PROGRAMMING
FOR
INTEGRATED
MATERNAL
AND
REBUILDING
STATES
NEWBORN CARE
A BASIC
BRIEFING
PAPERCOURSE
SKILLS
2009
REFERENCE MANUAL
September 2009
This publication was produced for review by the United States Agency for International Development. It
was prepared by USAID/BASICS and POPPHI.
The authors views expressed in this publication do not necessarily reflect the views of the United States
Agency for International Development or the United States Government.
Reference Manual
Support for this publication was provided by the USAID Bureau for Global Health.
USAID/BASICS (Basic Support for Institutionalizing Child Survival) is a global project to assist developing
countries in reducing infant and child mortality through the implementation of proven health interventions.
BASICS is funded by the U.S. Agency for International Development (contract no. GHA-I-00-04-0000200) and implemented by the Partnership for Child Health Care, Inc., comprised of the Academy for
Educational Development, John Snow, Inc., and Management Sciences for Health. Subcontractors
include the Manoff Group, Inc., the Program for Appropriate Technology in Health, and Save the Children
Federation, Inc.
The Prevention of Postpartum Hemorrhage Initiative (POPPHI) is a USAID-funded, five-year project
focusing on the reduction of postpartum hemorrhage, the single most important cause of maternal deaths
worldwide. The POPPHI project is led by PATH and includes four partners: RTI International,
EngenderHealth, the International Federation of Gynaecology and Obstetrics (FIGO), and the
International Confederation of Midwives (ICM).
iii
Recommended Citation
Basic Support for Institutionalizing Child Survival (BASICS) and the Prevention of Postpartum
Hemorrhage Initiative (POPPHI). 2009. Integrated Maternal and Newborn Care Basics Skills Course:
Reference Manual. Arlington, Va., USA: for the United States Agency for International Development
(USAID).
This publication is one in a series that make up the USAID/BASICS Newborn Health tool kit. The tool kit
comprises:
Facility Level Tools:
Reference Manual
Technical Presentations
Facilitators Guide
Participants Notebook
Clinical Logbook with Learning and Evaluation Checklists
iv
Guide for Training Community Health Workers/Volunteers to Provide Maternal and Newborn
Health Messages
Set of Counseling Cards
Reference Manual
ACKNOWLEDGEMENTS
Main Authors
Indira Narayanan
Sr. Technical Advisor, Newborn Health
USAID/BASICS, USA
Susheela Engelbrecht
Sr. Program Officer
USAID/POPPHI, PATH, USA
Additional Contributing Authors
USAID/BASICS Project
Goldy Mazia
Technical Officer, Newborn Health
USAID/BASICS, USA
Gloria Ekpo
Technical Officer, Pediatric HIV/AIDS
USAID/BASICS, USA
USAID/POPPHI Project
Deborah Armbruster
Director
USAID/POPPHI, PATH, USA
Saliou Diouf
Professeur of Pediatrics
Institute of Social Pediatrics
University C.A. Diop
Dakar
Aboubacry Thiam
Regional Advisor, Africa Region
USAID/BASICS, Senegal
Democratic Republic of Congo (DRC)
Celestin N. Nsibu
Pediatrician
University of Kinshasa
Delphin I. Muyila
Pediatrician
General Hospital, Kinshasa
Lucie M. Zikudieka
Coordinator, Newborn Health
USAID/BASICS, DRC
Madagascar
Kanza NSIMBA
Team Leader
USAID/BASICS, DRC
Julia Rasoaharimalala
Physician, Department of Pediatrics
Central Hospital for Mothers and Children
Antananarivo
Michel Mpunga
Focal Person, Newborn Health
USAID/AXxes, DRC
Os Andrianarivony
Physician, Dept of Obstetrics
Maternity Hospital, Befelatanana
Antananarivo
Charlotte Storti
Consultant
USAID/BASICS, USA
Senegal
Haby Signate Sy
Professor of Pediatrics
Albert Royer Central University Hospital
Dakar
Paul Crystal
Communications Manager
USAID/BASICS, USA
Christa Peccianti
Program Coordinator
USAID/BASICS, USA
NOTE:
Content on definitions, newborn resuscitation, and minor and major infections was adapted
from Le Manuel de RfrenceSante du Nouveau-n. Ministre de Sante et USAID/BASICS,
2005.
All unidentified black and white illustrations were taken from: Engelbrecht, SM. Guide de la
Matrone: Tome 2La consultation postnatale. Editions Nanondiral: Dakar, Sngal, 1998.
vi
Reference Manual
TABLE OF CONTENTS
INTRODUCTION ....................................................................................................................... 1
Four Million Neonatal Deaths: Where do they occur?................................................................. 1
Four Million Neonatal Deaths: What do babies die of? ............................................................... 2
Four Million Neonatal Deaths: When do they occur?.................................................................. 2
CHAPTER 1: PREVENTING INFECTION ................................................................................. 4
Principles of Infection Prevention ............................................................................................... 4
Equipment and Supplies Related to Resuscitation ....................................................................22
CHAPTER 2: CLINICAL DECISION-MAKING ........................................................................ 23
The Problem-Solving Method....................................................................................................23
Documentation of Care .............................................................................................................26
CHAPTER 3: MATERNAL CARE TO IMPROVE MATERNAL AND NEWBORN SURVIVAL..29
Every Pregnancy is At Risk.....................................................................................................29
Maternal Conditions Affecting Fetal and Newborn Survival .......................................................30
Antenatal Care..........................................................................................................................33
Delays Resulting in Maternal and Newborn Deaths ..................................................................40
Birth-Preparedness Plan ...........................................................................................................40
Complication-Readiness Plan ...................................................................................................42
CHAPTER 4: PREVENTING POSTPARTUM HEMORRHAGE ............................................... 44
Causes of Postpartum Hemorrhage ..........................................................................................44
PPH Prevention and Early Detection.........................................................................................45
CHAPTER 5: ROUTINE CARE DURING THE THIRD STAGE OF LABOR .......................... ..48
Preparation for the Birth ............................................................................................................48
Essential Newborn Care ...........................................................................................................55
Care During the Third Stage of Labor .......................................................................................62
CHAPTER 6: MONITORING THE WOMAN AND NEWBORN DURING THE FIRST SIX
HOURS POSTPARTUM .77
Monitoring the Woman ..............................................................................................................77
Monitoring the Newborn ............................................................................................................80
CHAPTER 7: ROUTINE POSTPARTUM CARE FOR THE WOMAN ...................................... 83
Male Involvement......................................................................................................................83
Postpartum Care.......................................................................................................................84
CHAPTER 8: RESUSCITATION FOR BIRTH ASPHYXIA ...................................................... 93
Causes of Birth Asphyxia ..........................................................................................................94
Preparation for Resuscitation ....................................................................................................94
Steps in Newborn Resuscitation ...............................................................................................99
Post-Resuscitation Care .........................................................................................................104
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List of Figures
Intro. 1
Intro. 2
Intro. 3
1.1
1.2
1.3
1.4
1.5
1.6
1.7
2.1
3.1
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
5.18
5.19
5.20
5.21
5.22
5.23
5.24
7.1
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
p. 1
p. 2
p. 3
p. 6
p. 8
p. 10
p. 10
p. 12
p. 13
p. 17
p. 28
p. 30
p. 51
p. 52
p. 53
p. 55
p. 56
p. 57
p. 59
p. 66
p. 66
p. 67
p. 67
p. 67
p. 68
p. 69
p. 69
p. 70
p. 70
p. 71
p. 71
p. 72
p. 72
p. 73
p. 73
p. 74
p. 84
p. 95
p. 96
p. 97
p. 98
p. 100
p. 101
p. 102
p. 103
p. 107
p. 108
ix
p. 127
p. 132
p. 133
p. 134
p. 135
p. 140
p. 142
p. 143
p. 144
p. 144
p. 146
p. 19
p. 23
p. 34
p. 36
p. 61
p. 64
p. 147
p. 148
p. 169
List of Tables
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Table 16
Table 17
Table A1
Table A2
Table A3
p. 65
p. 81
p. 84
p. 112
p. 115
p. 123
p. 124
p. 125
p. 139
p. 152
p. 157
p. 159
p. 160
p. 161
Reference Manual
The Reference Manual contains the theoretical content for the training course. It is
intended to serve as the textbook or reference for participants and facilitators.
The series of Technical Presentations contains PowerPoint slides of the different
sessions. This will help in having more uniform training sessions and, along with the
checklists, provide the key elements of each topic for easier learning.
The Facilitators Guide includes lesson plans, knowledge evaluation tests (pre-test,
mid-course test, and post-test) and their suggested answers, answers for learning
exercises, and guidelines for conducting a clinical training program.
The Participants Notebook assists participants throughout the training program. The
notebook has the following components: overview of and agenda for the training
program, learning objectives, learning exercises, and additional printed materials.
The Clinical Logbook contains learning/practice guides or checklists and checklists for
evaluating competencies, a logbook for clinical experiences, and a guide for the clinical
practicum. Note: The checklists for evaluating competencies are also available as a
separate document to be used after training during follow-up supervision.
xi
The above resources are distinguished within the series by an identifying icon located on the top
of the odd-numbered pages:
Reference Manual
Technical Presentations
Facilitators Guide
Participants Notebook
Clinical Logbook
xii
Reference Manual
List of Abbreviations
AFASS
AMTSL
ANC
ARV
BP
blood pressure
CCT
CHW
CMV
cytomegalovirus
CPT
DIC
EBM
ENC
FH
fundal height
FP
FIGO
family planning
International Federation of Gynecology and Obstetrics
Hb
hemoglobin
HLD
high-level disinfection
HIV
ICM
IM
intramuscular
IMCI
IPTp
IPTI
ITN
Insecticide-treated bednets
IU
international unit
IUD
intrauterine device
IUGR
IV
intravenous
LAM
LBW
MNH
MTCT
PMTCT
POPPHI
PPC
postpartum care
xiii
PPH
postpartum hemorrhage
PPPH
PROM
RAM
RPR
STI
TSL
TT
tetanus toxoid
USAID
UTI
VDRL
VVM
WHO
SP
xiv
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INTRODUCTION
While there has been a significant decrease in the mortality of children over the years, it has
occurred mostly among infants and in children from one to five years of age. The mortality in the
short but critical neonatal period (the first four weeks) still remains high and has not followed the
same declining trend. Globally, an estimated four million deaths occur in these four weeks, with
a similar number of stillbirths. During the past decade, a considerable amount of interest has
been focused on newborns, with increased advocacy in this area leading to a number of
operational research projects and programs.
4 Million Deaths:
Where do newborn babies die?
Prematurity
31%
Diarrhea 3%
Neonatal tetanus
3%
Neonatal Infections
25%
Birth asphyxia/trauma
23%
Source: WHO. The Global Burden of Disease: 2004 update. WHO, Geneva, 2008
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75% of neonatal
deaths are in
the first week
3 million deaths
Time
when most babies die is
when coverage of
quality care is lowest
Strategies to improve newborn health need to address policy issues, the supply side of health
system strengthening, and the demand side at home and in the community to improve family
behaviors. Current pre-service training for doctors, nurses, and midwives in essential newborn
care has often been inadequate and at times inappropriate, so that health workers upon
completion of their undergraduate course often lack basic skills in this area, including prevention
and treatment of infections and birth asphyxia. Continuing education programs in newborn care
are therefore essential to improving health worker skills. Still other support is needed to improve
supervision and to provide and maintain basic equipment and supplies.
Since the health and survival of the newborn are closely tied to that of the mother, it is important
to integrate maternal and newborn health care into training programs wherever possible.
Although it is not feasible to integrate all aspects of maternal and newborn care, this set of
materials links selected aspects, including active management of the third stage of labor with
care of the baby at birth, resuscitation for birth asphyxia, postnatal care of the mother and the
baby, basic examination of the baby, care of the low birth weight infant, and prevention and
treatment of major and minor infections.
anything wet: broken skin, mucous membranes, blood, or other body fluids.
when there is a special risk of transmitting infection to or from the client.
Use protective gear (aprons, face masks, eye goggles, and caps) when splashes
or spills of body fluids are expected.
Use safe work practices (e.g., do not recap or bend needles), following
guidelines for handling and cleaning instruments and disposal of sharps and
medical waste.
Hand Washing
Hand washing significantly reduces the number of potentially infection-causing organisms on
health workers hands and decreases the incidence of client sickness and death due to clinicacquired infections. It also protects the health worker from contact with blood and other body
fluids.
Wash hands on the following occasions:
This section provides guidelines on infection prevention practices to use when providing maternal and
newborn services and is mainly adapted from materials developed by JHPIEGO, EngenderHealth, and
WHO.
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Use of Gloves
Gloves protect the client from contact with micro-organisms on the health workers hands and
the health worker from contact with blood and other body fluids.
Three types of gloves are commonly used:
Examination gloves (for contact with skin and intact mucous membranes and
wherever there is risk of exposure for the health worker)
Sterile/disposable surgical gloves (for contact with tissues under the skin or with the
bloodstream, and preferably for conducting deliveries)
Utility or heavy-duty household gloves, reusable after cleaning (for handling dirty linen,
instruments, and waste, for housekeeping and cleaning contaminated surfaces)
performing a procedure.
there will be contact with intact mucous membranes.
there will be contact with the tissues under the skin or with the bloodstream.
handling soiled items (e.g., instruments and gloves).
disposing of contaminated waste.
When gloves are required, a separate pair of gloves must be used with each woman or baby to
avoid cross-contamination. Disposable gloves are preferred, but when resources are limited,
surgical gloves can be reused if they are:
Single-use or disposable surgical gloves should not be reused more than three times, even after
the above steps, because invisible tears may occur.
Note: Do not use gloves that are cracked, peeling, visibly torn, or
that contain holes.
Putting gloves on
Follow the steps below in putting gloves on.
Step 1. Preparation for putting on surgical gloves. Gloves are cuffed to make it easier to put
them on without contaminating them. When putting on sterile gloves, remember that the first
glove should be picked up by the cuff only (see drawing below). The second glove should then
be touched only by the other sterile glove. Follow steps 2-6 as illustrated below.
Step 7. Adjust the glove fingers until the glove fits comfortably.
Taking gloves off
10
coats/gowns
waterproof aprons
masks
caps
eye covers/face shields
boots/slippers
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Gowns and waterproof aprons protect clients against micro-organisms and protect the
providers skin and clothes from contact with blood and other fluids.
Always wear a clean, preferably sterile gown during delivery.
If the gown has long sleeves, place gloves over the gown sleeve to avoid contaminating
the gloves.
Ensure that gloved hands are held high above the level of the waist and do not come
into contact with the gown.
Masks protect clients against micro-organisms expelled during talking, coughing, and
breathing, provided they are worn and used correctly, covering the mouth and nose.
They also protect the providers nose and mouth from splashes of blood and other fluids.
Caps protect clients against micro-organisms in hair and skin shed from the provider's
head. No protection has been documented for providers.
Eye covers/face shields protect the providers eyes from splashes of blood and other
fluids. No protection has been documented for clients.
Changing slippers at entry into the delivery room prevents bringing in the dirt from
outside.
Treatment of Soiled Linen
Correct handling of linen prevents the spread of infections to hospital personnel who transport,
sort, and clean the linen. It also prevents accidental injuries to hospital personnel who transport,
sort, and clean the linen. Linen for delivery rooms, surgery, and neonatal units should be
sterilized.
The materials required to treat soiled linen include:
utility gloves
heavy duty plastic bags or buckets with covers
detergent
water
a washing machine (ideal and far better than washing by hand)
Housekeeping and laundry personnel should wear gloves and other personal protective
equipment as indicated when collecting, handling, transporting, sorting, and washing
soiled linen.
When collecting and transporting soiled linen, handle it as little as possible and with
minimum contact to avoid accidental injury and spreading of micro-organisms.
Consider all cloth items (e.g., surgical drapes, gowns, wrappers) used during a
procedure as infectious; even if there is no visible contamination, the item must be
laundered.
11
Carry soiled linen in covered containers or plastic bags to prevent spills and splashes,
and confine the soiled linen to designated areas (an interim storage area) until
transported to the laundry.
Carefully sort all linen in the laundry area before washing. Do not presort or wash linen
at the point of use.
Pre-soak heavily soiled linen in soap, water, and bleach; wash separately from nonsoiled linen.
Hand- or machine-wash (the latter is preferred).
Air- or machine-dry completely (latter preferred). If air-drying, keep linen off the ground
and away from animals and dirt.
Sterilize linen for delivery rooms, operation theaters, and neonatal units by autoclaving
that avoids burning. The linens should be in packs of not more than 5 kg; they may be in
suitable drums.
After autoclaving, store in a clean, dry, preferably closed storage area.
Do not leave sharp instruments or needles (sharps) in places other than safe zones.
Use a tray or basin to carry and pass sharp items.
Pass instruments with the handle (not the sharp end) pointing toward the receiver.
Warn others before passing sharps.
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Make hypodermic needles unusable by burning them or, when the above container is full,
seal the opening and burn the container or fill the container with decontaminating solution, seal
the opening, and bury the container.
Preventing Splashes
Wear appropriate protective goggles, gloves, and gown during delivery. Preventing splashes
protects the client, health worker, and housekeeping staff from accidental injuries and exposure
to blood and body fluids.
Prevent splashes from blood or amniotic fluid by following these guidelines:
Avoid snapping the gloves when removing them, as this may cause contaminants to
splash into the eyes, mouth, or onto the skin or on others.
Hold instruments and other items under the surface of the water while scrubbing and
cleaning to avoid splashing.
Place items gently into the decontamination bucket to avoid splashes.
Avoid rupturing membranes during a uterine contraction.
Stand to the side when rupturing membranes to avoid splashes from amniotic fluid.
Cut the cord, using sterile scissors or a scalpel blade, under cover of a gauze swab to
prevent blood spurting.
Always wear gloves when handling the placenta and handle it carefully. Keep it in a leakproof plastic bag or other container until it can be disposed of by burning or burying. The
placenta should not be disposed of in a river or open garbage pit.
Note: If blood or body fluids get in the mouth or on the skin, wash
liberally with soap and water as soon as it is safe for the woman
and baby. If blood or body fluids splash in your eyes, wash out
well with water.
13
clean water
chlorine solution/chlorine tablets/chlorine powder
buckets with covers
measuring cups
a clock or timer
detergent
buckets or basins
water
toothbrush/brush
utility gloves
items.
2) Using a soft brush, detergent, and water, scrub instruments and other items vigorously
to completely remove all blood, other body fluids, tissue, and other foreign matter. Hold
instruments and other items under the surface of the water while scrubbing and cleaning
to avoid splashing. Disassemble instruments and other items with multiple parts, and be
sure to brush in the grooves, teeth, and joints of items where organic material can
collect and stick.
3) Rinse items thoroughly with clean water to remove all detergent. Any detergent left on
the items can reduce the effectiveness of further chemical processing.
4) Allow items to air-dry (or dry them with a clean towel).
Note: Instruments that will be further processed with chemical solutions
must dry completely to avoid diluting the chemicals; items that will be
boiled or steamed do not need to be dried first.
3A. High-level disinfection (HLD) kills viruses (hepatitis B and C, HCV, HIV) and many other
germs, but does not reliably kill all bacterial endospores. It is the only acceptable alternative
when sterilization is not available.
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Immerse items fully in water, cover with a lid, and boil for 20 minutes (sufficient up to a
height of 5500 meters/18,000 feet).
Start timing when the water begins to boil. Do not add anything to the pot after timing
begins.
Drain off the water and keep covered before use or storage. Store for one week
maximum.
Steaming:
Steam instruments, gloves, and other items on the steaming tray for 20 minutes.
