Always begin with Rapid assessment and management [RAM] B3-B7.
Next, use the chart on Examine the woman in labour or with ruptured membranes
D2-D3 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
D4-D5.
Care for the woman according to the stage of labour D8-D13 and respond to problems during labour and delivery as on
D14-D18.
Use Give supportive care throughout labour D6-D7 to provide support and care throughout labour and delivery.
Record findings continually on labour record and partograph
N4-N6.
Keep mother and baby in labour room for one hour after delivery and use charts Care of the mother and newborn within first hour of delivery placenta on D19.
Next
use Care of the mother after the first hour following delivery of placenta D20 to provide care until discharge. Use chart on D25 to provide Preventive measures and Advise on postpartum care
D26-D28 to advise on care, danger signs, when to seek routine or emergency care, and family planning.
Examine the mother for discharge using chart on D21.
Do not discharge
mother from the facility before 12 hours.
If the mother is HIV-infected or adolescent, or has special needs, see G1-G11
H1-H4.
If attending a delivery at the woman's home, see D29.
D2. EXAMINE THE WOMAN IN LABOUR OR WITH RUPTURED MEMBRANES
First do
Rapid assessment and management B3-B7. Then use this chart to assess the woman's and fetal status and decide stage of labour.
ASK, CHECK RECORDLOOK, LISTEN, FEEL
History of this labour:When did contractions begin? How frequent are contractions? How strong? Have your waters broken? If yes, when? Were they clear or green? Have
you had any bleeding? If yes, when? How much? Is the baby moving? Do you have any concern? Check record, or if no record: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? Check abdomen for: →caesarean section scar. →horizontal ridge across lower abdomen [if present, empty bladder
B12 and observe again]. Feel abdomen for: →contractions frequency, duration, any continuous contractions? →fetal lie—longitudinal or transverse? →fetal presentation—head, breech, other? →more than one fetus? →fetal movement. -
Listen to the fetal heart beat: →Count number of beats in 1 minute. →If less than 100 beats per minute, or more than 180, turn woman on her left side and count again. Measure blood pressure. Measure temperature. Look for pallor. Look for sunken eyes, dry mouth. Pinch the skin of the forearm: does it go back quickly?
|
Next: Perform vaginal examination and decide stage of labour
D3. DECIDE STAGE OF LABOUR
ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYMANAGE
| Look at vulva for: →bulging perineum →any visible fetal parts →vaginal bleeding →leaking amniotic fluid; if yes, is it meconium stained, foul-smelling? →warts, keloid tissue or scars that may interfere with delivery. Perform vaginal examinationDO NOT
shave the perineal area. Prepare: →clean gloves →swabs, pads. Wash hands with soap before and after each examination. Wash vulva and perineal areas. Put on gloves. Position the woman with legs flexed and apart. DO NOT perform vaginal examination if bleeding now or at any time after 7 months of pregnancy. Perform gentle vaginal
examination [do not start during a contraction]: →Determine cervical dilatation in centimetres. →Feel for presenting part. Is it hard, round and smooth [the head]? If not, identify the presenting part. →Feel for membranes – are they intact? →Feel for cord – is it felt? Is it pulsating? If so, act immediately as on
D15.
|
| IMMINENT DELIVERY
|
|
|
Cervical dilatation: →multigravida ≥5 cm →primigravida ≥6 cm
| LATE ACTIVE LABOUR
| See first stage of labour – active labour D9. Start plotting partograph N5. Record in labour record
N5.
|
|
| EARLY ACTIVE LABOUR
|
|
| OBSTRUCTED LABOUR
| If distressed, insert an IV line and give fluids B9. If in labour >24 hours, give appropriate IM/IV antibiotics B15. Refer urgently to hospital
B17.
|
|
FOR ALL SITUATIONS IN RED BELOW, REFER URGENTLY TO HOSPITAL IF IN EARLY LABOUR, MANAGE ONLY IF IN LATE LABOUR
|
|
| UTERINE AND FETAL INFECTION
| Give appropriate IM/IV antibiotics B15. If late labour, deliver and refer to hospital after delivery B17. Plan to treat newborn
J5.
|
|
| PRE-ECLAMPSIA
|
|
|
|
|
| DEHYDRATION
|
|
|
| HIV-INFECTED
| Ensure that the woman takes ARV drugs as prescribed G6, G9 Support her choice of infant feeding
G7-G8.
|
|
| POSSIBLE FETAL DEATH
|
|
Next: Give supportive care throughout labour
D6-D7. GIVE SUPPORTIVE CARE THROUGHOUT LABOUR
Use this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman's wishes.
