I n t e g r a t e d M a n a g e m e n t o f Pr e g n a n c y a n d C h i l d b i r t h

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

World Health Organization

The World Bank Group

RR

Department of Reproductive Health and Research, Family and Community Health, World Health Organization, Geneva

Integrated Management of Pregnancy and Childbirth

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

World Health Organization Geneva 2003

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)

© World Health Organization 2003 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

the problem remains unrecognized or. considering the needs of the mother and her newborn baby. It is against this background that we are proud to present the document Pregnancy. during. and a few critical interventions for the newborn during the first days of life. the latter being largely due to a failure to reduce neonatal mortality. What is required is essential care during 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 for every newborn who dies. Recognizing the large burden of maternal and neonatal ill-health on the development capacity of individuals. delivery and in the postpartum period. 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. Most of these deaths are a consequence of the poor health and nutritional status of the mother coupled with inadequate care before. However. programme managers and health care providers in charting out their roadmap towards meeting the health needs of all mothers and children. another is stillborn. 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.worse. We have the knowledge. in large part because it is so common. over four million babies less than one month of age die. the assistance of a person with midwifery skills during childbirth and the immediate postpartum period. improvements in knowledge and technological advances have greatly improved the health of mother and children. and after delivery. evidencebased norms and standards that will enable health care providers to give high quality care during pregnancy. Dr. Unfortunately. We hope that the guide will be helpful for decision-makers. most of them during the critical first week of life.FOREWORD In modern times. Every year. as new additions to the Integrated Management of Pregnancy and Childbirth tool kit. Tomris Türmen Executive director Family and Community Health (FCH) FOREWORD Foreword . Childbirth.accepted as inevitable in many societies. Postpartum and Newborn Care: A guide for essential practice. 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. The reality is that many conditions that result in perinatal death can be prevented or treated without sophisticated and expensive technology.

Department of Reproductive Health and Research (RHR). 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. Japan and the United States of America is gratefully acknowledged. The guide has also been reviewed and endorsed by the International Confederation of Midwives. Sweden and the United Kingdom of Great Britain and Northern Ireland. Maggie Usher. Atlanta. Adepeyu Olukoya. and Jelka Zupan. In addition. This guide represents a common understanding between WHO. Rita Kabra. 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 Layout: rsdesigns. the International Federation of Gynecology and Obstetrics and International Pediatric Association. Jerker Liljestrand. as is financial support received from The World Bank. who took time to review this document at different stages of its development. Mathews Matthai. led by Jerker Liljestrand and Jelka Zupan. Felicity Savage. .Acknowledgements ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS The Guide was prepared by a team of the World Health Organization. These agencies co-operate closely in efforts to reduce maternal and perinatal mortality and morbidity. UNICEF.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. and Aafje Rietveld. Luc de Bernis. Rick Guidotti. and the World Bank of key elements of an approach to reducing maternal and perinatal mortality and morbidity. UNFPA. Elisabeth Hoff. Agostino Borra. Revisions were subsequently carried out by Annie Portela. WHO’s Making Pregnancy Safer initiative is grateful to the programme support received from the Governments of the Netherlands. Anne Thompson. The concept and first drafts were developed by Sandra Gove and Patricia Whitesell/ACT International. Denise Roth. 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. Betty Sweet. Norway. They came from over 35 countries and brought their expertise and wide experience to the final text. Ornella Lincetto. Monir Islam.

TABLE OF CONTENTS B EMERGENCY TREATMENTS FOR THE WOMAN A INTRODUCTION Introduction How to read the Guide Acronyms Content Structure and presentation Assumptions underlying the guide B9 Airway. 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. 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 A A2 A3 A4 A5 PRINCIPLES OF GOOD CARE Communication Workplace and administrative procedures Universal precautions and cleanliness Organising a visit B TABLE OF CONTENTS QUICK CHECK. non urgent 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 B21 B21 B21 Advise on self-care Advise and counsel on family planning Provide information and support after abortion Advise and counsel during follow-up visits Table of contents .

Table of contents
TABLE OF CONTENTS

C
C2

ANTENATAL CARE

D

CHILDBIRTH – LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE

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

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

D

CHILDBIRTH – LABOUR, 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

Give vitamin A postpartum Give iron and folic acid Give mebendazole Motivate on compliance with iron treatment Give preventive intermittent treatment for falciparum malaria Advise to use insecticide-treated bednet Give appropriate oral antimalarial treatment 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

F2 F3 F3 F3 F4 F4 F4 F4

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, 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

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 correct and consistent use of condoms Voluntary counselling and testing (VCT) services G3 Voluntary counselling and testing services G3 Discuss confidentiality of the result G3 Implications of test result G3 Benefits of involving and testing the male partner(s) Care and counselling on family planning 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 Prevent mother-to-child transmission of HIV G6 Give antiretroviral drug to prevent MCTC of HIV G6 Antiretroviral drug for prevention of MCTC of HIV Counsel on infant feeding choice G7 Explain the risks of HIV transmission through breastfeeding and not breastfeeding G7 If a woman has unknown or negative HIV status G7 If a woman knows and accepts that she is HIV-positive If the mother chooses replacement feeding G8 Teach the mother 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

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

I2

G6

I3

G7

G8

CARE. 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) J2 K9 K10 K11 K K2 BREASTFEEDING. 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 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 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 . PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN 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 K12 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.J K8 NEWBORN CARE Examine the newborn J3 If preterm.

SUPPLIES. supplies. drugs and tests for pregnancy and postpartum care 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 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 . DRUGS AND LABORATORY TESTS Equipment.Table of contents TABLE OF CONTENTS L L2 L3 L4 L5 EQUIPMENT.

INTRODUCTION The aim of Pregnancy. childbirth and postpartum. Introduction . and newborns during their first week of life. if necessary. thereby making pregnancy and childbirth safer. analysis. and be made consistent with national treatment guidelines and other policies. The guide is not designed for immediate use. malaria. childbirth. It is a generic guide and should first be adapted to local needs and resources. the overall content and presentation. All recommendations are for skilled attendants working at the primary level of health care. in delivery. How to use the guide. 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. 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. and to all newborns at birth and during the first week of life (or later) for routine and emergency care. Prevention and Eradication (tuberculosis. including timely referral. 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. 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. either at the facility or in the community. postpartum or post abortion care. and post abortion. describes how the guide is organized. and recommending appropriate research-based interventions. It is accompanied by an adaptation guide to help countries prepare their own national guides and training and other supporting materials. essential observations and/or examinations. or who come for emergency care. helminthiasis) Gender and Women’s Health Mental Health and Substance Dependence Blindness and Deafness INTRODUCTION The first section. It promotes the early detection of complications and the initiation of early and appropriate treatment. Each chapter begins with a short description of how to read and use it. It facilitates the collection. classification and use of relevant information by suggesting key questions. The PCPNC is a guide for clinical decision-making.

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, labour and delivery, postpartum and post abortion, as well as key preventive measures required to reduce the incidence of endemic and other diseases 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:

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.

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:

In addition to the clinical care outlined above, other sections in the guide include:
■ ■ ■ ■ ■ ■

■ ■ ■ ■ ■

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.

Advice on HIV. 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.

Managing complications of pregnancy and childbirth (WHO/RHR/00.7) Managing newborn problems.

These and other documents referred to in this Guide can be obtained from the Department of Reproductive Health and Research, Family and Community Health, World Health Organization, Geneva, Switzerland. E-mail: rhrpublications@who.int.

STRUCTURE AND PRESENTATION

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 crossreferenced 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.

■ ■ ■ ■

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.

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.

HOW TO READ THE GUIDE

3
ASK, CHECK RECORD LOOK, 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. These pages include information which is too detailed to include in the flow charts:

Structure and presentation

Assumptions underlying the Guide
HOW TO READ THE GUIDE ASSUMPTIONS UNDERLYING THE GUIDE

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, voluntary counselling and testing (VCT) 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.

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.

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.

■ Use simple and clear language. screen. ■ ■ Privacy and confidentiality In all contacts with the woman and her partner: ■ Ensure a private place for the examination and counselling. deaths and other indicators as required. →Wear a long apron made from plastic or other fluid resistant material. ■ Explain to her that the treatment will not harm her or her baby. ■ Support her in understanding her options and making decisions. ■ At the first emergency sign on Quick Check. ■ If baby is newly born. they are not repeated in each section. This produces disinfected gloves. at referral level. take care when handling any sharp instruments (use good light). Rinse off blood or other body fluids before washing with soap. also examine the baby: →Follow the appropriate charts according to pregnancy status/age of the baby and purpose of visit. Record treatments. ■ Give clear and helpful advice on how to take the drug regularly: →for example: take 2 tablets 3 times a day. assess the baby or ask to see the baby if not with the mother. check that equipment is clean and functioning and that supplies and drugs are in place. Ask her name (and the name of the baby). ■ 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. vaccines and contraceptives before they run out). in the morning. begin emergency assessment and management (RAM) B1-B7 for the woman. Begin each routine visit (for the woman and/or the baby) Greet the woman and offer her a seat. gloves and containers after disposal of infectious waste. Ask the name of the woman. that you cannot be overheard. Explain the side-effects to her. Fill the Home-Based Maternal Record (HBMR) and give her the appropriate information sheet. ■ Never discuss confidential information about clients with other providers. Discuss findings with her (and her partner). especially if no-one is receiving them B2 . Wear gloves Wear sterile or highly disinfected gloves when performing vaginal examination. reasons for referral. Ensure and respect privacy during examination and discussion. and keep the woman informed as much as you can Ask the woman if she has any questions. ■ Demonstrate the procedure. in leak-proof containers. and you as the health provider. ■ For a postpartum visit. or outside the health facility. during examination. PRINCIPLES OF GOOD CARE Workplace and administrative procedures A3 Universal precautions and cleanliness PRINCIPLES OF GOOD CARE UNIVERSAL PRECAUTIONS AND CLEANLINESS A4 A4 Observe these precautions to protect the woman and her baby. then hold under clean water and look for air leaks. ■ Summarize the most important information. 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. vaccine. wall). Advise her to return if she has any problems or concerns about taking the drugs. abrasions or broken skin with a waterproof bandage. →If possible. Ask permission before undertaking an examination or test. ■ Dry away from direct sunlight. Introduce yourself. If she came with a baby and the baby is well. ■ If she is in labour. ■ ■ about what you are doing. ■ Ensure. Check for understanding by asking her to explain or demonstrate treatment instructions. delivery. including HIV. ■ ■ Keep records of equipment. 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. ■ Organize the examination area so that. and for blood or body fluid spills. ■ If follow-up visit is within a week. postpartum or newborn visit according to the schedule →If antenatal visit. Drop all used (disposable) needles. Keep the facility clean by regular cleaning. ■ Wash hands. the woman/baby will be assessed. including the information on routine laboratory tests and treatments. ask permission. talk to the companion. cord cutting. At the end of the visit ■ ■ ■ ■ ■ Begin each emergency care visit ■ ■ ■ ■ Introduce yourself. afternoon and evening with some water and after a meal. counselled and advised on follow-up for that particular condition/ complication. and when and where to return. Be friendly. examine her immediately using Antenatal care. clean and disinfect equipment and supplies → replace linen. Watch her as she does the first treatment in the clinic. Check for damage: Blow gloves full of air. the woman is protected from the view of other people (curtain. protect your eyes from splashes of blood. bednet. A5 ORGANIZING A VISIT During the visit ■ ■ ■ ■ PRINCIPLES OF GOOD CARE PRINCIPLES OF GOOD CARE Explain all procedures. Normal spectacles are adequate eye protection. Use each needle and syringe only once. or have heard from others. 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. UNIVERSAL PRECAUTIONS AND CLEANLINESS Deal with contaminated laundry ■ Practice safe sharps disposal Keep a puncture resistant container nearby. Universal precautions and cleanliness A4 . bend or break needles after giving an injection. Explain how the treatment is given to the baby. Explain all procedures. It should also be tobacco free and support a tobacco-free environment. Prescribing and recommending treatments and preventive measures for the woman and/or her baby When giving a treatment (drug. ■ Ensure all records are confidential and kept locked away. wearing gloves or use a plastic bag. the underlying assumption of the Guide is that. ■ ■ ■ ■ ■ Verify that she understands emergency signs. Help her to think about how she will be able to purchase this. ■ Dust inside with talcum powder or starch. Keep nails short. give preventive measures if due even if the woman has a condition "in yellow" that requires special treatment. ■ Make sure you have the woman’s consent before discussing with her partner or family. The principles concern: ■ ■ ■ ■ Communicating with the woman (and her companion) Make the woman (and her companion) feel welcome. Workplace and administrative procedures A3 . ■ If she has priority signs. looks small. Keep the woman informed throughout. Postpartum or Post-abortion care charts C1-C18 E1-E10 B18-B22 . At the end of the service: → discard litter and sharps safely → prepare for disinfection. ■ Use bleach for cleaning bowls and buckets. Do not let the mother wait in the queue. Ask her if there are any points which need to be discussed and would she like support for this. ■ Clean and disinfect gloves Wash the gloves in soap and water. drugs. ORGANIZING A VISIT Receive and respond immediately Receive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). ■ ■ Always record findings on a clinical record and home-based record. supplies. and follow-up recommendations at the time the observation is made. and shoes. and that not taking it may be more dangerous. invite her to wait in the waiting room. Before beginning the services. ■ Wear long sterile or highly disinfected gloves for manual removal of placenta. ■ At any examination or before any procedure: → seek her permission and → inform her of what you are doing. repair of episiotomy or tear.5% available chlorine (made by adding 90 ml water to 10 ml bleach containing 5% available chlorine).They are not sterile. Protect yourself from blood and other body fluids during deliveries →Wear gloves. and without passing to another person. Discard if damaged. respectful and non-judgmental at all times. →the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition. prepare for washing → replenish supplies and drugs → ensure routine cleaning of all areas. Encourage the companion to stay with the woman. Complete periodic reports on births. ■ ■ Wash hands ■ ■ Wash hands with soap and water: →Before and after caring for a woman or newborn. because they may have holes →After changing soiled bedsheets or clothing. →Follow all steps on the chart and in relevant boxes. ■ Ask and provide information related to her needs. delivery and immediate postpartum care D1-D29 . always revise the birth plan at the end of the visit after completing the chart. Be on time with appointments or inform the woman/women if she/they need to wait. ■ Pour liquid waste down a drain or flushable toilet. ■ ■ ■ ■ ■ Daily and occasional administrative activities ■ ■ Record keeping ■ 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. ■ Wash hands after disposal of infectious waste. 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. treated. cover any cuts. plastic syringes and blades directly into this container. ■ Sterilize and clean contaminated equipment Make sure that instruments which penetrate the skin (such as needles) are adequately sterilized. Ensure privacy during the examination and discussion. blood drawing. and tell her how to manage them. Encourage her to return for a routine visit (tell her when) and if she has any concerns. ■ Soak overnight in bleach solution with 0. ■ Perform Quick Check on all new incoming women and babies and those in the waiting room. and practice safe sharps disposal. treatment instructions. ■ ■ ■ ■ ■ Collect clothing or sheets stained with blood or body fluids and keep them separately from other laundry. drugs and vaccines. ■ Burn or bury contaminated solid waste. A3 WORKPLACE AND ADMINISTRATIVE PROCEDURES Workplace Service hours should be clearly posted. ■ Wear clean gloves when: →Handling and cleaning instruments →Handling contaminated waste →Cleaning blood and body fluid spills. ■ If antenatal care. Good quality latex gloves can be disinfected 5 or more times. Maintain and file appropriately: → all clinical records → all other documentation. ■ Encourage her to ask questions. Check availability and functioning of essential equipment (order stocks of supplies. from infections with bacteria and viruses. Explore any barriers she or her family may have. twist the cuff closed. for 5 days. If she is unconscious. ■ Hand over essential information to the colleague who follows on duty. ■ Limit access to logbooks and registers to responsible providers only. Do not recap. Organizing a visit A5 . ■ Empty or send for incineration when the container is three-quarters full. ■ Unless the condition of the woman or the baby requires urgent referral to hospital. condom) at the clinic. Explain that they are not serious. Summarize the most important messages with her. or that single-use instruments are disposed of after one use. accompany her to an appropriate place and follow the steps as in Childbirth: labour. thus every 8 hours. Organizing a visit A5 Principles of good care A1 . or examine the newborn J1-J11 . DO NOT touch them directly. WORKPLACE AND ADMINISTRATIVE PROCEDURES Communication A2 . or prescribing measures to be followed at home: ■ Explain to the woman what the treatment is and why it should be given. Care-givers should therefore familiarize themselves with the following principles before using the Guide. Do not record confidential information on the home-based record if the woman is unwilling. ■ Thoroughly clean or disinfect any equipment which comes into contact with intact skin (according to instructions). 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. ■ If no emergency or priority sign on RAM or not in labour. or body fluid contaminated items. and if no other complaints: →Assess the woman for the specific condition requiring follow-up only →Compare with earlier assessment and reclassify. Discuss with her the importance of buying and taking the prescribed amount. Practice safe waste disposal Dispose of placenta or blood. examine immediately. without recapping. ■ Sterilize gloves ■ Sterilize by autoclaving or highly disinfect by steaming or boiling. according to instructions. revise the birth plan. about using the treatment. ■ Routine care continues at the primary care level where it was initiated. post-abortion. and try to clarify the incorrect information. Establish staffing lists and schedules.PRINCIPLES OF GOOD CARE Communication PRINCIPLES OF GOOD CARE COMMUNICATION A2 A2 COMMUNICATION These principles of good care apply to all contacts between the skilled attendant and all women and their babies. when discussing sensitive subjects. if she came with the baby.

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

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

Universal precautions and cleanliness
PRINCIPLES OF GOOD CARE UNIVERSAL PRECAUTIONS AND CLEANLINESS

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.

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. Normal spectacles are adequate eye protection.

Practice safe waste disposal
■ ■ ■ ■ ■

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.

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.

Clean and disinfect gloves
■ ■

Deal with contaminated laundry

Practice safe sharps disposal
■ ■ ■ ■

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.

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.

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.

■ ■

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 and clean contaminated equipment

Sterilize gloves

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.

Sterilize by autoclaving or highly disinfect by steaming or boiling.

ORGANIZING A VISIT

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) B1-B7 for the woman, or examine the newborn J1-J11 . ■ If she is in labour, accompany her to an appropriate place and follow the steps as in Childbirth: labour, delivery and immediate postpartum care D1-D29 . ■ If she has priority signs, examine her immediately using Antenatal care, Postpartum or Post-abortion care charts C1-C18 E1-E10 B18-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.

■ ■

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.

Begin each routine visit (for the woman and/or the baby)
■ ■ ■ ■

Care of woman or baby referred for special care to secondary level facility

PRINCIPLES OF GOOD CARE

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

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.

■ ■ ■

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 reclassify. 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

A5

Insert second IV line. Refer woman urgently to hospital* B17 . During transfer. Perform Quick check immediately after the woman arrives B2 . give appropriate IM/IV antibiotics B15 . This may be placenta previa. ruptured uterus. abruptio placentae. This may be ruptured uterus. transfer woman to labour room and proceed as on D1-D28 . ■ B2 QUICK CHECK ■ ASK. Insert an IV line and give fluids slowly (30 drops/min) B9 . This may be pneumonia. Do not cross ankles. Give fluids rapidly if heavy bleeding or shock B3 . or not pregnant (uterus NOT above umbilicus) BLEEDING HEAVY BLEEDING Pad or cloth soaked in < 5 minutes. →If no emergency or priority signs. If temperature >38ºC. If severe pallor. NEXT: Vaginal bleeding in postpartum QUICK CHECK. go to IF no emergency. vaginal or cervical tear. Apply bimanual uterine or aortic compression B10 . Insert an IV line B9 and give IV fluids with 20 IU oxytocin at 60 drops/minute. Give appropriate IM/IV antibiotics B15 . RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B6 EMERGENCY SIGNS CONVULSIONS OR UNCONSCIOUS ■ ■ MEASURE ■ ■ ■ TREATMENT Protect woman from fall and injury. ■ Keep her warm (cover her). ■ Refer her urgently to hospital* B17 . according to pregnancy status. Give 0. Continue massaging uterus till it is hard. Give first dose of appropriate IM/IV antibiotics B15 . RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B4 VAGINAL BLEEDING ■ Assess ■ Assess pregnancy status amount of bleeding B4 PREGNANCY STATUS EARLY PREGNANCY not aware of pregnancy. Check after 5 minutes. RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE PRIORITY SIGNS LABOUR ■ ■ MEASURE TREATMENT ■ Labour pains or Ruptured membranes Manage as for Childbirth D1-D28 . pneumonia. circulation (shock) B3 Rapid assessment and management (RAM) Vaginal bleeding QUICK CHECK. or not aware of pregnancy. DO NOT give ergometrine to women with eclampsia.QUICK CHECK. TREATMENT ■ ■ ■ ■ ■ ■ Insert an IV line B9 . Continue IV fluids with 20 units of oxytocin at 30 drops/minute. puerperal or postabortion sepsis. If systolic BP <90 mm Hg see B3 . thin perineum during contractions. or Unconscious If unconscious. visible fetal head). NEXT: Priority signs QUICK CHECK. septic shock. IF emergency for woman or baby or labour. ■ If temperature >38ºC. ectopic pregnancy. When uterus is hard. but: Insert an IV line B9 . ■ Refer woman urgently to hospital* B17 . If present. refer woman urgently to hospital B17 . continue IV fluids with 20 IU of oxytocin at 30 drops/minute. allow the woman to wait in line for routine care. Give artemether IM (if not available. Always begin a clinical visit with Rapid assessment and management (RAM) B3-B7 : →Check for emergency signs first B3-B6 . give antihypertensive B14 . CIRCULATION (SHOCK) ■ ■ Cold moist skin or Weak and fast pulse ■ ■ Measure blood pressure Count pulse Measure blood pressure. Examine the woman using Assess the mother after delivery D12 . provide postpartum care E1-E10 . also give treatment for dangerous fever (below). DURING LABOUR before delivery of baby BLEEDING MORE THAN 100 ML SINCE LABOUR BEGAN ■ ■ ■ DO NOT do vaginal examination. talk to her companion. This may be abortion. NON URGENT ■ ■ No emergency signs or No priority signs ■ ■ If pregnant (and not in labour). refer to health centre. Ask the mother to stay. Manage airway B9 . obstructed labour. ■ ■ ■ ■ ■ Examine the tear and determine the degree B12 . severe anaemia with heart failure. This may be haemorrhagic shock. Refer woman urgently to hospital* B17 . abruptio placenta. Massage uterus until it is hard and give oxytocin 10 IU IM B10 . remove placenta manually and check placenta B11 . ruptured uterus. Repeat 0. If unsuccessful and bleeding continues. Give magnesium sulphate B13 . give quinine IM) and glucose B16 . ■ Refer woman urgently to hospital* B17 . LATE PREGNANCY (uterus above umbilicus) ANY BLEEDING IS DANGEROUS ■ ■ ■ DO NOT do vaginal examination. give first dose of appropriate IM/IV antiobiotics B15 . retained placenta. RAPID ASSESSMENT AND MANAGEMENT (RAM) (5) priority signs Labour Other danger signs or symptoms Non-urgent IF NO EMERGENCY OR PRIORITY SIGNS. Give fluids rapidly B9 .2 mg IV B10 . 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. menorrhagia. FEEL ■ 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. ■ ■ ■ ■ ■ ■ ■ ■ This may be eclampsia. If systolic BP < 90 mmHg or pulse >110 per minute: ■ Position the woman on her left side with legs higher than chest. rapid assessment and management of women of childbearing age B1 . HEAVY BLEEDING Check if still bleeding ■ ■ ■ ■ ■ ■ ■ CONTROLLED BLEEDING NEXT: Convulsions or unconscious Rapid assessment and management (RAM) Vaginal bleeding: postpartum B5 Rapid assessment and management (RAM) Emergency signs QUICK CHECK. If recently given birth. If the baby is or has: ■ very small ■ convulsions ■ difficult breathing ■ just born ■ any maternal concern. with no danger signs A newborn with no danger signs or maternal complaints. ectopic pregnancy. After convulsion ends. RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE Quick check QUICK CHECK. Refer woman urgently to hospital* B17 . ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ CLASSIFY EMERGENCY FOR WOMAN TREAT ■ ■ ■ ■ ■ ■ Why did you come? → for yourself? → for the baby? How old is the baby? What is the concern? Is the woman being wheeled or carried in or: bleeding vaginally convulsing looking very ill unconscious in severe pain in labour delivery is imminent ■ ■ ■ ■ ■ ■ ■ Transfer woman to a treatment room for Rapid assessment and management B3-B7 . NEXT: Vaginal bleeding Rapid assessment and management (RAM) Airway and breathing. LISTEN. 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 recently given birth. obstructed breathing. also give treatment for dangerous fever (below). 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 ■ ■ B7 Measure blood pressure Measure temperature ■ ■ ■ ■ If pregnant (and not in labour). help woman onto her left side. If diastolic BP >110mm of Hg. use alternative B9 . Rapid assessment and management (RAM) Priority signs B7 Quick check. then refer the woman to hospital. ■ Give appropriate IM/IV antibiotics B15 . asthma. Give fluids slowly B9 . provide post-abortion care B20-B21 . Continue IV fluids with 20 IU oxytocin/litre at 30 drops/minute. Check and ask if placenta is delivered B5 PLACENTA DELIVERED Check placenta B11 If placenta is complete: Massage uterus to express any clots B10 . If suspect possible complicated abortion. * 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 . manage according to charts B7 . →Check for priority signs. If early pregnancy. 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. This may be uterine atony. Refer woman urgently to hospital B17 . if bleeding persists repair the tear B12 . but: Insert an IV line B9 . or after delivery. ■ ■ EMERGENCY FOR BABY ■ B3 Pregnant woman. This may be placenta previa. thin perineum during contractions. If uterus remains soft. Transfer the baby to the treatment room for immediate Newborn care J1-J11 . Give appropriate IM/IV antibiotics B15 . RAPID ASSESSMENT AND MANAGEMENT (RAM) (2) Vaginal bleeding LIGHT BLEEDING ■ ■ Examine woman as on B19 . If any danger sign is seen. ■ Give fluids rapidly B9 . This may be malaria. delivery and the postpartum period. or history of fever.2 mg ergometrine IM/IV if bleeding continues. go to relevant section B3 . Check if baby is or has: ■ very small ■ convulsing ■ breathing difficulty Imminent delivery or Labour LABOUR ■ ■ ■ ■ Transfer the woman to the labour ward. If present. ■ ■ 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). visible fetal head). transfer woman to labour room and proceed as on D1-D28 . Call for immediate assessment. Get help. help the woman and send her quickly to the emergency room. give diazepam IV or rectally B14 . septicemia. ROUTINE CARE ■ Keep the woman and baby in the waiting room for routine care. pre-eclampsia or known hypertension. ■ If not able to insert peripheral IV. provide emergency treatment and refer the woman urgently to hospital. Catheterize if necessary B12 . provide postpartum care D21 . provide antenatal care C1-C18 . ■ Insert an IV line B9 . Reassure the woman that she will be taken care of immediately. and E1-E10 . * But if birth is imminent (bulging. transfer woman to labour room and proceed as on D1-D28 . ■ If unable to remove. give ergometrine 0. Assess for all emergency and priority signs and give appropriate treatments. If placenta is incomplete (or not available for inspection): ■ Remove placental fragments B11 . For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. Refer woman urgently to hospital* B17 . refer woman urgently to hospital B17 . thin perineum during contractions. Check and record BP and pulse every 15 minutes and treat as on B3 . B6 Convulsing (now or recently). Empty bladder. Continue oxytocin infusion with 20 IU/litre of IV fluids at 20 drops/min for at least one hour after bleeding stops B10 . Keep nearby for 24 hours. or history of fever. on first arrival and periodically throughout labour. If pregnancy not likely. and also for women in labour. Complete the referral form N2 . Ask her companion to stay. give antihypertensive B14 . QUICK CHECK. meningitis. Call for help if needed. FIRST ASSESS EMERGENCY SIGNS Do all emergency steps before referral MEASURE TREATMENT AIRWAY AND BREATHING ■ ■ RAPID ASSESSMENT AND MANAGEMENT (RAM) (1) Airway and breathing Circulation and shock Very difficult breathing or Central cyanosis ■ ■ Manage airway and breathing B9 . CHECK RECORD LOOK. If unable to remove placenta. If recent abortion. deliver placenta by controlled cord traction D12 . ask relative “has there been a recent convulsion?” Measure blood pressure Measure temperature Assess pregnancy status RAPID ASSESSMENT AND MANAGEMENT (RAM) (4) Convulsions Severe abdominal pain Dangerous fever Measure BP and temperature ■ If diastolic BP >110mm of Hg. If a woman is very sick. 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 . RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE QUICK CHECK. abruptio placenta. provide antenatal care C1-C18 . Give fluids rapidly if heavy bleeding or shock B3 . * But if birth is imminent (bulging. Observe closely (every 30 minutes) for 4 hours. refer to other clinical guidelines. If early pregnancy. If temperature more than 38ºC. Refer woman urgently to hospital* B17 .2 mg ergometrine IM B10 . visible fetal head). ruptured uterus. refer woman urgently to hospital B17 . Refer woman urgently to hospital B17 . check for ectopic pregnancy B19 .

with no danger signs A newborn with no danger signs or maternal complaints. IF emergency for woman or baby or labour. ASK. FEEL ■ 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. Ask the mother to stay. LISTEN. go to IF no emergency. Reassure the woman that she will be taken care of immediately.Quick check QUICK CHECK. Ask her companion to stay. If the baby is or has: ■ very small ■ convulsions ■ difficult breathing ■ just born ■ any maternal concern. Call for immediate assessment. CHECK RECORD LOOK. ROUTINE CARE ■ Keep the woman and baby in the waiting room for routine care. ■ ■ CLASSIFY EMERGENCY FOR WOMAN TREAT ■ ■ ■ ■ ■ ■ Why did you come? → for yourself? → for the baby? How old is the baby? What is the concern? 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 Transfer woman to a treatment room for Rapid assessment and management B3-B7 . . go to relevant section B3 . or after delivery. ■ ■ EMERGENCY FOR BABY Pregnant woman. Imminent delivery or Labour LABOUR ■ ■ ■ ■ Transfer the woman to the labour ward. 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. Call for help if needed. talk to her companion. If a woman is very sick. Transfer the baby to the treatment room for immediate Newborn care J1-J11 .

* But if birth is imminent (bulging.QUICK CHECK. circulation (shock) B3 . If systolic BP < 90 mmHg or pulse >110 per minute: ■ Position the woman on her left side with legs higher than chest. ■ Give fluids rapidly B9 . This may be pneumonia. obstructed breathing. ■ If not able to insert peripheral IV. asthma. Refer woman urgently to hospital* B17 . 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. transfer woman to labour room and proceed as on D1-D28 . then refer the woman to hospital. NEXT: Vaginal bleeding Rapid assessment and management (RAM) Airway and breathing. on first arrival and periodically throughout labour. septic shock. thin perineum during contractions. visible fetal head). CIRCULATION (SHOCK) ■ ■ Cold moist skin or Weak and fast pulse ■ ■ Measure blood pressure Count pulse Measure blood pressure. ■ Insert an IV line B9 . use alternative B9 . and also for women in labour. FIRST ASSESS EMERGENCY SIGNS Do all emergency steps before referral MEASURE TREATMENT AIRWAY AND BREATHING ■ ■ Very difficult breathing or Central cyanosis ■ ■ Manage airway and breathing B9 . delivery and the postpartum period. This may be haemorrhagic shock. Assess for all emergency and priority signs and give appropriate treatments. severe anaemia with heart failure. ■ Keep her warm (cover her). ■ Refer her urgently to hospital* B17 .

■ Give fluids rapidly if heavy bleeding or shock ■ Refer woman urgently to hospital* B17 . transfer woman to labour room and proceed as on D1-D28 . ruptured uterus. NEXT: Vaginal bleeding in postpartum . menorrhagia. * But if birth is imminent (bulging. ■ Give fluids rapidly if heavy bleeding or shock ■ Refer woman urgently to hospital* B17 . This may be placenta previa.Rapid assessment and management (RAM) Vaginal bleeding QUICK CHECK. ruptured uterus. If suspect possible complicated abortion. LIGHT BLEEDING ■ ■ Examine woman as on B19 . give appropriate IM/IV antibiotics Refer woman urgently to hospital B17 . 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. DURING LABOUR before delivery of baby BLEEDING MORE THAN 100 ML SINCE LABOUR BEGAN B3 . If pregnancy not likely.2 mg ergometrine IM/IV if bleeding continues. B3 . abruptio placentae. DO NOT do vaginal examination. Repeat 0. refer to other clinical guidelines. LATE PREGNANCY (uterus above umbilicus) ANY BLEEDING IS DANGEROUS DO NOT do vaginal examination. but: ■ Insert an IV line B9 . or not pregnant (uterus NOT above umbilicus) BLEEDING HEAVY BLEEDING Pad or cloth soaked in < 5 minutes.2 mg ergometrine IM B10 . This may be placenta previa. Give fluids rapidly B9 . B15 . This may be abortion. visible fetal head). Give 0. abruptio placenta. but: ■ Insert an IV line B9 . TREATMENT ■ ■ ■ ■ ■ ■ Insert an IV line B9 . ectopic pregnancy. thin perineum during contractions.

Examine the woman using Assess the mother after delivery D12 . refer woman urgently to hospital B17 . If placenta is incomplete (or not available for inspection): ■ Remove placental fragments B11 . give ergometrine 0. ■ Give appropriate IM/IV antibiotics B15 . For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. pre-eclampsia or known hypertension. Refer woman urgently to hospital B17 . Check and record BP and pulse every 15 minutes and treat as on B3 . retained placenta. Catheterize if necessary B12 .2 mg IV B10 . During transfer. ■ Continue IV fluids with 20 IU oxytocin/litre at 30 drops/minute. Give appropriate IM/IV antibiotics B15 . ■ If unable to remove. Continue IV fluids with 20 units of oxytocin at 30 drops/minute. ■ ■ Check for perineal and lower vaginal tears IF PRESENT If third degree tear (involving rectum or anus). if bleeding persists repair the tear B12 . ■ Continue massaging uterus till it is hard. Check and ask if placenta is delivered B11 . ruptured uterus. Observe closely (every 30 minutes) for 4 hours. refer woman urgently to hospital B17 . 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. Massage uterus until it is hard and give oxytocin 10 IU IM B10 . refer woman urgently to hospital B17 . ■ Examine the tear and determine the degree B12 . If unable to remove placenta. Apply bimanual uterine or aortic compression B10 . If unsuccessful and bleeding continues. PLACENTA DELIVERED Check placenta B11 If placenta is complete: ■ Massage uterus to express any clots B10 . remove placenta manually and check placenta Give appropriate IM/IV antibiotics B15 . Insert second IV line. Empty bladder. continue IV fluids with 20 IU of oxytocin at 30 drops/minute.QUICK CHECK. DO NOT give ergometrine to women with eclampsia. ■ If uterus remains soft. refer to health centre. If severe pallor. Keep nearby for 24 hours. Do not cross ankles. deliver placenta by controlled cord traction D12 . vaginal or cervical tear. This may be uterine atony. Continue oxytocin infusion with 20 IU/litre of IV fluids at 20 drops/min for at least one hour after bleeding stops B10 . When uterus is hard. HEAVY BLEEDING Check if still bleeding ■ ■ ■ ■ ■ ■ ■ CONTROLLED BLEEDING NEXT: Convulsions or unconscious Rapid assessment and management (RAM) Vaginal bleeding: postpartum B5 . Insert an IV line B9 and give IV fluids with 20 IU oxytocin at 60 drops/minute. Check after 5 minutes.

If early pregnancy. Get help. give antihypertensive B14 . give antihypertensive B14 . This may be malaria. SEVERE ABDOMINAL PAIN ■ Severe abdominal pain (not normal labour) ■ ■ Measure blood pressure Measure temperature ■ ■ ■ ■ Insert an IV line and give fluids B9 . or history of fever. Give first dose of appropriate IM/IV antibiotics B15 . help woman onto her left side. pneumonia. This may be eclampsia. If systolic BP <90 mm Hg see B3 . visible fetal head). ■ If temperature >38ºC. B16 . also give treatment for dangerous fever (below). This may be ruptured uterus. also give treatment for dangerous fever (below). ectopic pregnancy. NEXT: Priority signs . Insert an IV line and give fluids slowly (30 drops/min) B9 . abruptio placenta. transfer woman to labour room and proceed as on D1-D28 . If temperature >38ºC. give diazepam IV or rectally B14 . puerperal or postabortion sepsis. obstructed labour. ask relative “has there been a recent convulsion?” Measure blood pressure Measure temperature Assess pregnancy status Protect woman from fall and injury. give quinine IM) and glucose Refer woman urgently to hospital* B17 . If temperature more than 38ºC. RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B6 EMERGENCY SIGNS CONVULSIONS OR UNCONSCIOUS ■ ■ MEASURE ■ ■ ■ TREATMENT ■ ■ ■ ■ ■ ■ ■ ■ ■ Convulsing (now or recently). After convulsion ends.Rapid assessment and management (RAM) Emergency signs QUICK CHECK. or history of fever. Give fluids slowly B9 . Manage airway B9 . Give magnesium sulphate B13 . meningitis. ■ Refer woman urgently to hospital* B17 . give first dose of appropriate IM/IV antiobiotics B15 . Refer woman urgently to hospital* B17 . 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 . Refer woman urgently to hospital* B17 . If diastolic BP >110mm of Hg. Give artemether IM (if not available. Measure BP and temperature ■ If diastolic BP >110mm of Hg. or Unconscious If unconscious. septicemia. thin perineum during contractions. * But if birth is imminent (bulging.

and E1-E10 . RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE PRIORITY SIGNS LABOUR ■ ■ MEASURE TREATMENT ■ Labour pains or Ruptured membranes Manage as for Childbirth D1-D28 . provide postpartum care D21 .QUICK CHECK. provide antenatal care C1-C18 . If recently given birth. or not aware of pregnancy. Rapid assessment and management (RAM) Priority signs B7 . 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). IF NO EMERGENCY OR PRIORITY SIGNS. check for ectopic pregnancy B19 . If recent abortion. If early pregnancy. provide post-abortion care B20-B21 . provide antenatal care C1-C18 . If recently given birth. NON URGENT ■ ■ No emergency signs or No priority signs ■ ■ If pregnant (and not in labour). provide postpartum care E1-E10 .

Give ampicillin 2 g IV/IM B15 . leave the wound open. and record. 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. ■ ■ BLEEDING (3) Repair the tear Empty bladder 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) B9 . do not give any more magnesium sulphate. If delivery is anticipated on the way Soap. with the back of the hand directed posteriorly and the knuckles in the anterior fornix. B11 REFER THE WOMAN URGENTLY TO THE HOSPITAL Preparation ■ Explain to the woman the need for manual removal of the placenta and obtain her consent. show assistant or relative how to apply pressure. If convulsions recur. ■ ■ B10 EMERGENCY TREATMENTS FOR THE WOMAN B10 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 ■ ■ B16 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** 1ml vial containing 80 mg/ml 3. →Make sure that the apex of the tear is reached before you begin suturing. ■ Record time and amount of fluids given. Maintenance dose ■ Give additional 10 mg (2 ml) every hour during transport. continue antibiotics IM/IV for 48 hours after woman is fever free. curved needle. Catheterize if necessary B12 . during convulsion). or if the placenta is retained due to constriction ring or closed cervix. or send: → a health worker trained in delivery care → a relative who can donate blood → baby with the mother. give appropriate treatment on the way → keep record of all IV fluids. ■ If heavy bleeding continues: → give ergometrine 0. give fluids slowly B9 . ■ Refer urgently to hospital unless delivery is imminent. ■ Stop the maintenance dose if breathing <16 breaths/minute. or the woman is in late labour. explore again the uterine cavity to remove them. 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. Cover it with a clean pad and refer the woman urgently to hospital B17 . repeat the dose at 30 minute intervals until diastolic BP is around 90 mmHg. give diazepam rectally. If the woman is not breathing: →Ventilate with bag and mask until she starts breathing spontaneously If woman still has great difficulty breathing. Massage fundus in a circular motion with cupped palm until uterus is well contracted. If no IV glucose is available. ■ Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. ■ Ensure the bladder is empty. ■ Attach Ringer’s lactate or normal saline. →Discharge the contents and leave the syringe in place. Repeat if necessary. →Ensure that edges of the tear match up well. Refer urgently to hospital B17 . if possible → essential emergency drugs and supplies B17 . OR If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered by controlled cord traction. Loading dose rectally ■ Give 20 mg (4 ml) in a 10 ml syringe (or urinary catheter): →Remove the needle. ■ Explore the inside of the uterine cavity to ensure all placental tissue has been removed. If delivery imminent or unable to refer immediately.0 mg) Give the loading dose of the most effective drug. or heavy vaginal bleeding: EMERGENCY TREATMENTS FOR THE WOMAN If the woman is unconscious: →Keep her on her back. 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. give 8. ■ To make sugar water. * These dosages are for quinine dihydrochloride. repeat 10 mg. Give the treatment and refer the woman urgently to hospital B17 . thirst. Move the fingers of the right hand sideways until edge of the placenta is located. ■ During transportation. Apply sufficient pressure until femoral pulse is not felt. IM IV 5g 4g 2g 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. If not bleeding. Airway.g. ■ After finding correct site. give sugar water by mouth or nasogastric tube. give magnesium sulphate and protect her from fall and injury.2 mg slowly Continuing dose IM: repeat 0. Loading dose IV Give diazepam 10 mg IV slowly over 2 minutes. If quinine base. breathing and circulation B9 Infection B15 Bleeding (1) EMERGENCY TREATMENTS FOR THE WOMAN BLEEDING Massage uterus and expel clots If heavy postpartum bleeding persists after placenta is delivered. ■ Place the other hand on the abdomen behind the uterus and squeeze the uterus firmly between the two hands. feel continuously whether uterus is well contracted (hard and round). time of administration and the woman’s condition. →Use absorbable polyglycon suture material. ■ If bleeding persists. ** Discontinue parenteral treatment as soon as woman is conscious and able to swallow. ■ DO NOT give the next dose if any of these signs: →knee jerk absent →urine output <100 ml/4 hrs →respiratory rate <16/min. →If respiratory depression (breathing less than 16/minute) occurs after magnesium sulphate. Give the antidote: calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes.2 mg/kg every 8 hours. 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 ■ ■ 1 antibiotic: ■ Ampicillin Antibiotic Ampicillin Gentamicin Metronidazole DO NOT GIVE IM Preparation Vial containing 500 mg as powder: to be mixed with 2. aseptic technique and sterile equipment. Rapid injection can cause respiratory failure or death. headache. also give gentamicin 80 mg IM B15 . refer urgently to hospital B17 . ■ With the left hand. add 4 ml of 50% solution to 6 ml sterile water If referral delayed for long. If convulsions recur After 15 minutes.5 ml sterile water Vial containing 40 mg/ml in 2 ml Vial containing 500 mg in 100 ml Vial containing 500 mg as powder Dosage/route First 2 g IV/IM then 1 g 80 mg IM 500 mg or 100 ml IV infusion 500 mg IV/IM Frequency every 6 hours every 8 hours every 8 hours every 6 hours If intravenous access not possible ■ ■ Erythromycin (if allergy to ampicillin) Give oral rehydration solution (ORS) by mouth if able to drink. ■ Provide bimanual or aortic compression if severe bleeding before and during transportation B10 . ■ DO NOT give intravenous fluids rapidly. If signs persist or mother becomes weak or has abdominal pain postpartum. or by nasogastric (NG) tube. This prevents inversion of the uterus. Refer woman to hospital. Proceed gradually all around the placental bed until the whole placenta is detached from the uterine wall. If IV not possible give IM. drying and wrapping the baby Clean clothes for the baby Plastic bag for placenta Resuscitation bag and mask for the baby 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: →The tear is small and involved only vaginal mucosa and connective tissues and underlying muscles (first or second degree tear). ■ Infuse 1 litre in 15-20 minutes (as rapid as possible). →Suture the tear using universal precautions. Refer urgently to hospital B17 . clenched fist. apply aortic compression and transport woman to hospital. →Use a needle holder and a 21 gauge. pre-eclampsia. pulse>110/minute. or hypertension ■ ■ Apply aortic compression If heavy postpartum bleeding persists despite uterine massage. dissolve 4 level teaspoons of sugar (20 g) in a 200 ml cup of clean water. ■ Give diazepam (10 mg IM/IV). ■ Apply pressure above the umbilicus to stop bleeding. DO NOT persist. give fluids rapidly. or uterus is not well contracted (is soft): Place cupped palm on uterine fundus and feel for state of contraction. keep her propped up. If bleeding. Quantity of ORS: 300 to 500 ml in 1 hour. B17 Remove placenta and fragments manually ■ ■ After manual removal of the placenta Repeat oxytocin 10 IU IM/IV. keep applying pressure while transporting Initial dose IM/IV:0. 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. ■ ■ ■ ■ Reduce the infusion rate to 0. Give fluids at slow rate if severe anaemia/severe pre-eclampsia or eclampsia: ■ Infuse 1 litre in 6-8 hours. B13 Important considerations in caring for a woman with eclampsia or pre-eclampsia Do not leave the woman on her own. If she is unable to urinate. If convulsions still continue. place fingers behind fundus and push down in one swift action to expel clots. ■ Collect blood in a container placed close to the vulva. ■ Before giving the next dose of magnesium sulphate. BREATHING AND CIRCULATION EMERGENCY TREATMENTS FOR THE WOMAN INFECTION Give appropriate IV/IM antibiotics ■ ■ B15 Give the first dose of antibiotic(s) before referral. give an additional 2 g of magnesium sulphate (10 ml of 20% solution) IV over 20 minutes. ■ Do not give more than 100 mg in 24 hours. If bleeding persists. Accompany the woman if at all possible. 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. 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). at least. ■ When well contracted. massage and repeat oxytocin 10 IU IM/IV. ■ Introduce the right hand into the vagina. Begin oral treatment according to national guidelines. ■ B12 B12 Empty bladder If bladder is distended and the woman is unable to pass urine: Encourage the woman to urinate. * 50% glucose solution is the same as 50% dextrose solution or D50. ■ Clean woman’s skin with spirit at site for IV line. oxytocin/ergometrine treatment and removal of placenta: ■ Wear sterile or clean gloves. systolic BP<90 mmHg.2 mg/kg 2 ml 1. ■ Clean vulva and perineal area. ■ Give IV 20% magnesium sulphate slowly over 20 minutes. and secure it to prevent aspiration (DO NOT attempt this during a convulsion).5 ml/minute if breathing difficulty or puffiness develops. remove if found →Clear secretions from throat. ■ ■ ECLAMPSIA AND PRE-ECLAMPSIA (2) Give diazepam Give appropriate antihypertensive ■ 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.2 mg IM → give 20 IU oxytocin in each litre of IV fluids and infuse rapidly → Refer urgently to hospital B17 .6 mg/kg 1 ml once daily for 3 days** Give oxytocin If heavy postpartum bleeding Initial dose IM/IV: 10 IU 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 MALARIA Give artemether or quinine IM Give glucose IV 50% glucose solution* 25-50 ml ■ ■ 25% glucose solution 50-100 ml 10% glucose solution (5 ml/kg) 125-250 ml Apply bimanual uterine compression If heavy postpartum bleeding persists despite uterine massage. oxytocin/ergometrine treatment and removal of placenta: ■ Feel for femoral pulse. ■ Reduce the infusion rate to 3 ml/minute (1 litre in 6-8 hours) when pulse slows to less than 100/minute. If fever >38. Clean area again →Insert catheter up to 4 cm →Measure urine and record amount →Remove catheter. nausea or may vomit. foul-smelling lochia or history of rupture of membranes for 18 or more hours. medications given. Quickly organize transport and possible financial aid. Do not delay referral by giving non-urgent treatments. Refer urgently to hospital B17 . according to the national policy. Then give amoxicillin orally 500 mg 3 times daily until 7 days of treatment completed.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. Technique With the left hand. 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). Massage the fundus of the uterus to encourage a tonic uterine contraction. ■ If convulsions recur. give the first dose of the drugs before referral. lubricate the barrel and insert the syringe into the rectum to half its length. If any placental lobe or tissue fragments are missing. →The tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa (third and fourth degree tear). ■ 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. ■ Monitor urine output: collect urine and measure the quantity. ■ ■ ■ ■ ■ If placenta not delivered 1 hour after delivery of the baby. ■ ■ B8 B14 B14 Give appropriate antihypertensive drug If diastolic blood pressure is > 110 mmHg: Give hydralazine 5 mg IV slowly (3-4 minutes). If referral is delayed or not possible. If the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage. ■ Insert an intravenous line (IV line) using a 16-18 gauge needle. 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 This section has details on emergency treatments identified during Rapid assessment and management (RAM) B3-B6 to be given before referral. If diastolic blood pressure remains > 90 mmHg. 3 ties) Clean cloths (3) for receiving. provide counter-traction to the fundus through the abdomen by pushing it in the opposite direction of the hand that is being withdrawn. systolic BP increases to 100 mmHg or higher. suspect placenta accreta. ■ During journey: → watch IV infusion → if journey is long.5°C. IV infusion: 20 IU in 1 litre at 60 drops/min Make sure IV drip is running well. woman to hospital. discuss decision with woman and relatives. Initial dose Second dose ■ ■ AIRWAY. Inform the referral centre if possible by radio or phone. If not. ■ 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. ■ Assist ventilation if necessary with mask and bag. ■ Monitor every 15 minutes for: → blood pressure (BP) and pulse → shortness of breath or puffiness. obstructed labour. Then pull the cord gently until it is horizontal. ■ Do not give more than 20 mg in total. This solution is irritating to veins. ■ Infuse 1 litre in 30 minutes at 30 ml/minute. catheterize the bladder: →Wash hands →Clean urethral area with antiseptic →Put on clean gloves →Spread labia. bringing the placenta with it. holding the buttocks together for 10 minutes to prevent expulsion of the drug.2 mg IM after 15 minutes if heavy bleeding persists Maximum dose Not more than 5 doses (total 1. If bleeding stops: → give fluids slowly for at least 1 hour after removal of placenta. and Refer the woman urgently to hospital. ■ Assist woman to get onto her back. it may not be possible to put the hand into the uterus. ■ Formulation of magnesium sulphate 50% solution: vial containing 5 g in 10 ml (1g/2ml) 20% solution: to make 10 ml of 20% solution. Insert right hand into the vagina and up into the uterus. continue treatment as above and refer after delivery. ■ Continue pressure until bleeding stops. ■ DO NOT give intravenously 50% magnesium sulphate without dilluting it to 20%. Withdraw the right hand from the uterus gradually. →If delivery imminent. arms at the side →Tilt her head backwards (unless trauma is suspected) →Lift her chin to open airway →Inspect her mouth for foreign body. → referral note N2 . ensure: →knee jerk is present →urine output >100 ml/4 hrs →respiratory rate >16/min. repeat 10 mg. one pair sterile 5 sets 1 1 small bottle 1 1 1 If hours or days have passed since delivery. DO NOT suture if more than 12 hours since delivery. give diazepam B14 . DO NOT persist in efforts to remove placenta. ■ If IV access is not possible (e. if necessary. dangerous fever or dehydration: ■ Infuse 1 litre in 2-3 hours. Give glucose by slow IV push. Eclampsia and pre-eclampsia (1) B13 . or if placenta is incomplete and bleeding continues. If quinine: →divide the required dose equally into 2 injections and give 1 in each anterior thigh →always give glucose with quinine. ■ Continue compression until bleeding stops (no bleeding if the compression is released). hold the umbilical cord with the clamp. ectopic pregnancy. Give fluids at moderate rate if severe abdominal pain. Dilute it with an equal quantity of sterile water or saline to produce 25% glucose solution. ■ Insert an IV line. If drug treatment. Measure or estimate blood loss.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) EMERGENCY TREATMENTS FOR THE WOMAN Remove placenta and fragments manually After manual removal of the placenta REFER THE WOMAN URGENTLY TO THE HOSPITAL Refer the woman urgently to the hospital Essential emergency drugs and supplies for transport and home delivery 2 sets 2 pairs. ■ Record findings and drugs given. 4 cm. ■ B9 Insert IV line and give fluids ■ Wash hands with soap and water and put on gloves. ■ Monitor urine output. DO NOT give ORS to a woman who is unconscious or has convulsions. Ensure infusion is running well. ANTIBIOTICS 3 antibiotics ■ Ampicillin ■ Gentamicin ■ Metronidazole 2 antibiotics: ■ Ampicillin ■ Gentamicin INFECTION Give appropriate IV/IM antibiotics Give fluids at rapid rate if shock. ■ Give 4 g of magnesium sulphate (20 ml of 20% solution) IV slowly over 20 minutes (woman may feel warm during injection). ■ ■ ■ ■ ■ ■ ■ BLEEDING (2) EMERGENCY TREATMENTS FOR THE WOMAN Refer the woman urgently to hospital After emergency management. ■ ■ ■ ■ 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 Strength and Form 10 IU vial 0. AIRWAY. If the tear is not bleeding. towels Disposable delivery kit (blade. →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-D29 and accompany the woman during transport →Keep her in the left side position →If a convulsion occurs during the journey.

Airway. Repeat if necessary. ectopic pregnancy. ■ ■ ■ Give fluids at rapid rate if shock. systolic BP<90 mmHg.AIRWAY. keep her propped up. Give fluids at moderate rate if severe abdominal pain. ■ Infuse 1 litre in 30 minutes at 30 ml/minute. ■ Reduce the infusion rate to 0. dangerous fever or dehydration: ■ Infuse 1 litre in 2-3 hours. Ensure infusion is running well. DO NOT give ORS to a woman who is unconscious or has convulsions. remove if found →Clear secretions from throat. ■ Record time and amount of fluids given. ■ Attach Ringer’s lactate or normal saline. If intravenous access not possible ■ ■ Give oral rehydration solution (ORS) by mouth if able to drink. ■ Monitor every 15 minutes for: → blood pressure (BP) and pulse → shortness of breath or puffiness. If the woman is not breathing: →Ventilate with bag and mask until she starts breathing spontaneously If woman still has great difficulty breathing.5 ml/minute if breathing difficulty or puffiness develops. ■ Monitor urine output. ■ Insert an intravenous line (IV line) using a 16-18 gauge needle. EMERGENCY TREATMENTS FOR THE WOMAN If the woman is unconscious: →Keep her on her back. ■ Clean woman’s skin with spirit at site for IV line. Give fluids at slow rate if severe anaemia/severe pre-eclampsia or eclampsia: ■ Infuse 1 litre in 6-8 hours. 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. or by nasogastric (NG) tube. ■ Insert IV line and give fluids ■ Wash hands with soap and water and put on gloves. systolic BP increases to 100 mmHg or higher. arms at the side →Tilt her head backwards (unless trauma is suspected) →Lift her chin to open airway →Inspect her mouth for foreign body. breathing and circulation B9 . and Refer the woman urgently to hospital. Quantity of ORS: 300 to 500 ml in 1 hour. pulse>110/minute. or heavy vaginal bleeding: ■ Infuse 1 litre in 15-20 minutes (as rapid as possible). ■ Reduce the infusion rate to 3 ml/minute (1 litre in 6-8 hours) when pulse slows to less than 100/minute. obstructed labour.

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

■ Examine the uterine surface of the placenta to ensure that lobes and membranes are complete. give fluids slowly B9 . hold the umbilical cord with the clamp. give fluids rapidly. Refer urgently to hospital B17 . ■ ■ Repeat oxytocin 10 IU IM/IV. ■ 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. ■ Ensure the bladder is empty. If bleeding stops: → give fluids slowly for at least 1 hour after removal of placenta. ■ Wash hands and forearms well and put on long sterile gloves (and an apron or gown if available). or if the placenta is retained due to constriction ring or closed cervix.2 mg IM → give 20 IU oxytocin in each litre of IV fluids and infuse rapidly → Refer urgently to hospital B17 . ■ 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. If hours or days have passed since delivery. also give gentamicin 80 mg IM B15 . Provide bimanual or aortic compression if severe bleeding before and during transportation B10 . Then pull the cord gently until it is horizontal. foul-smelling lochia or history of rupture of membranes for 18 or more hours. ■ Explore the inside of the uterine cavity to ensure all placental tissue has been removed. If bleeding. Give ampicillin 2 g IV/IM B15 . suspect placenta accreta. EMERGENCY TREATMENTS FOR THE WOMAN Bleeding (2) B11 . ■ Move the fingers of the right hand sideways until edge of the placenta is located. it may not be possible to put the hand into the uterus. This prevents inversion of the uterus. explore again the uterine cavity to remove them. ■ Insert right hand into the vagina and up into the uterus. During transportation. bringing the placenta with it. OR If heavy vaginal bleeding continues despite massage and oxytocin and placenta cannot be delivered by controlled cord traction. If the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage. ■ Give diazepam (10 mg IM/IV). Technique ■ With the left hand. Catheterize if necessary B12 . ■ With the left hand. If any placental lobe or tissue fragments are missing. massage and repeat oxytocin 10 IU IM/IV. feel continuously whether uterus is well contracted (hard and round). If fever >38. or if placenta is incomplete and bleeding continues.5°C.Remove placenta and fragments manually ■ ■ After manual removal of the placenta ■ ■ ■ ■ ■ ■ If placenta not delivered 1 hour after delivery of the baby. ■ Insert an IV line. Preparation ■ Explain to the woman the need for manual removal of the placenta and obtain her consent. ■ Clean vulva and perineal area. ■ Proceed gradually all around the placental bed until the whole placenta is detached from the uterine wall. Refer urgently to hospital B17 . Massage the fundus of the uterus to encourage a tonic uterine contraction. If not bleeding. provide counter-traction to the fundus through the abdomen by pushing it in the opposite direction of the hand that is being withdrawn. DO NOT persist in efforts to remove placenta. ■ Assist woman to get onto her back. ■ Withdraw the right hand from the uterus gradually. If not. DO NOT persist. If heavy bleeding continues: → give ergometrine 0.

■ If she is unable to urinate. ■ B12 Empty bladder If bladder is distended and the woman is unable to pass urine: ■ Encourage the woman to urinate. 4 cm. . →Suture the tear using universal precautions. DO NOT suture if more than 12 hours since delivery. →Make sure that the apex of the tear is reached before you begin suturing. catheterize the bladder: →Wash hands →Clean urethral area with antiseptic →Put on clean gloves →Spread labia. →Use a needle holder and a 21 gauge. Clean area again →Insert catheter up to 4 cm →Measure urine and record amount →Remove catheter. leave the wound open. aseptic technique and sterile equipment. →The tear is long and deep through the perineum and involves the anal sphincter and rectal mucosa (third and fourth degree tear). →Ensure that edges of the tear match up well. →Use absorbable polyglycon suture material. If the tear is not bleeding. curved needle. Cover it with a clean pad and 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: →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 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.

