Department of Making Pregnancy Safer

2nd Edition

Integrated Management of Pregnancy and Childbirth

Pregnancy, Childbirth, Postpartum and Newborn Care:A guide for essential practice

World Health OrganizationGeneva 2006

WHO Library Cataloguing-in-Publication Data

Pregnancy, childbirth, postpartum and newborn care : a guide for essential practice.

At head of title: Integrated Management of Pregnancy and Childbirth. 1.Labor, Obstetric 2.Delivery, Obstetric 3.Prenatal care 4.Perinatal care — methods 5.Postnatal care - methods 6.Pregnancy complications - diagnosis 7.Pregnancy complications - therapy 8.Manuals I.World Health Organization.

ISBN 92 4 159084 X (NLM classification: WQ 175)

First edition 2003 Second edition 2006

© World Health Organization 2006

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The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

Printed in Singapore

Foreword

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In modern times, improvements in knowledge and technological advances have greatly improved the health of mother and children. However, the past decade was marked by limited progress in reducing maternal mortality and a slow-down in the steady decline of childhood mortality observed since the mid 1950s in many countries, the latter being largely due to a failure to reduce neonatal mortality.

Every year, over four million babies less than one month of age die, most of them during the critical first week of life; and for every newborn who dies, another is stillborn. Most of these deaths are a consequence of the poor health and nutritional status of the mother coupled with inadequate care before, during, and after delivery. Unfortunately, the problem remains unrecognized or- worse- accepted as inevitable in many societies, in large part because it is so common.

Recognizing the large burden of maternal and neonatal ill-health on the development capacity of individuals, communities and societies, world leaders reaffirmed their commitment to invest in mothers and children by adopting specific goals and targets to reduce maternal and childhood-infant mortality as part of the Millennium Declaration.

There is a widely shared but mistaken idea that improvements in newborn health require sophisticated and expensive technologies and highly specialized staff. The reality is that many conditions that result in perinatal death can be prevented or treated without sophisticated and expensive technology. What is required is essential care during pregnancy, the assistance of a person with midwifery skills during childbirth and the immediate postpartum period, and a few critical interventions for the newborn during the first days of life.

It is against this background that we are proud to present the document Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice, as new additions to the Integrated Management of Pregnancy and Childbirth tool kit. The guide provides a full range of updated, evidence-based norms and standards that will enable health care providers to give high quality care during pregnancy, delivery and in the postpartum period, considering the needs of the mother and her newborn baby.

We hope that the guide will be helpful for decision-makers, programme managers and health care providers in charting out their roadmap towards meeting the health needs of all mothers and children. We have the knowledge, our major challenge now is to translate this into action and to reach those women and children who are most in need.

dr. Tomris TürmenExecutive director Family and Community Health (FCH)

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The Guide was prepared by a team of the World Health Organization, Department of Reproductive Health and Research (RHR), led by Jerker Liljestrand and Jelka Zupan.

The concept and first drafts were developed by Sandra Gove and Patricia Whitesell/ACT International, Atlanta, Jerker Liljestrand, Denise Roth, Betty Sweet, Anne Thompson, and Jelka Zupan.

Revisions were subsequently carried out by Annie Portela, Luc de Bernis, Ornella Lincetto, Rita Kabra, Maggie Usher, Agostino Borra, Rick Guidotti, Elisabeth Hoff, Mathews Matthai, Monir Islam, Felicity Savage, Adepeyu Olukoya, Aafje Rietveld, TinTin Sint, Ekpini, Ehounu, Suman Mehta.

Valuable inputs were provided by WHO Regional Offices and WHO departments:■ Reproductive Health and Research ■ Child and Adolescent Health and Development ■ HIV/AIDS■ Communicable Diseases ■ Nutrition for Health and Development ■ Essential Drugs and Medicines Policy ■ Vaccines and Biologicals ■ Mental Health and Substance Dependence ■ Gender and Women’s Health ■ Blindness and Deafness

editing: Nina Mattock, Richard Casnalayout: rsdesigns.com sàrlcover design: Maíre Ní Mhearáin

WHO acknowledges with gratitude the generous contribution of over 100 individuals and organizations in the field of maternal and newborn health, who took time to review this document at different stages of its development. They came from over 35 countries and brought their expertise and wide experience to the final text.

This guide represents a common understanding between WHO, UNFPA, UNICEF, and the World Bank of key elements of an approach to reducing maternal and perinatal mortality and morbidity. These agencies co-operate closely in efforts to reduce maternal and perinatal mortality and morbidity. The principles and policies of each agency are governed by the relevant decisions of each agency’s governing body and each agency implements the interventions described in this document in accordance with these principles and policies and within the scope of its mandate.

The guide has also been reviewed and endorsed by the International Confederation of Midwives, the International Federation of Gynecology and Obstetrics and International Pediatric Association.

The financial support towards the preparation and production of this document provided by UNFPA and the Governments of Australia, Japan and the United States of America is gratefully acknowledged, as is financial support received from The World Bank. In addition, WHO’s Making Pregnancy Safer initiative is grateful to the programme support received from the Governments of the Netherlands, Norway, