Reference Manual Final PDF

HEALTH
PROGRAMMING
FOR
INTEGRATED
MATERNAL
AND
REBUILDING
STATES
NEWBORN CARE
A BASIC
BRIEFING
PAPERCOURSE
SKILLS
2009
REFERENCE MANUAL
INTEGRATED MATERNAL AND

NEWBORN CARE
BASIC SKILLS COURSE
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
U.S. Agency for International Development

Bureau for Global Health
Office of Health, Infectious
Diseases and Nutrition
Ronald Reagan Building
1300 Pennsylvania Ave., NW
Washington, D.C. 20523
Tel: (202) 712-0000
Email: globalhealth@phnip.com
www.usaid.gov/our_work/global_health
Deborah Armbruster, Project Director

-orSusheela M. Engelbrecht, Sr. Program Officer
POPPHI
PATH
1800 K St., NW, Suite 800
Washington, DC 20006
Tel: (202) 822.0033
www.pphprevention.org
Indira Narayanan, Sr. Technical Advisor,

Newborn Health
-orGladys Mazia, Technical Officer,
Newborn Health
USAID/BASICS
4245 N. Fairfax Dr., Suite 850
Arlington, VA 22203
Tel: (703) 312-6800
Fax: (703) 312-6900
Email: basics@basics.org
www.basics.org
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).
Integrated maternal and newborn care

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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
Community Level Tools:
iv
Guide for Training Community Health Workers/Volunteers to Provide Maternal and Newborn
Health Messages
Set of Counseling Cards

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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
Jean Pierre Rakotovao

Team Leader
USAID/BASICS, Madagascar
Marie Claude Mbuyi

Coordinator, Reproductive Health
USAID/AXxes, 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

Basic skills course
Editing and Formatting
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

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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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CHAPTER 9: BASIC SYSTEMATIC EXAMINATION OF A NEWBORN AT PERIPHERAL

CENTERS. . 109
Preparing for the Examination.................................................................................................109
Carrying out the Exam ............................................................................................................110
CHAPTER 10: POSTNATAL CARE OF THE NEWBORN, AT THE FACILITY AND DURING
POSTNATAL VISITS .. 116
Timing of Most Neonatal Deaths .............................................................................................116
Components of Postnatal Care ...............................................................................................116
CHAPTER 11: DIAGNOSING AND TREATING BREASTFEEDING PROBLEMS................ 126
Common problems..................................................................................................................126
Prevention and Treatment.......................................................................................................126
Expressing and Feeding Breast Milk .......................................................................................132
CHAPTER 12: CARE OF THE LOW BIRTH WEIGHT BABY, INCLUDING KANGAROO
MOTHER CARE ............................................................................................................... ..137
Factors Associated with Low Birth Weight...............................................................................137
Preventing Low Birth Weight ...................................................................................................137
Care of Low Birth Weight Babies ............................................................................................141
Discharge of the Low Birth Weight Baby .................................................................................147
CHAPTER 13: TREATMENT OF INFECTIONS IN THE NEWBORN .................................... 149
The Timing of Infections..........................................................................................................149
Types of Neonatal Infection.....................................................................................................150
Identifying and Treating Major Infections.................................................................................151
Identifying and Treating Minor Infections.................................................................................154
APPENDIX A: Selection and Storage of Uterotonic Drugs.................................................158
APPENDIX B: Alternative Assessment/Physical Examination of the Newborn at More
Established Peripheral Centers ...........................................................................................163
APPENDIX C: Glossary.........................................................................................................168
REFERENCES .......................................................................................................................171
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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
Where do newborns die?

What do newborns die of?
When do newborns die?
Hand washing
Hand rubbing
Putting gloves on
Taking gloves off
One-hand technique for needle recapping
Sharps containers
0.5% chlorine solution
Clinical decision making algorithm
Signs of iron-deficiency anemia
Positions that a woman may adopt during labor
The modified WHO partograph
Positions that a woman may adopt during childbirth
Initial steps in the care of the baby at birth
Two measures to prevent thermal loss at the time of birth
Use of a pre-sterilized disposable cord clamp
Signs of proper attachment at the breast
Preparing oxytocin injection
Put the baby on the mothers abdomen
Rule out the presence of a second baby
Give a uterotonic drug
Pulsating and nonpulsating umbilical cord
Keep the baby in skin-to-skin contact
Clamping the umbilical cord near the perineum
Palpate the next contraction
Applying CCT with countertraction to support the uterus
Supporting the placenta with both hands
Delivering the placenta with a turning and up-and-down motion
Massaging the uterus immediately after the placenta delivers
Teach the woman how to massage her own uterus
Examining the maternal side of the placenta
Checking the membranes
Gently inspect the lower vagina and perineum for lacerations
Encourage breastfeeding within the first hour after birth
Routine postpartum physical, obstetrical, and gynecological exam
A warming table
De Lee mucous aspirator
Self-inflating bag and mask for ventilation of babies
Sample list of equipment for newborn resuscitation
Correct positioning
Methods for stimulating the baby
Correct positioning of the mask and formation of a good seal
Giving supplemental oxygen
Algorithm for resuscitation for birth asphyxia
Algorithm for integration of AMTSL, ENC and resuscitation for birth
asphyxia

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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
List of Figures (cont.)

11.1
11.2
11.3
11.4
11.5
12.1
12.2
12.3
12.4
12.5
12.6
12.7
12.8
Appendix C.1
Two positions for breastfeeding

Preparing and using a syringe for treatment of inverted nipples
Anatomy of the breast
How to express breast milk
Three methods of feeding
Basic evaluation of LBW babies to determine need for referral
The kangaroo with the baby in the pouch
Kangaroo mother care
How to dress the baby for kangaroo care
Photo example of kangaroo mother care
The mother, father, or another family member may keep the baby on the
chest
Key components of care of the LBW infant
Algorithm for care of the LBW baby
Newborn periods
p. 127
p. 132
p. 133
p. 134
p. 135
p. 140
p. 142
p. 143
p. 144
p. 144
p. 146
Mixing a 0.5% chlorine decontamination solution

Steps in the problem-solving method
Timing of SP dose
Schedule for giving tetanus toxoid
Key steps for immediate care of the newborn
Comparison of physiologic and active management of the third stage of
labor
Bristol and Hinchingbrooke study results comparing active and
physiologic management of the third stage of labor
Monitoring of the baby in the first six hours after birth
Schedule for routine postpartum visits
Guidelines for identifying danger signs at peripheral centers
Key steps in examining the newborn at a peripheral center
Suggested timings of postnatal visits
Care of the newborn during the 4-6 weeks after birth
Summary of Postnatal Evaluation and Care of the Baby
Complications in low birth weight and preterm babies
Practical guidelines for identifying and treating major infections at
peripheral centers
Summary of treatment of minor infections
Uterotonic drugs for AMTSL
Change in effectiveness of injectable uterotonic drugs after one year of
controlled storage
Recommended guidelines for transport and storage of uterotonic drugs
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

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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
About the Learning Materials

This learning package for integrated maternal and newborn care consists of a reference
manual, a series of technical presentations, a participants notebook, a facilitators guide, and a
clinical logbook. This learning package was developed for use by nurses, midwives, and doctors
providing childbirth and immediate postpartum care for the woman and newborn in peripheral
health care facilities.
These documents comprise a set and should be used together.
Facility Level Tools
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.
Community Level Tools
Guide for Training Community Health Workers/Volunteers to Provide Maternal and

Newborn Health Messages.
A set of counseling cards

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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
Guide for Training Community Health

Workers/Volunteers to Provide Maternal and
Newborn Health Messages
xii

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List of Abbreviations
AFASS
acceptable, feasible, affordable, sustainable, and safe
AMTSL
ANC
ARV
active management of the third stage of labor

antenatal care
antiretroviral
BP
blood pressure
CCT
CHW
controlled cord traction

community health worker
CMV
cytomegalovirus
CPT
cotrimoxazole prophylaxis therapy
DIC
EBM
disseminated intravascular coagulopathy

expressed breast milk
ENC
essential newborn care
FH
fundal height
FP
FIGO
family planning
International Federation of Gynecology and Obstetrics
Hb
hemoglobin
HLD
high-level disinfection
HIV
ICM
human immunodeficiency virus

International Confederation of Midwives
IM
intramuscular
IMCI
integrated management of childhood illnesses
IPTp
IPTI
intermittent preventive treatment in pregnancy

intermittent preventive treatment in infants
ITN
Insecticide-treated bednets
IU
international unit
IUD
intrauterine device
IUGR
intrauterine growth retardation
IV
intravenous
LAM
lactational amenorrhea method (for family planning)
LBW
MNH
low birth weight

maternal neonatal health
MTCT
mother-to-child transmission of HIV/AIDS
PMTCT
POPPHI
prevention of mother-to-child transmission of HIV/AIDS

postpartum hemorrhage prevention initiative
PPC
postpartum care

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PPH
postpartum hemorrhage
PPPH
prevention of postpartum hemorrhage
PROM
premature rupture of membranes
RAM
rapid assessment and management
RPR
STI
Reactive Plasma Reagin

sulfadoxine-pyrimethamine
sexually transmitted infections
TSL
third stage of labor
TT
tetanus toxoid
USAID
United States Agency for International Development
UTI
urinary tract infection
VDRL
Venereal Disease Research Laboratory
VVM
vaccine vial monitor
WHO
World Health Organization
SP
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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.
FOUR MILLION NEONATAL DEATHS: WHERE DO THEY OCCUR?
4 Million Deaths:
Where do newborn babies die?
1.1 million (28% of all

newborn deaths)
occur in Sub Saharan
Africa
Lancet series, 2005
1.5 million (38% of all

newborn deaths)
occur in 4 countries
of South Asia
99% of newborn deaths are in low/middle income countries

4
66% in Sub Saharan Africa and South Asia
Figure Intro. 1. Where do newborns die?

Reprinted with permission from Elsevier (The Lancet, 2005, Vol 365, pg. 13)

Basic skills course
FOUR MILLION NEONATAL DEATHS: WHAT DO BABIES DIE OF?

The major causes of death in the neonatal period are shown in Figure Intro. 2 and include
infections, birth asphyxia, and prematurity.
Causes of Neonatal Mortality

Others 9%
Congenital malformations
7%
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
Figure Intro. 2. What do newborns die of?
Among premature newborns, many die of complications of prematurity rather than of

prematurity itself. In low-resource developing countries, infections are the most common
complication and cause of death. Preventing infections, therefore, is a key strategy to reducing
neonatal mortality in these countries.
FOUR MILLION NEONATAL DEATHS: WHEN DO THEY OCCUR?

As short as the neonatal period is, covering only the first four weeks of life, it is the most critical;
indeed, 75 percent of all neonatal deaths take place in the first week and 50 percent within 24
hours after birth. The postpartum/postnatal period, especially the early phase, is also the most
neglected part of the pregnancy, delivery, and postpartum continuum of care. In short,
newborns are least likely to receive care during the period when they are at the greatest risk of
dying.

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4 Million Newborn Deaths:

When do newborn babies die?
Up to 50%
of neonatal
deaths are in
the first 24 hours
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
Figure Intro. 3. When do newborns die?

Adapted with permission from Elsevier (The Lancet, 2005, Vol 365, pg. 13)
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.

Basic skills course
CHAPTER 1: Preventing Infection1

PRINCIPLES OF INFECTION PREVENTION
Infection prevention practices are based on the following five principles/actions:
Every person (client or staff) is considered potentially infectious.
Hand washing is the single most important practice for preventing crosscontamination.
Wear gloves before touching:
o
o
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:
Immediately when you arrive at work.

Before examining each client (mother or baby).
After examining each client (mother or baby).
Before putting on gloves for clinical procedures (such as a pelvic exam or an IUD
insertion).
After touching any instrument or object that might be contaminated with blood or other
body fluids, or after touching mucous membranes.
After removing any kind of gloves (hands can become contaminated if gloves contain
tiny holes or tears).
After using the toilet or latrine.
Before leaving work.
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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Materials required for hand washing include:
clean running water

liquid soap (preferably in a receptacle fixed to the wall) or small pieces of soap, ideally
used only once. Where feasible, liquid antiseptic soap would be better for places such as
the delivery room and operation theater.
sink or bowls
veronica bucket (bucket with a tap)
individual towels
The steps in hand washing are:

1.
2.
3.
4.
5.
6.
7.
8.
Remove watches, bracelets, and rings.

Nails should be short and without nail polish; artificial nails should not be worn.
Wet hands with running water.
Rub hands together with soap and lather well up to the elbows, covering all surfaces for
15-30 seconds. When attending deliveries, carrying out procedures, and where the
hands are visibly soiled, wash longer, for about two minutes.
Weave fingers and thumbs together and slide them back and forth, taking care to rub
well between the fingers and the back of the hand.
Rinse hands under a stream of clean, running water until all soap is gone.
If there is no running water, hands should not be dipped inside the bowl of water;
instead, the water should be poured over the hands from another container.
Blot hands dry with a clean, dry towel or air-dry them; air-drying is the best, especially
when sterile gloves have to be worn.
These steps are illustrated in Figure 1.1.

Basic skills course
Figure 1.1. Hand washing.

(WHO Guidelines on Hand Hygiene, 2006).
6

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The Hand Rub

When hand washing is not possible, use of the hand rub is recommended. But so long as
running water is available, the hand rub should not be used as a substitute for attending
deliveries or when the hands are visibly soiled. The materials required are alcohol and a
glycerine solution. The steps in hand rubbing are:
1.
2.
3.
4.
Add 2 mL of glycerine, propylene glycol, or sorbitol to 100 mL of 60-90% alcohol.

Pour about 1 teaspoon of the rub in the palm of the hand.
Rub hands together, including in between the fingers and under the nails, until dry.
Wash hands with soap and water after using the hand rub 5 times.
The technique using the alcohol-based formulation is shown in Figure 1.2.

Basic skills course
Figure 1.2. Use of alcohol-based rub for hand hygiene.

(WHO Guidelines on Hand Hygiene, 2006.)

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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)
Wear gloves when:
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:
decontaminated by soaking in 0.5% chlorine for 10 minutes.

washed and rinsed.
sterilized by autoclaving or high-level disinfected by boiling or steaming.
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.

Basic skills course
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.
Figure 1.3. Putting gloves on. (EngenderHealth, online course:

http://www.engenderhealth.org/ip/surgical/sum4.html)
Step 7. Adjust the glove fingers until the glove fits comfortably.
Taking gloves off
Figure 1.4. Taking gloves off. (EngenderHealth, online course:

http://www.engenderhealth.org/ip/surgical/sum4.htm)
Additional Protective Clothing

Other kinds of protective clothing are listed and discussed below:
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)
No additional precautions (e.g., pre-rinsing, labelling, separating, or double bagging) are

necessary, regardless of the patient diagnosis, if standard precautions are used in all situations.
The guidelines for treating soiled linen are as follows:
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.

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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.
Handling Sharp Instruments

Careful handling of sharps protects the client, health worker, and housekeeping staff from
accidental injuries and exposure to blood and body fluids. Guidelines:
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.
Needles and syringes

Follow these guidelines to ensure safe handling of needles and
syringes:
Use each needle and syringe only once.
Do not take the needle and syringe apart after use.
Do not recap, bend, or break needles before disposal.
Dispose of needles and syringes in a puncture-proof
container.
It is not recommended to recap needles. Where it is
unavoidable, as in a situation where the needle cannot be
placed in an appropriate, safe receptacle for sharps, then
recap the needle, using the one-hand technique for recapping
(Figure 1.5).
Step 1: Place the cap on a hard, flat surface.
Step 2: Hold the syringe with one hand and use the needle to
scoop up the cap.
Step 3: When the cap covers the needle completely, hold the
base of the needle and use the other hand to make sure the cap
is firmly in place.
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Figure 1.5. One-hand technique for

needle recapping. (WHO and
CDC, 2007)

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Dispose of hypodermic needles and other sharps properly in a puncture-proof (heavy

cardboard, glass, metal, or thick plastic) container (sharps container shown below).
Figure 1.6. Sharps containers
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.
The Steps of Processing Instruments

Proper processing involves several steps that reduce the risk of transmitting infections from
used instruments and other items to health care workers and clients. These steps are:
1) decontamination, 2) cleaning, 3) either sterilization or high-level disinfection (HLD), and
4) storage. For proper processing, it is essential to perform the steps in the correct order.
1. Decontamination kills viruses (hepatitis B and C, HCV, HIV) and many other germs. It
makes items safer to handle during cleaning and easier to clean (hence, decontamination
should always be done before cleaning).

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The materials needed for decontamination are:
clean water
chlorine solution/chlorine tablets/chlorine powder
buckets with covers
measuring cups
a clock or timer
The four steps of decontamination are:

1) Fully immerse instruments and reusable gloves in 0.5% chlorine solution after use.
(Details of preparation of this solution are noted below.)
2) Soak for 10 minutes and rinse immediately.
3) Change the solution every day or earlier if it is dirty or cloudy.
4) Wipe surfaces (exam tables) and spills with chlorine solution.
2. Cleaning removes blood, other body fluids, tissue, and dirt. It also reduces the number of
germs and makes sterilization or HLD more effective. If a blood clot remains on an instrument,
germs in the clot may not be completely killed by sterilization or HLD.
The materials needed for cleaning are:
detergent
buckets or basins
water
toothbrush/brush
utility gloves
The steps of cleaning are:

1) Wear utility gloves, a mask, and protective eyewear when cleaning instruments and other
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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The materials needed for HLD include:
a pot with a lid

a clock or timer
a steamer used for HLD
disinfectant
boiled water
Three methods of high-level disinfection are described below:

Boiling:
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:
Sterilants used include 2.65% glutaraldehyde and hypochlorite/chlorine preparations

noted below in this chapter.
Cover all items completely with disinfectant.
Soak for 20 minutes.
Rinse with boiled water.
Air-dry before use and storage.
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.

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Steam sterilization (autoclave):
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:
Soak items in glutaraldehyde for 8 to10 hours or formaldehyde for 24 hours.

Rinse with sterile water.
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:
liquid household bleach (sodium hypochlorite)

bleach powder or chlorine compounds available in powder form (calcium hypochlorite or
chlorinated lime)
chlorine-releasing tablets (sodium dichloroisocyanurate)
Chlorine-containing compounds contain a certain percentage of "active" (or available) chlorine.

