Nekemte Health Science Collage

Department of Health Extension

Nekemte
Dec, 2023

04/09/2024 PNC 1
 MANAGING POST-NATAL
CARE

FOR HEALTH EXTENSION

LEVEL –IV
Prepared By G.F (BSC/MPH)

04/09/2024 PNC 2
 Managing Post-natal Care

At the end of the module the learner will be able to:

LO1. Promote postnatal services for newborn and
mother
LO2. Provide neonatal care
LO3. Provide postnatal care for mothers
LO4. Organize follow up of maternal and newborn
health services

04/09/2024 PNC 3
LO1. Promote postnatal services for newborn
and mother

At the end of this unit, you will be able to:

 Conduct observation for mother and infant and made
records in line with standard protocols and organizational
guidelines
 Provide information and support for self-care and
wellbeing
 Provide advice on routine care of the newborn to mothers
 Demonstrate how to establish and support exclusive breast-
feeding

04/09/2024 PNC 4
 CONT…
 Provide health education on nutrition, exercise,
rest, sleep and family care in the immediate
postnatal period
 Identify post-natal problems related to mothers and
newborn
 Discuss the information on: contraceptive options,
immunization practices, personal hygiene

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 Introduction

• Most maternal deaths in the world occur in the

postpartum period, especially within the first two days
• Only 34% of women reported receiving a PNC check-
up in the first 2 days after birth
• The communities may observe practices that keep
mothers and babies indoors for the first month after
birth a period of seclusion.
• If mothers or babies become ill during the period of
seclusion, seeking formal health care is often delayed.

04/09/2024 PNC 6
 CONT…
• Three crucial delays can be outlined:-
 delay in recognition of complications,
 delay in reaching appropriate care, and
 delay in receiving appropriate care.
• Giving newborns cold baths, discarding colostrum, and
providing food other than breast milk soon after birth can be
harmful.
• Applying butter, ash, or other substances such as cow dung to
the umbilical stump increase the risks of infection.

04/09/2024 PNC 7
 1.1 Observation for Mother and Infant
• A large proportion of maternal and neonatal deaths occur
during the first 48 hours after birth.
• PNC for both the mother and the child is important to treat any
complications arising from the delivery,
• provide information on how to care for herself and her child.
• Safe motherhood programmes recommend that all women
receive a check of their health within two days after delivery.
• It is recognized that the mother with her family may need a
time of privacy after the birth.
• Observation during postpartum period should focus on
physical; psychological and social components.

04/09/2024 PNC 8
 Physical Observation
 HEP can observe for a postpartum mother from head
to toe and check for signs of soaked clothes, bleeding,
lethargy, tiredness, and dehydration.
 The ability to move from one to another place, and
facial expression upon painful feelings can also be
observed.
 They must also be aware to note excess bleeding or a
change in the mother’s condition during this time.
 They must know when it is necessary to call for help
and how to do so if they are concerned
04/09/2024 PNC 9
 Psychological Observation

• After giving birth, many factors can pose the mother

for mood disorders.
• Lack of her partner and/or family support is one of
the main reasons for mood disorder during this
period.
• Lack of sleep and sufficient rest can also harm her
psychologically.

04/09/2024 PNC 10
 Social Observation
• Socially, the interaction with other family
members, her partner and the neonate can be
observed.
• Observation of the baby may be transferred to
family if this is deemed clinically appropriate.
• The baby must be well, the mother alert and the
family be responsible for the time specified.
• During this time the mother and her family must
understand the baby’s nose and mouth are clear and
observe the baby’s colour and respirations.
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• Ongoing observation of the baby includes,
but is not limited to, assessing the baby’s:
• Colour, heart rate, respiratory rate,
temperature, airway integrity and overall
condition
• Tone and activity
• Ability to breastfeed/feed

04/09/2024 PNC 12
 CONT…
Ongoing assessment of the mother includes but is not
limited to:
• Assessing the mother’s overall sense of wellbeing and
mobility
• Observing for uterine height, position and tone through
palpation
• Observing blood loss whether known loss is consistent
with maternal condition
• Monitoring temperature, pulse, respirations, blood pressure
and consciousness level following all births (frequency
depends on context)
04/09/2024 PNC 13
 CONT…
• Urine output
• Monitoring bleeding from lacerations, episiotomy or
caesarean section wound
• Assessing pain relief requirements
• Assessing block levels if epidural or spinal anaesthetic was
used
• Facilitating and supervising early skin-to-skin contact and
breastfeeding as soon as possible after birth,
• ensuring the baby’s nose and mouth are not occluded and
that parents also understand the importance of this
• Assessing bonding of mother, father, family and baby.
04/09/2024 PNC 14
 1.2 Information and Support for Self-
Care and Wellbeing
• The World Health Organization’s working definition of self-care
includes “the ability of individuals, families and communities to
promote health, prevent disease, maintain health, and cope with
illness and disability with or without the support of a health-care
provider” (Narasimhan M. 2019).
• Healthcare systems do exist, self-care remains a crucial
component for maintaining health for the postpartum woman and
her newborn.
• Perineal care is a daily self-care practice in which the mother is in
control of the health their genitalia
• Self-care interventions increase choice, accessibility, and
affordability, as well as opportunities for the mother to make
informed decisions regarding their health and healthcare
04/09/2024 PNC 15
.
• It can be thought of using two complementary frames:
people-centred and system-centred.
• Normative guidance will be essential to redraw the boundaries
of a stronger healthcare system that includes self-care.
• The ability to access and use societal and familial resources
contributes to personal agency and autonomy and determines
health outcomes.
• self-care is about caring and the relational context, finding
ways to enable good self-care and avoid social and cultural
iatrogenesis of self-medicalization.
• The capacity to meet physical, physiological, psychological,
and self-fulfillment needs is important.

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 1.3 Routine Postnatal Care
• What is routine PNC?It is preventive care practices and routine
assessments to identify and manage or refer complications for both
mother and baby including:
Essential routine PNC for all mothers
• Assess and check for bleeding, check temperature
• Support breastfeeding, checking the breasts to prevent mastitis
• Manage anaemia, promote nutrition and insecticide treated bed nets,
give vitamin A supplementation
• Complete tetanus toxoid immunisation, if required
• Provide counseling and a range of options for family planning
• Refer for complications such as bleeding, infections, or postnatal
depression
• Counsel on danger signs and home care
04/09/2024 PNC 17
 Essential routine PNC for all newborns

• Assess for danger signs, measure and record

weight, and check temperature and feeding
• Support optimal feeding practices, particularly
exclusive breastfeeding
• Promote hygiene and good skin, eye and cord
care
• If prophylactic eye care is local policy and has
not been given, it is still effective until 12 hours
after birth
• Promote clean, dry cord care
04/09/2024 PNC 18
 CONT…
• Identify superficial skin infections, such as pus draining
from umbilicus, redness extending from umbilicus to skin,
more than 10 skin pustules, and swelling, redness, and
hardness of skin, and treat or refer if the baby also has
danger signs
• Ensure warmth by delaying the baby’s first bath to after the
first 24 hours, practicing skin-to-skin care, and putting a hat
on the baby
• Encourage and facilitate birth registration
• Refer for routine immunizations
• Counsel on danger signs and home care
04/09/2024 PNC 19
 CONT…
Extra Care for LBW or Small Babies and Other
Vulnerable Babies, such as those born to HIV- infected
mothers (two or three extra visits)
• The majority of newborn deaths occur in LBW babies,
many of whom are preterm.
• Intensive care is not needed to save the majority of these
babies.
• Around one third could be saved with simple care,
including:-
 Identify the small baby
 Assess for danger signs and manage or refer as appropriate
04/09/2024 PNC 20
 CONT…
• Provide extra support for breastfeeding, including
expressing milk and cup feeding, if needed
• Pay extra attention to warmth promotion, such as
skin-to-skin care or Kangaroo Mother Care
• Ensure early identification and rapid referral of
babies who are unable to breastfeed or accept
expressed breast milk
• Provide extra care for babies whose mothers are
HIV-positive, particularly for feeding support
04/09/2024 PNC 21
1.4 Establishing and Supporting Exclusive Breast-feeding

1.4.1 Exclusive Breast-feeding:

• Early and exclusive breastfeeding (if HIV negative or
HIV status unknown; or HIV positive woman makes
informed decision to exclusively breastfeed):
This can be achieved by:
• Feeding guidelines
• Additional advice for woman
• Breast care
• Breastfeeding information and support provide as needed

04/09/2024 PNC 22
 Feeding Guidelines:

• Early skin to skin contact of mother and baby and immediate

initiation of breast feeding.
• Women should be encouraged to maintain exclusive breast
feeding for six months and should be educated about effective
breastfeeding practices,
• breastfeeding problems, how to continue breast feeding for two
years and to start complementary feeding after six months.
Postpartum education and counseling includes:
• Correct positioning of the baby at the breast
• Exclusive breast feeding.: No other fluids e.g. herbs, glucose, or
sugar water should be given
• Encouraging breast feeding on demand
04/09/2024 PNC 23
 CONT…
• Breastfeed on demand day and night every 2-3 hours during
first weeks
• Initiate breastfeeding within 2-3 hours of Caesarean section;
when the mother is conscious
• Incase breast feeding can’t be started due to either maternal or
newborn illness, feeding the baby has to be initiated if possible
by milk sucked from the mother herself
• Rooming in throughout the hospital stay of mother and baby

04/09/2024 PNC 24
 Additional Advice for breast feed women

• Choose position that is comfortable and effective

• Use both breasts at each feed; do not limit time at either
• Ensure adequate sleep/rest take nap when baby sleeps
• Ensure adequate food/fluid intake glass of fluids per feed;
extra meal per day.

04/09/2024 PNC 25
 Breast Care:

• To prevent engorgement, breastfeed every 2-3 hours

• Wear supportive (but not tight) brassier or binder
• Keep nipples clean and dry.
• Wash nipples with water only once per day no soap
• After breastfeeding, leave milk on nipples and allow to air
dry
• If there is a medical contraindication to breastfeeding, firm
support of the breasts can suppress lactation.
• For many women, tight binding of the breasts, cold packs,
and analgesics followed by firm support effectively control
temporary symptoms while lactation is being suppressed.
04/09/2024 PNC 26
 1.4.2 Counselling in Establishing and Supporting Exclusive
Breast-feeding

• Counseling is a process and interaction between

counselors and pregnant women or mothers.
• Breastfeeding counseling is therefore not intended to be
a “top-down”intervention of “telling women what to do”.
• The aim of breastfeeding counselling is to empower
women to breastfeed, while respecting their personal
situations and wishes.
• Breastfeeding counselling is, therefore, never to be
forced upon any woman.
• The following recommendations should be addressed
during counseling:
04/09/2024 PNC 27
 CONT…
• Breastfeeding counselling should be provided to all pregnant
women and mothers with young children.
• Breastfeeding counselling should be provided in both the
antenatal period and postnatally, and up to 24 months or
longer.
• Breastfeeding counselling should be provided at least six
times, and additionally as needed.

04/09/2024 PNC 28
 Explain to the mother that:

• Breast milk contains most optimal level of nutrients to satisfy the

baby needs.
• It is easily digestible and protects the baby against infection.
• Exclusive breastfeeding should be initiated within 1 hour of birth.
• This means babies should not have any other food or drink up to
the age of six months.
• Breastfeeding helps baby’s growth and development and
promotes mother-baby bonding.
• Encourage breastfeeding on demand, day and night, as long as
the baby wants, 8 or more times in 24 hours.
Note: Exclusive breastfeeding helps delay a new pregnancy.

04/09/2024 PNC 29
• Check that position and attachment are correct at the first feed.
• Offer assistance any time when the mother needs.
• Offer the breasts alternatively until each breast empties
• If the mother is ill and unable to breastfeed, help her to express
breast milk and feed the baby by cup.
• Advise the mother on medication and breastfeeding:
• Commonly given drugs to lactating mothers are generally
considered safe; thus the baby can continue to breastfed.
• If mother is taking some drugs, cotrimoxazole, Fansidar or the
like, monitor baby for jaundice and any other abnormal signs.
• If mother is not around, let her express breast milk and let
somebody else feed the expressed breast milk to the baby by cup.

04/09/2024 PNC 30
 Timing of Breastfeeding Counselling

• Postnatal breastfeeding counselling further supports

mothers and their families in enabling them to build
closeness, with skin-to-skin contact and responsive
feeding.
Frequency of Breastfeeding Counseling
• Provision of at least six breastfeeding counselling .
• Policy-makers and implementers are duty-bound to
ensure that breast feeding counselling contacts are of
sufficient quality and quantity to be effective,
• while ensuring that their use does not expose the
mothers and their families to financial hardship.
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• People-centred breastfeeding counselling means that the
counselling responds to the individual mothers’and
families’ needs, preferences and values.
• The minimum of six breastfeeding counselling contacts
may occur at the following time points:
 Before birth (antenatal period);
 During and immediately after birth (perinatal period up
to the first 2–3 days after birth);
 At 1–2 weeks after birth (neonatal period);
 In the first 3–4 months (early infancy);
 At 6 months (at the start of complementary feeding); and
 After 6 months (late infancy and early childhood),
04/09/2024 PNC 32
• People-centred breastfeeding counselling means that the
counselling responds to the individual mothers’and
families’ needs, preferences and values.
• The minimum of six breastfeeding counselling contacts
may occur at the following time points:
 Before birth (antenatal period);
 During and immediately after birth (perinatal period up
to the first 2–3 days after birth);
 At 1–2 weeks after birth (neonatal period);
 In the first 3–4 months (early infancy);
 At 6 months (at the start of complementary feeding); and
 After 6 months (late infancy and early childhood),
04/09/2024 PNC 33
 Mode of Breastfeeding Counseling
• Individual face-to-face counselling may be complemented but
not replaced by telephone c
• Anticipatory Breastfeeding Counseling refers to evaluating
and assessing potential and existing challenges that may
impact the mothers’ breastfeeding goals.
• The anticipatory nature of breastfeeding counselling helps to
reduce potential risks, problems or complications, for optimal
breastfeeding.
• In difficult or complicated circumstances, positive feedback
and emotional support are especially needed to support the
mothers’ confidence and self-efficacy in breastfeeding
counselling and/or other technologies.

04/09/2024 PNC 34
1.5 Nutrition in the Immediate Postnatal Period

• A regular diet should be offered as soon as the woman requests

food and is conscious.
• Intake should be increased by 10% (not physically active) to
20% (moderately or very active) to cover energy cost of lactation.
• Women should be advised to eat a diet that is rich in proteins and
fluids. That is:-
 Eating more of staple food (cereal or tuber)
 Greater consumption of non-saturated fats
 Encourage foods rich in iron (e.g., liver, dark green leafy
vegetables, etc.)
 Avoid all dietary restrictions

04/09/2024 PNC 35
 General Guidelines:

• Eat balanced diet including variety of foods each day

• Have at least one extra serving of staple food per day
• Try smaller, more frequent meals if necessary
• Take micronutrient supplements as directed.
• Folic acid, vitamin A, zinc, calcium, iron and other
nutrients if micronutrient requirements cannot be
met through food sources.

04/09/2024 PNC 36
 Guidelines for Breastfeeding Women:

• Inform the woman that during lactation she needs

approximately 550 kcal extra in a day during the first 6
months, and
• then 450 kcal extra during the next 6 months, compared to
her pre-pregnancy diet.
Per day breast feeding women needs:
• Two extra servings of staple food
• Eat a diverse diet with animal products and fortified foods –
no specific foods should be eaten or avoided
• Drink in response to thirst; excessive fluids not needed
• Avoid alcohol and tobacco, which can decrease milk
production
04/09/2024 PNC 37
 1.6 Exercise, Restand Sleep in the immediate
postnatal period
• All postpartum mothers need additional rest to speed
recovery.
• Breastfeeding women need even more rest wait at least 4
to 5 weeks to resume normal activity; start back gradually
Exercise
• Sit-ups or curl-ups, (rising from supine to semi-setting
position), done in bed with the hips and knees flexed,
tighten only abdominal muscles, usually without causing
backache.
• Kegel’s exercise is also recommended to strengthen the
pelvic floor

04/09/2024 PNC 38
• In association with bed rest, graduated exercises
restore muscle tone to stretched areas and maintain
venous flow in limbs and pelvis. They are focused on:
• Breathing exercises.
• Legs to prevent stagnation of blood in veins.
• Abdominal wall to restore tone of rectus muscles.
• Pelvic floor to restore levator ani muscle.
• Exercises are best taught by a physiotherapist in
hospital teaching women what to do after leaving.
• Fifteen minutes twice a day should be set aside for
these for some weeks.

04/09/2024 PNC 39
 Advantages of postnatal exercises

• Gives the women a sense of well beingness

• Maintains good circulation, lessens possibility of venous
thrombosis.
• Restores muscle tone of the abdominal wall & pelvic floor.
• Promotes for normal drainage of lochia.
• Prevents hypostatic pneumonia.
• Helps in emptying the bladder, bowels and uterus.
• Permits her to enjoy a daily bath.
• Enables her to take early care of her baby.
• Restores her body figure.
• Will accelerate involution of uterus
04/09/2024 PNC 40
 1.7 Personal Hygiene and Family Care in the
Immediate Postnatal Period

• Good general hygiene (hand washing, safe food and water

preparation/handling, bathing and general cleanliness)
• Good genital hygiene – especially important for postpartum
women because more susceptible to infection .
• Vaginal douching is avoided in early puerperium, till after
bleeding stops completely and all wounds are healed.
• The vulva should be cleaned from front to back.
• Women are encouraged to defecate before leaving the
hospital, although with early discharge.

