Next, use the chart on Examine the woman in labour or with ruptured membranes - to assess the clinical situation and obstetrical history, and decide the stage of labour. If an abnormal sign is identified, use the charts on Respond to obstetrical problems on admission . Care for the woman according to the stage of labour - and respond to problems during labour and delivery as on . Use Give supportive care throughout labour to provide support and care throughout labour and delivery. Record findings continually on labour record and partograph -. Keep mother and baby in labour room for one hour after delivery and use charts Care of the mother and newborn within first hour of delivery placenta on . Next use Care of the mother after the first hour following delivery of placenta to provide care until discharge. Use chart on to provide Preventive measures and Advise on postpartum care - to advise on care, danger signs, when to seek routine or emergency care, and family planning. Examine the mother for discharge using chart on . Do not discharge mother from the facility before 12 hours. If the mother is HIV-infected or adolescent, or has special needs, see G1- H1-. If attending a delivery at the woman's home, see . D2. EXAMINE THE WOMAN IN LABOUR OR WITH RUPTURED MEMBRANESFirst do Rapid assessment and management . Then use this chart to assess the woman's and fetal status and decide stage of labour. View in own window ASK, CHECK RECORDLOOK, LISTEN, FEELHistory of this labour: When did contractions begin? How frequent are contractions? How strong? Have your waters broken? If yes, when? Were they clear or green? Have you had any bleeding? If yes, when? How much?
Check record, or if no record:If prior pregnancies:Number of prior pregnancies/deliveries. Any prior caesarean section, forceps, or vacuum, or other complication such as postpartum haemorhage? Any prior third degree tear?
Current pregnancy:Observe the woman's response to contractions: →Is she coping well or is she distressed? Is she pushing or grunting? - →
caesarean section scar. →horizontal ridge across lower abdomen (if present, empty bladder and observe again). - →
contractions frequency, duration, any continuous contractions? →fetal lie—longitudinal or transverse? →fetal presentation—head, breech, other? →more than one fetus? →fetal movement. Listen to the fetal heart beat: →Count number of beats in 1 minute. →If less than 100 beats per minute, or more than 180, turn woman on her left side and count again. Look for sunken eyes, dry mouth. Pinch the skin of the forearm: does it go back quickly?
Next: Perform vaginal examination and decide stage of labourD3. DECIDE STAGE OF LABOURView in own window ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYMANAGE - →
bulging perineum →any visible fetal parts →vaginal bleeding →leaking amniotic fluid; if yes, is it meconium stained, foul-smelling? →warts, keloid tissue or scars that may interfere with delivery.
Perform vaginal examinationDO NOT shave the perineal area. - →
clean gloves →swabs, pads. Wash hands with soap before and after each examination. Wash vulva and perineal areas. Position the woman with legs flexed and apart.
DO NOT perform vaginal examination if bleeding now or at any time after 7 months of pregnancy.Perform gentle vaginal examination (do not start during a contraction): →Determine cervical dilatation in centimetres. →Feel for presenting part. Is it hard, round and smooth (the head)? If not, identify the presenting part. →Feel for membranes – are they intact? →Feel for cord – is it felt? Is it pulsating? If so, act immediately as on .
IMMINENT DELIVERY- →
multigravida ≥5 cm →primigravida ≥6 cm
LATE ACTIVE LABOURSee first stage of labour – active labour . Start plotting partograph . Record in labour record .
EARLY ACTIVE LABOURNOT YET IN ACTIVE LABOURNext: Respond to obstetrical problems on admission.D4-D5. RESPOND TO OBSTETRICAL PROBLEMS ON ADMISSIONUse this chart if abnormal findings on assessing pregnancy and fetal status -. View in own window SIGNSCLASSIFYTREAT AND ADVISE Constant pain between contractions. Sudden and severe abdominal pain. Horizontal ridge across lower abdomen.
OBSTRUCTED LABOURIf distressed, insert an IV line and give fluids . If in labour >24 hours, give appropriate IM/IV antibiotics . Refer urgently to hospital .
FOR ALL SITUATIONS IN RED BELOW, REFER URGENTLY TO HOSPITAL IF IN EARLY LABOUR, MANAGE ONLY IF IN LATE LABOURUTERINE AND FETAL INFECTIONRISK OF UTERINE AND FETAL INFECTION AND RESPIRATORY DISTRESS SYNDROMEGive appropriate IM/IV antibiotics . If late labour, deliver -. Discontinue antibiotic for mother after delivery if no signs of infection.
PRE-ECLAMPSIASEVERE ANAEMIAOBSTETRICAL COMPLICATIONWarts, keloid tissue that may interfere with delivery. Bleeding any time in third trimester. - →
caesarean secion →forceps or vacuum delivery.
RISK OF OBSTETRICAL COMPLICATIONDo a generous episiotomy and carefully control delivery of the head . If late labour, deliver -. Have help available during delivery.