Communication
Explain
all procedures, seek permission, and discuss findings with the woman.
Keep her informed about the progress of labour.
Praise her, encourage and reassure her that things are going well.
Ensure and respect privacy during examinations and discussions.
If known HIV-infected, find out what she has told the companion. Respect her wishes.
Cleanliness
Encourage the woman to bathe or
shower or wash herself and genitals at the onset of labour.
Wash the vulva and perineal areas before each examination.
Wash your hands with soap before and after each examination. Use clean gloves for vaginal examination.
Ensure cleanliness of labour and birthing area[s].
Clean up spills immediately.
DO NOT give enema.
Mobility
Encourage the woman to
walk around freely during the first stage of labour.
Support the woman's choice of position [left lateral, squating, kneeling, standing supported by the companion] for each stage of labour and delivery.
Urination
Eating, drinking
Encourage the woman to eat and drink as she wishes
throughout labour.
Nutritious liquid drinks are important, even in late labour.
If the woman has visible severe wasting or tires during labour, make sure she eats and drinks.
Breathing technique
Teach her to notice her normal breathing.
Encourage her to breathe out more slowly, making a sighing noise, and to relax with each breath.
If she feels dizzy, unwell, is feeling
pins-and-needles [tingling] in her face, hands and feet, encourage her to breathe more slowly.
To prevent pushing at the end of first stage of labour, teach her to pant, to breathe with an open mouth, to take in 2 short breaths followed by a long breath out.
During delivery of the head, ask her not to push but to breathe steadily or to pant.
Pain and discomfort relief
Suggest change of position.
Encourage mobility, as comfortable for her.
Encourage companion to:
→massage the woman's back if she finds this helpful.
→hold the woman's hand and sponge her face between contractions.
Encourage her to use the breathing technique.
Encourage warm bath or shower, if available.
If woman is distressed or anxious, investigate the cause
D2-D3.
If pain is constant [persisting between contractions] and very severe or sudden in onset D4.
Birth companion
Encourage support from
the chosen birth companion throughout labour.
Describe to the birth companion what she or he should do:
→Always be with the woman.
→Encourage her.
→Help her to breathe and relax.
→Rub her back, wipe her brow with a wet cloth, do other supportive actions.
→Give support using local practices which do not disturb labour or delivery.
→Encourage
woman to move around freely as she wishes and to adopt the position of her choice.
→Encourage her to drink fluids and eat as she wishes.
→Assist her to the toilet when needed.
Ask the birth companion to call for help if:
→The woman is bearing down with contractions.
→There is vaginal bleeding.
→She is suddenly in much more pain.
→She
loses consciousness or has fits.
→There is any other concern.
Tell the birth companion what she or he should NOT do and explain why:
DO NOT encourage woman to push.
DO NOT give advice other than that given by the health worker.
DO NOT keep woman in bed if she wants to move around.
D8. FIRST STAGE OF
LABOUR: NOT IN ACTIVE LABOUR
Use this chart for care of the woman when NOT IN ACTIVE LABOUR, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes.
MONITOR EVERY HOUR:MONITOR EVERY 4 HOURS:
For emergency signs, using rapid assessment [RAM] B3-B7. Frequency, intensity and
duration of contractions. Fetal heart rate D14. Mood and behaviour [distressed, anxious] D6.
| Cervical dilatation D3 D15. Unless indicated, do not do vaginal examination more frequently than every 4 hours. Temperature. Pulse
B3. Blood pressure D23.
|
Record findings regularly in Labour record and Partograph N4-N6. Record time of rupture of membranes and colour of amniotic fluid. Give Supportive care
D6-D7. Never leave the woman alone.
|
|
ASSESS PROGRESS OF LABOURTREAT AND ADVISE, IF REQUIRED
|
|
After 8 hours if: →no increase in contractions, and →membranes are not ruptured, and →no progress in cervical dilatation.
|
|
|
|
D9. FIRST STAGE OF LABOUR: IN ACTIVE LABOUR
Use this chart when the woman is IN ACTIVE LABOUR, when cervix dilated 4 cm or more.