04/09/2024 PNC 41
 CONT…
• Maintaining good bowel function can prevent or help
relieve existing hemorrhoids, which can be treated with
warm sitz baths.
• Encourage touching, holding, exploring
• Encourage Rooming-in
• Encourage sharing in care of newborn
• Assist in devising strategies for overcoming challenges
• Help build confidence
• Provide reassurance that woman is capable of caring for
newborn
04/09/2024 PNC 42
 Emotional Support
• Transient depression (baby blues) is common during the
first week after delivery.
• Symptoms are typically mild and usually subside by 7 to 10
days.
• Treatment is supportive care and reassurance.
• Persistent depression, lack of interest in the infant, suicidal
or homicidal thoughts, hallucinations, delusions, or
psychotic behavior may require intensive counseling and
antidepressants or antipsychotic.
• Women with a preexisting mental disorder are at high risk
of recurrence or exacerbation during the puerperium and
should be monitored closely
04/09/2024 PNC 43
 1.8 Contraceptive Options in the Immediate Postnatal
Period
• Return of fertility after birth is not predictable, can occur
before menstruation resumes.
• On average, women who do not breastfeed, ovulate by 11
weeks.
• Those who breastfeed exclusively for 3 months ovulate by 4-5
month sand breastfeed exclusively for 6 months; ovulate by 7
months (due to lactation amenorrhea).
• ovulation can occur as early as 4-6 weeks after birth.
• All postpartum women should receive family planning
education and counseling before discharge.
• counseling for postpartum contraception should start during
the antenatal period, and should be an integral part of
antenatal care.
04/09/2024 PNC 44
• Women should also be given a choice of receiving a family
planning method in the labor ward before discharge from
hospital or at a family planning clinic within the first 40 days
postpartum.
• Facilitate free informed choice for all women
• Reinforce that non-hormonal methods (lactation amenorrhea,
barrier methods, IUD and sterilization) are best options for
lactating mothers.
• Initiate progestin only methods after 6 weeks postpartum to
breastfeeding women, if woman chooses a hormonal method.
• Advise against use of combined oral contraceptives in
breastfeeding women in the first 6 months after childbirth or
until weaning, whichever comes first
04/09/2024 PNC 45
 CONT…

• Women who are interested in immediate initiation of

contraception should be offered a family planning
method before discharge.
• Women who were counseled during antenatal care and
who had indicated a desire for postpartum IUD insertion
or tubal ligation could have an IUD inserted at delivery
(post placental IUD insertion) or have mini lap for tubal
ligation.
• Other women could have an IUD inserted before
discharge or receive any other method depending on
their needs.
04/09/2024 PNC 46
 1.9 Immunization Practices in the Immediate
Postnatal Period
Iron and folate supplementation:
• To prevent anemia, prescribe: iron 60 mg + folate 400
mcg orally once daily for 3 months
• Dispense supply to last until next visit
• Eat foods rich in vitamin C, which help iron
absorption
• Avoid tea, coffee, and colas, which inhibit iron
absorption
• Possible side effects of iron/folate black stools,
constipation, and nausea.
04/09/2024 PNC 47
• Vitamin A: one dose of 200,000 IU within 30 days after
childbirth in vitamin A deficient regions.
• Iodine supplementation: 400–600 mg by mouth or IM as
soon as possible after childbirth if never given, or if given
before the third trimester (only in areas where deficiencies
exist).
• Tetanus Toxoid
• Six monthly presumptive treatments with broad-spectrum
anti-helminthic
• Insecticide-treated nets (ITNs) for malaria both mother and
baby should sleep under one ITN.
• VDRL/ RPR
• HIV testing (opt-out)
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 1.10 Post-natal Problems Related to Mothers
and Newborn
 Some of the list of minor maternal and neonatal problems
Maternal problems
• After pain
• Hemorrhoids, difficulty of defecation
• Hypotension, dehydration, restlessness
• Lack of sleep
• Full bladder
• Postpartum blues and other mood disorders
• Sub-involutions
• Problems related to breast like cracked nipples, engorgement
• Loss of appetite
• Abnormal vaginal discharge etc.
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 Neonatal problems
• Seizure
• Unable to feed breastmilk
• Poor or lack of reaction to stimuli
• High pitched cry
• Different types of birth injury like cephalohematoma, shoulder
dislocation, caput succedaneum etc.
• Dry oral mucosa with or without black lips
• Chest indrawning
• Unable to breastfeed (Unable to suck or sucking poorly)
• Convulsions
• Lethargy, drowsiness or coma (loss of consciousness), apnea
(cessation of breathing for >20 secs).
• Breathing ≤ 30 or ≥ 60 breaths per minute, grunting, severe chest in
drawing, blue tongue & lips, grunting, or gasping.
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• Feels cold to touch or axillary temperature < 35°C
(hypothermia)
• Feels hot to touch or axillary temperature ≥ 37.5°C (fever).
• Red swollen eyelids and pus discharge from the eyes
• Jaundice /yellow skin at age < 24 hours or > 2 weeks
Involving soles and palms
• Pallor, bleeding from any site (especially of the umbilicus).
• Repeated Vomiting, swollen abdomen, no stool after 24
hour.
• More than 10 skin lesions or rash.
• Redness of the umbilicus, or pussy discharge from the
umbilicus.
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 Self-Check Exercise-1
[Link] does a large proportion of maternal and
neonatal death occur?
[Link] the points that should be addressed in ongoing
assessment of the mother in postpartum period.
[Link] Post-natal Problems Related to Mothers
[Link] is routine PNC?
[Link] the components of routine PNC.
[Link] breastfeeding counseling.
[Link] does breastfeeding counseling be performed?
[Link] Post-natal Problems Related to Newborn.
04/09/2024 PNC 52
 LO2. Provide neonatal care

2.1. Providing essential new born care

2.2. Neonatal assessment
2.2.1 Asphyxia or respiratory distress
2.2.2. Bleeding from umbilical stump
2.2.3 Skin discoloration
2.2.4 Red swollen eyes
2.2.5 Discharge
2.2.6 Hypo or hyperthermia.
2.3. Measures based on the findings
2.4. Vaccination service for the newborn
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 Objectives of this learning outcome

After studying this LO, you should be able to:

• Provide essential Newborn care
• Conduct Neonatal Assessment
• Explain essential elements of early newborn
care
• Provide vaccination to the newborn baby

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 2. 1 Provide neonatal care
• Newborn Care is a package of basic care provided to newborns to
support their survival and wellbeing.
• Most babies breathe and cry at birth with no help.
• The care we give immediately after birth is simple but important
there for most babies require only simple supportive care at and
after delivery.
2.1.1 Providing Essential Newborn Care(ENC)
• Care given to all newborn infants at birth to optimize their chances
of survival .
• providing ENC is not commonly practiced this has resulted in
serious consequences of unacceptably high neonatal morbidity and
mortality in the first 24 hours of life
• ( eg. asphyxia , hypothermia , hypoglycemia , infection .)
04/09/2024 PNC 55
 Standardized procedures in Essential
Newborn Care (ENC)
Step 1: Dry and stimulate.
• Immediately dry the whole body including the head and limbs.
• Keep the newborn warm by placing on the abdomen of the
mother.
• Stimulate by rubbing the back or Slapping or flicking the soles
of the feet.
• Remove the wet towel.
• Let the baby stay in skin-to-skin contact on the abdomen and
cover the baby quickly, including the head, with a clean dry
cloth.
• Don’t let the baby remain wet, as this will cool the body and
make it hypothermic
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 Step 2: Evaluate Breathing
• Check if the baby is crying while drying it.
• If the baby does not cry, see if the baby is breathing
properly.
• If the baby is not breathing and/or is gasping: Call for
help, The assistant can provide basic care for the mother
while you provide the more specialized care for the baby
who is not breathing.
• Cut the cord rapidly and start resuscitation.
• If the baby breathes well, continue routine essential
newborn care.
• Do not do suction of the mouth and nose as a routine.
• Do it only if there is meconium, thick mucus, or blood.
04/09/2024 PNC 57
 Normal breathing

• Normal breathing rate in a newborn baby is 30

to 60 breaths per minute.
• The baby should not have any chest in-
drawing or grunting.
• Small babies(less than 2.5 kg at birth or born
before 37 weeks gestation) may have some
mild chest in-drawing and may periodically
stop breathing for a few seconds

04/09/2024 PNC 58
 Step 3: Cord care
• Clamping /tying the cord: If the baby does not need resuscitation, wait
for cord pulsations to cease
• approximately 1-3 minutes after birth, whichever comes first, and
then place one metal clamp/cord tie 2 centimeters from the baby’s
abdomen and the second clamp / tie another 2 centimeters from the
first clamp/tie .
• Cutting the cord soon after birth can decrease the amount of blood
that is transfused to the baby from the placenta and, in preterm babies;
it is likely to result in subsequent anemia and increased chances of
needing a blood transfusion.
• Cutting the cord: Cut the cord with sterile scissors or surgical blade,
under a piece of gauze in order to avoid splashing of blood.
• At every delivery, a clean separate pair of scissors or blade should be
designated for this purpose.
04/09/2024 PNC 59
 Counseling on cord care: -
• Check for bleeding/oozing and retie if necessary.
• The cord may be tied by using sterile cord ties.
• Advise the mother not to cover the cord with the diaper
• Don’t use bandages as it may delay healing and introduce
infection.
• Don’t use alcohol for cleansing as it may delay healing.
• Don’t apply traditional remedies to the cord as it may cause
tetanus and other infections.
• Watch out for Pus discharge from the cord stump.
• Redness around the cord especially if there is swelling.
• Fever (temperature more than 38°C) or other signs of
infection.
04/09/2024 PNC 60
 Step 4: Keep the newborn warm (Prevent
Hypothermia)

• Keep the baby warm by placing it in skin-to-

skin contact on the mother’s chest.
• Cover the baby’s body and head with clean
cloth.
• If the room is cool (<25 ºC), use a blanket to
cover the baby over the mother.

04/09/2024 PNC 61
Step 5: Initiate breastfeeding in the first
one hour.
• Early breastfeeding means breastfeeding within the first hour,
with counseling for correct positioning.
• Early breastfeeding reduces the risk of postpartum hemorrhage
for the mother.
• Colostrum (first milK) has many benefits for the baby,
especially antiinfective properties.
• Skin to skin contact while feeding helps the baby to stay warm.
• The full milk supply will start more quickly and more milk will
be produced in the long-term.
• Breastfeeding delays the mother's return to fertility because of
lactational amenorrhea.
• Breastfeeding provides the best possible nutrition for the baby.
04/09/2024 PNC 62
• Feed day and night, at least 8 times in 24 hours, allowing on-
demand sucking by the baby.
• If the baby is small (less than 2,500 grams), wake the baby to
feed every 3 hours.
• If the baby is not feeding well, seek help.
• Successful breastfeeding requires support for the mother
from the family and health institutions.
• There is no need for extra bottle feeds or water for normal
babies, even in hot climates
• Exposing the baby to water increases the likelihood of
infections, especially diarrhea.
• Supplementing water reduces the effectiveness of breast milk
in preventing infections and providing nutrition.
04/09/2024 PNC 63
 Cont…

Initiate breastfeeding within an hour

• Explain the importance of the Colostrum.
• Breastfeed frequently on demands, about 8 to
10 times day and night
Exclusive breastfeeding
• Avoid the use of the bottles and pacifiers

04/09/2024 PNC 64
 Step 6: Administer eye drops/eye ointment.

• Wash your hands with soap and water

• Clean eyes immediately after birth with swab soaked in
sterile water, using separate swab for each eye.
• Clean from medial to lateral side.
• Give tetracycline eye ointment/drops within 1 hour of birth
usually after initiating breast feeding.
• Don’t put anything else in baby's eyes as it can cause
infection.
• Watch out for discharge from the eyes, especially with
redness and swelling around the eyes.
Step [Link] Chlorhexidine gel (4%) on the cord within
30min of delivery and continue for the next six days
04/09/2024 PNC 65
 Step 8: Administer vitamin K
Intramuscularly (IM) .
• Why is vitamin K important? Vitamin K plays an important part in
making blood clot.
• How will I know if my baby has a vitamin K deficiency? How
serious is it?
• If a baby has a deficiency of vitamin K (hemorrhagic disease of
the newborn (HMD), he/she may spontaneously bruise or bleed.
• This can happen within the first 24 hours of birth or within the
first week of birth.
• The newborn may also have nose or mouth bleeds, or start to
bleed from umbilical stamp or gastrointestinal tract through
rectum.
• give Vitamin K with dose of 1 mg for babies with GA of 34
weeks or above 0.5 mg for premature babies less than 34 weeks g
04/09/2024 PNC 66
9: Weigh the newborn when it is stable and warm

• Place a clean linen or paper on the pan of the weighing

scale.
• Adjust the pointer to zero on the scale with the linen/paper
on the pan.
• Place the naked baby on the paper/linen. If the linen is
large, cover the baby with the cloth.
• Note the weight of the baby when the scale stops moving.
• Never leave the baby unattended on the scale.
• Record the baby’s weight in partograph/maternal/ newborn
charts and delivery room register and inform the mother
station
04/09/2024 PNC 67
Step 10: Place the newborn’s identification bands on the wrist
and ankle.

• Putting the identification bands on the hands and ankle

will save you from misshaping babies in a busy
delivery rooms.
Note
• Record all observations and treatment provided in the
registers/appropriate chart/cards.
• Defer the bath for at least 24 hours. Clean the newborn
of an HIV-infected mother recommended
• Organize transport if necessary
• Inform the mother of the newborn’s weight
04/09/2024 PNC 68
 Cont…
Skin Care
• Leave vernix on the skin
• Change diapers soon after they are wet or dirty.
• Ensure that caregivers wash their hands before
handling the baby.
• Don’t rub vernix off vigorously as it can damage
the skin.
Watch out for
• •Pustules especially in axilla,groin and neck.
04/09/2024 PNC 69
 2.1.2 Assessing Neonates for danger signs
(Figure 2.1) How to do a thorough hand wash before a post natal assessment.

04/09/2024 PNC 70
 [Link] Screening the newborn for general danger signs

• History of difficulty feeding, or unable to feed now;

ask the mother about the baby’s feeding pattern.
• History of convulsion or convulsing now; asks the
mother, has the baby had any fits?
• Newborn seems lethargic or unconscious.
• Movement only when stimulated.
• Fast breathing.
• Severe lower chest in-drawing.

04/09/2024 PNC 71
 Cont…
• Fever.
• Hypothermia (baby is cold to the touch less than
35.5).
• Baby developed yellowish discoloration before 24
hours of age; jaundice observed on the palms of
the hands and soles of the feet.
• There is swelling of the eyes or eye discharge.
• Umbilicus is draining pus.
• More than 10 pustules (spots) are found on the skin
04/09/2024 PNC 72
 Cont…
• Fever is temperature equal to or greaterthan37.5ºC.
• Temperature again after15minutes.
• If the temperature does not return to normal quickly, or ifit
is above37.5ºC,refer the baby immediately.
• Hypothermia is temperature of equal to or
lessthan35.5ºC,but this is dangerously low for anewborn
• If the baby feels chilled, don’t wait for its temperature to
fall lower than 36.5ºCbefore taking fast action to warm it.
• If the baby’s Temp does not start rising towards normal
within30minutes,or if it is below35.5ºC,orthe baby’s lips
are blue, refer the baby immediately.

04/09/2024 PNC 73
 Does the baby have jaundice?

• Jaundice are ayellow discoloration of the skin and of the sclera

(white of the eye).
• Sclera is often difficult to see in newborns so the skin colour is
used to detect jaundice.
• First,ask the mother if she noticed any yellowish discoloration of
the baby’s skin before it was 24hours of age.
• Check if the palm soft he baby’s hands and the soles of its feet are
yellow.
• Jaundice is caused by excess deposits of ayellow pigment called
bilirubin( hyper bilirubinaemia,‘too much bilirubin’).