Be sure there is enough water in the bottom pan for the entire steam cycle.
Bring water to a rolling boil. Start timing when the steam begins to come out from under
the lid. Do not add anything to the pan after timing starts.
Drain off the water and store in covered steamer pans. Store for one week maximum.
Chemical HLD:
3B. Sterilization kills all germs, including endospores, but is not possible in all settings.
The materials required are:
an autoclave
an oven
chemical or mechanical indicators
chemical products (e.g., glutaraldehyde)
wraps/drums for autoclaving
an autoclave tape
sterile pickups
a clock or timer
Sterilization can be done by dry (oven) or wet heat (autoclave), depending on the materials and
supplies to be sterilized. For example, glass items can be kept in the hot air oven, but some
items, such as those made of rubber and cloth, need to be autoclaved.
15
121 C (250 F); 106 kPa (15 lbs/in2) pressure: 20 minutes for unwrapped items, 30
minutes for wrapped items.
Decontaminate, clean, and dry items before sterilization.
Allow the pressure to drop to zero before opening the autoclave.
Allow items to dry before removing.
Dry-heat (oven): 170 C (340 F) for 1 hour or 160 C (320 F) for 2 hours.
Chemical sterilization:
4. Storage/Usage. If items are stored properly they will not become contaminated after
processing. Proper storage is as important as proper processing. Items processed through the
first three steps can be stored up to one week in an HLD/sterilized container.
Making a Chlorine Decontamination Solution
The ability to decontaminate instruments is a critical step in preventing infection. The most
common decontamination process is to soak instruments in a 0.5% chlorine solution for 10
minutes. Chlorine solutions made from sodium hypochlorite are usually the most inexpensive,
fast-acting, and effective for decontamination. A chlorine solution can be made from:
16
In countries where French products are available, the amount of active chlorine is
usually expressed in "degrees chlorum." One degree chlorum is equivalent to 0.3%
active chlorine.
Household bleach preparations can lose some of their chlorine over time. Use newly
manufactured bleach if possible. If the bleach does not smell strongly of chlorine, it may
not be satisfactory for the purpose and should not be used.
Thick bleach solutions should never be used for disinfection purposes (other than in
toilet bowls), as they contain potentially poisonous additives.
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Because of their low cost and wide availability, chlorine solutions prepared from liquid or
powdered bleach are recommended.
Organic matter destroys chlorine, and freshly diluted solutions must therefore be
prepared whenever the solution looks as though it needs to be changed (such as when it
becomes cloudy or heavily contaminated with blood or other body fluids).
Chlorine solutions gradually lose strength, and freshly diluted solutions must therefore
be prepared daily.
Calculate the ratio of water to liquid bleach, bleach powder, or chlorine-releasing tablets
(see the calculations below).
Clean, clear water should be used to make the solution because organic matter destroys
chlorine.
Use plastic containers for mixing and storing bleach solutions, as metal containers are
corroded rapidly and also affect the bleach.
Prepare bleach solutions in a well-ventilated area because they give off chlorine.
Label the container with the percentage of the diluted decontamination solution prepared
and note the day and time prepared.
A 0.5% bleach solution is caustic. Avoid direct contact with skin and eyes.
+
[3.5% divided by 0.5%] minus 1 = [7] minus 1 = 6 parts water for each part
chlorine
Figure 1.7. 0.5% chlorine solution
17
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% or grams
active chlorine
Water-to-chlorine =
0.5% solution
10 mL bleach in 40 mL water
1 part bleach to 4 parts water
8 Chlorum*
2.4%
3.5%
10 mL bleach in 60 mL water
12 Chlorum
3.6%
5%
6%
Lavandina (Bolivia)
8%
10%
15%
10 mL bleach in 90 mL water
1 part bleach to 9 parts water
10 mL bleach in 110 mL water
1 part bleach to 11 parts water
10 mL bleach in 150 mL water
1 part bleach to 15 parts water
10 mL bleach in 190 mL water
1 part bleach to 19 parts water
10 mL bleach in 290 mL water
1 part bleach to 29 parts water
Dry powders
Type or brand (by country)
% or grams
active chlorine
Water-to-chlorine =
0.5% solution
Calcium hypochlorite
70%
Calcium hypochlorite
35%
60%
Tablets
Type or brand (by country)
Chloramine tablets*
Sodium dichloroisocyanurate
(NaDCC-based tablets)
% or grams
active chlorine
1 gram chlorine
per tablet
1.5 grams
chlorine per tablet
Water-to-chlorine =
0.5% solution
20 grams per liter
(20 tablets per liter)
4 tablets per liter
*Chloramine releases chlorine slower than hypochlorite. Before using the solution, be sure the tablet is
completely dissolved.
19
Waste Disposal
Proper waste disposal:
minimizes the spread of infections and reduces the risk of accidental injury to staff who
handle the waste.
prevents the spread of infection to clients, visitors, and the local community.
helps provide an aesthetically pleasing atmosphere.
reduces odors.
attracts fewer insects and does not attract animals.
reduces the likelihood of contamination of the soil or ground water with chemicals or
micro-organisms.
There is no risk from uncontaminated waste such as office paper, boxes, packages, plastic
containers, and food-related trash which can be disposed of according to local guidelines.
Materials needed to dispose of waste include:
Proper handling of contaminated waste, such as items with blood or body fluid, is required to
minimize the spread of infection to other staff and the community. Proper handling includes:
Housekeeping
Good housekeeping reduces micro-organisms, reduces the risk of accidents, and provides an
appealing work and service-delivery space.
Materials required for good housekeeping include:
Detergent and water (for cleaning of walls, windows, ceilings, doors, floors, and
equipment such as stethoscopes and weighing scales)
Disinfectant solution (0.5% chlorine solution for decontamination of soiled area before
cleaning with detergent and water)
Disinfectant cleaning solution (0.5% chlorine solution with detergent):
o
o
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Cleaning procedures will depend upon the potential risk of contamination. Low-risk areas
include waiting rooms and administrative areas. High-risk areas are toilets, latrines, and
sluice rooms, and client-care areas such as operating theaters, procedure rooms,
laboratories, areas where instruments are cleaned and processed.
Develop and post cleaning schedules where all housekeeping staff can see them. Make
sure that cleaning schedules are closely maintained.
Clean immediately: after spills, procedures, and deliveries.
Clean daily (at each shift if work load is excessive): delivery, operation, and
examination/procedure rooms; floors, furniture, toilets/latrines, waste containers; and
wipe incubators and radiant warmers with disinfectant solutions.
Always wear gloves (preferably thick utility gloves) when cleaning.
Use a damp or wet mop or cloth for walls, floors, and surfaces, instead of dry-dusting or
sweeping, to reduce the spread of dust and micro-organisms.
Scrubbing is the most effective way to remove dirt and micro-organisms. Scrubbing
should be a part of every cleaning procedure.
Wash surfaces from top to bottom so that debris falls to the floor and is cleaned up last.
Clean the highest fixtures first and work downward; for example, clean ceiling lamps,
then shelves, then tables, and then the floor.
Change cleaning solutions whenever they appear to be dirty. A solution is less likely to
kill infectious micro-organisms if it is heavily soiled.
Clean up spills of potentially infectious fluids immediately. When cleaning up spills:
o
o
o
21
While the above may be acceptable at the community level, it is essential to take even greater
care at the facility level where with some advocacy and planning it will eventually be possible to
have as many sterile or disposable items as possible, especially those that come in direct
contact with the perineum or the baby. These precautions will help prevent hospital-acquired
infections which are particularly resistant to antibiotics and, hence, all the more dangerous.
While it may be initially difficult to achieve these goals, it is necessary to keep aiming high, to be
persistent on this important matter, and not be satisfied in just achieving cleanliness.
The text under this heading is reproduced from the WHO/Safe Motherhood Basic Neonatal
Resuscitation A Practical Guide.
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Step 3: Identification of
problems/needs
Step 5: Follow-up
23
visit, etc.). Listen carefully to all the answers; the clients answers are important and will help
you identify the problems. Write down the important points in the answers.
There are two types of histories:
A routine history: This type of history is taken for every woman coming in for routine
antenatal, postnatal, family planning, services, etc. Everyone who comes in for care will
be asked the same questions, and the information will be documented on a standard
form.
A targeted history: This type of history is taken when a client comes in with a complaint.
You will tailor the questions you ask around the complaint that the client has and will get
information from the client that will help you identify problems or make a diagnosis.
Ask specific questions about signs and symptoms to help identify the problem(s). The clients
answers about her problems are the findings of this first step. The results from this first step will
guide the provider through step 2.
Note: If the woman comes with an emergency, you will ask very few
questions, as immediate action may be required. You may have to ask
questions of the family who accompanies the woman.
Step 2: Perform a targeted physical examination
After explaining to the woman what you are planning to do, examine the areas of the clients
body that relate to the information you gathered in step 1. A physical examination includes
observation, palpation, percussion, auscultation, and smell.
There are two types of physical examinations:
Results from the physical examination are the findings of this step. Order laboratory or other
diagnostic tests as needed.
Examination of the baby has some other components that are described in chapter 9 and in
Appendix B.
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25
This is how the problem-solving method is used, over and over again until the problem is
resolved. Thank her for coming to see you and schedule an appointment for her return. Explain
why you want her to return. Make sure she knows the danger signs and emphasize that she
needs to come back immediately if she sees a danger sign in herself or her baby. When you are
scheduling a return visit, the time she should return will depend upon how severe her problem is
and how long it should take to improve. You may need to see her in 24 hours, 2-3 days, 2
weeks, or later. If she could develop a serious complication from her problem, she should be
seen frequently until she is out of danger. Newborn babies with minor problems are often asked
to be brought back after 48 hours. Low birth weight babies may be followed up on weekly until
they are gaining weight and doing well.
Step 5: Follow-up to evaluate the care provided
Repeat the problem-solving method when you see the client at her next visit, which could be
when she returns for a routine care appointment or for a check-up after treatment for a problem.
By repeating the problem-solving method, the provider will find out if the problem is solved, is
staying the same, or is getting worse. In some cases, the provider may need to develop a new
plan for treating the patient. The mother may need to have information repeated to be sure she
understands. She may need a different medication or treatment. She may need to be referred to
a doctor or hospital. The provider will also find out if there are other new problems or different
needs. Care needs to be taken to record all findings and actions taken. A clear report in the
clients record helps others to give continued quality care.
Somewhat similar plans apply to the newborn. However, since staff competence and facility
resources and supplies may be more limited related to the care of the sick newborn at
peripheral centers, babies with danger signs will frequently need to be referred to a suitable
higher center or hospital for appropriate care.
Documentation of Care
The problem-solving method provides a clear and organized way to record the information
about a womans problem and how it was managed. Along with the date and time record:
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When writing the plan of care, make sure it is tailored to respond to the problems and needs
identified in the mother and her baby. For each problem/need, write the following information:
treatments prescribed
prophylaxis prescribed
laboratory or other examinations ordered
counseling and education given
referrals made
date to return for care and evaluation.
All items should be clearly and carefully written in the records or cards of the mother/baby and
in the delivery room and clinic registers. When the recording is good and complete, the care is
usually good and complete.
27
Clinical Decision-Making
Yes
Danger signs?
No
Begin emergency
assessment and
management,
including plans for
referral where
required.
B1
Gather information: Take a
history and perform a
physical examination.
Identify problems/
make a diagnosis.
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To promote and maintain the physical, mental, and social health of the mother and baby
by providing education on nutrition, personal hygiene, and the birthing process.
To detect and manage complications during pregnancy, whether medical, surgical, or
obstetrical.
To develop a birth-preparedness and complication-readiness plan.
To help prepare the mother to breastfeed successfully, experience normal puerperium
(the period from 4-6 weeks after delivery), and take good care of the child physically,
psychologically, and socially.
So-called risk factors cannot predict complications because they are usually not the
direct cause of the complication; for example, although young age can be associated
with eclampsia, it does not always cause eclampsia. Women in older age groups can
also develop eclampsia.
Because maternal mortality is a relatively rare event in the population at risk, i.e., all
women of reproductive age, and because the so-called risk factors are relatively
common in the same population, these risk factors are not good indicators to identify
women who actually do experience complications.
The majority of women who actually did experience a complication were considered low
risk, while the majority of the women (90 percent) considered to be high risk gave birth
without experiencing a complication.
All health care providers and families understand that normal pregnancy and normal
birth are retrospective diagnoses and can only be made at the end of pregnancy and
childbirth.
All pregnancies be regarded as potentially at risk and managed with the utmost care.
29
All pregnant women receive at least four focused (quality) antenatal visits.
Detection of risk factors should be modified to put the emphasis on educating the
women, men, and family members about danger signs and the actions necessary to get
timely access to maternal health services if the woman experiences a complication.
The so-called risk factors, instead of being considered as markers or indicators of
complications, should be regarded as factors associated with complications, and their
importance for each pregnancy and childbirth should be considered on a case-by-case
basis.
The presence of risk factors implies a need for more careful monitoring, not because
they are necessarily predictive of complications. For many of them (e.g., age), nothing
can be done to alter the risk factor. However, additional care and watchfulness may
prevent a complication from arising or enable its early detection and management.
Iodine Deficiency
Iodine needs increase greatly during pregnancy because iodine is essential for the development
and maturation of the fetal nervous system. Iodine deficiency in the pregnant woman has been
associated with: 1) in the fetus: abortion, stillbirth, retardation of cerebral development, and
congenital anomalies; 2) in the newborn: low birth weight, goiter, and neonatal hypothyroidism;
and 3) in the adult: goiter and complications from goiters.
Malnutrition
Maternal undernutrition during pregnancy is associated with low birth weight. Low birth weight,
in turn, has been shown to correlate with an increased incidence of the following: neonatal,
infant, and child morbidity and mortality, small head circumference, mental retardation, cerebral
palsy, learning problems/disabilities, visual and hearing defects, neurologic defects, and poor
infant growth and development.
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Malaria
Susceptibility to malaria parasitemia is increased during
pregnancy, particularly in the primigravida or women in their
first malaria-exposed pregnancy. Malaria in pregnancy can
cause severe anemia, provoke an abortion, premature birth,
or the birth of a stillborn. Because placental sequestration of
malarial parasites can occur, newborns of women who have
suffered from malaria during pregnancy tend to be smaller,
weaker, and more vulnerable to infections.
Urinary Tract Infections
Urinary tract infections (UTI) during pregnancy increase the risk of low birth weight infants and
prematurity . Neonatal problems that are associated with UTI include sepsis and pneumonia.
The risk of urinary tract infection on adverse perinatal outcomes is greatest among those with
the most severe infection of the kidney, known as pyelonephritis.
Syphilis
Untreated maternal syphilis increases the risk of spontaneous abortion, stillbirth, congenital
infection in the newborn, and neonatal mortality. Early detection and treatment is necessary to
halt the devastating effects of progressive syphilis in the woman and to prevent transmission to
her baby and her partner. The test for syphilis should be repeated in the third trimester if the
woman or her partner engages in risky sexual behavior.
HIV
Infection with HIV affects many aspects of antenatal care. A woman infected with HIV requires
additional care to keep her as healthy as possible, to prevent transmission to her baby and her
partner, to treat her HIV infection, and to link her to appropriate support and help her make
decisions about the future, including avoiding unintended pregnancies. The risk of mother-tochild transmission (MTCT) of HIV is 15-45 percent; more than 90 percent of pediatric AIDS
cases are due to MTCT. Untreated maternal HIV can also result in increased incidence of
stillbirths and newborn deaths, low birth weight, intrauterine growth retardation, and possibly
spontaneous abortion and preterm birth.
Diabetes
Uncontrolled diabetes during pregnancy can result in maternal morbidity and mortality and is
associated with an increase in perinatal/neonatal mortality. In addition, certain fetal anomalies
are more common in babies of diabetic mothers, and the larger size of babies born to diabetic
mothers may contribute to cephalopelvic disproportion, obstructed labor, and increased
occurrence of birth asphyxia and birth trauma. Finally, the baby of a diabetic mother is also at
increased risk for hypoglycemia, which may occur in the immediate postpartum period, and for
jaundice, which may develop during the early neonatal period.
31
Perinatal outcome is strongly influenced by gestational age and the severity of hypertension.
Severe preeclampsia is associated with different degrees of fetal complications. The main
impact on the fetus is undernutrition as a result of utero-placental vascular insufficiency,
which leads to growth retardation. There are short and long-term effects; the immediate
impact observed is fetal growth retardation, resulting in greater fetal liability. Fetal health as
well as the fetus weight are highly compromised, leading to various degrees of fetal
morbidity, and fetal damage may be such as to cause fetal death.
Pre-Labor Rupture of Membranes
Pre-labor rupture of membranes (PROM) may pose immediate risks such as
cord prolapse, cord compression, and placental abruption. PROM is believed to
have an association with maternal and fetal infection, with the risk considered
to increase proportionally to the time between membrane rupture and birth, the
risk being greater when the duration exceeds 18 hours. PROM also increases
the risk of Caesarean operation and extends the duration of the hospital stay.
If PROM occurs before 37 weeks, there is an additional risk of giving birth to a
premature infant.
Vaginal Bleeding in Later Pregnancy and Labor
Any amount of bleeding during pregnancy and labor can put the life of the
woman and fetus in danger. Preterm delivery and low birth weight are associated
with second trimester hemorrhage. Abruptio placentae, placenta praevia, and
uterine rupture are all associated with fetal distress and death.
If the woman is Rh-negative, there is a risk of maternal iso-immunization if
maternal and fetal blood mix when hemorrhage occurs. This may have an impact
on the baby and will certainly have consequences for future pregnancies.
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ANTENATAL CARE
Antenatal care (ANC) should begin as early as possible in the pregnancy. Appropriate
scheduling depends on the gestational age of the pregnancy and also the womans individual
needs. For women whose pregnancies are progressing normally, the following schedule for a
minimum of four ANC visits may be sufficient:
1st Visit: 16 weeks (by the end of 4 months) or as soon as
the woman thinks she is pregnant
nd
2 Visit: 24-28 weeks (6-7 months)
3rd Visit: 32 weeks (8 months)
4th Visit: 36 weeks (9 months) for a total of 2 visits
during the 3rd trimester
Elements of a Routine Antenatal Visit
During a routine antenatal visit, a skilled provider should:
33
o
o
has been contaminated by blood (or if she has schistosomiasis), vaginal discharge,
or amniotic fluid.
Grouping and Rhesus factor: All pregnant women should have their blood grouped
for ABO and Rhesus (Rh) types. Knowing the womans blood type can facilitate
transfusion in the case of an emergency. Knowing her Rhesus type will allow timely
administration of Rhesus antibodies (anti-D immunoglobulin) to prevent maternal
iso-immunization. Women with Rh-negative blood group are screened for Rhesus
antibodies with an indirect Coombs test. If there are no antibodies, the blood will be
retested at 28 and 34 weeks of pregnancy. If antibodies are found at any stage,
referral to a specialist will be required to decide on management of the pregnancy
and the newborn.
Urine test for bacteriuria (as needed): This test is used to diagnose urinary tract
infections, which are conditions beyond the scope of basic care.
Other tests as needed based on findings in history and physical examination.
Provide prophylaxis for health promotion and disease prevention: TT, intermittent
preventive treatment (IPTp) of malaria, insecticide-treated bednets, iron/folate tablets,
broad-spectrum anti-helminthics, and other nutritional supplements as needed.
Provide treatment for any medical conditions, illnesses, and infections detected.
Manage any pregnancy-related complications.
Provide client-centered and gestational-age-specific counseling for women and partners/
supporters.
Help the woman and her partner/support person develop a birth-preparedness and
complication-readiness plan. Begin discussing the plan at the first visit and bring it up to
date at each subsequent visit.