PRETERM LABOURReassess fetal presentation (breech more common). If woman is lying, encourage her to lie on her left side. Call for help during delivery. Routine delivery by caesarean section for the purpose of improving preterm newborn outcomes is not recommended, regardless of cephalic or breech presentation. The use of magnesium sulfate is recommended for women at risk of imminent preterm birth before 32 weeks of gestation for prevention of cerebral palsy in the infant and child . Conduct delivery very carefully as small baby may pop out suddenly. In particular, control delivery of the head. Prepare equipment for resuscitation of newborn .
POSSIBLE FETAL DISTRESSRUPTURE OF MEMBRANESDEHYDRATIONHIV-INFECTEDPOSSIBLE FETAL DEATHNext: Give supportive care throughout labourD6-D7. GIVE SUPPORTIVE CARE THROUGHOUT LABOURUse this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman's wishes. CommunicationExplain all procedures, seek permission, and discuss findings with the woman. Keep her informed about the progress of labour. Praise her, encourage and reassure her that things are going well. Ensure and respect privacy during examinations and discussions. If known HIV-infected, find out what she has told the companion. Respect her wishes.
CleanlinessEncourage the woman to bathe or shower or wash herself and genitals at the onset of labour. Wash the vulva and perineal areas before each examination. Wash your hands with soap before and after each examination. Use clean gloves for vaginal examination. Ensure cleanliness of labour and birthing area(s). Clean up spills immediately.
MobilityEncourage the woman to walk around freely during the first stage of labour. Support the woman's choice of position (left lateral, squating, kneeling, standing supported by the companion) for each stage of labour and delivery.
UrinationEating, drinkingEncourage the woman to eat and drink as she wishes throughout labour. Nutritious liquid drinks are important, even in late labour. If the woman has visible severe wasting or tires during labour, make sure she eats and drinks.
Breathing techniqueTeach her to notice her normal breathing. Encourage her to breathe out more slowly, making a sighing noise, and to relax with each breath. If she feels dizzy, unwell, is feeling pins-and-needles (tingling) in her face, hands and feet, encourage her to breathe more slowly. To prevent pushing at the end of first stage of labour, teach her to pant, to breathe with an open mouth, to take in 2 short breaths followed by a long breath out. During delivery of the head, ask her not to push but to breathe steadily or to pant.
Pain and discomfort reliefSuggest change of position. Encourage mobility, as comfortable for her. - →
massage the woman's back if she finds this helpful. →hold the woman's hand and sponge her face between contractions. Encourage her to use the breathing technique. Encourage warm bath or shower, if available. If woman is distressed or anxious, investigate the cause -. If pain is constant (persisting between contractions) and very severe or sudden in onset .
Birth companionEncourage support from the chosen birth companion throughout labour. Describe to the birth companion what she or he should do: →Always be with the woman. →Encourage her. →Help her to breathe and relax. →Rub her back, wipe her brow with a wet cloth, do other supportive actions. →Give support using local practices which do not disturb labour or delivery. →Encourage woman to move around freely as she wishes and to adopt the position of her choice. →Encourage her to drink fluids and eat as she wishes. →Assist her to the toilet when needed. Ask the birth companion to call for help if: →The woman is bearing down with contractions. →There is vaginal bleeding. →She is suddenly in much more pain. →She loses consciousness or has fits. →There is any other concern. Tell the birth companion what she or he should NOT do and explain why: DO NOT encourage woman to push. DO NOT give advice other than that given by the health worker. DO NOT keep woman in bed if she wants to move around.
D8. FIRST STAGE OF LABOUR: NOT IN ACTIVE LABOURUse this chart for care of the woman when NOT IN ACTIVE LABOUR, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes. View in own window MONITOR EVERY HOUR:MONITOR EVERY 4 HOURS: For emergency signs, using rapid assessment (RAM) . Frequency, intensity and duration of contractions. Mood and behaviour (distressed, anxious) .
Record findings regularly in Labour record and Partograph -. Record time of rupture of membranes and colour of amniotic fluid. Give Supportive care . Never leave the woman alone.
View in own window ASSESS PROGRESS OF LABOURTREAT AND ADVISE, IF REQUIRED - →
no increase in contractions, and →membranes are not ruptured, and →no progress in cervical dilatation.
D9. FIRST STAGE OF LABOUR: IN ACTIVE LABOURUse this chart when the woman is IN ACTIVE LABOUR, when cervix dilated 4 cm or more. View in own window MONITOR EVERY 30 MINUTES:MONITOR EVERY 4 HOURS: For emergency signs, using rapid assessment (RAM) . Frequency, intensity and duration of contractions. Mood and behaviour (distressed, anxious) .
Record findings regularly in Labour record and Partograph -. Record time of rupture of membranes and colour of amniotic fluid. Give Supportive care . Never leave the woman alone.
View in own window ASSESS PROGRESS OF LABOURTREAT AND ADVISE, IF REQUIRED Reassess woman and consider criteria for referral. Call senior person if available. Alert emergency transport services. Encourage woman to empty bladder. Ensure adequate hydration but omit solid foods. Encourage upright position and walking if woman wishes. Monitor intensively. Reassess in 2 hours and refer if no progress. If referral takes a long time, refer immediately (DO NOT wait to cross action line).
Use this chart when cervix dilated 10 cm or bulging thin perineum and head visible. View in own window MONITOR EVERY 5 MINUTES: For emergency signs, using rapid assessment (RAM) . Frequency, intensity and duration of contractions. Perineum thinning and bulging. Visible descent of fetal head or during contraction. Mood and behaviour (distressed, anxious) . Record findings regularly in Labour record and Partograph -. Give Supportive care . Never leave the woman alone.
View in own window DELIVER THE BABYTREAT AND ADVISE IF REQUIRED Ensure all delivery equipment and supplies, including newborn resuscitation equipment, are available, and place of delivery is clean and warm (25°C) .
Assist the woman into a comfortable position of her choice, as upright as possible. Stay with her and offer her emotional and physical support .
If unable to pass urine and bladder is full, empty bladder . DO NOT let her lie flat (horizontally) on her back. If the woman is distressed, encourage pain discomfort relief .
DO NOT urge her to push.If, after 30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin and stretch with contractions, do a vaginal examination to confirm full dilatation of cervix. If cervix is not fully dilated, await second stage. Place woman on her left side and discourage pushing. Encourage breathing technique .
Wait until head visible and perineum distending. Wash hands with clean water and soap. Put on gloves just before delivery. See Universal precautions during labour and delivery .
If second stage lasts for 2 hours or more without visible steady descent of the head, call for staff trained to use vacuum extractor or refer urgently to hospital . If obvious obstruction to progress (warts/scarring/keloid tissue/previous third degree tear), do a generous episiotomy. DO NOT perform episiotomy routinely. If breech or other malpresentation, manage as on .
Ensure controlled delivery of the head: →Keep one hand gently on the head as it advances with contractions. →Support perineum with other hand and cover anus with pad held in position by side of hand during delivery →Leave the perineum visible (between thumb and first finger). →Ask the mother to breathe steadily and not to push during delivery of the head. →Encourage rapid breathing with mouth open.
If potentially damaging expulsive efforts, exert more pressure on perineum. Discard soiled pad to prevent infection.
If cord present and loose, deliver the baby through the loop of cord or slip the cord over the baby's head; if cord is tight, clamp and cut cord, then unwind. Gently wipe face clean with gauze or cloth, if necessary.
Await spontaneous rotation of shoulders and delivery (within 1-2 minutes). Apply gentle downward pressure to deliver top shoulder. Then lift baby up, towards the mother's abdomen to deliver lower shoulder. Place baby on abdomen or in mother's arms.
If delay in delivery of shoulders: →DO NOT panic but call for help and ask companion to assist →Manage as in Stuck shoulders . If placing newborn on abdomen is not acceptable, or the mother cannot hold the baby, place the baby in a clean, warm, safe place close to the mother.
Thoroughly dry the baby immediately. Wipe eyes. Discard wet cloth. Assess baby's breathing while drying. If the baby is not crying, observe breathing: →breathing well (chest rising)? →not breathing or gasping?
DO NOT leave the baby wet - she/he will become cold.If the baby is not breathing or gasping (unless baby is dead, macerated, severely malformed): →Cut cord quickly: transfer to a firm, warm surface; start Newborn resuscitation . CALL FOR HELP - one person should care for the mother.
Palpate mother's abdomen. Give 10 IU oxytocin IM to the mother. Watch for vaginal bleeding.
If second baby, DO NOT give oxytocin now. GET HELP. Deliver the second baby. Manage as in Multiple pregnancy . If heavy bleeding, repeat oxytocin 10-IU-IM.
Change gloves. If not possible, wash gloved hands. Clamp and cut the cord (1-3 minutes after birth): →put ties tightly around the cord at 2 cm and 5 cm from baby's abdomen. →cut between ties with sterile instrument. →observe for oozing blood.
DO NOT apply any substance to the stump.
DO NOT bandage or bind the stump.Leave baby on the mother's chest in skin-to-skin contact. Place identification label. Cover the baby, cover the head with a hat.
If HIV-infected mother has chosen replacement feeding, feed accordingly. Check ARV treatment needed , .
D12-D13. THIRD STAGE OF LABOUR: DELIVER THE PLACENTAUse this chart for care of the woman between birth of the baby and delivery of placenta. View in own window MONITOR MOTHER EVERY 5 MINUTES:MONITOR BABY EVERY 15 MINUTES: For emergency signs, using rapid assessment (RAM) . Feel if uterus is well contracted. Mood and behaviour (distressed, anxious) . Time since third stage began (time since birth).
Breathing: listen for grunting, look for chest in-drawing and fast breathing . Warmth: check to see if feet are cold to touch .
Record findings, treatments and procedures in Labour record and Partograph (pp.N4-N6). Never leave the woman alone.