Active chlorine in these products kills microorganisms. The amount of active chlorine is usually
stated as a percentage and differs among products, an important fact to ensure preparation of a
chlorine solution with 0.5% "active" chlorine that can be used to decontaminate gloves and
instruments.
With regard to chlorine products, note the following:
Different products may contain different concentrations of available chlorine, and the
concentration should be checked before use.
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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When preparing chlorine solutions for use note that:
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.
Calculating the water-to-liquid-household-bleach ratio to make a 0.5% chlorine solution

Chlorine content in liquid bleach is available in different concentrations. You can use any
concentration to make a 0.5% chlorine solution by using the following formula:
[% chlorine in liquid bleach divided by 0.5%] minus 1 = parts of water for each
part bleach
Note: "Parts" can be used for any unit of measure (e.g., ounce,
liter, or gallon) and do not have to represent a defined unit of
measure (e.g., a pitcher or container).
For example: To make a 0.5% chlorine solution from a 3.5% chlorine concentrate, use one part
chlorine and six parts water:
+
[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

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Calculating the water-to-bleach-powder ratio to make a 0.5% chlorine solution

When using bleach powder to make a decontamination solution, calculate the ratio of bleach to
water using the following formula:
[% chlorine desired divided by % chlorine in bleach powder] times 1,000 = grams
of powder for each liter of water.
Note: When bleach powder is used, the chlorine solution will likely
appear cloudy or milky.
For example: To make a 0.5% chlorine solution from calcium hypochlorite powder containing
35% available chlorine, use the following formula:
[0.5% divided by 35%] times 1,000 = [0.0143] times 1,000 = 14.3
Therefore, dissolve 14.3 grams of calcium hypochlorite powder in one liter of water in order to
get a 0.5% chlorine solution.
Calculating the water-to-chlorine-releasing-tablet ratio to make a 0.5% chlorine solution
Follow the manufacturer's instructions when using chlorine-releasing tablets because the
percentage of active chlorine in these products varies. If instructions are not available with the
tablets, ask for the product instruction sheet or contact the manufacturer. Table 1 provides
details on how to mix a decontamination solution with chlorine.
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Table 1. Mixing A 0.5% Chlorine Decontamination Solution
Liquid bleach (sodium hypochlorite solution)

Type or brand (by country)
% 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%
JIK (Kenya, Zambia), Robin Bleach

(Nepal)
3.5%
12 Chlorum
3.6%
Household Bleach (Indonesia, USA),

ACE (Turkey), Eau de Javel (France)
15 Chlorum, Lejia (Peru),
Blanquedor, Cloro (Mexico)
5%
6%
Lavandina (Bolivia)
8%
Chloros (United Kingdom)
10%
Chloros (United Kingdom), Extrait de

Javel (France), 48 Chlorum
15%
Dry powders
% or grams
active chlorine
Water-to-chlorine =
0.5% solution
Calcium hypochlorite
70%
7.1 grams per liter
Calcium hypochlorite
35%
14.2 grams per liter
Sodium dichloroisocyanurate (NaDCC)
60%
8.3 grams per liter
Tablets
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.

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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:
Separate waste containers for medical and nonmedical waste

Sharps containers
An interim storage area
An incinerator, an on-site burial pit
Protective gear, including utility gloves
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:
Wearing heavy-duty gloves.

Transporting solid contaminated waste to the disposal site in covered containers
Disposing of all sharp items in puncture-resistant containers
Carefully pouring liquid waste down a drain or flushable toilet
Burning or burying contaminated solid waste
Washing hands, gloves, and containers after disposal of infectious waste
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
20
Add detergent until the solution is slightly foamy.

Use for cleaning contaminated areas (examination and delivery rooms, operation
theaters, floors, sinks, toilets/latrines, waste containers, beds, mattresses, etc.).
Do not mix chlorine solution with cleaning solutions such as ammonia or phosphoric
acid.

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Recommended cleaning procedures are as follows:
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
Always wear gloves.

If the spill is small, wipe it with a cloth that has been saturated with a disinfectant
(0.5% chlorine) solution.
If the spill is large, cover (flood) the area with a disinfectant (0.5% chlorine) solution,
mop up the solution, and then clean the area with a disinfectant cleaning solution.
CLEAN DELIVERY CARE

Related to clean delivery practices, some promote the concept of the three "cleans"clean
hands, clean surface, and clean cord careor the five "cleans": clean hands, clean surface,
clean instrument for cutting the cord, clean ligatures for tying the cord, and then keeping the
cord clean and dry. There is also the seven cleans: the five cleans plus clean perineum and
keeping the vagina clean without introducing anything unclean inside it.
The main supplies needed for the cleans include:
A waterproof plastic cover (to provide a clean surface)

Soap
An unused razor blade kept in its cover for cutting the cord
Clean cord ties (both the razor blade and the cord ties should preferably be boiled for at
least 10 minutes before use)
Clean, washed, and sun-dried towels kept in a clean container for drying and wrapping
the baby
A clean perineum
A clean vagina without introducing anything unclean inside

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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.
EQUIPMENT AND SUPPLIES RELATED TO RESUSCITATION

Equipment must be cleaned and disinfected after each use, and consumable supplies must be
replaced. Manufacturers provide specific information on how to clean and disinfect/sterilize
various pieces of equipment. Their guidelines should be carefully observed; failure to respect
the guidelines may result in severe and/or lethal neonatal infection.
Resuscitator Bag and Mask2
The mask and the patient valve should both be disinfected after each use since they are
exposed to the newborn and to expiratory gases. The bag and the inlet valve should be
disinfected after use with an infected newborn, and otherwise occasionally.
The valve and the mask must first be disassembled, inspected for cracks and tears, washed
with water and detergent, and rinsed. Selection of the decontamination method will depend on
the material. Silicone and rubber bags and patient valves can be boiled for 10 minutes,
autoclaved at 136 C, or disinfected by soaking in a disinfectant. Dilution of disinfectant and
exposure time should be in accordance with the instructions of the manufacturer. All parts must
be rinsed with clean water after chemical disinfection and air-dried before assembling.
After re-assembling, the bag must be tested to check that it works correctly. Most manufacturers
give step-by-step instructions for this procedure. If instructions are not available, use the
following test: Block the valve outlet by making an airtight seal with the palm of the hand;
squeeze the bag and feel the pressure against the hand; observe if the bag re-inflates when the
seal is released; if the bag is not functioning correctly, it should be repaired before use. Repeat
the test with the mask attached to the bag.
The steps noted above relate to ideal conditions. Frequently, there is only one bag with no
possibility of fixing or replacing it in case of damage. Many health workers have difficulty in
reassembling the parts. If this is the case, it might be more feasible to clean the different parts
with a damp cloth. The mask can be easily separated and cleaned with at least soap and water,
dried, and fixed back on the front outlet of the bag.
Aspiration Catheters and Suction Devices
Disposable catheters and suction devices must be discarded; they are not recommended for reuse even after thorough cleaning. If these devices are not available on site, mothers should be
asked to bring a suction bulb when they come for the delivery since a new bulb can be washed,
sterilized, and used for the baby if required, and then discarded.
The text under this heading is reproduced from the WHO/Safe Motherhood Basic Neonatal
Resuscitation A Practical Guide.
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CHAPTER 2: Clinical Decision-Making

THE PROBLEM-SOLVING METHOD
Clinical decision-making is the systematic process by which skilled providers make judgments
regarding a patient's condition, diagnosis, and treatment. Skilled providers possess the skills
and knowledge to perform procedures correctly. It is not enough to just perform procedures
correctly, however. You must also choose the correct procedure to meet the woman or infants
needs. In addition, you must be able to choose the right time to use a particular clinical skill. The
problem-solving method guides you in giving care that is safe and effective, provides an
organized way to approach and manage care, and uses skills and processes that are common
in everyday life.
Why Is It Important to Use the Problem-Solving Method?
Using a methodical approach to solve problems has three advantages:
It helps you gather information in an organized manner.

It helps you gather complete information so that a problem can be correctly identified.
It helps you avoid using interventions that are not needed.
Steps in Resolving a Problem

The key steps in problem-solving are noted in Table 2.
Table 2. Steps in the Problem-Solving Method

Step 1: History
Take a targeted history.
Step 2: Physical examination
Perform a targeted physical examination.
Step 3: Identification of
problems/needs
Identify needs and problems.
Step 4: Care plan
Step 5: Follow-up
Make a plan of care based on identified needs and

problems.
Follow up with the client to evaluate the care that has
been provided.
This step repeats all the steps of the problem-solving
method, starting with step 1.
Step 1: Take a targeted history

In this step providers will ask specific questions (what, how, where, when, who, why) about a
problem to help make a diagnosis or determine the cause of the problem. Ask the client why
she has come. The reason for seeking care is called the chief complaint. The provider asks
the client about the problem (signs, symptoms, etc.) or stated need (vaccination, antenatal care

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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.
The following skills are important for taking a complete history:
Make sure the woman feels welcome.

Help the woman feel comfortable with your actions.
Provide a private area to talk and assure the woman of confidentiality.
Encourage the woman to talk and ask questions.
Ask questions in a kind and interested way.
Listen carefully to all the answers.
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:
A routine physical examination: Sometimes you will need to do a general or full

examination of the body. In the case of a woman registering (booking) for antenatal care,
you will need to know about the condition of her entire body. A general examination of
the body may also help you to find problems that the woman herself has not recognized.
This also applies to a baby who may be just brought in for a routine service such as
immunization.
A targeted physical examination: This type of physical examination is performed when a
client comes in or a baby is brought in with a problem. You will tailor the physical
examination around the complaint that the client has and will get information that will
help you identify problems or make a diagnosis.
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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Step 3: Identify needs and problems

This is the third step of the problem-solving method. Using the information from steps 1 and 2,
the provider will identify problems the client is experiencing. Identification of needs or problems
is done by thinking about findings, what the client has said (history), and what was found in the
physical examination. The provider will compare the findings with what is known about normal
findings to determine if the condition is normal or if there is a problem.
If the findings are all normal, the provider will proceed to identify the clients needs. These are
the things the client needs to remain healthy, such as immunizations, birth preparedness in the
antenatal period, or counseling on nutrition and basic care of the woman and her baby.
If the findings indicate there is a problem, the provider will compare the abnormal findings with
what she/he remembers or finds in references about complications. If the findings match those
for a complication, the provider will determine the diagnosis. Sometimes, it is difficult to
determine an exact diagnosis. In this case, either eliminate some diagnoses and use a
differential diagnosis or describe the problem and refer the woman/baby for further evaluation
and care.
It is important that all the clients problems and needs are treated, not just the problem that
caused her to come to you. A pregnant woman may need information on family planning
methods, good nutrition during pregnancy, how to relieve hemorrhoid pain, and where to go for
immunizations for her small childrenall in one visit. She may have come with only one
complaint, problem, or question. Make certain that you write all the problems or needs on her
record/antenatal form.
Step 4: Make a plan of care
This is the fourth step of the problem-solving method. The provider will decide what should be
done to solve each problem or meet each need. Ideally, the provider will develop the care plan
with the client, the clients mother, or the clients family members.
The following actions should be considered for each problem or need, and the provider must
decide which to do first, second, and so on. Sometimes medical treatment will be needed first.
For example, when a woman has a retained placenta and is bleeding heavily, you must stop the
bleeding by manually removing the placenta before laboratory tests can be done. You may then
give her more treatment, education or counseling, or refer her. Or, when a woman who is six
months pregnant comes to you and is feeling very tired, you will test her hemoglobin (Hb) before
giving her treatment, education and counseling, or referring her.
A baby brought with a danger sign needs referral to an appropriate center after giving the first
dose of antibiotics, whereas a newborn infant with a minor infection may be managed locally
along with routine basic care, such as giving immunizations.
Here are some appropriate actions a provider might write in the plan of care developed for the
client:
Medical treatment. Choose the correct medication, procedure, or treatment by following

the clinical protocols.
Education. Help the woman learn to care for herself well. Always teach women the
danger signs they should be aware of in themselves and their babies and where to go if
any of these signs or symptoms appear.
Counseling. Help the client understand the problem or needs. Work with her to develop
a way to treat the problem or meet the needs.

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Laboratory tests or other investigations. These include laboratory tests, ultrasound or

x-ray examination as required and as feasible. Follow the clinical protocol guidelines for
the appropriate use of these methods to obtain more information about the problem.
Referrals. Use other resources in the area, such as doctors, hospitals, education
programs, womens groups, or charity groups to help the woman meet her needs.
Plan for follow-up. After you take appropriate action, you will see the woman/baby again
and repeat the process.
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:
26
all symptoms, based on what the woman tells you

findings from the physical examination and laboratory information
problems and needs identified

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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.

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Clinical Decision-Making
Receive the client and

respond immediately.
Perform a quick check on

each patient to evaluate for
danger signs.
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.
Evaluate the plan of

care (begin the steps
all over again).
Make a plan of care.
Implement the plan of

care.
Figure 2.1. Clinical decision making algorithm
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CHAPTER 3: Maternal Care to Improve

Maternal and Newborn Survival
The fetus growth and development depend on the health of the mother. The mothers body
provides nutrition, rest, oxygen, and protection to the fetus. A healthy woman, who receives
good antenatal care, has a much greater chance of giving birth to a healthy, term baby and of
surviving pregnancy and childbirth.
The goals of antenatal care are as follows:
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.
EVERY PREGNANCY IS AT RISK

In the past, health services used a risk system to identify high risk pregnancies so that these
women could be referred to specialized care centers. A risk factor is anything that increases a
person's chances of developing a disease or a complication. Risk factors may be associated
with but do not necessarily cause a particular disease or complication. In addition, persons
without the risk factor can also develop the disease or complication.
More than 10 years of experience with the risk factor approach have shown us that it has many
limitations, including:
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.
What can be done, then? The literature strongly suggests that:
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.

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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.
MATERNAL CONDITIONS AFFECTING FETAL AND NEWBORN SURVIVAL

This section will discuss maternal conditions, pregnancy-related complications, and maternal
infections that have an impact on fetal and newborn health and survival.
Iron-deficiency Anemia
An anemic pregnant woman has a high risk of getting
ill (because of lowered resistance to infection), of
having a low birth weight (LBW) infant with a birth
weight of less than 2500 grams, of giving birth
prematurely before 37 completed weeks of gestation,
of suffering from postpartum hemorrhage and heart
failure, and of dying. Many women are already anemic
when they become pregnant; closely spaced
pregnancies, malaria, hookworm, sickle cell anemia,
and frequent and chronic infections are some of the
causes of anemia.
Figure 3.1. Signs of iron-deficiency anemia
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.

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Preeclampsia and Eclampsia

Women who develop preeclampsia during pregnancy are all at increased risk of complications
in the antenatal period, during labor and childbirth, and in the postpartum period. The
increased risk applies to the mother as well to the fetus. In cases of severe preeclampsia,
delivery should occur within 24 hours of the onset of symptoms. In cases of eclampsia,
delivery should occur within 12 hours of the onset of convulsions. Delivery should take place
as soon as the womans condition has stabilized, regardless of gestational age. Delaying
delivery to increase fetal maturity will risk the lives of both the woman and the fetus and may
result in the birth of a pre-term baby.
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:
Perform a systematic examination including a rapid assessment to recognize danger

signs and features of advanced labor and respond immediately and appropriately.
Detect pregnancy-related complications, fetal complications, medical conditions, and
infections.
Take a detailed history to identify abnormalities and problems/potential problems that
may affect the pregnancy: social problems, medical problems, history of obstetrical
complications with previous pregnancies or births, and reported symptoms/problems.
Perform a physical, obstetrical, and gynecological exam.
Perform the following laboratory tests to evaluate the womans health and her pregnancy
and screen for selected medical conditions and infections. Where essential tests are not
feasible at the peripheral center, the woman must be referred to an appropriate facility.
o Hemoglobin levels (first visit/as needed).
o RPR (Reactive Plasma Reagin) or VDRL (Venereal Disease Research Laboratory) at
first visit or as needed: The test should be repeated in the 3rd trimester if the woman
or her partner engages in risky sexual behavior.
o HIV (first visit/repeat in 3rd trimester/as needed): If the woman volunteers for testing
or if the testing is initiated by the health care provider, a test should be conducted as
early as possible during the pregnancy. A positive HIV status affects many aspects of
ANC. Therefore, steps should be taken to prevent transmission of the virus to the
baby and for appropriate treatment of the mother.
o Urine for glucose: This test is used to screen for diabetes, which is a condition
beyond the scope of basic care. Although many women with normal glucosetolerance tests spill sugar in their urine without any associated problems for mother
or child, this test can help identify women who actually do have high blood glucose
levels.
o Urine for protein: This test is used to screen for preeclampsia, which is a condition
beyond the scope of basic care. Although proteinuria is most commonly associated
with preeclampsia or eclampsia, a woman's urine can test positive for protein if she is
severely anemic, has kidney disease, or has a urinary tract infection, or if the urine

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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.
Health Promotion and Disease Prevention

Certain medications or simple health care measures can prevent or reduce the risk of suffering
from specific health problems. The following measures should be explained and offered to all
pregnant women.
Preventing malaria
Intermittent preventive treatment (IPTp)

of malaria with sulfadoxine-pyrimethamine
(SP) 500 mg + 25 mg. Do not give SP
during the first trimester of pregnancy or
during the 9th month of pregnancy.
Table 3. Timing of SP dose

SP Dose
1st dose
Provide SP to all pregnant women: give 2

doses to women who are not infected with
2nd dose
HIV; check national protocols for dose
recommendations for women infected with
HIV (if the woman is on cotrimoxazole
prophylaxis, use another anti-malarial drug for IPTp).
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Timing
From 18 weeks (after
quickening). Not before 16
weeks gestation.
At 28 weeks or 1 month
After the 1st dose.

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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.
An insecticide-treated bednet is another way to

protect the pregnant woman against malaria, reducing
cases of malaria and subsequent risks of maternal
anemia and death. Advise the mother to use an
insecticide-treated bednet (see also the chapter on
postpartum care of the mother).
Prevent iodine deficiency

In areas where iodine deficiency is high, consult country protocols for pregnant women.
Advise women to use iodized salt.
Prevent iron-deficiency anemia
Iron is essential to compensate for the increased blood volume that occurs during pregnancy
and to ensure adequate fetal growth and development. Iron needs increase during the
pregnancy as the fetus grows. The pregnant woman can help meet these increased needs for
iron by taking iron and folic acid tablets and by ensuring that she has an adequate and balanced
diet. Iron-rich foods include meat, especially liver and giblets, apricots, prunes, eggs, dry
legumes, peanuts, other nuts, and green leafy vegetables.
Iron/folate supplementation to prevent anemia is administered as follows:
If the womans hemoglobin is between 8-11 g/dL, give

ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic
acid 400 mcg by mouth once daily.
If the womans hemoglobin is 7 g/dL, treat for anemia: give
ferrous sulfate or ferrous fumarate 120 mg by mouth plus
folic acid 400 mcg by mouth once daily for 3 months/follow
national protocols.
Continue to give ferrous sulfate or ferrous fumarate 60 mg
by mouth plus folic acid 400 mcg by mouth once daily for at
least 3 months after childbirth.
Intermittent preventive treatment of hookworm to prevent anemia

Hookworm is a major cause of iron deficiency anemia and should be treated with a dose of
mebendazole or albendazole every 6 months. A pregnant woman can safely take mebendazole
or albendazole during the second and third trimesters of her pregnancy. Hookworm can also be
prevented by always wearing shoes when walking outside.