Ideally, during the antenatal visits, the mother should be counseled on basic preventive
care of herself and her baby after delivery, identification of danger signs, and the
required care-seeking. A number of women may end up delivering at home even after
having visited the antenatal clinic.
Refer all women who need specialized care for any reason to an appropriate hospital.
34
Timing
From 18 weeks (after
quickening). Not before 16
weeks gestation.
At 28 weeks or 1 month
After the 1st dose.
Reference Manual
Have the woman take the dose in front of the provider. Do not give the dose on an
empty stomach; ask the woman to eat something before taking the tablets. There should
be at least one month between doses.
Note: Studies are looking for evidence of an interaction between folic
acid and SP when these drugs have been used together in the
management of acute malaria. Refer to national protocols for the latest
recommendations.
35
In areas endemic for hookworm (prevalence of 20 percent or more), give one of the
following treatments starting after 16 weeks gestation and repeating every 6 months:
TT 1
TT 2
0.5 mL
TT 3
0.5 mL
TT 4
0.5 mL
TT 5
0.5 mL
Note: A woman has lifetime protection against tetanus after she has
received five doses of TT.
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Informing the pregnant woman about options for family planning gives her the time to reflect,
talk with friends, talk with her husband/partner, and become educated about what choices she
has. Contrary to popular practice, talking about family planning is very important during the
pregnancy, although it may be taboo in some cultures. If the woman is not ready to talk about
all the methods, you can plant the seed and provide future opportunities for discussion.
Nutrition during pregnancy
All pregnant women need particularly nutritious meals throughout their pregnancy. A pregnant
woman needs the nutritious foods available to the family: milk, fruit, vegetables, meat, fish,
eggs, grains, peas, and beans. All these foods are safe to eat during pregnancy.
Women will feel stronger and be healthier during pregnancy if
they eat foods that are rich in iron, vitamin A, and folic acid.
These foods include meat, fish, eggs, green leafy vegetables,
and orange or yellow fruits and vegetables. Growing
adolescent girls may have higher nutritional requirements in
order to support their own growth.
Health care providers can provide pregnant women with iron
tablets to prevent or treat anemia and, in vitamin-A-deficient
areas, an adequate dosage of vitamin A to help prevent
infection. Pregnant women should not take more than 10,000 international units (IU) of vitamin
A per day or 25,000 IU per week. Advise mothers to take iodized salt. Women who do not have
enough iodine in their diet are more likely to have miscarriages and risk having an infant who is
mentally or physically disabled. Goiter is a clear sign that a woman is not getting enough iodine.
Rest
A pregnant woman needs additional rest during pregnancy. In early pregnancy, the woman will
feel tired as her body becomes accustomed to being pregnant. As the pregnancy advances, the
larger fetus makes greater demands and causes greater strains on her body, and she will need
more and more rest. During pregnancy, in addition to whatever amount of sleep she normally
needs, she should have additional periodic rest periods during the day, preferably lying down
with her feet elevated. In addition, she should avoid sitting or standing for long periods during
the day.
In most cultures women do not get permission to rest during pregnancy. Many families feel that
if the woman works hard through pregnancy the delivery will be easier. It may be the providers
role to play advocate for the woman and help her find creative ways to reduce her workload and
find more time for rest.
Safer sex
To assure good relations between the woman and her partner, it is important to address the
issue of sexual intercourse. Sometimes the pregnant woman may not feel the desire to have
sex, and she needs to feel empowered enough to refuse. If she does desire having intercourse,
she needs to know that the only time that intercourse is discouraged is if there is suspected
premature rupture of membranes, bleeding, bleeding and cramps in the first trimester, or
infection of the partner; and that having sex will not harm the fetus. In addition, it may be
necessary to make changes in position to accommodate the enlarged abdomen or find
alternative methods of satisfying both male and female sexual needs.
37
It is important to discuss issues of safer sex because infidelity by the male partner can be
highest during the third trimester of pregnancy. The risk of getting HIV through sex can be
reduced if: 1) people don't have sex, 2) if they reduce the number of sex partners, 3) if
uninfected partners have sex only with each other, or 4) if people have safer sex, i.e., sex
without penetration or while using a condom. Correct and consistent use of condoms can save
lives by preventing the spread of HIV.
Hygiene
Due to hormonal changes brought about by the pregnancy, pregnant women sweat more and
have more vaginal discharge than women who are not pregnant. The pregnant woman needs,
therefore, to be vigilant about her personal hygiene to prevent infections and disease. Gentle
reminders about needs for bathing and wearing clean clothes are never misplaced.
When the woman comes in for antenatal care, the provider can remind her about other simple
hygiene rules that can help her prevent diseases: hand washing, treatment and care of drinking
water, avoiding raw meats, reheating leftovers well, and being careful about coming into contact
with people who are ill.
Dental care is also important during pregnancy because estrogen can make gum tissues
edematous. Using a dental stick or using a toothbrush and toothpaste are equally appropriate.
Breastfeeding
Provide advice on breastfeeding, especially on early initiation without pre-lacteal feeds and on
continuing exclusive breastfeeding on demand. Further details on normal breastfeeding are
noted in chapter 5 under care of the baby at birth.
Prevention of mother-to-child transmission (PMTCT) of HIV
Offer HIV testing and counseling to all pregnant women and their sexual partners. The following
are the standard HIV pre-test session messages in all PMTCT settings:
Help the client understand basic information on HIV transmission and prevention.
Explain in simple terms how HIV infection can be transmitted from mother to child.
Explain how transmission of the infection from mother to child can be prevented.
Explain the importance of HIV testing.
Explain HIV testing processes and procedures, including issues of confidentiality.
Discuss implications of positive and negative test results.
Explain the importance of partner testing:
o
o
38
discordance
disclosure and partner referral
prevention of sexual transmission of HIV
PMTCT interventions, including ARV prophylaxis and safer infant feeding
referral for prevention, care, treatment, and support
Discuss with HIV-positive clients the mode of delivery and feeding options. Assist them in
identifying HIV support services.
Provide information on health timing and spacing of pregnancy and family planning.
Encourage continuous healthcare attendance and delivery care.
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Provide post-test counseling to HIV-positive and negative women based on national guidelines.
Counseling for those whose HIV test results are negative should include the following minimum
information:
In the case of individuals whose HIV test results are positive, the health care provider should:
Discuss infant feeding options and support the woman to carry out her choice.
Encourage and offer referral for testing and counseling of partners and children, HIV
testing for the infant, and the follow-up that will be necessary.
Provide take-home information.
39
When delays occur in recognizing problems and referring women or newborns to appropriate
health care facilities, the result can lead to maternal and newborn deaths. One solution to
combat these problems is to work with the pregnant woman and her family to develop two
plans: a birth-preparedness plan and a complication-readiness plan.
BIRTH-PREPAREDNESS PLAN
Having a birth plan can reduce delayed decision-making and increase the probability of timely
care. A birth-preparedness plan is an action plan made by the woman, her family members, and
the health care provider. Often this plan is not a written document but an ongoing discussion
between all concerned parties to ensure that the woman receives the best care in a timely
manner. Each family should have the opportunity to make a plan for the birth. Health care
providers can help the woman and her family develop birth-preparedness plans and discuss
birth-related issues. Work with the woman to:
1. Make plans for the birth:
40
Discuss the idea of a birth plan and what to include during the first visit.
Inquire about the birth-preparedness plan during subsequent visits.
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Ask if arrangements are made for a skilled birth attendant and the birth setting during the
antenatal visit in the eighth month.
If the woman is planning a home delivery with a
skilled birth attendant, discuss access to a safe
delivery kit consisting of: 1) a piece of soap for
cleaning the birth attendants hands and the
womans perineum, 2) a plastic sheet about one
square meter for use as a clean delivery
surface, 3) a clean string for tying the umbilical
cord (usually two pieces), and 4) a clean razor
blade for cutting the cord. Advise the
woman/family to boil the threads to be used as
cord ties and the blade in water for 10 minutes
before use.
Discuss items needed for the birth (perineal pads/cloths, soap, clean bed sheets) on the
third antenatal visit.
Confirm necessary items are gathered near the due date.
Note: In some cultures, superstition surrounds buying items for an
unborn baby. If this is not the case, families can prepare for the birth
by buying baby supplies such as blankets, diapers, and clothes.
4. Save money:
Discuss why and how to save money in preparation for the birth during the first visit.
Discuss how to plan to make sure that any funds needed are available at birth.
Check that the woman and her family have begun saving money or that they have ways to
access necessary funds.
Note: Encourage the family to save money so necessary funds are
available for routine care during pregnancy and birth. Assess financial
needs with the women as well as sources for accessing these funds
so they are available before labor. If traditional beliefs do not permit
getting clothes ready, advise the family to keep aside at least pieces
of cloth/linen/blanket to dry and wrap the baby.
41
COMPLICATION-READINESS PLAN
The complication-readiness plan is an action plan that outlines steps that can be discussed and
determined prior to an emergency. Developing this plan helps the family to be prepared for and
respond quickly when the woman or newborn has a complication and needs medical care. It is
important that a complication-readiness plan is prepared with the woman and her chosen family
members. Unless others are involved, the woman may have difficulties putting the plan into
action should complications occur for her or her baby.
Recognizing maternal danger signs
Women, family members, and community caregivers must know the signs of life-threatening
complications. Many hours can be lost from the time a complication is recognized until the time
arrangements are made for the woman to reach help. For postpartum hemorrhage, the time
from the start of bleeding to death can be as little as two hours. In too many cases, families of
women who died in pregnancy, birth, or postpartum, did not recognize the problem in time. It is
critical to reduce the time needed to recognize problems and make arrangements to receive
care at the most appropriate level of care. Women, family members, and community caregivers
must know the signs of life-threatening complications.
Maternal danger signs include:
vaginal bleeding (any vaginal bleeding during pregnancy, heavy vaginal bleeding or a
sudden increase in vaginal bleeding during the postpartum period)
pre-labor rupture of membranes (PROM)
breathing difficulties
fever
severe abdominal pain
severe headache/blurred vision
convulsions or loss of consciousness
pain during urination, bloody or scanty urine
foul-smelling discharge from vagina, tears, and incisions
calf pain, with or without swelling
night blindness
verbalization or behavior indicating the mother may hurt the baby or herself
hallucinations
Note: A pregnant woman should seek care immediately even if she is
experiencing only one of the danger signs listed.
Save money
Similar to the birth-preparedness plan, the family should be encouraged to save money so
necessary funds are available for emergencies. In many situations, women either do not seek or
receive care because they lack funds to pay for services.
Choose a decision-maker in case of emergency
In many families, one person is the primary decision-maker. Too often other members of the
family do not feel they can make decisions if that person is absent. This can result in death
when an emergency occurs and the primary decision-maker is absent. It is important to discuss
how the family can make emergency decisions without disrupting or offending cultural and
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Reference Manual
family values. If possible, find out which family member can make a decision in the absence of
the chief decision-maker.
Have an emergency transportation plan
Too many women and newborns die because they suffer serious complications and do not have
access to transportation to the type of health care facility that can provide needed care. Each
family should develop a transportation plan during the womans early pregnancy in case the
woman experiences complications and urgently needs a higher level of care. This plan should
be prepared during pregnancy and after giving birth, either before discharge from the health
facility or immediately after returning home. The plan should address the following:
43
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Reference Manual
prolonged labor
induction or augmentation of labor
precipitous labor (labor lasting less than 3 hours)
a full bladder
Undetected or untreated lower genital tract lacerations, such as cervical, vaginal, or perineal
lacerations and episiotomy, are the second most common cause of PPH. Episiotomy causes
loss of blood and can lead to lacerations. Lacerations can also be caused by deliveries that are
poorly controlled, difficult, or managed with instruments (e.g., large baby, twins, or non-cephalic
presentation). When the woman has genital lacerations, it is still important to check for and treat
uterine atony because these conditions may occur together.
Other causes include:
retained placenta or placental fragments. If the uterus is not empty, it cannot contract
adequately. This can occur if even a small part of the placenta or membranes is
retained. A partially separated placenta may also cause bleeding.
uterine rupture and uterine inversion. Although rare, these conditions also cause PPH.
disseminated intravascular coagulation (DIC). Although uncommon, this clotting
disorderassociated with preeclampsia, eclampsia, prolonged labor, abruptio
placentae, and infectionsis a significant and serious cause of PPH. (Coagulation
means a defect in the body's mechanism for blood clotting. While there are several
possible causes for coagulopathies, they generally result in excessive bleeding and a
lack of clotting.)
harmful traditional practices. Women with genital lacerations caused by traditional birth
attendants and traditional healers for prolonged labor at home may be brought to the
facility with PPH.
Preventing PPH and careful monitoring during the first hours after birth are critical for every
woman at every birth. Despite the best strategies to prevent blood loss, approximately three
percent of women will still lose blood in excess of 1000 mL. Preparing for early treatment of
PPH (e.g., additional uterotonic drugs and arranging for blood where feasible) is critical to
womens health.
45
Develop a birth-preparedness plan. Women should plan to give birth with a skilled
attendant who can provide interventions to prevent PPH (including AMTSL), and can
identify and manage PPH, and refer the woman for additional treatment if needed.
Develop a complication-readiness plan that includes recognition of danger signs and
what to do if they occur, where to get help and how to get there, and how to save money
for transport and emergency care. For more information, see chapter 3.
Routinely screen to prevent and treat anemia during preconceptual, antenatal, and
postpartum visits. Counsel women on nutrition, focusing on available iron and folic acidrich foods, and provide iron/folate supplementation during pregnancy.
Help prevent anemia by addressing major causes, such as malaria and hookworm.
For malaria, encourage use of insecticide-treated bednets, provide intermittent
preventive treatment during pregnancy to prevent asymptomatic infections
among pregnant women living in areas of moderate or high transmission of
Plasmodium falciparum, and ensure effective case management for malaria
illness and anemia.
For hookworm, provide treatment at least once after the first trimester.
Determine the womans blood group where feasible.
In cases where the woman cannot give birth with a skilled attendant, prevent
prolonged/obstructed labor by providing information about the signs of labor, when labor
is too long, and when to come to the facility or contact the birth attendant.
Avoid procedures such as external cephalic version to correct abnormal lie of the baby.
Prevent harmful practices by helping women and their families recognize harmful
customs practiced during labor (e.g., providing herbal remedies to increase contractions,
health workers giving oxytocin by intramuscular injection during labor).
Take culturally sensitive actions to involve men and encourage understanding about the
urgency of labor and need for immediate assistance.
46
Use a partograph to monitor and guide management of labor and quickly detect
unsatisfactory progress.
Ensure early referral when progress of labor is unsatisfactory.
Encourage the woman to keep her bladder empty.
Limit induction or augmentation use for medical and obstetric reasons. (Induction means
stimulating uterine contractions to produce delivery before the onset of spontaneous
labor; augmentation means stimulating the uterus during labor to increase the frequency,
duration, and strength of contractions.)
Limit induction or augmentation of labor to facilities equipped to perform a Caesarean
delivery.
Do not encourage pushing before the cervix is fully dilated.
Do not use fundal pressure to assist the birth of the baby.
Do not perform routine episiotomy. Consider episiotomy only with complicated vaginal
delivery (e.g., breech, shoulder dystocia, forceps, vacuum, scarring from female genital
cutting or poorly healed third- or fourth-degree tears, and fetal distress).
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Assist the woman in the controlled delivery of the babys head and shoulders to help
prevent tears. Place the fingers of one hand against the babys head to keep it flexed
(bent), support the perineum, and instruct the woman to use breathing techniques to
push or stop pushing.
Provide active management of the third stage of labor (AMTSL)the single most
effective way to prevent PPH.
Do not use fundal pressure to assist the delivery of the placenta; instead, apply pressure
on a woman's abdomen to help expel the placenta.
Do not perform controlled cord traction (CCT) without administering a uterotonic drug.
Do not perform CCT without providing countertraction to support the uterus.
Routinely inspect the vulva, vagina, perineum, and anus to identify genital lacerations.
Cervical examination is only recommended when the cause of PPH has not been
diagnosed and uterine atony, lower genital lacerations, and retained placenta are ruled
out.
Inspect the placenta and membranes for completeness.
Evaluate if the uterus is well contracted and massage the uterus at regular intervals after
placental delivery to keep the uterus well-contracted and firm (at least every 15 minutes
for the first 2 hours after birth).
Teach the woman to massage her own uterus to keep it firm. Instruct her on how to
check her uterus and to call for assistance if her uterus is soft or if she experiences
increased vaginal bleeding.
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48
placing waste products and contaminated objects (from the previous birth) into the
appropriate containers.
wiping down surfaces with 0.5% chlorine solution.
tidying the area.
checking that the injection safety box is accessible and does not require changing.
making sure that buckets with 0.5% chlorine are available for decontamination and
that the solution does not need to be changed.
Make sure that the womans bodily privacy is protected (curtains, doors that close, etc.);
if permitted, ask the woman if she would like a companion with her during childbirth and
facilitate that persons presence in the delivery room.
Check that all needed equipment and instruments for delivery care, essential maternal
and newborn care, newborn resuscitation, and adult resuscitation are available, clean,
sterile/HLD, and in good working order and readily accessible.
Make sure that the room is warm (at least 25-28 C/77.0-82.4 F) and free from drafts
from open windows and doors or from fans. This is especially true for the area in the
room where newborns receive special care, such as resuscitation. Make sure that all of
the windows are closed.
If the temperature of the room is less than optimal, a heater should be available to warm
the room. In some circumstances, it might be easier to warm a small area of a room
rather than the whole room. In hot weather, air conditioning or fans should be turned off
or adjusted in the delivery room.
Make sure that supplies needed to keep the newborn baby warm are prepared. The
supplies should include as a minimum: two absorbent pieces of cloth/towels large
enough to cover a newborn baby's whole body and head, a cap, a sheet or blanket for
covering mother and baby, and suitable baby clothes if feasible/acceptable. In cool
weather, a source of heat should be available to pre-warm the clothes and towels.
Even though the care of a normal baby can be carried out while he/she is in skin-to-skin
contact with the mothers chest, it is important to have a corner or area for the newborn
in the delivery room where all the equipment and supplies can be collected and kept
together. Ideally there should be a heater/source of warmth under or near which the
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linen and blanket for the baby can be kept for pre-warming before the delivery, and
where resuscitation can be carried out.
Make sure that all surfaces the woman and baby will come in contact with are clean,
warm, and dry.
Make sure the room is well-lit.
Review and complete the womans medical records (if available):
o
o
the antenatal care card (take special care to check the womans HIV status, and if
she is infected with HIV, ask about her antiretroviral (ARV) regimen and if she has
brought ARV drugs for her baby)
partograph
any other records she may have with her
Encourage the woman to wash herself or bathe or shower at the onset of labor.
Put a clean, waterproof sheet under the womans bottom.
Clean the vulval and perineal areas before each examination.
Wash hands with soap before and after each examination.
Ensure cleanliness of laboring and birthing area(s).
Clean up all spills immediately.
Follow infection prevention practices to reduce exposure to blood and other body fluids
during labor and delivery, and thereby help protect the woman and providers from
infection:
o
Wash hands with soap and water and dry with a clean, dry cloth before examining
each client; after examining each client; before putting on gloves for clinical
procedures (such as a vaginal exam or examination of the placenta); after touching
any instrument or object that might be contaminated with blood or other body fluids,
or after touching mucous membranes; after handling blood, urine, or other
specimens; after removing any kind of gloves; after using the toilet or latrine.
Wear protective clothing: sterile/HLD gloves, masks, gowns, and waterproof aprons,
caps, eye covers/face shields.