MONITOR EVERY 30 MINUTES:MONITOR EVERY 4 HOURS:
For emergency signs, using rapid assessment [RAM] B3-B7. Frequency, intensity
and duration of contractions. Fetal heart rate D14. Mood and behaviour [distressed, anxious] D6.
| Cervical dilatation D3 D15. Unless indicated, do not do vaginal examination more frequently than every 4 hours. Temperature. Pulse
B3. Blood pressure D23.
|
Record findings regularly in Labour record and Partograph N4-N6. Record time of rupture of membranes and colour of amniotic fluid. Give Supportive care
D6-D7. Never leave the woman alone.
|
|
ASSESS PROGRESS OF 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].
|
|
|
|
|
D10-D11. SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE
Use this chart when cervix dilated 10 cm or bulging thin perineum and head visible.
MONITOR EVERY 5 MINUTES:
For emergency signs, using rapid assessment [RAM] B3-B7. Frequency, intensity and duration of contractions. Fetal heart rate
D14. Perineum thinning and bulging. Visible descent of fetal head or during contraction. Mood and behaviour [distressed, anxious] D6. Record findings regularly in Labour record and Partograph
N4-N6. Give Supportive care D6-D7. Never leave the woman alone.
|
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]
L3.
|
|
Ensure bladder is empty. Assist the woman into a comfortable position of her choice, as upright as possible. Stay with her and offer her emotional and physical support D10-D11.
| If unable to pass urine and bladder is full, empty bladder B12. DO NOT let her lie flat [horizontally] on her back. If the woman is distressed, encourage pain discomfort relief
D6.
|
| DO NOT urge her to push. If, after 30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin and stretch with contractions, do a vaginal examination to confirm full dilatation of cervix. If cervix is not fully dilated, await second stage. Place woman on her left side and discourage pushing. Encourage breathing technique
D6.
|
Wait until head visible and perineum distending. Wash hands with clean water and soap. Put on gloves just before delivery. See Universal precautions during labour and delivery A4.
| If second stage lasts for 2 hours or more without visible steady descent of the head, call for staff trained to use vacuum extractor or refer urgently to hospital B17. If obvious obstruction to progress [warts/scarring/keloid tissue/previous third degree tear], do a generous episiotomy. DO
NOT perform episiotomy routinely. If breech or other malpresentation, manage as on D16.
|
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. Note time of delivery.
| If delay in delivery of shoulders: →DO NOT panic but call for help and ask companion to assist →Manage as in Stuck shoulders D17. If placing newborn on abdomen is not acceptable, or the mother cannot hold the baby, place the baby in a
clean, warm, safe place close to the mother.
|
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 K11. CALL FOR HELP
- one person should care for the mother.
|
Exclude second baby. 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 D18. 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 G6, G9.
|
D12-D13. THIRD STAGE OF LABOUR: DELIVER THE PLACENTA
Use this chart for care of the woman between birth of the baby and delivery of placenta.
MONITOR MOTHER EVERY 5 MINUTES:MONITOR BABY EVERY 15 MINUTES:
For emergency signs, using rapid assessment [RAM] B3-B7. Feel
if uterus is well contracted. Mood and behaviour [distressed, anxious] D6. Time since third stage began [time since birth].
| Breathing: listen for grunting, look for chest in-drawing and fast breathing J2. Warmth: check to see if feet are cold to touch J2.
|
Record findings, treatments and procedures in Labour record and Partograph [pp.N4-N6]. Give Supportive care D6-D7 Never leave the woman alone.