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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:
albendazole 400 mg by mouth once; or

mebendazole 500 mg by mouth once or 100 mg twice a day for 3 days
In highly endemic areas (prevalence of 50 percent or more), repeat the antihelminthic

treatment 12 weeks after the first dose.
Prevent newborn tetanus with tetanus toxoid
Tetanus continues to kill many newborns and women in countries all
over the world, in spite of the fact that neonatal tetanus can be
prevented by immunizing women of childbearing age with tetanus toxoid
(TT), either during pregnancy or outside of pregnancy. All women need
to be informed about the series of five tetanus shots and should have a
permanent card. A woman also needs to know that the risk of tetanus
infection is much decreased if she is assisted by a skilled attendant at
birth.
Guidelines for giving tetanus toxoid:
TT 1
Table 4. Schedule for giving tetanus toxoid

Dose
Schedule
At first contact with woman of childbearing age or
0.5 mL
at first antenatal care visit, as early as possible.
TT 2
0.5 mL
At least 4 weeks after TT1.
TT 3
0.5 mL
At least 6 months after TT2.
TT 4
0.5 mL
At least 1 year after TT3.
TT 5
0.5 mL
At least 1 year after TT4.
Note: A woman has lifetime protection against tetanus after she has
received five doses of TT.
Health Education During Pregnancy

Birth spacing
Healthy timing and spacing of pregnancy through family planning is one of the most critical and
essential preventive ways of improving the health of women and children, with additional
benefits to the family and community. It is a key intervention associated with reduced risk of low
birth weight, prematurity, and deaths in newborns and infants, as well as decreased health risks
to mothers after abortions and births. Parents should use their family planning method of choice
and wait before conceiving again for a period of two years following a birth and for at least six
months after an abortion.
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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.

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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
Explain risk-reduction and available services:

o
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:
Provide the HIV test result.

Explain the test result, the window period, and a recommendation to retest in case of a
recent exposure.
Assess understanding of the result.
Identify and address client questions.
Discuss:
o
o
o
o
o
o
partner HIV testing and disclosure

safer sex and risk reduction (negative prevention)
exclusive breastfeeding
antenatal care, post-delivery care
importance of delivering in a healthcare facility
infant care
Provide referrals and take-home information.
In the case of individuals whose HIV test results are positive, the health care provider should:
Provide the HIV test result and support.

Assess understanding of the result.
Identify and address client questions.
Discuss:
o
o
o
o
o
o
o
o
o
ARV therapy or prophylaxis

other relevant preventive health measures, such as good nutrition, use of cotrimoxazole and, in malaria areas, use of insecticide-treated bednets
infant feeding options
treatment and support services for the client and family
partner HIV testing and disclosure
safer sex and risk reduction (positive prevention)
antenatal care, post-delivery care
importance of delivering in a healthcare facility
infant care and diagnosis
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.

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DELAYS RESULTING IN MATERNAL AND NEWBORN DEATHS

The factors that often prevent women and newborns from getting the life-saving health care they
need include:
distance from health services

cost (direct fees as well as the cost of transportation, drugs, and supplies)
multiple demands on womens time
womens lack of decision-making power within the family
poor quality services, including poor treatment by health providers and discourteous
behavior which makes women reluctant to use services
These have been described as the following delays:
Delay in recognizing the problem: When a woman or newborn experiences a danger

sign, someone must recognize that there is a problem. If pregnant women, their
families, and women caring for them dont know the danger signs that indicate the
woman or newborn is experiencing a complication, they will not know when they need to
seek care.
Delay in deciding to seek care: When a problem arises, the woman and her family
have to decide to seek care. If the primary decision-maker is not present, it may mean
that the woman is not allowed to seek care, or take her newborn for care, or that seeking
care is delayed.
Delay in arriving at the appropriate facility: Once a decision is made to seek care, the
woman and her family must find a means of transport and the necessary funds to go to
the appropriate facility. If there are no means of transport and/or the woman and her
family do not have the necessary funds, the woman or newborn will not get to the
appropriate health care facility in a timely fashion.
Delay in receiving quality care: Once the woman or newborn has reached the
appropriate facility, care providers must provide quality services for whatever emergency
has transpired. If the care provided is not good quality or appropriate, then the woman
or newborn will have reached the appropriate facility in vain.
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.
2. Make birth-related decisions:
where to give birth

who will be the skilled birth attendant
how to contact the provider
how to get to the place of birth
who will be the birth companion
who will take care of the family while the woman is absent
how much money is needed for care and transport and how to access these funds
what transport will be used and how to ensure its availability
3. Prepare for the birth:
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.

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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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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:
where to go if complications arise

how to get to the next level of care in case of an emergency
who in the family will accompany the woman
Have an emergency blood donation plan

Many health care facilities lack an adequate, safe blood supply for transfusions. After birth,
women are more likely to need blood transfusions because the complications they experience
from birth lead to blood loss. For these reasons, it is extremely important that the woman and
her family determine blood donors that can be available if needed.

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CHAPTER 4: Preventing Postpartum Hemorrhage3

The loss of some blood during childbirth and postpartum is normal and cannot be avoided.
However, losing any amount of blood beyond normal limits can cause serious problems even for
women with normal hemoglobin levels. For many anemic women, even the normal amount of
blood loss might be catastrophic. Fortunately, providers can take action to prevent unnecessary
blood loss.
Note: The importance of a given volume of blood loss varies with
the womans health status. A woman with a normal hemoglobin
level may tolerate blood loss that would be fatal for an anemic
woman. (WHO, 2007)
Postpartum hemorrhage (PPH) is defined as vaginal bleeding in excess of 500 mL occurring
less than 24 hours after delivery; severe PPH is blood loss exceeding 1000 mL. Delayed PPH
is excessive vaginal bleeding (vaginal bleeding increases rather than decreases after delivery),
occurring more than 24 hours after childbirth.
Because it is difficult to measure blood loss accurately, research shows that blood loss is
frequently underestimated. For instance, nearly half of women who deliver vaginally often lose
at least 500 mL of blood, and those who give birth by Caesarean delivery normally lose 1000
mL or more. For many women, this amount of blood loss does not lead to problems; however,
outcomes are different for each woman.
For severely anemic women, blood loss of as little as 200 to 250 mL can be fatal. This fact is
especially important to keep in mind for women living in developing countries where significant
numbers of women have severe anemia. For these reasons, a more accurate definition of PPH
might be any amount of bleeding that causes a change for the worse in the womans condition
(e.g., low systolic blood pressure, rapid pulse, signs of shock).
Predicting who will have PPH based on risk factors is difficult because two-thirds of women
who have PPH have no risk factors. Therefore, all women are considered at risk, and
preventing hemorrhage must be incorporated into the care provided at every birth.
Note: Every woman is at risk for postpartum hemorrhage.
CAUSES OF POSTPARTUM HEMORRHAGE

There are several possible reasons for severe bleeding during and after the third stage of labor.
Uterine atony, or inadequate uterine contraction, is the most common cause of severe PPH in
the first 24 hours after childbirth. Contractions of the uterine muscle fibers help to compress
maternal blood vessels. Bleeding may continue from the placental site if contractions are not
adequate. Many factors can contribute to the loss of uterine muscle tone, including:
retained placenta or placental fragments

partial placental separation
overdistention of the uterus due to multiple gestation, excess amniotic fluid, large baby,
or multiparity
Adapted from PATH. OUTLOOK Volume 19, Number 3, May 2002.
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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.
PPH PREVENTION AND EARLY DETECTION

It is impossible to predict which women are more likely to have a PPH. Many factors may
contribute to uterine atony or lacerations. Addressing these factors may help prevent PPH and
reduce the amount of bleeding a woman may have. Taking a preventive approach can save
womens lives.
Despite the best efforts of health providers, women may still suffer from PPH. If PPH does
occur, positive outcomes depend on how healthy the woman is when she has PPH (particularly
her hemoglobin level), how soon a diagnosis is made, and how quickly effective treatment is
provided after PPH begins.
To prevent PPH and reduce the risk of death, routine preventive actions should be offered to all
women from pregnancy through the immediate postpartum period.

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During Antenatal Care

Health care providers should take the following steps during antenatal care:
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.
During the First and Second Stages of Labor

Health care providers should take the following steps during the first and second stages of
labor:
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.
During the Third Stage of Labor

Health care providers should take the following steps during the third stage:
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.
After Delivery of the Placenta

Health care providers should provide the following care during the immediate postpartum period
(the first six hours after childbirth):
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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CHAPTER 5: Routine Care during the

Third Stage of Labor
PREPARATION FOR THE BIRTH

Developing a birth-preparedness plan during pregnancy will help ensure that the woman in labor
arrives at the health care facility in a timely manner and can be assisted by a skilled birth
attendant. Ideally there should be at least two qualified providers at each birth to ensure that
both the woman and her newborn receive the quality care they need. Having two qualified
providers is especially important if either the woman or her newborn require additional care.
Preparing the Delivery Room
The following guidelines will be helpful in preparing the delivery room.
Ensure that the client care area is adequately prepared by:

o
o
o
o
o
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
Maintain cleanliness of the woman and her environment:

o
o
o
o
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 .
Routine Care for the Woman in Labor

Regardless of how the third stage of labor is managed, basic care for the woman and baby
during labor and postpartum remains the same. The following actions represent the elements of
essential care for the woman during labor.

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Supportive care during labor
Encourage the woman to have personal support from a person of her choice throughout
labor and birth:
o
o
o
Ensure good communication and support by staff:

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 support from the chosen birth companion.

Arrange seating for the companion next to the woman.
Encourage the companion to give adequate support to the woman during labor and
childbirth (rub her back, wipe her brow with wet cloth, assist her to move about).
Encourage the woman to move about freely.

Support the womans choice of position for birth.
Encourage the woman to empty her bladder regularly.

Note: Do not routinely give an enema to women in labor.
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
Give her praise, encouragement, and reassurance.

Give her information on the process and progress of her labor.
Listen to the woman and be sensitive to her feelings.
If the woman is distressed by pain:
Suggest changes of position (Figure 5.1).

Encourage mobility.
Encourage her companion to massage her back or hold her hand and sponge her face
between contractions.
Encourage breathing techniques.
Encourage a warm bath or shower.
If necessary, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV
slowly or give morphine 0.1 mg/kg body weight IM. Do not give Pethidine (to avoid
respiratory depression and birth asphyxia in the baby) if you envisage that the baby is
likely to be delivered within 2 hours of administering the drug, especially not in peripheral
centers since Naloxone (0.1mg/kg) that can be used to reverse the respiratory
depressant effect of Pethidine may not be available.
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)
Monitor progress of the first stage of labor using the partograph

Findings which suggest satisfactory progress in the first stage of labor are:
regular contractions of progressively increasing frequency and duration.

rate of cervical dilatation at least 1 cm per hour during the active phase of labor (cervical
dilatation on or to the left of alert line).
cervix well applied to the presenting part.
Findings which suggest unsatisfactory progress in first stage of labor are:
irregular and infrequent contractions after the latent phase, or

rate of cervical dilatation slower than 1 cm per hour during the active phase of labor
(cervical dilatation to the right of alert line), or
cervix poorly applied to the presenting part.
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:
There is vaginal bleeding in labor and delivery.

The diastolic blood pressure is 90 mm Hg or more.
The woman complains of severe headache or blurred vision.
The woman is found unconscious or having convulsions.
The fetal heart rate is less than 100 or more than 180 beats per
minute after a contraction.
Membranes have been ruptured for more than 12 hours before
childbirth.
The woman has a fever.

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Follow national
protocols for
management
and referral of
complications.
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Figure 5.2. The modified WHO partograph. (WHO, 2003)
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Supportive care during childbirth

Encourage the woman to have a companion with her who can provide support for her
during childbirth.
Encourage the woman to assume the position she prefers.
Figure 5.3. Positions that a woman may adopt during

childbirth. (WHO, 2003)
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.
Preparation for Care of the Baby at Birth

The mother and her baby must, as far as possible, remain together. It is only when special care
is required for one of them, where it is not safe to have the two together, that the baby should be
looked after in a separate place.
As noted earlier, it is ideal to have two qualified persons attending the delivery so that both the
mother and baby can receive adequate care. This is particularly useful if either or both develop
problems needing care. However, this is usually not feasible, especially at peripheral centers.
However, with some advance planning one can explore training another staff member, even a
less qualified person, to assist the skilled birth attendant to facilitate the latter in dealing with the
key problems.
Preparation of the newborn corner in the delivery room
Ideally all items necessary for the baby should be kept in a designated area, the newborn baby
corner. This corner can also be used to resuscitate an asphyxiated baby or provide any special
care as required. This area should have a table and ideally an overhead heater/warmer. For
normal babies not requiring special care, most routine care can be carried out on the baby
placed on the mothers chest.
It is absolutely essential that the delivery room, including items for resuscitation (see chapter 8
on resuscitation for birth asphyxia), is ready at all times. In addition it is mandatory that the staff
on duty verify that this is so at the beginning of each day, every shift, and when called to attend
a delivery.
Make sure that all equipment, including those for resuscitation, is available, in functioning order,
and clean or sterile as needed.

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Checklist to prepare for the care of the baby at birth

Display the checklist of all required items on the wall near the table at eye level, framed with a
glass cover or within a display or notice board to protect the paper. More details related to the
equipment for resuscitation are noted in chapter 8 on resuscitation for birth asphyxia. The
checklist should contain the following items:
A warm room with no drafts or open windows.

A table with a firm mattress covered with a washable surface such as a plastic or rubber
sheet. Over this a clean, preferably sterile cloth/linen should be placed just before
delivery. The clean/sterile equipment and supplies can be placed on it, leaving enough
room for special care for the baby, such as resuscitation.
A source of heat. Ideally this should be an overhead heater (the heat source being a
heating rod or a set of bulbs). A hot water bottle is not recommended as it may result in
burns. If its use is unavoidable, make sure that the water is warm, not hot, and the bottle
is wrapped in several layers of cloth. In addition, for extra safety check the skin of the
baby in contact with the bottle frequently for excessive heat or redness.
Three to five pieces of clean, preferably sterile cloths to dry and wrap the baby (cap
where available) and blanket where required.
A wall thermometer to monitor the room temperature.
A clinical thermometer to measure the axillary temperature.
Suction equipment (for details see chapter 8 on resuscitation):
o
o
De Lee mucous extractor or

Suction machine (electrical/foot operated) with simple suction catheters 8F and 10F.
In the absence of a suction machine, a 10 mL syringe attached to the catheter can
be used to remove the secretions.
If a rubber bulb is used for suction, it should be sterilized. It is not recommended to
use the same bulb for multiple infants due to the risk of the transmitting major
infections.
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-toskin 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.
ESSENTIAL NEWBORN CARE

The initial steps in the care of the baby at birth, such as drying, wrapping, and evaluation of
breathing, are similar for all babies. Subsequent care, however, may be different if there are
problems such as birth asphyxia.
Dry the Infant
Place the infant on the abdomen of the mother.

Wipe the face and dry the baby thoroughly immediately after birth and discard the wet
cloth. Do not let the baby remain wet, as this will cool the body and make him/her
hypothermic.
Let the baby stay prone in skin-to-skin contact on the abdomen and cover the baby
quickly, including the head, with a fresh dry cloth.
Figure 5.4. Initial steps in the care of the baby at birth.

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Evaluate Breathing
Check if the baby is crying while drying him/her.

If the baby does not cry, see if the baby is breathing properly.
If the baby is not breathing and/or is gasping:
o
o
o
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.
Figure 5.6. Use of a pre-sterilized disposable cord clamp.
Eye Care
Apply prophylactic eye drops as recommended by the Ministry of Health (tetracycline

ophthalmic drops or ointment).
Apply prophylactic drops or ointment as follows:
o
o
o
o
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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Assess for Major Defects

The following defects may need special inputs at birth:
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:
Explain the procedure to the mother.

Wash your hands thoroughly with soap and water, air-dry or dry with clean paper towels
(use gloves in areas of HIV prevalence).
Gather the necessary equipment: disposable syringe, needle, medication,
alcohol/antiseptic solution, and clean, preferably sterile gauze/cotton.
Examine carefully the medications label to verify the name, expiration date, instructions
for dilution, if any, or any other special notes.
Calculate the amount to be given where required.
Draw out the medication:
o
o
o
o
58
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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Place an Identification Label on the Baby

Place the identification tag /label on the wrist and ankle (as recommended by the Ministry of
Health). If a ready-made disposable identification is not available, prepare one locally using
sticking plaster and gauze strips. Note, at a minimum, the names of the mother and, if available,
the father, and the date and time of birth.
Early, Exclusive Breastfeeding
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:
The babys chin is touching or nearly

touching the breast.
The mouth is wide open.
The lower lip is everted (turned outward).
Most of the areola is inside the mouth,
especially the part below so that the areola
is visible more above the mouth than
below.
The sucking is slow and deep and
swallowing is audible.
Figure 5.7. Signs of proper attachment at the breast. (WHO, 2003)

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Weigh the Baby and Record the Weight
Take the weight when the baby is stable and warm.

Place a clean cloth or paper on the pan of the weighing scale.
Adjust the weight so it reads zero with the paper/cloth on it.
Place the baby over the pan. If a cloth was used, fold it to cover the body of the baby.
Note the weight when the baby and pan are not moving.
Never leave the baby unattended on the scale.
Write down the weight of the baby in the partograph/maternal/baby charts and in the
delivery room registers as recommended by the Ministry of Health.
Return the baby to skin-to-skin contact with the mother.
Keep the Mother and Baby Together

If no emergency care is required, keep the baby warm by putting her/him in skin-to-skin contact
with the mother and covering both with a clean cloth/blanket as required. If the baby cannot be
in skin-to-skin contact with the mother due to issues such as a Cesarean operation, an ill
mother, or an ill baby, then wrap her/him with a clean dry cloth and/or blanket, taking care to
cover the head, and keep the baby away from drafts.
Note: Never leave the woman and newborn alone soon after delivery.
Avoid separating the mother and the baby.
Counsel the Mother and Family

Counsel the mother before she leaves the delivery room. However, if she is very tired after
delivery, only talk to her about the key points noted below.
Keep the baby warm.

Continue breastfeeding frequently on demand day and night.
Do not give any other fluids/food to the baby.
Do not apply any harmful substances on the cord, such as ash or herbal preparations.
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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If the mothers HIV status is positive:
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
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 (EBM) rendered safe by flash heating of the milk (see
below), continued with complementary feeds with semisolids from the age of six
months (see chapter 11 on breastfeeding).
use of formula feeds with complementary feeds from birth with semi-solids from the
age of six months. Formula feeds are applicable when replacement feeding is
acceptable, feasible, affordable, sustainable, and safe (AFASS); avoidance of all
breastfeeding by HIV-infected women is recommended. (WHO, 2009)
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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CARE DURING THE THIRD STAGE OF LABOR

The third stage of labor is usually uneventful, with delivery of the placenta taking place without
complications. During this stage of labor, however, the woman may encounter complications
that could lead to maternal morbidity and mortality. The most common complication is
postpartum hemorrhage or vaginal bleeding in excess of 500 mL that occurs less than 24 hours
after childbirth. (See chapter 4 for more information on PPH.)
PPH may cause or worsen anemia or deplete iron stores in women, causing weakness and
fatigue. If severe, PPH may result in shock or maternal death. A blood transfusion may help
improve anemia in women and shorten hospital stays, but transfusion carries risks of reaction
and infection and is not universally available. Because many health facilities lack an adequate
supply of safe blood, PPH can often strain the resources of the best blood banks.
PPH may increase the likelihood of other issues:
The need for emergency anesthetic services.

Manual exploration or use of instruments inside the uterus (increasing the risk of sepsis).
Prolonged hospitalization. New studies show that extended hospitalizations can cause
significant and long-term financial hardships for the woman and her family.
Delayed breastfeeding.
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.
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Controlled cord traction (CCT) with simultaneous countertraction to the uterus.