View in own window DELIVER THE PLACENTATREAT AND ADVISE IF REQUIRED Ensure 10-IU oxytocin IM is given . Await strong uterine contraction (2-3 minutes) and deliver placenta by controlled cord traction: →Place side of one hand (usually left) above symphysis pubis with palm facing towards the mother's umbilicus. This applies counter traction to the uterus during controlled cord traction. At the same time, apply steady, sustained controlled cord traction. →If placenta does not descend during 30-40 seconds of controlled cord traction, release both cord traction and counter traction on the abdomen and wait until the uterus is well contracted again. Then repeat controlled cord traction with counter traction. →As the placenta is coming out, catch in both hands to prevent tearing of the membranes. →If the membranes do not slip out spontaneously, gently twist them into a rope and move them up and down to assist separation without tearing them.
If, after 30 minutes of giving oxytocin, the placenta is not delivered and the woman is NOT bleeding: →Empty bladder →Encourage breastfeeding →Repeat controlled cord traction. If woman is bleeding, manage as on If placenta is not delivered in another 30 minutes (1 hour after delivery): →Remove placenta manually →Give appropriate IM/IV antibiotic . If in 1 hour unable to remove placenta: →Refer the woman to hospital →Insert an IV line and give fluids with 20 IU of oxytocin at 30 drops per minute during transfer .
DO NOT exert excessive traction on the cord.
DO NOT squeeze or push the uterus to deliver the placenta.If placenta is incomplete: →Remove placental fragments manually . →Give appropriate IM/IV antibiotic .
- →
Massage uterus to expel clots if any, until it is hard . →Give oxytocin 10 IU IM . →Call for help. →Start an IV line , add 20 IU of oxytocin to IV fluids and give at 60 drops per minute N9. →Empty the bladder . If bleeding persists and uterus is soft: →Continue massaging uterus until it is hard. →Apply bimanual or aortic compression . →Continue IV fluids with 20 IU of oxytocin at 30 drops per minute. →Refer woman urgently to hospital .
If third degree tear (involving rectum or anus), refer urgently to hospital . For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. Check after 5 minutes. If bleeding persists, repair the tear .
If blood loss ≈ 250 ml, but bleeding has stopped: →Plan to keep the woman in the facility for 24 hours. →Monitor intensively (every 30 minutes) for 4 hours: →BP, pulse →vaginal bleeding →uterus, to make sure it is well contracted. →Assist the woman when she first walks after resting and recovering. →If not possible to observe at the facility, refer to hospital .
- →
Use gloves when handling placenta. →Put placenta into a bag and place it into a leak-proof container. →Always carry placenta in a leak-proof container. →Incinerate the placenta or bury it at least 10 m away from a water source, in a 2 m deep pit.
RESPOND TO PROBLEMS DURING LABOUR AND DELIVERYD14. IF FHR <120 OR >160bpmView in own window ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF FETAL HEART RATE (FHR) <120 OR >160 BEATS PER MINUTE Position the woman on her left side. If membranes have ruptured, look at vulva for prolapsed cord. See if liquor was meconium stained. Repeat FHR count after 15 minutes
PROLAPSED CORDBABY NOT WELL- →
Refer the woman urgently to hospital →Keep her lying on her left side. - →
Call for help during delivery →Monitor after every contraction. If FHR does not return to normal in 15 minutes explain to the woman (and her companion) that the baby may not be well. →Prepare for newborn resuscitation .
BABY WELLNext: If prolapsed cordD15. IF PROLAPSED CORDThe cord is visible outside the vagina or can be felt in the vagina below the presenting part. View in own window ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT OBSTRUCTED LABOURFETUS ALIVEIf early labour:Push the head or presenting part out of the pelvis and hold it above the brim/pelvis with your hand on the abdomen until caesarean section is performed. Instruct assistant (family, staff) to position the woman's buttocks higher than the shoulder. Refer urgently to hospital . If transfer not possible, allow labour to continue.
If late labour:Call for additional help if possible (for mother and baby). Prepare for Newborn resuscitation . Ask the woman to assume an upright or squatting position to help progress. Expedite delivery by encouraging woman to push with contraction.
FETUS PROBABLY DEADNext: If breech presentationD16. IF BREECH PRESENTATIONView in own window LOOK, LISTEN, FEELSIGNSTREAT On external examination fetal head felt in fundus. Soft body part (leg or buttocks) felt on vaginal examination. Legs or buttocks presenting at perineum
Call for additional help. Confirm full dilatation of the cervix by vaginal examination Ensure bladder is empty. If unable to empty bladder see Empty bladder . Prepare for newborn resuscitation . - →
Assist the woman into a position that will allow the baby to hang down during delivery, for example, propped up with buttocks at edge of bed or onto her hands and knees (all fours position). →When buttocks are distending, make an episiotomy. →Allow buttocks, trunk and shoulders to deliver spontaneously during contractions. →After delivery of the shoulders allow the baby to hang until next contraction.
