEEL
■ Lookforvisiblewasting.
■ Lookforulcersandwhitepatchesin
themouth(thrush).
■ Lookattheskin:
→Istherearash?
→Arethereblistersalongtheribs
ononesideofthebody?
SIGNS
■ Twoofthefollowing:
→weightloss
→fever>1month
→diarrhoea>1month.
or
■ Oneoftheabovesignsand
→oneormoreothersignor
→fromahigh-riskgroup.
TREATANDADVISE
■ ReinforcetheneedtoknowHIVstatusandcounsel
forHIVtesting g3 .
■ Counselonthebenefitsoftestingherpartner g3 .
■ Counselonsafersexincludinguseofcondoms g2 .
■ Examinefurtherandmanageaccordingtonational
HIVguidelinesorrefertoappropriateHIVservices.
■ RefertoTBcentreifcough.
CLASSIFY
strong
likelihood oF hiv
inFeCtion
iF signs suggesting hiv inFeCtion
hiv status unknown or known hiv-positive.
Preventive measures and additional treatments for the woman
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Preventive measures and additional treatments for the woman
f2
Give tetanus toxoid
■ Immunize all women ■ Check the woman’s tetanus toxoid (TT) immunization status: →When was TT last given? →Which dose of TT was this? ■ If immunization status unknown, give TT1. Plan to give TT2 in 4 weeks.
if due: ■ Explain to the woman that the vaccine is safe to be given in pregnancy; it will not harm the baby. ■ The injection site may become a little swollen, red and painful, but this will go away in a few days. ■ If she has heard that the injection has contraceptive effects, assure her it does not, that it only protects her from disease. ■ Give 0.5 ml TT IM, upper arm. ■ Advise woman when next dose is due. ■ Record on mother’s card.
tetanus toxoid schedule At first contact with woman of childbearing age or at first antenatal care visit, as early as possible. TT1 At least 4 weeks after TT1 (at next antenatal care visit). TT2 At least 6 months after TT2. TT3 At least 1 year after TT3. TT4 At least 1 year after TT4. TT5
Give vitamin A postpartum
■ Give 200-000-IU vitamin A capsules after delivery or within 6 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.
vitamin a 1 capsule 200-000 1 capsule after delivery or within 6 weeks of delivery
Preventive measures
Preventive measures (1)
Preventive m
easures and additional treatm
ents for the wom
an
Preventive measures (2) Iron and mebendazole f3
Give iron and folic acid
■ To all pregnant, postpartum and post-abortion women: → Routinely once daily in pregnancy and until 3 months after delivery or abortion. → Twice daily as treatment for anaemia (double dose). ■ Check woman’s supply of iron and folic acid at each visit and dispense 3 months supply. ■ Advise to store iron safely: → Where children cannot get it → In a dry place.
iron and folate 1 tablet = 60-mg, folic acid = 400-µg all women women with anaemia 1 tablet 2 tablets in pregnancy Throughout the pregnancy 3 months Postpartum and 3 months 3 months post-abortion
Give mebendazole
■ Give 500 mg to every woman once in 6 months. ■ do not give it in the first trimester.
mebendazole 500 mg tablet 100 mg tablet 1 tablet 5 tablets
Motivate on compliance with iron treatment
Explore local perceptions about iron treatment (examples of incorrect perceptions: making more blood will make bleeding worse, iron will cause too large a baby). ■ Explain to mother and her family: →Iron is essential for her health during pregnancy and after delivery →The danger of anaemia and need for supplementation. ■ Discuss any incorrect perceptions. ■ Explore the mother’s concerns about the medication: →Has she used the tablets before? →Were there problems? →Any other concerns? ■ Advise on how to take the tablets →With meals or, if once daily, at night →Iron tablets may help the patient feel less tired. Do not stop treatment if this occurs →Do not worry about black stools.This is normal. ■ Give advice on how to manage side-effects: →If constipated, drink more water →Take tablets after food or at night to avoid nausea →Explain that these side effects are not serious →Advise her to return if she has problems taking the iron tablets. ■ If necessary, discuss with family member, TBA, other community-based health workers or other women, how to help in promoting the use of iron and folate tablets. ■ Counsel on eating iron-rich foods – see C16 d26 .
Preventive m
easures and additional treatm
ents for the wom
an
f4
Give preventive intermittent treatment for
falciparum malaria
■ Give sulfadoxine-pyrimethamine at the beginning of the second and third trimester to all women according to national policy. ■ Check when last dose of sulfadoxine-pyrimethamine given: →If no dose in last month, give sulfadoxine-pyrimethamine, 3 tablets in clinic. ■ Advise woman when next dose is due. ■ Monitor the baby for jaundice if given just before delivery. ■ Record on home-based record.
sulfadoxine pyrimethamine 1 tablet = 500 mg + 25 mg pyrimethamine sulfadoxine second trimester third trimester 3 tablets 3 tablets
Advise to use insecticide-treated bednet
■ Ask whether woman and newborn will be sleeping under a bednet. ■ If yes, →Has it been dipped in insecticide? →When? →Advise to dip every 6 months. ■ If not, advise to use insecticide-treated bednet, and provide information to help her do this.
Give appropriate oral antimalarial treatment
A highly effective antimalarial (even if second-line) is preferred during pregnancy
Chloroquine sulfadoxine + Pyrimethamine Give daily for 3 days Give single dose in clinic Tablet Tablet Tablet (150 mg base) (100 mg base) 500 mg sulfadoxine + 25 mg pyrimethamine Pregnant woman Day 1 Day 2 Day 3 Day 1 Day 2 Day 3 (for weight around 50 kg) 4 4 2 6 6 3 3
Give paracetamol
If severe pain
Paracetamol dose frequency 1 tablet = 500 mg 1-2 tablets every 4-6 hours
antimalarial treatment and ParaCetamol
Additional treatments for the woman (1) Antimalarial treatment and paracetamol
Preventive m
easures and additional treatm
ents for the wom
an
Additional treatments for the woman (2) Give appropriate oral antibiotics
COMMEnT
Avoid in late pregnancy and two weeks after delivery when breastfeeding.
not safe for pregnant or lactating women.
not safe for pregnant or lactating woman.
Do not use in the first trimester of pregnancy.
Teach the woman how to insert a pessary into vagina and to wash hands before and after each application.
Give aPProPriate oral antiBiotiCs
Preventive m
easures and additional treatm
ents for the wom
an
f5
AnTIBIOTIC
CloxaCillin 1 capsule (500 mg)
amoxyCillin 1 tablet (500 mg) OR trimethoPrim+ sulPhamethoxaZole 1 tablet (80 mg + 400 mg)
Ceftriaxone (Vial=250 mg)
CiProfloxaCin (1 tablet=250 mg)
erythromyCin (1 tablet=250 mg)
tetraCyCline (1 tablet=250 mg) OR doxyCyCline (1 tablet=100 mg)
metronidaZole (1 tablet=500 mg)
ClotrimaZole 1 pessary 200 mg or 500 mg
InDICATIOn
mastitis
lower urinary tract infection
Gonorrhoea Woman
Partner only
Chlamydia Woman
Partner only
trichomonas or bacterial vaginal infection
vaginal candida infection
DOsE
500 mg
500 mg
80 mg trimethoprim + 400 mg sulphamethoxazole
250 mg IM injection
500 mg (2 tablets)
500 mg (2 tablets)
500 mg (2 tablets)
100 mg
2 g or 500 mg
200 mg
500 mg
FREqUEnCy
every 6 hours
every 8 hours
two tablets every 12 hours
once only
once only
every 6 hours
every 6 hours
every 12 hours
once only every 12 hours
every night
once only
DURATIOn
10 days
3 days
3 days
once only
once only
7 days
7 days
7 days
once only 7 days
3 days
once only
Additional treatments for the woman (3) Give benzathine penicillin IM
Preventive m
easures and additional treatm
ents for the wom
an
f6
COMMEnT
Give as two IM injections at separate sites. Plan to treat newborn K12 . Counsel on correct and consistent use of condoms G2 .
not safe for pregnant or lactating woman.
AnTIBIOTIC
BenZathine PeniCillin im (2.4 million units in 5 ml)
erythromyCin (1 tablet = 250 mg)
tetraCyCline (1 tablet = 250 mg) OR doxyCyCline (1 tablet = 100 mg)
InDICATIOn
syphilis rPr test positive
if woman has allergy to penicillin
if partner has allergy to penicillin
DOsE
2.4 million units IM injection
500 mg (2 tablets)
500 mg (2 tablets)
100 mg
FREqUEnCy
once only
every 6 hours
every 6 hours
every 12 hours
DURATIOn
once only
15 days
15 days
15 days
Give BenZathine PeniCillin im
treat the partner. rule out history of allergy to antibiotics.
oBserve for siGns of allerGy
after giving penicillin injection, keep the woman for a few minutes and observe for signs of allergy.
Ask, CHECk RECORD
■ How are you feeling? ■ Do you feel tightness in the chest and throat? ■ Do you feel dizzy and confused?
LOOk, LIsTEn, FEEL
■ Look at the face, neck and tongue for swelling. ■ Look at the skin for rash or hives. ■ Look at the injection site for swelling and redness. ■ Look for difficult breathing. ■ Listen for wheezing.
sIGns
Any of these signs: ■ Tightness in the chest and throat. ■ Feeling dizzy and confused. ■ swelling of the face, neck and tongue. ■ Injection site swollen and red. ■ Rash or hives. ■ Difficult breathing or wheezing.
TREAT
■ Open the airway B9 . ■ Insert IV line and give fluids B9 . ■ Give 0.5 ml adrenaline 1:1000 in 10 ml saline solution IV slowly. Repeat in 5-15 minutes, if required. ■ DO nOT leave the woman on her own. ■ refer urgently to hospital B17 .
CLAssIFy
allerGy to PeniCillin
f2 Preventive measures (1)
Givetetanustoxoid
GivevitaminApostpartum
f3 Preventive measures (2)
Giveironandfolicacid
Motivateoncompliancewithirontreatment
Givemebendazole

f4 additional treatments
for the woman (1)
Givepreventiveintermittenttreatmentfor
falciparummalaria
Advisetouseinsecticide-treatedbednet
Giveparacetamol
f5 additional treatments
for the woman (2)
Giveappropriateoralantibiotics
f6 additional treatments
for the woman (3)
GivebenzathinepenicillinIM
Observeforsignsofallergy
■ Thissectionhasdetailsonpreventivemeasuresandtreatments
prescribedinpregnancyandpostpartum.
■ Generalprinciplesarefoundinthesectionongoodpractice a2 .
■ Foremergencytreatmentforthewomansee B8-B17.
■ Fortreatmentforthenewbornsee K9-K13 .
f2
Givetetanustoxoid
■ Immunizeallwomen
■ Checkthewoman’stetanustoxoid(TT)immunizationstatus:
→WhenwasTTlastgiven?
→WhichdoseofTTwasthis?
■ Ifimmunizationstatusunknown,giveTT1.
PlantogiveTT2in4weeks.
if due:
■ Explaintothewomanthatthevaccineissafetobegiveninpregnancy;itwillnotharmthebaby.
■ Theinjectionsitemaybecomealittleswollen,redandpainful,butthiswillgoawayinafewdays.
■ Ifshehasheardthattheinjectionhascontraceptiveeffects,assureheritdoesnot,thatitonly
protectsherfromdisease.
■ Give0.5mlTTIM,upperarm.
■ Advisewomanwhennextdoseisdue.
■ Recordonmother’scard.
tetanus toxoid schedule
Atfirstcontactwithwomanofchildbearingageor
atfirstantenatalcarevisit,asearlyaspossible. TT1
Atleast4weeksafterTT1(atnextantenatalcarevisit). TT2
Atleast6monthsafterTT2. TT3
Atleast1yearafterTT3. TT4
Atleast1yearafterTT4. TT5
GivevitaminApostpartum
■ Give200-000-IUvitaminAcapsulesafterdeliveryorwithin6weeksofdelivery:
■ ExplaintothewomanthatthecapsulewithvitaminAwillhelphertorecoverbetter,andthatthe
babywillreceivethevitaminthroughherbreastmilk.
→askhertoswallowthecapsuleinyourpresence.
→explaintoherthatifshefeelsnauseatedorhasaheadache,itshouldpassinacoupleofdays.
■ do notgivecapsuleswithhighdoseofvitaminAduringpregnancy.
vitamin a
1capsule 200-000IU 1capsuleafterdeliveryorwithin6weeksofdelivery
Preventive measures
Preventive measures (1)
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Preventive measures (2) Iron and mebendazole
f3
Giveironandfolicacid
■ Toallpregnant,postpartumandpost-abortionwomen:
→Routinelyoncedailyinpregnancyanduntil3monthsafterdeliveryorabortion.
→Twicedailyastreatmentforanaemia(doubledose).
■ Checkwoman’ssupplyofironandfolicacidateachvisitanddispense3monthssupply.
■ Advisetostoreironsafely:
→Wherechildrencannotgetit
→Inadryplace.
iron and folate
1tablet=60-mg,folicacid=400-µg
all women women with anaemia
1tablet 2tablets
in pregnancy Throughoutthepregnancy 3months
Postpartum and 3months 3months
post-abortion
Givemebendazole
■ Give500mgtoeverywomanoncein6months.
■ do notgiveitinthefirsttrimester.
mebendazole
500mgtablet 100mgtablet
1tablet 5tablets
Motivateoncompliancewithirontreatment
Explorelocalperceptionsaboutirontreatment(examplesofincorrectperceptions:makingmoreblood
willmakebleedingworse,ironwillcausetoolargeababy).
■ Explaintomotherandherfamily:
→Ironisessentialforherhealthduringpregnancyandafterdelivery
→Thedangerofanaemiaandneedforsupplementation.
■ Discussanyincorrectperceptions.
■ Explorethemother’sconcernsaboutthemedication:
→Hassheusedthetabletsbefore?
→Werethereproblems?
→Anyotherconcerns?
■ Adviseonhowtotakethetablets
→Withmealsor,ifoncedaily,atnight
→Irontabletsmayhelpthepatientfeellesstired.Donotstoptreatmentifthisoccurs
→Donotworryaboutblackstools.Thisisnormal.
■ Giveadviceonhowtomanageside-effects:
→Ifconstipated,drinkmorewater
→Taketabletsafterfoodoratnighttoavoidnausea
→Explainthatthesesideeffectsarenotserious
→Advisehertoreturnifshehasproblemstakingtheirontablets.
■ Ifnecessary,discusswithfamilymember,TBA,othercommunity-basedhealthworkersorother
women,howtohelpinpromotingtheuseofironandfolatetablets.
■ Counseloneatingiron-richfoods–see C16 d26 .
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Givepreventiveintermittenttreatmentfor
falciparummalaria
■ Givesulfadoxine-pyrimethamineatthebeginningofthesecondandthirdtrimestertoallwomen
accordingtonationalpolicy.
■ Checkwhenlastdoseofsulfadoxine-pyrimethaminegiven:
→Ifnodoseinlastmonth,givesulfadoxine-pyrimethamine,3tabletsinclinic.
■ Advisewomanwhennextdoseisdue.
■ Monitorthebabyforjaundiceifgivenjustbeforedelivery.
■ Recordonhome-basedrecord.
sulfadoxine pyrimethamine
1tablet=500mg+25mgpyrimethaminesulfadoxine
second trimester third trimester
3tablets 3tablets
Advisetouseinsecticide-treatedbednet
■ Askwhetherwomanandnewbornwillbesleepingunderabednet.
■ Ifyes,
→Hasitbeendippedininsecticide?
→When?
→Advisetodipevery6months.
■ Ifnot,advisetouseinsecticide-treatedbednet,andprovideinformationtohelpherdothis.
Giveappropriateoralantimalarialtreatment
Ahighlyeffectiveantimalarial(evenifsecond-line)ispreferredduringpregnancy
Chloroquine sulfadoxine +
Pyrimethamine
Givedailyfor3days Givesingledoseinclinic
Tablet Tablet Tablet
(150mgbase) (100mgbase) 500mgsulfadoxine+
25mgpyrimethamine
Pregnantwoman Day1 Day2 Day3 Day1 Day2 Day3
(forweightaround50kg) 4 4 2 6 6 3 3
Giveparacetamol
Ifseverepain
Paracetamol dose frequency
1tablet=500mg 1-2tablets every4-6hours
antimalarial treatment and ParaCetamol
Additional treatments for the woman (1) Antimalarial treatment and paracetamol
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Additional treatments for the woman (2) Give appropriate oral antibiotics
COMMEnT
Avoidinlatepregnancyandtwoweeksafterdelivery
whenbreastfeeding.
notsafeforpregnantorlactatingwomen.
notsafeforpregnantorlactatingwoman.
Donotuseinthefirsttrimesterofpregnancy.
Teachthewomanhowtoinsertapessaryintovagina
andtowashhandsbeforeandaftereachapplication.
Give aPProPriate oral antiBiotiCs
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AnTIBIOTIC
CloxaCillin
1capsule(500mg)
amoxyCillin
1tablet(500mg)
OR
trimethoPrim+
sulPhamethoxaZole
1tablet(80mg+400mg)
Ceftriaxone
(Vial=250mg)
CiProfloxaCin
(1tablet=250mg)
erythromyCin
(1tablet=250mg)
tetraCyCline
(1tablet=250mg)
OR
doxyCyCline
(1tablet=100mg)
metronidaZole
(1tablet=500mg)
ClotrimaZole
1pessary200mg
or
500mg
InDICATIOn
mastitis
lower urinary tract
infection
Gonorrhoea
Woman
Partneronly
Chlamydia
Woman
Partneronly
trichomonas or bacterial
vaginal infection
vaginal candida infection
DOsE
500mg
500mg
80mg
trimethoprim+
400mgsulphamethoxazole
250mg
IMinjection
500mg
(2tablets)
500mg
(2tablets)
500mg
(2tablets)
100mg
2g
or500mg
200mg
500mg
FREqUEnCy
every6hours
every8hours
twotablets
every12hours
onceonly
onceonly
every6hours
every6hours
every12hours
onceonly
every12hours
everynight
onceonly
DURATIOn
10days
3days
3days
onceonly
onceonly
7days
7days
7days
onceonly
7days
3days
onceonly
Additional treatments for the woman (3) Give benzathine penicillin IM
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COMMEnT
GiveastwoIMinjectionsatseparatesites.
Plantotreatnewborn K12 .
Counseloncorrectandconsistentuseofcondoms G2 .
notsafeforpregnantorlactatingwoman.
AnTIBIOTIC
BenZathine
PeniCillin im
(2.4millionunitsin5ml)
erythromyCin
(1tablet=250mg)
tetraCyCline
(1tablet=250mg)
OR
doxyCyCline
(1tablet=100mg)
InDICATIOn
syphilis rPr test positive
if woman has allergy to
penicillin
if partner has allergy to
penicillin
DOsE
2.4millionunits
IMinjection
500mg
(2tablets)
500mg
(2tablets)
100mg
FREqUEnCy
onceonly
every6hours
every6hours
every12hours
DURATIOn
onceonly
15days
15days
15days
Give BenZathine PeniCillin im
treat the partner. rule out history of allergy to antibiotics.
oBserve for siGns of allerGy
after giving penicillin injection, keep the woman for a few minutes and observe for signs of allergy.
Ask,CHECkRECORD
■ Howareyoufeeling?
■ Doyoufeeltightnessinthechest
andthroat?
■ Doyoufeeldizzyandconfused?
LOOk,LIsTEn,FEEL
■ Lookattheface,neckandtongue
forswelling.
■ Lookattheskinforrashorhives.
■ Lookattheinjectionsiteforswelling
andredness.
■ Lookfordifficultbreathing.
■ Listenforwheezing.
sIGns
Anyofthesesigns:
■ Tightnessinthechestandthroat.
■ Feelingdizzyandconfused.
■ swellingoftheface,neckand
tongue.
■ Injectionsiteswollenandred.
■ Rashorhives.
■ Difficultbreathingorwheezing.
TREAT
■ Opentheairway B9 .
■ InsertIVlineandgivefluids B9 .
■ Give0.5mladrenaline1:1000in10mlsaline
solutionIVslowly.
Repeatin5-15minutes,ifrequired.
■ DOnOTleavethewomanonherown.
■ refer urgently to hospital B17 .
CLAssIFy
allerGy to
PeniCillin
Inform and counsel on HIV
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Provide key information on HIV
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What is HIV (human immunodeficiency virus)
and how is HIV transmitted?
■ HIV is a virus that destroys parts of the body’s immune system. A person infected with HIV may not feel sick at first, but slowly the body’s immune system is destroyed. The person becomes ill and unable to fight infection. Once a person is infected with HIV, she or he can give the virus to others. ■ HIV can be transmitted through: → Exchange of HIV-infected body fluids such as semen, vaginal fluid or blood during unprotected sexual intercourse. → HIV-infected blood transfusions or contaminated needles. → From an infected mother to her child (MTCT) during: → pregnancy → labour and delivery → postpartum through breastfeeding. ■ Almost four out of 20 babies born to HIV positive women may be infected without any intervention. ■ HIV cannot be transmitted through hugging or mosquito bites. ■ A blood test is done to find out if the person is infected with HIV. ■ All pregnant women are offered this test. They can refuse the test.
Advantage of knowing the HIV status in pregnancy
kaow|ag the ßIV statas dar|ag pregaaac, |s |mportaat so that the womaa caa: ■ the woman knows her HIV status ■ can share information with her partner ■ encourage her partner to be tested If the woman is HIV-positive she can: ■ get appropriate medical care to treat and/or prevent HIV-associated illnesses. ■ reduce the risk of transmission of infection to the baby: → by taking antiretroviral drugs in pregnancy, and during labour G6 , G9 → by practicing safer infant feeding options G9 → by adapting birth and emergency plan and delivery practices G4 . ■ protect herself and her sexual partner(s) from infection or reinfection. ■ make a choice about future pregnancies. If the woman is HIV- negative she can: ■ learn how to remain negative.
Counsel on safer sex including use of condoms
SAI£k S£X IS ANY S£XuAl PkA0II0£ IßAI k£0u0£S Iߣ kISk 0I IkANSNIIIIN0 ßIV AN0 S£XuAllY IkANSNIII£0 INI£0II0NS (SIIs} Ik0N0N£ P£kS0N I0 AN0Iߣk
Iߣ 8£SI Pk0I£0II0N IS 08IAIN£0 8Y: ■ Correct and consistent use of condoms during every sexual act. ■ Choosing sexual activities that do not allow semen, fluid from the vagina, or blood to enter the mouth, anus or vagina of the partner. ■ Reducing the number of partners. → If the woman is HIV-negative explain to her that she is at risk of HIV infection and that it is important to remain negative during pregnancy and breastfeeding. The risk of infecting the baby is higher if the mother is newly infected. → If the woman is HIV-positive explain to her that condomuse during every sexual act during pregnancy and breast feeding will protect her and her baby fromsexually transmitted infections, or reinfection with another HIV strain and will prevent the transmission of HIV infection to her partner. → Make sure the woman knows how to use condoms and where to get them.
ßIV I£SIIN0AN0 00uNS£llIN0
HIV testing and counselling
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Voluntary counselling and testing (VCT) services
£sp|a|a ahoat ßIV test|ag: ■ HIV test is used to determine if the woman is infected with HIV. ■ It includes blood testing and counselling . ■ Result is available on the same day or at the next visit. ■ The test is offered routinely to every woman at every pregnancy to help protect her and her baby’s health. She may decline the test.
If ßIV test|ag |s aot ara||ah|e |a ,oar sett|ag, |aform the womaa ahoat: ■ Pre-test counselling. ■ Post-test counselling. ■ Infant feeding counselling.
If V0I |s aot ara||ah|e |a ,oar sett|ag, |aform the womaa ahoat: ■ Where to go. ■ How the test is performed. ■ How confidentiality is maintained ( see below). ■ When and how results are given. ■ When she should come back to the clinic with the test result ■ Costs involved. ■ Provide the address of HIV testing in your area’s nearest site :
✎____________________________________________________________________
✎____________________________________________________________________
Discuss confidentiality of HIV infection
■ Assure the woman that her test result is confidential and will be shared only with herself and any person chosen by her. ■ Ensure confidentiality when discussing HIV results, status, treatment and care related to HIV, opportunistic infections, additional visits and infant feeding options. A2 ■ Ensure all records are confidential and kept locked away and only health care workers taking care of her have access to the records. ■ 00 N0I label records as HIV-positive.
Counsel on implications of the HIV test result
■ Discuss the HIV results when the woman is alone or with the person of her choice. ■ State test results in a neutral tone. ■ Give the woman time to express any emotions.
II I£SI k£SulI IS N£0AIIV£: ■ Explain to the woman that a negative result can mean either that she is not infected with HIV or that she is infected with HIV but has not yet made antibodies against the virus (this is sometimes called the “window” period). ■ Counsel on the importance of staying negative by safer sex including use of condoms G2 .
II I£SI k£SulI IS P0SIIIV£: ■ Explain to the woman that a positive test result means that she is carrying the infection and has the possibility of transmitting the infection to her unborn child without any intervention. ■ Let her talk about her feelings. Respond to her immediate concerns. ■ Inform her that she will need further assessment to determine the severity of the infection, appropriate care and treatment needed for herself and her baby. Treatment will slow down the progression of her HIV infection and will reduce the risk of infection to the baby. ■ Provide information on how to prevent HIV re-infection. ■ Inform her that support and counselling is available if needed, to cope on living with HIV infection. ■ Discuss disclosure and partner testing. ■ Ask the woman if she has any concerns.
Benefits of disclosure (involving) and testing the male
partner(s)
Encourage the women to disclose the HIV results to her partner or another person she trusts. By disclosing her HIV status to her partner and family, the woman may be in a better position to: ■ Encourage partner to be tested for HIV. ■ Prevent the transmission of HIV to her partner(s). ■ Prevent transmission of HIV to her baby. ■ Protect herself from HIV reinfection. ■ Access HIV treatment, care and support services. ■ Receive support from her partner(s) and family when accessing antenatal care and HIV treatment, care and support services. ■ Help to decrease the risk of suspicion and violence.
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Care and counselling for the HIV-positive woman
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Additional care for the HIV- positive woman
■ Determine how much the woman has told her partner, labour companion and family, then respect this confidentiality. ■ Be sensitive to her special concerns and fears. Give her additional support G5 . ■ Advise on the importance of good nutrition C13D26. ■ Use standard precautions as for all women A4 . ■ Advise her that she is more prone to infections and should seek medical help as soon as possible if she has: → fever → persistent diarrhoea → cold and cough — respiratory infections → burning urination → vaginal itching/foul-smelling discharge → no weight gain → skin infections → foul-smelling lochia.
0ukIN0 Pk£0NAN0Y: ■ Revise the birth plan C2 C13. → Advise her to deliver in a facility. → Advise her to go to a facility as soon as her membranes rupture or labour starts. → Tell her to take ARV medicine at the onset of labour as instructed G6 . ■ Discuss the infant feeding options G8-G9 . ■ Modify preventive treatment for malaria, according to national strategy F4 .
0ukIN0 0ßIl08IkIß: ■ Check if nevirapine is taken at onset of labour. ■ Give ARV medicines as prescribed G6 , G9 . ■ Adhere to standard practice for labour and delivery. ■ Respect confidentiality when giving ARV to the mother and baby. ■ Record all ARV medicines given on labour record, postpartum record and on referral record, if woman is referred.
0ukIN0Iߣ P0SIPAkIuNP£kI00: ■ Tell her that lochia can cause infection in other people and therefore she should dispose of blood stained sanitary pads safely (list local options). ■ Counsel her on family planning G4 . ■ If not breastfeeding, advise her on breast care K8 . ■ Visit HIV services 2 weeks after delivery for further assessment.
Counsel the HIV-positive woman on family planning
■ Use the advice and counselling sections on C15during antenatal care and D27during postpartum visits. The following advice should be highlighted: → Explain to the woman that future pregnancies can have significant health risks for her and her baby. These include: transmission of HIV to the baby (during pregnancy, delivery or breastfeeding), miscarriage, preterm labour, stillbirth, low birth weight, ectopic pregnancy and other complications. → If she wants more children, advise her that waiting at least 2-3 years between pregnancies is healthier for her and the baby. → Discuss her options for preventing both pregnancy and infection with other sexually transmitted infections or HIV reinfection. ■ Condoms may be the best option for the woman with HIV. Counsel the woman on safer sex including the use of condoms G2 . ■ If the woman think that her partner will not use condoms, she may wish to use an additional method for pregnancy protection. ■ However, not all methods are appropriate for the HIV-positive woman: → Given the woman’s HIV status, she may not choose to breastfeed and lactational amenorrhoea method (LAM) may not be a suitable method. → Spermicides are not recommended for HIV-positive women. → Intrauterine device (IUD) use is not recommended for women with AIDS who are not on ARV therapy. → Due to changes in the menstrual cycle and elevated temperatures fertility awareness methods may be difficult if the woman has AIDS or is on treatment for HIV infections. → If the woman is taking pills for tuberculosis (rifampin), she usually cannot use contraceptive pills, monthly injectables or implants.
The family planning counsellor will provide more information.
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Pregaaat womea who are ßIV- pos|t|re heaef|t great|, from the fo||ow|ag sapport after the f|rst |mpact of the test resa|t has heea orercome.
Support to the HIV-positive woman
INI0kN
AN0 00uNS£l 0N ßIV
05
Provide emotional support to the woman
■ Empathize with her concerns and fears. ■ Use good counselling skills A2 . ■ Help her to assess her situation and decide which is the best option for her, her (unborn) child and her sexual partner. Support her choice. ■ Connect her with other existing support services including support groups, income- generatingactivities, religious support groups, orphan care, home care. ■ Help her to find ways to involve her partner and/or extended family members in sharing responsibility, to identify a figure from the community who will support and care for her. ■ Discuss how to provide for the other children and help her identify a figure from the extended family or community who will support her children. ■ Confirm and support information given during HIV testing and counselling, the possibility of ARV treatment, safe sex, infant feeding and family planning advice (help her to absorb the information and apply it in her own case). ■ If the woman has signs of AIDS and/or of other illness, refer her to appropriate services.
How to provide support
■ Conduct peer support groups for women who have HIV-infection and couples affected by HIV/AIDS: → Led by a social worker and/or woman who has come to terms with her own HIVinfection. ■ Establish and maintain constant linkages with other health, social and community workers support services: → To exchange information for the coordination of interventions → To make a plan for each family involved. ■ Refer individuals or couples for counselling by community counsellors.
Give antiretroviral (ARV) medicine(s) to treat HIV infection
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use these charts whea start|ag AkV med|c|ae(s} aad to sapport adhereace to AkV
Support the initiation of ARV
■ If the woman is already on ARV treatment continue the treatment during pregnancy, as prescribed. If she is in the first trimester of pregnancy and treatment includes efavirenz, replace it with nevirapine. ■ If the woman is not on ARV treatment and is tested HIV-positive, choose appropriate ARV regimens C9 , G10according to the stage of the disease. ■ If treatment with Zidovudine (AZT) is planned: measure haemoglobin; if less than 8 g/dl, refer to hospital C4 . ■ Write the treatment plan in the Home Based Maternal Record. ■ Give written instructions to the woman on how to take the medicines. ■ Give prophylaxis for opportunistic infections according to national guidelines. ■ Modify preventive treatment for malaria according to national guidelines F4 .
Explore local perceptions about ARVs
£sp|a|a to the womaa aad fam||, that: ■ ARV treatment will improve the woman’s health and will greatly reduce the risk of infection to her baby. The treatment will not cure the disease. ■ The choice of regimen depends on the stage of the disease C19. → If she is in early stage of HIV infection, she will need to take medicines during pregnancy, childbirth and only for a short period after delivery to prevent mother-to-child transmission of HIV infection (PMTCT). Progress of disease will be monitored to determine if she needs additional treatment. → If she has mild-severe HIV disease she will need to continue the treatment even after childbirth and postpartum period. ■ She may have some side effects but not all women have them. Common side effects like nausea, diarrohea, headache or fever often occur in the beginning but they usually disappear within 2–3 weeks. Other side effects like yellow eyes, pallor, severe abdominal pain, shortness of breath, skin rash, painful feet, legs or hands may appear at any time. If these signs persist, she should come to the clinic. ■ Give her enough ARV tablets for 2 weeks or till her next ANC visit. ■ Ask the woman if she has any concerns. Discuss any incorrect perceptions.
Support adherence to ARV
■ For ARV medicine to be effective: Advise woman on: ■ Explain to her that to receive ARV prophylactic treatment, she must: → which tablets she needs to take during pregnancy, when labour begins (painful abdominal contractions and/or membranes rupture) and after childbirth. → taking the medicine regularly, every day, at the right time. If she chooses to stop taking medicines during pregnancy, her HIV disease could get worse and she may pass the infection to her child. → if she forgets to take a dose, she should not double the next dose. → continue the treatment during and after the childbirth (if prescribed), even if she is breastfeeding. → taking the medicine(s) with meals in order to minimize side effects. For newborn: → Give the first dose of medicine to the newborn 8–12 hours after birth. → Teach the mother how to give treatment to the newborn. → Tell the mother that the baby must complete the full course of treatment and will need regular visits throughout the infancy. → If the mother received less than 4 weeks of Zidovudine (AZT) during pregnancy, give the treatment to the newborn for 4 weeks. ■ Record all treatment given. If the mother or baby is referred, write the treatment given and the regimen prescribed on the referral card.
■ 00 N0I label records as HIV-Positive ■ 00 N0I share drugs with family or friends.
Counsel on infant feeding options
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00uNS£l 0N INIANI I££0IN0 0PII0NS
Explain the risks of HIV transmission through
breastfeeding and not breastfeeding
■ Four out of 20 babies born to known HIV-positive mothers will be infected during pregnancy and delivery without ARV medication. Three more may be infected by breastfeeding. ■ The risk may be reduced if the baby is breastfed exclusively using good technique, so that the breasts stay healthy. ■ Mastitis and nipple fissures increase the risk that the baby will be infected. ■ The risk of not breastfeeding may be much higher because replacement feeding carries risks too: → diarrhoea because of contamination from unclean water, unclean utensils or because the milk is left out too long. → malnutrition because of insufficient quantity given to the baby, the milk is too watery, or because of recurrent episodes of diarrhoea. ■ Mixed feeding increases the risk of diarrhoea. It may also increase the risk of HIV transmission.
If a woman does not know her HIV status
■ Counsel on the importance of exclusive breastfeeding K2 . ■ Encourage exclusive breastfeeding. ■ Counsel on the need to know the HIV status and where to go for HIV testing and counselling G3 . ■ Explain to her the risks of HIV transmission: → even in areas where many women have HIV, most women are negative → the risk of infecting the baby is higher if the mother is newly infected → explain that it is very important to avoid infection during pregnancy and the breastfeeding period.
If a woman knows that she is HIV-positive
■ Inform her about the options for feeding, the advantages and risks: → If acceptable, feasible, safe and sustainable (affordable), she might choose replacement feeding with home-prepared formula or commercial formula. → Exclusive breastfeeding, stopping as soon as replacement feeding is possible. If replacement feeding is introduced early, she must stop breastfeeding. → Exclusive breastfeeding for 6 months, then continued breastfeeding plus complementary feeding after 6 months of age, as recommended for HIV-negative women and women who do not know their status. ■ In some situations additional possibilities are: → expressing and heat-treating her breast milk → wet nursing by an HIV-negative woman. ■ Help her to assess her situation and decide which is the best option for her, and support her choice. ■ If the mother chooses breastfeeding, give her special advice. ■ Make sure the mother understands that if she chooses replacement feeding this includes enriched complementary feeding up to 2 years. → If this cannot be ensured, exclusive breastfeeding, stopping early when replacement feeding is feasible, is an alternative. → All babies receiving replacement feeding need regular follow-up, and their mothers need support to provide correct replacement feeding.
G2

Pk0VI0£ k£Y INI0kNAII0N 0N ßIV
WhatisHIVandhowisHIVtransmitted?
AdvantageofknowingtheHIVstatusin
pregnancy
Counselonsafersexincludinguseofcondoms
G3 ßIV I£SIIN0 AN0 00uNS£llIN0
HIVtestingandcounselling
DiscussconfidentialityofHIVinfection
CounselonimplicationsoftheHIVtestresult
Benefitsofdisclosure(involving)andtestingthe
malepartner(s)
G4 0Ak£ AN0 00uNS£llIN0 I0k
Iߣ ßIV-P0SIIIIV£ w0NAN
AdditionalcarefortheHIV-positivewoman
CounseltheHIV-positivewomanonfamily
planning
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Provideemotionalsupporttothewoman
Howtoprovidesupport
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N£0I0IN£(S} I0 Ik£AI ßIV
INI£0II0N
SupporttheinitiationofARV
SupportadherencetoARV
G7 00uNS£l 0N INIANI I££0IN0
0PII0NS
ExplaintherisksofHIVtransmissionthrough
breastfeedingandnotbreastfeeding
IfawomandoesnotknowherHIVstatus
IfawomanknowsthatsheisHIV-positive
Support the mothers choice of infant feeding
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If the mother chooses replacement feeding,
teach her replacement feeding
■ Ask the mother what kind of replacement feeding she chose. For the first few feeds after delivery, prepare the formula for the mother, then teach her how to prepare the formula and feed the baby by cup K9 : → Wash hands with water and soap → Boil the water for few minutes → Clean the cup thoroughly with water, soap and, if possible, boil or pour boiled water in it → Decide how much milk the baby needs from the instructions → Measure the milk and water and mix them → Teach the mother how to feed the baby by cup → Let the mother feed the baby 8 times a day (in the first month). Teach her to be flexible and respond to the baby’s demands → If the baby does not finish the feed within 1 hour of preparation, give it to an older child or add to cooking. DO NOT give the milk to the baby for the next feed → Wash the utensils with water and soap soon after feeding the baby → Make a new feed every time. ■ Give her written instructions on safe preparation of formula. ■ Explain the risks of replacement feeding and how to avoid them. ■ Advise when to seek care. ■ Advise about the follow-up visit.
Explain the risks of replacement feeding
■ Her baby may get diarrhoea if: → hands, water, or utensils are not clean → the milk stands out too long. ■ Her baby may not grow well if: → she/he receives too little formula each feed or too few feeds → the milk is too watery → she/he has diarrhoea.
Follow-up for replacement feeding
■ Ensure regular follow-up visits for growth monitoring. ■ Ensure the support to provide safe replacement feeding. ■ Advise the mother to return if: → the baby is feeding less than 6 times, or is taking smaller quantities K6 → the baby has diarrhoea → there are other danger signs.
Give special counselling to the mother
who is HIV-positive and chooses breastfeeding
■ Support the mother in her choice of breastfeeding. ■ Ensure good attachment and suckling to prevent mastitis and nipple damage K3 . ■ Advise the mother to return immediately if: → she has any breast symptoms or signs → the baby has any difficulty feeding. ■ Ensure a visit in the first week to assess attachment and positioning and the condition of the mother’s breasts. ■ Arrange for further counselling to prepare for the possibility of stopping breastfeeding early. ■ Give psychosocial support G6 .
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8e|ow are esamp|es of AkV reg|meas. use aat|oaa| ga|de||aes for |oca| protoco|s.
Ior |oager reg|meas to farther redace the r|sk of traasm|ss|oa fo||ow aat|oaa| ga|de||aes.
kecord the AkV med|c|ae prescr|hed aad g|rea |a the appropr|ate records – fac|||t, aad home-hased. 00 N0I wr|te ßIV-pos|t|re.
Antiretrovirals for HIV-positive woman and her infant
womaa Newhora |afaat
Pregaaac, lahoar, de||rer, Postpartam**
AkVs 8efore 28 weeks Start|ag at 28 weeks At oaset of |ahoar* uat|| h|rth of the hah, After h|rth of the hah, AkVs 0ose (s,rap} 0|re f|rst dose Ihea g|re 0arat|oa
HIV-positive with HIV-AIDS related signs and symptoms
Triple therapy Continue the ARV treatment prescribed before pregnancy. In the first trimester replace Efavirenz with Nevirapine (200 mg once daily for 2 weeks, then every 12 hours) Zidovudine 4 mg/kg 8–12 hours after birth every 12 hours 7 days***
HIV-positive without HIV- related signs and symptoms
3TC 150 mg every 12 hours 7 days
Zidovudine 300 mg every 12 hours 300 mg every 3 hours every 12 hours 7 days Zidovudine 4 mg/kg 8–12 hours after birth every 12 hours 7 days***
Nevirapine 200 mg once Nevirapine 2 mg/kg within 72 hours once
ARVs during labour Zidovudine 300 mg every 3 hours Zidovudine 4 mg/kg 8–12 hours after birth every 12 hours 4 weeks
Or 600 mg
Nevirapine 200 mg once Nevirapine 2 mg/kg within 72 hours once
Only minimal range of ARV treatment Nevirapine 200 mg once Nevirapine 2 mg/kg within 72 hours once
* At onset of contractions or rupture of membranes, regardless of the previous schedule **Arrange follow-up for further assessment and treatment within 2 weeks after delivery *** Treat the newborn infant with Zidovudine for 4 weeks if mother received Zidovudine for less than 4 weeks during pregnancy,
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010 Respond to observed signs or volunteered problems
k£SP0N0 I0 08S£kV£0 SI0NS 0k V0luNI££k£0 Pk08l£NS
use th|s chart to maaage the womaa who has a proh|em wh||e tak|ag AkV med|c|aes. Ihese proh|ems ma, he s|de effects of AkV med|c|aes or of aa aader|,|ag d|sease.
ka|e oat ser|oas pregaaac,-re|ated d|seases hefore assam|ag that these are s|de effects of the drags. Io||ow ap |a 2 weeks or ear||er |f coad|t|oa worseas. Ia ao |mprore-
meat, refer the womaa to hosp|ta| for farther maaagemeat.
SIGNS
ßeadache
Naasea or rom|t|ag
Ierer
0|arrhoea
kash or h||sters,a|cers
Ye||ow e,es or macas memhraae
ADVISE ANDTREAT
■ Measure blood pressure and manage as in C2 and E3 . ■ If DBPʺ 90mm give paracetamol for headache F4 .
■ Measure blood pressure and manage as in C2 and E3 . ■ Advise to take medicines with food. ■ If in the first 3 months of pregnancy, reassure that the morning nausea and vomiting will disappear after a few weeks. ■ Refer to hospital if not passing urine.
■ Measure temperature. ■ Manage according to C7-C8 , C10-C11if during pregnancy, and E6-E8 if in postpartum period.
■ Advise to drink one cup of fluid after every stool. ■ Refer to hospital if blood in stool, not passing urine or fever >38ºC.
■ If rash is limited to skin, follow up in 2 weeks. ■ If severe rash, blisters and ulcers on skin, and mouth and fever >38ºC refer to hospital for further assessment and treatment.
■ Refer to hospital for further assessment and treatment.
IF WOMAN HAS ANy PROBLEM
INI0kN
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011 Prevent HIV infection in health-care workers after accidental exposure with body fluids (Post exposure prophylaxis)
Pk£V£NI ßIV INI£0II0N IN ߣAlIß-0Ak£ w0kk£kS AII£k A00I0£NIAl £XP0Suk£ wIIß 800Y IluI0S
(P0SI £XP0Suk£ Pk0PßYlAXIS}
If you are accidentally exposed to blood or body fluids by cuts
or pricks or splashes on face/eyes do the following steps:
■ If blood or bloody fluid splashes on intact skin, immediately wash the area with soap and water. ■ If the glove is damaged, wash the area with soap and water and change the glove. ■ If splashed in the face (eye, nose, mouth) wash with water only. ■ If a finger prick or a cut occurred during procedures such as suturing, allow the wound to bleed for a few seconds, do not squeeze out the blood. Wash with soap and water. Use regular wound care. Topical antiseptics may be used. ■ Check records for the HIV status of the pregnant woman.* → If woman is HIV-negative no further action is required. → If woman is HIV-positive take ARV medicines within 2 hours (see national guidelines for choice and duration of medicine). → If the HIV status of the pregnant woman is unknown: → Start the ARV medicine within 2 hours (see national guidelines for choice and duration of medicine). → Explain to the woman what has happened and seek her consent for rapid HIV test. DO NOT test the woman without her consent. Maintain confidentiality A2 . → Perform the HIV test L6. → If the woman’s HIV test is negative, discontinue the ARV medicines. → If the woman’s HIV test is positive, manage the woman as in C2 / E3 and health worker (yourself ) should complete the ARV and be tested after 6 weeks. ■ Inform the supervisor of the exposure type and the action taken for the health-care worker (yourself). Retest the health-care worker 6 weeks after the exposure.
* If the health-care worker (yourself) is HIV-positive no PEP is required. 00 N0I test the woman.
G8 SuPP0kI Iߣ N0Iߣk’S 0ß0I0£
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Ifmotherchoosesreplacementfeeding:
Teachherreplacementfeeding.
Explaintherisksofreplacementfeeding
Follow-upforreplacementfeeding
Givespecialcounsellingtothemotherwhois
HIV-positiveandchoosesbreastfeeding
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w0NAN AN0 Iߣ N£w80kN
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Ifawomanistakingantiretroviralmedicines
anddevelopsnewsigns/symptoms,respond
toherproblems
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Ifahealth-careworkerisexposedtobody
fluidsbycuts/pricks/splashes,givehim/her
appropriatecare
■ UsethissectionwhenaccurateinformationonHIVmustbegiven
tothewomanandherfamily.
■ ProvidekeyinformationonHIVtoallwomenandexplainatthe
firstantenatalcarevisithowHIVtransmittedandtheadvantages
ofknowingtheHIVstatusinpregnancy G2 .
■ ExplainaboutHIVtestingandcounselling,theimplicationsof
thetestresultandbenefitsofinvolvingandtestingthemale
partner(s).DiscussconfidentialityofHIVinfection G3 .
■ IfthewomanisHIV-positive:
→provideadditionalcareduringpregnancy,childbirthand
postpartum G4 .
→giveanyparticularsupportthatshemayrequire G5 .
→Ifantiretroviraltreatmentisindicatedgiveappropriate
treatment G6
,
G9 .
■ Counselthewomanoninfantfeedingoptions G7 .
■ Supportthemotherschoiceofinfantfeeding G8 .
■ Counselallwomenonsafersexincludinguseofcondomsduring
andafterpregnancy G2 .
■ Ifthewomantakingantiretroviraltreatmentishavingcomplaints,
respondtoherproblemsG10.
■ Ifthehealth-careworkerisaccidentallyexposedtoHIVinfection,
giveher/himappropriatecareG11.
Pk0VI0£ k£Y INI0kNAII0N 0N ßIV
Provide key information on HIV
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WhatisHIV(humanimmunodeficiencyvirus)
andhowisHIVtransmitted?
■ HIVisavirusthatdestroyspartsofthebody’simmunesystem.ApersoninfectedwithHIVmaynot
feelsickatfirst,butslowlythebody’simmunesystemisdestroyed.Thepersonbecomesilland
unabletofightinfection.OnceapersonisinfectedwithHIV,sheorhecangivethevirustoothers.
■ HIVcanbetransmittedthrough:
→ExchangeofHIV-infectedbodyfluidssuchassemen,vaginalfluidorbloodduringunprotected
sexualintercourse.
→HIV-infectedbloodtransfusionsorcontaminatedneedles.
→Fromaninfectedmothertoherchild(MTCT)during:
→pregnancy
→labouranddelivery
→postpartumthroughbreastfeeding.
■ Almostfouroutof20babiesborntoHIVpositivewomenmaybeinfectedwithoutanyintervention.
■ HIVcannotbetransmittedthroughhuggingormosquitobites.
■ AbloodtestisdonetofindoutifthepersonisinfectedwithHIV.
■ Allpregnantwomenareofferedthistest.Theycanrefusethetest.
AdvantageofknowingtheHIVstatusinpregnancy
kaow|ag the ßIV statas dar|ag pregaaac, |s |mportaat so that:
■ thewomanknowsherHIVstatus
■ canshareinformationwithherpartner
■ encourageherpartnertobetested
If the womaa |s ßIV-pos|t|re she caa:
■ getappropriatemedicalcaretotreatand/orpreventHIV-associatedillnesses.
■ reducetheriskoftransmissionofinfectiontothebaby:
→bytakingantiretroviraldrugsinpregnancy,andduringlabour G6
,
G9
→bypracticingsaferinfantfeedingoptions G9
→byadaptingbirthandemergencyplananddeliverypractices G4 .
■ protectherselfandhersexualpartner(s)frominfectionorreinfection.
■ makeachoiceaboutfuturepregnancies.
If the womaa |s ßIV- aegat|re she caa:
■ learnhowtoremainnegative.
Counselonsafersexincludinguseofcondoms
SAI£k S£X IS ANY S£XuAl PkA0II0£ IßAI k£0u0£S Iߣ kISk 0I IkANSNIIIIN0 ßIV AN0
S£XuAllY IkANSNIII£0 INI£0II0NS (SIIs} Ik0N 0N£ P£kS0N I0 AN0Iߣk
Iߣ 8£SI Pk0I£0II0N IS 08IAIN£0 8Y:
■ Correctandconsistentuseofcondomsduringeverysexualact.
■ Choosingsexualactivitiesthatdonotallowsemen,fluidfromthevagina,orbloodtoenterthe
mouth,anusorvaginaofthepartner.
■ Reducingthenumberofpartners.
→ IfthewomanisHIV-negativeexplaintoherthatsheisatriskofHIVinfectionandthatitis
importanttoremainnegativeduringpregnancyandbreastfeeding.Theriskofinfectingthebaby
ishigherifthemotherisnewlyinfected.
→ IfthewomanisHIV-positiveexplaintoherthatcondomuseduringeverysexualactduring
pregnancyandbreastfeedingwillprotectherandherbabyfromsexuallytransmittedinfections,or
reinfectionwithanotherHIVstrainandwillpreventthetransmissionofHIVinfectiontoherpartner.
→ Makesurethewomanknowshowtousecondomsandwheretogetthem.
ßIV I£SIIN0 AN0 00uNS£llIN0
HIV testing and counselling
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HIVtestingandCounsellingservices
£sp|a|a ahoat ßIV test|ag:
■ HIVtestisusedtodetermineifthewomanisinfectedwithHIV.
■ Itincludesbloodtestingandcounselling.
■ Resultisavailableonthesamedayoratthenextvisit.
■ Thetestisofferedroutinelytoeverywomanateverypregnancytohelpprotectherandherbaby’s
health.Shemaydeclinethetest.
If ßIV test|ag |s aot ara||ah|e |a ,oar sett|ag, |aform the womaa ahoat:
■ Wheretogo.
■ Howthetestisperformed.
■ Howconfidentialityismaintained(seebelow).
■ Whenandhowresultsaregiven.
■ Whensheshouldcomebacktotheclinicwiththetestresult
■ Costsinvolved.
■ ProvidetheaddressofHIVtestinginyourarea’snearestsite:
✎____________________________________________________________________
✎____________________________________________________________________
■ Askherifshehasanyquestionsorconcerns.
DiscussconfidentialityofHIVinfection
■ Assurethewomanthathertestresultisconfidentialandwillbesharedonlywithherselfandany
personchosenbyher.
■ EnsureconfidentialitywhendiscussingHIVresults,status,treatmentandcarerelatedtoHIV,
opportunisticinfections,additionalvisitsandinfantfeedingoptions A2
.
■ Ensureallrecordsareconfidentialandkeptlockedawayandonlyhealthcareworkerstakingcareof
herhaveaccesstotherecords.
■ 00 N0IlabelrecordsasHIV-positive.
CounselonimplicationsoftheHIVtestresult
■ DiscusstheHIVresultswhenthewomanisaloneorwiththepersonofherchoice.
■ Statetestresultsinaneutraltone.
■ Givethewomantimetoexpressanyemotions.
II I£SI k£SulI IS N£0AIIV£:
■ ExplaintothewomanthatanegativeresultcanmeaneitherthatsheisnotinfectedwithHIVorthat
sheisinfectedwithHIVbuthasnotyetmadeantibodiesagainstthevirus(thisissometimescalled
the“window”period).
■ Counselontheimportanceofstayingnegativebysafersexincludinguseofcondoms G2 .
II I£SI k£SulI IS P0SIIIV£:
■ Explaintothewomanthatapositivetestresultmeansthatsheiscarryingtheinfectionandhasthe
possibilityoftransmittingtheinfectiontoherunbornchildwithoutanyintervention.
■ Lethertalkaboutherfeelings.Respondtoherimmediateconcerns.
■ Informherthatshewillneedfurtherassessmenttodeterminetheseverityoftheinfection,
appropriatecareandtreatmentneededforherselfandherbaby.Treatmentwillslowdownthe
progressionofherHIVinfectionandwillreducetheriskofinfectiontothebaby.
■ ProvideinformationonhowtopreventHIVre-infection.
■ Informherthatsupportandcounsellingisavailableifneeded,tocopeonlivingwithHIVinfection.
■ Discussdisclosureandpartnertesting.
■ Askthewomanifshehasanyconcerns.
Benefitsofdisclosure(involving)andtestingthemale
partner(s)
EncouragethewomentodisclosetheHIVresultstoherpartneroranotherpersonshetrusts.By
disclosingherHIVstatustoherpartnerandfamily,thewomanmaybeinabetterpositionto:
■ EncouragepartnertobetestedforHIV.
■ PreventthetransmissionofHIVtoherpartner(s).
■ PreventtransmissionofHIVtoherbaby.
■ ProtectherselffromHIVreinfection.
■ AccessHIVtreatment,careandsupportservices.
■ Receivesupportfromherpartner(s)andfamilywhenaccessingantenatalcareandHIVtreatment,
careandsupportservices.
■ Helptodecreasetheriskofsuspicionandviolence.
0Ak£ AN0 00uNS£llIN0 I0k Iߣ ßIV-P0SIIIV£ w0NAN
Care and counselling for the HIV-positive woman
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AdditionalcarefortheHIV-positivewoman
■ Determinehowmuchthewomanhastoldherpartner,labourcompanionandfamily,then
respectthisconfidentiality.
■ Besensitivetoherspecialconcernsandfears.Giveheradditionalsupport G5 .
■ AdviseontheimportanceofgoodnutritionC13D26.
■ Usestandardprecautionsasforallwomen A4 .
■ Adviseherthatsheismorepronetoinfectionsandshouldseekmedicalhelp
assoonaspossibleifshehas:
→fever
→persistentdiarrhoea
→coldandcough—respiratoryinfections
→burningurination
→vaginalitching/foul-smellingdischarge
→noweightgain
→skininfections
→foul-smellinglochia.
0ukIN0 Pk£0NAN0Y:
■ Revisethebirthplan C2 C13.
→Advisehertodeliverinafacility.
→Advisehertogotoafacilityassoonashermembranesruptureorlabourstarts.
→TellhertotakeARVmedicineattheonsetoflabourasinstructed G6 .
■ Discusstheinfantfeedingoptions G8-G9 .
■ Modifypreventivetreatmentformalaria,accordingtonationalstrategy F4 .
0ukIN0 0ßIl08IkIß:
■ Checkifnevirapineistakenatonsetoflabour.
■ GiveARVmedicinesasprescribed G6 G9 .
■ Adheretostandardpracticeforlabouranddelivery.
■ RespectconfidentialitywhengivingARVtothemotherandbaby.
■ RecordallARVmedicinesgivenonlabourrecord,postpartumrecordandonreferralrecord,if
womanisreferred.
0ukIN0 Iߣ P0SIPAkIuN P£kI00:
■ Tellherthatlochiacancauseinfectioninotherpeopleandthereforesheshoulddisposeofblood
stainedsanitarypadssafely(listlocaloptions).
■ Counselheronfamilyplanning G4 .
■ Ifnotbreastfeeding,adviseheronbreastcare K8 .
■ VisitHIVservices2weeksafterdeliveryforfurtherassessment.
CounseltheHIV-positivewomanonfamilyplanning
■ UsetheadviceandcounsellingsectionsonC15duringantenatalcareandD27