During the first stage of labor, preferably in between contractions and before
contractions are very intense:
o
o
o
Explain and offer AMTSL to the woman and obtain her permission to apply it.
Explain skin-to-skin contact and that the newborn will be placed first on her abdomen
and then on her chest, and obtain her permission to do this.
Explain that essential newborn care will be provided while the baby is in skin-to-skin
contact with her and obtain her permission; care includes placing an identification
bracelet on the baby, eye and cord care, vitamin K1 injection, and early initiation of
breastfeeding .
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Encourage the woman to have personal support from a person of her choice throughout
labor and birth:
o
o
o
Explain all procedures, seek permission, and discuss findings with the woman.
Provide a supportive, encouraging atmosphere for birth, respectful of the womans
wishes.
Ensure privacy and confidentiality.
Ensure mobility:
o
o
Encourage the woman to eat and drink as she wishes. If the woman has visible severe
wasting or tires during labor, make sure she is fed. Nutritious liquid drinks are important,
even in late labor.
Teach breathing techniques for labor and delivery. Encourage the woman to breathe out
more slowly than usual and relax with each expiration.
Help the woman in labor who is anxious, fearful, or in pain:
o
o
o
If the woman is infected with HIV, follow national protocols to prevent mother-to-child
transmission of HIV/AIDS.
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Figure 5.1. Positions that a woman may adopt during labor. (WHO, 2003)
Use the partograph card (see Figure 5.2 below) to monitor progress of the first stage of labor.
Unsatisfactory progress in labor can lead to prolonged labor (the woman has been
experiencing labor pains for 12 hours or more without delivery). Be sure to transfer women
immediately to a facility with operative facilities as soon as unsatisfactory progress has been
identified.
Other signs that indicate the woman is experiencing a complication include:
Follow national
protocols for
management
and referral of
complications.
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Help the woman empty her bladder when the second stage is near.
Inform the woman of her babys sex and health status and provide information about the
care you are providing her baby.
Make sure the woman is comfortable.
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Newborn resuscitator bag (240-500 mL) with two baby face masks (#1 for normal size
babies, # 0 for LBW babies). In general, where resources are limited, the 500 mL bag is
preferable as it can be used for the normal weight and the larger proportion of low birth
weight infants.
A supplemental oxygen source, if available. If cylinders are used, check that they have
adequate oxygen. Note, however, that supplemental oxygen is not required for
resuscitation in most cases.
A wall clock with second hand for noting the time of birth and where necessary to count
the respiratory and heart rate if there is no timer or watch. In case of an emergency
situation such as asphyxia, it is easy to lose track of time. It is important to note the time
of birth and the time spent in the procedure, since there is a time limit to active
resuscitation. If no respiration is noted after twenty minutes, it is necessary to stop all
action.
A stethoscope where available.
Miscellaneous: sterile gauze/pieces of sterile cloth and gloves, either sterile or high-level
disinfected.
All equipment has to be disinfected and cleaned after use. The manufacturer gives specific
instructions for cleaning, disinfection, and sterilization of equipment. Follow these instructions
carefully.
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Advance preparation for skin-to-skin contact between baby and mother and early
breastfeeding
Close contact between the mother and baby after birth will promote temperature maintenance
and breastfeeding. Hence, where the mother and baby are normal, it is good for the baby to be
kept with the mother in skin-to- skin contact. In fact, most of the care that a normal baby
requires can be carried out while he/she is with the mother, initially on her abdomen and later,
after the cord is cut, on her chest. Because some centers may not have been following this
practice, mothers may not be aware of these steps or be prepared for them. To get the mothers
acceptance and cooperation, it is essential that these plans are discussed with the mother
before delivery so that she is prepared for them; otherwise, there may be some challenges in
implementing these steps.
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Evaluate Breathing
Call for help. The assistant can provide basic care for the mother while you provide
the more specialized care for the baby who is not breathing.
Cut the cord rapidly and start resuscitation as described in chapter 8 on
resuscitation.
If the baby breathes well, continue routine essential newborn care.
Do not do suction of the mouth and nose as a routine. Do it only if there is meconium,
thick mucous, or blood.
Announce the time of birth and the sex of the infant after you have made certain that the
baby is breathing well.
Prevent Hypothermia
Keep the baby warm by placing him/her in skin-to-skin contact on the mothers abdomen.
Cover the babys body and head with a cloth. If the room is cool (<25 C), use a blanket to
cover the baby over the mother.
Figure 5.5. Two measures to prevent thermal loss at the time of birth: breastfeeding and skin-to-skin
contact.
Cord Care
Good cord care consists of the following:
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Clamping the cord: If the baby does not need resuscitation, wait for cord pulsations to
cease or approximately 2-3 minutes after birth of the baby, whichever comes first, and
then place one metal clamp several centimeters from the babys abdomen so that there
is at least 4-5 cm of the cord to apply the ligature or small disposable clamp. Cutting the
cord soon after birth can decrease the amount of blood that is transfused to the baby
from the placenta and, in preterm babies, it is likely to result in subsequent anemia and
increased chances of needing a blood transfusion.
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Cutting the cord: Squeeze the cord at the site where it is to be cut to flatten it, but do not
milk the cord, especially towards the baby. Cut the cord with sterile scissors or a scalpel
blade, under a piece of gauze in order to avoid splashing of blood. At every delivery, a
pair of scissors or a scalpel with blade should be designated for this purpose. If an
episiotomy is performed, use a different pair of scissors for cutting the cord.
Tying the cord: Tie the cord firmly with sterile ligatures after the mother and baby are
stable and after implementation of AMTSL. In finally tying the cord, make sure that it is
tied tightly with 2-3 knots, about two fingers (about 2-3 cm) from the babys abdomen
and cut the cord 2 cm from the ligature. Check for bleeding/oozing and retie if
necessary. The cord may be tied by using sterile cotton ties, elastic bands, or presterilized disposable cord clamps (see Figure 5.6).
Advise the mother not to cover the cord with the diaper.
Counsel the family not to apply harmful substances such as clay, herb mixtures, or
butter on the cord.
If recommended by the Ministry of Health, apply an antiseptic on the umbilical stump
after washing hands with soap and water. In such cases, demonstrate to the mother
before she leaves the facility how to apply the antiseptic on the cord, including the base.
Eye Care
Wash your hands with soap and water if not washed earlier.
Place the infant on the back.
Clean the babys eyes by swabbing each eye separately with a sterilized cotton swab
or cloth (boiled for 10 minutes and then cooled).
Hold one eye open or depress the lower eyelid, allow one drop of medication to fall
into the eye. If using ointment, put a ribbon of ointment along the inside of the lower
eyelid. Repeat the procedure on the other eye.
Make sure the tip of the dropper or the tube does not touch the babys eyes or other
objects.
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cleft lip and palate. The mother will need additional support for feeding; she may need to
give expressed breast milk with a small cup.
esophageal atresia (usually associated with excessive secretion in the mouth)
open spinal defects
imperforate anus
The last three conditions need urgent referral to appropriate hospitals for surgery.
Give Vitamin K1
Give vitamin K1 intramuscular (1 mg for term infant and 0.5 mg for the very low birth weight
infant <1500 grams). The technique for giving an intramuscular injection in the newborn is as
follows:
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Clean the rubber stopper with alcohol swab/cut the ampoule at its neck.
Push the needle into the bottle/ampoule.
Draw the calculated amount and pull the needle out.
Remove the air while holding the syringe with the needle pointing up and tapping on
the syringe barrel.
Expose the babys thigh and gently hold the knee so the baby is unable to kick.
Grasp the muscle of the antero-lateral part of the upper thigh, clean the skin with the
alcohol/antiseptic, and let it dry for a few seconds.
In one quick movement put the needle in the muscle straight in, pull back on the plunger a
little bit to make sure that the tip of the needle is not in a blood vessel.
If blood comes to the syringe, take the needle out and apply pressure at the site to prevent
bleeding. Re-inject in a fresh spot.
Inject the drug slowly, remove the needle, and apply gentle pressure for a short while and
ensure that there is no oozing of blood upon removal of the swab.
Discard the needle and syringe immediately in a sharps disposal container.
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Inform the mother about the importance of colostrum and encourage her to initiate
breastfeeding early within one hour of birth, without giving the baby any other milks, fluids,
or foods.
Tell the mother to breastfeed the baby frequently and on demand, day and night (about 8-10
times in 24 hours).
Advise the mother not to use pacifiers.
Assist the mother to breastfeed the baby within the first hour after the birth/before
transferring out of the delivery room. Help the mother to find as comfortable a position as
feasible. Some of the steps noted below may need to be modified depending on the type of
table available in the delivery room. Make sure that:
o The babys whole body is fully supported and held close at the level of the breast and
turned toward the mother.
o The mother, if possible, holds the breast with thumb on top and other fingers at the
bottom without touching the nipple.
o When the baby opens his/her mouth widely, the nipple and most of the surrounding
areola are introduced into the mouth.
o The babys nose is not blocked by the breast tissue.
o The mother does not feel pain in the nipple when the baby sucks. If she does, show her
how to release the nipple from the babys mouth (by gently depressing the babys chin)
and reintroduce the nipple after the pain subsides.
o That attachment at the nipple is appropriate (see Figure 5.7 below).
o Unrestricted time is allowed for the feeding.
Signs of a proper attachment:
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More detailed counseling can be done in the postnatal period in the facility before the mother is
discharged and at subsequent postnatal visits. The major issues are noted in chapter 10 on
postnatal care.
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Take particular care not to suction the mouth and the nose unless it is absolutely
necessary.
Consider swabbing the whole body of the baby with chlorhexidine (0.25%) swabs/wipes as
recommended by the Ministry of Health.
Administer ARV prophylaxis (niverapine and AZT or others as recommended by the
Ministry of Health).
Infant feeding options for mothers whose HIV status is positive include the following:
o
The actual type of feeding will depend on the mothers choice. You as the health care
provider should ensure that she is given the counseling and support she needs.
It is important to stress the dangers of mixed feeding (breast milk and formula).
Table 5. Key Steps for Immediate Care of the Newborn
(The order may be changed according to the local needs, except for steps 1-3.)
Step 1
Dry the baby and keep him/her warm by placing the baby on the mothers
abdomen.
Step 2
Assess breathing. Make sure the baby is breathing well.
Step 3
If the baby does not breathe, clamp/tie and cut the cord immediately and start
resuscitation.
If the baby does cry/breathes well, clamp/tie and cut the cord after pulsations
stop or after 2-3 minutes.
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
Note
Place the infant in skin-to-skin contact on the mothers chest and cover both with
clean linen and blanket as required. Carry out all the steps noted below up to #9,
preferably with the baby on the mothers chest.
Administer eye drops/eye ointment.
Administer vitamin K1.
Place the baby identification bands on the wrist and ankle.
Initiate breastfeeding within the first hour.
Select the appropriate method of feeding for the HIV-infected mother, based on
informed choice.
Weigh the infant when he/she is stable.
Record observations and treatment provided in the registers/appropriate
chart/cards.
Defer the bath for at least six hours.
Clean the newborn of an HIV-infected mother as recommended by the Ministry of
Health.
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Additionally, women who have severe PPH and survive (near misses) are significantly more
likely to die in the year following the PPH.
Length of the Third Stage
Considerable research has examined how active management affects the third stage of labor.
Investigations found that 50 percent of placental deliveries occur within five minutes, and 90
percent are delivered within 15 minutes. Other large studies confirm the rapid delivery of the
placenta; a WHO study found a mean delivery time of 8.3 minutes. A third stage of labor lasting
longer than 18 minutes is associated with a significant risk of PPH. When the third stage of labor
lasts longer than 30 minutes, PPH occurs 6 times more often than it does among women whose
third stage lasted less than 30 minutes.
Description of Active Management of the Third Stage of Labor (AMTSL)
The majority of PPH occurs during the third stage of labor. During this stage, the muscles of the
uterus contract, helping the placenta to separate from the uterine wall. The amount of blood lost
depends on how quickly this happens, since the uterus can contract more effectively after the
placenta is expelled. The third stage of labor lasts between 5 and 15 minutes. If the third stage
lasts longer than 30 minutes, it is considered to be prolonged and is associated with
complications. If the uterus does not contract normally (such as in uterine atony) after the
placenta is delivered, the blood vessels at the placental site stay open and hemorrhage results.
Because the estimated blood flow to the uterus is 500 to 800 mL/minute at term, most of which
passes through the placenta, severe postpartum hemorrhage can happen within just a few
minutes.
Active management of the third stage of labor (AMTSL) is a combination of actions performed
during the third stage to speed delivery of the placenta and prevent uterine atony by increasing
uterine contractions. The components of AMTSL are:
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Administration of a uterotonic drug within one minute after the baby is born (oxytocin is
the uterotonic of choice) and a second baby has been ruled out.
Integrated maternal and newborn care
Basic skills course
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Current evidence indicates active management of the third stage of labor (administration of
uterotonic drugs, controlled cord traction, and fundal massage after delivery of the placenta) can
reduce the incidence of postpartum hemorrhage by up to 60 percent in situations where:
National guidelines support the use of AMTSL (active management of the third
stage of labor).
Health workers receive training in using AMTSL and administering uterotonic
drugs.
Injection safety is ensured.
Necessary resources (uterotonic drugs and cold chain for storage of
uterotonic drugs; equipment, supplies, and consumables for infection
prevention and injection safety) are available.
Skilled birth attendants all over the world can play an important role in preventing unnecessary
maternal deaths by applying this simple, low cost, evidence-based intervention.
Approaches for Managing the Third Stage
There are two main approaches for managing the third stage of labor: the physiologic (or
expectant) approach and the active approach. Table compares how the third stage is
managed using each of these approaches.
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Active management
Uterotonic is given within one
minute of the babys birth (after
ruling out the presence of a
second baby).
Do not wait for signs of
placental separation. Instead:
Palpate the uterus for a
contraction.
Wait for the uterus to contract.
Apply CCT with
countertraction.
Uterotonic
Signs of placental
separation
Delivery of the
placenta
Uterine massage
Advantages
Disadvantages
(The definition of active management as described in this table differs from the original research protocol
in the Bristol and Hinchingbrooke trials because the original protocols included immediate cord clamping
and did not include massage of the uterus. In the Hinchingbrooke trial, midwives used either CCT or
maternal effort to deliver the placenta.)
Rogers J, et al. 1998. Active versus expectant management of the third stage of labour: the
Hinchingbrooke randomized controlled trial. Lancet 351:693699.
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Study
5
PPH
Bristol
Hinchingbrooke
Active
Physiologic
5.9%
6.8%
17.9%
16.5%
Bristol
5 minutes
15 minutes
Hinchingbrooke
8 minutes
15 minutes
Bristol
2.9%
26%
Hinchingbrooke
3.3%
16.4%
Bristol
2.1%
5.6%
Hinchingbrooke
0.5%
2.6%
Bristol
6.4%
29.7%
Hinchingbrooke
3.2%
21.1%
Prendiville et al. 1988. The Bristol third stage trial: active versus physiological management of the third
stage of labour. BMJ, 297: 12951300.
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4. Place the clamp near the womans perineum to make CCT easier (Figure 5.14).
Figure 5.14. Clamping the umbilical cord near the perineum. (Gomez, et al, 2005)
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8. With the hand just above the pubic bone, apply external pressure on the uterus in
an upward direction (toward the womans head) (Figure 5.16).
If the placenta does not descend during 30-40 seconds of controlled cord traction (i.e.
there are no signs of placental separation), do not continue to pull on the cord:
Gently hold the cord and wait until the uterus is well contracted again. If
necessary, use a sponge forceps to clamp the cord closer to the perineum as it
lengthens;
With the next contraction, repeat controlled cord traction with countertraction.
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11. As the placenta is delivered, hold and gently turn it with both hands until the
membranes are twisted (Figure 5.18).
12. Slowly pull to complete the delivery. Gently move membranes up and down until
delivered (Figure 5.18).
Figure 5.18. Delivering the placenta with a turning and up-and-down motion.
(POPPHI, 2007; ANCM, 2008)
Figure 5.19. Massaging the uterus immediately after the placenta delivers. (POPPHI, 2007)
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Instruct the woman how to massage her own uterus, and ask her to call if her uterus becomes
soft (Figure 5.20).
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2. Hold the cord with one hand, allowing the placenta and
membranes to hang down. Place the other hand inside
the membranes, spreading your fingers to ensure that
membranes are complete (Figure 5.22).
3. Dispose of the placenta as appropriate.
3. Gently cleanse the vulva, perineum, buttocks, and back with warm water and a clean
compress.
4. Apply a clean pad or cloth to the vulva.
5. Evaluate blood loss.
6. Explain all examination findings to the woman and, if she desires, her family.
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Managing the Third Stage When the Birth Attendant Is Alone and the Baby Needs
Resuscitation
There is a potential conflict of interest in caring for the mother and baby when the baby needs
resuscitation. How the provider cares for each one will depend upon several factors: if the birth
attendant is alone or has an assistant and what type of resuscitative efforts are required for the
baby.
If the birth attendant is alone and the baby is not breathing or is gasping at birth, the birth
attendant will manage the third stage of labor as follows: If the baby begins breathing after
stimulation, active management of the third stage of labor will most likely be possible. Place the
baby in such a position that you can observe him/her during implementation of AMTSL:
1. Administer a uterotonic drug within one minute after the baby is born (oxytocin is the
uterotonic of choice) and a second twin has been ruled out.
2. Apply controlled cord traction with simultaneous countertraction to the uterus.
3. Perform uterine massage immediately after delivery of the placenta.
If the baby requires resuscitation with bag and mask, there are two possible scenarios:
Scenario 1: The provider is alone but is able to administer a uterotonic drug within one
minute after birth of the baby:
1. Administer a uterotonic drug within one minute after the baby is born (oxytocin 10 IU
IM or misoprostol 600 mcg by mouth) and a second twin has been ruled out.
2. Deliver the placenta either by maternal effort or with assistance of the provider.
3. Perform uterine massage immediately after delivery of the placenta.
Scenario 2: The provider is alone and is not able to administer a uterotonic drug within
one minute after birth of the baby:
1. Perform physiologic management of the third stage of labor.
2. Perform uterine massage immediate after delivery of the placenta.
Managing the Third Stage When the Woman Is Infected with HIV
The practice of AMTSL is the same for all women regardless of their HIV status. However,
women who are HIV-infected may choose not to breastfeed, so providers need to respect and
support the womans choice for infant feeding. In addition, providers need to ensure that
national guidelines for PMTCT are implemented for the woman and newborn in addition to
routine care during labor, childbirth, and in the immediate postpartum.
Recommendations for Selecting a Uterotonic Drug to Prevent PPH
In the context of active management of the third stage of labor, if all injectable uterotonic drugs
are available:
Skilled attendants should offer oxytocin to all women for prevention of PPH in preference
to ergometrine/methylergometrine. This recommendation places a high value on
avoiding adverse effects of ergometrine and assumes similar benefit for oxytocin and
ergometrine for preventing PPH.
Skilled attendants should offer oxytocin for prevention of PPH in preference to oral
misoprostol (600 mcg). This recommendation places a high value on the relative benefits
of oxytocin in preventing blood loss compared to misoprostol, as well as the increased
adverse effects of misoprostol compared to oxytocin.
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In the context of active management of the third stage of labor, if oxytocin is not available but
other injectable uterotonics are available:
In the context of prevention of PPH, if oxytocin is not available or the birth attendants skills are
limited, misoprostol should be administered soon after the birth of the baby. The usual
components of giving misoprostol include:
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Administration of 600 mcg misoprostol orally after the birth of the baby.
Controlled cord traction only when a skilled attendant is present at the birth.