Place the baby astride your left forearm with limbs hanging on each side. Place the middle and index fingers of the left hand over the malar cheek bones on either side to apply gentle downwards pressure to aid flexion of head. Keeping the left hand as described, place the index and ring fingers of the right hand over the baby's shoulders and the middle finger on the baby's head to gently aid flexion until the hairline is visible. When the hairline is visible, raise the baby in upward and forward direction towards the mother's abdomen until the nose and mouth are free. The assistant gives supra pubic pressure during the period to maintain flexion.
Feel the baby's chest for arms. If not felt: Hold the baby gently with hands around each thigh and thumbs on sacrum. Gently guiding the baby down, turn the baby, keeping the back uppermost until the shoulder which was posterior (below) is now anterior (at the top) and the arm is released. Then turn the baby back, again keeping the back uppermost to deliver the other arm. Then proceed with delivery of head as described above.
NEVER pull on the breech
DO NOT allow the woman to push until the cervix is fully dilated. Pushing too soon may cause the head to be trapped.Next: If stuck shouldersD17. IF STUCK SHOULDERS (SHOULDER DYSTOCIA)View in own window SIGNSTREAT Call for additional help. Prepare for newborn resuscitation. Explain the problem to the woman and her companion. Ask the woman to lie on her back while gripping her legs tightly flexed against her chest, with knees wide apart. Ask the companion or other helper to keep the legs in that position. Perform an adequate episiotomy. Ask an assistant to apply continuous pressure downwards, with the palm of the hand on the abdomen directly above the pubic area, while you maintain continuous downward traction on the fetal head.
Remain calm and explain to the woman that you need her cooperation to try another position. Assist her to adopt a kneeling on “all fours” position and ask her companion to hold her steady - this simple change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery. Introduce the right hand into the vagina along the posterior curve of the sacrum. Attempt to deliver the posterior shoulder or arm using pressure from the finger of the right hand to hook the posterior shoulder and arm downwards and forwards through the vagina. Complete the rest of delivery as normal. If not successful, refer urgently to hospital .
DO NOT pull excessively on the head.Next: If multiple birthsD18. IF MULTIPLE BIRTHSView in own window SIGNSTREAT Prepare delivery room and equipment for birth of 2 or more babies. Include: →more warm cloths →two sets of cord ties and razor blades →resuscitation equipment for 2 babies. Arrange for a helper to assist you with the births and care of the babies.
Deliver the first baby following the usual procedure. Resuscitate if necessary. Label her/him Twin 1. Ask helper to attend to the first baby. Palpate uterus immediately to determine the lie of the second baby. If transverse or oblique lie, gently turn the baby by abdominal manipulation to head or breech presentation. Check the presentation by vaginal examination. Check the fetal heart rate. Await the return of strong contractions and spontaneous rupture of the second bag of membranes, usually within 1 hour of birth of first baby, but may be longer. Stay with the woman and continue monitoring her and the fetal heart rate intensively. Remove wet cloths from underneath her. If feeling chilled, cover her. When the membranes rupture, perform vaginal examination to check for prolapsed cord. If present, see Prolapsed cord . When strong contractions restart, ask the mother to bear down when she feels ready. Deliver the second baby. Resuscitate if necessary. Label her/him Twin 2. After cutting the cord, ask the helper to attend to the second baby. Palpate the uterus for a third baby. If a third baby is felt, proceed as described above. If no third baby is felt, go to third stage of labour.
DO NOT attempt to deliver the placenta until all the babies are born.
DO NOT give the mother oxytocin until after the birth of all babies.Give oxytocin 10 IU IM after making sure there is not another baby. When the uterus is well contracted, deliver the placenta and membranes by applying traction to all cords together -. Before and after delivery of the placenta and membranes, observe closely for vaginal bleeding because this woman is at greater risk of postpartum haemorrhage. If bleeding, see . Examine the placenta and membranes for completeness. There may be one large placenta with 2 umbilical cords, or a separate placenta with an umbilical cord for each baby.
Monitor intensively as risk of bleeding is increased. Provide immediate Postpartum care -. - →
Keep mother in health centre for longer observation →Plan to measure haemoglobin postpartum if possible →Give special support for care and feeding of babies and .
Next: Care of the mother and newborn within first hour of delivery of placentaD19. CARE OF THE MOTHER AND NEWBORN WITHIN FIRST HOUR OF DELIVERY OF PLACENTAUse this chart for woman and newborn during the first hour after complete delivery of placenta. View in own window MONITOR MOTHER EVERY 15 MINUTES:MONITOR BABY EVERY 15 MINUTES: Breathing: listen for grunting, look for chest in-drawing and fast breathing . Warmth: check to see if feet are cold to touch .
Record findings, treatments and procedures in Labour record and Partograph -. Keep mother and baby in delivery room - do not separate them. Never leave the woman and newborn alone.