duringpostpartum
visits.Thefollowingadviceshouldbehighlighted:
→Explaintothewomanthatfuturepregnanciescanhavesignificanthealthrisksforherand
herbaby.Theseinclude:transmissionofHIVtothebaby(duringpregnancy,deliveryor
breastfeeding),miscarriage,pretermlabour,stillbirth,lowbirthweight,ectopicpregnancyand
othercomplications.
→Ifshewantsmorechildren,adviseherthatwaitingatleast2-3yearsbetweenpregnanciesis
healthierforherandthebaby.
→Discussheroptionsforpreventingbothpregnancyandinfectionwithothersexuallytransmitted
infectionsorHIVreinfection.
■ CondomsmaybethebestoptionforthewomanwithHIV.Counselthewomanonsafersexincluding
theuseofcondoms G2 .
■ Ifthewomanthinkthatherpartnerwillnotusecondoms,shemaywishtouseanadditional
methodforpregnancyprotection.However,notallmethodsareappropriatefortheHIV-positive
woman:
→Giventhewoman’sHIVstatus,shemaynotchoosetobreastfeedandlactationalamenorrhoea
method(LAM)maynotbeasuitablemethod.
→SpermicidesarenotrecommendedforHIV-positivewomen.
→Intrauterinedevice(IUD)useisnotrecommendedforwomenwithAIDSwhoarenotonARV
therapy.
→Duetochangesinthemenstrualcycleandelevatedtemperaturesfertilityawarenessmethods
maybedifficultifthewomanhasAIDSorisontreatmentforHIVinfections.
→Ifthewomanistakingpillsfortuberculosis(rifampin),sheusuallycannotusecontraceptivepills,
monthlyinjectablesorimplants.
Thefamilyplanningcounsellorwillprovidemoreinformation.
SuPP0kI I0 Iߣ ßIV-P0SIIIV£ w0NAN
Pregaaat womea who are ßIV- pos|t|re heaef|t great|, from the fo||ow|ag sapport after the f|rst |mpact of the test resa|t has heea orercome.
Support to the HIV-positive woman
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Provideemotionalsupporttothewoman
■ Empathizewithherconcernsandfears.
■ Usegoodcounsellingskills A2 .
■ Helphertoassesshersituationanddecidewhichisthebestoptionforher,her(unborn)childand
hersexualpartner.Supportherchoice.
■ Connectherwithotherexistingsupportservicesincludingsupportgroups,income-
generatingactivities,religioussupportgroups,orphancare,homecare.
■ Helphertofindwaystoinvolveherpartnerand/orextendedfamilymembersinsharing
responsibility,toidentifyafigurefromthecommunitywhowillsupportandcareforher.
■ Discusshowtoprovidefortheotherchildrenandhelpheridentifyafigurefromtheextendedfamily
orcommunitywhowillsupportherchildren.
■ ConfirmandsupportinformationgivenduringHIVtestingandcounselling,thepossibilityofARV
treatment,safesex,infantfeedingandfamilyplanningadvice(helphertoabsorbtheinformation
andapplyitinherowncase).
■ IfthewomanhassignsofAIDSand/orofotherillness,referhertoappropriateservices.
Howtoprovidesupport
■ ConductpeersupportgroupsforwomenwhohaveHIV-infectionandcouplesaffectedbyHIV/AIDS:
→Ledbyasocialworkerand/orwomanwhohascometotermswithherownHIVinfection.
■ Establishandmaintainconstantlinkageswithotherhealth,socialandcommunityworkerssupport
services:
→Toexchangeinformationforthecoordinationofinterventions
→Tomakeaplanforeachfamilyinvolved.
■ Referindividualsorcouplesforcounsellingbycommunitycounsellors.
Give antiretroviral (ARV) medicine(s) to treat HIV infection
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0IV£ ANIIk£Ik0VIkAl (AkV} N£0I0IN£(S} I0 Ik£AI ßIV INI£0II0N
use these charts whea start|ag AkV med|c|ae(s} aad to sapport adhereace to AkV
SupporttheinitiationofARV
■ IfthewomanisalreadyonARVtreatmentcontinuethetreatmentduringpregnancy,asprescribed.If
sheisinthefirsttrimesterofpregnancyandtreatmentincludesefavirenz,replaceitwithnevirapine.
■ IfthewomanisnotonARVtreatmentandistestedHIV-positive,chooseappropriateARVregimens
C19, G9 accordingtothestageofthedisease.
■ IftreatmentwithZidovudine(AZT)isplanned:measurehaemoglobin;iflessthan8g/dl,referto
hospital C4 .
■ WritethetreatmentplanintheHomeBasedMaternalRecord.
■ Givewritteninstructionstothewomanonhowtotakethemedicines.
■ Giveprophylaxisforopportunisticinfectionsaccordingtonationalguidelines.
■ Modifypreventivetreatmentformalariaaccordingtonationalguidelines F4 .
ExplorelocalperceptionsaboutARVs
£sp|a|a to the womaa aad fam||, that:
■ ARVtreatmentwillimprovethewoman’shealthandwillgreatlyreducetheriskofinfectiontoher
baby.Thetreatmentwillnotcurethedisease.
■ ThechoiceofregimendependsonthestageofthediseaseC19
.
→ IfsheisinearlystageofHIVinfection,shewillneedtotakemedicinesduringpregnancy,
childbirthandonlyforashortperiodafterdeliverytopreventmother-to-childtransmissionofHIV
infection(PMTCT).Progressofdiseasewillbemonitoredtodetermineifsheneedsadditional
treatment.
→ Ifshehasmild-severeHIVdiseaseshewillneedtocontinuethetreatmentevenafterchildbirth
andpostpartumperiod.
■ Shemayhavesomesideeffectsbutnotallwomenhavethem.Commonsideeffectslikenausea,
diarrohea,headacheorfeveroftenoccurinthebeginningbuttheyusuallydisappearwithin2–3
weeks.Othersideeffectslikeyelloweyes,pallor,severeabdominalpain,shortnessofbreath,skin
rash,painfulfeet,legsorhandsmayappearatanytime.Ifthesesignspersist,sheshouldcometo
theclinic.
■ GiveherenoughARVtabletsfor2weeksortillhernextANCvisit.
■ Askthewomanifshehasanyconcerns.Discussanyincorrectperceptions.
SupportadherencetoARV
ForARVmedicinetobeeffective:
■ Advisewomanon:
→whichtabletssheneedstotakeduringpregnancy,whenlabourbegins(painfulabdominal
contractionsand/ormembranesrupture)andafterchildbirth.
→takingthemedicineregularly,everyday,attherighttime.Ifshechoosestostoptakingmedicines
duringpregnancy,herHIVdiseasecouldgetworseandshemaypasstheinfectiontoherchild.
→ifsheforgetstotakeadose,sheshouldnotdoublethenextdose.
→continuethetreatmentduringandafterthechildbirth(ifprescribed),evenifsheisbreastfeeding.
→takingthemedicine(s)withmealsinordertominimizesideeffects.
■ Fornewborn:
→Givethefirstdoseofmedicinetothenewborn8–12hoursafterbirth.
→Teachthemotherhowtogivetreatmenttothenewborn.
→Tellthemotherthatthebabymustcompletethefullcourseoftreatmentandwillneedregular
visitsthroughouttheinfancy.
→Ifthemotherreceivedlessthan4weeksofZidovudine(AZT)duringpregnancy,givethetreatment
tothenewbornfor4weeks.
■ Recordalltreatmentgiven.Ifthemotherorbabyisreferred,writethetreatmentgivenandthe
regimenprescribedonthereferralcard.
■ 00 N0IlabelrecordsasHIV-Positive
■ 00 N0Isharedrugswithfamilyorfriends.
Counsel on infant feeding options
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ExplaintherisksofHIVtransmissionthrough
breastfeedingandnotbreastfeeding
■ Fouroutof20babiesborntoknownHIV-positivemotherswillbeinfectedduringpregnancyand
deliverywithoutARVmedication.Threemoremaybeinfectedbybreastfeeding.
■ Theriskmaybereducedifthebabyisbreastfedexclusivelyusinggoodtechnique,sothatthe
breastsstayhealthy.
■ Mastitisandnipplefissuresincreasetheriskthatthebabywillbeinfected.
■ Theriskofnotbreastfeedingmaybemuchhigherbecausereplacementfeedingcarriesriskstoo:
→diarrhoeabecauseofcontaminationfromuncleanwater,uncleanutensilsorbecausethemilkis
leftouttoolong.
→malnutritionbecauseofinsufficientquantitygiventothebaby,themilkistoowatery,orbecause
ofrecurrentepisodesofdiarrhoea.
■ Mixedfeedingincreasestheriskofdiarrhoea.ItmayalsoincreasetheriskofHIVtransmission.
IfawomandoesnotknowherHIVstatus
■ Counselontheimportanceofexclusivebreastfeeding K2 .
■ Encourageexclusivebreastfeeding.
■ CounselontheneedtoknowtheHIVstatusandwheretogoforHIVtestingandcounselling G3 .
■ ExplaintohertherisksofHIVtransmission:
→eveninareaswheremanywomenhaveHIV,mostwomenarenegative
→theriskofinfectingthebabyishigherifthemotherisnewlyinfected
→explainthatitisveryimportanttoavoidinfectionduringpregnancyandthebreastfeeding
period.
IfawomanknowsthatsheisHIV-positive
■ Informherabouttheoptionsforfeeding,theadvantagesandrisks:
→Ifacceptable,feasible,safeandsustainable(affordable),shemightchoosereplacementfeeding
withhome-preparedformulaorcommercialformula.
→Exclusivebreastfeeding,stoppingassoonasreplacementfeedingispossible.Ifreplacement
feedingisintroducedearly,shemuststopbreastfeeding.
→Exclusivebreastfeedingfor6months,thencontinuedbreastfeedingpluscomplementaryfeeding
after6monthsofage,asrecommendedforHIV-negativewomenandwomenwhodonotknow
theirstatus.
■ Insomesituationsadditionalpossibilitiesare:
→expressingandheat-treatingherbreastmilk
→wetnursingbyanHIV-negativewoman.
■ Helphertoassesshersituationanddecidewhichisthebestoptionforher,andsupportherchoice.
■ Ifthemotherchoosesbreastfeeding,giveherspecialadvice.
■ Makesurethemotherunderstandsthatifshechoosesreplacementfeedingthisincludesenriched
complementaryfeedingupto2years.
→Ifthiscannotbeensured,exclusivebreastfeeding,stoppingearlywhenreplacementfeedingis
feasible,isanalternative.
→Allbabiesreceivingreplacementfeedingneedregularfollow-up,andtheirmothersneedsupport
toprovidecorrectreplacementfeeding.
Support the mothers choice of infant feeding
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Ifthemotherchoosesreplacementfeeding,
teachherreplacementfeeding
■ Askthemotherwhatkindofreplacementfeedingshechose.
■Forthefirstfewfeedsafterdelivery,preparetheformulaforthemother,thenteachherhowto
preparetheformulaandfeedthebabybycup K9 :
→Washhandswithwaterandsoap
→Boilthewaterforfewminutes
→Cleanthecupthoroughlywithwater,soapand,ifpossible,boilorpourboiledwaterinit
→Decidehowmuchmilkthebabyneedsfromtheinstructions
→Measurethemilkandwaterandmixthem
→Teachthemotherhowtofeedthebabybycup
→Letthemotherfeedthebaby8timesaday(inthefirstmonth).Teachhertobeflexibleand
respondtothebaby’sdemands
→Ifthebabydoesnotfinishthefeedwithin1hourofpreparation,giveittoanolderchildoraddto
cooking.DONOTgivethemilktothebabyforthenextfeed
→Washtheutensilswithwaterandsoapsoonafterfeedingthebaby
→Makeanewfeedeverytime.
■ Giveherwritteninstructionsonsafepreparationofformula.
■ Explaintherisksofreplacementfeedingandhowtoavoidthem.
■ Advisewhentoseekcare.
■ Adviseaboutthefollow-upvisit.
Explaintherisksofreplacementfeeding
■ Herbabymaygetdiarrhoeaif:
→hands,water,orutensilsarenotclean
→themilkstandsouttoolong.
■ Herbabymaynotgrowwellif:
→she/hereceivestoolittleformulaeachfeedortoofewfeeds
→themilkistoowatery
→she/hehasdiarrhoea.
Follow-upforreplacementfeeding
■ Ensureregularfollow-upvisitsforgrowthmonitoring.
■ Ensurethesupporttoprovidesafereplacementfeeding.
■ Advisethemothertoreturnif:
→thebabyisfeedinglessthan6times,oristakingsmallerquantities K6
→thebabyhasdiarrhoea
→thereareotherdangersigns.
Givespecialcounsellingtothemother
whoisHIV-positiveandchoosesbreastfeeding
■ Supportthemotherinherchoiceofbreastfeeding.
■ Ensuregoodattachmentandsucklingtopreventmastitisandnippledamage K3 .
■ Advisethemothertoreturnimmediatelyif:
→shehasanybreastsymptomsorsigns
→thebabyhasanydifficultyfeeding.
■ Ensureavisitinthefirstweektoassessattachmentandpositioningandtheconditionofthe
mother’sbreasts.
■ Arrangeforfurthercounsellingtoprepareforthepossibilityofstoppingbreastfeedingearly.
■ Givepsychosocialsupport G6 .
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ANIIk£Ik0VIkAlS I0k ßIV-P0SIIIV£ w0NAN AN0 ߣk INIANI
8e|ow are esamp|es of AkV reg|meas. use aat|oaa| ga|de||aes for |oca| protoco|s.
Ior |oager reg|meas to farther redace the r|sk of traasm|ss|oa fo||ow aat|oaa| ga|de||aes.
kecord the AkV med|c|ae prescr|hed aad g|rea |a the appropr|ate records – fac|||t, aad home-hased. 00 N0I wr|te ßIV-pos|t|re.
Antiretrovirals for HIV-positive woman and her infant
womaa Newhora |afaat
Pregaaac, lahoar, de||rer, Postpartam**
AkVs
8efore
28 weeks
Start|ag at
28 weeks
At oaset of
|ahoar*
uat|| h|rth
of the hah,
After h|rth
of the hah,
AkVs
0ose
(s,rap}
0|re f|rst
dose
Ihea g|re 0arat|oa
HIV-positive
withHIV-AIDS
relatedsignsand
symptoms
Tripletherapy ContinuetheARVtreatmentprescribedbeforepregnancy.Inthefirsttrimesterreplace
EfavirenzwithNevirapine(200mgoncedailyfor2weeks,thenevery12hours)
Zidovudine 4mg/kg 8–12hours
afterbirth
every
12hours
7days***
HIV-positivewithout
HIV-relatedsigns
andsymptoms
3TC 150mg every12hours 7days
Zidovudine 300mgevery
12hours
300mg every
3hours
every
12hours
7days Zidovudine 4mg/kg 8–12hours
afterbirth
every
12hours
7days***
Nevirapine 200mgonce Nevirapine 2mg/kg within
72hours
once
ARVsduringlabour Zidovudine 300mg every
3hours
Zidovudine 4mg/kg 8–12hours
afterbirth
every
12hours
4weeks
Or600mg
Nevirapine 200mgonce Nevirapine 2mg/kg within
72hours
once
Onlyminimalrange
ofARVtreatment
Nevirapine 200mgonce Nevirapine 2mg/kg within
72hours
once
*Atonsetofcontractionsorruptureofmembranes,regardlessofthepreviousschedule
**Arrangefollow-upforfurtherassessmentandtreatmentwithin2weeksafterdelivery
***TreatthenewborninfantwithZidovudinefor4weeksifmotherreceivedZidovudineforlessthan4weeksduringpregnancy,
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Respond to observed signs or volunteered problems
k£SP0N0 I0 08S£kV£0 SI0NS 0k V0luNI££k£0 Pk08l£NS
use th|s chart to maaage the womaa who has a proh|em wh||e tak|ag AkV med|c|aes. Ihese proh|ems ma, he s|de effects of AkV med|c|aes or of aa aader|,|ag d|sease.
ka|e oat ser|oas pregaaac,-re|ated d|seases hefore assam|ag that these are s|de effects of the drags. Io||ow ap |a 2 weeks or ear||er |f coad|t|oa worseas. Ia ao |mprore-
meat, refer the womaa to hosp|ta| for farther maaagemeat.
SIGNS
ßeadache
Naasea or rom|t|ag
Ierer
0|arrhoea
kash or h||sters,a|cers
Ye||ow e,es or macas memhraae
ADVISEANDTREAT
■ Measurebloodpressureandmanageasin C2 and E3 .
■ IfDBP≤ 90mmgiveparacetamolforheadache F4 .
■ Measurebloodpressureandmanageasin C2 and E3 .
■ Advisetotakemedicineswithfood.
■ Ifinthefirst3monthsofpregnancy,reassurethatthemorningnauseaandvomitingwill
disappearafterafewweeks.
■ Refertohospitalifnotpassingurine.
■ Measuretemperature.
■ Manageaccordingto C7-C8 ,C10-C11ifduringpregnancy,and E6-E8 ifinpostpartumperiod.
■ Advisetodrinkonecupoffluidaftereverystool.
■ Refertohospitalifbloodinstool,notpassingurineorfever>38ºC.
■ Ifrashislimitedtoskin,followupin2weeks.
■ Ifsevererash,blistersandulcersonskin,andmouthandfever>38ºCrefertohospitalfor
furtherassessmentandtreatment.
■ Refertohospitalforfurtherassessmentandtreatment.
IFWOMANHASANyPROBLEM
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Prevent HIV infection in health-care workers after accidental exposure with body fluids (Post exposure prophylaxis)
Pk£V£NI ßIV INI£0II0N IN ߣAlIß-0Ak£ w0kk£kS AII£k A00I0£NIAl £XP0Suk£ wIIß 800Y IluI0S
(P0SI £XP0Suk£ Pk0PßYlAXIS}
Ifyouareaccidentallyexposedtobloodorbodyfluidsbycuts
orpricksorsplashesonface/eyesdothefollowingsteps:
■ Ifbloodorbloodyfluidsplashesonintactskin,immediatelywashtheareawithsoapandwater.
■ Ifthegloveisdamaged,washtheareawithsoapandwaterandchangetheglove.
■ Ifsplashedintheface(eye,nose,mouth)washwithwateronly.
■ Ifafingerprickoracutoccurredduringproceduressuchassuturing,allowthewoundtobleedforafewseconds,
donotsqueezeouttheblood.Washwithsoapandwater.Useregularwoundcare.Topicalantisepticsmaybeused.
■ CheckrecordsfortheHIVstatusofthepregnantwoman.*
→ IfwomanisHIV-negativenofurtheractionisrequired.
→IfwomanisHIV-positivetakeARVmedicineswithin2hours(seenationalguidelinesforchoiceanddurationof
medicine).
→IftheHIVstatusofthepregnantwomanisunknown:
→StarttheARVmedicinewithin2hours(seenationalguidelinesforchoiceanddurationofmedicine).
→ExplaintothewomanwhathashappenedandseekherconsentforrapidHIVtest.DONOTtestthewoman
withoutherconsent.Maintainconfidentiality A2
.
→PerformtheHIVtest L6 .
→Ifthewoman’sHIVtestisnegative,discontinuetheARVmedicines.
→Ifthewoman’sHIVtestispositive,managethewomanasin
C2
and
E3 .Thehealthworker(yourself)
shouldcompletetheARVtreatmentandbetestedafter6weeks.
■ Informthesupervisoroftheexposuretypeandtheactiontakenforthehealth-careworker(yourself).Retestthe
health-careworker6weeksaftertheexposure.
*Ifthehealth-careworker(yourself)isHIV-positivenoPEPisrequired.00 N0Itestthewoman.
The woman with special needs
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the Woman With special needs
emotional support for the Woman With special needs
You may need to refer many women to another level of care or to a support group. however, if such support is not available, or if the woman will not seek help, counsel
her as follows. Your support and willingness to listen will help her to heal.
Emotional support for the woman with special needs
the Wom
an With special needs
h
Sources of support
a key role of the health worker includes linking the health services with the community and other support services available. maintain existing links and, when possible, explore needs and alternatives for support through the following: ■ Community groups, women’s groups, leaders. ■ Peer support groups. ■ Other health service providers. ■ Community counsellors. ■ Traditional providers.
Emotional support
Principles of good care, including suggestions on communication with the woman and her family, are provided on a . When giving emotional support to the woman with special needs it is particularly important to remember the following: ■ Create a comfortable environment: →Be aware of your attitude →Be open and approachable →Use a gentle, reassuring tone of voice. ■ Guarantee confidentiality and privacy: →Communicate clearly about confidentiality. Tell the woman that you will not tell anyone else about the visit, discussion or plan. →If brought by a partner, parent or other family member, make sure you have time and space to talk privately. Ask the woman if she would like to include her family members in the examination and discussion. Make sure you seek her consent first. →Make sure the physical area allows privacy. ■ Convey respect: →Do not be judgmental →Be understanding of her situation →Overcome your own discomfort with her situation. ■ Give simple, direct answers in clear language: →Verify that she understands the most important points. ■ Provide information according to her situation which she can use to make decisions. ■ Be a good listener: →Be patient. Women with special needs may need time to tell you their problem or make a decision →Pay attention to her as she speaks. ■ Follow-up visits may be necessary.
Special considerations in managing the pregnant adolescent
the Wom
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When interacting with the adolescent
■ Do not be judgemental. You should be aware of, and overcome, your own discomfort with adolescent sexuality. ■ Encourage the girl to ask questions and tell her that all topics can be discussed. ■ Use simple and clear language. ■ Repeat guarantee of confidentiality a g . ■ Understand adolescent difficulties in communicating about topics related to sexuality (fears of parental discovery, adult disapproval, social stigma, etc).
Support her when discussing her situation and ask if she has any particular concerns: ■ Does she live with her parents, can she confide in them? Does she live as a couple? Is she in a long- term relationship? Has she been subject to violence or coercion? ■ Determine who knows about this pregnancy — she may not have revealed it openly. ■ Support her concerns related to puberty, social acceptance, peer pressure, forming relationships, social stigmas and violence.
Help the girl consider her options and to make
decisions which best suit her needs.
■ Birth planning: delivery in a hospital or health centre is highly recommended. She needs to understand why this is important, she needs to decide if she will do it and and how she will arrange it. ■ Prevention of STI or HIV/AIDS is important for her and her baby. If she or her partner are at risk of STI or HIV/AIDS, they should use a condom in all sexual relations. She may need advice on how to discuss condom use with her partner. ■ Spacing of the next pregnancy — for both the woman and baby’s health, it is recommended that any next pregnancy be spaced by at least 2 or 3 years. The girl, with her partner if applicable, needs to decide if and when a second pregnancy is desired, based on their plans. Healthy adolescents can safely use any contraceptive method. The girl needs support in knowing her options and in deciding which is best for her. Be active in providing family planning counselling and advice.
special considerations in managingthe pregnant adolescent
special training is required to work with adolescent girls and this guide does not substitute for special training.
however, when working with an adolescent, whether married or unmarried, it is particularly important to remember the following.
special considerations for supportingthe Woman livingWithviolence
violence against women by their intimate partners affects women’s physical and mental health, including their reproductive health. While you may not have been trained
to deal with this problem, women may disclose violence to you or you may see unexplained bruises and other injuries which make you suspect she may be suffering
abuse. the following are some recommendations on how to respond and support her.
The woman living with violence
the Wom
an With special needs
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Support the woman living with violence
■ Provide a space where the woman can speak to you in privacy where her partner or others cannot hear. Do all you can to guarantee confidentiality, and reassure her of this. ■ Gently encourage her to tell you what is happening to her. You may ask indirect questions to help her tell her story. ■ Listen to her in a sympathetic manner. Listening can often be of great support. Do not blame her or make a joke of the situation. She may defend her partner’s action. Reassure her that she does not deserve to be abused in any way. ■ Help her to assess her present situation. If she thinks she or her children are in danger, explore together the options to ensure her immediate safety (e.g. can she stay with her parents or friends? Does she have, or could she borrow, money?) ■ Explore her options with her. Help her identify local sources of support, either within her family, friends, and local community or through NGOs, shelters or social services, if available. Remind her that she has legal recourse, if relevant. ■ Offer her an opportunity to see you again. Violence by partners is complex, and she may be unable to resolve her situation quickly. ■ Document any forms of abuse identified or concerns you may have in the file.
Support the health service response to needs of women
living with violence
■ Help raise awareness among health care staff about violence against women and its prevalence in the community the clinic serves. ■ Find out what if training is available to improve the support that health care staff can provide to those women who may need it. ■ Display posters, leaflets and other information that condemn violence, and information on groups that can provide support. ■ Make contact with organizations working to address violence in your area. Identify those that can provide support for women in abusive relationships. If specific services are not available, contact other groups such as churches, women’s groups, elders, or other local groups and discuss with them support they can provide or other what roles they can play, like resolving disputes. Ensure you have a list of these resources available.
H2

emotional support for the
Woman With special needs
Sourcesofsupport
Emotionalsupport
H3 special considerations in
managing the pregnant
adolescent
Wheninteractingwiththeadolescent
Helpthegirlconsiderheroptionsandtomake
decisionswhichbestsuitherneeds
H4 special considerations for
supporting the Woman living
With violence
Supportthewomanlivingwithviolence
Supportthehealthserviceresponsetothe
needsofwomenlivingwithviolence
■ Ifawomanisanadolescentorlivingwithviolence,sheneeds
specialconsideration.Duringinteractionwithsuchwomen,use
thissectiontosupportthem.
emotional support for the Woman With special needs
You may need to refer many women to another level of care or to a support group. however, if such support is not available, or if the woman will not seek help, counsel
her as follows. Your support and willingness to listen will help her to heal.
Emotional support for the woman with special needs
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Sourcesofsupport
a key role of the health worker includes linking the health services with the community and
other support services available. maintain existing links and, when possible, explore needs and
alternatives for support through the following:
■ Communitygroups,women’sgroups,leaders.
■ Peersupportgroups.
■ Otherhealthserviceproviders.
■ Communitycounsellors.
■ Traditionalproviders.
Emotionalsupport
Principlesofgoodcare,includingsuggestionsoncommunicationwiththewomanandherfamily,are
providedon a .Whengivingemotionalsupporttothewomanwithspecialneedsitisparticularly
importanttorememberthefollowing:
■ Createacomfortableenvironment:
→Beawareofyourattitude
→Beopenandapproachable
→Useagentle,reassuringtoneofvoice.
■ Guaranteeconfidentialityandprivacy:
→Communicateclearlyaboutconfidentiality.Tellthewomanthatyouwillnottellanyoneelseabout
thevisit,discussionorplan.
→Ifbroughtbyapartner,parentorotherfamilymember,makesureyouhavetimeandspaceto
talkprivately.Askthewomanifshewouldliketoincludeherfamilymembersintheexamination
anddiscussion.Makesureyouseekherconsentfirst.
→Makesurethephysicalareaallowsprivacy.
■ Conveyrespect:
→Donotbejudgmental
→Beunderstandingofhersituation
→Overcomeyourowndiscomfortwithhersituation.
■ Givesimple,directanswersinclearlanguage:
→Verifythatsheunderstandsthemostimportantpoints.
■ Provideinformationaccordingtohersituationwhichshecanusetomakedecisions.
■ Beagoodlistener:
→Bepatient.Womenwithspecialneedsmayneedtimetotellyoutheirproblemormakea
decision
→Payattentiontoherasshespeaks.
■ Follow-upvisitsmaybenecessary.
Special considerations in managing the pregnant adolescent
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Wheninteractingwiththeadolescent
■ Donotbejudgemental.Youshouldbeawareof,andovercome,yourowndiscomfortwithadolescent
sexuality.
■ Encouragethegirltoaskquestionsandtellherthatalltopicscanbediscussed.
■ Usesimpleandclearlanguage.
■ Repeatguaranteeofconfidentiality a

g .
■ Understandadolescentdifficultiesincommunicatingabouttopicsrelatedtosexuality(fearsof
parentaldiscovery,adultdisapproval,socialstigma,etc).
Supportherwhendiscussinghersituationandaskifshehasanyparticularconcerns:
■ Doesshelivewithherparents,cansheconfideinthem?Doessheliveasacouple?Issheinalong-
termrelationship?Hasshebeensubjecttoviolenceorcoercion?
■ Determinewhoknowsaboutthispregnancy—shemaynothaverevealeditopenly.
■ Supportherconcernsrelatedtopuberty,socialacceptance,peerpressure,formingrelationships,
socialstigmasandviolence.
Helpthegirlconsiderheroptionsandtomake
decisionswhichbestsuitherneeds.
■ Birthplanning:deliveryinahospitalorhealthcentreishighlyrecommended.Sheneedsto
understandwhythisisimportant,sheneedstodecideifshewilldoitandandhowshewillarrangeit.
■ PreventionofSTIorHIV/AIDSisimportantforherandherbaby.Ifsheorherpartnerareatriskof
STIorHIV/AIDS,theyshoulduseacondominallsexualrelations.Shemayneedadviceonhowto
discusscondomusewithherpartner.
■ Spacingofthenextpregnancy—forboththewomanandbaby’shealth,itisrecommendedthatany
nextpregnancybespacedbyatleast2or3years.Thegirl,withherpartnerifapplicable,needsto
decideifandwhenasecondpregnancyisdesired,basedontheirplans.Healthyadolescentscan
safelyuseanycontraceptivemethod.Thegirlneedssupportinknowingheroptionsandindeciding
whichisbestforher.Beactiveinprovidingfamilyplanningcounsellingandadvice.
special considerations in managing the pregnant adolescent
special training is required to work with adolescent girls and this guide does not substitute for special training.
however, when working with an adolescent, whether married or unmarried, it is particularly important to remember the following.
special considerations for supporting the Woman living With violence
violence against women by their intimate partners affects women’s physical and mental health, including their reproductive health. While you may not have been trained
to deal with this problem, women may disclose violence to you or you may see unexplained bruises and other injuries which make you suspect she may be suffering
abuse. the following are some recommendations on how to respond and support her.
The woman living with violence
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Supportthewomanlivingwithviolence
■ Provideaspacewherethewomancanspeaktoyouinprivacywhereherpartnerorotherscannot
hear.Doallyoucantoguaranteeconfidentiality,andreassureherofthis.
■ Gentlyencouragehertotellyouwhatishappeningtoher.Youmayaskindirectquestionstohelpher
tellherstory.
■ Listentoherinasympatheticmanner.Listeningcanoftenbeofgreatsupport.Donotblameheror
makeajokeofthesituation.Shemaydefendherpartner’saction.Reassureherthatshedoesnot
deservetobeabusedinanyway.
■ Helphertoassessherpresentsituation.Ifshethinkssheorherchildrenareindanger,explore
togethertheoptionstoensureherimmediatesafety(e.g.canshestaywithherparentsorfriends?
Doesshehave,orcouldsheborrow,money?)
■ Exploreheroptionswithher.Helpheridentifylocalsourcesofsupport,eitherwithinherfamily,
friends,andlocalcommunityorthroughNGOs,sheltersorsocialservices,ifavailable.Remindher
thatshehaslegalrecourse,ifrelevant.
■ Offerheranopportunitytoseeyouagain.Violencebypartnersiscomplex,andshemaybeunableto
resolvehersituationquickly.
■ Documentanyformsofabuseidentifiedorconcernsyoumayhaveinthefile.
Supportthehealthserviceresponsetoneedsofwomen
livingwithviolence
■ Helpraiseawarenessamonghealthcarestaffaboutviolenceagainstwomenanditsprevalencein
thecommunitytheclinicserves.
■ Findoutwhatiftrainingisavailabletoimprovethesupportthathealthcarestaffcanprovideto
thosewomenwhomayneedit.
■ Displayposters,leafletsandotherinformationthatcondemnviolence,andinformationongroups
thatcanprovidesupport.
■ Makecontactwithorganizationsworkingtoaddressviolenceinyourarea.Identifythosethatcan
providesupportforwomeninabusiverelationships.Ifspecificservicesarenotavailable,contact
othergroupssuchaschurches,women’sgroups,elders,orotherlocalgroupsanddiscusswiththem
supporttheycanprovideorotherwhatrolestheycanplay,likeresolvingdisputes.Ensureyouhave
alistoftheseresourcesavailable.
Community support for maternal and newborn health
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Community support for maternal and newborn health
establish links
Establish links
Com
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aternal and newborn health
i
Coordinate with other health care providers
and community groups
■ Meet with others in the community to discuss and agree messages related to pregnancy, delivery, postpartum and post-abortion care of women and newborns. ■ Work together with leaders and community groups to discuss the most common health problems and find solutions. Groups to contact and establish relations which include: →other health care providers →traditional birth attendants and healers →maternity waiting homes →adolescent health services →schools →nongovernmental organizations →breastfeeding support groups →district health committees →women’s groups →agricultural associations →neighbourhood committees →youth groups →church groups. ■ Establish links with peer support groups and referral sites for women with special needs, including women living with HIV, adolescents and women living with violence. Have available the names and contact information for these groups and referral sites, and encourage the woman to seek their support.
Establish links with traditional
birth attendants and traditional healers
■ Contact traditional birth attendants and healers who are working in the health facility’s catchment area. Discuss how you can support each other. ■ Respect their knowledge, experience and influence in the community. ■ Share with them the information you have and listen to their opinions on this. Provide copies of health education materials that you distribute to community members and discuss the content with them. Have them explain knowledge that they share with the community. Together you can create new knowledge which is more locally appropriate. ■ Review how together you can provide support to women, families and groups for maternal and newborn health. ■ Involve TBAs and healers in counselling sessions in which advice is given to families and other community members. Include TBAs in meetings with community leaders and groups. ■ Discuss the recommendation that all deliveries should be performed by a skilled birth attendant. When not possible or not preferred by the woman and her family, discuss the requirements for safer delivery at home, postpartum care, and when to seek emergency care. ■ Invite TBAs to act as labour companions for women they have followed during pregnancy, if this is the woman’s wish. ■ Make sure TBAs are included in the referral system. ■ Clarify how and when to refer, and provide TBAs with feedback on women they have referred.
involve the Community in quality of serviCes
Involve the community in quality of services
Com
m
unity support for m
aternal and newborn health
i
all in the community should be informed and involved in the process of improving the health of their members. ask the different groups to provide feedback and suggestions on how to improve the services the health facility provides. ■ Find out what people know about maternal and newborn mortality and morbidity in their locality. Share data you may have and reflect together on why these deaths and illnesses may occur. Discuss with them what families and communities can do to prevent these deaths and illnesses. Together prepare an action plan, defining responsibilities. ■ Discuss the different health messages that you provide. Have the community members talk about their knowledge in relation to these messages. Together determine what families and communities can do to support maternal and newborn health. ■ Discuss some practical ways in which families and others in the community can support women during pregnancy, post-abortion, delivery and postpartum periods: →Recognition of and rapid response to emergency/danger signs during pregnancy, delivery and postpartum periods →Provision of food and care for children and other family members when the woman needs to be away from home during delivery, or when she needs to rest →Accompanying the woman after delivery →Support for payment of fees and supplies →Motivation of male partners to help with the workload, accompany the woman to the clinic, allow her to rest and ensure she eats properly. Motivate communication between males and their partners, including discussing postpartum family planning needs. ■ Support the community in preparing an action plan to respond to emergencies. Discuss the following with them: →Emergency/danger signs - knowing when to seek care →Importance of rapid response to emergencies to reduce mother and newborn death, disability and illness →Transport options available, giving examples of how transport can be organized →Reasons for delays in seeking care and possible difficulties, including heavy rains →What services are available and where →What options are available →Costs and options for payment →A plan of action for responding in emergencies, including roles and responsibilities.
I2

establish links
Coordinatewithotherhealthcareproviders
andcommunitygroups
Establishlinkswithtraditionalbirthattendants
andtraditionalhealers
I3 involve the Community in
quality of serviCes

■Everyoneinthecommunityshouldbeinformedandinvolvedintheprocessofimprovingthehealthoftheircommunitymembers.Thissection
providesguidanceonhowtheirinvolvementcanhelpimprovethehealthofwomenandnewborns.
■Differentgroupsshouldbeaskedtogivefeedbackandsuggestionsonhowtoimprovetheservicesthehealthfacilitiesprovide.
■Usethefollowingsuggestionswhenworkingwithfamiliesandcommunitiestosupportthecareofwomenandnewbornsduringpregnancy,
delivery,post-abortionandpostpartumperiods.
establish links
Establish links
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Coordinatewithotherhealthcareproviders
andcommunitygroups
■ Meetwithothersinthecommunitytodiscussandagreemessagesrelatedtopregnancy,delivery,
postpartumandpost-abortioncareofwomenandnewborns.
■ Worktogetherwithleadersandcommunitygroupstodiscussthemostcommonhealthproblems
andfindsolutions.Groupstocontactandestablishrelationswhichinclude:
→otherhealthcareproviders
→traditionalbirthattendantsandhealers
→maternitywaitinghomes
→adolescenthealthservices
→schools
→nongovernmentalorganizations
→breastfeedingsupportgroups
→districthealthcommittees
→women’sgroups
→agriculturalassociations
→neighbourhoodcommittees
→youthgroups
→churchgroups.
■ Establishlinkswithpeersupportgroupsandreferralsitesforwomenwithspecialneeds,including
womenlivingwithHIV,adolescentsandwomenlivingwithviolence.Haveavailablethenamesand
contactinformationforthesegroupsandreferralsites,andencouragethewomantoseektheir
support.
Establishlinkswithtraditional
birthattendantsandtraditionalhealers
■ Contacttraditionalbirthattendantsandhealerswhoareworkinginthehealthfacility’scatchment
area.Discusshowyoucansupporteachother.
■ Respecttheirknowledge,experienceandinfluenceinthecommunity.
■ Sharewiththemtheinformationyouhaveandlistentotheiropinionsonthis.Providecopiesof
healtheducationmaterialsthatyoudistributetocommunitymembersanddiscussthecontentwith
them.Havethemexplainknowledgethattheysharewiththecommunity.Togetheryoucancreate
newknowledgewhichismorelocallyappropriate.
■ Reviewhowtogetheryoucanprovidesupporttowomen,familiesandgroupsformaternaland
newbornhealth.
■ InvolveTBAsandhealersincounsellingsessions inwhichadviceisgiventofamiliesandother
communitymembers.IncludeTBAsinmeetingswithcommunityleadersandgroups.
■ Discusstherecommendationthatalldeliveriesshouldbeperformedbyaskilledbirthattendant.
Whennotpossibleornotpreferredbythewomanandherfamily,discusstherequirementsforsafer
deliveryathome,postpartumcare,andwhentoseekemergencycare.
■ InviteTBAstoactaslabourcompanionsforwomentheyhavefollowedduringpregnancy,ifthisis
thewoman’swish.
■ MakesureTBAsareincludedinthereferralsystem.
■ Clarifyhowandwhentorefer,andprovideTBAswithfeedbackonwomentheyhavereferred.
involve the Community in quality of serviCes
Involve the community in quality of services
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all in the community should be informed and involved in the process of improving the health of
their members. ask the different groups to provide feedback and suggestions on how to improve
the services the health facility provides.
■ Findoutwhatpeopleknowaboutmaternalandnewbornmortalityandmorbidityintheirlocality.
Sharedatayoumayhaveandreflecttogetheronwhythesedeathsandillnessesmayoccur.Discuss
withthemwhatfamiliesandcommunitiescandotopreventthesedeathsandillnesses.Together
prepareanactionplan,definingresponsibilities.
■ Discussthedifferenthealthmessagesthatyouprovide.Havethecommunitymemberstalkabout
theirknowledgeinrelationtothesemessages.Togetherdeterminewhatfamiliesandcommunities
candotosupportmaternalandnewbornhealth.
■ Discusssomepracticalwaysinwhichfamiliesandothersinthecommunitycansupportwomen
duringpregnancy,post-abortion,deliveryandpostpartumperiods:
→Recognitionofandrapidresponsetoemergency/dangersignsduringpregnancy,deliveryand
postpartumperiods
→Provisionoffoodandcareforchildrenandotherfamilymemberswhenthewomanneedstobe
awayfromhomeduringdelivery,orwhensheneedstorest
→Accompanyingthewomanafterdelivery
→Supportforpaymentoffeesandsupplies
→Motivationofmalepartnerstohelpwiththeworkload,accompanythewomantotheclinic,allow
hertorestandensuresheeatsproperly.Motivatecommunicationbetweenmalesandtheir
partners,includingdiscussingpostpartumfamilyplanningneeds.
■ Supportthecommunityinpreparinganactionplantorespondtoemergencies.Discussthefollowing
withthem:
→Emergency/dangersigns-knowingwhentoseekcare
→Importanceofrapidresponsetoemergenciestoreducemotherandnewborndeath,disabilityand
illness
→Transportoptionsavailable,givingexamplesofhowtransportcanbeorganized
→Reasonsfordelaysinseekingcareandpossibledifficulties,includingheavyrains
→Whatservicesareavailableandwhere
→Whatoptionsareavailable
→Costsandoptionsforpayment
→Aplanofactionforrespondinginemergencies,includingrolesandresponsibilities.
Newborn care
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Examine the newborn
N£w80kN 0Ak£
ASK, CHECK RECORD
0heck materaa| aad aewhora record or ask the mother: ■ How old is the baby? ■ Preterm (less than 37 weeks or 1 month or more early)? ■ Breech birth? ■ Difficult birth? ■ Resuscitated at birth? ■ Has baby had convulsions?
Ask the mother: ■ Do you have concerns? ■ How is the baby feeding?
Is the mother rer, ||| or traasferred?
LOOK, LISTEN, FEEL
■ Assess breathing (baby must be calm) →listen for grunting →count breaths: are they 60 or less per minute? Repeat the count if elevated →look at the chest for in-drawing. ■ Look at the movements: are they normal and symmetrical? ■ Look at the presenting part — is there swelling and bruises? ■ Look at abdomen for pallor. ■ Look for malformations. ■ Feel the tone: is it normal? ■ Feel for warmth. If cold, or very warm, measure temperature. ■ Weigh the baby.
SIGNS
■ Normal weight baby (2500-g or more). ■ Feeding well — suckling effectively 8 times in 24 hours, day and night. ■ No danger signs. ■ No special treatment needs or treatment completed. ■ Small baby, feeding well and gaining weight adequately.
■ Body temperature 35-36.4ºC.
■ Mother not able to breastfeed due to receiving special treatment. ■ Mother transferred.
TREAT ANDADVISE
If f|rst esam|aat|oa: ■ Ensure care for the newborn J10 . ■ Examine again for discharge.
If pre-d|scharge esam|aat|oa: ■ Immunize if due K13. ■ Advise on baby care K2 K9-K10 . ■ Advise on routine visit at age 3-7 days K14. ■ Advise on when to return if danger signs K14. ■ Record in home-based record. ■ If further visits, repeat advices.
■ Re-warm the baby skin-to-skin K9 . ■ If temperature not rising after 2 hours, reassess the baby.
■ Help the mother express breast milk K5 . ■ Consider alternative feeding methods until mother is well K5-K6 . ■ Provide care for the baby, ensure warmth K9 . ■ Ensure mother can see the baby regularly. ■ Transfer the baby with the mother if possible. ■ Ensure care for the baby at home.
CLASSIFY
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N£XI: If preterm, birth weight <2500 g or twin
£XANIN£ Iߣ N£w80kN
use th|s chart to assess the aewhora after h|rth, c|ass|f, aad treat, poss|h|, aroaad aa hoar; for d|scharge (aot hefore 12 hoars}; aad dar|ag the f|rst week of ||fe at roa-
t|ae, fo||ow-ap, or s|ck aewhora r|s|t. kecord the f|ad|ags oa the postpartam record N6 .
A|wa,s esam|ae the hah, |a the preseace of the mother.
I2

If preterm, birth weight <2500 g or twin
ASK, CHECK RECORD
■ Baby just born. ■ Birth weight →<1500-g →1500-g to <2500-g. ■ Preterm →<32 weeks →33-36 weeks. ■ Twin.
LOOK, LISTEN, FEEL
■ If this is repeated visit, assess weight gain
SIGNS
■ Birth weight <1500-g. ■ Very preterm <32 weeks or >2 months early).
■ Birth weight 1500-g-2500-g. ■ Preterm baby (32-36 weeks or 1-2 months early). ■ Several days old and weight gain inadequate. ■ Feeding difficulty.
■ Twin
TREAT ANDADVISE
■ kefer hah, argeat|, to hosp|ta| K14. ■ Ensure extra warmth during referral.
■ Give special support to breastfeed the small baby K4 . ■ Ensure additional care for a small baby J11 . ■ Reassess daily J11 . ■ Do not discharge before feeding well, gaining weight and body temperature stable. ■ If feeding difficulties persist for 3 days and otherwise well, refer for breastfeeding counselling.
■ Give special support to the mother to breastfeed twins K4 . ■ Do not discharge until both twins can go home.
CLASSIFY
V£kY SNAll 8A8Y
SNAll 8A8Y
IwIN
II Pk£I£kN, 8IkIßw£I0ßI <2500-0 0k IwIN
N£w80kN 0Ak£
I3
N£XI: Assess breastfeeding �
Assess breastfeeding
N£w80kN 0Ak£
ASK,CHECK RECORD
Ask the mother ■ How is the breastfeeding going? ■ Has your baby fed in the previous hour? ■ Is there any difficulty? ■ Is your baby satisfied with the feed? ■ Have you fed your baby any other foods or drinks? ■ How do your breasts feel? ■ Do you have any concerns?
If hah, more thaa oae da, o|d: ■ How many times has your baby fed in 24 hours?
To assess replacement feeding see J12 .
LOOK, LISTEN, FEEL
■ 0hserre a hreastfeed. If the baby has not fed in the previous hour, ask the mother to put the baby on her breasts and observe breastfeeding for about 5 minutes.
look ■ Is the baby able to attach correctly? ■ Is the baby well-positioned? ■ Is the baby suckling effectively?
If mother has fed in the last hour, ask her to tell you when her baby is willing to feed again.
SIGNS
■ Suckling effectively. ■ Breastfeeding 8 times in 24 hours on demand day and night
■ Not yet breastfed (first hours of life). ■ Not well attached. ■ Not suckling effectively. ■ Breastfeeding less than 8 times per 24 hours. ■ Receiving other foods or drinks. ■ Several days old and inadequate weight gain.
■ Not suckling (after 6 hours of age). ■ Stopped feeding.
TREAT ANDADVISE
■ Encourage the mother to continue breastfeeding on demand K3 .
■ Support exclusive breastfeeding K2-K3 . ■ Help the mother to initiate breastfeeding K3 . ■ Teach correct positioning and attachment K3 . ■ Advise to feed more frequently, day and night. Reassure her that she has enough milk. ■ Advise the mother to stop feeding the baby other foods or drinks. ■ Reassess at the next feed or follow-up visit in 2 days.
■ kefer hah, argeat|, to hosp|ta| K14.
CLASSIFY
I££0IN0w£ll
I££0IN0 0IIII0ulIY
N0I A8l£ I0 I££0
N£XI: Check for special treatment needs
ASS£SS 8k£ASII££0IN0
Assess hreastfeed|ag |a erer, hah, as part of the esam|aat|oa.
If mother |s comp|a|a|ag of a|pp|e or hreast pa|a, a|so assess the mother’s hreasts J9 .
I4

Check for special treatment needs
ASK, CHECK RECORD
0heck record for spec|a| treatmeat aeeds ■ Has the mother had within 2 days of delivery: →fever >38ºC? →infection treated with antibiotics? ■ Membranes ruptured >18 hours before delivery? ■ Mother tested RPR-positive? ■ Mother tested HIV-positive? →is or has been on ARV →has she received infant feeding counselling? ■ Is the mother receiving TB treatment which began <2 months ago?
LOOK, LISTEN, FEEL SIGNS
■ Baby <1 day old and membranes ruptured >18 hours before delivery, or ■ Mother being treated with antibiotics for infection, or ■ Mother has fever >38ºC.
■ Mother tested RPR-positive.
■ Mother known to be HIV-positive. ■ Mother has not been counselled on infant feeding. ■ Mother chose breastfeeding. ■ Mother chose replacement feeding.
■ Mother started TB treatment <2 months before delivery.
TREAT ANDADVISE
■ Give baby 2 IM antibiotics for 5 days K12. ■ Assess baby daily J2-J7 .
■ Give baby single dose of benzathine penicillin K12. ■ Ensure mother and partner are treated F6 . ■ Follow up in 2 weeks.
■ Give ARV to the newborn G9 . ■ Inform on infant feeding options G7 . ■ Give special counselling to mother who is breast feeding G8 . ■ Teach the mother replacement feeding. ■ Follow up in 2 weeks G8 .
■ Give baby isoniazid propylaxis for 6 months K13. ■ Give BCG vaccination to the baby only when baby’s treatment completed. ■ Follow up in 2 weeks.
CLASSIFY
kISk 0I 8A0I£kIAl INI£0II0N
kISk 0I 00N0£NIIAl SYPßIlIS
kISk 0I ßIV IkANSNISSI0N
kISk 0I Iu8£k0ul0SIS
N£XI: Look for signs of jaundice and local infection
0ߣ0k I0k SP£0IAl Ik£AIN£NI N££0S
N£w80kN 0Ak£
I5

Look for signs of jaundice and local infection
N£w80kN 0Ak£
ASK, CHECK RECORD
■ What has been applied to the umbilicus?
LOOK, LISTEN, FEEL
■ Look at the skin, is it yellow? →if baby is less than 24 hours old, look at skin on the face →if baby is 24 hours old or more, look at palms and soles. ■ Look at the eyes. Are they swollen and draining pus? ■ Look at the skin, especially around the neck, armpits, inguinal area: →Are there skin pustules? →Is there swelling, hardness or large bullae? ■ Look at the umbilicus: →Is it red? →Draining pus? →Does redness extend to the skin?
SIGNS
■ Yellow skin on face and only ≤24 hours old. ■ Yellow palms and soles and >24 hours old.
■ Eyes swollen and draining pus.
■ Red umbilicus or skin around it.
■ Less than 10 pustules
TREAT ANDADVISE
■ kefer hah, argeat|, to hosp|ta| K14. ■ Encourage breastfeeding on the way. ■ If feeding difficulty, give expressed breast milk by cup K6 .
■ Give single dose of appropriate antibiotic for eye infection K12. ■ Teach mother to treat eyes K13. ■ Follow up in 2 days. If no improvement or worse, refer urgently to hospital. ■ Assess and treat mother and her partner for possible gonorrhea E8 .
■ Teach mother to treat umbilical infection K13. ■ If no improvement in 2 days, or if worse, refer urgently to hospital.
■ Teach mother to treat skin infection K13. ■ Follow up in 2 days. ■ If no improvement of pustules in 2 days or more, refer urgently to hospital.
CLASSIFY
IAuN0I0£
00N00000Al £Y£ INI£0II0N
l00Al uN8IlI0Al INI£0II0N
l00Al SkIN INI£0II0N
N£XI: If danger signs
l00k I0k SI0NS 0I IAuN0I0£ AN0 l00Al INI£0II0N
I0

If danger signs
SIGNS
Aa, of the fo||ow|ag s|gas: ■ Fast breathing (more than 60 breaths per minute). ■ Slow breathing (less than 30 breaths per minute). ■ Severe chest in-drawing ■ Grunting ■ Convulsions. ■ Floppy or stiff. ■ Fever (temperature >38ºC). ■ Temperature <35ºC or not rising after rewarming. ■ Umbilicus draining pus or umbilical redness extending to skin. ■ More than 10 skin pustules or bullae, or swelling, redness, hardness of skin. ■ Bleeding from stump or cut.
TREAT ANDADVISE
■ Give first dose of 2 IM antibiotics K12. ■ kefer hah, argeat|, to hosp|ta| K14.
Ia add|t|oa: ■ Re-warm and keep warm during referral K9 .
■ Treat local umbilical infection before referral K13.
■ Treat skin infection before referral K13.
■ Stop the bleeding.
CLASSIFY
P0SSI8l£ S£kI0uS IllN£SS
N£XI: If swelling, bruises or malformation
II 0AN0£k SI0NS
N£w80kN 0Ak£
I7

J2

£XANIN£ Iߣ N£w80kN
J3

II Pk£I£kN,
8IkIß w£I0ßI <2500 0 0k IwIN

J4 ASS£SS 8k£ASII££0IN0
J5 0ߣ0k I0k SP£0IAl
Ik£AIN£NI N££0S
J6 l00k I0k SI0NS 0I IAuN0I0£ AN0
l00Al INI£0II0N
J7 II 0AN0£k SI0NS
If swelling, bruises or malformation
N£w80kN 0Ak£
SIGNS
■ Bruises, swelling on buttocks. ■ Swollen head — bump on one or both sides. ■ Abnormal position of legs (after breech presentation). ■ Asymmetrical arm movement, arm does not move.
■ Club foot
■ Cleft palate or lip
■ Odd looking, unusual appearance
■ Open tissue on head, abdomen or back
■ Other abnormal appearance.
TREAT ANDADVISE
■ Explain to parents that it does not hurt the baby, it will disappear in a week or two and no special treatment is needed. ■ DO NOT force legs into a different position. ■ Gently handle the limb that is not moving, do not pull.
■ Refer for special treatment if available.
■ Help mother to breastfeed. If not successful, teach her alternative feeding methods K5-K6 . Plan to follow up. ■ Advise on surgical correction at age of several months.
■ Refer for special evaluation.
■ Cover with sterile tissues soaked with sterile saline solution before referral. ■ Refer for special treatment if available.
■ Manage according to national guidelines.
CLASSIFY
8IkIß INIukY
NAlI0kNAII0N
S£V£k£ NAlI0kNAII0N
N£XI: Assess the mother’s breasts if complaining of nipple or breast pain
II Sw£llIN0, 8kuIS£S 0k NAlI0kNAII0N
I8

N£XI: Care of the newborn
Assess the mother’s breasts if complaining of nipple or breast pain
ASK, CHECK RECORD
■ How do your breasts feel?
LOOK, LISTEN, FEEL
■ Look at the nipple for fissure ■ Look at the breasts for: →swelling →shininess →redness. ■ Feel gently for painful part of the breast. ■ Measure temperature. ■ Observe a breastfeed if not yet done J4 .
SIGNS
■ No swelling, redness or tenderness. ■ Normal body temperature. ■ Nipple not sore and no fissure visible. ■ Baby well attached.
■ Nipple sore or fissured. ■ Baby not well attached.
■ Both breasts are swollen, shiny and patchy red. ■ Temperature <38ºC. ■ Baby not well attached. ■ Not yet breastfeeding.
■ Part of breast is painful, swollen and red. ■ Temperature >38ºC ■ Feels ill.
TREAT ANDADVISE
■ Reassure the mother.
■ Encourage the mother to continue breastfeeding. ■ Teach correct positioning and attachment K3 . ■ Reassess after 2 feeds (or 1 day). If not better, teach the mother how to express breast milk from the affected breast and feed baby by cup, and continue breastfeeding on the healthy side.
■ Encourage the mother to continue breastfeeding. ■ Teach correct positioning and attachment K3 . ■ Advise to feed more frequently. ■ Reassess after 2 feeds (1 day). If not better, teach mother how to express enough breast milk before the feed to relieve discomfort K5 .
■ Encourage mother to continue breastfeeding. ■ Teach correct positioning and attachment K3 . ■ Give cloxacillin for 10 days F5 . ■ Reassess in 2 days. If no improvement or worse, refer to hospital. ■ If mother is HIV+ let her breastfeed on the healthy breast. Express milk from the affected breast and discard until no fever K5 . ■ If severe pain, give paracetamol F4 .
CLASSIFY
8k£ASIS ߣAlIßY
NIPPl£ S0k£N£SS 0k IISSuk£
8k£ASI £N00k0£N£NI
NASIIIIS
ASS£SS Iߣ N0Iߣk’S 8k£ASIS II 00NPlAININ0 0I NIPPl£ 0k 8k£ASI PAIN
N£w80kN 0Ak£
I0

0Ak£ 0I Iߣ N£w80kN
use th|s chart for care of a|| hah|es aat|| d|scharge.
Care of the newborn
N£w80kN 0Ak£
I10
CARE AND MONITORING
■ Ensure the room is warm (not less than 25ºC and no draught). ■ Keep the baby in the room with the mother, in her bed or within easy reach. ■ Let the mother and baby sleep under a bednet.
■ Support exclusive breastfeeding on demand day and night. ■ Ask the mother to alert you if breastfeeding difficulty. ■ Assess breastfeeding in every baby before planning for discharge. 00 N0I discharge if baby is not yet feeding well.
■ Teach the mother how to care for the baby. →Keep the baby warm K9 →Give cord care K10 →Ensure hygiene K10. 00 N0I expose the baby in direct sun. 00 N0I put the baby on any cold surface. 00 N0I bath the baby before 6 hours.
■ Ask the mother and companion to watch the baby and alert you if →Feet cold →Breathing difficulty: grunting, fast or slow breathing, chest in-drawing →Any bleeding.
■ Give prescribed treatments according to the schedule K12.
■ Examine every baby before planning to discharge mother and baby J2-J9 . 00 N0I discharge before baby is 12 hours old.
RESPONDTOABNORMAL FINDINGS
■ If the baby is in a cot, ensure baby is dressed or wrapped and covered by a blanket. Cover the head with a hat.
■ If mother reports breastfeeding difficulty, assess breastfeeding and help the mother with positioning and attachment J3
■ If the mother is unable to take care of the baby, provide care or teach the companion K9-K10 ■ Wash hands before and after handling the baby.
■ If feet are cold: →Teach the mother to put the baby skin-to-skin K13. →Reassess in 1 hour; if feet still cold, measure temperature and re-warm the baby K9 . ■ If bleeding from cord, check if tie is loose and retie the cord. ■ If other bleeding, assess the baby immediately J2-J7 . ■ If breathing difficulty or mother reports any other abnormality, examine the baby as on J2-J7 .
N£XI: Additional care of a small baby (or twin) �
A00III0NAl 0Ak£ 0I A SNAll 8A8Y (0k IwIN}
use th|s chart for add|t|oaa| care of a sma|| hah,: preterm, 1-2 moaths ear|, or we|gh|ag 1500g-<2500g. kefer to hosp|ta| a rer, sma|| hah,: >2 moaths ear|,, we|gh|ag
<1500-g
Additional care of a small baby (twin)
N£w80kN 0Ak£
I11
CARE AND MONITORING
■ Plan to keep the small baby longer before discharging. ■ Allow visits to the mother and baby.
■ Give special support for breastfeeding the small baby (or twins) K4 : →Encourage the mother to breastfeed every 2-3 hours. →Assess breastfeeding daily: attachment, suckling, duration and frequency of feeds, and baby satisfaction with the feed J4 K6 . →If alternative feeding method is used, assess the total daily amount of milk given. →Weigh daily and assess weight gain K7 .
■ Ensure additional warmth for the small baby K9 : →Ensure the room is very warm (25º–28ºC). →Teach the mother how to keep the small baby warm in skin-to-skin contact →Provide extra blankets for mother and baby. ■ Ensure hygiene K10 . 00 N0I bath the small baby. Wash as needed.
■ Assess the small baby daily: →Measure temperature →Assess breathing (baby must be quiet, not crying): listen for grunting; count breaths per minute, repeat the count if >60 or <30; look for chest in-drawing →Look for jaundice (first 10 days of life): first 24 hours on the abdomen, then on palms and soles.
■ Plan to discharge when: →Breastfeeding well →Gaining weight adequately on 3 consecutive days →Body temperature between 36.5º and 37.5ºC on 3 consecutive days →Mother able and confident in caring for the baby →No maternal concerns. ■ Assess the baby for discharge.
RESPONSE TOABNORMAL FINDINGS
■ If the small baby is not suckling effectively and does not have other danger signs, consider alternative feeding methods K5-K6 . →Teach the mother how to hand express breast milk directly into the baby’s mouth K5 →Teach the mother to express breast milk and cup feed the baby K5-K6 →Determine appropriate amount for daily feeds by age K6 . ■ If feeding difficulty persists for 3 days, or weight loss greater than 10% of birth weight and no other problems, refer for breastfeeding counselling and management.
■ If difficult to keep body temperature within the normal range (36.5ºC to 37.5ºC): →Keep the baby in skin-to-skin contact with the mother as much as possible →If body temperature below 36.5ºC persists for 2 hours despite skin-to-skin contact with mother, assess the baby J2-J8 . ■ If breathing difficulty, assess the baby J2-J8 . ■ If jaundice, refer the baby for phototherapy. ■ If any maternal concern, assess the baby and respond to the mother J2-J8 .
■ If the mother and baby are not able to stay, ensure daily (home) visits or send to hospital.
N£w80kN 0Ak£
I12 Assess replacement feeding
ASS£SS k£PlA0£N£NI I££0IN0
If mother chose rep|acemeat feed|ag assess the feed|ag |a erer, hah, as part of the esam|aat|oa.
Adr|se the mother oa how to re||ere eagorgemeat K8 . If mother |s comp|a|a|ag of hreast pa|a, a|so assess the mother’s hreasts J9 .
ASK, CHECK RECORD
Ask the mother ■ What are you feeding the baby? ■ How are you feeding your baby? ■ Has your baby fed in the previous hour? ■ Is there any difficulty? ■ How much milk is baby taking per feed? ■ Is your baby satisfied with the feed? ■ Have you fed your baby any other foods or drinks? ■ Do you have any concerns?
If hah, more thaa oae da, o|d: ■ How many times has your baby fed in 24 hours? ■ How much milk is baby taking per day?
■ How do your breasts feel?
LOOK, LISTEN, FEEL
0hserre a feed ■ If the baby has not fed in the previous hour, ask the mother to feed the baby and observe feeding for about 5 minutes. Ask her to prepare the feed.
look ■ Is she holding the cup to the baby’s lips? ■ Is the baby alert, opens eyes and mouth? ■ Is the baby sucking and swallowing the milk effectively, spilling little?
If mother has fed in the last hour, ask her to tell you when her baby is willing to feed again.
SIGNS
■ Sucking and swallowing adequate amount of milk, spilling little. ■ Feeding 8 times in 24 hours on demand day and night.
■ Not yet fed (first 6 hours of life). ■ Not fed by cup. ■ Not sucking and swallowing effectively, spilling ■ Not feeding adequate amount per day. ■ Feeding less than 8 times per 24 hours. ■ Receiving other foods or drinks. ■ Several days old and inadequate weight gain.
■ Not sucking (after 6 hours of age). ■ Stopped feeding.
TREAT ANDADVISE
■ Encourage the mother to continue feeding by cup on demand K6 .
■ Teach the mother replacement feeding G8 . ■ Teach the mother cup feeding K6 . ■ Advise to feed more frequently, on demand, day and night. ■ Advise the mother to stop feeding the baby other foods or drinks or by bottle. ■ Reassess at the next feed or follow-up visit in 2 days.
■ kefer hah, argeat|, to hosp|ta| K14.
CLASSIFY
I££0IN0w£ll
I££0IN0 0IIII0ulIY
N0I A8l£ I0 I££0
J8 II Sw£llIN0, 8kuIS£S 0k
NAlI0kNAII0N
J9 ASS£SS Iߣ N0Iߣk’S 8k£ASIS II
00NPlAININ0 0I NIPPl£ 0k
8k£ASI PAIN
J10 0Ak£ 0I Iߣ N£w80kN
J11 A00III0NAl 0Ak£ 0I A
SNAll 8A8Y (0k IwIN}
J12 ASS£SS k£PlA0£N£NI I££0IN0
■ Examinineroutinelyallbabiesaroundanhourofbirth,for
discharge,atroutineandfollow-uppostnatalvisitsinthefirstweeks
oflife,andwhentheproviderormotherobservesdangersigns.
■ UsethechartAssessthemother’sbreastsifthemotheris
complainingofnippleorbreastpain J9 .
■ Duringthestayatthefacility,usetheCareofthenewbornchart
J10 .Ifthebabyissmallbutdoesnotneedreferral,alsousethe
Additionalcareforasmallbabyortwinchart J11 .
■ UsetheBreastfeeding,care,preventivemeasuresandtreatment
forthenewbornsectionsfordetailsofcare,resuscitationand
treatments K1-K13 .
■ UseAdviseonwhentoreturnwiththebabyK14foradvisingthe
motherwhentoreturnwiththebabyforroutineandfollow-up
visitsandtoseekcareorreturnifbabyhasdangersigns.Use
informationandcounsellingsheets M5-M6 .
■ Forcareatbirthandduringthefirsthoursoflife,useLabourand
deliveryD19.
AlS0 S££:
■ CounselonchoicesofinfantfeedingandHIV-relatedissues G7-G8 .
■ Equipment,suppliesanddrugs L1-L5 .
■ Records N1-N7 .
■ BabydiedD24.
Examine the newborn
N
£
w
8
0
k
N

0
A
k
£
ASK,CHECKRECORD
0heck materaa| aad
aewhora record or ask
the mother:
■ Howoldisthebaby?
■ Preterm(lessthan37weeks
or1monthormoreearly)?
■ Breechbirth?
■ Difficultbirth?
■ Resuscitatedatbirth?
■ Hasbabyhadconvulsions?
Ask the mother:
■ Doyouhaveconcerns?
■ Howisthebabyfeeding?
Is the mother rer, ||| or traasferred?
LOOK,LISTEN,FEEL
■ Assessbreathing(babymustbe
calm)
→ listenforgrunting
→countbreaths:arethey30-60
perminute?Repeatthecount
ifelevated
→lookatthechestforin-drawing.
■ Lookatthemovements:are
theynormalandsymmetrical?
■ Lookatthepresentingpart—
isthereswellingandbruises?
■ Lookatabdomenforpallor.
■ Lookformalformations.
■ Feelthetone:isitnormal?
■ Feelforwarmth.Ifcold,or
verywarm,measuretemperature.
■ Weighthebaby.
SIGNS
■ Normalweightbaby
(2500-gormore).
■ Feedingwell—sucklingeffectively
8timesin24hours,dayandnight.
■ Nodangersigns.
■ Nospecialtreatmentneedsor
treatmentcompleted.
■ Smallbaby,feedingwellandgaining
weightadequately.
■ Bodytemperature
35-36.4ºC.
■ Mothernotabletobreastfeed
duetoreceivingspecial
treatment.
■ Mothertransferred.
TREATANDADVISE
If f|rst esam|aat|oa:
■ Ensurecareforthenewborn J10 .
■ Examineagainfordischarge.
If pre-d|scharge esam|aat|oa:
■ ImmunizeifdueK13.
■ Adviseonbabycare K2 K9-K10 .
■ Adviseonroutinevisitatage3-7daysK14.
■ Adviseonwhentoreturnifdanger
signsK14.
■ Recordinhome-basedrecord.
■ Iffurthervisits,repeatadvices.
■ Re-warmthebabyskin-to-skin K9 .
■ Iftemperaturenotrisingafter2hours,reassess
thebaby.
■ Helpthemotherexpressbreastmilk K5 .
■ Consideralternativefeedingmethodsuntilmotheris
well K5-K6 .
■ Providecareforthebaby,ensurewarmth K9 .
■ Ensuremothercanseethebabyregularly.
■ Transferthebabywiththemotherifpossible.
■ Ensurecareforthebabyathome.
CLASSIFY
w£ll 8A8Y
NIl0
ßYP0IߣkNIA
N0Iߣk N0I A8l£
I0 IAk£ 0Ak£ I0k 8A8Y
N£XI:Ifpreterm,birthweight<2500gortwin
£XANIN£ Iߣ N£w80kN
use th|s chart to assess the aewhora after h|rth, c|ass|f, aad treat, poss|h|, aroaad aa hoar; for d|scharge (aot hefore 12 hoars}; aad dar|ag the f|rst week of ||fe at roa-
t|ae, fo||ow-ap, or s|ck aewhora r|s|t. kecord the f|ad|ags oa the postpartam record N6 .
A|wa,s esam|ae the hah, |a the preseace of the mother.
I2
t
If preterm, birth weight <2500 g or twin
ASK,CHECKRECORD
■ Babyjustborn.
■ Birthweight
→ <1500-g
→ 1500-gto<2500-g.
■ Preterm
→<32weeks
→33-36weeks.
■ Twin.
LOOK,LISTEN,FEEL
■ Ifthisisrepeatedvisit,
assessweightgain
SIGNS
■ Birthweight<1500g.
■ Verypreterm<32weeks
or>2monthsearly).
■ Birthweight1500g-<2500g.
■ Pretermbaby(32-36weeks
or1-2monthsearly).
■ Severaldaysoldand
weightgaininadequate.
■ Feedingdifficulty.
■ Twin
TREATANDADVISE
■ kefer hah, argeat|, to hosp|ta|K14.
■ Ensureextrawarmthduringreferral.
■ Givespecialsupporttobreastfeedthe
smallbaby K4 .
■ Ensureadditionalcareforasmallbaby J11 .
■ Reassessdaily J11 .
■ Donotdischargebeforefeedingwell,gainingweight
andbodytemperaturestable.
■ Iffeedingdifficultiespersistfor3daysand
otherwisewell,referforbreastfeedingcounselling.
■ Givespecialsupporttothemothertobreastfeed
twins K4 .
■ Donotdischargeuntilbothtwinscangohome.
CLASSIFY
V£kY SNAll 8A8Y
SNAll 8A8Y
IwIN
II Pk£I£kN, 8IkIß w£I0ßI <2500-0 0k IwIN
N
£
w
8
0
k
N

0
A
k
£
I3
N£XI:Assessbreastfeeding
t
Assess breastfeeding
N
£
w
8
0
k
N

0
A
k
£
ASK,CHECKRECORD
Ask the mother
■ Howisthebreastfeedinggoing?
■ Hasyourbabyfedintheprevious
hour?
■ Isthereanydifficulty?
■ Isyourbabysatisfiedwiththefeed?
■ Haveyoufedyourbabyanyother
foodsordrinks?
■ Howdoyourbreastsfeel?
■ Doyouhaveanyconcerns?
If hah, more thaa oae da, o|d:
■ Howmanytimeshasyourbabyfed
in24hours?
Toassessreplacementfeedingsee J12
.
LOOK,LISTEN,FEEL
■ 0hserre a hreastfeed.
Ifthebabyhasnotfedintheprevious
hour,askthemothertoputthe
babyonherbreastsandobserve
breastfeedingforabout5minutes.
look
■ Isthebabyabletoattachcorrectly?
■ Isthebabywell-positioned?
■ Isthebabysucklingeffectively?
Ifmotherhasfedinthelasthour,ask
hertotellyouwhenherbabyiswilling
tofeedagain.
SIGNS
■ Sucklingeffectively.
■ Breastfeeding8timesin24hours
ondemanddayandnight
■ Notyetbreastfed(firsthoursoflife).
■ Notwellattached.
■ Notsucklingeffectively.
■ Breastfeedinglessthan8timesper
24hours.
■ Receivingotherfoodsordrinks.
■ Severaldaysoldandinadequate
weightgain.
■ Notsuckling(after6hoursofage).
■ Stoppedfeeding.
TREATANDADVISE
■ Encouragethemothertocontinuebreastfeedingon
demand K3 .
■ Supportexclusivebreastfeeding K2-K3 .
■ Helpthemothertoinitiatebreastfeeding K3 .
■ Teachcorrectpositioningandattachment K3 .
■ Advisetofeedmorefrequently,dayandnight.
Reassureherthatshehasenoughmilk.
■ Advisethemothertostopfeedingthebabyother
foodsordrinks.
■ Reassessatthenextfeedorfollow-upvisitin2days.
■ kefer hah, argeat|, to hosp|ta|K14.
CLASSIFY
I££0IN0 w£ll
I££0IN0 0IIII0ulIY
N0I A8l£ I0 I££0
N£XI:Checkforspecialtreatmentneeds
ASS£SS 8k£ASII££0IN0
Assess hreastfeed|ag |a erer, hah, as part of the esam|aat|oa.
If mother |s comp|a|a|ag of a|pp|e or hreast pa|a, a|so assess the mother’s hreasts J9 .
I4
t
Check for special treatment needs
ASK,CHECKRECORD
0heck record for
spec|a| treatmeat aeeds
■ Hasthemotherhad
within2daysofdelivery:
→fever>38ºC?
→infectiontreatedwithantibiotics?
■ Membranesruptured>18hours
beforedelivery?
■ MothertestedRPR-positive?
■ MothertestedHIV-positive?
→isorhasbeenonARV
→hasshereceived
infantfeedingcounselling?
■ IsthemotherreceivingTBtreatment
whichbegan<2monthsago?
LOOK,LISTEN,FEEL SIGNS
■ Baby<1dayoldandmembranes
ruptured>18hoursbeforedelivery,
or
■ Motherbeingtreatedwith
antibioticsforinfection,
or
■ Motherhasfever>38ºC.
■ MothertestedRPR-positive.
■ MotherknowntobeHIV-positive.
■ Motherhasnotbeen
counselledoninfantfeeding.
■ Motherchosebreastfeeding.
■ Motherchosereplacementfeeding.