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. Important considerations in caring for a woman with eclampsia or pre-eclampsia ■ ■ EMERGENCY TREATMENTS FOR THE WOMAN If unable to give IV. 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. do not give any more magnesium sulphate. thirst. ■ ■ ■ Do not leave the woman on her own. give diazepam B14 . →If delivery imminent. give magnesium sulphate and protect her from fall and injury. or the woman is in late labour. If referral delayed for long. If convulsions still continue. ■ Before giving the next dose of magnesium sulphate. Rapid injection can cause respiratory failure or death. ■ Give 4 g of magnesium sulphate (20 ml of 20% solution) IV slowly over 20 minutes (woman may feel warm during injection). Eclampsia and pre-eclampsia (1) B13 . Formulation of magnesium sulphate 50% solution: vial containing 5 g in 10 ml (1g/2ml) 20% solution: to make 10 ml of 20% solution. manage as in Childbirth D1-D29 and accompany the woman during transport →Keep her in the left side position →If a convulsion occurs during the journey. DO NOT give intravenously 50% magnesium sulphate without dilluting it to 20%. If convulsions recur ■ After 15 minutes. Give IV 20% magnesium sulphate slowly over 20 minutes. and secure it to prevent aspiration (DO NOT attempt this during a convulsion). give an additional 2 g of magnesium sulphate (10 ml of 20% solution) IV over 20 minutes. ensure: →knee jerk is present →urine output >100 ml/4 hrs →respiratory rate >16/min. Refer urgently to hospital unless delivery is imminent. Give the antidote: calcium gluconate 1 g IV (10 ml of 10% solution) over 10 minutes. ■ Monitor urine output: collect urine and measure the quantity. headache. nausea or may vomit. →If respiratory depression (breathing less than 16/minute) occurs after magnesium sulphate. add 4 ml of 50% solution to 6 ml sterile water IM IV 5g 4g 2g 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. →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. ■ 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.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) B9 . 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 give intravenous fluids rapidly.

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. ■ Assist ventilation if necessary with mask and bag. ■ Stop the maintenance dose if breathing <16 breaths/minute. If IV not possible give IM. repeat 10 mg. holding the buttocks together for 10 minutes to prevent expulsion of the drug. ■ If convulsions recur. ■ Do not give more than 100 mg in 24 hours. ■ If IV access is not possible (e. repeat the dose at 30 minute intervals until diastolic BP is around 90 mmHg. Initial dose Second dose .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. ■ If diastolic blood pressure remains > 90 mmHg. 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 B14 Give appropriate antihypertensive drug If diastolic blood pressure is > 110 mmHg: ■ Give hydralazine 5 mg IV slowly (3-4 minutes). ■ If convulsions recur. ■ Do not give more than 20 mg in total. Maintenance dose ■ Give additional 10 mg (2 ml) every hour during transport. 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. Loading dose IV ■ Give diazepam 10 mg IV slowly over 2 minutes. during convulsion).g.

If referral is delayed or not possible. refer urgently to hospital B17 . If signs persist or mother becomes weak or has abdominal pain postpartum. ANTIBIOTICS 3 antibiotics ■ Ampicillin ■ Gentamicin ■ Metronidazole 2 antibiotics: ■ Ampicillin ■ Gentamicin EMERGENCY TREATMENTS FOR THE WOMAN 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 Antibiotic Ampicillin Gentamicin Metronidazole DO NOT GIVE IM 1 antibiotic: ■ Ampicillin Preparation Vial containing 500 mg as powder: to be mixed with 2. continue antibiotics IM/IV for 48 hours after woman is fever free.5 ml sterile water Vial containing 40 mg/ml in 2 ml Vial containing 500 mg in 100 ml Vial containing 500 mg as powder Dosage/route First 2 g IV/IM then 1 g 80 mg IM 500 mg or 100 ml IV infusion 500 mg IV/IM Frequency every 6 hours every 8 hours every 8 hours every 6 hours Erythromycin (if allergy to ampicillin) Infection B15 .INFECTION Give appropriate IV/IM antibiotics ■ ■ Give the first dose of antibiotic(s) before referral. Then give amoxicillin orally 500 mg 3 times daily until 7 days of treatment completed.

according to the national policy. ** Discontinue parenteral treatment as soon as woman is conscious and able to swallow.6 mg/kg 1 ml once daily for 3 days** 50% glucose solution* 25-50 ml ■ ■ ■ 25% glucose solution 50-100 ml 10% glucose solution (5 ml/kg) 125-250 ml Make sure IV drip is running well. This solution is irritating to veins. To make sugar water. Refer urgently to hospital B17 . Give glucose by slow IV push. If delivery imminent or unable to refer immediately. If quinine: →divide the required dose equally into 2 injections and give 1 in each anterior thigh →always give glucose with quinine.2 mg/kg every 8 hours. give 8. continue treatment as above and refer after delivery. Dilute it with an equal quantity of sterile water or saline to produce 25% glucose solution. Begin oral treatment according to national guidelines. give sugar water by mouth or nasogastric tube. If no IV glucose is available. * 50% glucose solution is the same as 50% dextrose solution or D50. If quinine base. ■ ■ Give the loading dose of the most effective drug. dissolve 4 level teaspoons of sugar (20 g) in a 200 ml cup of clean water. . * These dosages are for quinine dihydrochloride.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 ■ ■ 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** 1ml vial containing 80 mg/ml 3.2 mg/kg 2 ml 1.

medications given. During journey: → watch IV infusion → if journey is long.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. → referral note N2 . time of administration and the woman’s condition. 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 2 sets 2 sets 1 set 1 set 1 set 1set Refer the woman urgently to hospital B17 . 3 ties) Clean cloths (3) for receiving. at least.REFER THE WOMAN URGENTLY TO THE HOSPITAL Refer the woman urgently to hospital ■ ■ ■ ■ ■ EMERGENCY TREATMENTS FOR THE WOMAN After emergency management. Inform the referral centre if possible by radio or phone. discuss decision with woman and relatives. one pair sterile 5 sets 1 1 small bottle 1 1 1 If delivery is anticipated on the way Soap. Accompany the woman if at all possible. towels Disposable delivery kit (blade. or send: → a health worker trained in delivery care → a relative who can donate blood → baby with the mother. 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 Strength and Form 10 IU vial 0. if possible → essential emergency drugs and supplies B17 . give appropriate treatment on the way → keep record of all IV fluids.

■ Facilitate family and community support.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. →Inform them about the importance of family planning if another pregnancy is not desired. Use Advise and counsel on post-abprtion care visit. or simply being available to listen. and the scheduled next visit in the home-based and clinic recording forms. Refer urgently to hospital B17 . weakness →dizziness or fainting. (see The decision-making tool for family planning clients and providers for information on methods and on the counselling process). and may benefit from support: Allow the woman to talk about her worries. →Advise the woman to return immediately if bleeding increases. LISTEN. foul-smelling vaginal discharge. Note if there is foul-smelling vaginal discharge. →If decrease. by sharing or reducing her workload. Give 3 month’s supply of iron and counsel on compliance F3 . ■ Advise woman to return in if delay (6 weeks or more) in resuming menstrual periods. give first dose of appropriate IV/IM antibiotics B15 . Check HIV status C6 . Check preventive measures B20 . counsel on VCT G3 . Advise on correct and consistent condom use if she or her partner are at risk of sexually transmitted infection (STI) or HIV G2 . refer to hospital. . CHECK RECORDS ■ ■ ■ B20 GIVE PREVENTIVE MEASURES ■ TREAT AND ADVISE ■ ■ ■ ■ Check tetanus toxoid (TT) immunization status. If bleeding continues: ■ Assess and manage as in Bleeding in early pregnancy/post-abortion care B18-B22 . ■ Refer urgently to hospital B17 . measure temperature. do the RPR test L5 . link her to a peer support group or other women’s groups or community services which can provide her with additional support. Check woman’s supply of the prescribed dose of iron/folate. Advise and counsel on family planning B21 . Advise and counsel during follow-up visits If threatened abortion and bleeding stops: ■ Reassure the woman that it is safe to continue pregnancy. use G1-G8 H1-H4 BLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE Rest for a few days. History of heavy bleeding but: →now decreasing. feeling ill. If hot. ■ Encourage VCT G3 . If HIV-negative. B21 Give preventive measures BLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE GIVE PREVENTIVE MEASURES ASSESS. →counsel on correct and consistent use of condoms G4 . For information on options. CHECK RECORD ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ LOOK. Advise and counsel on post-abortion care B21 . to assess the woman with light vaginal ■ Two or more of the following signs: →abdominal pain →fainting →pale →very weak ECTOPIC PREGNANCY ■ ■ Insert an IV line and give fluids B9 . Give paracetamol for pain F4 . ■ Reinforce use of condoms G4 . Light vaginal bleeding ■ THREATENED ABORTION ■ ■ ■ Observe bleeding for 4-6 hours: →If no decrease. follow-up ■ ■ ■ Check RPR status in records C5 . →Inform them that post-abortion complications can have grave consequences for the woman’s health. If voluntary counselling and testing (VCT) status unknown.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. let the woman go home. ■ Feel for fever. ■ ■ ■ 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 ■ . adolescent or has special needs. ■ Feel for lower abdominal pain. AND POST-ABORTION CARE Use this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods B18 B19 BLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE ASK. if she is interested (depending on the circumstances. Advise on self-care B21 . Advise to return if bleeding does not stop within 2 days. If no RPR results. ■ Give appropriate IM/IV antibiotics B15 . →advise on opportunistic infection and need to seek medical help C10 . ■ B21 ADVISE AND COUNSEL ON POST-ABORTION CARE Advise on self-care Provide information and support after abortion A woman may experience different emotions after an abortion. ■ Provide antenatal care C1-C18 . family planning. Ask if she has any questions or concerns. see H4 . Use chart on Preventive measures B20 B3-B7 B19 . positive findings. Give tetanus toxoid if due F2 . If known HIV-positive: →give support G6 . especially if feeling tired. health and personal situation. →If the woman has an infection or injury: delay IUD insertion or female sterilization until healed. →Speak to them about how they can best support her. feelings. ■ ■ 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? Vaginal bleeding and any of: →Foul-smelling vaginal discharge →Abortion with uterine manipulation →Abdominal pain/tenderness →Temperature >38°C. FEEL Look at amount of bleeding. or →no bleeding at present. counsel on correct and consistent use of condoms G4 . ■ Advise on treating her partner. If the woman is HIV positive. →If fever. she may not wish to involve others). Advise on hygiene →change pads every 4 to 6 hours →wash the perineum daily →avoid sexual relations until bleeding stops. or abdominal pain. ■ If the woman discloses violence or you see unexplained bruises and other injuries which make you suspect she may be suffering abuse. or counsel her directly. ■ ■ SIGNS ■ CLASSIFY COMPLICATED ABORTION TREAT AND ADVISE Insert an IV line and give fluids B9 . Make arrangements for her to see a family planning counsellor as soon as possible. see Methods for non-breastfeeding women on D27 . ■ If the woman is interested. COMPLETE ABORTION ■ ■ ■ ■ EXAMINATION OF THE WOMAN WITH BLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE ■ ■ Always begin with Rapid assessment and management (RAM) Next use the Bleeding in early pregnancy/post abortion care bleeding or a history of missed periods. helping out with children. NEXT: Give preventive measures Bleeding in early pregnancy and post-abortion care B19 ■ B20 to provide preventive measures due to all women. ■ Record all treatment given. 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. ■ Look for pallor. danger signs. ■ Advise on correct and consistent use of condoms if she or her partner are at risk for STI or HIV G2 . Inform them of the danger signs and the importance of the woman returning to the health worker if she experiences any. Follow up in 2 days B21 . →Refer woman to hospital. Advise and counsel on family planning ■ ■ ■ Explain to the woman that she can become pregnant soon after the abortion . to advise on self care. If Rapid plasma reagin (RPR) positive: ■ Treat the woman for syphilis with benzathine penicillin F6 .

Note if there is foul-smelling vaginal discharge. let the woman go home. Light vaginal bleeding Insert an IV line and give fluids B9 . 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. FEEL ■ ■ ■ ■ ■ SIGNS ■ CLASSIFY COMPLICATED ABORTION TREAT AND ADVISE ■ ■ ■ ■ 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 at amount of bleeding. Give paracetamol for pain F4 . CHECK RECORD ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ LOOK. Advise and counsel on family planning B21 . →Advise the woman to return immediately if bleeding increases. Check preventive measures B20 . measure temperature. Refer urgently to hospital B17 . Vaginal bleeding and any of: →Foul-smelling vaginal discharge →Abortion with uterine manipulation →Abdominal pain/tenderness →Temperature >38°C. Advise to return if bleeding does not stop within 2 days. LISTEN. Look for pallor. If hot. ■ THREATENED ABORTION ■ ■ ■ Observe bleeding for 4-6 hours: →If no decrease. Follow up in 2 days B21 . Feel for lower abdominal pain. Advise on self-care B21 . →If decrease. Give appropriate IM/IV antibiotics B15 .EXAMINATION OF THE WOMAN WITH BLEEDING IN EARLY PREGNANCY. refer to hospital. NEXT: Give preventive measures Bleeding in early pregnancy and post-abortion care B19 . or →no bleeding at present. History of heavy bleeding but: →now decreasing. Feel for fever. Refer urgently to hospital B17 . COMPLETE ABORTION ■ ■ ■ ■ ■ Two or more of the following signs: →abdominal pain →fainting →pale →very weak ECTOPIC PREGNANCY ■ ■ Insert an IV line and give fluids B9 .

. G3 . do the RPR test L5 . CHECK RECORDS ■ ■ ■ B20 TREAT AND ADVISE ■ ■ ■ ■ Check tetanus toxoid (TT) immunization status. If HIV-negative. . →advise on opportunistic infection and need to seek medical help C10 . If Rapid plasma reagin (RPR) positive: ■ Treat the woman for syphilis with benzathine penicillin ■ Advise on treating her partner. ■ Reinforce use of condoms G4 . →counsel on correct and consistent use of condoms G4 . ■ Encourage VCT G3 . Check HIV status C6 Give tetanus toxoid if due F2 . counsel on correct and consistent use of condoms G4 . Check RPR status in records C5 . Check woman’s supply of the prescribed dose of iron/folate. counsel on VCT If known HIV-positive: →give support G6 . If no RPR results. F6 .Give preventive measures BLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE GIVE PREVENTIVE MEASURES ASSESS. F3 Give 3 month’s supply of iron and counsel on compliance . ■ ■ ■ If voluntary counselling and testing (VCT) status unknown.

Advise on correct and consistent condom use if she or her partner are at risk of sexually transmitted infection (STI) or HIV G2 . →Inform them that post-abortion complications can have grave consequences for the woman’s health. by sharing or reducing her workload. ■ If the woman is interested. Advise woman to return in if delay (6 weeks or more) in resuming menstrual periods. →Speak to them about how they can best support her. ■ Advise on correct and consistent use of condoms if she or her partner are at risk for STI or HIV G2 . →Refer woman to hospital. link her to a peer support group or other women’s groups or community services which can provide her with additional support. Advise and counsel during follow-up visits If threatened abortion and bleeding stops: ■ Reassure the woman that it is safe to continue pregnancy. weakness →dizziness or fainting. Advise and counsel on family planning ■ ■ ■ Explain to the woman that she can become pregnant soon after the abortion . see Methods for non-breastfeeding women on D27 . BLEEDING IN EARLY PREGNANCY AND POST-ABORTION 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). and may benefit from support: ■ Allow the woman to talk about her worries. ■ Provide antenatal care C1-C18 . For information on options. especially if feeling tired. Advise on hygiene →change pads every 4 to 6 hours →wash the perineum daily →avoid sexual relations until bleeding stops. see H4 . if she is interested (depending on the circumstances. 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. →If the woman has an infection or injury: delay IUD insertion or female sterilization until healed. health and personal situation. she may not wish to involve others). →If fever.ADVISE AND COUNSEL ON POST-ABORTION CARE Advise on self-care ■ Provide information and support after abortion A woman may experience different emotions after an abortion. →Inform them about the importance of family planning if another pregnancy is not desired. or abdominal pain. Inform them of the danger signs and the importance of the woman returning to the health worker if she experiences any. If bleeding continues: ■ Assess and manage as in Bleeding in early pregnancy/post-abortion care B18-B22 . or simply being available to listen. feeling ill. ■ If the woman discloses violence or you see unexplained bruises and other injuries which make you suspect she may be suffering abuse. or counsel her directly. Advise and counsel on post-abortion care B21 . ■ Facilitate family and community support. feelings. give first dose of appropriate IV/IM antibiotics B15 . helping out with children.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. Ask if she has any questions or concerns. Make arrangements for her to see a family planning counsellor as soon as possible.

labour signs. The birth plan should be reviewed during every follow-up visit. use the charts Respond to observed signs or volunteered problems C7-C11 to classify the condition and identify appropriate treatment(s). history of previous pregancies. adolescent or has special needs. C14-C15 .Antenatal care ANTENATAL CARE ANTENATAL CARE ■ Always begin with Rapid assessment and management (RAM) B3-B7 . Give preventive measures due C12 . anaemia. use this section for further care. In cases where an abnormal sign is identified (volunteered or observed). treatments given and the next scheduled visit in the homebased maternal card/clinic recording form. see G1-G8 H1-H4 ■ . If the woman has no emergency or priority signs and has come for antenatal care. If the woman is HIV positive. C15 . Decide on an appropriate place of birth for the woman using this chart and prepare the birth and emergency plan. danger signs and follow-up visits C17 using Information and Counselling sheets M1-M19 . syphilis and HIV status according to the charts C3-C6 ■ ■ ■ . ■ Record all positive findings. Check all women for pre-eclampsia. and check her for general danger signs. Next use the Pregnancy status and birth plan chart C2 to ask the woman about her present pregnancy status. family planning C16 . routine ■ ■ ■ Develop a birth and emergency plan Advise and counsel on nutrition C13 . . birth plan.

Abnormal vaginal discharge ■ ■ ■ ■ Give clotrimazole F5 . day or night. milk. A facility has staff. ■ Counsel on benefits of involving and testing the partner G3 . If treatment does not include streptomycin. cheese. ■ To wait for the placenta to deliver on its own. WITHOUT waiting Mother ■ Waters break and not in labour after 6 hours. refer to hospital. ■ severe abdominal pain. ■ Enquire about the ARV prophylactic treatment prescribed and ensure that the woman knows when to start ARV prophylaxis G6 . She should go to the health centre as soon as possible if any of the following signs: ■ fever. and Cough <3 weeks. ■ Talk to family members such as the partner and mother-in-law. If no improvement in 2 days or condition is worse. ■ Fever. ■ Feels cold. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (2) If fever or burning on urination C14 C14 DEVELOP A BIRTH AND EMERGENCY PLAN Use the information and counselling sheet to support your interaction with the woman. ACCORDING TO WOMAN’S PREFERENCE ■ ■ Explain why delivery needs to be with a skilled birth attendant. CHECK RECORD LOOK. IF RUPTURED MEMBRANES AND NO LABOUR ■ ■ Advise on self-care during pregnancy Advise the woman to: Take iron tablets (p. ■ Look for palmar pallor. ■ Labour pains/contractions continue for more than 12 hours. ■ abdominal pain. refer to hospital. Promote especially if at risk for STI or HIV G4 . →Look for lethargy. Facility delivery Explain why birth in a facility is recommended Any complication can develop during delivery . painful contractions every 20 minutes or less. ADVISE ON ROUTINE AND FOLLOW-UP VISITS Follow-up visits If anti-tubercular treatment includes streptomycin (injection). First visit ■ Develop a birth and emergency plan C14 . 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? ■ ■ ■ Look for breathlessness. No fetal heart beat. Counsel on compliance with treatment F3 . ■ ■ ■ ■ Check woman’s supply of the prescribed dose of iron/folate Check when last dose of mebendazole given. refer urgently to hospital. within the first hour after birth. Chest pain. Refer urgently to hospital B17 . MODERATE ANAEMIA Two of these signs: →weight loss →fever >1 month →diarrhoea >1month. ■ C16 C16 Special considerations for family planning counselling during pregnancy Counselling should be given during the third trimester of pregnancy. ■ ■ ■ ■ ■ ASSESS. ■ Clean cloths for washing. ■ Advise on when to seek care: C17 →routine visits →follow-up visits →danger signs. LISTEN. ■ Tubal ligation or IUD desired immediately after delivery. Sleep under an insecticide impregnated bednet. Use condoms correctly and consistently. Spend more time on nutrition counselling with very thin women and adolescents. OR Palmar or conjunctival pallor. →Look or feel for stiff neck. ■ burning on passing urine. ■ Refer to TB centre if cough. ■ Counsel on compliance with treatment F3 . Intense vulval itching. cow dung or other substance on umbilical cord/stump. FEEL IF COUGH OR BREATHING DIFFICULTY ■ ■ ■ ■ ■ SIGNS At least 2 of the following signs: Fever >38ºC. CHECK RECORD LOOK. ask her to wear a pad. If severe wheezing. plan to give INH prophylaxis to the newborn K13 . if needed I1–I3 . ■ Counsel on importance of exclusive breastfeeding K2 . she can become pregnant as soon as four weeks after delivery. PRE-ECLAMPSIA ■ ■ Revise the birth plan C2 . →Do you smoke. seeds. LISTEN. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS C7 CLASSIFY PROBABLY DEAD BABY ASK. Advise to have her home-based maternal record ready. Advise on correct and consistent use of condoms G2 . LISTEN. ■ To use the ties and razor blade from the disposable delivery kit to tie and cut the cord. ■ fast or difficult breathing. THIRD TRIMESTER Has she been counselled on family planning? If yes. advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. Listen for fetal heart after 6 months of pregnancy D2 . ■ Advise on correct and consistent use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. equipment. ■ To. First antenatal contact should be as early in pregnancy as possible. Give appropriate oral antimalarial if not given in the past month F4 . Refer urgently to hospital B17 .they are not always predictable. ■ To dispose of the placenta in a correct. TUBERCULOSIS NEXT: Check for HIV status ANTENATAL CARE ANTENATAL CARE If cough or breathing difficulty If taking anti-tuberculosis drugs If the problem was: Hypertension Severe anaemia Return in: 1 week if >8 months pregnant 2 weeks 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 Counsel all pregnant women for HIV at first visit. Third trimester ■ Counsel on family planning C16 . ■ ✎____________________________________________________________________ ✎____________________________________________________________________ Advise on danger signs If the mother or baby has any of these signs. Breathlessness. Determine if there are important taboos about foods which are nutritionally important for good health. Advise what to bring ■ Home-based maternal record. Give appropriate anti-hypertensives B14 . 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. C11 ADVISE ON ROUTINE AND FOLLOW-UP VISITS At least 1 of the following signs: ■ Cough or breathing difficulty for >3 weeks ■ Blood in sputum ■ Wheezing ■ ■ POSSIBLE CHRONIC LUNG DISEASE ■ ■ ■ Refer to hospital for assessment. ■ Clothes for mother and baby. ■ Enquire how she will be supplied with the drugs. OR ■ One of the above signs and →one or more other signs or →from a risk group. Measure temperature. ■ Fever >38°C and any of: →very fast breathing or →stiff neck →lethargy →very weak/not able to stand. ■ ■ ■ ■ ■ ■ ■ MALARIA 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. ■ ■ ■ ■ ■ ■ First birth. ■ ■ When did the baby last move? If no movement felt. HIV-NEGATIVE ■ ■ ■ Provide key information on HIV G2 . WITHOUT waiting if any of the following signs: ■ vaginal bleeding. ■ ■ ■ ■ ■ Assess if in high risk group: Occupational exposure? Is the woman commercial sex worker? Intravenous drug abuse? History of blood transfusion? Illness or death from AIDS in a sexual partner? ■ ■ Haemoglobin >11 g/dl. ■ For counselling on violence. Foul-smelling vaginal discharge. plan to give TT2 at next visit. NO CLINICAL ANAEMIA ■ ■ IF SMOKING. ■ Explain that after birth. During first antenatal visit. ask him if he has: ■ urethral discharge or pus. LISTEN. NOT to take medication unless prescribed at the health centre/hospital. Give appropriate oral antimalarial F4 . ■ Give appropriate oral antimalarial F4 . BIRTH AND EMERGENCY PLAN Use this chart to assess the pregnant woman at each of the four antenatal care visits. AND/OR ■ Severe palmar and conjunctival pallor or ■ ■ CLASSIFY SEVERE ANAEMIA TREAT AND ADVISE Revise birth plan so as to deliver in a facility with blood transfusion services C2 . Routine antenatal care visits 1st visit 2nd visit 3rd visit 4th visit Before 4 months 6 months 8 months 9 months C17 ■ ■ ■ ■ All pregnant women should have 4 routine antenatal visits. including the baby’s head. ■ Advise on additional care during pregnancy. or ■ Diastolic blood pressure ≥90 mmHg on two readings and 2+ proteinuria. FEEL ■ ■ SIGNS Haemoglobin <7 g/dl. 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. Feel for transverse lie. She should also keep her nails clean. ■ feels ill. Give 3 month’s supply of iron and counsel on compliance and safety F3 . if she has sex and is not exclusively breastfeeding. NO SYPHILIS Advise on correct and consistent use of condoms to prevent infection G2 . since when? Does the treatment include injection (streptomycin)? ■ ■ Taking anti-tuberculosis drugs. if at risk for STI or HIV G2 . FEEL IF VAGINAL DISCHARGE ■ ■ ■ SIGNS ■ ■ CLASSIFY POSSIBLE GONORRHOEA OR CHLAMYDIA INFECTION POSSIBLE CANDIDA INFECTION POSSIBLE BACTERIAL OR TRICHOMONAS INFECTION TREAT AND ADVISE ■ ■ ■ Blood pressure at the last visit? Measure blood pressure in sitting position. Record all visits and treatments given. ■ Bleeding increases. 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. Counsel on benefits of involving and testing her partner G3 . FEEL IF FEVER OR BURNING ON URINATION ■ ■ C8 TREAT AND ADVISE Insert IV line and give fluids slowly B9 . Feel for obvious multiple pregnancy. If she (and her partner) want more children. day or night. Prior delivery by forceps or vacuum. Known HIV-positive. Prior delivery with convulsions. 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 ASK. for cleaning the baby’s eyes. Check again in 1 hour. oils. If pallor: →Is it severe pallor? →Some pallor? →Count number of breaths in 1 minute. Avoid alcohol and smoking during pregnancy. CHECK RECORD LOOK. ■ Soap. ■ Not able to feed. WELL BABY Inform the woman that baby is fine and likely to be well but to return if problem persists. ■ ■ ■ ADVISE AND COUNSEL ON NUTRITION AND SELF-CARE Counsel on nutrition Advise on self-care during pregnancy ■ No fetal movement but fetal heart beat present. vegetables. ■ ■ 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. →plan for delivery in hospital or health centre where they are trained to carry out the procedure. More than six previous births. Rupture of membranes at <8 months of pregnancy. Ask if she (and children) are sleeping under insecticide treated bednets. reassess fetal movement. counsel to stop smoking. Partner has urethral discharge or burning on passing urine. ■ Bleeding. Reassess at next antenatal visit (4-6 weeks). ■ ■ ■ ■ ■ ■ 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. repeat after 1 hour rest. UPPER RESPIRATORY TRACT INFECTION ■ ■ Advise safe. 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. Measure temperature. repeat after 1 hour. soothing remedy. ■ fever and too weak to get out of bed. she should go at the first signs of labour. such as meat. Refer urgently to hospital B17 . CHECK RECORD LOOK. NEXT: Check for pre-eclampsia NEXT: If vaginal discharge C9 CHECK FOR PRE-ECLAMPSIA Screen all pregnant women at every visit. Advise the woman against these taboos. or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). Modify the birth plan if any complications arise. Give first dose of appropriate IM/IV antibiotics B15 . ask the woman if she would like her partner or another family member to be included in the counselling session. If yes. Fever <38ºC. LISTEN. Check duration of pregnancy. LISTEN. face. FEEL ■ CLASSIFY SEVERE PRE-ECLAMPSIA TREAT AND ADVISE ■ ■ ■ ■ CHECK FOR PRE-ECLAMPSIA ASK. ■ If the woman chooses an intrauterine device (IUD): →can be inserted immediately postpartum if no sign of infection (up to 48 hours. Separate the labia and look for abnormal vaginal discharge: →amount →colour →odour/smell. Feel for fetal movements. preferably at a facility. Give iron 1 tablet once daily for 3 months F3 . ■ None of the above. does she want tubal ligation or IUD A15 . Receiving injectable antituberculosis drugs. ■ STRONG LIKELIHOOD OF HIV INFECTION Reinforce the need to know HIV status and advise where to go for VCT G2-G3 . If partner could not be approached. ■ To ensure that the attendant should wash her hands with clean water and soap before/after touching mother/baby. and test is positive. fish. Advise to ask for help from the community. Prior delivery with heavy bleeding. Give intermittent preventive treatment in second and third trimesters F4 . ■ Look at the skin: →Is there a rash? →Are there blisters along the ribs on one side of the body? ■ ■ Any pallor with any of →>30 breaths per minute →tires easily →breathlessness at rest Haemoglobin 7-11 g/dl. C2 ANTENATAL CARE ANTENATAL CARE C2 ASK. Age less than 16 years. If the woman chooses female sterilization: →can be performed immediately postpartum if no sign of infection (ideally within 7 days. ■ Counsel on stopping smoking and alcohol and drug abuse. ■ Refer to hospital. counsel to stop smoking. CHECK RECORD LOOK. ■ Give double dose of iron (1 tablet twice daily) for 3 months F3 . Check status at every visit. Use Practical approach to lung health guidelines (PAL) for further management. UNKNOWN HIV STATUS Provide key information on HIV G2 . NOT to wait for waters to stop before going to health facility. Check status during each visit. Listen to fetal heart. examine with a gloved finger and look at the discharge on the glove. Refer urgently to hospital B17 . ■ If her sputum is TB positive within 2 months of delivery. or delay 4 weeks) →plan for delivery in hospital or health centre where they are trained to insert the IUD. Fever >38°C or history of fever (in last 48 hours). ■ To keep the mother and baby warm. If TT1. ■ If smoking. ■ Follow up in 2 weeks to check clinical progress. C4 ANTENATAL CARE ANTENATAL CARE C4 CHECK FOR ANAEMIA Respond to observed signs or volunteered problems (4) ASK. Advise her to bring her home-based maternal record to the health centre. →ensure counselling and informed consent prior to labour and delivery. Counsel on the benefits of testing the partner G3 .) ■ Has the partner been tested? ■ ■ SIGNS ■ CLASSIFY HIV-POSITIVE TREAT AND ADVISE Ensure that she visited adequate staff and received necessary information about MTCT prevention G6 . LOWER URINARY TRACT INFECTION ■ ■ ■ Explain supplies needed for home delivery ■ Warm spot for the birth with a clean surface or a clean cloth. even for an emergency visit. ■ Buckets of clean water and some way to heat this water. ■ ■ 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. ■ Obvious multiple pregnancy. ■ ADVISE AND COUNSEL ON FAMILY PLANNING Counsel on the importance of family planning Special considerations for family planning counselling during pregnancy ■ ■ Give double dose of iron (1 tablet twice daily) for 3 months F3 . Give appropriate oral antimalarial F4 . ■ ■ ■ Discuss how to prepare for an emergency in pregnancy ■ Advise on danger signs Advise to go to the hospital/health centre immediately. ■ UPPER URINARY TRACT INFECTION Give appropriate IM/IV antibiotics B15 . Schedule follow-up appointment for woman and partner (if possible). ■ Plastic for wrapping the placenta. LISTEN. FEEL IF NO FETAL MOVEMENT ■ ■ SIGNS ■ ■ TREAT AND ADVISE Inform the woman and partner about the possibility of dead baby. see G5 . The cord is cut when it stops pulsating. ■ Plan to treat the newborn K12 . ■ RPR test negative. FEEL Have you been tested for syphilis during this pregnancy? →If not. delivery and postpartum G2 . To wipe clean but not bathe the baby until after 6 hours. Treat partner with appropriate oral antibiotics F5 . ■ ■ ■ CLASSIFY POSSIBLE PNEUMONIA TREAT AND ADVISE ■ ■ ASK. birth and emergency plan ANTENATAL CARE ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS. ■ If diastolic blood pressure is ≥90 mmHg. 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. perform the rapid plasma reagin (RPR) test L5 . ask woman to move around for some time. legs. Age less than 14 years. Advise on correct and consistent use of condoms G2 . ■ Enquire about the infant feeding option chosen G7 . ■ ■ No fetal movement. ■ Reinforce advice to go for VCT G2-G3 . test results. ■ Advise to ask for help from the community. ■ Documented third degree tear. drying and wrapping the baby. her partner and family. if available. ■ Fits. and urge her to continue treatment for a successful outcome of pregnancy. Refer to hospital. if needed I2 . ■ Advise on correct and consistent use of condoms G2 . ■ ■ ASK. refer the woman to district hospital for revision of treatment as streptomycin is ototoxic to the fetus. do you know the result? (Explain to the woman that she has the right not to disclose the result. →Ask about plans for having more children. ■ Give them a disposable delivery kit and explain how to use it. If anaemia persists. ■ Additional clean cloths to use as sanitary pads after birth. Advise on correct and consistent use of condoms G2 . ■ To start breastfeeding when the baby shows signs of readiness. ■ severe headaches with blurred vision. Develop the birth and emergency plan C14 . ■ For HIV-positive women. More frequent visits or different schedules may be required according to national malaria or HIV policies. to help her feel well and strong (give examples of types of food and how much to eat). UTERINE AND FETAL INFECTION RISK OF UTERINE AND FETAL INFECTION RUPTURE OF MEMBRANES ■ ■ ■ ■ ■ Give appropriate IM/IV antibiotics B15 . 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. ■ To dry the baby after cutting the cord. NOT to put ashes. 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. Encourage sleeping under insecticide treated bednets. ■ 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. BIRTH AND EMERGENCY PLAN Respond to observed signs or volunteered problems (2) ASK. she/they must go to the health centre immediately. Revise the birth plan C2 . Rupture of membranes at >8 months of pregnancy. after delivery. ■ Advise on correct and consistent use of condoms to prevent new infection G2 . Advise on correct and consistent use of condoms G2 . ■ ■ ■ Fever 38ºC. All visits ■ Review and update the birth and emergency plan according to new findings C14-C15 . C13 Counsel on nutrition Advise the woman to eat a greater amount and variety of healthy foods. If hypertension persists after 1 week or at next visit. and any of: →severe headache →blurred vision →epigastric pain. ■ Encourage woman to bring her sexual partner for treatment. ■ ■ 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) IUD (within 48 hours or delay 4 weeks) 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 Female sterilization (within 7 days or delay 6 weeks) 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. Look for visible wasting. ALCOHOL OR DRUG ABUSE. explain importance of partner assessment and treatment to avoid reinfection. Advise on danger signs C15 . ■ Refer urgently to hospital B17 . Encourage helpful traditional practices: Check tetanus toxoid (TT) immunization status. Therefore it is important to start thinking early on about what family planning method they will use. ■ If diastolic blood pressure is still ≥90 mmHg. ■ Abnormal vaginal discharge. to encourage them to help ensure the woman eats enough and avoids hard physical work. ■ Refer urgently to hospital B17 . ask the woman if she has: →severe headache →blurred vision →epigastric pain and →check protein in urine. ■ Clean cloths of different sizes: for the bed. Look for ulcers and white patches in the mouth (thrush). DEVELOP A BIRTH AND EMERGENCY PLAN Facility delivery Home delivery with a skilled attendant ■ Burning on urination. ■ History of or current vaginal bleeding or other complication during this pregnancy. supplies and drugs available to provide best care if needed. ■ To cover the mother and the baby. ■ Give magnesium sulphate B13 . ■ If no discharge is seen. Refer urgently to hospital B17 . Give appropriate oral antibiotics to woman F5 . for the birth attendant to wash and dry her hands. 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 ANTENATAL CARE ■ No HIV test results or not willing to disclose result. Manage as Woman in childbirth D1-D28 . CHECK RECORD LOOK. ■ Advise to screen immediate family members and close contacts for tuberculosis. ■ ■ ■ Curd like vaginal discharge. ■ ■ ■ ■ ■ Do you tire easily? Are you breathless (short of breath) during routine household work? On first visit: Measure haemoglobin ■ On subsequent visits: ■ Look for conjunctival pallor. Transverse lie or other obvious malpresentation within one month of expected delivery. Reassess at the next antenatal visit or in 1 week if >8 months pregnant. FEEL Have you ever been tested for HIV? If yes. CHECK RECORD LOOK. Counsel on benefits of involving and testing the partner G3 .Assess the pregnant woman Pregancy status. Check when last dose of an antimalarial given. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (5) ANTENATAL CARE Encourage the woman to bring her partner or family member to at least 1 visit. Give appropriate oral antibiotics F5 . ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS. FEEL IF SIGNS SUGGESTING HIV INFECTION (HIV status unknown or known HIV-positive) Have you lost weight? Do you have fever? How long (>1 month)? ■ Have you got diarrhoea (continuous or intermittent)? How long. During the last visit. Listen for wheezing. NEXT: Respond to observed signs or volunteered problems If no problem. CHECK RECORD LOOK. go to page C12 . LISTEN. and compliance with treatment. →Make arrangements for the woman to see a family planning counsellor. Counsel on the importance of staying negative by correct and consistent use of condoms G2 . Give appropriate IM/IV antibiotic B15 .T3). If no improvement in 2 days or condition is worse. assure the woman that the drugs are not harmful to her baby. Give appropriate IM/IV antibiotics B15 . ■ If living far from the facility. NOT to pull on the cord to deliver the placenta. ■ HYPERTENSION ■ ■ ■ ■ Advise to reduce workload and to rest. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ PLACE OF DELIVERY REFERRAL LEVEL ADVISE ■ ■ ALL VISITS ■ Feel for trimester of pregnancy. refer to hospital or discuss case with the doctor or midwife. Encourage her to drink more fluids. C5 TEST RESULT ■ CHECK FOR SYPHILIS ASK. if needed I2 . Develop the birth and emergency plan C14 . Give mebendazole once in second or third trimester F3 . ■ ■ ■ ■ ■ ■ ■ ■ C8 Develop a birth and emergency plan (1) SIGNS ■ CLASSIFY VERY SEVERE FEBRILE DISEASE Have you had fever? Do you have burning on urination? If history of fever or feels hot: →Measure axillary temperature. NOT to push on the abdomen during labour or delivery. or vacuum →Prior third degree tear →Heavy bleeding during or after delivery →Convulsions →Stillbirth or death in first day. Inform her about VCT to determine HIV status G3 . Diastolic blood pressure 90-110 mmHg on two readings and 2+ proteinuria. waters have broken. ■ To NOT leave the mother alone for the first 24 hours. OR HISTORY OF VIOLENCE Counsel on stopping smoking For alcohol/drug abuse. ■ Percuss flanks for tenderness. ■ If no heart beat. ■ Placenta not expelled 1 hour after birth of the baby. CHECK RECORD LOOK. ■ ■ RPR test positive. >1 month? ■ Have you had cough? How long. Give metronidazole to woman F5 . Examine further and manage according to national HIV guidelines or refer to appropriate HIV services. ■ Blankets. 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. for use as sanitary pads. ■ Food and water for woman and support person. Advise to avoid harmful practices For example: NOT to use local medications to hasten labour. CHECK RECORD ■ TREAT AND ADVISE ■ ■ ■ ■ ■ ■ Instruct mother and family on clean and safer delivery at home If the woman has chosen to deliver at home without a skilled attendant. ■ swelling of fingers. If smoking. Diastolic blood pressure ≥90 mmHg on 2 readings. No pallor. If allergy. ■ None of the above. Develop the birth and emergency plan C14 . Baby ■ Very small.for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time. Fever >38°C and any of: →Flank pain →Burning on urination. her partner and family. >1 month? ■ ■ C10 TREAT AND ADVISE C10 SIGNS CLASSIFY ASK. refer to specialized care providers. Tell her/them: ■ To ensure a clean delivery surface for the birth. drink alcohol or use any drugs? ■ ■ ■ Explain why delivery needs to be at referral level C14 . ■ ■ IF TAKING ANTI-TUBERCULOSIS DRUGS ■ ■ Are you taking anti-tuberculosis drugs? If yes. see H4 . ■ Heavy bleeding after delivery (pad/cloth soaked in less than 5 minutes). refer to hospital. ■ 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 C13 Antenatal care C1 . ■ Difficulty in breathing. ■ convulsions. nuts. C3 SIGNS Diastolic blood pressure ≥110 mmHg and 3+ proteinuria. Advise on correct and consistent use of condoms G2 . PRIMARY HEALTH CARE LEVEL ■ ■ Explain why delivery needs to be at primary health care level C14 . give erythromycin F6 . LISTEN. ■ ■ ■ ■ RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (4) If signs suggesting HIV infection If smoking. Counsel on compliance with treatment F4 . NOT to insert any substances into the vagina during labour or after delivery. inform the woman to return if she does not deliver within 2 weeks after the expected date of delivery. ask “Are you allergic to penicillin?” ■ CLASSIFY POSSIBLE SYPHILIS TREAT AND ADVISE Give benzathine benzylpenicillin IM. CHECK. To dress or wrap the baby. forceps. safe and culturally appropriate manner (burn or burry). Last baby born dead or died in first day. Give tetanus toxoid if due F2 . ■ Counsel on safe sex and correct and consistent use of condoms. Rest and avoid lifting heavy objects. Give artemether/quinine IM B16 . ■ Bowls: 2 for washing and 1 for the placenta. C15 Advise on labour signs Advise on danger signs Discuss how to prepare for an emergency in pregnancy NEXT: Check for anaemia ANTENATAL CARE ANTENATAL CARE 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. RECORD ■ ■ ■ ■ ■ LOOK. ■ If test was positive. prepare a birth and emergency plan using this chart and review them during following visits. ■ Known HIV-negative. alcohol or drug abuse. ask the woman if she feels comfortable if you ask him similar questions. or delay for 6 weeks). for drying and wrapping the baby. FEEL INDICATIONS Prior delivery by caesarean. cereals. ■ Counsel on nutrition C13 . review these simple instructions with the woman and family members. have you and your partner been treated for syphilis? →If not. ■ Give glucose B16 . LISTEN. →Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not. and a referral system. beans. NO HYPERTENSION No treatment required.

birth and emergency plan ANTENATAL CARE ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS. Last baby born dead or died in first day. Tubal ligation or IUD desired immediately after delivery. does she want tubal ligation or IUD A15 . preferably at a facility. ■ 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. ■ 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. Age less than 14 years. ■ ■ ■ ■ ■ ■ ■ PRIMARY HEALTH CARE LEVEL ■ ■ Explain why delivery needs to be at primary health care level C14 . History of or current vaginal bleeding or other complication during this pregnancy. ■ None of the above. RECORD ALL VISITS ■ Check duration of pregnancy. prepare a birth and emergency plan using this chart and review them during following visits. C14 . Prior delivery by forceps or vacuum. Develop the birth and emergency plan C14 . NEXT: Check for pre-eclampsia . Prior delivery with heavy bleeding. LOOK. Age less than 16 years. Explain why delivery needs to be at referral level Develop the birth and emergency plan C14 . First birth. Obvious multiple pregnancy. FEEL INDICATIONS ■ PLACE OF DELIVERY REFERRAL LEVEL ADVISE ■ ■ Feel for trimester of pregnancy. or vacuum →Prior third degree tear →Heavy bleeding during or after delivery →Convulsions →Stillbirth or death in first day. More than six previous births. Documented third degree tear. Prior delivery with convulsions. Listen to fetal heart. forceps. CHECK. Modify the birth plan if any complications arise. Transverse lie or other obvious malpresentation within one month of expected delivery. ■ ■ ■ ■ ■ ■ ■ ■ Look for caesarean scar Prior delivery by caesarean. Feel for transverse lie. Develop the birth and emergency plan C14 . BIRTH AND EMERGENCY PLAN Use this chart to assess the pregnant woman at each of the four antenatal care visits. During first antenatal visit. ■ ■ ■ Feel for obvious multiple pregnancy. LISTEN.Assess the pregnant woman Pregancy status. ACCORDING TO WOMAN’S PREFERENCE ■ ■ Explain why delivery needs to be with a skilled birth attendant. C2 ASK. drink alcohol or use any drugs? THIRD TRIMESTER Has she been counselled on family planning? If yes. →Do you smoke.

If diastolic blood pressure is ≥90 mmHg. NO HYPERTENSION No treatment required. Diastolic blood pressure ≥110 mmHg and 3+ proteinuria. or Diastolic blood pressure ≥90 mmHg on two readings and 2+ proteinuria.CHECK FOR PRE-ECLAMPSIA Screen all pregnant women at every visit. and any of: →severe headache →blurred vision →epigastric pain. Give appropriate anti-hypertensives Revise the birth plan C2 . Give magnesium sulphate B13 . ask the woman if she has: →severe headache →blurred vision →epigastric pain and →check protein in urine. LISTEN. If hypertension persists after 1 week or at next visit. Reassess at the next antenatal visit or in 1 week if >8 months pregnant. ASK. Advise on danger signs C15 . C2 . ■ HYPERTENSION ■ ■ ■ ■ Advise to reduce workload and to rest. refer to hospital or discuss case with the doctor or midwife. FEEL ■ SIGNS ■ ■ CLASSIFY SEVERE PRE-ECLAMPSIA TREAT AND ADVISE ■ ■ ■ ■ Blood pressure at the last visit? ■ ■ ■ Measure blood pressure in sitting position. ■ PRE-ECLAMPSIA ■ ■ Revise the birth plan Refer to hospital. Refer urgently to hospital B17 . if available. repeat after 1 hour rest. ■ None of the above. CHECK RECORD LOOK. If diastolic blood pressure is still ≥90 mmHg. Diastolic blood pressure 90-110 mmHg on two readings and 2+ proteinuria. B14 . Diastolic blood pressure ≥90 mmHg on 2 readings. ANTENATAL CARE NEXT: Check for anaemia Assess the pregnant woman Check for pre-eclampsia C3 .

CHECK RECORD LOOK. and compliance with treatment. Give appropriate oral antimalarial F4 . No pallor. Counsel on compliance with treatment F4 . Haemoglobin <7 g/dl. ■ ■ MODERATE ANAEMIA ■ ■ ■ ■ ■ ■ Haemoglobin >11 g/dl. ■ Revise birth plan so as to deliver in a facility with blood transfusion services C2 . Give iron 1 tablet once daily for 3 months F3 . OR Palmar or conjunctival pallor. refer to hospital. Counsel on compliance with treatment F3 . Follow up in 2 weeks to check clinical progress. Give double dose of iron (1 tablet twice daily) for 3 months F3 . Counsel on compliance with treatment F3 . If anaemia persists. ■ Look for palmar pallor. LISTEN. If pallor: →Is it severe pallor? →Some pallor? →Count number of breaths in 1 minute. Give double dose of iron (1 tablet twice daily) for 3 months F3 . Refer urgently to hospital B17 . NO CLINICAL ANAEMIA ■ ■ NEXT: Check for syphilis . Reassess at next antenatal visit (4-6 weeks). 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.Assess the pregnant woman Check for anaemia ANTENATAL CARE CHECK FOR ANAEMIA Screen all pregnant women at every visit. C4 ASK. FEEL ■ ■ SIGNS ■ ■ CLASSIFY SEVERE ANAEMIA TREAT AND ADVISE ■ ■ ■ ■ ■ ■ Do you tire easily? Are you breathless (short of breath) during routine household work? On first visit: ■ Measure haemoglobin On subsequent visits: ■ Look for conjunctival pallor. Give appropriate oral antimalarial if not given in the past month F4 . test results.

NO SYPHILIS ■ ANTENATAL CARE NEXT: Check for HIV status Assess the pregnant woman Check for syphilis C5 . perform the rapid plasma reagin (RPR) test L5 .CHECK FOR SYPHILIS Test all pregnant women at first visit. Advise on correct and consistent use of condoms to prevent new infection G2 . If allergy. If test was positive. have you and your partner been treated for syphilis? →If not. and test is positive. CHECK RECORD LOOK. Plan to treat the newborn K12 . ■ RPR test negative. give erythromycin F6 . ASK. ask “Are you allergic to penicillin?” RPR test positive. Give benzathine benzylpenicillin IM. Encourage woman to bring her sexual partner for treatment. LISTEN. Check status at every visit. FEEL ■ TEST RESULT ■ CLASSIFY POSSIBLE SYPHILIS TREAT AND ADVISE ■ ■ ■ ■ ■ Have you been tested for syphilis during this pregnancy? →If not. Advise on correct and consistent use of condoms to prevent infection G2 .

Advise on correct and consistent use of condoms G2 . NEXT: Respond to observed signs or volunteered problems If no problem. ■ No HIV test results or not willing to disclose result. Provide key information on HIV G2 . Enquire about the ARV prophylactic treatment prescribed and ensure that the woman knows when to start ARV prophylaxis G6 . UNKNOWN HIV STATUS ■ ■ ■ ■ ■ Known HIV-negative. HIV-NEGATIVE ■ ■ ■ Provide key information on HIV G2 . Inform her about VCT to determine HIV status G3 .Assess the pregnant woman Check for HIV status ANTENATAL CARE CHECK FOR HIV STATUS Counsel all pregnant women for HIV at first visit. delivery and postpartum G2 . Counsel on benefits of involving and testing the partner G3 . Advise on additional care during pregnancy. Counsel on benefits of involving and testing the partner G3 . Enquire how she will be supplied with the drugs. C6 ASK. go to page C12 . Check status during each visit. ■ ■ ■ ■ ■ Ensure that she visited adequate staff and received necessary information about MTCT prevention G6 . . CHECK RECORD LOOK. Enquire about the infant feeding option chosen G7 .) Has the partner been tested? Known HIV-positive. Counsel on the importance of staying negative by correct and consistent use of condoms G2 . do you know the result? (Explain to the woman that she has the right not to disclose the result. LISTEN. Counsel on benefits of involving and testing her partner G3 . FEEL ■ ■ SIGNS ■ CLASSIFY HIV-POSITIVE TREAT AND ADVISE ■ ■ ■ Have you ever been tested for HIV? If yes. Advise on correct and consistent use of condoms G2 .

■ ■ ■ Fever 38ºC.RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS ASK. Inform the woman and partner about the possibility of dead baby. ANTENATAL CARE NEXT: If fever or burning on urination Respond to observed signs or volunteered problems (1) C7 . ask her to wear a pad. Listen for fetal heart after 6 months of pregnancy D2 . Manage as Woman in childbirth B15 . ■ ■ ■ Feel for fetal movements. CHECK RECORD LOOK. Check again in 1 hour. Refer to hospital. WELL BABY ■ 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. B15 . Give appropriate IM/IV antibiotic Refer urgently to hospital B17 . reassess fetal movement. FEEL IF NO FETAL MOVEMENT ■ ■ SIGNS ■ ■ CLASSIFY PROBABLY DEAD BABY TREAT AND ADVISE ■ ■ When did the baby last move? If no movement felt. LISTEN. If no heart beat. No fetal movement. Rupture of membranes at >8 months of pregnancy. Measure temperature. ■ No fetal movement but fetal heart beat present. Foul-smelling vaginal discharge. ■ D1-D28 . UTERINE AND FETAL INFECTION RISK OF UTERINE AND FETAL INFECTION RUPTURE OF MEMBRANES ■ ■ ■ ■ ■ Give appropriate IM/IV antibiotics Refer urgently to hospital B17 . Inform the woman that baby is fine and likely to be well but to return if problem persists. No fetal heart beat. ask woman to move around for some time. repeat after 1 hour. Rupture of membranes at <8 months of pregnancy.

→Look or feel for stiff neck. Percuss flanks for tenderness. Give glucose B16 . B15 . If no improvement in 2 days or condition is worse. LOWER URINARY TRACT INFECTION ■ ■ ■ NEXT: If vaginal discharge . Give artemether/quinine IM B16 . LISTEN. Give appropriate oral antibiotics F5 . FEEL IF FEVER OR BURNING ON URINATION ■ ■ C8 TREAT AND ADVISE ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ SIGNS ■ CLASSIFY VERY SEVERE FEBRILE DISEASE Have you had fever? Do you have burning on urination? ■ ■ If history of fever or feels hot: →Measure axillary temperature. Give appropriate IM/IV antibiotics Give appropriate oral antimalarial Refer urgently to hospital B17 .Respond to observed signs or volunteered problems (2) ANTENATAL CARE ASK. Fever >38°C and any of: →Flank pain →Burning on urination. Refer urgently to hospital B17 . If no improvement in 2 days or condition is worse. Insert IV line and give fluids slowly B9 . Fever >38°C or history of fever (in last 48 hours). ■ Burning on urination. refer to hospital. refer to hospital. →Look for lethargy. CHECK RECORD LOOK. Encourage her to drink more fluids. Fever >38°C and any of: →very fast breathing or →stiff neck →lethargy →very weak/not able to stand. F4 . ■ UPPER URINARY TRACT INFECTION ■ MALARIA Give appropriate oral antimalarial F4 . Give appropriate IM/IV antibiotics B15 .

FEEL IF VAGINAL DISCHARGE ■ ■ ■ SIGNS ■ ■ CLASSIFY POSSIBLE GONORRHOEA OR CHLAMYDIA INFECTION POSSIBLE CANDIDA INFECTION POSSIBLE BACTERIAL OR TRICHOMONAS INFECTION TREAT AND ADVISE ■ ■ ■ 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. Partner has urethral discharge or burning on passing urine. explain importance of partner assessment and treatment to avoid reinfection. ask the woman if she feels comfortable if you ask him similar questions. Advise on correct and consistent use of condoms G2 . examine with a gloved finger and look at the discharge on the glove. Advise on correct and consistent use of condoms G2 . If no discharge is seen. Treat partner with appropriate oral antibiotics F5 . Schedule follow-up appointment for woman and partner (if possible). ■ burning on passing urine. Intense vulval itching. If yes. Give appropriate oral antibiotics to woman F5 . Advise on correct and consistent use of condoms Give metronidazole to woman F5 . ANTENATAL CARE NEXT: If signs suggesting HIV infection Respond to observed signs or volunteered problems (3) C9 . Abnormal vaginal discharge ■ ■ ■ ■ Give clotrimazole F5 . If partner could not be approached. ask him if he has: ■ urethral discharge or pus. G2 . CHECK RECORD LOOK. Separate the labia and look for abnormal vaginal discharge: →amount →colour →odour/smell.ASK. LISTEN. ■ ■ ■ Curd like vaginal discharge. Abnormal vaginal discharge.

For counselling on violence. FEEL IF SIGNS SUGGESTING HIV INFECTION (HIV status unknown or known HIV-positive) ■ ■ ■ C10 TREAT AND ADVISE SIGNS CLASSIFY ■ Have you lost weight? Do you have fever? How long (>1 month)? Have you got diarrhoea (continuous or intermittent)? How long. CHECK RECORD LOOK. STRONG LIKELIHOOD OF HIV INFECTION ■ ■ ■ ■ ■ Reinforce the need to know HIV status and advise where to go for VCT G2-G3 . >1 month? Have you had cough? How long. Refer to TB centre if cough.Respond to observed signs or volunteered problems (4) ANTENATAL CARE ASK. OR HISTORY OF VIOLENCE ■ ■ ■ Counsel on stopping smoking For alcohol/drug abuse. Examine further and manage according to national HIV guidelines or refer to appropriate HIV services. Assess if in high risk group: ■ Occupational exposure? ■ Is the woman commercial sex worker? ■ Intravenous drug abuse? ■ History of blood transfusion? ■ Illness or death from AIDS in a sexual partner? IF SMOKING. OR One of the above signs and →one or more other signs or →from a risk group. refer to specialized care providers. Look at the skin: →Is there a rash? →Are there blisters along the ribs on one side of the body? ■ ■ Two of these signs: →weight loss →fever >1 month →diarrhoea >1month. see H4 . Look for ulcers and white patches in the mouth (thrush). NEXT: If cough or breathing difficulty . ALCOHOL OR DRUG ABUSE. >1 month? ■ ■ ■ Look for visible wasting. Advise on correct and consistent use of condoms G2 . Counsel on the benefits of testing the partner G3 . LISTEN.

If smoking. B15 . counsel to stop smoking. POSSIBLE CHRONIC LUNG DISEASE ■ ■ ■ Refer to hospital for assessment. UPPER RESPIRATORY TRACT INFECTION ■ ■ Advise safe. Reinforce advice to go for VCT G2-G3 . If severe wheezing. ■ Chest pain. CHECK RECORD LOOK. ■ Breathlessness. If smoking. since when? Does the treatment include injection (streptomycin)? ■ ■ Taking anti-tuberculosis drugs. Fever <38ºC. assure the woman that the drugs are not harmful to her baby. plan to give INH prophylaxis to the newborn K13 . If her sputum is TB positive within 2 months of delivery. refer the woman to district hospital for revision of treatment as streptomycin is ototoxic to the fetus. counsel to stop smoking. soothing remedy. Use Practical approach to lung health guidelines (PAL) for further management. NEXT: Give preventive measures Respond to observed signs or volunteered problems (5) C11 . refer urgently to hospital. and urge her to continue treatment for a successful outcome of pregnancy. FEEL IF COUGH OR BREATHING DIFFICULTY ■ ■ ■ ■ ■ SIGNS At least 2 of the following signs: ■ Fever >38ºC. Give first dose of appropriate IM/IV antibiotics Refer urgently to hospital B17 . Advise to screen immediate family members and close contacts for tuberculosis. IF TAKING ANTI-TUBERCULOSIS DRUGS ■ ■ Are you taking anti-tuberculosis drugs? If yes. and Cough <3 weeks. At least 1 of the following signs: ■ Cough or breathing difficulty for >3 weeks ■ Blood in sputum ■ Wheezing ■ ■ CLASSIFY POSSIBLE PNEUMONIA TREAT AND ADVISE ■ ■ 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? ■ ■ ■ Look for breathlessness. Measure temperature. Receiving injectable antituberculosis drugs. LISTEN. Listen for wheezing. If treatment does not include streptomycin.ASK. TUBERCULOSIS ■ ■ ■ ANTENATAL CARE ■ ■ ■ If anti-tubercular treatment includes streptomycin (injection).

Third trimester ■ Counsel on family planning ■ C16 . Check when last dose of an antimalarial given. Ask if she (and children) are sleeping under insecticide treated bednets. . ■ Counsel on safe sex and correct and consistent use of condoms. ■ Counsel on nutrition C13 . First visit ■ Develop a birth and emergency plan C14 . ■ Advise on when to seek care: C17 →routine visits →follow-up visits →danger signs. plan to give TT2 at next visit. Give tetanus toxoid if due F2 . ■ Counsel on importance of exclusive breastfeeding K2 . . . All visits ■ Review and update the birth and emergency plan according to new findings C14-C15 . ■ Counsel on stopping smoking and alcohol and drug abuse. Record all visits and treatments given. CHECK RECORD ■ TREAT AND ADVISE ■ ■ ■ ■ ■ ■ Check tetanus toxoid (TT) immunization status. F4 Give intermittent preventive treatment in second and third trimesters Encourage sleeping under insecticide treated bednets. If TT1.Give preventive Antenatal care measures ANTENATAL CARE GIVE PREVENTIVE MEASURES Advise and counsel all pregnant women at every antenatal care visit. Give 3 month’s supply of iron and counsel on compliance and safety Give mebendazole once in second or third trimester F3 F3 ■ ■ ■ ■ Check woman’s supply of the prescribed dose of iron/folate Check when last dose of mebendazole given. C12 ASSESS. .