Uterine massage after the delivery of the placenta as appropriate.
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Uterine contraction:
o Palpate the uterus to check for firmness.
o Massage the uterus until firm. (Ask the woman to
call for help if bleeding increases or her uterus gets
soft.)
o Ensure the uterus does not become soft after
massage is stopped.
o Instruct the woman how the uterus should feel and
how she can massage it herself.
Vaginal bleeding
Blood pressure and pulse
Note: Action should be taken immediately to evaluate and treat
PPH if excessive bleeding is detected.
ensure the woman has sanitary napkins or clean material to collect vaginal
blood.
encourage the woman to eat, drink, and rest.
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facilitate breastfeeding.
encourage the woman to empty her bladder and ensure that she has passed
urine.
ensure the room is warm (25 C).
ask the womans companion to watch her and call for help if bleeding or pain
increases, if the woman feels dizzy or has severe headaches, visual
disturbance, or epigastric distress.
keep the mother and baby together.
never leave the woman and newborn alone.
document all findings and care provided.
Just prior to transfer out of the delivery room or at least one hour after childbirth, ideally the
provider should perform a comprehensive exam of the woman.
Monitoring the Woman 1-6 Hours after Delivery of the Placenta
During the next five hours the woman and newborn should be placed in an area where
providers can easily continue to monitor their condition. During hours 1 to 5 after delivery of the
placenta, the provider will monitor the woman as follows:
Danger Signs: BP, pulse, vaginal bleeding,
and uterus
o
o
o
Diastolic BP 90 mmHg
Systolic BP <60 mmHg
Pulse >110 beats/minute
Pad soaked in less than 5 minutes
Constant trickle of blood
Estimated blood loss of 250 mL or more or a woman
who gave birth at home and presents with persistent
vaginal bleeding
Uterus is neither hard nor round
Genital laceration extending to the anus or rectum
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Breastfeeding 2 to 3
times in the 6 hours
Danger Sign
Counsel and care for the woman 1-6 hours after delivery of the placenta
During this time, the provider should:
Taking care to respect the familys culture and customs, congratulate the family and discuss
how they can help the woman care for herself.
Her body, clothing, bedding, and environment should be kept clean to prevent
infection.
She needs to eat well. Ask the family what foods they have available.
Encourage them to offer her plenty of the foods she wants. Keep cultural
beliefs and practices in mind.
She needs to drink frequently because fluids help her body produce milk and
replace lost fluids. A simple way to remember is to try and have something to
drink at the babys feed times.
She needs to get enough rest. She has just worked very hard so she needs
to rest after this job. Getting enough rest is one of the most important things
she can do to help herself and her baby. It will help her uterus stay hard and
get smaller sooner, so she bleeds less.
She can move around as much as she feels able. She shouldnt do any hard
work or lift any heavy objects. Someone should help her with any heavy
house work.
If she experiences pain after delivery, she can take some
paracetamol/acetaminophen to help relieve the discomfort.
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Monitoring of the baby in the first six hours is summarized in the chart below.
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Table 8. Monitoring of the baby in the first six hours after birth
Note: Wash hands with soap and water before touching the baby.
Ensure when using items such as the thermometer that it is washed
with soap and water and swabbed with alcohol before every use.
Parameter
Frequency of assessment
Danger signs
Respiration
Color
Temperature (Record
axillary temperature at
least once in the first 6
hours. At other times,
touch the babys hands
and feet and check
axillary temperature if
they are cold.)
Umbilical cord for
bleeding
Presence of other
danger signs
Ensure breastfeeding
within one hour of birth
and subsequent
exclusive breastfeeding
on demand
hours, then
every 30 minutes for 1
hour, then
every hour for the next 3
hours
Look first for the general status of the baby to see that he/she is active and has a good
pink color in the lips, palms, and soles.
Count the respiratory rate which is normally between 30-60/minute without flaring of the
nostrils and severe subcostal retraction.
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Temperature: Take the axillary temperature of the baby with a clinical thermometer cleaned
with an alcohol swab (normal = 36.5-37.5 C) at least once in the six hours. At other times,
at least verify the body temperature by touching the abdomen, palms, and soles and ensure
that they are all warm. If they are cold, recheck axillary temperature. If the palms and soles
are cold or blue, it suggests that the baby is
Danger Signs
not warm enough. If the abdomen is cold, it
Sucking
poor or weak or not
suggests an even more severe
sucking
at
all
hypothermia. Rewarm the baby, preferably
Inactivity/lethargy/moving only on
by placing in skin-to-skin contact with the
stimulation
mothers chest and covering the baby with
Fever/body too hot or
layers of clean cloth and a blanket. If,
however, this does not warm the baby, it
hypothermia/body too cold
represents a serious danger sign that
Rapid breathing/difficulty in
necessitates urgent referral.
breathing
Monitoring for danger signs: These signs,
Convulsions
adapted from research studies, are noted in
Persistent vomiting/abdominal
the adjacent box and described in greater
distension
detail in the session on major neonatal
Severe umbilical infections
infections or sepsis.
(redness/swelling surrounding the
Assess for major defects that need special
umbilicus and/or foul smell with or
inputs. Asses for these defects if they have
without pus)
not been monitored soon after birth:
The first five signs are the most important.
o cleft lip and palate (needs additional
Although all the danger signs have been
support for feeding and may need
listed for completeness, the last three
feeding of expressed breast milk with a
more often appear later in the postnatal
cup/spoon)
period. Related to the cord, on the first day
o esophageal atresia (usually associated
or two look particularly for oozing of blood/
with excessive secretion in the mouth)
bleeding for which the cord must be retied
o open spinal defects
properly.
o imperforate anus
If the baby is normal and no danger signs are noted, provide any routine care due and reassure
the mother. If there are any problems/danger signs take the necessary steps promptly.
In this period the baby continues to need basic care such as temperature maintenance, cord
care, cleanliness, steps for prevention of infection, and exclusive, frequent breastfeeding on
demand. Administer the first vaccines such as a dose of oral polio vaccine, BCG, and hepatitis
B based on the recommendations of the Ministry of Health.
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MALE INVOLVEMENT
In most communities, it is not traditional for men to be included in postpartum and newborn
care, but where men have been encouraged to participate, they have shown that they are willing
to do so. It may take several years before this becomes routine, but vaccination and homebased child health records also took several years to establish. Even small or busy clinics can
be encouraged to identify a space (even the porch) where men can feel comfortable to wait and
receive information from a trained male staff member about sex in the postpartum and the risk
that unprotected sex outside the marriage holds for their baby, their wife, and themselves.
Both men and women should be aware of the following facts:
Sexual relations may be resumed as soon as it is comfortable for the woman and she is
ready for it. The couple should use condoms when having sex, particularly if the woman
still has lochia.
The early weeks of breastfeeding are times when women are at particular risk of
becoming infected with HIV for the following reasons:
Men may have sex with partners other than their spouse(s) during the period of
pregnancy and childbirth-related abstinence at home.
o Women are more susceptible to HIV for a range of biological reasons at this time.
The risk of MTCT is much higher when the woman is newly infected with a very high
viral load.
Mixed feeding carries particular risks for MTCT of HIV and other newborn infections.
o
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POSTPARTUM CARE
Ideally a comprehensive examination of the woman should be performed at one hour and six
hours after delivery and before discharge from the health care facility. For women who are not
having any problems, the following schedule for routine postpartum visits may be sufficient:
Table 9. Schedule for routine postpartum visits
Visits
Timing
Within
the
first
week
postpartum,
1st Visit
preferably within 2 or 3 days
nd
2 Visit
4-6 weeks
During a routine postpartum visit, a skilled provider will:
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perform the following laboratory tests to evaluate the womans health and screen for
selected medical conditions and infections:
o
o
o
provide prophylaxis for health promotion and disease prevention: TT, intermittent
insecticide-treated bednets (ITN), iron/folate tablets, vitamin A, broad-spectrum antihelminthics, and other nutritional supplements as needed.
promote safer sexual practices.
if the womans HIV status is positive, provide prophylaxis for opportunistic infections
according to national guidelines.
provide treatment for any medical conditions, illnesses, and infections detected.
manage any pregnancy-related complications.
provide PMTCT interventions according to national guidelines. If the woman is not
already on ARV treatment, consider referring her for care with an HIV specialist.
provide client-centered counseling for women and partners/supporters.
help the woman and her partner/support person develop a complication-readiness plan.
refer all women who need specialized care for any reason.
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Prevent malaria
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Prevent tetanus
Counsel on nutrition
87
o
o
Advise on the need for rest and sleep during the postpartum
Explain to the woman:
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89
Method options for the breastfeeding woman that can be used immediately postpartum
include: lactational amenorrhea method, condoms, spermicide, female sterilization
(within 7 days or delay 6 weeks), copper IUD (within 48 hours or delay 4 weeks).
Method options for the breastfeeding woman that should be delayed for 6 weeks include:
Progestogen-only oral contraceptives, Progestogen-only injectables, implants,
diaphragm.
Method options for the breastfeeding woman that should be delayed for 6 months
include: combined oral contraceptives, combined injectables, fertility awareness
methods.
that she can have sex as soon as she is ready and it is comfortable, but she should use
a condom if she still has lochia discharge.
that unless partners have sex only with each other and are sure that they are both
uninfected, they should practice safer sex. Safer sex means non-penetrative sex (where
the penis does not enter the mouth, vagina, or rectum) or the use of a new latex condom
for every act of intercourse. (Latex condoms are less likely to break or leak than animalskin condoms or the thinner more sensitive condoms.) Condoms should never be
reused.
Vaginal bleeding: more than two or three pads soaked in 20-30 minutes
after delivery or bleeding increases rather than decreases after delivery.
Convulsions
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Feels ill
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Advise the woman to always have someone near for at least 24 hours after delivery to
respond to any change in her condition.
Discuss with the woman and her partner and family about emergency issues:
o
o
o
o
Advise the woman to ask for help from the community, if needed. I1Advise the woman to bring her home-based maternal record to the health center, even
for an emergency visit.
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It will not deal with cardiac massage, intubation, or the use of drugs because:
more than 80 percent of asphyxiated babies require only stimulation, clearing of airways,
and ventilation for revival.
health workers at peripheral centers (such as health centers and health posts) targeted
in this training program are likely to deal with far fewer cases of birth asphyxia and are
thus more likely to lose some of their skills unless there is constant supervision and
opportunities to practice, at least on mannequins which, in practice, does not often
happen. It is thus better to limit this discussion to the minimum actions required to deal
with most cases.
anticipation
appropriate preparation
timely recognition of the signs of asphyxia
rapid implementation of treatment
It is best to have two persons to provide appropriate care at resuscitation, even if the two are
not equally skilled. Hence, centers should plan in advance and train additional persons at the
site who can assist the more skilled person carrying out the specialized tasks for resuscitation.
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eclampsia
bleeding (e.g., placenta previa/abruption)
fever
maternal sedation/anesthesia
abnormal presentations
prolonged/difficult labor
infections such as malaria, syphilis, tuberculosis, and HIV/AIDS
cord prolapse/knot
thick meconium in the amniotic fluid (may be due to fetal distress, but if aspirated into
the lungs may perpetuate asphyxia after birth)
prematurity/IUGR
post-maturity
multiple births
selected congenital malformations
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A warm room. Make sure the room is warm, with no drafts or open windows.
A source of heat.
A clean treatment surface/table should be available, preferably with an overhead
warmer. Where overhead heaters are very expensive, a warming table can be
manufactured locally by fixing either a heating rod or 2-3 bulbs on a wooden frame (as
shown in Figure 8.1), taking care that the wiring is well done in order to avoid inadvertent
Integrated maternal and newborn care
Basic skills course
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shocks. Where a heating rod is fixed, an additional lamp will be required to provide
adequate lighting. Babies under the warmer should always be monitored to ensure that
that they are maintaining their body temperature appropriately and are not too cold or
hot. In general, water bottles are not recommended due to the risk of burns. If there is no
alternative to a bottle, the water must be warm and the bag containing the bottle must be
wrapped in a thick cloth or several layers of cloth. The baby must be frequently checked
to ensure that the skin is not excessively hot or red.
Three to five pieces of clean, preferably sterile, cloth to dry and wrap the baby, a cap
where available, and a washable blanket or several layers of cloth where required.
A wall thermometer to monitor the room temperature.
A thermometer to measure the axillary temperature of the baby.
De Lee mucous aspirator. This is perhaps the simplest item to use (see Figure 8.2). It
consists of two tubes attached to a transparent trap. One tube end is introduced into the
babys mouth and throat, and the health worker applies suction with his mouth at the tip
of the other tube; the trap is to prevent aspirated material from entering the health
workers mouth. The item comes in individual pre-sterilized packs. Since cleaning and
decontamination of the narrow tubes present challenges and due to the risk of infection,
especially of HIV/AIDS, only a single use with careful application of suction is
recommended to avoid any risk of the secretions entering the tube in the care providers
mouth. In fact, for safety, it might be better to use a fresh aspirator. After use, the item
should be discarded in a safe manner and not reused, even after cleaning and
disinfection. Some practitioners do not recommend the use of this aspirator because of
the potential risk of secretions entering the care providers mouth, despite the presence
of the trap.
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Suction machine (electrical/foot operated) used with single-use simple catheters 8F and
10F may be better than an aspirator, as there is no risk of secretions contaminating the
oral mucosa of the care provider. Notes on use:
o
o
o
o
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In newborn infants, the negative pressure used for the suction should not be more
than 100 mm/Hg or 130 cm of water. Most suction machines may attain pressures
often ranging from 400-600 mm/Hg and at times going up to 700 mm/Hg (when
being used for adults). Suction at a high negative pressure may result in bradycardia
and/or apnea in the baby due to vagal stimulation.
Since the same aspirator may be used for the mother and the newborn, care should
be taken to change the level of the negative pressure of the suction. A clearly visible
sticker should be attached permanently to the equipment with the following message:
Adjust the pressure to 100 mm/Hg or 130 cm of water for the newborn infant.
The suction tubes/catheters used with the machine should also be the pre-sterilized
single use variety and should not be reused.
In the absence of a suction machine, a 10 mL syringe attached to the suction
catheter can also be used to remove the secretions but may not be so effective.
In many centers in advanced countries, a rubber bulb is used for suction, but it
should be used only for one baby. The bulb is also readily available in many
countries in Africa, but it is commonly used repeatedly on several babies. It is not
possible to clean this properly or to even verify that it is clean, as the bulb is opaque.
Hence, the rubber bulb is not recommended in developing countries. If no other
item is available for suctioning, a new bulb may be washed, boiled, and used for only
one baby and then discarded.
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o
o
o
The resuscitator bag should be the self-inflating kind that inflates automatically after
it is squeezed and released. Bags that require a flow of air/oxygen mixes to inflate
are, in general, not appropriate for resuscitation.
In certain models the mask consists of one piece of silicone/siliconized rubber; in
others, it consists of two parts, a plastic component to which a different transparent
soft plastic/rubber/silicone piece is attached. Make sure that the pieces are
appropriately attached so that the soft part is the one that comes in contact with the
babys face and not the hard plastic part that can hurt the baby.
Check that the mask fits properly with the bag.
To check the functioning of the self-inflating bag, block the mask by making a seal
with the palm of the hand.
Then squeeze the bag. Make sure that you feel pressure against your hand that
indicates that the seal is working well without leaks. When the pressure is raised, it
can also force the pressure-release valve open. When the pressure is released, the
balloon should reinflate.
Squeeze the bag only to the extent necessary to expand the chest. Excessive
pressure carries a risk of injury to the lungs.
A supplemental oxygen source, if available. If cylinders are used, check that they have
adequate oxygen. Note that while it is good to have supplemental oxygen available, it is
not required in most cases.
A wall clock with a second hand. In dealing with emergency situations such as asphyxia,
it is easy to lose track of time. It is important to note the time of birth and the time spent
in resuscitation, since there is a time limit to active resuscitation. The clock can also be
used to check the heart and respiratory rate in the delivery room.
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Attempts should be made to procure as many sterile items as possible in order to avoid
nosocomial infection which will increase morbidity and mortality. All equipment has to be
cleaned and disinfected after use. The manufacturer gives specific instructions for cleaning,
disinfecting, and sterilizing equipment. Follow these instructions carefully.
To ensure that all the necessary items are kept ready for every delivery, attach a list on the wall
near the table for resuscitation in the baby corner. To protect the list it can be laminated or
framed with a glass cover or attached inside a locked notice board. Here is a sample:
Equipment and Supplies for Newborn Resuscitation in the
Baby Corner or Area of the Delivery Room
It is mandatory to ascertain (a) every morning, (b) at the beginning of every shift, and
(c) before each delivery that the equipment/supplies listed below are available, in
working order, sterile/clean, and ready to be used.
1. A heat and light source
2. A table for resuscitation with a mattress with a clean washable surface covered
with a clean, preferably sterile cloth. This could be part of the warming table.
3. Three to five pieces of clean, preferably sterile, cloth to dry and wrap the baby,
including the head, a cap or bonnet, where available, and a washable blanket or
several layers of cloth where required.
4. Sterile gauzes/pieces of cloth
5. Disposable sterile (preferable)/high-level disinfected gloves
6. Suction equipment with suction tubes/catheters
7. A self-inflating bag (500 mL) and masks (sizes 1 and 0)
8. A wall clock with a second hand
9. A wall thermometer
10. A clinical thermometer to record the axillary temperature of the baby
11. Disposable syringes (1 mL, 2 mL, 10 mL)
12. Vitamin K1
13. A weighing scale
Figure 8.4. Sample list of equipment for newborn resuscitation
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The Apgar score is used at hospitals to assess the status of the baby in relation to breathing,
heart rate, color, muscle tone, and reflex response to stimulation at 1, 5, and 10 minutes after
birth. Low scores at 5 and 10 minutes have also had some correlation with a poorer long-term
outcome, but this correlation is not always consistent. However, in most peripheral centers the
scoring is frequently carried out in a wrong/inappropriate manner. The score, in any case, is not
required and must not be used to make decisions to carry out resuscitation. Hence, the Apgar
score will not be covered in this training session.
Suction the mouth and nose as soon as the head is delivered on the perineum and before
the delivery of the shoulders. Tell the mother not to push for a little while, giving time to
suction the mouth and nose of the baby. Based on research results, this preliminary
suction before full delivery is not carried out in centers in advanced countries; instead,
early suction, including endotracheal suction, is carried out immediately after delivery if the
baby is not crying. However, in low-resource settings, such as peripheral centers in
developing countries where intubation is not feasible, suctioning of the mouth and nose
before delivery of the shoulders is likely to decrease the risk of meconium inhalation into
the lungs that could cause additional problems.
After full delivery of the baby, if no breathing is observed, suction the mouth and nostrils
before drying and stimulation. Do not suction a baby who is already crying.
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Drying the Baby and Keeping the Baby Warm (Initial Steps for All Babies)
In general, the first step immediately after birth is to dry the baby well. Drying the baby well
also serves to provide safe stimulation to a baby who is not breathing. While drying, verify
if the baby is breathing/crying.
If the baby is breathing well, follow the steps noted above in the section of care of the baby
immediately after birth.
If the baby is not breathing, discard the wet cloth. Wrap the babys body and head with a
fresh dry cloth, keeping the baby on the mothers abdomen, and verify again if he/she is
breathing. Where it is clean and feasible, placing the baby who is not breathing on the
table between the mothers legs will allow a better flow of blood to the baby.
If the baby is still not breathing, clamp and cut the cord. If you have an assistant who can
deal with/observe the mother and a separate place for special care, take the baby there
and place it under a warmer (if available) for commencing additional steps for
resuscitation.