04/09/2024 PNC 74
 Cont…
• It appears in the skin when too much hemoglobin(the oxygen-
carrying protein)in the red blood cells is brokendown,
• or when the liver is not functioning well and cannot deal with
the bilirubin,or when the bile excretory duct is obstructed
• (Bile is a substance produced by the bile gland which helps in
the breakdown of bilirubin).
• In untreated cases,the excess bilirubin will have serious
effects on the newborn baby’s brain and can be fatal;ifleft
untreated,
• It can have long-term neurological complications related to
abnormalities in the central nervous system,
• For eg partial paralysis,growth retardation or learning
difficulties
04/09/2024 PNC 75
 What are the signs of an infected umbilical cord stump?
• Look at the umbilicus:Is it red or draining pus?Infection of the
umbilical cord stump presents with the following danger signs:
• An offensively smelling cord with adischarge of pus.
• Redness of the cord that remains wet and soft and is not drying
properly.
• Skin around the base of the cord
What are the signs of skin infection?
• The two common forms of skin infection in the new born are:
• Impetigo caused by Staphylococcus bacteria in the skin,which
presents as pus-filled blisters(pustules) seen around the
umbilicus.
• Monilial rashis caused by afungus(Candida orMonilia species).
• This almost always occurs inthe nappy area and presents as
red,slightly raised spots,andisPNC
04/09/2024
most marked in the skin creases.76
 What is neonatal tetanus?
• Tetanus in the newborn is caused by bacteria(Clostridium
tetani)that infect dead tissues such as the umbilical cord stump
• Tetanus bacteria are present in soil and animal dung,which may
infect the cord or other wounds,(eg during some harmful
traditional practices.
• These bacteria produce apowerful toxin(poison)that affects the
nervous system.
• Suspect tetanus if you observe the following signs in the newborn;
• Increased muscle tone(spasm), the jaw muscles and abdomen.
• Generalized muscle spasms and convulsions,often precipitated by
stimulation such as handling or loud noises.
• The baby may are backwards during aspasm.
• Most babies with tetanus will develop severe breathing difficulty
04/09/2024 PNC 77
and even with good medical care many will die
Ask and check Classify Action taken

History of difficulty feeding o run able to If there is anyone of the Refer URGENTLY to
feed now General danger signs, Hospital or health
·History of convulsion or convulsing now Classify as: centre.
·Newborn is lethargic or unconscious POSSIBLE SERIOUS Keep the newborn baby
·Movement only when stimulated INFECTION Warm and give him or
·Fast breathing her
Breast milk on the way.
·Severe lower chest in-drawing
·Fever
Hypothermia
Baby developed yellowish discoloration If there is anyone of Refer URGENTLY to
before24hoursofage These danger signs, Hospital or HC
·Jaundice observed on the palms and soles Classify as: Keep the newborn baby
·There is swelling of the eyes or eye POSSIBLE Warm and give him or
discharge INFECTION her
·Umbilicus is draining pus OR JAUNDICE Breast milk on the way.
·More than10pustules are found on the skin
- None of the above NORMAL BABY Breast feeding and care
04/09/2024 PNC 78
to Prevent infection and
 Prevention of neonatal infections
• How can you prevent infection in newborns?
• The best way of preventing infection is to deliver a baby at the HF
using clean and sterile instruments by skilled personnel.
[Link] over crowding at home and keep normal new burns with their
mothers when eve r possible.
[Link] separate mothers and their new bourns unless absolutely
necessary.
[Link] contains antibodies, which help to
protect the new born from infections.
[Link] to persuade the mother not to wash the baby for the
first24hoursafter birth.
[Link] wash your hands thoroughly with soap before handling
newborns. Hand washing is probably the most important method of
preventing the spread of infection.
04/09/2024 PNC 79
[Link] the mother with her personal hygiene and cleanliness and
try and ensure that the room where mother and baby live is
clean.
[Link] use sterile and clean instruments to cut the umbilical
cord, and keep the stump clean and dry.
Clean all instruments used for maternal and newborn care
with alcohol before every examination
[Link] that routine prophylactic eye care immediately after
delivery with antibiotic ointment(tetracycline)prevents eye
infection, but you should use it only once.
[Link]'t forget immunization: all pregnant women should be
vaccinated with at least two doses(and preferably up to five
doses)of tetanus toxoid to prevent neonatal tetanus
04/09/2024 PNC 80
 [Link] Providing the necessary vaccination
services for the newborn

• Give BCG, OPV-0 vaccine in the first week of

life, preferably before discharge.
• If un-immunized newborn first seen in the first
two weeks of age, give BCG only and give
appointment to return after 4 weeks.
• Record on immunization card and child
record.
• Advise when to return for next immunization

04/09/2024 PNC 81
 CaseStudy2.1 Postnatal assessment of a female newborn

• Female baby was delivered by a 32year-old mother at a

gestational age of 39weeks. You assess the baby at 28hours
after the birth. She has abirth weight of 3,000gm and
presented with a history of convulsion, no feeding at all and
abody temperature of 38.5°C.
(a) How do you classify this baby based on her gestational age?
(b)How do you classify her according to her birth weight?
(c) List the general danger signs present in this newborn.
(d)What is your comment on the body temperature of this
baby?
(e) What will be your final classification of this newborn baby
and how Should you manage her condition
04/09/2024 PNC 82
 Case Study2.2 Postnatal assessment of amale newborn
• You assess an eight hour-old male newborn who was
delivered bya27 year-old first-time mother at a gestational
age of [Link] had a birth weight of 1,300gm,and
presented with a respiratory rate of 72 breaths per minute
and chest in-drawing. His body temperature is 34.5°C.
(a) How do you classify this baby’s gestational age?
(b)How do you classify him according to his birth weight?
(c)Is the respiratory rate of 72breaths per minute normal or
not? What is the normal range of respiration?
(d)What about the temperature of this new born?Is it normal?
(e) What should your management o f this new born be?

04/09/2024 PNC 83
 •THANK YOU

04/09/2024 PNC 84
 LO3. Provide postnatal care for
mothers
• promote postnatal services for the mother &
her newborn.
3.1. Recording postnatal observations
3.2. Providing Information for self-care
3.3. Advice on routine care of the newborn
3.4. Nutrition, exercise, rest, sleep, and support
3.5. Minor postnatal problems of mother and
newborn
04/09/2024 PNC 85
 Objectives of this learning outcome
At the end of this unit, you will be able to:
• Conduct Observation for mothers and recorded in line with standard
protocols and organizational guidelines
• Provide Information and support for self-care and wellbeing are
provided during post-natal period
• provide Advice on routine care of the newborn to mothers
• Provide Education to establish and support exclusive breast-feeding
• Discuss the importance of nutrition, exercise, rest, sleep, and
support,
• Identify Minor postnatal problems of mother and newborn &
provide appropriate advice and mgt
• provide Information on alternative family planning options,
immunization practices
04/09/2024 PNC 86
 3.1 Routine Postnatal Care for the Mother

• Postnatal care (PNC) for the mother should respond to her

special needs, starting with in an hour after the delivery of the
placenta and extending through the following six weeks.
• The care includes the prevention, early Detection and
treatment of complications, and the provision of counseling
on breastfeeding, birth spacing, immunization and maternal
nutrition.
• To standardize the PNC service, you are advised to use the
screening, counseling and postnatal care cards
• primarily on the routine checks you need to do to make sure
the mother is recovering well after the birth, both physically
and emotionally
04/09/2024 PNC 87
 3.1.1. Check the mother’s vital signs
• Check the mother’s v/s,i.e. temperature, PR and BP and make sure they are with
in the normal range.
• Check her PR and BP at least once every hour, and her temperature at least once
in the first six hour
• What should the normal vital signs be if the mother is recovering well from the
birth?
• Her temperature should be close to 37oC;
• Her PR should be b/n 60 to 80 beats per minute when she is resting quietly; her
systolic BP(the top number, when her heart contracts) should be 90-135 mmHg,
while her diastolic BP(the bottom number, which measures the pressure when
her heart relaxes) should be 60 to 85 mmHg
• If her BP is too low and falling, and her PR is too fast and rising, she is going
into shock.
• The most likely cause is life-threatening hemorrhage.
• If there are no signs of bleeding from the vagina,she maybe losing blood
internally.
04/09/2024 PNC 88
 Check if her uterus is contracting normally
• Palpate(feel)her abdomen to check contraction of the uterus to make sure it is firm.
• Immediately after the birth, you should be able to feel it contracting near the
mother’s umbilicus(bellybutton),and it gradually move slower in her pelvis over
the next two weeks.
• Check her uterus every15minutes for the first two hours after birth and every
30minutes for the third hour.
• If possible, check every hour for the following three hours.
• If the uterus is hard, leave it alone between checks.
• If it feels soft, rub the abdomen at the top of the uterus to help it to contract. Teach
the mother to do this for herself.
• The drugs you gave the mother to help expel the placenta and prevent
bleeding([Link] or oxytocin) will also help the uterus to contract. So will
breastfeeding her baby.
• The mother may also need to urinate if her bladder is full, because this can prevent
the uterus from contracting properly
• Check the contraction of her uterus at every postnatal visit

04/09/2024 PNC 89
 Clean the mother’s belly, genitals and legs

• Help the mother clean herself after the birth.

• Change any dirty bedding and wash blood off her body.
• Always wash your own hands first and put on surgical gloves
before you touch the mother’s genitals, just as you did before the
birth.
• This will protect her from any bacteria that may be on your hands.
• Clean the mother’s genitals very gently, using soap and very clean
water and aclean cloth (Do not use alcohol or any other
disinfectant that might irritate her delicate tissues.
• Wash downward, away from the vagina. Be careful not to bring
anything up from the anus toward the vagina.
• Even a piece of stool that is too small to see can cause infection

04/09/2024 PNC 90
 Check for heavy bleeding(haemorrhage)
• After the birth,it is normal for awoman to bleed the same amount as
aheavy monthly period.
• The blood should also look like monthly blood old and dark,orpinkish.
• At first,the blood comes out or gusheswhen the uterus contracts,orwhen
the mother coughs,moves,or stands up,but the flow should reduce over
thenext two to three days and become the more watery reddish discharge
known aslochia.
• Very heavy bleeding is [Link] check for heavy bleeding in the first
six hours after birthcheck the mother’spads often 500ml(about two cups)of
blood loss is too much.
• If she soaks one pad per hour,it is considered heavy [Link] the mother
is bleeding heavily and you cannot stopit,take herto the hospital.
• Watch for signs [Link] that postpartum haemorrhage is
amajor cause of MM and it can happen at any time in the postnatalperiod
though it is most common inthe first seven days.
04/09/2024 PNC 91
 Check the mother’s genitals for tears andother
problems
• Use agloved hand to gently examine the mother’s
genitalsfor tears,blood clots,or ahematoma(bleeding
under the skin).
• If the woman has atear that needs tobe seen,apply
pressure on it for10minutes witha clean cloth or pad
and refer her to the health center.
• If the tear is small,it can probably heal without being
seen,as long as it iskept very clean to prevent wound
infection.

04/09/2024 PNC 92
 Bleeding under the skin(hematoma)orpain in the vagina

• The uterus gets tight and hard and there does not seem tobe
much bleeding,yet the mother still feels dizzy andweak.
• bleeding under the skinin her vagina called ahematoma the
skin in this area is often swollen,dark incolor,tender
andsoft.
• Hematoma is painful,it is usually not serious unless it gets
very large.
• If the hematoma is growing,press on the area with sterile
gauze for 30minutesor untilit stopsgrowing.
• Ifthe mother has signs of shock,treat her for shock andtake
herto the nearest HF sothat the hematoma canbe opened
and the trappedblood canbe let out
04/09/2024 PNC 93
 Prolapsed cervix

• Check the cervix has prolapsed(dropped down to the

vaginal opening;
• This problem is not dangerous,and the cervix will
usually go backup inside the mother in afewdays.
• Ask her to do squeezing exercises with the muscles
of her vagina and pelvic floor atleast four times a
day.
• If the cervix stays at the vaginal opening for more
than two weeks,themother should be referred.
• Acervix that stays prolapsed can cause problems
ifthe woman has another child
04/09/2024 PNC 94
 Help the mother to urinate

• If she cannot urinate,it may help to pour

clean,warm water overher genitalswhile she tries.
• If the mother cannot urinate after
fourhours,andher bladder isnotfull,she
maybedehydrated. Helphertodrink fluids.
• Ifherbladderisfullandshestill
cannoturinate,sheneedstohaveacatheterinsertedto
drainher bladder.
• If youhave been trained todothis,catheterizeher.
04/09/2024 PNC 95
 3.1.2 Providing information and support to
mothers during postnatal period
Routine core PNC for the mother
Looking after the baby
• New mothers should be taught routine care ofthe
baby,including bathing and keeping itsbody and clothes clean
ofits faeces and urine.
• Teach the parents what can be expected from thebaby interms
of sleep,urination,bowelmovements,feeding and crying.
• The baby should be keptwarm,butnotwrappedtootightly
Rest and recovery for the mother
• All postpartum mothers need additional rest to speed recovery.
Breastfeeding women need even more rest wait at least 4 to 5
weeks to resume normal activity
04/09/2024 PNC 96
 Postpartum family planning / Birthcontroloptions
 Women should also be given a choice of receiving a family
planning Method in the health post or during home visit for
follow up within the first 40 days postpartum
Facilitate free informed choice forall women:
• The provider should make surethat the mother is not in pain
and that her other concerns have been addressed.
• Reinforce that non-hormonalmethods( lactational
amenorrhea,barrier methods,IUD and sterilization) are best
options for lactating mothers.
• Initiate progesterone-only methods after6weeks postpartum to
breastfeeding women, if woman chooses ahormonal method

04/09/2024 PNC 97
 Personal hygiene and perennialcare
• If delivery was uncomplicated, showering and bathing are allowed.
• Vaginal douching is avoided in early puerperium,till after bleeding
stops completely and all wounds are healed.
• The vulva should be cleaned from front to back.
• Maintaining good bowel function can prevent or help relieve
existing hemorrhoids, which can be treated with warm sitz baths.
• Sexual activity
• Intercourse may be resumed after cessation of bleeding and
discharge,andas soon as desired and comfortable tothewoman.
• adelay insexual activity shouldbe considered for women who
need to healfrom lacerations or episiotomy repairs.
• Sexual activity after childbirth maybe affected dueto decreased
sexual desire(due to fatigue and disturbed sleep patterns,genital
lacerations/episiotomy).
04/09/2024 PNC 98
 Bladder care
• Avoid distention & encourage urination: voiding must be encouraged
and monitored to prevent asymptomatic Bladder overfilling.
• Do not routinely catheterize unless retention necessitates catheterization(e.g.
retention ofurine due to pain from peri-urethral laceration at vaginal delivery)
Rapid diuresis mayoccur, especially when oxytocin is stopped.
• Pain management
• Common causes:after-pain and episiotomy
• Episiotomy pain: immediately after delivery, ice packs may help reduce pain
and edema at thesite ofan episiotomy or repaired laceration;later,warmsitz
baths several times a day can be used.
• Analgesics are used if not relieved.
• Contractions of the involution uterus, if painful (after-pains), may require
analgesics.
• Commonly used analgesics include: Aspirin 600 mg, Acetaminophen 650
mg. Ibuprofen 400 mgorallyevery4 to 6 hours.

04/09/2024 PNC 99
 [Link]
3.2.1Changes inreproductive organs during the puerperium.
• Uterus
• The full term uterus has grown atleast ten times bigger than it was before pregnancy.
• Onits own it weighs approximately1kg(not including the baby, placenta,amniotic
fluid,etc.),where asits prepregnant weight was only 50-100gm.
• Immediately after thebaby isborn,the uterus can be palpated at or nearthe woman’s
umbilicus(bellybutton),asit contracts to expel the placenta andfetalmembranes.
• It normally shrinks to itsnon-pregnant size..
• The capillaries that remain‘leak’blood plasma for atime, which results in anormal vaginal
discharge called lochia.
• This discharge often continues for several weeks afterthebirth.
• In the first week,the lochiais bloody and brownishred,but itgraduallychanges overtime to
amore watery consistency.
• Over aperiod of twoto three weeks,the discharge continuesto decrease in amountandthe
colorchanges topale yellow(strawcultured).

04/09/2024
PNC 100
 Cervix
• The first day the cervix has usuallynarrowed and regained its normal
muscula r consistency.
• On vaginal examination witha gloved hand,you should find the cervical
opening about two fingers in diameter by24hours after the delivery,and
bythe end ofthe firstpostnatal week the opening narrows to one
fingerwidth.
Vagina andvulva
• Physical readiness usually takes about three tofiveweeks, but the woman
may not feel ready for sexualintercourse for alonger period and she
shouldnot beforced toaccept it.
• Your role isto speak gently to her partner to ensure he understands and
respects her feelings.
• Inmost communities there is anorm forwhen sexualintercourse
starts,whichis often after the puerperium ends,at aroundsixweeksfrom
thebirth
04/09/2024 PNC 101
 What is the benefit to fusing postnatal FP to space
outthe births ofmore children?
• An intervalof at least two years between births,and preferably
alonger gap,reduces the risk ofcomplications occurring to the
mother duringthe next pregnancy
• Perineum
• Most of the muscle tone(strength)of the perineum isregained by
sixweeks after the birth,withmore improvement over the following
few months.
• Abdominal wall
• The abdominalwall remains soft andrelatively poorly toned for
many weeks after the birth,butit gradually becomes stronger
overtime

04/09/2024 PNC 102

 Ovaries
 The woman who exclusively breastfeeds her baby has alonger
periodof amenorrhoea(absence ofmonthly bleeding)and delayed
first ovulation after the birth,compared withthe mother who
chooses to bottle-feed.
 Awoman who doesnot breastfeed may ovulate as early as
fourweek s after delivery,andmost have amenstrual periodby
twelve weeks;the average timetothe first menstruation for awoman
whois not breastfeeding is sevento nineweeks after the birth
 Breasts andinitiation of lactation
 For the firstfewdays after the birth,the breasts secrete
colostrum (a substance).
 Colostrum is rich in nutrients for the baby andalso has
maternal antibodies which protect thenewborn from infection.