Counsel on nutrition ■ ■ ■ ■ Advise the woman to eat a greater amount and variety of healthy foods. to encourage them to help ensure the woman eats enough and avoids hard physical work. ■ Sleep under an insecticide impregnated bednet. fish. beans. ■ NOT to take medication unless prescribed at the health centre/hospital. Advise the woman against these taboos. vegetables. ■ Use condoms correctly and consistently. nuts. Talk to family members such as the partner and mother-in-law.ADVISE AND COUNSEL ON NUTRITION AND SELF-CARE Use the information and counselling sheet to support your interaction with the woman. ■ Rest and avoid lifting heavy objects. seeds. if at risk for STI or HIV G2 . Spend more time on nutrition counselling with very thin women and adolescents. cereals. ANTENATAL CARE Advise and counsel on nutrition and self-care C13 . to help her feel well and strong (give examples of types of food and how much to eat). cheese. Advise on self-care during pregnancy Advise the woman to: ■ Take iron tablets (p. ■ Avoid alcohol and smoking during pregnancy. milk. oils. Determine if there are important taboos about foods which are nutritionally important for good health. her partner and family. such as meat.T3).

for the birth attendant to wash and dry her hands. ■ Additional clean cloths to use as sanitary pads after birth. Advise what to bring ■ Home-based maternal record. ■ Soap. for drying and wrapping the baby. ■ Food and water for woman and support person. ■ A facility has staff.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. 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. for use as sanitary pads. ■ Clean cloths for washing. if needed I2 . ■ Clean cloths of different sizes: for the bed. her partner and family. ■ Clothes for mother and baby. 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 2-3 weeks before baby due date and stay either at the maternity waiting home or with family or friends near the facility. ■ Buckets of clean water and some way to heat this water. supplies and drugs available to provide best care if needed. 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. C14 Facility delivery Explain why birth in a facility is recommended ■ Any complication can develop during delivery . ■ Advise to have her home-based maternal record ready. . ■ Advise to ask for help from the community. and a referral system.they are not always predictable. for cleaning the baby’s eyes. if needed I2 . ■ If living far from the facility. ■ Advise to ask for help from the community. equipment. ■ Bowls: 2 for washing and 1 for the placenta. ■ Plastic for wrapping the placenta.

■ waters have broken. WITHOUT waiting if any of the following signs: ■ vaginal bleeding. ■ feels ill. ANTENATAL CARE Develop a birth and emergency plan (2) C15 . ■ severe abdominal pain. if needed I1–I3 . She should go to the health centre as soon as possible if any of the following signs: ■ fever.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. ■ convulsions. ■ abdominal pain. ■ ■ 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. day or night. Discuss how to prepare for an emergency in pregnancy ■ Advise on danger signs Advise to go to the hospital/health centre immediately. ■ severe headaches with blurred vision. ■ swelling of fingers. Advise her to bring her home-based maternal record to the health centre. ■ fast or difficult breathing. ■ painful contractions every 20 minutes or less. legs. face. ■ fever and too weak to get out of bed. even for an emergency visit.

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 has sex and is not exclusively breastfeeding. 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) IUD (within 48 hours or delay 4 weeks) 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 Female sterilization (within 7 days or delay 6 weeks) 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 .for family planning considerations Her partner can decide to have a vasectomy (male sterilization) at any time. or delay for 6 weeks).Advise and counsel on family planning ANTENATAL CARE ADVISE AND COUNSEL ON FAMILY PLANNING Counsel on the importance of family planning ■ ■ C16 ■ ■ ■ If appropriate. Explain that after birth. or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). ■ If the woman chooses an intrauterine device (IUD): →can be inserted immediately postpartum if no sign of infection (up to 48 hours. ■ If the woman chooses female sterilization: →can be performed immediately postpartum if no sign of infection (ideally within 7 days. Promote especially if at risk for STI or HIV G4 . →Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not. or delay 4 weeks) →plan for delivery in hospital or health centre where they are trained to insert the IUD. →Make arrangements for the woman to see a family planning counsellor. she can become pregnant as soon as four weeks after delivery. see G5 . Special considerations for family planning counselling during pregnancy Counselling should be given during the third trimester of pregnancy. →ensure counselling and informed consent prior to labour and delivery. ask the woman if she would like her partner or another family member to be included in the counselling session. If she (and her partner) want more children. For HIV-positive women. advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. Advise on correct and consistent use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. →plan for delivery in hospital or health centre where they are trained to carry out the procedure.

During the last visit. Follow-up visits If the problem was: Hypertension Severe anaemia Return in: 1 week if >8 months pregnant 2 weeks ANTENATAL CARE Advise on care Antenatal routine and follow-up visits C17 . First antenatal contact should be as early in pregnancy as possible. Routine antenatal care visits 1st visit 2nd visit 3rd visit 4th visit Before 4 months 6 months 8 months 9 months ■ ■ ■ ■ 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.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.

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

ANTENATAL CARE Antenatal care C17 .

DO NOT keep woman in bed if she wants to move around. is it meconium stained. → If mother HIV+ and chooses replacement feeding. If in labour >24 hours. Continuous contractions. Cover the baby. 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 . gaping and head visible. ■ Any prior caesarean section. encourage her to lie on her left side. ■ Record in partograph N5 . the placenta is not delivered and the woman is NOT bleeding: →Empty bladder B12 →Encourage breastfeeding →Repeat controlled cord traction. ■ Look at vulva for: →bulging perineum →any visible fetal parts →vaginal bleeding →leaking amniotic fluid. DELIVERY AND IMMEDIATE POSTPARTUM CARE EXAMINE THE WOMAN IN LABOUR OR WITH RUPTURED MEMBRANES First do Rapid assessment and management B3-B7 . THIRD STAGE OF LABOUR: DELIVER THE PLACENTA (1) Respond to problems during labour and delivery (5) If multiple births IF MULTIPLE BIRTHS SIGN ■ D18 D18 TREAT Prepare delivery room and equipment for birth of 2 or more babies. lower vagina and vulva for tears. await second stage. ■ Cervical dilatation: LATE ACTIVE LABOUR → multigravida ≥5 cm → primigravida ≥6 cm ■ Cervical dilatation ≥4 cm. with knees wide apart. ■ Measure temperature. HIV test positive. ■ Feel for transverse lie. Before and after delivery of the placenta and membranes. ■ ■ Partograph passes to the right of ACTION LINE. until it is hard B10 . Prepare equipment for resuscitation of newborn K11 . ■ When strong contractions restart. use additional blanket to cover the mother and baby. ■ Wash hands with soap before and after each examination. as comfortable for her. Birth companion D7 Third stage of labour: deliver the placenta D13 Care of the mother within first hour of delivery of placenta D19 . ■ Do vaginal examination to determine status of labour. If feet are cold to touch or mother and baby are separated: → Ensure the room is warm. →If less than 100 beats per minute. 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 . →observe for oozing blood. If not felt: Hold the baby gently with hands around each thigh and thumbs on sacrum. ■ If heavy 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 . Thoroughly dry the baby immediately. Describe to the birth companion what she or he should do: →Always be with the woman. hands and feet. ■ Await the return of strong contractions and spontaneous rupture of the second bag of membranes. ■ If delay in delivery of shoulders: ■ ■ ■ ■ ■ ■ ■ ■ Await spontaneous rotation of shoulders and delivery (within 1-2 minutes). If pain is constant (persisting between contractions) and very severe or sudden in onset D4 . Wipe eyes. SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE (2) D17 SIGN ■ IF STUCK SHOULDERS (SHOULDER DYSTOCIA) TREAT Call for additional help. making a sighing noise. Monitor intensively as risk of bleeding is increased. NEXT: If stuck shoulders DELIVER THE BABY SIGNS CHILDBIRTH: LABOUR. →Leave the perineum visible (between thumb and first finger). Encourage the woman to pass urine. Confirm full dilatation of the cervix by vaginal examination D3 . Feel if uterus is well contracted. Give Supportive care D6-D7 . Ask the woman to lie on her back while gripping her legs tightly flexed against her chest. ■ Breathing technique Teach her to notice her normal breathing. proceed as described above. Refer urgently to hospital B17 unless birth is imminent. Bleeding any time in third trimester. ■ If the baby is not breathing or gasping (unless baby is dead. ■ Mood and behaviour (distressed. If still cold. Never leave the woman and newborn alone. do a vaginal examination to confirm full dilatation of cervix. Remind her every 2 hours. encourage pain discomfort relief D6 . Palpate mother’s abdomen. or the mother cannot hold the baby. If referral takes a long time. feed accordingly. MONITOR EVERY 30 MINUTES: ■ ■ ■ ■ Explain to the woman that you will give her a vaginal examination and ask for her consent. Palpate uterus immediately to determine the lie of the second baby. NEXT: Give supportive care throughout labour 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. Keep the mother and baby in delivery room for a minimum of one hour after delivery of placenta. ■ Never leave the woman alone. Fetal heart rate D14 . ■ Check ARV treatment needed G6 . ■ Monitor intensively. ■ ■ ■ ■ Cord seen at vulva. Frequency. but shoulders are stuck and cannot be delivered. DO NOT perform vaginal examination if bleeding now or at any time after 7 months of pregnancy. again keeping the back uppermost to deliver the other arm. DELIVERY AND IMMEDIATE POSTPARTUM CARE CHILDBIRTH: LABOUR. NEXT: Respond to obstetrical problems on admission. deliver D10-D28 . Stay with her and offer her emotional and physical support D10-D11 . DELIVERY AND IMMEDIATE POSTPARTUM CARE CHILDBIRTH: LABOUR. →As the placenta is coming out. LISTEN. and discuss findings with the woman. Change gloves. →Allow buttocks. less than 2 in 10 minutes. ■ ■ ■ ■ ■ Pain and discomfort relief ■ ■ ■ Mobility ■ ■ Encourage the woman to walk around freely during the first stage of labour. After 8 hours if: →no increase in contractions. perform vaginal examination D3 to check for prolapsed cord. ■ If late labour: →Call for help during delivery →Monitor after every contraction. ■ Expedite delivery by encouraging woman to push with contraction. ■ Look for pallor. sustained controlled cord traction. ■ ■ Cervical dilatation: 0-3 cm. If bleeding persists and uterus is soft: → Continue massaging uterus until it is hard. → hold the woman’s hand and sponge her face between contractions.she/he will become cold. raise the baby in upward and forward direction towards the mother’s abdomen until the nose and mouth are free. Manage as in Second stage of labour D10-D11 . Place woman on her left side and discourage pushing. look for chest in-drawing and fast breathing J2 . If not possible. Ensure bladder is empty. Explain the problem to the woman and her companion. Gently guiding the baby down. refer urgently to hospital B17 . Dispose of placenta in the correct. Encourage breathing technique D6 . if available. D5 CHILDBIRTH: LABOUR. ■ 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. ■ Remove wet cloths from underneath her. → vaginal bleeding → uterus. ■ ■ ■ ■ RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY (3) If breech presentation ■ If the head does not deliver after several contractions ■ ■ ■ ■ If unable to pass urine and bladder is full. do not do vaginal examination more frequently than every 4 hours. Prepare for newborn resuscitation. D6 CHILDBIRTH: LABOUR. Ask the companion to stay with the mother. DELIVERY AND IMMEDIATE POSTPARTUM CARE Examine the woman in labour or with ruptured membranes CHILDBIRTH: LABOUR. ■ Examine the placenta and membranes for completeness. →Put placenta into a bag and place it into a leak-proof container. Sudden and severe abdominal pain. See Universal precautions during labour and delivery A4 . release both cord traction and counter traction on the abdomen and wait until the uterus is well contracted again. ■ If blood oozing. Provide immediate Postpartum care D19-D20 . are available. or if no record: ■ Ask when the delivery is expected. ■ Age less than 14 years . ■ If two or more of the following signs: →thirsty →sunken eyes →dry mouth →skin pinch goes back slowly. repair the tear B12 . Give oral fluids. ■ If not successful. ■ Prepare: →clean gloves →swabs. LISTEN. Fetal heart rate D14 . breech. DELIVERY AND IMMEDIATE POSTPARTUM CARE Use this chart when the woman is IN ACTIVE LABOUR. intensity and duration of contractions. Unless indicated. ■ Soft body part (leg or buttocks) felt on vaginal examination. Unless indicated. Give appropriate IM/IV antibiotics B15 . Conduct delivery very carefully as small baby may pop out suddenly. ■ Eating.. ■ Then turn the baby back. If obvious obstruction to progress (warts/scarring/keloid tissue/previous third degree tear). NEVER pull on the breech DO NOT allow the woman to push until the cervix is fully dilated. ■ ■ ■ ■ ■ CLASSIFY OBSTRUCTED LABOUR TREAT AND ADVISE If distressed.one person should care for the mother. If no third baby is felt. delivery and immediate postpartum care CHILDBIRTH: LABOUR. ■ ■ Discharge the woman and advise her to return if: →pain/discomfort increases →vaginal bleeding →membranes rupture. ■ During delivery of the head. CHECK RECORD LOOK. deliver D10-D28 . to take in 2 short breaths followed by a long breath out. ■ ■ ■ ■ ■ ■ ■ Immediate postpartum care ■ Check that placenta and membranes are complete. ■ ■ ■ RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY (5) If multiple births ■ Third stage of labour Give oxytocin 10 IU IM after making sure there is not another baby. Ask helper to attend to the first baby. →Help her to breathe and relax. DO NOT let her lie flat (horizontally) on her back. → either 1% silver nitrate drops or 2. ■ If transfer not possible. →Incinerate the placenta or bury it at least 10 m away from a water source. 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. ■ Wash vulva and perineal areas. go to third stage of labour. DO NOT give artificial teats or pre-lacteal feeds to the newborn: no water. then unwind. Discard wet cloth. GET HELP. D10 D10 MONITOR EVERY 5 MINUTES: For emergency signs. ■ 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. is feeling pins-and-needles (tingling) in her face. ■ Infant feeding plan G7-G8 . Breathing: listen for grunting. ■ Determine if preterm (less than 8 months pregnant). If woman is bleeding. Rupture of membranes at term and before labour. Then D2 CHILDBIRTH: LABOUR. or vacuum. Mood and behaviour (distressed. ask her not to push but to breathe steadily or to pant. Cervical dilatation D3 D15 . Repeat check every 5 minutes. manage as on B10 . DELIVERY AND IMMEDIATE POSTPARTUM CARE D4 . Deliver the first baby following the usual procedure. Constant pain between contractions.Childbirth: labour. Discontinue antibiotic for mother after delivery if no signs of infection. Examine the mother and newborn one hour after delivery of placenta. RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY (4) If stuck shoulders ■ If the shoulders are still not delivered and surgical help is not available immediately. exert more pressure on perineum. do a generous episiotomy. Cover mother and baby with a blanket → Reassess in 1 hour. Support the woman’s choice of position (left lateral. keloid tissue that may interfere with delivery. Check that uterus is well contracted and there is no heavy bleeding. Assist the woman into a comfortable position of her choice. DO NOT leave the baby wet . catch in both hands to prevent tearing of the membranes. Cervix dilated 10 cm or bulging perineum. Record time of rupture of membranes and colour of amniotic fluid. kneeling. →If the membranes do not slip out spontaneously. ■ ■ NEXT: Perform vaginal examination and decide stage of labour D3 CLASSIFY IMMINENT DELIVERY NEXT: If prolapsed cord DECIDE STAGE OF LABOUR FIRST STAGE OF LABOUR: IN ACTIVE LABOUR CHILDBIRTH: LABOUR. ■ Ensure and respect privacy during examinations and discussions. →horizontal ridge across lower abdomen (if present. Urination ■ ■ ■ ■ ■ Suggest change of position. ■ See first stage of labour – active labour D9 ■ Start plotting partograph N5 . →Feel for presenting part. ■ Discard soiled pad to prevent infection. Empty the bladder B12 . Warmth: check to see if feet are cold to touch J2 . ■ Repeat FHR count after 15 minutes. place the baby in a clean. forceps. FEEL ■ D9 MONITOR EVERY 4 HOURS: ■ ■ ■ ■ SIGNS ■ Bulging thin perineum. ■ ■ ■ ■ If room cool (less than 25°C). Ensure 10 IU oxytocin IM is given D11 . Perform vaginal examination ■ DO NOT shave the perineal area. → → → → → 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. DO NOT wash away the eye antimicrobial. ■ ■ ■ ■ Record findings regularly in Labour record and Partograph N4-N6 . →cut between ties with sterile instrument. If early labour: →Refer the woman urgently to hospital B17 →Keep her lying on her left side. DO NOT cross ankles. ■ Feel abdomen for: →contractions frequency. →If placenta does not descend during 30-40 seconds of controlled cord traction. ■ Refer urgently to hospital B17 . ■ Arrange for a helper to assist you with the births and care of the babies. ■ ■ Diastolic blood pressure >90 mmHg. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Clean the woman and the area beneath her.5% povidone iodine drops or 1% tetracycline ointment. ■ Hb results C4 . ■ ■ ■ ■ Partograph passes to the right of ALERT LINE. ■ Gently wipe face clean with gauze or cloth. IF REQUIRED ■ After 8 hours if: →Contractions stronger and more frequent but →No progress in cervical dilatation with or without membranes ruptured. encouraging atmosphere for birth. IF REQUIRED ■ ■ ■ ■ Examine perineum. using rapid assessment (RAM) B3-B7 . → Refer woman urgently to hospital B17 . feed accordingly G8 . ■ Legs or buttocks presenting at perineum. FEEL History of this labour: ■ When did contractions begin? ■ How frequent are contractions? How strong? ■ Have your waters broken? If yes. → Apply bimanual or aortic compression B10 . ■ If the woman has visible severe wasting or tires during labour. measure temperature. the perineum does not begin to thin and stretch with contractions. give supportive care to mother and her family D24 . Perineum thinning and bulging. using rapid assessment (RAM) B3-B7 . Warts. FEEL On external examination fetal head felt in fundus. FIRST STAGE OF LABOUR (2): IN ACTIVE LABOUR D15 SIGNS ■ ■ IF PROLAPSED CORD The cord is visible outside the vagina or can be felt in the vagina below the presenting part. or more than 180. LISTEN. Introduce the right hand into the vagina along the posterior curve of the sacrum. No fetal movement. ■ Ask an assistant to apply continuous pressure downwards. Breech or other malpresentation D16 . Is it hard. apply steady. DO NOT exert excessive traction on the cord. Note time of delivery. ■ When the membranes rupture. If breech or other malpresentation. DELIVERY AND IMMEDIATE POSTPARTUM CARE D2 use this chart to assess the woman’s and fetal status and decide stage of labour. Label her/him Twin 2. keeping the back uppermost until the shoulder which was posterior (below) is now anterior (at the top) and the arm is released. ■ Never leave the woman alone. SIGNS Transverse lie. If late labour: ■ Call for additional help if possible (for mother and baby). cover her. treatments and procedures in Labour record and Partograph N4-N6 . ■ ■ HIV-POSITIVE ■ ■ Ensure that the woman takes ARV drugs as soon as labour starts G6 . DO NOT bandage or bind the stump. Apply an antimicrobial within 1 hour of birth. →Always carry placenta in a leak-proof container. LISTEN. ■ Record in labour record N5 . Prior third degree tear. ■ Check after 5 minutes. wipe off with wet cloth and dry. after 30 minutes of spontaneous expulsive efforts. EARLY ACTIVE LABOUR NOT YET IN ACTIVE LABOUR ■ See first stage of labour — not active labour D8 ■ Record in labour record N4 . If feeling chilled. and No fetal heart beat on repeated examination DEHYDRATION ■ ■ Exclude second baby. dry mouth. round and smooth (the head)? If not. Wash the vulva and perineal areas before each examination. ■ Measure blood pressure. propped up with buttocks at edge of bed or onto her hands and knees (all fours position). Feel if uterus is hard and round. Check the fetal heart rate. FETUS PROBABLY DEAD ■ Explain to the parents that baby may not be well. ■ Give Supportive care D6-D7 . gently twist them into a rope and move them up and down to assist separation without tearing them. ■ If trapped head (and baby is dead) Tie a 1 kg weight to the baby’s feet and await full dilatation. DELIVERY AND IMMEDIATE POSTPARTUM CARE ■ ■ ■ ■ TREAT AND ADVISE. Call for help during delivery. ■ If known HIV positive. →There is vaginal bleeding. →If not possible to observe at the facility. ■ ■ ■ Wait until head visible and perineum distending. ■ Ensure adequate hydration but omit solid foods. sugar water. but may be longer. Horizontal ridge across lower abdomen. Call for additional help. If late labour. while you maintain continuous downward traction on the fetal head. Prolapsed cord D15 . If. ■ ■ 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. ■ Labour >24 hours. Complete the rest of delivery as normal. staff) to position the woman’s buttocks higher than the shoulder. teach her to pant. D19 CARE OF MOTHER AND NEWBORN WOMAN Assess the amount of vaginal bleeding. Apply gentle downward pressure to deliver top shoulder. refer to hospital B17 . ■ Encourage woman to empty bladder. If a third baby is felt. deliver and refer to hospital after delivery B17 . ■ ■ Collect. anxious) D6 . CHILDBIRTH: LABOUR. Severe palmar and conjunctival pallor and/or haemoglobin <7 g/dl. Refer the woman urgently to hospital B17 . Visible descent of fetal head or during contraction. BABY WELL Monitor FHR every 15 minutes. Ask the companion or other helper to keep the legs in that position. Encourage her to breathe out more slowly. ■ Give Supportive care D6-D7 . →Ask the mother to breathe steadily and not to push during delivery of the head. anxious) D6 . ■ Praise her. or other complication such as postpartum haemorhage? ■ Any prior third degree tear? Current pregnancy: ■ RPR status C5 . ASK. repeat oxytocin 10 IU IM. ■ ■ ■ ■ ■ FOR ALL SITUATIONS IN RED BELOW. examine the baby as on J2-J8 . gently turn the baby by abdominal manipulation to head or breech presentation. ■ RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY (1) If fetal heart rate <120 or >160 bpm ■ FHR returns to normal. Use Assess the mother after delivery D21 and Examine the newborn J2-J8 . →Encourage woman to move around freely as she wishes and to adopt the position of her choice. DELIVERY AND IMMEDIATE POSTPARTUM CARE GIVE SUPPORTIVE CARE THROUGHOUT LABOUR Use this chart to provide a supportive. PROLAPSED CORD BABY NOT WELL ■ ■ Manage urgently as on D15 . DELIVERY AND IMMEDIATE POSTPARTUM CARE CHILDBIRTH: LABOUR. as upright as possible. warm. DELIVERY AND IMMEDIATE POSTPARTUM CARE CHILDBIRTH: LABOUR. manage as on D22 . Then proceed with delivery of head as described above. Use clean gloves for vaginal examination. make an episiotomy. DO NOT give enema. Encourage mobility. ■ Position the woman with legs flexed and apart. For emergency signs. DO NOT squeeze or push the uterus to deliver the placenta. ■ ■ Cleanliness ■ ■ ■ ■ ■ ■ 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. MONITOR MOTHER EVERY 15 MINUTES: ■ ■ ■ ■ ■ MONITOR BABY EVERY 15 MINUTES: ■ ■ For emergency signs. see Prolapsed cord D15 . Record findings. to make sure it is well contracted. for example. deliver the baby through the loop of cord or slip the cord over the baby’s head. ■ ■ ■ Give appropriate IM/IV antibiotics if rupture of membrane >18 hours B15 . FEEL SIGNS CLASSIFY TREAT AND ADVISE D14 IF FETAL HEART RATE (FHR) <120 OR >160 BEATS PER MINUTE Position the woman on her left side. If third degree tear (involving rectum or anus). towards the mother’s abdomen to deliver lower shoulder. Feel gently around baby’s neck for the cord. Explain to the parents that the baby is not doing well. ■ If she feels dizzy. squating. unwell. contractions weak and <2 in 10 minutes. If FHR does not return to normal in 15 minutes explain to the woman (and her companion) that the baby may not be well. Clamp and cut the cord. →Give support using local practices which do not disturb labour or delivery. Give Supportive care D6-D7 . Temperature. ■ Pulse B3 . If not able to drink. duration. Begin plotting the partograph N5 and manage the woman as in Active labour D9 . If less than 36. ASK. REFER URGENTLY TO HOSPITAL IF IN EARLY LABOUR. Allow her to push as she wishes with contractions. any continuous contractions? →fetal lie—longitudinal or transverse? →fetal presentation—head. empty bladder B12 . control delivery of the head. Encourage warm bath or shower.There may be one large placenta with 2 umbilical cords. →Feel for membranes – are they intact? →Feel for cord – is it felt? Is it pulsating? If so. If second stage lasts for 2 hours or more without visible steady descent of the head. UTERINE AND FETAL INFECTION ■ ■ ■ Give appropriate IM/IV antibiotics B15 . if necessary. If bleeding persists. → Continue IV fluids with 20 IU of oxytocin at 30 drops per minute. ASSESS PROGRESS OF LABOUR ■ TREAT AND ADVISE. Include: →more warm cloths →two sets of cord ties and razor blades →resuscitation equipment for 2 babies. and →membranes are not ruptured. DO NOT do vaginal examination more frequently than every 4 hours. other? →more than one fetus? →fetal movement. ■ Prepare for Newborn resuscitation K11 . or a separate placenta with an umbilical cord for each baby. even in late labour.The assistant gives supra pubic pressure during the period to maintain flexion. investigate the cause D2-D3 . or constant trickle of blood. ■ Encourage upright position and walking if woman wishes. ■ Check the presentation by vaginal examination. ■ ■ ■ If pad soaked in less than 5 minutes. Remain calm and explain to the woman that you need her cooperation to try another position. refer immediately (DO NOT wait to cross action line). ■ If placing newborn on abdomen is not acceptable. CHECK RECORD LOOK. using rapid assessment (RAM) B3-B7 . Respect her wishes. Plan to treat newborn J5 . When the uterus is well contracted. Cervical dilatation 4 cm or greater. wipe her brow with a wet cloth. Ask the birth companion to call for help if: →The woman is bearing down with contractions. wash gloved hands. DELIVERY AND IMMEDIATE POSTPARTUM CARE ■ ■ DELIVER THE PLACENTA CHILDBIRTH: LABOUR. Record time of rupture of membranes and colour of amniotic fluid. DO NOT apply any substance to the stump. DO NOT remove vernix or bathe the baby. DELIVERY AND IMMEDIATE POSTPARTUM CARE ASK. ■ ■ ■ If late labour. Support her choice of infant feeding G7-G8 . DO NOT give the mother oxytocin until after the birth of all babies. Give oxytocin 10 IU IM B10 . ■ ■ ■ ■ ■ ■ If second baby. ■ Review the birth plan. LISTEN. Place baby on abdomen or in mother’s arms. →put ties tightly around the cord at 2 cm and 5 cm from baby’s abdomen. CARE OF THE MOTHER AND NEWBORN WITHIN FIRST HOUR OF DELIVERY OF PLACENTA ■ ■ ■ If disposing placenta: →Use gloves when handling placenta. pads. Prepare for newborn resuscitation K11 . If present. and →no progress in cervical dilatation. Multiple pregnancy D18 . D12 D12 MONITOR MOTHER EVERY 5 MINUTES: ■ ■ ■ ■ ■ ■ MONITOR BABY EVERY 15 MINUTES: ■ ■ For emergency signs. if cord is tight. Keep mother and baby in delivery room . safe and culturally appropriate manner. ■ Cord is not pulsating Perform gentle vaginal examination (do not start during a contraction): →Determine cervical dilatation in centimetres. Encourage companion to: → massage the woman’s back if she finds this helpful. vagina MANAGE ■ See second stage of labour D10-D11 . Ensure bladder is empty. Manage as on D14 . Plan to treat the newborn J5 . add 20 IU of oxytocin to IV fluids and give at 60 drops per minute N9 . turn the baby. Encourage the woman to empty her bladder frequently. when cervix dilated 4 cm or more. find out what she has told the companion. observe closely for vaginal bleeding because this woman is at greater risk of postpartum haemorrhage. see B5 . foul-smelling? →warts. →She is suddenly in much more pain. If baby is stillborn or dead. DELIVERY AND IMMEDIATE POSTPARTUM CARE CHILDBIRTH: LABOUR. DELIVERY AND IMMEDIATE POSTPARTUM CARE D6 Communication Explain all procedures. Reassess in 2 hours and refer if no progress. DELIVER THE BABY ■ TREAT AND ADVISE IF REQUIRED Ensure all delivery equipment and supplies. Clean up spills immediately. ■ Perform an adequate episiotomy. ■ Record findings regularly in Labour record and Partograph (pp. do other supportive actions. Wash your hands with soap before and after each examination. ASSESS PROGRESS OF LABOUR ■ TREAT AND ADVISE. full cervical dilatation. Frequency. In particular. look for chest in-drawing and fast breathing J2 . If blood or meconium. anxious) D6 . act immediately as on D15 . Refer to hospital now if woman had serious complications at admission or during delivery but was in late labour. intensity and duration of contractions. place a second tie between the skin and the first tie. estimate and record blood loss throughout third stage and immediately afterwards. anxious) D6 . ■ CLASSIFY OBSTRUCTED LABOUR FETUS ALIVE TREAT ■ RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY (2) If prolapsed cord Transverse lie Cord is pulsating Refer urgently to hospital B17 . using rapid assessment (RAM) B3-B7 . Pulse B3 . Assess baby’s breathing while drying. Label her/him Twin 1. call for staff trained to use vacuum extractor or refer urgently to hospital B17 . If the baby is not crying. when? How much? ■ Is the baby moving? ■ Do you have any concern? Check record. macerated. →Support perineum with other hand and cover anus with pad held in position by side of hand during delivery. ■ Deliver the second baby. Encourage the woman to bathe or shower or wash herself and genitals at the onset of labour. Place identification label. Ensure cleanliness of labour and birthing area(s). Resuscitate if necessary. ■ Never leave the woman alone. cover the head with a hat. ■ Tetanus immunization status F2 . allow labour to continue. ■ ■ ■ ■ ■ ■ ■ ■ ■ OBSTETRICAL COMPLICATION ■ Follow specific instructions (see page numbers in left column). ■ ■ ■ If cord present and loose. Assess further and manage as on D23 . Warmth: check to see if feet are cold to touch J2 . PRE-ECLAMPSIA SEVERE ANAEMIA ■ ■ DO NOT urge her to push. drinking Encourage the woman to eat and drink as she wishes throughout labour. after 30 minutes of giving oxytocin. ■ ■ FIRST STAGE OF LABOUR (1): WHEN THE WOMAN IS NOT IN ACTIVE LABOUR D14 RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY ASK. 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. Blood pressure D23 . Prior delivery by: →caesarean section →forceps or vacuum delivery. Continue keeping the baby warm and in skin-to-skin contact with the mother. DELIVERY AND IMMEDIATE POSTPARTUM CARE CLASSIFY TREAT AND ADVISE D11 ■ Labour before 8 completed months of pregnancy (more than one month before estimated date of delivery). Tell the birth companion what she or he SHOULD NOT DO and explain why: DO NOT encourage woman to push. usually within 1 hour of birth of first baby. ask the helper to attend to the second baby. ■ ■ ■ ■ INTERVENTIONS. Time since third stage began (time since birth). and place of delivery is clean and warm (25°C) L3 .50C. ■ ■ ■ ■ Fetal head is delivered. Breathing: listen for grunting. Offer her help. Frequency. standing supported by the companion) for each stage of labour and delivery. →She loses consciousness or has fits. refer urgently to hospital B17 . ■ Put on gloves. 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. If unable to initiate breastfeeding (mother has complications): → Plan for alternative feeding method K5-K6 . CHECK RECORD LOOK. including newborn resuscitation equipment. when? Were they clear or green? ■ Have you had any bleeding? If yes. If blood loss ≈ 250 ml. ■ Fetal heart rate <120 or >160 beats per minute. DO NOT perform episiotomy routinely. →Assist the woman when she first walks after resting and recovering. Give 10 IU oxytocin IM to the mother. with the palm of the hand on the abdomen directly above the pubic area. Have help available during delivery. Assist her to adopt a kneeling on “all fours” position and ask her companion to hold her steady . Put on gloves just before delivery. If unable to empty bladder see Empty bladder B12 . Then repeat controlled cord traction with counter traction. ■ Nutritious liquid drinks are important. DELIVERY AND IMMEDIATE POSTPARTUM CARE DECIDE STAGE OF LABOUR CHILDBIRTH: LABOUR. Leave baby on the mother’s chest in skin-to-skin contact.N4-N6). give 1 litre IV fluids over 3 hours B9 . Then lift baby up. FHR remains >160 or <120 after 30 minutes observation. If bleeding. Put sanitary pad or folded clean cloth under her buttocks to collect blood. manage as on K9 . trunk and shoulders to deliver spontaneously during contractions. Encourage initiation of breastfeeding K2 . NEXT: Care of the mother and newborn within first hour of delivery of placenta CHILDBIRTH: LABOUR. →Encourage her to drink fluids and eat as she wishes. Encourage the mother to initiate breastfeeding when baby shows signs of readiness. Manage as in Multiple pregnancy D18 . ■ Stay with the woman and continue monitoring her and the fetal heart rate intensively. Manage as on D24 . → → If placenta is incomplete: Remove placental fragments manually B11 . DELIVERY AND IMMEDIATE POSTPARTUM CARE Birth companion CHILDBIRTH: LABOUR. keloid tissue or scars that may interfere with delivery. ■ NEWBORN Wipe the eyes. ■ Palpate the uterus for a third baby. insert an IV line and give fluids B9 . If woman is distressed or anxious. ■ Look for sunken eyes. ■ Temperature. If bleeding from a perineal tear. ask the mother to bear down when she feels ready. 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. severely malformed): →Cut cord quickly: transfer to a firm. For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. ■ ■ POSSIBLE FETAL DEATH ■ ■ If HIV-positive mother has chosen replacement feeding. 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. ■ Prepare for delivery ■ Second stage of labour DELIVER THE PLACENTA ■ ■ TREAT AND ADVISE IF REQUIRED If. PRETERM LABOUR ■ ■ ■ ■ ■ Reassess fetal presentation (breech more common). warm surface. IF REQUIRED ■ D13 Encourage support from the chosen birth companion throughout labour. observe breathing: →breathing well (chest rising)? →not breathing or gasping? →DO NOT panic but call for help and ask companion to assist →Manage as in Stuck shoulders D17 . ■ If cervix is not fully dilated. This applies counter traction to the uterus during controlled cord traction. ■ See if liquor was meconium stained. . D7 BIRTH COMPANION ■ ■ If heavy bleeding: Massage uterus to expel clots if any. empty bladder B12 and observe again). when cervix dilated 0-3 cm and contractions are weak. Await strong uterine contraction (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. ■ Deliver the baby: →Assist the woman into a position that will allow the baby to hang down during delivery.N4-N6). chest in-drawing or fast breathing. start Newborn resuscitation K11 . encourage her to breathe more slowly. →Encourage her. Mood and behaviour (distressed. deliver the placenta and membranes by controlled cord traction. →Monitor intensively (every 30 minutes) for 4 hours: → BP pulse . Call senior person if available. Help her to change clothes if necessary. ■ Blood pressure D23 . applying traction to all cords together D12-D23 . Fetal distress D14 . give appropriate IM/IV antibiotics B15 . if yes. encourage and reassure her that things are going well. MANAGE ONLY IF IN LATE LABOUR ■ Rupture of membranes and any of: →Fever >38˚C →Foul-smelling vaginal discharge. If uterus soft. respectful of the woman’s wishes. If the woman is distressed. When the hairline is visible. ■ To prevent pushing at the end of first stage of labour. ■ Watch for vaginal bleeding. Pushing too soon may cause the head to be trapped. IF REQUIRED Reassess woman and consider criteria for referral. . CHECK RECORD LOOK . DO NOT give advice other than that given by the health worker. If prior pregnancies: ■ Number of prior pregnancies/deliveries. FEEL Look at or feel the cord gently for pulsations. ■ ■ ■ ■ If breathing with difficulty — grunting. and to relax with each breath. ■ ■ ■ ■ Rupture of membranes at <8 months of pregnancy. turn woman on her left side and count again. ■ Listen to the fetal heart beat: →Count number of beats in 1 minute. ■ ■ ■ ■ ■ DO NOT pull excessively on the head. →Prepare for newborn resuscitation K11 . ■ ■ ■ ■ ■ If trapped arms or shoulders Feel the baby’s chest for arms. ■ Refer urgently to hospital B17 . DO NOT attempt to deliver the placenta until all the babies are born. make sure she eats and drinks. in a 2 m deep pit. ■ CALL FOR HELP . →There is any other concern. Never leave the woman alone. ■ D16 D16 SIGN ■ ■ TREAT ■ ■ ■ ■ ■ If early labour If late labour Refer urgently to hospital B17 . Place the baby astride your left forearm with limbs hanging on each side. Call for help. look at vulva for prolapsed cord. ■ Mood and behaviour (distressed. using rapid assessment (RAM) B3-B7 . ■ Keep her informed about the progress of labour. Give appropriate IM/IV antibiotic B15 . treatments and procedures in Labour record and Partograph (pp. Alert emergency transport services. At the same time. clamp and cut cord. D8 D8 Respond to problems during labour and delivery (1) If FHR <120 or >160 bpm MONITOR EVERY HOUR: For emergency signs. Record findings. repair if required B12 or refer to hospital B17 . or local feeds. ■ After cutting the cord. DELIVERY AND IMMEDIATE POSTPARTUM CARE ■ ■ TREAT AND ADVISE. to breathe with an open mouth. Encourage the woman to eat and drink. Start an IV line B9 .this simple change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery. If membranes have ruptured. RISK OF UTERINE AND FETAL INFECTION ■ ■ ■ ■ SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE (1) Respond to problems during labour and delivery (3) If breech presentation IF BREECH PRESENTATION LOOK. Keeping the left hand as described. Plan to treat newborn J5 . →Assist her to the toilet when needed. identify the presenting part. →Rub her back. ■ ■ ■ MONITOR EVERY 4 HOURS: Cervical dilatation D3 D15 . ■ Record findings regularly in Labour record and Partograph N4-N6 . ■ Then proceed with delivery of head as described above. If woman is lying. ■ Instruct assistant (family. safe place close to the mother. DO NOT give oxytocin now. ■ Ask the woman to assume an upright or squatting position to help progress. If late labour. →After delivery of the shoulders allow the baby to hang until next contraction. manage as on D16 . Resuscitate if necessary. Fetal heart rate D14 . ■ Deliver the second baby. Wash hands with clean water and soap. →When buttocks are distending.do not separate them. ■ HIV status C6 . seek permission. 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. IF REQUIRED ■ If potentially damaging expulsive efforts. Encourage her to use the breathing technique. POSSIBLE FETAL DISTRESS RUPTURE OF MEMBRANES ■ RESPOND TO OBSTETRICAL PROBLEMS ON ADMISSION (2) Ensure controlled delivery of the head: →Keep one hand gently on the head as it advances with contractions. If transverse or oblique lie. intensity and duration of contractions. Counselled on ARV treatment and infant feeding. Check if the face is clear of mucus and membranes. →Encourage rapid breathing with mouth open. but bleeding has stopped: →Plan to keep the woman in the facility for 24 hours. RISK OF OBSTETRICAL COMPLICATION ■ Do a generous episiotomy and carefully control delivery of the head D10-D11 .

Accompany the mother and baby to ward. →Offer the parents and family to be with the dead baby in privacy as long as they need. Give tetanus toxoid if due F2 . If uterus not firm. →Show the baby to the mother. → Ask about plans for having more children. See J10 D20 CHILDBIRTH: LABOUR. Feel the uterus. and family planning. ■ Counsel on nutrition D26 . see G1-G8 H1-H4 . DELIVERY AND IMMEDIATE POSTPARTUM CARE SIGNS ■ ■ TREAT AND ADVISE ■ ■ D22 A pad is soaked in less than 5 minutes. including at least once at night: no daytime feedings more than 4 hours apart and no night feedings more than 6 hours apart. Advise on breastfeeding and breast care B3 . ■ Ensure preventive measures D25 . ■ No fever. DELIVERY AND IMMEDIATE POSTPARTUM CARE Ensure that all are given before discharge. If in early labour or postpartum. ■ Talk to family members such as partner and mother-in-law. treatments and procedures in Labour record and Partograph N4-N6 . 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. ASSESS THE MOTHER AFTER DELIVERY CHILDBIRTH: LABOUR. massage the fundus to make it contract and expel any clots B6 . to encourage them to help ensure the woman eats enough and avoids hard physical work. ■ Follow up in 4 weeks. ■ ■ ■ ■ ■ If diastolic blood pressure is ≥90 mmHg. CHECK FOR ANAEMIA ■ Bleeding during labour. ■ Give appropriate IM/IV antibiotics B15 . Assess the mother after delivery D21 Counsel on birth spacing and family planning D27 ■ Respond to problems immediately postpartum (1) CHILDBIRTH: LABOUR. DELIVERY AND IMMEDIATE POSTPARTUM CARE For emergency signs. RESPOND TO PROBLEMS IMMEDIATELY POSTPARTUM (3) If pallor on screening. Refer urgently to hospital B17 . especially if at risk for sexually transmitted infection (STI) or HIV G2 . If pad is soaked in less than 5 minutes. where culturally appropriate. Maintain the partograph and labour record N4-N6 . Counsel on breastfeeding K2 . FEEL SIGNS CLASSIFY TREAT AND ADVISE D24 D24 IF PALLOR ON SCREENING. NO ANAEMIA Give iron/folate for 3 months F3 . If pallor: →Is it severe pallor? →Some pallor? →Count number of breaths in 1 minute ■ ■ Haemoglobin <7 g/dl. milk. ■ Assess the newborn J2-J8 . 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. ■ Tear extending to anus or rectum. ■ ■ ■ ■ 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 . ■ ■ MODERATE ANAEMIA DO NOT discharge before 24 hours. More than 1 pad soaked in 5 minutes Uterus not hard and not round See B5 for treatment. ■ ■ CHILDBIRTH: LABOUR. use the charts on Respond to obstetrical problems on admission D4-D5 . vegetables. If diastolic blood pressure is still ≥90 mmHg. refer to appropriate services within 48 hours. Examine the baby before leaving N2-N8 . If possible. ■ Spend more time on nutrition counselling with very thin women and adolescents. DO NOT discharge before 12 hours. day or night. refer woman to hospital E17 . make plans before discharge. →Discuss with them the events before the death and the possible causes of death. CHECK RECORD LOOK. Ensure that the family prepares. Advise the family about danger signs and when and where to seek care B14 . Haemoglobin 7-11 g/dl. IF REQUIRED Make sure the woman has someone with her and they know when to call for help. refer to hospital within 7 days of delivery. If blood pressure remains elevated after delivery. nutrition and family planning D26-D27 . ■ If baby and placenta delivered: → Give oxytocin 10 IU IM B10 . ■ ■ Diastolic blood pressure 90-110 mmHg on two readings. Promote their use. 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. NEXT: If elevated diastolic blood pressure IF ELEVATED DIASTOLIC BLOOD PRESSURE CHILDBIRTH: LABOUR. Never leave the woman and newborn alone. Give mebendazole once in 6 months F3 . ■ Advise on when to seek care and next routine postpartum visit D28 . Advise on newborn care B9-B10 . DELIVERY AND IMMEDIATE POSTPARTUM CARE D20 for care of the baby. FEEL 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? ■ CLASSIFY MOTHER WELL TREAT AND ADVISE Keep the mother at the facility for 12 hours after delivery. 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. ■ No perineal problem. If bleeding is from perineal tear. DELIVERY AND IMMEDIATE POSTPARTUM CARE ASK. HOME DELIVERY BY SKILLED ATTENDANT Preparation for home delivery Delivery care Immediate postpartum care of the mother Postpartum care of the newborn ■ Keep mother and baby in labour room for one hour after delivery and use charts Care of the mother and newborn within first hour of delivery placenta on D19 . do the RPR test L5 . swollen or draining pus? ■ Look for conjunctival pallor. Preparation for home delivery ■ ■ ■ ■ Immediate postpartum care of mother ■ ■ ■ ■ D29 Check emergency arrangements. DO NOT catheterize unless you have to. CHECK RECORD LOOK. Advise on routine and follow-up postpartum visits D28 . if needed I1-I3 . even for an emergency visit. ■ Palmar or conjunctival pallor. palpate the uterus. Ask the mother’s companion to watch her and call for help if bleeding or pain increases. Advise on Postpartum care and hygiene D26 . Carry with you all essential drugs B17 . See K2-K3 . red or tender breasts. danger signs. DELIVERY AND IMMEDIATE POSTPARTUM CARE CHILDBIRTH: LABOUR. Treat if any sign of infection. If attending a delivery at the woman’s home. nuts. ■ Give double dose of iron for 3 months F3 . to help her feel well and strong (give examples of types of food and how much to eat). help her by gently pouring water on vulva. ■ ■ ■ ■ ■ Haemoglobin >11 g/dl No pallor. LISTEN. ■ Blood pressure normal. fish. Advise on postpartum care. LISTEN. Check haemoglobin after 3 days. Examine the mother before leaving her D21 . If temperature persists for >12 hours. see G4 for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time. ■ ■ A breastfeeding woman is protected from pregnancy only if: →she is no more than 6 months postpartum. Next use Care of the mother after the first hour following delivery of placenta D20 to provide care until discharge. Counsel and advise all women. ■ To avoid sexual intercourse until the perineal wound heals. If bleeding persists. FEEL IF VAGINAL BLEEDING ■ D22 CLASSIFY HEAVY BLEEDING CHILDBIRTH: LABOUR. give the baby to the mother to hold. For examining the newborn use the chart on J2-J8 . Stay until baby has had the first breastfeed and help the mother good positioning and attachment B2 . If no RPR during this pregnancy. advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. Encourage the mother to eat. ■ Continue any treatments initiated earlier. ■ Provide certificate of death and notify authorities as required N7 . Advise the woman against these taboos. Immunize the baby if possible B13 . Help her to establish or re-establish breastfeeding as soon as possible. Ensure baby receives mother’s milk K8 . D27 ■ COUNSEL ON BIRTH SPACING AND FAMILY PLANNING Counsel on importance of family planning Lactation and amenorrhoea method (LAM) ■ 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) IUD (within 48 hours or delay 4 weeks) Delay 3 weeks Combined oral contraceptives Combined injectables Diaphragm Fertility awareness methods 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) 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. Measure temperature every 4 hours. repair the tear or episiotomy B12 . ASSESS. oils. ■ → → → If heavy vaginal bleeding. use the chart on Examine the woman in labour or with ruptured membranes D2-D3 to assess the clinical situation and obstetrical history. Check when last dose of mebendazole was given. she can become pregnant as soon as 4 weeks after delivery. ■ Discuss how to prepare for an emergency in postpartum D28 .Care of the mother one hour after delivery of placenta CHILDBIRTH: LABOUR. if she has sex and is not exclusively breastfeeding. Advise when to seek care D28 . manage as on B5 . → Information on when to start a method after delivery will vary depending on whether a woman is breastfeeding or not. and →her menstrual cycle has not returned. as on C18 . check for anaemia If mother severely ill or separated from baby If baby stillborn or dead ■ ■ ■ Any bleeding. FEEL ■ ■ CLASSIFY SEVERE PRE-ECLAMPSIA TREAT AND ADVISE Give magnesium sulphate B13 . refer urgently to hospital E17 . using rapid assessment (RAM). ■ Look for palmar pallor. If late labour: →monitor blood pressure every hour →DO NOT give ergometrine after delivery. Check woman’s supply of prescribed dose of iron/folate. cereals. seeds. If the mother is HIV-positive or adolescent. LISTEN. D21 SIGNS Uterus hard. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ D25 GIVE PREVENTIVE MEASURES ■ Encourage sleeping under insecticide treated bednet F4 . Ensure the room is warm (25°C). Diastolic blood pressure ≥110 mmHg OR Diastolic blood pressure ≥90 mmHg and 2+ proteinuria and any of: →severe headache →blurred vision →epigastric pain. ■ Determine if there are important taboos about foods which are nutritionally healthy. return within a day to check the mother and baby. ■ Reassure the mother that she can eat any normal foods – these will not harm the breastfeeding baby. Give preventive measures D25 Childbirth: labour. Delivery care ■ ■ ■ ■ ■ ■ Postpartum care of newborn ■ ■ ■ ■ ■ ■ ■ ■ Follow the labour and delivery procedures D2-D28 K11 . MONITOR MOTHER AT 2. Observe universal precautions A4 . For baby. see J2-J8 . ■ RISK OF UTERINE AND FETAL INFECTION Encourage woman to drink plenty of fluids. Counsel on correct and consistent use of condoms G2 . ■ fever and too weak to get out of bed. DELIVERY AND IMMEDIATE POSTPARTUM CARE ASK. refer urgently to hospital B17 . If an abnormal sign is identified. ■ ■ Lactational amenorrhoea method (LAM) ■ ASK. or more frequently if heavy lochia →wash used pads or dispose of them safely →wash the body daily. →Treat the newborn K12 . ■ ■ ■ ■ ■ ■ Check tetanus toxoid (TT) immunization status. Look for conjunctival pallor. go to page D25 . repair or refer to hospital B17 . ■ No pallor. Ask whether woman and baby are sleeping under insecticide treated bednet. Use chart on D25 to provide Preventive measures and Advise on postpartum care D26-D28 to advise on care. PRE-ECLAMPSIA ■ If early labour. Perineal tear Episiotomy THIRD DEGREE TEAR SMALL PERINEAL TEAR ■ ■ Refer woman urgently to hospital B15 . Counsel on nutrition D26 . Monitor blood pressure every hour. no complementary foods or fluids). ■ Look for palmar pallor. Ensure the mother has sanitary napkins or clean material to collect vaginal blood. Keep emergency transport arrangements up-to-date. give appropriate antibiotic and refer to hospital B15 . Stay with the woman for first two hours after delivery of placenta C2 C13-C14 . Keep the mother and baby together. If late labour: →monitor intensively →minimize blood loss →refer urgently to hospital after delivery B17 . ■ Encourage the mother to empty her bladder and ensure that she has passed urine. → Make arrangements for the woman to see a family planning counsellor. discontinue antibiotics. ■ Advise the woman to ask for help from the community. see D29 . Not to insert anything into the vagina. If RPR positive: →Treat woman and the partner with benzathine penicillin F6 . CHECK RECORDS ■ ■ TREAT AND ADVISE ■ Check RPR status in records. and the delivery kit. Advise the mother on postpartum care and nutrition D26 . 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. ■ Record all treatments given N6 . Measure haemoglobin. Ensure that someone will stay with the mother for the first 24 hours. refer to hospital E17 . ■ SEVERE ANAEMIA ■ ■ If early labour or postpartum. Little bleeding. ■ 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. Involve the companion in care and support D6-D7 . Therefore it is important to start thinking early about what family planning method they will use. ■ For HIV-positive women. ■ 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. Give 3 month’s supply of iron and counsel on compliance F3 . If mother is on antibiotics because of rupture of membranes >18 hours but shows no signs of infection now. 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. records. THEN EVERY 4 HOURS: ■ ■ ■ ■ ■ ■ CHILDBIRTH: LABOUR.. → Listen to fetal heart rate → feel lower abdomen for tenderness ■ ■ 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 UTERINE AND FETAL INFECTION Insert an IV line and give fluids rapidly B9 . Counsel on birth spacing and family planning D27 . If she (and her partner) want more children. WITHOUT WAITING. CHECK RECORD LOOK. ■ ■ D26 D26 ADVISE ON POSTPARTUM CARE Advise on postpartum care and hygiene Counsel on nutrition ■ ■ Always begin with Rapid assessment and management (RAM) B3-B7 . Refer to facility as soon as possible if any abnormal finding in mother or baby B17 K14 . ■ Advise on danger signs D28 . ■ Measure temperature. →Is there a tear or cut? →Is it red. 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 birth spacing and other family planning methods D27 . ■ Reassess for discharge D21 . preferably within 2-3 days 4-6 weeks Advise on danger signs Advise to go to a hospital or health centre immediately. D28 D28 ADVISE ON WHEN TO RETURN Routine postpartum visits Advise on danger signs Discuss how to prepare for an emergency postpartum ■ ■ Routine postpartum care visits FIRST VISIT D19 SECOND VISIT E2 Within the first week. HYPERTENSION ■ ■ ■ NEXT: If pallor on screening. check for anaemia Respond to problems immediately postpartum (2) D23 Home delivery by skilled attendant D29 Respond to problems immediately postpartum (3) CHILDBIRTH: LABOUR. when to seek routine or emergency care. drink and rest. or has special needs. Use Give supportive care throughout labour D6-D7 to provide support and care throughout labour and delivery. AND/OR ■ Severe palmar and conjunctival pallor or ■ Any pallor with >30 breaths per minute. Counsel on nutrition Advise the woman to eat a greater amount and variety of healthy foods. Is it hard and round? ■ Look for vaginal bleeding ■ Look at perineum. Provide newborn care J2-J8 . ■ To have enough rest and sleep. Feel uterus if hard and round. ■ Counsel on appropriate family planning method D27 . 2+ proteinuria (on admission). Advise a postpartum visit for the mother and baby within the first week B14 . ■ convulsions. 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. ■ Advise the correct and consistent use of condoms for dual protection from sexually transmitted infection (STI) or HIV and pregnancy. LISTEN. A breastfeeding woman can also choose any other family planning method. If IUD desired. ■ If tubal ligation desired. ■ Counsel on birth spacing and family planning D27 . Help her to express breast milk if necessary. IF PERINEAL TEAR OR EPISIOTOMY (DONE FOR LIFESAVING CIRCUMSTANCES) Is there bleeding from the tear or episiotomy ■ Does it extend to anus or rectum? ■ ■ ■ ■ 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. Explain that after birth. ■ Refer urgently to hospital after delivery B17 . CHECK RECORD LOOK. Go to health centre as soon as possible if any of the following signs: ■ fever ■ abdominal pain ■ feels ill ■ breasts swollen. Record findings continually on labour record and partograph N4-N6 . refer urgently to hospital B17 . cheese. ■ Do not discharge mother from the facility before 12 hours. K14 . →DO NOT give ergometrine after delivery. delivery or postpartum. ■ Advise the woman to bring her home-based maternal record to the health centre. ■ severe abdominal pain. IF BABY STILLBORN OR DEAD Give supportive care: →Inform the parents as soon as possible after the baby’s death. 3 AND 4 HOURS. beans. Examine the mother for discharge using chart on D21 . Advise on postpartum care D26 . Give vitamin A if due F2 . DELIVERY AND IMMEDIATE POSTPARTUM CARE ASSESS THE MOTHER AFTER DELIVERY COUNSEL ON BIRTH SPACING AND FAMILY PLANNING Counsel on the importance of family planning If appropriate. If BP remains elevated after delivery. ■ Advise on postpartum care and hygiene D26 . If tubal ligation or IUD desired. ■ Pulse normal. Repeat examination of the mother before discharge using Assess the mother after delivery D21 . but no later than in 2 weeks. visual disturbance or epigastric distress. IF FEVER (TEMPERATURE >38ºC) Time since rupture of membranes ■ Abdominal pain ■ Chills ■ Repeat temperature measurement after 2 hours ■ If temperature is still >38ºC → Look for abnormal vaginal discharge. ■ Advise the mother on breast care K8 . ask the woman if she has: →severe headache →blurred vision →epigastric pain and →check protein in urine. ■ fast or difficult breathing. Care for the woman according to the stage of labour D8-D13 and respond to problems during labour and delivery as on D14-D18 . ask the woman if she would like her partner or another family member to be included in the counselling session. Record findings. ■ Refer woman urgently to hospital B17 . if mother feels dizzy or has severe headaches. either to use alone or together with LAM. delivery and immediate postpartum care D1 . and decide the stage of labour. is very high or rises rapidly. if possible. ■ ■ Next. such as meat. DELIVERY AND IMMEDIATE POSTPARTUM CARE D23 SIGNS ■ ■ ASK. ■ Diastolic blood pressure ≥90 mmHg on 2 readings. If late labour: →continue magnesium sulphate treatment B13 →monitor blood pressure every hour. ■ CARE OF MOTHER ■ ■ ■ ■ ■ ■ INTERVENTIONS. Give Supportive care. repeat after 1 hour rest. and →she is breastfeeding exclusively (8 or more times a day. IF MOTHER SEVERELY ILL OR SEPARATED FROM THE BABY ■ ■ ■ Teach mother to express breast milk every 3 hours K5 . ■ ■ ■ ■ ■ ■ Check record and give any treatment or prophylaxis which is due. Check if vitamin A given. If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is uncomfortable. NEXT: Give preventive measures GIVE PREVENTIVE MEASURES CHILDBIRTH: LABOUR.

or other complication such as postpartum haemorhage? ■ Any prior third degree tear? Current pregnancy: ■ RPR status C5 . ASK. ■ Listen to the fetal heart beat: →Count number of beats in 1 minute. ■ Feel abdomen for: →contractions frequency. any continuous contractions? →fetal lie—longitudinal or transverse? →fetal presentation—head. ■ Hb results C4 . ■ Measure blood pressure. breech. when? How much? ■ Is the baby moving? ■ Do you have any concern? Check record. ■ HIV status C6 . empty bladder B12 and observe again). DELIVERY AND IMMEDIATE POSTPARTUM CARE EXAMINE THE WOMAN IN LABOUR OR WITH RUPTURED MEMBRANES First do Rapid assessment and management B3-B7 . Then D2 use this chart to assess the woman’s and fetal status and decide stage of labour. or if no record: ■ Ask when the delivery is expected. If prior pregnancies: ■ Number of prior pregnancies/deliveries. duration. ■ Measure temperature. other? →more than one fetus? →fetal movement.Examine the woman in labour or with ruptured membranes CHILDBIRTH: LABOUR. ■ Tetanus immunization status F2 . forceps. turn woman on her left side and count again. ■ 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. →If less than 100 beats per minute. ■ Review the birth plan. LISTEN. ■ Any prior caesarean section. or vacuum. when? Were they clear or green? ■ Have you had any bleeding? If yes. dry mouth. ■ Infant feeding plan G7-G8 . CHECK RECORD LOOK . ■ Look for pallor. FEEL History of this labour: ■ When did contractions begin? ■ How frequent are contractions? How strong? ■ Have your waters broken? If yes. ■ Look for sunken eyes. →horizontal ridge across lower abdomen (if present. or more than 180. ■ Determine if preterm (less than 8 months pregnant). ■ Pinch the skin of the forearm: does it go back quickly? NEXT: Perform vaginal examination and decide stage of labour .