■ MotherstartedTBtreatment
<2monthsbeforedelivery.
TREATANDADVISE
■ Givebaby2IMantibioticsfor5daysK12.
■ Assessbabydaily J2-J7 .
■ GivebabysingledoseofbenzathinepenicillinK12.
■ Ensuremotherandpartneraretreated F6 .
■ Followupin2weeks.
■ GiveARVtothenewborn G9
.
■ Counseloninfantfeedingoptions G7
.
■ Givespecialcounsellingtomotherwhoisbreast
feeding G8
.
■ Teachthemotherreplacementfeeding.
■ Followupin2weeks G8
.
■ Givebabyisoniazidpropylaxisfor6monthsK13.
■ GiveBCGvaccinationtothebabyonlywhenbaby’s
treatmentcompleted.
■ Followupin2weeks.
CLASSIFY
kISk 0I
8A0I£kIAl INI£0II0N
kISk 0I
00N0£NIIAl SYPßIlIS
kISk 0I
ßIV IkANSNISSI0N
kISk 0I
Iu8£k0ul0SIS
N£XI:Lookforsignsofjaundiceandlocalinfection
0ߣ0k I0k SP£0IAl Ik£AIN£NI N££0S
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Look for signs of jaundice and local infection
N
£
w
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k
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0
A
k
£
ASK,CHECKRECORD
■ Whathasbeenappliedtothe
umbilicus?
LOOK,LISTEN,FEEL
■ Lookattheskin,isityellow?
→ifbabyislessthan24hoursold,
lookatskinontheface
→ifbabyis24hoursoldormore,
lookatpalmsandsoles.
■ Lookattheeyes.Aretheyswollen
anddrainingpus?
■ Lookattheskin,especiallyaround
theneck,armpits,inguinalarea:
→Arethereskinpustules?
→Isthereswelling,hardnessor
largebullae?
■ Lookattheumbilicus:
→Isitred?
→Drainingpus?
→Doesrednessextendtotheskin?
SIGNS
■ Yellowskinonfaceand
only<24hoursold.
■ Yellowpalmsandsolesand
≥24hoursold.
■ Eyesswollenanddrainingpus.
■ Redumbilicusorskinaroundit.
■ Lessthan10pustules
TREATANDADVISE
■ kefer hah, argeat|, to hosp|ta|K14.
■ Encouragebreastfeedingontheway.
■ Iffeedingdifficulty,giveexpressedbreastmilkbycup K6 .
■ Givesingledoseofappropriateantibioticforeye
infectionK12.
■ TeachmothertotreateyesK13.
■ Followupin2days.Ifnoimprovementorworse,
referurgentlytohospital.
■ Assessandtreatmotherandherpartnerforpossible
gonorrhea E8 .
■ TeachmothertotreatumbilicalinfectionK13.
■ Ifnoimprovementin2days,orifworse,refer
urgentlytohospital.
■ TeachmothertotreatskininfectionK13.
■ Followupin2days.
■ Ifnoimprovementofpustulesin2daysormore,
referurgentlytohospital.
CLASSIFY
IAuN0I0£
00N00000Al
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l00Al
uN8IlI0Al
INI£0II0N
l00Al SkIN
INI£0II0N
N£XI:Ifdangersigns
l00k I0k SI0NS 0I IAuN0I0£ AN0 l00Al INI£0II0N
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If danger signs
SIGNS
Aa, of the fo||ow|ag s|gas:
■ Fastbreathing
(morethan60breathsperminute).
■ Slowbreathing
(lessthan30breathsperminute).
■ Severechestin-drawing
■ Grunting
■ Convulsions.
■ Floppyorstiff.
■ Fever(temperature>38ºC).
■ Temperature<35ºCornotrising
afterrewarming.
■ Umbilicusdrainingpusorumbilical
rednessextendingtoskin.
■ Morethan10skinpustules
orbullae,orswelling,redness,
hardnessofskin.
■ Bleedingfromstumporcut.
■ Pallor.
TREATANDADVISE
■ Givefirstdoseof2IMantibioticsK12.
■ kefer hah, argeat|, to hosp|ta|K14.
Ia add|t|oa:
■ Re-warmandkeepwarmduringreferral K9 .
■ TreatlocalumbilicalinfectionbeforereferralK13.
■ TreatskininfectionbeforereferralK13.
■ Stopthebleeding.
CLASSIFY
P0SSI8l£
S£kI0uS
IllN£SS
N£XI:Ifswelling,bruisesormalformation
II 0AN0£k SI0NS
N
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w
8
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£
I7
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If swelling, bruises or malformation
N
£
w
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k
N

0
A
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£
SIGNS
■ Bruises,swellingonbuttocks.
■ Swollenhead—bumpon
oneorbothsides.
■ Abnormalpositionoflegs
(afterbreechpresentation).
■ Asymmetricalarmmovement,
armdoesnotmove.
■ Clubfoot
■ Cleftpalateorlip
■ Oddlooking,unusualappearance
■ Opentissueonhead,
abdomenorback
■ Otherabnormalappearance.
TREATANDADVISE
■ Explaintoparentsthatitdoesnothurtthebaby,
itwilldisappearinaweekortwoandnospecial
treatmentisneeded.
■ DONOTforcelegsintoadifferentposition.
■ Gentlyhandlethelimbthatisnotmoving,
donotpull.
■ Referforspecialtreatmentifavailable.
■ Helpmothertobreastfeed.Ifnotsuccessful,
teachheralternativefeedingmethods K5-K6 .
Plantofollowup.
■ Adviseonsurgicalcorrectionatageofseveralmonths.
■ Referforspecialevaluation.
■ Coverwithsteriletissuessoakedwith
sterilesalinesolutionbeforereferral.
■ Referforspecialtreatmentifavailable.
■ Manageaccordingtonationalguidelines.
CLASSIFY
8IkIß INIukY
NAlI0kNAII0N
S£V£k£
NAlI0kNAII0N
N£XI:Assessthemother’sbreastsifcomplainingofnippleorbreastpain
II Sw£llIN0, 8kuIS£S 0k NAlI0kNAII0N
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N£XI:Careofthenewborn
Assess the mother’s breasts if complaining of nipple or breast pain
ASK,CHECKRECORD
■ Howdoyourbreastsfeel?
LOOK,LISTEN,FEEL
■ Lookatthenippleforfissure
■ Lookatthebreastsfor:
→swelling
→shininess
→redness.
■ Feelgentlyforpainfulpartofthe
breast.
■ Measuretemperature.
■ Observeabreastfeed
ifnotyetdone J4 .
SIGNS
■ Noswelling,rednessortenderness.
■ Normalbodytemperature.
■ Nipplenotsoreandnofissure
visible.
■ Babywellattached.
■ Nipplesoreorfissured.
■ Babynotwellattached.
■ Bothbreastsareswollen,
shinyandpatchyred.
■ Temperature<38ºC.
■ Babynotwellattached.
■ Notyetbreastfeeding.
■ Partofbreastispainful,
swollenandred.
■ Temperature>38ºC
■ Feelsill.
TREATANDADVISE
■ Reassurethemother.
■ Encouragethemothertocontinuebreastfeeding.
■ Teachcorrectpositioningandattachment K3 .
■ Reassessafter2feeds(or1day).Ifnotbetter,
teachthemotherhowtoexpressbreastmilkfrom
theaffectedbreastandfeedbabybycup,and
continuebreastfeedingonthehealthyside.
■ Encouragethemothertocontinuebreastfeeding.
■ Teachcorrectpositioningandattachment K3 .
■ Advisetofeedmorefrequently.
■ Reassessafter2feeds(1day).Ifnotbetter,teach
motherhowtoexpressenoughbreastmilkbefore
thefeedtorelievediscomfort K5 .
■ Encouragemothertocontinuebreastfeeding.
■ Teachcorrectpositioningandattachment K3 .
■ Givecloxacillinfor10days F5 .
■ Reassessin2days.Ifnoimprovementorworse,
refertohospital.
■ IfmotherisHIV+letherbreastfeedonthehealthy
breast.Expressmilkfromtheaffectedbreastand
discarduntilnofever K5 .
■ Ifseverepain,giveparacetamol F4 .
CLASSIFY
8k£ASIS
ߣAlIßY
NIPPl£
S0k£N£SS
0k IISSuk£
8k£ASI
£N00k0£N£NI
NASIIIIS
ASS£SS Iߣ N0Iߣk’S 8k£ASIS II 00NPlAININ0 0I NIPPl£ 0k 8k£ASI PAIN
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0Ak£ 0I Iߣ N£w80kN
use th|s chart for care of a|| hah|es aat|| d|scharge.
Care of the newborn
N
£
w
8
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N

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A
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£
I10
CAREANDMONITORING
■ Ensuretheroomiswarm(notlessthan25ºCandnodraught).
■ Keepthebabyintheroomwiththemother,inherbedorwithineasyreach.
■ Letthemotherandbabysleepunderabednet.
■ Supportexclusivebreastfeedingondemanddayandnight.
■ Askthemothertoalertyouifbreastfeedingdifficulty.
■ Assessbreastfeedingineverybabybeforeplanningfordischarge.
00 N0Idischargeifbabyisnotyetfeedingwell.
■ Teachthemotherhowtocareforthebaby.
→Keepthebabywarm K9
→GivecordcareK10
→EnsurehygieneK10
.
00 N0Iexposethebabyindirectsun.
00 N0Iputthebabyonanycoldsurface.
00 N0Ibaththebabybefore6hours.
■ Askthemotherandcompaniontowatchthebabyandalertyouif
→Feetcold
→Breathingdifficulty:grunting,fastorslowbreathing,chestin-drawing
→Anybleeding.
■ GiveprescribedtreatmentsaccordingtothescheduleK12.
■ Examineeverybabybeforeplanningtodischargemotherandbaby J2-J9 .
00 N0Idischargebeforebabyis12hoursold.
RESPONDTOABNORMALFINDINGS
■ Ifthebabyisinacot,ensurebabyisdressedorwrappedandcoveredbyablanket.
Covertheheadwithahat.
■ Ifmotherreportsbreastfeedingdifficulty,assessbreastfeedingandhelpthemotherwithpositioning
andattachment J3
■ Ifthemotherisunabletotakecareofthebaby,providecareorteachthecompanionK9-K10
■ Washhandsbeforeandafterhandlingthebaby.
■ Iffeetarecold:
→Teachthemothertoputthebabyskin-to-skinK13.
→Reassessin1hour;iffeetstillcold,measuretemperatureandre-warmthebaby K9
.
■ Ifbleedingfromcord,checkiftieislooseandretiethecord.
■ Ifotherbleeding,assessthebabyimmediately J2-J7
.
■ Ifbreathingdifficultyormotherreportsanyotherabnormality,examinethebabyason J2-J7
.
N£XI:Additionalcareofasmallbaby(ortwin)
t
A00III0NAl 0Ak£ 0I A SNAll 8A8Y (0k IwIN}
use th|s chart for add|t|oaa| care of a sma|| hah,: preterm, 1-2 moaths ear|, or we|gh|ag 1500g-<2500g. kefer to hosp|ta| a rer, sma|| hah,: >2 moaths ear|,, we|gh|ag <1500g
Additional care of a small baby (twin)
N
£
w
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N

0
A
k
£
I11
CAREANDMONITORING
■ Plantokeepthesmallbabylongerbeforedischarging.
■ Allowvisitstothemotherandbaby.
■ Givespecialsupportforbreastfeedingthesmallbaby(ortwins) K4 :
→Encouragethemothertobreastfeedevery2-3hours.
→Assessbreastfeedingdaily:attachment,suckling,durationandfrequencyoffeeds,andbaby
satisfactionwiththefeed J4 K6
.
→Ifalternativefeedingmethodisused,assessthetotaldailyamountofmilkgiven.
→Weighdailyandassessweightgain K7
.
■ Ensureadditionalwarmthforthesmallbaby K9 :
→Ensuretheroomisverywarm(25º–28ºC).
→Teachthemotherhowtokeepthesmallbabywarminskin-to-skincontact
→Provideextrablanketsformotherandbaby.
■ Ensurehygiene K10 .
00 N0Ibaththesmallbaby.Washasneeded.
■ Assessthesmallbabydaily:
→Measuretemperature
→Assessbreathing(babymustbequiet,notcrying):listenforgrunting;countbreathsperminute,
repeatthecountif>60or<30;lookforchestin-drawing
→Lookforjaundice(first10daysoflife):first24hoursontheabdomen,thenonpalmsandsoles.
■ Plantodischargewhen:
→Breastfeedingwell
→Gainingweightadequatelyon3consecutivedays
→Bodytemperaturebetween36.5ºand37.5ºCon3consecutivedays
→Motherableandconfidentincaringforthebaby
→Nomaternalconcerns.
■ Assessthebabyfordischarge.
RESPONSETOABNORMALFINDINGS
■ Ifthesmallbabyisnotsucklingeffectivelyanddoesnothaveotherdangersigns,consider
alternativefeedingmethods K5-K6 .
→Teachthemotherhowtohandexpressbreastmilkdirectlyintothebaby’smouth K5
→Teachthemothertoexpressbreastmilkandcupfeedthebaby K5-K6
→Determineappropriateamountfordailyfeedsbyage K6 .
■ Iffeedingdifficultypersistsfor3days,orweightlossgreaterthan10%ofbirthweightand
nootherproblems,referforbreastfeedingcounsellingandmanagement.
■ Ifdifficulttokeepbodytemperaturewithinthenormalrange(36.5ºCto37.5ºC):
→Keepthebabyinskin-to-skincontactwiththemotherasmuchaspossible
→Ifbodytemperaturebelow36.5ºCpersistsfor2hoursdespiteskin-to-skincontactwithmother,
assessthebaby J2-J8 .
■ Ifbreathingdifficulty,assessthebaby J2-J8 .
■ Ifjaundice,referthebabyforphototherapy.
■ Ifanymaternalconcern,assessthebabyandrespondtothemother J2-J8 .
■ Ifthemotherandbabyarenotabletostay,ensuredaily(home)visitsorsendtohospital.
N
£
w
8
0
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I12
Assess replacement feeding
ASS£SS k£PlA0£N£NI I££0IN0
If mother chose rep|acemeat feed|ag assess the feed|ag |a erer, hah, as part of the esam|aat|oa.
Adr|se the mother oa how to re||ere eagorgemeat K8 . If mother |s comp|a|a|ag of hreast pa|a, a|so assess the mother’s hreasts J9 .
ASK,CHECKRECORD
Ask the mother
■ Whatareyoufeedingthebaby?
■ Howareyoufeedingyourbaby?
■ Hasyourbabyfedintheprevious
hour?
■ Isthereanydifficulty?
■ Howmuchmilkisbabytakingper
feed?
■ Isyourbabysatisfiedwiththefeed?
■ Haveyoufedyourbabyanyother
foodsordrinks?
■ Doyouhaveanyconcerns?
If hah, more thaa oae da, o|d:
■ Howmanytimeshasyourbabyfed
in24hours?
■ Howmuchmilkisbabytakingper
day?
■ Howdoyourbreastsfeel?
LOOK,LISTEN,FEEL
0hserre a feed
■ Ifthebabyhasnotfedinthe
previoushour,askthemotherto
feedthebabyandobservefeeding
forabout5minutes.Askherto
preparethefeed.
look
■ Issheholdingthecuptothebaby’s
lips?
■ Isthebabyalert,openseyesand
mouth?
■ Isthebabysuckingandswallowing
themilkeffectively,spillinglittle?
Ifmotherhasfedinthelasthour,ask
hertotellyouwhenherbabyiswilling
tofeedagain.
SIGNS
■ Suckingandswallowingadequate
amountofmilk,spillinglittle.
■ Feeding8timesin24hourson
demanddayandnight.
■ Notyetfed(first6hoursoflife).
■ Notfedbycup.
■ Notsuckingandswallowingeffectively,
spilling
■ Notfeedingadequateamountperday.
■ Feedinglessthan8timesper24
hours.
■ Receivingotherfoodsordrinks.
■ Severaldaysoldandinadequate
weightgain.
■ Notsucking(after6hoursofage).
■ Stoppedfeeding.
TREATANDADVISE
■ Encouragethemothertocontinuefeedingbycupon
demand K6 .
■ Teachthemotherreplacementfeeding G8 .
■ Teachthemothercupfeeding K6 .
■ Advisetofeedmorefrequently,ondemand,dayand
night.
■ Advisethemothertostopfeedingthebabyotherfoods
ordrinksorbybottle.
■ Reassessatthenextfeedorfollow-upvisitin2days.
■ kefer hah, argeat|, to hosp|ta|K14.
CLASSIFY
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I££0IN0 0IIII0ulIY
N0I A8l£ I0 I££0
Breastfeeding, care, preventive measures and treatment for the newborn
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Breastfeeding, care, preventive measures and treatment for the newBorn
Counsel on breastfeeding (1)
Breastfeeding, care, preventive measures and treatment for the newBorn
K2
counsel on Breastfeeding
Counsel on importance of exclusive breastfeeding
during pregnancy and after birth
include partner or other family memBers if possiBle
explain to the mother that: ■ Breast milk contains exactly the nutrients a baby needs →is easily digested and efficiently used by the baby’s body →protects a baby against infection. ■ Babies should start breastfeeding within 1 hour of birth. They should not have any other food or drink before they start to breastfeed. ■ Babies should be exclusively breastfed for the first 6 months of life.
■ Breastfeeding →helps baby’s development and mother/baby attachment →can help delay a new pregnancy (see d27 for breastfeeding and family planning).
For counselling if mother HIV-positive, see g7 .
Help the mother to initiate breastfeeding
within 1 hour, when baby is ready
■ After birth, let the baby rest comfortably on the mother’s chest in skin-to-skin contact. ■ Tell the mother to help the baby to her breast when the baby seems to be ready, usually within the first hour. Signs of readiness to breastfeed are: →baby looking around/moving →mouth open →searching. ■ Check that position and attachment are correct at the first feed. Offer to help the mother at any time K3 . ■ Let the baby release the breast by her/himself; then offer the second breast. ■ If the baby does not feed in 1 hour, examine the baby J2–J9. If healthy, leave the baby with the mother to try later. Assess in 3 hours, or earlier if the baby is small J4 . ■ If the mother is ill and unable to breastfeed, help her to express breast milk and feed the baby by cup K6 . On day 1 express in a spoon and feed by spoon. ■ If mother cannot breastfeed at all, use one of the following options: →donated heat-treated breast milk. →If not available, then commercial infant formula. →If not available, then home-made formula from modified animal milk.
Counsel on breastfeeding (2)
Breastfeeding, care, preventive measures and treatment for the newBorn
K3
Support exclusive breastfeeding
■ Keep the mother and baby together in bed or within easy reach. do not separate them. ■ Encourage breastfeeding on demand, day and night, as long as the baby wants. →A baby needs to feed day and night, 8 or more times in 24 hours from birth. Only on the first day may a full-term baby sleep many hours after a good feed. →A small baby should be encouraged to feed, day and night, at least 8 times in 24 hours from birth. ■ Help the mother whenever she wants, and especially if she is a first time or adolescent mother. ■ Let baby release the breast, then offer the second breast. ■ If mother must be absent, let her express breast milk and let somebody else feed the expressed breast milk to the baby by cup.
do not force the baby to take the breast. do not interrupt feed before baby wants. do not give any other feeds or water. do not use artificial teats or pacifiers.
■ Advise the mother on medication and breastfeeding →Most drugs given to the mother in this guide are safe and the baby can be breastfed. →If mother is taking cotrimoxazole or fansidar, monitor baby for jaundice.
Teach correct positioning and attachment
for breastfeeding
■ Show the mother how to hold her baby. She should: →make sure the baby’s head and body are in a straight line →make sure the baby is facing the breast, the baby’s nose is opposite her nipple →hold the baby’s body close to her body →support the baby’s whole body, not just the neck and shoulders ■ Show the mother how to help her baby to attach. She should: →touch her baby’s lips with her nipple →wait until her baby’s mouth is opened wide →move her baby quickly onto her breast, aiming the infant’s lower lip well below the nipple. ■ Look for signs of good attachment: → more of areola visible above the baby's mouth →mouth wide open →lower lip turned outwards →baby's chin touching breast ■ Look for signs of effective suckling (that is, slow, deep sucks, sometimes pausing). ■ If the attachment or suckling is not good, try again. Then reassess. ■ If breast engorgement, express a small amount of breast milk before starting breastfeeding to soften nipple area so that it is easier for the baby to attach.
if mother is hiv-positive, see g7 for special counselling to the mother who is hiv-positive and breastfeeding.
if mother chose replacement feedings, see g8 .
Counsel on breastfeeding (3)
Breastfeeding, care, preventive measures and treatment for the newBorn
K4
counsel on Breastfeeding
Give special support to breastfeed
the small baby (preterm and/or low birth weight)
counsel the mother: ■ Reassure the mother that she can breastfeed her small baby and she has enough milk. ■ Explain that her milk is the best food for such a small baby. Feeding for her/him is even more important than for a big baby. ■ Explain how the milk’s appearance changes: milk in the first days is thick and yellow, then it becomes thinner and whiter. Both are good for the baby. ■ A small baby does not feed as well as a big baby in the first days: →may tire easily and suck weakly at first →may suckle for shorter periods before resting →may fall asleep during feeding →may have long pauses between suckling and may feed longer →does not always wake up for feeds. ■ Explain that breastfeeding will become easier if the baby suckles and stimulates the breast her/ himself and when the baby becomes bigger. ■ Encourage skin-to-skin contact since it makes breastfeeding easier.
help the mother: ■ Initiate breastfeeding within 1 hour of birth. ■ Feed the baby every 2-3 hours. Wake the baby for feeding, even if she/he does not wake up alone, 2 hours after the last feed. ■ Always start the feed with breastfeeding before offering a cup. If necessary, improve the milk flow (let the mother express a little breast milk before attaching the baby to the breast). ■ Keep the baby longer at the breast. Allow long pauses or long, slow feed. Do not interrupt feed if the baby is still trying. ■ If the baby is not yet suckling well and long enough, do whatever works better in your setting: →Let the mother express breast milk into baby’s mouth K5 . →Let the mother express breast milk and feed baby by cup K6 . On the first day express breast milk into, and feed colostrum by spoon. ■ Teach the mother to observe swallowing if giving expressed breast milk. ■ Weigh the baby daily (if accurate and precise scales available), record and assess weight gain K7 .
Give special support to breastfeed twins
counsel the mother: ■ Reassure the mother that she has enough breast milk for two babies. ■ Encourage her that twins may take longer to establish breastfeeding since they are frequently born preterm and with low birth weight.
help the mother: ■ Start feeding one baby at a time until breastfeeding is well established. ■ Help the mother find the best method to feed the twins: →If one is weaker, encourage her to make sure that the weaker twin gets enough milk. →If necessary, she can express milk for her/him and feed her/him by cup after initial breastfeeding. →Daily alternate the side each baby is offered.
Counsel on breastfeeding (3)
Breastfeeding, care, preventive measures and treatment for the newBorn
K4
counsel on Breastfeeding
Give special support to breastfeed
the small baby (preterm and/or low birth weight)
counsel the mother: ■ Reassure the mother that she can breastfeed her small baby and she has enough milk. ■ Explain that her milk is the best food for such a small baby. Feeding for her/him is even more important than for a big baby. ■ Explain how the milk’s appearance changes: milk in the first days is thick and yellow, then it becomes thinner and whiter. Both are good for the baby. ■ A small baby does not feed as well as a big baby in the first days: →may tire easily and suck weakly at first →may suckle for shorter periods before resting →may fall asleep during feeding →may have long pauses between suckling and may feed longer →does not always wake up for feeds. ■ Explain that breastfeeding will become easier if the baby suckles and stimulates the breast her/ himself and when the baby becomes bigger. ■ Encourage skin-to-skin contact since it makes breastfeeding easier.
help the mother: ■ Initiate breastfeeding within 1 hour of birth. ■ Feed the baby every 2-3 hours. Wake the baby for feeding, even if she/he does not wake up alone, 2 hours after the last feed. ■ Always start the feed with breastfeeding before offering a cup. If necessary, improve the milk flow (let the mother express a little breast milk before attaching the baby to the breast). ■ Keep the baby longer at the breast. Allow long pauses or long, slow feed. Do not interrupt feed if the baby is still trying. ■ If the baby is not yet suckling well and long enough, do whatever works better in your setting: →Let the mother express breast milk into baby’s mouth K5 . →Let the mother express breast milk and feed baby by cup K6 . On the first day express breast milk into, and feed colostrum by spoon. ■ Teach the mother to observe swallowing if giving expressed breast milk. ■ Weigh the baby daily (if accurate and precise scales available), record and assess weight gain K7 .
Give special support to breastfeed twins
counsel the mother: ■ Reassure the mother that she has enough breast milk for two babies. ■ Encourage her that twins may take longer to establish breastfeeding since they are frequently born preterm and with low birth weight.
help the mother: ■ Start feeding one baby at a time until breastfeeding is well established. ■ Help the mother find the best method to feed the twins: →If one is weaker, encourage her to make sure that the weaker twin gets enough milk. →If necessary, she can express milk for her/him and feed her/him by cup after initial breastfeeding. →Daily alternate the side each baby is offered.
Alternative feeding methods (2)
Breastfeeding, care, preventive measures and treatment for the newBorn
K6
alternative feeding methods
Cup feeding expressed breast milk
■ Teach the mother to feed the baby with a cup. Do not feed the baby yourself. The mother should: ■ Measure the quantity of milk in the cup ■ Hold the baby sitting semi-upright on her lap ■ Hold the cup of milk to the baby’s lips: →rest cup lightly on lower lip →touch edge of cup to outer part of upper lip →tip cup so that milk just reaches the baby’s lips →but do not pour the milk into the baby’s mouth. ■ Baby becomes alert, opens mouth and eyes, and starts to feed. ■ The baby will suck the milk, spilling some. ■ Small babies will start to take milk into their mouth using the tongue. ■ Baby swallows the milk. ■ Baby finishes feeding when mouth closes or when not interested in taking more. ■ If the baby does not take the calculated amount: →Feed for a longer time or feed more often →Teach the mother to measure the baby’s intake over 24 hours, not just at each feed. ■ If mother does not express enough milk in the first few days, or if the mother cannot breastfeed at all, use one of the following feeding options: →donated heat-treated breast milk →home-made or commercial formula. ■ Feed the baby by cup if the mother is not available to do so. ■ Baby is cup feeding well if required amount of milk is swallowed, spilling little, and weight gain is maintained.
Quantity to feed by cup
■ Start with 80 ml/kg body weight per day for day 1. Increase total volume by 10-20 ml/kg per day, until baby takes 150 ml/kg/day. See table below. ■ Divide total into 8 feeds. Give every 2-3 hours to a small size or ill baby. ■ Check the baby’s 24 hour intake. Size of individual feeds may vary. ■ Continue until baby takes the required quantity. ■ Wash the cup with water and soap after each feed.
approximate quantity to feed By cup (in ml) every 2-3 hours fromBirth (By weight)
weight (kg) day 0 2 3 4 5 6 7
.5-.9 15ml 17ml 19ml 21ml 23ml 25ml 27ml 27+ml
2.0-2.4 20ml 22ml 25ml 27ml 30ml 32ml 35ml 35+ml
2.5+ 25ml 28ml 30ml 35ml 35ml 40+ml 45+ml 50+ml
Signs that baby is receiving
adequate amount of milk
■ Baby is satisfied with the feed. ■ Weight loss is less than 10% in the first week of life. ■ Baby gains at least 160-g in the following weeks or a minimum 300-g in the first month. ■ Baby wets every day as frequently as baby is feeding. ■ Baby’s stool is changing from dark to light brown or yellow by day 3.
Weigh and assess weight gain
Breastfeeding, care, preventive measures and treatment for the newBorn
K7
weighand assess weight gain
Weigh baby in the first month of life
weighthe BaBy ■ Monthly if birth weight normal and breastfeeding well. Every 2 weeks if replacement feeding or treatment with isoniazid. ■ When the baby is brought for examination because not feeding well, or ill.
weighthe small BaBy ■ Every day until 3 consecutive times gaining weight (at least 15-g/day). ■ Weekly until 4-6 weeks of age (reached term).
Assess weight gain
use this table for guidance when assessing weight gain in the first month of life
age acceptable weight loss/gain in the first month of life
week Loss up to 10%
2-4 weeks Gain at least 160 g per week (at least 15 g/day)
month Gain at least 300 g in the first month
if weighing daily with a precise and accurate scale
first week No weight loss or total less than 10%
afterward daily gain in small babies at least 20 g
Scale maintenance
Daily/weekly weighing requires precise and accurate scale (10-g increment): →Calibrate it daily according to instructions. →Check it for accuracy according to instructions.
Simple spring scales are not precise enough for daily/weekly weighing.
K2

counsel on Breastfeeding ()
Counselonimportanceofexclusivebreast
feeding
Helpthemothertoinitiatebreastfeeding
K3

counsel on Breastfeeding (2)
Supportexclusivebreastfeeding
Teachcorrectpositioningandattachmentfor
breastfeeding
K4

counsel on Breastfeeding (3)
Givespecialsupporttobreastfeedthesmall
baby(pretermand/orlowbirthweight)
Givespecialsupporttobreastfeedtwins
K5

alternative
feeding methods ()
Expressbreastmilk
Handexpressbreastmilkdirectlyintothe
baby’smouth
K6

alternative
feeding methods (2)
Cupfeedingexpressedbreastmilk
Quantitytofeedbycup
Signsthatbabyisreceivingadequateamount
ofmilk
K7

weigh and assess weight gain
Weighbabyinthefirstmonthoflife
Assessweightgain
Scalemaintenance
Other breastfeeding support
Breastfeeding, care, preventive measures and treatment for the newBorn
K8
other Breastfeeding support
Give special support to the mother
who is not yet breastfeeding
(mother or baby ill, or baby too small to suckle) ■ Teach the mother to express breast milk K5 . Help her if necessary. ■ Use the milk to feed the baby by cup. ■ If mother and baby are separated, help the mother to see the baby or inform her about the baby’s condition at least twice daily. ■ If the baby was referred to another institution, ensure the baby gets the mother’s expressed breast milk if possible. ■ Encourage the mother to breastfeed when she or the baby recovers.
If the baby does not have a mother
■ Give donated heat treated breast milk or home-based or commercial formula by cup. ■ Teach the carer how to prepare milk and feed the baby K6 . ■ Follow up in 2 weeks; weigh and assess weight gain.
Advise the mother who is not breastfeeding
at all on how to relieve engorgement
(Baby died or stillborn, mother chose replacement feeding) ■ Breasts may be uncomfortable for a while. ■ Avoid stimulating the breasts. ■ Support breasts with a well-fitting bra or cloth. Do not bind the breasts tightly as this may increase her discomfort. ■ Apply a compress. Warmth is comfortable for some mothers, others prefer a cold compress to reduce swelling. ■ Teach the mother to express enough milk to relieve discomfort. Expressing can be done a few times a day when the breasts are overfull. It does not need to be done if the mother is uncomfortable. It will be less than her baby would take and will not stimulate increased milk production. ■ Relieve pain. An analgesic such as ibuprofen, or paracetamol may be used. Some women use plant products such as teas made from herbs, or plants such as raw cabbage leaves placed directly on the breast to reduce pain and swelling. ■ Advise to seek care if breasts become painful, swollen, red, if she feels ill or temperature greater than 38ºC.
pharmacological treatments to reduce milk supply are not recommended. The above methods are considered more effective in the long term.
Ensure warmth for the baby
Breastfeeding, care, preventive measures and treatment for the newBorn
K9
ensure warmth for the BaBy
Keep the baby warm
at Birthand within the first hour(s) ■ Warmdelivery room: for the birth of the baby the roomtemperature should be 25-28ºC, no draught. ■ Dry baby: immediately after birth, place the baby on the mother’s abdomen or on a warm, clean and dry surface. Dry the whole body and hair thoroughly, with a dry cloth. ■ Skin-to-skin contact: Leave the baby on the mother’s abdomen (before cord cut) or chest (after cord cut) after birth for at least 2 hours. Cover the baby with a soft dry cloth. ■ If the mother cannot keep the baby skin-to-skin because of complications, wrap the baby in a clean, dry, warmcloth and place in a cot. Cover with a blanket. Use a radiant warmer if roomnot warmor baby small.
suBsequently (first day) ■ Explain to the mother that keeping baby warmis important for the baby to remain healthy. ■ Dress the baby or wrap in soft dry clean cloth. Cover the head with a cap for the first fewdays, especially if baby is small. ■ Ensure the baby is dressed or wrapped and covered with a blanket. ■ Keep the baby within easy reach of the mother. Do not separate them(rooming-in). ■ If the mother and baby must be separated, ensure baby is dressed or wrapped and covered with a blanket. ■ Assess warmth every 4 hours by touching the baby’s feet: if feet are cold use skin-to-skin contact, add extra blanket and reassess (see Rewarmthe newborn). ■ Keep the roomfor the mother and baby warm. If the roomis not warmenough, always cover the baby with a blanket and/or use skin-to-skin contact.
at home ■ Explain to the mother that babies need one more layer of clothes than other children or adults. ■ Keep the roomor part of the roomwarm, especially in a cold climate. ■ During the day, dress or wrap the baby. ■ At night, let the baby sleep with the mother or within easy reach to facilitate breastfeeding.
do not put the baby on any cold or wet surface. do not bath the baby at birth. Wait at least 6 hours before bathing. do not swaddle – wrap too tightly. Swaddling makes them cold. do not leave the baby in direct sun.
Keep a small baby warm
■ The room for the baby should be warm (not less than 25°C) with no draught. ■ Explain to the mother the importance of warmth for a small baby. ■ After birth, encourage the mother to keep the baby in skin-to-skin contact as long as possible. ■ Advise to use extra clothes, socks and a cap, blankets, to keep the baby warm or when the baby is not with the mother. ■ Wash or bath a baby in a very warm room, in warm water. After bathing, dry immediately and thoroughly. Keep the baby warm after the bath. Avoid bathing small babies. ■ Check frequently if feet are warm. If cold, rewarm the baby (see below). ■ Seek care if the baby’s feet remain cold after rewarming.
Rewarm the baby skin-to-skin
■ Before rewarming, remove the baby’s cold clothing. ■ Place the newborn skin-to-skin on the mother’s chest dressed in a pre-warmed shirt open at the front, a nappy (diaper), hat and socks. ■ Cover the infant on the mother’s chest with her clothes and an additional (pre-warmed) blanket. ■ Check the temperature every hour until normal. ■ Keep the baby with the mother until the baby’s body temperature is in normal range. ■ If the baby is small, encourage the mother to keep the baby in skin-to-skin contact for as long as possible, day and night. ■ Be sure the temperature of the room where the rewarming takes place is at least 25°C. ■ If the baby’s temperature is not 36.5ºC or more after 2 hours of rewarming, reassess the baby J2–J7 . ■ If referral needed, keep the baby in skin-to-skin position/contact with the mother or other person accompanying the baby.
Other baby care
Breastfeeding, care, preventive measures and treatment for the newBorn
K0
other BaBy care
always wash hands before and after taking care of the baby. do not share supplies with other babies.
Cord care
■ Wash hands before and after cord care. ■ Put nothing on the stump. ■ Fold nappy (diaper) below stump. ■ Keep cord stump loosely covered with clean clothes. ■ If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth. ■ If umbilicus is red or draining pus or blood, examine the baby and manage accordingly J2–J7 . ■ Explain to the mother that she should seek care if the umbilicus is red or draining pus or blood.
do not bandage the stump or abdomen. do not apply any substances or medicine to stump. Avoid touching the stump unnecessarily.
Sleeping
■ Use the bednet day and night for a sleeping baby. ■ Let the baby sleep on her/his back or on the side. ■ Keep the baby away from smoke or people smoking. ■ Keep the baby, especially a small baby, away from sick children or adults.
Hygiene (washing, bathing)
at Birth:
■ Only remove blood or meconium.
do not remove vernix. do not bathe the baby until at least 6 hours of age.
later and at home:
■ Wash the face, neck, underarms daily. ■ Wash the buttocks when soiled. Dry thoroughly. ■ Bath when necessary: →Ensure the room is warm, no draught →Use warm water for bathing →Thoroughly dry the baby, dress and cover after bath.
other BaBy care:
■ Use cloth on baby’s bottom to collect stool. Dispose of the stool as for woman’s pads. Wash hands.
do not bathe the baby before 6 hours old or if the baby is cold. do not apply anything in the baby’s eyes except an antimicrobial at birth.
small BaBies require more careful attention:
■ The room must be warmer when changing, washing, bathing and examining a small baby.
Newborn resuscitation
Breastfeeding, care, preventive measures and treatment for the newBorn
K
newBorn resuscitation
start resuscitation within minute of birth if baby is not breathing or is gasping for breath.
observe universal precautions to prevent infection a4 .
Keep the baby warm
■ Clamp and cut the cord if necessary. ■ Transfer the baby to a dry, clean and warm surface. ■ Informthe mother that the baby has difficulty initiating breathing and that you will help the baby to breathe. ■ Keep the baby wrapped and under a radiant heater if possible.
Open the airway
■ Position the head so it is slightly extended. ■ Suction first the mouth and then the nose. ■ Introduce the suction tube into the newborn’s mouth 5-cm from lips and suck while withdrawing. ■ Introduce the suction tube 3-cm into each nostril and suck while withdrawing until no mucus. ■ Repeat each suction if necessary but no more than twice and no more than 20 seconds in total.
If still no breathing, VENTILATE:
■ Place mask to cover chin, mouth, and nose. ■ Form seal. ■ Squeeze bag attached to the mask with 2 fingers or whole hand, according to bag size, 2 or 3 times. ■ Observe rise of chest. If chest is not rising: →reposition head →check mask seal. ■ Squeeze bag harder with whole hand. ■ Once good seal and chest rising, ventilate at 40 squeezes per minute until newborn starts crying or breathing spontaneously.
If breathing or crying, stop ventilating
■ Look at the chest for in-drawing. ■ Count breaths per minute. ■ If breathing more than 30 breaths per minute and no severe chest in-drawing: →do not ventilate any more →put the baby in skin-to-skin contact on mother’s chest and continue care as on d9 →monitor every 15 minutes for breathing and warmth →tell the mother that the baby will probably be well.
do not leave the baby alone
If breathing less than 30 breaths per minute or
severe chest in-drawing:
■ continue ventilating ■ arrange for immediate referral ■ explain to the mother what happened, what you are doing and why ■ ventilate during referral ■ record the event on the referral form and labour record.
If no breathing or gasping at all
after 20 minutes of ventilation
■ Stop ventilating.The baby is dead. ■ Explain to the mother and give supportive care d24 . ■ Record the event.
Treat and immunize the baby (1)
Breastfeeding, care, preventive measures and treatment for the newBorn
K2
treat the BaBy
Treat the baby
■ Determine appropriate drugs and dosage for the baby’s weight. ■ Tell the mother the reasons for giving the drug to the baby. ■ Give intramuscular antibiotics in thigh. Use a new syringe and needle for each antibiotic.
teachthe mother to give treatment to the BaBy at home ■ Explain carefully how to give the treatment. Label and package each drug separately. ■ Check mother’s understanding before she leaves the clinic. ■ Demonstrate how to measure a dose. ■ Watch the mother practice measuring a dose by herself. ■ Watch the mother give the first dose to the baby.
Give 2 IM antibiotics (first week of life)
■ Give first dose of both ampicillin and gentamicin IM in thigh before referral for possible serious illness, severe umbilical infection or severe skin infection. ■ Give both ampicillin and gentamicin IM for 5 days in asymptomatic babies classified at risk of infection. ■ Give intramuscular antibiotics in thigh. Use a new syringe and needle for each antibiotic.
ampicillin im gentamicin im dose: 50 mg per kg dose: 5 mg per kg every 12 hours every 24 hours if term; Add 2.5 ml sterile water 4 mg per kg every 24 hours if preterm
weight to 500 mg vial = 200 mg/ml 20 mg per 2 ml vial = 10 mg/ml
.0 — .4 kg 0.35 ml 0.5 ml
.5 — .9 kg 0.5 ml 0.7 ml
2.0 — 2.4 kg 0.6 ml 0.9 ml
2.5 — 2.9 kg 0.75 ml 1.35 ml
3.0 — 3.4 kg 0.85 ml 1.6 ml
3.5 — 3.9 kg 1 ml 1.85 ml
4.0 — 4.4 kg 1.1 ml 2.1 ml
Give IM benzathine penicillin
to baby (single dose) if mother tested RPR-positive
Benzathine penicillin im dose: 50 000 units/kg once Add 5 ml sterile water to vial containing 1.2 million units = 1.2 million units/(6ml total volume) weight = 200 000 units/ml
.0 - .4 kg 0.35 ml
.5 - .9 kg 0.5 ml
2.0 - 2.4 kg 0.6 ml
2.5 - 2.9 kg 0.75 ml
3.0 - 3.4 kg 0.85 ml
3.5 - 3.9 kg 1.0 ml
4.0 - 4.4 kg 1.1 ml
Give IM antibiotic for possible gonococcal eye infection
(single dose)
ceftriaxone (st choice) Kanamycin (2nd choice) dose: 50 mg per kg once dose: 25 mg per kg once, max 75 mg weight 250 mg per 5 ml vial=mg/ml 75 mg per 2 ml vial = 37.5 mg/ml
.0 - .4 kg 1 ml 0.7 ml
.5 - .9 kg 1.5 ml 1 ml
2.0 - 2.4 kg 2 ml 1.3 ml
2.5 - 2.9 kg 2.5 ml 1.7 ml
3.0 - 3.4 kg 3 ml 2 ml
3.5 - 3.9 kg 3.5 ml 2 ml
4.0 - 4.4 kg 4 ml 2 ml
Treat and immunize the baby (2)
Breastfeeding, care, preventive measures and treatment for the newBorn
K3
Treat local infection
teach mother to treat local infection
■ Explain and show how the treatment is given. ■ Watch her as she carries out the first treatment. ■ Ask her to let you know if the local infection gets worse and to return to the clinic if possible. ■ Treat for 5 days.
treat sKin pustules or umBilical infection
do the following 3 times daily: ■ Wash hands with clean water and soap. ■ Gently wash off pus and crusts with boiled and cooled water and soap. ■ Dry the area with clean cloth. ■ Paint with gentian violet. ■ Wash hands.
treat eye infection
do the following 6-8 times daily: ■ Wash hands with clean water and soap. ■ Wet clean cloth with boiled and cooled water. ■ Use the wet cloth to gently wash off pus from the baby’s eyes. ■ Apply 1% tetracycline eye ointment in each eye 3 times daily. ■ Wash hands.
reassess in 2 days:
■ Assess the skin, umbilicus or eyes. ■ If pus or redness remains or is worse, refer to hospital. ■ If pus and redness have improved, tell the mother to continue treating local infection at home.
Give isoniazid (INH) prophylaxis to newborn
if the mother is diagnosed as having tuberculosis and started treatment less than 2 months before delivery: ■ Give 5-mg/kg isoniazid (INH) orally once a day for 6 months (1 tablet = 200-mg). ■ Delay BCG vaccination until INH treatment completed, or repeat BCG. ■ Reassure the mother that it is safe to breastfeed the baby. ■ Follow up the baby every 2 weeks, or according to national guidelines, to assess weight gain.
Immunize the newborn
■ Give BCG, OPV-0, Hepatitis B (HB-1) vaccine in the first week of life, preferably before discharge. ■ If un-immunized newborn first seen 1-4 weeks of age, give BCG only. ■ Record on immunization card and child record. ■ Advise when to return for next immunization.
age vaccine
Birth < week BCG OPV-0 HB1
6 weeks DPT OPV-1 HB-2
Give ARV medicine to newborn
■ Give the first dose of ARV medicines to newborn 8–12 hours after birth: → Give Nevirapine 2 mg/kg once only. → Give Zidovudine 4 mg/kg every 12 hours. ■ If the newborn spills or vomits within 30 minutes repeat the dose.
Teach mother to give oral arv medicines at home
■ Explain and show how the medicine is given. → Wash hands. → Demonstrate how to measure the dose on the spoon. → Begin feeding the baby by cup. → Give medicine by spoon before the end of the feed. → Complete the feed. ■ Watch her as she carries out the next treatment. ■ Explain to the mother that she should watch her baby after giving a dose of Zidovudine. If baby vomits or spills within 30 minutes, she should repeat the dose. ■ Give Zidovudine every 12 hours for 7 days.
K8 other Breastfeeding support
Givespecialsupporttothemotherwhoisnot
yetbreastfeeding
Advisethemotherwhoisnotbreastfeedingat
allonhowtorelieveengorgement
Ifthebabydoesnothaveamother
K9 ensure warmth for the BaBy
Keepthebabywarm
Keepasmallbabywarm
Rewarmthebabyskin-to-skin
K10 other BaBy care
Cordcare
Sleeping
Hygiene
K11 newBorn resuscitation
Keepthebabywarm
Opentheairway
Ifstillnotbreathing,ventilate...
Ifbreathingorcrying,stopventilating
Ifnotbreathingorgaspingatallafter20
minutesofventilation
K12

treat and immunize the BaBy ()
Treatthebaby
Give2IMantibiotics(firstweekoflife)
GiveIMbenzathinepenicillintobaby(single
dose)ifmothertestedRPRpositive
GiveIMantibioticforpossiblegonococcaleye
infection(singledose)
K13 treat and immunize the BaBy (2)
Treatlocalinfection
Giveisoniazid(INH)prophylaxistonewborn
Immunizethenewborn
Advise when to return with the baby
Breastfeeding, care, preventive measures and treatment for the newBorn
K4
advise when to return withthe BaBy
for maternal visits see schedule on d28 .
Routine visits
return postnatal visit Within the first week, preferably within 2-3 days immunization visit At age 6 weeks (If BCG, OPV-0 and HB-1 given in the first week of life)
Follow-up visits
if the problem was: return in Feeding difficulty 2 days Red umbilicus 2 days Skin infection 2 days Eye infection 2 days Thrush 2 days Mother has either: →breast engorgement or 2 days →mastitis. 2 days Low birth weight, and either →first week of life or 2 days →not adequately gaining weight 2 days Low birth weight, and either →older than 1 week or 7 days →gaining weight adequately 7 days Orphan baby 14 days INH prophylaxis 14 days Treated for possible congenital syphilis 14 days Mother HIV-positive 14 days
Advise the mother to seek care for the baby
Use the counselling sheet to advise the mother when to seek care, or when to return, if the baby has any of these danger signs:
return or go to the hospital immediately if the BaBy has
■ difficulty breathing. ■ convulsions. ■ fever or feels cold. ■ bleeding. ■ diarrhoea. ■ very small, just born. ■ not feeding at all.
go to health centre as quicKly as possiBle if the BaBy has
■ difficulty feeding. ■ pus from eyes. ■ skin pustules. ■ yellow skin. ■ a cord stump which is red or draining pus. ■ feeds <5 times in 24 hours.
Refer baby urgently to hospital
■ After emergency treatment, explain the need for referral to the mother/father. ■ Organize safe transportation. ■ Always send the mother with the baby, if possible. ■ Send referral note with the baby. ■ Inform the referral centre if possible by radio or telephone.
duringtransportation
■ Keep the baby warm by skin-to-skin contact with mother or someone else. ■ Cover the baby with a blanket and cover her/his head with a cap. ■ Protect the baby from direct sunshine. ■ Encourage breastfeeding during the journey. ■ If the baby does not breastfeed and journey is more than 3 hours, consider giving expressed breast milk by cup K6 .
K14 advise when to return
with the BaBy
Routinevisits
Follow-upvisits
Advisethemothertoseekcareforthebaby
Referbabyurgentlytohospital
■ Thissectionhasdetailsonbreastfeeding,careofthebaby,
treatments,immunization,routineandfollow-upvisitsandurgent
referraltohospital.
■ Generalprinciplesarefoundinthesectionongoodcare a-a6 .
■ IfmotherHIV-positive,seealsog7-g.
Counsel on breastfeeding (1)
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counsel on Breastfeeding
Counselonimportanceofexclusivebreastfeeding
duringpregnancyandafterbirth
include partner or other family memBers if possiBle
explain to the mother that:
■ Breastmilkcontainsexactlythenutrientsababyneeds
→iseasilydigestedandefficientlyusedbythebaby’sbody
→protectsababyagainstinfection.
■ Babiesshouldstartbreastfeedingwithin1hourofbirth.Theyshouldnothaveanyotherfoodor
drinkbeforetheystarttobreastfeed.
■ Babiesshouldbeexclusivelybreastfedforthefirst6monthsoflife.
■ Breastfeeding
→helpsbaby’sdevelopmentandmother/babyattachment
→canhelpdelayanewpregnancy(see d27 forbreastfeedingandfamilyplanning).
ForcounsellingifmotherHIV-positive,see g7 .
Helpthemothertoinitiatebreastfeeding
within1hour,whenbabyisready
■ Afterbirth,letthebabyrestcomfortablyonthemother’schestinskin-to-skincontact.
■ Tellthemothertohelpthebabytoherbreastwhenthebabyseemstobeready,usuallywithinthe
firsthour.Signsofreadinesstobreastfeedare:
→babylookingaround/moving
→mouthopen
→searching.
■ Checkthatpositionandattachmentarecorrectatthefirstfeed.Offertohelpthemotheratanytime K3 .
■ Letthebabyreleasethebreastbyher/himself;thenofferthesecondbreast.
■ Ifthebabydoesnotfeedin1hour,examinethebabyJ2–J9.Ifhealthy,leavethebabywiththe
mothertotrylater.Assessin3hours,orearlierifthebabyissmall J4 .
■ Ifthemotherisillandunabletobreastfeed,helphertoexpressbreastmilkandfeedthebabyby
cup K6 .Onday1expressinaspoonandfeedbyspoon.
■ Ifmothercannotbreastfeedatall,useoneofthefollowingoptions:
→donatedheat-treatedbreastmilk.
→Ifnotavailable,thencommercialinfantformula.
→Ifnotavailable,thenhome-madeformulafrommodifiedanimalmilk.
Counsel on breastfeeding (2)
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Supportexclusivebreastfeeding
■ Keepthemotherandbabytogetherinbedorwithineasyreach.do notseparatethem.
■ Encouragebreastfeedingondemand,dayandnight,aslongasthebabywants.
→Ababyneedstofeeddayandnight,8ormoretimesin24hoursfrombirth.Onlyonthefirstday
mayafull-termbabysleepmanyhoursafteragoodfeed.
→Asmallbabyshouldbeencouragedtofeed,dayandnight,atleast8timesin24hoursfrom
birth.
■ Helpthemotherwhenevershewants,andespeciallyifsheisafirsttimeoradolescentmother.
■ Letbabyreleasethebreast,thenofferthesecondbreast.
■ Ifmothermustbeabsent,letherexpressbreastmilkandletsomebodyelsefeedtheexpressed
breastmilktothebabybycup.
do notforcethebabytotakethebreast.
do notinterruptfeedbeforebabywants.
do notgiveanyotherfeedsorwater.
do notuseartificialteatsorpacifiers.
■ Advisethemotheronmedicationandbreastfeeding
→Mostdrugsgiventothemotherinthisguidearesafeandthebabycanbebreastfed.
→Ifmotheristakingcotrimoxazoleorfansidar,monitorbabyforjaundice.
Teachcorrectpositioningandattachment
forbreastfeeding
■ Showthemotherhowtoholdherbaby.Sheshould:
→makesurethebaby’sheadandbodyareinastraightline
→makesurethebabyisfacingthebreast,thebaby’snoseisoppositehernipple
→holdthebaby’sbodyclosetoherbody
→supportthebaby’swholebody,notjusttheneckandshoulders
■ Showthemotherhowtohelpherbabytoattach.Sheshould:
→touchherbaby’slipswithhernipple
→waituntilherbaby’smouthisopenedwide
→moveherbabyquicklyontoherbreast,aimingtheinfant’slowerlipwellbelowthenipple.
■ Lookforsignsofgoodattachment:
→ moreofareolavisibleabovethebaby'smouth
→mouthwideopen
→lowerlipturnedoutwards
→baby'schintouchingbreast
■ Lookforsignsofeffectivesuckling(thatis,slow,deepsucks,sometimespausing).
■ Iftheattachmentorsucklingisnotgood,tryagain.Thenreassess.
■ Ifbreastengorgement,expressasmallamountofbreastmilkbeforestartingbreastfeedingtosoften
nippleareasothatitiseasierforthebabytoattach.
if mother is hiv-positive, see g7 for special counselling to the mother who is hiv-positive and
breastfeeding.
if mother chose replacement feedings, see g8 .
Counsel on breastfeeding (3)
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counsel on Breastfeeding
Givespecialsupporttobreastfeed
thesmallbaby(pretermand/orlowbirthweight)
counsel the mother:
■ Reassurethemotherthatshecanbreastfeedhersmallbabyandshehasenoughmilk.
■ Explainthathermilkisthebestfoodforsuchasmallbaby.Feedingforher/himisevenmore
importantthanforabigbaby.
■ Explainhowthemilk’sappearancechanges:milkinthefirstdaysisthickandyellow,thenit
becomesthinnerandwhiter.Botharegoodforthebaby.
■ Asmallbabydoesnotfeedaswellasabigbabyinthefirstdays:
→maytireeasilyandsuckweaklyatfirst
→maysuckleforshorterperiodsbeforeresting
→mayfallasleepduringfeeding
→mayhavelongpausesbetweensucklingandmayfeedlonger
→doesnotalwayswakeupforfeeds.
■ Explainthatbreastfeedingwillbecomeeasierifthebabysucklesandstimulatesthebreasther/
himselfandwhenthebabybecomesbigger.
■ Encourageskin-to-skincontactsinceitmakesbreastfeedingeasier.
help the mother:
■ Initiatebreastfeedingwithin1hourofbirth.
■ Feedthebabyevery2-3hours.Wakethebabyforfeeding,evenifshe/hedoesnotwakeupalone,
2hoursafterthelastfeed.
■ Alwaysstartthefeedwithbreastfeedingbeforeofferingacup.Ifnecessary,improvethemilkflow
(letthemotherexpressalittlebreastmilkbeforeattachingthebabytothebreast).
■ Keepthebabylongeratthebreast.Allowlongpausesorlong,slowfeed.Donotinterruptfeedifthe
babyisstilltrying.
■ Ifthebabyisnotyetsucklingwellandlongenough,dowhateverworksbetterinyoursetting:
→Letthemotherexpressbreastmilkintobaby’smouth K5 .
→Letthemotherexpressbreastmilkandfeedbabybycup K6 .Onthefirstdayexpressbreast
milkinto,andfeedcolostrumbyspoon.
■ Teachthemothertoobserveswallowingifgivingexpressedbreastmilk.
■ Weighthebabydaily(ifaccurateandprecisescalesavailable),recordandassessweightgain K7 .
Givespecialsupporttobreastfeedtwins
counsel the mother:
■ Reassurethemotherthatshehasenoughbreastmilkfortwobabies.
■ Encourageherthattwinsmaytakelongertoestablishbreastfeedingsincetheyarefrequentlyborn
pretermandwithlowbirthweight.
help the mother:
■ Startfeedingonebabyatatimeuntilbreastfeedingiswellestablished.
■ Helpthemotherfindthebestmethodtofeedthetwins:
→Ifoneisweaker,encouragehertomakesurethattheweakertwingetsenoughmilk.
→Ifnecessary,shecanexpressmilkforher/himandfeedher/himbycupafterinitialbreastfeeding.
→Dailyalternatethesideeachbabyisoffered.
Alternative feeding methods (1)
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alternative feeding methods
Expressbreastmilk
■ Themotherneedscleancontainerstocollectandstorethemilk.
Awideneckedjug,jar,bowlorcupcanbeused.
■ Onceexpressed,themilkshouldbestoredwithawell-fittinglidorcover.
■ Teachthemothertoexpressbreastmilk:
→Toprovidemilkforthebabywhensheisaway.Tofeedthebabyifthebabyis
smallandtooweaktosuckle
→Torelieveengorgementandtohelpbabytoattach
→Todrainthebreastwhenshehasseveremastitisorabscesses.
■ Teachthemothertoexpresshermilkbyherself.do notdoitforher.
■ Teachherhowto:
→Washherhandsthoroughly.
→Sitorstandcomfortablyandholdacleancontainerunderneathherbreast.
→Putherfirstfingerandthumboneithersideoftheareola,behindthenipple.
→Pressslightlyinwardstowardsthebreastbetweenherfingerandthumb.
→Expressonesideuntilthemilkflowslows.Thenexpresstheotherside.
→Continuealternatingsidesforatleast20-30minutes.
■ Ifmilkdoesnotflowwell:
→Applywarmcompresses.
→Havesomeonemassageherbackandneckbeforeexpressing.
→Teachthemotherbreastandnipplemassage.
→Feedthebabybycupimmediately.Ifnot,storeexpressedmilkinacool,cleanandsafeplace.
■ Ifnecessary,repeattheproceduretoexpressbreastmilkatleast8timesin24hours.Expressas
muchasthebabywouldtakeormore,every3 hours.
■ Whennotbreastfeedingatall,expressjustalittletorelievepain K5 .
■ Ifmotherisveryill,helphertoexpressordoitforher.
Handexpressbreastmilk
directlyintothebaby’smouth
■ Teachthemothertoexpressbreastmilk.
■ Holdthebabyinskin-to-skincontact,themouthclosetothenipple.
■ Expressthebreastuntilsomedropsofbreastmilkappearonthenipple.
■ Waituntilthebabyisalertandopensmouthandeyes,orstimulatethebabylightlytoawakenher/him.
■ Letthebabysmellandlickthenipple,andattempttosuck.
■ Letsomebreastmilkfallintothebaby’smouth.
■ Waituntilthebabyswallowsbeforeexpressingmoredropsofbreastmilk.
■ Aftersometime,whenthebabyhashadenough,she/hewillcloseher/hismouthand
takenomorebreastmilk.
■ Askthemothertorepeatthisprocessevery1-2hoursifthebabyisverysmall
(orevery2-3hoursifthebabyisnotverysmall).
■ Beflexibleateachfeed,butmakesuretheintakeisadequatebycheckingdailyweightgain.
Alternative feeding methods (2)
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alternative feeding methods
Cupfeedingexpressedbreastmilk
■ Teachthemothertofeedthebabywithacup.Donotfeedthebabyyourself.Themothershould:
■ Measurethequantityofmilkinthecup
■ Holdthebabysittingsemi-uprightonherlap
■ Holdthecupofmilktothebaby’slips:
→restcuplightlyonlowerlip
→touchedgeofcuptoouterpartofupperlip
→tipcupsothatmilkjustreachesthebaby’slips
→butdonotpourthemilkintothebaby’smouth.
■ Babybecomesalert,opensmouthandeyes,andstartstofeed.
■ Thebabywillsuckthemilk,spillingsome.
■ Smallbabieswillstarttotakemilkintotheirmouthusingthetongue.
■ Babyswallowsthemilk.
■ Babyfinishesfeedingwhenmouthclosesorwhennotinterestedintakingmore.
■ Ifthebabydoesnottakethecalculatedamount:
→Feedforalongertimeorfeedmoreoften
→Teachthemothertomeasurethebaby’sintakeover24hours,notjustateachfeed.
■ Ifmotherdoesnotexpressenoughmilkinthefirstfewdays,orifthemothercannotbreastfeedat
all,useoneofthefollowingfeedingoptions:
→donatedheat-treatedbreastmilk
→home-madeorcommercialformula.
■ Feedthebabybycupifthemotherisnotavailabletodoso.
■ Babyiscupfeedingwellifrequiredamountofmilkisswallowed,spillinglittle,andweightgainis
maintained.
Quantitytofeedbycup
■ Startwith80ml/kgbodyweightperdayforday1.Increasetotalvolumeby10-20ml/kgperday,
untilbabytakes150ml/kg/day.Seetablebelow.
■ Dividetotalinto8feeds.Giveevery2-3hourstoasmallsizeorillbaby.
■ Checkthebaby’s24hourintake.Sizeofindividualfeedsmayvary.
■ Continueuntilbabytakestherequiredquantity.
■ Washthecupwithwaterandsoapaftereachfeed.
approximate quantity to feed By cup (in ml) every 2-3 hours from Birth (By weight)
weight (kg) day 0 2 3 4 5 6 7
.5-.9 15ml 17ml 19ml 21ml 23ml 25ml 27ml 27+ml
2.0-2.4 20ml 22ml 25ml 27ml 30ml 32ml 35ml 35+ml
2.5+ 25ml 28ml 30ml 35ml 35ml 40+ml 45+ml 50+ml

Signsthatbabyisreceiving
adequateamountofmilk
■ Babyissatisfiedwiththefeed.
■ Weightlossislessthan10%inthefirstweekoflife.
■ Babygainsatleast160-ginthefollowingweeksoraminimum300-ginthefirstmonth.
■ Babywetseverydayasfrequentlyasbabyisfeeding.
■ Baby’sstoolischangingfromdarktolightbrownoryellowbyday3.
Weigh and assess weight gain
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weigh and assess weight gain
Weighbabyinthefirstmonthoflife
weigh the BaBy
■ Monthlyifbirthweightnormalandbreastfeedingwell.Every2weeksifreplacementfeedingor
treatmentwithisoniazid.
■ Whenthebabyisbroughtforexaminationbecausenotfeedingwell,orill.
weigh the small BaBy
■ Everydayuntil3consecutivetimesgainingweight(atleast15-g/day).
■ Weeklyuntil4-6weeksofage(reachedterm).
Assessweightgain
use this table for guidance when assessing weight gain in the first month of life
age acceptable weight loss/gain in the first month of life
week Lossupto10%
2-4 weeks Gainatleast160gperweek(atleast15g/day)
month Gainatleast300ginthefirstmonth
if weighing daily with a precise and accurate scale
first week Noweightlossortotallessthan10%
afterward dailygaininsmallbabiesatleast20g
Scalemaintenance
Daily/weeklyweighingrequirespreciseandaccuratescale(10-gincrement):
→Calibrateitdailyaccordingtoinstructions.
→Checkitforaccuracyaccordingtoinstructions.
Simplespringscalesarenotpreciseenoughfordaily/weeklyweighing.
Other breastfeeding support
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other Breastfeeding support
Givespecialsupporttothemother
whoisnotyetbreastfeeding
(mother or baby ill, or baby too small to suckle)
■ Teachthemothertoexpressbreastmilk K5 .Helpherifnecessary.
■ Usethemilktofeedthebabybycup.
■ Ifmotherandbabyareseparated,helpthemothertoseethebabyorinformheraboutthebaby’s
conditionatleasttwicedaily.
■ Ifthebabywasreferredtoanotherinstitution,ensurethebabygetsthemother’sexpressedbreast
milkifpossible.
■ Encouragethemothertobreastfeedwhensheorthebabyrecovers.
Ifthebabydoesnothaveamother
■ Givedonatedheattreatedbreastmilkorhome-basedorcommercialformulabycup.
■ Teachthecarerhowtopreparemilkandfeedthebaby K6
.
■ Followupin2weeks;weighandassessweightgain.
Advisethemotherwhoisnotbreastfeeding
atallonhowtorelieveengorgement
(Baby died or stillborn, mother chose replacement feeding)
■ Breastsmaybeuncomfortableforawhile.
■ Avoidstimulatingthebreasts.
■ Supportbreastswithawell-fittingbraorcloth.Donotbindthebreaststightlyasthismayincrease
herdiscomfort.
■ Applyacompress.Warmthiscomfortableforsomemothers,otherspreferacoldcompressto
reduceswelling.
■ Teachthemothertoexpressenoughmilktorelievediscomfort.Expressingcanbedoneafewtimes
adaywhenthebreastsareoverfull.Itdoesnotneedtobedoneifthemotherisuncomfortable.It
willbelessthanherbabywouldtakeandwillnotstimulateincreasedmilkproduction.
■ Relievepain.Ananalgesicsuchasibuprofen,orparacetamolmaybeused.Somewomenuseplant
productssuchasteasmadefromherbs,orplantssuchasrawcabbageleavesplaceddirectlyon
thebreasttoreducepainandswelling.
■ Advisetoseekcareifbreastsbecomepainful,swollen,red,ifshefeelsillortemperaturegreaterthan38ºC.
pharmacological treatments to reduce milk supply are not recommended.
Theabovemethodsareconsideredmoreeffectiveinthelongterm.
Ensure warmth for the baby
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ensure warmth for the BaBy
Keepthebabywarm
at Birth and within the first hour(s)
■ Warmdeliveryroom:forthebirthofthebabytheroomtemperatureshouldbe25-28ºC,nodraught.
■ Drybaby:immediatelyafterbirth,placethebabyonthemother’sabdomenoronawarm,cleanand
drysurface.Drythewholebodyandhairthoroughly,withadrycloth.
■ Skin-to-skincontact:Leavethebabyonthemother’sabdomen(beforecordcut)orchest(aftercord
cut)afterbirthforatleast2hours.Coverthebabywithasoftdrycloth.
■ Ifthemothercannotkeepthebabyskin-to-skinbecauseofcomplications,wrapthebabyinaclean,
dry,warmclothandplaceinacot.Coverwithablanket.Usearadiantwarmerifroomnotwarmorbaby
small.
suBsequently (first day)
■ Explaintothemotherthatkeepingbabywarmisimportantforthebabytoremainhealthy.
■ Dressthebabyorwrapinsoftdrycleancloth.Covertheheadwithacapforthefirstfewdays,especiallyif
babyissmall.
■ Ensurethebabyisdressedorwrappedandcoveredwithablanket.
■ Keepthebabywithineasyreachofthemother.Donotseparatethem(rooming-in).
■ Ifthemotherandbabymustbeseparated,ensurebabyisdressedorwrappedandcoveredwitha
blanket.
■ Assesswarmthevery4hoursbytouchingthebaby’sfeet:iffeetarecolduseskin-to-skincontact,add
extrablanketandreassess(seeRewarmthenewborn).
■ Keeptheroomforthemotherandbabywarm.Iftheroomisnotwarmenough,alwayscoverthebaby
withablanketand/oruseskin-to-skincontact.
at home
■ Explaintothemotherthatbabiesneedonemorelayerofclothesthanotherchildrenoradults.
■ Keeptheroomorpartoftheroomwarm,especiallyinacoldclimate.
■ Duringtheday,dressorwrapthebaby.
■ Atnight,letthebabysleepwiththemotherorwithineasyreachtofacilitatebreastfeeding.
do notputthebabyonanycoldorwetsurface.
do notbaththebabyatbirth.Waitatleast6hoursbeforebathing.
do notswaddle–wraptootightly.Swaddlingmakesthemcold.
do notleavethebabyindirectsun.
Keepasmallbabywarm
■ Theroomforthebabyshouldbewarm(notlessthan25°C)withnodraught.
■ Explaintothemothertheimportanceofwarmthforasmallbaby.
■ Afterbirth,encouragethemothertokeepthebabyinskin-to-skincontactaslongaspossible.
■ Advisetouseextraclothes,socksandacap,blankets,tokeepthebabywarmorwhenthebabyis
notwiththemother.
■ Washorbathababyinaverywarmroom,inwarmwater.Afterbathing,dryimmediatelyand
thoroughly.Keepthebabywarmafterthebath.Avoidbathingsmallbabies.
■ Checkfrequentlyiffeetarewarm.Ifcold,rewarmthebaby(seebelow).
■ Seekcareifthebaby’sfeetremaincoldafterrewarming.
Rewarmthebabyskin-to-skin
■ Beforerewarming,removethebaby’scoldclothing.
■ Placethenewbornskin-to-skinonthemother’schestdressedinapre-warmedshirtopenatthe
front,anappy(diaper),hatandsocks.
■ Covertheinfantonthemother’schestwithherclothesandanadditional(pre-warmed)blanket.
■ Checkthetemperatureeveryhouruntilnormal.
■ Keepthebabywiththemotheruntilthebaby’sbodytemperatureisinnormalrange.
■ Ifthebabyissmall,encouragethemothertokeepthebabyinskin-to-skincontactforaslongas
possible,dayandnight.
■ Besurethetemperatureoftheroomwheretherewarmingtakesplaceisatleast25°C.
■ Ifthebaby’stemperatureisnot36.5ºCormoreafter2hoursofrewarming,reassessthebaby J2–J7 .
■ Ifreferralneeded,keepthebabyinskin-to-skinposition/contactwiththemotherorotherperson
accompanyingthebaby.
Other baby care
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other BaBy care
always wash hands before and after taking care of the baby. do not share supplies with other babies.
Cordcare
■ Washhandsbeforeandaftercordcare.
■ Putnothingonthestump.
■ Foldnappy(diaper)belowstump.
■ Keepcordstumplooselycoveredwithcleanclothes.
■ Ifstumpissoiled,washitwithcleanwaterandsoap.Dryitthoroughlywithcleancloth.
■ Ifumbilicusisredordrainingpusorblood,examinethebabyandmanageaccordingly J2–J7 .
■ Explaintothemotherthatsheshouldseekcareiftheumbilicusisredordrainingpusorblood.
do notbandagethestumporabdomen.
do notapplyanysubstancesormedicinetostump.
Avoidtouchingthestumpunnecessarily.
Sleeping
■ Usethebednetdayandnightforasleepingbaby.
■ Letthebabysleeponher/hisbackorontheside.
■ Keepthebabyawayfromsmokeorpeoplesmoking.
■ Keepthebaby,especiallyasmallbaby,awayfromsickchildrenoradults.
Hygiene(washing,bathing)
at Birth:
■ Onlyremovebloodormeconium.
do notremovevernix.
do notbathethebabyuntilatleast6hoursofage.
later and at home:
■ Washtheface,neck,underarmsdaily.
■ Washthebuttockswhensoiled.Drythoroughly.
■ Bathwhennecessary:
→Ensuretheroomiswarm,nodraught
→Usewarmwaterforbathing
→Thoroughlydrythebaby,dressandcoverafterbath.
other BaBy care:
■ Useclothonbaby’sbottomtocollectstool.Disposeofthestoolasforwoman’spads.Washhands.
do notbathethebabybefore6hoursoldorifthebabyiscold.
do notapplyanythinginthebaby’seyesexceptanantimicrobialatbirth.
small BaBies require more careful attention:
■ Theroommustbewarmerwhenchanging,washing,bathingandexaminingasmallbaby.
Newborn resuscitation
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newBorn resuscitation
start resuscitation within minute of birth if baby is not breathing or is gasping for breath.
observe universal precautions to prevent infection a4 .
Keepthebabywarm
■ Clampandcutthecordifnecessary.
■ Transferthebabytoadry,cleanandwarmsurface.
■ Informthemotherthatthebabyhasdifficultyinitiatingbreathingandthatyouwillhelpthebabytobreathe.
■ Keepthebabywrappedandunderaradiantheaterifpossible.
Opentheairway
■ Positiontheheadsoitisslightlyextended.
■ Suctionfirstthemouthandthenthenose.
■ Introducethesuctiontubeintothenewborn’smouth5-cmfromlipsandsuckwhilewithdrawing.
■ Introducethesuctiontube3-cmintoeachnostrilandsuckwhilewithdrawinguntilnomucus.
■ Repeateachsuctionifnecessarybutnomorethantwiceandnomorethan20secondsintotal.
Ifstillnobreathing,VENTILATE:
■ Placemasktocoverchin,mouth,andnose.
■ Formseal.
■ Squeezebagattachedtothemaskwith2fingersorwholehand,accordingtobagsize,2or3times.
■ Observeriseofchest.Ifchestisnotrising:
→repositionhead
→checkmaskseal.
■ Squeezebagharderwithwholehand.
■ Oncegoodsealandchestrising,ventilateat40squeezesperminuteuntilnewbornstartscryingor
breathingspontaneously.
Ifbreathingorcrying,stopventilating
■ Lookatthechestforin-drawing.
■ Countbreathsperminute.
■ Ifbreathingmorethan30breathsperminuteandnoseverechestin-drawing:
→donotventilateanymore
→putthebabyinskin-to-skincontactonmother’schestandcontinuecareason d9
→monitorevery15minutesforbreathingandwarmth
→tellthemotherthatthebabywillprobablybewell.
do notleavethebabyalone
Ifbreathinglessthan30breathsperminuteor
severechestin-drawing:
■ continueventilating
■ arrangeforimmediatereferral
■ explaintothemotherwhathappened,whatyouaredoingandwhy
■ ventilateduringreferral
■ recordtheeventonthereferralformandlabourrecord.