Uterine massage immediately after delivery of the placenta.
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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Table 6. Comparison of Physiologic and Active Management

of the Third Stage of Labor (AMTSL)4
Physiologic (expectant)
management
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
Uterotonic is not given before

the placenta is delivered.
Signs of placental
separation
Wait for signs of separation:

gush of blood
lengthening of cord
uterus becomes rounder and
smaller as the placenta
descends
Delivery of the
placenta
Placenta delivered by gravity

assisted by maternal effort.
Placenta delivered by controlled

cord traction (CCT) while
supporting and stabilizing the
uterus by applying countertraction.
Uterine massage
Massage the uterus before the

placenta is delivered.
Massage the uterus after the

placenta is delivered.
Advantages
Disadvantages
Does not interfere with normal

labor process.
Does not require special
drugs/supplies.
May be appropriate when
immediate care is needed for
the baby (such as
resuscitation) and no trained
assistant is available.
May not require a birth
attendant with injection skills.
The length of the third stage is

longer compared to AMTSL.
o Blood loss is greater
compared to AMTSL.
o Increased risk of PPH.
Decreases the length of the

third stage.
Decreases the likelihood of
prolonged third stage.
Decreases average blood loss.
Decreases the number of PPH
cases.
Decreases the need for blood
transfusion.
Requires uterotonic drugs and
items needed for
injection/injection safety.
Requires a birth attendant with
experience and skills giving
injections and using CCT.
(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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Scientific evidence supporting AMTSL

Giving a uterotonic drug to prevent PPH promotes strong uterine contractions and leads to
faster retraction and placental separation and delivery. Several large, randomized controlled
trials have investigated whether physiologic management or active management is more
effective in preventing PPH. These trials have consistently shown that active management
provides several benefits for the mother compared to physiologic management. Table 7
provides detailed results from two important studies comparing active and physiologic
management of the third stage of labor.
These results show that only 12 women need to receive AMTSL to prevent one case of PPH.
This means that AMTSL is a very effective and cost-efficient public health intervention. These
studies also confirm that AMTSL decreases:
the incidence of PPH

the length of the third stage of labor
the percentage of third stages of labor lasting longer than 30 minutes
the need for blood transfusion
the need for uterotonic drugs to manage PPH
Table 7. Bristol and Hinchingbrooke Study Results Comparing Active and
Physiologic Management of the Third Stage of Labor
Management
Factors
Study
5
PPH
Bristol
Hinchingbrooke
Active
Physiologic
5.9%
6.8%
17.9%
16.5%
Average length of the third stage

of labor
Bristol
5 minutes
15 minutes
Hinchingbrooke
8 minutes
15 minutes
Third stage of labor longer than

30 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%
Blood transfusion needed

Additional uterotonic drugs
needed to manage PPH
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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Preparing for Active Management

Before or during the second stage of labor:
Prepare the injectable uterotonic (10 IU of oxytocin is the

preferred injectable uterotonic) in a sterile syringe before
second stage (Figure 5.8) or have oxytocin in Uniject or
600 mcg of misoprostol available.
Prepare other essential equipment and supplies for birth, the
third stage of labor, and the care of the baby, including
resuscitation, before onset of the second stage of labor.
Ask the woman to empty her bladder when the second stage
is near.
Assist the woman into her preferred position for giving birth
(e.g., squatting, semi-sitting).
Figure 5.8. Preparing oxytocin injection.
(Gomez et al., 2005)
Steps for AMTSL

There are three main components or steps of AMTSadministering a uterotonic drug, CCT,
and massaging the uteruswhich should be implemented along with the provision of immediate
newborn care. Before reading this part of the Reference Manual, watch the DVD AMTSL: A
demonstration. If you cant watch it at this time, continue with your reading but try to watch it at
some other time before you begin practicing AMTSL.
1. Thoroughly dry the baby, assess the babys breathing and perform resuscitation if
needed, and place the baby in skin-to-skin contact with the mother.
After delivery, immediately dry the infant and assess the
babys breathing. Then place the reactive infant, prone, on
the mothers abdomen.* Remove the cloth used to dry the
baby and keep the infant covered with a dry cloth or towel to
prevent heat loss.
*If the infant is pale, limp, or not breathing, it is best to keep
the infant at the level of the perineum to allow optimal blood
flow and oxygenation while resuscitative measures are
performed. Early cord clamping may be necessary if
immediate attention cannot be provided without clamping
and cutting the cord.
Figure 5.9. Put the baby on the mothers
abdomen. (POPPHI, 2007)
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2. Administer a uterotonic drug within one minute of the babys birth.

Administering a uterotonic drug within one minute of the babys birth stimulates uterine
contractions that will facilitate separation of the placenta from the uterine wall. Before giving the
uterotonic drug, it is important to rule out the presence of another baby. If the uterotonic drug is
administered when there is a second baby, there is a small risk that the second baby could be
trapped in the uterus.
The steps for administering a uterotonic drug include:
1. Before performing AMTSL, gently palpate the
womans abdomen (Figure 5.10) to rule out the
presence of another baby. At this point, do not
massage the uterus.
Figure 5.10. Rule out the presence of a

second baby. (POPPHI, 2007)
2. If there is not another baby, begin the procedure by

giving the woman 10 IU of oxytocin IM in the upper
thigh (Figure 5.11). This should be done within one
minute of childbirth. If available, a qualified assistant
should give the injection.
Figure 5.11. Give a uterotonic drug.

(POPPHI, 2007)
3. Cut the umbilical cord.

Clamp and cut the cord (Figure 5.12) following strict hygienic techniques after cord pulsations
have ceased or approximately 2-3 minutes after the birth of the baby, whichever comes first.
Figure 5.12. Pulsating and nonpulsating umbilical cord. (POPPHI, 2007)

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4. Keep the baby warm.
Place the infant directly on the mothers chest, prone,

with the newborns skin touching the mothers skin
(Figure 5.13). While the mothers skin will help
regulate the infants temperature, cover both the
mother and infant with a dry, warm cloth or towel to
prevent heat loss. Cover the babys head with a cap
or cloth.
Figure 5.13. Keep the baby in skin-to-skin

contact. (POPPHI, 2007)
5. Perform controlled cord traction.
CCT helps the placenta descend into the vagina after it has separated from the uterine wall
and facilitates its delivery. It is important that the placenta be removed quickly once it has
separated from the uterine wall because the uterus cannot contract efficiently if the placenta is
still inside. CCT includes supporting the uterus by applying pressure on the lower segment of
the uterus in an upward direction towards the womans head, while at the same time pulling with
a firm, steady tension on the cord in a downward direction during contractions. Supporting or
guarding the uterus (sometimes called counter-pressure or countertraction) helps prevent
uterine inversion during CCT. CCT should only be done during a contraction.
Note: CCT is not designed to separate the placenta from the uterine wall
but to facilitate its expulsion only. If the birth attendant keeps pulling on an
unseparated placenta, inversion of the uterus may occur.
The steps for CCT include:
1. Wait for cord pulsations to cease or approximately 2-3 minutes after birth of the
baby, whichever comes first, and then place one clamp 4 cm from the babys
abdomen.
Note: Delaying cord clamping allows for transfer of red blood cells from
the placenta to the baby that can decrease the incidence of anemia
during infancy.
2. Gently milk the cord towards the womans perineum and place a second clamp
on the cord approximately 2 cm from the first clamp.
3. Cut the cord using sterile scissors under cover of a gauze swab to prevent blood
spatter. After the mother and baby are safely cared for, tie the cord.
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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)
5. Hold the cord close to the perineum

using a clamp. (Figure 5.15)
6. Place the palm of the other hand on the
lower abdomen just above the womans
pubic bone to assess for uterine
contractions (Figure 5.15). If a clamp is
not available, controlled cord traction
can be applied by encircling the cord
around the hand.
Figure 5.15. Palpate the next contraction.

(POPPHI, 2007)
7. Wait for a uterine contraction. Only do CCT when there is a contraction.

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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).
9. At the same time with your other hand,

pull with firm and steady tension on the
cord in a downward direction (follow
the direction of the birth canal). Avoid
jerky or forceful pulling.
Figure 5.16. Applying CCT with

countertraction to support the uterus. (POPPHI, 2007; Gomez, et al, 2005)
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.
10. Do not release support on the uterus

until the placenta is visible at the
vulva. Deliver the placenta slowly
and support it with both hands
(Figure 5.17).
Figure 5.17. Supporting the placenta with both hands.

(POPPHI, 2007)
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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)
Note: If the membranes tear, gently examine the upper vagina

and cervix wearing high-level disinfected or sterile gloves and use
a sponge forceps to remove any pieces of remaining membrane.
6. Massage the uterus.
Massage the uterus immediately after delivery

of the placenta and membranes until it is firm
(Figure 5.19). Massaging the uterus stimulates
uterine contractions and helps to prevent PPH.
Sometimes blood and clots will be expelled
during this process. After stopping massage, it
is important that the uterus does not relax
again.
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).
Figure 5.20. Teach the woman how to

massage her own uterus. (POPPHI, 2007)
Care after delivery of the placenta

7. Examine the placenta.
Examine the fetal and maternal sides of the placenta and membranes to ensure they are
complete. A small amount of placental tissue or membranes remaining in the woman can
prevent uterine contractions and cause PPH.
Note: Follow infection prevention guidelines when handling
contaminated equipment, supplies, and sharps.
1. To examine the placenta for completeness hold the placenta in the palms of the
hands with the maternal side facing upward and make sure that all lobules are
present and fit together (Figure 5.21).
Figure 5.21. Examining the maternal side of the placenta.

(Gomez, et al, 2005)
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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.
Figure 5.22. Checking the membranes.

(Gomez et al, 2005)
8. Examine the lower vagina and perineum.
1. Gently separate the labia and inspect the lower

vagina and perineum for lacerations that may
need to be repaired to prevent further blood loss
(Figure 5.23).
2. Repair lacerations or episiotomy.
Figure 5.23. Gently inspect the lower vagina and

perineum for lacerations. (POPPHI, 2007)
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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9. Provide immediate care.

After examining the placenta and external genitals, continue caring for the mother and newborn.
If the woman has chosen to breastfeed, the

mother and baby may need assistance to
breastfeed within the first hour after the birth
and before transferring them out of the
delivery room (Figure 5.24). Assess the
readiness of the woman and newborn to
breastfeed before initiating breastfeeding;
do not force the mother and baby to
breastfeed if they are not ready.
Figure 5.24. Encourage breastfeeding within the first

hour after birth. (POPPHI, 2007)
Also ensure that:

Infection prevention practices are strictly followed.
The baby is kept warm.
The mother and baby are kept together.
The mother and baby are not left alone.
The woman and baby stay in the delivery room for at least one hour after delivery of the
placenta.
PMTCT interventions are provided per national guidelines.
AMTSL practices are recorded as required by local protocols (on the partograph,
womans chart, or delivery log).
The woman receives information about how she will be cared for during the next few
hours.
The woman is given a chance to ask questions and receive information about her
queries and concerns.
10. Monitor the woman and newborn immediately after delivery

of the placenta.
During the first two hours after the delivery of the placenta, monitor the woman at least every 15
minutes (more often if needed). Perform a comprehensive examination of the woman and
newborn one and six hours after childbirth. Continue with routine care for the woman and
newborn, provide interventions to prevent/reduce the risk of MTCT of HIV according to national
guidelines, and follow applicable requirements for recording information about the birth,
monitoring of the woman and newborn, and any care provided.
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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:
Skilled attendants should offer ergometrine/methylergometrine or the fixed drug

combination of oxytocin and ergometrine to women without hypertension or heart
disease for prevention of PPH.
Skilled attendants should offer 600 mcg misoprostol orally for prevention of PPH to
women with hypertension or heart disease for prevention of PPH.
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:
76
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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CHAPTER 6: Monitoring the Woman and Newborn

during the First Six Hours Postpartum
The first six hours after childbirth is a critical period for maternal and newborn health and
survival, and providers need to carefully monitor the woman and her newborn to detect and
appropriately manage complications in a timely manner. Early recognition of danger signs by
providers, women, and families and timely, appropriate management of complications could
significantly reduce the incidence of maternal and newborn death and disability.
The woman and her newborn should remain in the delivery room for at least one hour after
delivery of the placenta, and for longer periods as necessary. After this, they should be
transferred to an area where they can continue to be closely monitored for at least an additional
five hours. If at all possible, women and newborns should not be discharged from the facility
before 12 hours after delivery of the placenta.
MONITORING THE WOMAN

PPH is the most important single cause of maternal death in the world, and the majority of these
deaths (88 percent) occur within four hours of delivery, indicating that they are a consequence
of events in the third stage of labor. It is therefore imperative that the provider carefully monitor
the woman to assess if the uterus is well contracted and how much the woman is bleeding
during the hours following childbirth.
During the first hour after delivery of the placenta, while the woman is still in the delivery room,
the provider should monitor the following parameters at least every 15 minutes (more often if
needed):
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.
Before beginning, explain

what you will be doing to the
woman.
If all vital and other signs
are normal, reassure the
woman. If they are not
normal, act immediately.
Vaginal bleeding
Blood pressure and pulse
Note: Action should be taken immediately to evaluate and treat
PPH if excessive bleeding is detected.
During this time the provider will also:
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
Uterine contraction, vaginal bleeding,

blood pressure, and pulse:
o
o
o
every 15 minutes for 1 hour

then every 30 minutes for the third
hour
then every hour for three hours
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
Danger Signs: Temperature and Respiration

Temperature >38 C
Rapid breathing
Palmar or conjunctival pallor associated with 30 respirations
per minute or more (the woman is quickly fatigued or has
rapid breathing at rest)
Temperature and respiration

every 4 hours
Danger Signs: Bladder
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Urinary bladder (assist the woman to

empty her bladder, if distended/full, every
hour)
The woman cannot void on her own and her

bladder is distended and the woman is
uncomfortable.
Urinary incontinence

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Danger Signs: Breastfeeding
The baby is not taking the breast well.

Breastfeeding has not yet been initiated.
Breastfeeding 2 to 3
times in the 6 hours
Danger Sign
Psychological reactions every hour
Negative feelings about herself or the baby
Counsel and care for the woman 1-6 hours after delivery of the placenta
During this time, the provider should:
Encourage the woman to eat, drink, and rest.

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.
Monitor the mother and baby frequently as noted.
Document all findings and care provided.
Perform a comprehensive exam of the woman six hours after childbirth.
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 THE NEWBORN

The mother and the baby should be kept together as far as possible and separation must be
avoided. Evaluate the baby when the mother is examined. In these early hours the key
elements to be monitored include breathing, color, temperature, the cord, and evaluation for
danger signs.
Before the evaluation, explain to the mother what will be done. Check the baby whenever the
mother is evaluated:
every 15 minutes during the first 2 hours after birth

every 30 minutes during the third hour after delivery
every hour during the next 3 hours
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
First voiding of urine

(within 48 hours)
First stool (within 24
hours)
Assess the baby in general

when the mother is
assessed in the AMTSL
strategy:
immediately after birth

then
every 15 minutes for 2
hours, then
every 30 minutes for 1
hour, then
every hour for the next 3
hours
Check anal opening after

birth.
Ask about urine and stools
every day and before
discharge from the health
care facility.
Rapid respirations (more than 60

respirations per minute)
Slow respirations (less than 30
respirations per minute)
Flaring of the nostrils
Grunting
Severe subcostal retractions
Poor sucking/not sucking
Cyanosis, especially of the lips and
tongue. (Cyanosis of the hands and
feet may also be due to hypothermia
for which the baby needs to be
warmed.)
Hypothermia: body feeling cold
(temperature <36.5 C.)
Fever: usually later in the postnatal
period; while the usual
recommendation is >38 C, some feel
that in the newborn its better to act
when the temperature is even 37.5 C.
Convulsions.
Umbilical cord bleeding usually in the
first day or two; needs retying of the
cord; referral not required if that is the
only sign.
Absence of stool or urine after the 24

hours and 48 hours, respectively
As part of newborn monitoring, the following guidelines are standard:
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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CHAPTER 7: Routine Postpartum Care for the Woman

It is usually a joyful event when a woman gives birth to a baby she wants. Despite the pain and
discomfort, birth is the long-awaited culmination of pregnancy and the start of a new life.
However, birth is also a critical time for the health of the mother and her baby. Problems may
arise that, if not treated promptly and effectively, can lead to ill health and even death for one or
both of them. Nonetheless, the postpartum period is often neglected by maternity care. The lack
of postpartum care ignores the fact that the majority of maternal deaths and disabilities occur
during the postpartum period and that early neonatal mortality remains high.
Postpartum care needs to be a collaborative effort between the woman, her family, community
health workers, facility health care providers, health care managers, community groups, and
policy makers. All members need to be informed of the components of quality postpartum care.
In spite of the fact that so many deaths occur in the postpartum, very few women seek care and
very few providers offer early postpartum services. Providers must offer quality services to
ensure that women use these essential services that can substantially improve their chance of
survival.
This section covers various components of postpartum care. Individual Ministries of Health and
implementing organizations can determine by consensus the priorities to be covered, especially
in the early phases of implementation, depending on funds and time available for training,
follow-up supervision, and monitoring and evaluation.
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.
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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:
perform a rapid assessment to recognize danger signs and signs/symptoms of

complications or problems and respond immediately and appropriately.
detect pregnancy-related complications, hemorrhage, medical conditions, and infections
by:
o taking a detailed history to identify any problems/potential problems; social problems,
medical problems, problems during the most recent pregnancy and birth; and
reported symptoms/problems.
o performing a physical, obstetrical, and gynecological exam.
o if the womans HIV status is positive, carrying out clinical staging and assessing for
opportunistic infections.
Figure 7.1. Routine postpartum physical, obstetrical, and gynecological exam

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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
hemoglobin levels (as needed).

RPR (or VDRL): The test should be done if the womans status is not known.
HIV (first visit/if last test >3 months ago/as needed): If the woman does not know
her status and volunteers for testing, a test should be conducted. A positive HIV
status affects many aspects of care for the woman and her newborn.
check CD4 count according to national protocols if the womans HIV status is
positive.
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.
Importance of Routine Couple Visits

A routine couple visit prior to discharge from the facility enables discussion with the
partner/father about warning signs of complications in the woman and newborn and the need to
make a plan for urgent transport and referral. He can also learn what he can do to protect his
wife's and newborns health and understand the importance of exclusive breastfeeding. In these
ways a couple discharge visit can contribute to maternal and perinatal health.
The couple visit also provides an opportunity for both partners to be educated about treatment
and prevention of sexually transmitted infections, the importance of family planning, and the
availability of different family planning methods, including vasectomy.
If the male partner has not yet been tested for HIV, the couple can be counseled and
encouraged to be tested without the danger of blame being put on the woman because she has
been tested first. Where appropriate, condoms can be demonstrated, promoted, and provided.
A couple visit acknowledges the usual gender role of men in protecting their family and in
making decisions.
Health Promotion and Disease Prevention
Certain medications or simple health care measures can prevent or reduce the risk of suffering
from specific health problems. The following measures should be explained and offered to all
women.

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Prevent malaria
Ask whether the woman and newborn will be sleeping

under a bednet. If yes:
o
o
Ask if it has it been dipped in insecticide.