Perform vaginal examination ■ DO NOT shave the perineal area. DELIVERY AND IMMEDIATE POSTPARTUM CARE ASK. pads. →Feel for membranes – are they intact? →Feel for cord – is it felt? Is it pulsating? If so. ■ Record in partograph N5 . NEXT: Respond to obstetrical problems on admission. ■ Record in labour record N5 . ■ Wash hands with soap before and after each examination. round and smooth (the head)? If not. keloid tissue or scars that may interfere with delivery. ■ Prepare: →clean gloves →swabs. Is it hard. DO NOT perform vaginal examination if bleeding now or at any time after 7 months of pregnancy. full cervical dilatation. act immediately as on D15 . Look at vulva for: →bulging perineum →any visible fetal parts →vaginal bleeding →leaking amniotic fluid. . foul-smelling? →warts. is it meconium stained. FEEL ■ SIGNS ■ Bulging thin perineum. contractions weak and <2 in 10 minutes. Decide stage of labour D3 . identify the presenting part. ■ Position the woman with legs flexed and apart. ■ Cervical dilatation: LATE ACTIVE LABOUR → multigravida ≥5 cm → primigravida ≥6 cm ■ Cervical dilatation ≥4 cm. Perform gentle vaginal examination (do not start during a contraction): →Determine cervical dilatation in centimetres. CHECK RECORD ■ LOOK. if yes. →Feel for presenting part.DECIDE STAGE OF LABOUR CHILDBIRTH: LABOUR. ■ ■ Cervical dilatation: 0-3 cm. Explain to the woman that you will give her a vaginal examination and ask for her consent. EARLY ACTIVE LABOUR NOT YET IN ACTIVE LABOUR ■ See first stage of labour — not active labour D8 ■ Record in labour record N4 . ■ Wash vulva and perineal areas. gaping and head visible. ■ See first stage of labour – active labour D9 ■ Start plotting partograph N5 . . ■ Put on gloves. LISTEN. vagina CLASSIFY IMMINENT DELIVERY MANAGE ■ See second stage of labour D10-D11 .

MANAGE ONLY IF IN LATE LABOUR ■ Rupture of membranes and any of: →Fever >38˚C →Foul-smelling vaginal discharge. FOR ALL SITUATIONS IN RED BELOW. If late labour. RISK OF UTERINE AND FETAL INFECTION ■ ■ ■ ■ ■ ■ Diastolic blood pressure >90 mmHg. Sudden and severe abdominal pain. PRE-ECLAMPSIA SEVERE ANAEMIA ■ ■ ■ ■ ■ ■ OBSTETRICAL COMPLICATION ■ Follow specific instructions (see page numbers in left column). Plan to treat newborn J5 .Respond to obstetrical problems on admission CHILDBIRTH: LABOUR. If late labour. insert an IV line and give fluids B9 . Fetal distress D14 . If distressed. Constant pain between contractions. deliver and refer to hospital after delivery B17 . . deliver D10-D28 . SIGNS ■ ■ ■ ■ ■ ■ CLASSIFY OBSTRUCTED LABOUR TREAT AND ADVISE ■ ■ ■ Transverse lie. D16 . Refer urgently to hospital B17 . Give appropriate IM/IV antibiotics B15 . 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 . Severe palmar and conjunctival pallor and/or haemoglobin <7 g/dl. Labour >24 hours. Continuous contractions. D23 . give appropriate IM/IV antibiotics B15 . Discontinue antibiotic for mother after delivery if no signs of infection. Assess further and manage as on Manage as on D24 . Breech or other malpresentation Multiple pregnancy D18 . Prolapsed cord D15 . REFER URGENTLY TO HOSPITAL IF IN EARLY LABOUR. ■ Rupture of membranes at <8 months of pregnancy. If in labour >24 hours. UTERINE AND FETAL INFECTION ■ ■ ■ Give appropriate IM/IV antibiotics B15 . Horizontal ridge across lower abdomen. Plan to treat newborn J5 .

Prior delivery by: →caesarean section →forceps or vacuum delivery. Labour before 8 completed months of pregnancy (more than one month before estimated date of delivery). Prior third degree tear. Age less than 14 years . ■ ■ If late labour. DELIVERY AND IMMEDIATE POSTPARTUM CARE ■ ■ ■ ■ CLASSIFY RISK OF OBSTETRICAL COMPLICATION TREAT AND ADVISE ■ Warts. keloid tissue that may interfere with delivery. Prepare equipment for resuscitation of newborn K11 . ■ Fetal heart rate <120 or >160 beats per minute. No fetal movement. HIV test positive. Have help available during delivery. POSSIBLE FETAL DISTRESS RUPTURE OF MEMBRANES ■ ■ ■ ■ Give appropriate IM/IV antibiotics if rupture of membrane >18 hours B15 . Plan to treat the newborn J5 . ■ ■ PRETERM LABOUR ■ ■ ■ ■ ■ Reassess fetal presentation (breech more common). In particular. Rupture of membranes at term and before labour. If not able to drink. and No fetal heart beat on repeated examination DEHYDRATION ■ ■ B9 . If woman is lying. deliver D10-D28 . Manage as on D14 . Explain to the parents that the baby is not doing well. Counselled on ARV treatment and infant feeding. control delivery of the head. Conduct delivery very carefully as small baby may pop out suddenly.SIGNS CHILDBIRTH: LABOUR. encourage her to lie on her left side. Bleeding any time in third trimester. give 1 litre IV fluids over 3 hours ■ If two or more of the following signs: →thirsty →sunken eyes →dry mouth →skin pinch goes back slowly. Support her choice of infant feeding G7-G8 . Call for help during delivery. ■ ■ HIV-POSITIVE ■ ■ Ensure that the woman takes ARV drugs as soon as labour starts G6 . ■ ■ POSSIBLE FETAL DEATH ■ NEXT: Give supportive care throughout labour Respond to obstetrical problems on admission D5 . Do a generous episiotomy and carefully control delivery of the head D10-D11 . Give oral fluids.

if available. → hold the woman’s hand and sponge her face between contractions. DO NOT give enema. Breathing technique ■ ■ ■ ■ ■ Cleanliness ■ ■ ■ ■ ■ ■ Encourage the woman to bathe or shower or wash herself and genitals at the onset of labour. to breathe with an open mouth. Wash your hands with soap before and after each examination. Ensure cleanliness of labour and birthing area(s). If she feels dizzy. and to relax with each breath. Encourage companion to: → massage the woman’s back if she finds this helpful. kneeling. Support the woman’s choice of position (left lateral. as comfortable for her. Clean up spills immediately. find out what she has told the companion. Encourage the woman to eat and drink as she wishes throughout labour. even in late labour. standing supported by the companion) for each stage of labour and delivery. Encourage her to breathe out more slowly. investigate the cause D2-D3 . Encourage warm bath or shower. seek permission. encouraging atmosphere for birth. If woman is distressed or anxious. Respect her wishes. Pain and discomfort relief ■ ■ ■ Mobility ■ ■ Encourage the woman to walk around freely during the first stage of labour. D4 . During delivery of the head. ask her not to push but to breathe steadily or to pant. hands and feet. encourage her to breathe more slowly. drinking ■ ■ ■ Explain all procedures. Nutritious liquid drinks are important. squating. If known HIV positive. Remind her every 2 hours. To prevent pushing at the end of first stage of labour. Ensure and respect privacy during examinations and discussions. Encourage her to use the breathing technique. encourage and reassure her that things are going well. Wash the vulva and perineal areas before each examination. Keep her informed about the progress of labour. make sure she eats and drinks. respectful of the woman’s wishes. Teach her to notice her normal breathing. making a sighing noise.Give supportive care throughout labour CHILDBIRTH: LABOUR. If the woman has visible severe wasting or tires during labour. . is feeling pins-and-needles (tingling) in her face. and discuss findings with the woman. D6 Communication ■ ■ ■ ■ ■ Eating. DELIVERY AND IMMEDIATE POSTPARTUM CARE GIVE SUPPORTIVE CARE THROUGHOUT LABOUR Use this chart to provide a supportive. Urination ■ ■ ■ ■ ■ Suggest change of position. Use clean gloves for vaginal examination. If pain is constant (persisting between contractions) and very severe or sudden in onset Encourage the woman to empty her bladder frequently. teach her to pant. unwell. Encourage mobility. to take in 2 short breaths followed by a long breath out. Praise her.

do other supportive actions. →Assist her to the toilet when needed. →Encourage her. DELIVERY AND IMMEDIATE POSTPARTUM CARE ■ ■ Encourage support from the chosen birth companion throughout labour. →She is suddenly in much more pain. →There is vaginal bleeding. →Rub her back. →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. →Give support using local practices which do not disturb labour or delivery. →She loses consciousness or has fits. DO NOT keep woman in bed if she wants to move around. →Help her to breathe and relax. →Encourage woman to move around freely as she wishes and to adopt the position of her choice. wipe her brow with a wet cloth.Birth companion CHILDBIRTH: LABOUR. Ask the birth companion to call for help if: →The woman is bearing down with contractions. Describe to the birth companion what she or he should do: →Always be with the woman. ■ ■ Birth companion D7 . DO NOT give advice other than that given by the health worker. →Encourage her to drink fluids and eat as she wishes.

Temperature. using rapid assessment (RAM) Frequency.First stage of labour (1): when the woman is not in active labour CHILDBIRTH: LABOUR. Pulse B3 . . Give Supportive care D6-D7 . Fetal heart rate D14 . ■ ■ ■ ■ Record findings regularly in Labour record and Partograph N4-N6 . ASSESS PROGRESS OF LABOUR ■ TREAT AND ADVISE. Blood pressure D23 . Cervical dilatation 4 cm or greater. After 8 hours if: →no increase in contractions. . DO NOT do vaginal examination more frequently than every 4 hours. Record time of rupture of membranes and colour of amniotic fluid. less than 2 in 10 minutes. ■ ■ ■ ■ Cervical dilatation D3 D15 . Refer the woman urgently to hospital B17 . anxious) D6 . Mood and behaviour (distressed. and →membranes are not ruptured. DELIVERY AND IMMEDIATE POSTPARTUM CARE FIRST STAGE OF LABOUR: NOT IN ACTIVE LABOUR Use this chart for care of the woman when NOT IN ACTIVE LABOUR. D8 MONITOR EVERY HOUR: ■ ■ ■ ■ MONITOR EVERY 4 HOURS: B3-B7 For emergency signs. when cervix dilated 0-3 cm and contractions are weak. Begin plotting the partograph N5 ■ ■ and manage the woman as in Active labour D9 . IF REQUIRED ■ After 8 hours if: →Contractions stronger and more frequent but →No progress in cervical dilatation with or without membranes ruptured. Unless indicated. ■ ■ Discharge the woman and advise her to return if: →pain/discomfort increases →vaginal bleeding →membranes rupture. Never leave the woman alone. and →no progress in cervical dilatation. intensity and duration of contractions.

FIRST STAGE OF LABOUR: IN ACTIVE LABOUR CHILDBIRTH: LABOUR. IF REQUIRED ■ ■ ■ ■ ■ ■ Partograph passes to the right of ALERT LINE. ■ ■ ■ ■ Cervical dilatation D3 D15 . Encourage woman to empty bladder. Never leave the woman alone. Refer urgently to hospital B17 ■ ■ Partograph passes to the right of ACTION LINE. intensity and duration of contractions. Manage as in Second stage of labour D10-D11 . refer immediately (DO NOT wait to cross action line). Pulse B3 . Encourage upright position and walking if woman wishes. using rapid assessment (RAM) Frequency. Blood pressure D23 . ■ ■ ■ ■ Record findings regularly in Labour record and Partograph N4-N6 . when cervix dilated 4 cm or more. Mood and behaviour (distressed. Unless indicated. ASSESS PROGRESS OF LABOUR ■ TREAT AND ADVISE. If referral takes a long time. Cervix dilated 10 cm or bulging perineum. anxious) D6 . Reassess in 2 hours and refer if no progress. Call senior person if available. Record time of rupture of membranes and colour of amniotic fluid. Reassess woman and consider criteria for referral. do not do vaginal examination more frequently than every 4 hours. MONITOR EVERY 30 MINUTES: ■ ■ ■ ■ MONITOR EVERY 4 HOURS: B3-B7 For emergency signs. Ensure adequate hydration but omit solid foods. Monitor intensively. Give Supportive care D6-D7 . Alert emergency transport services. Fetal heart rate D14 . . DELIVERY AND IMMEDIATE POSTPARTUM CARE Use this chart when the woman is IN ACTIVE LABOUR. First stage of labour (2): when the woman is in active labour D9 . ■ ■ unless birth is imminent. Temperature.

Ensure bladder is empty. empty bladder B12 . Give Supportive care D6-D7 . encourage pain discomfort relief D6 . Encourage breathing technique D6 . manage as on D16 . intensity and duration of contractions. If breech or other malpresentation. DO NOT urge her to push. as upright as possible. Visible descent of fetal head or during contraction. do a vaginal examination to confirm full dilatation of cervix. Assist the woman into a comfortable position of her choice. ■ ■ ■ ■ ■ ■ ■ If unable to pass urine and bladder is full. Never leave the woman alone. Frequency. DO NOT let her lie flat (horizontally) on her back. If obvious obstruction to progress (warts/scarring/keloid tissue/previous third degree tear). are available. N4-N6 Record findings regularly in Labour record and Partograph (pp. after 30 minutes of spontaneous expulsive efforts. call for staff trained to use vacuum extractor or refer urgently to hospital B17 . do a generous episiotomy. anxious) D6 . Allow her to push as she wishes with contractions. D10 MONITOR EVERY 5 MINUTES: ■ ■ ■ ■ ■ ■ ■ ■ ■ For emergency signs. using rapid assessment (RAM) B3-B7 . Put on gloves just before delivery. If second stage lasts for 2 hours or more without visible steady descent of the head. Perineum thinning and bulging. DELIVERY AND IMMEDIATE POSTPARTUM CARE 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. Mood and behaviour (distressed. Place woman on her left side and discourage pushing. DELIVER THE BABY ■ TREAT AND ADVISE IF REQUIRED Ensure all delivery equipment and supplies. including newborn resuscitation equipment. DO NOT perform episiotomy routinely.Second stage of labour: deliver the baby and give immediate newborn care (1) CHILDBIRTH: LABOUR. and place of delivery is clean and warm (25°C) L3 . the perineum does not begin to thin and stretch with contractions.N4-. ■ If cervix is not fully dilated. ■ ■ ■ ■ ■ ■ Wait until head visible and perineum distending. . Stay with her and offer her emotional and physical support D10-D11 . await second stage. Wash hands with clean water and soap. Fetal heart rate D14 . See Universal precautions during labour and delivery A4 . If the woman is distressed.

cover the head with a hat. Palpate mother’s abdomen. →Support perineum with other hand and cover anus with pad held in position by side of hand during delivery. if necessary. →cut between ties with sterile instrument. ■ Deliver the second baby. GET HELP. ■ ■ ■ If cord present and loose. place the baby in a clean. Then lift baby up. →Ask the mother to breathe steadily and not to push during delivery of the head. DO NOT bandage or bind the stump. IF REQUIRED ■ If potentially damaging expulsive efforts. deliver the baby through the loop of cord or slip the cord over the baby’s head. towards the mother’s abdomen to deliver lower shoulder. DO NOT leave the baby wet . Feel gently around baby’s neck for the cord. →Leave the perineum visible (between thumb and first finger). ■ If heavy bleeding. ■ ■ ■ ■ ■ ■ ■ If second baby. start Newborn resuscitation K11 . Second stage of labour: deliver the baby and give immediate newborn care (2) D11 . feed accordingly. ■ CALL FOR HELP . Note time of delivery. exert more pressure on perineum.she/he will become cold. macerated. clamp and cut cord. repeat oxytocin 10 IU IM. →observe for oozing blood. Cover the baby. place a second tie between the skin and the first tie. Discard wet cloth. DELIVERY AND IMMEDIATE POSTPARTUM CARE Ensure controlled delivery of the head: →Keep one hand gently on the head as it advances with contractions. or the mother cannot hold the baby. If not possible. If the baby is not crying. wash gloved hands. Place identification label. ■ ■ ■ ■ If room cool (less than 25°C). Apply gentle downward pressure to deliver top shoulder. Assess baby’s breathing while drying. ■ If HIV-positive mother has chosen replacement feeding. CHILDBIRTH: LABOUR. Watch for vaginal bleeding. DO NOT apply any substance to the stump. DO NOT give oxytocin now. if cord is tight. Clamp and cut the cord. →put ties tightly around the cord at 2 cm and 5 cm from baby’s abdomen.one person should care for the mother.DELIVER THE BABY ■ TREAT AND ADVISE. ■ If placing newborn on abdomen is not acceptable. ■ Discard soiled pad to prevent infection. ■ If blood oozing. Leave baby on the mother’s chest in skin-to-skin contact. observe breathing: →breathing well (chest rising)? →not breathing or gasping? Exclude second baby. →Encourage rapid breathing with mouth open. safe place close to the mother. then unwind. warm. . ■ Check ARV treatment needed G6 . use additional blanket to cover the mother and baby. Thoroughly dry the baby immediately. Check if the face is clear of mucus and membranes. severely malformed): →Cut cord quickly: transfer to a firm. Wipe eyes. ■ ■ ■ ■ ■ ■ ■ ■ Await spontaneous rotation of shoulders and delivery (within 1-2 minutes). Place baby on abdomen or in mother’s arms. Give 10 IU oxytocin IM to the mother. warm surface. Change gloves. Manage as in Multiple pregnancy D18 . ■ Gently wipe face clean with gauze or cloth. ■ If the baby is not breathing or gasping (unless baby is dead. Encourage initiation of breastfeeding K2 ■ 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 placenta does not descend during 30-40 seconds of controlled cord traction. J2 . Await strong uterine contraction (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. . →As the placenta is coming out. At the same time. ■ ■ Ensure 10 IU oxytocin IM is given D11 .Third stage of labour: deliver the placenta CHILDBIRTH: LABOUR. Give Supportive care D6-D7 . B11 . ■ 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 . Breathing: listen for grunting. Time since third stage began (time since birth).N4-N6). →If the membranes do not slip out spontaneously. release both cord traction and counter traction on the abdomen and wait until the uterus is well contracted again. sustained controlled cord traction. D12 MONITOR MOTHER EVERY 5 MINUTES: ■ ■ ■ ■ ■ ■ ■ MONITOR BABY EVERY 15 MINUTES: ■ ■ For emergency signs. B3-B7 . anxious) D6 . ■ Check that placenta and membranes are complete. the placenta is not delivered and the woman is NOT bleeding: →Empty bladder B12 →Encourage breastfeeding →Repeat controlled cord traction. This applies counter traction to the uterus during controlled cord traction. 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 . DELIVER THE PLACENTA ■ ■ TREAT AND ADVISE IF REQUIRED If. treatments and procedures in Labour record and Partograph (pp. ■ If woman is bleeding. DO NOT squeeze or push the uterus to deliver the placenta. Never leave the woman alone. look for chest in-drawing and fast breathing Warmth: check to see if feet are cold to touch J2 . using rapid assessment (RAM) Feel if uterus is well contracted. Record findings. catch in both hands to prevent tearing of the membranes. DO NOT exert excessive traction on the cord. DELIVERY AND IMMEDIATE POSTPARTUM CARE THIRD STAGE OF LABOUR: DELIVER THE PLACENTA Use this chart for care of the woman between birth of the baby and delivery of placenta. → → If placenta is incomplete: Remove placental fragments manually Give appropriate IM/IV antibiotic B15 . apply steady. after 30 minutes of giving oxytocin. gently twist them into a rope and move them up and down to assist separation without tearing them. Mood and behaviour (distressed. Then repeat controlled cord traction with counter traction.

For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. lower vagina and vulva for tears. ■ Examine perineum. in a 2 m deep pit. Third stage of labour: deliver the placenta D13 . Repeat check every 5 minutes. Dispose of placenta in the correct. safe and culturally appropriate manner. ■ ■ Clean the woman and the area beneath her. →If not possible to observe at the facility. ■ ■ ■ If disposing placenta: →Use gloves when handling placenta. refer to hospital B17 . If bleeding persists. →Put placenta into a bag and place it into a leak-proof container. repair the tear B12 . →Incinerate the placenta or bury it at least 10 m away from a water source. Help her to change clothes if necessary. refer urgently to hospital B17 . until it is hard B10 . ■ If heavy bleeding: Massage uterus to expel clots if any. → Start an IV line B9 . but bleeding has stopped: →Plan to keep the woman in the facility for 24 hours. → Refer woman urgently to hospital B17 . → → → N9 .DELIVER THE PLACENTA CHILDBIRTH: LABOUR. Give oxytocin 10 IU IM B10 . Put sanitary pad or folded clean cloth under her buttocks to collect blood. Keep the mother and baby in delivery room for a minimum of one hour after delivery of placenta. add 20 IU of oxytocin to IV fluids and give at 60 drops per minute → Empty the bladder B12 . →Monitor intensively (every 30 minutes) for 4 hours: → BP pulse . Call for help. →Assist the woman when she first walks after resting and recovering. DELIVERY AND IMMEDIATE POSTPARTUM CARE ■ ■ TREAT AND ADVISE. estimate and record blood loss throughout third stage and immediately afterwards. ■ ■ ■ If third degree tear (involving rectum or anus). DO NOT cross ankles. → vaginal bleeding → uterus. → Apply bimanual or aortic compression B10 . ■ Collect. IF REQUIRED ■ Check that uterus is well contracted and there is no heavy bleeding. →Always carry placenta in a leak-proof container. Check after 5 minutes. to make sure it is well contracted. If blood loss ≈ 250 ml. If bleeding persists and uterus is soft: → Continue massaging uterus until it is hard. → Continue IV fluids with 20 IU of oxytocin at 30 drops per minute.

■ If early labour: →Refer the woman urgently to hospital B17 →Keep her lying on her left side. FHR remains >160 or <120 after 30 minutes observation.Respond to problems during labour and delivery (1) If FHR <120 or >160 bpm CHILDBIRTH: LABOUR. 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. CHECK RECORD LOOK. LISTEN. ■ ■ Cord seen at vulva. DELIVERY AND IMMEDIATE POSTPARTUM CARE RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY ASK. BABY WELL ■ NEXT: If prolapsed cord . Repeat FHR count after 15 minutes. If membranes have ruptured. ■ FHR returns to normal. Monitor FHR every 15 minutes. FEEL SIGNS CLASSIFY TREAT AND ADVISE D14 IF FETAL HEART RATE (FHR) <120 OR >160 BEATS PER MINUTE ■ ■ ■ ■ Position the woman on her left side. See if liquor was meconium stained. →Prepare for newborn resuscitation K11 . PROLAPSED CORD BABY NOT WELL ■ ■ Manage urgently as on D15 . look at vulva for prolapsed cord.

allow labour to continue. Feel for transverse lie. ■ Refer urgently to hospital B17 . FEEL ■ ■ ■ SIGNS ■ ■ CLASSIFY OBSTRUCTED LABOUR FETUS ALIVE TREAT ■ Look at or feel the cord gently for pulsations. ASK. staff) to position the woman’s buttocks higher than the shoulder. 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. If late labour: ■ Call for additional help if possible (for mother and baby). DELIVERY AND IMMEDIATE POSTPARTUM CARE The cord is visible outside the vagina or can be felt in the vagina below the presenting part. ■ Prepare for Newborn resuscitation K11 . ■ Expedite delivery by encouraging woman to push with contraction. LISTEN. ■ Instruct assistant (family. ■ If transfer not possible. ■ Cord is not pulsating FETUS PROBABLY DEAD ■ Explain to the parents that baby may not be well.IF PROLAPSED CORD CHILDBIRTH: LABOUR. Transverse lie Cord is pulsating Refer urgently to hospital B17 . ■ Ask the woman to assume an upright or squatting position to help progress. NEXT: If breech presentation Respond to problems during labour and delivery (2) If prolapsed cord D15 . Do vaginal examination to determine status of labour. CHECK RECORD LOOK.

for example. Prepare for newborn resuscitation K11 . If early labour If late labour Refer urgently to hospital B17 . 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. Ensure bladder is empty. When the hairline is visible. Feel the baby’s chest for arms. DELIVERY AND IMMEDIATE POSTPARTUM CARE IF BREECH PRESENTATION LOOK. trunk and shoulders to deliver spontaneously during contractions. Place the baby astride your left forearm with limbs hanging on each side. Deliver the baby: →Assist the woman into a position that will allow the baby to hang down during delivery. →After delivery of the shoulders allow the baby to hang until next contraction. Then proceed with delivery of head as described above.The assistant gives supra pubic pressure during the period to maintain flexion. LISTEN. Then proceed with delivery of head as described above. Legs or buttocks presenting at perineum. NEVER pull on the breech DO NOT allow the woman to push until the cervix is fully dilated. raise the baby in upward and forward direction towards the mother’s abdomen until the nose and mouth are free. Confirm full dilatation of the cervix by vaginal examination D3 . Then turn the baby back. If not felt: Hold the baby gently with hands around each thigh and thumbs on sacrum. Gently guiding the baby down. FEEL ■ ■ ■ D16 SIGN ■ ■ TREAT ■ ■ ■ ■ ■ ■ On external examination fetal head felt in fundus. ■ If the head does not deliver after several contractions ■ ■ ■ ■ ■ If trapped arms or shoulders ■ ■ ■ ■ ■ ■ If trapped head (and baby is dead) Tie a 1 kg weight to the baby’s feet and await full dilatation. 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.Respond to problems during labour and delivery (3) If breech presentation CHILDBIRTH: LABOUR. →When buttocks are distending. make an episiotomy. keeping the back uppermost until the shoulder which was posterior (below) is now anterior (at the top) and the arm is released. Keeping the left hand as described. Call for additional help. turn the baby. Pushing too soon may cause the head to be trapped. again keeping the back uppermost to deliver the other arm. ■ ■ NEXT: If stuck shoulders . If unable to empty bladder see Empty bladder B12 . propped up with buttocks at edge of bed or onto her hands and knees (all fours position). →Allow buttocks. Soft body part (leg or buttocks) felt on vaginal examination.

■ If the shoulders are still not delivered and surgical help is not available immediately.this simple change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery. refer urgently to hospital B17 . Assist her to adopt a kneeling on “all fours” position and ask her companion to hold her steady . 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. Introduce the right hand into the vagina along the posterior curve of the sacrum. ■ ■ Call for additional help. with knees wide apart. Ask the woman to lie on her back while gripping her legs tightly flexed against her chest. NEXT: If multiple births Respond to problems during labour and delivery (4) If stuck shoulders D17 . Ask an assistant to apply continuous pressure downwards. Ask the companion or other helper to keep the legs in that position. If not successful. DELIVERY AND IMMEDIATE POSTPARTUM CARE SIGN ■ TREAT ■ ■ ■ ■ Fetal head is delivered. with the palm of the hand on the abdomen directly above the pubic area. ■ ■ ■ ■ ■ ■ DO NOT pull excessively on the head. Prepare for newborn resuscitation. Explain the problem to the woman and her companion.IF STUCK SHOULDERS (SHOULDER DYSTOCIA) CHILDBIRTH: LABOUR. 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. Complete the rest of delivery as normal. but shoulders are stuck and cannot be delivered. Perform an adequate episiotomy.

usually within 1 hour of birth of first baby. Before and after delivery of the placenta and membranes. Second stage of labour Deliver the first baby following the usual procedure. If no third baby is felt. gently turn the baby by abdominal manipulation to head or breech presentation. Stay with the woman and continue monitoring her and the fetal heart rate intensively. NEXT: Care of the mother and newborn within first hour of delivery of placenta . Include: →more warm cloths →two sets of cord ties and razor blades →resuscitation equipment for 2 babies. cover her. applying traction to all cords together D12-D23 . DO NOT attempt to deliver the placenta until all the babies are born. DELIVERY AND IMMEDIATE POSTPARTUM CARE IF MULTIPLE BIRTHS SIGN ■ D18 TREAT ■ Prepare for delivery ■ ■ Prepare delivery room and equipment for birth of 2 or more babies. 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 ■ Immediate postpartum care ■ ■ ■ K4 . If transverse or oblique lie. Label her/him Twin 2. Palpate uterus immediately to determine the lie of the second baby. DO NOT give the mother oxytocin until after the birth of all babies. Check the presentation by vaginal examination. Arrange for a helper to assist you with the births and care of the babies. proceed as described above.Respond to problems during labour and delivery (5) If multiple births CHILDBIRTH: LABOUR. observe closely for vaginal bleeding because this woman is at greater risk of postpartum haemorrhage. When the membranes rupture. If a third baby is felt. ask the mother to bear down when she feels ready. Provide immediate Postpartum care D19-D20 . Ask helper to attend to the first baby. If feeling chilled. Monitor intensively as risk of bleeding is increased. go to third stage of labour. Check the fetal heart rate. Resuscitate if necessary. Examine the placenta and membranes for completeness. Palpate the uterus for a third baby. Remove wet cloths from underneath her. Deliver the second baby. If bleeding. When the uterus is well contracted. but may be longer. ask the helper to attend to the second baby. see B5 . see Prolapsed cord D15 . Resuscitate if necessary. When strong contractions restart. Label her/him Twin 1. or a separate placenta with an umbilical cord for each baby.There may be one large placenta with 2 umbilical cords. deliver the placenta and membranes by controlled cord traction. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Third stage of labour Give oxytocin 10 IU IM after making sure there is not another baby. After cutting the cord. perform vaginal examination D3 to check for prolapsed cord. If present. Await the return of strong contractions and spontaneous rupture of the second bag of membranes.

Cover mother and baby with a blanket → Reassess in 1 hour. → either 1% silver nitrate drops or 2. sugar water.5% povidone iodine drops or 1% tetracycline ointment. ■ Refer to hospital now if woman had serious complications at admission or during delivery but was in late labour.50C. manage as on If uterus soft. ■ DO NOT give artificial teats or pre-lacteal feeds to the newborn: no water. ■ INTERVENTIONS. J2-J8 . ■ Encourage the woman to pass urine. ■ DO NOT wash away the eye antimicrobial. ■ Encourage the woman to eat and drink. ■ DO NOT remove vernix or bathe the baby.do not separate them. MONITOR MOTHER EVERY 15 MINUTES: ■ ■ ■ ■ ■ MONITOR BABY EVERY 15 MINUTES: ■ ■ N4-N6 . B3-B7 . manage as on B10 . give supportive care to mother and her family D24 .CARE OF THE MOTHER AND NEWBORN WITHIN FIRST HOUR OF DELIVERY OF PLACENTA CHILDBIRTH: LABOUR. ■ If blood or meconium. If bleeding from a perineal tear. If baby is stillborn or dead. Use Assess the mother after delivery D21 and Examine the newborn J2-J8 . Offer her help. using rapid assessment (RAM) Feel if uterus is hard and round. manage as on If unable to initiate breastfeeding (mother has complications): → Plan for alternative feeding method K5-K6 . Breathing: listen for grunting. J2 . If still cold.. If less than 36. ■ Ask the companion to stay with the mother. or constant trickle of blood. examine the baby as on If feet are cold to touch or mother and baby are separated: → Ensure the room is warm. Examine the mother and newborn one hour after delivery of placenta. For emergency signs. measure temperature. Record findings. D22 . or local feeds. ■ Apply an antimicrobial within 1 hour of birth. NEWBORN ■ Wipe the eyes. look for chest in-drawing and fast breathing Warmth: check to see if feet are cold to touch J2 . ■ ■ ■ ■ If breathing with difficulty — grunting. DELIVERY AND IMMEDIATE POSTPARTUM CARE Use this chart for woman and newborn during the first hour after complete delivery of placenta. CARE OF MOTHER AND NEWBORN WOMAN ■ Assess the amount of vaginal bleeding. repair if required B12 or refer to hospital B17 . treatments and procedures in Labour record and Partograph Keep mother and baby in delivery room . wipe off with wet cloth and dry. IF REQUIRED ■ ■ ■ If pad soaked in less than 5 minutes. K9 . → If mother HIV+ and chooses replacement feeding. ■ 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. Care of the mother and newborn within first hour of delivery of placenta D19 . Never leave the woman and newborn alone. feed accordingly G8 . chest in-drawing or fast breathing.

Ask the mother’s companion to watch her and call for help if bleeding or pain increases. If uterus not firm. B6 . Feel uterus if hard and round. ■ → → → ■ If heavy vaginal bleeding. Ensure the mother has sanitary napkins or clean material to collect vaginal blood. help her by gently pouring water on vulva. ■ ■ ■ ■ ■ Check record and give any treatment or prophylaxis which is due. THEN EVERY 4 HOURS: ■ ■ ■ ■ ■ ■ For emergency signs. Advise when to seek care D28 . ■ Encourage the mother to empty her bladder and ensure that she has passed urine. massage the fundus to make it contract and expel any clots If pad is soaked in less than 5 minutes. Never leave the woman and newborn alone. MONITOR MOTHER AT 2. If tubal ligation or IUD desired. palpate the uterus. 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. Record findings.Care of the mother one hour after delivery of placenta CHILDBIRTH: LABOUR. If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is uncomfortable. Ensure the room is warm (25°C). Advise the mother on postpartum care and nutrition D26 . drink and rest. If mother is on antibiotics because of rupture of membranes >18 hours but shows no signs of infection now. using rapid assessment (RAM). see J2-J8 . Repeat examination of the mother before discharge using Assess the mother after delivery baby. ■ ■ D21 . discontinue antibiotics. If bleeding is from perineal tear. CARE OF MOTHER ■ ■ ■ ■ ■ ■ INTERVENTIONS. Counsel on birth spacing and other family planning methods D27 . DO NOT discharge before 12 hours. treatments and procedures in Labour record and Partograph Keep the mother and baby together. if mother feels dizzy or has severe headaches. DO NOT catheterize unless you have to. 3 AND 4 HOURS. N4-N6 . Advise on Postpartum care and hygiene D26 . Accompany the mother and baby to ward. manage as on B5 . visual disturbance or epigastric distress. Encourage the mother to eat. repair or refer to hospital B17 . For . make plans before discharge. See J10 D20 for care of the baby. IF REQUIRED Make sure the woman has someone with her and they know when to call for help.

Reassess for discharge D21 . Is it hard and round? Look for vaginal bleeding Look at perineum. Uterus hard. Counsel on birth spacing and family planning D27 . Advise on postpartum care and hygiene D26 . Blood pressure normal. go to page D25 . Feel the uterus. Counsel on nutrition D26 . If tubal ligation desired. refer to hospital within 7 days of delivery. If IUD desired.ASSESS THE MOTHER AFTER DELIVERY CHILDBIRTH: LABOUR. Assess the mother after delivery D21 . For examining the newborn use the chart on J2-J8 . LISTEN. Advise on when to seek care and next routine postpartum visit D28 . No perineal problem. CHECK RECORD LOOK. refer to appropriate services within 48 hours. No pallor. Little bleeding. →Is there a tear or cut? →Is it red. NEXT: Respond to problems immediately postpartum If no problems. Continue any treatments initiated earlier. Look for palmar pallor. Keep the mother at the facility for 12 hours after delivery. FEEL ■ SIGNS ■ ■ ■ ■ ■ ■ ■ CLASSIFY MOTHER WELL TREAT AND ADVISE ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 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? ■ ■ ■ ■ ■ ■ Measure temperature. Ensure preventive measures D25 . 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. swollen or draining pus? Look for conjunctival pallor. ASK. No fever. Pulse normal.

Respond to problems immediately postpartum (1) CHILDBIRTH: LABOUR. Treat if any sign of infection. If temperature persists for >12 hours. If baby and placenta delivered: → Give oxytocin 10 IU IM B10 . IF FEVER (TEMPERATURE >38ºC) ■ ■ ■ Time since rupture of membranes Abdominal pain Chills Repeat temperature measurement after 2 hours ■ If temperature is still >38ºC → Look for abnormal vaginal discharge. Perineal tear Episiotomy THIRD DEGREE TEAR SMALL PERINEAL TEAR ■ ■ Refer woman urgently to hospital B15 . ■ ■ ■ ■ ■ ■ ■ RISK OF UTERINE AND FETAL INFECTION Encourage woman to drink plenty of fluids. B12 . If bleeding persists. See B5 for treatment. give appropriate antibiotic and refer to hospital B15 . FEEL IF VAGINAL BLEEDING ■ D22 CLASSIFY HEAVY BLEEDING SIGNS More than 1 pad soaked in 5 minutes ■ Uterus not hard and not round ■ TREAT AND ADVISE ■ ■ A pad is soaked in less than 5 minutes. ■ Refer woman urgently to hospital B17 . repair the tear or episiotomy NEXT: If elevated diastolic blood pressure . LISTEN. DELIVERY AND IMMEDIATE POSTPARTUM CARE ASK. Measure temperature every 4 hours. CHECK RECORD LOOK. Refer urgently to hospital B17 . IF PERINEAL TEAR OR EPISIOTOMY (DONE FOR LIFESAVING CIRCUMSTANCES) Is there bleeding from the tear or episiotomy ■ Does it extend to anus or rectum? ■ ■ ■ ■ Tear extending to anus or rectum. ■ Assess the newborn J2-J8 . is very high or rises rapidly. Give appropriate IM/IV antibiotics B15 . → Listen to fetal heart rate → feel lower abdomen for tenderness ■ ■ 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 UTERINE AND FETAL INFECTION Insert an IV line and give fluids rapidly B9 .

If in early labour or postpartum. FEEL If diastolic blood pressure is ≥90 mmHg. ■ ■ ■ ■ ■ ■ Diastolic blood pressure ≥90 mmHg on 2 readings. ■ CLASSIFY SEVERE PRE-ECLAMPSIA TREAT AND ADVISE Give magnesium sulphate B13 . check for anaemia Respond to problems immediately postpartum (2) D23 . DO NOT give ergometrine after delivery. If blood pressure remains elevated after delivery. ■ ■ Diastolic blood pressure 90-110 mmHg on two readings. →DO NOT give ergometrine after delivery. ■ Refer urgently to hospital after delivery B17 . refer woman to hospital E17 . refer urgently to hospital B17 . refer urgently to hospital E17 . refer to hospital E17 . LISTEN. NEXT: If pallor on screening. ■ If diastolic blood pressure is still ≥90 mmHg.IF ELEVATED DIASTOLIC BLOOD PRESSURE CHILDBIRTH: LABOUR. ■ PRE-ECLAMPSIA If early labour. ask the woman if she has: →severe headache →blurred vision →epigastric pain and →check protein in urine. ■ 2+ proteinuria (on admission). DELIVERY AND IMMEDIATE POSTPARTUM CARE ASK. If late labour: →monitor blood pressure every hour →DO NOT give ergometrine after delivery. ■ SIGNS Diastolic blood pressure ≥110 mmHg OR ■ Diastolic blood pressure ≥90 mmHg and 2+ proteinuria and any of: →severe headache →blurred vision →epigastric pain. repeat after 1 hour rest. HYPERTENSION Monitor blood pressure every hour. ■ If late labour: →continue magnesium sulphate treatment B13 →monitor blood pressure every hour. ■ If BP remains elevated after delivery. CHECK RECORD LOOK.

IF MOTHER SEVERELY ILL OR SEPARATED FROM THE BABY ■ ■ ■ Teach mother to express breast milk every 3 hours K5 . Help her to establish or re-establish breastfeeding as soon as possible. CHECK RECORD LOOK. Counsel on appropriate family planning method D27 . Haemoglobin 7-11 g/dl. Look for conjunctival pallor. ■ ■ Haemoglobin >11 g/dl No pallor. AND/OR Severe palmar and conjunctival pallor or Any pallor with >30 breaths per minute. B17 . ■ ■ ■ Measure haemoglobin. refer urgently to hospital If late labour: →monitor intensively →minimize blood loss →refer urgently to hospital after delivery DO NOT discharge before 24 hours. Ensure baby receives mother’s milk K8 . SEVERE ANAEMIA ■ ■ If early labour or postpartum. Palmar or conjunctival pallor. If pallor: →Is it severe pallor? →Some pallor? →Count number of breaths in 1 minute ■ ■ ■ Haemoglobin <7 g/dl. Help her to express breast milk if necessary. FEEL SIGNS CLASSIFY TREAT AND ADVISE D24 IF PALLOR ON SCREENING. Advise the mother on breast care K8 . . →Discuss with them the events before the death and the possible causes of death. where culturally appropriate. LISTEN. NO ANAEMIA . DELIVERY AND IMMEDIATE POSTPARTUM CARE ASK. Give double dose of iron for 3 months Follow up in 4 weeks. IF BABY STILLBORN OR DEAD ■ NEXT: Give preventive measures ■ ■ ■ Give supportive care: →Inform the parents as soon as possible after the baby’s death. Give iron/folate for 3 months F3 B17 . →Offer the parents and family to be with the dead baby in privacy as long as they need. →Show the baby to the mother.Respond to problems immediately postpartum (3) CHILDBIRTH: LABOUR. delivery or postpartum. Provide certificate of death and notify authorities as required N7 . CHECK FOR ANAEMIA ■ Bleeding during labour. ■ ■ ■ Any bleeding. give the baby to the mother to hold. Check haemoglobin after 3 days. MODERATE ANAEMIA ■ ■ ■ ■ ■ F3 . See K2-K3 . if possible. Look for palmar pallor.

Discuss how to prepare for an emergency in postpartum D28 . Advise on postpartum care D26 . do the RPR test . Give mebendazole once in 6 months F6 . Counsel on breastfeeding K2 . F3 Give 3 month’s supply of iron and counsel on compliance Give vitamin A if due F2 . ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ F3 . Counsel on correct and consistent use of condoms G2 . DELIVERY AND IMMEDIATE POSTPARTUM CARE Ensure that all are given before discharge. .GIVE PREVENTIVE MEASURES CHILDBIRTH: LABOUR. If no RPR during this pregnancy. Counsel on birth spacing and family planning D27 . Check when last dose of mebendazole was given. Give preventive measures D25 . Encourage sleeping under insecticide treated bednet F4 . ■ Record all treatments given N6 . Counsel on nutrition D26 . ■ ■ ■ ■ ■ ■ Check tetanus toxoid (TT) immunization status. ASSESS. If RPR positive: →Treat woman and the partner with benzathine penicillin →Treat the newborn K12 . Check if vitamin A given. Advise on routine and follow-up postpartum visits D28 . Advise on danger signs D28 . Ask whether woman and baby are sleeping under insecticide treated bednet. Check woman’s supply of prescribed dose of iron/folate. Give tetanus toxoid if due F2 . CHECK RECORDS ■ ■ TREAT AND ADVISE ■ L5 Check RPR status in records. Counsel and advise all women.

DELIVERY AND IMMEDIATE 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. ■ Reassure the mother that she can eat any normal foods – these will not harm the breastfeeding baby. ■ Talk to family members such as partner and mother-in-law. ■ Determine if there are important taboos about foods which are nutritionally healthy. to help her feel well and strong (give examples of types of food and how much to eat). milk. beans. or more frequently if heavy lochia →wash used pads or dispose of them safely →wash the body daily. Advise the woman against these taboos. oils. fish. seeds. to encourage them to help ensure the woman eats enough and avoids hard physical work. ■ . such as meat.Advise on postpartum care CHILDBIRTH: LABOUR. D26 Counsel on nutrition Advise the woman to eat a greater amount and variety of healthy foods. ■ To avoid sexual intercourse until the perineal wound heals. nuts. vegetables. ■ 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. cereals. ■ Spend more time on nutrition counselling with very thin women and adolescents. cheese.

■ 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) IUD (within 48 hours or delay 4 weeks) Delay 3 weeks Combined oral contraceptives Combined injectables Diaphragm Fertility awareness methods 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) 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 spacing and family planning D27 . see G4 for family planning considerations ■ Her partner can decide to have a vasectomy (male sterilization) at any time. no complementary foods or fluids). → Information on when to start a method after delivery will vary depending on whether a woman is breastfeeding or not. → Ask about plans for having more children. especially if at risk for sexually transmitted infection (STI) or HIV G2 . ask the woman if she would like her partner or another family member to be included in the counselling session. Promote their use. or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). including at least once at night: no daytime feedings more than 4 hours apart and no night feedings more than 6 hours apart. she can become pregnant as soon as 4 weeks after delivery. ■ Advise the correct and consistent use of condoms for dual protection from sexually transmitted infection (STI) or HIV and pregnancy. If she (and her partner) want more children. ■ For HIV-positive women. if she has sex and is not exclusively breastfeeding. ■ Explain that after birth. A breastfeeding woman can also choose any other family planning method. and →she is breastfeeding exclusively (8 or more times a day. DELIVERY AND IMMEDIATE POSTPARTUM CARE Counsel on the importance of family planning If appropriate. ■ Lactational amenorrhoea method (LAM) ■ A breastfeeding woman is protected from pregnancy only if: →she is no more than 6 months postpartum. and →her menstrual cycle has not returned. Therefore it is important to start thinking early about what family planning method they will use.COUNSEL ON BIRTH SPACING AND FAMILY PLANNING CHILDBIRTH: LABOUR. advise that waiting at least 2-3 years between pregnancies is healthier for the mother and child. → Make arrangements for the woman to see a family planning counsellor. either to use alone or together with LAM.

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. preferably within 2-3 days 4-6 weeks SECOND VISIT 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. K14 . For newborn babies see the schedule on Encourage woman to bring her partner or family member to at least one visit. Advise the woman to ask for help from the community. ■ severe abdominal pain. but no later than in 2 weeks. or sore nipple ■ urine dribbling or pain on micturition ■ pain in the perineum or draining pus ■ foul-smelling lochia Within the first week. ■ convulsions. even for an emergency visit. Go to health centre as soon as possible if any of the following signs: ■ fever ■ abdominal pain ■ feels ill ■ breasts swollen. DELIVERY AND IMMEDIATE POSTPARTUM CARE ADVISE ON WHEN TO RETURN Use this chart for advising on postpartum care on D21 or E2 . if needed I1-I3 . 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 on when to return CHILDBIRTH: LABOUR. D28 Routine postpartum care visits FIRST VISIT D19 E2 Advise on danger signs Advise to go to a hospital or health centre immediately. day or night. ■ fever and too weak to get out of bed. . WITHOUT WAITING.. ■ fast or difficult breathing. red or tender breasts. Advise the woman to bring her home-based maternal record to the health centre. 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.

Maintain the partograph and labour record N4-N6 .HOME DELIVERY BY SKILLED ATTENDANT CHILDBIRTH: LABOUR. return within a day to check the mother and baby. Delivery care ■ ■ ■ ■ ■ ■ Postpartum care of newborn ■ ■ ■ ■ ■ ■ ■ ■ Follow the labour and delivery procedures D2-D28 K11 . and the delivery kit. Ensure that the family prepares. records. Immunize the baby if possible B13 . Involve the companion in care and support D6-D7 . Keep emergency transport arrangements up-to-date. Ensure that someone will stay with the mother for the first 24 hours. B2 . Preparation for home delivery ■ ■ ■ ■ Immediate postpartum care of mother ■ ■ ■ ■ Check emergency arrangements. nutrition and family planning D26-D27 . Refer to facility as soon as possible if any abnormal finding in mother or baby B17 K14 . as on C18 . Stay with the woman for first two hours after delivery of placenta C2 Examine the mother before leaving her D21 . Advise a postpartum visit for the mother and baby within the first week B14 . Advise on newborn care B9-B10 . Examine the baby before leaving N2-N8 . Carry with you all essential drugs B17 . Advise the family about danger signs and when and where to seek care B14 . DELIVERY AND IMMEDIATE POSTPARTUM CARE Use these instructions if you are attending delivery at home. Advise on postpartum care. Observe universal precautions A4 . C13-C14 . Stay until baby has had the first breastfeed and help the mother good positioning and attachment Advise on breastfeeding and breast care B3 . If possible. Home delivery by skilled attendant D29 . Provide newborn care J2-J8 . Give Supportive care.

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If the woman is HIV positive. IF FEELING UNHAPPY OR CRYING EASILY 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. ■ Refer urgently to hospital B17 . and counsel on nutrition D26 . and Advise and ■ Fever >38°C. ■ Temperature >38°C and any of: →stiff neck →lethargy. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (5) If dribbling urine If puss or perineal pain If feeling unhappy or crying easily ■ . Use Practical Approach to Lung health guidelines (PAL) for further management. FEEL IF ELEVATED DIASTOLIC BLOOD PRESSURE ■ SIGNS History of pre-eclampsia or eclampsia in pregnancy. Give appropriate oral antibiotics for lower urinary tract infection F5 . If partner could not be approached. ■ ■ ■ ■ ■ CLASSIFY NORMAL POSTPARTUM TREAT AND ADVISE ■ ■ ■ Measure blood pressure and temperature. ■ ■ ■ CLASSIFY POSSIBLE PNEUMONIA TREAT AND ADVISE ■ ■ 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? ■ ■ ■ Look for breathlessness. If smoking. TREAT AND ADVISE Give 0. Follow up in 2 days. ■ Blood in sputum. ■ Not been tested. If her sputum is TB-positive within 2 months of delivery. Diastolic blood pressure <90 mmHg after 2 readings. Give any treatment or prophylaxis due: →tetanus immunization if she has not had full course F2 . refer to hospital. Refer urgently to hospital B17 . FEEL ■ ■ E8 CLASSIFY POSSIBLE GONORRHOEA OR CHLAMYDIA INFECTION POSSIBLE CANDIDA INFECTION SIGNS ■ TREAT AND ADVISE ■ ■ ■ E8 IF VAGINAL DISCHARGE 4 WEEKS AFTER DELIVERY Do you have itching at the vulva? Has your partner had a urinary problem? Separate the labia and look for abnormal vaginal discharge: →amount →colour →odour/smell. ■ Feel uterus. Counsel HIV-positive woman on family planning G4 . CHECK RECORD LOOK. FEEL 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. refer to hospital. No additional treatment. ■ Advise on correct and consistent use of condoms G2 . refer to hospital. E9 ■ At least 1 of the following: ■ Cough or breathing difficulty for >3 weeks. IF TAKING ANTI-TUBERCULOSIS DRUGS ■ RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (7) If cough or breathing difficulty If taking anti-tuberculosis drugs Are you taking anti-tuberculosis drugs? If yes. Manage as in Rapid assessment and management B3-B7 . If yes. ■ No fever or pain or concern. Reassess in 1 week. for less than 2 weeks. Follow up in 2 weeks. ■ LOWER URINARY TRACT INFECTION ■ ■ ■ Give appropriate oral antibiotic F5 . Feels tired. Uterus well contracted and hard. Counsel on the benefits of testing her partner G3 . Advise on correct and consistent use of condoms G2 . ■ RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (3) Check for HIV status ■ ■ ■ Known HIV-negative. E2 POSTPARTUM CARE E2 ASK. if present. ■ Refer to TB centre if cough. and of the need to continue treatment. If partner is present in the clinic. Give appropriate IM/IV antibiotics B15 . Blood pressure. POSTPARTUM EXAMINATION OF THE MOTHER (UP TO 6 WEEKS) Respond to observed signs or volunteered problems (6) ASK. Advise on correct and consistent use of condoms F4 . ■ ■ ■ SIGNS Mother feeling well. Refer urgently to hospital B17 . LISTEN. Have you had heavy bleeding since delivery? Do you tire easily? Are you breathless (short of breath) during routine housework? Measure haemoglobin if history of bleeding. To examine the baby see J2-J8 . refer urgently to hospital. ■ No pallor. Promote use of impregnated bednet for the mother and baby. waking early). use G1-G8 H1-H4 D21 IF FEVER OR FOUL-SMELLING LOCHIA ■ Have you had: →heavy bleeding? →foul-smelling lochia? →burning on urination? ■ ■ ■ ■ ■ Feel lower abdomen and flanks for tenderness. If conditions persists more than 1 week. Follow up in 2 weeks to check clinical progress and compliance with treatment. Refer urgently to hospital B17 . ■ ■ ■ 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. ■ Counsel on the benefits of involving and testing her partner G3 . Give oral antimalarial F4 . Burning on urination. Advise on correct and consistent use of condoms G2 . UPPER RESPIRATORY TRACT INFECTION ■ ■ Advise safe. Make sure she has key information on HIV G2 . Give appropriate antihypertensive B14 . For the first or second postpartum visit during the first week after delivery. FEEL ■ ■ ■ ■ SIGNS ■ ■ ■ CLASSIFY SEVERE ANAEMIA TREAT AND ADVISE ■ ■ ■ Check record for bleeding in pregnancy. repeat after a 1 hour rest. Counsel on the benefits of involving and testing her partner G3 . Decreased interest or pleasure. Reinforce advice to go for VCT G3 . Is it hard and round? ■ Look at vulva and perineum for: →tear →swelling →pus. Look for abnormal lochia. PERINEAL TRAUMA PERINEAL INFECTION OR PAIN ■ Refer the woman to hospital. Haemoglobin >11 g/dl. Refer urgently to hospital B17 . ■ UPPER URINARY TRACT INFECTION ■ ■ Give appropriate IM/IV antibiotics B15 . If no improvement. Breathlessness. Illness or death from AIDS in a sexual partner. Dispense 3 months iron supply and counsel on compliance F3 . Fever >38ºC and any of: →burning on urination →flank pain. Haemoglobin 7-11 g/dl OR Palmar or conjunctival pallor. ■ Diminished ability to think or concentrate. Give appropriate IM/IV antibiotics B15 .) Has her partner been tested? Known HIV-positive. LISTEN. use the Postpartum examination chart counselling section D26 to examine and advise the mother. CHECK RECORD LOOK. Look at the skin: →Is there a rash? →Are there blisters along the ribs on one side of the body? RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (8) If signs suggesting HIV infection ■ ■ ■ ■ MODERATE ANAEMIA ■ ■ Give double dose of iron for 3 months F3 . ■ Diastolic blood pressure ≥110 mmHg. refer to hospital.2 mg ergometrine IM B10 . Advise on Postpartum care and hygiene. No perineal swelling. and refer if no improvement. delivery or postpartum. Disturbed sleep (sleeping too much or too little. Refer urgently to hospital B17 . Did not bleed >250 ml. agitated all the time. ■ ■ ■ ■ ■ ■ Remove sutures. Respond to observed signs or volunteered problems (5) E7 Postpartum care E1 . ■ If no discharge is seen. FEEL IF HEAVY VAGINAL BLEEDING ■ E6 CLASSIFY POSTPARTUM BLEEDING E6 SIGNS More than 1 pad soaked in 5 minutes. ask the woman if she feels comfortable if you ask him similar questions. ■ ■ ■ ■ ■ ■ POSTPARTUM DEPRESSION (USUALLY AFTER FIRST WEEK) ■ ■ Provide emotional support. Pain in perineum. Measure temperature. positive findings. ■ ■ ■ RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (4) If heavy vaginal bleeding If fever or foul-smelling lochia ■ ■ ■ If an abnormal sign is identified (volunteered or observed). Refer urgently the woman to hospital B7 . ■ ASK. CHECK RECORD LOOK. Look for lethargy. LISTEN. refer the woman to hospital. CHECK RECORD LOOK. Advise on additional care during postpartum G4 . or not willing to disclose result. If severe wheezing. refer the woman to hospital. E3-E10 . IF BREAST PROBLEM See J9 . DELIVERY AND POSTPARTUM CARE ASK. POSTPARTUM CARE NEXT: If pallor. check for anaemia NEXT: If signs suggesting HIV infection Respond to observed signs or volunteered problems (1) If elevated diastolic blood pressure E3 Respond to observed signs or volunteered problems (7) E9 Respond to observed signs or volunteered problems (2) If pallor. Pus in perineum. Give appropriate oral antibiotics to woman F5 . counsel to stop smoking. Treat partner with appropriate oral antibiotics F5 . Reassess at next postnatal visit (in 4 weeks). If smoking. Look for palmar pallor. is breastfeeding well. ■ ■ ■ Give clotrimazole F5 . CHECK RECORD LOOK. LISTEN. TUBERCULOSIS ■ ■ ■ ■ ■ Assure the woman that the drugs are not harmful to her baby. IF PUS OR PERINEAL PAIN ■ Excessive swelling of vulva or perineum. adolescent or has special needs. LISTEN. Counsel on the benefits of involving and testing her partner G3 . and the scheduled next visit in the home-based and clinic recording form. Counsel partner and family to provide assistance to the woman. Find out what she knows about HIV. If no improvement. Look for ulcers and white patches in the mouth (thrush). ■ ■ Curd-like vaginal discharge and/or Intense vulval itching. use the charts Respond to observed signs or volunteered problems Record all treatment given. ■ ■ ■ ■ ■ ■ Make sure woman and family know what to watch for and when to seek care D28 .check for anaemia POSTPARTUM CARE IF PALLOR. Give appropriate IM/IV antibiotics B15 . 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)? ■ ■ ■ ■ POSTPARTUM CARE 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. MALARIA ■ ■ NEXT: If dribbling urine ASK. If no improvement. UNKNOWN HIV STATUS Find out what she knows about HIV. LISTEN. Look for conjunctival pallor. NEXT: If heavy vaginal bleeding Respond to observed signs or volunteered problems (3) Check for HIV status E5 . Counsel on care and hygiene D26 . Give double dose of iron (1 tablet 60 mg twice daily for 3 months) F3 . Listen for wheezing. CHECK FOR ANAEMIA E4 E4 ASK. CHECK RECORD LOOK. Make sure she has key information on HIV G2 . Always begin with Rapid assessment and management (RAM) Next use the Postpartum examination of the mother E2 B2-B7 . and partner has urethral discharge or burning on passing urine.POSTPARTUM CARE Postpartum care POSTPARTUM CARE 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. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (2) If pallor. →Does it smell? →Is it profuse? ■ Look for pallor. ■ ■ ■ ■ Look for visible wasting. HIV-NEGATIVE ■ ■ POSTPARTUM CARE ■ Find out what she knows about HIV. CHECK RECORD LOOK. ■ No breast problem. Refer for family planning counselling. Cough for <3 weeks. use the chart Assess the mother after delivery D21 . LISTEN. Give artemether IM (or quinine IM if artemether not available) and glucose B16 . RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (1) If elevated diastolic pressure POSTPARTUM CARE ASK. UTERINE INFECTION ■ ■ ■ Insert an IV line and give fluids rapidly B9 . ■ No problem with urination. Check perineal trauma. If anaemia persists. FEEL 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)? ■ ■ ■ ■ ■ ■ CLASSIFY STRONG LIKELIHOOD OF HIV INFECTION TREAT AND ADVISE Reinforce the need to know HIV status and advise where to go for VCT G3 . NEXT: Respond to observed signs or volunteered problems NEXT: If cough or breathing difficulty RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS E3 CLASSIFY TREAT AND ADVISE SEVERE HYPERTENSION MODERATE HYPERTENSION BLOOD PRESSURE NORMAL ■ ■ ■ POSTPARTUM CARE CHILDBIRTH: LABOUR. ■ Marked loss of appetite. Refer urgently to hospital B17 . ■ ■ ■ ■ ■ NO ANAEMIA ■ Assess if in a high risk group: Occupational exposure Is the woman a commercial sex worker? Intravenous drug abuse History of blood transfusion. Follow up in 2 days. FEEL ■ ■ SIGNS ■ CLASSIFY HIV-POSITIVE TREAT AND ADVISE ■ ■ ■ ■ ■ ■ E5 ■ Have you ever been tested for HIV? If yes. CHECK RECORD LOOK. plan to give INH prophylaxis to the newborn K13 . ■ ■ POSSIBLE CHRONIC LUNG DISEASE ■ ■ ■ Refer to hospital for assessment. OR ■ One of the above signs and →one or more other sign or →from a high-risk group. no HIV test results. Advise to screen immediate family members and close contacts for tuberculosis. do you know the result? (Explain to the woman that she has the right not to disclose the result. FEEL IF DRIBBLING URINE SIGNS ■ CLASSIFY URINARY INCONTINENCE TREAT ■ ■ ■ E7 Dribbling or leaking urine. CHECK RECORD LOOK. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS (6) If vaginal discharge 4 weeks after delivery If breast problem J9 ■ Abnormal vaginal discharge. Clean wound. Advise to return to health centre within 4-6 weeks. Counsel on the importance of staying negative by correct and consistent use of condoms G2 . ASK. Cries easily. Give paracetamol for pain F4 . ■ ■ Temperature <38ºC. FEEL IF COUGH OR BREATHING DIFFICULTY ■ ■ ■ ■ ■ SIGNS At least 2 of the following: Temperature >38ºC. NEXT: Check for HIV status CHECK FOR HIV STATUS If HIV status not already discussed. E10 E10 SIGNS Two of the following: →weight loss →fever >1 month →diarrhoea >1 month. VERY SEVERE FEBRILE DISEASE ■ ■ ■ ■ Insert an IV line B9 . ■ 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. LISTEN. Counsel on the importance of birth spacing and family planning D27 . examine with a gloved finger and look at the discharge on the glove. delivery or after delivery? ■ If diastolic blood pressure is ≥90 mmHg . ■ Abnormal vaginal discharge. since when? ■ Taking anti-tuberculosis drugs. LISTEN. Listen to her concerns. soothing remedy. Follow up in 2 days. Follow up in 2 weeks. pulse and temperature normal. Make sure she has key information on HIV G2-G3 . No pallor. refer to hospital. ask him if he has: ■ urethral discharge or pus ■ burning on passing urine. Diastolic blood pressure ≥90 mmHg on 2 readings. POSTPARTUM BLUES (USUALLY IN FIRST WEEK) ■ ■ ■ ■ NEXT: If vaginal discharge 4 weeks after delivery Assure the woman that this is very common. If hypertension persists. If no improvement. Advise on correct and consistent use of condoms G2 . Any of the above. Measure temperature. If pallor: →is it severe pallor? →some pallor? ■ Count number of breaths in 1 minute. ■ Inform her about VCT to determine HIV status G3 . check for anaemia Respond to observed signs or volunteered problems (8) If signs suggesting HIV infection POSTPARTUM CARE IF SIGNS SUGGESTING HIV INFECTION HIV status unknown or known HIV-positive. Respond to observed signs or volunteered problems (4) POSTPARTUM CARE ASK. Look or feel for stiff neck. ■ Wheezing. POSSIBLE BACTERIAL OR TRICHOMONAS INFECTION ■ ■ Give metronidazole to woman F5 . Continue treatment with iron for 3 months altogether F3 . Give first dose of appropriate IM/IV antibiotics B15 . ■ Look at pad for bleeding and lochia. Encourage her to drink more fluids. Examine further and manage according to national HIV guidelines or refer to appropriate HIV services. explain importance of partner assessment and treatment to avoid reinfection. Give emotional encouragement and support. Advise on correct and consistent use of condoms G2 . Record on the mother’s home-based maternal record. Chest pain. If breast problem see J9 . counsel to stop smoking.