View in own window CARE OF MOTHER AND NEWBORNINTERVENTIONS, IF REQUIREDWOMAN Assess the amount of vaginal bleeding. Encourage the woman to eat and drink. Ask the companion to stay with the mother. Encourage the woman to pass urine.
If pad soaked in less than 5 minutes, or constant trickle of blood, manage as on . If uterus soft, manage as on . If bleeding from a perineal tear, repair if required or refer to hospital .
NEWBORNApply an antimicrobial within 1 hour of birth. →either 1% silver nitrate drops or 2.5% povidone iodine drops or 1% tetracycline ointment. DO NOT wash away the eye antimicrobial. If blood or meconium, wipe off with wet cloth and dry. DO NOT remove vernix or bathe the baby. Continue keeping the baby warm and in skin-to-skin contact with the mother. Encourage the mother to initiate breastfeeding when baby shows signs of readiness. Offer her help. DO NOT give artificial teats or pre-lacteal feeds to the newborn: no water, sugar water, or local feeds.
If breathing with difficulty — grunting, chest in-drawing or fast breathing, examine the baby as on -. If feet are cold to touch or mother and baby are separated: Ensure the room is warm. Cover mother and baby with a blanket →Reassess in 1 hour. If still cold, measure temperature. If less than 36.5°C, manage as on . If unable to initiate breastfeeding (mother has complications): →Plan for alternative feeding method -. →If mother HIV-infected: give treatment to the newborn . →Support the mother's choice of newborn feeding . If baby is stillborn or dead, give supportive care to mother and her family .
D20. CARE OF THE MOTHER ONE HOUR AFTER DELIVERY OF PLACENTAUse this chart for continuous care of the mother until discharge. See for care of the baby. View in own window MONITOR MOTHER AT 2, 3 AND 4 HOURS, THEN EVERY 4 HOURS: Record findings, treatments and procedures in Labour record and Partograph -. Keep the mother and baby together. Never leave the woman and newborn alone. DO NOT discharge before 24 hours.
View in own window CARE OF MOTHERINTERVENTIONS, IF REQUIRED Accompany the mother and baby to ward. Advise on Postpartum care and hygiene . Ensure the mother has sanitary napkins or clean material to collect vaginal blood. Encourage the mother to eat, drink and rest. Ensure the room is warm (25°C).
Make sure the woman has someone with her and they know when to call for help. If HIV-infected: give her appropriate treatment , .
If heavy vaginal bleeding, palpate the uterus. →If uterus not firm, massage the fundus to make it contract and expel any clots . →If pad is soaked in less than 5 minutes, manage as on . →If bleeding is from perineal tear, repair or refer to hospital .
DO NOT catheterize unless you have to.Check record and give any treatment or prophylaxis which is due. Advise the mother on postpartum care and nutrition . Advise when to seek care . Counsel on birth spacing and other family planning methods . Repeat examination of the mother before discharge using Assess the mother after delivery . For baby, see -
If tubal ligation or IUD desired, make plans before discharge. If mother is on antibiotics because of rupture of membranes >18 hours but shows no signs of infection now, discontinue antibiotics.
D21. ASSESS THE MOTHER AFTER DELIVERYAfter an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. Use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge. For examining the newborn use the chart on -. View in own window ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE - →
bleeding more than 250 ml? →completeness of placenta and membranes? →complications during delivery or postpartum? →special treatment needs? →needs tubal ligation or IUD? Do you have any concerns? How do your breasts feel?
Feel the uterus. Is it hard and round? Look for vaginal bleeding - →
Is there a tear or cut? →Is it red, swollen or draining pus? Look for conjunctival pallor.
MOTHER WELLKeep the mother at the facility for 24 hours after delivery. Ensure preventive measures Advise on postpartum care and hygiene . Counsel on birth spacing and family planning Advise on when to seek care and next routine postpartum visit . Reassess for discharge Continue any treatments initiated earlier. If tubal ligation desired, refer to hospital within 7 days of delivery. If IUD desired, refer to appropriate services within 48 hours.
Next: Respond to problems immediately postpartumIf no problems, go to page . D22-D24. RESPOND TO PROBLEMS IMMEDIATELY POSTPARTUMView in own window ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF VAGINAL BLEEDING HEAVY BLEEDINGIF FEVER (TEMPERATURE > 38°C)Repeat temperature measurement after 2 hours If temperature is still >38ºC →Look for abnormal vaginal discharge. →Listen to fetal heart rate →feel lower abdomen for tenderness
Temperature still >38°C and any of: →Chills →Foul-smelling vaginal discharge →Low abdomen tenderness →FHR remains >160 after →30 minutes of observation →rupture of membranes >18 hours
UTERINE AND FETAL INFECTIONInsert an IV line and give fluids rapidly . Give appropriate IM/IV antibiotics . If baby and placenta delivered: →Give oxytocin 10 IU IM . Refer woman urgently to hospital . Treat if any sign of infection.