Incorrect positions
Neck hyperextended
Neck flexed
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If the baby is still not breathing, clear the airways by suction. Make sure that:
o The suction tube is introduced enough to suction effectively, but no more than 5 cm into
the mouth or 3 cm into the nostrils. Suction the mouth before the nostrils because if the
nose is suctioned first, it may stimulate the baby to breathe and if there is thick mucus
in the mouth/throat, it may get inhaled or aspirated.
o Suction should be carried out gently and only when pulling out the tube, not when
introducing it.
o Suction should not be applied for more than 20 seconds.
Re-examine the baby. If the baby starts to cry or breathe well, proceed with routine
essential care of the newborn.
If the baby is still not breathing or is just gasping, carry out the steps noted below.
Tactile Stimulation
Usually stimulation through proper drying and suctioning of the mouth and nose are adequate.
At the most, if the baby is still not breathing, very brief additional stimulation by flicking or
slapping the soles of the feet may be tried before commencing ventilation with the bag and
mask. Perform these steps quickly. All the above steps should take approximately 30 seconds.
Do not slap repeatedly; it is not only harmful but will also waste precious time which could be
better used in ventilating the baby as noted below.
All the above steps should be carried out quickly to ensure that ventilation where required
is started within one minute after birth.
Verify that the babys neck is in slight extension, either held in position with a hand or by
placing a small cloth roll (2.5 cm-3.0 cm) under the shoulders (whichever is more
convenient for the care provider).
Use the proper size mask:
o
o
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Form a proper seal between the masks edge and the babys face so that air does not leak
out during ventilation.
CORRECT
INCORRECT
Figure 8.7: Correct positioning of the mask and formation of a good seal.
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o If the heart rate cannot be evaluated, continue ventilation as long as the chest is
expanding well. If not, clear the infants airways again, reposition the bag, and continue
bagging until spontaneous breathing is established.
If the baby is blue, especially in the mouth and tongue, give supplemental oxygen, if
available. (Figure 8.8.) Remember, most babies do not require supplemental oxygen for
resuscitation. If oxygen is administered, it can be carried out with the bag and mask.
Attach the oxygen tube to the resuscitator bag at the oxygen inlet end. Remember: if the
resuscitator bag is used, oxygen will reach the baby only if the bag is squeezed
repeatedly as in ventilation. Oxygen can be given to a baby that is already breathing but is
blue by holding the mask of the resuscitator bag above the face and squeezing the bag
periodically.
Other methods of giving oxygen to a baby who is breathing are indicated in the diagrams
below. They include holding the oxygen tube with the flow of oxygen with or without a
cupped hand or through a facemask. In general a flow of 1-2 L/minute of oxygen should be
adequate.
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Vigorous aspiration of the mouth and nose of the baby. It may result in bradycardia or
cardiac arrest due to vagal stimulation.
Postural drainage with head down.
Slapping of the babys back.
Compression of the chest to eliminate secretions. This is dangerous since it may lead to
rib fractures, pulmonary lesions, and even death.
Strong stimulation of the newborn, such as slapping the buttock.
Immersing the baby in cold water and then in hot water.
Introducing a glass thermometer in the anus, as this may result in injury.
Use of medication such as sodium bicarbonate administered without indication before
breathing is established or rapidly in high concentrations.
POST-RESUSCITATION CARE
After resuscitating the asphyxiated baby, the health care worker has to provide routine essential
care, monitor the infant for problems/complications, counsel the family, and document all events
and actions. All equipment needs to be decontaminated/cleaned/sterilized before it can be used
again (see chapter 1) and all disposable or consumable/single-use supplies need to be
replenished.
Care Following A Successful Resuscitation
Prevent hypothermia; keep the baby warm and dry and if feasible in skin-to-skin contact
with the mother, covering his/her body and head over the mothers chest, keeping the
face exposed.
Examine the baby and evaluate the respiratory rate:
o
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If the infant has cyanosis, breathing problems such as rapid breathing with a rate of
more than 60/minute, intercostal retractions, and/or expiratory grunting, administer
supplemental oxygen as illustrated above. If these do not subside, refer the baby.
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After resuscitation, reassess the baby periodically every 15 minutes for 2 hours and
every 30 minutes for 6 hours for breathing, color, and activity. Continue assessment,
including evaluation of feeding, every 3 hours for the next 48-72 hours.
If the baby develops respiratory difficulty or any one of the danger signs noted in
chapter 13 on major infections, refer him/her to the appropriate referral center following
the guidelines for appropriate referral in the same chapter.
If the baby improves, commence routine essential newborn care:
o
o
o
o
o
o
o
o
Keep him/her warm and dry, if feasible in skin-to-skin contact with the mother.
Administer vitamin K (1mg intramuscular for a normal weight baby) to the baby.
As soon as the baby is stable, help the mother to start breastfeeding. A newborn
that required resuscitation is at risk for hypoglycemia.
If the baby does not suck well, transfer him/her to a hospital that cares for sick
newborns. If the baby has a good suck, it is sign that he is improving.
Defer the first bath preferably for at least 24 hours, until the baby is much more
stable, warm, and continues to breathe and feed normally.
Provide all the routine care and counseling noted in the chapter on care of the
normal baby at birth.
Record all the findings and treatment provided for birth asphyxia in the mother/baby
records and in the delivery register.
Make sure that all equipment is decontaminated, cleaned, and sterilized as
appropriate and all disposable supplies are replenished and kept ready for the next
delivery.
What was done for the baby and why, in simple terms.
Continuing breastfeeding on demand, and ask them to inform you if the baby does
not demand to be fed or does not suck well.
Keeping the baby warm, in skin-to-skin contact where required, and to verify that the
baby remains warm.
Identification of danger signs noted in chapter 9 on systematic examination of the
baby. Even the presence of a single danger sign is important and requires referral to
a higher center/hospital.
Where the baby has to be referred, follow all the steps for referral outlined in chapter 13
on major infections.
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Indicate that everything possible was done to save the baby. Respond to the questions
the family may wish to ask and let them express their feelings.
Show the baby to the parents and family members and, if culturally appropriate, provide
them with an opportunity to hold the baby. Ensure that the family has privacy for holding
the baby in these sad circumstances.
Explain that the mother will need rest, good nutrition, and emotional support at home.
With the babys death, the mother will face mammary engorgement 2-3 days after
delivery. Advise the mother to:
o
o
o
o
o
Make arrangements to follow the mother for at least three days to make sure she is
improving.
Discuss the options of family planning and explain that in this case there is a greater
chance of the woman conceiving earlier and that for the health of the mother and future
babies it is better to have an interval of three years before the birth of the next baby.
Prepare the death certificate and follow the protocol to register the death.
The key steps in resuscitation and for integrating with AMTSL are summarized in the algorithms
given below (Figures 8.9 and 8.10).
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107
Breathing well
Not breathing/
gasping
Figure 8.10 Algorithm for integration of AMTSL, ENC and resuscitation for birth asphyxia
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As soon as feasible after birth when the baby is stable and warm.
At least once a day as long as the baby is in the facility.
Before discharge. This is extremely important in order to detect any high risk factors or a
danger sign in the early stages. The latter may necessitate a longer stay at the facility,
beginning treatment/referral to the hospital, or recommending an earlier follow-up visit.
The early postpartum period is very important as 75 percent of deaths in newborns take
place in the first week following birth.
At the first and subsequent follow-up visits in the postpartum period.
a source of clean water, soap, alcohol/glycerine hand rub and clean towels
a clean examination table/mothers bed (should be free of drafts and well-lit)
a baby weighing scale
a clean stethoscope
a clinical thermometer for recording axillary temperature
cotton swabs and alcohol
a tape measure
a watch or clock with a second hand or a timer to aid in measuring the respiratory rate
a mother/baby card
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Preparation
Pregnancy: Note any care received by the mother and risk factors for infection.
Regarding the delivery, note:
o
o
o
o
110
condition at birth, when the baby cried after birth and if it was spontaneous; if not,
note what actions were taken to initiate the cry
birth weight
care given at birth (eye and cord care, vitamin K1 injection)
immunizations
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IDENTIFICATION
(Ask and look for)
Sucking less
or not
sucking at all
Not sucking at all; sucking less than usual; not opening the mouth when offered
feeds; not demanding feeds.
Lethargy/
inactivity
Fever/
low body
temperature
Fever: Body hot to touch, history of the mouth feeling excessively hot during
breastfeeding; temperature 38 C or more. (While the temperature is usually
>38 C, some feel that in the newborn it is better to be on more watchful when
the temperature is even 37.5 C.)
Low body temperature/hypothermia: body feels colder than normal;
temperature less than 36.5 C.
Fast
breathing/
respiratory
difficulty
Convulsions
Persistent
vomiting
and/or
abdominal
distension
Severe
umbilical
infection
Lift the cord to see the base. Look for spreading redness or swelling around the
umbilicus and/foul smell with or without pus discharge.
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Evaluate feeding
This can be done at any convenient time as noted above, especially after excluding danger
signs, such as the inability to suck, that need immediate attention. If the baby can suck well,
evaluate the latching or attachment of the babys mouth at the breast. Note that:
The key elements of the basic systematic examination of the newborn at peripheral centers are
summarized in Table 11.
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normal. Skilled health workers do not generally carry out home visits in most countries; in some
areas, it may be difficult to have community health workers make home visits at suitable times.
Promotion of early postnatal visits is essential, but it is likely that strategies to deal with the
different scenarios that exist and for covering the first week of life, including the first 2-3 days,
are even more important. The possible scenarios for this critical period include the following.
Deliveries may take place at home, and both the mother and the baby may remain there
throughout the neonatal/postpartum period, bound frequently by strong cultural practices
that, in general, prevent them from going outside their homes.
Where deliveries take place at the facility level, the stay for a normal delivery may vary
considerably, from a few hours to 2-3 days. Too early a discharge is frequently
associated with inadequate time for evaluation, care, and counseling. Longer stays are
associated with overcrowding, potential risk of nosocomial infections, increased costs,
and poor compliance by families.
Chances of an early first visit to the health center after a home delivery and return after
discharge from a facility birth depend on the degree of motivation, constraints due to
challenges in family finances and transport, resulting in poor access, quality, and the
cost of the care provided.
Thus strategies for postnatal assessment and basic care need to include both facility and
community components, involving trained skilled health workers and community health workers
(CHWs), with links between the two. These may include home visits by CHWs and visits by
mothers and babies at the facility, depending on the above scenarios.
Through community mobilization and communication strategies, including interpersonal
communication and traditional methods and use of mass media, families at home can learn
about basic preventive care, identifying danger signs, and seeking appropriate care. Trained
CHWs making home visits can also contribute to the latter components. It is far more difficult in
most countries for skilled birth attendants to make home visits. Good links between community
and facility level workers can help promote referrals to health centers as required.
In facility deliveries, after birth, it is critical to ensure careful examinations of the mother and
baby by the skilled birth attendant, with appropriate actions at three points:
just before transferring them out of the delivery room to the rooming-in ward
at least once a day during their stay at the facility
just before discharge
These evaluations will help to identify special risk factors or problems in the early stages that
may necessitate some treatment, a longer stay at the facility, special advice, and/or an earlier
follow-up appointment. Proper counseling, especially at discharge, on preventive care at home,
identifying danger signs, and appropriate care seeking are also extremely important.
Content of the Postnatal Visit
In addition to having an early visit/contact at the appropriate time, the content and quality of the
visit need to be considered. Key components are noted below:
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Management Issues
Proper management is required to ensure that postnatal care at the facility is implemented
effectively. Key tasks include the following.
Develop supportive strategies to implement basic postnatal care during a facility stay
and at postnatal visits.
Prepare the site (space, basic furniture, equipment, supplies and drugs).
Develop a user-friendly follow-up clinic.
Provide a client flow that aids the mother and baby to receive evaluation and care
(routine MNH care, HIV/AIDS, PMTCT, family planning, and counseling) in a reasonable
amount of time.
Ensure recording of information, maintenance, local review, and central transmission of
data.
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If a danger sign exists (even just one), administer the first dose of antibiotics and refer
the baby.
Administer treatment for minor infections.
Administer immunizations, OPV, BCG, hepatitis B, if not already done.
For newborns with minor infection, schedule a visit after two days.
For low birth weight babies follow up once a week until the baby is at least 2000 grams.
119
Where feasible and available, place the mother/family in contact with a trained
community health worker or volunteer.
Continue exclusive breastfeeding on demand, day and night, for six months. After that,
start semisolid food but continue breastfeeding into the second year of life. Tell the
mother that if breastfeeding is exclusive, frequent, and on demand, and if the woman
has not resumed menstruation, it can also prevent pregnancy during the first six months.
Keep the baby warm:
o The room where the baby stays should be warm and free of drafts. In cold weather
the baby should be wearing warm clothes with a hat/cloth covering the head. Wet
diapers should be changed quickly. The baby should sleep with the mother in bed.
o Check the babys temperature, touching feet, hands, and abdomen (if the abdomen
is cold, moderate to severe hypothermia is present).
o Skin-to-skin contact is the best way of keeping the baby warm at home if the
newborn is hypothermic, especially for a LBW baby. (See kangaroo mother care in
chapter 12.)
o Teach the mother/family how to avoid chilling during a bath (the section below also
includes a few additional points for promoting cleanliness during bathing):
Wash hands with soap and water before handling the newborn.
Delay the first bath for at least 6 hours, preferably 24 hours after delivery.
Have everything ready before the bath.
Bathe the baby in a warm room with no drafts.
Make sure the water is warm (verify this by touching the water with a clean hand
or elbow).
Take care to expose and clean all skin folds.
Wash the babys hair last; dry the baby fast with a cloth or towel.
Place the baby in skin-to-skin contact with the mother after the bath (if
necessary).
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Wash hands with soap and water before handling the baby, especially after changing
the diaper/napkin, after cleaning the house, and after using the toilet. Hands should
be washed every time before handling a low birth weight baby.
The baby should be cleaned/bathed daily, taking care to ensure that the folds of skin
are exposed and cleaned.
Birth spacing and family planning: see chapter 7 on maternal postpartum care.
Prevention of malaria: see chapter 7 on maternal postpartum care.
Integrated maternal and newborn care
Basic skills course
Reference Manual
The first five danger signs are the most important. Although these are standard danger
signs, it is essential to inform mothers that they should look at their babies carefully at least
once a day in adequate light. Even if they do not detect a specific danger sign, mothers
should still seek care from an appropriate health worker if they feel their baby is not looking
or doing well. In this way, sick newborns can be identified and treated early which is
particularly important in the newborn period when the condition can deteriorate rapidly.
Preparation for emergency issues in the mother or baby. Discuss with the woman and
her partner and family about emergency issues:
o
o
o
o
Advise the woman to ask for help from the community, if needed.
Advise the woman to bring her home-based maternal record to the health center, even
for an emergency visit.
Was ARV medication for prophylaxis administered to the baby (according to the
recommendation of the Ministry of Health)? If possible verify from any available records.
Is the baby currently on any ARV prophylaxis?
Is the baby receiving cotrimoxazole prophylaxis? (If not, counsel for commencing
cotrimoxazole prophylaxis according to national guidelines.)
Has the baby been tested for HIV?
o
o
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Refer the mother for clinical assessment and evaluation of the need for ARV treatment if
eligible.
Provide cotrimoxazole prophylaxis therapy (CPT) for the mother, according to national
guidelines.
Counsel the mother on:
o
The benefits of birth spacing if she is not already using a family planning method:
o
o
o
o
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If no clinical HIV services are immediately available for referral of the mother and infant,
counsel the mother about HIV in infants and the need to get testing and treatment as
soon as possible.
Provide psychosocial support and link the mother to community support for HIV care and
services.
Make an appointment for the next visit for HIV care according to national guidelines.
Place the family in contact with an available community health worker/volunteer where
available and feasible.
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2d postnatal visit
3d postnatal
visit
4-6 weeks
4-7 days
Second week
4-6 weeks
Delivery by Cesarean
section, normal baby and
discharged after a week, in
some cases earlier
2 weeks
4-6 weeks
Home delivery
Visit every week until weight gain is adequate, e.g., 2000-2500 grams
and the baby is doing well.
4-6 weeks
The number and timing of home visits by the CHW can vary based on feasibility and the
recommendations of the program implementing agency/MOH and on existing problems, but advocacy
should be carried out for coverage during the first week, especially during the first 2 3 days.
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Table 13. Care of the Newborn during the 4-6 Weeks after Birth
(Use with the learning checklist on the postnatal visit)
From birth to six weeks
Action
Provide care/
counseling
Observe/look for
Provide
counseling
Give specific
care
Weigh
Document
information in
mother/baby
card registers
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At birth
Before
mother and
baby leave
the delivery
room
At least once a
day during stay
in postnatal
ward
At discharge
First
postnatal
visit
Second
postnatal
visit
Third
postnatal visit
at 4-6 weeks
weight
weight
X
Full counseling
DPT,
oral polio, and
BCG if not
administered
earlier and
cotrimoxazole
for babies of
HIV positive
mothers
Weight
weight
weight
weight
weight
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2. Carry out a basic systematic examination of the baby (see session 9 for details).
3. Provide appropriate care:
If a danger sign exists (even if only one), give the first dose of antibiotics and
refer the baby.
Administer/prescribe treatment for minor infections.
Give immunizations: OPV, BCG, hepatitis B (based on recommendations of the
Ministry of Health) if this was not already done.
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Breast conditions which sometimes cause difficulties with breastfeeding include but are not
limited to:
Diagnosis and management of these breast conditions are important both to relieve the mother
and to enable breastfeeding to continue. Care for breast conditions will need to include both
management of the condition and assistance with breastfeeding technique.
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Underarm position
Management
o
o
o
o
Not to wash her breasts more than once a day and not to use soap or rub hard with a
towel. Breasts do not need to be washed before or after feeds; normal washing as for
the rest of the body is all that is necessary. Washing removes natural oils from the
skin and makes soreness more likely.
Not to use medicated lotions and ointments because these can irritate the skin, and
there is no evidence that they are helpful.
To rub a little expressed breast milk over the nipple and areola with her finger after
breastfeeding; this promotes healing.
To expose her breasts to the air for brief periods.
To start the feed on the unaffected breast. This may help if the pain seems to be
preventing the oxytocin reflex. Change to the affected breast after the reflex starts
working.
To breastfeed the baby in different positions at different feeds.
Breast Engorgement
Breast engorgement is an exaggeration of the lymphatic and venous engorgement that occurs
prior to lactation; it is not the result of over-distension of the breast with milk. Engorgement may
occur between days 2 and 4, causing the breast to become hard and tense and the nipples to
become taut, shiny, and hard; this usually resolves spontaneously in 24 to 48 hours.
Symptoms of engorgement
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Prevention
It is normal for breasts to become larger, heavier, and a little tender when the milk becomes
more plentiful on the second to sixth day following birth. This normal fullness usually decreases
within the first few weeks after birth if the baby is feeding regularly and well. Breast fullness may
develop into engorgement if the baby has not been feeding often or long enough. The key to
preventing engorgement is to nurse frequently and unrestrictedly.
Management
If the baby is not able to suckle, encourage the woman to express milk by hand or with a
clean pump.
If the baby is able to suckle:
o
o
o
Encourage the woman to breastfeed more frequently, using both breasts at each
feeding.
Show the woman how to hold the baby and help him/her attach.
Relief measures before feeding may include:
applying warm compresses to the breasts just before breastfeeding, or
pain.
giving paracetamol 2 tablets or 1000 mg by mouth as needed, not to exceed 4
times or 8 tablets a day.
Carefully examine the breast for signs of infection such as redness, inflammation, or
pus. Check the womans temperature and ask if she has chills.
Follow up three days after initiating management to ensure response.