Ifnobreathingorgaspingatall
after20minutesofventilation
■ Stopventilating.Thebabyisdead.
■ Explaintothemotherandgivesupportivecare d24 .
■ Recordtheevent.
Treat and immunize the baby (1)
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treat the BaBy
Treatthebaby
■ Determineappropriatedrugsanddosageforthebaby’sweight.
■ Tellthemotherthereasonsforgivingthedrugtothebaby.
■ Giveintramuscularantibioticsinthigh.Useanewsyringeandneedleforeachantibiotic.
teach the mother to give treatment to the BaBy at home
■ Explaincarefullyhowtogivethetreatment.Labelandpackageeachdrugseparately.
■ Checkmother’sunderstandingbeforesheleavestheclinic.
■ Demonstratehowtomeasureadose.
■ Watchthemotherpracticemeasuringadosebyherself.
■ Watchthemothergivethefirstdosetothebaby.
Give2IMantibiotics(firstweekoflife)
■ GivefirstdoseofbothampicillinandgentamicinIMinthighbeforereferralforpossibleserious
illness,severeumbilicalinfectionorsevereskininfection.
■ GivebothampicillinandgentamicinIMfor5daysinasymptomaticbabiesclassifiedatriskof
infection.
■ Giveintramuscularantibioticsinthigh.Useanewsyringeandneedleforeachantibiotic.
ampicillin im gentamicin im
dose:50mgperkg dose:5mgperkg
every12hours every24hoursifterm;
Add2.5mlsterilewater 4mgperkgevery24hoursifpreterm
weight to500mgvial=200mg/ml 20mgper2mlvial=10mg/ml
.0 — .4 kg 0.35ml 0.5ml
.5 — .9 kg 0.5ml 0.7ml
2.0 — 2.4 kg 0.6ml 0.9ml
2.5 — 2.9 kg 0.75ml 1.35ml
3.0 — 3.4 kg 0.85ml 1.6ml
3.5 — 3.9 kg 1ml 1.85ml
4.0 — 4.4 kg 1.1ml 2.1ml
GiveIMbenzathinepenicillin
tobaby(singledose)ifmothertestedRPR-positive
Benzathine penicillin im
dose:50000units/kgonce
Add5mlsterilewatertovial
containing1.2millionunits
=1.2millionunits/(6mltotalvolume)
weight =200000units/ml
.0 - .4 kg 0.35ml
.5 - .9 kg 0.5ml
2.0 - 2.4 kg 0.6ml
2.5 - 2.9 kg 0.75ml
3.0 - 3.4 kg 0.85ml
3.5 - 3.9 kg 1.0ml
4.0 - 4.4 kg 1.1ml
GiveIMantibioticforpossiblegonococcaleyeinfection
(singledose)
ceftriaxone (st choice) Kanamycin (2nd choice)
dose:50mgperkgonce dose:25mgperkgonce,max75mg
weight 250mgper5mlvial=mg/ml 75mgper2mlvial=37.5mg/ml
.0 - .4 kg 1ml 0.7ml
.5 - .9 kg 1.5ml 1ml
2.0 - 2.4 kg 2ml 1.3ml
2.5 - 2.9 kg 2.5ml 1.7ml
3.0 - 3.4 kg 3ml 2ml
3.5 - 3.9 kg 3.5ml 2ml
4.0 - 4.4 kg 4ml 2ml
Treat and immunize the baby (2)
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Treatlocalinfection
teach mother to treat local infection
■ Explainandshowhowthetreatmentisgiven.
■ Watchherasshecarriesoutthefirsttreatment.
■ Askhertoletyouknowifthelocalinfectiongetsworseandtoreturntotheclinicifpossible.
■ Treatfor5days.
treat sKin pustules or umBilical infection
do the following 3 times daily:
■ Washhandswithcleanwaterandsoap.
■ Gentlywashoffpusandcrustswithboiledandcooledwaterandsoap.
■ Drytheareawithcleancloth.
■ Paintwithgentianviolet.
■ Washhands.
treat eye infection
do the following 6-8 times daily:
■ Washhandswithcleanwaterandsoap.
■ Wetcleanclothwithboiledandcooledwater.
■ Usethewetclothtogentlywashoffpusfromthebaby’seyes.
■ Apply1%tetracyclineeyeointmentineacheye3timesdaily.
■ Washhands.
reassess in 2 days:
■ Assesstheskin,umbilicusoreyes.
■ Ifpusorrednessremainsorisworse,refertohospital.
■ Ifpusandrednesshaveimproved,tellthemothertocontinuetreatinglocalinfectionathome.
Giveisoniazid(INH)prophylaxistonewborn
if the mother is diagnosed as having tuberculosis and started treatment
less than 2 months before delivery:
■ Give5-mg/kgisoniazid(INH)orallyonceadayfor6months(1tablet=200-mg).
■ DelayBCGvaccinationuntilINHtreatmentcompleted,orrepeatBCG.
■ Reassurethemotherthatitissafetobreastfeedthebaby.
■ Followupthebabyevery2weeks,oraccordingtonationalguidelines,toassessweightgain.
Immunizethenewborn
■ GiveBCG,OPV-0,HepatitisB(HB-1)vaccineinthefirstweekoflife,preferablybeforedischarge.
■ Ifun-immunizednewbornfirstseen1-4weeksofage,giveBCGonly.
■ Recordonimmunizationcardandchildrecord.
■ Advisewhentoreturnfornextimmunization.
age vaccine
Birth < week BCGOPV-0HB1
6 weeks DPTOPV-1HB-2

GiveARVmedicinetonewborn
■ GivethefirstdoseofARVmedicinestonewborn8–12hoursafterbirth:
→ GiveNevirapine2mg/kgonceonly.
→ GiveZidovudine4mg/kgevery12hours.
■ Ifthenewbornspillsorvomitswithin30minutesrepeatthedose.
TeachmothertogiveoralARVmedicinesathome
■ Explainandshowhowthemedicineisgiven.
→ Washhands.
→ Demonstratehowtomeasurethedoseonthespoon.
→ Beginfeedingthebabybycup.
→ Givemedicinebyspoonbeforetheendofthefeed.
→ Completethefeed.
■ Watchherasshecarriesoutthenexttreatment.
■ ExplaintothemotherthatsheshouldwatchherbabyaftergivingadoseofZidovudine.Ifbaby
vomitsorspillswithin30minutes,sheshouldrepeatthedose.
■ GiveZidovudineevery12hoursfor7days.
Advise when to return with the baby
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advise when to return with the BaBy
for maternal visits see schedule on d28 .
Routinevisits
return
postnatal visit Withinthefirstweek,preferably
within2-3days
immunization visit Atage6weeks
(IfBCG,OPV-0andHB-1
giveninthefirstweekoflife)
Follow-upvisits
if the problem was: return in
Feedingdifficulty 2days
Redumbilicus 2days
Skininfection 2days
Eyeinfection 2days
Thrush 2days
Motherhaseither:
→breastengorgementor 2days
→mastitis. 2days
Lowbirthweight,andeither
→firstweekoflifeor 2days
→notadequatelygainingweight 2days
Lowbirthweight,andeither
→olderthan1weekor 7days
→gainingweightadequately 7days
Orphanbaby 14days
INHprophylaxis 14days
Treatedforpossiblecongenitalsyphilis 14days
MotherHIV-positive 14days
Advisethemothertoseekcareforthebaby
Usethecounsellingsheettoadvisethemotherwhentoseekcare,orwhentoreturn,if
thebabyhasanyofthesedangersigns:
return or go to the hospital immediately if the BaBy has
■ difficultybreathing.
■ convulsions.
■ feverorfeelscold.
■ bleeding.
■ diarrhoea.
■ verysmall,justborn.
■ notfeedingatall.
go to health centre as quicKly as possiBle if the BaBy has
■ difficultyfeeding.
■ pusfromeyes.
■ skinpustules.
■ yellowskin.
■ acordstumpwhichisredordrainingpus.
■ feeds<5timesin24hours.
Referbabyurgentlytohospital
■ Afteremergencytreatment,explaintheneedforreferraltothemother/father.
■ Organizesafetransportation.
■ Alwayssendthemotherwiththebaby,ifpossible.
■ Sendreferralnotewiththebaby.
■ Informthereferralcentreifpossiblebyradioortelephone.
during transportation
■ Keepthebabywarmbyskin-to-skincontactwithmotherorsomeoneelse.
■ Coverthebabywithablanketandcoverher/hisheadwithacap.
■ Protectthebabyfromdirectsunshine.
■ Encouragebreastfeedingduringthejourney.
■ Ifthebabydoesnotbreastfeedandjourneyismorethan3hours,considergivingexpressedbreast
milkbycup K6 .
Equipment, supplies, drugs and laboratory tests
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EQUIPMENT, SUPPLIES, DRUGS AND LABORATORY TESTS
Equipment, supplies, drugs and tests for pregnancy and postpartum care
EQUIPM
ENT, SUPPLIES, DRUGS AND LABORATORY TESTS
L2
EQUIPMENT, SUPPLIES, DRUGS AND TESTS fOR ROUTINE AND EMERGENcY PREGNANcY AND POSTPARTUMcARE
Warm and clean room
■ Examination table or bed with clean linen ■ Light source ■ Heat source
Hand washing
■ Clean water supply ■ Soap ■ Nail brush or stick ■ Clean towels
Waste
■ Bucket for soiled pads and swabs ■ Receptacle for soiled linens ■ Container for sharps disposal
Sterilization
■ Instrument sterilizer ■ Jar for forceps
Miscellaneous
■ Wall clock ■ Torch with extra batteries and bulb ■ Log book ■ Records ■ Refrigerator
Equipment
■ Blood pressure machine and stethoscope ■ Body thermometer ■ Fetal stethoscope ■ Baby scale
Supplies
■ Gloves: →utility →sterile or highly disinfected →long sterile for manual removal of placenta ■ Urinary catheter ■ Syringes and needles ■ IV tubing ■ Suture material for tear or episiotomy repair ■ Antiseptic solution (iodophors or chlorhexidine) ■ Spirit (70% alcohol) ■ Swabs ■ Bleach (chlorine base compound) ■ Impregnated bednet ■ Condoms
Tests
■ RPR testing kit ■ Proteinuria sticks ■ Container for catching urine ■ HIV testing kit (2 types) ■ Haemoglobin testing kit
Disposable delivery kit
■ Plastic sheet to place under mother ■ Cord ties (sterile) ■ Sterile blade
Drugs
■ Oxytocin ■ Ergometrine ■ Magnesium sulphate ■ Calcium gluconate ■ Diazepam ■ Hydralazine ■ Ampicillin ■ Gentamicin ■ Metronidazole ■ Benzathine penicillin ■ Cloxacillin ■ Amoxycillin ■ Ceftriaxone ■ Trimethoprim + sulfamethoxazole ■ Clotrimazole vaginal pessary ■ Erythromycin ■ Ciprofloxacin ■ Tetracycline or doxycycline ■ Arthemether or quinine ■ Chloroquine tablet ■ Lignocaine ■ Adrenaline ■ Ringer lactate ■ Normal saline 0.9% ■ Glucose 50% solution ■ Water for injection ■ Paracetamol ■ Gentian violet ■ Iron/folic acid tablet ■ Mebendazole ■ Sulphadoxine-pyrimethamine ■ Nevirapine (adult, infant) ■ Zidovudine (AZT) (adult, infant) ■ Lamivudine (3TC)
Vaccine
■ Tetanus toxoid
Laboratory tests (1)
EQUIPM
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L
LABORATORY TESTS
Check urine for protein
■ Label a clean container. ■ Give woman the clean container and explain where she can urinate. ■ Teach woman how to collect a clean-catch urine sample. Ask her to: →Clean vulva with water →Spread labia with fingers →Urinate freely (urine should not dribble over vulva; this will ruin sample) →Catch the middle part of the stream of urine in the cup. Remove container before urine stops. ■ Analyse urine for protein using either dipstick or boiling method.
DIPSTIck METhOD
■ Dip coated end of paper dipstick in urine sample. ■ Shake off excess by tapping against side of container. ■ Wait specified time (see dipstick instructions). ■ Compare with colour chart on label. Colours range from yellow (negative) through yellow-green and green-blue for positive.
BOILING METhOD
■ Put urine in test tube and boil top half. Boiled part may become cloudy. After boiling allow the test tube to stand. A thick precipitate at the bottom of the tube indicates protein. ■ Add 2-3 drops of 2-3% acetic acid after boiling the urine (even if urine is not cloudy) →If the urine remains cloudy, protein is present in the urine. →If cloudy urine becomes clear, protein is not present. →If boiled urine was not cloudy to begin with, but becomes cloudy when acetic acid is added, protein is present.
Check haemoglobin
■ Draw blood with syringe and needle or a sterile lancet. ■ Insert below instructions for method used locally.
✎____________________________________________________________________
✎____________________________________________________________________
EQUIPM
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L Perform Rapid HIV test (type of test use depends on the national policy)
PERfORMRAPID hIV TEST (TYPE Of TEST USE DEPENDS ON ThE NATIONAL POLIcY)
■ Explain the procedure and seek consent according to the national policy. ■ Use test kits recommended by the national and/or international bodies and follow the instructions of the HIV rapid test selected. ■ Prepare your worksheet, label the test, and indicate the test batch number and expiry date. Check that expiry time has not lapsed. ■ Wear gloves when drawing blood and follow standard safety precautions for waste disposal. ■ Inform the women when to return to the clinic for their test results (same day or they will have to come again). ■ Draw blood for all tests at the same time (tests for Hb, syphilis and HIV can often be coupled at the same time). →Use a sterile needle and syringe when drawing blood from a vein. →Use a lancet when doing a finger prick. ■ Perform the test following manufacturer’s instructions. ■ Interpret the results as per the instructions of the HIV rapid test selected. →If the first test result is negative, no further testing is done. Record the result as – Negative for HIV. →If the first test result is positive, perform a second HIV rapid test using a different test kit. →If the second test is also positive, record the result as – Positive for HIV. →If the first test result is positive and second test result is negative, record the result as inconclusive. Repeat the test after 6 weeks or refer the woman to hospital for a confirmatory test. →Send the results to the health worker. Respect confidentiality A2 . ■ Record all results in the logbook.
Equipment, suplies and drugs
Perform rapid plasmareagin (RPR) test for syphilis
■ Seek consent.
■ Explain procedure.
■ Use a sterile needle and syringe. Draw up 5 ml blood from a vein. Put in a clear test tube.
■ Let test tube sit 20 minutes to allow serum to separate (or centrifuge 3-5 minutes at 2000– 3000-rpm). In the separated sample, serum will be on top.
■ Use sampling pipette to withdraw some of the serum. Take care not to include any red blood cells from the lower part of the separated sample.
■ Hold the pipette vertically over a test card circle. Squeeze teat to allow one drop (50‑µl) of serum to fall onto a circle. Spread the drop to fill the circle using a toothpick or other clean spreader.
Important: Several samples may be tested on one card. Be careful not to contaminate the remaining test circles. Use a clean spreader for every sample. carefully label each sample with a patient’s name or number.
■ Attach dispensing needle to a syringe. Shake antigen.* Draw up enough antigen for the number of tests to be done (one drop per test).
■ Holding the syringe vertically, allow exactly one drop of antigen (20‑µl) to fall onto each test sample. DO NOT stir.
■ Rotate the test card smoothly on the palm of the hand for 8 minutes.** (Or rotate on a mechanical rotator.)
* Make sure antigen was refrigerated (not frozen) and has not expired.
** Room temperature should be 73º-85ºF (22.8º–29.3ºC).
Laboratory tests (2) Perform rapid plasmareagin (RPR) test for syphilis
EQUIPM
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EQUIPM
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PERfORMRAPID PLASMAREAGIN (RPR) TEST fOR SYPhILIS
Interpreting results
■ After 8 minutes rotation, inspect the card in good light. Turn or lift the card to see whether there is clumping (reactive result). Most test cards include negative and positive control circles for comparison.
1. Non‑reactive (no clumping or only slight roughness) – Negative for syphilis 2. Reactive (highly visible clumping) - Positive for syphilis 3. Weakly reactive (minimal clumping) - Positive for syphilis
NOTE: Weakly reactive can also be more finely granulated and difficult to see than in this illsutration.
ExAMPLE Of A TEST cARD
1 2 3
Equipment, suplies and drugs
Warm and clean room
■ Delivery bed: a bed that supports the woman in a semi-sitting or lying in a lateral position, with removable stirrups (only for repairing the perineum or instrumental delivery) ■ Clean bed linen ■ Curtains if more than one bed ■ Clean surface (for alternative delivery position) ■ Work surface for resuscitation of newborn near delivery beds ■ Light source ■ Heat source ■ Room thermometer
Hand washing
■ Clean water supply ■ Soap ■ Nail brush or stick ■ Clean towels
Waste
■ Container for sharps disposal ■ Receptacle for soiled linens ■ Bucket for soiled pads and swabs ■ Bowl and plastic bag for placenta
Sterilization
■ Instrument sterilizer ■ Jar for forceps
Miscellaneous
■ Wall clock ■ Torch with extra batteries and bulb ■ Log book
Equipment, supplies and drugs for childbirth care
EQUIPM
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L3
EQUIPM
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EQUIPMENT, SUPPLIES AND DRUGS fOR chILDBIRTh cARE
Equipment
■ Blood pressure machine and stethoscope ■ Body thermometer ■ Fetal stethoscope ■ Baby scale ■ Self inflating bag and mask - neonatal size ■ Mucus extractor with suction tube
Delivery instruments (sterile)
■ Scissors ■ Needle holder ■ Artery forceps or clamp ■ Dissecting forceps ■ Sponge forceps ■ Vaginal speculum
Supplies
■ Gloves: →utility →sterile or highly disinfected →long sterile for manual removal of placenta →Long plastic apron ■ Urinary catheter ■ Syringes and needles ■ IV tubing ■ Suture material for tear or episiotomy repair ■ Antiseptic solution (iodophors or chlorhexidine) ■ Spirit (70% alcohol) ■ Swabs ■ Bleach (chlorine-base compound) ■ Clean (plastic) sheet to place under mother ■ Sanitary pads ■ Clean towels for drying and wrapping the baby ■ Cord ties (sterile) ■ Blanket for the baby ■ Baby feeding cup ■ Impregnated bednet
Drugs
■ Oxytocin ■ Ergometrine ■ Magnesium sulphate ■ Calcium gluconate ■ Diazepam ■ Hydralazine ■ Ampicillin ■ Gentamicin ■ Metronidazole ■ Benzathine penicillin ■ Lignocaine ■ Adrenaline ■ Ringer lactate ■ Normal saline 0.9% ■ Water for injection ■ Eye antimicrobial (1% silver nitrate or 2.5% povidone iodine) ■ Tetracycline 1% eye ointment ■ Vitamin A ■ Izoniazid ■ Nevirapine (adult, infant) ■ Zidovudine (AZT) (adult, infant) ■ Lamivudine (3TC)
Vaccine
■ BCG ■ OPV ■ Hepatitis B
Contraceptives
(see Decision-making tool for family planning providers and clients)
Test
■ RPR testing kits ■ HIV testing kits (2 types) ■ Haemoglobin testing kit
L2

EQUIPMENT, SUPPLIES, DRUGS
AND TESTS fOR ROUTINE AND
EMERGENcY cARE
L3 EQUIPMENT, SUPPLIES AND DRUGS
fOR chILDBIRTh cARE
L4 LABORATORY TESTS (1)
Checkurineforprotein
Checkhaemoglobin
L5 LABORATORY TESTS (2)
Performrapidplamareagin(RPR)testfor
syphilis
L6 LABORATORY TESTS (3)
PerformrapidtestforHIV
Equipment, supplies, drugs and tests for pregnancy and postpartum care
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EQUIPMENT, SUPPLIES, DRUGS AND TESTS fOR ROUTINE AND EMERGENcY PREGNANcY AND POSTPARTUM cARE
Warmandcleanroom
■ Examinationtableorbedwithcleanlinen
■ Lightsource
■ Heatsource

Handwashing
■ Cleanwatersupply
■ Soap
■ Nailbrushorstick
■ Cleantowels
Waste
■ Bucketforsoiledpadsandswabs
■ Receptacleforsoiledlinens
■ Containerforsharpsdisposal
Sterilization
■ Instrumentsterilizer
■ Jarforforceps
Miscellaneous
■ Wallclock
■ Torchwithextrabatteriesandbulb
■ Logbook
■ Records
■ Refrigerator
Equipment
■ Bloodpressuremachineandstethoscope
■ Bodythermometer
■ Fetalstethoscope
■ Babyscale
Supplies
■ Gloves:
→utility
→sterileorhighlydisinfected
→longsterileformanualremovalofplacenta
■ Urinarycatheter
■ Syringesandneedles
■ IVtubing
■ Suturematerialfortearorepisiotomyrepair
■ Antisepticsolution(iodophorsorchlorhexidine)
■ Spirit(70%alcohol)
■ Swabs
■ Bleach(chlorinebasecompound)
■ Impregnatedbednet
■ Condoms
Tests
■ RPRtestingkit
■ Proteinuriasticks
■ Containerforcatchingurine
■ HIVtestingkit(2types)
■ Haemoglobintestingkit
Disposabledeliverykit
■ Plasticsheettoplaceundermother
■ Cordties(sterile)
■ Sterileblade
Drugs
■ Oxytocin
■ Ergometrine
■ Magnesiumsulphate
■ Calciumgluconate
■ Diazepam
■ Hydralazine
■ Ampicillin
■ Gentamicin
■ Metronidazole
■ Benzathinepenicillin
■ Cloxacillin
■ Amoxycillin
■ Ceftriaxone
■ Trimethoprim+sulfamethoxazole
■ Clotrimazolevaginalpessary
■ Erythromycin
■ Ciprofloxacin
■ Tetracyclineordoxycycline
■ Arthemetherorquinine
■ Chloroquinetablet
■ Lignocaine
■ Adrenaline
■ Ringerlactate
■ Normalsaline0.9%
■ Glucose50%solution
■ Waterforinjection
■ Paracetamol
■ Gentianviolet
■ Iron/folicacidtablet
■ Mebendazole
■ Sulphadoxine-pyrimethamine
■ Nevirapine(adult,infant)
■Zidovudine(AZT)(adult,infant)
■ Lamivudine(3TC)
Vaccine
■ Tetanustoxoid
Equipment, suplies and drugs
Warmandcleanroom
■ Deliverybed:abedthatsupportsthewomaninasemi-sittingor
lyinginalateralposition,withremovablestirrups(onlyforrepairing
theperineumorinstrumentaldelivery)
■ Cleanbedlinen
■ Curtainsifmorethanonebed
■ Cleansurface(foralternativedeliveryposition)
■ Worksurfaceforresuscitationofnewbornneardeliverybeds
■ Lightsource
■ Heatsource
■ Roomthermometer
Handwashing
■ Cleanwatersupply
■ Soap
■ Nailbrushorstick
■ Cleantowels
Waste
■ Containerforsharpsdisposal
■ Receptacleforsoiledlinens
■ Bucketforsoiledpadsandswabs
■ Bowlandplasticbagforplacenta
Sterilization
■ Instrumentsterilizer
■ Jarforforceps
Miscellaneous
■ Wallclock
■ Torchwithextrabatteriesandbulb
■ Logbook
Equipment, supplies and drugs for childbirth care
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EQUIPMENT, SUPPLIES AND DRUGS fOR chILDBIRTh cARE
Equipment
■ Bloodpressuremachineandstethoscope
■ Bodythermometer
■ Fetalstethoscope
■ Babyscale
■ Selfinflatingbagandmask-neonatalsize
■ Mucusextractorwithsuctiontube
Deliveryinstruments(sterile)
■ Scissors
■ Needleholder
■ Arteryforcepsorclamp
■ Dissectingforceps
■ Spongeforceps
■ Vaginalspeculum
Supplies
■ Gloves:
→utility
→sterileorhighlydisinfected
→longsterileformanualremovalofplacenta
→Longplasticapron
■ Urinarycatheter
■ Syringesandneedles
■ IVtubing
■ Suturematerialfortearorepisiotomyrepair
■ Antisepticsolution(iodophorsorchlorhexidine)
■ Spirit(70%alcohol)
■ Swabs
■ Bleach(chlorine-basecompound)
■ Clean(plastic)sheettoplaceundermother
■ Sanitarypads
■ Cleantowelsfordryingandwrappingthebaby
■ Cordties(sterile)
■ Blanketforthebaby
■ Babyfeedingcup
■ Impregnatedbednet
Drugs
■ Oxytocin
■ Ergometrine
■ Magnesiumsulphate
■ Calciumgluconate
■ Diazepam
■ Hydralazine
■ Ampicillin
■ Gentamicin
■ Metronidazole
■ Benzathinepenicillin
■ Lignocaine
■ Adrenaline
■ Ringerlactate
■ Normalsaline0.9%
■ Waterforinjection
■ Eyeantimicrobial(1%silvernitrateor2.5%povidoneiodine)
■ Tetracycline1%eyeointment
■ VitaminA
■ Izoniazid
■ Nevirapine(adult,infant)
■Zidovudine(AZT)(adult,infant)
■ Lamivudine(3TC)
Vaccine
■ BCG
■ OPV
■ HepatitisB
Contraceptives
(seeDecision-making tool for family planning providers and
clients)
Test
■ RPRtestingkit
■ HIVtestingkits(2types)
■ Haemoglobintestingkit
Laboratory tests (1)
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LABORATORY TESTS
Checkurineforprotein
■ Labelacleancontainer.
■ Givewomanthecleancontainerandexplainwhereshecanurinate.
■ Teachwomanhowtocollectaclean-catchurinesample.Askherto:
→Cleanvulvawithwater
→Spreadlabiawithfingers
→Urinatefreely(urineshouldnotdribbleovervulva;thiswillruinsample)
→Catchthemiddlepartofthestreamofurineinthecup.Removecontainerbeforeurinestops.
■ Analyseurineforproteinusingeitherdipstickorboilingmethod.
DIPSTIck METhOD
■ Dipcoatedendofpaperdipstickinurinesample.
■ Shakeoffexcessbytappingagainstsideofcontainer.
■ Waitspecifiedtime(seedipstickinstructions).
■ Comparewithcolourchartonlabel.Coloursrangefromyellow(negative)throughyellow-greenand
green-blueforpositive.
BOILING METhOD
■ Puturineintesttubeandboiltophalf.Boiledpartmaybecomecloudy.Afterboilingallowthetest
tubetostand.Athickprecipitateatthebottomofthetubeindicatesprotein.
■ Add2-3dropsof2-3%aceticacidafterboilingtheurine(evenifurineisnotcloudy)
→Iftheurineremainscloudy,proteinispresentintheurine.
→Ifcloudyurinebecomesclear,proteinisnotpresent.
→Ifboiledurinewasnotcloudytobeginwith,butbecomescloudywhenaceticacidisadded,
proteinispresent.
Checkhaemoglobin
■ Drawbloodwithsyringeandneedleorasterilelancet.
■ Insertbelowinstructionsformethodusedlocally.
✎____________________________________________________________________
✎____________________________________________________________________
Equipment, suplies and drugs
Performrapidplasmareagin(RPR)testforsyphilis
■Seekconsent.
■Explainprocedure.
■Useasterileneedleandsyringe.Drawup5mlbloodfromavein.Putinacleartesttube.
■Lettesttubesit20minutestoallowserumtoseparate(orcentrifuge3-5minutesat2000–
3000-rpm).Intheseparatedsample,serumwillbeontop.
■Usesamplingpipettetowithdrawsomeoftheserum.
Takecarenottoincludeanyredbloodcellsfromthelowerpartoftheseparatedsample.
■Holdthepipetteverticallyoveratestcardcircle.Squeezeteattoallowonedrop(50‑µl)ofserumto
fallontoacircle.Spreadthedroptofillthecircleusingatoothpickorothercleanspreader.
Important: Several samples may be tested on one card. Be careful not to contaminate the
remaining test circles. Use a clean spreader for every sample. carefully label each sample with a
patient’s name or number.
■Attachdispensingneedletoasyringe.Shakeantigen.*
Drawupenoughantigenforthenumberofteststobedone(onedroppertest).
■Holdingthesyringevertically,allowexactlyonedropofantigen(20‑µl)tofallontoeachtestsample.
DO NOT stir.
■Rotatethetestcardsmoothlyonthepalmofthehandfor8minutes.**
(Orrotateonamechanicalrotator.)
*Makesureantigenwasrefrigerated(notfrozen)andhasnotexpired.
**Roomtemperatureshouldbe73º-85ºF(22.8º–29.3ºC).
Laboratory tests (2) Perform rapid plasmareagin (RPR) test for syphilis
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PERfORM RAPID PLASMAREAGIN (RPR) TEST fOR SYPhILIS
Interpretingresults
■After8minutesrotation,inspectthecardingoodlight.Turnorliftthecardtoseewhetherthere
isclumping(reactiveresult).Mosttestcardsincludenegativeandpositivecontrolcirclesfor
comparison.
1. Non‑reactive(noclumpingoronlyslightroughness)–Negativeforsyphilis
2. Reactive(highlyvisibleclumping)-Positiveforsyphilis
3. Weakly reactive (minimalclumping)-Positiveforsyphilis
NOTE:Weaklyreactivecanalsobemorefinelygranulatedanddifficulttoseethaninthisillsutration.
ExAMPLE Of A TEST cARD
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Perform Rapid HIV test
PERfORM RAPID hIV TEST (TYPE Of TEST USE DEPENDS ON ThE NATIONAL POLIcY)
■ Explaintheprocedureandseekconsentaccordingtothenationalpolicy.
■ Usetestkitsrecommendedbythenationaland/orinternationalbodiesandfollowtheinstructions
oftheHIVrapidtestselected.
■ Prepareyourworksheet,labelthetest,andindicatethetestbatchnumberandexpirydate.Check
thatexpirytimehasnotlapsed.
■ Weargloveswhendrawingbloodandfollowstandardsafetyprecautionsforwastedisposal.
■ Informthewomenwhentoreturntotheclinicfortheirtestresults(samedayortheywillhaveto
comeagain).
■ Drawbloodforalltestsatthesametime(testsforHb,syphilisandHIVcanoftenbecoupledatthe
sametime).
→Useasterileneedleandsyringewhendrawingbloodfromavein.
→Usealancetwhendoingafingerprick.
■ Performthetestfollowingmanufacturer’sinstructions.
■ InterprettheresultsaspertheinstructionsoftheHIVrapidtestselected.
→Ifthefirsttestresultisnegative,nofurthertestingisdone.Recordtheresultas–NegativeforHIV.
→Ifthefirsttestresultispositive,performasecondHIVrapidtestusingadifferenttestkit.
→Ifthesecondtestisalsopositive,recordtheresultas–PositiveforHIV.
→Ifthefirsttestresultispositiveandsecondtestresultisnegative,recordtheresultas
inconclusive.Repeatthetestafter6weeksorreferthewomantohospitalforaconfirmatorytest.
→Sendtheresultstothehealthworker.Respectconfidentiality A2 .
■ Recordallresultsinthelogbook.
Information and counselling sheets
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INI0kNAII0N AN0 00uNS£llIN0 Sߣ£IS
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Care during pregnancy
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Visit the health worker during pregnancy
■ Go to the health centre if you think you are pregnant. It is important to begin care as early in your pregnancy as possible. ■ Visit the health centre at least 4 times during your pregnancy, even if you do not have any problems. The health worker will tell you when to return. ■ If at any time you have any concerns about your or your baby’s health, go to the health centre. ■ During your visits to the health centre, the health worker will: → Check your health and the progress of the pregnancy → Help you make a birth plan → Answer questions or concerns you may have → Provide treatment for malaria and anaemia → Give you a tetanus toxoid immunization → Advise and counsel on: → breastfeeding → birthspacing after delivery → nutrition → HIV counselling and testing → correct and consistent condom use → laboratory tests → other matters related to your and your baby’s health. ■ Bring your home-based maternal record to every visit.
Care for yourself during pregnancy
■ Eat more and healthier foods, including more fruits and vegetables, beans, meat, fish, eggs, cheese, milk. ■ Take iron tablets every day as explained by the health worker. ■ Rest when you can. Avoid lifting heavy objects. ■ Sleep under a bednet treated with insecticide. ■ Do not take medication unless prescribed at the health centre. ■ Do not drink alcohol or smoke. ■ Use a condom correctly in every sexual relation to prevent sexually transmitted infection (STI) or HIV/AIDS if you or your companion are at risk of infection.
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Routine visits to the health centre
1st r|s|t Before 4 months 2ad r|s|t 6-7 months 3rd r|s|t 8 months 4th r|s|t 9 months
Know the signs of labour
If you have any of these signs, go to the health centre as soon as you can. If these s|gas coat|aae for 12 hoars or more, ,oa aeed to go |mmed|ate|,. ■ Painful contractions every 20 minutes or less. ■ Bag of water breaks. ■ Bloody sticky discharge.
When to seek care on danger signs
Go to the hospital or health centre |mmed|ate|,, da, or a|ght, 00 N0I wa|t, if any of the following signs: ■ vaginal bleeding ■ convulsions/fits ■ severe headaches with blurred vision ■ fever and too weak to get out of bed ■ severe abdominal pain ■ fast or difficult breathing.
Go to the health centre as sooa as poss|h|e if any of the following signs: ■ fever ■ abdominal pain ■ water breaks and not in labour after 6 hours ■ feel ill ■ swollen fingers, face and legs.
Pk£PAkIN0A 8IkIßAN0 £N£k0£N0Y PlAN
Preparing a birth and emergency plan
INI0kN
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Preparing a birth plan
The health worker will provide you with information to help you prepare a birth plan. Based on your health condition, the health worker can make suggestions as to where it would be best to deliver. Whether in a hospital, health centre or at home, it is important to deliver with a skilled attendant.
AI £V£kY VISII I0 Iߣ ߣAlIß 0£NIk£, k£VI£wAN0 0IS0uSS Y0uk 8IkIß PlAN. Ihe p|aa caa chaage |f comp||cat|oas dere|op.
Planning for delivery at home
■ Who do you choose to be the skilled attendant for delivery? ■ Who will support you during labour and delivery? ■ Who will be close by for at least 24 hours after delivery? ■ Who will help you to care for your home and other children? ■ Organize the following: →A clean and warm room or corner of a room. →Home-based maternal record. →A clean delivery kit which includes soap, a stick to clean under the nails, a new razor blade to cut the baby’s cord, 3 pieces of string (about 20 cm. each) to tie the cord. →Clean cloths of different sizes: for the bed, for drying and wrapping the baby, for cleaning the baby’s eyes, and for you to use as sanitary pads. →Warm covers for you and the baby. →Warm spot for the birth with a clean surface or clean cloth. →Bowls: two for washing and one for the placenta. →Plastic for wrapping the placenta. →Buckets of clean water and some way to heat this water. →For handwashing, water, soap and a towel or cloth for drying hands of the birth attendant. →Fresh drinking water, fluids and food for the mother.
Preparing an emergency plan
■To plan for an emergency, consider: →Where should you go? →How will you get there? →Will you have to pay for transport to get there? How much will it cost? →What costs will you have to pay at the health centre? How will you pay for this? →Can you start saving for these possible costs now? →Who will go with you to the health centre? →Who will help to care for your home and other children while you are away?
Planning for delivery at the hospital or health centre
■ How will you get there? Will you have to pay for transport to get there? ■ How much will it cost to deliver at the facility? How will you pay for this? ■ Can you start saving for these costs now? ■Who will go with you and support you during labour and delivery? ■Who will help you while you are away and care for your home and other children? ■ Bring the following: →Home-based maternal record. →Clean cloths of different sizes: for the bed, for drying and wrapping the baby, and for you to use as sanitary pads. →Clean clothes for you and the baby. →Food and water for you and the support person.
0Ak£ I0k Iߣ N0Iߣk AII£k 8IkIß
Care for the mother after birth
INI0kN
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Care of the mother
■ Eat more and healthier foods, including more meat, fish, oils, coconut, nuts, cereals, beans, vegetables, fruits, cheese and milk. ■ Take iron tablets as explained by the health worker. ■ Rest when you can. ■ Drink plenty of clean, safe water. ■ Sleep under a bednet treated with insecticide. ■ Do not take medication unless prescribed at the health centre. ■ Do not drink alcohol or smoke. ■ Use a condom in every sexual relation, if you or your companion are at risk of sexually transmitted infections (STI) or HIV/AIDS. ■ Wash all over daily, particularly the perineum. ■ Change pad every 4 to 6 hours. Wash pad or dispose of it safely.
Family planning
■ You can become pregnant within several weeks after delivery if you have sexual relations and are not breastfeeding exclusively. ■ Talk to the health worker about choosing a family planning method which best meets your and your partner’s needs.
Routine visits to the health centre
First week after birth:
✎____________________________________________________________________
✎____________________________________________________________________
6 weeks after birth: ✎____________________________________________________________________
✎____________________________________________________________________
When to seek care for danger signs
Go to hospital or health centre |mmed|ate|,, da, or a|ght, 00 N0I wait, if any of the following signs: ■ Vaginal bleeding has increased. ■ Fits. ■ Fast or difficult breathing. ■ Fever and too weak to get out of bed. ■ Severe headaches with blurred vision.
Go to health centre as sooa as poss|h|e if any of the following signs: ■ Swollen, red or tender breasts or nipples. ■ Problems urinating, or leaking. ■ Increased pain or infection in the perineum. ■ Infection in the area of the wound. ■ Smelly vaginal discharge.
0Ak£ AII£k AN A80kII0N
Care after an abortion
INI0kN
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Self-care
■ Rest for a few days, especially if you feel tired. ■ Change pads every 4 to 6 hours. Wash used pad or dispose of it safely. Wash perineum. ■ Do not have sexual intercourse until bleeding stops. ■ You and your partner should use a condom correctly in every act of sexual intercourse if at risk of STI or HIV. ■ Return to the health worker as indicated.
Family planning
■ Remember you can become pregnant as soon as you have sexual relations. Use a family planning method to prevent an unwanted pregnancy. ■ Talk to the health worker about choosing a family planning method which best meets your and your partner’s needs.
Know these danger signs
If you have any of these signs, go to the health centre |mmed|ate|,, da, or a|ght. 00 N0I wa|t: ■ Increased bleeding or continued bleeding for 2 days. ■ Fever, feeling ill. ■ Dizziness or fainting. ■ Abdominal pain. ■ Backache. ■ Nausea, vomiting. ■ Foul-smelling vaginal discharge.
Additional support
■ The health worker can help you identify persons or groups who can provide you with additional support if you should need it.
0Ak£ I0k Iߣ 8A8Y AII£k 8IkIß
Care for the baby after birth
INI0kN
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Care of the newborn
k££P Y0uk N£w80kN 0l£AN ■ Wash your baby’s face and neck daily. Bathe her/him when necessary. After bathing, thoroughly dry your baby and then dress and keep her/him warm. ■ Wash baby’s bottom when soiled and dry it thoroughly. ■ Wash your hands with soap and water before and after handling your baby, especially after touching her/his bottom.
0Ak£ I0k Iߣ N£w80kN’S uN8IlI0Al 00k0 ■ Keep cord stump loosely covered with a clean cloth. Fold diaper and clothes below stump. ■ Do not put anything on the stump. ■ If stump area is soiled, wash with clean water and soap. Then dry completely with clean cloth. ■ Wash your hands with soap and water before and after care.
k££P Y0uk N£w80kN wAkN ■ In cold climates, keep at least an area of the room warm. ■ Newborns need more clothing than other children or adults. ■ If cold, put a hat on the baby’s head. During cold nights, cover the baby with an extra blanket.
0Iߣk A0VI0£ ■ Let the baby sleep on her/his back or side. ■ Keep the baby away from smoke.
Routine visits to the health centre
I|rst week after h|rth:
✎____________________________________________________________________
✎____________________________________________________________________
At 0 weeks :
✎____________________________________________________________________
✎____________________________________________________________________
At these visits your baby will be vaccinated. ßare ,oar hah, |mmaa|ted.
When to seek care for danger signs
Go to hospital or health centre |mmed|ate|,, da, or a|ght, 00 N0I wa|t, if your baby has any of the following signs: ■ Difficult breathing ■ Fits ■ Fever ■ Feels cold ■ Bleeding ■ Stops feeding ■ Diarrhoea.
Go to the health centre as sooa as poss|h|e if your baby has any of the following signs: ■ Difficulty feeding. ■ Feeds less than every 5 hours. ■ Pus coming from the eyes. ■ Irritated cord with pus or blood. ■ Yellow eyes or skin.
8k£ASII££0IN0
Breastfeeding
INI0kN
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Breastfeeding has many advantages
I0k Iߣ 8A8Y ■ During the first 6 months of life, the baby needs nothing more than breast milk — not water, not other milk, not cereals, not teas, not juices. ■ Breast milk contains exactly the water and nutrients that a baby’s body needs. It is easily digested and efficiently used by the baby’s body. It helps protect against infections and allergies and helps the baby’s growth and development.
I0k Iߣ N0Iߣk ■ Postpartum bleeding can be reduced due to uterine contractions caused by the baby’s sucking. ■ Breastfeeding can help delay a new pregnancy.
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Suggestions for successful breastfeeding
■ Immediately after birth, keep your baby in the bed with you, or within easy reach. ■ Start breastfeeding within 1 hour of birth. ■ The baby’s suck stimulates your milk production. The more the baby feeds, the more milk you will produce. ■ At each feeding, let the baby feed and release your breast, and then offer your second breast. At the next feeding, alternate and begin with the second breast. ■ Give your baby the first milk (colostrum). It is nutritious and has antibodies to help keep your baby healthy. ■ At night, let your baby sleep with you, within easy reach. ■ While breastfeeding, you should drink plenty of clean, safe water. You should eat more and healthier foods and rest when you can.
The health worker can support you in
starting and maintaining breastfeeding
■ The health worker can help you to correctly position the baby and ensure she/he attaches to the breast. This will reduce breast problems for the mother. ■ The health worker can show you how to express milk from your breast with your hands. If you should need to leave the baby with another caretaker for short periods, you can leave your milk and it can be given to the baby in a cup. ■ The health worker can put you in contact with a breastfeeding support group.
If ,oa hare aa, d|ff|ca|t|es w|th hreastfeed|ag, see the hea|th worker |mmed|ate|,.
Breastfeeding and family planning
■ During the first 6 months after birth, if you breastfeed exclusively, day and night, and your menstruation has not returned, you are protected against another pregnancy. ■ If you do not meet these requirements, or if you wish to use another family planning method while breastfeeding, discuss the different options available with the health worker.
M2

0Ak£ 0ukIN0 Pk£0NAN0Y
Visitthehealthworkerduringpregnancy
Careforyourselfduringpregnancy
Routinevisitstothehealthcentre
Knowthesignsoflabour
Whentoseekcareondangersigns
M3

Pk£PAkIN0 A 8IkIß AN0
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Preparingabirthplan
Planningfordeliveryathome
Preparinganemergencyplan
Planningfordeliveryatthehospitalorhealth
centre
M4

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Careofthemother
Familyplanning
Routinevisitstothehealthcentre
Whentoseekcarefordangersigns
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Self-care
Familyplanning
KnowtheseDANGERsigns
Additionalsupport
M6 0Ak£ I0k Iߣ 8A8Y
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Careofthenewborn
Routinevisitstothehealthcentre
Whentoseekcarefordangersigns
M7 8k£ASII££0IN0
Breastfeedinghasmanyadvantagesforthe
babyandthemother
Suggestionsforsuccessfulbreastfeeding
Healthworkersupport
Breastfeedingandfamilyplanning
0l£AN ß0N£ 0£lIV£kY
kegard|ess of the s|te of de||rer,, |t |s stroag|, recommeaded that a|| womea de||rer w|th a sk|||ed atteadaat.
Ior a womaa who prefers to de||rer at home the fo||ow|ag recommeadat|oas are pror|ded for a c|eaa home de||rer, to he rer|ewed dar|ag aateaata| care r|s|ts.
Clean home delivery (1)
INI0kN
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Delivery at home with an attendant
■Ensure the attendant and other family members know the emergency plan and are aware of danger signs for yourself and your baby. ■ Arrange for a support person to assist the attendant and to stay with you during labour and after delivery. →Have these supplies organized for a clean delivery: new razor blade, 3 pieces of string about 20-cm each to tie the cord, and clean cloths to cover the birth place. →Prepare the home and the supplies indicated for a safe birth: →Clean, warm birth place with fresh air and a source of light →Clean warm blanket to cover you →Clean cloths: →for drying and wrapping the baby →for cleaning the baby’s eyes →to use as sanitary pads after birth →to dry your body after washing →for birth attendant to dry her hands. →Clean clothes for you to wear after delivery →Fresh drinking water, fluids and food for you →Buckets of clean water and soap for washing, for you and the skilled attendant →Means to heat water →Three bowls, two for washing and one for the placenta →Plastic for wrapping the placenta →Bucket for you to urinate in.
Instructions to mother and family
for a clean and safer delivery at home
■ Make sure there is a clean delivery surface for the birth of the baby. ■ Ask the attendant to wash her hands before touching you or the baby. The nails of the attendant should be short and clean. ■ When the baby is born, place her/him on your abdomen/chest where it is warm and clean. Dry the baby thoroughly and wipe the face with a clean cloth. Then cover with a clean dry cloth. ■ Cut the cord when it stops pulsating, using the disposable delivery kit, according to instructions. ■ Wait for the placenta to deliver on its own. ■ Make sure you and your baby are warm. Have the baby near you, dressed or wrapped and with head covered with a cap. ■ Start breastfeeding when the baby shows signs of readiness, within the first hour of birth. ■ Dispose of placenta _____________________________________________ (describe correct, safe culturally accepted way to dispose of placenta)
00 N0I be alone for the 24 hours after delivery. 00 N0I bath the baby on the first day.
Clean home delivery (2)
INI0kN
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Avoid harmful practices
I0k £XANPl£: 00 N0I use local medications to hasten labour. 00 N0I wait for waters to stop before going to health facility. 00 N0I insert any substances into the vagina during labour or after delivery. 00 N0I push on the abdomen during labour or delivery. 00 N0I pull on the cord to deliver the placenta. 00 N0I put ashes, cow dung or other substance on umbilical cord/stump.
✎____________________________________________________________________
✎____________________________________________________________________
Encourage helpful traditional practices:
✎____________________________________________________________________
✎____________________________________________________________________
Danger signs during delivery
If you or your baby has any of these signs, go to the hosp|ta| or hea|th ceatre |mmed|ate|,, da, or a|ght, 00 N0I wa|t.
N0Iߣk ■ If waters break and not in labour after 6 hours. ■ Labour pains (contractions) continue for more than 12 hours. ■ Heavy bleeding (soaks more than 2-3 pads in 15 minutes). ■ Placenta not expelled 1 hour after birth of baby.
8A8Y ■ Very small. ■ Difficulty in breathing. ■ Fits. ■ Fever. ■ Feels cold. ■ Bleeding. ■ Not able to feed.
Routine visits to the health centre
■ Go to the health centre or arrange a home visit by a skilled attendant as soon as possible after delivery, preferably within the first days, for the examination of you and your baby and to receive preventive measures. ■ Go for a routine postpartum visit at 6 weeks.
M8 0l£AN ß0N£ 0£lIV£kY (1}
Deliveryathomewithanattendant
Instructionstomotherandfamilyforaclean
andsaferdeliveryathome
M9 0l£AN ß0N£ 0£lIV£kY (2}
Avoidharmfulpractices
Encouragehelpfultraditionalpractices
Dangersignsduringdelivery
Routinevisitstothehealthcentre
■ Theseindividualsheetshavekeyinformationforthemother,her
partnerandfamilyoncareduringpregnancy,preparingabirth
andemergencyplan,cleanhomedelivery,careforthemother
andbabyafterdelivery,breastfeedingandcareafteranabortion.
■ Individualsheetsareusedsothatthewomancanbegiven
therelevantsheetattheappropriatestageofpregnancyand
childbirth.
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Care during pregnancy
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Visitthehealthworkerduringpregnancy
■ Gotothehealthcentreifyouthinkyouarepregnant.Itisimportanttobegincareasearlyinyour
pregnancyaspossible.
■ Visitthehealthcentreatleast4timesduringyourpregnancy,evenifyoudonothaveanyproblems.
Thehealthworkerwilltellyouwhentoreturn.
■ Ifatanytimeyouhaveanyconcernsaboutyouroryourbaby’shealth,gotothehealthcentre.
■ Duringyourvisitstothehealthcentre,thehealthworkerwill:
→ Checkyourhealthandtheprogressofthepregnancy
→ Helpyoumakeabirthplan
→ Answerquestionsorconcernsyoumayhave
→ Providetreatmentformalariaandanaemia
→ Giveyouatetanustoxoidimmunization
→ Adviseandcounselon:
→ breastfeeding
→ birthspacingafterdelivery
→ nutrition
→ HIVcounsellingandtesting
→ correctandconsistentcondomuse
→ laboratorytests
→ othermattersrelatedtoyourandyourbaby’shealth.
■ Bringyourhome-basedmaternalrecordtoeveryvisit.
Careforyourselfduringpregnancy
■ Eatmoreandhealthierfoods,includingmorefruitsandvegetables,beans,meat,fish,eggs,cheese,milk.
■ Takeirontabletseverydayasexplainedbythehealthworker.
■ Restwhenyoucan.Avoidliftingheavyobjects.
■ Sleepunderabednettreatedwithinsecticide.
■ Donottakemedicationunlessprescribedatthehealthcentre.
■ Donotdrinkalcoholorsmoke.
■ Useacondomcorrectlyineverysexualrelationtopreventsexuallytransmittedinfection(STI)or
HIV/AIDSifyouoryourcompanionareatriskofinfection.
Pk£0NAN0Y IS A SP£0IAl IIN£. 0Ak£ I0k Y0ukS£lI AN0 Y0uk 8A8Y.
Routinevisitstothehealthcentre
1st r|s|t Before4months
2ad r|s|t 6-7months
3rd r|s|t 8months
4th r|s|t 9months
Knowthesignsoflabour
Ifyouhaveanyofthesesigns,gotothehealthcentreassoonasyoucan.
If these s|gas coat|aae for 12 hoars or more, ,oa aeed to go |mmed|ate|,.
■ Painfulcontractionsevery20minutesorless.
■ Bagofwaterbreaks.
■ Bloodystickydischarge.
Whentoseekcareondangersigns
Gotothehospitalorhealthcentre|mmed|ate|,, da, or a|ght,00 N0I wa|t,ifanyofthefollowingsigns:
■ vaginalbleeding
■ convulsions/fits
■ severeheadacheswithblurredvision
■ feverandtooweaktogetoutofbed
■ severeabdominalpain
■ fastordifficultbreathing.
Gotothehealthcentreas sooa as poss|h|eifanyofthefollowingsigns:
■ fever
■ abdominalpain
■ waterbreaksandnotinlabourafter6hours
■ feelill
■ swollenfingers,faceandlegs.
Pk£PAkIN0 A 8IkIß AN0 £N£k0£N0Y PlAN
Preparing a birth and emergency plan
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Preparingabirthplan
Thehealthworkerwillprovideyouwithinformationtohelpyouprepareabirthplan.Basedonyour
healthcondition,thehealthworkercanmakesuggestionsastowhereitwouldbebesttodeliver.
Whetherinahospital,healthcentreorathome,itisimportanttodeliverwithaskilledattendant.
AI £V£kY VISII I0 Iߣ ߣAlIß 0£NIk£, k£VI£w AN0 0IS0uSS Y0uk 8IkIß PlAN.
Ihe p|aa caa chaage |f comp||cat|oas dere|op.
Planningfordeliveryathome
■ Whodoyouchoosetobetheskilledattendantfordelivery?
■ Whowillsupportyouduringlabouranddelivery?
■ Whowillbeclosebyforatleast24hoursafterdelivery?
■ Whowillhelpyoutocareforyourhomeandotherchildren?
■ Organizethefollowing:
→Acleanandwarmroomorcornerofaroom.
→Home-basedmaternalrecord.
→Acleandeliverykitwhichincludessoap,asticktocleanunderthenails,anewrazorbladetocut
thebaby’scord,3piecesofstring(about20cm.each)totiethecord.
→Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,forcleaningthe
baby’seyes,andforyoutouseassanitarypads.
→Warmcoversforyouandthebaby.
→Warmspotforthebirthwithacleansurfaceorcleancloth.
→Bowls:twoforwashingandonefortheplacenta.
→Plasticforwrappingtheplacenta.
→Bucketsofcleanwaterandsomewaytoheatthiswater.
→Forhandwashing,water,soapandatowelorclothfordryinghandsofthebirthattendant.
→Freshdrinkingwater,fluidsandfoodforthemother.
Preparinganemergencyplan
■Toplanforanemergency,consider:
→Whereshouldyougo?
→Howwillyougetthere?
→Willyouhavetopayfortransporttogetthere?Howmuchwillitcost?
→Whatcostswillyouhavetopayatthehealthcentre?Howwillyoupayforthis?
→Canyoustartsavingforthesepossiblecostsnow?
→Whowillgowithyoutothehealthcentre?
→Whowillhelptocareforyourhomeandotherchildrenwhileyouareaway?
Planningfordeliveryatthehospitalorhealthcentre
■Howwillyougetthere?Willyouhavetopayfortransporttogetthere?
■Howmuchwillitcosttodeliveratthefacility?Howwillyoupayforthis?
■Canyoustartsavingforthesecostsnow?
■Whowillgowithyouandsupportyouduringlabouranddelivery?
■Whowillhelpyouwhileyouareawayandcareforyourhomeandotherchildren?
■Bringthefollowing:
→Home-basedmaternalrecord.
→Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,andforyoutouseas
sanitarypads.
→Cleanclothesforyouandthebaby.
→Foodandwaterforyouandthesupportperson.
0Ak£ I0k Iߣ N0Iߣk AII£k 8IkIß
Care for the mother after birth
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Careofthemother
■ Eatmoreandhealthierfoods,includingmoremeat,fish,oils,coconut,nuts,cereals,beans,
vegetables,fruits,cheeseandmilk.
■ Takeirontabletsasexplainedbythehealthworker.
■ Restwhenyoucan.
■ Drinkplentyofclean,safewater.
■ Sleepunderabednettreatedwithinsecticide.
■ Donottakemedicationunlessprescribedatthehealthcentre.
■ Donotdrinkalcoholorsmoke.
■ Useacondomineverysexualrelation,ifyouoryourcompanionareatriskofsexuallytransmitted
infections(STI)orHIV/AIDS.
■ Washalloverdaily,particularlytheperineum.
■ Changepadevery4to6hours.Washpadordisposeofitsafely.
Familyplanning
■ Youcanbecomepregnantwithinseveralweeksafterdeliveryifyouhavesexualrelationsandarenot
breastfeedingexclusively.
■ Talktothehealthworkeraboutchoosingafamilyplanningmethodwhichbestmeetsyourandyour
partner’sneeds.
Routinevisitstothehealthcentre
Firstweekafterbirth:
✎____________________________________________________________________
✎____________________________________________________________________
6weeksafterbirth:

✎____________________________________________________________________
✎____________________________________________________________________

Whentoseekcarefordangersigns
Gotohospitalorhealthcentre|mmed|ate|,, da, or a|ght, 00 N0Iwait,ifanyofthefollowingsigns:
■ Vaginalbleedinghasincreased.
■ Fits.
■ Fastordifficultbreathing.
■ Feverandtooweaktogetoutofbed.
■ Severeheadacheswithblurredvision.
Gotohealthcentreas sooa as poss|h|eifanyofthefollowingsigns:
■ Swollen,redortenderbreastsornipples.
■ Problemsurinating,orleaking.
■ Increasedpainorinfectionintheperineum.
■ Infectionintheareaofthewound.
■ Smellyvaginaldischarge.
0Ak£ AII£k AN A80kII0N
Care after an abortion
I
N
I
0
k
N
A
I
I
0
N

A
N
0

0
0
u
N
S
£
l
l
I
N
0

S
ß
£
£
I
S
N5
Self-care
■ Restforafewdays,especiallyifyoufeeltired.
■ Changepadsevery4to6hours.Washusedpadordisposeofitsafely.Washperineum.
■ Donothavesexualintercourseuntilbleedingstops.
■ YouandyourpartnershoulduseacondomcorrectlyineveryactofsexualintercourseifatriskofSTI
orHIV.
■ Returntothehealthworkerasindicated.
Familyplanning
■ Rememberyoucanbecomepregnantassoonasyouhavesexualrelations.
Useafamilyplanningmethodtopreventanunwantedpregnancy.
■ Talktothehealthworkeraboutchoosingafamilyplanningmethodwhichbestmeetsyourandyour
partner’sneeds.
Knowthesedangersigns
Ifyouhaveanyofthesesigns,gotothehealthcentre|mmed|ate|,, da, or a|ght. 00 N0I wa|t:
■ Increasedbleedingorcontinuedbleedingfor2days.
■ Fever,feelingill.
■ Dizzinessorfainting.
■ Abdominalpain.
■ Backache.
■ Nausea,vomiting.
■ Foul-smellingvaginaldischarge.
Additionalsupport
■ Thehealthworkercanhelpyouidentifypersonsorgroupswhocanprovideyou
withadditionalsupportifyoushouldneedit.
0Ak£ I0k Iߣ 8A8Y AII£k 8IkIß
Care for the baby after birth
I
N
I
0
k
N
A
I
I
0
N

A
N
0

0
0
u
N
S
£
l
l
I
N
0

S
ß
£
£
I
S
N0
Careofthenewborn
k££P Y0uk N£w80kN 0l£AN
■ Washyourbaby’sfaceandneckdaily.Batheher/himwhennecessary.Afterbathing,thoroughlydry
yourbabyandthendressandkeepher/himwarm.
■ Washbaby’sbottomwhensoiledanddryitthoroughly.
■ Washyourhandswithsoapandwaterbeforeandafterhandlingyourbaby,especiallyaftertouching
her/hisbottom.
0Ak£ I0k Iߣ N£w80kN’S uN8IlI0Al 00k0
■ Keepcordstumplooselycoveredwithacleancloth.Folddiaperandclothesbelowstump.
■ Donotputanythingonthestump.
■ Ifstumpareaissoiled,washwithcleanwaterandsoap.Thendrycompletelywithcleancloth.
■ Washyourhandswithsoapandwaterbeforeandaftercare.
k££P Y0uk N£w80kN wAkN
■ Incoldclimates,keepatleastanareaoftheroomwarm.
■ Newbornsneedmoreclothingthanotherchildrenoradults.
■ Ifcold,putahatonthebaby’shead.Duringcoldnights,coverthebabywithanextrablanket.
0Iߣk A0VI0£
■ Letthebabysleeponher/hisbackorside.
■ Keepthebabyawayfromsmoke.
Routinevisitstothehealthcentre
I|rst week after h|rth:
✎____________________________________________________________________
✎____________________________________________________________________
At 0 weeks :
✎____________________________________________________________________
✎____________________________________________________________________
Atthesevisitsyourbabywillbevaccinated.ßare ,oar hah, |mmaa|ted.
Whentoseekcarefordangersigns
Gotohospitalorhealthcentre|mmed|ate|,, da, or a|ght, 00 N0I wa|t,ifyourbabyhasanyofthe
followingsigns:
■ Difficultybreathing
■ Fits
■ Fever
■ Feelscold
■ Bleeding
■ Stopsfeeding
■ Diarrhoea.
Gotothehealthcentreas sooa as poss|h|eifyourbabyhasanyofthefollowingsigns:
■ Difficultyfeeding.
■ Feedslessthanevery5hours.
■ Puscomingfromtheeyes.
■ Irritatedcordwithpusorblood.
■ Yelloweyesorskin.
8k£ASII££0IN0
Breastfeeding
I
N
I
0
k
N
A
I
I
0
N

A
N
0

0
0
u
N
S
£
l
l
I
N
0

S
ß
£
£
I
S
N7
Breastfeedinghasmanyadvantages
I0k Iߣ 8A8Y
■ Duringthefirst6monthsoflife,thebabyneedsnothingmorethanbreastmilk—notwater,not
othermilk,notcereals,notteas,notjuices.
■ Breastmilkcontainsexactlythewaterandnutrientsthatababy’sbodyneeds.Itiseasilydigested
andefficientlyusedbythebaby’sbody.Ithelpsprotectagainstinfectionsandallergiesandhelps
thebaby’sgrowthanddevelopment.
I0k Iߣ N0Iߣk
■ Postpartumbleedingcanbereducedduetouterinecontractionscausedbythebaby’ssucking.
■ Breastfeedingcanhelpdelayanewpregnancy.
I0k Iߣ IIkSI 0 N0NIßS 0I lII£, 0IV£ 0NlY 8k£ASI NIlk I0 Y0uk 8A8Y, 0AY AN0 NI0ßI
AS 0II£N AN0 AS l0N0 AS Sߣ,ߣ wANIS.
Suggestionsforsuccessfulbreastfeeding
■ Immediatelyafterbirth,keepyourbabyinthebedwithyou,orwithineasyreach.
■ Startbreastfeedingwithin1hourofbirth.
■ Thebaby’ssuckstimulatesyourmilkproduction.Themorethebabyfeeds,themoremilkyouwill
produce.
■ Ateachfeeding,letthebabyfeedandreleaseyourbreast,andthenofferyoursecondbreast.Atthe
nextfeeding,alternateandbeginwiththesecondbreast.
■ Giveyourbabythefirstmilk(colostrum).Itisnutritiousandhasantibodiestohelpkeepyourbaby
healthy.
■ Atnight,letyourbabysleepwithyou,withineasyreach.
■ Whilebreastfeeding,youshoulddrinkplentyofclean,safewater.Youshouldeatmoreandhealthier
foodsandrestwhenyoucan.
Thehealthworkercansupportyouin
startingandmaintainingbreastfeeding
■ Thehealthworkercanhelpyoutocorrectlypositionthebabyandensureshe/heattachestothe
breast.Thiswillreducebreastproblemsforthemother.
■ Thehealthworkercanshowyouhowtoexpressmilkfromyourbreastwithyourhands.Ifyoushould
needtoleavethebabywithanothercaretakerforshortperiods,youcanleaveyourmilkanditcan
begiventothebabyinacup.
■ Thehealthworkercanputyouincontactwithabreastfeedingsupportgroup.
If ,oa hare aa, d|ff|ca|t|es w|th hreastfeed|ag, see the hea|th worker |mmed|ate|,.
Breastfeedingandfamilyplanning
■ Duringthefirst6monthsafterbirth,ifyoubreastfeedexclusively,dayandnight,andyour
menstruationhasnotreturned,youareprotectedagainstanotherpregnancy.
■ Ifyoudonotmeettheserequirements,orifyouwishtouseanotherfamilyplanningmethodwhile
breastfeeding,discussthedifferentoptionsavailablewiththehealthworker.
0l£AN ß0N£ 0£lIV£kY
kegard|ess of the s|te of de||rer,, |t |s stroag|, recommeaded that a|| womea de||rer w|th a sk|||ed atteadaat.
Ior a womaa who prefers to de||rer at home the fo||ow|ag recommeadat|oas are pror|ded for a c|eaa home de||rer, to he rer|ewed dar|ag aateaata| care r|s|ts.
Clean home delivery (1)
I
N
I
0
k
N
A
I
I
0
N

A
N
0

0
0
u
N
S
£
l
l
I
N
0

S
ß
£
£
I
S
N8
Deliveryathomewithanattendant
■Ensuretheattendantandotherfamilymembersknowtheemergencyplanandareawareofdanger
signsforyourselfandyourbaby.
■ Arrangeforasupportpersontoassisttheattendantandtostaywithyouduringlabourandafter
delivery.
→Havethesesuppliesorganizedforacleandelivery:newrazorblade,3piecesofstringabout
20-cmeachtotiethecord,andcleanclothstocoverthebirthplace.
→Preparethehomeandthesuppliesindicatedforasafebirth:
→Clean,warmbirthplacewithfreshairandasourceoflight
→Cleanwarmblankettocoveryou
→Cleancloths:
→fordryingandwrappingthebaby
→forcleaningthebaby’seyes
→touseassanitarypadsafterbirth
→todryyourbodyafterwashing
→forbirthattendanttodryherhands.
→Cleanclothesforyoutowearafterdelivery
→Freshdrinkingwater,fluidsandfoodforyou
→Bucketsofcleanwaterandsoapforwashing,foryouandtheskilledattendant
→Meanstoheatwater
→Threebowls,twoforwashingandonefortheplacenta
→Plasticforwrappingtheplacenta
→Bucketforyoutourinatein.
Instructionstomotherandfamily
foracleanandsaferdeliveryathome
■ Makesurethereisacleandeliverysurfaceforthebirthofthebaby.
■ Asktheattendanttowashherhandsbeforetouchingyouorthebaby.Thenailsoftheattendant
shouldbeshortandclean.
■ Whenthebabyisborn,placeher/himonyourabdomen/chestwhereitiswarmandclean.Drythe
babythoroughlyandwipethefacewithacleancloth.Thencoverwithacleandrycloth.
■ Cutthecordwhenitstopspulsating,usingthedisposabledeliverykit,accordingtoinstructions.
■ Waitfortheplacentatodeliveronitsown.
■ Makesureyouandyourbabyarewarm.Havethebabynearyou,dressedorwrappedandwithhead
coveredwithacap.
■ Startbreastfeedingwhenthebabyshowssignsofreadiness,withinthefirsthourofbirth.
■ Disposeofplacenta_____________________________________________
(describecorrect,safeculturallyacceptedwaytodisposeofplacenta)
00 N0Ibealoneforthe24hoursafterdelivery.
00 N0Ibaththebabyonthefirstday.
Clean home delivery (2)
I
N
I
0
k
N
A
I
I
0
N