Advise her to dip it every six months.
If not, advise her to use an insecticide-treated bednet, and

provide information to help her do this.
Note that WHO/GMP (Global Malaria Program) now recommends use of long lasting
insecticidal nets (LLINs) that maintain efficacy for at least 3 years.6
Prevent vitamin A deficiency
Give 200,000 IU vitamin A capsules after delivery

or within six weeks of delivery.
Explain to the woman that the capsule with vitamin
A will help her to recover better and that the baby
will receive the vitamin through her breast milk.
Ask her to swallow the capsule in your presence.
Explain to her that if she feels nauseated or has a
headache, it should pass in a couple of days.
Do not give capsules with high dose of vitamin A
during pregnancy.
Prevent iron-deficiency anemia
For intermittent preventive treatment of hookworm to

prevent anemia, provide doses of a broad antihelminthic
(to be taken every six months) to women living in
hookworm endemic areas.
Iron/folate supplementation to prevent anemia.
If hemoglobin is between 811 g/dL, give ferrous sulfate or
ferrous fumerate 60 mg by mouth plus folic acid 400 mcg by
mouth once daily for at least three months after childbirth.
If hemoglobin is 7 g/dL, treat for anemia according to
national protocols.
(Note: The ferrous sulfate or fumerate dose will depend upon
the womans hemoglobin. Follow national guidelines on the
specific treatment, as this may vary from country to country.)
Source: http://www.who.int/mediacentre/news/releases/2007/pr43/en/index.html; accessed on March

26, 2009
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Prevent tetanus
Tetanus toxoid (TT). Provide TT if a dose is due and remind

women to keep the TT cards and vaccinations up to date.
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, and 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 counseling 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 the partner and mother-in-law, to encourage them to
help ensure the woman eats enough and avoids hard physical work.

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Remind the woman and her family that a

breastfeeding woman needs to eat extra. In
order to eat enough for herself and to
produce enough milk, she should ideally eat
five to seven times a day. If possible, she
should try to eat smaller quantities of food at
more frequent intervals during the day. In
low-resource settings in developing countries
where women eat less frequently, she should
take at least one extra meal a day.
A breastfeeding woman needs to drink a lot. She should try

to drink something after every time her baby breastfeeds.
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Advise on postpartum care and hygiene

Advise 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 avoid sexual intercourse until the perineal wound heals and it is comfortable for her.
To have enough rest and sleep.
About the importance of washing to prevent infection of the mother and her baby:
o
o
o
o
Wash the perineum daily and

after fecal excretion.
Change perineal pads every 4
to 6 hours, or more frequently if
there is heavy lochia.
Wash used pads or dispose of
them safely.
Wash the body once daily
during bathing with soap and
water.
Wash hands before handling
the baby, at least after
changing the diaper/napkin,
after using the toilet herself,
and after cleaning the house.
Wash hands every time before handling a low birth weight baby.
Advise on the need for rest and sleep during the postpartum
Explain to the woman:
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That a breastfeeding woman needs

additional time to rest. This is because
she is recovering from pregnancy and
childbirth, breastfeeding, and taking
care of a little baby, which takes up a
lot of her time.
That she can try to negotiate with
family members to help with
household chores so that she can take
more time to rest.
That she can ask a health care
provider to help her explain her needs in the postpartum to her partner and family
members.

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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 counseling session.
Explain that after birth, if she has sex and is
not exclusively breastfeeding, she can
become pregnant as soon as four weeks after
delivery. Therefore it is important to start
thinking early about what family planning
method she and her partner will use.
Her fertility can return even before she
commences menstruation after childbirth.
Ask about plans for having more children. If
she (and her partner) want more children,
advise that waiting at least 3-5 years between
pregnancies is healthier for the mother and child.
After a live birth, couples should use an effective family planning (FP) method of their choice
consistently for at least two years before trying to become pregnant again, and not more
than five years after the last birth. After a miscarriage or abortion, couples should use an
effective FP method of their choice consistently for at least six months before trying to
become pregnant again.
Counsel on safe sex, including use of condoms for dual protection from sexually transmitted
infections (STI) or HIV and pregnancy. Promote their use, especially if there is a risk of
sexually transmitted infections or HIV.
For HIV-positive women, follow guidelines for family planning considerations.
Her partner can decide to have a vasectomy (male sterilization) at any time.
Family planning methods

Information on when to start family planning methods after delivery and the actual method to be
used will vary depending on whether a woman is breastfeeding or not. Make arrangements for
the woman to see a family planning counselor or counsel her directly.
Family planning options for the non-breastfeeding woman that can be used immediately
postpartum include: condoms, 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). Options for the nonbreastfeeding woman that should be delayed for 3 weeks include: combined oral
contraceptives, combined injectables, and fertility awareness methods.
A breastfeeding woman may choose the lactational amenorrhea method (LAM), but she will be
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.

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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.
Advise on sexual intercourse during the postpartum period

Explain to the woman:
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.
Advise on danger signs

Advise the woman to go to a hospital or health center immediately, day or night without
waiting, if she experiences any of the following signs:
Vaginal bleeding: more than two or three 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
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Severe abdominal pain
Swollen, red or tender breasts, or sore nipple

(seek advise as soon as feasible)
Feels ill
Urine dribbling or pain on micturition
Pain in the perineum or draining pus

Foul-smelling lochia

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Discuss how to prepare for an emergency in postpartum
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
where to go if there are danger signs

how to reach the hospital
how to meet the costs involved
options for family and community support
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.
Advise on when to return
Encourage the woman to bring her partner or family

member to at least one visit.
Explain the timing of routine postpartum visits. When the

mother and baby are normal:
o
o
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the first visit should be within the first week, preferably

within 2-3 days.
the second visit should be 4-6 weeks postpartum.

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CHAPTER 8: Resuscitation for Birth Asphyxia

Birth asphyxia is a major cause of death in the newborn period, accounting for about 23 percent
of deaths in the first four weeks of life. From 3-5 percent of newborns do not start spontaneous
breathing at birth. A great number of newborns do not receive appropriate care because many
birth attendants do not have the knowledge, ability, or the appropriate equipment and supplies
to perform the necessary steps of resuscitation in an optimal manner. It is extremely important
to train healthcare personnel in this area to prevent neonatal deaths and disability.
The term birth asphyxia indicates the babys inability to commence and maintain
breathing. A normal baby at birth has a good cry; continues to breathe well; has a pink tongue,
lips, palms and soles; and has adequate reactions and good muscle tone, with the limbs well
flexed and moving well. The slight bluish tinge of the palms and soles commonly seen in babies
at birth is due to vasoconstriction of the local blood vessels as a result of the chilling that takes
place at birth. This chilling is due to the baby coming from a warm intrauterine environment to
the colder exterior and to the evaporation of the amniotic fluid. The blue color changes rapidly
to pink as the baby is dried, wrapped, and warmed.
Basic resuscitation of the newborn is not the exclusive field of a specialist. Midwives, nurses,
and doctors who attend deliveries at all levels should have the skills and resources to
resuscitate babies with birth asphyxia in order to decrease neonatal mortality and morbidity.
This training program of staff at the peripheral health centers will focus on:
drying and stimulation and maintenance of temperature

clearing of the airways
ventilation with bag and mask
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.
Each of the following is a prerequisite to successful neonatal resuscitation:
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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CAUSES OF BIRTH ASPHYXIA

Some causes of birth asphyxia are noted below. It should be noted, however, that up to 50
percent of newborns who require resuscitation may have no identifiable risk factors before birth.
Hence, persons attending any delivery should be prepared and ready to initiate resuscitation, if
required.
Maternal causes for birth asphyxia include:
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
Causes in the newborn include:
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
PREPARATION FOR RESUSCITATION

The cry of the baby at birth is generally considered to be the first sign of extrauterine life and
good health. Most newborns cry and start breathing immediately after birth and adapt well to the
extrauterine environment. All that is needed is to be surrounded by a clean and warm
environment and to be carefully monitored. Breathing must be established before the baby is
given to the mother to be kept warm.
A suitable room and the necessary equipment should be ready, and health workers should be
well prepared for resuscitation at every birth without delay. The life and brain of the infant are
at stake. While routine essential care of the baby can be carried out while the baby is placed on
the mothers abdomen or chest, it is convenient to designate a newborn baby corner or area
where resuscitation and other special care for the baby can be carried out. It should have a
table with a firm mattress covered with a clean rubber or plastic sheet and a clean, preferably
sterile cloth, under a warmer where all necessary equipment and supplies can be placed and
readily accessed.
Equipment for Preventing Hypothermia
The following equipment is recommended for preventing hypothermia:
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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
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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.
Figure 8.1. A warming table. (USAID/BASICS Senegal Newborn Health Program)
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.
Equipment for Aspiration of Secretions

The following suction equipment is recommended:
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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Figure 8.2. De Lee mucous aspirator. (WHO: Safe Motherhood:

Basic Newborn Resuscitation-A Practical Guide)
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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Equipment for Ventilation

Bag and mask: a newborn resuscitator bag (240-500 mL) with appropriate size face
masks (#1 for normal size newborn babies, #0 for LBW babies). (See Figure 8.3.) In
general, where resources are limited, the 500 mL bag is preferable as it can be used for
the normal weight baby and for the larger low birth weight infants which constitute the
biggest proportion of the high-risk group. Notes:
Figure 8.3. Self-inflating bag and mask for ventilation of babies.
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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A stethoscope where available.

Miscellaneous: sterile gauze/pieces of sterile cloth and sterile/HLD gloves.
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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Identifying a Baby with Birth Asphyxia

The baby may have the following features:
does not cry at birth

is either not breathing or has very slow breathing (less than 20/minute) or is gasping
is blue or pale
is limp and not moving or not responding properly to stimulation
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.
STEPS IN NEWBORN RESUSCITATION

The initial actions for resuscitation are similar for all babies, irrespective of the status of the baby
and presence or absence of asphyxia. After each step, an evaluation of the condition must be
made to judge progress so that the appropriate next step can be implemented. Evaluation and
action constitute a cycle that has to be repeated in a timely manner until the baby recovers or a
decision is made to discontinue an unsuccessful resuscitation. Universal precautions for the
safety of the baby and the staff and steps for prevention of infection are also mandatory.
Preparation
Switch on the heating source before the delivery to warm the table top/mattress for the baby.
Place the linen for the baby on the table under the warmer so that it gets warmed up before the
delivery. Wash your hands and wear sterile gloves.
Immediate Care in the Case of Meconium in the Amniotic Fluid
If the amniotic fluid is stained by meconium, and especially in case of thick meconium:
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.
Position of the Baby

Initially during the steps noted above, the baby can be turned on one side with the head slightly
extended. However, if the baby is still not breathing, it is convenient to have the baby on its back
on a warm, firm surface with the head towards you. The head should be slightly extended,
which you can do either by extending the head slightly with your hand or by placing a roll of
linen under the shoulders to raise them by 2-3 cm (see Figure 8.5).
Positioning during Resuscitation

Correct position
(Neck slightly extended)
Newborn with elevated shoulders 2 to 3 cm. with a small linen roll,

placed below, to slightly extend the neck.
The neck may be extended by positioning with the hand
without the linen roll
Incorrect positions
Neck hyperextended
Neck flexed
Figure 8.5. Correct positioning.
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Clearing of the Airways
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.
Figure 8.6. Methods for stimulating the baby.
Ventilating the Newborn with the Bag and Mask
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
Use #1 for normal size babies and #0 for LBW babies.

Make sure the mask covers the babys chin, mouth, and nose, but not the eyes (see
Figure 8.7).

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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.
FORM A PROPER SEAL

BETWEEN THE MASK
AND FACE
CORRECT
INCORRECT
Figure 8.7: Correct positioning of the mask and formation of a good seal.
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Commence ventilation at about 40 times a minute (the range for ventilation is

40-60 breaths/minute). A simple way is to count one two breathe and squeeze the
bag at each breathe.
Make sure the babys chest rises and the valve of the self-inflating bag moves with each
inflation; this is an indication that ventilation is efficient. If this does not happen, adjust the
position of the head of the infant and the bag, suction the mouth and nose again to remove
secretions, and proceed with ventilation with a slightly higher pressure. You must see the
chest rise.

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Reassess the babys breathing after one minute.

o If the newborn cries and spontaneous breathing is established, stop ventilation and
observe for at least 5 minutes. If the baby is breathing normally (30-60 respiratory
movements/minute), proceed with routine essential newborn care.
o If the baby is still not breathing or is gasping, assess the heart rate with a stethoscope if
available, or by feeling the umbilical cord pulsations. Count the heart rate or the umbilical
pulsations for 6 seconds and multiply by 10 to obtain the heart rate per minute.

If the heart rate is more than 100/minute, continue ventilation.

If the heart rate is less than 100/minute, clear the infants airways again, reposition
the bag, and continue bagging until spontaneous breathing is established.
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.
Figure 8.8. Giving supplemental oxygen.

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When to Discontinue Resuscitation

While it is essential to carry out the steps for resuscitation in a correct and timely manner, it is
equally important to know when the process should be terminated. Conventionally, if a newborn
does not breathe and does not cry for 20 minutes, resuscitation should be discontinued. A
newborn who is not breathing 20 minutes after appropriately managed resuscitation has already
suffered from significant hypoxia and merely continuing ventilation without ancillary support
carries the risk of further brain damage and long-term disability. Intensive care is appropriate at
this time. At a peripheral center, where it is not feasible to provide such care, a baby who is not
breathing should be managed as best as feasible locally, unless facilities exist to transport the
baby with effective ventilation to an appropriate higher referral center where intensive care is
available. Otherwise, the baby is likely to die on the way or reach the center in a state from
which it cannot be revived or that may be associated with severe disability.
Dangerous/Inefficient Resuscitation Practices
Avoid harmful practices such as:
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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Measure the axillary temperature:

o If the temperature remains above or equal to 36.5 C, keep the baby on the mothers
chest.
o If the temperature is less than 36.5 C, warm the baby by skin-to-skin contact or by
placing under a warmer as is most appropriate, based on available equipment and
the status of the baby and mother. If the infant remains hypothermic, this represents
a danger sign; refer the baby to the appropriate referral center.
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
Counsel the mother and the family regarding:

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.
Care Following an Unsuccessful Resuscitation

When resuscitation attempts are not successful, it is extremely important to inform the parents
and provide an explanation.

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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
support the breasts with a large cloth band or a bra.

apply cold compresses on the breasts to decrease congestion and pain.
avoid breast massage or exposure to heat.
avoid stimulating the nipples.
prescribe oral paracetamol when necessary for pain.
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.
Completing Medical Records

All healthcare facilities must keep charts/documents that record each birth and information
about the events surrounding the birth. The basic protocols must provide the necessary
information, such as the condition of the infant at birth and if resuscitation or any other treatment
was administered. This information must be copied into the health records of the baby where
separate records exist for the baby.
All problems detected at birth as well as procedures and treatment applied must be written
legibly in the chart for future reference in case it is needed for healthcare or administrative
reasons. The systematic collection of information is important to establish health statistics and
to serve as educational material to improve the quality of care. Good documentation is also
extremely important in case of medico-legal issues that may surface later. The following details
should be present:
date and time of birth

condition of the baby at birth
procedures used to initiate breathing where applicable
time delay between birth and the first breath
observations during and after resuscitation, if any
result of resuscitation procedures
in case of unsuccessful resuscitation, list the likely reason(s) for failure
name of the healthcare worker(s) present at resuscitation
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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Figure 8.9 Algorithm for resuscitation for birth asphyxia

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Integration of AMTSL and ENC

Keep required items for the mother and baby close by, load oxytocin in syringe.
Inform the woman what is being planned in a way she can understand.
Receive and dry the baby, discard wet linen.
Baby cries well
Place the baby on the mot hers

abdomen; cover with a dry cloth.
Inform the mother about her baby

and AMTSL; administer uterotonic
after checking for a second baby.
Clamp cord when pulsations

stop/2-3 minut es after birth. Place
the baby on the mothers chest
and keep the baby warm.
Apply controlled cord traction +

countertraction; perform uterine
massage.
Cry not heard
Place the baby on the mothers abdomen; c over the

baby with a dry cloth.
Breathing well
Not breathing/
gasping
Inform the mot her about

her baby and AMTSL;
administ er ut erotonic
after checking for a
second baby.
Cut the cord; resuscit at e

the baby. If possible,
administer uterotonic
after checking for a
second baby.
Clamp cord when

puls at ions stop/2-3 mins.
after birth. Place the baby
on the mothers chest and
keep warm.
Apply cont rolled cord

traction + countertraction; perform uteri ne
massage.
Depending on the level of

resuscitat ion efforts
needed and whether an
assistant is present,
del iver placent a by
maternal effort or
controlled cord traction.
Monitor the woman and baby closely.

Implement ENC at birth: eye prophylaxis; cord care; warmth (skin-to-ski n); breastfeeding.
Continue rout ine c are for the woman and her baby.
Figure 8.10 Algorithm for integration of AMTSL, ENC and resuscitation for birth asphyxia
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CHAPTER 9: Basic Systematic Examination of a

Newborn at Peripheral Centers
In major hospitals the pediatrician/neonatologist performs a systematic and complete
examination of the newborn. This kind of evaluation is presently not feasible in the peripheral
centers where such specialists are not available. The purpose of this manual is for peripheral
healthcare workers to acquire competence in basic evaluation and care of the newborn infant,
and the manual will therefore focus on basic components of care and evaluation. A somewhat
more detailed systematic examination, noted in Appendix B, may be relevant at some of the
larger, more established centers.
While in general there is a systematic method of examination, it is important in some cases to
adapt the steps to take into consideration certain situations that apply to very young babies such
as newborns. The newborn infant is frequently asleep, for example, so it is advisable to take
advantage of this to carry out those steps that require a quiet infant, such as counting the
respiratory rate. On the other hand, if the baby is crying, it becomes easier to look into the
mouth to identify the presence of problems such as a cleft lip or an infection such as thrush. If
necessary, newborns can usually be calmed with breastfeeding, which provides an opportunity
to evaluate sucking and attachment at the breast.
PREPARING FOR THE EXAMINATION

Timing of the Examination
Examinations should be done at the following times:
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.
Equipment and Supplies Needed for the Examination
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
Promote cleanliness of the site where the baby is examined.

Arrange to have adequate light.
Welcome the mother and her family/companion, install them comfortably in a draft-free
area, and explain what you are going to do.
Wash hands with soap and water; if these are unavailable, use alcohol/glycerine
hand rub.
Prevent heat loss/hypothermia. Select a draft-free area, keep the baby warm during
examination with a heat source, or, if not available, keep the baby covered, close to the
mother, and expose only the part(s) to be examined.
CARRYING OUT THE EXAM

Main Steps of the Exam
1. Prepare a suitable place.
2. Plan to maintain the babys temperature during the examination.
3. Greet the mother and make her feel comfortable.
4. Review available records of the mother and baby.
5. Ask about danger signs and other problems.
6. Check for danger signs (and refer the baby if even one sign is present).
7. Check for jaundice.
8. Check for minor infections.
9. Evaluate breastfeeding.
10. Weigh the baby.
11. Document observations and care of the baby in appropriate charts/cards/registers.
12. Counsel the mother on basic newborn care.
Detailed advice for some of these 12 steps is provided in the following sections.
Review the mothers and babys records and ask about danger signs
Look for information related to:
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
Inquire about danger signs (see below).