Feel uterus. No breast problem. Mother feeling well. E2 ASK. pulse and temperature normal. Is it hard and round? Look at vulva and perineum for: →tear →swelling →pus. Promote use of impregnated bednet for the mother and baby. No fever or pain or concern. Counsel on the importance of birth spacing and family planning D27 . Uterus well contracted and hard. If breast problem see J9 . Look at pad for bleeding and lochia. Blood pressure. Did not bleed >250 ml. To examine the baby see J2-J8 . Advise on Postpartum care and hygiene. FEEL ■ ■ ■ ■ ■ ■ ■ ■ SIGNS ■ ■ ■ ■ ■ ■ ■ ■ ■ CLASSIFY NORMAL POSTPARTUM TREAT AND ADVISE ■ ■ ■ 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. ■ ■ ■ ■ ■ Make sure woman and family know what to watch for and when to seek care D28 . NEXT: Respond to observed signs or volunteered problems . No pallor. and counsel on nutrition D26 . No perineal swelling. Give any treatment or prophylaxis due: →tetanus immunization if she has not had full course F2 . CHECK RECORD LOOK. ■ ■ ■ ■ ■ Measure blood pressure and temperature.Postpartum care POSTPARTUM CARE 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. No problem with urination. use the chart Assess the mother after delivery D21 . is breastfeeding well. Dispense 3 months iron supply and counsel on compliance F3 . Refer for family planning counselling. Record on the mother’s home-based maternal record. LISTEN. →Does it smell? →Is it profuse? Look for pallor. Advise to return to health centre within 4-6 weeks.

refer to hospital. LISTEN. CHECK RECORD LOOK. No additional treatment. Diastolic blood pressure ≥90 mmHg on 2 readings.RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS ASK. repeat after a 1 hour rest. If hypertension persists. ■ ■ POSTPARTUM CARE NEXT: If pallor. delivery or after delivery? ■ If diastolic blood pressure is ≥90 mmHg . Diastolic blood pressure <90 mmHg after 2 readings. SEVERE HYPERTENSION MODERATE HYPERTENSION BLOOD PRESSURE NORMAL ■ ■ ■ Give appropriate antihypertensive Refer urgently to hospital B17 . FEEL IF ELEVATED DIASTOLIC BLOOD PRESSURE ■ SIGNS CLASSIFY TREAT AND ADVISE History of pre-eclampsia or eclampsia in pregnancy. check for anaemia Respond to observed signs or volunteered problems (1) If elevated diastolic blood pressure E3 . B14 . ■ Diastolic blood pressure ≥110 mmHg. ■ Reassess in 1 week.

Refer urgently to hospital B17 . LISTEN. Give double dose of iron (1 tablet 60 mg twice daily for 3 months) F3 . Haemoglobin 7-11 g/dl OR Palmar or conjunctival pallor. 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. Continue treatment with iron for 3 months altogether F3 . Have you had heavy bleeding since delivery? Do you tire easily? Are you breathless (short of breath) during routine housework? ■ ■ ■ ■ Measure haemoglobin if history of bleeding. FEEL ■ ■ ■ ■ SIGNS ■ ■ ■ CLASSIFY SEVERE ANAEMIA TREAT AND ADVISE ■ ■ ■ Check record for bleeding in pregnancy. Look for conjunctival pallor. CHECK RECORD LOOK. delivery or postpartum. If anaemia persists. NO ANAEMIA ■ NEXT: Check for HIV status .check for anaemia POSTPARTUM CARE IF PALLOR. CHECK FOR ANAEMIA E4 ASK. ■ ■ ■ ■ MODERATE ANAEMIA ■ ■ Give double dose of iron for 3 months F3 . Reassess at next postnatal visit (in 4 weeks). Follow up in 2 weeks to check clinical progress and compliance with treatment. refer to hospital.Respond to observed signs or volunteered problems (2) If pallor. No pallor. If pallor: →is it severe pallor? →some pallor? Count number of breaths in 1 minute. Haemoglobin >11 g/dl. Look for palmar pallor.

■ Known HIV-negative. Counsel HIV-positive woman on family planning G4 .) Has her partner been tested? Known HIV-positive. Make sure she has key information on HIV G2 . Find out what she knows about HIV. UNKNOWN HIV STATUS ■ ■ ■ ■ Find out what she knows about HIV. LISTEN. ASK. Advise on correct and consistent use of condoms G2 . ■ Not been tested. no HIV test results. FEEL ■ ■ SIGNS ■ CLASSIFY HIV-POSITIVE TREAT AND ADVISE ■ ■ ■ ■ ■ ■ ■ Have you ever been tested for HIV? If yes.CHECK FOR HIV STATUS If HIV status not already discussed. NEXT: If heavy vaginal bleeding Respond to observed signs or volunteered problems (3) Check for HIV status E5 . Make sure she has key information on HIV G2-G3 . do you know the result? (Explain to the woman that she has the right not to disclose the result. Follow up in 2 weeks. CHECK RECORD LOOK. Make sure she has key information on HIV G2 . HIV-NEGATIVE ■ ■ POSTPARTUM CARE ■ Find out what she knows about HIV. Counsel on the benefits of involving and testing her partner G3 . Counsel on the benefits of involving and testing her partner G3 . Advise on correct and consistent use of condoms G2 . Advise on additional care during postpartum G4 . Counsel on the importance of staying negative by correct and consistent use of condoms G2 . Counsel on the benefits of involving and testing her partner G3 . or not willing to disclose result. Inform her about VCT to determine HIV status G3 .

Fever >38ºC and any of: →burning on urination →flank pain. IF FEVER OR FOUL-SMELLING LOCHIA ■ Have you had: →heavy bleeding? →foul-smelling lochia? →burning on urination? ■ ■ ■ ■ ■ Feel lower abdomen and flanks for tenderness. Encourage her to drink more fluids. B15 . refer to hospital. If no improvement. Manage as in Rapid assessment and management B3-B7 .2 mg ergometrine IM B10 . Give oral antimalarial F4 . Look for lethargy. Follow up in 2 days.Respond to observed signs or volunteered problems (4) POSTPARTUM CARE ASK. Refer urgently to hospital B17 . If no improvement. Give appropriate IM/IV antibiotics B15 . TREAT AND ADVISE ■ ■ ■ ■ Give 0. Measure temperature. LISTEN. FEEL IF HEAVY VAGINAL BLEEDING ■ E6 CLASSIFY POSTPARTUM BLEEDING SIGNS More than 1 pad soaked in 5 minutes. ■ LOWER URINARY TRACT INFECTION ■ ■ ■ Give appropriate oral antibiotic F5 . Burning on urination. ■ UPPER URINARY TRACT INFECTION ■ ■ Give appropriate IM/IV antibiotics Refer urgently to hospital B17 . Refer urgently to hospital B17 . Give artemether IM (or quinine IM if artemether not available) and glucose B16 . CHECK RECORD LOOK. Look or feel for stiff neck. VERY SEVERE FEBRILE DISEASE ■ ■ ■ ■ Insert an IV line B9 . ■ Temperature >38°C and any of: →stiff neck →lethargy. UTERINE INFECTION ■ ■ ■ Insert an IV line and give fluids rapidly B9 . Give appropriate IM/IV antibiotics B15 . Follow up in 2 days. ■ Fever >38°C. Look for abnormal lochia. MALARIA ■ ■ NEXT: If dribbling urine . Give appropriate IM/IV antibiotics B15 . refer to hospital. Refer urgently to hospital B17 . ■ 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.

ASK. Follow up in 2 days. If conditions persists more than 1 week. Any of the above. Respond to observed signs or volunteered problems (5) E7 . FEEL IF DRIBBLING URINE SIGNS ■ CLASSIFY URINARY INCONTINENCE TREAT ■ ■ ■ Dribbling or leaking urine. if present. for less than 2 weeks. Give emotional encouragement and support. ■ Decreased interest or pleasure. Give appropriate oral antibiotics for lower urinary tract infection F5 . waking early). IF FEELING UNHAPPY OR CRYING EASILY ■ ■ ■ ■ ■ ■ 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. agitated all the time. Pus in perineum. ■ Marked loss of appetite. Pain in perineum. PERINEAL TRAUMA PERINEAL INFECTION OR PAIN ■ Refer the woman to hospital. refer to hospital. CHECK RECORD LOOK. and refer if no improvement. ■ Diminished ability to think or concentrate. LISTEN. Clean wound. Listen to her concerns. refer the woman to hospital. ■ Disturbed sleep (sleeping too much or too little. ■ ■ ■ ■ ■ ■ Remove sutures. IF PUS OR PERINEAL PAIN ■ Excessive swelling of vulva or perineum. Follow up in 2 weeks. 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)? POSTPARTUM CARE 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. Give paracetamol for pain F4 . Counsel on care and hygiene D26 . ■ POSTPARTUM DEPRESSION (USUALLY AFTER FIRST WEEK) ■ ■ Provide emotional support. ■ Feels tired. POSTPARTUM BLUES (USUALLY IN FIRST WEEK) ■ ■ ■ ■ NEXT: If vaginal discharge 4 weeks after delivery Assure the woman that this is very common. Counsel partner and family to provide assistance to the woman. If no improvement. Check perineal trauma. Refer urgently the woman to hospital B7 . ■ Cries easily.

Abnormal vaginal discharge. explain importance of partner assessment and treatment to avoid reinfection. ask him if he has: ■ urethral discharge or pus ■ burning on passing urine. If no discharge is seen.Respond to observed signs or volunteered problems (6) POSTPARTUM CARE ASK. and partner has urethral discharge or burning on passing urine. ■ ■ ■ Give clotrimazole F5 . Advise on correct and consistent use of condoms If no improvement. Treat partner with appropriate oral antibiotics F5 . LISTEN. ask the woman if she feels comfortable if you ask him similar questions. NEXT: If cough or breathing difficulty . ■ Separate the labia and look for abnormal vaginal discharge: →amount →colour →odour/smell. F4 . If partner could not be approached. examine with a gloved finger and look at the discharge on the glove. IF BREAST PROBLEM See J9 . CHECK RECORD LOOK. Give appropriate oral antibiotics to woman F5 . Advise on correct and consistent use of condoms G2 . If yes. POSSIBLE BACTERIAL OR TRICHOMONAS INFECTION ■ ■ Give metronidazole to woman F5 . ■ Abnormal vaginal discharge. FEEL ■ ■ E8 CLASSIFY POSSIBLE GONORRHOEA OR CHLAMYDIA INFECTION POSSIBLE CANDIDA INFECTION SIGNS ■ TREAT AND ADVISE ■ ■ ■ IF VAGINAL DISCHARGE 4 WEEKS AFTER DELIVERY Do you have itching at the vulva? Has your partner had a urinary problem? ■ If partner is present in the clinic. refer the woman to hospital. Advise on correct and consistent use of condoms G2 . ■ ■ Curd-like vaginal discharge and/or Intense vulval itching.

and of the need to continue treatment. plan to give INH prophylaxis to the newborn K13 . LISTEN. IF TAKING ANTI-TUBERCULOSIS DRUGS ■ Are you taking anti-tuberculosis drugs? If yes. Advise to screen immediate family members and close contacts for tuberculosis. Listen for wheezing. If severe wheezing. Reinforce advice to go for VCT G3 . ■ Breathlessness. ■ ■ CLASSIFY POSSIBLE PNEUMONIA TREAT AND ADVISE ■ ■ 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? ■ ■ ■ Look for breathlessness. At least 1 of the following: ■ Cough or breathing difficulty for >3 weeks. POSTPARTUM CARE NEXT: If signs suggesting HIV infection Respond to observed signs or volunteered problems (7) E9 . TUBERCULOSIS ■ ■ ■ ■ ■ Assure the woman that the drugs are not harmful to her baby. Use Practical Approach to Lung health guidelines (PAL) for further management. Give first dose of appropriate IM/IV antibiotics Refer urgently to hospital B17 . ■ Wheezing.ASK. refer urgently to hospital. If smoking. CHECK RECORD LOOK. counsel to stop smoking. If smoking. UPPER RESPIRATORY TRACT INFECTION ■ ■ Advise safe. soothing remedy. FEEL IF COUGH OR BREATHING DIFFICULTY ■ ■ ■ ■ ■ SIGNS At least 2 of the following: ■ Temperature >38ºC. Temperature <38ºC. counsel to stop smoking. If her sputum is TB-positive within 2 months of delivery. Cough for <3 weeks. Measure temperature. POSSIBLE CHRONIC LUNG DISEASE ■ ■ ■ Refer to hospital for assessment. ■ Chest pain. ■ Blood in sputum. B15 . since when? ■ Taking anti-tuberculosis drugs.

Look for ulcers and white patches in the mouth (thrush). Examine further and manage according to national HIV guidelines or refer to appropriate HIV services. ■ CLASSIFY STRONG LIKELIHOOD OF HIV INFECTION TREAT AND ADVISE ■ ■ ■ ■ ■ ■ 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 for visible wasting. E10 ASK. Advise on correct and consistent use of condoms G2 . FEEL ■ ■ ■ SIGNS Two of the following: →weight loss →fever >1 month →diarrhoea >1 month. CHECK RECORD LOOK. OR ■ One of the above signs and →one or more other sign or →from a high-risk group. ■ Illness or death from AIDS in a sexual partner.Respond to observed signs or volunteered problems (8) If signs suggesting HIV infection POSTPARTUM CARE IF SIGNS SUGGESTING HIV INFECTION HIV status unknown or known HIV-positive. Look at the skin: →Is there a rash? →Are there blisters along the ribs on one side of the body? Reinforce the need to know HIV status and advise where to go for VCT G3 . . LISTEN. Refer to TB centre if cough. Counsel on the benefits of testing her partner G3 . Assess if in a high risk group: ■ Occupational exposure ■ Is the woman a commercial sex worker? ■ Intravenous drug abuse ■ History of blood transfusion.

■ 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. ■ Record on home-based record. Iron and folate 1 tablet = 60 mg. ■ The injection site may become a little swollen. neck and tongue. DO NOT give it in the first trimester. Chlamydia Woman 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 500 mg (2 tablets) 500 mg (2 tablets) 100 mg every 6 hours 7 days ADDITIONAL TREATMENTS FOR THE WOMAN (2) Give appropriate oral antibiotics Partner only every 6 hours 7 days Not safe for pregnant or lactating woman. Insert IV line and give fluids B9 . F5 Gonorrhoea Woman CEFTRIAXONE (Vial=250 mg) CIPROFLOXACIN (1 tablet=250 mg) 250 mg IM injection 500 mg (2 tablets) once only once only Partner only once only once only Not safe for pregnant or lactating women. ■ ■ F2 F2 PREVENTIVE MEASURES (1) Give tetanus toxoid Give vitamin A postpartum ■ 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. folic acid = 400 µg All women 1 tablet In pregnancy Throughout the pregnancy Postpartum and 3 months post-abortion Women with anaemia 2 tablets 3 months 3 months Give mebendazole ■ ■ Give 500 mg to every woman once in 6 months. →Has it been dipped in insecticide? →When? →Advise to dip every 6 months. Refer urgently to hospital B17 . Give 0. →ask her to swallow the capsule in your presence. but this will go away in a few days. At least 1 year after TT4. Check when last dose of sulfadoxine-pyrimethamine given: →If no dose in last month. Do not stop treatment if this occurs →Do not worry about black stools. Plan to treat newborn K12 . ■ Give advice on how to manage side-effects: →If constipated. other community-based health workers or other women. ■ Check woman’s supply of iron and folic acid at each visit and dispense 3 months supply. every 12 hours 15 days OBSERVE FOR SIGNS OF ALLERGY After giving penicillin injection. ■ ■ F4 F4 Give paracetamol If severe pain Paracetamol 1 tablet = 500 mg Dose 1-2 tablets Frequency every 4-6 hours ADDITIONAL TREATMENTS FOR THE WOMAN (1) Give preventive intermittent treatment for falciparum malaria Advise to use insecticide-treated bednet Give paracetamol Sulfadoxine pyrimethamine 1 tablet = 500 mg + 25 mg pyrimethamine sulfadoxine Second trimester 3 tablets Third trimester 3 tablets Advise to use insecticide-treated bednet ■ ■ ■ Ask whether woman and newborn will be sleeping under a bednet. ■ Advise to store iron safely: → Where children cannot get it → In a dry place. CHECK RECORD LOOK. that it only protects her from disease.4 million units in 5 ml) ERYTHROMYCIN (1 tablet = 250 mg) TETRACYCLINE (1 tablet = 250 mg) OR DOXYCYCLINE (1 tablet = 100 mg) DOSE 2. iron will cause too large a baby). it should pass in a couple of days. If woman has allergy to penicillin If partner has allergy to penicillin 500 mg (2 tablets) 500 mg (2 tablets) 100 mg every 6 hours 15 days ADDITIONAL TREATMENTS FOR THE WOMAN (3) Give benzathine penicillin IM Observe for signs of allergy every 6 hours 15 days Not safe for pregnant or lactating woman. If yes. A2 ■ If due: ■ Explain to the woman that the vaccine is safe to be given in pregnancy. advise to use insecticide-treated bednet. ■ Rash or hives. if required. Additional treatments for the woman (2) Give appropriate oral antibiotics F5 Additional treatments for the woman (3) Give benzathine penicillin IM PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN GIVE BENZATHINE PENICILLIN IM Treat the partner. ■ Counsel on eating iron-rich foods – see C16 D26 . Feeling dizzy and confused. ■ If necessary. At least 1 year after TT3. ASK.5 ml TT IM. upper arm. it will not harm the baby. keep the woman for a few minutes and observe for signs of allergy. DO NOT give capsules with high dose of vitamin A during pregnancy. PREVENTIVE MEASURES (2) Give iron and folic acid Motivate on compliance with iron treatment Give mebendazole ■ ■ PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN Give iron and folic acid To all pregnant. ■ Monitor the baby for jaundice if given just before delivery. discuss with family member. how to help in promoting the use of iron and folate tablets.This is normal. → Twice daily as treatment for anaemia (double dose). Repeat in 5-15 minutes. Look at the skin for rash or hives. at night →Iron tablets may help the patient feel less tired. red and painful. ■ Difficult breathing or wheezing. ■ Injection site swollen and red. ■ Advise woman when next dose is due. and provide information to help her do this. Preventive measures and additional treatments for the woman F1 . At least 6 months after TT2. Look at the injection site for swelling and redness. ■ If she has heard that the injection has contraceptive effects. Look for difficult breathing.5 ml adrenaline 1:1000 in 10 ml saline solution IV slowly.PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN Preventive measures (1) PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN PREVENTIVE MEASURES 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 sulfadoxine-pyrimethamine. ■ Motivate on compliance with iron treatment Explore local perceptions about iron treatment (examples of incorrect perceptions: making more blood will make bleeding worse. ■ 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.4 million units IM injection FREQUENCY once only DURATION once only COMMENT Give as two IM injections at separate sites. ■ ■ Open the airway B9 . Listen for wheezing. 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. B8-B17 . ■ Give 0. This section has details on preventive measures and treatments prescribed in pregnancy and postpartum. Mebendazole 500 mg tablet 1 tablet 100 mg tablet 5 tablets Preventive measures (2) Iron and mebendazole F3 Additional treatments for the woman (1) Antimalarial treatment and paracetamol PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN ANTIMALARIAL TREATMENT AND PARACETAMOL 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. if once daily. 3 tablets in clinic. as early as possible. ■ Record on mother’s card. and that the baby will receive the vitamin through her breast milk. DO NOT leave the woman on her own. neck and tongue for swelling. ■ Discuss any incorrect perceptions. assure her it does not. every 12 hours 7 days Trichomonas or bacterial vaginal infection Vaginal candida infection 2g or 500 mg once only every 12 hours once only 7 days Do not use in the first trimester of pregnancy. If not. TBA. Swelling of the face. LISTEN. ■ Advise woman when next dose is due. postpartum and post-abortion women: → Routinely once daily in pregnancy and until 3 months after delivery or abortion. give TT1. Vitamin A 1 capsule 200 000 1 capsule after delivery or within 6 weeks of delivery TT1 TT2 TT3 TT4 TT5 ■ F3 . Rule out history of allergy to antibiotics. Counsel on correct and consistent use of condoms G2 . ■ ■ ■ CLASSIFY ALLERGY TO PENICILLIN TREAT ■ ■ ■ How are you feeling? Do you feel tightness in the chest and throat? Do you feel dizzy and confused? ■ ■ ■ ■ ■ Look at the face. Tetanus toxoid schedule At first contact with woman of childbearing age or at first antenatal care visit. Plan to give TT2 in 4 weeks. General principles are found in the section on good practice For emergency treatment for the woman see For treatment for the newborn see K9-K13 . At least 4 weeks after TT1 (at next antenatal care visit). FEEL ■ ■ ■ SIGNS Any of these signs: Tightness in the chest and throat. Give appropriate oral antimalarial treatment A highly effective antimalarial (even if second-line) is preferred during pregnancy Chloroquine Give daily for 3 days Tablet (150 mg base) Pregnant woman Day 1 (for weight around 50 kg) 4 Day 2 4 Day 3 2 Sulfadoxine + Pyrimethamine Give single dose in clinic Tablet 500 mg sulfadoxine + 25 mg pyrimethamine Day 3 3 3 Tablet (100 mg base) Day 1 6 Day 2 6 PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN GIVE APPROPRIATE ORAL ANTIBIOTICS INDICATION Mastitis ANTIBIOTIC CLOXACILLIN 1 capsule (500 mg) AMOXYCILLIN 1 tablet (500 mg) OR TRIMETHOPRIM+ SULPHAMETHOXAZOLE 1 tablet (80 mg + 400 mg) DOSE 500 mg FREQUENCY every 6 hours DURATION 10 days COMMENT Lower urinary tract infection 500 mg every 8 hours 3 days 80 mg trimethoprim + 400 mg sulphamethoxazole two tablets every 12 hours 3 days Avoid in late pregnancy and two weeks after delivery when breastfeeding. F6 F6 INDICATION Syphilis RPR test positive ANTIBIOTIC BENZATHINE PENICILLIN IM (2. →explain to her that if she feels nauseated or has a headache. 200 mg 500 mg every night once only 3 days once only Teach the woman how to insert a pessary into vagina and to wash hands before and after each application.

■ If she has heard that the injection has contraceptive effects. as early as possible. →explain to her that if she feels nauseated or has a headache. it will not harm the baby. red and painful.5 ml TT IM. ■ Advise woman when next dose is due. At least 4 weeks after TT1 (at next antenatal care visit). ■ If due: ■ Explain to the woman that the vaccine is safe to be given in pregnancy. it should pass in a couple of days. ■ The injection site may become a little swollen. ■ ■ F2 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. that it only protects her from disease. Vitamin A 1 capsule 200 000 IU 1 capsule after delivery or within 6 weeks of delivery TT1 TT2 TT3 TT4 TT5 . upper arm. Tetanus toxoid schedule At first contact with woman of childbearing age or at first antenatal care visit. and that the baby will receive the vitamin through her breast milk. At least 1 year after TT4. →ask her to swallow the capsule in your presence. assure her it does not. Plan to give TT2 in 4 weeks. ■ Record on mother’s card.Preventive measures (1) PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN PREVENTIVE MEASURES 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. DO NOT give capsules with high dose of vitamin A during pregnancy. ■ Give 0. At least 6 months after TT2. but this will go away in a few days. give TT1. At least 1 year after TT3.

Do not stop treatment if this occurs →Do not worry about black stools. Twice daily as treatment for anaemia (double dose). folic acid = 400 µg All women 1 tablet In pregnancy Throughout the pregnancy Postpartum and 3 months post-abortion Women with anaemia 2 tablets 3 months 3 months Give mebendazole ■ ■ Give 500 mg to every woman once in 6 months. discuss with family member. ■ Give advice on how to manage side-effects: →If constipated. postpartum and post-abortion women: Routinely once daily in pregnancy and until 3 months after delivery or abortion. Mebendazole 500 mg tablet 1 tablet 100 mg tablet 5 tablets Preventive measures (2) Iron and mebendazole F3 . Check woman’s supply of iron and folic acid at each visit and dispense 3 months supply. how to help in promoting the use of iron and folate tablets. 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. Advise to store iron safely: → Where children cannot get it → In a dry place. DO NOT give it in the first trimester. To all pregnant. → → Iron and folate 1 tablet = 60 mg. ■ 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. at night →Iron tablets may help the patient feel less tired. ■ Discuss any incorrect perceptions.PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN Give iron and folic acid ■ ■ ■ Motivate on compliance with iron treatment Explore local perceptions about iron treatment (examples of incorrect perceptions: making more blood will make bleeding worse.This is normal. ■ If necessary. ■ Counsel on eating iron-rich foods – see C16 D26 . other community-based health workers or other women. ■ 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. if once daily. TBA. iron will cause too large a baby).

Monitor the baby for jaundice if given just before delivery. Give appropriate oral antimalarial treatment A highly effective antimalarial (even if second-line) is preferred during pregnancy Chloroquine Give daily for 3 days Tablet (150 mg base) Pregnant woman Day 1 (for weight around 50 kg) 4 Day 2 4 Day 3 2 Sulfadoxine + Pyrimethamine Give single dose in clinic Tablet 500 mg sulfadoxine + 25 mg pyrimethamine Day 3 3 3 Tablet (100 mg base) Day 1 6 Day 2 6 . 3 tablets in clinic. Advise woman when next dose is due. advise to use insecticide-treated bednet. give sulfadoxine-pyrimethamine. Record on home-based record. Sulfadoxine pyrimethamine 1 tablet = 500 mg + 25 mg pyrimethamine sulfadoxine Second trimester 3 tablets Third trimester 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. and provide information to help her do this. Check when last dose of sulfadoxine-pyrimethamine given: →If no dose in last month.Additional treatments for the woman (1) Antimalarial treatment and paracetamol PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN ANTIMALARIAL TREATMENT AND PARACETAMOL Give preventive intermittent treatment for falciparum malaria ■ ■ ■ ■ ■ F4 Give paracetamol If severe pain Paracetamol 1 tablet = 500 mg Dose 1-2 tablets Frequency every 4-6 hours Give sulfadoxine-pyrimethamine at the beginning of the second and third trimester to all women according to national policy.

200 mg 500 mg every night once only 3 days once only Teach the woman how to insert a pessary into vagina and to wash hands before and after each application.PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN GIVE APPROPRIATE ORAL ANTIBIOTICS INDICATION Mastitis ANTIBIOTIC CLOXACILLIN 1 capsule (500 mg) AMOXYCILLIN 1 tablet (500 mg) OR TRIMETHOPRIM+ SULPHAMETHOXAZOLE 1 tablet (80 mg + 400 mg) DOSE 500 mg FREQUENCY every 6 hours DURATION 10 days COMMENT Lower urinary tract infection 500 mg every 8 hours 3 days 80 mg trimethoprim + 400 mg sulphamethoxazole two tablets every 12 hours 3 days Avoid in late pregnancy and two weeks after delivery when breastfeeding. Additional treatments for the woman (2) Give appropriate oral antibiotics F5 . Gonorrhoea Woman CEFTRIAXONE (Vial=250 mg) CIPROFLOXACIN (1 tablet=250 mg) 250 mg IM injection 500 mg (2 tablets) once only once only Partner only once only once only Not safe for pregnant or lactating women. every 12 hours 7 days Trichomonas or bacterial vaginal infection Vaginal candida infection 2g or 500 mg once only every 12 hours once only 7 days Do not use in the first trimester of pregnancy. Chlamydia Woman 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 500 mg (2 tablets) 500 mg (2 tablets) 100 mg every 6 hours 7 days Partner only every 6 hours 7 days Not safe for pregnant or lactating woman.

■ ■ Open the airway B9 . ■ Swelling of the face. Rule out history of allergy to antibiotics. Look at the skin for rash or hives.4 million units in 5 ml) ERYTHROMYCIN (1 tablet = 250 mg) TETRACYCLINE (1 tablet = 250 mg) OR DOXYCYCLINE (1 tablet = 100 mg) DOSE 2. Repeat in 5-15 minutes. ASK. Plan to treat newborn K12 . DO NOT leave the woman on her own. CLASSIFY ALLERGY TO PENICILLIN TREAT ■ ■ ■ How are you feeling? Do you feel tightness in the chest and throat? Do you feel dizzy and confused? ■ ■ ■ ■ ■ Look at the face. CHECK RECORD LOOK. keep the woman for a few minutes and observe for signs of allergy. Look for difficult breathing. If woman has allergy to penicillin If partner has allergy to penicillin 500 mg (2 tablets) 500 mg (2 tablets) 100 mg every 6 hours 15 days every 6 hours 15 days Not safe for pregnant or lactating woman.Additional treatments for the woman (3) Give benzathine penicillin IM PREVENTIVE MEASURES AND ADDITIONAL TREATMENTS FOR THE WOMAN GIVE BENZATHINE PENICILLIN IM Treat the partner. ■ Injection site swollen and red. FEEL ■ ■ ■ SIGNS Any of these signs: ■ Tightness in the chest and throat.4 million units IM injection FREQUENCY once only DURATION once only COMMENT Give as two IM injections at separate sites. ■ Rash or hives. LISTEN. ■ Feeling dizzy and confused. Listen for wheezing. Insert IV line and give fluids B9 . every 12 hours 15 days OBSERVE FOR SIGNS OF ALLERGY After giving penicillin injection. . F6 INDICATION Syphilis RPR test positive ANTIBIOTIC BENZATHINE PENICILLIN IM (2. neck and tongue. neck and tongue for swelling. Refer urgently to hospital B17 . Counsel on correct and consistent use of condoms G2 . Give 0.5 ml adrenaline 1:1000 in 10 ml saline solution IV slowly. Look at the injection site for swelling and redness. ■ Difficult breathing or wheezing. if required.

she may need further counselling and support from the health worker who referred her for testing. Discuss confidentiality of results G3 . PREVENT MOTHER-T0-CHILD TRANSMISSION OF HIV Give antiretroviral drug to prevent MTCT Antiretroviral drugs for MTCT of HIV Antiretroviral drugs for prevention of MTCT of HIV (give according to national policy) Zidovudine 1 tablet = 300 mg OR Nevirapine 1 tablet = 200 mg (woman) Oral solution 50 mg/5 ml (baby) When to give From 36 weeks of pregnancy till onset of labour From onset of labour to delivery Dose 300 mg (1 tablet) 300 mg (1 tablet) Frequency every 12 hours every 3 hours Comment No treatment for the baby. miscarriage. Advise the mother to return if: → the baby is feeding less than 6 times. ■ ■ SUPPORT TO THE HIV-POSITIVE WOMAN Provide emotional support to the woman How to provide support ■ INFORM AND COUNSEL ON HIV INFORM AND COUNSEL ON HIV Support to the HIV-positive woman G5 ■ Prevent mother-to-child transmission of HIV INFORM AND COUNSEL ON HIV PREVENT MOTHER-TO-CHILD TRANSMISSION (MTCT) OF HIV Give antiretroviral (ARV) drug to prevent mother-to-child transmission (MTCT) of HIV ■ ■ See also F5 . → A family planning method needs to be chosen to protect from pregnancy and from infection with other sexually transmitted infections (STI) or HIV reinfection. or to touch the skin of the partner where there is an open cut or sore. counsel her on the benefits of testing her partner. Involving them will: Have greater impact on the increasing acceptance of condom use and practice of safer sex to avoid infection or unwanted pregnancy. treat anaemia urgently and remeasure to assure adequate level for treatment. give her special advice. G6 G6 ■ ■ ■ Explain to the pregnant woman that the drug has been shown to greatly reduce the risk of infection of the baby. ■ Encourage the woman to motivate her partner(s) to be tested. ■ Counsel on the importance of staying negative by correct and consistent use of condoms. ■ Make sure the mother understands that if she chooses replacement feeding this includes enriched complementary feeding up to 2 years. advise her as follows: G5 Provide emotional support to the woman Empathize with her concerns and fears. IF TEST RESULT IS POSITIVE: ■ Explain to the woman that a positive test result means that she is carrying the infection and has (40%) possibility of transmitting the infection to her unborn child without any intervention. AZT) is planned: → obtain a haemoglobin determination early. The risk may be reduced if the baby is breastfed exclusively using good technique. Give psychosocial support G6 . or blood to enter the mouth. ■ Testing is voluntary. If the woman is HIV-positive. she may not choose to exclusively breastfeed. Condoms are the best option for the woman with HIV. If replacement feeding is introduced early. ■ HIV can be transmitted through: → Exchange of HIV-infected body fluids such as semen. IF THE WOMAN HAS NOT BEEN TESTED OR DOES NOT DISCLOSE THE RESULT: ■ Assure her that you would keep the result confidential if she were to disclose it. Refer her to appropriate services. If VCT is available in your setting and you are trained to do VCT. counsel her as follows. ■ Assure the woman that her test result is confidential. or is taking smaller quantities → the baby has diarrhoea → there are other danger signs. safe and sustainable (affordable). if possible. she or he can give the virus to others. advise her that waiting at least 2-3 years between pregnancies is healthier for her and the baby. advise the woman about the choices G7 . the milk is too watery. The person becomes ill and unable to fight infection. ■ Explain the importance of avoiding reinfection during pregnancy and breastfeeding. blood testing and post-test counselling.4 ml) (3 kg baby: 0. ■ How the test is performed. Mixed feeding may also increase the risk of HIV transmission and diarrhoea. counsel her and support the infant feeding she has chosen replacement feeding or breastfeeding G8 . delivery or breastfeeding). Once a person is infected with HIV. infant feeding and family planning advice (help her to absorb the information and apply it in her own case). Establish and maintain constant linkages with other health. ■ If her partner’s status is unknown. → If she wants more children. Give psychosocial support G6 . repeat dose If mother received nevirapine less than 1 hour before delivery. ■ A special blood test is done to find out if the person is infected with HIV. ■ Costs involved. Modify preventive treatment for malaria. Explain the risks of replacement feeding Her baby may get diarrhoea if: hands. Give special counselling to the mother who is HIV-positive and chooses breastfeeding ■ ■ ■ ■ ■ ■ Advantage of knowing the HIV status in pregnancy Knowing the HIV status during pregnancy is important so that the woman can: get appropriate medical care and interventions to treat and/or prevent HIV-associated illnesses. Reassure her that you will keep the result confidential. They should use a condom during every sexual act. →If antiretroviral prophylactic treatment to prevent mother-tochild transmission is a policy. fluid from the vagina. home care. ■ In some situations additional possibilities are: → expressing and heat-treating her breast milk → wet nursing by an HIV-negative woman. She has a right not to disclose her results. or niverapine during labour G7 → by adapting infant feeding practices G9 → by adapting birth plan and delivery practices G4 . ■ Explain the risks of replacement feeding and how to avoid them. according to national strategy F4 . A person infected with HIV may not feel sick at first. then respect this confidentiality. stopping early when replacement feeding is feasible. Tell her to take the labour dose of the drug as soon as labour starts and show her how to take it. → Advise her to deliver in a facility. water. Counsel on the need to know the HIV status and where to go for VCT G3 . For woman: as early as possible in labour For newborn: Give within 72 hours of birth (before discharge from facility) 200 mg (1 tablet) 2 mg/kg (2 kg baby: 0. However. → Exclusive breastfeeding. 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 K9 → Let the mother feed the baby 8 times a day (in the first month). Encourage exclusive breastfeeding. The family planning counsellor will provide more information. then continued breastfeeding plus complementary feeding after 6 months of age. SUPPORT TO THE HIV-POSITIVE WOMAN Pregnant women who are HIV-positive benefit greatly from the following support after the first impact of the test result has been overcome. However. and prevent transmission of STI or HIV to her partner. use national HIV guidelines to provide: ■ Pre-test counselling. but slowly the body’s immune system is destroyed. as recommended for HIV-negative women and women who do not know their status. If treatment with zidovudine (ZDV. ■ VCT includes pre-test counselling. Explain to her the risks of HIV transmission: → even in areas where many women have HIV. exclusive breastfeeding. another family planning method can be used for additional protection against pregnancy. she might choose replacement feeding with home-prepared formula or commercial formula. ■ Make sure she knows how to use condoms and where to get them. vaginal fluid or blood during unprotected sexual intercourse. ■ Help to decrease the risk of suspicion and violence. and support her choice. childbirth and postpartum G4 . ectopic pregnancy and other complications. she usually cannot use contraceptive pills. COUNSEL ON INFANT FEEDING CHOICE Explain the risks of HIV transmission through breastfeeding and not breastfeeding If a woman has unknown or negative HIV status If a woman knows and accepts that she is HIV-positive If a woman has unknown HIV status INFORM AND COUNSEL ON HIV ■ ■ ■ ■ Counsel on the importance of exclusive breastfeeding K2 . ■ If not breastfeeding. Counsel her on antiretroviral prophylactic treatment G7 . → From an infected mother to her child (MTCT) during: → pregnancy → labour and delivery → postpartum through breastfeeding. IF THE WOMAN IS HIV-NEGATIVE OR RESULT IS UNKNOWN: ■ Explain to her that she is at risk of HIV and that it is important to remain negative during pregnancy and breastfeeding. she must: → attend antenatal care regularly → know her HIV status → be counselled on infant feeding → deliver with a skilled attendant preferably in a hospital → be able and willing to take drugs as prescribed. Explain about voluntary counselling and testing (VCT) services. Ensure a visit in the first week to assess attachment and positioning and the condition of the mother’s breasts. religious support groups. give treatment according to that policy G6 . The following advice should be highlighted: Explain to the woman that future pregnancies can have significant health risks for her and her baby. IF THE MOTHER CHOOSES REPLACEMENT FEEDING Teach the mother replacement feeding Explain the risks of replacement feeding Follow-up for replacement feeding Give special counselling to the mother who is HIV-positive and chooses breastfeeding ■ Use this section when accurate information on HIV must be given to the woman and her family. ■ When and how results are given. ■ 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 → severe weight loss → skin infections → foul-smelling lochia. → Held outside the clinic in order to not reveal the HIV status of the woman involved. ■ If the woman has signs of AIDS and/or of terminal illness. ■ Use universal precautions as for all women A4 . advise her on breast care K8 . social and community workers support services: → To exchange information for the coordination of interventions → To make a plan for each family involved. or the woman will not seek the help of a trained counsellor. advise her to use a family planning method immediately D27 . → determine when woman will be at 36 weeks gestation and explain to her when to start treatment. ■ G4 G4 Counsel the HIV-positive woman on family planning Use the advice and counselling sections on during antenatal care and during postpartum visits. stillbirth. ■ Address of VCT service in your area: G3 Implications of test result ■ ■ Although the woman will have been counselled at the VCT site. VOLUNTARY COUNSELLING AND TESTING (VCT) Voluntary counselling and testing services Discuss confidentiality of the result Implications of test result Benefits of involving and testing the male partner(s) ■ INFORM AND COUNSEL ON HIV ✎____________________________________________________________________ ✎____________________________________________________________________ Discuss confidentiality of the result ■ ■ ■ Benefits of involving and testing the male partner(s) Men are generally the decision-makers in the family and community. DURING THE POSTPARTUM PERIOD: ■ Tell her that lochia can cause infection in other people and therefore she should dispose of blood stained sanitary pads safely (list local options). the possibility of ARV treatment. ■ Advise on the importance of good nutrition C16 D26 . ■ Confirm and support information given during VCT on mother-to-child transmission. ■ HIV cannot be transmitted through hugging or mosquito bites. The risk of not breastfeeding may be much higher because replacement feeding carries risks too: → diarrhoea because of contamination from unclean water. then teach her how to prepare the formula and feed the baby by cup: → Wash hands with water and soap → Boil the water for few minutes → Clean the cup thoroughly with water. her (unborn) child and her sexual partner. Choosing sexual activities that do not allow semen. Advise the mother to return immediately if: → she has any breast symptoms or signs → the baby has any difficulty feeding. G7 COUNSEL ON INFANT FEEDING CHOICE Special training is required to counsel an HIV-positive mother about infant feeding choices and to support her chosen method. Use good counselling skills A2 . 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. preterm labour. ■ Advise about the follow-up visit. 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. and their mothers need support to provide correct replacement feeding. ■ Advise the woman on correct and consistent use of condoms G4 . ■ Help to increase support to their partners. Help her to assess her situation and decide which is the best option for her. counsel her on the benefits of testing her partner. ■ → → ■ VOLUNTARY COUNSELLING AND TESTING (VCT) Voluntary counselling and testing (VCT) services Explain about VCT services: ■ VCT is used to determine the HIV status of an individual. ■ ■ Follow-up for replacement feeding ■ ■ ■ Ensure regular follow-up visits for growth monitoring. ■ VCT provides an opportunity to learn and accept the HIV status in a confidential environment. or because of recurrent episodes of diarrhoea. feasible. Mastitis and nipple fissures increase the risk that the baby will be infected. However. This guide does not substitute for special training. ■ ■ Support the mother in her choice of breastfeeding. the implications of the test result and benefits of involving and testing the male partner(s). The risk of infecting the baby is higher if the mother is reinfected. If a trained counsellor on infant feeding is not available. she must stop breastfeeding. ■ Her baby may not grow well if: → s/he receives too little formula each feed or too few feeds → the milk is too watery → s/he has diarrhoea. ■ Post-test counselling. give the treatment to the newborn soon after birth. monthly injectables or implants. Arrange for further counselling to prepare for the possibility of stopping breastfeeding early. Explain to her that to receive ARV prophylactic treatment. → If this cannot be ensured. Counsel all women on correct and consistent use of condoms during and after pregnancy G2 . Ensure good attachment and suckling to prevent mastitis and nipple damage K3 . Support her choice. ■ C15 D27 → CARE AND COUNSELLING ON FAMILY PLANNING Additional care for the HIV-positive woman Counsel the HIV-positive woman on family planning ■ ■ ■ ■ ■ DURING PREGNANCY: Revise the birth plan C2 C13 . ■ If not breastfeeding exclusively. ■ ■ G8 G8 Counsel on correct and consistent use of condoms SAFER SEX IS ANY SEXUAL PRACTICE THAT REDUCES THE RISK OF TRANSMITTING HIV AND SEXUALLY TRANSMITTED INFECTIONS (STIs) FROM ONE PERSON TO ANOTHER THE BEST PROTECTION IS OBTAINED BY: Correct and consistent use of condoms during every sexual act. unclean utensils or because the milk is left out too long. inform the woman about: ■ Where to go. Discuss the infant feeding plan G8-G9 . Supply her with enough tablets for the beginning of labour. ■ 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. respond. → Advise her to go to a facility as soon as her membranes rupture or labour starts. or that she is infected with HIV but has not yet made antibodies against the virus (this is sometimes called the “window” period). if a trained counsellor is not available. ■ → ■ Five out of 20 babies born to known HIV-positive mothers will be infected during pregnancy and delivery without ARV medication. Provide key information on HIV to all women and explain at the first antenatal care visit how HIV is tramsitted and the advantages of knowing the HIV status in pregnancy G2 . ■ Help her to assess her situation and decide which is the best option for her. → malnutrition because of insufficient quantity given to the baby. →give any particular support that she may require G5 . Special training is required to counsel HIV-positive women and this guide does not substitute for special training. → Intrauterine device (IUD) use is only recommended if other methods are not available or acceptable. not all methods are appropriate for the HIV-positive woman: → Given the woman’s HIV status. in case of any delay in reaching the hospital or clinic. ■ ■ ■ ■ How to provide support Conduct peer support groups for women who have tested HIV-positive and couples affected by HIV/AIDS: → Led by a social worker and/or woman who has come to terms with her own HIV-positive status. For the first few feeds after delivery. ■ How confidentiality is maintained. ■ G2 INFORM AND COUNSEL ON HIV G2 PROVIDE KEY INFORMATION ON HIV What is HIV and how is HIV transmitted? Advantage of knowing the HIV status in pregnancy Counsel on correct and consistent use of condoms If the mother chooses replacement feeding IF THE MOTHER CHOOSES REPLACEMENT FEEDING Teach the mother replacement feeding Ask the mother what kind of replacement feeding she chose.INFORM AND COUNSEL ON HIV Provide key information on HIV INFORM AND COUNSEL ON HIV PROVIDE KEY INFORMATION ON HIV What is HIV (human immunodeficiency virus) and how is HIV transmitted? HIV is a virus that destroys parts of the body’s immune system. If VCT is not available in your setting. give it to an older child or add to cooking. IF TEST RESULT IS NEGATIVE: ■ Explain to the woman that a negative result can mean either that she is not infected with 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. Connect her with other existing support services including support groups. labour companion and family. → If the woman is taking pills for tuberculosis (rifampin). ■ Advise when to seek care. ■ protect her sexual partner(s) from infection. is an alternative. ■ If her partner’s status is unknown. Ask the woman if she is willing to disclose the result. → Fertility awareness methods may be difficult if the woman has AIDS or is on treatment for HIV infections due to changes in the menstrual cycle and elevated temperatures. → HIV-infected blood transfusions or contaminated needles. ■ With the condom. ■ 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. low birth weight. Repeat HIV-testing can be offered after 3 months. Explain the risks of HIV transmission through breastfeeding and not breastfeeding ■ ■ ■ ■ If a woman knows and accepts that she is HIV-positive Inform her about the options for feeding. orphan care. so that the breasts stay healthy. ■ Reinforce the importance of testing and the benefits of knowing the result G2 . Counsel on infant feeding choice G7 Inform and counsel on HIV G1 . and lactational amenorrhoea method (LAM) may not be a suitable method. HIV-positive women should be referred to a health worker trained in infant-feeding counselling. or utensils are not clean the milk stands out too long. → Sharing of instruments and needles for drug abuse or tattoos. ■ Refer individuals or couples for counselling by community counsellors. ■ Give her written instructions on safe preparation of formula. These include: transmission of HIV to the baby (during pregnancy. ■ Infant feeding counselling. IF THE WOMAN IS HIV-POSITIVE: ■ Explain to the woman that she is infected and can transmit the infection to her partner. reduce the risk of transmission of infection to the baby: → by taking antiretroviral drugs such as AZT in pregnancy. the advantages and risks: If acceptable. anus or vagina of the partner. ■ Be sensitive to her special concerns and fears. Ensure the support to provide safe replacement feeding. → All babies receiving replacement feeding need regular follow-up. The woman has a right to refuse. stopping as soon as replacement feeding is possible. if less than 8 g/dl. ■ make a choice about future pregnancies. prepare the formula for the mother. Use universal precautions as for all women A4 . Three more may be infected by breastfeeding. The risk of infecting the baby is higher if the mother is newly infected. If the woman is HIV-positive (and willing to disclose the results): →provide additional care during pregnancy. soap and.6 ml) once only once only If she vomits within first hour. Her result will be shared only with herself and any individual chosen by her. Voluntary counselling and testing (VCT) services G3 ■ Care and counselling on family planning for the HIV-positive woman INFORM AND COUNSEL ON HIV CARE AND COUNSELLING ON FAMILY PLANNING FOR THE HIV-POSITIVE WOMAN Additional care for the HIV-positive woman Determine how much the woman has told her partner. ■ If the mother chooses breastfeeding. → Exclusive breastfeeding for 6 months. if a trained counsellor is not available or the woman will not seek the help of a trained counsellor. safer sex. income-generating activities.

■ Explain the importance of avoiding reinfection during pregnancy and breastfeeding. IF THE WOMAN IS HIV-POSITIVE: ■ Explain to the woman that she is infected and can transmit the infection to her partner. counsel her on the benefits of testing her partner. ■ If her partner’s status is unknown. or to touch the skin of the partner where there is an open cut or sore. . anus or vagina of the partner. HIV cannot be transmitted through hugging or mosquito bites. → HIV-infected blood transfusions or contaminated needles.Provide key information on HIV INFORM AND COUNSEL ON HIV PROVIDE KEY INFORMATION ON HIV What is HIV (human immunodeficiency virus) and how is HIV transmitted? ■ ■ G2 Counsel on correct and consistent use of condoms SAFER SEX IS ANY SEXUAL PRACTICE THAT REDUCES THE RISK OF TRANSMITTING HIV AND SEXUALLY TRANSMITTED INFECTIONS (STIs) FROM ONE PERSON TO ANOTHER THE BEST PROTECTION IS OBTAINED BY: ■ Correct and consistent use of condoms during every sexual act. she or he can give the virus to others. but slowly the body’s immune system is destroyed. or blood to enter the mouth. IF THE WOMAN IS HIV-NEGATIVE OR RESULT IS UNKNOWN: ■ Explain to her that she is at risk of HIV and that it is important to remain negative during pregnancy and breastfeeding. ■ protect her sexual partner(s) from infection. ■ make a choice about future pregnancies. vaginal fluid or blood during unprotected sexual intercourse. HIV can be transmitted through: → Exchange of HIV-infected body fluids such as semen. ■ reduce the risk of transmission of infection to the baby: → by taking antiretroviral drugs such as AZT in pregnancy. ■ ■ HIV is a virus that destroys parts of the body’s immune system. → Sharing of instruments and needles for drug abuse or tattoos. ■ Make sure she knows how to use condoms and where to get them. They should use a condom during every sexual act. Once a person is infected with HIV. fluid from the vagina. A special blood test is done to find out if the person is infected with HIV. The risk of infecting the baby is higher if the mother is newly infected. ■ Choosing sexual activities that do not allow semen. or niverapine during labour G7 → by adapting infant feeding practices G9 → by adapting birth plan and delivery practices G4 . counsel her on the benefits of testing her partner. → From an infected mother to her child (MTCT) during: → pregnancy → labour and delivery → postpartum through breastfeeding. The risk of infecting the baby is higher if the mother is reinfected. A person infected with HIV may not feel sick at first. Advantage of knowing the HIV status in pregnancy Knowing the HIV status during pregnancy is important so that the woman can: ■ get appropriate medical care and interventions to treat and/or prevent HIV-associated illnesses. The person becomes ill and unable to fight infection. ■ If her partner’s status is unknown.

VOLUNTARY COUNSELLING AND TESTING (VCT) Voluntary counselling and testing (VCT) services
Explain about VCT services: ■ VCT is used to determine the HIV status of an individual. ■ Testing is voluntary. The woman has a right to refuse. ■ VCT provides an opportunity to learn and accept the HIV status in a confidential environment. ■ VCT includes pre-test counselling, blood testing and post-test counselling. If VCT is available in your setting and you are trained to do VCT, use national HIV guidelines to provide: ■ Pre-test counselling. ■ Post-test counselling. ■ Infant feeding counselling. If VCT is not available in your setting, inform the woman about: ■ Where to go. ■ How the test is performed. ■ How confidentiality is maintained. ■ When and how results are given. ■ Costs involved. ■ Address of VCT service in your area:

Implications of test result
■ ■

Although the woman will have been counselled at the VCT site, she may need further counselling and support from the health worker who referred her for testing. Ask the woman if she is willing to disclose the result. Reassure her that you will keep the result confidential.

IF TEST RESULT IS POSITIVE: ■ Explain to the woman that a positive test result means that she is carrying the infection and has (40%) possibility of transmitting the infection to her unborn child without any intervention. IF TEST RESULT IS NEGATIVE: ■ 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). Repeat HIV-testing can be offered after 3 months. ■ Counsel on the importance of staying negative by correct and consistent use of condoms. IF THE WOMAN HAS NOT BEEN TESTED OR DOES NOT DISCLOSE THE RESULT: ■ Assure her that you would keep the result confidential if she were to disclose it. ■ Reinforce the importance of testing and the benefits of knowing the result G2 .

INFORM AND COUNSEL ON HIV

✎____________________________________________________________________ ✎____________________________________________________________________
Discuss confidentiality of the result
■ ■ ■

Benefits of involving and testing the male partner(s)
Men are generally the decision-makers in the family and community. Involving them will: ■ Have greater impact on the increasing acceptance of condom use and practice of safer sex to avoid infection or unwanted pregnancy. ■ Help to decrease the risk of suspicion and violence. ■ Help to increase support to their partners. ■ Encourage the woman to motivate her partner(s) to be tested.

Assure the woman that her test result is confidential. Her result will be shared only with herself and any individual chosen by her. She has a right not to disclose her results.

Voluntary counselling and testing (VCT) services

G3

Care and counselling on family planning for the HIV-positive woman
INFORM AND COUNSEL ON HIV CARE AND COUNSELLING ON FAMILY PLANNING FOR THE HIV-POSITIVE WOMAN Additional care for the HIV-positive woman
■ ■ ■ ■ ■

G4

Counsel the HIV-positive woman on family planning

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 psychosocial support G6 . Advise on the importance of good nutrition C16 D26 . Use universal 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 → severe weight loss → skin infections → foul-smelling lochia.

■ ■

DURING PREGNANCY: ■ 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. ■ Counsel her on antiretroviral prophylactic treatment G7 . ■ Discuss the infant feeding plan G8-G9 . ■ Modify preventive treatment for malaria, according to national strategy F4 . ■ Use universal precautions as for all women A4 . DURING THE POSTPARTUM PERIOD: ■ Tell her that lochia can cause infection in other people and therefore she should dispose of blood stained sanitary pads safely (list local options). ■ If not breastfeeding exclusively, advise her to use a family planning method immediately D27 . ■ If not breastfeeding, advise her on breast care K8 .

Use the advice and counselling sections on C15 during antenatal care and D27 during 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. → A family planning method needs to be chosen to protect from pregnancy and from infection with other sexually transmitted infections (STI) or HIV reinfection, and prevent transmission of STI or HIV to her partner. Condoms are the best option for the woman with HIV. Advise the woman on correct and consistent use of condoms G4 . With the condom, another family planning method can be used for additional protection against pregnancy. However, not all methods are appropriate for the HIV-positive woman: → Given the woman’s HIV status, she may not choose to exclusively breastfeed, and lactational amenorrhoea method (LAM) may not be a suitable method. → Intrauterine device (IUD) use is only recommended if other methods are not available or acceptable. → Fertility awareness methods may be difficult if the woman has AIDS or is on treatment for HIV infections due to changes in the menstrual cycle and elevated temperatures. → 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.

SUPPORT TO THE HIV-POSITIVE WOMAN
Pregnant women who are HIV-positive benefit greatly from the following support after the first impact of the test result has been overcome. Special training is required to counsel HIV-positive women and this guide does not substitute for special training. However, if a trained counsellor is not available or the woman will not seek the help of a trained counsellor, advise her as follows:

Provide emotional support to the woman
■ ■ ■ ■ ■ ■ ■

How to provide support

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-generating activities, 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 VCT on mother-to-child transmission, the possibility of ARV treatment, safer 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 terminal illness, respond. Refer her to appropriate services.

Conduct peer support groups for women who have tested HIV-positive and couples affected by HIV/AIDS: → Led by a social worker and/or woman who has come to terms with her own HIV-positive status. → Held outside the clinic in order to not reveal the HIV status of the woman involved. 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.

INFORM AND COUNSEL ON HIV

Support to the HIV-positive woman

G5

→ determine when woman will be at 36 weeks gestation and explain to her when to start treatment. treat anaemia urgently and remeasure to assure adequate level for treatment. repeat dose If mother received nevirapine less than 1 hour before delivery. If treatment with zidovudine (ZDV. G6 ■ ■ ■ Explain to the pregnant woman that the drug has been shown to greatly reduce the risk of infection of the baby. Antiretroviral drugs for prevention of MTCT of HIV (give according to national policy) Zidovudine 1 tablet = 300 mg OR Nevirapine 1 tablet = 200 mg (woman) Oral solution 50 mg/5 ml (baby) When to give From 36 weeks of pregnancy till onset of labour From onset of labour to delivery Dose 300 mg (1 tablet) 300 mg (1 tablet) Frequency every 12 hours every 3 hours Comment No treatment for the baby. Explain to her that to receive ARV prophylactic treatment. . For woman: as early as possible in labour For newborn: Give within 72 hours of birth (before discharge from facility) 200 mg (1 tablet) 2 mg/kg (2 kg baby: 0.6 ml) once only once only If she vomits within first hour. give the treatment to the newborn soon after birth.4 ml) (3 kg baby: 0.Prevent mother-to-child transmission of HIV INFORM AND COUNSEL ON HIV PREVENT MOTHER-TO-CHILD TRANSMISSION (MTCT) OF HIV Give antiretroviral (ARV) drug to prevent mother-to-child transmission (MTCT) of HIV ■ ■ See also F5 . Supply her with enough tablets for the beginning of labour. if less than 8 g/dl. in case of any delay in reaching the hospital or clinic. AZT) is planned: → obtain a haemoglobin determination early. Tell her to take the labour dose of the drug as soon as labour starts and show her how to take it. she must: → attend antenatal care regularly → know her HIV status → be counselled on infant feeding → deliver with a skilled attendant preferably in a hospital → be able and willing to take drugs as prescribed.