04/09/2024 PNC 103

 Suppression of lactation innon-breastfeeding women
• Care should betaken not to stimulate the breasts inany way that would
encourage milk production.
• Ice packs canbe applied tothe breasts and pain-control tablets
containing aspirin or paracetamol maybe given to relieve thebreast
tenderness.
• Excretion of excessbody fluids
• During the pregnancy,thewoman’sbody contains more body fluids
thanin thenon-pregnant state.
• Someof this additionalwater is heldinher tissues, someinher increased
volume ofblood,andsome intheuterus.
• This excess water is rapidly eliminated after thebirth.
• The bladder increases its capacity during the periodin which
excess bodyfluids are being eliminated, filling
withbetween1,000to1,500mlofurine withoutdiscomfort
04/09/2024 PNC 104
 3.3. TheAbnormal Puerperium
[Link]
• Labor andDelivery CareModule explained thatalife-threatening
postpartum haemorrhage(PPH)involveslos least 500ml of
blood from the uterus or vagina.
• The most critical periodto develop aPPH isduring the third and
fourth stages of labour.
■ What are the third and fourth stagesof labour?
□ the third stageis deliveryof theplacenta and fetalmembranes;
the fourth stage is the nextfour hours.
• About 90%ofdeaths dueto PPHtakeplace within four
hoursofdelivery.
• During thefirst fourtosixhours,youshould make surethat
theuterus remainswellcontracted.
04/09/2024 PNC 105
 CONT…
• Awoman can develop ahaemorrhage atany time
during the puerperium,generally in the firstweek
after delivery,but even uptosix weeks postpartum
• This type of bleeding is referred to as secondary
(late) postpartum haemorrhage.
• The presence of anemia or a heart condition can be
life-threatening for the mother even if the loss of
blood is less than 500 ml.
• A woman who is malnourished is also usually less
able to cope with blood loss than a woman who is
well nourished.
04/09/2024 PNC 106
Figure 3.4 The uterus should be well contracted 4-6 hours after the birth.

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 Causes of late postpartum haemorrhage
• The bleeding is usually as a result of poor contraction of the uterus
after the birth, which fails to close off the torn blood capillaries
where the placenta has pulled away.
• If the uterus is unable to reduce in size as it should do normally, it
may be because of infection, or retention of a piece of the placenta,
which later tears loose from the wall of the uterus and causes a
haemorrhage
summarises thecommon causesof late PPH.
• Endometrial wall infection.
• When the site of placental implantation(the placental bed)isnot yet
healed,infection in the uterus can cause the blood capillaries in the
placentalbed tostart bleeding again.
• Poorly contracted uterus:The uterus maynot contract wellbecause
of infection,retained placental fragments,or an unknown [Link]
aresult,bleedingcan start again
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 CONT…
• Retained placenta:Remnants ofplacental tissueor
fetalmembranes retained intheuterus arecommon
causes of latePPH.
• Sloughing of the placentalbed:There is apossibility
that the healed placental bedpeels away(sloughs)and
opens theblood capillaries again.
• Molarpregnancy:Although it is uncommonfor
awomanto developa molar pregnancy after
delivery,itsoccurrence canhave life-threatening
complications; the rapidly growing massofgrape-like
tissues in theuterus can cause profuse hemorrhaging
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 [Link]-referral management of PPH
• Amount of active(fresh or bright red)vaginal bleeding after
24hours may be due to one of the causes listed
• refer these women to ahospital regardless of the amount of
bleeding.
• if bleeding is severe,only ablood transfusion can save the life of
the mother.
■ What did these study sessions tell you to do before referring
awomen with PPH?
□Put up an intravenous(IV)line, and start the woman on intravenous
fluid therapy with Ringer’s Lactate or NormalSaline,using a
1,000ml(1litre) bag and aflow rate set to run as fast as possible.
• As apre-referral treatment, you should also give her asecond dose
of misoprostol(400micrograms orallyor rectally),or oxytocin10IU
(InternationalUnits)by intramuscular injection
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 Figure (3. 5 )Inject 10 IU of oxytocin(or give 400 micrograms
misoprostol)before referring a woman with PPH

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 3.3.3 Puerperal sepsis andfever
• Puerperal sepsis refers to any wide spread bacterial
infectionof the reproductive tract in awoman following
childbirth.
• Some women are more vulnerable to puerperal sepsis,for
example those who are anemic and/or malnourished.
• Fever(raised body temperature)in amother during the
postnatal period is ageneraldangersign.
• She suddenly feels chills with shivering, followed by
feeling hot and sweating.

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 Cont…
 Fever in the postpartum period maybe due to puerperal sepsis,
but it can also becaused by:
• Urinary tract infection
• Wound infection
• Mastitis or breast abscess
• Infections not related to the pregnancy or delivery,suchas
HIV,malaria, typhoid,tetanus, meningitis,pneumonia,etc.
• In the majority of cases, postnatal maternalinfection is
preventable either by conducting aclean andsafe delivery,by
immunizing all pregnant women against tetanus,andby providing
timely treatment of pre-existing infections.
• In malaria endemic areas,donot forget to give long lasting
insecticide-treated bednets(ITNs
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 Endometritis
• Endometritis is an infectious process involving the inner wall of the uterus (the
endometrium).
• It is commonly caused by bacteria ascending from the vagina, or bacteria
transferred to the reproductive tract from the rectum and anus.
Commonly known and avoidable risk factors contributing to the risk of
endometritis include:
• Long labour: This risk can be managed by timely referral of women in
prolonged labour.
• Prolonged and premature rupture of fetal membranes (PROM):
• The risk of infection is greatest if PROM has occurred long before the baby is
delivered. You can reduce the risk by early referral.
• Repeated vaginal examinations: You can avoid this risk by not doing
unnecessary internal examinations.
• Poor standard of hygiene and cleanliness during delivery: For example,
insertion of an unclean hand into the vagina, or use of non-sterile instruments,
can transmit infection
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• Pre-existing infection: Colonization of the vagina and uterus
from untreated sexually transmitted infections (STIs)or urinary
tract infections (UTIs).
• Retained placenta or fetal membranes: The dead cells in
these tissues favor the multiplication of bacteria.
• Manual removal of the placenta: If the umbilical cord tears
(breaks) when you apply
• Controlled cord traction to help delivery of the placenta, it may
be retained and the woman may start to bleed profusely.
• In these circumstances, you will be forced to remove the
placenta manually by inserting your fingers into the endometrial
cavity, locating the placenta and removing it in pieces or in
totality.

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 Cont…
• In addition to the risk to the mother from the
haemorrhage, there is also a risk of endometrial
infection.
• Anemia: Whether it is due to blood loss during
pregnancy, labor and delivery, or due to nutritional
deficiency, anemia is a well-known risk factor for
endometritis and other types of puerperal infection.
• Traumatic delivery: (e.g. assisted by forceps, or by
Caesarean section) Postpartum hemorrhage.

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Figure 3.7 Pain inthe abdomen may be a sign of endometritis

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 Signs of endometritis
• A woman with endometritis typically has a fever of 38°C or
higher, a rapid pulse and pain (tenderness) when you palpate the
abdomen (Figure 3.4).
• Some women may also develop a yellowish, curd-like vaginal
discharge which has a bad odor, whereas others have a little odor
less discharge.
In short, to assess the mother for uterine infection, ask if she has:
• History of fever or if she feels hot. Measure her temperature and
she has a fever if it is equal to or greater than 38°C.
• Lower abdominal pain.
• Foul-smelling, curd-like discharge from her vagina.
t
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• woman in the puerperium may have endometritis when you do
your early postnatal visits, it is important that you refer her
quickly for further treatment.
• If she has low blood pressure (diastolic less than 60 mmHg), you
may begin an IV infusion of Normal Saline.
• Keep her lying flat with her legs lifted up by putting pillows
underneath her knees (shock position), before transporting her to
a health facility.
• Which of the risk factors for developing endometritis can you,
personally, do most about?
• Ensuring the highest standards of hygiene and cleanliness during
delivery;and avoiding,where possible,repeated
vaginalexaminations of the mother.

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 Urinary tract infections
• common causeof pain and fever in the puerperium isaurinary
tract infection(UTI).
• Awoman with a UTI complains of urine coming too
frequently,aburning sensation when she passes urine,and the
urge to urinate veryoften.
• When you gently press onher abdomen over lyingthe pelvisshe
will have pain.
• This woman needsreferral for treatment with antibiotics.
• UTIis common during pregnancy and the puerperium because
ofurinary retention dueto urinary tract obstruction insome
women inlate pregnancy manipulation and trauma tothe urethra
during labour anddelivery,
• which increases the risk of bacteriafrom the birthcanal and
rectum ascending intothe bladder andfrom there tothe kidneys
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 Puerperal mastitis

• Mastitis is painful inflammation of the breast duetobacterial

infection.
• Thebacteria most often causing mastitis,or amore serious breast
abscess,arecalled Staphylococcus aurous.
• The main sourceofthese bacteria is the sucklingbaby.
• Mastitis ismorelikelytodevelop duringlactationthan when
thebreastisnot producing milk.
• Commonly,itresults from milk remaining in the breastfor long
periods(incomplete emptying),becausethe baby
isnotsucklingwell,orfrom cracked nipples.
• How might cracked nipples bearisk factor for mastitis?
• Pain from thecracked nipples may make themother reluctantto
breast feed,soher breasts remain engorged
withmilk;also,bacteriafromthe baby’smouth orfromthemother’s
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skincan getinto thebreastthrough the cracked nipples.
 Figure 3.5 pain in the breast may be as sign of mastitis

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 Cont…
• Pus isa yellowish white,sticky fluid formed in infected
tissue,consisting ofbacteria, white bloodcells,cellular debris
anddying tissue.
• Women with mastitis often experience pain,fever,chills
andmuscleaches overthebody.
• The breast will lookred,hotandisvery painfulto touch. When
the examination reveals atender,hardmass
withoverlyingredness,abreastabscess islikely.
• If you make adiagnosis of mastitis or breast abscess,give pain
relief with paracetamol,supporting thebreast with brassieres
or anything that canbe wrapped around the chest,and
• refer thewoman totheHC and/or nearest hospital for
antibiotic treatment.
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 Wound infections
• Wound infections in the puerperium usually affect torn tissues
inthe perineum,infection of an episiotomy(an incision made
towiden thevaginal opening tolet thebaby pass through),or
• asurgical wound inthe abdomen after acaesarean birthconducted
at ahealthfacility.
• Wound infections become apparentonthethirdorfourth
postpartum dayanda rediagnosedonthebasis of
erythema(reddeningofthe area ofinfection), andthetissue
overlyingthe affected areathickens,gets warm
andispainfultotouch.
• Itmay drainyellowish pus fromthewoundsite, andmay
occurwithorwithoutfever.
.
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• Treatment ofperineal wound infections includesrelieving pain
with paracetamol,and bathing withwarm waterinwhich
oneteaspoon ofsalthas been dissolvedforeveryliterofwater
• If there is pus coming from awound on the perineum,further
drainage ofthepus canbe achieved by compressing theareawith
acloth soaked inwarm salty water.
• In the case ofawoman whoalso hasfever and chills,and you
suspect thereis pus which isnot drainingoutofthe wound,
• Youshould referher tothenext higher healthfacilitysothat
shecanbe treatedwithantibiotics.
• Ifshe hasan abscess,itmay needtobedrainedsurgically.
• Most patients respond quicklyto the antibiotics oncethewound
isdrained.
• Antibioticsaregenerallycontinued untilafter thepatienthasno
feverfor24-48hours..
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 Figure 3.7 An infected wound in the perineum may be treated by
bathing with warm salt water, or compresses to draw out the pus

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 Screening for postpartum hypertension
• The hallmarkof pregnancy-induced hypertension is high
bloodpressure, usually adiastolic bloodpressure morethan
90mmHg.
Inorder toscreen forthis youshould askthe mother aboutthe
following symptoms:
• Severeheadache,withorwithout visual disturbances
(blurringofvision), andsometimes with nausea andvomiting.
• Convulsions/fits in the most severecases(eclampsia).
• Makesurethatyou know thelocal terminologyfor aconvulsion.
• Itcan be explained asan abnormal and uncontrol lablerhythmic
movement of the armsandlegs, withorwithout losing
consciousness.
• Swelling(edema)of hand sandfeet,orespecially theface.
• Severe pain in the upper partofthe abdomen
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• When urine is tested with adipstick forthepresence of
protein,awoman with hypertension islikely totestpositive.
• The positive values on the dipstick are graded
from+1upto+3andmore.
• If any oneof the above findings is present,suspect
pregnancy-induced hypertension and refer the woman
urgently tothenearest healthfacility.
• postpartum hypertension can developin any woman,even
one who had normal blood pressure andwas symptom-
free duringpregnancy,laborand delivery.
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 Deepveinthrombosis (DVT)
 DVT ablood clot,almost alwaysin one ofthe deep veins
in thelegs is arare complication during the puerperium.
 When it occurs itcan be rapidly fatal ifthe clot breaks
away from the vein in the leg and travels to the
heart,lungs orbrain,blocking vitalblood vessels.
• The chance of developing a DVT ismore common during
pregnancy thanin the non-pregnant state,andtherisk
increases duringthe puerperium.

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• Why deep veins in thelegs develop
clots(thrombosis)isnot exactly known.
• The riskis much higher whenthe postnatal
woman spends mostof the time in bedand
doesn’t walk about muchfor severaldays after
thebirth.
• Inmostpartsof Ethiopia,thelocal customisfor
postnatalwomentoremain inbed,with noactivity
except ashortwalk touse thelatrine.
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 Box3.1.5 Clinical features of deep vein
thrombosis(DVT)

• Pain in one leg only:usuallysudden onset,persistent and

achingtype of pain.
• Tenderness:the areais painfulwhen you touchit.
• Swelling:the affected leg is swollen with greater than 2cm
difference in circumference compared to the other (healthy)leg.
• The swelling may be inthecalforthe thigh.
• Palpable cord:you may feelacord-like structure deep in the
swollen leg.
• Change inlimbcolour:theaffectedleg appears alittlebit red.
• Calfpain:she will feel pain when you tryto do extreme
extension the anklejoint

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 Psychiatric disorders in the postnatal period
• Psychiatric disorders arerelatively commonafterchildbirth andmayinclude
postpartum‘blues’,postpartum depression(PPD),and postpartumpsychosis.
• Postpartum‘blues’and postpartum depression
• Hormone changes are thought tobethecauseof postpartum
blues,amild,transient,self-limiting disorder(it resolves onitsown),which
commonly arises during the first fewdays after delivery,andlastsup to two
weeks.
• It is characterized bybouts ofsadness,crying,anxiety,irritation,restlessness,
moodswings,headache,confusion,forgetfulness, andinsomnia.
• It rarely has much effect on the woman’s ability to function,orcare forher baby.
• Providing loving support,care and education has beenshown tohavea positive
effecton recovery( But if awomen develops aserious postpartum depression
• (persistent sadness, lowmood,difficulty infinding motivation todo
anything),itwill greatly affecther ability to complete the normal activities
associated with daily living.

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 Cont…
• If two or more ofthefollowing symptoms occur during the first two
weeksof the puerperium,refer themother:
• In appropriate guilt or negative feelings towards herself
• Decreased interest or pleasure
• Feel stired and agitated allthetime
• Disturbed sleep,sleeping toomuchor sleeping toolittle
• Diminished ability tothink or concentrate
• Marked lossof appetite.
• There mayalsobe episodes ofpostpartum psychosis,markedby
delusionsor hallucinations–seeing orbelieving things that arenot
real.
• We return tothis more serious problem in
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 Maternal assessment for danger signs during
postnatal period
Postpartum danger signs in the woman
• She should go to the hospital or health center immediately, day or night.
• SHE SHOULD NOT WAIT if she has any of the following danger signs:
• Excessive vaginal bleeding (e.g., more than 2 or 3 pads soaked in 20-
30minutes after delivery or bleeding increases rather than decreases after
delivery)
• Convulsions
• Fast or difficult breathing
• Fever and being too weak to get out of bed
• Severe abdominal pain
• Foul smelling vaginal discharge (lochia)
• Severe headache and swelling of the hands and face
• Red patches or streaks and or pain in the legs
• Severe painful, engorged breasts and/or sore, cracked, bleeding nipples.
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Providing woman-centered education and counseling

• The education and counseling should address postpartum needs

such as nutrition, breastfeeding, family planning, sexual
activity, early symptoms of complications and preparations for
possible complications.
• Postpartum counseling should take place at a private area to
allow women to ask Questions and express their concerns
freely.
• If this is not possible, counseling could be done during home
visit.
• Husbands of postpartum women (after the permission of the
woman) should be participated in this counseling and in
receiving instructions before discharge.
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[Link] advice and management for minor post-natal problems of
mother and newborn

• [Link] Minor post-natal problems of mother.

• Breast engorgement
• Breast engorgement occurs in the mammary glands
due to expansion and pressure exerted by the
synthesis and storage of breast milk.
• It is also a main factor in altering the ability of the
infant to latch-on.
• Engorgement changes the shape and curvature of the
nipple region by making the breast inflexible, flat,
hard, and swollen.
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 What is breast engorgement?

• Engorgement is when the breast tissue overfills with milk,

blood and other fluids.
• This causes breasts to feel very full, to become hard and
painful and the nipples to appear flattened and tight. Breast
engorgement can be severe.
• It usually occurs if the baby is not feeding properly, so the
milk builds up.
• Breast engorgement can also occur at any time you are
breastfeeding, especially when the baby’s feeding pattern
changes and they feed less.
• Engorgement is usually temporary – eventually you will
produce just as much milk as your baby needs.
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 How to prevent breast engorgement

• To reduce the chance of breast engorgement, feed the new born baby often
and on demand (not by the clock) from birth, with at least 8 to 12 feeds in
the first 24 hours.
• It will help to sleep in the same room as your baby to keep up these feeds.
• Also, avoid giving your baby any fluids other than breast milk unless
needed for a specific medical reason, and don’t limit your baby’s time at
the breast.
• How to relieve breast engorgement
• If your breasts become engorged, there are things you can do to
relieve the discomfort.
• The best way to is to empty the breast, either by feeding your baby at
the breast, or by expressing your milk.
• It’s okay to wake your baby and offer a breastfeed day or night if
your breasts become full and uncomfortable between feeds
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The following tips might also help:
• Apply a warm washer to the breast, or have a warm shower before a
feed, for comfort and to help the milk flow.
• Remove your bra before breastfeeding (and leave it off).
• Hand-express a little milk before feeding your baby, or try ‘reverse
pressure softening’ (applying pressure around the nipples to push
fluid back into the breasts).
• Gently massage the breast in a downward motion from the chest wall
toward the nipple while your baby is feeding.
• Use a cold compress, like a cool gel pack from the fridge, or a chilled
washed cabbage leaf over the breast to relieve inflammation.
• Express milk after a feed, either by hand or with a breast pump, if
your breasts still feel full.
• Sometimes, if the engorgement does not improve, a complete ‘pump
out’ with an electric pump may be necessary to relieve the milk
pressure that is causing increased blood and fluid within the breast
tissue (refer her to health center or
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the nearest hospital). 139
 Constipation
• Normally, bowel movements will resume within the first few days following
your baby's birth.
• Constipation can occur after having a baby. If you experience postpartum
constipation, here are a few suggestions:
• Cause
• Long labor with little food.
• A C-section. (It can take up to 3-4 days for your digestive system to start
working normally following this major surgery.)
• pain relievers during delivery, or using them currently for postpartum pain
relief. (Particularly systemic narcotics can slow down the digestive tract).
• a sore perineum possibly caused by episiotomy or by postpartum
hemorrhoids.
• (In this case, most likely the constipation is not so much a physical problem
as a mental one. You may be afraid of tearing your stitches or more pain.
That fear is causing you to retain your stool.)

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 How Can Postpartum Constipation Be Treated

• In most cases, you can treat your constipation at home with successful
results.
Here are some simple tips you should follow to both treat and prevent
constipation.
• Drink at least eight to ten large glasses of fluid a day.
• Try eating prunes - they are a natural mild laxative.
• Get plenty of rest every day.
• Drink warm liquids each morning.
• Eat foods such as fruits, green vegetables and whole grain cereals and
breads.
• A mild laxative or fiber supplement can be used if other measures do
not work.
• Call your health care provider if you do not have a bowel movement by
the third or fourth day after having your baby
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 Hemorrhoids (Piles)
• A hemorrhoid is a painful swelling of a vein in the rectum.
• After having a baby especially after a vaginal delivery many women develop
hemorrhoids. Symptoms include pain, rectal itching, bleeding after having a bowel
movement, or a swollen area around the anus.
• How to treat:
• You can use a sitz bath (a basin filled with warm water) or a bath to soak yourself in
warm water.
• This will help hemorrhoids to shrink. Do this two to four times a day.
• Sit on a pillow to relieve pressure on the rectum.
• Hemorrhoid creams, ointments, suppositories or sprays are available over-the-
counter and can produce short term relief.
• Increase dietary fiber and your intake of fluids. This will help to prevent
constipation.
• You may be prescribed a stool softener, and this may take a few days to work.
• Drinking extra water will also help keep your stools soft.
• If the pain does not go away within a few days, contact your health care provider
for further assistance.
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 Postpartum Blues (or "Baby Blues")
• The birth of a baby is a joyful and happy time, but for various
reasons, many women (60-80%) experience a mild and temporary
form of depression commonly referred to as the "Baby Blues.
• " Possible triggers include the sudden hormonal changes
following delivery, the stress and lack of sleep that occur while
caring for a newborn.
• Symptoms of the Baby Blues usually appear within the first week
or two following delivery, and may last for several weeks
following.
• Symptoms include: feelings of tiredness; mood swings; feelings of
loss, frustration or anger; unexplained weeping; irritability;
inability to sleep.
• How should you deal with these feelings? First, try to get some
help with the baby and some rest.
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 Postpartum Depression(PPD)
• symptoms of PPD are similar to the Baby Blues, but become more intense.
• symptoms include: insomnia; persistent sadness; lack of interest in nearly all activity;
anxiety; change in appetite; persistent feelings of guilt; thoughts of harming oneself or the
baby.
• You or a family member need to be aware that sometimes the feelings of guilt will keep
some mothers from admitting that they are depressed.
• Partners or other family members may need to be the ones to contact your health care
provider.
• So how do you know when the baby Blues have become PPD, and you need to seek
medical attention? Contact your health care provider:
• If you or your family suspect that you are experiencing postpartum depression;
• If the "Blues" do not seem to go away two to three weeks following delivery, or feelings
seem to intensify;
• If you do not want to be with your baby;
• If you become so angry or frustrated that you worry that you may harm yourself or your
baby;
• If you are overeating or not eating at all;
• If you are having increased difficulty coping with everyday frustrations;
• If you are experiencing little satisfaction and enjoyment with motherhood
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 3.4.1. Minor post-natal problems of the Newborn
• Sticky eye
• If your baby’s eye is very watery and there is some discharge, it’s probably a
blocked tear duct.
• Also known as ‘sticky eye’, this condition usually gets better by itself, but
it’s still wise to check by health care provider.
• If your baby’s eyes become red, puffy or sore, with a greenish discharge that
can cause their eyelids to stick together, the eye may be infected. This is
called conjunctivitis. It may need antibiotic eye drops or ointment
• Cause
• Tears are produced by glands inside the upper eyelids above each eye. They
flow over the surface of the eye and drain away into a small opening in the
inside corner of the upper and lower eyelids.
• The tears then flow through the tear duct to the nose.
• Some babies are born with tear ducts that are too narrow. Sometimes the tube
gets blocked by a plug of mucus or cells that developed before the baby was
born.
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 Treatment
• Sticky eye normally clears up by the time your baby is 12 months.
• Cleaning the eyes
• If your baby has sticky eye, it is important to keep their eyes clean. You will
need:
• a gauze cotton swab, which you can buy from your chemist - do not use cotton
wool balls because these can shed pieces of cotton into the eye
• weak saline solution (1 teaspoon of salt in 500mL of boiled water which has
been left to cool)
• Wash the affected eye or eyes as needed, following the directions below:
• Wash your hands thoroughly with soap and water.
• Pat the eye dry with a clean (or disposable) towel.
• Gently swipe away any discharge with a disposable cotton swab soaked in weak
saline solution.
• Do not touch the eye itself or clean inside the eyelid because you may damage
the eye.
• Wash your hands again.

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 Nappy rash

• Almost all babies get nappy rash at some stage no matter how well you look after
your baby’s bottom, but there are ways to prevent it.
• Causes of nappy rash
• Most babies get nappy rash at some time in the first 18 months. The main cause of
nappy rash is long contact with wetness.
• The longer the nappy is wet or soiled, the higher the risk of developing a rash.
• Other causes include:
• wearing plastic pants
• sensitive skin or skin conditions like eczema or psoriasis
• soap, detergent
• baby wipes
• diarrhea or other illness
• There may be red patches on your baby’s bottom, or the whole area may be red. The
skin may look sore and feel hot to touch, and there may be spots, pimples or blisters.

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 Preventing nappy rash
• Change wet or soiled nappies as soon as possible after they
become wet or soiled.
• Young babies need changing as many as 10 or 12 times a
day; older babies at least 6 to 8 times.
• Clean the whole nappy area thoroughly, wiping from front to
back. Use cotton wool soaked in lukewarm water, rinse the
area thoroughly and pat dry with a towel.
• It is best not to use baby wipes if your baby has nappy rash.
If you must use baby wipes, make sure they don’t contain
alcohol or anything else that can irritate your baby’s skin.
• Disposable nappies help to prevent nappy rash as they
contain superabsorbent material that pulls moisture away
from the skin.
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• They are also designed to minimize leakage. If you use
cloth nappies, use a nappy liner and avoid plastic pants.
• Lie your baby on a towel and leave the nappy off for as
long and as often as you can to let fresh air get to the skin.
• Use a barrier cream, such as zinc and castor oil.
• If the rash doesn’t go away or the baby develops a
persistent bright red, moist rash with white or red pimples,
which spreads to the folds of the skin, they may have a
thrush infection.
• You’ll need to refer to the nearest treatment.

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 3.5 POSTNATAL CARE AT THE HEALTH POST AND IN THE
COMMUNITY
• Postnatal care(PNC)is the care given to the mother and her newbornbaby immediately
• Neonate — a newborn baby
• Neonatal period - from birth to 28th day after birth
• Early neonatal period- the time just after the delivery and through the first seven days
of life
• Perinatal mortality is the number of late foetal deaths (also called still births) and
early neonatal deaths (before day 7 (168 hours) per 1000 births.
• Neonatal mortality rate (the number of babies who die in the first 28 days) per 1,000
live births.
• A maternal mortality is 'the death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration or site of pregnancy, from any
cause related to or aggravated by the pregnancy or its management but not from
accidental or incidental causes
• Maternal Mortality Rate: Number of maternal deaths per year for every 100,000
women aged 15-49.
• Maternal Mortality Ratio: Number of maternal deaths per 100,000 live births during
a given time period
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 3.5.1Whendomost mothers andnewborns die in the
postnatalperiod

• Mothers and theirnew bornbabies area thighest riskof

dying duringthe early neonatalperiod,especiallyin thefirst
24hours following birthand overthe first seven
daysafterdelivery(seeTable 3.1).
• As youcan see from thetable, 45-50%ofthe mothers
andnewborns who die doso inthefirst24hours after
birth,and65-75%ofthe maternaland neonataldeaths
occurwith in one week ofbirth.
• This is compelling evidenceto provide optimum and
integrated maternalandnewborncare duringthefirstfewdays
afterdelivery
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 Table4.1 Globale stimatesof maternal and new born mortality inthefirst
sevendays afterthebirth

Deaths after First 24 hours First seven Deaths after

delivery (%) days (%) delivery

Maternal 45 65 Maternal
mortality mortality

Neonatal 50 75 Neonatal
mortality mortality

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3.5.2Causes of maternal and newborn deaths during
the postnatal period
• The main purpose of providing optimalpostnatalcareis
toavert both maternal andneonataldeath,aswellaslong-
term complications.
• To be effective you therefore need toknow themajor
causesofdeath inthe postnatalperiod,sothatyou can
provide quality andtimelypostnatalcare at thedomestic
andHealthPostlevel.
• Knowing what mothers andnewborns are dying from is
important in orderto identify thehigh impact
interventions that addressall themajor causesof
deathduring thepostnatal period.
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 Table3.5.2shows thepercentage ofmaternal deaths from the major
causes forwomeninAfrica.

Causes of maternal death %

Postpartum hemorrhage (bleeding after childbirth) 34
Puerperal sepsis (bloodstream infection after childbirth). 16
Eclampsia (caused by dangerously high blood pressure 9
during pregnancy)
HIV/AIDS 6.2

Obstructed labour 4
Unsafe abortion 4
Anaemia 4
All other causes of death 30
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 Table3.5.3showsthecausesof newborn deathsinEthiopia

Causes of newborn deaths %

Diarrhea 3
Neonatal tetanus 7
Neonatal sepsis & other infections 37
Birth asphyxia
25
Prematurity and low birth weight 17
Congenital anomaly (birth defect) 4
Other causes 7

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 Why is it really important foryou to understand the main factors
causing?

• Mothers and babies to die in the postnatalperiod?

• You probably thought of many reasons,butthemost
obvious one isthe huge difference that the delivery of
appropriate andprompt postnatal care could have on
Ethiopia's neonatal mortalityrate:areductionof between
10-27%,or upto60,000newborn lives saved everyyear.
• Think for amoment about the main causes o f
maternalandneonatal death.
• Which ones doyou expect tosee most inyour HEP?
• You might also have picked out eclampsia
(mothers)andneonatal asphyxia(babies).
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 3.5.3Why are women and newborns at high risk in the postnatal
period?
• The most critical periodfor complications in the postnatal
mother arisingfrom bleeding(post-partum hemorrhage)isinthe
first4-6hours after delivery, dueto excessive bloodloss
fromthesite where the placenta was attachedto the
mother’suterus,orfrom rupture of the uterus during labor and
delivery.
• Hemorrhage can also threaten thebaby’s life if itoccurs before
delivery and the baby is starved of oxygen andnutrients.
• Both the mother and the baby are also athighrisk ofdeveloping
other complications ifthe physiological adjustments that take
place intheir bodies after thebirth donotoccur properly.
• This canresult inlossof functionor interruption of essential
supplies of oxygen and nutrients needed tosustain life.
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3.5.4Communitymobilizationforpostnatalcare

• Community mobilization is an action stimulated bya

community, or by others,which are planned,carried
outand evaluated by community members,or
generations or group s to solve community health
problems.
• The focus is onhealth problems arising during the
postnatal period.
• Community mobilisation is acontinuous andcumulative
processof communication,education andorganization
tobuild leadershipand implementation capacity

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 3.5.5 Methods for mobilizing community action.
• Posters:Well-designed posters,placed andlocated in
the right place can facilitate messages tokeep
reminding peopleaboutthe issueofconcern.
• Letter writing:This isone way ofdelivering health
messages to literate members ofthecommunity.
• Itgives the exact message andcanbekept for future
reference.
• Illustrated leaflets:Pictures are agood wayofgetting the
message to people whose levelofliteracy isinsufficient
tounder standletters because you can be sure that the
message has been delivered.
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 4.3.2 Whyis community participations is
important
• When people are involved and participate in anactivity,theydevelop
asense ofownership and responsibility,which helps tosustain
initiatives,activities and programs.
• Italso hasthefollowingbenefits:
• Increased availability ofresources as community members willingly
contribute timeand resources towhatthey consider tobetheirown
initiatives andactivities.
• Asenseof unity among communitymembers.
• Increasing confidence as the successes oftheircontributions
areregistered.
• People are empowered toexercise theirskills,talents anddeveloptheir
potential.
• Behavior changewillbe quickerand easier.
• Controlling harmfultraditionalpracticesbecomes easier.
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 3.5.6Establishing partnerships with community gatekeepers

• The primary targetsof PNC are themother,her newborn babyand thefather.

• The community gatekeepers who can influence decision-making thataffects t hemother
and baby’s health.
• You need toinvolve these people rightfromthe outsetwhen you introduce PNC
serviceinyourcommunity.
• Give particular attentionto involving:-
• Official village administrators
• Religious leaders,church ormosque groups
• Opinion leadersandvillage elders
• Women’s associations orwomen’sclubs
• Youth associations
• Neighborhood social committees
• Farmers’associations or agriculture associations
• Traditional birthattendants(TBAs),traditional healers
• Village drug vendors
• Anyothers youthink arerelevant tothespecificcircumstances.
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 Box 3.5.2 Establishing a partnership with traditional birth attendants

• Contact the TBAs in your community and discuss how you can support each other
in providing postnatal care to women, new born and families.
• Together you can create new knowledge which is more locally appropriate.
• Respect their knowledge, experience, opinions and influence. Ask them to explain
the knowledge they share with the community.
• Share with them your information about postnatal care. Provide copies of health
education materials that you wish to distribute to community members and discuss
the content with them.
• Involve them in counselling sessions for families and other community members.
Include them in meetings with community leaders and influential groups.
• Discuss the recommendation that all deliveries should be performed by a skilled
birth attendant like you.
• When this is not possible, or not preferred by the woman and her family, discuss
how the TBAs can provide more effective postnatal care, and when to make an
emergency referral to you or to a higher health facility.
• Make sure TBAs are included in the referral system and provide them with feedback
on women they have referred to you.
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 3.5.7 Conducting acommunityprofile
• Know the total populationyou are goingtoserve andhowto
collectvitalstatistics,suchas births,deaths and informationon migrationof
people intoandoutofthearea.
• Inaddition you needtorecord all womenin thereproductive age
group(15to45years),whomay become pregnant in the future,andthenumber
ofcurrently pregnant womenwiththeir expected dateofdelivery.
• You shouldalso record thenames and addresses ofallTBAs,localhealers,
village drug vendors andanyother privatepractitioners.
• Register all communityorganizations thatmay supportyouin mobilizing
human,financial andtransportation resources,incase emergency
medicalreferrals arerequired forthemotherandbaby.
• Youwilllearn aboutthereferrallinkinthefinal studysessionofthisModule.
• Allofthe aboveinformationneedstobe updatedeveryfourtosixmonths.
• Youmay notneedtoconduct communityMobilisationseparatelyforPNC.
• It shouldbedone inanintegrated andharmonizedwaywithallother community-
basedmaternal,neonatalandchildhealthservices
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• Box 4.3 Community based postnatal services
• Visit individual community leaders, TBAs and traditional
healers to engage their support.
• Organise orientation meetings for all opinion leaders and
gatekeepers.
• With community leaders and TBAs, plan and organise
community meetings to educate community members about
postnatal care.
• Carry out home visits to teach parents and caregivers about
postnatal care (Figure 1.4 on the next page).
• Distribute information, education and communication (IEC)
materials to community leaders and community members.
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 Operation Sheet 3
Performing Emergency Management of PPH

• procedure

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 LO4. Organize follow up of maternal and
newborn health services
4.1. Registration of postnatal care and newborn
4.2. Schedules of postnatal care
4.3. Assistance and providing care for lactating
mother
4.4. Referral and communication networks
4.5. Keeping antenatal care and birthing outcome
records

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 Objectives of this learning outcome

At the end of this unit, you will be able to:

• Register mothers and newborns under postnatal care
• Perform a postnatal home visit
• Demonstrate counseling for postnatal mothers
• Identify the routine care and follow up of postnatal care for the
mother and new born
• Encourage care seeking behavior
• Do routine Screening for newborns life-threatening conditions
• Practice special care for preterm, low birth weight and babies
with congenital anomalies
• Make a referral for postnatal care
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 4.1. Registering Mothers and Newborns under
Postnatal Care
[Link] for Postpartum Care
4.2.1 Homevisits:the best opportunity toprovide
postnatalcare
• The ideal way toprovide maternaland childhealth
servicesis throughhealth caredeliveredbyskilled
personnelinahealthfacility..
• It may take many yearsto solveall these challenges.
• Therefore,whileworking hardto strengthen
thehealthsystem and improve access tofacilitybasedcare
inrural communities,your currentroleasa HEP to
focuson homevisits forthedeliveryof postnatalcare
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 4.2.2 Barriersto facility-basedpostnatalcare

• The most important barriers hindering facility-basedpostnatalcareare:

• Socialand culturalbarriers: The tradition of keeping mothersand
newbornbabies indoors forafewdays afterthebirthin aperiodof
seclusion,andcertain community spritualsduringthisperiod hinders
mothersfrom goingto healthfacilities forPNC.
• You should gradually explore these barriers inyour localityandwork
together with the community leaders to changethesepractices.
• Geographicbarriers: Walking across mountains,crossing rivers
without bridges during the rainyseason,andlackofroads,are someofthe
geographicalbarriers that hinder mothersfrom accessing
healthfacilities forPNC).
• Physical access:Eventhough somemothers would prefertogoto ahealth
facility,the nearest healthcentreor hospitalisnot within areachable
distance onfoot or withavailable transport.