Mastitis
Mastitis is an infection of the breast associated with pain, redness, swelling, fever, and chills.
Mastitis usually develops when bacteria enter the breast tissue through an injury to the breast.
Injury to the breast may be caused by bruising from rough manipulation, breast over-distention,
milk staying in the breast (stasis), or cracking or fissures of the nipple.
Symptoms of mastitis
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Management
The most important part of treatment is to improve the drainage of milk from the affected part of
the breast. Look for a cause of poor drainage and correct it:
Whether or not you find a cause, advise the mother to do these things:
Breastfeed frequently. The best way is to rest with her baby, so that she can respond to
him/her and feed him/her whenever the infant is willing.
Gently massage the breast while her baby is suckling. Show her how to massage over
the blocked area and over the duct which leads from the blocked area down to the
nipple. This helps to remove the block from the duct.
o She may notice that a plug of thickened milk comes out with her milk. (It is safe for
the baby to swallow the plug.)
Apply warm compresses to her breast between feeds.
Start the feed on the unaffected breast. This may help if pain seems to be preventing the
oxytocin reflex. Change to the affected breast after the reflex starts working.
Breastfeed the baby in different positions at different feeds. This helps to remove milk
from different parts of the breast more equally. Show the mother how to hold her baby in
the underarm position or how to lie down to feed him/her, instead of holding him/her
across the front at every feed. However, do not make her breastfeed in a position that is
uncomfortable for her.
If breastfeeding is difficult, help her to express the milk:
o
o
o
Sometimes a mother is unwilling to feed her baby from the affected breast, especially
if it is very painful.
Sometimes a baby refuses to feed from an infected breast, possibly because the
taste of the milk changes.
In these situations, it is necessary to express the milk (see below). If the milk stays
in her breast, an abscess is more likely.
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Breast Abscess
Breast abscesses occur when mastitis is not appropriately or adequately treated, or if it is not
treated in a timely manner. Intervention at the first signs of mastitis may prevent the condition
from worsening and developing into a breast abscess.
Symptoms
firmness
very tender breast
overlying erythema
fluctuant swelling in the breast
draining pus
Management
o
o
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General anesthesia is usually required. Hence, the mother may need to be referred
to an appropriate center.
Make the incision radially, extending from near the alveolar margin towards the
periphery of the breast to avoid injury to the milk ducts.
Wearing high-level disinfected gloves, use a finger or tissue forceps to break up the
pockets of pus.
Loosely pack the cavity with gauze.
Remove the gauze pack after 24 hours and replace with a smaller gauze pack.
If there is still pus in the cavity, place a small gauze pack in the cavity and bring the edge
out through the wound as a wick to facilitate drainage of any remaining pus.
Encourage the woman to:
o
Continue breastfeeding on the normal side and express out milk from the affected
side.
Support her breasts with a binder or brassiere.
Apply cold compresses to the breasts between feedings to reduce swelling and pain.
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Inverted Nipples
Some women have flat or inverted nipples which may reduce their confidence in their ability to
breastfeed and cause some babies frustration when they are starting to breastfeed. There is no
reason why women with inverted nipples cannot breastfeed. Antenatal treatment may not
always be helpful. Assisting women with inverted nipples is most important soon after birth,
when the baby starts breastfeeding.
Management of flat and inverted nipples
o
o
Explain that it may be difficult at the beginning, but with patience and persistence she
can succeed. Explain that her breasts will improve and become softer in the week or
two after delivery. Her baby's suckling will help to pull her nipples out.
Explain that a baby suckles from the breast not from the nipple.
Her baby needs to take a large mouthful of breast. Explain also that as her baby
breastfeeds, he/she will pull the breast and nipple out.
Encourage her to give plenty of skin-to-skin contact and to let her baby explore her
breasts. Let him/her try to attach to the breast on his/her own, whenever he/she is
interested. Some babies learn best by themselves.
If a baby does not attach well by himself/herself, help the mother to position the baby
so that he/she can attach better. Give her this help early, in the first day, before her
breast milk comes in and her breasts are full.
Help her to try different positions to hold her baby. Sometimes putting a baby to the
breast in a different position makes it easier for him/her to attach. For example, some
mothers find that the underarm position is helpful (see Figure 11.1).
Help her to make her nipple stand out more before a feed. Sometimes making the nipple
stand out before a feed helps a baby to attach. Stimulating her nipple may be all that a
mother needs to do. Or she can use a hand breast pump or a syringe to pull her nipple
out (see Figure 11.2).
Express her milk and feed it to her baby with a cup. Expressing milk helps to keep
breasts soft so that it is easier for the baby to attach to the breast, and it helps to keep
up the supply of breast milk.
She should not use a bottle because that makes it more difficult for her baby to take her
breast.
Express a little milk directly into her baby's mouth; some mothers find that this is helpful.
The baby gets some milk straight away so he/she is less frustrated, and he/she may be
more willing to try to suckle.
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Figure 11.2. Preparing and using a syringe for treatment of inverted nipples.
(WHO, 1993)
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Sometimes in a lactating breast it is possible to feel the sinuses; they are like pods or
peanuts. If she can feel them, she can press on them.
Press and release, press and release.
o
o
o
o
o
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1) Place a finger and thumb on each side of the areola and press inwards
towards the chest wall.
2) Press behind the nipple and areola between your finger and thumb.
3) Press from the sides to empty all segments.
Figure 11.4. How to express breast milk. (WHO, 1993)
Express one breast for at least 3-5 minutes until the flow slows; then express the other
side; and then repeat both sides. She can use either hand for either breast, and change
when they tire.
Explain that to express breast milk adequately takes 20-30 minutes, especially in the first
few days when only a little milk may be produced. It is important not to try to express in a
shorter time.
The mother should express as much as she can as often as her baby would breastfeed.
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An LBW baby starts to take the milk into his/her mouth with the tongue.
A full term or older baby sucks the milk, spilling some of it.
Do not pour the milk into the baby's mouth. Just hold the cup to his/her lips and let the
baby take it him/herself.
When the baby has had enough, he/she closes the mouth and will not take any more. If
he/she has not taken the calculated amount, he/she may take more next time, or you
may need to feed the baby more often.
Measure the babys intake over 24 hours, not just at each feed.
Advise the mother to burp the baby after the feed by placing him/her on the shoulder and
gently rubbing or patting the back.
Encourage the mother to begin breastfeeding as soon as she is ready.
Figure 11.5. Three methods of feeding: A. by cup, B. paladai, or C. by a cup and spoon.
(WHO/IMPAC, 2003)
Note: If the electricity is not stable, expressed breast milk should only be stored for short periods
in the refrigerator.
If the mother has stored the milk either at ambient temperature or in a refrigerator or freezer,
she needs to warm the milk by placing the closed container in a bowl of really warm or hot water
before giving it to the baby and make sure the baby drinks it immediately.
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Exclusive breastfeeding, taking care to avoid problems such as engorged breasts and
sore nipples, until six months, followed by rapid switch to formula feeds and
complementary feeding with semi-solids.
Use of expressed breast milk rendered safe by flash heating of the milk (see below),
along with complementary feeds with semi-solids from the age of six months.
Use of formula feeds from birth, if AFASS conditions are met (when replacement feeding
is acceptable, feasible, affordable, sustainable, and safe WHO 2009) with semi-solids
from the age of six months.
Items required:
o
o
o
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Wash all utensils with soap and water. Sterilize these by boiling in a container of water
for 10 minutes.
Express breast milk into the glass jar as noted above in this chapter. Remember to
express the breasts as completely as possible so as to get the nutritious milk obtained at
the end. The amount of milk to be collected in one jar is between 50-150 mL. If there is
more milk, divide it into two jars.
Place the jar in a pan/container of water, making sure that the level of water is two
fingers above the level of milk.
Heat the water on a very hot fire or, if on a stove top, turn the knob/dial to the highest
setting until the water reaches a rolling boil (when it is boiling well with large bubbles).
Stay close by because the process after this takes only a few minutes. Do not let the
water boil too long as it will destroy the special nutrients in breast milk.
Remove the jar from the container as soon as the water comes to a good boil. Place the
jar in a container of cool water, cover it with its clean lid, and let it stand until it reaches
room temperature. This milk can then be kept at room temperature for six hours and fed
to the baby.
Use a small cup, preferably directly to feed the baby. It is better than using a bottle which
is more difficult to clean and carries the risk of causing diarrhea in the baby.
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are born too early, before 37 completed weeks of gestation (preterm or premature).
have suffered intrauterine malnutrition or intrauterine growth retardation (IUGR), making
them small for date or small for gestational age. Such babies may be term, preterm, or
post-term (>42 completed weeks).
Although the basic aspects of essential newborn care for LBW newborns are similar to those for
normal infants, LBW babies, being vulnerable, need additional support, especially for
temperature maintenance, feeding, prevention of infection, and detection and management of
problems and complications. They are also associated with a greater risk for complications and
a higher neonatal mortality. In fact, 60-80 percent of deaths in the neonatal period are among
low birth weight babies, and they continue to have a high mortality during infancy.
Even though LBW babies need extra care, most of them are the larger ones, above
1500 grams. They can be managed with some extra care and with methods such as kangaroo
mother care that are simple and low cost. The very small LBW babies needing more costly
intensive care represent a much smaller proportion.
malnutrition
severe anemia
preeclampsia/eclampsia
infections during pregnancy such as urinary tract infection, malaria, syphilis,
toxoplasmosis, herpes, CMV, Rubella, HIV/AIDS
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Ideally take preventive steps early with appropriate care and nourishment of the girl
child.
o
o
receive quality prenatal care, including taking iron and folic acid to manage anemia
and preventing malaria through the intermittent preventive treatment of malaria and
use of insecticide-treated bednets.
recognize danger signs and seek appropriate care.
follow birth spacing (2-3 years) through being encouraged to use contraception.
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1.
2.
3.
Immature sucking
reflex and gastrointestinal system
Difficulty in sucking,
retaining, and
assimilating feeds
4.
Immature immune
systems and
increased exposure,
being dependent for
care on others with
frequent
handling/procedures
Increased infections
associated with high
mortality
5.
Bleeding due to
immaturity of the liver
and poor production
of clotting factors
Administration of vitamin K
Prevention and treatment of
problems such as asphyxia,
infections and hypothermia
6.
Increased risk of
jaundice
139
peripheral health center and later at home. Mothers and family members must be provided with
appropriate counseling and support.
Knowing the exact gestational age is not important in peripheral centers. In practical terms, what
is more important is to determine the status of an individual baby to decide what actions need to
be taken. Thus, the health worker should verify if the baby:
Can maintain temperature with simple aids such as extra clothing or skin-to-skin contact
(kangaroo mother care, see further details below).
Can accept frequent breast feeds or expressed breast milk fed with alternate methods of
feeding, such as the use of a cup, spoon, or an appropriate traditional feeding device
(see chapter 11 on breastfeeding).
Is free of problems or danger signs (see chapter 9 on physical examination).
Babies who fulfill the above criteria can be managed in peripheral centers and at home; ideally,
however, if access to a suitable center is easy, they should be taken there for an assessment
and counseling. Newborns not meeting the above criteria need to be referred to appropriate
facilities that have the competence, equipment, and supplies to manage them.
Fig. 12.1. Basic evaluation of LBW babies to determine need for referral.
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Temperature maintenance: They require extra clothing, covering, or prolonged skin-toskin contact (kangaroo mother care).
Early initiation of and more frequent feeding: They need additional support for feeding,
including the use of expressed breast milk fed with a cup, spoon, or a suitable traditional
feeding device.
Prevention of infection: As such babies are particularly prone to infection, great care
should be taken to prevent infection, including:
o
o
o
Keep the baby in continuous skin-to-skin contact with the mother (see the section on
kangaroo mother care below).
Cover the babys head with a hat or scarf.
If the LBW baby requires additional care, such as resuscitation, keep him/her under
a warmer/heater.
Delay the babys first bath for one week after birth. Clean the dirty areas such as the
face, groin, and skin folds with a damp cloth, using soap as required. If necessary
give a sponge bath, exposing small portions at a time. Dry quickly and maintain
temperature as noted above.
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Follow the other guidelines for referral noted in chapter 13 on major infections.
Advantages of KMC
For the baby:
It helps to empower the mother as she plays the main role by providing warmth to her
baby, protection against infections, and nutrition through breastfeeding.
It promotes mother-infant bonding and decreased rejection of preterm babies.
The method includes participation of the mother and family in the care of the baby.
It allows the mother to return to activities at home while caring for the baby.
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Start KMC as soon as possible after birth, when breathing has been well established and
the baby does not require any medical treatment.
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Explain the reasons for and advantages of KMC to the mother and the family:
o KMC replaces the warmth within the uterus.
o The baby is very close to the breast, facilitating frequent feedings.
o KMC favors the milk ejection reflex and successful feeding.
o The newborn is protected from exposure to the external environment and infections.
Requirements include:
o a warm room without drafts
o appropriate clothing for the mother, as needed and influenced by the weather
o a square piece of clothing folded diagonally or a Lycra band to fix the baby to the
mothers chest
o a cap, socks, and diapers for the newborn
o a chair with an inclined back or a bed that can be adjusted with pillows, for example,
at a 15-30 degree angle for the mother
weight less than 2500 grams, although KMC can be used for any weight group
stable cardio-respiratory condition
ability to suck and swallow
maternal acceptance and family support
Advise the mother to maintain good hygiene, including daily baths, change of clothes,
frequent hand washing, and short and clean fingernails.
Place the baby in skin-to-skin contact between the mothers breasts with the babys feet
below her breasts and the babys hands above; the babys hips should be in a frog
position and the arms flexed (Figure 12.3).
Extend the head slightly and turn it to one side. Avoid excessive flexion or
hyperextension of the neck. Turn the head to alternate sides periodically. This position
keeps the airway open and allows eye contact between the mother and her baby.
Support the babys head by pulling the wrap under the babys ear.
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Place an additional cloth or a towel under the buttock of the baby to prevent dirtying the
mothers chest and dress if cloth diapers are used. Change the diapers frequently.
Some use a small baby vest to cover the back for extra thermal protection. Make sure in
such cases that the front of the vest is open to allow the chest of the baby to be in direct
contact with the chest of the mother (Figure 12.4).
Fix the baby to the mothers chest by wrapping the clean cloth around the mother and
the baby, leaving room to permit the babys abdominal breathing but being tight enough
so that the baby does not slip out when the mother stands. Secure the cloth with a safe,
secure knot and tuck the loose ends under the tied band. Alternatively, a circular Lycra
band can be used to fix the baby.
Practice with the mother and supervise her until she is totally comfortable with the
method.
Through advocacy and counseling encourage the other members of the family, including
the father, to assist the mother in KMC.
Figure 12.5. Photo of kangaroo mother care. (Source: Delphin Muyila, DRC)
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Explain to the mother the benefits of breast milk, especially for a LBW baby.
The baby is ready to start breastfeeding when he/she starts moving the tongue and
mouth and shows interest in sucking his/her fingers or the mothers skin.
Start breastfeeding when the baby is awake.
Promote frequent breastfeeding (about every 2-3 hours).
Help the mother get in a comfortable position on an armless chair in a quiet place, if
possible.
Before starting to breastfeed, loosen the cloth wrap around the baby.
With the baby in skin-to-skin contact, follow the same steps for attachment and
positioning as for the normal baby.
Being small, the baby will need more frequent breastfeeding, with several pauses during
feeding. The baby needs to be allowed to feed while he/she still shows interest in
sucking.
If the baby gags, coughs, or spits up, teach the mother to take the baby off the breast
and the cloth wrap, hold the baby covered against her chest until she/he quiets down
and breathes normally before retrying again. If the ejection reflex is strong, express a
little milk before restarting feeding.
When the mothers breasts are engorged, express enough breast milk to make the
areola soft enough to introduce into the babys mouth to facilitate his/her sucking.
Some babies may need additional support:
o
o
o
o
o
o
o
o
o
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To feed the baby by breastfeeding/use of expressed breast milk frequently. If the LBW
baby does not suck well or tires easily while sucking, advise use of expressed breast
milk with a cup, spoon, or a suitable traditional feeding device (clean with soap and
water and, ideally, boiled for 10 minutes.).
To remove the baby out of the skin-to-skin contact only for changing diapers, hygiene,
and cord care. The low birth weight baby need not be bathed daily. The dirty parts,
especially skin folds, can be sponged clean. When the baby is bathed, it is important to
do so in a warm room with no draft, using warm water, finish as soon as possible, dry
the body well, and recommence the skin-to-skin contact quickly.
To have continuous 24-hour kangaroo care until the babys weight increases. Another
family member may replace the mother for periods of time to relieve the mother.
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Follow-up checks by skilled health workers are ideal, but where the latter is not feasible at
times, additional support through visits by trained community health workers should be
instituted. Even in facility births try to link the family with a trained community health worker for
additional follow-up.
Care for the LBW baby is summarized in the diagram and the algorithm below.
Figure 12.7: Key components of care of the LBW infant: KMC/well wrapped close to the mother,
cleanliness including frequent hand washing, early exclusive breastfeeding without pre-lacteal feeds,
monitoring of weight gain/growth (Source: Counseling cards from Senegal).
Integrated maternal and newborn care
Basic skills course
147
NO
At follow-up, if poor
weight gain or baby has
danger sign
Send to referral
center
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149
maternal infections, including urinary tract infection during the last months of pregnancy
premature rupture of the membranes (>18 hours)
unhygienic delivery practices, including poor cord care
These risk factors are significant and have important practical implications:
Babies with these maternal risk factors may appear normal at birth.
The signs may appear after the baby has returned home.
Identification of the maternal risk factors can lead to prophylactic antibiotic treatment that
may be life saving.
These babies need careful follow-up and should benefit from a longer stay at the health
center.
Even in the absence of laboratory tests in peripheral health centers, just taking a good
maternal history may help identify these risk factors and enable suitable actions.
Late-onset infections (day 4-28) are usually acquired from the environment in the home or
facility. They are caused by several factors including:
Unhygienic use of formulas, other milk, and fluids instead of exclusive breastfeeding.
Poor newborn care practices, such as lack of proper hand washing, contact with unclean
clothes and other items, infected persons, use of improperly cleaned/sterilized
supplies/equipment (the last mentioned is particularly common at the facility level).
Excessive, invasive hospital procedures with poor infection control practices.
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Major infections in the newborn period are identified by the presence of one or more danger
signs, as noted below in Table 16 (on practical guidelines for identifying and treating major
infections at peripheral centers).
Minor Infections
The most common minor infections are:
thrush
conjunctivitis
skin infections
umbilical infection (localized)
While the focus in this manual will be on the most common major and minor infections listed
above, other newborn infections include syphilis, HIV/AIDS, Hepatitis B, and tetanus.
The first five danger signs are the most important. Although these are standard danger signs, it
is essential that health workers should look at babies carefully at least once a day in adequate
light while they remain in the facility. Even if they do not detect a specific danger sign, health
workers should take care if they feel the baby is not looking or doing well. In this way, sick
newborns can be identified and treated early which is particularly important in the newborn
period when the condition can deteriorate rapidly. Mothers should also be counseled on these
points to promote early careseeking.
Training personnel in good follow-up supervision is necessary to identify these danger signs.
Since they are difficult to remember, especially when health workers do not see very many
Integrated maternal and newborn care
Basic skills course
151
cases, it is very useful to have easily accessible job aids available (which could be adapted from
Table 16 below).
Use of Antibiotics
Administer antibiotics using these guidelines:
Ampicillin 50 mg/kg IM/IV every 12 hours in first 7 days and every 8 hours after day 8.