|
|
DELIVER THE PLACENTATREAT AND ADVISE IF REQUIRED
Ensure 10-IU oxytocin IM is given D11. 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 B12 →Encourage breastfeeding →Repeat controlled cord traction. If woman is bleeding, manage as
on B5 If placenta is not delivered in another 30 minutes [1 hour after delivery]: →Remove placenta manually B11 →Give appropriate IM/IV antibiotic
B15. If in 1 hour unable to remove placenta: →Refer the woman to hospital B17 →Insert an IV line and give fluids with 20 IU of oxytocin at 30 drops per minute during transfer
B9. DO NOT exert excessive traction on the cord. DO NOT squeeze or push the uterus to deliver the placenta.
|
| If placenta is incomplete: →Remove placental fragments manually B11. →Give appropriate IM/IV antibiotic B15.
|
| If heavy bleeding: →Massage uterus to expel clots if any, until it is hard B10. →Give oxytocin 10 IU IM B10. →Call for help.
→Start an IV line B9, add 20 IU of oxytocin to IV fluids and give at 60 drops per minute N9. →Empty the bladder B12. If bleeding persists and uterus is soft: →Continue massaging
uterus until it is hard. →Apply bimanual or aortic compression B10. →Continue IV fluids with 20 IU of oxytocin at 30 drops per minute. →Refer woman urgently to hospital B17.
|
| If third degree tear [involving rectum or anus], refer urgently to hospital B17. For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together. Check after 5 minutes. If bleeding persists, repair the tear
B12.
|
| If blood loss ≈ 250 ml, but bleeding has stopped: →Plan to keep the woman in the facility for 24 hours. →Monitor intensively [every 30 minutes] for 4 hours: →BP, pulse →vaginal bleeding →uterus, to make sure it is well contracted. →Assist the woman when she first
walks after resting and recovering. →If not possible to observe at the facility, refer to hospital B17.
|
|
|
|
|
| If disposing placenta: →Use gloves when handling placenta. →Put placenta into a bag and place it into a leak-proof container. →Always carry placenta in a leak-proof container. →Incinerate the placenta or bury it at least 10 m away from a water source, in a 2 m deep pit.
|
RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY
D14. IF FHR 160bpm
ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
IF FETAL HEART RATE [FHR] 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 CORD
|
|
|
|
D21. ASSESS THE MOTHER AFTER DELIVERY
After 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
J2-J8.
ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
Check record: →bleeding more than 250 ml? →completeness of placenta and membranes? →complications during delivery or postpartum? →special treatment needs? →needs tubal ligation or IUD? How are you feeling? Do you have any pains? Do you have any concerns? How is your baby? How
do your breasts feel?
| Measure temperature. Feel the uterus. Is it hard and round? Look for vaginal bleeding Look at perineum. →Is there a tear or cut? →Is it red, swollen or draining pus? Look for conjunctival pallor. Look for palmar pallor.
| Uterus hard. Little bleeding. No perineal problem. No pallor. No fever. Blood pressure normal. Pulse normal.
| MOTHER WELL
| Keep the mother at the facility for 24 hours after delivery. Ensure preventive measures D25 Advise on postpartum care and hygiene D26. Counsel on nutrition
D26. Counsel on birth spacing and family planning D27 Advise on when to seek care and next routine postpartum visit D28. Reassess for discharge
D21 Continue any treatments initiated earlier. If tubal ligation desired, refer to hospital within 7 days of delivery. If IUD desired, refer to appropriate services within 48 hours.
|
Next: Respond to problems immediately postpartum
If no problems, go to page D25.
D22-D24. RESPOND TO PROBLEMS IMMEDIATELY POSTPARTUM
ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
IF VAGINAL BLEEDING
|
|
|
| HEAVY BLEEDING
|
|
|
IF 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 INFECTION
| Insert an IV line and give fluids rapidly B9. Give appropriate IM/IV antibiotics B15. If baby and placenta delivered: →Give
oxytocin 10 IU IM B10. Refer woman urgently to hospital B17. Assess the newborn
J2-J8. Treat if any sign of infection.
|
|
| RISK OF UTERINE AND FETAL INFECTION
| Encourage woman to drink plenty of fluids. Measure temperature every 4 hours. If temperature persists for >12 hours, is very high or rises rapidly, give appropriate antibiotic and refer to hospital B15.
|
|
IF PERINEAL TEAR OR EPISIOTOMY [DONE FOR LIFESAVING CIRCUMSTANCES]
|
|
|
| THIRD DEGREE TEAR
|
|
|
| SMALL PERINEAL TEAR
|
|
|
Next: If elevated diastolic blood pressure
IF ELEVATED DIASTOLIC BLOOD PRESSURE
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-ECLAMPSIA
| Give magnesium sulphate B13. If in early labour or postpartum, refer urgently to hospital B17. If late labour: →continue magnesium sulphate
treatment B13 →monitor blood pressure every hour. →DO NOT give ergometrine after delivery. Refer urgently to hospital after delivery B17.
|
|
| PRE-ECLAMPSIA
| If early labour, refer urgently to hospital E17. If late labour: →monitor blood pressure every hour →DO NOT give ergometrine after delivery. If BP remains elevated after delivery, refer to hospital E17.
|
|
| HYPERTENSION
| Monitor 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 anaemia
ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
IF 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
|
| SEVERE ANAEMIA
| If early labour or postpartum, refer urgently to hospital B17 If late labour: →monitor intensively →minimize blood loss →refer urgently to hospital after delivery
B17.
|
|
| MODERATE ANAEMIA
|
|
|
Haemoglobin >11 g/dl No pallor.
| NO ANAEMIA
|
|
|
IF MOTHER SEVERELY ILL OR SEPARATED FROM THE BABY
|
|
|
|
| Teach mother to express breast milk every 3 hours K5. Help her to express breast milk if necessary. Ensure baby receives mother's milk K8.
Help her to establish or re-establish breastfeeding as soon as possible. See K2-K3.
|
|
IF BABY STILLBORN OR DEAD
|
|
|
|
| Give supportive care: →Inform the parents as soon as possible after the baby's death. →Show the baby to the mother, give the baby to the mother to hold, where culturally appropriate. →Offer the parents and family to be with the dead baby in privacy as long as they need. →Discuss with them the
events before the death and the possible causes of death. Advise the mother on breast care K8. Counsel on appropriate family planning method D27.
|
|
Next: Give preventive measures
D25. GIVE PREVENTIVE MEASURES
Ensure that all are given before discharge.
ASSESS, CHECK RECORDSTREAT AND ADVISE
|
|
|
|
|
|
| Encourage sleeping under insecticide treated bednet F4. Advise on postpartum care D26. Counsel on nutrition
D26. Counsel on birth spacing and family planning D27. Counsel on breastfeeding K2. Counsel on safer sex including use of condoms
G2. Advise on routine and follow-up postpartum visits D28. Advise on danger signs D28. Discuss how to prepare for an emergency in postpartum
D28. Counsel of continued abstinence from tobacco, alcohol and drugs D26.
|
|
|
| If HIV-infected: →Support adherence to ARV G6. →Treat the newborn G9 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 C6, E5, L6.
|
D26. ADVISE ON POSTPARTUM CARE
Advise on postpartum care and hygiene
Advise and explain to the woman:
To always have someone near her for the first 24 hours to respond to any change in her condition.
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 nutrition
Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong [give examples of types of food and how much to eat].
Reassure the mother that she can eat any normal foods – these will not 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 Abuse
Advise 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
Alcohol
Drugs
Dependence
D27. COUNSEL ON BIRTH SPACING AND FAMILY PLANNING
Counsel on the
importance of family planning
If appropriate, ask the woman if she would like her partner or another family member to be included in the counselling session.
Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as 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 G2.
For HIV-infected women, see
G4 for family planning considerations
Her partner can decide to have a vasectomy [male sterilization] at any time.
Method options for the non-breastfeeding woman
Can be used immediately 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 woman
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 Diaphragm
|
Delay 6 monthsCombined oral contraceptives Combined injectables Fertility awareness methods
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D28. ADVISE ON WHEN TO RETURN
Use this chart for advising on postnatal care after delivery in health facility on D21 or E2. For newborn babies see the schedule on
K14. Encourage woman to bring her partner or family member to at least one visit.