→ If this cannot be ensured. or because of recurrent episodes of diarrhoea. If replacement feeding is introduced early. Inform her about the options for feeding. However. 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. Make sure the mother understands that if she chooses replacement feeding this includes enriched complementary feeding up to 2 years. This guide does not substitute for special training. the advantages and risks: → If acceptable. unclean utensils or because the milk is left out too long. Help her to assess her situation and decide which is the best option for her. if a trained counsellor is not available. give her special advice. Encourage exclusive breastfeeding. she might choose replacement feeding with home-prepared formula or commercial formula. Explain the risks of HIV transmission through breastfeeding and not breastfeeding ■ ■ ■ ■ If a woman knows and accepts that she is HIV-positive ■ ■ Five out of 20 babies born to known HIV-positive mothers will be infected during pregnancy and delivery without ARV medication. HIV-positive women should be referred to a health worker trained in infant-feeding counselling. so that the breasts stay healthy. as recommended for HIV-negative women and women who do not know their status. counsel her as follows. Mixed feeding may also increase the risk of HIV transmission and diarrhoea. or the woman will not seek the help of a trained counsellor. Three more may be infected by breastfeeding. and support her choice. → malnutrition because of insufficient quantity given to the baby. Explain to her the risks of HIV transmission: → even in areas where many women have HIV. The risk may be reduced if the baby is breastfed exclusively using good technique. and their mothers need support to provide correct replacement feeding. is an alternative. the milk is too watery. → Exclusive breastfeeding for 6 months. Mastitis and nipple fissures increase the risk that the baby will be infected. Counsel on infant feeding choice G7 . stopping as soon as replacement feeding is possible.COUNSEL ON INFANT FEEDING CHOICE Special training is required to counsel an HIV-positive mother about infant feeding choices and to support her chosen method. then continued breastfeeding plus complementary feeding after 6 months of age. she must stop breastfeeding. Counsel on the need to know the HIV status and where to go for VCT G3 . stopping early when replacement feeding is feasible. → Exclusive breastfeeding. ■ If a woman has unknown HIV status INFORM AND COUNSEL ON HIV ■ ■ ■ ■ ■ ■ ■ Counsel on the importance of exclusive breastfeeding K2 . In some situations additional possibilities are: → expressing and heat-treating her breast milk → wet nursing by an HIV-negative woman. feasible. If the mother chooses breastfeeding. exclusive breastfeeding. The risk of not breastfeeding may be much higher because replacement feeding carries risks too: → diarrhoea because of contamination from unclean water. safe and sustainable (affordable). → All babies receiving replacement feeding need regular follow-up.

Give special counselling to the mother who is HIV-positive and chooses breastfeeding ■ ■ ■ ■ ■ ■ Support the mother in her choice of breastfeeding. 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. Ensure regular follow-up visits for growth monitoring. if possible. Advise the mother to return if: → the baby is feeding less than 6 times. Advise about the follow-up visit. prepare the formula for the mother. then teach her how to prepare the formula and feed the baby by cup: → Wash hands with water and soap → Boil the water for few minutes → Clean the cup thoroughly with water. For the first few feeds after delivery. Explain the risks of replacement feeding ■ ■ Her baby may get diarrhoea if: → hands. Arrange for further counselling to prepare for the possibility of stopping breastfeeding early.If the mother chooses replacement feeding INFORM AND COUNSEL ON HIV IF THE MOTHER CHOOSES REPLACEMENT FEEDING Teach the mother replacement feeding ■ ■ G8 Follow-up for replacement feeding ■ ■ ■ ■ ■ ■ ■ Ask the mother what kind of replacement feeding she chose. Advise the mother to return immediately if: → she has any breast symptoms or signs → the baby has any difficulty feeding. Ensure the support to provide safe replacement feeding. . Her baby may not grow well if: → s/he receives too little formula each feed or too few feeds → the milk is too watery → s/he has diarrhoea. or utensils are not clean → the milk stands out too long. 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. or is taking smaller quantities → the baby has diarrhoea → there are other danger signs. Ensure good attachment and suckling to prevent mastitis and nipple damage K3 . Advise when to seek care. Explain the risks of replacement feeding and how to avoid them. soap and. 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 K9 → Let the mother feed the baby 8 times a day (in the first month). water. Ensure a visit in the first week to assess attachment and positioning and the condition of the mother’s breasts. give it to an older child or add to cooking. Give psychosocial support G6 .

money?) Explore her options with her. or if the woman will not seek help. H3 THE WOMAN WITH SPECIAL NEEDS SPECIAL CONSIDERATIONS IN MANAGING THE PREGNANT ADOLESCENT When interacting with the adolescent Help the girl consider her options and to make decisions which best suit her needs Special considerations in managing the pregnant adolescent H3 The woman living with violence THE WOMAN WITH SPECIAL NEEDS SPECIAL CONSIDERATIONS FOR SUPPORTING THE WOMAN LIVING WITH VIOLENCE H4 H4 Violence against women by their intimate partners affects women’s physical and mental health. ■ Be a good listener: →Be patient. use this section to support them. adult disapproval. needs to decide if and when a second pregnancy is desired. based on their plans. →Make sure the physical area allows privacy. leaflets and other information that condemn violence. ■ Display posters. when working with an adolescent. H2 H2 Sources of support A key role of the health worker includes linking the health services with the community and other support services available. Violence by partners is complex. Spacing of the next pregnancy — for both the woman and baby’s health. ■ Find out what if training is available to improve the support that health care staff can provide to those women who may need it. Reassure her that she does not deserve to be abused in any way. ■ ■ ■ ■ ■ Emotional support Principles of good care. Listen to her in a sympathetic manner. Peer support groups. Healthy adolescents can safely use any contraceptive method. Tell the woman that you will not tell anyone else about the visit. Traditional providers. etc). leaders. counsel her as follows. social stigma. Other health service providers. explore needs and alternatives for support through the following: Community groups. reassuring tone of voice. ■ EMOTIONAL SUPPORT FOR THE WOMAN WITH SPECIAL NEEDS Sources of support Emotional support ■ If a woman is an adolescent or living with violence. women’s groups. they should use a condom in all sexual relations. social stigmas and violence. ■ SPECIAL CONSIDERATIONS FOR SUPPORTING THE WOMAN LIVING WITH VIOLENCE Support the woman living with violence Support the health service response to the needs of women living with violence THE WOMAN WITH SPECIAL NEEDS The woman with special needs H1 . or other local groups and discuss with them support they can provide or other what roles they can play. with her partner if applicable. ■ Convey respect: →Do not be judgmental →Be understanding of her situation →Overcome your own discomfort with her situation. and local community or through NGOs. The girl needs support in knowing her options and in deciding which is best for her. Community counsellors. The girl. or could she borrow. are provided on A2 . women’s groups.THE WOMAN WITH SPECIAL NEEDS Emotional support for the woman with special needs 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. Gently encourage her to tell you what is happening to her. shelters or social services. ■ ■ ■ Support her when discussing her situation and ask if she has any particular concerns: Does she live with her parents. including suggestions on communication with the woman and her family. Be active in providing family planning counselling and advice. However. ■ Follow-up visits may be necessary.g. either within her family. Document any forms of abuse identified or concerns you may have in the file. your own discomfort with adolescent sexuality. 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. If she or her partner are at risk of STI or HIV/AIDS. when possible. ■ Guarantee confidentiality and privacy: →Communicate clearly about confidentiality. Ask the woman if she would like to include her family members in the examination and discussion. make sure you have time and space to talk privately. ■ Provide information according to her situation which she can use to make decisions. While you may not have been trained to deal with this problem. friends. Women with special needs may need time to tell you their problem or make a decision →Pay attention to her as she speaks. ■ Make contact with organizations working to address violence in your area. elders. and she may be unable to resolve her situation quickly. She may need advice on how to discuss condom use with her partner. Encourage the girl to ask questions and tell her that all topics can be discussed. Understand adolescent difficulties in communicating about topics related to sexuality (fears of parental discovery. Help the girl consider her options and to make decisions which best suit her needs. Make sure you seek her consent first. like resolving disputes. 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. direct answers in clear language: →Verify that she understands the most important points. if available. However. including their reproductive health. Offer her an opportunity to see you again. it is recommended that any next pregnancy be spaced by at least 2 or 3 years. She needs to understand why this is important. During interaction with such women. You may ask indirect questions to help her tell her story. if relevant. and reassure her of this. Your support and willingness to listen will help her to heal. Listening can often be of great support. Maintain existing links and. and information on groups that can provide support. discussion or plan. can she confide in them? Does she live as a couple? Is she in a longterm relationship? Has she been subject to violence or coercion? ■ Determine who knows about this pregnancy — she may not have revealed it openly. parent or other family member. peer pressure. 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. she needs to decide if she will do it and and how she will arrange it. whether married or unmarried. Do not blame her or make a joke of the situation. can she stay with her parents or friends? Does she have. ■ Give simple. it is particularly important to remember the following. Use simple and clear language. Help her to assess her present situation. if such support is not available. Ensure you have a list of these resources available. If specific services are not available. 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. You should be aware of. She may defend her partner’s action. Remind her that she has legal recourse. women may disclose violence to you or you may see unexplained bruises and other injuries which make you suspect she may be suffering abuse. she needs special consideration. social acceptance. The following are some recommendations on how to respond and support her. and overcome. Prevention of STI or HIV/AIDS is important for her and her baby. Repeat guarantee of confidentiality A2 G3 . When interacting with the adolescent ■ ■ ■ ■ ■ Do not be judgemental. If she thinks she or her children are in danger. Do all you can to guarantee confidentiality. forming relationships. explore together the options to ensure her immediate safety (e. contact other groups such as churches. Help her identify local sources of support. ■ Support her concerns related to puberty. Identify those that can provide support for women in abusive relationships. →If brought by a partner. ■ Birth planning: delivery in a hospital or health centre is highly recommended.

Emotional support Principles of good care. discussion or plan. reassuring tone of voice. ■ Community counsellors. ■ Provide information according to her situation which she can use to make decisions. including suggestions on communication with the woman and her family. ■ Traditional providers. Sources of support A key role of the health worker includes linking the health services with the community and other support services available. if such support is not available.Emotional support for the woman with special needs THE WOMAN WITH SPECIAL NEEDS EMOTIONAL SUPPORT FOR THE WOMAN WITH SPECIAL NEEDS H2 You may need to refer many women to another level of care or to a support group. when possible. or if the woman will not seek help. However. make sure you have time and space to talk privately. ■ Be a good listener: →Be patient. leaders. parent or other family member. direct answers in clear language: →Verify that she understands the most important points. Tell the woman that you will not tell anyone else about the visit. Maintain existing links and. women’s groups. ■ Other health service providers. counsel her as follows. ■ Convey respect: →Do not be judgmental →Be understanding of her situation →Overcome your own discomfort with her situation. ■ Follow-up visits may be necessary. ■ Guarantee confidentiality and privacy: →Communicate clearly about confidentiality. Women with special needs may need time to tell you their problem or make a decision →Pay attention to her as she speaks. 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. . ■ Peer support groups. Make sure you seek her consent first. are provided on A2 . →Make sure the physical area allows privacy. Ask the woman if she would like to include her family members in the examination and discussion. →If brought by a partner. Your support and willingness to listen will help her to heal. explore needs and alternatives for support through the following: ■ Community groups. ■ Give simple.

The girl needs support in knowing her options and in deciding which is best for her. forming relationships. needs to decide if and when a second pregnancy is desired. and overcome. If she or her partner are at risk of STI or HIV/AIDS. they should use a condom in all sexual relations. with her partner if applicable. your own discomfort with adolescent sexuality. Encourage the girl to ask questions and tell her that all topics can be discussed. social acceptance. adult disapproval. Use simple and clear language. ■ Support her concerns related to puberty. ■ ■ ■ Support her when discussing her situation and ask if she has any particular concerns: ■ Does she live with her parents. peer pressure. THE WOMAN WITH SPECIAL NEEDS Special considerations in managing the pregnant adolescent H3 . it is recommended that any next pregnancy be spaced by at least 2 or 3 years. However. whether married or unmarried. Birth planning: delivery in a hospital or health centre is highly recommended. Healthy adolescents can safely use any contraceptive method. Repeat guarantee of confidentiality A2 G3 . Be active in providing family planning counselling and advice. She may need advice on how to discuss condom use with her partner. Help the girl consider her options and to make decisions which best suit her needs.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. she needs to decide if she will do it and and how she will arrange it. it is particularly important to remember the following. social stigmas and violence. social stigma. based on their plans. When interacting with the adolescent ■ ■ ■ ■ ■ Do not be judgemental. when working with an adolescent. She needs to understand why this is important. etc). can she confide in them? Does she live as a couple? Is she in a longterm relationship? Has she been subject to violence or coercion? ■ Determine who knows about this pregnancy — she may not have revealed it openly. Prevention of STI or HIV/AIDS is important for her and her baby. The girl. Spacing of the next pregnancy — for both the woman and baby’s health. You should be aware of. Understand adolescent difficulties in communicating about topics related to sexuality (fears of parental discovery.

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.g. including their reproductive health. Reassure her that she does not deserve to be abused in any way. explore together the options to ensure her immediate safety (e. leaflets and other information that condemn violence. The following are some recommendations on how to respond and support her. . friends. Gently encourage her to tell you what is happening to her.The woman living with violence THE WOMAN WITH SPECIAL NEEDS SPECIAL CONSIDERATIONS FOR SUPPORTING THE WOMAN LIVING WITH VIOLENCE H4 Violence against women by their intimate partners affects women’s physical and mental health. Violence by partners is complex. While you may not have been trained to deal with this problem. Offer her an opportunity to see you again. Make contact with organizations working to address violence in your area. and information on groups that can provide support. money?) Explore her options with her. She may defend her partner’s action. Listen to her in a sympathetic manner. can she stay with her parents or friends? Does she have. If specific services are not available. or other local groups and discuss with them support they can provide or other what roles they can play. Help her to assess her present situation. 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. Identify those that can provide support for women in abusive relationships. if available. and local community or through NGOs. Listening can often be of great support. Remind her that she has legal recourse. women may disclose violence to you or you may see unexplained bruises and other injuries which make you suspect she may be suffering abuse. contact other groups such as churches. Find out what if training is available to improve the support that health care staff can provide to those women who may need it. If she thinks she or her children are in danger. if relevant. like resolving disputes. and she may be unable to resolve her situation quickly. Do not blame her or make a joke of the situation. women’s groups. Document any forms of abuse identified or concerns you may have in the file. or could she borrow. and reassure her of this. either within her family. shelters or social services. You may ask indirect questions to help her tell her story. elders. Ensure you have a list of these resources available. Help her identify local sources of support. Display posters.

INVOLVE THE COMMUNITY IN QUALITY OF SERVICES All in the community should be informed and involved in the process of improving the health of their members. including women living with HIV. Discuss with them what families and communities can do to prevent these deaths and illnesses. Discuss the following with them: →Emergency/danger signs . Together you can create new knowledge which is more locally appropriate. and provide TBAs with feedback on women they have referred. adolescents and women living with violence. 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.knowing when to seek care →Importance of rapid response to emergencies to reduce mother and newborn death. Review how together you can provide support to women. discuss the requirements for safer delivery at home. Establish links with peer support groups and referral sites for women with special needs. Have them explain knowledge that they share with the community. families and groups for maternal and newborn health. Work together with leaders and community groups to discuss the most common health problems and find solutions. ■ Discuss some practical ways in which families and others in the community can support women during pregnancy. Together prepare an action plan. Make sure TBAs are included in the referral system. ■ Support the community in preparing an action plan to respond to emergencies. Discuss the recommendation that all deliveries should be performed by a skilled birth attendant. ■ Discuss the different health messages that you provide. experience and influence in the community. if this is the woman’s wish. 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. Clarify how and when to refer. 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. post-abortion. Share with them the information you have and listen to their opinions on this. ■ Different groups should be asked to give feedback and suggestions on how to improve the services the health facilities provide. Have the community members talk about their knowledge in relation to these messages. delivery. Together determine what families and communities can do to support maternal and newborn health. giving examples of how transport can be organized →Reasons for delays in seeking care and possible difficulties. Motivate communication between males and their partners. postpartum care. Share data you may have and reflect together on why these deaths and illnesses may occur. Discuss how you can support each other. delivery and postpartum periods: →Recognition of and rapid response to emergency/danger signs during pregnancy.COMMUNITY SUPPORT FOR MATERNAL AND NEWBORN HEALTH Establish links COMMUNITY SUPPORT FOR MATERNAL AND NEWBORN HEALTH I2 ESTABLISH LINKS Coordinate with other health care providers and community groups ■ ■ I2 ESTABLISH LINKS Coordinate with other health care providers and community groups Establish links with traditional birth attendants and traditional healers ■ Everyone in the community should be informed and involved in the process of improving the health of their community members. Involve TBAs and healers in counselling sessions in which advice is given to families and other community members. including discussing postpartum family planning needs. accompany the woman to the clinic. postpartum and post-abortion care of women and newborns. COMMUNITY SUPPORT FOR MATERNAL AND NEWBORN HEALTH delivery. post-abortion and postpartum periods. Provide copies of health education materials that you distribute to community members and discuss the content with them. disability and illness →Transport options available. including roles and responsibilities. and encourage the woman to seek their support. Invite TBAs to act as labour companions for women they have followed during pregnancy. Ask the different groups to provide feedback and suggestions on how to improve the services the health facility provides. 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. ■ ■ ■ ■ ■ ■ Contact traditional birth attendants and healers who are working in the health facility’s catchment area. Include TBAs in meetings with community leaders and groups. and when to seek emergency care. defining responsibilities. I3 INVOLVE THE COMMUNITY IN QUALITY OF SERVICES Involve the community in quality of services I3 Community support for maternal and newborn health I1 . allow her to rest and ensure she eats properly. When not possible or not preferred by the woman and her family. ■ Use the following suggestions when working with families and communities to support the care of women and newborns during pregnancy. Respect their knowledge. This section Establish links with traditional birth attendants and traditional healers ■ ■ ■ COMMUNITY SUPPORT FOR MATERNAL AND NEWBORN HEALTH ■ Meet with others in the community to discuss and agree messages related to pregnancy. Have available the names and contact information for these groups and referral sites. ■ Find out what people know about maternal and newborn mortality and morbidity in their locality. provides guidance on how their involvement can help improve the health of women and newborns.

. Have available the names and contact information for these groups and referral sites. When not possible or not preferred by the woman and her family. Work together with leaders and community groups to discuss the most common health problems and find solutions. Review how together you can provide support to women. Invite TBAs to act as labour companions for women they have followed during pregnancy. ■ ■ ■ ■ ■ ■ Contact traditional birth attendants and healers who are working in the health facility’s catchment area. and encourage the woman to seek their support. experience and influence in the community. Establish links with peer support groups and referral sites for women with special needs. discuss the requirements for safer delivery at home. and when to seek emergency care.Establish links COMMUNITY SUPPORT FOR MATERNAL AND NEWBORN HEALTH ESTABLISH LINKS Coordinate with other health care providers and community groups ■ ■ I2 Establish links with traditional birth attendants and traditional healers ■ ■ ■ ■ Meet with others in the community to discuss and agree messages related to pregnancy. and provide TBAs with feedback on women they have referred. including women living with HIV. Together you can create new knowledge which is more locally appropriate. delivery. families and groups for maternal and newborn health. adolescents and women living with violence. Make sure TBAs are included in the referral system. 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. Respect their knowledge. 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. Discuss the recommendation that all deliveries should be performed by a skilled birth attendant. if this is the woman’s wish. Involve TBAs and healers in counselling sessions in which advice is given to families and other community members. Clarify how and when to refer. postpartum care. postpartum and post-abortion care of women and newborns. Include TBAs in meetings with community leaders and groups. Discuss how you can support each other. Share with them the information you have and listen to their opinions on this.

Ask the different groups to provide feedback and suggestions on how to improve the services the health facility provides. defining responsibilities. disability and illness →Transport options available. Together prepare an action plan. Share data you may have and reflect together on why these deaths and illnesses may occur.INVOLVE THE COMMUNITY IN QUALITY OF SERVICES All in the community should be informed and involved in the process of improving the health of their members. accompany the woman to the clinic. 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. ■ Support the community in preparing an action plan to respond to emergencies. COMMUNITY SUPPORT FOR MATERNAL AND NEWBORN HEALTH Involve the community in quality of services I3 . allow her to rest and ensure she eats properly. including roles and responsibilities. Together determine what families and communities can do to support maternal and newborn health. ■ Discuss the different health messages that you provide. ■ Discuss some practical ways in which families and others in the community can support women during pregnancy.knowing when to seek care →Importance of rapid response to emergencies to reduce mother and newborn death. Motivate communication between males and their partners. giving examples of how transport can be organized →Reasons for delays in seeking care and possible difficulties. post-abortion. Discuss the following with them: →Emergency/danger signs . Discuss with them what families and communities can do to prevent these deaths and illnesses. 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. including discussing postpartum family planning needs. 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. delivery and postpartum periods: →Recognition of and rapid response to emergency/danger signs during pregnancy. ■ Find out what people know about maternal and newborn mortality and morbidity in their locality. Have the community members talk about their knowledge in relation to these messages.

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and when the provider or mother observes danger signs. and continue breastfeeding on the healthy side. ■ ■ ■ ■ ■ ■ IF PRETERM. Nipple not sore and no fissure visible. redness or tenderness. gaining weight and body temperature stable. ■ Temperature <35ºC or not rising after rewarming. Cover with sterile tissues soaked with sterile saline solution before referral. If no improvement of pustules in 2 days or more. LISTEN. Manage according to national guidelines. Advise on surgical correction at age of several months. If cold. ■ Twin. J5 CARE AND MONITORING RESPONSE TO ABNORMAL FINDINGS ■ Mother tested RPR-positive. do not pull. ■ ■ ADDITIONAL CARE OF A SMALL BABY (OR TWIN) RISK OF TUBERCULOSIS Give baby isoniazid propylaxis for 6 months K13 . Reassure her that she has enough milk. BREAST ENGORGEMENT ■ ■ ■ ■ ■ NEWBORN CARE ■ ■ Part of breast is painful.5º and 37. → Reassess in 1 hour. also use the Additional care for a small baby or twin chart J11 . examine the baby as on J2-J7 . and during the first week of life at routine. in her bed or within easy reach. J10 J10 CARE OF THE NEWBORN CARE AND MONITORING ■ ■ ■ ■ ■ ■ RESPOND TO ABNORMAL FINDINGS ■ ASK. J7 IF DANGER SIGNS ■ ■ ■ In addition: Re-warm and keep warm during referral K9 . ensure warmth K9 . Encourage the mother to continue breastfeeding. ensure baby is dressed or wrapped and covered by a blanket. DO NOT bath the small baby.NEWBORN CARE Examine the newborn NEWBORN CARE EXAMINE THE NEWBORN Use this chart to assess the newborn after birth. If feeding difficulty. or Mother being treated with antibiotics for infection.5ºC): → Keep the baby in skin-to-skin contact with the mother as much as possible → If body temperature below 36. birth weight <2500 g or twin IF PRETERM. ■ Record in home-based record. Reassess after 2 feeds (or 1 day). NIPPLE SORENESS OR FISSURE ■ ■ ■ ■ Twin TWIN Give special support to the mother to breastfeed twins K4 . weighing <1500g ASK. Teach correct positioning and attachment K3 . Mother chose breastfeeding. CHECK RECORD LOOK. Not suckling (after 6 hours of age). 1-2 months early or weighing 1500g-<2500g. Encourage breastfeeding on the way. Use the chart Assess the mother’s breasts if the mother is complaining of nipple or breast pain J9 . bruises or malformation IF SWELLING. ■ More than 10 skin pustules or bullae. refer for breastfeeding counselling and management. for discharge. look at skin on the face → if baby is 24 hours old or more. ■ Look at the eyes. hardness of skin. day and night. Teach correct positioning and attachment K3 . Help the mother express breast milk K5 . ■ ■ ■ ■ ASSESS THE MOTHER’S BREASTS IF COMPLAINING OF NIPPLE OR BREAST PAIN CLASSIFY VERY SMALL BABY SIGNS ■ ■ TREAT AND ADVISE ■ ■ If this is repeated visit. Encourage mother to continue breastfeeding. ■ If feeding difficulties persist for 3 days and otherwise well. IF SWELLING. Teach mother to treat skin infection K13 . suckling. ■ ■ Body temperature 35-36. Ensure additional care for a small baby J11 . count breaths per minute. Give special support for breastfeeding the small baby (or twins) K4 : → Encourage the mother to breastfeed every 2-3 hours. BIRTH WEIGHT <2500 G OR TWIN NEWBORN CARE ASK. Treat skin infection before referral K13 . If bleeding from cord. assess the baby J2-J8 . → If alternative feeding method is used. give expressed breast milk by cup K6 . Baby not well attached. ■ Small baby. Keep the baby in the room with the mother. ■ ■ ■ ■ ■ Support exclusive breastfeeding on demand day and night. For care at birth and during the first hours of life. ■ Abnormal position of legs (after breech presentation). assess the baby and respond to the mother J2-J8 . Are they swollen and draining pus? ■ Look at the skin. ■ If further visits. consider alternative feeding methods K5-K6 . Express milk from the affected breast and discard until no fever K5 . NEWBORN CARE NEXT: If swelling. ■ Feeding well — suckling effectively 8 times in 24 hours. ■ Fever (temperature >38ºC). Swollen head — bump on one or both sides. Temperature <38ºC. ■ Advise on when to return if danger signs K14 . Teach mother to treat eyes K13 . Ask the mother and companion to watch the baby and alert you if → Feet cold → Breathing difficulty: grunting. RISK OF CONGENITAL SYPHILIS ■ ■ ■ ■ ■ ■ Give baby single dose of benzathine penicillin K12 . refer to hospital. MILD HYPOTHERMIA ■ ■ Re-warm the baby skin-to-skin K9 . Help the mother to initiate breastfeeding K3 . ■ ■ ■ Assess the small baby daily: → Measure temperature → Assess breathing (baby must be quiet. Follow up in 2 days. birth weight <2500 g or twin J3 Assess the mother’s breasts if complaining of nipple or breast pain J9 ■ Assess breastfeeding NEWBORN CARE ASSESS BREASTFEEDING Assess breastfeeding in every baby as part of the examination. ■ No special treatment needs or treatment completed. ■ Plan to discharge when: → Breastfeeding well → Gaining weight adequately on 3 consecutive days → Body temperature between 36. arm does not move. GONOCOCCAL EYE INFECTION ■ ■ ■ ■ Give single dose of appropriate antibiotic for eye infection K12 . CHECK RECORD LOOK. LOCAL UMBILICAL INFECTION LOCAL SKIN INFECTION ■ ■ ■ Less than 10 pustules ■ ■ ■ NEXT: If danger signs IF DANGER SIGNS SIGNS Any of the following signs: ■ Fast breathing (more than 60 breaths per minute). NEXT: Look for signs of jaundice and local infection Check for special treatment needs J5 Additional care of a small baby (twin) J11 ALSO SEE: ■ Counsel on choices of infant feeding and HIV-related issues ■ Equipment. Look for malformations. ■ Teach the mother how to care for the baby. provide care or teach the companion K9-K10 Wash hands before and after handling the baby. ■ Feeding difficulty. refer urgently to hospital. repeat advices. Give BCG vaccination to the baby only when baby’s treatment completed. Mother has not been counselled on infant feeding. J11 ■ ■ ■ ■ Mother known to be HIV-positive. Follow up in 2 weeks. If the mother and baby are not able to stay. If feeding difficulty persists for 3 days. Feel the tone: is it normal? Feel for warmth. or swelling. is it yellow? → if baby is less than 24 hours old. Examine every baby before planning to discharge mother and baby J2-J9 . Ensure care for the baby at home. CHECK RECORD LOOK. ■ Stop the bleeding. look at palms and soles. FEEL ■ SIGNS Yellow skin on face and only ≤24 hours old. Examine again for discharge. Not well attached. teach the mother how to express breast milk from the affected breast and feed baby by cup. Feel gently for painful part of the breast. ■ Severe chest in-drawing ■ Grunting ■ Convulsions. BRUISES OR MALFORMATION J8 J8 ASK. ■ ■ SIGNS Bruises. FEEL ■ Observe a breastfeed. If pre-discharge examination: ■ Immunize if due K13 . Consider alternative feeding methods until mother is well K5-K6 . If any maternal concern. → Weigh daily and assess weight gain K7 . swelling on buttocks. If the baby is in a cot. ■ Receiving other foods or drinks. especially around the neck. Follow up in 2 days. Provide care for the baby.5ºC persists for 2 hours despite skin-to-skin contact with mother. Give cloxacillin for 10 days F5 . If mother is HIV+ let her breastfeed on the healthy breast. Breastfeeding 8 times in 24 hours on demand day and night Encourage the mother to continue breastfeeding on demand K3 . Refer for counselling on infant feeding G7 . MOTHER NOT ABLE TO TAKE CARE FOR BABY ■ ■ ■ ■ ■ ■ ■ Other abnormal appearance. chest in-drawing → Any bleeding. Teach mother to treat umbilical infection K13 . ■ ■ If the small baby is not suckling effectively and does not have other danger signs. or weight loss greater than 10% of birth weight and no other problems. ■ ■ ■ ■ ■ ■ FEEDING DIFFICULTY Support exclusive breastfeeding K2-K3 . ■ Yellow palms and soles and >24 hours old. Stopped feeding. ■ Floppy or stiff. ensure daily (home) visits or send to hospital. Ensure extra warmth during referral. unusual appearance Open tissue on head. armpits. Refer baby urgently to hospital K14 . SIGNS ■ ■ CLASSIFY FEEDING WELL TREAT AND ADVISE ■ Suckling effectively. Use Advise on when to return with the baby K14 for advising the mother when to return with the baby for routine and follow-up visits and to seek care or return if baby has danger signs. ask her to tell you when her baby is willing to feed again. redness. NEWBORN CARE J4 ASSESS BREASTFEEDING Care of the newborn CARE OF THE NEWBORN Use this chart for care of all babies until discharge. LISTEN. Ask the mother to alert you if breastfeeding difficulty. BRUISES OR MALFORMATION ■ ■ ■ Club foot Cleft palate or lip MALFORMATION ■ ■ Refer for special treatment if available. for discharge (not before 12 hours). ■ Umbilicus draining pus or umbilical redness extending to skin. LISTEN. Refer for special treatment if available. → 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 . LISTEN. not crying): listen for grunting. If the baby has not fed in the previous hour. Ensure the room is warm (not less than 25ºC and no draught). Let the mother and baby sleep under a bednet. repeat the count if >60 or <30. If not successful. DO NOT expose the baby in direct sun. Mother transferred. measure temperature. 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. BIRTH WEIGHT <2500 G OR TWIN ASK. Refer baby urgently to hospital K14 . MASTITIS ■ ■ ■ ■ ■ ASSESS THE MOTHER’S BREASTS IF COMPLAINING OF NIPPLE OR BREAST PAIN ■ NEXT: Assess breastfeeding ■ ■ NEXT: Care of the newborn If preterm. Use information and counselling sheets M5-M6 . FEEL Check record for special treatment needs ■ 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+? →has she received infant feeding counselling? ■ Is the mother receiving TB treatment which began <2 months ago? SIGNS ■ CLASSIFY RISK OF BACTERIAL INFECTION TREAT AND ADVISE ■ ■ ■ ■ Baby <1 day old and membranes ruptured >18 hours before delivery. or very warm. ■ Bleeding from stump or cut. assess weight gain Birth weight <1500 g. → Keep the baby warm K9 → Give cord care K10 → Ensure hygiene K10 . assess breastfeeding and help the mother with positioning and attachment J3 ■ ■ If the mother is unable to take care of the baby. Allow visits to the mother and baby. ■ Records N1-N7 . ■ Reassess at the next feed or follow-up visit in 2 days. check if tie is loose and retie the cord. assess the baby immediately J2-J7 . abdomen or back ■ ■ ■ ■ ■ Mother not able to breastfeed due to receiving special treatment. Assess baby daily J2-J7 . Breastfeeding less than 8 times per 24 hours. look for chest in-drawing → Look for jaundice (first 10 days of life): first 24 hours on the abdomen. ■ CLASSIFY JAUNDICE TREAT AND ADVISE ■ ■ ■ What has been applied to the umbilicus? NEWBORN CARE Look at the skin. Advise to feed more frequently. then on palms and soles. ■ If baby more than one day old: How many times has your baby fed in 24 hours? Not yet breastfed (first hours of life). if feet still cold. J3 Birth weight 1500 g-2500 g. Temperature >38ºC Feels ill. FEEL ■ SIGNS ■ ■ ■ ■ CLASSIFY BREASTS HEALTHY TREAT AND ADVISE ■ How do your breasts feel? ■ ■ ■ ■ ■ Look at the nipple for fissure Look at the breasts for: → swelling → shininess → redness. refer the baby for phototherapy. Weigh the baby. use Labour and delivery D19 . Advise to feed more frequently. If no improvement in 2 days.5ºC on 3 consecutive days → Mother able and confident in caring for the baby → No maternal concerns. ■ ■ SMALL BABY Give special support to breastfeed the small baby K4 . use the Care of the newborn chart J10 .5ºC to 37. swollen and red. Help mother to breastfeed. give paracetamol F4 . FEEL Check maternal and newborn 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 very ill or transferred? ■ SIGNS Normal weight baby (2500 g or more). DO NOT discharge if baby is not yet feeding well. LISTEN. If other bleeding. or Mother has fever >38ºC. ■ ■ ■ Give prescribed treatments according to the schedule K12 . follow-up. Reassess after 2 feeds (1 day). Give baby 2 IM antibiotics for 5 days K12 . Cover the head with a hat. teach her alternative feeding methods K5-K6 . ■ DO NOT force legs into a different position. Reassure the mother. Very preterm <32 weeks or >2 months early). shiny and patchy red. → Teach the mother how to keep the small baby warm in skin-to-skin contact → Provide extra blankets for mother and baby. Observe a breastfeed if not yet done J4 . ■ Several days old and inadequate weight gain. Assess the baby for discharge. Birth weight → <1500 g → 1500 g to <2500 g. bruises or malformation If danger signs J7 Newborn care J1 . Baby well attached. LOOK FOR SIGNS OF JAUNDICE AND LOCAL INFECTION ■ Eyes swollen and draining pus.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? ■ ■ LOOK. teach mother how to express enough breast milk before the feed to relieve discomfort K5 . J2 NEWBORN CARE J2 EXAMINE THE NEWBORN If swelling. ■ Asymmetrical arm movement. If severe pain. Treat local umbilical infection before referral K13 . ■ Advise on baby care K2 K9-K10 . If no improvement or worse. ■ ■ If mother reports breastfeeding difficulty. ■ Advise the mother to stop feeding the baby other foods or drinks. SEVERE MALFORMATION ■ ■ NEXT: Assess the mother’s breasts if complaining of nipple or breast pain NEXT: If preterm. DO NOT put the baby on any cold surface. J9 ■ ■ Nipple sore or fissured. ■ Ensure hygiene K10 . Ensure mother and partner are treated F6 . Normal body temperature. If mother is complaining of nipple or breast pain. assess the baby J2-J8 . or if worse. hardness or large bullae? ■ Look at the umbilicus: → Is it red? → Draining pus? → Does redness extend to the skin? ■ Refer baby urgently to hospital K14 . ■ ■ CLASSIFY BIRTH INJURY TREAT AND ADVISE Explain to parents that it does not hurt the baby. at routine and follow-up postnatal visits in the first weeks of life. Do not discharge before feeding well. ■ Follow up in 2 weeks. CHECK RECORD LOOK. refer urgently to hospital. Refer for special evaluation. classify and treat. Give special counselling to mother who is breastfeeding G8 . DO NOT bath the baby before 6 hours. G7-G8 . Teach correct positioning and attachment K3 . ■ ■ Odd looking. Measure temperature. assess the total daily amount of milk given. Use the Breastfeeding. ask the mother to put the baby on her breasts and observe breastfeeding for about 5 minutes. ■ ■ ■ ■ Encourage the mother to continue breastfeeding. reassess the baby. If not better. Teach correct positioning and attachment K3 . NEWBORN CARE Look for signs of jaundice and local infection NEWBORN CARE LOOK FOR SIGNS OF JAUNDICE AND LOCAL INFECTION J6 J6 ASK. care. ■ Gently handle the limb that is not moving. Assess breastfeeding in every baby before planning for discharge. ■ ■ ■ ■ If feet are cold: → Teach the mother to put the baby skin-to-skin K13 . If not better. refer urgently to hospital. Baby not well attached. If no improvement or worse. resuscitation and treatments K1-K13 . Wash as needed. ■ Red umbilicus or skin around it. Refer to hospital a very small baby: >2 months early. Follow up in 2 weeks. CLASSIFY POSSIBLE SERIOUS ILLNESS TREAT AND ADVISE ■ ■ Give first dose of 2 IM antibiotics K12 . possibly around an hour. or sick newborn visit. If temperature not rising after 2 hours. → Assess breastfeeding daily: attachment. Both breasts are swollen. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 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. Record the findings on the postpartum record N6 . ■ CLASSIFY WELL BABY TREAT AND ADVISE If first examination: Ensure care for the newborn J10 . and baby satisfaction with the feed J4 K6 . Preterm → <32 weeks → 33-36 weeks. If the baby is small but does not need referral. Mother started TB treatment <2 months before delivery. Look at the movements: are they normal and symmetrical? Look at the presenting part — is there swelling and bruises? Look at abdomen for pallor. Always examine the baby in the presence of the mother. feeding well and gaining weight adequately. Not yet breastfeeding. RISK OF HIV TRANSMISSION Ensure additional warmth for the small baby K9 : → Ensure the room is very warm (25º–28ºC). CHECK FOR SPECIAL TREATMENT NEEDS NEWBORN CARE ■ ■ ■ Plan to keep the small baby longer before discharging. ■ Baby died D24 . CHECK FOR SPECIAL TREATMENT NEEDS ADDITIONAL CARE OF A SMALL BABY (OR TWIN) Use this chart for additional care of a small baby: preterm. ■ ■ ■ ■ ■ If difficult to keep body temperature within the normal range (36. Reassess daily J11 . supplies and drugs L1-L5 . If jaundice. Assess and treat mother and her partner for possible gonorrhea E8 . Do not discharge until both twins can go home. If breathing difficulty. Transfer the baby with the mother if possible. NEXT: Additional care of a small baby (or twin) NEXT: Check for special treatment needs Examinine routinely all babies around an hour of birth. During the stay at the facility. refer for breastfeeding counselling. fast or slow breathing. Plan to follow up. day and night. Not suckling effectively. Preterm baby (32-36 weeks or 1-2 months early). Ensure mother can see the baby regularly. also assess the mother’s breasts J9 J4 . CHECK RECORD LOOK. Reassess in 2 days.4ºC. No swelling. DO NOT discharge before baby is 12 hours old. ■ No danger signs. ■ Slow breathing (less than 30 breaths per minute). ■ Several days old and weight gain inadequate. inguinal area: → Are there skin pustules? → Is there swelling. ■ Advise on routine visit at age 3-7 days K14 . NOT ABLE TO FEED Refer baby urgently to hospital K14 . it will disappear in a week or two and no special treatment is needed. FEEL Baby just born. LISTEN. If breathing difficulty or mother reports any other abnormality. measure temperature and re-warm the baby K9 . preventive measures and treatment for the newborn sections for details of care. duration and frequency of feeds.

Look at the movements: are they normal and symmetrical? Look at the presenting part — is there swelling and bruises? Look at abdomen for pallor. feeding well and gaining weight adequately. ■ Advise on baby care K2 K9-K10 . ■ ■ Mother not able to breastfeed due to receiving special treatment. ■ Record in home-based record. Help the mother express breast milk K5 . measure temperature. ■ Advise on routine visit at age 3-7 days ■ Advise on when to return if danger signs K14 . Record the findings on the postpartum record N6 . →look at the chest for in-drawing. reassess the baby. Feel the tone: is it normal? Feel for warmth. ■ If further visits. If cold. Ensure care for the baby at home. MILD HYPOTHERMIA ■ ■ Re-warm the baby skin-to-skin K9 . repeat advices. If pre-discharge examination: ■ Immunize if due K13 . FEEL Check maternal and newborn 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 very ill or transferred? ■ SIGNS ■ ■ ■ ■ ■ CLASSIFY WELL BABY TREAT AND ADVISE If first examination: ■ Ensure care for the newborn J10 . Small baby. follow-up. Normal weight baby (2500 g or more). birth weight <2500 g or twin . No special treatment needs or treatment completed. ASK. ■ ■ ■ ■ ■ ■ ■ Assess breathing (baby must be calm) → listen for grunting →count breaths: are they 30-60 per minute? Repeat the count if not. LISTEN. Mother transferred.4ºC. ■ Examine again for discharge. No danger signs. Ensure mother can see the baby regularly. CHECK RECORD LOOK. Transfer the baby with the mother if possible. possibly around an hour. ■ Body temperature 35-36.Examine the newborn NEWBORN CARE EXAMINE THE NEWBORN J2 Use this chart to assess the newborn after birth. or very warm. If temperature not rising after 2 hours. Look for malformations. MOTHER NOT ABLE TO TAKE CARE FOR BABY ■ ■ ■ ■ ■ ■ NEXT: If preterm. Consider alternative feeding methods until mother is well K5-K6 . Weigh the baby. Feeding well — suckling effectively 8 times in 24 hours. ensure warmth K9 . Provide care for the baby. K14 . Always examine the baby in the presence of the mother. classify and treat. for discharge (not before 12 hours). day and night. and during the first week of life at routine. or sick newborn visit.

■ ■ ■ ■ SMALL BABY ■ ■ ■ ■ ■ Give special support to breastfeed the small baby K4 . gaining weight and body temperature stable. Do not discharge before feeding well. Reassess daily J11 . FEEL ■ ■ SIGNS ■ ■ CLASSIFY VERY SMALL BABY TREAT AND ADVISE ■ ■ ■ ■ Baby just born. ■ Twin TWIN ■ ■ NEWBORN CARE NEXT: Assess breastfeeding If preterm. Twin. LISTEN. Feeding difficulty. refer for breastfeeding counselling. BIRTH WEIGHT <2500 G OR TWIN ASK. Give special support to the mother to breastfeed twins K4 . assess weight gain Birth weight <1500 g. Refer baby urgently to hospital K14 . ■ If this is repeated visit. Birth weight → <1500 g → 1500 g to <2500 g. Ensure additional care for a small baby J11 . Do not discharge until both twins can go home.IF PRETERM. Several days old and weight gain inadequate. Very preterm <32 weeks or >2 months early). Preterm → <32 weeks → 33-36 weeks. Preterm baby (32-36 weeks or 1-2 months early). If feeding difficulties persist for 3 days and otherwise well. Ensure extra warmth during referral. Birth weight 1500 g-<2500 g. birth weight <2500 g or twin J3 . CHECK RECORD LOOK.

Not well attached. also assess the mother’s breasts J9 J4 . Breastfeeding less than 8 times per 24 hours. ■ ■ ■ ■ ■ ■ FEEDING DIFFICULTY ■ ■ ■ ■ ■ ■ Support exclusive breastfeeding K2-K3 . Reassure her that she has enough milk. Breastfeeding 8 times in 24 hours on demand day and night Not yet breastfed (first hours of life). Advise the mother to stop feeding the baby other foods or drinks. Teach correct positioning and attachment K3 . Help the mother to initiate breastfeeding K3 . Several days old and inadequate weight gain. day and night. Encourage the mother to continue breastfeeding on demand K3 . If the baby has not fed in the previous hour. Reassess at the next feed or follow-up visit in 2 days. Receiving other foods or drinks. ■ ■ NOT ABLE TO FEED ■ NEXT: Check for special treatment needs . Advise to feed more frequently. ASK. Stopped feeding. LISTEN. If mother is complaining of nipple or breast pain. Not suckling (after 6 hours of age). FEEL Observe a breastfeed. Not suckling effectively. Refer baby urgently to hospital K14 . ask her to tell you when her baby is willing to feed again.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 baby more than one day old: ■ How many times has your baby fed in 24 hours? LOOK. 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 the mother to put the baby on her breasts and observe breastfeeding for about 5 minutes.Assess breastfeeding NEWBORN CARE ASSESS BREASTFEEDING Assess breastfeeding in every baby as part of the examination. ■ SIGNS ■ ■ CLASSIFY FEEDING WELL TREAT AND ADVISE ■ Suckling effectively.

■ Mother tested RPR-positive. or Mother being treated with antibiotics for infection. K12 . Refer for counselling on infant feeding G7 . FEEL Check record for special treatment needs ■ 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+? →has she received infant feeding counselling? ■ Is the mother receiving TB treatment which began <2 months ago? SIGNS ■ CLASSIFY RISK OF BACTERIAL INFECTION TREAT AND ADVISE ■ ■ ■ ■ Baby <1 day old and membranes ruptured >18 hours before delivery. NEWBORN CARE NEXT: Look for signs of jaundice and local infection Check for special treatment needs J5 . Give baby 2 IM antibiotics for 5 days Assess baby daily J2-J7 . Mother has not been counselled on infant feeding. RISK OF CONGENITAL SYPHILIS ■ ■ ■ ■ ■ ■ Give baby single dose of benzathine penicillin Ensure mother and partner are treated F6 . Give special counselling to mother who is breastfeeding G8 . ■ ■ ■ ■ Mother known to be HIV-positive. CHECK RECORD LOOK. or Mother has fever >38ºC. LISTEN. Mother started TB treatment <2 months before delivery.CHECK FOR SPECIAL TREATMENT NEEDS ASK. RISK OF HIV TRANSMISSION RISK OF TUBERCULOSIS ■ ■ ■ Give baby isoniazid propylaxis for 6 months K13 . Mother chose breastfeeding. Follow up in 2 weeks. Follow up in 2 weeks. Follow up in 2 weeks. K12 . Give BCG vaccination to the baby only when baby’s treatment completed.

■ Red umbilicus or skin around it. If no improvement of pustules in 2 days or more. Follow up in 2 days. If no improvement in 2 days. Yellow palms and soles and ≥24 hours old. Assess and treat mother and her partner for possible gonorrhea E8 . Follow up in 2 days. Teach mother to treat skin infection K13 . CHECK RECORD LOOK. refer urgently to hospital. FEEL ■ SIGNS ■ ■ CLASSIFY JAUNDICE TREAT AND ADVISE ■ ■ ■ What has been applied to the umbilicus? ■ ■ ■ ■ Look at the skin. give expressed breast milk by cup K6 . Teach mother to treat umbilical infection K13 . armpits. inguinal area: → Are there skin pustules? → Is there swelling. Encourage breastfeeding on the way. LISTEN. refer urgently to hospital. or if worse. Teach mother to treat eyes K13 . Are they swollen and draining pus? Look at the skin. hardness or large bullae? Look at the umbilicus: → Is it red? → Draining pus? → Does redness extend to the skin? Yellow skin on face and only <24 hours old. If feeding difficulty. If no improvement or worse. Look at the eyes. look at palms and soles. refer urgently to hospital. LOCAL UMBILICAL INFECTION LOCAL SKIN INFECTION ■ ■ ■ Less than 10 pustules ■ ■ ■ NEXT: If danger signs . GONOCOCCAL EYE INFECTION ■ ■ ■ ■ Give single dose of appropriate antibiotic for eye infection K12 . look at skin on the face → if baby is 24 hours old or more. is it yellow? → if baby is less than 24 hours old. ■ Eyes swollen and draining pus.Look for signs of jaundice and local infection NEWBORN CARE LOOK FOR SIGNS OF JAUNDICE AND LOCAL INFECTION J6 ASK. Refer baby urgently to hospital K14 . especially around the neck.

IF DANGER SIGNS SIGNS Any of the following signs: ■ Fast breathing (more than 60 breaths per minute). ■ Pallor. ■ Fever (temperature >38ºC). bruises or malformation If danger signs J7 . ■ More than 10 skin pustules or bullae. CLASSIFY POSSIBLE SERIOUS ILLNESS TREAT AND ADVISE ■ ■ Give first dose of 2 IM antibiotics K12 . redness. or swelling. NEWBORN CARE NEXT: If swelling. Refer baby urgently to hospital K14 . ■ Floppy or stiff. ■ Umbilicus draining pus or umbilical redness extending to skin. ■ Severe chest in-drawing ■ Grunting ■ Convulsions. In addition: ■ Re-warm and keep warm during referral ■ ■ K9 . hardness of skin. ■ Stop the bleeding. ■ Bleeding from stump or cut. ■ Temperature <35ºC or not rising after rewarming. ■ Slow breathing (less than 30 breaths per minute). Treat local umbilical infection before referral Treat skin infection before referral K13 . K13 .

bruises or malformation NEWBORN CARE IF SWELLING. ■ ■ ■ Odd looking. do not pull. Advise on surgical correction at age of several months. Swollen head — bump on one or both sides.If swelling. Refer for special evaluation. ■ ■ Explain to parents that it does not hurt the baby. BRUISES OR MALFORMATION J8 SIGNS ■ ■ ■ ■ CLASSIFY BIRTH INJURY TREAT AND ADVISE ■ Bruises. Help mother to breastfeed. If not successful. it will disappear in a week or two and no special treatment is needed. Abnormal position of legs (after breech presentation). Refer for special treatment if available. abdomen or back ■ ■ ■ ■ Other abnormal appearance. swelling on buttocks. unusual appearance Open tissue on head. Manage according to national guidelines. Asymmetrical arm movement. arm does not move. Plan to follow up. Gently handle the limb that is not moving. DO NOT force legs into a different position. Cover with sterile tissues soaked with sterile saline solution before referral. teach her alternative feeding methods K5-K6 . ■ ■ Club foot Cleft palate or lip MALFORMATION ■ ■ Refer for special treatment if available. SEVERE MALFORMATION ■ NEXT: Assess the mother’s breasts if complaining of nipple or breast pain .

MASTITIS ■ ■ ■ ■ ■ ■ NEXT: Care of the newborn Assess the mother’s breasts if complaining of nipple or breast pain J9 . Express milk from the affected breast and discard until no fever K5 . If mother is HIV+ let her breastfeed on the healthy breast. ■ ■ Nipple sore or fissured. If no improvement or worse. Teach correct positioning and attachment K3 . If not better. Measure temperature. FEEL ■ SIGNS ■ ■ ■ ■ CLASSIFY BREASTS HEALTHY TREAT AND ADVISE ■ How do your breasts feel? ■ ■ ■ ■ ■ Look at the nipple for fissure Look at the breasts for: → swelling → shininess → redness. Teach correct positioning and attachment K3 . LISTEN. Observe a breastfeed if not yet done J4 . BREAST ENGORGEMENT ■ ■ ■ ■ ■ NEWBORN CARE ■ ■ Part of breast is painful. Advise to feed more frequently. Encourage mother to continue breastfeeding. CHECK RECORD LOOK. Temperature <38ºC. Give cloxacillin for 10 days F5 . Not yet breastfeeding. Normal body temperature. Temperature >38ºC Feels ill. Reassure the mother. and continue breastfeeding on the healthy side. redness or tenderness. refer to hospital. Feel gently for painful part of the breast. Teach correct positioning and attachment K3 . No swelling. teach the mother how to express breast milk from the affected breast and feed baby by cup. teach mother how to express enough breast milk before the feed to relieve discomfort K5 . If not better. Reassess after 2 feeds (or 1 day). If severe pain.ASSESS THE MOTHER’S BREASTS IF COMPLAINING OF NIPPLE OR BREAST PAIN ASK. Encourage the mother to continue breastfeeding. swollen and red. Nipple not sore and no fissure visible. Baby not well attached. Reassess in 2 days. ■ ■ ■ ■ Both breasts are swollen. Baby not well attached. shiny and patchy red. give paracetamol F4 . NIPPLE SORENESS OR FISSURE ■ ■ ■ Encourage the mother to continue breastfeeding. Reassess after 2 feeds (1 day). Baby well attached.

Ask the mother to alert you if breastfeeding difficulty. Cover the head with a hat. assess breastfeeding and help the mother with positioning and attachment J3 ■ ■ If the mother is unable to take care of the baby. Assess breastfeeding in every baby before planning for discharge. Ask the mother and companion to watch the baby and alert you if → Feet cold → Breathing difficulty: grunting. assess the baby immediately J2-J7 . in her bed or within easy reach. If bleeding from cord. check if tie is loose and retie the cord. Keep the baby in the room with the mother. NEXT: Additional care of a small baby (or twin) . Let the mother and baby sleep under a bednet. DO NOT bath the baby before 6 hours. examine the baby as on J2-J7 . → Reassess in 1 hour. ■ ■ ■ If mother reports breastfeeding difficulty. If the baby is in a cot. Support exclusive breastfeeding on demand day and night. J10 CARE AND MONITORING ■ ■ ■ ■ ■ ■ RESPOND TO ABNORMAL FINDINGS ■ Ensure the room is warm (not less than 25ºC and no draught). provide care or teach the companion K9-K10 Wash hands before and after handling the baby. If breathing difficulty or mother reports any other abnormality.Care of the newborn NEWBORN CARE CARE OF THE NEWBORN Use this chart for care of all babies until discharge. DO NOT expose the baby in direct sun. measure temperature and re-warm the baby K9 . ■ ■ ■ ■ If feet are cold: → Teach the mother to put the baby skin-to-skin K13 . DO NOT discharge if baby is not yet feeding well. if feet still cold. chest in-drawing → Any bleeding. . J2-J9 Examine every baby before planning to discharge mother and baby DO NOT discharge before baby is 12 hours old. Teach the mother how to care for the baby. fast or slow breathing. → Keep the baby warm K9 → Give cord care K10 → Ensure hygiene K10 . DO NOT put the baby on any cold surface. ensure baby is dressed or wrapped and covered by a blanket. If other bleeding. ■ ■ Give prescribed treatments according to the schedule K12 .

not crying): listen for grunting. or weight loss greater than 10% of birth weight and no other problems. assess the baby J2-J8 . Wash as needed. ■ ■ ■ ■ ■ If difficult to keep body temperature within the normal range (36. Additional care of a small baby (twin) J11 . If feeding difficulty persists for 3 days. and baby satisfaction with the feed J4 K6 . assess the total daily amount of milk given. consider alternative feeding methods K5-K6 . If the mother and baby are not able to stay. 1-2 months early or weighing 1500g-<2500g. Assess the baby for discharge. assess the baby and respond to the mother J2-J8 . ensure daily (home) visits or send to hospital.5ºC to 37. refer the baby for phototherapy. duration and frequency of feeds.5ºC on 3 consecutive days → Mother able and confident in caring for the baby → No maternal concerns. suckling. If any maternal concern. look for chest in-drawing → Look for jaundice (first 10 days of life): first 24 hours on the abdomen. Give special support for breastfeeding the small baby (or twins) K4 : → Encourage the mother to breastfeed every 2-3 hours. then on palms and soles. ■ Ensure hygiene K10 . If breathing difficulty. weighing <1500g CARE AND MONITORING ■ ■ ■ RESPONSE TO ABNORMAL FINDINGS Plan to keep the small baby longer before discharging. count breaths per minute. ■ ■ If the small baby is not suckling effectively and does not have other danger signs.5ºC): → Keep the baby in skin-to-skin contact with the mother as much as possible → If body temperature below 36. Ensure additional warmth for the small baby K9 : → Ensure the room is very warm (25º–28ºC). NEWBORN CARE ■ ■ Plan to discharge when: → Breastfeeding well → Gaining weight adequately on 3 consecutive days → Body temperature between 36. Allow visits to the mother and baby. → Assess breastfeeding daily: attachment. If jaundice. → Weigh daily and assess weight gain K7 . DO NOT bath the small baby. assess the baby J2-J8 . ■ ■ Assess the small baby daily: → Measure temperature → Assess breathing (baby must be quiet. → 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 .5º and 37. → Teach the mother how to keep the small baby warm in skin-to-skin contact → Provide extra blankets for mother and baby. Refer to hospital a very small baby: >2 months early. refer for breastfeeding counselling and management.ADDITIONAL CARE OF A SMALL BABY (OR TWIN) Use this chart for additional care of a small baby: preterm. repeat the count if >60 or <30. → If alternative feeding method is used.5ºC persists for 2 hours despite skin-to-skin contact with mother.

.

■ If the baby does not feed in 1 hour. Put nothing on the stump. CARE. see G7 for special counselling to the mother who is HIV-positive and breastfeeding. ■ Support breasts with a well-fitting bra or cloth. aiming the infant’s lower lip well below the nipple. If the room is not warm enough.5+ Day 0 15ml 20ml 25ml 1 17ml 22ml 28ml 2 19ml 25ml 30ml 3 21ml 27ml 35ml 4 23ml 30ml 35ml 5 25ml 32ml 40+ml 6 27ml 35ml 45+ml 7 27+ml 35+ml 50+ml Baby becomes alert. If chest is not rising: → reposition head → check mask seal. Express the breast until some drops of breast milk appear on the nipple. ■ Teach the mother to observe swallowing if giving expressed breast milk. CARE. Wait until the baby is alert and opens mouth and eyes. DO NOT force the baby to take the breast. Bath when necessary: → Ensure the room is warm. DO NOT apply anything in the baby’s eyes except an antimicrobial at birth.0 . ■ If the baby’s temperature is not 36. Do not feed the baby yourself. DO NOT use artificial teats or pacifiers. SMALL BABIES REQUIRE MORE CAREFUL ATTENTION: ■ The room must be warmer when changing. 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 D19 → monitor every 15 minutes for breathing and warmth → tell the mother that the baby will probably be well. Signs of readiness to breastfeed are: → baby looking around/moving → mouth open → searching. SUBSEQUENTLY (FIRST DAY) ■ Explain to the mother that keeping baby warm is important for the baby to remain healthy.9 kg 2. let the baby rest comfortably on the mother’s chest in skin-to-skin contact. ■ Watch the mother give the first dose to the baby.4 kg 1.4 2. Warmth is comfortable for some mothers.9 kg 3. ■ Be flexible at each feed. she can express milk for her/him and feed her/him by cup after initial breastfeeding. underarms daily.9 kg 2. Use the wet cloth to gently wash off pus from the baby’s eyes. then it becomes thinner and whiter. Expressing can be done a few times a day when the breasts are overfull. ■ Check that position and attachment are correct at the first feed. Wash hands before and after cord care. If mother must be absent. Rewarm the baby skin-to-skin Before rewarming.35 ml 1. Wet clean cloth with boiled and cooled water. ■ ■ ■ ■ ■ ■ ■ ■ K5 small and too weak to suckle → To relieve engorgement and to help baby to attach → To drain the breast when she has severe mastitis or abscesses. until baby takes 150 ml/kg/day. Dry the whole body and hair thoroughly. ■ If necessary. CARE. ■ ■ Advise the mother who is not breastfeeding at all on how to relieve engorgement (Baby died or stillborn. Help the mother find the best method to feed the twins: → If one is weaker..9 kg 4.1 ml Baby is satisfied with the feed. and starts to feed. ■ If breast engorgement. encourage the mother to keep the baby in skin-to-skin contact for as long as possible. K3 Support exclusive breastfeeding ■ ■ COUNSEL ON BREASTFEEDING (2) Support exclusive breastfeeding Teach correct positioning and attachment for breastfeeding Refer baby urgently to hospital ■ ■ ■ ■ ■ After emergency treatment. ■ Babies should be exclusively breastfed for the first 6 months of life. ■ ■ BREASTFEEDING. Do not leave the baby in direct sun. red.0 — 4. Introduce the suction tube 3 cm into each nostril and suck while withdrawing until no mucus.5 . PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN K4 COUNSEL ON BREASTFEEDING (3) Give special support to breastfeed the small baby (preterm and/or low birth weight) Give special support to breastfeed twins Other baby care OTHER BABY CARE Always wash hands before and after taking care of the baby.4 kg 0.4. socks and a cap. away from sick children or adults. ■ Cover the infant on the mother’s chest with her clothes and an additional (pre-warmed) blanket.4 kg 1. → Check it for accuracy according to instructions. Fold nappy (diaper) below stump. Keep cord stump loosely covered with clean clothes. It will be less than her baby would take and will not stimulate increased milk production. Let the baby smell and lick the nipple.1 ml 1. Dry the area with clean cloth. Record on immunization card and child record. K9 ENSURE WARMTH FOR THE BABY Keep the baby warm Keep a small baby warm Rewarm the baby skin-to-skin Advise the mother on medication and breastfeeding → Most drugs given to the mother in this guide are safe and the baby can be breastfed. always cover the baby with a blanket and/or use skin-to-skin contact. what you are doing and why ventilate during referral record the event on the referral form and labour record. Keep the baby wrapped and under a radiant heater if possible. Allow long pauses or long. 8 or more times in 24 hours from birth. TREAT SKIN PUSTULES OR UMBILICAL INFECTION Do the following 3 times daily: Wash hands with clean water and soap. day and night. Give intramuscular antibiotics in thigh. Only on the first day Teach correct positioning and attachment for breastfeeding ■ ENSURE WARMTH FOR THE BABY Keep the baby warm AT BIRTH AND WITHIN THE FIRST HOUR(S) Warm delivery room: for the birth of the baby the room temperature should be 25-28ºC. use one of the following options: → home-made or commercial formula → donated heat-treated breast milk. If the attachment or suckling is not good.0 — 3.0 . Encourage her that twins may take longer to establish breastfeeding since they are frequently born preterm and with low birth weight. blankets. → Daily alternate the side each baby is offered. ■ Advise to seek care if breasts become painful. ■ Keep the room for the mother and baby warm. Squeeze bag attached to the mask with 2 fingers or whole hand. Do not interrupt feed if the baby is still trying. clean and warm surface. If cold. ■ Delay BCG vaccination until INH treatment completed. Keep the baby warm after the bath. Keep the baby away from smoke or people smoking. ■ Weekly until 4-6 weeks of age (reached term). ■ Teach her how to: → Wash her hands thoroughly. very small. If pus or redness remains or is worse. Only remove blood or meconium. Apply 1% tetracycline eye ointment in each eye 3 times daily. bleeding. ■ Ask the mother to repeat this process every 1-2 hours if the baby is very small (or every 2-3 hours if the baby is not very small). immunization. and weight gain is maintained.9 2. Age Vaccine TREAT EYE INFECTION Do the following 6-8 times daily: Wash hands with clean water and soap.The baby is dead. Wash hands. ■ ■ ■ ■ ■ ■ TEACH THE MOTHER TO GIVE TREATMENT TO THE BABY AT HOME ■ Explain carefully how to give the treatment. BREASTFEEDING.5 . Every 2 weeks if replacement feeding or treatment with isoniazid.5 . warm cloth and place in a cot. ■ At night. Use a new syringe and needle for each antibiotic. see also G7-G8 . Observe universal precautions to prevent infection A4 . DO NOT give any other feeds or water. Start with 80 ml/kg body weight per day for day 1. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN NEWBORN RESUSCITATION Keep the baby warm Open the airway If still not breathing. opens mouth and eyes. Encourage breastfeeding during the journey.5 ml 4 ml 0. ■ Weigh the baby daily (if accurate and precise scales available). Explain to the mother the importance of warmth for a small baby. Hold the baby in skin-to-skin contact. especially in a cold climate. Let some breast milk fall into the baby’s mouth. leave the baby with the mother to try later.0 ml 1. → Have someone massage her back and neck before expressing. or ill.1. After bathing. → A baby needs to feed day and night. Repeat each suction if necessary but no more than twice and no more than 20 seconds in total. help the mother to see the baby or inform her about the baby’s condition at least twice daily. Dry baby: immediately after birth. See table below.1 ml 0. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN BREASTFEEDING. 2 hours after the last feed. CARE. encourage her to make sure that the weaker twin gets enough milk. Wash the cup with water and soap after each feed. Cover the head with a cap for the first few days. ALTERNATIVE FEEDING METHODS (2) Cup feeding expressed breast milk Quantity to feed by cup Signs that baby is receiving adequate amount of milk Treat and immunize the baby (1) TREAT THE BABY Treat the baby ■ ■ ■ K12 K12 TREAT AND IMMUNIZE THE BABY (1) Treat the baby Give 2 IM antibiotics (first week of life) Give IM benzathine penicillin to baby (single dose) if mother tested RPR positive Give IM antibiotic for possible gonococcal eye infection (single dose) Determine appropriate drugs and dosage for the baby’s weight. Cover the baby with a soft dry cloth. If stump is soiled. Sleeping ■ ■ ■ ■ This section has details on breastfeeding. ensure the baby gets the mother’s expressed breast milk if possible.2 million units/(6ml total volume) = 200 000 units/ml APPROXIMATE QUANTITY TO FEED BY CUP (IN ML) EVERY 2-3 HOURS FROM BIRTH (BY WEIGHT) Weight (kg) 1. Tell the mother the reasons for giving the drug to the baby. ■ If mother does not express enough milk in the first few days. If umbilicus is red or draining pus or blood. ■ Encourage skin-to-skin contact since it makes breastfeeding easier.2. ■ 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. ADVISE WHEN TO RETURN WITH THE BABY Routine visits Follow-up visits Advise the mother to seek care for the baby Refer baby urgently to hospital If the baby does not have a mother ■ ■ ■ Breastfeeding → helps baby’s development and mother/baby attachment → can help delay a new pregnancy (see D27 for breastfeeding and family planning). clean and safe place. slow feed. ■ If the baby is not yet suckling well and long enough. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN K2 COUNSEL ON BREASTFEEDING (1) Counsel on importance of exclusive breast feeding Help the mother to initiate breastfeeding Other breastfeeding support OTHER BREASTFEEDING SUPPORT Give special support to the mother who is not yet breastfeeding (Mother or baby ill. store expressed milk in a cool. → Express one side until the milk flow slows. pus from eyes. bathing) AT BIRTH: ■ ■ ■ HELP THE MOTHER: Start feeding one baby at a time until breastfeeding is well established.0 . refer to hospital. do whatever works better in your setting: → Let the mother express breast milk into baby’s mouth K5 . see G8 . ■ ■ Squeeze bag harder with whole hand. ■ Relieve pain.5 ml 0. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN Keep the mother and baby together in bed or within easy reach. swollen. use one of the following feeding options: → donated heat-treated breast milk → home-made or commercial formula. → Press slightly inwards towards the breast between her finger and thumb. ■ Follow up the baby every 2 weeks. On day 1 express in a spoon and feed by spoon. Explain that her milk is the best food for such a small baby. clean and dry surface. others prefer a cold compress to reduce swelling. or baby too small to suckle) Teach the mother to express breast milk K5 . wrap the baby in a clean. ■ Explain how the milk’s appearance changes: milk in the first days is thick and yellow. or when to return. or earlier if the baby is small J4 . Do not bath the baby at birth. jar.0 . she/he will close her/his mouth and take no more breast milk. ■ ■ Cord care ■ ■ ■ ■ ■ ■ ■ Hygiene (washing. To feed the baby if the baby is Hand express breast milk directly into the baby’s mouth Teach the mother to express breast milk. stop ventilating ■ ■ ■ Clamp and cut the cord if necessary.35 ml 0. if she feels ill or temperature greater than 38ºC. Hepatitis B (HB-1) vaccine in the first week of life. CARE. dry. Do not bind the breasts tightly as this may increase her discomfort. monitor baby for jaundice. Pharmacological treatments to reduce milk supply are not recommended. let the baby sleep with the mother or within easy reach to facilitate breastfeeding. Divide total into 8 feeds. then offer the second breast. Give intramuscular antibiotics in thigh.5 . difficulty feeding.5 — 1.0 . Then reassess.5 . ■ Teach the mother to express her milk by herself. Avoid bathing small babies. day and night. Protect the baby from direct sunshine. K14 Help the mother to initiate breastfeeding within 1 hour. A1-A6 .9 kg 3. the milk should be stored with a well-fitting lid or cover. Encourage breastfeeding on demand. Form seal. DO NOT interrupt feed before baby wants. rewarm the baby (see below). ■ If mother and baby are separated. After birth. CARE. Advise when to return for next immunization. day and night. Baby gains at least 160 g in the following weeks or a minimum 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 Give BCG. with a dry cloth. encourage the mother to keep the baby in skin-to-skin contact as long as possible.4. express a small amount of breast milk before starting breastfeeding to soften nipple area so that it is easier for the baby to attach. → Feed the baby by cup immediately. Always send the mother with the baby. HELP THE MOTHER: ■ Initiate breastfeeding within 1 hour of birth. DURING TRANSPORTATION ■ ■ ■ ■ ■ Keep the baby warm by skin-to-skin contact with mother or someone else. 2 or 3 times. → Continue alternating sides for at least 20-30 minutes. CARE.35 ml 0. ■ Look for signs of good attachment and effective suckling (that is. Increase total volume by 10-20 ml/kg per day. preferably before discharge. or repeat BCG. CARE. a cord stump which is red or draining pus. washing.1. Swaddling makes them cold. Wash or bath a baby in a very warm room. 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. ■ K11 NEWBORN RESUSCITATION Start resuscitation within 1 minute of birth if baby is not breathing or is gasping for breath. care of the baby. usually within the first hour. routine and follow-up visits and urgent referral to hospital. ■ Use the milk to feed the baby by cup. when baby is ready After birth. sometimes pausing). ■ When not breastfeeding at all. ■ Keep the room or part of the room warm. Some women use plant products such as teas made from herbs. K10 K10 OTHER BABY CARE Cord care Sleeping Hygiene ■ Give special support to breastfeed twins COUNSEL THE MOTHER: Reassure the mother that she has enough breast milk for two babies.5 ml 3 ml 3. Let baby release the breast. ■ Keep the baby longer at the breast. Then express the other side.BREASTFEEDING. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN ALTERNATIVE FEEDING METHODS Express breast milk ■ ■ ■ BREASTFEEDING.0-2. 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. to keep the baby warm or when the baby is not with the mother. when the baby has had enough. Paint with gentian violet.85 ml 2. ■ ■ ■ Keep a small baby warm ■ ■ ■ ■ ■ ■ ■ Help the mother whenever she wants. no draught → Use warm water for bathing → Thoroughly dry the baby. If breathing or crying. ensure baby is dressed or wrapped and covered with a blanket. a nappy (diaper). Give IM antibiotic for possible gonococcal eye infection (single dose) Weight Ceftriaxone (1st choice) Dose: 50 mg per kg once 250 mg per 5 ml vial=mg/ml Kanamycin (2nd choice) Dose: 25 mg per kg once. Low birth weight. convulsions. Explain to the mother and give supportive care D24 . ■ Dress the baby or wrap in soft dry clean cloth. Observe rise of chest.4 kg 2.5 .5 ml 0. explain the need for referral to the mother/father. ■ Feed the baby by cup if the mother is not available to do so. Feeding for her/him is even more important than for a big baby. improve the milk flow (let the mother express a little breast milk before attaching the baby to the breast). → Teach the mother breast and nipple massage.5ºC or more after 2 hours of rewarming. CARE. ventilate.4 kg 3. Once expressed. Give 2 IM antibiotics (first week of life) ■ ■ ■ Signs that baby is receiving adequate amount of milk ■ ■ ■ ■ ■ Give first dose of both ampicillin and gentamicin IM in thigh before referral for possible serious illness. ■ When the baby is brought for examination because not feeding well. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN Counsel on breastfeeding (1) BREASTFEEDING. fever or feels cold.0 . Inform the referral centre if possible by radio or telephone. → Let the mother express breast milk and feed baby by cup K6 . ■ Check the temperature every hour until normal. Do not swaddle – wrap too tightly.9 kg 4. wash it with clean water and soap. ■ If the mother is ill and unable to breastfeed. Gently wash off pus and crusts with boiled and cooled water and soap. ■ Explain that breastfeeding will become easier if the baby suckles and stimulates the breast her/himself and when the baby becomes bigger. let her express breast milk and let somebody else feed the expressed breast milk to the baby by cup. ■ Routine visits Postnatal visit Immunization visit (If BCG. mouth. 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.75 ml 0. → If necessary. Transfer the baby to a dry. record and assess weight gain K7 . On the first day express breast milk into.5 ml sterile water to 500 mg vial = 200 mg/ml Gentamicin IM Dose: 5 mg per kg every 24 hours if term. Treat for 5 days. Baby finishes feeding when mouth closes or when not interested in taking more. bathing and examining a small baby. Cover the baby with a blanket and cover her/his head with a cap. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN BREASTFEEDING. stop ventilating If not breathing or gasping at all after 20 minutes of ventilation ■ The mother needs clean containers to collect and store the milk. place the baby on the mother’s abdomen or on a warm. feeds <5 times in 24 hours. to assess weight gain. treatments. ■ K8 K8 Advise when to return with the baby OTHER BREASTFEEDING SUPPORT Give special support to the mother who is not yet breastfeeding Advise the mother who is not breastfeeding at all on how to relieve engorgement If the baby does not have a mother K14 ADVISE WHEN TO RETURN WITH THE BABY For maternal visits see schedule on D28 . Give donated heat treated breast milk or home-based or commercial formula by cup. try again. Wait until the baby swallows before expressing more drops of breast milk. every 3 hours. TREAT AND IMMUNIZE THE BABY (2) Treat local infection Give isoniazid (INH) prophylaxis to newborn Immunize the newborn REASSESS IN 2 DAYS: ■ ■ ■ Assess the skin. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN 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. Let the baby sleep on her/his back or on the side. Inform the mother that the baby has difficulty initiating breathing and that you will help the baby to breathe. Do not put the baby on any cold or wet surface. dress and cover after bath. ■ Apply a compress. but make sure the intake is adequate by checking daily weight gain. Teach the carer how to prepare milk and feed the baby K6 . The above methods are considered more effective in the long term. even if she/he does not wake up alone. Use a radiant warmer if room not warm or baby small. An analgesic such as ibuprofen. consider giving expressed breast milk by cup K6 . Cover with a blanket. behind the nipple.4 kg 1 ml 1.6 ml 0. VENTILATE: ■ ■ ■ ■ If breathing less than 30 breaths per minute or severe chest in-drawing: ■ ■ ■ ■ ■ Place mask to cover chin.4 kg 3.3. ALTERNATIVE FEEDING METHODS (1) Express breast milk Hand express breast milk directly into the baby’s mouth Keep the baby warm ■ ■ ■ ■ If breathing or crying. CARE. examine the baby J2–J9 . ■ Encourage the mother to breastfeed when she or the baby recovers. preventive measures and treatment for the newborn K1 . She should: → make sure the baby’s head and body are in a straight line → make sure the baby is facing the breast. mother chose replacement feeding) Breasts may be uncomfortable for a while. Advise to use extra clothes. at least 8 times in 24 hours from birth. Wait at least 6 hours before bathing. Avoid touching the stump unnecessarily. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN WEIGH AND ASSESS WEIGHT GAIN Weigh baby in the first month of life WEIGH THE BABY Monthly if birth weight normal and breastfeeding well. ■ ■ ■ ■ ■ Immunize the newborn ■ ■ ■ ■ WEIGH THE SMALL BABY ■ Every day until 3 consecutive times gaining weight (at least 15 g/day). DO NOT leave the baby alone If still no breathing. ■ BREASTFEEDING. Wake the baby for feeding. Use the bednet day and night for a sleeping baby. Dry thoroughly. ■ The room for the baby should be warm (not less than 25°C) with no draught.75 ml 0. ■ Show the mother how to help her baby to attach.4 kg 1. ■ ■ BREASTFEEDING. Place the newborn skin-to-skin on the mother’s chest dressed in a pre-warmed shirt open at the front. ■ If milk does not flow well: → Apply warm compresses. Record the event.0 — 1. especially if baby is small. ■ Feed the baby every 2-3 hours. Small babies will start to take milk into their mouth using the tongue. or paracetamol may be used. ■ Teach the mother to express enough milk to relieve discomfort. Help her if necessary. ■ If mother cannot breastfeed at all. ■ Assess warmth every 4 hours by touching the baby’s feet: if feet are cold use skin-to-skin contact.1. ■ Let the baby release the breast by her/himself. keep the baby in skin-to-skin position/contact with the mother or other person accompanying the baby. care. CARE. Explain to the mother that she should seek care if the umbilicus is red or draining pus or blood. dress or wrap the baby. and either → older than 1 week or → gaining weight adequately Orphan baby INH prophylaxis Treated for possible congenital syphilis Mother HIV-positive Return in 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 7 days 7 days 14 days 14 days 14 days 14 days difficulty breathing.6 ml 0. General principles are found in the section on good care If mother HIV-positive.7 ml 0. Check frequently if feet are warm. BREASTFEEDING. and feed colostrum by spoon. Label and package each drug separately. Follow up in 2 weeks. ■ Always start the feed with breastfeeding before offering a cup. yellow skin.4 kg 2. ■ Check mother’s understanding before she leaves the clinic. ■ If the baby is small. Watch her as she carries out the first treatment.4 kg 0. ■ Ensure the baby is dressed or wrapped and covered with a blanket. If necessary.0 — 2. severe umbilical infection or severe skin infection. 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. If pus and redness have improved. not just the neck and shoulders may a full-term baby sleep many hours after a good feed. Express as much as the baby would take or more. examine the baby and manage accordingly J2–J7 . If healthy.1. Suction first the mouth and then the nose. Open the airway ■ ■ ■ ■ ■ Position the head so it is slightly extended. give BCG only. ■ Reassure the mother that it is safe to breastfeed the baby. in warm water. OPV-0. Wash the buttocks when soiled. Use a new syringe and needle for each antibiotic. ■ Avoid stimulating the breasts. umbilicus or eyes. or stimulate the baby lightly to awaken her/him. Wash hands. CARE. help her to express breast milk and feed the baby by cup K6 .2. not just at each feed. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN K6 BREASTFEEDING. max 75 mg 75 mg per 2 ml vial = 37.9 kg 3. Baby swallows the milk. CARE. and either → first week of life or → not adequately gaining weight Low birth weight. ■ If referral needed. Once good seal and chest rising. Dry it thoroughly with clean cloth. Teach the mother to express breast milk: → To provide milk for the baby when she is away. spilling little. deep sucks. Seek care if the baby’s feet remain cold after rewarming. ■ Demonstrate how to measure a dose. If no breathing or gasping at all after 20 minutes of ventilation ■ ■ ■ Stop ventilating. Baby’s stool is changing from dark to light brown or yellow by day 3. Send referral note with the baby. DO NOT separate them. GO TO HEALTH CENTRE AS QUICKLY AS POSSIBLE IF THE BABY HAS ■ ■ ■ ■ ■ ■ For counselling if mother HIV-positive. DO NOT apply any substances or medicine to stump. ■ Keep the baby with the mother until the baby’s body temperature is in normal range. ■ Baby is cup feeding well if required amount of milk is swallowed.2. DO NOT remove vernix. the mouth close to the nipple. Ampicillin IM Dose: 50 mg per kg every 12 hours Add 2. ■ Keep the baby within easy reach of the mother. DO NOT bathe the baby until at least 6 hours of age. express just a little to relieve pain K5 . add extra blanket and reassess (see Rewarm the newborn). Ask her to let you know if the local infection gets worse and to return to the clinic if possible.6 ml 1. bowl or cup can be used. If the baby does not breastfeed and journey is more than 3 hours. A wide necked jug.3. Continue until baby takes the required quantity.5 ml 0. → Sit or stand comfortably and hold a clean container underneath her breast. CARE.5 — 3. ■ Babies should start breastfeeding within 1 hour of birth. tell the mother to continue treating local infection at home. then offer the second breast. Give every 2-3 hours to a small size or ill baby. ■ During the day. Offer to help the mother at any time K3 . dry immediately and thoroughly. neck. ■ If the mother cannot keep the baby skin-to-skin because of complications. If mother chose replacement feedings. Alternative feeding methods (1) K5 Newborn resuscitation K11 Alternative feeding methods (2) BREASTFEEDING. continue ventilating arrange for immediate referral explain to the mother what happened. or if the mother cannot breastfeed at all. Check the baby’s 24 hour intake. Do not separate them (rooming-in). diarrhoea. 4 mg per kg every 24 hours if preterm 20 mg per 2 ml vial = 10 mg/ml Weight 1. → Put her first finger and thumb on either side of the areola. see G7 . just born. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN ALTERNATIVE FEEDING METHODS Cup feeding expressed breast milk ■ ■ ■ ■ K6 Quantity to feed by cup ■ ■ ■ ■ ■ Teach the mother to feed the baby with a cup.7 ml 2 ml 2 ml 2 ml BREASTFEEDING. → If mother is taking cotrimoxazole or fansidar. Tell the mother to help the baby to her breast when the baby seems to be ready.5-1. or plants such as raw cabbage leaves placed directly on the breast to reduce pain and swelling. ■ ■ ■ ■ ■ Birth < 1 week 6 weeks BCG OPV-0 HB1 DPT OPV-1 HB-2 K13 Scale maintenance Daily/weekly weighing requires precise and accurate scale (10 g increment): → Calibrate it daily according to instructions.85 ml 1. DO NOT bathe the baby before 6 hours old or if the baby is cold. repeat the procedure to express breast milk at least 8 times in 24 hours. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN K2 BREASTFEEDING. or according to national guidelines. help her to express or do it for her.5 ml 2 ml 2. Dispose of the stool as for woman’s pads. preferably within 2-3 days At age 6 weeks Advise the mother to seek care for the baby Use the counselling sheet to advise the mother when to seek care. reassess the baby J2–J7 . OPV-0 and HB-1 given in the first week of life) Return Within the first week. hat and socks. if the baby has any of these danger signs: RETURN OR GO TO THE HOSPITAL IMMEDIATELY IF THE BABY HAS ■ ■ ■ ■ ■ ■ ■ Follow-up visits If the problem was: Feeding difficulty Red umbilicus Skin infection Eye infection Thrush Mother has either: → breast engorgement or → mastitis. ventilate at 40 squeezes per minute until newborn starts crying or breathing spontaneously.7 ml 1 ml 1.4 kg 3. and attempt to suck. slow.3. not feeding at all.4 kg 2. as long as the baby wants. weigh and assess weight gain.0 .2 million units = 1. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN Treat local infection TEACH MOTHER TO TREAT LOCAL INFECTION ■ ■ ■ ■ 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). spilling some.9 kg 4. Wash hands. ■ Watch the mother practice measuring a dose by herself. Baby wets every day as frequently as baby is feeding. especially a small baby. Weight loss is less than 10% in the first week of life. if possible. If un-immunized newborn first seen 1-4 weeks of age. It does not need to be done if the mother is uncomfortable. Simple spring scales are not precise enough for daily/weekly weighing. Look at the chest for in-drawing. 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. DO NOT share supplies with other babies. DO NOT bandage the stump or abdomen. and especially if she is a first time or adolescent mother. LATER AND AT HOME: ■ ■ ■ Wash the face. the baby’s nose is opposite her nipple → hold the baby’s body close to her body → support the baby’s whole body. Introduce the suction tube into the newborn’s mouth 5 cm from lips and suck while withdrawing.5 — 2. They should not have any other food or drink before they start to breastfeed. ■ Be sure the temperature of the room where the rewarming takes place is at least 25°C. Organize safe transportation. Weigh and assess weight gain K7 Treat and immunize the baby (2) K13 Breastfeeding. Keep the baby. ■ If the mother and baby must be separated. AT HOME ■ Explain to the mother that babies need one more layer of clothes than other children or adults. Give both ampicillin and gentamicin IM for 5 days in asymptomatic babies classified at risk of infection. DO NOT do it for her. Both are good for the baby.3. according to bag size. skin pustules.3 ml 1. ■ If the baby was referred to another institution.5 mg/ml Weight 1. Assess in 3 hours. ■ ■ Show the mother how to hold her baby. ■ ■ Counsel on breastfeeding (2) K3 Ensure warmth for the baby K9 Counsel on breastfeeding (3) BREASTFEEDING. CARE. Count breaths per minute. Assess weight gain Use this table for guidance when assessing weight gain in the first month of life Age 1 week 2-4 weeks 1 month Acceptable weight loss/gain in the first month of life Loss up to 10% Gain at least 160 g per week (at least 15 g/day) Gain at least 300 g in the first month K7 WEIGH AND ASSESS WEIGHT GAIN Weigh baby in the first month of life Assess weight gain Scale maintenance Explain and show how the treatment is given. and nose.9 ml 1. If not. If mother is HIV-positive. Size of individual feeds may vary. The baby will suck the milk.9 kg 2. no draught.85 ml 1 ml 1. OTHER BABY CARE: ■ Use cloth on baby’s bottom to collect stool. remove the baby’s cold clothing. → A small baby should be encouraged to feed.0 .2. ■ If mother is very ill. After some time. ■ 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.

Tell the mother to help the baby to her breast when the baby seems to be ready. ■ 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). ■ Help the mother to initiate breastfeeding within 1 hour. 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. usually within the first hour. help her to express breast milk and feed the baby by cup K6 . ■ Check that position and attachment are correct at the first feed. They should not have any other food or drink before they start to breastfeed. ■ If mother cannot breastfeed at all. leave the baby with the mother to try later. Assess in 3 hours. For counselling if mother HIV-positive. ■ If the baby does not feed in 1 hour. ■ If the mother is ill and unable to breastfeed. when baby is ready After birth. ■ Babies should start breastfeeding within 1 hour of birth. then offer the second breast. see G7 . On day 1 express in a spoon and feed by spoon. Signs of readiness to breastfeed are: → baby looking around/moving → mouth open → searching. examine the baby J2–J9 .Counsel on breastfeeding (1) BREASTFEEDING. Offer to help the mother at any time K3 . CARE. let the baby rest comfortably on the mother’s chest in skin-to-skin contact. . If healthy. use one of the following options: → home-made or commercial formula → donated heat-treated breast milk. ■ Let the baby release the breast by her/himself. or earlier if the baby is small J4 .

8 or more times in 24 hours from birth. 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 taking cotrimoxazole or fansidar. DO NOT separate them. → A small baby should be encouraged to feed. and especially if she is a first time or adolescent mother. DO NOT interrupt feed before baby wants. then offer the second breast.BREASTFEEDING. ■ ■ Teach correct positioning and attachment for breastfeeding ■ Show the mother how to hold her baby. the baby’s nose is opposite her nipple → hold the baby’s body close to her body → support the baby’s whole body. see breastfeeding. If the attachment or suckling is not good. deep sucks. Then reassess. slow. If mother is HIV-positive. as long as the baby wants. day and night. at least 8 times in 24 hours from birth. ■ Help the mother whenever she wants. DO NOT force the baby to take the breast. try again. Counsel on breastfeeding (2) K3 . G7 Advise the mother on medication and breastfeeding → Most drugs given to the mother in this guide are safe and the baby can be breastfed. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN Support exclusive breastfeeding Keep the mother and baby together in bed or within easy reach. Encourage breastfeeding on demand. aiming the infant’s lower lip well below the nipple. → A baby needs to feed day and night. see G8 . day and night. Only on the first day may a full-term baby sleep many hours after a good feed. ■ ■ ■ Look for signs of good attachment and effective suckling (that is. CARE. 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. DO NOT use artificial teats or pacifiers. If breast engorgement. sometimes pausing). ■ If mother must be absent. DO NOT give any other feeds or water. for special counselling to the mother who is HIV-positive and If mother chose replacement feedings. let her express breast milk and let somebody else feed the expressed breast milk to the baby by cup. monitor baby for jaundice. She should: → make sure the baby’s head and body are in a straight line → make sure the baby is facing the breast. ■ Let baby release the breast.

2 hours after the last feed. ■ Keep the baby longer at the breast. ■ Explain that breastfeeding will become easier if the baby suckles and stimulates the breast her/himself and when the baby becomes bigger. 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. slow feed. ■ Encourage skin-to-skin contact since it makes breastfeeding easier. ■ Teach the mother to observe swallowing if giving expressed breast milk. ■ Explain how the milk’s appearance changes: milk in the first days is thick and yellow. On the first day express breast milk into. CARE. Allow long pauses or long. ■ Explain that her milk is the best food for such a small baby. HELP THE MOTHER: ■ Start feeding one baby at a time until breastfeeding is well established. ■ If the baby is not yet suckling well and long enough. If necessary. ■ Feed the baby every 2-3 hours. even if she/he does not wake up alone. ■ Always start the feed with breastfeeding before offering a cup. → Daily alternate the side each baby is offered. HELP THE MOTHER: ■ Initiate breastfeeding within 1 hour of birth. encourage her to make sure that the weaker twin gets enough milk. then it becomes thinner and whiter. she can express milk for her/him and feed her/him by cup after initial breastfeeding. ■ 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. ■ Encourage her that twins may take longer to establish breastfeeding since they are frequently born preterm and with low birth weight. record and assess weight gain K7 . do whatever works better in your setting: → Let the mother express breast milk into baby’s mouth K5 . Both are good for the baby. ■ Weigh the baby daily (if accurate and precise scales available). → If necessary. Give special support to breastfeed twins COUNSEL THE MOTHER: ■ Reassure the mother that she has enough breast milk for two babies. ■ Help the mother find the best method to feed the twins: → If one is weaker.Counsel on breastfeeding (3) BREASTFEEDING. and feed colostrum by spoon. Wake the baby for feeding. Feeding for her/him is even more important than for a big baby. improve the milk flow (let the mother express a little breast milk before attaching the baby to the breast). Do not interrupt feed if the baby is still trying. → Let the mother express breast milk and feed baby by cup K6 . .

every 3 hours. help her to express or do it for her.BREASTFEEDING. clean and safe place. Then express the other side. ■ If necessary. → Put her first finger and thumb on either side of the areola. Express the breast until some drops of breast milk appear on the nipple. ■ If milk does not flow well: → Apply warm compresses. the milk should be stored with a well-fitting lid or cover. Let some breast milk fall into the baby’s mouth. A wide necked jug. when the baby has had enough. → Have someone massage her back and neck before expressing. DO NOT do it for her. but make sure the intake is adequate by checking daily weight gain. → Sit or stand comfortably and hold a clean container underneath her breast. Express as much as the baby would take or more. store expressed milk in a cool. the mouth close to the nipple. → Feed the baby by cup immediately. ■ Teach her how to: → Wash her hands thoroughly. ■ Teach the mother to express her milk by herself. and attempt to suck. CARE. Let the baby smell and lick the nipple. Ask the mother to repeat this process every 1-2 hours if the baby is very small (or every 2-3 hours if the baby is not very small). jar. To feed the baby if the baby is small and too weak to suckle → To relieve engorgement and to help baby to attach → To drain the breast when she has severe mastitis or abscesses. repeat the procedure to express breast milk at least 8 times in 24 hours. ■ If mother is very ill. ■ Once expressed. express just a little to relieve pain K5 . ■ Teach the mother to express breast milk: → To provide milk for the baby when she is away. If not. or stimulate the baby lightly to awaken her/him. Wait until the baby swallows before expressing more drops of breast milk. → Continue alternating sides for at least 20-30 minutes. bowl or cup can be used. After some time. → Express one side until the milk flow slows. Hold the baby in skin-to-skin contact. Be flexible at each feed. Wait until the baby is alert and opens mouth and eyes. → Press slightly inwards towards the breast between her finger and thumb. ■ When not breastfeeding at all. Alternative feeding methods (1) K5 . PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN ALTERNATIVE FEEDING METHODS Express breast milk The mother needs clean containers to collect and store the milk. ■ Hand express breast milk directly into the baby’s mouth ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Teach the mother to express breast milk. → Teach the mother breast and nipple massage. behind the nipple. she/he will close her/his mouth and take no more breast milk.

■ If mother does not express enough milk in the first few days. spilling little. and weight gain is maintained. ■ 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.5-1. Divide total into 8 feeds. spilling some. 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.0-2. Give every 2-3 hours to a small size or ill baby. Check the baby’s 24 hour intake. ■ The baby will suck the milk. Baby gains at least 160 g in the following weeks or a minimum 300 g in the first month.4 2. opens mouth and eyes. 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. and starts to feed. Wash the cup with water and soap after each feed. CARE. ■ Baby swallows the milk. or if the mother cannot breastfeed at all. ■ Feed the baby by cup if the mother is not available to do so. Increase total volume by 10-20 ml/kg per day. ■ Baby finishes feeding when mouth closes or when not interested in taking more. ■ Baby is cup feeding well if required amount of milk is swallowed. .5+ Day 0 15ml 20ml 25ml 1 17ml 22ml 28ml 2 19ml 25ml 30ml 3 21ml 27ml 35ml 4 23ml 30ml 35ml 5 25ml 32ml 40+ml 6 27ml 35ml 45+ml 7 27+ml 35+ml 50+ml Signs that baby is receiving adequate amount of milk ■ ■ ■ ■ ■ Baby is satisfied with the feed. until baby takes 150 ml/kg/day. APPROXIMATE QUANTITY TO FEED BY CUP (IN ML) EVERY 2-3 HOURS FROM BIRTH (BY WEIGHT) Weight (kg) 1.Alternative feeding methods (2) BREASTFEEDING. not just at each feed. Continue until baby takes the required quantity. Baby wets every day as frequently as baby is feeding. Weight loss is less than 10% in the first week of life. use one of the following feeding options: → donated heat-treated breast milk → home-made or commercial formula. Do not feed the baby yourself. Baby’s stool is changing from dark to light brown or yellow by day 3. ■ Baby becomes alert.9 2. Size of individual feeds may vary. ■ ■ ■ ■ Quantity to feed by cup ■ ■ ■ ■ ■ Start with 80 ml/kg body weight per day for day 1. ■ Small babies will start to take milk into their mouth using the tongue. See table below.

Simple spring scales are not precise enough for daily/weekly weighing.BREASTFEEDING. ■ When the baby is brought for examination because not feeding well. Every 2 weeks if replacement feeding or treatment with isoniazid. WEIGH THE SMALL BABY ■ Every day until 3 consecutive times gaining weight (at least 15 g/day). or ill. Weigh and assess weight gain K7 . Assess weight gain Use this table for guidance when assessing weight gain in the first month of life Age 1 week 2-4 weeks 1 month Acceptable weight loss/gain in the first month of life Loss up to 10% Gain at least 160 g per week (at least 15 g/day) 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. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN WEIGH AND ASSESS WEIGHT GAIN Weigh baby in the first month of life WEIGH THE BABY ■ Monthly if birth weight normal and breastfeeding well. CARE. ■ Weekly until 4-6 weeks of age (reached term). → Check it for accuracy according to instructions.

■ Use the milk to feed the baby by cup. Warmth is comfortable for some mothers. ■ If the baby was referred to another institution. If the baby does not have a mother ■ ■ ■ Give donated heat treated breast milk or home-based or commercial formula by cup. help the mother to see the baby or inform her about the baby’s condition at least twice daily. or baby too small to suckle) ■ Teach the mother to express breast milk K5 . 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. ■ Encourage the mother to breastfeed when she or the baby recovers.Other breastfeeding support BREASTFEEDING. ■ Relieve pain. . Follow up in 2 weeks. CARE. ■ Advise to seek care if breasts become painful. red. Some women use plant products such as teas made from herbs. The above methods are considered more effective in the long term. Advise the mother who is not breastfeeding at all on how to relieve engorgement (Baby died or stillborn. It does not need to be done if the mother is uncomfortable. if she feels ill or temperature greater than 38ºC. weigh and assess weight gain. mother chose replacement feeding) ■ Breasts may be uncomfortable for a while. It will be less than her baby would take and will not stimulate increased milk production. An analgesic such as ibuprofen. Help her if necessary. ■ Apply a compress. ensure the baby gets the mother’s expressed breast milk if possible. Expressing can be done a few times a day when the breasts are overfull. Pharmacological treatments to reduce milk supply are not recommended. ■ If mother and baby are separated. swollen. or plants such as raw cabbage leaves placed directly on the breast to reduce pain and swelling. Teach the carer how to prepare milk and feed the baby K6 . Do not bind the breasts tightly as this may increase her discomfort. or paracetamol may be used. ■ Support breasts with a well-fitting bra or cloth. ■ Teach the mother to express enough milk to relieve discomfort. ■ Avoid stimulating the breasts. others prefer a cold compress to reduce swelling.

dry. Cover with a blanket. Dry the whole body and hair thoroughly. Place the newborn skin-to-skin on the mother’s chest dressed in a pre-warmed shirt open at the front. rewarm the baby (see below). ■ If the mother and baby must be separated. keep the baby in skin-to-skin position/contact with the mother or other person accompanying the baby. Swaddling makes them cold. ■ Keep the baby within easy reach of the mother. CARE. Keep a small baby warm ■ ■ ■ ■ ■ ■ ■ The room for the baby should be warm (not less than 25°C) with no draught. If cold. Keep the baby warm after the bath. Ensure warmth for the baby K9 . with a dry cloth. encourage the mother to keep the baby in skin-to-skin contact as long as possible. clean and dry surface. a nappy (diaper). Rewarm the baby skin-to-skin ■ ■ ■ ■ ■ ■ ■ ■ ■ Before rewarming. Use a radiant warmer if room not warm or baby small.BREASTFEEDING. wrap the baby in a clean. ■ Dry baby: immediately after birth. ensure baby is dressed or wrapped and covered with a blanket.5ºC or more after 2 hours of rewarming. Do not bath the baby at birth. ■ Dress the baby or wrap in soft dry clean cloth. day and night. socks and a cap. warm cloth and place in a cot. dry immediately and thoroughly. add extra blanket and reassess (see Rewarm the newborn). Keep the baby with the mother until the baby’s body temperature is in normal range. dress or wrap the baby. Do not put the baby on any cold or wet surface. After birth. Explain to the mother the importance of warmth for a small baby. let the baby sleep with the mother or within easy reach to facilitate breastfeeding. Cover the baby with a soft dry cloth. Cover the infant on the mother’s chest with her clothes and an additional (pre-warmed) blanket. ■ At night. If the baby’s temperature is not 36. If the room is not warm enough. Wait at least 6 hours before bathing. Be sure the temperature of the room where the rewarming takes place is at least 25°C. AT HOME ■ Explain to the mother that babies need one more layer of clothes than other children or adults. Do not separate them (rooming-in). Check the temperature every hour until normal. Advise to use extra clothes. ■ Ensure the baby is dressed or wrapped and covered with a blanket. Do not swaddle – wrap too tightly. in warm water. blankets. Cover the head with a cap for the first few days. ■ Keep the room or part of the room warm. place the baby on the mother’s abdomen or on a warm. After bathing. no draught. encourage the mother to keep the baby in skin-to-skin contact for as long as possible. Avoid bathing small babies. especially in a cold climate. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN ENSURE WARMTH FOR THE BABY Keep the baby warm AT BIRTH AND WITHIN THE FIRST HOUR(S) ■ Warm delivery room: for the birth of the baby the room temperature should be 25-28ºC. ■ During the day. reassess the baby J2–J7 . ■ Keep the room for the mother and baby warm. always cover the baby with a blanket and/or use skin-to-skin contact. Wash or bath a baby in a very warm room. remove the baby’s cold clothing. to keep the baby warm or when the baby is not with the mother. If referral needed. ■ 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. ■ If the mother cannot keep the baby skin-to-skin because of complications. especially if baby is small. ■ Assess warmth every 4 hours by touching the baby’s feet: if feet are cold use skin-to-skin contact. Seek care if the baby’s feet remain cold after rewarming. SUBSEQUENTLY (FIRST DAY) ■ Explain to the mother that keeping baby warm is important for the baby to remain healthy. hat and socks. Check frequently if feet are warm. If the baby is small. Do not leave the baby in direct sun.

examine the baby and manage accordingly J2–J7 . If stump is soiled. Keep the baby. Keep the baby away from smoke or people smoking. Wash hands. neck. washing. If umbilicus is red or draining pus or blood. DO NOT share supplies with other babies. Cord care ■ ■ ■ ■ ■ ■ ■ Hygiene (washing. underarms daily. especially a small baby. wash it with clean water and soap. OTHER BABY CARE: ■ Use cloth on baby’s bottom to collect stool. Wash the buttocks when soiled. bathing) AT BIRTH: ■ Wash hands before and after cord care. Fold nappy (diaper) below stump. Dispose of the stool as for woman’s pads. away from sick children or adults. Only remove blood or meconium.Other baby care BREASTFEEDING. DO NOT apply any substances or medicine to stump. Dry it thoroughly with clean cloth. dress and cover after bath. Dry thoroughly. DO NOT bathe the baby before 6 hours old or if the baby is cold. SMALL BABIES REQUIRE MORE CAREFUL ATTENTION: ■ The room must be warmer when changing. Let the baby sleep on her/his back or on the side. DO NOT apply anything in the baby’s eyes except an antimicrobial at birth. DO NOT bathe the baby until at least 6 hours of age. DO NOT remove vernix. bathing and examining a small baby. DO NOT bandage the stump or abdomen. Explain to the mother that she should seek care if the umbilicus is red or draining pus or blood. Put nothing on the stump. Bath when necessary: → Ensure the room is warm. Keep cord stump loosely covered with clean clothes. Wash the face. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN K10 OTHER BABY CARE Always wash hands before and after taking care of the baby. Avoid touching the stump unnecessarily. no draught → Use warm water for bathing → Thoroughly dry the baby. LATER AND AT HOME: ■ ■ ■ Sleeping ■ ■ ■ ■ Use the bednet day and night for a sleeping baby. CARE. .

Squeeze bag attached to the mask with 2 fingers or whole hand. clean and warm surface. stop ventilating ■ ■ ■ Clamp and cut the cord if necessary. Observe rise of chest. ■ Squeeze bag harder with whole hand. Transfer the baby to a dry. 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 → monitor every 15 minutes for breathing and warmth → tell the mother that the baby will probably be well. and nose.The baby is dead. Newborn resuscitation K11 . ■ ■ ■ ■ 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. CARE. Form seal. If chest is not rising: → reposition head → check mask seal. 2 or 3 times.BREASTFEEDING. according to bag size. Look at the chest for in-drawing. Count breaths per minute. If no breathing or gasping at all after 20 minutes of ventilation ■ ■ ■ Stop ventilating. Introduce the suction tube 3 cm into each nostril and suck while withdrawing until no mucus. Keep the baby wrapped and under a radiant heater if possible. Explain to the mother and give supportive care Record the event. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN NEWBORN RESUSCITATION Start resuscitation within 1 minute of birth if baby is not breathing or is gasping for breath. Repeat each suction if necessary but no more than twice and no more than 20 seconds in total. ventilate at 40 squeezes per minute until newborn starts crying or breathing spontaneously. D24 . what you are doing and why ventilate during referral record the event on the referral form and labour record. VENTILATE: Place mask to cover chin. D19 DO NOT leave the baby alone If still no breathing. Open the airway ■ ■ ■ ■ ■ Position the head so it is slightly extended. mouth. Inform the mother that the baby has difficulty initiating breathing and that you will help the baby to breathe. Introduce the suction tube into the newborn’s mouth 5 cm from lips and suck while withdrawing. Observe universal precautions to prevent infection A4 . Suction first the mouth and then the nose. ■ Once good seal and chest rising. Keep the baby warm ■ ■ ■ ■ If breathing or crying.

5 .0 .75 ml 0.6 ml 0.9 kg 2.85 ml 1.3.7 ml 1 ml 1.0 .Treat and immunize the baby (1) BREASTFEEDING.1.9 kg 4.9 kg 4.4 kg 1.9 kg 3.4.5 — 3. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN K12 TREAT THE BABY Treat the baby ■ ■ ■ Determine appropriate drugs and dosage for the baby’s weight.1 ml 0.0 .5 ml 0.0 .2 million units = 1.4 kg 1.5 .75 ml 0.5 — 2.4 kg 3.35 ml 0.1.7 ml 2 ml 2 ml 2 ml .85 ml 2.0 — 4.9 kg 3. Give both ampicillin and gentamicin IM for 5 days in asymptomatic babies classified at risk of infection.1 ml 1.2.4 kg 0.3.4 kg 2.5 ml 0.5 — 1. ■ Demonstrate how to measure a dose.5 ml 2 ml 2.0 .85 ml 1 ml 1. ■ Watch the mother practice measuring a dose by herself. max 75 mg 75 mg per 2 ml vial = 37.9 kg 2. 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 1.4 kg 1 ml 1.0 .4.9 ml 1.4 kg 0.1.5 ml 3 ml 3.5 ml sterile water to 500 mg vial = 200 mg/ml Gentamicin IM Dose: 5 mg per kg every 24 hours if term.5 . ■ Watch the mother give the first dose to the baby. Use a new syringe and needle for each antibiotic. Use a new syringe and needle for each antibiotic.3 ml 1.3.6 ml 0.0 .2 million units/(6ml total volume) = 200 000 units/ml TEACH THE MOTHER TO GIVE TREATMENT TO THE BABY AT HOME ■ Explain carefully how to give the treatment. Give intramuscular antibiotics in thigh.5 ml 4 ml 0.5 ml 0.5 .1.0 — 2. Label and package each drug separately. Ampicillin IM Dose: 50 mg per kg every 12 hours Add 2.5 .4 kg 2.7 ml 0.0 .0 — 3. Tell the mother the reasons for giving the drug to the baby.35 ml 1. severe umbilical infection or severe skin infection.2.1 ml Give IM antibiotic for possible gonococcal eye infection (single dose) Weight Ceftriaxone (1st choice) Dose: 50 mg per kg once 250 mg per 5 ml vial=mg/ml Kanamycin (2nd choice) Dose: 25 mg per kg once.9 kg 2. Give intramuscular antibiotics in thigh. CARE.4 kg 2.4 kg 1.4 kg 3.0 ml 1. 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.2.5 mg/ml Weight 1.6 ml 1.9 kg 4.2.3.9 kg 3.4 kg 3. 4 mg per kg every 24 hours if preterm 20 mg per 2 ml vial = 10 mg/ml Weight 1.0 — 1. ■ Check mother’s understanding before she leaves the clinic.5 .35 ml 0.

Treat for 5 days. to assess weight gain. Birth < 1 week 6 weeks BCG OPV-0 HB1 DPT OPV-1 HB-2 REASSESS IN 2 DAYS: ■ ■ ■ Assess the skin. ■ Dry the area with clean cloth. ■ Wash hands. If pus or redness remains or is worse. Explain and show how the treatment is given. or repeat BCG. ■ Apply 1% tetracycline eye ointment in each eye 3 times daily. Treat and immunize the baby (2) K13 .BREASTFEEDING. ■ Follow up the baby every 2 weeks. refer to hospital. tell the mother to continue treating local infection at home. Age Vaccine TREAT EYE INFECTION Do the following 6-8 times daily: ■ Wash hands with clean water and soap. umbilicus or eyes. ■ Wash hands. Immunize the newborn ■ ■ ■ ■ Give BCG. give BCG only. Record on immunization card and child record. ■ Use the wet cloth to gently wash off pus from the baby’s eyes. ■ Gently wash off pus and crusts with boiled and cooled water and soap. Ask her to let you know if the local infection gets worse and to return to the clinic if possible. Hepatitis B (HB-1) vaccine in the first week of life. CARE. ■ Reassure the mother that it is safe to breastfeed the baby. preferably before discharge. or according to national guidelines. Watch her as she carries out the first treatment. If un-immunized newborn first seen 1-4 weeks of age. OPV-0. TREAT SKIN PUSTULES OR UMBILICAL INFECTION Do the following 3 times daily: ■ Wash hands with clean water and soap. ■ Paint with gentian violet. ■ Delay BCG vaccination until INH treatment completed. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN Treat local infection TEACH MOTHER TO TREAT LOCAL INFECTION ■ ■ ■ ■ 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). ■ Wet clean cloth with boiled and cooled water. If pus and redness have improved. Advise when to return for next immunization.

CARE. skin pustules. Cover the baby with a blanket and cover her/his head with a cap. not feeding at all. PREVENTIVE MEASURES AND TREATMENT FOR THE NEWBORN K14 ADVISE WHEN TO RETURN WITH THE BABY For maternal visits see schedule on D28 . if possible. convulsions. GO TO HEALTH CENTRE AS QUICKLY AS POSSIBLE IF THE BABY HAS ■ ■ ■ ■ ■ ■ difficulty feeding. pus from eyes. if the baby has any of these danger signs: RETURN OR GO TO THE HOSPITAL IMMEDIATELY IF THE BABY HAS ■ ■ ■ ■ ■ ■ ■ Follow-up visits If the problem was: Feeding difficulty Red umbilicus Skin infection Eye infection Thrush Mother has either: → breast engorgement or → mastitis. just born. and either → older than 1 week or → gaining weight adequately Orphan baby INH prophylaxis Treated for possible congenital syphilis Mother HIV-positive Return in 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 7 days 7 days 14 days 14 days 14 days 14 days difficulty breathing. a cord stump which is red or draining pus. Routine visits Postnatal visit Immunization visit (If BCG. or when to return. fever or feels cold. consider giving expressed breast milk by cup K6 . Always send the mother with the baby. Encourage breastfeeding during the journey. yellow skin. very small. bleeding. Refer baby urgently to hospital ■ ■ ■ ■ ■ After emergency treatment. Send referral note with the baby. and either → first week of life or → not adequately gaining weight Low birth weight. diarrhoea. preferably within 2-3 days At age 6 weeks Advise the mother to seek care for the baby Use the counselling sheet to advise the mother when to seek care. feeds <5 times in 24 hours. Protect the baby from direct sunshine. Organize safe transportation. OPV-0 and HB-1 given in the first week of life) Return Within the first week. .Advise when to return with the baby BREASTFEEDING. DURING TRANSPORTATION ■ ■ ■ ■ ■ Keep the baby warm by skin-to-skin contact with mother or someone else. Low birth weight. If the baby does not breastfeed and journey is more than 3 hours. Inform the referral centre if possible by radio or telephone. explain the need for referral to the mother/father.

Use a clean spreader for every sample. Reactive (highly visible clumping) – Positive for syphilis 3. Use a sterile needle and syringe. Take care not to include any red blood cells from the lower part of the separated sample. allow exactly one drop of antigen (20 µl) to fall onto each test sample. drugs and laboratory tests L1 .* Draw up enough antigen for the number of tests to be done (one drop per test). protein is present in the urine. Use sampling pipette to withdraw some of the serum. BOILING METHOD ■ ■ Put urine in test tube and boil top half. Put in a clear test tube. DRUGS AND ■ ■ ■ After 8 minutes rotation. Draw up 5 ml blood from a vein. Be careful not to contaminate the remaining test circles. Laboratory tests (2) Perform rapid plasmareagin (RPR) test for syphilis L5 Equipment. Shake off excess by tapping against side of container. DRUGS AND LABORATORY TESTS L2 EQUIPMENT. Weakly reactive (minimal clumping) – Positive for syphilis L5 LABORATORY TESTS (2) Perform rapid plamareagin (RPR) test for syphilis ■ ■ Important: Several samples may be tested on one card.5% povidone iodine) Tetracycline 1% eye ointment Vitamin A Izoniazid EQUIPMENT. SUPPLIES AND DRUGS FOR CHILDBIRTH CARE Warm and clean room ■ ■ ■ ■ ■ ■ ■ ■ L3 Drugs ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Equipment ■ ■ ■ ■ ■ ■ EQUIPMENT.) EXAMPLE OF A TEST CARD 1 2 3 ■ ■ * Make sure antigen was refrigerated (not frozen) and has not expired. SUPPLIES. Attach dispensing needle to a syringe. Boiled part may become cloudy. A thick precipitate at the bottom of the tube indicates protein. 1. PERFORM RAPID PLASMAREAGIN (RPR) TEST FOR SYPHILIS Perform rapid plasmareagin (RPR) test for syphilis ■ Interpreting results ■ Seek consent. Insert below instructions for method used locally. this will ruin sample) →Catch the middle part of the stream of urine in the cup. Let test tube sit 20 minutes to allow serum to separate (or centrifuge 3-5 minutes at 2000–3000 rpm). supplies. Give woman the clean container and explain where she can urinate. supplies. DRUGS AND TESTS FOR ROUTINE AND EMERGENCY CARE Vaccine ■ Tetanus toxoid EQUIPMENT. EQUIPMENT. ** Room temperature should be 73º-85ºF (22. Non-reactive (no clumping or only slight roughness) – Negative for syphilis 2. Spread the drop to fill the circle using a toothpick or other clean spreader. →If cloudy urine becomes clear. serum will be on top. SUPPLIES AND DRUGS FOR CHILDBIRTH CARE Vaccine ■ ■ ■ Sterilization ■ ■ BCG OPV Hepatitis B Instrument sterilizer Jar for forceps Miscellaneous ■ ■ ■ ■ ■ Contraceptives (see Decision-making tool for family planning providers and clients) Wall clock Torch with extra batteries and bulb Log book Records Refrigerator Equipment. Rotate the test card smoothly on the palm of the hand for 8 minutes.neonatal size Mucus extractor with suction tube Delivery instruments (sterile) ■ ■ ■ ■ ■ ■ Hand washing ■ ■ ■ ■ Clean water supply Soap Nail brush or stick Clean towels 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 ■ ■ ■ ■ ■ ■ ■ ■ Waste ■ ■ ■ ■ Container for sharps disposal Receptacle for soiled linens Bucket for soiled pads and swabs Bowl and plastic bag for placenta Oxytocin Ergometrine Magnesium sulphate Calcium gluconate Diazepam Hydralazine Ampicillin Gentamicin Metronidazole Benzathine penicillin Nevirapine or zidovudine Lignocaine Adrenaline Ringer lactate Normal saline 0. SUPPLIES. Remove container before urine stops. Carefully label each sample with a patient’s name or number. SUPPLIES. DRUGS AND LABORATORY TESTS Equipment.EQUIPMENT. After boiling allow the test tube to stand.** (Or rotate on a mechanical rotator. but becomes cloudy when acetic acid is added.3ºC). Turn or tilt the card to see whether there is clumping (reactive result). Wait specified time (see dipstick instructions). SUPPLIES AND DRUGS LABORATORY TESTS SUPPLIES. drugs and tests for pregnancy and postpartum care EQUIPMENT.9% Water for injection Eye antimicrobial (1% silver nitrate or 2. ■ Analyse urine for protein using either dipstick or boiling method. SUPPLIES. Holding the syringe vertically. inspect the card in good light. DRUGS AND LABORATORY TESTS LABORATORY TESTS L4 L4 LABORATORY TESTS (1) Check urine for protein Check haemoglobin Check urine for protein Label a clean container. 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 Blood pressure machine and stethoscope Body thermometer Fetal stethoscope Baby scale Self inflating bag and mask . Compare with colour chart on label. In the separated sample. DO NOT stir. Teach woman how to collect a clean-catch urine sample. ■ NOTE: Weakly reactive can also be more finely granulated and difficult to see than in this illustration. →If boiled urine was not cloudy to begin with. Squeeze teat to allow one drop (50 µl) of serum to fall onto a circle. SUPPLIES AND DRUGS LABORATORY TESTS SUPPLIES. ■ ■ ■ Check haemoglobin ■ ■ Draw blood with syringe and needle or a sterile lancet. supplies and drugs for childbirth care L3 Laboratory tests (1) EQUIPMENT. SUPPLIES.9% Glucose 50% solution Water for injection Paracetamol Gentian violet Iron/folic acid tablet Mebendazole Sulphadoxine-pyrimethamine EQUIPMENT. SUPPLIES. ✎____________________________________________________________________ ✎____________________________________________________________________ DIPSTICK METHOD ■ ■ ■ ■ Dip coated end of paper dipstick in urine sample. protein is not present. Colours range from yellow (negative) through yellow-green and green-blue for positive.8º–29. DRUGS AND EQUIPMENT. DRUGS AND TESTS FOR ROUTINE AND EMERGENCY PREGNANCY AND POSTPARTUM CARE Warm and clean room ■ ■ ■ L2 Equipment ■ ■ ■ ■ Drugs ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Examination table or bed with clean linen Light source Heat source Blood pressure machine and stethoscope Body thermometer Fetal stethoscope Baby scale Hand washing ■ ■ ■ ■ Clean water supply Soap Nail brush or stick Clean towels Supplies ■ Waste ■ ■ ■ Bucket for soiled pads and swabs Receptacle for soiled linens Container for sharps disposal Sterilization ■ ■ Instrument sterilizer Jar for forceps ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 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 Miscellaneous ■ ■ ■ ■ ■ Tests RPR testing kit Proteinuria sticks ■ Container for catching urine ■ ■ Wall clock Torch with extra batteries and bulb Log book Records Refrigerator Disposable delivery kit ■ ■ ■ Plastic sheet to place under mother Cord ties (sterile) Sterile blade 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 Nevirapine or zidovudine Lignocaine Adrenaline Ringer lactate Normal saline 0. protein is present. DRUGS AND LABORATORY TESTS Delivery bed: a bed that supports the woman in a semi-sitting or lying in a lateral position. Shake antigen. Add 2-3 drops of 2-3% acetic acid after boiling the urine (even if urine is not cloudy) →If the urine remains cloudy. Most test cards include negative and positive control circles for comparison. Explain procedure. Hold the pipette vertically over a test card circle. Ask her to: →Clean vulva with water →Spread labia with fingers →Urinate freely (urine should not dribble over vulva.

SUPPLIES.9% Glucose 50% solution Water for injection Paracetamol Gentian violet Iron/folic acid tablet Mebendazole Sulphadoxine-pyrimethamine Vaccine ■ Tetanus toxoid . drugs and tests for pregnancy and postpartum care EQUIPMENT. DRUGS AND LABORATORY TESTS L2 EQUIPMENT. supplies.Equipment. DRUGS AND TESTS FOR ROUTINE AND EMERGENCY PREGNANCY AND POSTPARTUM CARE Warm and clean room ■ ■ ■ Equipment ■ ■ ■ ■ Drugs ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Examination table or bed with clean linen Light source Heat source Hand washing ■ ■ ■ ■ Blood pressure machine and stethoscope Body thermometer Fetal stethoscope Baby scale Clean water supply Soap Nail brush or stick Clean towels Supplies ■ Waste ■ ■ ■ Bucket for soiled pads and swabs Receptacle for soiled linens Container for sharps disposal Sterilization ■ ■ Instrument sterilizer Jar for forceps ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 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 Miscellaneous ■ ■ ■ ■ ■ Tests ■ ■ ■ Wall clock Torch with extra batteries and bulb Log book Records Refrigerator RPR testing kit Proteinuria sticks Container for catching urine Disposable delivery kit ■ ■ ■ Plastic sheet to place under mother Cord ties (sterile) Sterile blade 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 Nevirapine or zidovudine Lignocaine Adrenaline Ringer lactate Normal saline 0. SUPPLIES.