Ask about any other problems the newborn may have.
Ask about the passage of stools and urine, specifically the approximate number
per day (urine being passed more than six times a day is reasonable evidence of
adequate breastfeeding).

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The following three adaptations may be necessary during an examination of a newborn:
Count the respiratory rate whenever the baby is quiet.

If the baby cries, take advantage to examine the mouth to look for cleft palate or thrush.
If feeding is necessary to calm the baby, take advantage to observe attachment at the
breast and quality and adequacy of the sucking.
Check for danger signs

Check for the following newborn danger signs:
Difficulty in sucking. The danger signs related to sucking/feeding can be assessed by

asking the mother and verified by direct observation.
Lethargy, diminished activity, moving only when stimulated. Except in deep sleep,
babies move frequently, both spontaneously and on stimulation. The arms and legs are
flexed. If a limb is consistently kept straight, evaluate for paralysis. Note also if the limbs
seem very limp or flaccid.
Fever or hypothermia. Assess the body temperature by at least touching the babys
abdomen, hands, and feet and ensuring that all are warm. Where possible, note the
axillary temperature with a thermometer leaving it in place for four minutes or as
recommended by the manufacturer for axillary temperature recording. The normal
temperature is 36.5-37.5 C. The thermometer should be clean, preferably washed with
soap and clean water, and wiped with an alcohol swab to prevent cross infection. Storing
in liquid antiseptics should be done only if they are changed frequently. Otherwise there
is risk of infections with Pseudomonas sps which may be highly resistant organisms. It is
not recommended to take a rectal temperature 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, especially if they are not
reversed rapidly with simple steps, such as warming through skin-to-skin contact, or
through removal of excess clothes, or covering in the hot weather.
Rapid breathing/difficulty in breathing. Assess respiration: the normal respiratory rate
is 30-60 breaths/minute. There should be no flaring of the nostrils, grunting, or subcostal
retractions. Although breathing can be somewhat irregular with short pauses, there
should be no apnea, which is defined as cessation of breathing lasting for more than 20
seconds or of a shorter duration associated with cyanosis, pallor, or bradycardia with a
heart rate less than 110/minute. The normal heart rate ranges between 110-160
beats/minute, with the lower rates when the baby is asleep and the higher rates when
the baby is active or crying.
Convulsions. Features of convulsions are often atypical in the newborn, such as a
staring look, blinking of eyelids, chapping movements of the lips, and clonic/tonic
movements of the limbs.
Persistent vomiting and/or abdominal fullness . Vomiting is determined from the
history taken from the mother. Occasional vomiting is normal, but persistent vomiting or
green-colored vomitus are abnormal.
Severe umbilical infection. Lift the cord to see the base; check for pus discharge,
redness, swelling, and foul smell. In the first day or two also check the cord for bleeding
or oozing of blood.
The danger signs are summarized in Table 10 below.

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Table 10. Guidelines for Identifying Danger Signs at Peripheral Centers

DANGER
SIGNS
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
Not as active as usual, sleeping excessively, difficult to arouse, not waking up

for feeds, lying limp, loose-limbed, excessively quiet or too good.
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
Respirations more than 60/minute (count a second to verify), flaring of the

nostrils, groaning or grunting, subcostal retraction.
Persistent
vomiting
and/or
abdominal
distension
Severe
umbilical
infection
Occasional vomiting is common, but persistent vomiting or green-colored

vomitus are abnormal. Abdominal distension or fullness may be present.
Features of convulsions are often atypical in the newborn such as a staring

look, blinking of eyelids, chapping movements of the lips, clonic/tonic
movements of the limbs.
Lift the cord to see the base. Look for spreading redness or swelling around the
umbilicus and/foul smell with or without pus discharge.
Earlier detection of problems such as major infections

Babies with danger signs have to be taken long distances to the appropriate centers. Hence,
ideally, infections need to be detected even earlier. Very early signs of infection are vague and
difficult to recognize. They include the baby not looking well or having a sick look or facial
grimace. They require careful daily observation.
Mothers, family members, and health care providers (depending on whether the baby is at
home or at a facility) should be encouraged to see the baby in adequate light at least once a
day, especially in the first week.
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Check for jaundice

Unlike in older infants, it is not easy to see jaundice in the early phase in the eyes of the
newborn. It is best assessed in the skin. Jaundice starts in the face and spreads down to the
hands and feet. Gently press the tip of the nose, release the pressure, 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 is normal, and this used to be termed physiologic
jaundice of the newborn. 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/100mL (or 256.5mols/L). Such babies require
referral for assessment and treatment, such as phototherapy.
These guidelines apply only to full-term normal weight babies. Preterm and low birth weight
babies require treatment at far lower levels of bilirubin. Hence, such babies with any jaundice
need to be referred to a competent person/center for assessment and treatment. They should
not be considered to have physiological jaundice.
Here is a summary of referral criteria for jaundice:
starting early, within 24 hours of birth

present on the palms and soles
associated with a danger sign
occurring in a low preterm/birth weight baby
persisting beyond the second week of life
Check for minor infections

Conjunctivitis: Subconjunctival hemorrhage can be a normal finding following the delivery.
Check for conjunctivitis, seen as redness and/or discharge.
Thrush: 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 coating which may be seen over the middle of the tongue in some babies.
It is best to look into the mouth when the baby cries or yawns. Avoid introducing a spatula or
spoon into the mouth to open it. If doing this is unavoidable, then it must be done very gently, as
vagal stimulation may result in bradycardia or even cardiac arrest.
Skin infection including pustules on the skin: The lesions may be seen as yellowish
pustules or as areas of peeling with underlying redness. Examine the skin from head to toe.
Look particularly in the neck folds and elbow, behind the ears, in the axilla and groin. Turn the
baby over and examine the back.
Minor infections of the umbilicus: Look for pus discharge from the umbilicus or base of the
cord (lift the cord to see the base) without redness or swelling over the surrounding skin and/or
a foul smell.

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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 babys chin is touching or nearly touching the breast.

The lower lip is everted.
Most of the areola is inside the mouth, especially the part below, so that the areola is
visible more above the mouth than below.
The sucking is slow and deep and swallowing is audible.
Weigh the baby
Place a clean cloth or paper on the baby scale pan.

Adjust the scale so it reads zero with the paper/cloth on it.
Place the baby over the cloth or paper. If it is a cloth and of adequate size, fold it to
cover the body of the baby.
Write down the weight of the baby in the mother/baby and delivery room records, based
on recommendations of the Ministry of Health.
The normal weight range is 2.5-4 kg. Low birth weight is below 2500 grams.
Document key findings

Record all key observations in writing in the babys health cards and chart/delivery register.
Counsel the mother/family
Advise the mother on the following:
frequent breastfeeding on demand day and night

keeping the baby appropriately warm
cord care
general cleanliness, including washing hands before handling the baby at least after
using the toilet, after changing the napkin/diaper, and after cleaning the house
having additional fluids and eating an extra meal
the danger signs to look for in herself and in the baby
The key elements of the basic systematic examination of the newborn at peripheral centers are
summarized in Table 11.
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Table 11. Key Steps in Examining the Newborn at a Peripheral Center
Ask the mother for danger signs.

Ask about other problems.
Check/assess for danger signs that are features of major infections. (Even if
there is only one danger sign, institute steps for transfer of the baby to an
appropriate referral center).
Check for jaundice.
Check for minor infections.
Evaluate feeding.
Weigh the baby.
Prescribe treatment of minor infections.
Document the findings and care provided on cards/chart/record books.
Take advantage of this contact to provide care such as the necessary
vaccines.
Counsel the mother/family members on basic care at home.

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CHAPTER 10: Postnatal Care of the Newborn, at the

Facility and During Postnatal Visits
Some use the words postpartum and postnatal synonymously. Others use the word postpartum
(after delivery) for the mother and the word postnatal (after birth) for the baby. In this session
the word postpartum will be used for the mother and the word postnatal for the baby, for easy
differentiation.
The postnatal/postpartum period starts after the delivery of the placenta and extends to 6 weeks
after birth. Guidelines for assessment and care may be followed during specific time intervals,
as with the WHO classification: at birth, the first hour, around 6 hours, after 6 days, and after 6
weeks. However, the length of the stay in the delivery room and the postnatal ward and the day
of discharge vary considerably in different countries and at different levels of facilities. Thus,
these intervals, especially the hourly ones, may at times be difficult to identify and adhere to.
An alternative classificationwith specific, easily identifiable times for specific activities rather
than just the period of time that has elapsedmay be easier to use. This classification is as
follows:
at birth (in the delivery room)

before the mother and baby leave the delivery room
every day during the stay at the facility
at discharge from the facility
at the postnatal visits
TIMING OF MOST NEONATAL DEATHS

As noted in the introduction, 50 percent of deaths in the newborn period take place within 24
hours of birth and 75 percent by the end of the first week of life.
There are currently no specific recommendations based on evidence for the timing and numbers
of contacts in the postnatal period at the facility and in the community. There is some evidence
to suggest that home visits by community health workers on day two have been correlated with
a decrease in neonatal mortality. However, in view of the high mortality during the first week, it
is clear that these recommendations for the postnatal period need to focus on this period,
especially the first 48-72 hours.
COMPONENTS OF POSTNATAL CARE

The postnatal period has been the most neglected period in the pregnancy/delivery/postnatal
continuum of care. Both health workers and mothers/families are not, in general, aware of the
potential dangers and high mortality in the early postnatal period. Mothers and babies tend to
stay home after a delivery, and there is also a lack of motivation among families to bring
mothers and babies for early and regular check-ups, especially if the babies or mothers seem
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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:
courteous, supportive behavior towards the mother/family

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basic, systematic examination and care at appropriate times

provision of essential newborn care (ENC) through health workers, mothers and families,
including:
o
o
o
o
o
o
cleanliness for prevention of infection

maintaining body temperature
continued cord care
exclusive breastfeeding on demand
additional care such as vaccines
identification and treatment of problems and referral
recording key information

treatment of any problems detected, locally or through referral
counseling the mother/family on ENC and follow-up
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.
Equipment and Supplies for Postnatal Visits
118
a clean, draft-free, and well-lit environment

water, soap, or alcohol-based hand scrub and clean towel/paper towel
a clean examining table with a mattress with a surface that can be cleaned (during the
hospital stay the baby may be examined on the mothers bed)
a thermometer for recording axillary temperature
a stethoscope
a baby weighing scale
a measuring tape
sterile syringes, cotton swabs, and alcohol
vitamin K1
antiseptic solutions
vaccines (BCG, oral polio vaccine and hepatitis B, as recommended by the Ministry of
Health)
medication for the baby as recommended by the Ministry of Health, such as oral
amoxicillin, cloxacillin, injectable ampicillin and gentamycin, tetracycline eye drops /
ointment, mycostatin, gentian violet solution, Betadine solution

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Steps of Postnatal Care at the Facility Level

The following are the key steps of quality postnatal care at the facility level:
Step 1: Carry out all tasks at the appropriate time.
Step 2: Carry out a basic systematic examination of the baby.
Step 3: Provide relevant care.
Step 4: Document findings and care in a baby card/register.
Step 5: Promote continued follow-up and schedule the next appointment.
Step 6: Counsel the mother and family.
These steps are explained in more detail below.
Step 1: Carry out all tasks at the appropriate time
Arrange for proper assessment and care at the following times:
at birth and during the first six hours

at least once a day during any stay at the facility
just before discharge
during postnatal follow-up visits
Step 2: Carry out a basic systematic examination of the baby

The examination should include the following steps:
Prepare to maintain the babys temperature during the examination.

Greet the mother and make her feel comfortable.
Review available records of the mother and baby.
Ask and asess for danger signs and other problems.
Check for jaundice.
Check for minor infections.
Evaluate infant feeding.
Weigh the baby.
Document all findings and care.
Step 3: Provide relevant care
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.
Step 4: Document findings and care in a baby card/register

Step 5: Promote continued follow-up and schedule the next appointment
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.

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Where feasible and available, place the mother/family in contact with a trained
community health worker or volunteer.
Step 6: Counsel the mother and family.

Counsel the mother and family in the following topics:
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).
Keep the cord and umbilicus clean:

o
o
o
o
Additional basic hygiene/cleanliness of the baby:

o
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Keep the cord dry and clean.

Fold the diaper below the cord so that it does not touch the cord.
Dont apply harmful substances on the cord (e.g., ash, mud, clay, or herbs).
If recommended by the Ministry of Health/health center, apply the appropriate
antiseptic on the cord, taking care to apply it to the base.
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.
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Identification of danger signs:

o
o
o
o
o
o
o
poor sucking or not sucking at all

inactivity or lethargy
fever (body too hot) or hypothermia (body too cold)
difficulty in breathing/rapid breathing
convulsions
repeated or persistent vomiting and/or abdominal distention
redness and/or swelling surrounding the base of the umbilicus, with our without pus
discharge, and/or foul smell
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
where to go if there are danger signs

how to reach the hospital
how to meet the costs involved
options for family and community support
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.
Care for HIV-Positive Mothers and Their Exposed Infants

For the baby, ask the following questions:
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
If yes, note and record the test result.

If not, refer the baby for HIV testing as early as six weeks after birth.
Check infant feeding options:

o
o
Provide support for the infant feeding choice.

If breastfeeding:
Reinforce messages on care of the breast and prevention of problems.
Address any questions, concerns, and problems related to breastfeeding.
Warn about the risks of mixed feeding, giving both breast milk and formula.

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Check the infant for the following:

o
o
o
inadequate weight gain

skin rashes
oral thrush
For the mother, do the following:
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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Stress the special importance and benefits of birth spacing/family planning.

Provide information on available methods.
Support her in her choice of the method, including LAM.
Arrange for follow-up counseling and support on her chosen method.
Continued safer sex practices.

Frequent occurrence in the baby of diarrhea, acute respiratory infections, acute otitis
media, opportunistic infections such as thrush and failure to thrive.
Symptoms of opportunistic infections in herself, such as fever, cough, night sweats,
weight loss, diarrhea.
When to bring the child for immunization, weight check-up/growth monitoring, and for
supplements such as vitamin A.
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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Table 12. Suggested Timings of Postnatal Visits

Ideally should be provided by a skilled attendant who is usually at the facility level, linked with a
community health worker/volunteer (CHW). If access to the facility is extremely difficult, have the
postnatal visit through the CHW.
Scenario
1st postnatal visit
2d postnatal visit
3d postnatal
visit
Facility delivery, normal

baby, discharge within 24
hours
In the first 2-3 days,

ideally 2 days after
birth
5-7 days (may coincide

with special events)
4-6 weeks
Facility delivery, normal

baby discharge day 2 or 3
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
Ideally on day of birth

and within day 48-72
hours; If not feasible,
at least one visit within
48 hours.
5-7 days (may be adjusted

to accommodate special
family events)
LBW should ideally stay at

least 3-7 days at facility.
Refer very small babies and
those with problems to
higher center.
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
Essential Newborn Care

Brief examination, look for
danger signs
Targeted counseling,
i.e., breastfeeding, protection
against hypothermia, danger
signs.
Eye care
Cord care
Vitamin K
Identification band
Breastfeeding
weight
weight
X
Full basic systematic examination
Full counseling
DPT,
oral polio, and
BCG if not
administered
earlier and
cotrimoxazole
for babies of
HIV positive
mothers
BCG, OPV, and hepatitis B any time in the postpartum period

according to the recommendations of the Ministry of Health.
Care of the baby of the HIV positive mother including ARV.
Weight
weight
weight
weight
weight

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Table 14. Summary of Postnatal Evaluation and Care of the Baby

1. Implement tasks at the appropriate time. After birth, evaluate and provide care:
before transfer out of the delivery room.

at least once a day during the stay of the baby at the facility (more frequently for
low birth weight babies and if a problem needing observation was noted).
at discharge.
during postnatal visits.
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.
4. Document findings/care in mother/baby card/register.

5. Promote continued follow-up and schedule the next appointment.
6. Counsel the mother/family on basic preventive care at home, identifying danger signs
and appropriate care seeking.
7. Where the mother is HIV-positive, ensure appropriate care for the mother and baby.
8. Where feasible and appropriate, put the family in contact with an available trained
community health worker.

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CHAPTER 11: Diagnosing and Treating Breastfeeding

Problems
COMMON PROBLEMS
Breastfeeding difficulties may be due to problems in breastfeeding techniques, problems with
the baby, or breast conditions in the mother. Problems with the baby include but are not limited
to:
congenital anomalies such as cleft lip or palate

prematurity
small baby or twin
inability to suck as with sepsis
Breast conditions which sometimes cause difficulties with breastfeeding include but are not
limited to:
sore nipples and nipple fissure

engorgement
mastitis
breast abscess
flat or inverted nipples
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.
PREVENTION AND TREATMENT

Cracked or Sore Nipples
Sore nipples and superficial breaks in the skin, sometimes called cracks, are usually caused
by poor attachment or feeding techniques.
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Make sure the baby is properly attached to the breast.

Counsel the mother to keep her breasts clean and dry and to only use soap once per
day when taking her bath. If she uses soap more often than once daily, she may get
cracked nipples.
Help mothers find positions that are comfortable and help them feel relaxed; two
common positions are the underarm position (holding the baby with the arm opposite the
breast) and lying on the side.

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Underarm position
Side lying position
Figure 11.1. Two positions for breastfeeding. (WHO, 1993)
Management
Build the mother's confidence.

Improve attachment and continue breastfeeding.
Reduce engorgement; suggest frequent feeding and express breast milk if needed.
Treat for Candida if the skin is red, shiny, flaky; if there is itchiness or deep pain; or if
soreness persists.
Advise the mother:
o
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.
If breastfeeding is difficult, help the mother to express the milk.
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
breast pain and tenderness

symptoms occurring 3-5 days after delivery
hard enlarged breasts
both breasts affected

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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
encourage the woman to take a warm shower.

massaging the womans neck and back.
having the woman express some milk manually prior to breastfeeding and wet
the nipple area to help the baby latch on properly and easily.
o
Relief measures after feeding may include:

supporting breasts with a binder or brassiere.
applying cold compress to the breasts between feedings to reduce swelling and
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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breast pain and tenderness

reddened, wedge-shaped area on breast
symptoms occurring 3-4 weeks after delivery
inflammation preceded by engorgement
usually only one breast affected

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Management
Treat with antibiotics:

o Cloxacillin 500 mg by mouth 4 times per day for 10 days, or
o Erythromycin 250 mg by mouth 3 times per day for 10 days
Encourage the woman to:
o Continue breastfeeding.
o Support breasts with a binder or brassiere.
o Apply cold compresses to the breasts between feedings to reduce swelling and pain.
Give paracetamol 500 mg by mouth as needed.
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:
Look for poor attachment.

Look for pressure from clothes, usually a tight bra, especially if worn at night, or pressure
from lying on the breast.
Notice what the mother does with her fingers as she breastfeeds. Does she hold the
areola and possibly block milk flow?
Notice if she has large, pendulous breasts, and if the blocked duct is in the lower part of
her breast. If so, suggest that she lifts the breast more while she feeds the baby, to help
the lower part of the breast to drain better.
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.
Sometimes it is helpful to do these things:
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
Treat with antibiotics:

o
o
Drain the abscess:

o
o
o
o
o
o
o
130
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
Cloxacillin 500 mg by mouth 4 times per day for 10 days, or

Erythromycin 500 mg by mouth 3 times (in severe cases up to 4 times) per day for 10
days.
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.
Give paracetamol 500 mg by mouth as needed.