Routine postnatal contacts
FIRST CONTACT: within 24 hours after childbirth.
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SECOND CONTACT: on day 3 [48-72 hours]
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THIRD CONTACT: between day 7 and 14 after birth.
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FINAL POSTNATAL CONTACT [CLINIC VISIT]: at 6 weeks after birth
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Follow-up visits for problems
If the problem was:Return in:
Fever
| 2 days
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Lower urinary tract infection
| 2 days
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Perineal infection or pain
| 2 days
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Hypertension
| 1 week
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Urinary incontinence
| 1 week
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Severe anaemia
| 2 weeks
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Postpartum blues
| 2 weeks
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HIV-infected
| 2 weeks
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Moderate anaemia
| 4 weeks
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If treated in hospital for any complication
| According to hospital instructions or according to national guidelines, but no later than in 2 weeks.
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Advise on danger signs
Advise to go to a hospital or health centre immediately, day or night, WITHOUT WAITING, if any of the following signs:
vaginal bleeding:
→more than 2 or 3 pads soaked in 20-30 minutes after delivery OR
→bleeding increases rather than decreases after delivery.
convulsions.
fast or
difficult breathing.
fever and too weak to get out of bed.
severe abdominal pain.
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:
fever
abdominal pain
feels ill
breasts swollen, red or tender breasts, or sore nipple
urine dribbling or pain on micturition
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pain in the perineum or draining pus
foul-smelling lochia
severe depression or suicidal behaviour [ideas or attempts]
Discuss how to prepare for an emergency in postpartum
Advise to always have someone near for at least 24 hours after delivery to respond to any change in condition.
Discuss with woman and her partner and family about emergency issues:
→where to go
if danger signs
→how to reach the hospital
→costs involved
→family and community support.
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-I3.
Advise the woman to bring her home-based maternal record to the health centre, even for an emergency visit.
D29. HOME DELIVERY BY SKILLED ATTENDANT
Use these instructions if you are attending
delivery at home.
Preparation for home delivery
Check emergency arrangements.
Keep emergency transport arrangements up-to-date.
Carry with you all essential drugs B17, records, and the delivery kit.
Ensure that the family prepares, as on
C18.
Delivery care
Follow the labour and delivery procedures D2-D28
K11.
Observe universal precautions A4.
Give Supportive care. Involve the companion in care and support D6-D7.
Maintain the
partograph and labour record N4-N6.
Provide newborn care J2-J8.
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 B17 K14.
Immediate
postpartum care of mother
Stay with the woman for first two hours after delivery of placenta C2 C13-C14.
Examine the mother before leaving her
D21.
Advise on postpartum care, nutrition and family planning D26-D27.
Ensure that someone will stay with the mother for the first 24 hours.
Postnatal care of newborn
Stay until baby has had the first breastfeed and help the mother good positioning and attachment K3.
Advise on breastfeeding and breast care
K2-K4.
Examine the baby before leaving J2-J8.
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Immunize the baby if possible K13.
Advise the family about danger signs and when and where to seek care K14.
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 K14.
For both
Where is the fundus located 3 days postpartum?
The fundus is usually midway between the umbilicus and symphysis 1 to 2 hours after delivery, 1 cm above or at the level of the umbilicus 12 hours after delivery, and about 3 cm below the umbilicus by the third day after delivery.
Where should the fundus be 1 day after birth?
Immediately after delivery, the upper portion of the uterus, known as the fundus, is midline and palpable halfway between the symphysis pubis and the umbilicus.
What level the Fundus of uterus on the 1 day after labor is found at?
Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus.
Where should the fundus be 4 days postpartum?
Therefore, 24 hours after birth the fundus should 1 cm [or one finger breadth] BELOW the belly button…… 48 hours it should be 2 cm below the belly button. At 7 days the fundus should be at the symphysis pubis. At 10-14 days the fundus should be back in the pelvic cavity and can't be palpated.