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• Financial barriers: In Ethiopia healthservicesfor labour and deliveryand
postnatalhealth services are considered tobefreeof charge,but inreality
families have topay for transport for the woman to the healthfacility,and
for consumables including drugs and surgicalgloves.
• These extra costs remain amajor barrierto facility-basedcare.
• Quality barriers: After reaching thehealthfacility,the motherand
newborn maynotget the expected qualityof PNCservice because of lack
of adequately trained healthworkers,orshortages ofequipmentordrugs.
• Poor quality services reduce confidence inother mothersinthe community,
whoare lesslikely tomakethe effortofgoingtothe healthfacility.
• An important secondary target for yourPNC visitsisto explore someof
thesocialandculturalbarriers mentioned aboveandworkwith community
leadersto tryto change these.

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 4.2.3Evidence that home visits improve the effectiveness of PNC

• There will be cultural differences between countries,but the results

are encouraging.
• Forexample,studies conductedinIndia,BangladeshandPakistan have
shown that home visits can reducede at ofnew bornsby30-
61%indeveloping countries where thereis high mortality.
• Inparticular,home visits improved coverage of the key high-impact
and cost-effective neonatal interventions suchas:
• Early initiation of breastfeeding
• Skin-to-skin contact between newborns andtheirmothers(Figure4.1).
• Delayed bathing ofthenew born until atleast24hoursafterthebirth
• Attention tohygiene,suchas handwashingwithsoapandwater
• Hygienic careofthe baby’sumbilicalcord stump.

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• Figure4.1Skin-to-skin contacts between mother and
newborn supports bonding and helps to regulate the baby’s
temperature
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 4.2.4SchedulesforPostnatalHomeVisits
• Based on the available information from the experiences
ofother countries,and the feasibility of applying each option
inEthiopia,the WorldHealthOrganization has recommended
ascheduleof visits for postnatalcare.
• For allnormal deliveries withan outcome of afullterm
andnormal birthweight baby,
• The recommended frequency of home visits shouldbe as
follows:
[Link] first visit shouldtake place 6 –24hours of the
birth;whenever feasible dothe visit as early as possible.
[Link] visit ison the 3 day after thebirth.
[Link] visit ison the 7day afterthebirth.
[Link] visitis during the 6week afterthebirth.
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PNC
 Cont…
Additional visits are needed on the 5 and 10day after the birthin
special circumstances,forexample in:
• Preterm babies,i.e. Those delivered before 37weeksof gestation
• Low birth weight babies,[Link] weighing lessthan2.5Kg
• All sick mothers and newborn babies
• HIV-positive mothers.
• Family members should alsosendfor youto come immediately if
amother orthe babyhas aproblem at any time during the
postnatalperiod.
• Some families maybe reluctant to bother you,soitisimportant that
you always reassure each family that contacting you is the right
thing todo if they become worried about the health of the mother
orthebaby.
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 4.2.5 PreparationsforaPostnatalHomeVisit

• Personalhygiene
• Before you attend for ahomevisit,makesure you havetakencareofyour
own personal hygiene withparticular emphasis toyour hair,nails
andclothes.
• This instruction may seem very basic andsimple,butapoor appearance
and lack of hygiene can have anegative effect onyour relationship with
the community and families andcan also easily affect the credibility
ofyour work.
• Always wear simple but very clean clotheswhen yougofor ahome visit
to provide PNC.
• Why else is it important to emphasize hygiene?.
• attention to cleanliness and hygiene during birth and postnatal visits
helps to prevent postpartum infections.
• If you stress your own personal hygiene itwillbe easier to persuade the
mother andher family of the importance of cleanliness ifher next baby
isahome birth.
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 Equipment

• Put the items listed in Box4.2 into yourbag,which should be specially

prepared to carry supplies during homevisits.
Box4.2 Equipment for apostnatal homevisit
• Salter scaleto weigh thebaby
• Blood pressure measuringapparatus
• Stethoscope
• Thermometer
• Wrist watch or timer,tohelp you count the mother’s PR and the baby’s RR.
• Soap for washing yourhands
• Aclean towel todry yourhands
• Vitamin Acapsules
• Iron and folate tablets
• Tetracycline eyeointment
• Counselling cardand screeningcard forPNC.
• Record book,referral form andpen.

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 4.2.6Key steps to follow while conducting ahomevisit

• To creating acaring environment and to develop confidence in your

ability among the family members,youshould apply the following
practices:
• Know and show that you respect the local beliefs,culture and norms
during communication.
• Greet everyone usingthe local terms.
• Explain the reasons for the visit to the mother andfamily
members,using simple words inlocal language.
• Allow enough time for general conversation andconfidence building
• Act with confidence,and speak confidentlywith agent let one and
voice
• Be respectful to every member of the family.

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• Ask about the wellbeingofthe mother andthe babyand discover
whether either of themhave anyhealth problems,or ifthere
isanydifficultyin making the adjustments tohaving anew babyin
thefamily.
• Use the standard screening approach:ask,check,classify andtakeaction.
• The most critical task is to usethe screening cards tohelp youto
identify anylife-threatening conditionsor general dangersigns
inpostpartumm othersandnewborns.
• Using the counselling cards,counsel themother abouther ownhealth
andthe baby’shealth andcondition.
• Always check her understanding after counselling
• Complete the postnatal homevisit form and make anappointment for
thenext visit.
• Thank everyone formakingyou welcome intheirhome.

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 4.3 Counselingmothers during thepostnatalperiod

• Counselling mothers,it is always important touse

thefollowingskills:
• Ask andlisten: Findout what the motheris already doingfor
herchild andherself by asking thoughtful questions
andlistening carefully toher answers. Thenyou willknow
what sheisdoing well,and what practices needto bechanged.
• Praise: Praise the mother for somethinghelpful shehasdone.
• It is likely that’s heisdoing something helpfulfor
herselfandthenewborn;
• for eg, she may be eatinga good diet,breastfeeding thebaby
exclusively,and keeping herselfandher babyclean.

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• Advise: Limity our advice to whatis relevant to the motheratthis particular
time.
• Too much advice,or advice given atthe wrong time,can beover whelming and
the mother may ignore it.
• Use language thatthe mother will understand.
• Ifpossible,use pictures,screening cards,orreal objects tohelp explain
clearlywhat youwanthertodo,knowor understand.
• Check understanding:When you explain something tothemother,ask
questions tofindout whatshe understands and what needs further explanation.
• Avoid askingl eadingquestions(thatis,questions which suggest the right
answertoher evenifshe doesnotunderstand)also avoid questions that canbe
answered with asimple yes orno,because they donot help youtocheck exactly
whatthemotherhasunderstood.

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 Box 4.3 Health issues to counsel the mother on

• Identification of general danger signs

• Emotional support
• Support for maternal nutrition
• Establishing optimum breastfeeding
• Hygiene and infection prevention
• Support for family planning
• Special care for HIV-infected mothers
• Early care seeking for the mother and the newborn baby if
problems arise
• Routine care of a normal baby.
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 4.4NutritionafterChildbirth
4.4.1 Eating anddrinkinginthefirstfewhours
• Most mothers are readytoeatsoonafterthebirth,anditisgoodforthemto eat
anykindofnutritiousfoodtheywant.
• If anew mother isnot hungry,she should atleasthave something [Link]
juiceoratmit teaisgood becauseit givesenergy(Figure5.2).
• Many womenwant somethingwarmto drink,liketea.
• Somejuices,like orangejuice,alsohave vitaminC,whichcanhelp healing.
• (But she should avoid sodapoplikeCoke,whichis full of sugar and chemicals but has
no nutrition.)
• Ifthe mother cannot(orwillnot)eat ordrink withintwo tothreehoursafter the birth:
• Shemay [Link],fever,ahypertensivedisorder,or other signs ofillness
thatmaybetaking away herappetite.
• Shemaybe depressed(sad,angry,orwithout anyfeelings).
• Encourage her totalk aboutherfeelingsandneeds
• Shemay believe that certain foods arebad toeat afterabirth.
• Gently explain toher that shemust eat torecover from the birth andto beableto carefor
herbaby.
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Figure 4.7. Encourage her to eat soon, within the first few hours, and to drink often.

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 4.4.2 CounselingonPostnatalNutrition

• After delivery,women’s routine foodintakeshouldbeincreased to coverthe

energycost ofbreastfeedingandforher torecoverhernormal energyandhealth.
• She should eat about10%morethan before shewas pregnantifsheis
notmovingaround muchordoing herusualworkandabout20% moreifshe
isphysicallyactive.
• Inpractical terms,sheisadvised totake atleast oneortwo additional meals
[Link] counsellings houldinclude:
• Advisingthemother toeat avarietyof highprotein,highenergyfoods(as muchas
thefamilycan afford),suchas meat,milk,fish,oils,nuts,seeds, cereals,beans and
cheese,tokeepher healthyandstrong.
• Your nutritional advice should depend onwhat is available athome
andonwhat they eat as their staple diet.
• The most important thing isto tellthem thatshe needs to eatmore than usual.
.

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• Exploring whether thereareimportant culturaltaboos about
eating foods whichare really nutritionally healthy.
• Forexample,insome culturesitis considered badto
eathighprotein foods,spicyfoods,orcoldfoodsafterabirth.
• Respectfully advise against these taboos andtellthe womanthat
thereis no nutritious food itemthatneeds tobe restricted.
• Talktofamily members,particularlythepartnerand/orthemother-
in-law, and encourage them tohelp ensure thewoman eats
enough ofawide variety of foods andavoidshard physicalwork.
• Advise the motherto take micronutrient supplementation
regularly toprevent deficiency disorders and anaemia,as
wedescribe next
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 4.4.3 PreventingIodineDeficiency

• Adding iodine tosalt is called iodination and using iodised salt

incooking is recommended in the postnatal period,especially in
areas of the countrywhere goiteris common as aresult of too little
iodine in the diet(Figure5.3).
• Iodination of salt has been shown to be ahighly effective means
of preventing iodine deficiency.
• Giving iodised oil by mouth orinjection canbe used as an interim
measure in endemic regions where provision of iodised salt
maynot befeasible
• .Encourage themother touse iodised salt everydayduringthe
postnatalperiod,ifitis available.
• Otherwise,adose of iodisedoil canbe giventothe mother soon
after delivery ifgoitre iscommon locally
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Figure 4.3 Goitre is a swelling in the front of the neck, caused by enlargement of the
thyroid gland.

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 4.4.4Preventing vitaminAdeficiency
• Counsel the mother on prevention of vitaminAdeficiency,which
notonly threatens her sight,butis amajor causeof childhoodblindness
inbabies fedby vitaminA-deficient mothers.
• VitaminA inthe dietincreases resistance to infection and is especially
important inproducing nourishing breastmilk.
• Yellow vegetables like carrots,yellow fruits like mangoes,and
darkgreen leafy vegetables such as cabbage and spinach have alotof
vitaminA.
• So do liver,fish liveroil,milk,eggs and butter.
• Part of routine PNC is to check if avitamin A capsule has been given to
the mother.
• The recommended dose for breastfeeding mothers isone
200,000IU(International Units)
• Vitamin Acapsule once after delivery or within sixweeks of delivery.

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 4.4.5 Preventing IronandFolateDeficiency
• Preexisting anaemia canbe aggravated bytheeffects of
maternalbloodloss andis one ofthe major contributors to
maternalmortality inthepostnatalperiod.
• Encourage mothers toeat foods richin iron([Link]
vegetables,beans,peas andlentils,poultryandredmeat,organ meats
suchas liver and kidney,and whole grain products),andfoods which
enhance iron absorption(fruits andvegetables richin vitaminC).
• Tellher totake onetablet containing60mg ofironand400micrograms
offolate(folicacid)everyday for three months after thebirth,andgive
herathree months’ supply.
• Insome places you may have separate ironand folate tablets,but the
dosageisthe same.)
• Advise herto store thetablets safely where children cannot easily find
them.
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 4.5Emotional SupportfortheMother .
Fathers and other family memberscan help
• Encourage the partner tobe around themother atleastforthefirstweek
ofthepostnatalperiodto provide emotionalsupportandtotake careofherand
thebaby(Figure5.9).
• IntheEthiopian context,caringfor the new motheris usuallytheresponsibility of the
grandmother and/orthe mother-in-law.
• As they have already gone through allof these experiences, they aregood at providing
physicalandemotional support tothemotherandherbaby.
• They canfreeherfromtheroutinedomesticchores,andthisshouldbeencouraged.
When themother isn’tinterested inherbaby
• Some mothers donot feelgood abouttheir newbabies(Figure5.4).
• There canbe many reasons [Link] may beverytired,orshemay beill or bleeding.
• Shemaynothavewantedababy,ormaybeworriedthatshecannottakecareofone.
• shemaybeverydepressed:signs ofthis areifthewomanseems sad,quiet,andhas
nointerestinanything.
• Also watch forother signs of abnormal behaviour which are differentfrom her usual
wayofbehaving.
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 Figure 4.4Amother who rejects her baby maybe
suffering from postnataldepression

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What todoif you are concernedaboutamother’slackofinterestinherbaby:
• Check her carefully forsigns ofbloodloss orinfection,orahypertensive
disorder.
• Shemaybeill,ratherthan depressedoranxious.
• You might talk to themother about her feelings,oryou mayfeel itis
betterto leave her alone,and towatchandwait.
• Ifyouknow that shewas seriously depressed afterapast birth,talktothe
family about giving herextra attention andsupport inthenext fewweeks.
• Usually this depression passes intime,butsometimes ittakes afew weeks
or evenmonths,andyou may needto refer her foradditional assessment
and treatment.
• Ifshe demonstrates any ofthesignsof postpartum
psychosis(Box4.4),refer her urgently.
• Make sure someonein thefamilytakes care ofthe newbaby ifthemother
cannot orwill not
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 Box4.4 Signsofpostpartum psychosis

• This condition is rare(affecting about one

in1,000women),butitisvery serious andthemother
should be referred urgently for specialist treatment
ifshe is experiencing any of the following symptoms:
• Hearing sounds or voices when no-oneis there
• Seeing things that are not real
• Feeling as though her thoughts are not herown
• Feeling afraid that she might harm herself orherbaby
• Rapid weightloss andrefusal toeat
• Going without sleep for48hoursormore
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 4.6. Encouraging Care-seekingBehaviour
• Delays are avery important causeof maternaland neonataldeaths
in the early postnatalperiod andinclude:
• Delay inearly recognition anddecision
makingtoseekhelp,duetowrong beliefs andculturaltaboos.
• Families mayalsobe afraid of the costs involved ifthey access the
health system.
• Delay ingetting transportation to the HealthPostor higherlevel
health facility,or getting ahealthworker tovisit thehouse.
• Delay inreceiving appropriate care onceinthe healthfacility,dueto
inadequate staffing or lackof equipment orsupplies.
• Empowering themother and the family on earlycareseeking
isfundamental in delivering optimum postnatalcare.

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 4.7 Breastfeeding, the Warm Chain Principle and Counselling HIV-Positive
Mothers

• During the postnatal period, counselling the mother of a normal

healthy newborn baby focuses on many issues, such as infection
prevention, nutrition for the mother, and family planning.
• The first part of this study session is about feeding the normal weight,
healthy, full-term baby.
• Then we will look at the special counselling that HIV-positive mothers
need about feeding babies who are full term and normal weight
4.7.1 Counseling the mother on newborn feeding
• It is always advisable to provide counselling about newborn feeding
during the antenatal period and continue reinforcing it during the
postnatal period.
• This teaching should focus on establishing and maintaining optimum
breastfeeding

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 Box 4.4 Optimum breastfeeding criteria

• Initiation of breastfeeding within one hour after birth (early

breastfeeding).
• Nothing is given to the baby other than breast milk for the first
six months (exclusive breastfeeding).
• Colostrum is not thrown away. It is rich in protein and
antibodies and is useful to the newborn; you should tell the
mother to feed it to her newborn, because it is the first
immunization that her baby will get.
• The mother is sitting in a good position while breastfeeding.
• The baby has good attachment to the breast while breastfeeding.
• There is effective suckling.

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 Four signs of good positioning
• To begin with, the mother should sit comfortably (see Figure
4.4(a), maintaining the four signs of good positioning:
• With the newborn’s head and body straight facing her breast,
with baby’s nose opposite her nipple
• With the newborn’s body close to her body supporting the baby ’s
whole body, not just the neck and shoulders.
• If the mother has had a caesarean delivery, or her abdomen is
sore for some other reason, she may be more comfortable
supporting the baby as shown in Figure 4.4 (b).
• It keeps the baby’s weight off her abdomen. She can feed twins
this way too, with one on each breast.
• At night, or if she is tired and needs to rest, she can feed the baby
while lying down (Figure 4.4 (c), but only if she stays awake.

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04/09/2024 PNC 198
• Figure 5.4 (a) This mother is in the correct sitting position for
optimum breastfeeding.
• (b) This is a good position for breastfeeding when the mother
has had abdominal surgery, or if she is feeding twins.
• (c) A baby can be fed lying down, but only if the mother is
awake.
■ Giving breastfeeding in the lying down position (Figure 4.4 c) is
not advisable unless the mother is awake. Can you suggest why
not?
□ If the mother is falling asleep she may roll onto the newborn,
who may be unable to breathe and asphyxiate (die from lack of
oxygen
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 Four signs of good attachment
• Once good positioning is established, show the
mother how to help the newborn to attach to the
nipple. She should:
• Touch her newborn’s lips with her nipple
• Wait until her newborn’s mouth is opening wide
• Move her newborn quickly onto her breast,
aiming the newborn’s lower lip well below the
nipple.
• Then check for signs of good attachment (see
Figure 4.5)
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 Figure 4.5 (a) This baby has a good mouthful of breast; (b) This baby does not
have enough breasts in its mouth.

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The four signs of good attachment are:
• Mouth widely opened
• Lower lip turned upward
• Chin touching the breast
• More of the areola (the dark ring around the nipple) is
seen above the baby’s mouth than below it.
 Advise the mother to empty one breast before
switching to the other, so that the newborn gets the
nutrient-rich hind milk (last milk), which is produced
when the breast is almost empty
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 Effective suckling

• Good signs of effective suckling are if the newborn takes slow,

regular and deep sucks, sometimes pausing.
• The mother should tell you that she is comfortable and pain
free.
• If you observe that the attachment and suckling are inadequate,
ask the mother to try again and reassess how well the baby is
feeding.
• If they still cannot establish optimum breastfeeding, then you
should assume that the newborn has a feeding problem and/or
the mother has breast problems that make attachment difficult.
• If so refer the baby and the mother to a health facility for
further advice and care.
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 What are the benefits of breastfeeding?

• Breastfeeding provides many benefits to both the newborn and mother.

• You should encourage mothers to breastfeed exclusively for at least the
first six months by explaining the benefits to them.
• Benefits to the newborn of breastfeeding
• Breast milk is the ideal feed for full term newborns as it provides all
the nutrients in the correct amount and proportion for normal growth
and development until the age of six months.
• It is easily digested and absorbed. Also, breast milk is clean and warm,
and avoids the dangers of feeding formula milk which comes as a
powder and has to be made up with water and fed in a bottle.
• Can you suggest the sources of risk to the newborn from badly made
formula milk?
□ There is a risk of infection from making the milk with contaminated
water, or if the bottles and teats are not properly sterilized
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• If the mother makes several feeds at one time, and she cannot keep them
cold because she has no refrigeration facilities, bacteria may grow in the
warm milk.
• Also, if she puts too little or too much milk powder in each bottle, the baby
will suffer from malnourishment if the formula is too weak, or it will get an
excessive load on its organs from too concentrated formula.
• Breast milk contains many anti-infective factors, such as antibodies, living
cells and molecules that help the baby's body to fight infection.
• It also encourages the growth of beneficial bacteria in the newborn's bowel.
These properties of breast milk help to prevent diarrhoeal diseases, the
major cause of death of newborns in poor communities.
• Breast milk also decreases the risk of allergy in the newborn.
• Allergies are adverse reactions of the body against components of the diet,
pollen from plants, animals and other harmless things that touch the body or
get into it through the nose, mouth or eyes.
• Newborns are more at risk of allergies if there is a strong family history of
allergy.
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 Benefits to the mother of breastfeeding
• Breastfeeding is (almost) free–the mother needs additional food while she is
breastfeeding, but the cost is much cheaper than buying formula feeds, bottles and
teats.
• It is instantly available at all times, so the mother does not have the trouble of
sterilizing bottles and teats, and preparing formula feeds many times every day.
• It is emotionally satisfying for the mother to successfully breastfeed her baby and the
close contact helps to form a strong bond between mother and newborn.
• The hormone (oxytocin) that triggers the milk to spurt from the breast by contracting
the tiny muscles around the nipple also makes the muscles in the uterus contract.
• So breastfeeding helps the uterus to return to its normal size.
■ What other benefit can you suggest results from the contractions of the myometrium
(the muscle layer in the uterus) during breastfeeding?
□ The contractions help to close the torn blood vessels where the placenta detached from
the uterine wall, and this reduces the amount of normal vaginal bleeding during the
puerperium, and decreases the risk of postpartum haemorrhage.
• Breastfeeding helps the mother to lose excessive weight if she gained too much
during the pregnancy.
• 04/09/2024
Pregnancy, not breastfeeding, alters thePNCshape of a woman’s breasts. 206
 Breastfeeding and birth control
• Exclusive breastfeeding (feeding only breast milk to the baby and
no other fluids or foods) greatly reduces the chance of the mother
becoming pregnant again if it is begun early (within an hour of the
birth), and maintained for the recommended first six months.
• Explain to the mother and her partner that if a woman has sex and
is not exclusively breastfeeding, she can become pregnant as soon
as four weeks after delivery.
• Therefore, information on when to start a contraceptive method
will vary depending on whether the woman is breastfeeding or not.
• In Ethiopia it is recommended that you try to convince mothers to
put their babies on exclusive breastfeeding for six months for
many reasons, including that it will suppress her menstrual cycle,
but only if she fulfills the following criteria:

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[Link] baby should be exclusively breastfed on demand (whenever the baby
wants to be fed) a minimum of 8-12 times a day, including at least one feed
during the night
[Link] interval between daytime feeds should not be more than four hours apart
and night feeds should not be more than six hours apart
[Link] her menstrual periods return even while she is exclusively breastfeeding,
she could easily become pregnant
• Emphasize that after six months, she will not be protected from becoming
pregnant by breastfeeding alone.
• She should choose another family planning method.
• You will learn all about this in the Module on Family Planning in this
curriculum.
• Table 4.1 summarises the benefits to the mother and the newborn of
exclusive breastfeeding.
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 Table4.1 Thebene fi ts of breast milkand breastfeeding.

Mother Newborn
It is much cheaper than formula Itisfullynutritious

Always available(ready) Easily digested andabsorbed

Mental satisfaction Itiscleanandwarm

Reducedbleeding Itcontainsanti-infectivesubstances

Canbeused as birth control Preventsdiarrhoealdisease

Helpsloseexcessive weight Decreasesallergyrisk

Increases bonding with thenewborn Increases bonding with themother

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 4.7.2 Counseling the HIV-positive mother about feeding her
baby
• Mothers who are HIV-positive and their babies need special care before, during and
after labour and delivery.
• Therefore, if the mother is counseled and HIV-tested before or during pregnancy,
and she knows that she is HIVpositive, you should try to convince her to deliver
her baby in a health facility.
• That way she and her baby will get special care from health professionals with
special training in delivering babies from HIV-positive mothers, and preventing
maternal to child transmission (PMTCT of HIV).
• In the postnatal period, she may need to take antiretroviral (ARV) drugs prescribed
for her by the HIV clinic, and your support is vital in helping her to keep to her
drug regimen.
• Maintain confidentiality about her status and conduct frequent visits to this woman
as she may require a lot of psychosocial support immediately after the delivery.
• If it is available link her with the community social support group. Always make
sure her partner is counseled and HIV-tested and also involved in the whole care
process.

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 Breast milk or formula?

• In this study session our focus is on the risk of HIV being transmitted
from the mother to her newborn baby in her breast milk, and how you
can support and counsel her about feeding options.
• If 20 HIV-positive mothers breastfeed their HIV-negative babies
exclusively for the first six months, on average one to three of the
babies will become infected with HIV through its mother ’s breast milk.
• So the mother has a difficult choice to make. She has to balance the
risk to her baby from HIV transmission during breastfeeding, against
the risk of not breastfeeding and losing all the benefits described above.
• Formula feeding also exposes the baby to increased risk of infection
from unsterilized bottles and malnutrition from incorrectly made feeds.

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 Replacement feeding and the AFASS criteria

• Exclusive breastfeeding is NOT recommended for the babies

of HIV-positive women, since the only way to protect the
baby completely from HIV transmission from its mother is to
feed it on formula milk.
• This is known as replacement feeding.
• However, many families cannot afford to buy milk formula
to feed the baby, and bottle feeding may be socially
unacceptable in some communities.
• With all these issues in mind the World Health Organization
(WHO) has set the following criteria (known as the AFASS
criteria), which need to be met before counselling an HIV-
positive mother to use formula milk:
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• Acceptable: Replacement feeding for breast milk is acceptable by
the mother, the family and others who are close to the family.
• Feasible: The mother has access to clean and safe water for
cleaning the feeding bottles, teats, measuring cup and spoon, and
diluting the formula milk if it comes as a powder.
• Affordable: The family can afford to buy enough formula milk or
animal milk to feed the baby adequately.
• Sustainable: The mother is able to prepare feeds for the child as
frequently as recommended and as the baby demands.
• Safe: The formula milk should be safe and nutritious for the health
of the baby. The AFASS criteria are illustrated in Figure 5.6. When
replacement feeding fulfills the AFASS criteria, avoidance of all
breastfeeding by HIV-positive mothers is recommended.

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Figure 4.6 The AFASS criteria help you to counsel HIV-positive mothers about
feeding options for their newborns. (Source: Ethiopian Federal Ministry of
Health, based on WHO, 2010, Guidelines on HIV and Infant Feeding)

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• NOTE. Safer infant feeding practices, either
exclusive breastfeeding for the first 6 months
or exclusive replacement feeding for the first 6
months.
• Avoid mixed feeding. Introduce appropriate
complementary food after6 months, and
continue breastfeeding for12 months.
(PMTCT 2016 )

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 Reducing the HIV risk from breastfeeding

• If replacement feeding is rejected by the HIV-positive mother, for whatever

reasons, there are some things that she can do to reduce the risk of HIV
transmission during breastfeeding. Counsel her to:
• Keep the intervals between breast feeds as short as possible (no longer than
three hours) to avoid accumulation of the virus in her breast milk.
• If she develops a bacterial infection (mastitis) of the breast, or she has a
cracked nipple, stop feeding from the infected breast and seek urgent treatment.
• Check the infant’s mouth for sores and seek treatment if necessary.
• Make a transition to replacement feeding if her circumstances change and she
can meet the AFASS criteria.
• At six months, if replacement feeding is still not acceptable, feasible,
affordable, sustainable and safe, counsel her to continue breastfeeding, but with
additional complementary foods.
• All breastfeeding should stop once a nutritionally adequate and safe diet
without breast milk can be provided
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 Keeping the baby warm
• Newborn babies cool down or heat up much quicker than older children or
adults because they cannot regulate their body temperature as easily.
• They are particularly vulnerable to hypothermia, which means excessive
cooling of the baby, so the body temperature falls below 35.5 oC measured
in the baby’s armpit (or use a rectal thermometer).
• If this low temperature continues even for a short time, it will cause the
baby’s body systems to stop functioning properly and this is life-
threatening.
• Hypothermia is a major cause of morbidity and mortality in a newborn
baby, particularly pre-term babies (born before 36 weeks of gestation) and
those with low birth weight (below 2,500 gm).
• Hypothermia is usually caused more by the mother’s lack of knowledge
rather than lack of covers and clothes to keep the baby warm.
• So make sure you explain to the mother the importance of keeping the
baby warm all the time to ensure that a normal body temperature of above
36.5°C and below 37.5°C can be maintained.
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 How to take the newborn’s temperature

• Place the thermometer in the newborn's armpit (or

rectum if you have a rectal thermometer) for two to
three minutes, then read the temperature according to
the type of thermometer you have.
• Thermometers should be stored dry when not in use.
• Before and after you take anyone’s temperature, the
thermometer should be cleaned with antiseptic to
prevent carrying infection from one person to another.
• It is important to notice when the temperature is even
a little bit lower than normal, before it reaches as low
as 35.5oC.
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 When are newborns at greatest risk of hypothermia?

• Newborns that have particular problems in producing enough heat in their

bodies, or who lose too much heat because of poor care by the mother, are
at the greatest risk.
• Newborns who may not produce enough heat include those who are:
– Preterm
– Underweight for gestational age
– Wasted (thin)
– Infected
– Hypoxic (starved of oxygen during labour and delivery).
• Newborns that lose too much heat include those who are:
– Wet after washing, or left in wet clothes
– Have not been fed enough
– Exposed to a cold environment, not enough clothes or covers, especially when
they are sleeping
– Naked when they are breastfed
– Fed close to a cold window, in a draught of cold air.
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 How do newborns lose heat?

• The mechanisms of how the newborn loses heat are summarized in

Figure 5.7, and described below.
• Convection: This is the loss of heat from the newborn's skin to the
surrounding air. Newborns lose a lot of heat by convection when
exposed to cold air or draughts.
• Conduction: This is the loss of heat when the newborn lies on a cold
surface. Newborns lose heat by conduction when placed naked on a
cold table, weighing scale or are wrapped in a cold blanket or towel.
• Evaporation: This is the loss of heat from a newborn's wet skin to
the surrounding air. Newborns lose heat by evaporation after delivery
or after a bath. Even a newborn in a wet nappy can lose heat by
evaporation.
• Radiation: This is the loss of heat from a newborn's skin to distant
cold objects, such as a cold window or wall etc.

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 Figure 5.7 Mechanisms of heat loss from a newborn baby’s skin.
(Source: WHO, 1997, Safe Motherhood: Thermal Protection of the
Newborn, a Practical Guide, accessed from)

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 The warm chain principle in postnatal care

• A warm chain is a system of keeping a baby warm immediately after

delivery, at a health facility or the mother’s home, during transportation
and while feeding and caring for the baby.
Box 5.7 Components of the warm chain
• Drying and wrapping the baby immediately at birth.
• Keeping the baby warm during any procedure, including resuscitation.
• Keeping the immediate newborn in skin-to-skin contact with the mother.
• Early initiation of breastfeeding within one hour of the birth; the warm
milk and contact with the mother's body helps to keep the newborn baby
warm.
• Postponing bathing the newborn for the first 24 hours.
• Keeping the baby warm during transportation.
• Dressing the baby in appropriate clothing and bedding at all times.

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 4.8. Special Care for Preterm and Low Birth Weight
Babies
• Special attention needed by preterm and low birth weight
babies.
• We will explain the many reasons why they need special
care, and how to give it, and also how to counsel mothers
and other family members on looking after them.
• The focus is on managing the problems of feeding preterm
and low birth weight babies, and of keeping them warm.
• In particular, you will learn about a relatively recent and
highly successful method of maintaining the body heat of
early or tiny babies, known as Kangaroo Mother Care.

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 4.8.1 Why do preterm or low birth weight babies need special care?