A
N
0

0
0
u
N
S
£
l
l
I
N
0

S
ß
£
£
I
S
N0
Avoidharmfulpractices
I0k £XANPl£:
00 N0Iuselocalmedicationstohastenlabour.
00 N0Iwaitforwaterstostopbeforegoingtohealthfacility.
00 N0Iinsertanysubstancesintothevaginaduringlabourorafterdelivery.
00 N0Ipushontheabdomenduringlabourordelivery.
00 N0Ipullonthecordtodelivertheplacenta.
00 N0Iputashes,cowdungorothersubstanceonumbilicalcord/stump.
✎____________________________________________________________________
✎____________________________________________________________________
Encouragehelpfultraditionalpractices:
✎____________________________________________________________________
✎____________________________________________________________________
Dangersignsduringdelivery
Ifyouoryourbabyhasanyofthesesigns,go to the hosp|ta| or hea|th ceatre |mmed|ate|,,
da, or a|ght, 00 N0I wa|t.
N0Iߣk
■ Ifwatersbreakandnotinlabourafter6hours.
■ Labourpains(contractions)continueformorethan12hours.
■ Heavybleeding(soaksmorethan2-3padsin15minutes).
■ Placentanotexpelled1hourafterbirthofbaby.
8A8Y
■ Verysmall.
■ Difficultyinbreathing.
■ Fits.
■ Fever.
■ Feelscold.
■ Bleeding.
■ Notabletofeed.
Routinevisitstothehealthcentre
■ Gotothehealthcentreorarrangeahomevisitbyaskilledattendantassoonaspossibleafter
delivery,preferablywithinthefirstdays,fortheexaminationofyouandyourbabyandtoreceive
preventivemeasures.
■ Goforaroutinepostpartumvisitat6weeks.
Records and forms
R
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s

a
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f
o
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s
n
Referral record
RecoRds and foRm
s
n
ReFeRRal RecoRd
Who is ReFeRRiNG RecoRd NuMbeR ReFeRRed daTe TiMe
NaMe aRRival daTe TiMe
FaciliTy
accoMpaNied by The healTh WoRkeR
WoMaN
NaMe aGe
addRess
MaiN ReasoNs FoR ReFeRRal ■ emergency ■ Non-emergency ■ To accompany the baby
MajoR FiNdiNGs (cliNica aNd bp, TeMp., lab.)
lasT (bReasT)Feed (TiMe)
TReaTMeNTs GiveNaNdTiMe
beFoRe ReFeRRal
duRiNGTRaNspoRT
iNFoRMaTioN GiveNToThe WoMaNaNd coMpaNioNabouT The ReasoNs FoR ReFeRRal
baby
NaMe daTe aNd houR oF biRTh
biRTh WeiGhT GesTaTioNal aGe
MaiN ReasoNs FoR ReFeRRal ■ emergency ■ Non-emergency ■ To accompany the mother
MajoR FiNdiNGs (cliNica aNdTeMp.)
lasT (bReasT)Feed (TiMe)
TReaTMeNTs GiveNaNdTiMe
beFoRe ReFeRRal
duRiNGTRaNspoRT
iNFoRMaTioN GiveNToThe WoMaNaNd coMpaNioNabouT The ReasoNs FoR ReFeRRal
sample form to be adapted. Revised on 13 june 2003.
Feedback record
RecoRds and foRm
s
n
Feedback RecoRd
Who is ReFeRRiNG RecoRd NuMbeR adMissioN daTe TiMe
NaMe dischaRGe daTe TiMe
FaciliTy
WoMaN
NaMe aGe
addRess
MaiN ReasoNs FoR ReFeRRal ■ emergency ■ Non-emergency ■ To accompany the baby
diaGNoses
TReaTMeNTs GiveNaNdTiMe
TReaTMeNTs aNd RecoMMeNdaTioNs oN FuRTheR caRe
FolloW-up visiT WheN WheRe
pReveNTive MeasuRes
iF deaTh: daTe
causes
baby
NaMe daTe oF biRTh
biRTh WeiGhT aGe aT dischaRGe (days)
MaiN ReasoNs FoR ReFeRRal ■ emergency ■ Non-emergency ■ To accompany the mother
diaGNoses
TReaTMeNTs GiveNaNdTiMe
TReaTMeNTs aNd RecoMMeNdaTioNs oN FuRTheR caRe
FolloW-up visiT WheN WheRe
pReveNTive MeasuRes
iF deaTh: daTe
causes
sample form to be adapted. Revised on 25 august 2003.
Labour record
RecoRds and foRm
s
n
labouR RecoRd
use thIs RecoRd foR monItoRIng duRIng labouR, delIveRy and PostPaRtum RecoRd NuMbeR
NaMe aGe paRiTy
addRess
duRIng labouR at oR afteR bIRth – motheR at oR afteR bIRth – newboRn Planned newboRn tReatment
adMissioN daTe biRTh TiMe livebiRTh ■ sTillbiRTh: FResh ■ MaceRaTed ■
adMissioNTiMe oxyTociN – TiMe GiveN ResusciTaTioN No ■yes ■
TiMe acTive labouR sTaRTed placeNTa coMpleTe No ■yes ■ biRTh WeiGhT
TiMe MeMbRaNes RupTuRed TiMe deliveRed GesT. aGe ----------oR pReTeRM No ■yes ■
TiMe secoNd sTaGe sTaRTs esTiMaTed blood loss secoNd baby
entRy examInatIon
stage of labouR NoT iNacTive labouR ■ acTive labouR ■
not In actIve labouR Planned mateRnal tReatment
houRs siNce aRRival 1 2 3 4 5 6 7 8 9 10 11 12
houRs siNce RupTuRed MeMbRaNes
vaGiNal bleediNG (0 + ++)
sTRoNG coNTRacTioNs iN 10 MiNuTes
FeTal heaRT RaTe (beaTs peR MiNuTe)
T (axillaRy)
pulse (beaTs/MiNuTe)
blood pRessuRe (sysTolic/diasTolic)
uRiNe voided
ceRvical dilaTaTioN (cM)
PRoblem tIme onset tReatments otheR than noRmal suPPoRtIve caRe
0
0
If motheR RefeRRed duRIng labouR oR delIveRy, RecoRd tIme and exPlaIn
0
sample form to be adapted. Revised on 13 june 2003.
Partograph
RecoRds and foRm
s
n
fIndIngs tIme
hours in active labour 6 7 8 9 0
hours since ruptured membranes
Rapid assessment b3-b7
vaginal bleeding (0 + ++)
amniotic fluid (meconium stained)
contractions in 10 minutes
Fetal heart rate (beats/minute)
urine voided
T (axillary)
pulse (beats/minute)
blood pressure (systolic/diastolic)
cervical dilatation (cm)
delivery of placenta (time)
oxytocin (time/given)
problem-note onset/describe below
paRToGRaph
use thIs foRmfoR monItoRIngactIve labouR 0 cm
9 cm
8 cm
7 cm
6 cm
cm
cm
sampleformtobeadapted.Revisedon13june2003.
Postpartum record
RecoRds and foRm
s
n6
posTpaRTuM RecoRd
monItoRIngafteR bIRth eveRy - mIn foR st houR hR hR hR 8 hR hR 6 hR 0 hR hR
TiMe
RapidassessMeNT
bleediNG (0 + ++)
uTeRus haRd/RouNd?
mateRnal: blood pRessuRe
pulse
uRiNe voided
vulva
newboRn: bReaThiNG
WaRMTh
newboRn abnoRmal sIgns (lIst)
0
tIme feedIng obseRved ■ FeediNGWell ■ diFFiculTy
coMMeNTs
0
Planned tReatment tIme tReatment gIven
MoTheR
0
0
NeWboRN
0
iF ReFeRRed (MoTheR oR NeWboRN), RecoRdTiMe aNd explaiN:
0
iF deaTh (MoTheR oR NeWboRN), daTe, TiMe aNd cause:
advIse and counsel
motheR
■ postpartum care and hygiene
■ Nutrition
■ birth spacing and family planning
■ danger signs
■ Follow-up visits
baby
■ exclusive breastfeeding
■ hygiene, cord care and warmth
■ special advice if low birth weight
■ danger signs
■ Follow-up visits
PReventIve measuRes
foR motheR
■ iron/folate
■ vitamin a
■ Mebendazole
■ sulphadoxine-pyrimethamine
■ Tetanus toxoid immunization
■ RpR test result and treatment
■ aRv
foR baby
■ Risk of bacterial infection and treatment
■ bcG, opv-0, hep-0
■ RpR result and treatment
■ Tb test result and prophylaxis
■ aRv
sample form to be adapted. Revised on 25 august 2003.
International form of medical certificate of cause of death
RecoRds and foRm
s
n7
iNTeRNaTioNal FoRM oF Medical ceRTiFicaTe oF cause oF deaTh
aPPRoxImate InteRval cause of death between onset and death
I (a). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . disease or condition directly due to (or as consequence of) . . . . . . . . . . . leading to death* (b). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
antecedent causes due to (or as consequence of) . . . . . . . . . . . . . . . . . . . . . . Morbid conditions, if any, giving (c). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . rise to the above cause, stating due to (or as consequence of) . . . . . . . . . . . . . . . . . . . . . . (d). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
II . . . . . . . . . . . . . . . . . . . . . . other significant conditions contributing to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . the death, but not related to the disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . or condition causing it. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* This does not mean the mode of dying, e.g. heart failure, respiratory failure. it means the disease, injury or complication that caused death.
consIdeR collectIngthe followIng InfoRmatIon III if the deceased is a female, was she ■ Not pregnant ■ Not pregnant, but pregnant within 42 days of death ■ pregnant at the time of death ■ unknown if pregnant or was pregnant within 42 days of death
0Iv if the deceased is an infant and less than one month old What was the birth weight: . . . . . . . . . g if exact birth weight not known, was baby weighing: ■ 2500 g or more ■ less than 2500 g
N2

RefeRRal RecoRd
N3

feedback RecoRd
N4

labouR RecoRd
N5

PaRtogRaPh
N6

PostPaRtum RecoRd
N7

InteRnatIonal foRm of medIcal
ceRtIfIcate of cause of death
■ Recordsaresuggestednotsomuchfortheformatasforthecontent.
ThecontentoftherecordsisadjustedtothecontentoftheGuide.
■ Modifynationalorlocalrecordstoincludealltherelevantsectionsneededtorecord
importantinformationfortheprovider,thewomanandherfamily,forthepurposesof
monitoringandsurveillanceandofficialreporting.
■ Filloutotherrequiredrecordssuchasimmunizationcardsforthemotherandbaby.
RecoRds and foRms
Referral record
R
e
c
o
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d
s

a
n
d

f
o
R
m
s
n
ReFeRRalRecoRd
WhoisReFeRRiNG RecoRdNuMbeR ReFeRReddaTe TiMe
NaMe aRRivaldaTe TiMe
FaciliTy
accoMpaNiedbyThehealThWoRkeR
WoMaN
NaMe aGe
addRess
MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythebaby
MajoRFiNdiNGs(cliNicaaNdbp,TeMp.,lab.)
lasT(bReasT)Feed(TiMe)
TReaTMeNTsGiveNaNdTiMe
beFoReReFeRRal
duRiNGTRaNspoRT
iNFoRMaTioNGiveNToTheWoMaNaNdcoMpaNioNabouTTheReasoNsFoRReFeRRal
baby
NaMe daTeaNdhouRoFbiRTh
biRThWeiGhT GesTaTioNalaGe
MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythemother
MajoRFiNdiNGs(cliNicaaNdTeMp.)
lasT(bReasT)Feed(TiMe)
TReaTMeNTsGiveNaNdTiMe
beFoReReFeRRal
duRiNGTRaNspoRT
iNFoRMaTioNGiveNToTheWoMaNaNdcoMpaNioNabouTTheReasoNsFoRReFeRRal
sampleformtobeadapted.Revisedon13june2003.
Feedback record
R
e
c
o
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d
s

a
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d

f
o
R
m
s
n
FeedbackRecoRd
WhoisReFeRRiNG RecoRdNuMbeR adMissioNdaTe TiMe
NaMe dischaRGedaTe TiMe
FaciliTy
WoMaN
NaMe aGe
addRess
MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythebaby
diaGNoses
TReaTMeNTsGiveNaNdTiMe
TReaTMeNTsaNdRecoMMeNdaTioNsoNFuRTheRcaRe
FolloW-upvisiT WheN WheRe
pReveNTiveMeasuRes
iFdeaTh:daTe
causes
baby
NaMe daTeoFbiRTh
biRThWeiGhT aGeaTdischaRGe(days)
MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythemother
diaGNoses
TReaTMeNTsGiveNaNdTiMe
TReaTMeNTsaNdRecoMMeNdaTioNsoNFuRTheRcaRe
FolloW-upvisiT WheN WheRe
pReveNTiveMeasuRes
iFdeaTh:daTe
causes
sampleformtobeadapted.Revisedon25august2003.
Labour record
R
e
c
o
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d
s

a
n
d

f
o
R
m
s
n
labouRRecoRd
use thIs RecoRd foR monItoRIng duRIng labouR, delIveRy and PostPaRtum RecoRdNuMbeR
NaMe aGe paRiTy
addRess
duRIng labouR at oR afteR bIRth – motheR at oR afteR bIRth – newboRn Planned newboRn tReatment
adMissioNdaTe biRThTiMe livebiRTh■sTillbiRTh:FResh■MaceRaTed■
adMissioNTiMe oxyTociN–TiMeGiveN ResusciTaTioNNo■yes■
TiMeacTivelabouRsTaRTed placeNTacoMpleTeNo■yes■ biRThWeiGhT
TiMeMeMbRaNesRupTuRed TiMedeliveRed GesT.aGe----------oRpReTeRMNo■yes■
TiMesecoNdsTaGesTaRTs esTiMaTedbloodloss secoNdbaby
entRy examInatIon
stage of labouR NoTiNacTivelabouR■ acTivelabouR■
not In actIve labouR Planned mateRnal tReatment
houRssiNceaRRival 1 2 3 4 5 6 7 8 9 10 11 12
houRssiNceRupTuRedMeMbRaNes
vaGiNalbleediNG(0+++)
sTRoNGcoNTRacTioNsiN10MiNuTes
FeTalheaRTRaTe(beaTspeRMiNuTe)
T(axillaRy)
pulse(beaTs/MiNuTe)
bloodpRessuRe(sysTolic/diasTolic)
uRiNevoided
ceRvicaldilaTaTioN(cM)
PRoblem tIme onset tReatments otheR than noRmal suPPoRtIve caRe
0
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If motheR RefeRRed duRIng labouR oR delIveRy, RecoRd tIme and exPlaIn
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sampleformtobeadapted.Revisedon13june2003.
Partograph
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hourssincerupturedmembranes
Rapidassessment b3-b7
vaginalbleeding(0+++)
amnioticfluid(meconiumstained)
contractionsin10minutes
Fetalheartrate(beats/minute)
urinevoided
T(axillary)
pulse(beats/minute)
bloodpressure(systolic/diastolic)
cervicaldilatation(cm)
deliveryofplacenta(time)
oxytocin(time/given)
problem-noteonset/describebelow
paRToGRaph
use thIs foRm foR monItoRIng actIve labouR
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9 cm
8 cm
7 cm
6 cm
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Postpartum record
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advIse and counsel
motheR
■ postpartumcareandhygiene
■ Nutrition
■ birthspacingandfamilyplanning
■ dangersigns
■ Follow-upvisits
baby
■ exclusivebreastfeeding
■ hygiene,cordcareandwarmth
■ specialadviceiflowbirthweight
■ dangersigns
■ Follow-upvisits
PReventIve measuRes
foR motheR
■ iron/folate
■ vitamina
■ Mebendazole
■ sulphadoxine-pyrimethamine
■ Tetanustoxoidimmunization
■ RpRtestresultandtreatment
■ aRv
foR baby
■ Riskofbacterialinfectionandtreatment
■ bcG,opv-0,hep-0
■ RpRresultandtreatment
■ Tbtestresultandprophylaxis
■ aRv
sampleformtobeadapted.Revisedon25august2003.
International form of medical certificate of cause of death
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iNTeRNaTioNalFoRMoFMedicalceRTiFicaTeoFcauseoFdeaTh
aPPRoxImate InteRval
cause of death between onset and death
I (a). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
diseaseorconditiondirectly dueto(orasconsequenceof). . . . . . . . . . .
leadingtodeath* (b). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
antecedent causes dueto(orasconsequenceof) . . . . . . . . . . . . . . . . . . . . . .
Morbidconditions,ifany,giving (c). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
risetotheabovecause,stating dueto(orasconsequenceof) . . . . . . . . . . . . . . . . . . . . . .
(d). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . .
II . . . . . . . . . . . . . . . . . . . . . .
othersignificantconditionscontributingto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
thedeath,butnotrelatedtothedisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
orconditioncausingit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
*Thisdoesnotmeanthemodeofdying,e.g.heartfailure,respiratoryfailure.
itmeansthedisease,injuryorcomplicationthatcauseddeath.
consIdeR collectIng the followIng InfoRmatIon
III
ifthedeceasedisafemale,wasshe ■ Notpregnant
■ Notpregnant,butpregnantwithin42daysofdeath
■ pregnantatthetimeofdeath
■ unknownifpregnantorwaspregnantwithin42daysofdeath
0
Iv
ifthedeceasedisaninfantandlessthanonemonthold Whatwasthebirthweight:. . . . . . . . . g
ifexactbirthweightnotknown,wasbabyweighing:
■ 2500gormore
■ lessthan2500g
Glossary and acronyms
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abortion
Termination of pregnancy from
whatever cause before the fetus is
capable of extrauterine life.
adolescent
Young person 10–19 years old.
advise
To give information and suggest to
someone a course of action.
antenatal care
Care for the woman and fetus during
pregnancy.
assess
To consider the relevant information
and make a judgement. As used in this
guide, to examine a woman or baby
and identify signs of illness.
baby
A very young boy or girl in the first
week(s) of life.
birth
Expulsion or extraction of the baby
(regardless of whether the cord has
been cut).
birth and emergency plan
A plan for safe childbirth developed in
antenatal care visit which considers
the woman’s condition, preferences
and available resources. A plan to seek
care for danger signs during pregnancy,
childbirth and postpartum period, for
the woman and newborn.
birth weight
The first of the fetus or newborn
obtained after birth.
For live births, birth weight should
preferably be measured within the first
hour of life before significant postnatal
weight loss has occurred, recorded to
the degree of accuracy to which it is
measured.
chart
As used in this guide, a sheet
presenting information in the form of
a table.
childbirth
Giving birth to a baby or babies and
placenta.
classify
To select a category of illness and
severity based on a woman’s or baby’s
signs and symptoms.
clinic
As used in this guide, any first-level
outpatient health facility such as a
dispensary, rural health post, health
centre or outpatient department of a
hospital.
community
As used in this guide, a group of
people sometimes living in a defined
geographical area, who share common
culture, values and norms. Economic
and social differences need to be taken
into account when determining needs
and establishing links within a given
community.
birth companion
Partner, other family member or friend
who accompanies the woman during
labour and delivery.
childbearing age (woman)
15-49 years. As used in this guide, also
a girl 10-14 years, or a woman more
than 49 years, when pregnant, after
abortion, after delivery.
complaint
As described in this guide, the
concerns or symptoms of illness or
complication need to be assessed and
classified in order to select treatment.
concern
A worry or an anxiety that the woman
may have about herself or the
baby(ies).
complication
A condition occurring during pregnancy
or aggravating it. This classification
includes conditions such as obstructed
labour or bleeding.
confidence
A feeling of being able to succeed.
contraindication
A condition occurring during another
disease or aggravating it. This
classification includes conditions such
as obstructed labour or bleeding.
counselling
As used in this guide, interaction with a
woman to support her in solving actual
or anticipated problems, reviewing
options, and making decisions. It
places emphasis on provider support
for helping the woman make decisions.
danger signs
Terminology used to explain to the
woman the signs of life-threatening and
other serious conditions which require
immediate intervention.
emergency signs
Signs of life-threatening conditions
which require immediate intervention.
essential
Basic, indispensable, necessary.
facility
A place where organized care is
provided: a health post, health centre,
hospital maternity or emergency unit,
or ward.
family
Includes relationships based on blood,
marriage, sexual partnership, and
adoption, and a broad range of groups
whose bonds are based on feelings
of trust mutual support, and a shared
destiny.
follow-up visit
A return visit requested by a health
worker to see if further treatment or
referral is needed.
gestational age
Duration of pregnancy from the
last menstrual period. In this guide,
duration of pregnancy (gestational age)
is expressed in 3 different ways:
trimester months weeks
First less than 4 months less than 16 weeks
Second 4-6 months 16-28 weeks
Third 7-9+ months 29-40+ weeks
grunting
Soft short sounds that a baby makes
when breathing out. Grunting occurs
when a baby is having difficulty
breathing.
Glossary
home delivery
Delivery at home (with a skilled
attendant, a traditional birth attendant, a
family member, or by the woman herself).
hospital
As used in this guide, any health facility
with inpatient beds, supplies and
expertise to treat a woman or newborn
with complications.
integrated management
A process of caring for the woman in
pregnancy, during and after childbirth,
and for her newborn, that includes
considering all necessary elements:
care to ensure they remain healthy, and
prevention, detection and management
of complications in the context of her
environment and according to her
wishes.
labour
As used in this guide, a period from
the onset of regular contractions to
complete delivery of the placenta.
low birth weight baby
Weighing less than 2500-g at birth.
maternity clinic
Health centre with beds or a hospital
where women and their newborns
receive care during childbirth and
delivery, and emergency first aid.
miscarriage
Premature expulsion of a non-viable
fetus from the uterus.
monitoring
Frequently repeated measurements of
vital signs or observations of danger
signs.
newborn
Recently born infant. In this guide used
interchangeable with baby.
partner
As used in this guide, the male
companion of the pregnant woman
(husband, “free union”) who is the
father of the baby or the actual sexual
partner.
postnatal care
Care for the baby after birth. For the
purposes of this guide, up to two weeks.
postpartum care
Care for the woman provided in the
postpartum period, e.g. from complete
delivery of the placenta to 42 days
after delivery.
pre-referral
Before referral to a hospital.
pregnancy
Period from when the woman misses
her menstrual period or the uterus can
be felt, to the onset of labour/elective
caesarian section or abortion.
premature
Before 37 completed weeks of
pregnancy.
preterm baby
Born early, before 37 completed weeks
of pregnancy. If number of weeks not
known, 1 month early.
primary health care*
Essential health care accessible at a
cost the country and community can
afford, with methods that are practical,
scientifically sound and socially
acceptable. (Among the essential
activities are maternal and child
health care, including family planning;
immunization; appropriate treatment of
common diseases and injuries; and the
provision of essential drugs).
primary health care level
Health post, health centre or maternity
clinic; a hospital providing care for
normal pregnancy and childbirth.
priority signs
Signs of serious conditions which
require interventions as soon as
possible, before they become life-
threatening.
Quick check
A quick check assessment of the
health status of the woman or her
baby at the first contact with the health
provider or services in order to assess if
emergency care is required.
rapid assessment and
management
Systematic assessment of vital
functions of the woman and the most
severe presenting signs and symptoms;
immediate initial management of the
life-threatening conditions; and urgent
and safe referral to the next level of
care.
reassessment
As used in this guide, to examine the
woman or baby again for signs of a
specific illness or condition to see if
she or the newborn are improving.
recommendation
Advice. Instruction that should be
followed.
referral, urgent
As used in this guide, sending a woman
or baby, or both, for further assessment
and care to a higher level of care;
including arranging for transport
and care during transport, preparing
written information (referral form),
and communicating with the referral
institution.
referral hospital
A hospital with a full range of obstetric
services including surgery and blood
transfusion and care for newborns with
problems.
reinfection
Infection with same or a different strain
of HIV virus.
replacement feeding
The process of feeding a baby who is
not receiving breast milk with a diet
that provides all the nutrients she/he
needs until able to feed entirely on
family foods.
secondary health care
More specialized care offered
at the most peripheral level, for
example radiographic diagnostic,
general surgery, care of women with
complications of pregnancy and
childbirth, and diagnosis and treatment
of uncommon and severe diseases.
(This kind of care is provided by trained
staff at such institutions as district or
provincial hospitals).
shock
A dangerous condition with
severe weakness, lethargy, or
unconsciousness, cold extremeties,
and fast, weak pulse. It is caused by
severe bleeding, severe infection, or
obstructed labour.
sign
As used in this guide, physical evidence
of a health problem which the health
worker observes by looking, listening,
feeling or measuring. Examples
of signs: bleeding, convulsions,
hypertension, anaemia, fast breathing.
g
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Glossary
g
l
o
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s
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y

a
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d

a
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m
s
skilled attendant
Refers exclusively to people with
midwifery skills (for example, midwives,
doctors and nurses) who have been
trained to proficiency in the skills
necessary to manage normal deliveries
and diagnose or refer obstetric
complications.
For the purposes of this guide, a person
with midwifery skills who:
■ has acquired the requisite
qualifications to be registered
and/or legally licensed to practice
training and licensing requirements
are country-specific;
■ May practice in hospitals, clinics,
health units, in the home, or in any
other service setting.
■ Is able to do the following:
→ give necessary care and advice
to women during pregnancy and
postpartum and for their newborn
infants;
→ conduct deliveries on her/his
own and care for the mother and
newborn; this includes provision
of preventive care, and detection
and appropriate referral of
abnormal conditions.
→ provide emergency care for
the woman and newborn;
perform selected obstetrical
procedures such as manual
removal of placenta and newborn
resuscitation; prescribe and give
drugs (IM/IV) and infusions to
the mother and baby as needed,
including for post-abortion care.
→ provide health information and
counselling for the woman, her
family and community.
small baby
A newly born infant born preterm and/
or with low birth weight.
stable
Staying the same rather than getting
worse.
stillbirth
Birth of a baby that shows no signs of
life at birth (no gasping, breathing or
heart beat).
surveillance, permanent
Continuous presence and observation
of a woman in labour.
symptom
As used in this guide, a health problem
reported by a woman, such as pain or
headache.
term, full-term
Word used to describe a baby
born after 37 completed weeks of
pregnancy.
trimester of pregnancy
See Gestational age.
very small baby
Baby with birth weight less than 1500-g
or gestational age less than 32 weeks.
WHO definitions have been used where
possible but, for the purposes of this
guide, have been modified where
necessary to be more appropriate to
clinical care (reasons for modification
are given). For conditions where
there are no official WHO definitions,
operational terms are proposed, again
only for the purposes of this guide.
Acronyms
aids Acquired immunodeficiency
syndrome, caused by infection with
human immunodeficiency virus
(HIV). AIDS is the final and most
severe phase of HIV infection.
anc Care for the woman and fetus
during pregnancy.
arv Antiretroviral drug, a drug to treat
HIV infection, or to prevent mother-
to-child transmission of HIV.
bcg An immunization to prevent
tuberculosis, given at birth.
bp Blood pressure.
bpm Beats per minute.
fhr Fetal heart rate.
hb Haemoglobin.
hb-1 Vaccine given at birth to prevent
hepatitis B.
hmbr Home-based maternal record:
pregnancy, delivery and inter-
pregnancy record for the woman
and some information about the
newborn.
hiv Human immunodeficiency virus.
HIV is the virus that causes AIDS.
inh Isoniazid, a drug to treat
tuberculosis.
iv Intravenous (injection or infusion).
im Intramuscular injection.
iu International unit.
iud Intrauterine device.
lam Lactation amenorrhea.
lbw Low birth weight: birth weight less
than 2500 g.
lmp Last menstrual period: a date
from which the date of delivery is
estimated.
mtct Mother-to-child transmission of HIV.
ng Naso-gastric tube, a feeding tube
put into the stomach through the
nose.
ors Oral rehydration solution.
opv-0 Oral polio vaccine. To prevent
poliomyelitis, OPV-0 is given at birth.
Qc A quick check assessment of the
health status of the woman or her
baby at the first contact with the
health provider or services in order
to assess if emergency care is
required.
ram Systematic assessment of
vital functions of the woman and
the most severe presenting signs
and symptoms; immediate initial
management of the life-threatening
conditions; and urgent and safe
referral to the next level of care.
rpr Rapid plasma reagin, a rapid test
for syphilis. It can be performed in
the clinic.
sti Sexually transmitted infection.
tba A person who assists the mother
during childbirth. In general, a TBA
would initially acquire skills by
delivering babies herself or through
apprenticeship to other TBAs.
tt An immunization against tetanus
> More than
≥ Equal or more than
< Less than
≤ Equal or less than
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acronyms
For more information, please contact:
Department of Making Pregnancy Safer
Family and Community Health, World Health Organization
Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Tel: +41 22 791 4447 / 3346
Fax: +41 22 791 5853
Email: MPSinfo@who.int
For updates to this publication, please visit:
www.who.int/making_pregnancy_safer

Integrated Management of Pregnancy and Childbirth

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

World Health Organization Geneva 2006

Switzerland (tel: +41 22 791 2476. or concerning the delimitation of its frontiers or boundaries. Obstetric 3. Printed in Singapore (NLM classification: WQ 175) . city or area or of its authorities.Perinatal care — methods 5.diagnosis 7.Pregnancy complications . Requests for permission to reproduce or translate WHO publications — whether for sale or for noncommercial distribution — should be addressed to Publications. Obstetric 2.Postnatal care .methods 6. 1211 Geneva 27. at the above address (fax: +41 22 791 4806. 20 Avenue Appia. the names of proprietary products are distinguished by initial capital letters. email: bookorders@who.int). Publications of the World Health Organization can be obtained from Marketing and Dissemination.WHO Library Cataloguing-in-Publication Data Pregnancy.int). Errors and omissions excepted.Labor.Manuals I. 1. World Health Organization. postpartum and newborn care : a guide for essential practice.Pregnancy complications . Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. fax: +41 22 791 4857. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country. ISBN 92 4 159084 X First edition 2003 Second edition 2006 © World Health Organization 2006 All rights reserved.Delivery. At head of title: Integrated Management of Pregnancy and Childbirth.therapy 8.World Health Organization.Prenatal care 4. email: permissions@who. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. territory. childbirth.

The guide provides a full range of updated. There is a widely shared but mistaken idea that improvements in newborn health require sophisticated and expensive technologies and highly specialized staff. The reality is that many conditions that result in perinatal death can be prevented or treated without sophisticated and expensive technology. world leaders reaffirmed their commitment to invest in mothers and children by adopting specific goals and targets to reduce maternal and childhood-infant mortality as part of the Millennium Declaration.worse. evidence-based norms and standards that will enable health care providers to give high quality care during pregnancy. the problem remains unrecognized or. Childbirth. over four million babies less than one month of age die.FOreWOrd In modern times. We hope that the guide will be helpful for decision-makers. Every year. However. another is stillborn. What is required is essential care during pregnancy. the latter being largely due to a failure to reduce neonatal mortality. the assistance of a person with midwifery skills during childbirth and the immediate postpartum period. communities and societies. our major challenge now is to translate this into action and to reach those women and children who are most in need. and after delivery. Postpartum and Newborn Care: A guide for essential practice. most of them during the critical first week of life. as new additions to the Integrated Management of Pregnancy and Childbirth tool kit. It is against this background that we are proud to present the document Pregnancy. the past decade was marked by limited progress in reducing maternal mortality and a slow-down in the steady decline of childhood mortality observed since the mid 1950s in many countries. and a few critical interventions for the newborn during the first days of life. and for every newborn who dies. dr. programme managers and health care providers in charting out their roadmap towards meeting the health needs of all mothers and children. Tomris Türmen Executive director Family and Community Health (FCH) FOreWOrd Foreword .accepted as inevitable in many societies. Most of these deaths are a consequence of the poor health and nutritional status of the mother coupled with inadequate care before. Unfortunately. improvements in knowledge and technological advances have greatly improved the health of mother and children. delivery and in the postpartum period. We have the knowledge. considering the needs of the mother and her newborn baby. in large part because it is so common. during. Recognizing the large burden of maternal and neonatal ill-health on the development capacity of individuals.

Ehounu. who took time to review this document at different stages of its development. The guide has also been reviewed and endorsed by the International Confederation of Midwives. Monir Islam. Agostino Borra. Rita Kabra. Elisabeth Hoff. Felicity Savage. Revisions were subsequently carried out by Annie Portela. Maggie Usher. In addition. Sweden and the United Kingdom of Great Britain and Northern Ireland. the International Federation of Gynecology and Obstetrics and International Pediatric Association. Valuable inputs were provided by WHO Regional Offices and WHO departments: ■ Reproductive Health and Research ■ Child and Adolescent Health and Development ■ HIV/AIDS ■ Communicable Diseases ■ Nutrition for Health and Development ■ Essential Drugs and Medicines Policy ■ Vaccines and Biologicals ■ Mental Health and Substance Dependence ■ Gender and Women’s Health ■ Blindness and Deafness editing: Nina Mattock. Adepeyu Olukoya. . Anne Thompson. Ornella Lincetto. International Confederation of Midwives International Federation of Gynecology and Obstetrics International Pediatric Association The financial support towards the preparation and production of this document provided by UNFPA and the Governments of Australia. Ekpini. The principles and policies of each agency are governed by the relevant decisions of each agency’s governing body and each agency implements the interventions described in this document in accordance with these principles and policies and within the scope of its mandate. Suman Mehta. This guide represents a common understanding between WHO. as is financial support received from The World Bank. TinTin Sint. Jerker Liljestrand. Betty Sweet. led by Jerker Liljestrand and Jelka Zupan. Rick Guidotti. Aafje Rietveld. Japan and the United States of America is gratefully acknowledged. and the World Bank of key elements of an approach to reducing maternal and perinatal mortality and morbidity. WHO’s Making Pregnancy Safer initiative is grateful to the programme support received from the Governments of the Netherlands. Department of Reproductive Health and Research (RHR). UNICEF. These agencies co-operate closely in efforts to reduce maternal and perinatal mortality and morbidity. They came from over 35 countries and brought their expertise and wide experience to the final text. Richard Casna layout: rsdesigns.Acknowledgements AcknOWledgemenTs AcknOWledgemenTs The Guide was prepared by a team of the World Health Organization.com sàrl cover design: Maíre Ní Mhearáin WHO acknowledges with gratitude the generous contribution of over 100 individuals and organizations in the field of maternal and newborn health. Norway. and Jelka Zupan. Mathews Matthai. Denise Roth. The concept and first drafts were developed by Sandra Gove and Patricia Whitesell/ACT International. Atlanta. UNFPA. Luc de Bernis.

rAPId AssessmenT And mAnAgemenT OF WOmen OF cHIldbeArIng Age b2 Quick check b3-b7 Rapid assessment and management b3 Airway and breathing b3 Circulation (shock) b4-b5 Vaginal bleeding b6 Convulsions or unconscious b6 Severe abdominal pain b6 Dangerous fever b7 Labour b7 Other danger signs or symptoms b7 If no emergency or priority signs. non urgent b9 Airway.TAble OF cOnTenTs A B emergency TreATmenTs FOr THe WOmAn InTrOducTIOn Introduction How to read the guide Acronyms Content Structure and presentation Assumptions underlying the guide A A2 A3 A4 A5 PrIncIPles OF gOOd cAre Communication Workplace and administrative procedures Standard precautions and cleanliness Organising a visit b TAble OF cOnTenTs QuIck cHeck. breathing and circulation b9 Manage the airway and breathing b9 Insert IV line and give fluids b9 If intravenous access not possible b10-b12 Bleeding b10 Massage uterus and expel clots b10 Apply bimanual uterine compression b10 Apply aortic compression b10 Give oxytocin b10 Give ergometrine b11 Remove placenta and fragments manually b11 After manual removal of placenta b12 Repair the tear and empty bladder b12 Repair the tear or episiotomy b13-b14 Important considerations in caring for a woman with eclampsia or pre-eclampsia b13 Give magnesium sulphate b13 Important considerations in caring for a woman with eclampsia b14 Give diazepam b14 Give appropriate antihypertensive drug b15 Infection b15 Give appropriate IV/IM antibiotics b16 Malaria b16 Give arthemether or quinine IM b16 Give glucose IV b17 Refer the woman urgently to the hospital b17 Essential emergency drugs and supplies for transport and home delivery b bleedIng In eArly PregnAncy And POsT-AbOrTIOn cAre b19 Examination of the woman with bleeding in early pregnancy and post-abortion care b20 Give preventive measures b21 Advise and counsel on post-abortion care b21 Advise on self-care b21 Advise and counsel on family planning b21 Provide information and support after abortion b21 Advise and counsel during follow-up visits Table of contents .

Table of contents TAble OF cOnTenTs c AnTenATAl cAre d cHIldbIrTH – lAbOur. birth and emergency plan c3 Check for pre-eclampsia c4 Check for anaemia c5 Check for syphilis c6 Check for HIV status c7 Respond to observed signs or volunteered problems c7 If no fetal movement c7 If ruptured membranes and no labour c8 If fever or burning on urination c9 If vaginal discharge c10 If signs suggesting HIV infection c10 If smoking. alcohol or drug abuse. drinking d6 Breathing technique d6 Pain and discomfort relief d7 Birth companion d8-d9 First stage of labour d8 Not in active labour d9 In active labour d10-d11 Second stage of labour: deliver the baby and give immediate newborn care d12-d13 Third stage of labour: deliver the placenta d14-d18 Respond to problems during labour and delivery d14 If fetal heart rate <120 or >160 beats per minute d15 If prolapsed cord d16 If breech presentation d17 If stuck shoulders (Shoulder dystocia) d18 If multiple births d19 Care of the mother and newborn within first hour of delivery of placenta d20 Care of the mother one hour after delivery of placenta d21 Assess the mother after delivery d22-d25 Respond to problems immediately postpartum d22 If vaginal bleeding d22 If fever (temperature >38°C) d22 If perineal tear or episiotomy (done for lifesaving circumstances) d23 If elevated diastolic blood pressure d24 If pallor on screening. check for anaemia d24 If mother severely ill or separated from the child d24 If baby stillborn or dead d25 Give preventive measures . delIvery And ImmedIATe POsTPArTum cAre c2 Assess the pregnant woman: pregnancy status. or history of violence c11 If cough or breathing difficulty c11 If taking antituberculosis drugs c12 Give preventive measures c13 Advise and counsel on nutrition and self-care c14-c15 Develop a birth and emergency plan c14 Facility delivery c14 Home delivery with a skilled attendant c15 Advise on labour signs c15 Advise on danger signs c15 Discuss how to prepare for an emergency in pregnancy c16 Advise and counsel on family planning c16 Counsel on the importance of family planning c16 Special consideration for family planning counselling during pregnancy c17 Advise on routine and follow-up visits c18 Home delivery without a skilled attendant c19 Assess eligibility of ARV for HIV-positive pregnant woman d2 Examine the woman in labour or with ruptured membranes d3 Decide stage of labour d4-d5 Respond to obstetrical problems on admission d6-d7 Give supportive care throughout labour d6 Communication d6 Cleanliness d6 Mobility d6 Urination d6 Eating.

d cHIldbIrTH – lAbOur. check for anaemia e5 Check for HIV status e6 If heavy vaginal bleeding e6 If fever or foul-smelling lochia e7 If dribbling urine e7 If pus or perineal pain e7 If feeling unhappy or crying easily e8 If vaginal discharge 4 weeks after delivery e8 If breast problem e9 If cough or breathing difficulty e9 If taking anti-tuberculosis drugs e10 If signs suggesting HIV infection Table of contents . delIvery And ImmedIATe POsTPArTum cAre (cOnTInued) F PrevenTIve meAsures And AddITIOnAl TreATmenTs FOr THe WOmAn d26 Advise on postpartum care d26 Advise on postpartum care and hygiene d26 Counsel on nutrition d27 Counsel on birth spacing and family planning d27 Counsel on the importance of family planning d27 Lactation amenorrhea method (LAM) d28 Advise on when to return d28 Routine postpartum visits d28 Follow-up visits for problems d28 Advise on danger signs d28 Discuss how to prepare for an emergency in postpartum d29 Home delivery by skilled attendant d29 Preparation for home delivery d29 Delivery care d29 Immediate postpartum care of mother d29 Postpartum care of newborn F2–F4 Preventive measures F2 Give tetanus toxoid F2 Give vitamin A postpartum F3 Give iron and folic acid F3 Give mebendazole F3 Motivate on compliance with iron treatment F4 Give preventive intermittent treatment for falciparum malaria F4 Advise to use insecticide-treated bednet F4 Give appropriate oral antimalarial treatment F4 Give paracetamol F5–F6 Additional treatments for the woman F5 Give appropriate oral antibiotics F6 Give benzathine penicillin IM F6 Observe for signs of allergy e TAble OF cOnTenTs POsTPArTum cAre e2 Postpartum examination of the mother (up to 6 weeks) e3-e10 Respond to observed signs or volunteered problems e3 If elevated diastolic blood pressure e4 If pallor.

positive woman and the newborn Respond to observed signs and volunteered problems G10 If a woman is taking Antiretroviral medicines and develop new signs/symptoms. H H2 THe WOmAn WITH sPecIAl needs Emotional support for the woman with special needs H2 Sources of support H2 Emotional support H3 Special considerations in managing the pregnant adolescent H3 When interacting with the adolescent H3 Help the girl consider her options and to make decisions which best suit her needs H4 Special considerations for supporting the woman living with violence H4 Support the woman living with violence H4 Support the health service response to needs of women living with violence G4 G5 I cOmmunITy suPPOrT FOr mATernAl And neWbOrn HeAlTH Establish links I2 Coordinate with other health care providers and community groups I2 Establish links with traditional birth attendants and traditional healers Involve the community in quality of services G6 I2 G7 I3 G8 G9 G10 G11 . give him appropriate care. respond to her problems Prevent HIV infection in health care workers after accidental exposure with body fluids (post exposure prophylaxis) G11 If a health care worker is exposed to body fluids by cuts/pricks/ splashes.Table of contents TAble OF cOnTenTs g G2 G3 InFOrm And cOunsel On HIv Provide key information on HIV G2 What is HIV and how is HIV transmitted? G2 Advantage of knowing the HIV status in pregnancy G2 Counsel on safer sex including use of condoms HIV testing and counselling G3 HIV testing and counselling G3 Discuss confidentiality of HIV infection G3 Counsel on implications of the HIV test result G3 Benefits of disclosure (involving) and testing the male partner(s) Care and counselling for the HIV -positive woman G4 Additional care for the HIV -positive woman G4 Counsel the HIV -positive woman on family planning Support to the HIV-positive woman G5 Provide emotional support to the woman G5 How to provide support Give antiretroviral (ARV) medicine(s) to treat HIV infection G6 Support the initiation of ARV G6 Support adherence to ARV Counsel on infant feeding options G7 Explain the risks of HIV transmission through breastfeeding and not breastfeeding G7 If a woman does not know her HIV status G7 If a woman knows that she is HIV positive Support the mothers choice of newborn feeding G8 If mother chooses replacement feeding : teach her replacement feeding G8 Explain the risks of replacement feeding G8 Follow-up for replacement feeding G8 Give special counselling to the mother who is HIV-positive and chooses breastfeeding Give appropriate antiretroviral to HIV.

J K8 neWbOrn cAre Examine the newborn J3 If preterm. stop ventilating K11 If not breathing or gasping at all after 20 minutes of ventilation Treat and immunize the baby K12 Treat the baby K12 Give 2 IM antibiotics (first week of life) K12 Give IM benzathine penicillin to baby (single dose) if mother tested RPR-positive K12 Give IM antibiotic for possible gonococcal eye infection (single dose) K13 Treat local infection K13 Give isoniazid (INH) prophylaxis to newborn K13 Immunize the newborn K13 Give antiretroviral (ARV) medicine to newborn Advise when to return with the baby K14 Routine visits K14 Follow-up visits K14 Advise the mother to seek care for the baby K14 Refer baby urgently to hospital Table of contents . cAre. ventilate K11 If breathing less than 30 breaths per minute or severe chest in-drawing. bruises or malformation J9 Assess the mother’s breasts if complaining of nipple or breast pain J10 Care of the newborn J11 Additional care of a small baby (or twin) J12 Assess replacement feeding J2 K9 K10 K11 k K2 breAsTFeedIng. PrevenTIve meAsures And TreATmenT FOr THe neWbOrn K12 TAble OF cOnTenTs Counsel on breastfeeding K2 Counsel on importance of exclusive breastfeeding K2 Help the mother to initiate breastfeeding K3 Support exclusive breastfeeding K3 Teach correct positioning and attachment for breastfeeding K4 Give special support to breastfeed the small baby (preterm and/or low birth weight) K4 Give special support to breastfeed twins K5 Alternative feeding methods K5 Express breast milk K5 Hand express breast milk directly into the baby’s mouth K6 Cup feeding expressed breast milk K6 Quantity to feed by cup K6 Signs that baby is receiving adequate amount of milk K7 Weigh and assess weight gain K7 Weigh baby in the first month of life K7 Assess weight gain K7 Scale maintenance K14 Other breastfeeding support K8 Give special support to the mother who is not yet breastfeeding K8 If the baby does not have a mother K8 Advise the mother who is not breastfeeding at all on how to relieve engorgement Ensure warmth for the baby K9 Keep the baby warm K9 Keep a small baby warm K9 Rewarm the baby skin-to-skin Other baby care K10 Cord care K10 Sleeping K10 Hygiene Newborn resuscitation K11 Keep the baby warm K11 Open the airway K11 If still not breathing. birth weight <2500 g or twin J4 Assess breastfeeding J5 Check for special treatment needs J6 Look for signs of jaundice and local infection J7 If danger signs J8 If swelling.

drugs And lAbOrATOry TesTs Equipment. supplies and drugs for childbirth care Laboratory tests L4 Check urine for protein L4 Check haemoglobin Perform rapid plamareagin (RPR) test for syphilis L5 Interpreting results Perform rapid test for HIV m InFOrmATIOn And cOunsellIng sHeeTs M2 Care during pregnancy M3 Preparing a birth and emergency plan M4 Care for the mother after birth M5 Care after an abortion M6 Care for the baby after birth M7 Breastfeeding M8-M9 Clean home delivery n N2 N3 N4 N5 N6 N7 recOrds And FOrms Referral record Feedback record Labour record Partograph Postpartum record International form of medical certificate of cause of death O glOssAry And AcrOnyms . supplies. drugs and tests for pregnancy and postpartum care Equipment.Table of contents TAble OF cOnTenTs l L2 L3 L4 L5 L6 eQuIPmenT. suPPlIes.

in delivery. the overall content and presentation. childbirth. Correct use of this guide should help reduce the high maternal and perinatal mortality and morbidity rates prevalent in many parts of the developing world. The PCPNC is a guide for clinical decision-making. and newborns during their first week of life. It is accompanied by an adaptation guide to help countries prepare their own national guides and training and other supporting materials. How to use the guide. and to all newborns at birth and during the first week of life (or later) for routine and emergency care. It should cover the most serious endemic conditions that the skilled birth attendant must be able to treat. They apply to all women attending antenatal care. childbirth and postpartum. classification and use of relevant information by suggesting key questions. including management of endemic diseases like malaria. The Guide has been developed by the Department of Reproductive Health and Research with contributions from the following WHO programmes: ■ ■ ■ ■ ■ ■ ■ ■ ■ Child and Adolesscent Health and Development HIV/AIDS Nutrition for Health and Development Essential drugs and Medicines Policy Vaccines and Biologicals Communicable Diseases Control. malaria. and recommending appropriate research-based interventions. helminthiasis) Gender and Women’s Health Mental Health and Substance Dependence Blindness and Deafness InTrOducTIOn Introduction . Prevention and Eradication (tuberculosis. and be made consistent with national treatment guidelines and other policies. postpartum or post abortion care. Each chapter begins with a short description of how to read and use it. It is a generic guide and should first be adapted to local needs and resources. thereby making pregnancy and childbirth safer. It facilitates the collection. describes how the guide is organized. to help the reader use the guide correctly. The guide is not designed for immediate use. All recommendations are for skilled attendants working at the primary level of health care. TB and anaemia. The first section. essential observations and/or examinations. or who come for emergency care. HIV/AIDS. and post abortion. postpartum and newborn care guide for essential practice (PCPNC) is to provide evidence-based recommendations to guide health care professionals in the management of women during pregnancy. if necessary. either at the facility or in the community. It promotes the early detection of complications and the initiation of early and appropriate treatment.InTrOducTIOn The aim of Pregnancy. analysis. including timely referral.

http://www. supplies. towards universal access: Recommendations for a public health approach Web-based public review. Geneva. Labour and delivery. ■ ■ ■ In addition to the clinical care outlined above. which add to maternal and perinatal morbidity and mortality.pdf. which applies to overall care.int/hiv/pub/prev_ care/en ISBN 92 4 159368 7 Malaria and HIV Interactions and their Implications for Public Health Policy.pdf ■ Sexually Transmitted and other Reproductive Tract Infections: A Guide to Essential Practice: http://www. ■ Guidelines for the Management of Sexually Transmitted Infections: http://www.int/reproductivehealth/publications/spr/spr.who. The principles are not repeated for each visit. int/child-adolescent-health/publications/ NUTRITION/ISBN_92_4_159123_4. World Health Organization.How to read the guide HOW TO reAd THe guIde HOW TO reAd THe guIde Content The Guide includes routine and emergency care for women and newborns during pregnancy. Postpartum care.who. This includes principles of good care for all women. Post-abortion care. including those with special needs. ■ Preventive measures. Support for women with special needs. Antenatal care. equipment. emergency management (called Rapid Assessment and Management or RAM) and referral. including monitoring the well-being of the mother and/ or baby.who. However. Other related WHO documents can be downloaded from the following links: Medical Eligibility Criteria 3rd edition: http://www.who.who. postpartum and post abortion.htm Integrated Management of Adolescent and adult illness http://www. ■ Recommendations for the management of complications at secondary (referral) health care level can be found in the following guides for midwives and doctors: Managing complications of pregnancy and childbirth (WHO/RHR/00.int/reproductive-health/ publications/mec/mec. http://www. as well as key preventive measures required to reduce the incidence of endemic and other diseases like malaria. Advice on HIV. ■ Early detection and management of complications.who.int/hiv/pub/prev_care/en: ISNB 92 4 159335 0 Interim WHO clinical staging of HIV/AIDS and HIV/AIDS case definitions for surveillance African Region.who. It explains the organization of each visit to a healthcare facility. Drugs. A guide for health-care managers and supervisors http://www.int/reproductive-health/ publications/rtis_gep/rtis_gep. prevention and treatment. int/reproductive-health/publications/rhr_01_ 10_mngt_stis/guidelines_mngt_stis.int/3by5/publications/ documents/imai/en/index.02 HIV and Infant Feeding. the small proportion of women/newborns who are ill. ■ Selected Practice Recommendations 2nd edition: http://www.int/childadolescent-health/publications/NUTRITION/ ISBN_92_4_159122_6.int/hiv/pub/prev_care/en WHO consultation on technical and operational recommendations for scale-up of laboratory services and monitoring HIV antiretroviral therapy in resource-limited settings. Switzerland.who. The clinical content is divided into six sections which are as follows: ■ In each of the six clinical sections listed above there is a series of flow.html . ■ ■ Antiretroviral treatment of HIV infection in infants and children in resource-limited settings. Family and Community Health.pdf. need urgent attention and care.int/hiv/pub/ prev_care/en Ref no:: WHO/HIV/2005.int.pdf ■ ■ ■ ■ ■ ■ ■ Quick check (triage). Links with the community. Counselling and key messages for women and families. Newborn care. Most women and newborns using the services described in the Guide are not ill and/or do not have complications. HIV/AIDS and TB. They are able to wait in line when they come for a scheduled visit. ■ ■ There is an important section at the beginning of the Guide entitled Principles of good care A1-A5 . http://www. e-mail: mpspublications@who. treatment and information charts which include: Guidance on routine care. followed by a chapter on emergency treatments for the woman. anaemia.htm HIV and Infant Feeding.who.7) ■ Managing newborn problems. 3–12 November 2005 http://www. Examples of clinical records. Guidelines for decision-makers http://www.who. ■ Advice and counselling. other sections in the guide include: ■ ■ ■ ■ ■ ■ Documents referred to in this Guide can be obtained from the Department of Making Pregnancy Safer. have complications or are in labour. universal precautions and laboratory tests.who. labour and delivery.

enabling her/him to classify the condition according to severity and give appropriate treatment. The framework is based on a syndromic approach whereby the skilled attendant identifies a limited number of key clinical signs and symptoms. examinations. “Treat. 7. observations and. clean home delivery. acceptability and attractiveness. while the column on the right has interventions which may be required if problems arise during delivery. yellow for less urgent conditions which nevertheless need attention. Key sequential steps The charts for normal and abnormal deliveries are presented in a framework of key sequential steps for a clean safe delivery. her partner and family at the appropriate stage of pregnancy and childbirth. prescribing drugs or other treatments. 3. and are cross-referenced to other parts of the Guide.The treat and advise column is often crossreferenced to other treatment and/or information charts. breastfeeding and care after an abortion) to be given to the mother. The key sequential steps for delivery are in a column on the left side of the page. Turn to these charts for more information. These sheets are presented in a generic format. Different programmes may prefer a different format such as a booklet or flip chart. and the addition of illustrations to enhance understanding. a section is included at the back of the Guide to support the skilled attendant in this effort. 2. where appropriate. Yellow indicates that there is a problem that can be treated without referral. 4. Key questions to be asked. 6. 8. These pages include information which is too detailed to include in the flow charts: Structure and presentation . Classification of the findings. Interventions may be linked to relevant treatment and/or information pages. CHECK RECORD LOOK. Individual sheets are provided with simplified versions of the messages on care during pregnancy (preparing a birth and emergency plan. Severity is marked in colour: red for emergencies. The content is presented in a frame work of coloured flow charts supported by information and treatment charts which give further details of care. ■ ■ ■ ■ Treatments. They will require adaptation to local conditions and language. care for the mother and baby after delivery. as outlined in the guide. with appropriate advice for home care and follow up. Green usually indicates no abnormal condition and therefore normal care is given. HOW TO reAd THe guIde 3 ASK. Relevant procedures. Advice and counselling. Treatment and advice related to the signs and classification. Important observations and examinations to be made. Use of colour Colour is used in the flow charts to indicate the severity of a condition. her partner and family. Preventive measures. in most cases. 5. LISTEN FEEL SIGNS 4 CLASSIFY 5 TREAT AND ADVISE 1 2 6 7 8 Treatment and information pages The flow charts are linked (cross-referenced) to relevant treatment and/or information pages in other parts of the Guide. and green for normal care. Flow charts The flow charts include the following information: 1. advising on possible side-effects and how to overcome them) and giving advice on other important practices. In addition. advise” means giving the treatment indicated (performing a procedure. Information and counselling sheets These contain appropriate advice and counselling messages to provide to the woman.sTrucTure And PresenTATIOn This Guide is a tool for clinical decision-making. urgent referral to a higher level health facility. Possible findings (signs) based on information elicited from the questions. Red highlights an emergency which requires immediate treatment and.

capacity and organization of services. It could also be a hospital with a delivery ward and outpatient clinic providing routine care to women from the neighbourhood. not only within the context of existing health priorities and resources. to the woman's home. at the facility near where the woman lives. 7 days a week. at the same facility or at the referral hospital. initial treatment and referral are done by the skilled attendant. including HIV/AIDS → Vitamin A and iron/folate deficiencies. that require specific training. newborns and the communities to which they belong. and infant feeding counselling. treatment for HIV. health centre or maternity clinic.Assumptions underlying the Guide HOW TO reAd THe guIde AssumPTIOns underlyIng THe guIde Recommendations in the Guide are generic. resources and settings. such as management of malaria. delivery and postpartum care are provided at the primary level of the health care. The adaptation guide offers some alternatives. Referral and transportation are appropriate for the distance and other circumstances. or the woman delivers alone (but home delivery without a skilled attendant is not recommended). ■ ■ . childbirth and postpartum care to women other than those referred. They must be safe for the mother and the baby. Routine visits and follow-up visits are “scheduled” during office hours. for different demographic and epidemiological conditions. Women who are first seen by the health worker in late labour are offered the test after the childbirth. or severe illness or deterioration are provided 24/24 hours. equipment. Human resources. tuberculosis and other lung diseases. resources and staffing). Women and babies with complications or expected complications are referred for further care to the secondary level of care. Health workers are trained to provide HIV testing and counselling. HIV testing kits and ARV medicines are available at the Primary health-care Adaptation of the Guide It is essential that this generic Guide is adapted to national and local situations. ■ All pregnant woman are routinely offered HIV testing and counselling at the first contact with the health worker. e. attended by traditional birth attendants (TBAs) or relatives. Some deliveries are conducted at home. Detection. Links with the community and traditional providers are established. which could be during the antenatal visits. supplies and drugs are limited. She may work at the health care centre. ■ Other programme activities. infrastructure. An adaptation guide is available to assist national experts in modifying the Guide according to national needs. are delivered by a different provider. However. It includes guidance on developing information and counselling tools so that each programme manager can develop a format which is most comfortable for her/him. However there may be other health workers who receive the woman or support the skilled attendant when emergency complications occur. but also within the context of respect and sensitivity to the needs of women. supplies. ■ ■ ■ Health care system The Guide assumes that: ■ Routine and emergency pregnancy. IV fluids. Primary health care services and the community are involved in maternal and newborn health issues. Emergency services (“unscheduled” visits) for labour and delivery. gloves and essential equipment are available. If a health worker with higher levels of skill (at the facility or a referral hospital) is providing pregnancy.g. This facility could be a health post. essential drugs. ■ A single skilled attendant is providing care. if necessary. ■ Population and endemic conditions ■ ■ ■ ■ High maternal and perinatal mortality Many adolescent pregnancies High prevalence of endemic conditions: → Anaemia → Stable transmission of falciparum malaria → Hookworms (Necator americanus and Ancylostoma duodenale) → Sexually transmitted infections. a maternity unit of a hospital or she may go ■ Knowledge and skills of care providers This Guide assumes that professionals using it have the knowledge and skills in providing the care it describes. in early labour or in the postpartum period. complications. Other training materials must be used to bring the skills up to the level assumed by the Guide. she follows the recommendations described in this Guide. a referral hospital. made on many assumptions about the health characteristics of the population and the health care system (the setting.

■ ■ Wash hands ■ ■ Wash hands with soap and water: → Before and after caring for a woman or newborn. PrinciPles of good cAre Workplace and administrative procedures A3 Standard precautions and cleanliness PrinciPles of good cAre universAl PrecAutions And cleAnliness observe these precautions to protect the woman and her baby. ■ Sterilize gloves ■ Sterilize by autoclaving or highly disinfect by steaming or boiling. begin emergency assessment and management (RAM) B-B7 for the woman. thus every 8 hours. ■ Thoroughly clean or disinfect any equipment which comes into contact with intact skin (according to instructions). ■ Wash hands after disposal of infectious waste. Do not recap. Explore any barriers she or her family may have. from infections with bacteria and viruses. check that equipment is clean and functioning and that supplies and drugs are in place. drugs. Keep the woman informed throughout. Standard precautions and cleanliness A4 . → Follow all steps on the chart and in relevant boxes. that you cannot be overheard. Explain all procedures. Rinse off blood or other body fluids before washing with soap. Workplace and administrative procedures A3 . or have heard from others. and keep the woman informed as much as Ask the woman if she has any questions. looks small. ask the companion to take care of the baby during the maternal examination and treatment. drugs and vaccines. gloves and containers after disposal of infectious waste. or outside the health facility. Ask permission before undertaking an examination or test. Wear gloves Wear sterile or highly disinfected gloves when performing vaginal examination. ■ Organize the examination area so that. Care-givers should therefore familiarize themselves with the following principles before using the Guide. ■ Wear long sterile or highly disinfected gloves for manual removal of placenta. including the information on routine laboratory tests and treatments. ■ If follow-up visit is within a week. ■ If antenatal care. Demonstrate the procedure. deaths and other indicators as required. and shoes. Ask her: → Why did you come? For yourself or for your baby? → For a scheduled (routine) visit? → For specific complaints about you or your baby? → First or follow-up visit? → Do you want to include your companion or other family member (parent if adolescent) in the examination and discussion? ■ If the woman is recently delivered. Encourage her to ask questions. invite her to wait in the waiting room. ■ Soak overnight in bleach solution with 0. post-abortion. and that not taking it may be more dangerous. according to instructions. assess the baby or ask to see the baby if not with the mother. Discuss with her the importance of buying and taking the prescribed amount. cover any cuts. Ask the name of the woman. take care when handling any sharp instruments (use good light). orgAnizing A visit Receive and respond immediately receive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). plastic syringes and blades directly into this container. ■ If she is in labour. Ask and provide information related to her needs. At any examination or before any procedure: → seek her permission and → inform her of what you are doing. If she came with a baby and the baby is well. The principles concern: ■ ■ ■ ■ WorkPlAce And AdministrAtive Procedures Workplace Service hours should be clearly posted. If a follow-up visit is more than a week after the initial examination (but not the next scheduled visit): → Repeat the whole assessment as required for an antenatal. ■ Routine care continues at the primary care level where it was initiated. ■ ■ Keep records of equipment. Do not record confidential information on the home-based record if the woman is unwilling. clean and disinfect equipment and supplies → replace linen. If she is unconscious. examine her immediately using Antenatal care. Keep the facility clean by regular cleaning. accompany her to an appropriate place and follow the steps as in Childbirth: labour. These principles of good care apply to all contacts between the skilled attendant and all women and their babies. ■ Never discuss confidential information about clients with other providers. Encourage the companion to stay with the woman. Support her in understanding her options and making decisions. ■ Empty or send for incineration when the container is three-quarters full. for 5 days. Be friendly. and follow-up recommendations at the time the observation is made. Organizing a visit A5 . They are not sterile. Do not let the mother wait in the queue. ■ Hand over essential information to the colleague who follows on duty. Use simple and clear language. if she came with the baby. about using the treatment. and for blood or body fluid spills. or examine the newborn J-J . also examine the baby: → Follow the appropriate charts according to pregnancy status/age of the baby and purpose of visit. Discard if damaged. delivery. respectful and non-judgmental at all times. prepare for washing → replenish supplies and drugs → ensure routine cleaning of all areas. counselled and advised on follow-up for that particular condition/ complication. Complete periodic reports on births. because they may have holes → After changing soiled bedsheets or clothing. and before any treatment procedure → Whenever the hands (or any other skin area) are contaminated with blood or other body fluids → After removing the gloves. supplies. Check for damage: Blow gloves full of air. Keep nails short. Explain the side-effects to her. ■ For a postpartum visit. Ensure privacy during the examination and discussion. Maintain and file appropriately: → all clinical records → all other documentation. screen. Fill the Home-Based Maternal Record (HBMR) and give her the appropriate information sheet. especially if no-one is receiving them B2 . Summarize the most important information. At the end of the service: → discard litter and sharps safely → prepare for disinfection. ■ Use bleach for cleaning bowls and buckets. wearing gloves or use a plastic bag. ■ Wear clean gloves when: → Handling and cleaning instruments → Handling contaminated waste → Cleaning blood and body fluid spills ■ Drawing blood. stAndArd PrecAutions And cleAnliness Deal with contaminated laundry ■ Practice safe sharps disposal Keep a puncture resistant container nearby. Explain how the treatment is given to the baby. wall). Ask her name (and the name of the baby). ■ Ensure. cord cutting. Check availability and functioning of essential equipment (order stocks of supplies. ■ ■ ■ ■ ■ ■ ■ Verify that she understands emergency signs. Explain that they are not serious. treated. including Hiv. blood drawing. ■ If no emergency or priority sign on RAM or not in labour. or that single-use instruments are disposed of after one use. give preventive measures if due even if the woman has a condition "in yellow" that requires special treatment. ■ If baby is newly born. Introduce yourself. they are not repeated in each section. reasons for referral. WorkPlAce And AdministrAtive Procedures Communication A2 . revise the birth plan. Before beginning the services. during examination. afternoon and evening with some water and after a meal. Ensure and respect privacy during examination and discussion. abrasions or broken skin with a waterproof bandage. and if no other complaints: → Assess the woman for the specific condition requiring follow-up only → Compare with earlier assessment and reclassify. in the morning. always revise the birth plan at the end of the visit after completing the chart. Watch her as she does the first treatment in the clinic. Advise her to return if she has any problems or concerns about taking the drugs. ■ ■ ■ ■ ■ Collect clothing or sheets stained with blood or body fluids and keep them separately from other laundry. you can about what you are doing. ■ Follow-up for that specific condition will be either: → organized by the referral facility or → written instructions will be given to the woman/baby for the skilled attendant at the primary level who referred the woman/ baby. ■ ■ ■ ■ ■ A3 Record keeping ■ Daily and occasional administrative activities ■ ■ International conventions The health facility should not allow distribution of free or low-cost suplies or products within the scope of the International Code of Marketing of Breast Milk Substitutes. bednet. vaccine. and when and where to return. do not touch them directly. ■ At the first emergency sign on Quick Check. ■ Explain to her that the treatment will not harm her or her baby. twist the cuff closed. ask permission. ■ Clean and disinfect gloves Wash the gloves in soap and water. Summarize the most important messages with her. ■ Make the woman (and her companion) feel welcome. and tell her how to manage them. ■ Perform Quick Check on all new incoming women and babies and those in the waiting room. Drop all used (disposable) needles. where possible: → Has she or anyone she knows used the treatment or preventive measure before? → Were there problems? → Reinforce the correct information that she has. and you as the health provider. treatment instructions. ■ ■ Always record findings on a clinical record and home-based record. and without passing to another person. Discuss findings with her (and her partner). in leak-proof containers. ■ Make sure you have the woman’s consent before discussing with her partner or family. Good quality latex gloves can be disinfected 5 or more times. protect your eyes from splashes of blood. the underlying assumption of the Guide is that. Ask her if there are any points which need to be discussed and would she like support for this. It should also be tobacco free and support a tobacco-free environment. ■ Ensure all records are confidential and kept locked away. ■ Wash hands. Practice safe waste disposal Dispose of placenta or blood. Encourage her to return for a routine visit (tell her when) and if she has any concerns. Use each needle and syringe only once. condom) at the clinic. This produces disinfected gloves. vaccines and contraceptives before they run out). ■ Dust inside with talcum powder or starch. bend or break needles after giving an injection. ■ Burn or bury contaminated solid waste. Be on time with appointments or inform the woman/women if she/they need to wait. talk to the companion. and try to clarify the incorrect information. A5 orgAnizing A visit During the visit ■ ■ ■ ■ PrinciPles of good cAre PrinciPles of good cAre Explain all procedures. A4 A4 Protect yourself from blood and other body fluids during deliveries → Wear gloves. ■ Sterilize and clean contaminated equipment Make sure that instruments which penetrate the skin (such as needles) are adequately sterilized. the woman is protected from the view of other people (curtain. Establish staffing lists and schedules. At the end of the visit ■ ■ ■ ■ ■ Begin each emergency care visit ■ ■ ■ ■ Introduce yourself. Record treatments. ■ Pour liquid waste down a drain or flushable toilet. Help her to think about how she will be able to purchase this. at referral level. ■ ■ ■ ■ ■ ■ Care of woman or baby referred for special care to secondary level facility When a woman or baby is referred to a secondary level care facility because of a specific problem or complications. or body fluid contaminated items. Check for understanding by asking her to explain or demonstrate treatment instructions. examine immediately. postpartum or newborn visit according to the schedule → If antenatal visit.PrinciPles of good cAre Communication PrinciPles of good cAre communicAtion Communicating with the woman (and her companion) ■ ■ ■ ■ ■ ■ ■ A2 A2 communicAtion Privacy and confidentiality In all contacts with the woman and her partner: ■ Ensure a private place for the examination and counselling. and practice safe sharps disposal. → the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition. delivery and immediate postpartum care d-d29 . → If possible. ■ Give clear and helpful advice on how to take the drug regularly: → for example: take 2 tablets 3 times a day. ■ If she has priority signs. ■ Limit access to logbooks and registers to responsible providers only. Prescribing and recommending treatments and preventive measures for the woman and/or her baby When giving a treatment (drug. when discussing sensitive subjects. Organizing a visit A5 Principles of good care A . ■ Dry away from direct sunlight. ■ Unless the condition of the woman or the baby requires urgent referral to hospital. Postpartum or Post-abortion care charts c-c8 e-e0 B8-B22 . or prescribing measures to be followed at home: Explain to the woman what the treatment is and why it should be given. then hold under clean water and look for air leaks. without recapping. → Wear a long apron made from plastic or other fluid resistant material. repair of episiotomy or tear.5% available chlorine (made by adding 90 ml water to 10 ml bleach containing 5% available chlorine). the woman/baby will be assessed. ■ ■ Begin each routine visit (for the woman and/or the baby) Greet the woman and offer her a seat.