Gentamycin IM/IV once daily 3 mg/kg for babies < 2500 grams. and 5 mg/kg in babies
> 2500 grams.
Duration of treatment: 10 days.
At the peripheral health center, give the first doses IM prior to transfer to a higher level of
care.
Continue to provide additional support such as feeding where feasible, temperature
maintenance and cleanliness/avoidance of superadded or secondary infection.
Danger Signs
Table 16: Practical Guidelines for Identifying and Treating
Major Infections at Peripheral Centers
Note: The first five danger signs are the most important.
Management of the newborn at risk for early infection:
For a newborn with maternal infections and premature rupture of membranes of 18 hours or
more, even in the absence of symptoms, give intramuscular antibiotic treatment (ampicillin and
gentamycin), for at least 3 days and preferably for 5 days, as blood cultures are not feasible at
peripheral centers. Observe the baby at the facility. If there are no danger signs, discharge the
infant. If there are danger signs, transfer to a higher level of care.
DANGER
SIGNS
IDENTIFICATION
(Ask and look for/verify)
Sucking less,
or poorly, or
not sucking at
all
Lethargy/
inactivity
Fever/low
body
temperature
Rapid
breathing/
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MANAGEMENT
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difficulty in
breathing
Abdominal
distension
Severe
umbilical
infection
Convulsions
Persistent
vomiting
The first five danger signs are the most important. Although these are standard danger
signs, it is essential that health workers should look at babies carefully at least once a day in
adequate light while they remain in the facility. Even if they do not detect a specific danger
sign, health workers should take care if they feel the baby is not looking or doing well. In this
way, sick newborns can be identified and treated early which is particularly important in the
newborn period when the condition can deteriorate rapidly. Mothers should also be counseled
on these points to promote early careseeking.
Keep the baby warm during the transport by placing him/her in skin-to-skin with the
mother, covered with a cloth, with or without blanket, depending on the weather. This
will also protect the baby from drafts and insects.
To prevent hypoglycemia, offer breastfeeds. If the suck is weak or absent, try to feed
the baby expressed breast milk with a clean cup. Do not feed an infant who cannot
swallow.
Check the babys condition frequently to detect other complications.
153
o
o
o
Document the referral and its time in the record book of the peripheral center.
The referral document of the baby to be sent with the family should contain the following:
o
o
o
o
o
o
Transfer the mother and baby along with a family member. If possible, have a health
care worker accompany them.
If possible, inform the referral center by telephone of the condition of the baby,
including the maternal history.
Prepare for the transfer by stabilizing the babys condition to the extent possible and
giving the first dose of antibiotics.
154
Continue cleaning the eyes and apply 1% tetracycline ointment to the affected eye(s)
3-4 times a day until symptoms disappear.
If the problem persists after 2 days of general management and/or pus appears, start
erythromycin by mouth 12.5 mg/kg every 8 hours for 14 days.
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As Chlamydia may be the cause, treat mother and partner, if not already treated,
with erythromycin 500 mg orally 4 times a day for 7 days for the mother; tetracycline
500 mg orally 4 times a day for 7 days or doxycycline 100 mg orally twice a day for 7
days for her partner.
Thrush
Thrush is a fungal infection due to Candida species which is usually localized in the mouth or in
the diaper area.
Treating thrush in the mouth:
Oral thrush is seen as irregular, dirty white patches on the tongue and inner sides of the
cheeks.
It is different from the normal smooth white patch that may be seen coating the middle of
the tongue in some babies. If in doubt treat as thrush.
Apply mycostatin/nystatin oral solution or 0.5% gentian violet 4 times daily after feeds,
continuing for 2 days after lesions have healed.
Have the mother apply mycostatin/nystatin cream or 0.5% gentian violet on her breasts
after breastfeeding for as long as the baby is being treated.
Mothers should be advised to clean their breasts once a day with soap and water when
bathing. Repeated washing with soap should not be done, as it will lead to drying and
sore nipples.
Apply nystatin cream or 0.5% gentian violet at every diaper change, continuing for 2-3
days after the lesions have healed.
Ensure the diaper is changed as soon as possible when soiled or wet, taking care to
clean and dry the skin well.
While wearing gloves, clean the area with 60-90% alcohol or an antiseptic solution (2.5%
polyvidone iodide, 4% chlorhexidine gluconate, triple dye, or gentian violet) 3-4 times a
day.
Take care to lift the cord and apply the antiseptic to the base of the cord or, if the cord
has fallen off, to the depth of the umbilicus.
Demonstrate the application to the mother.
Ask the mother to return for follow-up after 2 days.
Any worsening or signs of more serious infection noted above should be treated as
sepsis and the baby should be referred to a higher center after giving the first doses of
the antibiotics.
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Skin Infection
The severity of skin infection is classified by the number and size of the lesions, and signs of
sepsis as follows :
babies < 2 kg, 5 mg/kg once daily for babies 2 kg; day 8 and over: 7.5 mg/kg
once daily for all weights and treat for 7-10 days.
For cellulitis/abscess:
o
If there is fluctuant swelling, incise and drain the abscess. If this is not feasible in the
peripheral center, refer to the referral center after giving the first dose of the
antibiotic. If cloxacillin cannot be given IV, give oral cloxacillin with IM injection of
gentamycin
If admitted locally, assess the baby daily:
If the baby improves, continue to complete 10 days of treatment.
If there is no improvement, refer to the appropriate center.
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Source: WHO. 2003. Managing Newborn Problems: A Guide for Doctors, Nurses and Midwives.
PREVENTING INFECTIONS
During the prenatal period:
During delivery:
Follow clean delivery practices; at the facility, as many of the items as possible coming
in contact with the baby and for the delivery should be sterile.
Provide basic care of the newborn, including temperature maintenance, early and
exclusive breastfeeding, eye care, cord and skin care, general hygiene, including hand
washing.
During the postnatal period give preventive care for the mother and the newborn, including
general hygiene, hand washing, and the other components noted above.
Follow-up care:
Ask the mother to bring back the baby after two days for follow-up.
Counsel the mother on identification of danger signs and to return immediately should
even one danger sign be present.
Counsel the mother on basic preventive essential newborn care, including
breastfeeding, cord care, and temperature maintenance.
Make an appointment for when the next immunizations are due.
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Ergometrine
(methylergometrine),
also known as
ergonovine
(methylergonovine)
Preparation of ergot
(usually comes in dark
brown ampoule).
Commonly used brand
names include
Methergine, Ergotrate,
Ergotrate Maleate
Syntometrine
Combination of 5 IU
oxytocin plus 0.5 mg
ergometrine.
Dosage
and route
Give 10
units IM
injection.*
Give 600
mcg (three
200 mcg
tablets)
orally.
minutes.
Effect lasts
about 15-30
minutes.
Orally:
Acts within 6
minutes.
Peak serum
concentration
between 18
and 34
minutes.
Effect lasts 75
minutes.
First choice.
No known contraindications for
postpartum use.**
Minimal or no side effects.
Give 0.2 mg
IM injection.
Give 1 mL
IM injection.
Combined rapid
action of oxytocin
and sustained
action of
ergometrine.
If a woman has an IV, an option may be to give her 5 IU of oxytocin by slow IV push.
This is intended as a guide for using these uterotonic drugs during the third stage of labor. Different
guidelines apply when using these uterotonic drugs at other times or for other reasons.
***
Lists of contraindications are not meant to be complete; evaluate each client for sensitivities and
appropriateness before using any uterotonic drug. Only some of the major postpartum contraindications
are listed for the above drugs.
IM = intramuscular; IV = intravenous
**
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DRUG EFFECTIVENESS
Effects of Heat and Light on Uterotonic Drugs
Two factors can influence the effectiveness of uterotonic drugs: temperature and light. This is
especially important in hot temperatures and in conditions where refrigeration is not always
available or reliable. A WHO research program examined the effectiveness of different
injectable uterotonic drugs at various temperatures and light conditions. Table A.2 shows one
comparison from this study.
Dark
4-8 C
Dark
30 C
Light
21-25 C
Oxytocin
0% loss
14% loss
7% loss
Ergometrine
5% loss
31% loss
90% loss
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Transport
Storage
Oxytocin
Unrefrigerated transport is
possible if no more than one
month at 30 C.
Misoprostol
Ergometrine /
Syntometrine
Unrefrigerated transport in
the dark is possible if no
more than one month at 30
C. Protect from freezing.
Check manufacturers
recommendations; some
manufacturers are producing oxytocin
that is more heat stable than
previously available.
Temporary storage outside the
refrigerator at a maximum of 30 C is
acceptable for no more than 3
months.
If possible, keep refrigerated at 2-8
C.
Store at room temperature in closed
container and protected from
humidity.
Store in the dark.
Keep refrigerated at 2-8 C.
Store in closed container.
Protect from freezing.
161
o
o
o
Record the temperature in the delivery room on a regular basis, preferably at the hottest
times of the day.
Periodically remove ampoules from the refrigerator for use in the delivery room; carefully
calculate the number removed from the refrigerator based on anticipated need.
Only remove ampoules or vials from their box just before using them.
Make sure that there are adequate stocks of syringes and injection safety materials.
Avoid keeping injectable uterotonics in open kidney dishes, trays, or coat pockets.
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Assess the body temperature by at least touching the babys abdomen, hands, and
feet and ensuring all are warm.
163
Where possible note the axillary temperature with a thermometer leaving it in place
for 4 minutes. The normal temperature is 36.5-37.5 C. (The thermometer should be
clean and wiped with at least an alcohol swab to prevent cross infection. Storing in
liquid antiseptics should be done only if they are changed frequently. Otherwise there
is a risk of infections with Pseudomonas. It is not recommended to take rectal
temperature as a routine as it is associated with a higher risk of infection and
trauma.)
In the newborn infant, both fever and low body temperature outside the normal range
of 36.5-37.5 C are danger signs.
164
Note the general shape of the head and inspect the scalp for cuts or bruises from
forceps or vacuum. Elongated or asymmetrical shape may be due to molding during
birth.
Palpate the anterior fontanel and check for any bulging.
Caput succedaneum is a soft swelling over the part of the head that presented first. It
disappears by 48 hours.
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Eyes
The lips, mouth, tongue, palms, and soles should be pink. If the palms and soles are
bluish, it suggests that the baby may be not warm enough and may actually be
maintaining temperature in a stressful manner through vaso-constriction of the
peripheral vessels. If blueness persists after warming, it may be due to problems such
as shock or a congenital heart defect.
The skin may also show other features that are normal for this age that disappear over
varying periods of days or weeks, such as:
o
o
o
o
Gently press the tip of the nose, release, and observe the blanched area for any yellow
tinge/color. It can also be seen in the grooves of the skin when the baby frowns or cries.
This is the only time in life that some jaundice in a full term baby does not require any
treatment if it starts after the first 24 hours on the face and does not spread to the palms
and soles, and disappears by two weeks.
When the color reaches the palms or soles, it correlates with a serum bilirubin of about
15 mg/100 mL (or 256.5 mols/L). Such babies require referral for assessment and
treatment.
These guidelines apply only to full term normal weight babies. Preterm and low birth
weight babies require treatment at far lower levels. Hence, such babies with any
jaundice need to be referred to a competent person/center for assessment and
treatment and should not be considered to have physiological jaundice.
Mouth
Check for cleft lip and look inside the mouth for cleft palate.
Examine the tongue and the inner side of the mouth for oral thrush, seen as irregular,
dirty white patches on the tongue and inner sides of the cheeks. Thrush is different from
the normal smooth white patch that may be seen over the middle of the tongue in some
babies.
165
Chest
Abdomen
The presence of two arteries and one vein which is normal. The vein is seen as an
elongated open slit and the arteries as thin cord-like structures.
Oozing of blood. If present, tie the cord again.
Signs of infection. In case of a pus discharge from umbilicus or the base of the cord,
lift the cord to see the base. Redness or swelling over the surrounding skin and/or a
foul smell are features of a major infection.
Later, after the umbilicus heals well, a small umbilical hernia may develop in some
babies. It usually resolves spontaneously. Do not apply a coin or a pressure bandage
over it.
Gently palpate the abdomen for masses. The liver and spleen are normally palpable.
Anus
Note when the baby passes stools (usually at birth or within 24-48 hours of the delivery).
At birth or when seen for the first time during the first few days after birth, check the
position of the anus and ensure the patency of the anal opening. Where there is doubt,
verify patency carefully and gently with a clean blunt rectal thermometer.
Male genitalia
Hernias are reducible and are not trans-illuminated with a torch/flashlight. Although,
usually it is not an emergency unless impacted or strangulated, such babies need to
be referred to an appropriate hospital for assessment and planned management.
Hydroceles which can be trans-illuminated with a torch/flashlight may also be noted.
They usually disappear in a few months or by the first birthday.
Female genitalia
166
Examine the labia and clitoris; make sure there is no fusion of the labia.
The hymen is often prominent and may project out as the hymenal tag, which is
normal.
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A white discharge from the vagina, with or without blood, is normal in the first week of
life. Referral is required only if bleeding is excessive and should be done after
administration of vitamin K1 (1 mg).
Turn the baby over gently, ensuring that the head is turned to one side, and examine the
back for obvious defects such as a swelling or an open spina bifida along the vertebral
column. Sometimes spina bifida occulta may be present without any obvious swelling or
an opening but may manifest with a tuft of hair or a dimple. Although not urgent, such
babies need referral to a higher center for x-rays of the spine.
Assess Feeding
This can be done at any convenient time after excluding danger signs, such as the inability to
suck, that need immediate attention. If the baby can suck well, assess attachment of the babys
mouth. Note that:
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APPENDIX C: Glossary
Active management of the third stage of labor (AMTSL): A combination of actions
performed during the third stage of labor to prevent PPH. AMTSL speeds delivery of the
placenta by increasing uterine contractions and prevents PPH by minimizing uterine
atony. The components of AMTSL are:
Administration of a uterotonic drug within one minute after the baby is born (oxytocin is
the uterotonic of choice) after verifying that there is no second baby.
Controlled cord traction (CCT).
Uterine massage immediately after delivery of the placenta.
Controlled cord traction (CCT): Traction on the cord during a contraction combined
with countertraction upward on the uterus with the providers hand placed immediately
above the symphysis pubis. CCT facilitates expulsion of the placenta once it has
separated from the uterine wall.
Delayed cord clamping: Clamping the umbilical cord after cord pulsations have
ceased. Studies show that delaying clamping and cutting of the umbilical cord is helpful
to both full-term and preterm babies. In situations where cord clamping and cutting was
delayed for preterm babies, these infants had higher hematocrit and hemoglobin levels
and a lesser need for transfusions in the first 4 to 6 weeks of life than preterm babies
whose cords were clamped and cut immediately after birth.
Delayed PPH: Excessive vaginal bleeding (vaginal bleeding increases rather than
decreases after delivery), occurring more than 24 hours after childbirth.
Immediate PPH: Vaginal bleeding in excess of 500 mL, occurring less than 24 hours
after childbirth.
Immediate postpartum period: See fourth stage of labor.
Infant mortality rate: Number of deaths during the first year of life, expressed per 1000
live births.
Live birth: A baby who is born alive as indicated by the baby moving, crying, breathing, having
heart beats, or showing cord pulsations.
Low birth weight infant: A newborn weighing less than 2500 grams at birth. A low birth weight
infant (LBW) may be preterm, with or without intrauterine growth retardation (IUGR), or full term,
or post term with IUGR.
Neonatal mortality rate: Number of newborn deaths during the first 28 days of life, expressed
per 1000 live births.
Neonatal period: This period commences at birth and ends at 28 completed days of life. The
neonatal period is divided into two parts: the early neonatal period extends from day 1 to 7
completed days; the late neonatal period extends from day 8 to 28 completed days.
Perinatal mortality rate: The number of stillbirths and deaths in the first week of life, expressed
per 1000 live plus stillbirths.
Perinatal period: This period extends from the 22d week of gestation to the end of the first
week of life (7 completed days). In some developing countries, authorities feel that since
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survival of babies born before 28 weeks is in practice not feasible, the definition of the
commencement of the perinatal period should only be from 28 weeks. However, it is better to
have definitions uniform across countries so that data can be compared. As conditions
ameliorate in countries, outcomes will improve.
Newborn - Definitions
Perinatal Period
Early
neonatal
period
22 wk
Pregnancy
Birth
Late
neonatal
period
1 wk
4 wk
Newborn period
Waiting for signs of separation of the placenta (cord lengthening, small blood loss,
uterus firm and globular on palpation at the umbilicus).
Encouraging maternal effort to bear down with contractions and, if necessary, to
encourage an upright position.
Uterine massage after the delivery of the placenta as appropriate.
Placenta accreta: A severe obstetric complication occurring when the placenta attaches itself
too deeply and too firmly into the wall of the uterus, preventing separation of the placenta from
the uterus.
Post term infant: A baby who is born after 42 completed weeks of gestation.
Preterm infant: A baby who is born before 37 completed weeks of gestation.
Retraction: The act of the uterine muscle pulling back. Retraction is the ability of the
uterine muscle to keep its shortened length after each contraction. Together with
contractions, retraction helps the uterus become smaller after the delivery of the baby.
169
Severe PPH: Vaginal bleeding in excess of 1000 mL, occurring less than 24 hours after
childbirth.
Stages of labor
First stage of labor. The first stage of labor begins with the onset of contractions and
ends when the cervix is fully dilated (10 cm). This stage is divided into two phases,
known as the latent and active phases of labor. During the latent phase, the uterine
cervix gradually effaces (thins out) and dilates (opens). This is followed by active labor,
when the uterine cervix begins to dilate more rapidly and contractions are longer,
stronger, and closer together.
Second stage of labor. The second stage of labor begins when the uterine cervix is
fully dilated and ends with the birth of the baby. This is sometimes referred to as the
pushing stage.
Third stage of labor. The third stage of labor begins with the birth of the newborn and
ends with the delivery of the placenta and its attached membranes.
Fourth stage of labor (also known as the immediate postpartum period). The fourth
stage of labor begins with the delivery of the placenta and goes from one to six hours
after delivery of the placenta, or until the uterus remains firm on its own. In this
stabilization phase, the uterus makes its initial readjustment to the nonpregnant state.
The primary goal is to prevent hemorrhage from uterine atony and cervical or vaginal
lacerations.
Stillbirth: A baby who is born with no signs of life noted under live birth. Stillbirths are of two
types: macerated stillbirth (when the body may be distorted, soft, often smaller than normal,
and the skin is unhealthy with discoloration and peeling) and fresh stillbirth (when the body
appears normal unless associated with a major congenital malformations and the skin appears
normal in texture and consistency, although it may appear pale). Here the death has occurred
fairly close to the time of birth. It may have been due to problems during labor. On some
occasions a live birth with minimal signs of life, such as just a few cord pulsations or an
occasional faint gasp, may mistakenly be passed off as a stillbirth. Improved care during labor
and better recognition and reporting will result in a decrease in the number of fresh stillbirths.
Hence, in maintaining records, it is worthwhile to try and differentiate between macerated and
fresh stillbirths.
Term infant: A baby who is born within 37-42 completed weeks of gestation.
Uterine atony: Loss of tone in the uterine muscle. Normally, contraction of the uterine
muscles compresses the uterine blood vessels and reduces blood flow, increasing the
chance of coagulation and helping to prevent bleeding. The lack of uterine muscle
contraction or tone can cause an acute hemorrhage. Clinically, 75 to 80 percent of PPH
cases are due to uterine atony.
Uterine massage: An action used after the delivery of the placenta in which the provider
places one hand on top of the uterus to rub or knead the uterus until it is firm.
Sometimes blood and clots are expelled during uterine massage.
Uterotonic drugs: Substances that stimulate uterine contractions or increase uterine
tone.
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