• Preterm and low birth weight babies are at increased risk of dying from
hypothermia, infection, breathing problems and immaturity of their vital organs.
• As a result they may be unable to adapt to life outside the uterus.
Box 4.8 Characteristics of preterm and low birth weight babies
• Parts of their nervous system are not yet well developed.
• They have little fat under the skin; especially their brown fat is low.
• Brown fat is very important to generate heat for the newborn baby; it is
found mainly over the shoulders, back, kidneys, neck and armpits.
• They lie very still so they can't generate heat by moving much.
• They have a high ratio of surface area to body weight compared to that of a
child or adult, so they lose heat quickly from their skin.
• They have immature lungs so they have breathing problems.
• They don't have much immunity so they will be extra vulnerable to infection.
• The veins in their brain are thin and immature and are prone to bleeding.
• They may be too weak to feed well.
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 4.8.2 Classification of preterm and low birth weight babies

• The lower the birth weight and gestational age of the

newborn, the higher the risk of complications and death
and the more special care he or she needs.
• The special care they will need should take into account the
classification of early and tiny babies, as described below.
• Classification on birth weight
• In relation to birth weight, most preterm babies are low
birth weight or very low birth weight, as classified below:
• Low birth weight: Babies born with birth weight between
1,500-2,499 gm.
• These babies can usually be managed safely at home with
some extra care and support.
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• Very low birth weight: Babies born with birth weight less than
1,500 gm.
• A life-threatening problem in such tiny babies is that suckling,
swallowing and breathing are not well coordinated, so they require
special attention in order to feed them adequately and safely.
• They also have great difficulty in maintaining their body
temperature, so they are at increased risk of hypothermia.
• These babies need advanced life support and should be referred
immediately to a hospital with special care facilities for very tiny
babies.
• However, at the present time, such facility-based care may not be
accessible to rural families in some parts of Ethiopia.

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 Classification on gestational age
• A premature baby is a baby born before 37 completed weeks of pregnancy.
• Based on the gestational age, preterm babies are further classified as follows:
• Preterm baby: Babies born between the gestational ages of 32 -36 weeks of
gestation, as calculated from the mother’s last normal menstrual period
(LNMP date).
• These babies can usually be managed safely at home with some extra care
and support, which you will learn later in this study session.
• Very preterm baby: Babies born between the gestational ages of 28 -31 weeks
as calculated from the LNMP date.
• very low birth weight babies and for the same reasons, they have problems in
feeding and maintaining their body temperature.
• If possible, they should be referred urgently for specialist care at a hospital.

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 Table4.2 : Classification of newborn babies according to birth weight and
gestational age

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 Counselling on how to feed preterm and low birth weight babies

• The breast milk produced by the mothers of

preterm babies is even more nutritious than the
milk produced by mothers whose babies were
born at full term.
• Therefore, a preterm mother’s milk is the best
milk for the preterm or low birth weight baby
and it should not be discarded, as no other
milk can replace its benefits.

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 Breastfeeding and cup feeding
• During the first week of the baby’s life, the mother needs
extra support from you and from the family to encourage
her to initiate exclusive breastfeeding and maintain it
until her tiny baby is able to suckle without any problem.
• Babies born between 34-36 weeks of gestation can
usually suckle breast milk adequately, but very preterm
babies may have difficulty breastfeeding.
• Breastfeeding a very preterm baby is a challenge.
• The frequency of feeding should be every two hours,
including through the night.
• If babies born before 34 weeks cannot suckle adequately,
they can be fed expressed breast milk using a small very
clean cup.
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• Tiny or early babies who are able to suckle breast milk may
also need feeding with additional expressed breast milk from a
cup occasionally, to make sure they are getting enough
nourishment.
• All babies who are on cup feeding have to be given around 60
ml/kg/day (that is 60 ml of breast milk for every kilogram of
the baby’s weight every day) and increase this by 20
ml/kg/day as the baby demands more feeding
• Extremely preterm babies born before 32 weeks of gestation
may not be able to breastfeed at all and need to be started on
intravenous fluids.
• This is one of the reasons why all babies less than 32 weeks
of gestation should be referred to health facilities immediately.
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 Tips to help a mother breastfeed a preterm or low birth weight baby

• Express a few drops of milk on the baby’s lip to help the baby start
nursing.
• Offer the whole breast, not just the nipple, so the baby can get a good
mouthful (Figure 4.8).
• Give the baby short rests during a breastfeed; suckling is hard work for
a preterm or tiny baby.
• If the baby coughs, gags, or spits up milk when starting to breastfeed,
the milk may be spurting out too fast for the little baby.
• Teach the mother to take the baby off the breast if this happens.
• Hold the baby against her chest until the baby can breathe well again.
• Then put it back to the breast after the first gush of milk has passed.
• If the preterm baby does not have enough energy to suck for long, or
its sucking reflex is not strong enough, teach the mother how to
express her breast milk by hand and then feed it to the baby from a cup.
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 Expressing breast milk
• Expressing breast milk can take 20-30 minutes or longer to start with, but it gets
quicker with practice.
• First tell the mother to wash her hands and her breasts with soap and water, and dry
them with a very clean towel.
• Then prepare a cleaned and boiled cup or jar with a wide opening.
• If she is unable to boil the whole container, pour some boiling water into it and leave it
there until just before she is ready to put milk into it; then pour the water away. This
will keep the milk safe from bacteria.
• The mother should sit comfortably and lean slightly towards the container.
• Show her how to hold the breast in a ‘C-hold’(her hand is shaped like a big letter C;
Figure 4.9a).
• Press the thumb and fingers back toward the chest wall (Figure 4.9b), then role the
thumb forward as if taking a thumb print, so that milk is expressed from all areas of the
breast.
• Express the milk from one breast for at least three to four minutes until the flow slows
and then shift to the other breast.
• Thinking about feeding her baby while she expresses her milk may help the milk to
flow out more easily.
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Figure 4.9aExpressing breast milk (a) Hold the breast in a C-shaped grip; (b) roll the
fingers and thumb backwards and then forwards so milk spurts from the nipple into a
sterilized container.

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• Breast milk can be saved at room temperature for up to six
hours if the room is not very hot and the milk is stored in a
sterilized container.
• Or it can be stored for longer in a refrigerator, if the
mother has one.
• Wherever it is stored the milk must be warmed to body
temperature before it is fed to the baby.
• To warm up the stored breast milk, put the container to
stand for a while in a bowl of warm water.
• Never boil breast milk!Boiling destroys nutrients and
antibodies.
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 Show mothers how to cup feed the baby

• Show the mother and other family members how to hold the baby closely
sitting a little upright.
• Hold a small very clean cup half-filled with expressed breast milk to the
baby’s lower lip (Figure 4.10).
• When the baby becomes awake and opens its mouth, keep the cup at the
baby’s lips letting the baby take the milk slowly.
• Give the baby time to swallow and rest between sips.
• When the baby takes enough and refuses any more, put the baby up to the
shoulder and ‘burp’ her or him by rubbing the baby’s back to expel air that
may have been swallowed with the milk.
■ What are the special tips and skills about breastfeeding that you may need
to explain or teach the mother of a preterm baby?
□ You should tell her about the importance of always using her own breast
milk to feed the baby; putting a few drops of milk onto the baby ’s lip to
encourage it to start suckling; how to express her breast milk and store it
safely; and how to cup feed the baby.
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 4.8.3 Special care to keep preterm and low birth weight babies warm

• Immediately after the birth, put the baby in skin-to-skin contact with the
mother, followed by Kangaroo Mother Care, which is described below.
• Extra blankets or any extra local cloth made of cotton are needed to cover
both the mother and the baby.
• An important thing to remember (which is often forgotten) is that the
baby’s head needs to be well covered.
• This is because more than 90% of the heat loss is through the head if it is
left uncovered.
• There should be an extra heat source in the room where the preterm baby
is looked after.
• Delay bathing for at least 48 hours after delivery, and always use warm
water.
• Initiate breastfeeding or cup feeding as early as possible and feed the
baby at least every two hours.

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 4.9. Kangaroo Mother Care
• Kangaroo Mother Care (KMC), called after the way that
kangaroos look after their young, has been shown to be an
extremely effective method of caring for preterm and low birth
weight babies.
• It involves holding a newborn in skin-to-skin contact, day and
night, prone and upright on the chest of the mother, or another
responsible person if the mother is unable to do it all the time.
• Evidence from using KMC to support preterm and low birth
weight babies shows that it results in greater stability of the
baby’s heart rate and breathing, lower rates of infection and
better weight gain.
• In the mother it results in increased breast milk supply, and she
is more likely to succeed in exclusive breastfeeding
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 [Link] Procedures
• Box 5.8 Preparations for Kangaroo Mother Care
• Make sure the room is clean and warm.
• Provide privacy to the mother so she can open her clothing at the front,
exposing her breasts.
• Request the mother to sit or recline comfortably.
• Undress the baby gently, except for cap, nappy (diaper) and socks.
• Place the baby lying flat, facing the mother’s chest in an upright and
extended posture, between the mother’s breasts, in skin-to-skin contact.
• Turn the baby’s head to one side to keep the airways clear. Keep the
baby in this position for 24 hours every day except for brief breaks.
• Cover the baby with the mother’s shawl, or gown; wrap the baby mother
together with an added blanket, and put a cap on the baby’s head.
• Breastfeed the baby frequently, at least 8-12 times a day.

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 Checking the baby is OK in KMC

• At every postnatal visit you should:

• Count the baby’s respiratory rate and make sure
there is no fast breathing.
• Observe that the baby is breastfeeding optimally.
• Measure the baby’s temperature in the armpit and
make sure it is normal.
• If everything is OK, reassure the family but tell
them to send for you immediately if there is any
problem
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 Counselling the family on the benefits of KMC

• what are the benefits of KMC?

• Breastfeeding: KMC increases breastfeeding rates as well as
increasing the duration of breastfeeding.
• Thermal control: Prolonged skin-to-skin contact between the
mother and her preterm/low birth weight newborn provides
effective temperature control with a reduced risk of
hypothermia.
• Early weight gain: Tiny babies gain more weight on KMC
than on conventional postnatal care.
• Less morbidity: Babies receiving KMC have more regular
breathing and are less likely to stop breathing. It also
protects her baby against infection.
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 How long should KMC continue?
• When the mother and baby are comfortable with the process, KMC
should continue for as long as possible, or until the gestational age
reaches term (40 weeks) or the baby’s weight reaches 2,500 gm.
• But if the baby weighs more than 1,800 gm and its temperature is
stable, there are no respiratory problems and the baby is feeding
well, it can be safely weaned from KMC before 40 weeks.
• And when the baby has had enough of being in KMC, it starts to
communicate with the mother in its own ways, by wriggling, by
moving a lot, pulling their limbs out of the wrapping and by crying
until they are removed from the wrapping.
• Finally, if you follow all these guidelines and help your families
with preterm or low birth weight babies to care for them as
described in this study session, you are sure to save some young
lives.
• And what could be better than that!
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 4.10. Making a Referral for Postnatal Care

• Health Extension Practitioners (HEPs) like you not only promote the
health of mothers and newborn babies in your community, but you save
lives too.
• The postnatal care you provide is part of the continuum of maternal and
child health care.
• The continuum of care begins even before the women in your community
become pregnant; it then continues through the ANC you give them
during their pregnancy and the skill and support you bring to their labour
and delivery.
• It merges seamlessly into your role in the postnatal period.
• Of course the continuum does not stop there: later you will study the
Module on the IMNCI which teaches you how to preserve and protect the
health of infants and older children.
• So you can see this continuum as an ongoing process of giving support
at all stages of from birth through to childhood, including support to their
mothers.
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 Effective Referral
• Whether or not a sick mother or sick newborn can reach a fully
functional HF in time can literally be the difference between life and
death. It helps a great deal if:
• You have taken care to develop and establish strong links with the health
facilities that you use (and the health workers in them), so that referrals
can be dealt with quickly and efficiently.
• You have mobilized the community to be alert to the need for
psychosocial, financial and practical support in cases where critically
sick mothers and newborns must reach the health facility urgently.
• You have convinced the mother and family to trust your judgment before
the emergency happens, so they are ready to follow your advice if an
emergency occurs.
• You are active in following up and checking that the mother and baby get
to the health facility.
• The traditional way of telling the mother or the caregivers to go to the
health facility, or just writing a referral note and doing nothing else, is
never a sufficient solution.
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 The referral link: a two-way street
• The referral link between a higher-level health facility and you, the (HEP) at the Health
Post, is a two-way street (Figure 5.12).
• For this system to be fully functional, you have to know the health workers in the nearby
health centre or hospital, and they should know all the HEPs at the Health Posts in their
catchment area.
■ Why do you think it is important to know the health workers at the higher-level facilities?
□ One reason is that it is so much easier to write an effective referral note to people you
know than to people you don’t.
• Another reason is that if they know you, they will be more able to trust your judgment
and act quickly on it when you refer a mother or baby to them.
• Receiving feedback
• Of course, it is not just a case of referring the mother/baby to the health facility and that
is the end of it.
• For eg, if you refer a sick mother, the health facility staff should write a note to you
when the mother is discharged back to the village, giving you feedback about what
happened to her while she was in their care, and giving you instructions on how to
manage her health problem in the future.
• That way you can continue to care for the mother and newborn in the most optimum way
possible.
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 Figure 5.12The referral link: a two-way street

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 Receiving feedback
• Of course, it is not just a case of referring the
mother/baby to the health facility and that is the end of
it.
• For eg, if you refer a sick mother, the health facility
staff should write a note to you when the mother is
discharged back to the village, giving you feedback
about what happened to her while she was in their care,
and giving you instructions on how to manage her
health problem in the future.
• That way you can continue to care for the mother and
newborn in the most optimum way possible.
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 Knowing about local health facilities
• To be really effective in your referrals you will need a list of all the health centres
and any hospitals in your catchment area, together with information about the
services each of them offers.
• This is so that if, for example, you deliver a very low birth weight baby, you
immediately know which health facility has the right capacity, equipment and trained
staff to give emergency care to very tiny babies.
• This information enables you to refer the mother and baby quickly to the right place.
■ What could happen if you don’t have information about the services offered at a
higher-level health facility?
□ The main risk is of sending a sick mother or baby on a difficult and expensive
journey, only for them to discover that the health facility does not have the
appropriate care services.
• This could be disastrous because it means so much precious time will have already
been lost on the road.
• To sum up, for there to be the best chance of a positive outcome, all health workers
in the community need to know how to refer their patients and exactly where to refer
them so they can receive appropriate services to meet their needs.

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What prevents referrals from happening effectively?

• There are many reasons why a referral doesn’t happen at all, or does
not happen in time, including the following:
• Lack of proper counselling to the mother, father and other caregivers,
so they don’t realize how serious the problem is.
• Far distance and lack of means of transportation to the health facility.
• The family has not saved the financial resources to make the journey.
• Health facilities are not attractive to some patients.
• Often they don’t have proper supplies of essential medicines and
equipment, or they lack the correctly trained person for the service
required.
• Hence, due to the poor reputation of some health facilities, parents
may be reluctant to go to them.

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 How to make referrals happen
• Writing a referral note and telling people to go to the health facility is not
the problem.
• As we have discussed already, the problem is getting them to the
appropriate facility where they will receive the right care.
• What else helps to make a referral happen effectively?
• Good documentation
• During pregnancy, every mother should be advised to get prepared for
birth, including what to do if emergency problems occur either in the baby
or herself.
• You should have the standard counselling card from your Region to help
you convince the mother and other caregivers to agree to a referral if
necessary.
• In other words, if you tell them she or the baby needs specialist help and
treatment from a higher-level health facility, they should be ready to trust
your judgement and go.
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■ What information should a referral note contain?
□ It should cover the following:
• Date of the referral and time
• Name of the health facility you are sending the patient to
• Name, date of birth, ID number (if known) and address of the patient
• Relevant medical history of the patient
• Your findings from physical examinations and tests
• Your suspected diagnosis
• Any treatment you have given to the patient
• reason for referring the patient
• Your name, date and signature
• Your address, so the health facility can communicate back to you.

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 Transport and the emergency evacuation plan

• Ideally, each village or community will have an emergency

evacuation system in place that will automatically be triggered
by a health crisis.
• That way it should be possible to ensure ready transport to enable
critically sick mothers or babies to get to the health facility in
time.
• Transport and the emergency evacuation plan
■ Quickly write down two actions that you would take when you
have a mother or baby who needs to get to a health facility for
specialist care
□ You would write the referral note; and support the family in
mobilizing the necessary human and financial resources to
transport mother and baby to the nearest appropriate health
facility.
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• Once you have ensured that mother and baby have transport, check
that there is adequate support for any other children or frail
dependents who remain at home while the mother and any other
caregivers are away.
• If possible, aim to accompany the critically sick mother or baby to the
health facility.
• If you cannot go with them, make sure that a responsible adult
accompanies them instead.
• Remember to ask this person to contact you as soon as he or she gets
back to the village, so that you know that the patient reached the
health facility safely.
• She or he can also tell you how the mother or baby is being treated.
• If you do not hear anything within a day or two, visit the home to
check whether they have returned from the health facility, and how
they are progressing
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 Making sure the health facility knows how to communicate with you

• Health workers in the nearby health facilities should map and

know the names of the kebeles and the HEPs (or other health
workers) in the H P surrounding their HF.
• Check that they have all the information they need about you,
especially where to find you and how best to contact you.
• If you find that they fail to communicate all the information
you need when they discharge a patient back into your care,
contact them and ask them for written feedback, setting out
the diagnosis, what they have done so far and what needs to
be followed up by you.
• Impress them with your professionalism and make sure that
they see you as a valued member of the health workforce in
the community
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• In other words, for the whole health system to be effective, health
workers in the higher-level health facilities and the health workers
in the community need to work hand in hand as a single team.
• If everybody’s efforts are coordinated, there is a better chance of
achieving the main goal –saving the lives of mothers and
newborns.
• And finally, we all want to see continuous improvement in the
whole system of health care.
• One way of achieving this is through regular performance review.
• Bringing together everybody involved to discuss how you can
better harmonize and coordinate your activities can make the
continuum of care successful for all concerned.

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