Be friendly. ■ ■ ■ ■ ■ ■ Verify that she understands emergency signs. when discussing sensitive subjects. Prescribing and recommending treatments and preventive measures for the woman and/or her baby When giving a treatment (drug. ■ Explain to her that the treatment will not harm her or her baby. ■ Make the woman (and her companion) feel welcome. ■ Organize the examination area so that. and try to clarify the incorrect information. or have heard from others. treatment instructions. Help her to think about how she will be able to purchase this. Explain how the treatment is given to the baby. respectful and non-judgmental at all times. Explain that they are not serious. thus every 8 hours. Encourage her to ask questions. and when and where to return. Advise her to return if she has any problems or concerns about taking the drugs. and tell her how to manage them.Communication PrinciPles of good cAre communicAtion Communicating with the woman (and her companion) ■ ■ ■ ■ ■ ■ ■ A2 Privacy and confidentiality In all contacts with the woman and her partner: ■ Ensure a private place for the examination and counselling. Check for understanding by asking her to explain or demonstrate treatment instructions. the woman is protected from the view of other people (curtain. where possible: → Has she or anyone she knows used the treatment or preventive measure before? → Were there problems? → Reinforce the correct information that she has. Use simple and clear language. during examination. At any examination or before any procedure: → seek her permission and → inform her of what you are doing. wall). or prescribing measures to be followed at home: ■ Explain to the woman what the treatment is and why it should be given. Explore any barriers she or her family may have. ■ Limit access to logbooks and registers to responsible providers only. vaccine. for 5 days. Watch her as she does the first treatment in the clinic. ■ Make sure you have the woman’s consent before discussing with her partner or family. screen. Discuss with her the importance of buying and taking the prescribed amount. bednet. Ask and provide information related to her needs. condom) at the clinic. including the information on routine laboratory tests and treatments. ■ Ensure all records are confidential and kept locked away. Support her in understanding her options and making decisions. Summarize the most important information. . and that not taking it may be more dangerous. Explain the side-effects to her. about using the treatment. that you cannot be overheard. ■ Ensure. ■ Never discuss confidential information about clients with other providers. Demonstrate the procedure. in the morning. or outside the health facility. afternoon and evening with some water and after a meal. ■ Give clear and helpful advice on how to take the drug regularly: → for example: take 2 tablets 3 times a day.

supplies. drugs and vaccines. Hand over essential information to the colleague who follows on duty. ■ Maintain and file appropriately: → all clinical records → all other documentation. ■ Complete periodic reports on births. Be on time with appointments or inform the woman/women if she/they need to wait. reasons for referral.WorkPlAce And AdministrAtive Procedures Workplace ■ ■ ■ ■ ■ ■ Service hours should be clearly posted. vaccines and contraceptives before they run out). according to instructions. ■ International conventions The health facility should not allow distribution of free or low-cost suplies or products within the scope of the International Code of Marketing of Breast Milk Substitutes. and follow-up recommendations at the time the observation is made. At the end of the service: → discard litter and sharps safely → prepare for disinfection. Before beginning the services. Daily and occasional administrative activities Keep records of equipment. deaths and other indicators as required. ■ Check availability and functioning of essential equipment (order stocks of supplies. check that equipment is clean and functioning and that supplies and drugs are in place. ■ Record keeping Always record findings on a clinical record and home-based record. clean and disinfect equipment and supplies → replace linen. prepare for washing → replenish supplies and drugs → ensure routine cleaning of all areas. It should also be tobacco free and support a tobacco-free environment. PrinciPles of good cAre Workplace and administrative procedures A3 . ■ Establish staffing lists and schedules. ■ Do not record confidential information on the home-based record if the woman is unwilling. drugs. Keep the facility clean by regular cleaning. Record treatments.

■ Keep nails short. They are not sterile. Wear gloves Wear sterile or highly disinfected gloves when performing vaginal examination. without recapping. . ■ Dry away from direct sunlight. repair of episiotomy or tear. abrasions or broken skin with a waterproof bandage. and for blood or body fluid spills. cord cutting. or that single-use instruments are disposed of after one use. → If possible. ■ Soak overnight in bleach solution with 0. take care when handling any sharp instruments (use good light). A4 Protect yourself from blood and other body fluids during deliveries → Wear gloves. and shoes. ■ Empty or send for incineration when the container is three-quarters full. delivery. ■ Dust inside with talcum powder or starch. ■ Sterilize gloves ■ Sterilize by autoclaving or highly disinfect by steaming or boiling. ■ Use bleach for cleaning bowls and buckets. or body fluid contaminated items. bend or break needles after giving an injection. protect your eyes from splashes of blood. ■ ■ ■ This produces disinfected gloves. gloves and containers after disposal of infectious waste. cover any cuts. Practice safe waste disposal ■ ■ ■ ■ ■ Wash hands Wash hands with soap and water: → Before and after caring for a woman or newborn. wearing gloves or use a plastic bag. do not touch them directly. and practice safe sharps disposal. Do not recap. and without passing to another person. plastic syringes and blades directly into this container. including Hiv.Standard precautions and cleanliness PrinciPles of good cAre stAndArd PrecAutions And cleAnliness observe these precautions to protect the woman and her baby. ■ Thoroughly clean or disinfect any equipment which comes into contact with intact skin (according to instructions).5% available chlorine (made by adding 90 ml water to 10 ml bleach containing 5% available chlorine). Burn or bury contaminated solid waste. and before any treatment procedure → Whenever the hands (or any other skin area) are contaminated with blood or other body fluids → After removing the gloves. blood drawing. then hold under clean water and look for air leaks. Wash hands. ■ Drop all used (disposable) needles. Wash hands after disposal of infectious waste. from infections with bacteria and viruses. ■ Wear long sterile or highly disinfected gloves for manual removal of placenta. Pour liquid waste down a drain or flushable toilet. in leak-proof containers. ■ Dispose of placenta or blood. Discard if damaged. ■ ■ Deal with contaminated laundry Collect clothing or sheets stained with blood or body fluids and keep them separately from other laundry. Clean and disinfect gloves Wash the gloves in soap and water. → Wear a long apron made from plastic or other fluid resistant material. twist the cuff closed. ■ Wear clean gloves when: → Handling and cleaning instruments → Handling contaminated waste → Cleaning blood and body fluid spills ■ Drawing blood. Good quality latex gloves can be disinfected 5 or more times. ■ Sterilize and clean contaminated equipment Make sure that instruments which penetrate the skin (such as needles) are adequately sterilized. Check for damage: Blow gloves full of air. ■ Rinse off blood or other body fluids before washing with soap. and you as the health provider. ■ Practice safe sharps disposal Keep a puncture resistant container nearby. because they may have holes → After changing soiled bedsheets or clothing. Use each needle and syringe only once.

■ ■ ■ ■ PrinciPles of good cAre Begin each emergency care visit ■ ■ ■ ■ ■ Introduce yourself. ■ During the visit Explain all procedures. you can about what you are doing. ■ If she has priority signs. and keep the woman informed as much as Greet the woman and offer her a seat. ■ Ensure privacy during the examination and discussion. Ask her: → Why did you come? For yourself or for your baby? → For a scheduled (routine) visit? → For specific complaints about you or your baby? → First or follow-up visit? → Do you want to include your companion or other family member (parent if adolescent) in the examination and discussion? If the woman is recently delivered. at referral level. ■ If no emergency or priority sign on RAM or not in labour. counselled and advised on follow-up for that particular condition/ complication. If antenatal care. invite her to wait in the waiting room. ■ Routine care continues at the primary care level where it was initiated. Encourage her to return for a routine visit (tell her when) and if she has any concerns. Encourage the companion to stay with the woman. Begin each routine visit (for the woman and/or the baby) ■ ■ ■ ■ Care of woman or baby referred for special care to secondary level facility When a woman or baby is referred to a secondary level care facility because of a specific problem or complications. ■ Keep the woman informed throughout. ■ If she is in labour. always revise the birth plan at the end of the visit after completing the chart. talk to the companion. Ask her name (and the name of the baby). Explain all procedures. the woman/baby will be assessed. revise the birth plan. ■ Perform Quick Check on all new incoming women and babies and those in the waiting room. begin emergency assessment and management (RAM) B-B7 for the woman. and if no other complaints: → Assess the woman for the specific condition requiring follow-up only → Compare with earlier assessment and reclassify. assess the baby or ask to see the baby if not with the mother. examine her immediately using Antenatal care.orgAnizing A visit Receive and respond immediately receive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). ■ Ask her if there are any points which need to be discussed and would she like support for this. ■ Ensure and respect privacy during examination and discussion. ■ Follow-up for that specific condition will be either: → organized by the referral facility or → written instructions will be given to the woman/baby for the skilled attendant at the primary level who referred the woman/ baby. treated. Postpartum or Post-abortion care charts c-c9 e-e0 B8-B22 . post-abortion. → Follow all steps on the chart and in relevant boxes. accompany her to an appropriate place and follow the steps as in Childbirth: labour. For a postpartum visit. if she came with the baby. delivery and immediate postpartum care d-d29 . looks small. ■ ■ ■ Organizing a visit A5 . ask the companion to take care of the baby during the maternal examination and treatment. Summarize the most important messages with her. or examine the newborn J-J . ■ If a follow-up visit is more than a week after the initial examination (but not the next scheduled visit): → Repeat the whole assessment as required for an antenatal. Discuss findings with her (and her partner). ■ Fill the Home-Based Maternal Record (HBMR) and give her the appropriate information sheet. give preventive measures if due even if the woman has a condition "in yellow" that requires special treatment. Ask permission before undertaking an examination or test. the underlying assumption of the Guide is that. ■ If she came with a baby and the baby is well. ask permission. ■ At the first emergency sign on Quick Check. ■ ■ At the end of the visit Ask the woman if she has any questions. examine immediately. Do not let the mother wait in the queue. also examine the baby: → Follow the appropriate charts according to pregnancy status/age of the baby and purpose of visit. Ask the name of the woman. If follow-up visit is within a week. → the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition. ■ If baby is newly born. postpartum or newborn visit according to the schedule → If antenatal visit. especially if no-one is receiving them B2 . Unless the condition of the woman or the baby requires urgent referral to hospital. If she is unconscious. Introduce yourself.

.

This may be ruptured uterus. . or history of fever. retained placenta. ■ Reassure the woman that she will be taken care of is the woman being wheeled or carried in or: ■ bleeding vaginally ■ convulsing ■ looking very ill ■ unconscious ■ in severe pain ■ in labour ■ delivery is imminent . help woman onto her left side. ■ Give fluids slowly b9 . if a woman is very sick. ■ Apply bimanual uterine or aortic compression b0 . deliver placenta by controlled cord traction d2 . B6 B7 If unconscious. B4 This may be placenta previa. check if still bleeding heavy bleeding controlled bleeding � next: Convulsions or unconscious ■ Observe closely (every 30 minutes) for 4 hours. ■ Give artemether IM (if not available. ■ Keep her warm (cover her). ■ Give appropriate IM/IV antibiotics b5 . ■ Empty bladder. ruptured uterus. This may be haemorrhagic shock. allow the woman to wait in line for routine care. ■ If early pregnancy. ■ If recently given birth. ask relative “has there been a recent convulsion?” . ■ If uterus remains soft. meningitis. If present. ■ Give fluids rapidly if heavy bleeding or shock b3 . ■ refer her urgently to hospital* b7 . Keep nearby for 24 hours. check and ask if placenta is delivered ■ When uterus is hard. � if emergency for woman or baby or labour. ■ Call for immediate assessment. * But if birth is imminent (bulging. ■ refer woman urgently to hospital b7 .Quick check. severe abdominal pain ■ Severe abdominal pain (not normal labour) ■ Measure blood pressure ■ Measure temperature ■ Insert an IV line and give fluids b9 . give first dose of appropriate IM/IV antiobiotics b5 . ■ Call for help if needed. ■ Continue massaging uterus till it is hard. ruptured uterus. non urgent ■ No emergency signs or ■ No priority signs ■ If pregnant (and not in labour). ■ If pregnancy not likely. obstructed labour. ■ Pregnant woman. ■ refer woman urgently to hospital* b7 . vaginal or cervical tear. or history of fever. refer woman urgently to hospital b7 . light bleeding late pregnancy (uterus above umbilicus) any bleeding is dangerous ■ Examine woman as on b9 . ■ If suspect possible complicated abortion. go to relevant section ■ Always begin a clinical visit with Rapid assessment and management (RAM) b3-b7 : → heck for emergency signs first b3-b6 . ■ Transfer the baby to the treatment room for immediate Newborn care J-J . ■ Give first dose of appropriate IM/IV antibiotics b5 . do not give ergometrine to women with eclampsia. if placenta is incomplete (or not available for inspection): ■ Remove placental fragments b . ■ Continue oxytocin infusion with 20 Iu/litre of IV fluids at 20 drops/min for at least one hour after bleeding stops b0 . or not aware of pregnancy. rapid assessment and management of women of childbearing age Quick check Quick check. → Check for priority signs. ■ Manage airway b9 . do not do vaginal examination. thin perineum during contractions. rapid assessment and management (ram) (5) priority signs Labour Other danger signs or symptoms Non-urgent Rapid assessment and management (RAM) Priority signs b7 Quick check. ■ If systolic BP <90 mm Hg see b3 . Complete the referral form n2 . transfer woman to labour room and proceed as on d-d28 . provide antenatal care c-c8 . ■ Give fluids rapidly b9 . During transfer. B5 b5 placenta delivered check placenta b rapid assessment and management (ram) (3) Vaginal bleeding: postpartum check for perineal and lower vaginal tears if present If third degree tear (involving rectum or anus). give appropriate IM/IV antibiotics b5 . → If no emergency or priority signs. provide postpartum care e-e0 . pre-eclampsia or known hypertension. check for ectopic pregnancy b9 . assess for all emergency and priority signs and give appropriate treatments. This may be pneumonia. ■ Give fluids rapidly if heavy bleeding or shock b3 ■ refer woman urgently to hospital* b7 . If present. then refer the woman to hospital. ■ If temperature >38ºC. refer to health centre. rapid assessment and management of women of childbearing age rapid assessment and management (ram) use this chart for rapid assessment and management (ram) of all women of childbearing age. airway and breathing ■ Very difficult breathing or ■ Central cyanosis rapid assessment and management (ram) () Airway and breathing Circulation and shock circulation (shock) ■ Cold moist skin or ■ Weak and fast pulse ■ Measure blood pressure ■ Count pulse Measure blood pressure. refer woman urgently to hospital b7 . provide post-abortion care b20-b2 . ■ Continue IV fluids with 20 units of oxytocin at 30 drops/minute. ■ If not able to insert peripheral IV. dangerous fever Fever (temperature more than 38ºC) and any of: ■ Very fast breathing ■ Stiff neck ■ Lethargy ■ Very weak/not able to stand ■ Measure temperature ■ Insert an IV line b9 .first assess EMERGENCY SIGNS do all emergency steps before referral MEASuRE TREATMENT ■ Manage airway and breathing b9 . ■ Ask her companion to stay. � next: Priority signs Quick check. If severe pallor. ■ If temperature >38ºC. If any danger sign is seen. visible fetal head). refer woman urgently to hospital* b7 .2 mg ergometrine IM/IV if bleeding continues. ■ Examine the woman using Assess the mother after delivery d2 . or after delivery. visible fetal head). ■ Give appropriate IM/IV antibiotics b5 . if no emergency or priority signs. * But if birth is imminent (bulging. rapid assessment and management (ram) (2) Vaginal bleeding do not do vaginal examination. or ■ unconscious MEASuRE ■ Measure blood pressure ■ Measure temperature ■ Assess pregnancy status TREATMENT ■ Protect woman from fall and injury. Catheterize if necessary b2 . ■ After convulsion ends. transfer woman to labour room and proceed as on d-d28 . also give treatment for dangerous rapid assessment and management (ram) (4) Convulsions Severe abdominal pain Dangerous fever fever (below). refer to other clinical guidelines. delivery and the postpartum period. ■ Insert an IV line b9 and give IV fluids with 20 Iu oxytocin at 60 drops/minute. ■ Ask the mother to stay. obstructed breathing. This may be eclampsia. ■ Check after 5 minutes. This may be abortion. check if baby is or has: ■ very small ■ convulsing ■ breathing difficulty labour emergency for baby ■ Transfer the woman to the labour ward. ■ If unable to remove. � next: Vaginal bleeding in postpartum Quick check. If systolic BP < 90 mmHg or pulse >110 per minute: ■ Position the woman on her left side with legs higher than chest. * But if birth is imminent (bulging. give antihypertensive b4 . This may be malaria. other danger signs or symptoms If any of: ■ Severe pallor ■ Epigastric or abdominal pain ■ Severe headache ■ Blurred vision ■ Fever (temperature more than 38ºC) ■ Breathing difficulty ■ Measure blood pressure ■ Measure temperature ■ If pregnant (and not in labour). and e-e0 . B2 Quick check ■ Perform Quick check immediately after the woman arrives b2 ASK. ectopic pregnancy. circulation (shock) b3 Rapid assessment and management (RAM) Vaginal bleeding Quick check. if bleeding persists repair the tear b2 . give ergometrine 0. if placenta is complete: ■ Massage uterus to express any clots b0 . ■ If unable to remove placenta. thin perineum during contractions. Get help. go to b3 . but: ■ Insert an IV line b9 . ■ refer woman urgently to hospital* b7 . thin perineum during contractions. also give treatment for dangerous ■ fever (below). talk to her companion. ■ Give fluids rapidly b9 . severe anaemia with heart failure. but: ■ Insert an IV line b9 . remove placenta manually and check placenta b . This may be placenta previa. help the woman and send her quickly to the emergency room. refer woman urgently to hospital b7 . use alternative b9 . pneumonia. routine care ■ Keep the woman and baby in the waiting room for with no danger signs ■ A newborn with no danger signs or routine care. menorrhagia. manage according to charts b7 . ■ If early pregnancy. rapid assessment and management of women of childbearing age b . ■ Repeat 0.2 mg IV b0 . ■ refer woman urgently to hospital* b7 . ■ For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. ■ If recent abortion. give quinine IM) and glucose b6 . give antihypertensive b4 . ■ Massage uterus until it is hard and give oxytocin 10 Iu IM b0 . rapid assessment and management of women of childbearing age PREGNANCY STATuS postpartum (baby is born) BLEEDING heavy bleeding ■ Pad or cloth soaked in < 5 minutes ■ Constant trickling of blood ■ Bleeding >250 ml or delivered outside health centre and still bleeding placenta not delivered TREATMENT ■ Call for extra help. septicemia. continue IV fluids with 20 Iu of oxytocin at 30 drops/minute. ■ Insert an IV line b9 . ■ Check and record BP and pulse every 15 minutes and treat as on b3 This may be uterine atony. septic shock. maternal complaints. if no emergency. rapid assessment and management of women of childbearing age PRIORITY SIGNS labour ■ Labour pains or ■ Ruptured membranes MEASuRE TREATMENT ■ Manage as for Childbirth d-d28 . rapid assessment and management of women of childbearing age b2 Quick check a person responsible for initial reception of women of childbearing age and newborns seeking care should: ■ assess the general condition of the careseeker(s) immediately on arrival ■ periodically repeat this procedure if the line is long. transfer woman to labour room and proceed as on d-d28 . CHECK RECORD LOOK. or not pregnant (uterus NOT above umbilicus) BLEEDING heavy bleeding Pad or cloth soaked in < 5 minutes. abruptio placentae. If the baby is or has: ■ very small ■ convulsions ■ difficult breathing ■ just born ■ any maternal concern. ■ refer woman urgently to hospital* b7 . provide antenatal care c-c8 . rapid assessment and management of women of childbearing age Quick check. immediately. ■ refer woman urgently to hospital* b7 . ■ Give appropriate IM/IV antibiotics b5 . FEEL ■ Why did you come? → for yourself? → for the baby? ■ How old is the baby? ■ What is the concern? SIGNS If the woman is or has: ■ unconscious (does not answer) ■ convulsing ■ bleeding ■ severe abdominal pain or looks very ill ■ headache and visual disturbance ■ severe difficulty breathing ■ fever ■ severe vomiting. TREATMENT ■ Insert an IV line b9 . ectopic pregnancy.2 mg ergometrine IM b0 . Insert second IV line. ■ If temperature more than 38ºC. provide emergency treatment and refer the woman urgently to hospital. ■ If recently given birth. ■ Give 0. give diazepam IV or rectally b4 . � next: Vaginal bleeding Rapid assessment and management (RAM) Airway and breathing. ■ If diastolic BP >110mm of Hg. ■ If unsuccessful and bleeding continues. and also for women in labour. ■ Imminent delivery or ■ Labour CLASSIFY emergency for woman TREAT ■ Transfer woman to a treatment room for Rapid assessment and management b3-b7 . C B3 Quick check. puerperal or postabortion sepsis. according to pregnancy status. measure bp and temperature ■ If diastolic BP >110mm of Hg. during labour before delivery of baby bleeding more than 00 ml since labour began . ■ Continue IV fluids with 20 Iu oxytocin/litre at 30 drops/minute. Rapid assessment and management (RAM) Vaginal bleeding: postpartum Rapid assessment and management (RAM) Emergency signs Quick check. ruptured uterus. ■ refer woman urgently to hospital b7 . abruptio placenta. ■ Examine the tear and determine the degree b2 . rapid assessment and management of women of childbearing age b4 vaginal bleeding ■ assess ■ assess pregnancy status amount of bleeding PREGNANCY STATuS early pregnancy not aware of pregnancy. provide postpartum care d2 . abruptio placenta. rapid assessment and management of women of childbearing age b6 EMERGENCY SIGNS convulsions or unconscious ■ Convulsing (now or recently). Do not cross ankles. visible fetal head). LISTEN. on first arrival and periodically throughout labour. ■ Insert an IV line and give fluids slowly (30 drops/min) b9 ■ Give magnesium sulphate b3 . asthma.

■ Call for immediate assessment. ■ Call for help if needed. ASK. go to relevant section b3 .Quick check Quick check. ■ Reassure the woman that she will be taken care of is the woman being wheeled or carried in or: ■ bleeding vaginally ■ convulsing ■ looking very ill ■ unconscious ■ in severe pain ■ in labour ■ delivery is imminent check if baby is or has: ■ very small ■ convulsing ■ breathing difficulty immediately. If the baby is or has: ■ very small ■ convulsions ■ difficult breathing ■ just born ■ any maternal concern. or after delivery. rapid assessment and management of women of childbearing age b2 Quick check a person responsible for initial reception of women of childbearing age and newborns seeking care should: ■ assess the general condition of the careseeker(s) immediately on arrival ■ periodically repeat this procedure if the line is long. routine care ■ Keep the woman and baby in the waiting room for with no danger signs ■ A newborn with no danger signs or maternal complaints. ■ Imminent delivery or ■ Labour CLASSIFY emergency for woman TREAT ■ Transfer woman to a treatment room for Rapid assessment and management b3-b7 . go to if no emergency. FEEL ■ Why did you come? → for yourself? → for the baby? ■ How old is the baby? ■ What is the concern? SIGNS If the woman is or has: ■ unconscious (does not answer) ■ convulsing ■ bleeding ■ severe abdominal pain or looks very ill ■ headache and visual disturbance ■ severe difficulty breathing ■ fever ■ severe vomiting. . CHECK RECORD LOOK. ■ Ask the mother to stay. routine care. if a woman is very sick. talk to her companion. labour emergency for baby ■ Transfer the woman to the labour ward. ■ Transfer the baby to the treatment room for immediate Newborn care J-J . ■ Ask her companion to stay. ■ Pregnant woman. LISTEN. t if emergency for woman or baby or labour.

visible fetal head). ■ refer woman urgently to hospital* b7 . ■ Keep her warm (cover her). asthma. t next: Vaginal bleeding Rapid assessment and management (RAM) Airway and breathing. assess for all emergency and priority signs and give appropriate treatments. ■ Give fluids rapidly b9 . on first arrival and periodically throughout labour. circulation (shock) b3 . This may be haemorrhagic shock. * But if birth is imminent (bulging. obstructed breathing.Quick check. use alternative b9 . ■ refer her urgently to hospital* b7 .first assess EMERGENCY SIGNS do all emergency steps before referral MEASuRE TREATMENT ■ Manage airway and breathing b9 . ■ Insert an IV line b9 . thin perineum during contractions. then refer the woman to hospital. airway and breathing ■ Very difficult breathing or ■ Central cyanosis circulation (shock) ■ Cold moist skin or ■ Weak and fast pulse ■ Measure blood pressure ■ Count pulse Measure blood pressure. septic shock. transfer woman to labour room and proceed as on d-d28 . and also for women in labour. rapid assessment and management of women of childbearing age rapid assessment and management (ram) use this chart for rapid assessment and management (ram) of all women of childbearing age. severe anaemia with heart failure. delivery and the postpartum period. ■ If not able to insert peripheral IV. This may be pneumonia. If systolic BP < 90 mmHg or pulse >110 per minute: ■ Position the woman on her left side with legs higher than chest.

ectopic pregnancy. This may be placenta previa. during labour before delivery of baby bleeding more than 00 ml since labour began do not do vaginal examination. light bleeding late pregnancy (uterus above umbilicus) any bleeding is dangerous do not do vaginal examination. transfer woman to labour room and proceed as on d-d28 . rapid assessment and management of women of childbearing age b4 vaginal bleeding ■ assess pregnancy status ■ assess amount of bleeding PREGNANCY STATuS early pregnancy not aware of pregnancy. but: ■ Insert an IV line b9 . ■ Give fluids rapidly if heavy bleeding or shock b3 ■ refer woman urgently to hospital* b7 . This may be abortion. * But if birth is imminent (bulging. ■ Give fluids rapidly if heavy bleeding or shock b3 ■ refer woman urgently to hospital* b7 . ■ Give fluids rapidly b9 . ruptured uterus. ruptured uterus. give appropriate IM/IV antibiotics b5 . or not pregnant (uterus NOT above umbilicus) BLEEDING heavy bleeding Pad or cloth soaked in < 5 minutes. visible fetal head). t next: Vaginal bleeding in postpartum . refer to other clinical guidelines.2 mg ergometrine IM/IV if bleeding continues. .Rapid assessment and management (RAM) Vaginal bleeding Quick check. abruptio placenta. ■ Give 0. menorrhagia. ■ Examine woman as on b9 . ■ If pregnancy not likely. ■ refer woman urgently to hospital b7 . ■ If suspect possible complicated abortion. abruptio placentae. ■ Repeat 0. TREATMENT ■ Insert an IV line b9 . This may be placenta previa.2 mg ergometrine IM b0 . but: ■ Insert an IV line b9 . . thin perineum during contractions.

This may be uterine atony. ■ Continue massaging uterus till it is hard. check and ask if placenta is delivered ■ When uterus is hard. ■ Give appropriate IM/IV antibiotics b5 . ■ Check and record BP and pulse every 15 minutes and treat as on b3 . If third degree tear (involving rectum or anus). refer to health centre. ■ refer woman urgently to hospital b7 . heavy bleeding check if still bleeding ■ Continue IV fluids with 20 units of oxytocin at 30 drops/minute. ■ Massage uterus until it is hard and give oxytocin 10 Iu IM b0 . ■ If unable to remove. If severe pallor. During transfer. if placenta is incomplete (or not available for inspection): ■ Remove placental fragments b . controlled bleeding t next: Convulsions or unconscious Rapid assessment and management (RAM) Vaginal bleeding: postpartum b5 . remove placenta manually and check placenta b . rapid assessment and management of women of childbearing age PREGNANCY STATuS postpartum (baby is born) BLEEDING heavy bleeding ■ Pad or cloth soaked in < 5 minutes ■ Constant trickling of blood ■ Bleeding >250 ml or delivered outside health centre and still bleeding placenta not delivered TREATMENT ■ Call for extra help. ■ If uterus remains soft. ■ Empty bladder. do not give ergometrine to women with eclampsia. vaginal or cervical tear. pre-eclampsia or known hypertension. Keep nearby for 24 hours. ■ Give appropriate IM/IV antibiotics b5 . Do not cross ankles. check for perineal and lower vaginal tears if present ■ Examine the tear and determine the degree b2 . ■ Continue oxytocin infusion with 20 Iu/litre of IV fluids at 20 drops/min for at least one hour after bleeding stops b0 . ■ Examine the woman using Assess the mother after delivery d2 . ■ If unsuccessful and bleeding continues. ■ For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. Insert second IV line. ■ Observe closely (every 30 minutes) for 4 hours. retained placenta. ■ Insert an IV line b9 and give IV fluids with 20 Iu oxytocin at 60 drops/minute. deliver placenta by controlled cord traction d2 . ■ Apply bimanual uterine or aortic compression b0 .Quick check. ruptured uterus. if bleeding persists repair the tear b2 . give ergometrine 0.2 mg IV b0 . refer woman urgently to hospital b7 . refer woman urgently to hospital b7 . ■ Continue IV fluids with 20 Iu oxytocin/litre at 30 drops/minute. ■ If unable to remove placenta. refer woman urgently to hospital b7 . placenta delivered check placenta b if placenta is complete: ■ Massage uterus to express any clots b0 . Catheterize if necessary b2 . ■ Check after 5 minutes. continue IV fluids with 20 Iu of oxytocin at 30 drops/minute. ■ Give appropriate IM/IV antibiotics b5 .

visible fetal head). ■ refer woman urgently to hospital* b7 . give antihypertensive b4 . ■ If temperature more than 38ºC. rapid assessment and management of women of childbearing age b6 EMERGENCY SIGNS convulsions or unconscious ■ Convulsing (now or recently). ectopic pregnancy. help woman onto her left side. thin perineum during contractions. ■ After convulsion ends. ■ If diastolic BP >110mm of Hg. meningitis. give diazepam IV or rectally b4 . ■ Insert an IV line and give fluids slowly (30 drops/min) b9 ■ Give magnesium sulphate b3 . or history of fever. or ■ unconscious MEASuRE ■ Measure blood pressure ■ Measure temperature ■ Assess pregnancy status TREATMENT ■ Protect woman from fall and injury. puerperal or postabortion sepsis. also give treatment for dangerous fever (below). Get help. ■ refer woman urgently to hospital* b7 . septicemia. give first dose of appropriate IM/IV antiobiotics b5 . ■ Manage airway b9 . measure bp and temperature ■ If diastolic BP >110mm of Hg. ■ If temperature >38ºC.Rapid assessment and management (RAM) Emergency signs Quick check. abruptio placenta. ■ Give fluids slowly b9 . ■ If temperature >38ºC. dangerous fever Fever (temperature more than 38ºC) and any of: ■ Very fast breathing ■ Stiff neck ■ Lethargy ■ Very weak/not able to stand ■ Measure temperature ■ Insert an IV line b9 . This may be eclampsia. * But if birth is imminent (bulging. severe abdominal pain ■ Severe abdominal pain (not normal labour) ■ Measure blood pressure ■ Measure temperature ■ Insert an IV line and give fluids b9 . refer woman urgently to hospital* b7 . ■ refer woman urgently to hospital* b7 . or history of fever. t next: Priority signs . transfer woman to labour room and proceed as on d-d28 . ask relative “has there been a recent convulsion?” . ■ Give artemether IM (if not available. If unconscious. give antihypertensive b4 . This may be ruptured uterus. ■ If systolic BP <90 mm Hg see b3 . obstructed labour. ■ If early pregnancy. pneumonia. give quinine IM) and glucose b6 . This may be malaria. ■ Give first dose of appropriate IM/IV antibiotics b5 . also give treatment for dangerous ■ fever (below).

non urgent ■ No emergency signs or ■ No priority signs ■ If pregnant (and not in labour). other danger signs or symptoms If any of: ■ Severe pallor ■ Epigastric or abdominal pain ■ Severe headache ■ Blurred vision ■ Fever (temperature more than 38ºC) ■ Breathing difficulty ■ Measure blood pressure ■ Measure temperature ■ If pregnant (and not in labour). provide antenatal care c-c9 . or not aware of pregnancy. Rapid assessment and management (RAM) Priority signs b7 . provide postpartum care d2 . provide post-abortion care b20-b2 . and e-e0 . ■ If recent abortion. ■ If recently given birth. check for ectopic pregnancy b9 . ■ If early pregnancy. provide antenatal care c-c9 . rapid assessment and management of women of childbearing age PRIORITY SIGNS labour ■ Labour pains or ■ Ruptured membranes MEASuRE TREATMENT ■ Manage as for Childbirth d-d28 . provide postpartum care e-e0 . ■ If recently given birth.Quick check. if no emergency or priority signs.

5 ml sterile water Vial containing 40 mg/ml in 2 ml Vial containing 500 mg in 100 ml dosage/route frequency If intravenous access not possible ■ Give oral rehydration solution (ORS) by mouth if able to drink. B B14 Give appropriate antihypertensive drug If diastolic blood pressure is > 110-mmHg: ■ Give hydralazine 5 mg IV slowly (3-4 minutes).0 mg) * 50% glucose solution is the same as 50% dextrose solution or D50. oxytocin/ergometrine treatment and removal of placenta: ■ Feel for femoral pulse. drying and wrapping the baby Clean clothes for the baby Plastic bag for placenta Resuscitation bag and mask for the baby strength and form 10 IU vial 0. Apply sufficient pressure until femoral pulse is not felt. obstructed labour. repeat 10 mg. continue antibiotics IM/IV for 48 hours after woman is fever free. This prevents inversion of the uterus. ■ Inform the referral centre if possible by radio or phone. repeat the dose at 30 minute intervals until B14 diastolic BP is around 90 mmHg. show assistant or relative how to apply pressure. if the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage. keep her propped up. Manage the airway and breathing Insert IV line and give fluids condition ■ Severe abdominal pain ■ Dangerous fever/very severe febrile disease ■ Complicated abortion ■ Uterine and fetal infection ■ Postpartum bleeding → lasting > 24 hours → occurring > 24 hours after delivery ■ Upper urinary tract infection ■ Pneumonia ■ Manual removal of placenta/fragments ■ Risk of uterine and fetal infection ■ In labour > 24 hours antiBiotics 3 antibiotics ■ Ampicillin ■ Gentamicin ■ Metronidazole 2 antibiotics: ■ Ampicillin ■ Gentamicin 1 antibiotic: ■ Ampicillin ■ If drug treatment. if possible → essential emergency drugs and supplies B17 . and: ■ Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% solution) IM deep in upper outer quadrant of each buttock with 1 ml of 2% lignocaine in the same syringe. and secure it to prevent aspiration (do not attempt this during a convulsion). curved needle. ■ Move the fingers of the right hand sideways until edge of the placenta is located. → Use absorbable polyglycon suture material. ■ Massage the fundus of the uterus to encourage a tonic uterine contraction. add 4 ml of 50% solution to 6 ml sterile water if referral delayed for long. Clean area again → Insert catheter up to 4 cm → Measure urine and record amount → Remove catheter. Then give amoxicillin orally 500 mg 3 times daily until 7 days of treatment completed. ■ If convulsions recur. ■ Leave the cord and hold the fundus with the left hand in order to support the fundus of the uterus and to provide counter-traction during removal. ■ If she is unable to urinate.2 mg slowly continuing dose IM: repeat 0. or send: B17 Essential emergency drugs and supplies for transport and home delivery Emergency drugs Oxytocin Ergometrine Magnesium sulphate Diazepam (parenteral) Calcium gluconate Ampicillin Gentamicin Metronidazole Ringer’s lactate Emergency supplies IV catheters and tubing Gloves Sterile syringes and needles Urinary catheter Antiseptic solution Container for sharps Bag for trash Torch and extra battery if delivery is anticipated on the way Soap. ■ Insert an IV line. apply aortic compression and transport woman to hospital. If referral is delayed or not possible. systolic BP increases to 100 mmHg or higher. ■ Proceed gradually all around the placental bed until the whole placenta is detached from the uterine wall. Give fluids at slow rate if severe anaemia/severe pre-eclampsia or eclampsia: ■ Infuse 1 litre in 6-8 hours. ■ Insert an intravenous line (IV line) using a 16-18 gauge needle. repeat 10 mg. ■ Continue pressure until bleeding stops. ■ Ensure the bladder is empty. loading dose rectally ■ Give 20 mg (4 ml) in a 10 ml syringe (or urinary catheter): → Remove the needle. ■ refer urgently to hospital unless delivery is imminent. ■ Give the loading dose of the most effective drug. 2 sets 2 sets 1 set 1 set 1 set 1set Bleeding (2) B11 Refer the woman urgently to hospital B17 Bleeding (3) EmErgEncy trEatmEnts for thE woman rEpair thE tEar and Empty BladdEr Repair the tear or episiotomy ■ Examine the tear and determine the degree: B12 Empty bladder If bladder is distended and the woman is unable to pass urine: ■ Encourage the woman to urinate. Rapid injection can cause respiratory failure or death. Give glucose by slow IV push. and ■ refer the woman urgently to hospital. give 8. Give fluids at moderate rate if severe abdominal pain. ■ Reduce the infusion rate to 0. → referral note n2 . nausea or may vomit. or uterus is not well contracted (is soft): ■ Place cupped palm on uterine fundus and feel for state of contraction. ■ do not give the next dose if any of these signs: →knee jerk absent →urine output <100 ml/4 hrs →respiratory rate <16/min.5°C. ■ After finding correct site. ■ Apply pressure above the umbilicus to stop bleeding. ■ Collect blood in a container placed close to the vulva. ■ During transportation. → Use a needle holder and a 21 gauge. or heavy vaginal bleeding: airway. ■ When well contracted. ■ Give IV 20% magnesium sulphate slowly over 20 minutes. discuss decision with woman and relatives. manage as in Childbirth d1-d2 and accompany the woman during Eclampsia and prE-Eclampsia (1) Important considerations in caring for a woman with eclampsia and pre-eclampsia Give magnesium sulphate EmErgEncy trEatmEnts for thE woman if unable to give iV. and record. ■ Give diazepam (10-mg IM/IV). do not persist in efforts to remove placenta. 4 cm. Eclampsia and pre-eclampsia (1) B13 . If bleeding persists. it may not be possible to put the hand into the uterus. * These dosages are for quinine dihydrochloride. If IV not possible give IM. headache. → Ensure that edges of the tear match up well. ■ Monitor urine output: collect urine and measure the quantity. if convulsions recur ■ After 15 minutes. give the first dose of the drugs before referral. ■ If convulsions recur.6 mg/kg 1 ml once daily for 3 days** B16 Give glucose IV If dangerous fever or very severe febrile disease treated with quinine Quinine* 2 ml vial containing 300 mg/ml 20 mg/kg 4 ml 10 mg/kg 2 ml/8 hours for a total of 7 days** B16 25% glucose solution 10% glucose solution (5 ml/kg) 50-100 ml 125-250 ml malaria Give artemether or quinine IM Give glucose IV 50% glucose solution* 25-50 ml Apply bimanual uterine compression If heavy postpartum bleeding persists despite uterine massage. Airway. or if the placenta is retained due to constriction ring or closed cervix. loading dose iV ■ Give diazepam 10 mg IV slowly over 2 minutes. ■ Refer urgently to hospital B17 . ■ Infuse 1 litre in 30 minutes at 30 ml/minute. ■ If heavy bleeding continues: → give ergometrine 0. if hours or days have passed since delivery. ■ Monitor urine output. im iV 5 g 4 g 2 g 10 ml and 1 ml 2% lignocaine 8 ml 4 ml Not applicable 20 ml 10 ml After receiving magnesium sulphate a woman feel flushing. ■ Massage fundus in a circular motion with cupped palm until uterus is well contracted. B15 infEction Give appropriate IV/IM antibiotics EmErgEncy trEatmEnts for thE woman → Keep her on her back. Then pull the cord gently until it is horizontal. dangerous fever or dehydration: ■ Infuse 1 litre in 2-3 hours. → divide the required dose equally into 2 injections and give 1 in each anterior thigh → always give glucose with quinine. antibiotic ampicillin gentamicin metronidazole preparation Vial containing 500 mg as powder: to be mixed with 2. or hypertension initial dose IM/IV:0.2 mg vial 5 g vials (20 g) 10 mg vial 1 g vial 500 mg vial 80 mg vial 500 mg vial 1 litre bottle Quantity for carry 6 2 4 3 1 4 3 2 4 (if distant referral) 2 sets 2 pairs. ■ Before giving the next dose of magnesium sulphate. refer woman to hospital. give sugar water by mouth or nasogastric tube. ■ Do not give more than 20 mg in total. If the tear is not bleeding. Begin oral D treatment according to national guidelines. B13 → Help her into the left side position and protect her from fall and injury → Place padded tongue blades between her teeth to prevent a tongue bite. → If respiratory depression (breathing less than 16/minute) occurs after magnesium sulphate. give an additional 2 g of magnesium sulphate (10 ml of 20% solution) IV over 20 minutes. ■ Attach Ringer’s lactate or normal saline. breathing and circulation B Infection B15 Bleeding (1) EmErgEncy trEatmEnts for thE woman BlEEding Massage uterus and expel clots If heavy postpartum bleeding persists after placenta is delivered. ■ Make sure IV drip is running well. feel continuously whether uterus is well contracted (hard and round). thirst. hold the umbilical cord with the clamp. do not persist. ■ Explore the inside of the uterine cavity to ensure all placental tissue has been removed. → Ventilate with bag and mask until she starts breathing spontaneously ■ If woman still has great difficulty breathing. do not suture if more than 12 hours since delivery. ■ Assist woman to get onto her back. ■ Reduce the infusion rate to 3 ml/minute (1 litre in 6-8 hours) when pulse slows to less than 100/ minute. ■ Quickly organize transport and possible financial aid. ** iscontinue parenteral treatment as soon as woman is conscious and able to swallow. or if placenta is incomplete and bleeding continues. provide counter-traction to the fundus through the abdomen by pushing it in the opposite direction of the hand that is being withdrawn. ■ Clean vulva and perineal area. give fluids rapidly. ensure: → knee jerk is present → urine output >100 ml/4 hrs → respiratory rate >16/min. ■ Give 4-g of magnesium sulphate (20 ml of 20% solution) IV slowly over 20 minutes (woman may feel warm during injection). diazepam: vial containing 10 mg in 2 ml iV rectally 10 mg = 2 ml 20 mg = 4 ml 10 mg = 2 ml 10 mg = 2 ml initial dose second dose ■ Give the treatment and refer the woman urgently to hospital B17 . → Make sure that the apex of the tear is reached before you begin suturing. ■ Continue compression until bleeding stops (no bleeding if the compression is released). according to the national policy. aseptic technique and sterile equipment. ■ If fever >38. ■ If first or second degree tear and heavy bleeding persists after applying pressure over the wound: → Suture the tear or refer for suturing if no one is available with suturing skills. ■ Place the other hand on the abdomen behind the uterus and squeeze the uterus firmly between the two hands. ■ Clean woman’s skin with spirit at site for IV line. medications given. catheterize the bladder: B12 BlEEding (3) Repair the tear Empty bladder → The tear is small and involved only vaginal mucosa and connective tissues and underlying muscles (first or second degree tear). give fluids slowly B . If not. refer urgently to hospital B17 . arms at the side → Tilt her head backwards (unless trauma is suspected) → Lift her chin to open airway → Inspect her mouth for foreign body. explore again the uterine cavity to remove them. massage and repeat oxytocin 10 IU IM/IV. formulation of magnesium sulphate 50% solution: vial containing 5 g in 10 ml (1g/2ml) 20% solution: to make 10 ml of 20% solution. give appropriate treatment on the way → keep record of all IV fluids. OR ■ If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered After manual removal of the placenta ■ Repeat oxytocin 10-IU IM/IV. ■ If bleeding stops: by controlled cord traction. lubricate the barrel and insert the syringe into the rectum to half its length. foul-smelling lochia or history of rupture of membranes for 18 or more hours. preparation ■ Explain to the woman the need for manual removal of the placenta and obtain her consent. ■ do not give intravenous fluids rapidly. → Wash hands → Clean urethral area with antiseptic → Put on clean gloves → Spread labia. clenched fist. ■ If quinine: Give ergometrine If heavy bleeding in early pregnancy or postpartum bleeding (after oxytocin) but do not give if eclampsia. ■ Wash hands and forearms well and put on long sterile gloves (and an apron or gown if available). Repeat if necessary. at least. ■ During journey: rEfEr thE woman urgEntly to thE hospital Refer the woman urgently to the hospital Essential emergency drugs and supplies for transport and home delivery → watch IV infusion → if journey is long. ■ If diastolic blood pressure remains > 90 mmHg. suspect placenta accreta. refer urgently to hospital B17 . ■ Stop the maintenance dose if breathing <16 breaths/minute. If not bleeding. or by nasogastric (NG) tube. BlEEding (2) EmErgEncy trEatmEnts for thE woman rEfEr thE woman urgEntly to thE hospital Refer the woman urgently to hospital ■ After emergency management. ■ do not give intravenously 50% magnesium sulphate without dilluting it to 20%. transport → Keep her in the left side position → If a convulsion occurs during the journey.5 ml/minute if breathing difficulty or puffiness develops. Give the antidote: calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes. ■ Assist ventilation if necessary with mask and bag. Catheterize if necessary B12 . ■ Insert right hand into the vagina and up into the uterus. refer urgently to hospital B17 . airway. give diazepam B14 . continue treatment as above and refer after delivery. continue treatment: ■ Give 5 g of 50% magnesium sulphate solution IM with 1 ml of 2% lignocaine every 4 hours in alternate buttocks until 24 hours after birth or after last convulsion (whichever is later). Do not delay referral by giving non-urgent treatments. Ensure infusion is running well. towels Disposable delivery kit (blade. with the back of the hand directed posteriorly and the knuckles in the anterior fornix. give magnesium sulphate and protect her from fall and injury. bringing the placenta with it. 3 ties) Clean cloths (3) for receiving. do not give any more magnesium sulphate. ectopic pregnancy. ■ If bleeding persists. ■ Detach the placenta from the implantation site by keeping the fingers tightly together and using the Remove placenta and fragments manually After manual removal of the placenta → a health worker trained in delivery care → a relative who can donate blood → baby with the mother. ■ If signs persist or mother becomes weak or has abdominal pain postpartum. maintenance dose ■ Give additional 10 mg (2 ml) every hour during transport. → Suture the tear using universal precautions.2 mg/kg 2 ml 1. remove if found → Clear secretions from throat. systolic BP<90 mmHg. also give gentamicin 80 mg IM B15 . given before referral. place fingers behind fundus and push down in one swift action to expel clots. if necessary. If bleeding. Dilute it with an equal quantity of sterile water or saline to produce 25% glucose solution.2 mg IM after 15 minutes if heavy bleeding persists maximum dose Not more than 5 doses (total 1. keep applying pressure while transporting woman to hospital. holding the buttocks together for 10 minutes to prevent expulsion of the drug. edge of the hand to gradually make a space between the placenta and the uterine wall. ■ Provide bimanual or aortic compression if severe bleeding before and during transportation B10 . Remove placenta and fragments manually ■ If placenta not delivered 1 hour after delivery of the baby. one pair sterile 5 sets 1 1 small bottle 1 1 1 EmErgEncy trEatmEnts for thE woman ■ With the left hand. Give fluids at rapid rate if shock. ■ Quantity of ORS: 300 to 500 ml in 1 hour. ■ Record time and amount of fluids given.2 mg/kg every 8 hours. pre-eclampsia.2 mg IM → give 20 IU oxytocin in each litre of IV fluids and infuse rapidly → refer urgently to hospital B17 . If convulsions still continue. Measure or estimate blood loss. ■ Introduce the right hand into the vagina. ■ If IV access is not possible (e. give im only (loading dose) ■ Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% solution) IM deep in upper outer quadrant of each buttock with 1 ml of 2% lignocaine in the same syringe. ■ Withdraw the right hand from the uterus gradually. during convulsion). → The tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa (third and fourth degree tear).g. ■ Accompany the woman if at all possible. ■ Give ampicillin 2 g IV/IM B15 . ■ To make sugar water. Apply aortic compression If heavy postpartum bleeding persists despite uterine massage. ■ Monitor every 15 minutes for: → blood pressure (BP) and pulse → shortness of breath or puffiness. ■ If the woman is unconscious: B9 Insert IV line and give fluids ■ Wash hands with soap and water and put on gloves. ■ Record findings and drugs given. Eclampsia and prE-Eclampsia (2) Give diazepam Give appropriate antihypertensive ■ This section has details on emergency treatments identified during Rapid assessment and management (RAM) B3-B6 to be maintenance dose ■ Give diazepam 40 mg in 500 ml IV fluids (normal saline or Ringer’s lactate) titrated over 6-8 hours to keep the woman sedated but rousable. → Discharge the contents and leave the syringe in place. → If delivery imminent. ■ With the left hand. leave the wound open. ■ Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. give diazepam rectally. or the woman is in late labour. Important considerations in caring for a woman with eclampsia or pre-eclampsia ■ Do not leave the woman on her own. Cover it with a clean pad and refer the woman urgently to hospital B17 . do not giVE im First 2 g IV/IM then 1 g every 6 hours 80 mg IM every 8 hours 500 mg or 100 ml IV infusion every 8 hours 500 mg IV/IM every 6 hours Erythromycin Vial containing 500 mg as powder (if allergy to ampicillin) do not give ORS to a woman who is unconscious or has convulsions. time of administration and the woman’s condition. If quinine base. ■ If the woman is not breathing: ■ Infuse 1 litre in 15-20 minutes (as rapid as possible). ■ If delivery imminent or unable to refer immediately. BrEathing and circulation Manage the airway and breathing If the woman has great difficulty breathing and: ■ If you suspect obstruction: → Try to clear the airway and dislodge obstruction → Help the woman to find the best position for breathing → urgently refer the woman to hospital. oxytocin/ergometrine treatment and removal of placenta: ■ Wear sterile or clean gloves. dissolve 4 level teaspoons of sugar (20 g) in a 200 ml cup of clean water. ■ If no IV glucose is available. This solution is irritating to veins. If any placental lobe or tissue fragments are missing. ■ Do not give more than 100 mg in 24 hours. Eclampsia and prE-Eclampsia (1) Give magnesium sulphate If severe pre-eclampsia and eclampsia iV/im combined dose (loading dose) ■ Insert IV line and give fluids slowly (normal saline or Ringer’s lactate) — 1 litre in 6-8 hours (3-ml/minute) B . BrEathing and circulation EmErgEncy trEatmEnts for thE woman infEction Give appropriate IV/IM antibiotics ■ Give the first dose of antibiotic(s) before referral. technique → give fluids slowly for at least 1 hour after removal of placenta. pulse>110/minute. B10 Give oxytocin If heavy postpartum bleeding initial dose IM/IV: 10 IU IV infusion: 20 IU in 1 litre at 60 drops/min continuing dose IM/IV: repeat 10 IU after 20 minutes if heavy bleeding persists IV infusion: 10 IU in 1 litre at 30 drops/min maximum dose Not more than 3 litres of IV fluids containing oxytocin EmErgEncy trEatmEnts for thE woman B10 B11 BlEEding (1) Massage uterus and expel clots Apply bimanual uterine compression Apply aortic compression Give oxytocin Give ergometrine Malaria malaria Give arthemeter or quinine IM If dangerous fever or very severe febrile disease arthemeter leading dose for assumed weight 50-60 kg continue treatment if unable to refer 1ml vial containing 80 mg/ml 3.Emergency treatments for the woman EmErgEncy trEatmEnts for thE woman EmErgEncy trEatmEnts for thE woman Eclampsia and pre-eclampsia (2) EmErgEncy trEatmEnts for thE woman Eclampsia and prE-Eclampsia (2) Give diazepam If convulsions occur in early pregnancy or If magnesium sulphate toxicity occurs or magnesium sulphate is not available.

pulse>110/minute. ■ If the woman is unconscious: Insert IV line and give fluids ■ Wash hands with soap and water and put on gloves. Repeat if necessary. ■ Attach Ringer’s lactate or normal saline.airway. ■ If the woman is not breathing: ■ Infuse 1 litre in 15-20 minutes (as rapid as possible). Airway. obstructed labour. ■ Monitor urine output. ectopic pregnancy. BrEathing and circulation Manage the airway and breathing If the woman has great difficulty breathing and: ■ If you suspect obstruction: → Try to clear the airway and dislodge obstruction → Help the woman to find the best position for breathing → urgently refer the woman to hospital. remove if found → Clear secretions from throat. or by nasogastric (NG) tube. or heavy vaginal bleeding: EmErgEncy trEatmEnts for thE woman → Keep her on her back. ■ Reduce the infusion rate to 0. do not give ORS to a woman who is unconscious or has convulsions. ■ Monitor every 15 minutes for: → Ventilate with bag and mask until she starts breathing spontaneously ■ If woman still has great difficulty breathing. ■ Reduce the infusion rate to 3 ml/minute (1 litre in 6-8 hours) when pulse slows to less than 100/ minute. dangerous fever or dehydration: ■ Infuse 1 litre in 2-3 hours. keep her propped up. ■ Insert an intravenous line (IV line) using a 16-18 gauge needle. If intravenous access not possible ■ Give oral rehydration solution (ORS) by mouth if able to drink. Ensure infusion is running well. Give fluids at slow rate if severe anaemia/severe pre-eclampsia or eclampsia: ■ Infuse 1 litre in 6-8 hours. systolic BP<90 mmHg. ■ Clean woman’s skin with spirit at site for IV line. arms at the side → Tilt her head backwards (unless trauma is suspected) → Lift her chin to open airway → Inspect her mouth for foreign body. systolic BP increases to 100 mmHg or higher. ■ Record time and amount of fluids given.5 ml/minute if breathing difficulty or puffiness develops. Give fluids at moderate rate if severe abdominal pain. breathing and circulation B . ■ Quantity of ORS: 300 to 500 ml in 1 hour. and ■ refer the woman urgently to hospital. → blood pressure (BP) and pulse → shortness of breath or puffiness. Give fluids at rapid rate if shock. ■ Infuse 1 litre in 30 minutes at 30 ml/minute.

or uterus is not well contracted (is soft): ■ Place cupped palm on uterine fundus and feel for state of contraction. Apply sufficient pressure until femoral pulse is not felt. ■ Massage fundus in a circular motion with cupped palm until uterus is well contracted. ■ When well contracted. ■ Continue compression until bleeding stops (no bleeding if the compression is released). keep applying pressure while transporting woman to hospital. place fingers behind fundus and push down in one swift action to expel clots. ■ Apply pressure above the umbilicus to stop bleeding. show assistant or relative how to apply pressure. or hypertension initial dose IM/IV:0. ■ After finding correct site. clenched fist. if necessary. If bleeding persists. with the back of the hand directed posteriorly and the knuckles in the anterior fornix. .2 mg slowly continuing dose IM: repeat 0. Give ergometrine If heavy bleeding in early pregnancy or postpartum bleeding (after oxytocin) but do not give if eclampsia. oxytocin/ergometrine treatment and removal of placenta: ■ Wear sterile or clean gloves. B10 Give oxytocin If heavy postpartum bleeding initial dose IM/IV: 10 IU IV infusion: 20 IU in 1 litre at 60 drops/min continuing dose IM/IV: repeat 10 IU after 20 minutes if heavy bleeding persists IV infusion: 10 IU in 1 litre at 30 drops/min maximum dose Not more than 3 litres of IV fluids containing oxytocin Apply bimanual uterine compression If heavy postpartum bleeding persists despite uterine massage. pre-eclampsia. apply aortic compression and transport woman to hospital. Measure or estimate blood loss. ■ If bleeding persists.Bleeding (1) EmErgEncy trEatmEnts for thE woman BlEEding Massage uterus and expel clots If heavy postpartum bleeding persists after placenta is delivered.0 mg) Apply aortic compression If heavy postpartum bleeding persists despite uterine massage. ■ Place the other hand on the abdomen behind the uterus and squeeze the uterus firmly between the two hands. ■ Introduce the right hand into the vagina. and record. ■ Collect blood in a container placed close to the vulva. ■ Continue pressure until bleeding stops. oxytocin/ergometrine treatment and removal of placenta: ■ Feel for femoral pulse.2 mg IM after 15 minutes if heavy bleeding persists maximum dose Not more than 5 doses (total 1.

■ Explore the inside of the uterine cavity to ensure all placental tissue has been removed. feel continuously whether uterus is well contracted (hard and round). This prevents inversion of the uterus. ■ Ensure the bladder is empty. provide counter-traction to the fundus through the abdomen by pushing it in the opposite direction of the hand that is being withdrawn. give fluids rapidly. ■ Give diazepam (10-mg IM/IV). If any placental lobe or tissue fragments are missing.Remove placenta and fragments manually ■ If placenta not delivered 1 hour after delivery of the baby. Catheterize if necessary B12 . refer urgently to hospital B17 . ■ Proceed gradually all around the placental bed until the whole placenta is detached from the uterine wall. Bleeding (2) B11 . ■ During transportation.5°C. ■ Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall. OR ■ If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered After manual removal of the placenta ■ Repeat oxytocin 10-IU IM/IV. foul-smelling lochia or history of rupture of membranes for 18 or more hours. if hours or days have passed since delivery. ■ With the left hand. ■ Withdraw the right hand from the uterus gradually. or if placenta is incomplete and bleeding continues. also give gentamicin 80 mg IM B15 . ■ Insert right hand into the vagina and up into the uterus. ■ Give ampicillin 2 g IV/IM B15 . do not persist. ■ Wash hands and forearms well and put on long sterile gloves (and an apron or gown if available). If not. Then pull the cord gently until it is horizontal. ■ Assist woman to get onto her back. preparation ■ Explain to the woman the need for manual removal of the placenta and obtain her consent. refer urgently to hospital B17 . ■ If heavy bleeding continues: EmErgEncy trEatmEnts for thE woman technique ■ With the left hand. massage and repeat oxytocin 10 IU IM/IV. it may not be possible to put the hand into the uterus. or if the placenta is retained due to constriction ring or closed cervix. If bleeding. ■ Move the fingers of the right hand sideways until edge of the placenta is located.2 mg IM → give 20 IU oxytocin in each litre of IV fluids and infuse rapidly → refer urgently to hospital B17 . → give ergometrine 0. suspect placenta accreta. ■ If bleeding stops: by controlled cord traction. hold the umbilical cord with the clamp. if the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage. ■ Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. ■ Provide bimanual or aortic compression if severe bleeding before and during transportation B10 . ■ Massage the fundus of the uterus to encourage a tonic uterine contraction. ■ Leave the cord and hold the fundus with the left hand in order to support the fundus of the uterus and to provide counter-traction during removal. explore again the uterine cavity to remove them. If not bleeding. ■ Insert an IV line. give fluids slowly B . → give fluids slowly for at least 1 hour after removal of placenta. do not persist in efforts to remove placenta. bringing the placenta with it. ■ Clean vulva and perineal area. ■ If fever >38.

→ The tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa (third and fourth degree tear). . → Use absorbable polyglycon suture material.Bleeding (3) EmErgEncy trEatmEnts for thE woman rEpair thE tEar and Empty BladdEr Repair the tear or episiotomy ■ Examine the tear and determine the degree: B12 Empty bladder If bladder is distended and the woman is unable to pass urine: ■ Encourage the woman to urinate. → Make sure that the apex of the tear is reached before you begin suturing. Cover it with a clean pad and refer the woman urgently to hospital B17 . Clean area again → Insert catheter up to 4 cm → Measure urine and record amount → Remove catheter. → Use a needle holder and a 21 gauge. ■ If first or second degree tear and heavy bleeding persists after applying pressure over the wound: → Suture the tear or refer for suturing if no one is available with suturing skills. ■ If she is unable to urinate. aseptic technique and sterile equipment. catheterize the bladder: → Wash hands → Clean urethral area with antiseptic → Put on clean gloves → Spread labia. → The tear is small and involved only vaginal mucosa and connective tissues and underlying muscles (first or second degree tear). refer woman to hospital. If the tear is not bleeding. → Ensure that edges of the tear match up well. → Suture the tear using universal precautions. do not suture if more than 12 hours since delivery. 4 cm. curved needle. leave the wound open.

if convulsions recur ■ After 15 minutes. ■ do not give intravenous fluids rapidly. Rapid injection can cause respiratory failure or death. → If respiratory depression (breathing less than 16/minute) occurs after magnesium sulphate. → If delivery imminent. and secure it to prevent aspiration (do not attempt this during a convulsion). formulation of magnesium sulphate 50% solution: vial containing 5 g in 10 ml (1g/2ml) 20% solution: to make 10 ml of 20% solution. give magnesium sulphate and protect her from fall and injury. ■ do not give the next dose if any of these signs: →knee jerk absent →urine output <100 ml/4 hrs →respiratory rate <16/min. ■ refer urgently to hospital unless delivery is imminent. ■ Monitor urine output: collect urine and measure the quantity. Important considerations in caring for a woman with eclampsia or pre-eclampsia ■ Do not leave the woman on her own. or the woman is in late labour. ■ do not give intravenously 50% magnesium sulphate without dilluting it to 20%. Eclampsia and pre-eclampsia (1) B13 . → Help her into the left side position and protect her from fall and injury → Place padded tongue blades between her teeth to prevent a tongue bite. manage as in Childbirth d1-d2 and accompany the woman during transport → Keep her in the left side position → If a convulsion occurs during the journey. if referral delayed for long. EmErgEncy trEatmEnts for thE woman if unable to give iV. ■ Record findings and drugs given. ensure: → knee jerk is present → urine output >100 ml/4 hrs → respiratory rate >16/min. thirst. ■ Give IV 20% magnesium sulphate slowly over 20 minutes. ■ Give 4-g of magnesium sulphate (20 ml of 20% solution) IV slowly over 20 minutes (woman may feel warm during injection). and: ■ Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% solution) IM deep in upper outer quadrant of each buttock with 1 ml of 2% lignocaine in the same syringe. add 4 ml of 50% solution to 6 ml sterile water im iV 5 g 4 g 2 g 10 ml and 1 ml 2% lignocaine 8 ml 4 ml Not applicable 20 ml 10 ml After receiving magnesium sulphate a woman feel flushing. do not give any more magnesium sulphate. Give the antidote: calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes. If convulsions still continue.Eclampsia and prE-Eclampsia (1) Give magnesium sulphate If severe pre-eclampsia and eclampsia iV/im combined dose (loading dose) ■ Insert IV line and give fluids slowly (normal saline or Ringer’s lactate) — 1 litre in 6-8 hours (3-ml/minute) B . give diazepam B14 . continue treatment: ■ Give 5 g of 50% magnesium sulphate solution IM with 1 ml of 2% lignocaine every 4 hours in alternate buttocks until 24 hours after birth or after last convulsion (whichever is later). headache. nausea or may vomit. give an additional 2 g of magnesium sulphate (10 ml of 20% solution) IV over 20 minutes. ■ Before giving the next dose of magnesium sulphate. give im only (loading dose) ■ Give 10 g of magnesium sulphate IM: give 5 g (10 ml of 50% solution) IM deep in upper outer quadrant of each buttock with 1 ml of 2% lignocaine in the same syringe.

→ Discharge the contents and leave the syringe in place. to keep the woman sedated but rousable. ■ Assist ventilation if necessary with mask and bag.Eclampsia and pre-eclampsia (2) EmErgEncy trEatmEnts for thE woman Eclampsia and prE-Eclampsia (2) Give diazepam If convulsions occur in early pregnancy or If magnesium sulphate toxicity occurs or magnesium sulphate is not available. maintenance dose ■ Give diazepam 40 mg in 500 ml IV fluids (normal saline or Ringer’s lactate) titrated over 6-8 hours B14 Give appropriate antihypertensive drug If diastolic blood pressure is > 110-mmHg: ■ Give hydralazine 5 mg IV slowly (3-4 minutes). lubricate the barrel and insert the syringe into the rectum to half its length. ■ If IV access is not possible (e. during convulsion). ■ If diastolic blood pressure remains > 90 mmHg.g. ■ If convulsions recur. maintenance dose ■ Give additional 10 mg (2 ml) every hour during transport. ■ Do not give more than 20 mg in total. initial dose second dose diazepam: vial containing 10 mg in 2 ml iV rectally 10 mg = 2 ml 20 mg = 4 ml 10 mg = 2 ml 10 mg = 2 ml . holding the buttocks together for 10 minutes to prevent expulsion of the drug. repeat 10 mg. ■ If convulsions recur. repeat 10 mg. give diazepam rectally. ■ Stop the maintenance dose if breathing <16 breaths/minute. loading dose iV ■ Give diazepam 10 mg IV slowly over 2 minutes. loading dose rectally ■ Give 20 mg (4 ml) in a 10 ml syringe (or urinary catheter): → Remove the needle. repeat the dose at 30 minute intervals until diastolic BP is around 90 mmHg. ■ Do not give more than 100 mg in 24 hours. If IV not possible give IM.

Then give amoxicillin orally 500 mg 3 times daily until 7 days of treatment completed. If referral is delayed or not possible. condition ■ Severe abdominal pain ■ Dangerous fever/very severe febrile disease ■ Complicated abortion ■ Uterine and fetal infection ■ Postpartum bleeding EmErgEncy trEatmEnts for thE woman → lasting > 24 hours → occurring > 24 hours after delivery ■ Upper urinary tract infection ■ Pneumonia ■ Manual removal of placenta/fragments ■ Risk of uterine and fetal infection ■ In labour > 24 hours antibiotic ampicillin gentamicin metronidazole antiBiotics 3 antibiotics ■ Ampicillin ■ Gentamicin ■ Metronidazole 2 antibiotics: ■ Ampicillin ■ Gentamicin 1 antibiotic: ■ Ampicillin dosage/route First 2 g IV/IM then 1 g 80 mg IM 500 mg or 100 ml IV infusion 500 mg IV/IM preparation Vial containing 500 mg as powder: to be mixed with 2. continue antibiotics IM/IV for 48 hours after woman is fever free. refer urgently to hospital B17 .5 ml sterile water Vial containing 40 mg/ml in 2 ml Vial containing 500 mg in 100 ml frequency every 6 hours every 8 hours every 8 hours every 6 hours do not giVE im Erythromycin Vial containing 500 mg as powder (if allergy to ampicillin) Infection B15 . ■ If signs persist or mother becomes weak or has abdominal pain postpartum.infEction Give appropriate IV/IM antibiotics ■ Give the first dose of antibiotic(s) before referral.

** iscontinue parenteral treatment as soon as woman is conscious and able to swallow.Malaria EmErgEncy trEatmEnts for thE woman malaria Give arthemeter or quinine IM If dangerous fever or very severe febrile disease arthemeter leading dose for assumed weight 50-60 kg continue treatment if unable to refer 1ml vial containing 80 mg/ml 3. Give glucose by slow IV push. . ■ Give the loading dose of the most effective drug. Begin oral D treatment according to national guidelines.2 mg/kg every 8 hours. give 8. Dilute it with an equal quantity of sterile water or saline to produce 25% glucose solution. If quinine base.2 mg/kg 2 ml 1. This solution is irritating to veins. ■ To make sugar water. → divide the required dose equally into 2 injections and give 1 in each anterior thigh → always give glucose with quinine. * These dosages are for quinine dihydrochloride. according to the national policy.6 mg/kg 1 ml once daily for 3 days** B16 Give glucose IV If dangerous fever or very severe febrile disease treated with quinine Quinine* 2 ml vial containing 300 mg/ml 20 mg/kg 4 ml 10 mg/kg 2 ml/8 hours for a total of 7 days** 50% glucose solution* 25-50 ml 25% glucose solution 10% glucose solution (5 ml/kg) 50-100 ml 125-250 ml ■ Make sure IV drip is running well. give sugar water by mouth or nasogastric tube. ■ If quinine: * 50% glucose solution is the same as 50% dextrose solution or D50. continue treatment as above and refer after delivery. ■ If no IV glucose is available. ■ Refer urgently to hospital B17 . ■ If delivery imminent or unable to refer immediately. dissolve 4 level teaspoons of sugar (20 g) in a 200 ml cup of clean water.