RISK OF UTERINE AND FETAL INFECTIONEncourage woman to drink plenty of fluids. Measure temperature every 4 hours. If temperature persists for >12 hours, is very high or rises rapidly, give appropriate antibiotic and refer to hospital .
IF PERINEAL TEAR OR EPISIOTOMY (DONE FOR LIFESAVING CIRCUMSTANCES)THIRD DEGREE TEARSMALL PERINEAL TEARNext: If elevated diastolic blood pressureIF ELEVATED DIASTOLIC BLOOD PRESSURE View in own window ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE If diastolic blood pressure is ≥90 mmHg, repeat after 1 hour rest. If diastolic blood pressure is still ≥90 mmHg, ask the woman if she has: →severe headache →blurred vision →epigastric pain and →check protein in urine.
SEVERE PRE-ECLAMPSIAGive magnesium sulphate . If in early labour or postpartum, refer urgently to hospital . - →
continue magnesium sulphate treatment →monitor blood pressure every hour. →DO NOT give ergometrine after delivery. Refer urgently to hospital after delivery .
PRE-ECLAMPSIAIf early labour, refer urgently to hospital E17. - →
monitor blood pressure every hour →DO NOT give ergometrine after delivery. If BP remains elevated after delivery, refer to hospital E17.
HYPERTENSIONMonitor blood pressure every hour. Do not give ergometrine after delivery. If blood pressure remains elevated after delivery, refer woman to hospital E17.
Next: If pallor on screening, check for anaemiaView in own window ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISEIF PALLOR ON SCREENING, CHECK FOR ANAEMIA Measure haemoglobin, if possible. Look for conjunctival pallor. Look for palmar pallor. If pallor: →Is it severe pallor? →Some pallor? →Count number of breaths in →1 minute
Haemoglobin <7 g/dl. AND/OR Severe palmar and conjunctival pallor or Any pallor with >30 breaths per minute.
SEVERE ANAEMIAIf early labour or postpartum, refer urgently to hospital - →
monitor intensively →minimize blood loss →refer urgently to hospital after delivery .
MODERATE ANAEMIANO ANAEMIAIF MOTHER SEVERELY ILL OR SEPARATED FROM THE BABYTeach mother to express breast milk every 3 hours . Help her to express breast milk if necessary. Ensure baby receives mother's milk . Help her to establish or re-establish breastfeeding as soon as possible. See -.
IF BABY STILLBORN OR DEAD- →
Inform the parents as soon as possible after the baby's death. →Show the baby to the mother, give the baby to the mother to hold, where culturally appropriate. →Offer the parents and family to be with the dead baby in privacy as long as they need. →Discuss with them the events before the death and the possible causes of death. Advise the mother on breast care . Counsel on appropriate family planning method .
Next: Give preventive measuresD25. GIVE PREVENTIVE MEASURESEnsure that all are given before discharge. View in own window ASSESS, CHECK RECORDSTREAT AND ADVISE Encourage sleeping under insecticide treated bednet . Advise on postpartum care . Counsel on birth spacing and family planning . Counsel on breastfeeding . Counsel on safer sex including use of condoms . Advise on routine and follow-up postpartum visits . Advise on danger signs . Discuss how to prepare for an emergency in postpartum . Counsel of continued abstinence from tobacco, alcohol and drugs .
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Support adherence to ARV . →Treat the newborn If HIV test not done, the result of the latest test not known or if tested HIV-negative in early pregnancy, offer her the rapid HIV test , , .
D26. ADVISE ON POSTPARTUM CAREAdvise on postpartum care and hygieneAdvise and explain to the woman: To always have someone near her for the first 24 hours to respond to any change in her condition. Not to insert anything into the vagina. To have enough rest and sleep. The importance of washing to prevent infection of the mother and her baby: →wash hands before handling baby →wash perineum daily and after faecal excretion →change perineal pads every 4 to 6 hours, or more frequently if heavy lochia →wash used pads or dispose of them safely →wash the body daily. To avoid sexual intercourse until the perineal wound heals. To sleep with the baby under an insecticide-treated bednet.
Counsel on nutritionAdvise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong (give examples of types of food and how much to eat). Reassure the mother that she can eat any normal foods – these will not harm the breastfeeding baby. Spend more time on nutrition counselling with very thin women and adolescents. Determine if there are important taboos about foods which are nutritionally healthy. Advise the woman against these taboos. Talk to family members such as partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work.
Counsel on Substance AbuseAdvise the woman to continue abstinence from tobacco Do not take any drugs or medications for tobacco cessation Talk to family members such as partner and mother-in-law, to encourage them to help ensure the woman avoids second-hand smoke exposure
D27. COUNSEL ON BIRTH SPACING AND FAMILY PLANNINGCounsel on the importance of family planningIf appropriate, ask the woman if she would like her partner or another family member to be included in the counselling session. Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as 4 weeks after delivery. Therefore it is important to start thinking early about what family planning method they will use. →Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 2 years before trying to become pregnant again is good for the mother and for the baby's health. →Information on when to start a method after delivery will vary depending on whether a woman is breastfeeding or not. →Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process). Councel on safer sex including use of condoms for dual protection from sexually transmitted infection (STI) or HIV and pregnancy. Promote their use, especially if at risk for sexually transmitted infection (STI) or HIV . For HIV-infected women, see for family planning considerations Her partner can decide to have a vasectomy (male sterilization) at any time.