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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
Build the mother's confidence.

o
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.
Help her to position her baby.

o
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)
EXPRESSING AND FEEDING BREAST MILK

There are many situations in which expressing breast milk is useful and important to enable a
mother to initiate or continue breastfeeding. The most useful way for a mother to express milk is
by hand. It needs no appliance, so she can do it anywhere and at any time. With a good
technique, it can be very efficient. It is easy to hand express when the breasts are soft; it is
more difficult when the breasts are engorged or tender. Many mothers are able to express
plenty of breast milk using unusual techniques, but if a mother's technique works for her, let her
do it that way. If a mother is having difficulty expressing enough milk, however, then teach her a
more effective technique.
How to Prepare a Container for Expressed Breast Milk
Choose a cup, glass, jug, or jar with a wide mouth.
Wash the cup in soap and water. (She can do this the day before.)
Ideally, boil the cup for 10 minutes before use.
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How to Express Breast Milk by Hand

Teach a mother to do this herself; do not express her milk for her. Touch her only to show her
what to do. Be gentle. Teach her to:
Wash her hands thoroughly.

Sit or stand comfortably and hold the container near her breast.
Put her thumb on her breast above the nipple and areola and her first finger on the
breast below the nipple and areola, opposite the thumb. She supports the breast with her
other fingers.
Press her thumb and first finger slightly inwards towards the chest wall. She should
avoid pressing too far because that can block the milk ducts.
Press her breast behind the nipple and areola between her finger and thumb. She must
press on the lactiferous sinuses beneath the areola.
Figure 11.3. Anatomy of the breast. (WHO, 1993)
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
This should not hurt; if it hurts, the technique is wrong.

At first no milk may come, but after pressing a few times, milk starts to drip out. It
may flow in streams if the oxytocin reflex is active.
Press the areola in the same way from the sides to make sure that milk is expressed
from all segments of the breast.
Avoid rubbing or sliding her fingers along the skin; the movement of the fingers
should be more like rolling.
Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the
milk; this is the same as the baby sucking only the nipple.

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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.
How to Feed a Baby by Cup

Teach the mother to:
134
Hold the baby sitting upright or semi-upright on her lap.

Hold the small cup of milk to the baby's lips.
Rest the cup (or paladai or spoon) lightly on the babys lower lip and touch the outer part
of the babys upper lip with the edge of the cup (see Figure 11.5).
Tip the cup (or paladai or spoon) so the milk just reaches the babys lips.
The baby becomes alert and opens his/her mouth and eyes.
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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)
Storing Expressed Milk

Unheated expressed breast milk should be stored in as cool a place as possible. In general,
unheated expressed breast milk may be stored:
for 1-2 hours if the ambient temperature is higher than 26 C.

for up to 6 hours if the ambient temperature is 26 C.
for up to 10 hours if the ambient temperature is between 19 C and 22 C.
for up to 24 hours in a refrigerator.
for up to 2 weeks in the freezer section of a refrigerator.
for up to 3 months in a stand-alone freezer.
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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Special Guidelines for Mothers Who Are HIV-Positive

Feeding options for HIV-positive mothers include the following:
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.
Flash heating of expressed milk

Flash heating of expressed breast milk is a method to destroy the HIV while still retaining the
nutrients and much of the anti-infective factors unique to breast milk. This permits the HIVpositive mother to give breast milk to the baby and avoid formulas.
Guidelines for the mother and family
Items required:
o
o
o
136
cups and spoons for feeding

jars with lids to collect and sterilize EBM
a container to boil the milk
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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CHAPTER 12: Care of the Low Birth Weight Baby,

Including Kangaroo Mother Care
Low birth weight (LBW) babies weigh less than 2500 grams at birth. Babies may be low birth
weight because they:
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.
FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT

Mothers may have a history of:
previously having had a LBW baby

being young (less than 16 years) or older (more than 35 years)
performing excessive physical work without appropriate rest
belonging to a low socio-economic group
having short intervals (less than two years) between pregnancies
having multiple pregnancies
Mothers may have problems during pregnancy such as:
malnutrition
severe anemia
preeclampsia/eclampsia
infections during pregnancy such as urinary tract infection, malaria, syphilis,
toxoplasmosis, herpes, CMV, Rubella, HIV/AIDS
The fetus may be abnormal with:
certain congenital malformations

intrauterine acquired infection
In 30-50 percent of cases of low birth weight, no obvious cause is found.
PREVENTING LOW BIRTH WEIGHT

Prevention of LBW presents challenges. Some interventions are noted below:
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Ideally take preventive steps early with appropriate care and nourishment of the girl
child.
Counsel families/mothers to ensure that women in general:

o
o
o
o
delay child bearing until they are at least 20 years old.

have adequate nutrition.
have sufficient rest and are not subjected to hard work during pregnancy.
have basic care to detect and treat problems before pregnancy.
Ensure through care and counseling that pregnant women:

o
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.
Complications of Low Birth Weight

Low birth weight babies have several handicaps that make them more susceptible to a number
of problems, many of which can be life threatening, especially in smaller, more preterm infants.
Some of the key issues are noted in Table 15, along with some strategies for treatment and
management.
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1.
2.
Table 15. Complications in Low Birth Weight and Preterm Babies

Handicap
Problems
Management
Lung immaturity
Respiratory distress
Need referral to higher center
syndrome
Apnea less with KMC
Apnea (pauses in
respiration)
Difficulty in
Hypothermia very
KMC very useful in maintaining body
maintaining body
common
temperature
temperature
Hyperthermia in hot
Use of appropriate clothing
weather
3.
Immature sucking
reflex and gastrointestinal system
Difficulty in sucking,
retaining, and
assimilating feeds
Frequent breast feeds

Expressed breast milk fed with
cup/spoon
4.
Immature immune
systems and
increased exposure,
being dependent for
care on others with
frequent
handling/procedures
Increased infections
associated with high
mortality
Prevention of infection (hygienic

practices such as frequent hand
washing, breastfeeding, use of EBM)
Early identification and treatment of
infections
Avoidance of needless handling and
procedures
5.
Bleeding due to
immaturity of the liver
and poor production
of clotting factors
High risk for bleeding at

various sites, including
intracranial bleeding
Administration of vitamin K
Prevention and treatment of
problems such as asphyxia,
infections and hypothermia
6.
Increased risk of
jaundice
LBW babies can have

more prolonged jaundice
and can have brain
damage at lower levels
of bilirubin
LBW babies with any jaundice should

be referred early to an appropriate
center for evaluation and treatment
Evaluation of Infants with Low Birth Weight

Since this manual primarily relates to basic care at peripheral health facilities, it will not deal with
how to differentiate between premature and growth-retarded babies. Rather, it will focus on
how to identify babies that need to be transferred to a higher level of care and those that may be
managed locally at the place of birth. It will also focus on a simple low-cost method of
management of these vulnerable babies, namely, kangaroo mother care.
In general, babies weighing more than 1800 grams at birth, without problems and danger signs,
can fare well if managed appropriately. They may, thus, be cared for by trained personnel in a

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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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CARE OF LOW BIRTH WEIGHT BABIES

Provide extra care for these vulnerable babies. While in general the same basic care should be
followed as with normal newborn babies, the LBW baby will require extra attention in three
areas:
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
washing of hands before handling the baby

breastfeeding/use of breast milk and avoidance of other milks and fluids
avoiding unnecessary visitors and needless handling
Other care is the same as that for all newborns:
Weigh the baby at birth.

Check breathing and temperature frequently: every 15 minutes for the first 2 hours,
every 30 minutes in the third hour, then every hour until 6 hours, and then every 3 hours
or at feed times. Very small babies tend to stop breathing periodically (apnea). Such
babies need to be stimulated by rubbing the back or a limb and will need to be taken to
the referral hospital in the kangaroo mother care position with stimulation as required.
The mothers respiratory movements serve to stimulate the baby to breathe better with
fewer apneic pauses.
If the baby has no breathing problems and sucks well:
o
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.
At birth give a dose of 1 mg of vitamin K IM (0.5 mg if the baby weighs <1500grams).

Refer babies <1800 grams and those with problems irrespective of weight to a higher
level health facility using skin-to skin contact during transport. Make sure that if the baby
is able to swallow, he/she is breastfed or receives breast milk by cup/spoon/ appropriate
traditional feeding device (see section on transport of babies). Before transfer, take care
to:
o
o
Stabilize the baby.

Provide the first dose of antibiotic if:
there is a danger sign
the mother had fever or other features of infection and/or

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there is premature rupture of membranes or leaking of the amniotic fluid for

more than 18 hours
o
Follow the other guidelines for referral noted in chapter 13 on major infections.
Kangaroo Mother Care

Kangaroo mother care (KMC) is a simple method that promotes the health and the well-being of
the LBW/preterm baby by skin-to-skin contact with his/her
mother or another person through maintaining the babys body
temperature and encouraging exclusive breastfeeding.
In some countries, mothers do not like being compared to an
animal. If this is the case, describe this method of care as skinto-skin contact to protect the vulnerable low birth weight infant.
Figure 12.2. The kangaroo with the

baby in the pouch.
Advantages of KMC
For the baby:
It is a low cost method that is a good alternative to conventional care of preterm/LBW

babies in low resource countries.
The outcome has been similar to use of an incubator, which is more expensive and more
difficult to maintain.
The baby is comfortable in this position and is quieter, crying less frequently than in
incubators.
The vertical position decreases the risk of aspiration, improves cardio-respiratory
functions, and decreases apnea.
Closeness to the breast favors frequent sucking that prolongs the duration of
breastfeeding.
The hospital stay is shorter.
For the mother:
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
Selecting Babies for KMC:

The common criteria for deciding whether to use KMC for an LBW baby include:
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
The KMC Technique
Advise the mother to maintain good hygiene, including daily baths, change of clothes,
frequent hand washing, and short and clean fingernails.
Figure 12.3. Kangaroo mother care.

(WHO, 2003)
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 12.4. How to dress the baby for Kangaroo Care.

(WHO, 2003)
Figure 12.5. Photo of kangaroo mother care. (Source: Delphin Muyila, DRC)
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Breastfeeding the LBW Baby in KMC
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
Wait until the baby is awake.

Loosen the wrap around the baby.
Hold the baby with the mouth close to the nipple.
Express a few drops of breast milk.
Let the baby smell and lick the nipple and open the mouth.
Express milk into the babys open mouth.
Wait for the baby to swallow the milk.
Repeat the procedure until the baby closes his/her mouth and will not take any more
milk even after stimulation.
Alternatively, milk can be expressed from the breast into a clean container that has
been sterilized by boiling for 10 minutes, and feed the baby by cup, spoon, or a
suitable traditional feeding device.
Note: If the infant cannot suck/accept feeds, he/she needs referral for care
at a higher level facility. Do not introduce milk into the mouth of the baby
who cannot swallow.
Counsel the Mother and Family about KMC

Counsel the mother and the family:
On the benefits of KMC.

To use an extra cloth or towel beneath the babys bottom to avoid soiling of the mothers
clothes, and change the cloth/diaper frequently. If a cloth is used, advise to always use a
clean, dry cloth for the newborns diaper.

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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.
Figure 12.6. The mother, the father, or another family

member may keep the baby on the chest.
Practicing KMC after Discharge

Advise the mother and family to:
Continue kangaroo mother care at home.

Seek care with an appropriate health worker/center as designated if the baby develops
any of the following danger signs (the first five are most important):
o
o
o
o
o
o
o
Come for regular follow-up care:

o
o
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difficulty in sucking or not sucking at all

lethargy/inactivity
fever/body too hot or hypothermia/body feeling too cold
fast breathing/difficulty in breathing
convulsions
persistent vomiting, abdominal distension
redness, swelling around the umbilicus and/or foul smell, with or without pus
discharge and/or pus discharge
Make the first follow-up appointment one week after discharge.

While the exact intervals may vary in individual cases, in general, counsel for
continued weekly follow-up of the LBW infant until the baby is doing well and
preferably until the weight reaches 2000 grams.
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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.
DISCHARGE OF THE LOW BIRTH WEIGHT BABY

Babies are fit for discharge if:
Their general health is good.

There are no features of infection or danger signs.
The baby is sucking well, and breastfeeding is well established.
The baby is gaining weight or at least the weight is stabilized for three consecutive days
(but some wait until the babys weight reaches 1800 grams).
The baby is maintaining temperature well, with extra clothing or with kangaroo mother
care, for at least three consecutive days.
The baby has no obvious problems.
The health personnel judges that the mother is able to take care of her baby, and the
mother/family feels confident with caring for the baby.
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).
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Care of the LBW baby

(Birth weight less than 2500 gm; preterm - < 37 wks.,
intrauterine growth retardation, or both)
Wash hands before touching the baby
Dry and wrap the baby including head/start skin-to-skin contact
Practice early and frequent exclusive breastfeeding
Keep the baby warm, ideally through practicing kangaroo mother care
Delay bathing for one week or until baby is well stabilized
When bathing, use warm water, dry, wrap well or place in skin-to skin contact
Evaluate baby
Sucking well
Maintaining temperature
Has no danger signs
YES
Manage at centre/home
Counsel mother/family
Advise mother to check
baby at home at feed
times until s/he is doing
well. Weekly follow-up
by health worker
NO
At follow-up, if poor
weight gain or baby has
danger sign
Send to referral
center
Figure 12.8. Algorithm for care of the LBW baby.
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CHAPTER 13: Treatment of Infections

in the Newborn
Infections are the major cause of death during the neonatal period accounting for 35 percent of
deaths in the first four weeks of life. Newborn infants, especially low birth weight infants, are at a
particularly high risk for infection because of their underdeveloped immune processes and their
increased exposure to germs since, being totally dependent on the mother, family members and
other care providers, they come in frequent physical contact with a number of persons.
Newborn babies are also susceptible to germs that do not readily cause major infections in
normal older infants. Common organisms include E. coli, Klebsiella sps, Staphylococcus sps,
and group B streptococci. Organisms vary by region, over time, and due to long-term use of
antibiotics.
In the newborn, minor/localized infections may spread easily. Rapid progression of disease is
very common and it may become life threatening. This necessitates early identification and
prompt treatment with antibiotics. In the later stages babies not only stop sucking but are also
unable to accept and retain feeds, thereby necessitating intravenous fluids and antibiotics that
are feasible only at higher level health centers. Hence, early identification and prompt treatment
are essential.
Socio-cultural factors also influence the impact of infections. Mothers and babies are confined to
their homes, and even those who have facility births go home early and then continue to remain
there. Danger signs, even if identified, are often attributed to nonmedical reasons, and
appropriate care is not sought early so that when babies reach facilities, the disease has
advanced considerably. Many families, moreover, do not have adequate faith in the care
provided at facilities. Women are frequently not empowered, and major decisions in the family
are made by the men. While paternal grandmothers may have some influence, mothers often
have very little influence when medical decisions are being made. Some families are also
handicapped by little or no access to services, either because of distance or due to lack of
finances.
Pre-service education of doctors, nurses, and midwives related to newborn care is often
inadequate and inappropriate, so that basic health workers do not have the competence to
manage newborn infants, especially sick babies. They also do not have the support of the
necessary equipment, supplies, and drugs of appropriate sizes and strengths. Their interaction
with families also presents challenges in some cases due to lack of courtesy. They often do not
have the time nor the skills to establish rapport and to counsel mothers and families effectively.
THE TIMING OF INFECTIONS

Some infections are early onset and some are late onset. Early onset infections (from delivery
through day 3) are usually acquired from maternal risk factors and during delivery. These
factors include:
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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.
TYPES OF NEONATAL INFECTION

Major Infections
Specific entities such as pneumonia, diarrhea, septicemia, and meningitis are difficult to
diagnose in the newborn, as the signs may be nonspecific and the disease spreads rapidly to
involve several organs. Hence, the catch-all term neonatal sepsis is used in the public health
area.
Relevant to diarrheas in the newborn period, babies receiving breast milk pass loose stools
with separate watery and curdy portions several times a day, being particularly frequent in
days 3-5. These are termed transitional stools and may be wrongly diagnosed as diarrhea,
and oral rehydration solution/therapy may be given. The latter is not only needless, but it may
also carry a risk of causing real infection if given in an unhygienic manner.
The risk of diarrheas and other major infections is particularly high if initiation of breastfeeding is
delayed and the newborn and the infant under six months receive other milks and fluids. Thus,
even when the mother is HIV-positive and opts to give formula feeds, the health workers should
counsel and support the family adequately to ensure that the feeds are given in a clean manner.
Otherwise there is a real risk of the baby developing diarrhea with spread of infection that can
result in complications and even death. Where appropriate care is not taken, especially in
illiterate, low socio-economic groups, there will actually be a greater chance of babies dying of
such infections than from HIV/AIDS.
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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.
IDENTIFYING AND TREATING MAJOR INFECTIONS

Very early signs of major infection/neonatal sepsis are vague and sometimes difficult to
recognize, but early detection is needed as it takes time to effect referral to suitable centers.
These early features include vague signs such as the baby just not looking well or appearing
as if he/she is just not well, at times described as a facial grimace. However, these early
features are more difficult to detect and require careful daily observation. Mothers, family
members, and health care providers should be encouraged to view the baby in adequate light at
least once a day, especially in the first week or two.
More conventional clinical features labeled as danger signs used to identify newborn sepsis
include the following (the first five are the most important):
sucking less or poor/no sucking

lethargy or diminished activity/inactivity
fever (body too hot) or hypothermia (body feeling too cold)
rapid breathing/difficulty in breathing
convulsions
repeated or persistent vomiting and/or abdominal fullness
features of severe umbilical infection (peri-umbilical redness, swelling and/or foul
smelling, with or without pus discharge and/or foul smell)
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
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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
Not sucking at all; sucking less than

usual; not opening the mouth when
offered feeds; not demanding feeds.
Fever/low
body
temperature
Rapid
breathing/
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Not as active as usual, sleeping

excessively, difficult to arouse,
moving only when stimulated, not
waking up for feeds, lying limp,
loose-limbed, excessively quiet or
too good.
Fever: Body hot to touch, history of
the mouth feeling excessively hot
during breastfeeding; temperature
more than 37.5 C
Hypothermia: Body colder than
normal; temperature less than 36.5
C.
Respiration more than 60/minute
(verify by counting a second time),
MANAGEMENT
Administer (a) First doses of the two

antibiotics: ampicillin and
gentamycin; (b) vitamin K 1 mg if it
was not given at birth; (c) Diazepam
if convulsions: 0.5 mL rectally, or IM
(thigh) or slow IV .
Send the baby to the referral
hospital.
Explain to the mother why the baby
needs referral and advise her to go
along with another attendant.
Advise how to care for the baby
during transport:
o Keep the baby warm by skin-toskin contact (see chapter 12 on
LBW and KMC).
o To prevent hypoglycemia, if the
baby can accept feeds give
direct breastfeeding or
expressed breast milk with cup.
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difficulty in
breathing
Abdominal
distension
flaring of the nostrils, groaning or

grunting, severe sub-costal
retraction.
Features of convulsions are often
atypical in the newborn, such as a
staring look, blinking of eyelids,
chapping movements of the lips,
clonic/tonic movements of the limbs.
Occasional vomiting is common but
persistent vomiting is abnormal, as
is green-colored vomitus.
Distension or fullness of the
abdomen.
Severe
umbilical
infection
Spreading redness or swelling

around the umbilicus and/or foul
smell, with or without pus discharge.
Convulsions
Persistent
vomiting
Do not attempt to feed a baby

that cannot swallow fluids.
o Check the baby frequently to
ensure that there is no additional
problem.
o If possible, contact the referral
center to inform them.
Send a referral note with the mother
indicating:
o name and address of the mother
o date and time of birth
o problems if any at birth
o reasons for referral
o treatment given
o advice given
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.
Referral and Transport of Sick Newborns

The condition of the sick newborn with sepsis may deteriorate rapidly. It is important to stabilize
the baby prior to transfer. Some of the key tasks are noted below:
Provide information and counseling to the mother and family.