■ Inform the referral centre if possible by radio or phone. 3 ties) Clean cloths (3) for receiving. time of administration and the woman’s condition. give appropriate treatment on the way → keep record of all IV fluids. towels Disposable delivery kit (blade. ■ Quickly organize transport and possible financial aid. drying and wrapping the baby Clean clothes for the baby Plastic bag for placenta Resuscitation bag and mask for the baby strength and form 10 IU vial 0. ■ During journey: → watch IV infusion → if journey is long. discuss decision with woman and relatives. medications given. one pair sterile 5 sets 1 1 small bottle 1 1 1 EmErgEncy trEatmEnts for thE woman → a health worker trained in delivery care → a relative who can donate blood → baby with the mother.2 mg vial 5 g vials (20 g) 10 mg vial 1 g vial 500 mg vial 80 mg vial 500 mg vial 1 litre bottle Quantity for carry 6 2 4 3 1 4 3 2 4 (if distant referral) 2 sets 2 pairs. ■ Accompany the woman if at all possible.rEfEr thE woman urgEntly to thE hospital Refer the woman urgently to hospital ■ After emergency management. or send: Essential emergency drugs and supplies for transport and home delivery Emergency drugs Oxytocin Ergometrine Magnesium sulphate Diazepam (parenteral) Calcium gluconate Ampicillin Gentamicin Metronidazole Ringer’s lactate Emergency supplies IV catheters and tubing Gloves Sterile syringes and needles Urinary catheter Antiseptic solution Container for sharps Bag for trash Torch and extra battery if delivery is anticipated on the way Soap. at least. if possible → essential emergency drugs and supplies B17 . → referral note n2 . 2 sets 2 sets 1 set 1 set 1 set 1set Refer the woman urgently to hospital B17 .

→ Speak to them about how they can best support her. . give first dose of appropriate IV/IM antibiotics B15 . ■ Advise woman to return in if delay (6 weeks or more) in resuming menstrual periods. ■ Treat the woman for syphilis with benzathine penicillin f6 ■ Advise on treating her partner. helping out with children. counsel on correct and consistent use of condoms g4 . CHECK RECORDS ■ Check tetanus toxoid (TT) immunization status. weakness → dizziness or fainting. ■ Give paracetamol for pain f4 . ■ If the woman is interested. and may benefit from support: ■ Allow the woman to talk about her worries. ■ If the woman discloses violence or you see unexplained bruises and other injuries which make you suspect she may be suffering abuse. ■ Check RPR status in records c5 . ■ If the woman is HIV positive. → If fever. family planning. see h4 . sexual intercourse — if she does not use a contraceptive: → Any family planning method can be used immediately after an uncomplicated first trimester abortion. → Refer woman to hospital. ■ Two or more of the following signs: ectopic pregnancy → abdominal pain → fainting → pale → very weak ■ Insert an IV line and give fluids B9 ■ refer urgently to hospital B17 . especially if feeling tired. ■ Check woman’s supply of the prescribed dose of iron/folate. see Methods for non-breastfeeding women on d27 . or counsel her Advise and counsel during follow-up visits If threatened abortion and bleeding stops: ■ Reassure the woman that it is safe to continue pregnancy. LISTEN. . ■ Feel for fever. → give support g4 . ■ Advise woman to return immediately if she has any of the following danger signs: any questions or concerns. if she is interested (depending on the circumstances. health and personal situation. do the RPR test l5 visit. ■ Advise on safer sex including use of condom if she or her partner are at risk of sexually transmitted infection (STI) or HIV g2 . or simply being available to listen. adolescent or has special needs. → If decrease. ■ Check HIV status c6 B20 TREAT AND ADVISE ■ Give tetanus toxoid if due f2 give preventive measures ■ Use Advise and Counsel on post-abortion care B21 to advise on self care. → Foul-smelling vaginal discharge → Abortion with uterine manipulation → Abdominal pain/tenderness → Temperature >38°C. ■ Look for pallor. or → no bleeding at present. danger signs. For information on options. ■ Advise and counsel on family planning B21 . → Inform them that post-abortion complications can have grave consequences for the woman’s health. directly. . or abdominal pain. ■ Advise on self-care B21 . → Advise the woman to return immediately if bleeding increases. Advise and counsel on family planning ■ Explain to the woman that she can become pregnant soon after the abortion - as soon as she has may not wish to involve others). ■ Facilitate family and community support. . FEEL ■ Look at amount of bleeding. use g1-g11 h1-h4 → change pads every 4 to 6 hours → wash the perineum daily → avoid sexual relations until bleeding stops. follow-up . . B20 Give preventive measures Bleeding in early pregnancy and post-aBortion care give preventive measures ASSESS. ■ Light vaginal bleeding threatened aBortion ■ Observe bleeding for 4-6 hours: → If no decrease. → If the woman has an infection or injury: delay IUD insertion or female sterilization until healed. ■ If no RPR results. Provide information and support after abortion A woman may experience different emotions after an abortion. ■ Provide antenatal care c1-c18 . she → increased bleeding → continued bleeding for 2 days → foul-smelling vaginal discharge → abdominal pain → fever. counsel on HIV testing g3 ■ If known HIV-positive: . link her to a peer support group or other women’s groups or community services which can provide her with additional support. → refer to HIV services for further assessment and treatment. ■ Follow up in 2 days B21 . measure decreasing? ■ Could you be pregnant? ■ When was your last period? ■ Have you had a recent abortion? ■ Did you or anyone else do anything to induce an abortion? ■ Have you fainted recently? ■ Do you have abdominal pain? ■ Do you have any other concerns to discuss? temperature. ■ If HIV-negative. positive findings. ■ refer urgently to hospital B17 . ■ Give 3 month’s supply of iron and counsel on compliance f3 ■ If HIV status is unknown. ■ Advise to return if bleeding does not stop within ■ History of heavy bleeding but: complete aBortion → now decreasing. ■ Encourage HIV testing and counselling g3 ■ Reinforce use of condoms g2 . and post-aBortion care use this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods B18 Bleeding in early pregnancy and post-aBortion care ASK. If bleeding continues: ■ Assess and manage as in Bleeding in early pregnancy/post-abortion care B18-B22 . foul-smelling vaginal discharge.Bleeding in early pregnancy and post-abortion care Bleeding in early pregnancy and post-aBortion care Bleeding in early pregnancy and post-aBortion care examination of the woman with Bleeding in early pregnancy. refer to hospital. ■ Note if there is foul-smelling vaginal SIGNS ■ Vaginal bleeding and any of: CLASSIFY complicated aBortion TREAT AND ADVISE ■ Insert an IV line and give fluids B9 . → Inform them about the importance of family planning if another pregnancy is not desired. Inform them of the danger signs and the importance of the woman returning to the health worker if she experiences any. Advise and counsel on post-abortion care B21 . discharge. and the scheduled next visit in the home-based and B21 If Rapid plasma reagin (RPR) positive: . CHECK RECORD ■ When did bleeding start? ■ How much blood have you lost? ■ Are you still bleeding? ■ Is the bleeding increasing or LOOK. ■ Check preventive measures B20 . let the woman go home. ■ Record all treatment given. by sharing or reducing her workload. → advise on opportunistic infection and need to seek medical help c10 . feeling ill. feelings. Ask if she has Bleeding in early pregnancy and post-aBortion care ■ Advise on hygiene advise and counsel on post-aBortion care Advise on self-care Advise and counsel on family planning Provide information and support after abortion Advise and counsel during follow-up visits clinic recording forms. B19 examination of the woman ■ Always begin with Rapid assessment and management (RAM) B3-B7 . → counsel on safer sex including use of condoms g2 . with Bleeding in early pregnancy and post-aBortion care ■ Next use the Bleeding in early pregnancy/post abortion care B19 to assess the woman with light vaginal bleeding or a history of missed periods. � next: Give preventive measures Bleeding in early pregnancy and post-abortion care B19 ■ Use chart on Preventive measures B20 to provide preventive measures due to all women. 2 days. advise and counsel on post-aBortion care Advise on self-care ■ Rest for a few days. (see The decision-making tool for family planning clients and providers for information on methods and on the counselling process). ■ Make arrangements for her to see a family planning counsellor as soon as possible. ■ Advise on safer sex including use of condoms if she or her partner are at risk for STI or HIV g2 . . If hot. ■ Give appropriate IM/IV antibiotics B15 . . ■ Feel for lower abdominal pain.

■ Give appropriate IM/IV antibiotics B15 . ■ Light vaginal bleeding threatened aBortion ■ Observe bleeding for 4-6 hours: to induce an abortion? ■ Have you fainted recently? ■ Do you have abdominal pain? ■ Do you have any other concerns to discuss? ■ History of heavy bleeding but: → If no decrease. ■ Check preventive measures B20 . ■ Two or more of the following signs: ectopic pregnancy → abdominal pain → fainting → pale → very weak ■ Insert an IV line and give fluids B9 ■ refer urgently to hospital B17 . t next: Give preventive measures Bleeding in early pregnancy and post-abortion care B19 . → Foul-smelling vaginal discharge → Abortion with uterine manipulation → Abdominal pain/tenderness → Temperature >38°C. ■ Advise and counsel on family planning B21 . → Advise the woman to return immediately if bleeding increases. ■ refer urgently to hospital B17 . FEEL ■ Look at amount of bleeding. LISTEN. ■ Advise to return if bleeding does not stop within complete aBortion → now decreasing. ■ Advise on self-care B21 . CHECK RECORD ■ When did bleeding start? ■ How much blood have you lost? ■ Are you still bleeding? ■ Is the bleeding increasing or LOOK. → If decrease. and post-aBortion care use this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods Bleeding in early pregnancy and post-aBortion care ASK. refer to hospital. If hot. ■ Look for pallor.examination of the woman with Bleeding in early pregnancy. ■ Note if there is foul-smelling vaginal SIGNS ■ Vaginal bleeding and any of: CLASSIFY complicated aBortion TREAT AND ADVISE ■ Insert an IV line and give fluids B9 . discharge. ■ Feel for lower abdominal pain. ■ Give paracetamol for pain f4 . let the woman go home. ■ Feel for fever. or → no bleeding at present. measure decreasing? ■ Could you be pregnant? ■ When was your last period? ■ Have you had a recent abortion? ■ Did you or anyone else do anything temperature. 2 days. . ■ Follow up in 2 days B21 .

■ Check RPR status in records c5 . ■ Encourage HIV testing and counselling g3 . ■ Reinforce use of condoms g2 . ■ Treat the woman for syphilis with benzathine penicillin f6 ■ Advise on treating her partner. → counsel on safer sex including use of condoms g2 . . ■ If no RPR results. . → advise on opportunistic infection and need to seek medical help c10 .Give preventive measures Bleeding in early pregnancy and post-aBortion care give preventive measures ASSESS. → refer to HIV services for further assessment and treatment. ■ If HIV-negative. do the RPR test l5 If Rapid plasma reagin (RPR) positive: . CHECK RECORDS ■ Check tetanus toxoid (TT) immunization status. ■ Check HIV status c6 B20 TREAT AND ADVISE ■ Give tetanus toxoid if due f2 . . ■ Check woman’s supply of the prescribed dose of iron/folate. . ■ Give 3 month’s supply of iron and counsel on compliance f3 ■ If HIV status is unknown. counsel on safer sex including use of condoms g4 . counsel on HIV testing g3 ■ If HIV-positive: . → give support g4 .

see Methods for non-breastfeeding women on d27 . by sharing or reducing her workload. see h4 . ■ Counsel on safer sex including use of condoms if she or her partner are at risk for STI or HIV g2 . and may benefit from support: ■ Allow the woman to talk about her worries. ■ Facilitate family and community support. ■ Make arrangements for her to see a family planning counsellor as soon as possible. Ask if she has any questions or concerns. she may not wish to involve others). → If fever. → Speak to them about how they can best support her. helping out with children. ■ Advise on hygiene Provide information and support after abortion A woman may experience different emotions after an abortion. link her to a peer support group or other women’s groups or community services which can provide her with additional support. health and personal situation. feelings. weakness → dizziness or fainting. → If the woman has an infection or injury: delay IUD insertion or female sterilization until healed. → change pads every 4 to 6 hours → wash the perineum daily → avoid sexual relations until bleeding stops. Advise and counsel on post-abortion care B21 . (see The decision-making tool for family planning clients and providers for information on methods and on the counselling process). → Inform them that post-abortion complications can have grave consequences for the woman’s health. Advise and counsel during follow-up visits If threatened abortion and bleeding stops: ■ Reassure the woman that it is safe to continue pregnancy. Advise and counsel on family planning ■ Explain to the woman that she can become pregnant soon after the abortion - as soon as she has sexual intercourse — if she does not use a contraceptive: → Any family planning method can be used immediately after an uncomplicated first trimester abortion. foul-smelling vaginal discharge. → Inform them about the importance of family planning if another pregnancy is not desired. or counsel her directly. especially if feeling tired. ■ If the woman is interested. ■ Advise woman to return immediately if she has any of the following danger signs: → increased bleeding → continued bleeding for 2 days → foul-smelling vaginal discharge → abdominal pain → fever. Inform them of the danger signs and the importance of the woman returning to the health worker if she experiences any.advise and counsel on post-aBortion care Advise on self-care Bleeding in early pregnancy and post-aBortion care ■ Rest for a few days. If bleeding continues: ■ Assess and manage as in Bleeding in early pregnancy/post-abortion care B18-B22 . or abdominal pain. For information on options. ■ If the woman discloses violence or you see unexplained bruises and other injuries which make you suspect she may be suffering abuse. if she is interested (depending on the circumstances. ■ Provide antenatal care c1-c18 . or simply being available to listen. → Refer woman to hospital. ■ Counsel on safer sex including use of condom if she or her partner are at risk of sexually transmitted infection (STI) or HIV g2 . give first dose of appropriate IV/IM antibiotics B15 . feeling ill. ■ Advise woman to return in if delay (6 weeks or more) in resuming menstrual periods.

use this section for further care. danger signs c15 . see G1-G11 H1-H4 . treatments given and the next scheduled visit in the home- based maternal card/clinic recording form. ■ Check all women for pre-eclampsia. labour signs. history of previous pregancies. ■ Advise and counsel on nutrition c13 . adolescent or has special needs. anaemia. use the charts respond to observed signs or volunteered problems c7-c11 to classify the condition and identify appropriate treatment(s). ■ Next use the Pregnancy status and birth plan chart C2 to ask the woman about her present pregnancy status. ■ Assess eligibility of ARV for HIV-positive woman c19 . ■ Record all positive findings. family planning c16 . . If the woman has no emergency or priority signs and has come for antenatal care. routine and follow-up visits c17 using Information and counselling sheets M1-M19 . Decide on an appropriate place of birth for the woman using this chart and prepare the birth and emergency plan. birth plan. ■ Develop a birth and emergency plan c14-c15 . The birth plan should be reviewed during every follow-up visit. ■ If the woman is HIV positive. ■ Give preventive measures due c12 .Antenatal care AntenAtAl cAre AntenAtAl cAre ■ Always begin with rapid assessment and management (rAM) B3-B7 . syphilis and HIV status according to the charts c3-c6 ■ In cases where an abnormal sign is identified (volunteered or observed). and check her for general danger signs. .

■ Advise to screen immediate family members and close contacts for tuberculosis. not to push on the abdomen during labour or delivery. ■ Reinforce advice on HIV testing and counselling G2-G3 . . encourage helpful traditional practices: ■ Check woman’s supply of the prescribed dose of iron/folate ■ Check when last dose of mebendazole given. ■ Difficulty in breathing. ■ Look for palmar pallor. >1 month? Assess if in high risk group: ■ occupational exposure? ■ Multiple sexual partner? ■ Intravenous drug abuse? ■ History of blood transfusion? ■ Illness or death from AIDS in a → Is there a rash? → Are there blisters along the ribs on one side of the body? → weight loss → fever >1 month → diarrhoea >1month. . ■ refer urgently to hospital B17 . BIrtH And eMerGency PlAn c2 AntenAtAl cAre AntenAtAl cAre use this chart to assess the pregnant woman at each of the four antenatal care visits. ■ Feel for obvious multiple � next: If vaginal discharge refer to hospital. Ask the woman: ■ Have you been tested for HIV? ■ erform the Rapid HIV test if not P performed in this pregnancy l6 . vaginal discharge? ■ Do you have itching at the vulva? ■ Has your partner had a urinary position. wItHout waiting Mother ■ Waters break and not in labour after 6 hours. ■ If no discharge is seen. ■ Advise on when to seek care: c17 → routine visits → follow-up visits → danger signs. ask the woman if she has: → severe headache → severe headache → blurred vision → blurred vision → epigastric pain. ■ If smoking. If yes. ■ To NoT leave the mother alone for the first 24 hours. ■ History of or current vaginal bleeding or other complication during this pregnancy. during first antenatal visit. or ■ Diastolic blood pressure mmHg. and compliance with treatment. ■ Heavy bleeding after delivery (pad/cloth soaked in less than 5 minutes). ■ To keep the mother and baby warm. if available. AntenAtAl cAre first visit ■ Develop a birth and emergency plan c14 . LISTeN. If allergy. ■ Food and water for woman and support person. safe and culturally appropriate manner (burn or burry). HIv-neGAtIve counsel on implications of a negative test G3 . of dead baby. if needed I1–I3 . not to insert any substances into the vagina during labour or after delivery. ■ severe abdominal pain. LISTeN. unless she refuses. there is no record ask about: → Number of prior pregnancies/deliveries → Prior caesarean section. TReAT AND ADVISe ■ Inform the woman and partner about the possibility to move around for some time. for use as sanitary pads. she can become pregnant Special considerations for family planning counselling during pregnancy counselling should be given during the third trimester of pregnancy. ■ Counsel on compliance with treatment f3 . seeds. ■ Counsel on safer sex including use of condoms G2 . ■ Counsel on stopping smoking and alcohol and drug abuse. >1 month? ■ Have you had cough? How long. If she (and her partner) want more children. c4 AntenAtAl cAre AntenAtAl cAre C4 cHeck for AnAeMIA Respond to observed signs or volunteered problems (4) ASk. ■ Blankets. or HIstory of vIolence ■ Counsel on stopping smoking ■ For alcohol/drug abuse. not to wait for waters to stop before going to health facility. uterIne And fetAl InfectIon rIsk of uterIne And fetAl InfectIon ruPture of MeMBrAnes ■ Give appropriate IM/IV antibiotics B15 . ■ fast or difficult breathing. have you and your partner been treated for syphilis? → If not. ■ Ask her to return in 2 weeks with her documents. ■ Give appropriate anti-hypertensives B14 . . L ■ eel the head. . ■ Check when last dose of an antimalarial given. examine with a gloved finger and look at the discharge on the glove. health. ■ encourage her to drink more fluids. to encourage them to help ensure the woman eats enough and avoids hard physical work. ■ Develop the birth and emergency plan c14 . ✎____________________________________________________________________ ✎____________________________________________________________________ Advise on danger signs If the mother or baby has any of these signs. refer to hospital. ■ Tubal ligation or IUD desired immediately after delivery. ■ Placenta not expelled 1 hour after birth of the baby. ■ If no improvement in 2 days or condition is worse. C5 TeST ReSULT ■ RPR test positive. no syPHIlIs ■ Counsel on safer sex including use of condoms to prevent infection G2 . . she should go at the first signs of labour. ■ Measure temperature. ■ Counsel on safer sex including use of condoms. LISTeN. pregnancy. equipment. or ■ one of the above signs and stronG lIkelIHood of HIv InfectIon ■ Reinforce the need to know HIV status and advise on HIV testing and counselling G2-G3 . ■ refer urgently to hospital B17 . ■ obvious multiple pregnancy. ■ explain that after birth. well BABy ■ Inform the woman that baby is fine and likely to be resPond to oBserved sIGns or volunteered ProBleMs (1) If no fetal movement If ruptured membrane and no labour AntenAtAl cAre AdvIse And counsel on nutrItIon And self-cAre use the information and counselling sheet to support your interaction with the woman. ■ If no heart beat. (explain to I her that she has a right not to disclose the result. Advise the woman against these taboos. c6 AntenAtAl cAre AntenAtAl cAre C6 cHeck for HIv stAtus Give preventive Antenatal care measures GIve PreventIve MeAsures Advise and counsel all pregnant women at every antenatal care visit. ■ No pallor. HIv-PosItIve wItHout HIv-relAted sIGns And syMPtoMs ■ Give appropriate ARVs G9 . ■ Give them a disposable delivery kit and explain how to use it. ask “Are you allergic to penicillin?” At least 1 of the following signs: ■ Cough or breathing difficulty PossIBle cHronIc lunG dIseAse ■ Refer to hospital for assessment. ■ If hypertension persists after 1 week or at next visit. FeeL ■ Do you tire easily? ■ Are you breathless (short of breath) SIGNS ■ Haemoglobin <7-g/dl. maternity waiting home or with family or friends near the facility. refer to hospital. . legs. and urge her to continue treatment for a successful outcome of pregnancy. Routine antenatal care visits 1st visit 2nd visit 3rd visit 4th visit Before 4 months 6 months 8 months 9 months 12-16 weeks 24-28 weeks 30-32 weeks 36-38 weeks C17 ■ All pregnant women should have 4 routine antenatal visits. ■ Age less than 16 years. Promote especially if at risk for STI or HIV G4 . if at risk for STI or HIV G2 ■ Avoid alcohol and smoking during pregnancy. ■ Prior delivery with heavy bleeding. ■ Counsel on nutrition c13 . alcohol or drug abuse. does she want tubal ligation or IUD A15 . ■ Buckets of clean water and some way to heat this water. or delay for 6 weeks). ■ Give 3 month’s supply of iron and counsel on compliance and safety f3 ■ Give mebendazole once in second or third trimester f3 Instruct mother and family on clean and safer delivery at home If the woman has chosen to deliver at home without a skilled attendant. resPond to oBserved sIGns or volunteered ProBleMs (4) If signs suggesting HIV infection If smoking. Modify the birth plan if any complications arise. → epigastric pain and → check protein in urine. ■ Check duration of pregnancy. place the baby on the mother’s chest with skin-to-skin contact and wipe the baby’s eyes using a clean cloth for each eye. ■ If women are HIV-positive ensure a visit between 26-28 weeks. CHeCk ReCoRD Look. ■ To start breastfeeding when the baby shows signs of readiness. SIGNS ■ No fetal movement. or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). ■ Counsel on benefits of disclosure (involving) and testing her partner G3 . milk. ■ If the woman chooses female sterilization: results. tell her/them: ■ To ensure a clean delivery surface for the birth. ■ Give appropriate IM/IV antibiotic B15 . ■ More than six previous births. c14 C14 Facility delivery explain why birth in a facility is recommended ■ Any complication can develop during delivery - they are not always predictable. ■ If TT1. SIGNS ■ Positive HIV-positive. ■ Counsel on the benefits of testing the partner G3 . CHeCk ReCoRD Look. ■ Haemoglobin >11-g/dl. ≥110 mmHg and 3+ proteinuria. check status at every visit. CHeCk ReCoRD Look. resPond to oBserved sIGns or volunteered ProBleMs (5) AntenAtAl cAre AdvIse on routIne And follow-uP vIsIts encourage the woman to bring her partner or family member to at least 1 visit. LISTeN. inform the woman to return if she does not deliver within 2 weeks after the expected date of delivery. She should also keep her nails clean. ■ Clothes for mother and baby. ■ Measure temperature. → ensure counselling and informed consent prior to labour and delivery. refer to hospital or discuss case with the doctor or midwife. ■ Advise on danger signs c15 . AccordInG to woMAn’s Preference ■ explain why delivery needs to be with a skilled birth attendant. If HIv services available: ■ Refer the woman to HIV services for further assessment. ■ Develop the birth and emergency plan c14 . day. If sexual partner? ■ History of forced sex? as soon as four weeks after delivery. ■ Counsel on safer sex including use of condoms G2 ■ Counsel on benefits of involving and testing the partner G3 . ■ Advise her to bring her home-based maternal record to the health centre. ■ Look for ulcers and white patches in ■ Two of these signs: c10 TReAT AND ADVISe SIGNS CLASSIFY C10 ASk.T3). ■ Follow up in 2 weeks to check clinical progress. third trimester ■ Counsel on family planning c16 . ■ Sleep under an insecticide impregnated bednet. ■ For counselling on violence. ■ Do you have any concerns? fIrst vIsIt ■ How many months pregnant are you? ■ When was your last period? ■ When do you expect to deliver? ■ How old are you? ■ Have you had a baby before? If yes: ■ Check record for prior pregnancies or if ■ Look for caesarean scar malpresentation within one month of expected delivery. FeeL If vAGInAl dIscHArGe ■ Have you noticed changes in your ■ Separate the labia and look for SIGNS ■ Abnormal vaginal discharge. Schedule follow-up appointment for woman and partner (if possible). CHeCk ReCoRD Look. ■ For HIV-positive women. if needed I2 referral system. including use of condoms G2 . LISTeN. ASk. HyPertensIon ≥90 mmHg on 2 readings. she should go 2-3 weeks before baby due date and stay either at the ■ Advise to ask for help from the community. her partner and family. SIGNS ■ Fever >38°C and any of: CLASSIFY very severe feBrIle dIseAse C8 → Measure axillary temperature. counsel to stop smoking. to help her feel well and strong (give examples of types of food and how much to eat). lower urInAry trAct InfectIon ■ Give appropriate oral antibiotics f5 eyes. see G5 for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time. ■ Rest and avoid lifting heavy objects. FeeL If couGH or BreAtHInG dIffIculty ■ How long have you been coughing? ■ How long have you had difficulty in SIGNS At least 2 of the following signs: ■ Fever >38ºC. ■ Provide additional care for HIV-positive woman G4 . → Make arrangements for the woman to see a family planning counsellor. ■ Complications are more common in HIV-positive women and her newborns. FeeL ■ Have you been tested for syphilis CLASSIFY PossIBle syPHIlIs TReAT AND ADVISe ■ ive benzathine benzylpenicillin IM. Women should deliver in develoP A BIrtH And eMerGency PlAn Facility delivery Home delivery with a skilled attendant a facility. → Is there a rash? → re there blisters along the ribs A on one side of the body? ■ ook for visible wasting. ■ Develop the birth and emergency plan c14 . ■ severe headaches with blurred vision. ■ If smoking. ASk. If pallor: → Is it severe pallor? → Some pallor? → Count number of breaths in 1 minute. ■ Abnormal vaginal discharge ■ Give clotrimazole f5 . ≥90-mmHg on two readings and 2+ ■ If diastolic blood pressure is still ≥90 proteinuria. refer the woman to district hospital for revision of treatment as streptomycin is ototoxic to the fetus. birth and emergency plan AntenAtAl cAre Assess tHe PreGnAnt woMAn: PreGnAncy stAtus. FeeL ■ Have you lost weight? ■ Have you got diarrhoea (continuous or intermittent)? ■ o you have fever? D How long (>1 month)? ■ ave you had cough? H How long (> 1 month)? ■ ave you any difficulty in breathing? H How long (> 1 month)? ■ Have you noticed any change in vaginal discharge? ■ ook for ulcers and white patches in L SIGNS HIV-positive and any of the following: ■ Weight loss or no weight gain ■ Visible wasting ■ Diarrhoea > 1 month ■ Fever > 1 month ■ Cough > 1 month or difficult CLASSIFY HIv-PosItIve wItH HIv-relAted sIGns And syMPtoMs TReAT AND ADVISe ■ Refer to hospital for further assessment. ■ Counsel on safer sex including use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. And/or ■ Severe palmar and conjunctival How long (>1 month)? ■ Have you got diarrhoea (continuous the mouth (thrush). CHeCk ReCoRD Look. ■ feels ill. repeat after 1 hour. burning on passing urine. ■ Give appropriate oral antimalarial f4 resPond to oBserved sIGns or volunteered ProBleMs (2) If fever or burning on urination Develop a birth and emergency plan (1) develoP A BIrtH And eMerGency PlAn use the information and counselling sheet to support your interaction with the woman. ■ Counsel on the importance of staying negative by practising safer sex. face. ■ Percuss flanks for → very fast breathing or → stiff neck → lethargy → very weak/not able to stand. ■ During the last visit. ■ To wait for the placenta to deliver on its own. ■ Reassess at next antenatal visit (4-6 weeks). nuts. ■ Bleeding increases. or history of violence Advise and counsel on family planning AdvIse And counsel on fAMIly PlAnnInG Counsel on the importance of family planning ■ If appropriate. ■ encourage woman to bring her sexual partner for breathing? ■ Do you have chest pain? ■ Do you have any blood in sputum? ■ Do you smoke? ■ Look for breathlessness. ■ To dry the baby after cutting the cord. months of pregnancy. FeeL INDICATIoNS ■ Prior delivery by caesarean. ■ Soap. ■ Give appropriate oral antimalarial if not given in the past month f4 . ■ Not able to feed. ■ NoT to take medication unless prescribed at the health centre/hospital. plan to give TT2 at next visit. oils. ■ Record all visits and treatments given. the mouth (thrush). fish. day or night. ■ abdominal pain. and ■ Cough <3 weeks. ■ Diastolic blood pressure problem? If partner is present in the clinic. BIrtH And eMerGency PlAn Respond to observed signs or volunteered problems (2) ASk. ■ refer urgently to hospital B17 . ■ She refuses the test or is not willing unknown HIv stAtus to disclose the result of previous test or no test results available. neck. → Flank pain → Burning on urination. FeeL ■ lood pressure at the last visit? B ■ Measure blood pressure in sitting ■ If diastolic blood pressure is ≥90 SIGNS ■ Diastolic blood pressure CLASSIFY severe Pre-eclAMPsIA TReAT AND ADVISe ■ Give magnesium sulphate B13 . ■ A facility has staff. ■ Rupture of membranes at <8 months of pregnancy. ■ Transverse lie or other obvious PLACe oF DeLIVeRY referrAl level ADVISe ■ explain why delivery needs to be at referral level c14 . ■ Listen for wheezing. ■ To. forceps. ■ Feels cold. treatment. ■ Partner has urethral discharge or CLASSIFY PossIBle GonorrHoeA or cHlAMydIA InfectIon PossIBle cAndIdA InfectIon PossIBle BActerIAl or trIcHoMonAs InfectIon TReAT AND ADVISe ■ Give appropriate oral antibiotics to woman f5 . ■ Advise to reduce workload and to rest. ■ Plan to treat the newborn k12 . ■ ook at the skin: L Advise on self-care during pregnancy Advise the woman to: ■ Take iron tablets (p. ■ Counsel on safer sex including use of condoms G2 . Inform the women that HIV test will be done routinely and that she may refuse the HIV test. If HIv services are not available: ■ Determine the severity of the disease and assess eligibility for ARVs c19 . repeat after 1 hour rest. . ■ explain about HIV testing and counselling including confidentiality of the result G3 . TReAT AND ADVISe ■ Give tetanus toxoid if due f2 . ■ Fits. ask him if he has: ■ urethral discharge or pus. Pre-eclAMPsIA ■ Revise the birth plan c2 ■ Refer to hospital. CHeCk ReCoRD ■ Check tetanus toxoid (TT) immunization status. ■ Refer to hospital. ■ Rupture of membranes at >8 pad. ■ Determine if there are important taboos about foods which are nutritionally important for good ■ No fetal movement but fetal heart beat present. ■ refer urgently to hospital B17 . � next: Respond to observed signs or volunteered problems If no problem. counsel to stop smoking. FeeL If no fetAl MoveMent ■ When did the baby last move? ■ If no movement felt. perform the rapid plasma reagin (RPR) test l5 . Check again in 1 hour. ■ convulsions. ask woman ■ Feel for fetal movements. ■ Refer to TB centre if cough. To dress or wrap the baby. review these simple instructions with the woman and family members. ■ Talk to family members such as the partner and mother-in-law. The cord is cut when it stops pulsating. or intermittent)? How long. CLASSIFY PossIBle PneuMonIA TReAT AND ADVISe ■ Give first dose of appropriate IM/IV antibiotics B15 . → f yes: Check result. ■ Curd like vaginal discharge. . for cleaning the baby’s (in last 48 hours). ■ Receiving injectable anti- tuBerculosIs ■ If anti-tubercular treatment includes streptomycin tuberculosis drugs. AntenAtAl cAre � next: If fever or burning on urination Respond to observed signs or volunteered problems (1) c7 Advise and counsel on nutrition and self-care Assesses eligibility of ARV for HIV-positive pregnant woman c19 Antenatal care c1 . ■ Labour pains/contractions continue for more than 12 hours. advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. ■ Advise to have her home-based maternal record ready. cow dung or other substance on umbilical cord/stump. ■ To ensure that the attendant should wash her hands with clean water and soap before/after touching mother/baby. she/they must go to the health centre immediately. CHeCk ReCoRD Look. adolescent and HIV-positive woman. ■ refer urgently to hospital B17 . ■ Give appropriate IM/IV antibiotics B15 . ask the woman if she feels comfortable if you ask him similar questions. ■ Clean cloths for washing. ■ None of the above. → Ask about plans for having more children. explain importance of partner assessment and treatment to avoid reinfection. ■ Breathlessness. refer urgently to hospital. if she has sex and is not exclusively breastfeeding. → f not: tell her that she will be I tested for HIV. ■ If treatment does not include streptomycin. ■ Give double dose of iron (1 tablet twice daily) for 3 months f3 . ask the woman if she would like her partner or another family member to be included c16 C16 in the counselling session. G9 . C13 c13 Counsel on nutrition ■ Advise the woman to eat a greater amount and variety of healthy foods. ■ First antenatal contact should be as early in pregnancy as possible. ■ Counsel on safer sex including use of condoms G2 resPond to oBserved sIGns or volunteered ProBleMs (3) If vaginal discharge AntenAtAl cAre Advise on labour signs Advise to go to the facility or contact the skilled birth attendant if any of the following signs: ■ a bloody sticky discharge. ■ Fever >38°C or history of fever uPPer urInAry trAct InfectIon MAlArIA ■ Give appropriate IM/IV antibiotics B15 . ■ Counsel on benefits of involving and testing the partner G3 . soothing remedy. assure AntenAtAl cAre � AntenAtAl cAre the woman that the drugs are not harmful to her baby. if needed I2 . ■ Intense vulval itching. not to put ashes. ■ Additional clean cloths to use as sanitary pads after birth. → one or more other signs or → from a risk group. T Advise to avoid harmful practices For example: not to use local medications to hasten labour. ReCoRD Look. If ruPtured MeMBrAnes And no lABour ■ When did the membranes rupture? ■ When is your baby due? ■ Look at pad or underwear for evidence of: → amniotic fluid → foul-smelling vaginal discharge ■ If no evidence. drink alcohol or use any drugs? tHIrd trIMester Has she been counselled on family planning? If yes.Assess the pregnant woman Pregancy status. ■ fever and too weak to get out of bed. → Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not. breathing ■ Cracks/ulcers around lips/mouth ■ Itching rash ■ Blisters along the ribs on one side Assess elIGIBIlIty of Arv for HIv-PosItIve woMAn of the body ■ enlarged lymph nodes ■ Abnormal vaginal discharge HIV-positive and none of the above signs . C3 cHeck for Pre-eclAMPsIA ASk. no clInIcAl AnAeMIA ■ Give iron 1 tablet once daily for 3 months f3 ■ Counsel on compliance with treatment f4 . → Do you smoke. ■ swelling of fingers. cHeck for syPHIlIs ASk. beans. ASk. ask her to wear a ■ Fever 38ºC. FeeL If sIGns suGGestInG HIv InfectIon (HIv status unknown) ■ Have you lost weight? ■ Do you have fever? ■ Look for visible wasting. ■ If the woman chooses an intrauterine device (IUD): → can be inserted immediately postpartum if no sign of infection (up to 48 hours. ■ Burning on urination. AntenAtAl cAre � AntenAtAl cAre next: Check for anaemia � C15 Advise on labour signs Advise on danger signs Discuss how to prepare for an emergency in pregnancy next: If signs suggesting HIV infection Assess the pregnant woman Check for pre-eclampsia c3 Respond to observed signs or volunteered problems (3) c9 Develop a birth and emergency plan (2) c15 Assess the pregnant woman Check for anaemia AntenAtAl cAre cHeck for AnAeMIA screen all pregnant women at every visit. for all women: ■ Support adherence to ARV G6 . ■ Treat partner with appropriate oral antibiotics f5 ■ Counsel on safer sex including use of condoms G2 C9 . ■ Give her appropriate ARV G6 . If partner could not be approached. . ■ More frequent visits or different schedules may be required according to national malaria or HIV policies. CHeCk. including the baby’s head. AlcoHol or druG ABuse. → where will she go? → how will they get there? → how much it will cost for services and transport? → can she start saving straight away? → who will go with her for support during labour and delivery? → who will care for her home and other children? ■ Advise the woman to ask for help from the community. ■ Give glucose B16 . not to pull on the cord to deliver the placenta. LISTeN. All visits ■ Review and update the birth and emergency plan according to new findings c14-c15 . abnormal vaginal discharge: → amount → colour → odour/smell. test on first visit: ■ Measure haemoglobin on subsequent visits: ■ Look for conjunctival pallor. ■ Foul-smelling vaginal discharge. uPPer resPIrAtory trAct InfectIon ■ Advise safe. Method options for the non-breastfeeding woman can be used immediately postpartum 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) delay 3 weeks Combined oral contraceptives Combined injectables Diaphragm Fertility awareness methods → can be performed immediately postpartum if no sign of infection (ideally within 7 days. C11 during this pregnancy? → If not. give G erythromycin f6 . ModerAte AnAeMIA or ■ Palmar or conjunctival pallor. . ■ Revise the birth plan c2 . ■ Give artemether/quinine IM B16 . Therefore it is important to start thinking early on about what family planning method they will use. To wipe clean but not bathe the baby until after 6 hours. ■ AIf HIV-positive she will need appropriate ARV treatment for herself and her baby during childbirth. ■ Ask if she (and children) are sleeping under insecticide treated bednets. � next: Check for pre-eclampsia cHeck for Pre-eclAMPsIA screen all pregnant women at every visit. ■ Support initiation of ARV G6 ■ Revise ANC visit accordingly. → plan for delivery in hospital or health centre where they are trained to carry out the procedure. . ASSeSS. see H4 . ■ Provide support to the HIV-positive woman G5 . CLASSIFY severe AnAeMIA TReAT AND ADVISe ■ Revise birth plan so as to deliver in a facility with blood transfusion services c2 . ■ refer urgently to hospital B17 . ■ If test was positive. and any of: mmHg. ■ waters have broken. ■ Fever >38°C and any of: tenderness. ■ burning on passing urine. ■ To use the ties and razor blade from the disposable delivery kit to tie and cut the cord. CHeCk ReCoRD Look. ■ refer urgently to hospital B17 . CHeCk ReCoRD Look. She should go to the health centre as soon as possible if any of the following signs: ■ fever. If cough or breathing difficulty If taking anti-tuberculosis drugs Follow-up visits If the problem was: Hypertension Severe anaemia HIV-positive return in: 1 week if >8 months pregnant 2 weeks 2 weeks after HIV testing next: Check for HIV status � next: Give preventive measures Assess the pregnant woman Check for syphilis c5 Respond to observed signs or volunteered problems (5) c11 Advise on care Antenatal routine and follow-up visits c17 Assess the pregnant woman Check for HIV status AntenAtAl cAre cHeck for HIv stAtus test and counsel all pregnant women for HIv at the first antenatal visit. for the birth attendant to wash and dry her hands.) → Are you taking any ARV? → Check ARV treatment plan. ■ If severe wheezing. ■ ook for any abnormal vaginal L discharge c9 . ■ Chest pain. FeeL If fever or BurnInG on urInAtIon ■ Have you had fever? ■ Do you have burning on urination? ■ If history of fever or feels hot: c8 TReAT AND ADVISe ■ Insert IV line and give fluids slowly B9 . ■ What is HIV and how is HIV transmitted G2 ? ■ Advantage of knowing the HIV status in pregnancy G2 . or vacuum → Prior third degree tear → Heavy bleeding during or after delivery → Convulsions → Stillbirth or death in first day. within the first hour after birth. ■ Where do you plan to deliver? ■ Any vaginal bleeding since last visit? ■ Is the baby moving? (after 4 months) ■ Check record for previous complications and treatments received during this pregnancy. ■ Counsel on compliance with treatment f3 . AdvIse And counsel on nutrItIon And self-cAre Counsel on nutrition Advise on self-care during pregnancy AntenAtAl cAre Assess elIGIBIlIty of Arv for HIv-PosItIve PreGnAnt woMAn use this chart to assess HIv-related signs and symptoms and to determine Arv needs for HIv-positive woman and her baby when appropriate HIv services and cd4 count are not available. ■ If no improvement in 2 days or condition is worse. AdvIse And counsel on fAMIly PlAnnInG Counsel on the importance of family planning Special considerations for family planning counselling during pregnancy anaemia persists. even for an emergency visit. ■ None of the above. resPond to oBserved sIGns or volunteered ProBleMs C7 CLASSIFY ProBABly deAd BABy ASk. ■ Plastic for wrapping the placenta. and a Home delivery with a skilled attendant Advise how to prepare Review the following with her: ■ Who will be the companion during labour and delivery? ■ Who will be close by for at least 24 hours after delivery? ■ Who will help to care for her home and other children? ■ Advise to call the skilled attendant at the first signs of labour. check status at every visit. ■ Give appropriate oral antimalarial f4 . ■ Reassess at the next antenatal visit or in 1 week if >8 months pregnant. wItHout waiting if any of the following signs: ■ vaginal bleeding. Discuss how to prepare for an emergency in pregnancy ■ Discuss emergency issues with the woman and her partner/family: Advise on danger signs Advise to go to the hospital/health centre immediately. ■ First birth. ■ painful contractions every 20 minutes or less. → Look for lethargy. Lactational amenorrhoea method (LAM) Condoms Spermicide Female sterilization (within 7 days or delay 6 weeks) Copper IUD (within 48 hours or delay 4 weeks) Progestogen-only oral contraceptives Progestogen-only injectables Implants Diaphragm Combined oral contraceptives Combined injectables Fertility awareness methods � next: Check for syphilis � next: If cough or breathing difficulty cHeck for syPHIlIs test all pregnant women at first visit. ■ Counsel on safer sex including use of condoms to prevent new infection G2 . ■ Has the partner been tested? ■ Negative HIV test. C2 ASk. ■ Feel for transverse lie. ■ To cover the mother and the baby. ■ RPR test negative. after delivery. . for drying and wrapping the baby. cereals. explain supplies needed for home delivery ■ Warm spot for the birth with a clean surface or a clean cloth. LISTeN. ■ No fetal heart beat. ■ Fever. ■ Last baby born dead or died in first PrIMAry HeAltH cAre level ■ explain why delivery needs to be at primary health care level c14 . her partner and family. reassess fetal movement. CLASSIFY HIv-PosItIve TReAT AND ADVISe ■ Counsel on implications of a positive test G3 . well but to return if problem persists. Baby ■ Very small. . supplies and drugs available to provide best care if needed. ■ Listen for fetal heart after 6 months of pregnancy d2 . ■ Age less than 14 years. → Look or feel for stiff neck. ■ If her sputum is TB positive within 2 months of delivery. ■ Give double dose of iron (1 tablet twice daily) for 3 months f3 . ■ Manage as Woman in childbirth d1-d28 . vegetables. All vIsIts ■ Feel for trimester of pregnancy. since when? ■ Does the treatment include injection ■ Taking anti-tuberculosis drugs. c12 C12 GIve PreventIve MeAsures Antenatal care HoMe delIvery wItHout A skIlled AttendAnt reinforce the importance of delivery with a skilled birth attendant c18 C18 C19 ASk. ■ Counsel on importance of exclusive breastfeeding k2 . ■ Counsel on infant feeding options G7 . for >3 weeks ■ Blood in sputum ■ Wheezing ■ Fever <38ºC. ■ Prior delivery with convulsions. CHeCk ReCoRD Look. ■ Look at the skin: during routine household work? pallor or ■ Any pallor with any of → >30 breaths per minute → tires easily → breathlessness at rest ■ Haemoglobin 7-11-g/dl. drying and wrapping the baby. ■ Spend more time on nutrition counselling with very thin. CHeCk ReCoRD Look. and underarm F for enlarged lymph nodes. ■ HIV-positive woman. or delay 4 weeks) → plan for delivery in hospital or health centre where they are trained to insert the IUD. ■ o dispose of the placenta in a correct. ■ Counsel on safer sex including use of condoms. (streptomycin)? (injection). ■ Prior delivery by forceps or vacuum. AdvIse on routIne And follow-uP vIsIts If tAkInG AntI-tuBerculosIs druGs ■ Are you taking anti-tuberculosis drugs? If yes. cheese. ■ Give appropriate oral antimalarial f4 . Advise what to bring ■ Home-based maternal record. and test is positive. LISTeN. ■ Counsel on safer sex including use of condoms G2 ■ Give metronidazole to woman f5 . preferably at a facility. go to page c12 . prepare a birth and emergency plan using this chart and review them during following visits. ■ Bleeding. ■ Diastolic blood pressure 90-110-mmHg on two readings and 2+ proteinuria. ■ Clean cloths of different sizes: for the bed. HoMe delIvery wItHout A skIlled AttendAnt Instruct mother and family on clean and safer delivery at home Advise to avoid harmful practices Advise on danger signs ■ Give intermittent preventive treatment in second and third trimesters f4 ■ encourage sleeping under insecticide treated bednets. FeeL Provide key information on HIv G2 . LISTeN. day or night. ■ Counsel on family planning G4 . ■ Listen to fetal heart. Assess tHe PreGnAnt woMAn: PreGnAncy stAtus. Advise how to prepare Review the arrangements for delivery: ■ How will she get there? Will she have to pay for transport? ■ How much will it cost to deliver at the facility? How will she pay? ■ Can she start saving straight away? ■ Who will go with her for support during labour and delivery? ■ Who will help while she is away to care for her home and other children? Advise when to go ■ If the woman lives near the facility. plan to give INH prophylaxis to the newborn k13 . ■ Bowls: 2 for washing and 1 for the placenta. ■ Documented third degree tear. ■ If living far from the facility. ■ Advise to ask for help from the community. such as meat. no HyPertensIon No treatment required. LISTeN. LISTeN. refer to specialized care Method options for the breastfeeding woman can be used immediately postpartum delay 6 weeks delay 6 months providers. If sMokInG.

during first antenatal visit. ■ Age less than 16 years. ■ Prior delivery with convulsions. ■ explain why delivery needs to be at primary health care level c14 . preferably at a facility. ■ Age less than 14 years. does she want tubal ligation or IUD A15 . CHeCk. ■ Tubal ligation or IUD desired immediately after delivery. ■ Transverse lie or other obvious PLACe oF DeLIVeRY referrAl level ADVISe ■ explain why delivery needs to be at referral level c14 . ■ Feel for obvious multiple malpresentation within one month of expected delivery. ■ Documented third degree tear. ■ Last baby born dead or died in first PrIMAry HeAltH cAre level day. ■ Listen to fetal heart. ■ First birth. AccordInG to woMAn’s Preference ■ explain why delivery needs to be with a skilled birth attendant. birth and emergency plan AntenAtAl cAre Assess tHe PreGnAnt woMAn: PreGnAncy stAtus. ■ Develop the birth and emergency plan c14 . FeeL INDICATIoNS ■ Prior delivery by caesarean. ■ None of the above. BIrtH And eMerGency PlAn c2 use this chart to assess the pregnant woman at each of the four antenatal care visits. ■ Develop the birth and emergency plan c14 . ■ Develop the birth and emergency plan c14 . t next: Check for pre-eclampsia . drink alcohol or use any drugs? tHIrd trIMester Has she been counselled on family planning? If yes. ■ Where do you plan to deliver? ■ Any vaginal bleeding since last visit? ■ Is the baby moving? (after 4 months) ■ Check record for previous complications and treatments received during this pregnancy. ■ Prior delivery with heavy bleeding. pregnancy. forceps. ■ obvious multiple pregnancy. ■ Do you have any concerns? fIrst vIsIt ■ Look for caesarean scar ■ How many months pregnant are you? ■ When was your last period? ■ When do you expect to deliver? ■ How old are you? ■ Have you had a baby before? If yes: ■ Check record for prior pregnancies or if there is no record ask about: → Number of prior pregnancies/deliveries → Prior caesarean section. All vIsIts ■ Feel for trimester of pregnancy.Assess the pregnant woman Pregnancy status. ■ Feel for transverse lie. LISTeN. or vacuum → Prior third degree tear → Heavy bleeding during or after delivery → Convulsions → Stillbirth or death in first day. ■ HIV-positive woman. ■ Check duration of pregnancy. prepare a birth and emergency plan using this chart and review them during following visits. ASk. ■ More than six previous births. Modify the birth plan if any complications arise. ReCoRD Look. → Do you smoke. ■ History of or current vaginal bleeding or other complication during this pregnancy. ■ Prior delivery by forceps or vacuum.

■ Diastolic blood pressure 90-110-mmHg on two readings and 2+ proteinuria. . no HyPertensIon No treatment required. ■ Revise the birth plan c2 . ASk. if available. repeat after 1 hour rest. ■ Diastolic blood pressure Pre-eclAMPsIA ■ Revise the birth plan c2 ■ Refer to hospital. ■ refer urgently to hospital B17 . ≥90-mmHg on two readings and 2+ ■ If diastolic blood pressure is still ≥90 proteinuria. ■ If hypertension persists after 1 week or at next visit. AntenAtAl cAre t next: Check for anaemia Assess the pregnant woman Check for pre-eclampsia c3 . ≥110 mmHg and 3+ proteinuria. HyPertensIon ≥90 mmHg on 2 readings. ■ Reassess at the next antenatal visit or in 1 week if >8 months pregnant. LISTeN. ■ None of the above. or ■ If diastolic blood pressure is ≥90 ■ Diastolic blood pressure mmHg. → epigastric pain and → check protein in urine. ■ Diastolic blood pressure position. ask the woman if she has: → severe headache → severe headache → blurred vision → blurred vision → epigastric pain. refer to hospital or discuss case with the doctor or midwife. CHeCk ReCoRD Look. ■ Advise on danger signs c15 . FeeL ■ lood pressure at the last visit? B ■ Measure blood pressure in sitting SIGNS CLASSIFY severe Pre-eclAMPsIA TReAT AND ADVISe ■ Give magnesium sulphate B13 . ■ Give appropriate anti-hypertensives B14 . ■ Advise to reduce workload and to rest. and any of: mmHg.cHeck for Pre-eclAMPsIA screen all pregnant women at every visit.

test on first visit: ■ Measure haemoglobin on subsequent visits: ■ Look for conjunctival pallor. ■ Look for palmar pallor.Assess the pregnant woman Check for anaemia AntenAtAl cAre cHeck for AnAeMIA screen all pregnant women at every visit. ■ refer urgently to hospital B17 . ■ Counsel on compliance with treatment f3 . ■ Counsel on compliance with treatment f3 . CLASSIFY severe AnAeMIA TReAT AND ADVISe ■ Revise birth plan so as to deliver in a facility with blood transfusion services c2 . c4 ASk. no clInIcAl AnAeMIA ■ Give iron 1 tablet once daily for 3 months f3 ■ Counsel on compliance with treatment f4 . If pallor: → Is it severe pallor? → Some pallor? → Count number of breaths in 1 minute. refer to hospital. ■ Haemoglobin >11-g/dl. . ■ No pallor. ■ Give double dose of iron (1 tablet twice daily) for 3 months f3 . ModerAte AnAeMIA or ■ Palmar or conjunctival pallor. results. ■ Give double dose of iron (1 tablet twice daily) for 3 months f3 . FeeL ■ Do you tire easily? ■ Are you breathless (short of breath) SIGNS ■ Haemoglobin <7-g/dl. CHeCk ReCoRD Look. t next: Check for syphilis . ■ Follow up in 2 weeks to check clinical progress. If anaemia persists. LISTeN. ■ Give appropriate oral antimalarial f4 . ■ Give appropriate oral antimalarial if not given in the past month f4 . during routine household work? And/or ■ Severe palmar and conjunctival pallor or ■ Any pallor with any of → >30 breaths per minute → tires easily → breathlessness at rest ■ Haemoglobin 7-11-g/dl. ■ Reassess at next antenatal visit (4-6 weeks). and compliance with treatment.

no syPHIlIs ■ Counsel on safer sex including use of condoms to prevent infection G2 . and test is positive. check status at every visit. CLASSIFY PossIBle syPHIlIs TReAT AND ADVISe ■ ive benzathine benzylpenicillin IM. CHeCk ReCoRD Look. ask “Are you allergic to penicillin?” treatment. ASk. have you and your partner been treated for syphilis? → If not. ■ Counsel on safer sex including use of condoms to prevent new infection G2 . give G erythromycin f6 . ■ If test was positive. If allergy. LISTeN. AntenAtAl cAre t next: Check for HIV status Assess the pregnant woman Check for syphilis c5 . FeeL ■ Have you been tested for syphilis TeST ReSULT ■ RPR test positive. ■ encourage woman to bring her sexual partner for during this pregnancy? → If not. perform the rapid plasma reagin (RPR) test l5 . ■ RPR test negative.cHeck for syPHIlIs test all pregnant women at first visit. ■ Plan to treat the newborn k12 .

. c6 ASk. SIGNS ■ Positive HIV test. → f yes: Check result. including use of condoms G2 . FeeL Provide key information on HIv G2 . ■ Counsel on benefits of disclosure (involving) and testing her partner G3 . ■ Negative HIV test. ■ Counsel on safer sex including use of condoms G2 . ■ Counsel on benefits of involving and testing the partner G3 . ■ Counsel on infant feeding options G7 . ■ Counsel on the importance of staying negative by practising safer sex. HIv-neGAtIve ■ She refuses the test or is not willing unknown HIv stAtus to disclose the result of previous test or no test results available. ■ Give her appropriate ARV G6 . unless she refuses. ■ Counsel on family planning G4 . check status at every visit. Inform the women that HIV test will be done routinely and that she may refuse the HIV test. CHeCk ReCoRD Look. ■ What is HIV and how is HIV transmitted G2 ? ■ Advantage of knowing the HIV status in pregnancy G2 . ■ Has the partner been tested? ■ erform the Rapid HIV test if not P performed in this pregnancy l6 . If HIv services are not available: ■ Determine the severity of the disease and assess eligibility for ARVs c19 . (explain to I her that she has a right not to disclose the result. ■ Ask her to return in 2 weeks with her documents. Ask the woman: ■ Have you been tested for HIV? → f not: tell her that she will be I tested for HIV. go to page c12 . If HIv services available: ■ Refer the woman to HIV services for further assessment.) → Are you taking any ARV? → Check ARV treatment plan. ■ explain about HIV testing and counselling including confidentiality of the result G3 . LISTeN. ■ Provide support to the HIV-positive woman G5 . ■ Provide additional care for HIV-positive woman G4 . ■ Counsel on implications of a negative test G3 . for all women: ■ Support adherence to ARV G6 . G9 . ■ Counsel on safer sex including use of condoms G2 ■ Counsel on benefits of involving and testing the partner G3 . .Assess the pregnant woman Check for HIV status AntenAtAl cAre cHeck for HIv stAtus test and counsel all pregnant women for HIv at the first antenatal visit. CLASSIFY HIv-PosItIve TReAT AND ADVISe ■ Counsel on implications of a positive test G3 . t next: Respond to observed signs or volunteered problems If no problem.

reassess fetal movement. ask woman ■ Feel for fetal movements. ■ Listen for fetal heart after 6 months of pregnancy d2 .resPond to oBserved sIGns or volunteered ProBleMs ASk. If ruPtured MeMBrAnes And no lABour ■ When did the membranes rupture? ■ When is your baby due? ■ Look at pad or underwear for evidence of: → amniotic fluid → foul-smelling vaginal discharge ■ If no evidence. ■ No fetal movement but fetal heart well BABy ■ Inform the woman that baby is fine and likely to be beat present. CLASSIFY ProBABly deAd BABy TReAT AND ADVISe ■ Inform the woman and partner about the possibility of dead baby. ■ Rupture of membranes at <8 months of pregnancy. ■ Fever 38ºC. ■ Foul-smelling vaginal discharge. ■ Rupture of membranes at >8 months of pregnancy. FeeL If no fetAl MoveMent ■ When did the baby last move? ■ If no movement felt. ■ If no heart beat. AntenAtAl cAre t next: If fever or burning on urination Respond to observed signs or volunteered problems (1) c7 . ■ refer urgently to hospital B17 . ■ No fetal heart beat. ■ refer urgently to hospital B17 . ■ Refer to hospital. Check again in 1 hour. ask her to wear a pad. well but to return if problem persists. ■ Manage as Woman in childbirth d1-d28 . CHeCk ReCoRD Look. to move around for some time. repeat after 1 hour. LISTeN. uterIne And fetAl InfectIon rIsk of uterIne And fetAl InfectIon ruPture of MeMBrAnes ■ Give appropriate IM/IV antibiotics B15 . ■ Give appropriate IM/IV antibiotic B15 . SIGNS ■ No fetal movement. ■ Measure temperature.

Respond to observed signs or volunteered problems (2) AntenAtAl cAre ASk. t next: If vaginal discharge . SIGNS ■ Fever >38°C and any of: CLASSIFY very severe feBrIle dIseAse → Measure axillary temperature. ■ Burning on urination. ■ Give artemether/quinine IM B16 . ■ Fever >38°C or history of fever uPPer urInAry trAct InfectIon MAlArIA (in last 48 hours). → very fast breathing or → stiff neck → lethargy → very weak/not able to stand. ■ encourage her to drink more fluids. → Look for lethargy. ■ If no improvement in 2 days or condition is worse. refer to hospital. ■ refer urgently to hospital B17 . ■ Give appropriate oral antimalarial f4 . FeeL If fever or BurnInG on urInAtIon ■ Have you had fever? ■ Do you have burning on urination? ■ If history of fever or feels hot: c8 TReAT AND ADVISe ■ Insert IV line and give fluids slowly B9 . ■ Percuss flanks for tenderness. ■ Give appropriate IM/IV antibiotics B15 . ■ Give glucose B16 . → Look or feel for stiff neck. CHeCk ReCoRD Look. lower urInAry trAct InfectIon ■ Give appropriate oral antibiotics f5 . refer to hospital. LISTeN. ■ Give appropriate IM/IV antibiotics B15 . ■ refer urgently to hospital B17 . ■ Give appropriate oral antimalarial f4 . ■ Fever >38°C and any of: → Flank pain → Burning on urination. ■ If no improvement in 2 days or condition is worse.

ASk. examine with a gloved finger and look at the discharge on the glove. CHeCk ReCoRD Look. If yes. . LISTeN. . ■ Counsel on safer sex including use of condoms G2 . ■ Curd like vaginal discharge. burning on passing urine. ■ Give clotrimazole f5 . ask the woman if she feels comfortable if you ask him similar questions. ■ Partner has urethral discharge or CLASSIFY PossIBle GonorrHoeA or cHlAMydIA InfectIon PossIBle cAndIdA InfectIon PossIBle BActerIAl or trIcHoMonAs InfectIon TReAT AND ADVISe ■ Give appropriate oral antibiotics to woman f5 . If partner could not be approached. ■ If no discharge is seen. abnormal vaginal discharge: → amount → colour → odour/smell. Schedule follow-up appointment for woman and partner (if possible). ask him if he has: ■ urethral discharge or pus. ■ Abnormal vaginal discharge . FeeL If vAGInAl dIscHArGe ■ Have you noticed changes in your ■ Separate the labia and look for SIGNS ■ Abnormal vaginal discharge. AntenAtAl cAre t next: If signs suggesting HIV infection Respond to observed signs or volunteered problems (3) c9 . ■ Intense vulval itching. explain importance of partner assessment and treatment to avoid reinfection. ■ Treat partner with appropriate oral antibiotics f5 ■ Counsel on safer sex including use of condoms G2 vaginal discharge? ■ Do you have itching at the vulva? ■ Has your partner had a urinary problem? If partner is present in the clinic. ■ burning on passing urine. ■ Counsel on safer sex including use of condoms G2 ■ Give metronidazole to woman f5 .

>1 month? Assess if in high risk group: ■ occupational exposure? ■ Multiple sexual partner? ■ Intravenous drug abuse? ■ History of blood transfusion? ■ Illness or death from AIDS in a sexual partner? ■ History of forced sex? → Is there a rash? → Are there blisters along the ribs on one side of the body? → weight loss → fever >1 month → diarrhoea >1month. LISTeN. ■ Counsel on the benefits of testing the partner G3 . stronG lIkelIHood of HIv InfectIon ■ Reinforce the need to know HIV status and advise on HIV testing and counselling G2-G3 .Respond to observed signs or volunteered problems (4) AntenAtAl cAre ASk. ■ For counselling on violence. ■ Look for ulcers and white patches in ■ Two of these signs: c10 TReAT AND ADVISe SIGNS CLASSIFY How long (>1 month)? ■ Have you got diarrhoea (continuous the mouth (thrush). FeeL If sIGns suGGestInG HIv InfectIon (HIv status unknown) ■ Have you lost weight? ■ Do you have fever? ■ Look for visible wasting. >1 month? ■ Have you had cough? How long. refer to specialized care providers. or ■ one of the above signs and → one or more other signs or → from a risk group. t next: If cough or breathing difficulty . AlcoHol or druG ABuse. CHeCk ReCoRD Look. ■ Refer to TB centre if cough. see H4 . or HIstory of vIolence ■ Counsel on stopping smoking ■ For alcohol/drug abuse. ■ Look at the skin: or intermittent)? How long. ■ Counsel on safer sex including use of condoms G2 . If sMokInG.

■ If smoking. and urge her to continue treatment for a successful outcome of pregnancy. At least 1 of the following signs: ■ Cough or breathing difficulty for >3 weeks ■ Blood in sputum ■ Wheezing ■ Fever <38ºC. refer the woman to district hospital for revision of treatment as streptomycin is ototoxic to the fetus. since when? ■ Does the treatment include injection (streptomycin)? ■ Taking anti-tuberculosis drugs. t next: Give preventive measures Respond to observed signs or volunteered problems (5) c11 . LISTeN. CHeCk ReCoRD Look. ■ If treatment does not include streptomycin. ■ Chest pain. FeeL If couGH or BreAtHInG dIffIculty ■ How long have you been coughing? ■ How long have you had difficulty in SIGNS At least 2 of the following signs: ■ Fever >38ºC. uPPer resPIrAtory trAct InfectIon ■ Advise safe. ■ Breathlessness. CLASSIFY PossIBle PneuMonIA TReAT AND ADVISe ■ Give first dose of appropriate IM/IV antibiotics B15 .ASk. ■ If smoking. soothing remedy. ■ If severe wheezing. ■ Advise to screen immediate family members and close contacts for tuberculosis. refer urgently to hospital. counsel to stop smoking. breathing? ■ Do you have chest pain? ■ Do you have any blood in sputum? ■ Do you smoke? ■ Look for breathlessness. PossIBle cHronIc lunG dIseAse ■ Refer to hospital for assessment. ■ refer urgently to hospital B17 . ■ Measure temperature. assure the woman that the drugs are not harmful to her baby. counsel to stop smoking. ■ Receiving injectable anti- tuBerculosIs ■ If anti-tubercular treatment includes streptomycin tuberculosis drugs. ■ Listen for wheezing. ■ Reinforce advice on HIV testing and counselling G2-G3 . If tAkInG AntI-tuBerculosIs druGs ■ Are you taking anti-tuberculosis drugs? If yes. and ■ Cough <3 weeks. AntenAtAl cAre (injection). plan to give INH prophylaxis to the newborn k13 . ■ If her sputum is TB positive within 2 months of delivery.

. ■ Record all visits and treatments given. ■ Give 3 month’s supply of iron and counsel on compliance and safety f3 ■ Give mebendazole once in second or third trimester f3 ■ Check woman’s supply of the prescribed dose of iron/folate ■ Check when last dose of mebendazole given. ■ Check when last dose of an antimalarial given. ■ Advise on when to seek care: c17 → routine visits → follow-up visits → danger signs. ■ If TT1. ■ Counsel on safer sex including use of condoms. ■ Ask if she (and children) are sleeping under insecticide treated bednets. CHeCk ReCoRD ■ Check tetanus toxoid (TT) immunization status. . TReAT AND ADVISe ■ Give tetanus toxoid if due f2 . third trimester ■ Counsel on family planning c16 .Give preventive measures Antenatal care AntenAtAl cAre GIve PreventIve MeAsures Advise and counsel all pregnant women at every antenatal care visit. ■ Give intermittent preventive treatment in second and third trimesters f4 ■ encourage sleeping under insecticide treated bednets. first visit ■ Develop a birth and emergency plan c14 . All visits ■ Review and update the birth and emergency plan according to new findings c14-c15 . ■ Counsel on nutrition c13 . . ■ Counsel on importance of exclusive breastfeeding k2 . ■ Counsel on stopping smoking and alcohol and drug abuse. . plan to give TT2 at next visit. c12 ASSeSS.

■ Talk to family members such as the partner and mother-in-law. nuts. if at risk for STI or HIV G2 . ■ Counsel on safer sex including use of condoms.AdvIse And counsel on nutrItIon And self-cAre use the information and counselling sheet to support your interaction with the woman. ■ NoT to take medication unless prescribed at the health centre/hospital. cheese. milk. Advise the woman against these taboos. ■ Determine if there are important taboos about foods which are nutritionally important for good health. adolescent and HIV-positive woman. cereals. ■ Rest and avoid lifting heavy objects. beans. vegetables. to help her feel well and strong (give examples of types of food and how much to eat). AntenAtAl cAre Advise and counsel on nutrition and self-care c13 .T3). seeds. oils. ■ Sleep under an insecticide impregnated bednet. her partner and family. Advise on self-care during pregnancy Advise the woman to: ■ Take iron tablets (p. to encourage them to help ensure the woman eats enough and avoids hard physical work. ■ Avoid alcohol and smoking during pregnancy. ■ Spend more time on nutrition counselling with very thin. Counsel on nutrition ■ Advise the woman to eat a greater amount and variety of healthy foods. fish. such as meat.

for the birth attendant to wash and dry her hands. ■ Advise to ask for help from the community. ■ Buckets of clean water and some way to heat this water. for cleaning the baby’s eyes. ■ A facility has staff. c14 Facility delivery explain why birth in a facility is recommended ■ Any complication can develop during delivery - they are not always predictable. ■ If HIV-positive she will need appropriate ARV treatment for herself and her baby during childbirth. Advise what to bring ■ Home-based maternal record. Home delivery with a skilled attendant Advise how to prepare Review the following with her: ■ Who will be the companion during labour and delivery? ■ Who will be close by for at least 24 hours after delivery? ■ Who will help to care for her home and other children? ■ Advise to call the skilled attendant at the first signs of labour. ■ Blankets. if needed I2 . ■ Advise to ask for help from the community. she should go at the first signs of labour. explain supplies needed for home delivery ■ Warm spot for the birth with a clean surface or a clean cloth. drying and wrapping the baby. she should go 2-3 weeks before baby due date and stay either at the maternity waiting home or with family or friends near the facility. . her partner and family. Advise how to prepare Review the arrangements for delivery: ■ How will she get there? Will she have to pay for transport? ■ How much will it cost to deliver at the facility? How will she pay? ■ Can she start saving straight away? ■ Who will go with her for support during labour and delivery? ■ Who will help while she is away to care for her home and other children? Advise when to go ■ If the woman lives near the facility. equipment. for drying and wrapping the baby. ■ Complications are more common in HIV-positive women and her newborns. ■ Soap. ■ Clean cloths of different sizes: for the bed. ■ Clean cloths for washing. if needed I2 . for use as sanitary pads. ■ Bowls: 2 for washing and 1 for the placenta. ■ If living far from the facility.Develop a birth and emergency plan (1) AntenAtAl cAre develoP A BIrtH And eMerGency PlAn use the information and counselling sheet to support your interaction with the woman. ■ Food and water for woman and support person. ■ Clothes for mother and baby. ■ Additional clean cloths to use as sanitary pads after birth. and a referral system. ■ Plastic for wrapping the placenta. ■ Advise to have her home-based maternal record ready. HIV-positive women should deliver in a facility. supplies and drugs available to provide best care if needed.