Method options for the non-breastfeeding womanView in own window Can be used immediately postpartumCondoms
Progestogen-only oral contraceptives
Progestogen-only injectables
Implant
Spermicide
Female sterilization (within 7 days or delay 6 weeks)
Copper IUD (immediately following expulsion of placenta or within 48 hours)Delay 3 weeksCombined oral contraceptives
Combined injectables
Fertility awareness methods Lactational amenorrhoea method (LAM)A breastfeeding woman is protected from pregnancy only if: →she is no more than 6 months postpartum, and →she is breastfeeding exclusively (8 or more times a day, including at least once at night: no daytime feedings more than 4 hours apart and no night feedings more than 6 hours apart; no complementary foods or fluids), and →her menstrual cycle has not returned. A breastfeeding woman can also choose any other family planning method, either to use alone or together with LAM.
Method options for the breastfeeding womanView in own window Can be used immediately postpartumLactational amenorrhoea method (LAM)
Condoms
Spermicide
Female sterilisation (within 7 days or delay 6 weeks)
Copper IUD (within 48 hours or delay 4 weeks)Delay 6 weeksProgestogen-only oral contraceptives
Progestogen-only injectables
Implants
DiaphragmDelay 6 monthsCombined oral contraceptives
Combined injectables
Fertility awareness methods D28. ADVISE ON WHEN TO RETURNUse this chart for advising on postnatal care after delivery in health facility on or . For newborn babies see the schedule on . Encourage woman to bring her partner or family member to at least one visit. Routine postnatal contactsView in own window FIRST CONTACT: within 24 hours after childbirth.SECOND CONTACT: on day 3 (48-72 hours)THIRD CONTACT: between day 7 and 14 after birth.FINAL POSTNATAL CONTACT (CLINIC VISIT): at 6 weeks after birth Follow-up visits for problemsView in own window If the problem was:Return in:Fever2 daysLower urinary tract infection2 daysPerineal infection or pain2 daysHypertension1 weekUrinary incontinence1 weekSevere anaemia2 weeksPostpartum blues2 weeksHIV-infected2 weeksModerate anaemia4 weeksIf treated in hospital for any complicationAccording to hospital instructions or according to national guidelines, but no later than in 2 weeks. Advise on danger signsAdvise to go to a hospital or health centre immediately, day or night, WITHOUT WAITING, if any of the following signs: - →
more than 2 or 3 pads soaked in 20-30 minutes after delivery OR →bleeding increases rather than decreases after delivery. fast or difficult breathing. fever and too weak to get out of bed. calf pain, redness or swelling, shortness of breath or chest pain.
Go to health centre as soon as possible if any of the following signs: breasts swollen, red or tender breasts, or sore nipple urine dribbling or pain on micturition pain in the perineum or draining pus severe depression or suicidal behaviour (ideas or attempts)
Discuss how to prepare for an emergency in postpartumAdvise to always have someone near for at least 24 hours after delivery to respond to any change in condition. Discuss with woman and her partner and family about emergency issues: →where to go if danger signs →how to reach the hospital →costs involved →family and community support. Discuss home visits: in addition to the scheduled routine postnatal contacts, which can occur in clinics or at home, the mother and newborn may receive postnatal home visits by community health workers. Advise the woman to ask for help from the community, if needed I1-. Advise the woman to bring her home-based maternal record to the health centre, even for an emergency visit.
D29. HOME DELIVERY BY SKILLED ATTENDANTUse these instructions if you are attending delivery at home. Preparation for home deliveryCheck emergency arrangements. Keep emergency transport arrangements up-to-date. Carry with you all essential drugs , records, and the delivery kit. Ensure that the family prepares, as on .
Delivery careFollow the labour and delivery procedures - . Observe universal precautions . Give Supportive care. Involve the companion in care and support . Maintain the partograph and labour record -. Provide newborn care -. In settings with high neonatal mortality apply chlorhexidine to the umbilical stump daily for the first week of life. Refer to facility as soon as possible if any abnormal finding in mother or baby .
Immediate postpartum care of motherStay with the woman for first two hours after delivery of placenta -. Examine the mother before leaving her . Advise on postpartum care, nutrition and family planning -. Ensure that someone will stay with the mother for the first 24 hours.
Postnatal care of newbornStay until baby has had the first breastfeed and help the mother good positioning and attachment . Advise on breastfeeding and breast care -. Examine the baby before leaving -. Immunize the baby if possible . Advise the family about danger signs and when and where to seek care . If possible, return within a day to check the mother and baby. Advise on the first postnatal contact for the mother and the baby which should be as early as possible within 24 hours of birth .
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