5% povidone iodine) Tetracycline 1% eye ointment Vitamin A Izoniazid Vaccine ■ ■ ■ BCG OPV Hepatitis B Contraceptives (see Decision-making tool for family planning providers and clients) Equipment.neonatal size Mucus extractor with suction tube Delivery instruments (sterile) ■ ■ ■ ■ ■ ■ Hand washing ■ ■ ■ ■ Clean water supply Soap Nail brush or stick Clean towels Scissors Needle holder Artery forceps or clamp Dissecting forceps Sponge forceps Vaginal speculum Supplies ■ 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 Records Refrigerator 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 Oxytocin Ergometrine Magnesium sulphate Calcium gluconate Diazepam Hydralazine Ampicillin Gentamicin Metronidazole Benzathine penicillin Nevirapine or zidovudine Lignocaine Adrenaline Ringer lactate Normal saline 0. supplies and drugs for childbirth care L3 .9% Water for injection Eye antimicrobial (1% silver nitrate or 2.EQUIPMENT. SUPPLIES AND DRUGS FOR CHILDBIRTH CARE Warm and clean room ■ ■ ■ ■ ■ ■ ■ ■ Equipment ■ ■ ■ ■ ■ ■ Drugs ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ EQUIPMENT. 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 Blood pressure machine and stethoscope Body thermometer Fetal stethoscope Baby scale Self inflating bag and mask . DRUGS AND Delivery bed: a bed that supports the woman in a semi-sitting or lying in a lateral position. SUPPLIES AND DRUGS LABORATORY TESTS SUPPLIES.

Add 2-3 drops of 2-3% acetic acid after boiling the urine (even if urine is not cloudy) →If the urine remains cloudy. Wait specified time (see dipstick instructions). Shake off excess by tapping against side of container. SUPPLIES. Teach woman how to collect a clean-catch urine sample. DRUGS AND LABORATORY TESTS LABORATORY TESTS L4 Check urine for protein ■ ■ ■ Check haemoglobin ■ ■ ■ Label a clean container. →If cloudy urine becomes clear. Draw blood with syringe and needle or a sterile lancet. BOILING METHOD ■ ■ Put urine in test tube and boil top half. Give woman the clean container and explain where she can urinate. Colours range from yellow (negative) through yellow-green and green-blue for positive. protein is present. . this will ruin sample) →Catch the middle part of the stream of urine in the cup. Boiled part may become cloudy.Laboratory tests (1) EQUIPMENT. but becomes cloudy when acetic acid is added. ✎____________________________________________________________________ ✎____________________________________________________________________ DIPSTICK METHOD ■ ■ ■ ■ Dip coated end of paper dipstick in urine sample. Analyse urine for protein using either dipstick or boiling method. After boiling allow the test tube to stand. Remove container before urine stops. protein is not present. Compare with colour chart on label. Ask her to: →Clean vulva with water →Spread labia with fingers →Urinate freely (urine should not dribble over vulva. protein is present in the urine. A thick precipitate at the bottom of the tube indicates protein. →If boiled urine was not cloudy to begin with. Insert below instructions for method used locally.

SUPPLIES AND DRUGS LABORATORY TESTS SUPPLIES.8º–29. Rotate the test card smoothly on the palm of the hand for 8 minutes.3ºC).) EXAMPLE OF A TEST CARD 1 2 3 ■ ■ * Make sure antigen was refrigerated (not frozen) and has not expired. Shake antigen. Hold the pipette vertically over a test card circle. Be careful not to contaminate the remaining test circles. Laboratory tests (2) Perform rapid plasmareagin (RPR) test for syphilis L5 . Put in a clear test tube.** (Or rotate on a mechanical rotator. Most test cards include negative and positive control circles for comparison. Explain procedure. Turn or tilt the card to see whether there is clumping (reactive result). Draw up 5 ml blood from a vein. EQUIPMENT. Spread the drop to fill the circle using a toothpick or other clean spreader. Use a sterile needle and syringe. allow exactly one drop of antigen (20 µl) to fall onto each test sample. Reactive (highly visible clumping) – Positive for syphilis 3. Use sampling pipette to withdraw some of the serum. inspect the card in good light.* Draw up enough antigen for the number of tests to be done (one drop per test). DO NOT stir. Carefully label each sample with a patient’s name or number. Let test tube sit 20 minutes to allow serum to separate (or centrifuge 3-5 minutes at 2000–3000 rpm). Weakly reactive (minimal clumping) – Positive for syphilis ■ Seek consent. serum will be on top. Attach dispensing needle to a syringe. ■ NOTE: Weakly reactive can also be more finely granulated and difficult to see than in this illustration. Non-reactive (no clumping or only slight roughness) – Negative for syphilis 2. DRUGS AND ■ ■ ■ ■ ■ Important: Several samples may be tested on one card. Take care not to include any red blood cells from the lower part of the separated sample. Use a clean spreader for every sample. Holding the syringe vertically. ** Room temperature should be 73º-85ºF (22.PERFORM RAPID PLASMAREAGIN (RPR) TEST FOR SYPHILIS Perform rapid plasmareagin (RPR) test for syphilis ■ Interpreting results After 8 minutes rotation. Squeeze teat to allow one drop (50 µl) of serum to fall onto a circle. In the separated sample. 1.

Care after an abortion M5 Care for the baby after birth INFORMATION AND COUNSELLING SHEETS CARE FOR THE BABY AFTER BIRTH Care of the newborn KEEP YOUR NEWBORN CLEAN ■ ■ ■ M6 M6 Routine visits to the health centre First week after birth: Wash your baby’s face and neck daily. fluids and food for you →Buckets of clean water and soap for washing. ■ Bring your home-based maternal record to every visit. Do not take medication unless prescribed at the health centre. ■ When the baby is born. Then dry completely with clean cloth. day or night. DO NOT wait: ■ Increased bleeding or continued bleeding for 2 days. for you and the skilled attendant →Means to heat water →Three bowls. When to seek care for danger signs Go to hospital or health centre immediately. especially if you feel tired. Breastfeeding and family planning ■ ■ Suggestions for successful breastfeeding Immediately after birth. Change pad every 4 to 6 hours. safe water. ■ ■ ■ ■ Care for yourself during pregnancy ■ ■ ■ ■ ■ ■ ■ Eat more and healthier foods. It is nutritious and has antibodies to help keep your baby healthy. Smelly vaginal discharge. Infection in the area of the wound. breastfeeding and care after an abortion. face and legs. ■ Cut the cord when it stops pulsating. M7 Postpartum bleeding can be reduced due to uterine contractions caused by the baby’s sucking. ■ Bag of water breaks. Take iron tablets as explained by the health worker. Start breastfeeding within 1 hour of birth. ■ Fast or difficult breathing. day or night. ■ Nausea. go to the health centre immediately. ■ Fever. Heavy bleeding (soaks more than 2-3 pads in 15 minutes). You should eat more and healthier foods and rest when you can. feeling ill. keep your baby in the bed with you. a new razor blade to cut the baby’s cord. →Clean cloths of different sizes: for the bed. Go to the health centre as soon as possible if any of the following signs: ■ fever ■ abdominal pain ■ water breaks and not in labour after 6 hours ■ feel ill ■ swollen fingers. →Buckets of clean water and some way to heat this water. even if you do not have any problems. soap and a towel or cloth for drying hands of the birth attendant. →Clean cloths of different sizes: for the bed. Breastfeeding can help delay a new pregnancy. Have the baby near you. Based on your health condition. safe culturally accepted way to dispose of placenta) ■ ■ DO NOT be alone for the 24 hours after delivery. go to the health centre. →Plastic for wrapping the placenta. Do not take medication unless prescribed at the health centre. ■ Painful contractions every 20 minutes or less. ■ Fits. safe water. 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. dressed or wrapped and with head covered with a cap. ■ Backache. not teas. go to the hospital or health centre immediately. 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. DAY AND NIGHT AS OFTEN AND AS LONG AS SHE/HE WANTS. →Prepare the home and the supplies indicated for a safe birth: → Clean. cereals. Yellow eyes or skin. DO NOT pull on the cord to deliver the placenta. Then cover with a clean dry cloth. Go for a routine postpartum visit at 6 weeks. not cereals. You can become pregnant within several weeks after delivery if you have sexual relations and are not breastfeeding exclusively. →Bowls: two for washing and one for the placenta. ■ ■ ■ During the first 6 months after birth. Wash used pad or dispose of it safely. Feeds less than every 5 hours. fish. ■ Wait for the placenta to deliver on its own. →Warm spot for the birth with a clean surface or clean cloth. if your baby has any of the following signs: ■ Difficult breathing ■ Fits ■ Fever ■ Feels cold ■ Bleeding ■ Stops feeding ■ Diarrhoea. ■ ■ ■ ■ ■ CARE AFTER AN ABORTION Self-care ■ ■ ■ ■ ■ Know these danger signs If you have any of these signs. for the examination of you and your baby and to receive preventive measures. not other milk. ■ Bleeding. Wash your hands with soap and water before and after care. ✎____________________________________________________________________ ✎____________________________________________________________________ At 6 weeks : CARE FOR THE BABY AFTER BIRTH Care of the newborn Routine visits to the health centre When to seek care for danger signs CARE FOR THE NEWBORN’S UMBILICAL CORD ■ ■ ■ ■ Keep cord stump loosely covered with a clean cloth. Wash perineum. DO NOT push on the abdomen during labour or delivery. You and your partner should use a condom correctly in every act of sexual intercourse if at risk of STI or HIV. keep at least an area of the room warm. Arrange for a support person to assist the attendant and to stay with you during labour and after delivery. a stick to clean under the nails. including more meat. cheese. including more fruits and vegetables. BREASTFEEDING Breastfeeding has many advantages for the baby and the mother Suggestions for successful breastfeeding Health worker support Breastfeeding and family planning INFORMATION AND COUNSELLING SHEETS FOR THE FIRST 6 MONTHS OF LIFE. it is important to deliver with a skilled attendant. it is strongly recommended that all women deliver with a skilled attendant. red or tender breasts or nipples. eggs. and your menstruation has not returned. for drying and wrapping the baby. the more milk you will produce. ■ Abdominal pain. see the health worker immediately. When to seek care on danger signs Go to the hospital or health centre immediately. ✎____________________________________________________________________ ✎____________________________________________________________________ At these visits your baby will be vaccinated. Breastfeeding M7 Information and counselling sheets M1 . →Clean clothes for you and the baby. DO NOT put ashes. oils. Whether in a hospital. and then offer your second breast. →Food and water for you and the support person. ■ Dizziness or fainting. Ask the attendant to wash her hands before touching you or the baby. ■ Dispose of placenta _____________________________________________ (describe correct. GIVE ONLY BREAST MILK TO YOUR BABY. The health worker can show you how to express milk from your breast with your hands. Danger signs during delivery If you or your baby has any of these signs. her partner and family on care during pregnancy. you are protected against another pregnancy. Rest when you can. If cold. DO NOT wait. Sleep under a bednet treated with insecticide. If stump area is soiled. ■ Fever and too weak to get out of bed. signs for yourself and your baby. clean home delivery. Talk to the health worker about choosing a family planning method which best meets your and your partner’s needs. This will reduce breast problems for the mother. MOTHER If waters break and not in labour after 6 hours. 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. 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. If these signs continue for 12 hours or more. PREGNANCY IS A SPECIAL TIME. Pus coming from the eyes. within easy reach. Do not drink alcohol or smoke. discuss the different options available with the health worker. KEEP YOUR NEWBORN WARM ■ ■ ■ In cold climates. coconut. 3 pieces of string about 20 cm each to tie the cord. ✎____________________________________________________________________ ✎____________________________________________________________________ Encourage helpful traditional practices: ■ ■ ■ ■ →Home-based maternal record. Use a condom in every sexual relation. Rest for a few days. Fold diaper and clothes below stump. and for you to use as sanitary pads. →Home-based maternal record. milk. Irritated cord with pus or blood. put a hat on the baby’s head. ■ At night. particularly the perineum. fish. Change pads every 4 to 6 hours. for cleaning the baby’s eyes. The plan can change if complications develop. Problems urinating. Take iron tablets every day as explained by the health worker. These individual sheets have key information for the mother. Do not put anything on the stump. or if you wish to use another family planning method while breastfeeding. If you have any difficulties with breastfeeding. beans. go to the health centre as soon as you can. ■ CARE AFTER AN ABORTION Self-care Family planning Know these DANGER signs Additional support Additional support ■ The health worker can help you identify persons or groups who can provide you with additional support if you should need it. It helps protect against infections and allergies and helps the baby’s growth and development. according to instructions. For a woman who prefers to deliver at home the following recommendations are provided for a clean home delivery to be reviewed during antenatal care visits. M8 M8 CLEAN HOME DELIVERY (1) Delivery at home with an attendant Instructions to mother and family for a clean and safer delivery at home ■ Routine visits to the health centre 1st visit Before 4 months 2nd visit 6-7 months 3rd visit 8 months 4th visit 9 months Delivery at home with an attendant ■ Ensure the attendant and other family members know the emergency plan and are aware of danger ■ Know the signs of labour If you have any of these signs. REVIEW AND DISCUSS YOUR BIRTH PLAN. health centre or at home. Go to health centre as soon as possible if any of the following signs: Swollen. Increased pain or infection in the perineum. Dry the baby thoroughly and wipe the face with a clean cloth. 3 pieces of string (about 20 cm. let your baby sleep with you. the baby needs nothing more than breast milk — not water. Wash baby’s bottom when soiled and dry it thoroughly. if you or your companion are at risk of sexually transmitted infections (STI) or HIV/AIDS. ■ Talk to the health worker about choosing a family planning method which best meets your and your partner’s needs. →Have these supplies organized for a clean delivery: new razor blade. CARE FOR YOURSELF AND YOUR BABY. Newborns need more clothing than other children or adults. if you breastfeed exclusively. ■ Not able to feed. fluids and food for the mother. or leaking. Wash all over daily. ■ Fits. thoroughly dry your baby and then dress and keep her/him warm. DO NOT wait. two for washing and one for the placenta →Plastic for wrapping the placenta →Bucket for you to urinate in. During cold nights. ■ During your visits to the health centre. M5 Family planning INFORMATION AND COUNSELLING SHEETS Remember you can become pregnant as soon as you have sexual relations. →Clean clothes for you to wear after delivery →Fresh drinking water. AT EVERY VISIT TO THE HEALTH CENTRE. water. nuts. →Fresh drinking water. Individual sheets are used so that the woman can be given the relevant sheet at the appropriate stage of pregnancy and childbirth. ■ At each feeding. ■ M2 INFORMATION AND COUNSELLING SHEETS M2 CARE DURING PREGNANCY Visit the health worker during pregnancy Care for yourself during pregnancy Routine visits to the health centre Know the signs of labour When to seek care on danger signs Clean home delivery (1) CLEAN HOME DELIVERY Regardless of the site of delivery. Bathe her/him when necessary. The more the baby feeds. you can leave your milk and it can be given to the baby in a cup. day or night. vomiting. Wash your hands with soap and water before and after handling your baby. ■ Feels cold. Do not drink alcohol or smoke. The health worker can put you in contact with a breastfeeding support group. each) to tie the cord. Sleep under a bednet treated with insecticide. cover the baby with an extra blanket. PREPARING A BIRTH AND EMERGENCY PLAN Preparing a birth plan The health worker will provide you with information to help you prepare a birth plan. ■ Make sure you and your baby are warm. Avoid lifting heavy objects. Preparing a birth and emergency plan M3 Clean home delivery (2) M9 Care for the mother after birth INFORMATION AND COUNSELLING SHEETS CARE FOR THE MOTHER AFTER BIRTH Care of the mother ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ M4 M4 Routine visits to the health centre First week after birth: INFORMATION AND COUNSELLING SHEETS Eat more and healthier foods. not juices. day and night. FOR THE MOTHER ■ ■ ■ The health worker can help you to correctly position the baby and ensure she/he attaches to the breast. ■ ■ ■ ■ ■ BREASTFEEDING Breastfeeding has many advantages FOR THE BABY ■ ■ The health worker can support you in starting and maintaining breastfeeding ■ ■ During the first 6 months of life. within the first hour of birth. preferably within the first days. →Warm covers for you and the baby. the health worker can make suggestions as to where it would be best to deliver. cheese and milk. Return to the health worker as indicated. Keep the baby away from smoke. you need to go immediately. vegetables. ■ Fever. for drying and wrapping the baby. beans. →A clean delivery kit which includes soap. Do not have sexual intercourse until bleeding stops.INFORMATION AND COUNSELLING SHEETS Care during pregnancy INFORMATION AND COUNSELLING CARE DURING PREGNANCY Visit the health worker during pregnancy Go to the health centre if you think you are pregnant. Wash pad or dispose of it safely. 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: PREPARING A BIRTH AND EMERGENCY PLAN Preparing a birth plan Planning for delivery at home Preparing an emergency plan Planning for delivery at the hospital or health centre Avoid harmful practices FOR EXAMPLE: DO NOT use local medications to hasten labour. and for you to use as sanitary pads.The health worker will tell you when to return. Have your baby immunized. →For handwashing. especially after touching her/his bottom. preparing a birth and emergency plan. ■ If at any time you have any concerns about your or your baby’s health. using the disposable delivery kit. consider: CLEAN HOME DELIVERY (2) Avoid harmful practices Encourage helpful traditional practices Danger signs during delivery Routine visits to the health centre ■ Planning for delivery at home INFORMATION AND COUNSELLING SHEETS ■ ■ ■ ■ ■ →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? M3 INFORMATION AND COUNSELLING SHEETS 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. ■ Visit the health centre at least 4 times during your pregnancy. Rest when you can. ■ While breastfeeding. The baby’s suck stimulates your milk production. alternate and begin with the second breast. 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. or within easy reach. If you should need to leave the baby with another caretaker for short periods. After bathing. DO NOT wait. day or night. DO NOT bath the baby on the first day. ✎____________________________________________________________________ ✎____________________________________________________________________ 6 weeks after birth: CARE FOR THE MOTHER AFTER BIRTH Care of the mother Family planning Routine visits to the health centre When to seek care for danger signs Family planning ■ ■ ✎____________________________________________________________________ ✎____________________________________________________________________ When to seek care for danger signs Go to hospital or health centre immediately. wash with clean water and soap. place her/him on your abdomen/chest where it is warm and clean. you should drink plenty of clean. Use a family planning method to prevent an unwanted pregnancy. ■ Start breastfeeding when the baby shows signs of readiness. day or night. Go to the health centre as soon as possible if your baby has any of the following signs: Difficulty feeding. fruits. and clean cloths to cover the birth place. Placenta not expelled 1 hour after birth of baby. It is easily digested and efficiently used by the baby’s body. ■ Give your baby the first milk (colostrum). Breast milk contains exactly the water and nutrients that a baby’s body needs. Drink plenty of clean. care for the mother and baby after delivery. At the next feeding. ■ Difficulty in breathing. If you do not meet these requirements. Labour pains (contractions) continue for more than 12 hours. DO NOT wait. DO NOT insert any substances into the vagina during labour or after delivery. OTHER ADVICE ■ ■ Let the baby sleep on her/his back or side. ✎____________________________________________________________________ ✎____________________________________________________________________ BABY ■ Very small. if any of the following signs: ■ Vaginal bleeding has increased. ■ Foul-smelling vaginal discharge. M9 Preparing an emergency plan ■ To plan for an emergency. cow dung or other substance on umbilical cord/stump. ■ Severe headaches with blurred vision. It is important to begin care as early in your pregnancy as possible. DO NOT wait for waters to stop before going to health facility. meat. The nails of the attendant should be short and clean. ■ Bloody sticky discharge. 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. let the baby feed and release your breast.

cheese. fish. CARE FOR YOURSELF AND YOUR BABY.Care during pregnancy INFORMATION AND COUNSELLING CARE DURING PREGNANCY Visit the health worker during pregnancy ■ ■ ■ ■ M2 Routine visits to the health centre 1st visit 2nd visit 3rd visit 4th visit Before 4 months 6-7 months 8 months 9 months ■ Go to the health centre if you think you are pregnant. beans. Sleep under a bednet treated with insecticide. Go to the health centre as soon as possible if any of the following signs: ■ fever ■ abdominal pain ■ water breaks and not in labour after 6 hours ■ feel ill ■ swollen fingers. Bring your home-based maternal record to every visit. Visit the health centre at least 4 times during your pregnancy. including more fruits and vegetables. DO NOT wait. eggs. . Rest when you can. 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. go to the health centre as soon as you can. If at any time you have any concerns about your or your baby’s health. ■ Bloody sticky discharge. 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. ■ Painful contractions every 20 minutes or less.The health worker will tell you when to return. During your visits to the health centre. face and legs. Avoid lifting heavy objects. Do not drink alcohol or smoke. Do not take medication unless prescribed at the health centre. If these signs continue for 12 hours or more. even if you do not have any problems. meat. PREGNANCY IS A SPECIAL TIME. 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. Take iron tablets every day as explained by the health worker. go to the health centre. day or night. Care for yourself during pregnancy ■ ■ ■ ■ ■ ■ ■ Eat more and healthier foods. When to seek care on danger signs Go to the hospital or health centre immediately. milk. Know the signs of labour If you have any of these signs. It is important to begin care as early in your pregnancy as possible. you need to go immediately. ■ Bag of water breaks.

fluids and food for the mother. consider: Planning for delivery at home INFORMATION AND COUNSELLING SHEETS ■ ■ ■ ■ ■ →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? 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. →Warm spot for the birth with a clean surface or clean cloth. and for you to use as sanitary pads. a stick to clean under the nails. Whether in a hospital. →Fresh drinking water. The plan can change if complications develop. Preparing a birth and emergency plan M3 . 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. the health worker can make suggestions as to where it would be best to deliver. →Clean cloths of different sizes: for the bed. and for you to use as sanitary pads. →Warm covers for you and the baby. for drying and wrapping the baby. →Plastic for wrapping the placenta. 3 pieces of string (about 20 cm. Based on your health condition. AT EVERY VISIT TO THE HEALTH CENTRE. for drying and wrapping the baby. Preparing an emergency plan ■ To plan for an emergency. water. a new razor blade to cut the baby’s cord. →Home-based maternal record. health centre or at home. →For handwashing. →Clean clothes for you and the baby. →Bowls: two for washing and one for the placenta. it is important to deliver with a skilled attendant. →A clean delivery kit which includes soap. each) to tie the cord. →Food and water for you and the support person. →Buckets of clean water and some way to heat this water. for cleaning the baby’s eyes.PREPARING A BIRTH AND EMERGENCY PLAN Preparing a birth plan The health worker will provide you with information to help you prepare a birth plan. soap and a towel or cloth for drying hands of the birth attendant. →Clean cloths of different sizes: for the bed. REVIEW AND DISCUSS YOUR BIRTH PLAN.

Sleep under a bednet treated with insecticide. particularly the perineum. Use a condom in every sexual relation. including more meat. Wash pad or dispose of it safely. Rest when you can. Do not drink alcohol or smoke. beans. Drink plenty of clean. ■ Severe headaches with blurred vision. or leaking. cheese and milk. if you or your companion are at risk of sexually transmitted infections (STI) or HIV/AIDS. ■ Fits. ■ Fast or difficult breathing. DO NOT wait. oils. fish. red or tender breasts or nipples. Wash all over daily. if any of the following signs: ■ Vaginal bleeding has increased. fruits. Change pad every 4 to 6 hours. ■ Fever and too weak to get out of bed.Care for the mother after birth INFORMATION AND COUNSELLING SHEETS CARE FOR THE MOTHER AFTER BIRTH Care of the mother ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ M4 Routine visits to the health centre First week after birth: Eat more and healthier foods. ■ Problems urinating. . coconut. day or night. Take iron tablets as explained by the health worker. ■ Smelly vaginal discharge. Go to health centre as soon as possible if any of the following signs: ■ Swollen. vegetables. ■ Increased pain or infection in the perineum. ■ Infection in the area of the wound. Do not take medication unless prescribed at the health centre. cereals. ✎____________________________________________________________________ ✎____________________________________________________________________ 6 weeks after birth: Family planning ■ ■ ✎____________________________________________________________________ ✎____________________________________________________________________ When to seek care for danger signs Go to hospital or health centre immediately. nuts. Talk to the health worker about choosing a family planning method which best meets your and your partner’s needs. safe water. You can become pregnant within several weeks after delivery if you have sexual relations and are not breastfeeding exclusively.

■ Fever. Do not have sexual intercourse until bleeding stops. Return to the health worker as indicated. Family planning ■ ■ INFORMATION AND COUNSELLING SHEETS Remember you can become pregnant as soon as you have sexual relations. go to the health centre immediately. ■ Dizziness or fainting. Wash used pad or dispose of it safely. Wash perineum. Use a family planning method to prevent an unwanted pregnancy. ■ Abdominal pain. You and your partner should use a condom correctly in every act of sexual intercourse if at risk of STI or HIV. Talk to the health worker about choosing a family planning method which best meets your and your partner’s needs. Rest for a few days. ■ 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. DO NOT wait: ■ Increased bleeding or continued bleeding for 2 days.CARE AFTER AN ABORTION Self-care ■ ■ ■ ■ ■ Know these danger signs If you have any of these signs. day or night. Care after an abortion M5 . Change pads every 4 to 6 hours. ■ Nausea. feeling ill. vomiting. especially if you feel tired. ■ Backache.

DO NOT wait. wash with clean water and soap. Wash baby’s bottom when soiled and dry it thoroughly. cover the baby with an extra blanket. keep at least an area of the room warm. if your baby has any of the following signs: ■ Difficulty breathing ■ Fits ■ Fever ■ Feels cold ■ Bleeding ■ Stops feeding ■ Diarrhoea. ■ Pus coming from the eyes. put a hat on the baby’s head. day or night. Wash your hands with soap and water before and after handling your baby. Bathe her/him when necessary. Do not put anything on the stump. ✎____________________________________________________________________ ✎____________________________________________________________________ At 6 weeks : CARE FOR THE NEWBORN’S UMBILICAL CORD ■ ■ ■ ■ Keep cord stump loosely covered with a clean cloth. Go to the health centre as soon as possible if your baby has any of the following signs: ■ Difficulty feeding. During cold nights. After bathing. When to seek care for danger signs Go to hospital or health centre immediately. Newborns need more clothing than other children or adults. Then dry completely with clean cloth. ■ Yellow eyes or skin. If stump area is soiled. . Wash your hands with soap and water before and after care. OTHER ADVICE ■ ■ Let the baby sleep on her/his back or side. Have your baby immunized. thoroughly dry your baby and then dress and keep her/him warm.Care for the baby after birth INFORMATION AND COUNSELLING SHEETS CARE FOR THE BABY AFTER BIRTH Care of the newborn KEEP YOUR NEWBORN CLEAN ■ ■ ■ M6 Routine visits to the health centre First week after birth: Wash your baby’s face and neck daily. ■ Irritated cord with pus or blood. ✎____________________________________________________________________ ✎____________________________________________________________________ At these visits your baby will be vaccinated. ■ Feeds less than every 5 hours. If cold. KEEP YOUR NEWBORN WARM ■ ■ ■ In cold climates. Fold diaper and clothes below stump. especially after touching her/his bottom. Keep the baby away from smoke.

Postpartum bleeding can be reduced due to uterine contractions caused by the baby’s sucking. If you have any difficulties with breastfeeding. Start breastfeeding within 1 hour of birth. Give your baby the first milk (colostrum). within easy reach. DAY AND NIGHT AS OFTEN AND AS LONG AS SHE/HE WANTS. At the next feeding. If you do not meet these requirements. you should drink plenty of clean. It is easily digested and efficiently used by the baby’s body. INFORMATION AND COUNSELLING SHEETS FOR THE FIRST 6 MONTHS OF LIFE. let the baby feed and release your breast. alternate and begin with the second breast. The baby’s suck stimulates your milk production.BREASTFEEDING Breastfeeding has many advantages FOR THE BABY ■ ■ The health worker can support you in starting and maintaining breastfeeding ■ ■ During the first 6 months of life. and then offer your second breast. While breastfeeding. not other milk. The health worker can show you how to express milk from your breast with your hands. not teas. keep your baby in the bed with you. safe water. let your baby sleep with you. This will reduce breast problems for the mother. discuss the different options available with the health worker. GIVE ONLY BREAST MILK TO YOUR BABY. if you breastfeed exclusively. the more milk you will produce. It helps protect against infections and allergies and helps the baby’s growth and development. At night. If you should need to leave the baby with another caretaker for short periods. not juices. Breastfeeding can help delay a new pregnancy. The health worker can put you in contact with a breastfeeding support group. It is nutritious and has antibodies to help keep your baby healthy. Breastfeeding and family planning ■ ■ Suggestions for successful breastfeeding ■ ■ ■ ■ ■ ■ ■ Immediately after birth. you are protected against another pregnancy. or if you wish to use another family planning method while breastfeeding. the baby needs nothing more than breast milk — not water. see the health worker immediately. you can leave your milk and it can be given to the baby in a cup. not cereals. At each feeding. FOR THE MOTHER ■ ■ ■ The health worker can help you to correctly position the baby and ensure she/he attaches to the breast. You should eat more and healthier foods and rest when you can. or within easy reach. Breastfeeding M7 . The more the baby feeds. and your menstruation has not returned. During the first 6 months after birth. Breast milk contains exactly the water and nutrients that a baby’s body needs. day and night.

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. Arrange for a support person to assist the attendant and to stay with you during labour and after delivery. →Prepare the home and the supplies indicated for a safe birth: → Clean. Make sure you and your baby are warm. within the first hour of birth. 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. two for washing and one for the placenta →Plastic for wrapping the placenta →Bucket for you to urinate in. and clean cloths to cover the birth place.Clean home delivery (1) INFORMATION AND COUNSELLING SHEETS CLEAN HOME DELIVERY Regardless of the site of delivery. Ask the attendant to wash her hands before touching you or the baby. fluids and food for you →Buckets of clean water and soap for washing. according to instructions. The nails of the attendant should be short and clean. Start breastfeeding when the baby shows signs of readiness. Then cover with a clean dry cloth. DO NOT bath the baby on the first day. For a woman who prefers to deliver at home the following recommendations are provided for a clean home delivery to be reviewed during antenatal care visits. 3 pieces of string about 20 cm each to tie the cord. →Have these supplies organized for a clean delivery: new razor blade. Wait for the placenta to deliver on its own. Cut the cord when it stops pulsating. using the disposable delivery kit. . Dry the baby thoroughly and wipe the face with a clean cloth. safe culturally accepted way to dispose of placenta) DO NOT be alone for the 24 hours after delivery. →Clean clothes for you to wear after delivery →Fresh drinking water. When the baby is born. for you and the skilled attendant →Means to heat water →Three bowls. M8 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. place her/him on your abdomen/chest where it is warm and clean. Have the baby near you. Dispose of placenta _____________________________________________ (describe correct. it is strongly recommended that all women deliver with a skilled attendant. dressed or wrapped and with head covered with a cap.

cow dung or other substance on umbilical cord/stump.Avoid harmful practices FOR EXAMPLE: DO NOT use local medications to hasten labour. preferably within the first days. Labour pains (contractions) continue for more than 12 hours. DO NOT push on the abdomen during labour or delivery. MOTHER If waters break and not in labour after 6 hours. Danger signs during delivery If you or your baby has any of these signs. DO NOT wait. ■ Not able to feed. Go for a routine postpartum visit at 6 weeks. Clean home delivery (2) M9 . DO NOT wait for waters to stop before going to health facility. ✎____________________________________________________________________ ✎____________________________________________________________________ INFORMATION AND COUNSELLING SHEETS Encourage helpful traditional practices: ■ ■ ■ ■ ✎____________________________________________________________________ ✎____________________________________________________________________ BABY ■ Very small. ■ Fever. 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. Heavy bleeding (soaks more than 2-3 pads in 15 minutes). go to the hospital or health centre immediately. ■ Fits. ■ Bleeding. Placenta not expelled 1 hour after birth of baby. DO NOT put ashes. DO NOT insert any substances into the vagina during labour or after delivery. ■ Difficulty in breathing. DO NOT pull on the cord to deliver the placenta. for the examination of you and your baby and to receive preventive measures. day or night. ■ Feels cold.

.. . . was baby weighing: 2500 g or more less than 2500 g International form of medical certificate of cause of death N7 Records and forms N1 ..... . Fill out other required records such as immunization cards for the mother and baby. ..... .... Revised on 25 August 2003... . FEEDBACK RECORD ■ FEEDBACK RECORD WHO IS REFERRING NAME FACILITY RECORD NUMBER ADMISSION DATE DISCHARGE DATE TIME TIME WOMAN NAME ADDRESS MAIN REASONS FOR REFERRAL DIAGNOSES ■ Emergency ■ Non-emergency ■ To accompany the baby BABY AGE NAME BIRTH WEIGHT MAIN REASONS FOR REFERRAL DIAGNOSES DATE OF BIRTH AGE AT DISCHARGE (DAYS) ■ Emergency ■ Non-emergency ■ To accompany the mother TREATMENTS GIVEN AND TIME TREATMENTS GIVEN AND TIME TREATMENTS AND RECOMMENDATIONS ON FURTHER CARE TREATMENTS AND RECOMMENDATIONS ON FURTHER CARE RECORDS AND FORMS FOLLOW-UP VISIT WHEN WHERE FOLLOW-UP VISIT WHEN WHERE PREVENTIVE MEASURES PREVENTIVE MEASURES IF DEATH: DATE CAUSES Sample form to be adapted.. . for the purposes of monitoring and surveillance and official reporting.. ...... Due to (or as consequence of) (d) .. .. . .. .. Due to (or as consequence of) (C) .. . .. ... Hep-0 RPR result and treatment TB test result and prophylaxis ARV IF REFERRED (MOTHER OR NEWBORN).. respiratory failure. the woman and her family... . . .... .... ... . .. . ... .. stating (a) .... . e.. . ... Modify national or local records to include all the relevant sections needed to record important information for the provider.... . . .. . .. .. ... . ... . . ..RECORDS AND FORMS Referral record RECORDS AND FORMS REFERRAL RECORD WHO IS REFERRING NAME FACILITY ACCOMPANIED BY THE HEALTH WORKER RECORD NUMBER REFERRED DATE ARRIVAL DATE TIME TIME N2 N2 REFERRAL RECORD ■ WOMAN NAME ADDRESS MAIN REASONS FOR REFERRAL ■ Emergency ■ Non-emergency ■ To accompany the baby BABY AGE NAME BIRTH WEIGHT MAIN REASONS FOR REFERRAL MAJOR FINDINGS (CLINICA AND TEMP . heart failure...... Revised on 13 June 2003.. . . .. .) DATE AND HOUR OF BIRTH GESTATIONAL AGE ■ Emergency ■ Non-emergency ■ To accompany the mother Records are suggested not so much for the format as for the content.. ... .. . .. injury or complication that caused death. ... .. . (b) ..... ... . but not related to the disease or condition causing it... .. Revised on 25 August 2003. ... . Revised on 13 June 2003. .. .. ..... .. . ... ........ ... . . .. .. LAST (BREAST)FEED (TIME) TREATMENTS GIVEN AND TIME BEFORE REFERRAL TREATMENTS GIVEN AND TIME BEFORE REFERRAL DURING TRANSPORT DURING TRANSPORT ■ N3 INFORMATION GIVEN TO THE WOMAN AND COMPANION ABOUT THE REASONS FOR REFERRAL INFORMATION GIVEN TO THE WOMAN AND COMPANION ABOUT THE REASONS FOR REFERRAL Sample form to be adapted.... . . giving rise to the above cause...... . . DELIVERY AND POSTPARTUM NAME ADDRESS DURING LABOUR ADMISSION DATE ADMISSION TIME TIME ACTIVE LABOUR STARTED TIME MEMBRANES RUPTURED TIME SECOND STAGE STARTS ENTRY EXAMINATION STAGE OF LABOUR NOT IN ACTIVE LABOUR ■ NOT IN ACTIVE LABOUR HOURS SINCE ARRIVAL 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 1 2 3 4 5 6 7 8 9 10 11 12 ACTIVE LABOUR ■ PLANNED MATERNAL TREATMENT AT OR AFTER BIRTH – MOTHER BIRTH TIME OXYTOCIN – TIME GIVEN PLACENTA COMPLETE NO ■ YES ■ TIME DELIVERED ESTIMATED BLOOD LOSS AT OR AFTER BIRTH – NEWBORN LIVEBIRTH ■ STILLBIRTH: FRESH ■ MACERATED ■ RESUSCITATION NO ■ YES ■ BIRTH WEIGHT GEST... .. .. .. . .. . .. RECORD TIME AND EXPLAIN Sample form to be adapted.. . .. ...... . .. The content of the records is adjusted to the content of the Guide. .. APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH . .) . . . . It means the disease.. .. .... Revised on 13 June 2003... ..... AGE SECOND BABY OR PRETERM NO ■ YES ■ PLANNED NEWBORN TREATMENT AGE PARITY RECORD NUMBER N4 N4 LABOUR RECORD IF MOTHER REFERRED DURING LABOUR OR DELIVERY. .. II Other significant conditions contributing to the death. . . MAJOR FINDINGS (CLINICA AND BP TEMP LAB.. ...... .. .. .. N5 RECORDS AND FORMS Postpartum record RECORDS AND FORMS POSTPARTUM RECORD MONITORING AFTER BIRTH TIME RAPID ASSESSMENT BLEEDING (0 + ++) UTERUS HARD/ROUND? EVERY 5-15 MIN FOR 1ST HOUR 2 HR 3 HR 4 HR 8 HR 12 HR 16 HR 20 HR 24 HR N6 ADVISE AND COUNSEL MOTHER ■ ■ ■ ■ ■ N6 Postpartum care and hygiene Nutrition Birth spacing and family planning Danger signs Follow-up visits POSTPARTUM RECORD MATERNAL: BLOOD PRESSURE PULSE URINE VOIDED VULVA NEWBORN: BREATHING WARMTH NEWBORN ABNORMAL SIGNS (LIST) BABY ■ ■ ■ ■ ■ Exclusive breastfeeding Hygiene.. . .. cord care and warmth Special advice if low birth weight Danger signs Follow-up visits PREVENTIVE MEASURES FOR MOTHER ■ FEEDING WELL ■ DIFFICULTY ■ ■ ■ TIME FEEDING OBSERVED COMMENTS Iron/folate Vitamin A Mebendazole Sulphadoxine-pyrimethamine Tetanus toxoid immunization RPR test result and treatment ARV PLANNED TREATMENT MOTHER TIME TREATMENT GIVEN ■ ■ ■ ■ FOR BABY NEWBORN ■ ■ Risk of bacterial infection and treatment BCG. .. .. .. . .. .. . . PARTOGRAPH USE THIS FORM FOR MONITORING ACTIVE LABOUR 10 cm 9 cm N5 PARTOGRAPH 8 cm 7 cm 6 cm 5 cm 4 cm FINDINGS Hours in active labour Hours since ruptured membranes Rapid assessment B3-B7 Vaginal bleeding (0 + ++) Amniotic fluid (meconium stained) TIME 1 2 3 4 5 6 7 8 9 10 11 12 RECORDS AND FORMS 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 Sample form to be adapted.... .. Due to (or as consequence of) . .. ... TIME AND CAUSE: ■ Sample form to be adapted.. .. ... .. . . . INTERNATIONAL FORM OF MEDICAL CERTIFICATE OF CAUSE OF DEATH CAUSE OF DEATH I Disease or condition directly leading to death* Antecedent causes Morbid conditions.. . IF DEATH: DATE CAUSES Feedback record N3 Labour record RECORDS AND FORMS LABOUR RECORD USE THIS RECORD FOR MONITORING DURING LABOUR... . .. g If exact birth weight not known.. . ... .... ...... CONSIDER COLLECTING THE FOLLOWING INFORMATION III If the deceased is a female. . ... . . if any. but pregnant within 42 days of death Pregnant at the time of death Unknown if pregnant or was pregnant within 42 days of death IV If the deceased is an infant and less than one month old ■ ■ What was the birth weight: . DATE. was she ■ ■ RECORDS AND FORMS ■ ■ Not pregnant Not pregnant...g... ........ . RECORD TIME AND EXPLAIN: ■ ■ IF DEATH (MOTHER OR NEWBORN). OPV-0... .. ... ...... N7 INTERNATIONAL FORM OF MEDICAL CERTIFICATE OF CAUSE OF DEATH * This does not mean the mode of dying. .. . .... ...... . ... ... . .. . . .. .. ........ ... . . . .. . . . . . ... .

) DATE AND HOUR OF BIRTH GESTATIONAL AGE ■ Emergency ■ Non-emergency ■ To accompany the mother MAJOR FINDINGS (CLINICA AND BP TEMP LAB. LAST (BREAST)FEED (TIME) TREATMENTS GIVEN AND TIME BEFORE REFERRAL TREATMENTS GIVEN AND TIME BEFORE REFERRAL DURING TRANSPORT DURING TRANSPORT INFORMATION GIVEN TO THE WOMAN AND COMPANION ABOUT THE REASONS FOR REFERRAL INFORMATION GIVEN TO THE WOMAN AND COMPANION ABOUT THE REASONS FOR REFERRAL Sample form to be adapted. .Referral record RECORDS AND FORMS REFERRAL RECORD WHO IS REFERRING NAME FACILITY ACCOMPANIED BY THE HEALTH WORKER RECORD NUMBER REFERRED DATE ARRIVAL DATE TIME TIME N2 WOMAN NAME ADDRESS MAIN REASONS FOR REFERRAL ■ Emergency ■ Non-emergency ■ To accompany the baby BABY AGE NAME BIRTH WEIGHT MAIN REASONS FOR REFERRAL MAJOR FINDINGS (CLINICA AND TEMP . .. Revised on 13 June 2003.) .

Revised on 25 August 2003. IF DEATH: DATE CAUSES Feedback record N3 .FEEDBACK RECORD WHO IS REFERRING NAME FACILITY RECORD NUMBER ADMISSION DATE DISCHARGE DATE TIME TIME WOMAN NAME ADDRESS MAIN REASONS FOR REFERRAL DIAGNOSES ■ Emergency ■ Non-emergency ■ To accompany the baby BABY AGE NAME BIRTH WEIGHT MAIN REASONS FOR REFERRAL DIAGNOSES DATE OF BIRTH AGE AT DISCHARGE (DAYS) ■ Emergency ■ Non-emergency ■ To accompany the mother TREATMENTS GIVEN AND TIME TREATMENTS GIVEN AND TIME TREATMENTS AND RECOMMENDATIONS ON FURTHER CARE TREATMENTS AND RECOMMENDATIONS ON FURTHER CARE RECORDS AND FORMS FOLLOW-UP VISIT WHEN WHERE FOLLOW-UP VISIT WHEN WHERE PREVENTIVE MEASURES PREVENTIVE MEASURES IF DEATH: DATE CAUSES Sample form to be adapted.

Revised on 13 June 2003. DELIVERY AND POSTPARTUM NAME ADDRESS DURING LABOUR ADMISSION DATE ADMISSION TIME TIME ACTIVE LABOUR STARTED TIME MEMBRANES RUPTURED TIME SECOND STAGE STARTS ENTRY EXAMINATION STAGE OF LABOUR NOT IN ACTIVE LABOUR ■ NOT IN ACTIVE LABOUR HOURS SINCE ARRIVAL 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 1 2 3 4 5 6 7 8 9 10 11 12 ACTIVE LABOUR ■ PLANNED MATERNAL TREATMENT AT OR AFTER BIRTH – MOTHER BIRTH TIME OXYTOCIN – TIME GIVEN PLACENTA COMPLETE NO ■ YES ■ TIME DELIVERED ESTIMATED BLOOD LOSS AT OR AFTER BIRTH – NEWBORN LIVEBIRTH ■ STILLBIRTH: FRESH ■ MACERATED ■ RESUSCITATION NO ■ YES ■ BIRTH WEIGHT GEST. AGE SECOND BABY OR PRETERM NO ■ YES ■ PLANNED NEWBORN TREATMENT AGE PARITY RECORD NUMBER N4 IF MOTHER REFERRED DURING LABOUR OR DELIVERY. . RECORD TIME AND EXPLAIN Sample form to be adapted.Labour record RECORDS AND FORMS LABOUR RECORD USE THIS RECORD FOR MONITORING DURING LABOUR.

Revised on 13 June 2003.PARTOGRAPH USE THIS FORM FOR MONITORING ACTIVE LABOUR 10 cm 9 cm 8 cm 7 cm 6 cm 5 cm 4 cm FINDINGS Hours in active labour Hours since ruptured membranes Rapid assessment B3-B7 Vaginal bleeding (0 + ++) Amniotic fluid (meconium stained) TIME 1 2 3 4 5 6 7 8 9 10 11 12 RECORDS AND FORMS 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 Sample form to be adapted. N5 .

OPV-0. DATE. TIME AND CAUSE: ■ Sample form to be adapted. Revised on 25 August 2003. cord care and warmth Special advice if low birth weight Danger signs Follow-up visits PREVENTIVE MEASURES FOR MOTHER ■ FEEDING WELL ■ DIFFICULTY ■ ■ ■ TIME FEEDING OBSERVED COMMENTS Iron/folate Vitamin A Mebendazole Sulphadoxine-pyrimethamine Tetanus toxoid immunization RPR test result and treatment ARV PLANNED TREATMENT MOTHER TIME TREATMENT GIVEN ■ ■ ■ ■ FOR BABY NEWBORN ■ ■ Risk of bacterial infection and treatment BCG. . Hep-0 RPR result and treatment TB test result and prophylaxis ARV IF REFERRED (MOTHER OR NEWBORN). RECORD TIME AND EXPLAIN: ■ ■ IF DEATH (MOTHER OR NEWBORN).Postpartum record RECORDS AND FORMS POSTPARTUM RECORD MONITORING AFTER BIRTH TIME RAPID ASSESSMENT BLEEDING (0 + ++) UTERUS HARD/ROUND? EVERY 5-15 MIN FOR 1ST HOUR 2 HR 3 HR 4 HR 8 HR 12 HR 16 HR 20 HR 24 HR N6 ADVISE AND COUNSEL MOTHER ■ ■ ■ ■ ■ Postpartum care and hygiene Nutrition Birth spacing and family planning Danger signs Follow-up visits MATERNAL: BLOOD PRESSURE PULSE URINE VOIDED VULVA NEWBORN: BREATHING WARMTH NEWBORN ABNORMAL SIGNS (LIST) BABY ■ ■ ■ ■ ■ Exclusive breastfeeding Hygiene.

.. ... was she ■ ■ RECORDS AND FORMS ■ ■ Not pregnant Not pregnant. .. . ....g. .. .. . .... .... .. . ... It means the disease. . . .. . . . . .. .... injury or complication that caused death.. .... . ... .... ..... ... .. . . ... .... ...... .... . ... ... ... ... ..... . . ...... . .. . . .... . but not related to the disease or condition causing it. ... .. ....... ..... . ... . but pregnant within 42 days of death Pregnant at the time of death Unknown if pregnant or was pregnant within 42 days of death IV If the deceased is an infant and less than one month old What was the birth weight: ... .. ... . . g If exact birth weight not known......... .. . . ... . * This does not mean the mode of dying.... ........ .... APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH . ... . .. ... ... .. .. . ... ... . ..... . .. . .... .. . . . ... . . e. . .......... . ... .... . CONSIDER COLLECTING THE FOLLOWING INFORMATION III If the deceased is a female. .. ..... . ...... Due to (or as consequence of) (d) . . .. . . . . (b) . .. ... . . . . .. . ... . . .. . . . if any. ..... respiratory failure. was baby weighing: ■ 2500 g or more ■ less than 2500 g International form of medical certificate of cause of death N7 . .. ... ... . ....... . . . giving rise to the above cause. . . ..... ..INTERNATIONAL FORM OF MEDICAL CERTIFICATE OF CAUSE OF DEATH CAUSE OF DEATH I Disease or condition directly leading to death* Antecedent causes Morbid conditions...... ...... ... . . II Other significant conditions contributing to the death. heart failure. Due to (or as consequence of) (C) . .... . . stating (a) .. Due to (or as consequence of) . .... ... . . ..

A plan to seek care for danger signs during pregnancy. CONTRAINDICATION A condition occurring during another disease or aggravating it. Economic and social differences need to be taken into account when determining needs and establishing links within a given community. ADVISE To give information and suggest to someone a course of action. BABY A very young boy or girl in the first week(s) of life. ANTENATAL CARE Care for the woman and fetus during pregnancy. FOLLOW-UP VISIT A return visit requested by a health worker to see if further treatment or referral is needed. CLINIC As used in this guide.Glossary and acronyms GLOSSARY AND ACRONYMS ABORTION Termination of pregnancy from whatever cause before the fetus is capable of extrauterine life. reviewing options. duration of pregnancy (gestational age) is expressed in 3 different ways: Trimester First Second Third Months less than 4 months 4-6 months 7-9+ months Weeks less than 16 weeks 16-28 weeks 29-40+ weeks GRUNTING Soft short sounds that a baby makes when breathing out. indispensable. and a shared destiny. COMPLICATION A condition occurring during pregnancy or aggravating it. CHILDBIRTH Giving birth to a baby or babies and placenta. COMPLAINT As described in this guide. This classification includes conditions such as obstructed labour or bleeding. or a woman more than 49 years. birth weight should preferably be measured within the first hour of life before significant postnatal weight loss has occurred. or ward. ADOLESCENT Young person 10–19 years old. . It places emphasis on provider support for helping the woman make decisions. Grunting occurs when a baby is having difficulty breathing. and adoption. As used in this guide. childbirth and postpartum period. after abortion. COMMUNITY As used in this guide. ESSENTIAL Basic. after delivery. for the woman and newborn. a group of people sometimes living in a defined geographical area. hospital maternity or emergency unit. BIRTH Expulsion or extraction of the baby (regardless of whether the cord has been cut). to examine a woman or baby and identify signs of illness. marriage. the concerns or symptoms of illness or complication need to be assessed and classified in order to select treatment. CONFIDENCE A feeling of being able to succeed. sexual partnership. FACILITY A place where organized care is provided: a health post. For live births. CHILDBEARING AGE (WOMAN) 15-49 years. rural health post. COUNSELLING As used in this guide. a sheet presenting information in the form of a table. who share common culture. and making decisions. FAMILY Includes relationships based on blood. necessary. and a broad range of groups whose bonds are based on feelings of trust mutual support. when pregnant. values and norms. GESTATIONAL AGE Duration of pregnancy from the last menstrual period. In this guide. ASSESS To consider the relevant information and make a judgement. EMERGENCY SIGNS Signs of life-threatening conditions which require immediate intervention. health centre. CONCERN A worry or an anxiety that the woman may have about herself or the baby(ies). any first-level outpatient health facility such as a dispensary. other family member or friend who accompanies the woman during labour and delivery. also a girl 10-14 years. CHART As used in this guide. DANGER SIGNS Terminology used to explain to the woman the signs of life-threatening and other serious conditions which require immediate intervention. preferences and available resources. BIRTH COMPANION Partner. CLASSIFY To select a category of illness and severity based on a woman’s or baby’s signs and symptoms. As used in this guide. recorded to the degree of accuracy to which it is measured. BIRTH AND EMERGENCY PLAN A plan for safe childbirth developed in antenatal care visit which considers the woman’s condition. This classification includes conditions such as obstructed labour or bleeding. BIRTH WEIGHT The first of the fetus or newborn obtained after birth. interaction with a woman to support her in solving actual or anticipated problems. health centre or outpatient department of a hospital.

and urgent and safe referral to the next level of care. In this guide used interchangeable with baby. including family planning. LABOUR As used in this guide. physical evidence of a health problem which the health worker observes by looking. SECONDARY HEALTH CARE More specialized care offered at the most peripheral level. detection and management of complications in the context of her environment and according to her wishes. For the purposes of this guide. lethargy. anaemia.g. or by the woman herself). PRE-REFERRAL Before referral to a hospital. INTEGRATED MANAGEMENT A process of caring for the woman in pregnancy. weak pulse. and emergency first aid. convulsions. hypertension. from complete delivery of the placenta to 42 days after delivery. 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. or unconsciousness. listening. URGENT As used in this guide. PRETERM BABY Born early. for further assessment and care to a higher level of care. SHOCK A dangerous condition with severe weakness. and communicating with the referral institution. (Among the essential activities are maternal and child health care. health centre or maternity clinic. a hospital providing care for normal pregnancy and childbirth. e. a family member. SIGN As used in this guide. care of women with complications of pregnancy and childbirth. PREMATURE Before 37 completed weeks of pregnancy. during and after childbirth. MISCARRIAGE Premature expulsion of a non-viable fetus from the uterus. immediate initial management of the life-threatening conditions. sending a woman or baby. RAPID ASSESSMENT AND MANAGEMENT Systematic assessment of vital functions of the woman and the most severe presenting signs and symptoms. fast breathing. feeling or measuring. a period from the onset of regular contractions to complete delivery of the placenta. 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. that includes considering all necessary elements: care to ensure they remain healthy. POSTPARTUM CARE Care for the woman provided in the postpartum period. PREGNANCY Period from when the woman misses her menstrual period or the uterus can be felt. a traditional birth attendant. before 37 completed weeks of pregnancy. and for her newborn. PRIMARY HEALTH CARE* Essential health care accessible at a cost the country and community can afford. PARTNER As used in this guide. for example radiographic diagnostic. “free union”) who is the father of the baby or the actual sexual partner. PRIMARY HEALTH CARE LEVEL Health post. and diagnosis and treatment of uncommon and severe diseases. to the onset of labour/elective caesarian section or abortion. or obstructed labour. REASSESSMENT As used in this guide. Instruction that should be followed. general surgery. supplies and expertise to treat a woman or newborn with complications. to examine the woman or baby again for signs of a specific illness or condition to see if she or the newborn are improving. MONITORING Frequently repeated measurements of vital signs or observations of danger signs.HOME DELIVERY Delivery at home (with a skilled attendant. and the provision of essential drugs). and fast. and prevention. appropriate treatment of common diseases and injuries. It is caused by severe bleeding. NEWBORN Recently born infant. severe infection. REFERRAL HOSPITAL A hospital with a full range of obstetric services including surgery and blood transfusion and care for newborns with problems. RECOMMENDATION Advice. MATERNITY CLINIC Health centre with beds or a hospital where women and their newborns receive care during childbirth and delivery. (This kind of care is provided by trained staff at such institutions as district or provincial hospitals). GLOSSARY AND ACRONYMS Glossary . any health facility with inpatient beds. or both. HOSPITAL As used in this guide. LOW BIRTH WEIGHT BABY Weighing less than 2500 g at birth. immunization. POSTNATAL CARE Care for the baby after birth. PRIORITY SIGNS Signs of serious conditions which require interventions as soon as possible. If number of weeks not known. before they become lifethreatening. the male companion of the pregnant woman (husband. REFERRAL. cold extremeties. 1 month early. scientifically sound and socially acceptable. Examples of signs: bleeding. including arranging for transport and care during transport. up to two weeks. preparing written information (referral form). with methods that are practical.

STILLBIRTH Birth of a baby that shows no signs of life at birth (no gasping. health units. a health problem reported by a woman. SYMPTOM As used in this guide. TRIMESTER OF PREGNANCY See Gestational age. →conduct deliveries on her/his own and care for the mother and newborn. this includes provision of preventive care. perform selected obstetrical procedures such as manual removal of placenta and newborn resuscitation. 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. →provide emergency care for the woman and newborn. clinics. PERMANENT Continuous presence and observation of a woman in labour. VERY SMALL BABY Baby with birth weight less than 1500g or gestational age less than 32 weeks. breathing or heart beat). such as pain or headache. For conditions where there are no official WHO definitions. SURVEILLANCE. prescribe and give drugs (IM/IV) and infusions to the mother and baby as needed. . midwives.Glossary GLOSSARY AND ACRONYMS SKILLED ATTENDANT Refers exclusively to people with midwifery skills (for example. TERM. and detection and appropriate referral of abnormal conditions. her family and community. for the purposes of this guide. FULL-TERM Word used to describe a baby born after 37 completed weeks of pregnancy. ■ Is able to do the following: →give necessary care and advice to women during pregnancy and postpartum and for their newborn infants. →provide health information and counselling for the woman. STABLE Staying the same rather than getting worse. SMALL BABY A newly born infant born preterm and/or with low birth weight. again only for the purposes of this guide. WHO definitions have been used where possible but. or in any other service setting. have been modified where necessary to be more appropriate to clinical care (reasons for modification are given). 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. operational terms are proposed. in the home. including for post-abortion care.

delivery and interpregnancy record for the woman and some information about the newborn. INH Isoniazid. TBA A person who assists the mother during childbirth. PAL Practical approach to lung health guidelines RAM Systematic assessment of vital functions of the woman and the most severe presenting signs and symptoms. IV Intravenous (injection or infusion). caused by infection with human immunodeficiency virus (HIV). given at birth. TT An immunization against tetanus VCT Voluntary counselling and testing for HIV > More than ≥ Equal or more than < Less than ≤ Equal or less than GLOSSARY AND ACRONYMS Acronyms . a drug to treat tuberculosis. LBW Low birth weight: birth weight less than 2500 g. Hb Haemoglobin. FHR Fetal heart rate. HMBR Home-based maternal record: pregnancy. To prevent poliomyelitis. LAM Lactation amenorrhea. OPV-0 Oral polio vaccine. HIV Human immunodeficiency virus. ORS Oral rehydration solution. ANC Care for the woman and fetus during pregnancy. immediate initial management of the life-threatening conditions. HIV is the virus that causes AIDS. a TBA would initially acquire skills by delivering babies herself or through apprenticeship to other TBAs. AIDS is the final and most severe phase of HIV infection. OPV-0 is given at birth. a feeding tube put into the stomach through the nose. As used in this guide. and urgent and safe referral to the next level of care. IUD Intrauterine device. BPM Beats per minute. HB-1 Vaccine given at birth to prevent hepatitis B. a drug to treat HIV infection. LMP Last menstrual period: a date from which the date of delivery is estimated. BCG An immunization to prevent tuberculosis. In general. NG Naso-gastric tube. It can be performed in the clinic. ARV Antiretroviral drug. IM Intramuscular injection.ACRONYMS AIDS Acquired immunodeficiency syndrome. BP Blood pressure. 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. RPR Rapid plasma reagin. IU International unit. MTCT Mother-to-child transmission of HIV. a drug used to prevent mother-to-child transmission of HIV. a rapid test for syphilis. STI Sexually transmitted infection.

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h e a l t h . i n t / r e p r o d u c t i v e . please contac t: D e p a r t m e n t o f R e p r o d u c t i v e H e a l t h a n d R e s e a r c h RR F a m i l y a n d C o m m u n i t y H e a l t h . w h o . S w i t z e r l a n d Fa x : + 4 1 2 2 7 9 1 4 1 8 9 / 4 1 7 1 E . Wo r l d H e a l t h O r g a n i z a t i o n Av e n u e A p p i a 2 0 .1 2 1 1 G e n e v a 2 7 . i n t For updates to this publication.m a i l : re p ro d u c t i ve h e a l t h @ w h o. C H .Design: M·ire NÌ Mhear·in For more information. please visit the maternal and newborn health section of WHO's reproductive health web site at: ISBN 92 4 159084 X w w w.

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