■ fast or difficult breathing. ■ severe abdominal pain. ■ feels ill. → where will she go? → how will they get there? → how much it will cost for services and transport? → can she start saving straight away? → who will go with her for support during labour and delivery? → who will care for her home and other children? ■ Advise the woman to ask for help from the community. She should go to the health centre as soon as possible if any of the following signs: ■ fever. if needed I1–I3 . AntenAtAl cAre Develop a birth and emergency plan (2) c15 . even for an emergency visit. face. ■ abdominal pain. ■ waters have broken. ■ swelling of fingers. day or night. wItHout waiting if any of the following signs: ■ vaginal bleeding. Discuss how to prepare for an emergency in pregnancy ■ Discuss emergency issues with the woman and her partner/family: Advise on danger signs Advise to go to the hospital/health centre immediately. ■ fever and too weak to get out of bed. ■ Advise her to bring her home-based maternal record to the health centre.Advise on labour signs Advise to go to the facility or contact the skilled birth attendant if any of the following signs: ■ a bloody sticky discharge. ■ painful contractions every 20 minutes or less. ■ convulsions. legs. ■ severe headaches with blurred vision.

■ For HIV-positive women. she can become pregnant Special considerations for family planning counselling during pregnancy counselling should be given during the third trimester of pregnancy. If she (and her partner) want more children. ■ explain that after birth. ■ If the woman chooses female sterilization: → can be performed immediately postpartum if no sign of infection (ideally within 7 days. ■ Counsel on safer sex including use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. Promote especially if at risk for STI or HIV G4 . or delay 4 weeks) → plan for delivery in hospital or health centre where they are trained to insert the IUD. → ensure counselling and informed consent prior to labour and delivery. → Make arrangements for the woman to see a family planning counsellor. see G5 for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time. ask the woman if she would like her partner or another family member to be included c16 in the counselling session. or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). → Ask about plans for having more children. → Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not. or delay for 6 weeks). if she has sex and is not exclusively breastfeeding. as soon as four weeks after delivery. Therefore it is important to start thinking early on about what family planning method they will use. ■ If the woman chooses an intrauterine device (IUD): → can be inserted immediately postpartum if no sign of infection (up to 48 hours. → plan for delivery in hospital or health centre where they are trained to carry out the procedure.Advise and counsel on family planning AntenAtAl cAre AdvIse And counsel on fAMIly PlAnnInG Counsel on the importance of family planning ■ If appropriate. Method options for the non-breastfeeding woman can be used immediately postpartum Condoms Progestogen-only oral contraceptives Progestogen-only injectables Implant Spermicide Female sterilization (within 7 days or delay 6 weeks) C opper IUD (immediately following expulsion of placenta or within 48 hours) delay 3 weeks Combined oral contraceptives Combined injectables Diaphragm Fertility awareness methods Method options for the breastfeeding woman can be used immediately postpartum delay 6 weeks delay 6 months Lactational amenorrhoea method (LAM) Condoms Spermicide F emale sterilization (within 7 days or delay 6 weeks) C opper IUD (within 48 hours or delay 4 weeks) Progestogen-only oral contraceptives Progestogen-only injectables Implants Diaphragm Combined oral contraceptives Combined injectables Fertility awareness methods . advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child.

■ If women is HIV-positive ensure a visit between 26-28 weeks.AdvIse on routIne And follow-uP vIsIts encourage the woman to bring her partner or family member to at least 1 visit. inform the woman to return if she does not deliver within 2 weeks after the expected date of delivery. ■ First antenatal contact should be as early in pregnancy as possible. Follow-up visits If the problem was: Hypertension Severe anaemia HIV-positive return in: 1 week if >8 months pregnant 2 weeks 2 weeks after HIV testing AntenAtAl cAre Advise on routine and follow-up visits Antenatal care c17 . Routine antenatal care visits 1st visit 2nd visit 3rd visit 4th visit Before 4 months 6 months 8 months 9 months Before 16 weeks 24-28 weeks 30-32 weeks 36-38 weeks ■ All pregnant women should have 4 routine antenatal visits. ■ More frequent visits or different schedules may be required according to national malaria or HIV policies. ■ During the last visit.

To wipe clean but not bathe the baby until after 6 hours. within the first hour after birth. ■ Bleeding. after delivery. ■ Feels cold. ■ Give them a disposable delivery kit and explain how to use it. not to wait for waters to stop before going to health facility. not to put ashes. encourage helpful traditional practices: touching mother/baby. To dress or wrap the baby. ■ To keep the mother and baby warm. ■ To start breastfeeding when the baby shows signs of readiness. ■ To. cow dung or other substance on umbilical cord/stump. T ✎____________________________________________________________________ ✎____________________________________________________________________ Advise on danger signs If the mother or baby has any of these signs. ■ To ensure that the attendant should wash her hands with clean water and soap before/after Advise to avoid harmful practices For example: not to use local medications to hasten labour. review these simple instructions with the woman and family members. including the baby’s head. ■ Bleeding increases. wItHout waiting Mother ■ Waters break and not in labour after 6 hours. ■ Fever. not to push on the abdomen during labour or delivery. ■ Difficulty in breathing. ■ Not able to feed. Baby ■ Very small. ■ To wait for the placenta to deliver on its own. day or night. she/they must go to the health centre immediately. ■ To NoT leave the mother alone for the first 24 hours. She should also keep her nails clean. ■ Heavy bleeding after delivery (pad/cloth soaked in less than 5 minutes). not to insert any substances into the vagina during labour or after delivery. ■ To dry the baby after cutting the cord. safe and culturally appropriate manner (burn or burry). . ■ Placenta not expelled 1 hour after birth of the baby. not to pull on the cord to deliver the placenta. place the baby on the mother’s chest with skin-to-skin contact and wipe the baby’s eyes using a clean cloth for each eye. ■ Fits. ■ o dispose of the placenta in a correct. ■ To cover the mother and the baby. The cord is cut when it stops pulsating.Antenatal care AntenAtAl cAre HoMe delIvery wItHout A skIlled AttendAnt reinforce the importance of delivery with a skilled birth attendant c18 Instruct mother and family on clean and safer delivery at home If the woman has chosen to deliver at home without a skilled attendant. tell her/them: ■ To ensure a clean delivery surface for the birth. ■ Labour pains/contractions continue for more than 12 hours. ■ To use the ties and razor blade from the disposable delivery kit to tie and cut the cord.

■ ook for any abnormal vaginal L discharge c9 . CHeCk ReCoRD Look. ■ ook at the skin: L → Is there a rash? → re there blisters along the ribs A on one side of the body? ■ ook for visible wasting. LISTeN. (continuous or intermittent)? ■ o you have fever? D How long (>1 month)? ■ ave you had cough? H How long (> 1 month)? ■ ave you any difficulty in breathing? H How long (> 1 month)? ■ Have you noticed any change in vaginal discharge? the mouth (thrush).Assess elIGIBIlIty of Arv for HIv-PosItIve PreGnAnt woMAn use this chart to determine Arv needs for HIv-positive woman and her baby when appropriate HIv services and cd4 count are not available. AntenAtAl cAre Assesses eligibility of ARV for HIV-positive pregnant woman c19 . and underarm F for enlarged lymph nodes. FeeL ■ Have you lost weight? ■ Have you got diarrhoea ■ ook for ulcers and white patches in L SIGNS HIV-positive and any of the following: ■ Weight loss or no weight gain ■ Visible wasting ■ Diarrhoea > 1 month ■ Fever > 1 month ■ Cough > 1 month or difficult breathing ■ Cracks/ulcers around lips/mouth ■ Itching rash ■ Blisters along the ribs on one side of the body ■ enlarged lymph nodes ■ Abnormal vaginal discharge HIV-positive and none of the above signs CLASSIFY HIv-PosItIve wItH HIv-relAted sIGns And syMPtoMs TReAT AND ADVISe ■ Refer to hospital for further assessment. ■ Support initiation of ARV G6 . ■ Revise ANC visit accordingly c17 . ASk. neck. L ■ eel the head. HIv-PosItIve wItHout HIv-relAted sIGns And syMPtoMs ■ Give appropriate ARVs G9 .

This applies counter traction to the uterus during controlled cord traction. mouth. ■ Begin plotting the partograph n5 and manage the woman as in Active labour d9 . anxious) d6 . ■ Mood and behaviour (distressed. ■ Palpate uterus immediately to determine the lie of the second baby. ■ Explain to the parents that the baby is not doing ■ If room cool (less than 25°C). do not squeeze or push the uterus to deliver the placenta. ■ Ensure bladder is empty. observe closely for vaginal bleeding because this woman is at greater risk of postpartum haemorrhage. If referral takes a long time. ■ Provide immediate Postpartum care d19-d20 . but bleeding has stopped: → Plan to keep the woman in the facility for 24 hours. ■ Diastolic blood pressure >90 mmHg. ■ Cervical dilatation: late aCtive labour → multigravida ≥5 cm → primigravida ≥6 cm ■ Cervical dilatation ≥4 cm. and → no progress in cervical dilatation. FEEL ■ Look at vulva for: SIGNS ■ Bulging thin perineum. → Put placenta into a bag and place it into a leak-proof container. � next: Perform vaginal examination and decide stage of labour D3 CLASSIFY imminent delivery Childbirth: labour. At the same time. ■ Tell the birth companion what she or he should not do and explain why: do not encourage woman to push. d12 MONITOR BABY EVERY 15 MINUTES: ■ Breathing: listen for grunting. MANAGE ONLY IF IN LATE LABOUR ■ Rupture of membranes and any of: ■ Record findings regularly in Labour record and Partograph (pp. ■ Apply an antimicrobial within 1 hour of birth. ask the helper to attend to the second baby. ■ Note time of delivery. ■ If transfer not possible. ■ Gently wipe face clean with gauze or cloth. FEEL SIGNS CLASSIFY TREAT AND ADVISE d14 D14 if fetal heart rate (fhr) <120 or >160 beats per minute ■ Position the woman on her left side. ■ Visible descent of fetal head or during contraction. seek permission. do not give the mother oxytocin until after the birth of all babies. ■ If the woman is distressed. anxious) d6 . ■ Wait until head visible and perineum distending. treatments and procedures in Labour record and Partograph (pp. traction: → Place side of one hand (usually left) above symphysis pubis with palm facing towards the mother’s umbilicus. early aCtive labour not yet in aCtive labour ■ See first stage of labour — not active labour d8 ■ Record in labour record n4 . until it is hard b10 . of pregnancy (more than one month before estimated date of delivery). the perineum does not begin to thin and pre-eClampsia severe anaemia obstetriCal CompliCation ■ Assess further and manage as on d23 . ■ Fetal heart rate <120 or >160 beats per minute. ■ Assess baby’s breathing while drying. if necessary. do not pull excessively on the head. ■ Conduct delivery very carefully as small baby may pop out suddenly. ■ If bleeding from a perineal tear.Childbirth: labour. making a sighing noise. severely malformed): → Cut cord quickly: transfer to a firm. lower vagina and vulva for tears. → caesarean section → forceps or vacuum delivery. control delivery of the head. ■ To prevent pushing at the end of first stage of labour. ■ ■ if woman is distressed or anxious. deliver d10-d28 . find out what she has told the companion. ■ Check after 5 minutes. → If placenta does not descend during 30-40 seconds of controlled cord traction. There may be one large placenta with 2 umbilical cords. FEEL history of this labour: ■ When did contractions begin? ■ How frequent are contractions? How strong? ■ Have your waters broken? If yes. ■ Record time of rupture of membranes and colour of amniotic fluid. → Encourage woman to move around freely as she wishes and to adopt the position of her choice. . make an episiotomy. ■ If the head does not deliver ■ Place the baby astride your left forearm with limbs hanging on each side. safe place close to the mother. ■ DO NOT remove vernix or bathe the baby. d10 D10 MONITOR EVERY 5 MINUTES: ■ For emergency signs. D15 respond to problems during SIGNS ■ Transverse lie ■ Cord is pulsating LOOK. → Ask the mother to breathe steadily and not to push during delivery of the head. ■ Check the presentation by vaginal examination. ■ Wash your hands with soap before and after each examination. ■ Await the return of strong contractions and spontaneous rupture of the second bag of membranes. again keeping the back uppermost to deliver the other arm. first stage of labour (2): in aCtive labour ASK. ■ If. ■ Nutritious liquid drinks are important. ■ Pinch the skin of the forearm: does it go back quickly? examine the woman in labour or with ruptured membres First stage of labour (1): when the woman is not in active labour first stage of labour: not in aCtive labour use this chart for care of the woman when not in aCtive labour. INTERVENTIONS. ■ If trapped arms or shoulders ■ Feel the baby’s chest for arms. M chest. ■ Have help available during delivery. ■ Horizontal ridge across lower CLASSIFY obstruCted labour TREAT AND ADVISE ■ If distressed. ■ Introduce the right hand into the vagina along the posterior curve of the sacrum. ■ Record time of rupture of membranes and colour of amniotic fluid. exert more pressure on perineum. If not possible. ■ FHR remains >160 or <120 after 30 prolapsed Cord baby not well ■ Manage urgently as on d15 . observe breathing: → o not panic but call for help and ask companion to assist d → anage as in Stuck shoulders d17 . in a 2 m deep pit. ■ Continuous contractions. ■ Ask the companion to stay with the mother. do other supportive actions. Place identification label. ■ If not successful. → pain/discomfort increases → vaginal bleeding → membranes rupture. drinking ■ Encourage the woman to eat and drink as she wishes throughout labour. If a third baby is felt. ■ Give oral fluids. duration. do not perform episiotomy routinely. another position. Use clean gloves for vaginal give supportive Care throughout labour Third stage of labour: deliver the placenta third stage of labour: deliver the plaCenta use this chart for care of the woman between birth of the baby and delivery of placenta. ■ Encourage the woman to pass urine. manage as on b5 ■ If placenta is not delivered in another 30 minutes (1 hour after delivery): → Remove placenta manually b11 → Give appropriate IM/IV antibiotic b15 . LISTEN. ■ If late labour: respond to problems during labour and delivery (1) If fetal heart rate <120 or >160 bpm → Call for help during delivery → Monitor after every contraction. ■ Call for additional help. and ■ No fetal heart beat on ■ Ensure that the woman takes ARV drugs prescribed g9 . release both cord traction and counter traction on the abdomen and wait until the uterus is well contracted again. wash gloved hands. ■ Watch for vaginal bleeding. ■ Change gloves. insert an IV line and give fluids b9 ■ If in labour >24 hours. delivery and immediate postpartum Care use this chart to assess the woman’s and fetal status and decide stage of labour. ■ Ask the woman to assume an upright or squatting position to help progress. ■ Clean up spills immediately. ■ Examine the placenta and membranes for completeness. IF REqUIRED ■ If heavy bleeding: → Massage uterus to expel clots if any. TREAT AND ADVISE. manage as on d16 . give appropriate IM/IV antibiotics b15 . D12 MONITOR MOTHER EVERY 5 MINUTES: ■ For emergency signs. to take in 2 short breaths followed by a long breath out. ■ If obvious obstruction to progress (warts/scarring/keloid tissue/previous third degree tear). delivery and immediate postpartum Care Childbirth: labour. ■ Then proceed with delivery of head as described above. → Rub her back. are available. → If the membranes do not slip out spontaneously. when cervix dilated 4 cm or more. ■ Call for help during delivery. ■ Prepare equipment for resuscitation of newborn k11 . manage as on k9 . Label her/him Twin 2. . or if no record: ■ Ask when the delivery is expected. ■ never leave the woman alone. ■ Ask an assistant to apply continuous pressure downwards. look for chest in-drawing and fast breathing J2 ■ Warmth: check to see if feet are cold to touch J2 . when cervix dilated 0-3 cm and contractions are weak. ■ Record findings. perform vaginal examination ■ do not shave the perineal area. ■ Record in labour record n5 . ■ If breech or other malpresentation. → Give appropriate IM/IV antibiotic b15 . ■ Sudden and severe abdominal pain. → Assist the woman into a position that will allow the baby to hang down during delivery. ■ Listen to the fetal heart beat: → Count number of beats in 1 minute. → hold the woman’s hand and sponge her face between contractions. ■ never leave the woman and newborn alone. → Support perineum with other hand and cover anus with pad held in position by side of hand during delivery. the nose and mouth are free. ■ Cervical dilatation 4 cm or greater. pulse → vaginal bleeding → uterus. � next: If breech presentation Decide stage of labour d3 First stage of labour (2): when the woman is in active labour d9 Respond to problems during labour and delivery (2) If prolapsed cord d15 Respond to obstetrical problems on admission Childbirth: labour. then unwind. delivery and immediate postpartum Care Childbirth: labour. IF REqUIRED ■ If pad soaked in less than 5 minutes. → Monitor intensively (every 30 minutes) for 4 hours: → BP . ■ Feel for transverse lie. ■ Record findings. ■ Second stage of labour ■ Deliver the first baby following the usual procedure. ■ Attempt to deliver the posterior shoulder or arm using pressure from the finger of → thirsty → sunken eyes → dry mouth → skin pinch goes back slowly. ■ Ask helper to attend to the first baby. ■ Arrange for a helper to assist you with the births and care of the babies. ■ Put on gloves. minutes observation. with the palm of the ■ If placing newborn on abdomen is not acceptable. ■ If early labour: vulva for prolapsed cord. if cord is tight. ■ If bleeding persists and uterus is soft: → Continue massaging uterus until it is hard. ■ If feet are cold to touch or mother and baby are separated: Ensure the room is warm. CHECK RECORD LOOK. any continuous contractions? → fetal lie—longitudinal or transverse? → fetal presentation—head. ■ Prolapsed cord d15 . ■ When strong contractions restart. ■ Before and after delivery of the placenta and membranes. if pain is constant (persisting between contractions) and very severe or sudden in onset d4 . delivery and immediate postpartum Care ■ Warts. ■ Feel abdomen for: → contractions frequency. ■ Mood and behaviour (distressed. generous episiotomy. ■ If not able to drink. → Contractions stronger and more frequent but → No progress in cervical dilatation with or without membranes ruptured. turn woman on her left side and count again. if prolapsed Cord the cord is visible outside the vagina or can be felt in the vagina below the presenting part. trunk and shoulders to deliver spontaneously during contractions. hands and feet. TREAT AND ADVISE IF REqUIRED ■ Rupture of membranes at <8-months of pregnancy. If still cold. delivery and immediate postpartum Care Childbirth: labour. → Encourage her to drink fluids and eat as she wishes. → After delivery of the shoulders allow the baby to hang until next contraction. ■ Blood pressure d23 . ■ If woman is bleeding. ■ Give Supportive care d6-d7 . do not cross ankles. cover the head with a hat. and discuss findings with the woman. deliver the placenta and membranes by controlled cord traction. ■ If baby is stillborn or dead. ■ HIV test positive. ■ Cervix dilated 10 cm or bulging perineum. apply steady. ■ Ask the woman to lie on her back while gripping her legs tightly flexed against her SIGN ■ Fetal head is delivered. → Allow buttocks. using rapid assessment (RAM) b3-b7 ■ Feel if uterus is hard and round. ■ Rupture of membranes at term and possible fetal distress rupture of membranes dehydration ■ Manage as on d14 . ■ If woman is lying. D4 SIGNS ■ Transverse lie. to breathe with an open examination. ■ Then turn the baby back. respond to obstetriCal problems on admission (2) → Keep one hand gently on the head as it advances with contractions. call for staff trained to use vacuum extractor or refer urgently to hospital b17 . is it meconium stained. uterine and fetal infeCtion ■ Give appropriate IM/IV antibiotics b15 . treatments and procedures in Labour record and Partograph n4-n6 . await second stage. LISTEN. Is it hard. → Feel for presenting part. ■ Keep the mother and baby in delivery room for a minimum of one hour after delivery of placenta. ■ Deliver the second baby. LISTEN. use additional blanket to cover the mother and baby. turn the baby. encouraging atmosphere for birth. ■ Ask the birth companion to call for help if: D7 birth Companion third stage of labour: deliver the plaCenta (2) Care of the mother and newborn within first hour of delivery of plaCenta use this chart for woman and newborn during the first hour after complete delivery of placenta. catch in both hands to prevent tearing of the membranes. FEEL ■ On external examination fetal head felt d16 D16 SIGN ■ If early labour ■ If late labour TREAT ■ refer urgently to hospital b17 . d8 D8 MONITOR EVERY HOUR: ■ For emergency signs. ■ Constant pain between contractions. delivery and immediate postpartum Care Childbirth: labour. delivery and immediate postpartum Care respond to obstetriCal problems on admission use this chart if abnormal findings on assessing pregnancy and fetal status d2-d3 d4 Childbirth: labour. Reassess in 2 hours and refer if no progress. place the index and ring fingers of the right hand over the baby’s shoulders and the middle finger on the baby’s head to gently aid flexion until the hairline is visible. ■ Encourage woman to empty bladder. ■ If heavy bleeding. usually within 1 hour of birth of first baby. ■ Perform gentle vaginal examination (do not start with contraction. ■ Wash the vulva and perineal areas before each examination. ■ If in 1 hour unable to remove placenta: → Refer the woman to hospital b17 do not attempt to deliver the placenta until all the babies are born. warm. ■ Stay with her and offer her emotional and physical support d10-d11 . using rapid assessment (RAM) b3-b7 ■ Frequency. ■ Look for sunken eyes. intensity and duration of contractions. for example. → Incinerate the placenta or bury it at least 10 m away from a water source. ■ Ensure bladder is empty. ■ Apply gentle downward pressure to deliver top shoulder. kneeling. do not do vaginal examination more frequently than every 4 hours. → She is suddenly in much more pain. unwell. while you maintain continuous downward traction on the fetal head. If not felt: ■ Hold the baby gently with hands around each thigh and thumbs on sacrum. ■ Severe palmar and conjunctival ■ If unable to pass urine and bladder is full. hand on the abdomen directly above the pubic area. ■ Encourage her to use the breathing technique. when? How much? ■ Is the baby moving? ■ Do you have any concern? Check record. Cover mother and baby with a blanket → → Reassess in 1 hour. see Prolapsed cord d15 . ■ If delay in delivery of shoulders: shoulders are stuck and cannot be delivered. ■ Check that placenta and membranes are complete. ■ Perform an adequate episiotomy. ■ Pulse b3 . cover her. ■ Ensure adequate hydration but omit solid foods. perform vaginal examination d3 to check for prolapsed cord. ■ If membranes have ruptured. D13 . ■ Fetal heart rate d14 . Childbirth: labour. CARE OF MOTHER AND NEWBORN woman ■ Assess the amount of vaginal bleeding. ■ Praise her. ■ Observe the woman’s response to contractions: → Is she coping well or is she distressed? → Is she pushing or grunting? ■ Check abdomen for: → caesarean section scar. delivered and surgical help is not available immediately. ■ Discard soiled pad to prevent infection. FOR ALL SITUATIONS IN RED BELOW. DELIVER THE PLACENTA ■ Ensure 10-IU oxytocin IM is given d11 . ■ If the baby is not breathing or gasping (unless baby is dead. Put sanitary pad or folded clean cloth under her newborn ■ Wipe the eyes. ■ Give Supportive care d6-d7 . ■ Repeat FHR count after 15 minutes. warm surface. ■ Then lift baby up. ■ Labour before 8 completed months D5 . go to third stage of labour. repair if required b12 or refer to hospital b17 . ■ If the woman has visible severe wasting or tires during labour. ■ If late labour. raise the baby in upward and forward direction towards the mother’s abdomen until . ■ Soft body part (leg or buttocks) felt on vaginal examination. ■ Prepare for newborn resuscitation. →Support the mother's choice of newborn feeding g8 . ■ CALL FOR HELP - one person should care for the mother. ■ Place baby on abdomen or in mother’s arms. ■ If known HIV positive. respond to problems during labour and delivery (5) If multiple births encourage her to breathe more slowly. → Give oxytocin 10 IU IM b10 . → If less than 100 beats per minute. if early labour: ■ Push the head or presenting part out of the pelvis and hold it above the brim/pelvis with your hand on the abdomen until caesarean section is performed. ■ never leave the woman alone. ■ Gently guiding the baby down. respond to obstetriCal problems on admission (1) Second stage of labour: deliver the baby and give immediate newborn care (1) seCond stage of labour: deliver the baby and give immediate newborn Care use this chart when cervix dilated 10 cm or bulging thin perineum and head visible. ■ If third degree tear (involving rectum or anus). see b5 . do not exert excessive traction on the cord. Put on gloves just before delivery. ■ Check ARV treatment needed g9 . ■ Palpate mother’s abdomen. MONITOR MOTHER EVERY 15 MINUTES: ■ For emergency signs. anxious) d6 . → Use gloves when handling placenta. risk of uterine and fetal infeCtion signs of infection. ■ If two or more of the following signs: ■ Give appropriate IM/IV antibiotics if rupture of membrane >18 hours b15 . ■ Measure blood pressure. examine the baby as on J2-J8 . Include: → more warm cloths → two sets of cord ties and razor blades → resuscitation equipment for 2 babies. ■ Encourage warm bath or shower. FEEL ■ Look at or feel the cord gently for CLASSIFY obstruCted labour fetus alive TREAT ■ refer urgently to hospital b17 . after 30 minutes of spontaneous expulsive efforts. → either 1% silver nitrate drops or 2. ■ Cervical dilatation: 0-3 cm. delivery and immediate postpartum Care D6 Communication ■ Explain all procedures. . or other complication such as postpartum haemorhage? ■ Any prior third degree tear? Current pregnancy: ■ RPR status C5 . ■ Clean the woman and the area beneath her. or the mother cannot hold the baby. ■ Allow her to push as she wishes with contractions. Check the fetal heart rate. or local feeds. MONITOR EVERY 4 HOURS: . ■ Never leave the woman alone. ■ Fetal distress d14 . but may be longer. ■ Encourage companion to: Mobility ■ Encourage the woman to walk around freely during the first stage of labour. identify the presenting part. ■ If cervix is not fully dilated. dry mouth. � next: Care of the mother and newborn within first hour of delivery of placenta Childbirth: labour. Wipe eyes. ■ DO NOT give artificial teats or pre-lacteal feeds to the newborn: no water. repeat oxytocin 10-IU-IM. ■ Give Supportive care d6-d7 . full cervical dilatation. ■ Multiple pregnancy d18 . ■ Support her choice of infant feeding g7-g8 . . � DELIVER THE BABY TREAT AND ADVISE. look for chest in-drawing and fast breathing J2 ■ Warmth: check to see if feet are cold to touch J2 . → There is vaginal bleeding. . ■ If blood loss ≈ 250-ml. → Fever >38˚C → Foul-smelling vaginal discharge. If unable to empty bladder see Empty bladder b12 . ■ Immediate postpartum care ■ Monitor intensively as risk of bleeding is increased. D2 ASK. deliver and refer to hospital after delivery b17 . → She loses consciousness or has fits. → Help her to breathe and relax. ■ Any prior caesarean section. ■ Labour >24 hours. refer to hospital b17 . ■ Assist the woman into a comfortable position of her choice. gently turn the baby by abdominal manipulation to head or breech presentation. ■ When the membranes rupture. D19 → The woman is bearing down with contractions. you will give her a vaginal examination and ask for her consent. ■ If uterus soft. Then repeat controlled cord traction with counter traction. If FHR does not return to normal in 15 minutes explain to the woman (and her companion) that the baby may not be well. ■ Wash hands with clean water and soap. ■ Infant feeding plan g7-g8 . sugar water. keloid tissue or scars that may interfere with delivery. refer urgently to hospital if in early labour. ■ Prepare for newborn resuscitation k11 . ■ Legs or buttocks presenting at perineum. ■ Encourage her to breathe out more slowly. sustained controlled cord traction. D9 ASSESS PROGRESS OF LABOUR ■ Partograph passes to the right of ALERT LINE. Breathing technique ■ Teach her to notice her normal breathing. ■ Manage as on d24 . ■ Cervical dilatation d3 d15 . empty bladder b12 . encourage and reassure her that things are going well. keeping the back uppermost until the shoulder which was do not urge her to push. → Feel for membranes – are they intact? → Feel for cord – is it felt? Is it pulsating? If so. ■ If placenta is incomplete: → Remove placental fragments manually b11 . ■ If HIV-positive mother has chosen replacement feeding. Childbirth: labour. deliver the baby through the loop of cord or slip the cord over the baby’s head. ■ Taking ARV treatment or prophylaxis ■ If blood oozing. ■ FHR returns to normal. ■ Keep mother and baby in delivery room - do not separate them. ■ In addition: → Insert an IV line and give fluids with 20 IU of oxytocin at 30 drops per minute during transfer b9 . ■ Pulse b3 . If bleeding persists. delivery and immediate postpartum Care . ■ Hb results C4 . ■ Clamp and cut the cord. add 20 IU of oxytocin to IV fluids and give at 60 drops per minute n9 → Empty the bladder b12 . ■ Time since third stage began (time since birth). using rapid assessment (RAM) b3-b7 ■ Frequency. labour and delivery (2) If prolapsed cord pulsations. ■ Remove wet cloths from underneath her. ■ Wash vulva and perineal areas. ■ For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. ■ Fetal heart rate d14 . do not keep woman in bed if she wants to move around. ■ DO NOT wash away the eye antimicrobial. ■ If unable to initiate breastfeeding (mother has complications): → Plan for alternative feeding method k5-k6 . ■ Determine if preterm (less than 8 months pregnant). → Start an IV line b9 . → cut between ties with sterile instrument. ■ Palpate the uterus for a third baby. ■ If late labour. deliver d10-d28 . delivery and immediate postpartum Care SIGNS CLASSIFY TREAT AND ADVISE ■ Ensure controlled delivery of the head: D11 if stuCk shoulders (shoulder dystoCia) D17 TREAT ■ Call for additional help. when? Were they clear or green? ■ Have you had any bleeding? If yes. safe and culturally appropriate manner. ■ Bleeding any time in third trimester. ■ HIV status C6 . delivery and immediate postpartum Care Examine the woman in labour or with ruptured membranes Childbirth: labour. In particular. ■ Feel gently around baby’s neck for the cord. ■ Manage as in Second stage of labour d10-d11 . ■ See if liquor was meconium stained. If present. ■ Age less than 14 years . ■ Position the woman with legs flexed and apart. estimate and record blood loss throughout third stage and immediately afterwards. ■ After 8 hours if: ■ Discharge the woman and advise her to return if: first stage of labour (1): when the woman is not in aCtive labour Respond to problems during labour and delivery (1) If FHR <120 or >160 bpm respond to problems during labour and delivery ASK. wipe her brow with a wet cloth. to make sure it is well contracted. forceps. do not bandage or bind the stump. IF REqUIRED ■ Reassess woman and consider criteria for referral. ■ Check if the face is clear of mucus and membranes. intensity and duration of contractions. ■ Deliver the second baby. delivery and immediate postpartum Care Childbirth: labour. hiv-positive → put ties tightly around the cord at 2 cm and 5 cm from baby’s abdomen. ■ Record in partograph n5 . ■ Dispose of placenta in the correct. ■ Encourage upright position and walking if woman wishes. ■ If she feels dizzy. as comfortable for her. the placenta is not delivered and the woman is NOT bleeding: → Empty bladder b12 Pain and discomfort relief ■ Suggest change of position. after 30 minutes of giving oxytocin. next: If stuck shoulders Childbirth: labour. ■ Blood pressure d23 . ■ never leave the woman alone. If feeling chilled. do not leave the baby wet - she/he will become cold. standing supported by the companion) for each stage of labour and delivery. ■ Support the woman’s choice of position (left lateral. get help. pallor and/or haemoglobin <7-g/dl. Offer her help. never pull on the breech do not allow the woman to push until the cervix is fully dilated. → If not possible to observe at the facility. ■ Mood and behaviour (distressed. ■ Partograph passes to the right of ACTION LINE. LISTEN. breech. vagina MANAGE ■ See second stage of labour d10-d11 . ■ Breech or other malpresentation d16 . ■ Describe to the birth companion what she or he should do: DELIVER THE PLACENTA ■ Check that uterus is well contracted and there is no heavy bleeding. Birth companion d7 Third stage of labour: deliver the placenta d13 Care of the mother within first hour of delivery of placenta d19 . Encourage breathing technique d6 . do not do vaginal examination more frequently than every 4 hours. → Continue IV fluids with 20 IU of oxytocin at 30 drops per minute. ■ Prior delivery by: risk of obstetriCal CompliCation ■ Do a generous episiotomy and carefully control delivery of the head d10-d11 . chest in-drawing or fast breathing. empty bladder b12 and observe again). MONITOR BABY EVERY 15 MINUTES: ■ Breathing: listen for grunting. ASSESS PROGRESS OF LABOUR ■ After 8 hours if: TREAT AND ADVISE. MONITOR EVERY 30 MINUTES: ■ For emergency signs. ■ Encourage the woman to eat and drink. ask her not to push but to breathe steadily or to pant. applying traction to all cords together d12-d23 . teach her to pant. ■ Examine perineum. ■ If second stage lasts for 2 hours or more without visible steady descent of the head. delivery and immediate postpartum Care examine the woman in labour or with ruptured membranes first do rapid assessment and management b3-b7 . as upright as possible.50C. but ■ If cord present and loose. place a second tie between the skin and the first tie. ■ Assist her to adopt a kneeling on “all fours” position and ask her companion to before labour. d6 Eating. staff) to position the woman’s buttocks higher than the shoulder. ■ Wash hands with soap before and after each contractions weak and <2 in 10 minutes. stretch with contractions. IF REqUIRED ■ If potentially damaging expulsive efforts. ■ Instruct assistant (family. or more than 180. ■ Do vaginal examination to determine status of labour. Resuscitate if necessary. ■ Perineum thinning and bulging. abdomen. anxious) d6 . ■ Cervical dilatation d3 d15 . IF REqUIRED ■ refer the woman urgently to hospital b17 . The assistant gives supra pubic pressure during the period to maintain flexion. delivery and immediate postpartum Care Childbirth: labour. → Assist her to the toilet when needed. → When buttocks are distending. and → membranes are not ruptured. ■ If the shoulders are still not ■ Remain calm and explain to the woman that you need her cooperation to try → breathing well (chest rising)? → not breathing or gasping? ■ Exclude second baby. ■ Encourage mobility. encourage her to lie on her left side. or a separate placenta with an umbilical cord for each baby. ■ Fetal heart rate d14 . respectful of the woman’s wishes. ■ Thoroughly dry the baby immediately. Ask the companion or other helper to keep the legs in that position. or vacuum. Help her to change clothes if necessary. investigate the cause d2-d3 . ■ Third stage of labour ■ Give oxytocin 10 IU IM after making sure there is not another baby. macerated. MONITOR EVERY 4 HOURS: . CHECK RECORD LOOK . CHECK RECORD LOOK. → As the placenta is coming out. � next: If multiple births Respond to obstetrical problems on admission d5 Second stage of labour: deliver the baby and give immediate newborn care (2) d11 Respond to problems during labour and delivery (4) If stuck shoulders d17 Give supportive care throughout labour Childbirth: labour. → Encourage her. refer examination. → observe for oozing blood. Respect her wishes. do a vaginal examination to confirm full dilatation of cervix. ■ Repeat check every 5 minutes. → refer the woman urgently to hospital b17 → Keep her lying on her left side. � next: Give supportive care throughout labour repeated examination well. ■ Place the middle and index fingers of the left hand over the malar cheek bones on either side to apply respond to problems during labour and delivery (3) If breech presentation after several contractions gentle downwards pressure to aid flexion of head. manage as on d22 . third stage of labour: deliver the plaCenta (1) Respond to problems during labour and delivery (5) If multiple births if multiple births SIGN ■ Prepare for delivery d18 D18 TREAT ■ Prepare delivery room and equipment for birth of 2 or more babies. including newborn resuscitation equipment. → Always carry placenta in a leak-proof container. ■ Prior third degree tear. give supportive care to mother and her family d24 . → bulging perineum → any visible fetal parts → vaginal bleeding → leaking amniotic fluid. squating. Manage as in Multiple pregnancy d18 . and to relax with each breath. keloid tissue that may interfere with delivery. delivery and immediate postpartum Care give supportive Care throughout labour use this chart to provide a supportive. ■ Explain the problem to the woman and her companion. ■ Plan to treat the newborn J5 . ■ do not let her lie flat (horizontally) on her back. ■ See Universal precautions during labour and delivery a4 . do not give oxytocin now. ■ Follow specific instructions (see page numbers in left column). → If mother HIV-positive: give treatment to the newborn g9 . → Call for help. baby well ■ Monitor FHR every 15 minutes. act immediately as on d15 . delivery and immediate postpartum Care Childbirth: labour. Unless indicated. fetus probably dead ■ Explain to the parents that baby may not be well. refer urgently to hospital b17 . ■ Mood and behaviour (distressed. ■ If late labour. If less than 36. LISTEN. buttocks to collect blood. with knees wide apart. feed accordingly. . ■ No fetal movement. ■ Plan to treat newborn J5 . ■ Cover the baby. → Encourage breastfeeding → Repeat controlled cord traction. ■ Give Supportive care d6-d7 . and place of delivery is clean and warm (25°C) l3 . if prior pregnancies: ■ Number of prior pregnancies/ deliveries. ■ Give 10 IU oxytocin IM to the mother. other? → more than one fetus? → fetal movement. If no third baby is felt. ■ Encourage initiation of breastfeeding k2 do not apply any substance to the stump. respond to problems during labour and delivery (4) If stuck shoulders ■ Await spontaneous rotation of shoulders and delivery (within 1-2 minutes). allow labour to continue. → Encourage rapid breathing with mouth open. ■ Call senior person if available. ■ Ensure and respect privacy during examinations and discussions. → Always be with the woman. → Assist the woman when she first walks after resting and recovering. hold her steady - this simple change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery. → Give support using local practices which do not disturb labour or delivery. delivery and immediate postpartum Care Childbirth: labour. Use Assess the mother after delivery d21 and Examine the newborn J2-J8 . start Newborn resuscitation k11 . less than 2 in 10 minutes. ■ Discontinue antibiotic for mother after delivery if no DELIVER THE BABY ■ Ensure all delivery equipment and supplies. ■ Await strong uterine contraction (2-3 minutes) and deliver placenta by controlled cord TREAT AND ADVISE IF REqUIRED ■ If. ■ do not give enema. ■ Encourage the mother to initiate breastfeeding when baby shows signs of readiness. look at ■ Cord seen at vulva. ■ Record findings regularly in Labour record and Partograph n4-n6 . TREAT AND ADVISE. → refer woman urgently to hospital b17 . → Apply bimanual or aortic compression b10 . ■ Tetanus immunization status f2 . ■ Monitor intensively. or constant trickle of blood. manage as on b10 . ■ If trapped head (and baby is dead) ■ Tie a 1 kg weight to the baby’s feet and await full dilatation. Discard wet cloth. preterm labour ■ Reassess fetal presentation (breech more common). Place woman on her left side and discourage pushing. repair the tear b12 . → horizontal ridge across lower abdomen (if present. CHECK RECORD ■ Explain to the woman that deCide stage of labour � next: If prolapsed cord first stage of labour: in aCtive labour use this chart when the woman is in aCtive labour.N4-N6). → Prepare for newborn resuscitation k11 . ■ Review the birth plan. Unless indicated. if late labour: ■ Call for additional help if possible (for mother and baby). place the baby in a clean. if yes. possible fetal death .. ■ Cord is not pulsating immediately (DO NOT wait to cross action line). ■ Prepare: gaping and head visible. ■ Ensure cleanliness of labour and birthing area(s). Alert emergency transport services. ask the mother to bear down when she feels ready. do not give advice other than that given by the health worker. → no increase in contractions. delivery and immediate postpartum Care deCide stage of labour ASK. ■ If blood or meconium. Cleanliness ■ Encourage the woman to bathe or shower or wash herself and genitals at the onset of labour. clamp and cut cord. . ■ Give appropriate IM/IV antibiotics b15 . ■ Keep her informed about the progress of labour. foul-smelling? → warts. ■ Plan to treat newborn J5 . refer urgently to hospital b17 . Care of the mother and newborn within first hour of delivery of plaCenta ■ Examine the mother and newborn one hour after delivery of placenta. ■ Deliver the baby: in fundus. round and smooth (the head)? If not. propped up with buttocks at edge of bed or onto her hands and knees (all fours position). ■ Confirm full dilatation of the cervix by vaginal examination d3 . ■ Then proceed with delivery of head as described above. ■ Leave baby on the mother’s chest in skin-to-skin contact. ■ When the uterus is well contracted. Urination ■ Encourage the woman to empty her bladder frequently. ■ Collect. Remind her every 2 hours.5% povidone iodine drops or 1% tetracycline ointment. → clean gloves → swabs. ■ refer urgently to hospital b17 . → There is any other concern. using rapid assessment (RAM) b3-b7 ■ Feel if uterus is well contracted. ■ Stay with the woman and continue monitoring her and the fetal heart rate intensively. ■ After cutting the cord. ■ refer to hospital now if woman had serious complications at admission or during delivery but was in late labour. Pushing too soon may cause the head to be trapped. → Keep mother in health centre for longer observation → Plan to measure haemoglobin postpartum if possible → Give special support for care and feeding of babies J11 and k4 . ■ refer urgently to hospital b17 .N4-N6). ■ Keeping the left hand as described. If bleeding. gently twist them into a rope and move them up and down to assist separation without tearing them. intensity and duration of contractions. If transverse or oblique lie. Resuscitate if necessary. wipe off with wet cloth and dry. then d2 Childbirth: labour. pads. ■ refer urgently to hospital b17 unless birth is imminent. ■ If the baby is not crying. make sure she eats and drinks. give 1 litre IV fluids over 3 hours b9 ■ If second baby. Label her/him Twin 1. � next: Respond to obstetrical problems on admission. ■ Expedite delivery by encouraging woman to push do not perform vaginal examination if bleeding now or at any time after 7 months of pregnancy. delivery and immediate postpartum Care Birth companion ■ Encourage support from the chosen birth companion throughout labour. towards the mother’s abdomen to deliver lower shoulder. ■ Prepare for Newborn resuscitation k11 . encourage pain discomfort relief d6 seCond stage of labour: deliver the baby and give immediate newborn Care (1) seCond stage of labour: deliver the baby and give immediate newborn Care (2) Respond to problems during labour and delivery (3) If breech presentation if breeCh presentation LOOK. do a posterior (below) is now anterior (at the top) and the arm is released. is feeling pins-and-needles (tingling) in her face. ■ During delivery of the head. using rapid assessment (RAM) b3-b7 ■ Frequency. and infant feeding. during a contraction): → Determine cervical dilatation in centimetres. → massage the woman’s back if she finds this helpful. delivery and immediate postpartum care Childbirth: labour. ■ See first stage of labour – active labour d9 ■ Start plotting partograph n5 . ■ Temperature. ■ Record findings regularly in Labour record and Partograph n4-n6 . ■ Look for pallor. ■ Measure temperature. measure temperature. → Leave the perineum visible (between thumb and first finger). ■ Temperature. ■ Complete the rest of delivery as normal. delivery and immediate postpartum Care Childbirth: labour. even in late labour. ■ Continue keeping the baby warm and in skin-to-skin contact with the mother. the right hand to hook the posterior shoulder and arm downwards and forwards through the vagina. ■ If disposing placenta: ■ If breathing with difficulty — grunting. ■ When the hairline is visible. proceed as described above. . if available.

see g1-g11 h1-h4 . ■ Measure temperature every 4 hours. ■ Check when last dose of mebendazole was given. see J2-J8 . Give preventive measures d25 Childbirth: labour. CheCk for anaemia ■ Bleeding during labour. Assess the mother after delivery d21 Counsel on birth spacing and family planning d27 Respond to problems immediately postpartum (1) Childbirth: labour. ■ if late labour: ≥90 mmHg. ■ Examine the baby before leaving n2-n8 . no complementary foods or fluids). Advise the woman against these taboos. ■ Counsel on nutrition d26 . If pallor: and/or ■ Severe palmar and conjunctival pallor or ■ Any pallor with >30 breaths per minute. ■ Palmar or conjunctival pallor. refer woman to hospital e17 . and the delivery kit. and family planning. ■ 2+ proteinuria (on admission). ■ Feel uterus if hard and round. feels dizzy or has severe headaches. ask the woman if she would like her partner or another family member to be included Childbirth: labour. for examining the newborn use the chart on J2-J8 . Immediate postpartum care of mother ■ Stay with the woman for first two hours after delivery of placenta C2 C13-C14 . ■ Maintain the partograph and labour record n4-n6 . ■ Pulse normal. ask the woman if she has: → severe headache → blurred vision → epigastric pain and → check protein in urine. ■ Look for palmar pallor. advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. days of delivery. offer her the test e5 . ■ Determine if there are important taboos about foods which are nutritionally healthy. visual disturbance or epigastric distress. ■ Check if vitamin A given. Childbirth: labour. if she has sex and is not exclusively breastfeeding. LISTEN. ■ If BP remains elevated after delivery. ■ For HIV-positive women. ■ Discuss with woman and her partner and family about emergency issues: episiotomy ■ Does it extend to anus or rectum? . and → her menstrual cycle has not returned. delivery and immediate postpartum Care ASK. ■ Ensure the room is warm (25°C). FEEL ■ If diastolic blood pressure is SIGNS ■ Diastolic blood pressure CLASSIFY severe pre-eClampsia TREAT AND ADVISE ■ Give magnesium sulphate b13 . ■ If temperature persists for >12 hours. ■ Keep mother and baby in labour room for one hour after delivery rises rapidly. CHECK RECORD LOOK. Counsel on birth spaCing and family planning Counsel on importance of family planning Lactation and amenorrhoea method (LAM) ■ If an abnormal sign is identified. ■ If in early labour or postpartum. → If uterus not firm. hypertension ■ Diastolic blood pressure ≥90 mmHg on 2 readings. ■ Feel the uterus. ■ ■ Advise on postpartum care d26 . using rapid assessment (RAM). refer urgently to hospital b17 . Postpartum care of newborn ■ Stay until baby has had the first breastfeed and help the mother good positioning and attachment b2 ■ Advise on breastfeeding and breast care b3 . repair the tear or episiotomy b12 condition. Delivery care ■ Follow the labour and delivery procedures d2-d28 k11 . ■ To have enough rest and sleep. ■ Advise on newborn care b9-b10 . ■ Look for palmar pallor. ≥90 mmHg and 2+ proteinuria and any of: → severe headache → blurred vision → epigastric pain. LISTEN. delivery and immediate postpartum Care give preventive measures ensure that all are given before discharge. ■ If attending a delivery at the woman’s home. ■ refer urgently to hospital after delivery b17 . check for anaemia If mother severely ill or separated from baby If baby stillborn or dead ■ Examine the mother for discharge using chart on d21 . ■ Advise the woman to bring her home-based maternal record to the health centre. ■ No perineal problem. ■ Counsel on nutrition d26 . ■ Encourage the mother to empty her bladder and ensure that she has ■ If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is passed urine. ■ To avoid sexual intercourse until the perineal wound heals. cheese. CARE OF MOTHER ■ Accompany the mother and baby to ward. ■ Continue any treatments initiated earlier. ■ If HIV-positive: → Support adherence to ARV g6 . ■ Keep the mother and baby together. delivery and immediate postpartum Care assess the mother after delivery D21 TREAT AND ADVISE ■ Keep the mother at the facility for 12 hours after assess the mother after delivery Lactational amenorrhoea method (LAM) ■ A breastfeeding woman is protected from pregnancy only if: ASK. nutrition and family planning d26-d27 . � next: If elevated diastolic blood pressure Childbirth: labour. refer urgently to hospital b17 . ■ never leave the woman and newborn alone. Preparation for home delivery ■ Check emergency arrangements. ■ Ask whether woman and baby are sleeping under insecticide treated bednet. risk of uterine and fetal infeCtion ■ Encourage woman to drink plenty of fluids. → Show the baby to the mother. delivery and immediate postpartum Care Childbirth: labour. help her by gently pouring water on vulva. refer urgently to hospital e17 . manage as on b5 . ■ Observe universal precautions a4 . ■ severe abdominal pain. ■ Advise on routine and follow-up postpartum visits d28 . treatments and procedures in Labour record and Partograph n4-n6 . ■ Counsel on birth spacing and family planning d27 . ■ Advise the family about danger signs and when and where to seek care b14 . refer to hospital e17 . make plans before discharge. Is it hard and delivery. Counsel on birth spaCing and family planning Counsel on the importance of family planning ■ If appropriate. do not catheterize unless you have to. ■ Counsel on birth spacing and other family planning methods d27 . FEEL if vaginal bleeding ■ A pad is soaked in less than 5 ■ More than 1 pad soaked in d22 CLASSIFY heavy bleeding Childbirth: labour. ■ Encourage the mother to eat. such as meat. → monitor blood pressure every hour → do not give ergometrine after delivery. for newborn babies see the schedule on encourage woman to bring her partner or family member to at least one visit. red or tender breasts. vegetables. moderate anaemia ■ do not discharge before 24 hours. ■ Advise on when to seek care and next routine postpartum visit d28 . beans. and decide the stage of labour. ■ Explain that after birth. when mmHg on two readings. fish. ■ No pallor. ■ Examine the mother before leaving her d21 . ■ Carry with you all essential drugs b17 . as soon as 4 weeks after delivery. see g4 for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time. Respond to problems immediately postpartum (3) Childbirth: labour. FEEL SIGNS ■ Haemoglobin <7 g/dl. delivery or postpartum. . as on C18 . to encourage them to help ensure the woman eats enough and avoids hard physical work. home delivery by skilled attendant Preparation for home delivery Delivery care Immediate postpartum care of the mother Postpartum care of the newborn and use charts Care of the mother and newborn within first hour of delivery placenta on d19 . CHECK RECORD LOOK. seeds. pre-eClampsia ■ Diastolic blood pressure 90-110 → continue magnesium sulphate treatment b13 → monitor blood pressure every hour. g9 . use the charts on respond to obstetrical problems on admission d4-d5 . ■ Discuss how to prepare for an emergency in postpartum d28 . danger signs. obstetrical history. day or night. if mother severely ill or separated from the baby ■ Teach mother to express breast milk every 3 hours k5 . delivery and immediate postpartum Care Care of the mother one hour after delivery of plaCenta use this chart for continuous care of the mother until discharge. ■ Repeat examination of the mother before discharge using Assess the mother after delivery d21 . even for an emergency visit. LISTEN. Ensure baby receives mother’s milk k8 . delivery and immediate postpartum Care for care of the baby. � next: Give preventive measures ■ Advise the mother on breast care k8 . ■ Assess the newborn J2-J8 . ■ If late labour: respond to problems immediately postpartum (2) If elevated diastolic blood pressure home delivery by skilled attendant use these instructions if you are attending delivery at home. Routine postpartum care visits first visit d19 seCond visit e2 Within the first week. If she (and her partner) want more children. method options for the non-breastfeeding woman Can be used immediately postpartum Condoms Progestogen-only oral contraceptives Progestogen-only injectables Implant Spermicide Female sterilization (within 7 days or delay 6 weeks) c opper IUD (immediately following expulsion of placenta or within 48 hours) delay 3 weeks Combined oral contraceptives Combined injectables Fertility awareness methods → she is no more than 6 months postpartum. Childbirth: labour. ■ Give tetanus toxoid if due f2 . if perineal tear or episiotomy (done for lifesaving CirCumstanCes) ■ Is there bleeding from the tear or ■ Tear extending to anus or rectum. → Treat the newborn g9 . records. ■ Give mebendazole once in 6 months f3 ■ Check tetanus toxoid (TT) immunization status. → do not give ergometrine after delivery. ■ Use give supportive care throughout labour d6-d7 to provide method options for the breastfeeding woman Can be used immediately postpartum Lactational amenorrhoea method (LAM) Condoms Spermicide Female sterilisation (within 7 days or delay 6 weeks) copper IUD (within 48 hours or delay 4 weeks) delay 6 weeks Progestogen-only oral contraceptives Progestogen-only injectables Implants Diaphragm delay 6 months Combined oral contraceptives Combined injectables Fertility awareness methods � next: Respond to problems immediately postpartum If no problems. . without waiting. do the RPR test l5 TREAT AND ADVISE ■ If RPR positive: . cereals. ■ Check record and give any treatment or prophylaxis which is due. return within a day to check the mother and baby. delivery and immediate postpartum Care use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge. or more frequently if heavy lochia → wash used pads or dispose of them safely → wash the body daily. . → Treat the newborn k12 . D29 . Involve the companion in care and support d6-d7 . massage the fundus to make it contract and expel any clots b6 → If pad is soaked in less than 5 minutes. CHECK RECORD LOOK. delivery and immediate postpartum care d1 . ■ refer urgently to hospital b17 . ■ Check woman’s supply of prescribed dose of iron/folate. ■ If HIV test not done. where culturally appropriate. repair or refer to hospital b17 . 5 minutes ■ Uterus not hard and not round if fever (temperature >38ºC) ■ Time since rupture of membranes ■ Abdominal pain ■ Chills ■ Repeat temperature measurement ■ Temperature still >380C and any of: after 2 hours ■ If temperature is still >38ºC → Look for abnormal vaginal discharge. ■ If diastolic blood pressure is still ≥110 mmHg OR ■ Diastolic blood pressure ≥90-mmHg. give the baby to the mother to hold. → Discuss with them the events before the death and the possible causes of death. ■ If HIV-positive: give her appropriate treatment g6 . ■ Counsel on birth spacing and family planning d27 . no anaemia ■ Give iron/folate for 3 months f3 . ■ Counsel on safer sex including use of condoms g2 . ■ convulsions. ■ Spend more time on nutrition counselling with very thin women and adolescents. or sore nipple ■ urine dribbling or pain on micturition ■ pain in the perineum or draining pus ■ foul-smelling lochia Follow-up visits for problems if the problem was: Fever Lower urinary tract infection Perineal infection or pain Hypertension Urinary incontinence Severe anaemia Postpartum blues HIV-positive Moderate anaemia If treated in hospital for any complication return in: 2 days 2 days 2 days 1 week 1 week 2 weeks 2 weeks 2 weeks 4 weeks According to hospital instructions or according to national guidelines. respond to problems immediately postpartum (3) If pallor on screening. ■ Councel on safer sex including use of condoms for dual protection from sexually transmitted infection (STI) or HIV and pregnancy. especially if at risk for sexually transmitted infection (STI) or HIV g2 .Care of the mother one hour after delivery of placenta Childbirth: labour. ■ If early labour. → Is there a tear or cut? → Is it red. ■ Next. FEEL ■ Check record: SIGNS ■ Uterus hard. ■ If bleeding persists. ■ do not discharge before 12 hours. CHECK RECORDS ■ Check RPR status in records. D22 D23 minutes. use the chart on examine the woman in labour or with ruptured membranes d2-d3 to assess the clinical situation and → wash hands before handling baby → wash perineum daily and after faecal excretion → change perineal pads every 4 to 6 hours. ■ Monitor blood pressure every hour. ■ Counsel on appropriate family planning method d27 . ■ Record all treatments given n6 ■ Check HIV status in records. discontinue antibiotics. ■ If no RPR during this pregnancy. D25 give preventive measures Encourage sleeping under insecticide treated bednet f4 . ■ Look for conjunctival pallor. but no later than in 2 weeks. ■ Advise on Postpartum care and hygiene d26 . ■ Check haemoglobin after 3 days. ■ Ensure that someone will stay with the mother for the first 24 hours. → Information on when to start a method after delivery will vary depending on whether a woman is breastfeeding or not. ■ If mother is on antibiotics because of rupture of membranes >18 hours but shows no signs of infection now. go to page d25 . preferably within 2-3 days 4-6 weeks Advise on danger signs advise to go to a hospital or health centre immediately. If IUD desired. ■ Any bleeding. give appropriate antibiotic and refer to hospital b15 . ■ Record findings. delivery and immediate postpartum Care ASK. Therefore it is important to start thinking early about what family planning method they will use. oils. Treat if any sign of infection. ■ Advise on danger signs d28 . CHECK RECORD LOOK. delivery and immediate postpartum Care SIGNS TREAT AND ADVISE ■ See b5 for treatment. if needed i1-i3 . � next: If pallor on screening. . including at least once at night: no daytime feedings more than 4 hours apart and no night feedings more than 6 hours apart. ■ Counsel and advise all women. ■ Haemoglobin >11-g/dl ■ No pallor. For baby. ■ fast or difficult breathing. IF REqUIRED ■ Make sure the woman has someone with her and they know when to call for help. ■ Provide newborn care J2-J8 . LISTEN. ■ Next use Care of the mother after the first hour following delivery of placenta d20 to provide care until discharge. see d29 . ■ Reassess for discharge d21 . ASSESS. to help her feel well and strong (give examples of types of food and how much to eat). ■ Measure haemoglobin. see J10 d20 Childbirth: labour. → where to go if danger signs → how to reach the hospital → costs involved → family and community support. THEN EVERY 4 HOURS: ■ For emergency signs. → Listen to fetal heart rate → feel lower abdomen for tenderness → Chills → Foul-smelling vaginal discharge → Low abdomen tenderness → FHR remains >160 after 30 minutes of observation → rupture of membranes >18 hours ■ Temperature still >380C uterine and fetal infeCtion ■ Insert an IV line and give fluids rapidly b9 ■ Give appropriate IM/IV antibiotics b15 . swollen or draining pus? ■ Look for conjunctival pallor. palpate the uterus. ■ If the mother is HIV-positive or adolescent. ■ Reassure the mother that she can eat any normal foods – these will not harm the breastfeeding baby. ■ Keep emergency transport arrangements up-to-date. ■ Ask the mother’s companion to watch her and call for help if bleeding or pain increases. ■ Help her to express breast milk if necessary. ■ Advise the woman to ask for help from the community. . ■ If tubal ligation or IUD desired. milk. ■ Talk to family members such as partner and mother-in-law. . repeat after 1 hour rest. is very high or ■ Record findings continually on labour record and partograph n4-n6 . ■ if late labour: D24 if pallor on sCreening. respond to problems immediately postpartum (1) If vaginal bleeding If fever If perineal tear or episiotomy Advise on when to return advise on when to return use this chart for advising on postpartum care on d21 or e2 . ■ A breastfeeding woman can also choose any other family planning method. ■ do not discharge mother from the facility before 12 hours. Go to health centre as soon as possible if any of the following signs: ■ fever ■ abdominal pain ■ feels ill ■ breasts swollen. 3 AND 4 HOURS. or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). Use chart on d25 to provide preventive measures and advise on postpartum care d26-d28 to advise on care. ■ Help her to establish or re-establish breastfeeding as soon as possible. ■ Blood pressure normal. ■ No fever. if any of the following signs: ■ vaginal bleeding: → more than 2 or 3 pads soaked in 20-30 minutes after delivery or → bleeding increases rather than decreases after delivery. ■ Advise when to seek care d28 . → Make arrangements for the woman to see a family planning counsellor. ■ Little bleeding. or has special needs. k14 . ■ refer woman urgently to hospital b17 . d28 D28 advise on when to return Routine postpartum visits Advise on danger signs Discuss how to prepare for an emergency postpartum support and care throughout labour and delivery. → Is it severe pallor? → Some pallor? → Count number of breaths in 1-minute → monitor intensively → minimize blood loss → refer urgently to hospital after delivery b17 . ■ If tubal ligation desired. drink and rest. ■ refer to facility as soon as possible if any abnormal finding in mother or baby b17 k14 . ■ Ensure the mother has sanitary napkins or clean material to collect vaginal blood. → If bleeding is from perineal tear. ■ Care for the woman according to the stage of labour d8-d13 and respond to problems during labour and delivery as on d14-d18 . CLASSIFY mother well in the counselling session. ■ do not give ergometrine after delivery. ■ Advise the mother on postpartum care and nutrition d26 . ■ Haemoglobin 7-11-g/dl. D26 advise on postpartum Care Advise on postpartum care and hygiene Counsel on nutrition ■ Always begin with rapid assessment and management (ram) b3-b7 . and → she is breastfeeding exclusively (8 or more times a day. she can become pregnant → bleeding more than 250 ml? → completeness of placenta and membranes? → complications during delivery or postpartum? → special treatment needs? → needs tubal ligation or IUD? ■ How are you feeling? ■ Do you have any pains? ■ Do you have any concerns? ■ How is your baby? ■ How do your breasts feel? ■ Measure temperature. nuts. ■ Immunize the baby if possible b13 . if mother INTERVENTIONS. ■ Give double dose of iron for 3 months f3 ■ Follow up in 4 weeks. D20 Childbirth: labour. ■ fever and too weak to get out of bed. refer to appropriate services within 48 hours. delivery and immediate postpartum Care if elevated diastoliC blood pressure ASK. ■ If heavy vaginal bleeding. if possible. if baby stillborn or dead ■ Give supportive care: → Inform the parents as soon as possible after the baby’s death. ■ Perineal tear ■ Episiotomy Discuss how to prepare for an emergency in postpartum ■ Advise to always have someone near for at least 24 hours after delivery to respond to any change in third degree tear small perineal tear ■ refer woman urgently to hospital b15 . → Offer the parents and family to be with the dead baby in privacy as long as they need. ■ Give 3 month’s supply of iron and counsel on compliance f3 ■ Give vitamin A if due f2 . delivery and immediate postpartum Care MONITOR MOTHER AT 2. Promote their use. ■ Advise on postpartum care. Care of the mother one hour after delivery of plaCenta Advise on postpartum care advise on postpartum Care Advise on postpartum care and hygiene Advise and explain to the woman: ■ To always have someone near her for the first 24 hours to respond to any change in her condition. ■ If possible. ■ Not to insert anything into the vagina. check for anaemia Respond to problems immediately postpartum (2) d23 Home delivery by skilled attendant d29 to seek routine or emergency care. ■ Give supportive care. either to use alone or D27 together with LAM. ■ Ensure that the family prepares. ■ Advise on postpartum care and hygiene d26 . d24 CLASSIFY TREAT AND ADVISE severe anaemia ■ if early labour or postpartum. → Ask about plans for having more children. ■ Ensure preventive measures d25 . ■ If blood pressure remains elevated after delivery. ■ Counsel on breastfeeding k2 . → Treat woman and the partner with benzathine penicillin f6 . refer to hospital within 7 round? ■ Look for vaginal bleeding ■ Look at perineum. See k2-k3 . ■ The importance of washing to prevent infection of the mother and her baby: d26 Counsel on nutrition ■ Advise the woman to eat a greater amount and variety of healthy foods. ■ Advise a postpartum visit for the mother and baby within the first week b14 . uncomfortable. ■ If baby and placenta delivered: → Give oxytocin 10 IU IM b10 .

delivery and immediate postpartum Care examine the woman in labour or with ruptured membranes first do rapid assessment and management b3-b7 . ■ Review the birth plan. dry mouth. when? How much? ■ Is the baby moving? ■ Do you have any concern? Check record. other? → more than one fetus? → fetal movement. or vacuum. ■ HIV status C6 . → If less than 100 beats per minute. ■ Determine if preterm (less than 8 months pregnant). breech. or if no record: ■ Ask when the delivery is expected. FEEL history of this labour: ■ When did contractions begin? ■ How frequent are contractions? How strong? ■ Have your waters broken? If yes. ■ Measure temperature. CHECK RECORD LOOK . ■ Infant feeding plan g7-g8 . or more than 180. ■ Pinch the skin of the forearm: does it go back quickly? t next: Perform vaginal examination and decide stage of labour . ■ Listen to the fetal heart beat: → Count number of beats in 1 minute. then d2 use this chart to assess the woman’s and fetal status and decide stage of labour. when? Were they clear or green? ■ Have you had any bleeding? If yes. ■ Observe the woman’s response to contractions: → Is she coping well or is she distressed? → Is she pushing or grunting? ■ Check abdomen for: → caesarean section scar. → horizontal ridge across lower abdomen (if present. ■ Feel abdomen for: → contractions frequency.Examine the woman in labour or with ruptured membranes Childbirth: labour. ■ Receiving any medicine. if prior pregnancies: ■ Number of prior pregnancies/ deliveries. ■ Measure blood pressure. turn woman on her left side and count again. ■ Look for sunken eyes. duration. LISTEN. ASK. forceps. ■ Any prior caesarean section. ■ Tetanus immunization status f2 . or other complication such as postpartum haemorhage? ■ Any prior third degree tear? Current pregnancy: ■ RPR status C5 . empty bladder b12 and observe again). any continuous contractions? → fetal lie—longitudinal or transverse? → fetal presentation—head. ■ Hb results C4 . ■ Look for pallor.

vagina CLASSIFY imminent delivery MANAGE ■ See second stage of labour d10-d11 . pads. ■ Record in partograph n5 . LISTEN. . do not perform vaginal examination if bleeding now or at any time after 7 months of pregnancy. ■ Put on gloves. ■ Prepare: → clean gloves → swabs. delivery and immediate postpartum Care deCide stage of labour ASK. FEEL ■ Explain to the woman that ■ Look at vulva for: SIGNS ■ Bulging thin perineum. ■ Wash vulva and perineal areas. ■ Perform gentle vaginal examination (do not start gaping and head visible. → Feel for membranes – are they intact? → Feel for cord – is it felt? Is it pulsating? If so. → Feel for presenting part. ■ Cervical dilatation: 0-3 cm. during a contraction): → Determine cervical dilatation in centimetres. you will give her a vaginal examination and ask for her consent. ■ Record in labour record n5 . contractions weak and <2 in 10 minutes. ■ See first stage of labour – active labour d9 ■ Start plotting partograph n5 . is it meconium stained. Is it hard. ■ Cervical dilatation: late aCtive labour → multigravida ≥5 cm → primigravida ≥6 cm ■ Cervical dilatation ≥4 cm.Childbirth: labour. round and smooth (the head)? If not. early aCtive labour not yet in aCtive labour ■ See first stage of labour — not active labour d8 ■ Record in labour record n4 . act immediately as on d15 . full cervical dilatation. foul-smelling? → warts. . ■ Wash hands with soap before and after each examination. CHECK RECORD LOOK. → bulging perineum → any visible fetal parts → vaginal bleeding → leaking amniotic fluid. ■ Position the woman with legs flexed and apart. keloid tissue or scars that may interfere with delivery. if yes. perform vaginal examination ■ do not shave the perineal area. t next: Respond to obstetrical problems on admission Decide stage of labour . identify the presenting part. d3 .

■ Discontinue antibiotic for mother after delivery if no ■ Rupture of membrane