Explain to the mother and family members the problem and reason for the transfer.
Answer their questions.
Explain that even if the transport has its own risk, the required treatment cannot be
provided at the peripheral health center or at home.
Describe what to expect at the referral center.
Explain care of the newborn during transport:
o
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.
Prepare the baby for transport:

o
Arrange for the fastest means of transportation.

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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.
name and address of the mother

date and time of birth
reason for referral
treatment initiated
all available information on pregnancy, labor, delivery, postnatal period, and
supplemental information on the baby
advice given
If the transfer is delayed or not possible for any reason:

o
o
Continue the antibiotic treatment, breast feeding/feeding of expressed breast milk,

and skin-to-skin contact.
Continue family support.
IDENTIFYING AND TREATING MINOR INFECTIONS

Conjunctivitis/Eye Infections
At peripheral health centers it is not possible to carry out cultures. Unfortunately, gonococcal
infection is a serious problem and can lead to blindness. Assume and treat as gonococcal
infection if there is frank pus discharge in endemic areas in babies within the first week, with or
without swelling:
Give ceftriaxone IM 50 mg/kg in a single dose.

While wearing gloves, clean the eyelids using cotton swabs that have been sterilized by
boiling in clean water for at least 10 minutes and then cooled down before putting in the
eye drops/ointment, such as tetracycline, as recommended by the Ministry of Health.
Teach the mother and ask her to repeat the treatment 4 times/day.
If the mother and baby are near a health facility, there is no need to admit the mother
and baby; otherwise they need to be admitted.
Treat the mother and partner, if not already treated. Give ceftriaxone 250 mg IM as a
single dose to the mother and give a ciprofloxacin, 500 mg orally as a single dose to the
partner.
Where the above drugs are not available, refer to an appropriate hospital.
If you are in a non-endemic area and the eyes are red and sticky, without excess pus
discharge:
o
o
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.
Treating thrush in the diaper area
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.
Local Infection of the Umbilicus

Local umbilical infection may be associated with stickiness or pus discharge from the base of
the cord or from the umbilicus after the cord falls off. Redness and swelling of the skin around
the umbilicus and a foul smell are features of a serious umbilical infection. Treat the infection as
follows:
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 :
Fewer than ten pustules/blisters, with no signs of sepsis:

o
o
o
o
Wash the affected areas with an antiseptic.

Swab the pustules/blisters with gentian violet 4 times a day until they are healed.
Ask the mother to bring the baby for follow-up after 2 days.
If the lesions dont clear but there are no danger signs, give erythromycin or
cloxacillin by mouth for 5 days (50 mg/kg every 12 hours the first week of life; every 8
hours the 2nd week of life; and subsequently every 6 hours). If not available, try oral
amoxicillin (every 12 hours the first week of life, older than 1 week, every 8 hours).
Ten or more pustules/blisters with no danger signs of sepsis:

o
o
o
o
Continue local treatment as noted above.

Give cloxacillin orally.
Ask the mother to come back for follow-up, ideally the next day or at least after 2
days.
Assess the baby for signs of improvement (not spreading and drying):
If there is improvement, continue treatment to complete 5-7 days.
If there is no improvement, add gentamicin (Day 1-7): 4 mg/kg IM once daily for
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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Table 17: Summary of Treatment of Minor Infections

IDENTIFICATION
TREATMENT
Pus discharge from Treat as gonococcal infection in endemic
the eyes with or
areas: (ceftrioxone 50 mg/kgIM) plus
without redness
eye toilet and tetracycline drops or
ointment. Treat parents.
Minor umbilical
Pus discharge from Clean the cord base/depth of the umbilicus
infection
umbilicus or base of well with alcohol and apply antiseptic (such
cord
as chlorhexidine, Betadine, triple dye, or
gentian violet).
Thrush
Dirty white patches Local application of nystatin or gentian
on the tongue, inner violet: a drop or two in the mouth 4 times a
cheeks, and palate day.
Pustules, boils,
Pustules or peeling Clean the skin with an antiseptic solution. If
impetigo
of skin
not available, use soap and water. If less
than 10 pustules, apply gentian violet paint
twice a day. If more than 10, give oral
antibiotics amoxicillin or erythromycin. If no
improvement in 2 days change to oral
cloxacillin for 7-10 days.
PROBLEM
Conjunctivitis
Source: WHO. 2003. Managing Newborn Problems: A Guide for Doctors, Nurses and Midwives.
PREVENTING INFECTIONS
During the prenatal period:
Give tetanus immunization.

Follow guidelines for preventing and treating sexually transmitted diseases, HIV/AIDS,
and malaria.
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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APPENDIX A: Selection and Storage

of Uterotonic Drugs
The information in this appendix comes from POPPHI. Prevention of Postpartum Hemorrhage:
Implementing Active Management of the Third Stage of Labor (AMTSL): A Reference Manual
for Health Care Providers. Seattle: PATH; 2007. Available at:
http://www.pphprevention.org/AMTSLlearningmaterials.php. Accessed October 16, 2008.
Uterotonics act directly on the smooth muscle of the uterus and increase the tone, rate, and
strength of rhythmic contractions. The body produces a natural uterotonicthe hormone
oxytocinthat acts to stimulate uterine contractions at the start of labor and throughout the birth
process.
Drugs such as oxytocin, ergometrine, and misoprostol have strong uterotonic properties and are
used to treat uterine atony and reduce the amount of blood lost after childbirth. Oxytocin is
widely used for induction and augmentation of labor. The use of a uterotonic drug immediately
after the delivery of the newborn is one of the most important actions used to prevent
postpartum hemorrhage.
UTEROTONIC DRUGS USED FOR AMTSL

Oxytocin is fast-acting, inexpensive, and in most cases has no side effects or contraindications
for use during the third stage of labor. Oxytocin is also more stable than ergometrine in hot
climates and light (when cold/dark storage is not possible). WHO recommends oxytocin as the
drug of choice for AMTSL and advises that ergometrine, Syntometrine, or misoprostol be used
only when oxytocin is not available.
WHO recommends oxytocin as the drug of choice for AMTSL.
Table A.1 compares dosage, route of administration, drug action and effectiveness, side effects,
and cautions for the most common uterotonic drugs used for AMTSL.
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Table A.1. Uterotonic Drugs for AMTSL

Name of
drug/preparation
Oxytocin
Posterior pituitary
extract. Commonly
used brand names
include Pitocin or
Syntocinon.
Misoprostol
Synthetic prostaglandin
E1 (PGE1) analogue.
Commonly used brand
names include Cytotec,
Gymiso, Prostokos,
Vagiprost, U-Miso
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
Drug action and

effectiveness
Acts within 2-3
Give 10
units IM
injection.*
Give 600
mcg (three
200 mcg
tablets)
orally.
Side effects and cautions
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.
No known contraindications for

postpartum use.**
Common side effects: shivering
and elevated temperature.
Contraindicated in women with

a history of hypertension, heart
disease, retained placenta,
preeclampsia, or eclampsia.***
Causes tonic contractions (may
increase risk of retained
placenta).
Side effects: nausea, vomiting,
headaches, and hypertension.
Note: Do not use if the drug is
cloudy; this means it has been
exposed to excess heat or light and
is no longer effective.
Give 0.2 mg
IM injection.
Give 1 mL
IM injection.
Acts within 6-7

minutes IM.
Effect lasts 24 hours.
Combined rapid
action of oxytocin
and sustained
action of
ergometrine.
Same cautions and

contraindications as
ergometrine.
Side effects: nausea, vomiting,
headaches, and hypertension.
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.
Table A.2. Change in Effectiveness of Injectable Uterotonic Drugs

after One Year of Controlled Storage
Uterotonic
drug
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
Effects of heat and light/key

findings
Minimal effect from light, more
stable for longer time at higher
temperatures than ergometrine.
Significantly more affected by heat
and light, not stable at higher
temperatures.
Keeping Uterotonic Drugs Effective

The stability of a drug is defined by how well it maintains active ingredient potency (and other
measures such as pH) when stored over time. Pharmaceutical companies conduct stability
studies to determine the appropriate shelf-life, storage conditions, and expiration dating for safe
storage of the oxytocin they produce. Manufacturers will recommend storage conditions based
on the conditions under which they have performed stability studies, and will set the expiry date
to be consistent with this. It is therefore important to read storage recommendations made by
the manufacturer.
Since ergometrine and Syntometrine are sensitive to heat and light, and oxytocin is sensitive to
heat, following the storage guidelines is critical to ensure the optimal effectiveness of injectable
uterotonic drugs. When drugs are inadequately stored, drug effectiveness can diminish, posing
serious consequences for the postpartum woman.
Storage practices in health care facilities vary widely and may not follow guidelines for correct
storage. For example, vials of uterotonic drugs might be kept on open trays or containers in the
labor ward, leaving them exposed to heat and light. Pharmacists, pharmacy managers, and birth
attendants using oxytocin need to carefully read and follow recommended guidelines for
transporting and storing uterotonic drugs. Recommended guidelines for transporting and storing
specific uterotonic drugs are noted in Table A.3.
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Table A.3. Recommended Guidelines for Transport and

Storage of Uterotonic Drugs
Drug
Transport
Storage
Oxytocin
Unrefrigerated transport is
possible if no more than one
month at 30 C.
Misoprostol
Protect from humidity.
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.
Tips To Increase Uterotonic Drug Effectiveness

In the pharmacy:
Make sure that there are adequate stocks of uterotonic drugs, syringes, and injection
safety materials.
Check the manufacturers label for storage recommendations.
Make sure that there is a system in place to monitor the temperature of the
refrigerator/cold box; record the temperature in the refrigerator on a regular basis,
preferably at the hottest times of the day (put thermometers in different parts of the
refrigerator).
Make sure that there is a back-up system in place in case of frequent electricity cuts; for
example, gas or solar refrigerators, placing ice packs in the refrigerator to keep it cool,
etc.
Follow the rule of first expired-first out (or first in-first out) and maintain a log to keep
track of expiration dates to reduce wastage of uterotonic drugs.
Store misoprostol at room temperature and away from excess heat and moisture.
To ensure the longest life possible of injectable uterotonics, keep them refrigerated at 28 C.
Protect ergometrine and Syntometrine from freezing and light.
In the delivery room:
Check the manufacturers label for recommendations on how to store injectable

uterotonic drugs outside the refrigerator. In general:

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o
o
o
Oxytocin may be kept outside the refrigerator at a maximum of 30 C (warm, ambient

climate) for up to three months and then discarded.
Ergometrine and Syntometrine vials may be kept outside the refrigerator in closed
boxes and protected from the light for up to one month at 30 C and then discarded.
Misoprostol should be stored at room temperature away from excess heat and
moisture.
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.
Ergometrine loses 21-27 percent potency in one month of exposure to indirect

sunlight.
Oxytocin has no loss of potency after one month of exposure to indirect sunlight.
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APPENDIX B: Alternative Assessment/Physical

Examination of the Newborn at More
Established Peripheral Centers
TIMING OF ASSESSMENTS
As soon as feasible after birth.

At least once a day as long as the baby is in the facility.
Before discharge. This is extremely important to detect any high risk factor or a danger
sign in the early stages. These may necessitate a longer stay at the facility,
commencement of treatment/referral to the hospital, or the recommendation of an earlier
follow-up visit. The early postpartum period is very important; 75 percent of deaths in
babies take place in the first week following the birth.
At first and follow-up visits in the postnatal period.
CONDUCTING THE ASSESSMENT

Preparation
Wash your hands with soap and water.

Greet the mother/attendant, make her and the baby comfortable in a warm place free of
drafts, and explain what is going to be done.
Ask the Mother/Family
about any problems noted by them in the baby

how the baby is feeding
about stools, and urination (number, quality, etc)
about the presence of specific danger signs including:
o
o
o
o
o
o
o
difficulty in/poor feeding

lethargy or diminished activity
fever or body feeling too cold
fast breathing/difficulty in breathing
repeated vomiting and/or abdominal fullness
convulsions
signs related to severe umbilical infection (surrounding redness, swelling, foul smell
with or without pus discharge)
Assess for Danger Signs

Check for general alertness and activity. Except in deep sleep, babies move frequently,
spontaneously, and on stimulation. The arms and legs are flexed. If a limb is consistently
kept straight, evaluate for paralysis. Note also if the limbs seem very limp or flaccid.
Assess temperature:
o
Assess the body temperature by at least touching the babys abdomen, hands, and
feet and ensuring all are warm.

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Assess respiration: Normal respiratory rate is 30-60 breaths/minute. Although breathing

can be somewhat irregular with short pauses, there should be no apnea which is defined
as cessation of breathing lasting for more than 20 seconds or of a shorter duration
associated with cyanosis, pallor, or bradycardia, with heart rate less than 110/minute.
The normal heart rate ranges between 110-160 beats/minute, with the lower rates when
the baby is asleep and the higher rates when the baby is active or crying. There should
be no:
o
o
o
o
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.
flaring of the nostrils

grunting
increased respiratory rate above 60/minutes
severe subcostal retractions
Look for abdominal fullness.

Examine the umbilical cord, taking care to lift it to see the base/umbilicus. Check for pus
discharge, redness, swelling, foul smell.
Take the Babys Weight
Place a clean cloth or paper on the baby scale pan.

Adjust the weight so it reads zero with the paper/cloth on it.
Place the baby over a paper or a cloth. If cloth, fold it to cover the body of the baby.
Write down the weight of the baby in the mother/baby and ward records based on
recommendations of the Ministry of Health.
The normal weight range is 2.5-4 kg. Low birth weight is below 2.5 kg.
Examine the Newborn

In general newborn babies are examined from head to toe and front to back.
Head
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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Cephalhematoma is a subperiostial hemorrhage that is usually seen as a fluctuant

swelling 48-72 hours after delivery. It never extends across the suture line. Most resolve
within a few weeks and need no treatment.
Eyes
Subconjunctival hemorrhage can be a normal finding following the delivery.

Check for conjunctivitis, seen as redness and/or discharge.
Skin and mucous membranes
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
tiny raised white/pale yellow dots on the face (milia)

collections of tiny capillary vessels on the face over the forehead and upper lips
(telangiectasia)
bluish areas over the back and limbs (Mongolian spots/patches)
reddish spots/patches on the skin (toxic erythema)
Check for jaundice

Unlike in older infants, it is not easy to see jaundice in the early phase in the eyes of the
newborn; it is best assessed in the skin. Jaundice starts in the face and spreads down to the
hands and feet.
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.

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Chest
Look for symmetry and movement during breathing.

The breasts in both boys and girls may be engorged and secrete a small amount of milk.
Do not express the babys breasts, as it may lead to trauma and infection.
Listen to the heart sounds with a stethoscope. The rate is faster in the newborn period,
the range being 110-160/minute. Soft murmurs may be normal in the early newborn
period.
Abdomen
The abdomen should be rounded and soft.

Check the umbilical cord for:
o
o
o
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
The urethra opens at the end of the penis.

Do not try to retract the prepuce, as it is often adherent at this stage.
One or both the testes are felt in the scrotum in a full term baby, but they may be
undescended in a preterm infant.
If the baby has been circumcised, check for any signs of bleeding or infection.
Examine the groin and scrotal sac for hernias and hydroceles:
o
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
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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).
Check the back
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:
The babys chin is touching or nearly touching the breast.

The lower lip is everted.
Most of the areola is inside the mouth, especially the part below, so that it is visible more
above the mouth than below.
The sucking is slow and deep and swallowing is often audible.
Counsel the Mother/Family

Advise the mother on:
frequent breastfeeding on demand day and night

keeping the baby appropriately warm
washing hands before handling the baby, at least after using the toilet and after
changing the napkin/diaper
having an extra meal and additional fluids
the danger signs to look for in herself and in the baby
when she has to come with the baby for follow-up and for immunization (make an
appointment)

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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
Figure C.1. Newborn periods.
Physiologic (expectant) management of the third stage of labor (PMTSL):

Management of the third stage of labor that involves waiting for signs of placental
separation and allowing for spontaneous delivery of the placenta aided by gravity and/or
nipple stimulation. The components of PMTSL are:
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.

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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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HEALTH

INTEGRATED MATERNAL AND

U.S. Agency for International Development

Deborah Armbruster, Project Director

Indira Narayanan, Sr. Technical Advisor,

Integrated maternal and newborn care

Community Level Tools:

Integrated maternal and newborn care

Jean Pierre Rakotovao

Marie Claude Mbuyi

Integrated maternal and newborn care

Editing and Formatting

Integrated maternal and newborn care

Integrated maternal and newborn care

CHAPTER 9: BASIC SYSTEMATIC EXAMINATION OF A NEWBORN AT PERIPHERAL

Integrated maternal and newborn care

Where do newborns die?

Integrated maternal and newborn care

List of Figures (cont.)

Two positions for breastfeeding

Mixing a 0.5% chlorine decontamination solution

Integrated maternal and newborn care

About the Learning Materials

Community Level Tools

Guide for Training Community Health Workers/Volunteers to Provide Maternal and

Integrated maternal and newborn care

Guide for Training Community Health

Integrated maternal and newborn care

acceptable, feasible, affordable, sustainable, and safe

active management of the third stage of labor

controlled cord traction

cotrimoxazole prophylaxis therapy

disseminated intravascular coagulopathy

essential newborn care

human immunodeficiency virus

integrated management of childhood illnesses

intermittent preventive treatment in pregnancy

intrauterine growth retardation

lactational amenorrhea method (for family planning)

low birth weight

mother-to-child transmission of HIV/AIDS

prevention of mother-to-child transmission of HIV/AIDS

Integrated maternal and newborn care

prevention of postpartum hemorrhage

premature rupture of membranes

rapid assessment and management

Reactive Plasma Reagin

third stage of labor

United States Agency for International Development

urinary tract infection

Venereal Disease Research Laboratory

vaccine vial monitor

World Health Organization

Integrated maternal and newborn care

FOUR MILLION NEONATAL DEATHS: WHERE DO THEY OCCUR?

1.1 million (28% of all

Lancet series, 2005

1.5 million (38% of all

99% of newborn deaths are in low/middle income countries

Figure Intro. 1. Where do newborns die?

Integrated maternal and newborn care

FOUR MILLION NEONATAL DEATHS: WHAT DO BABIES DIE OF?

Causes of Neonatal Mortality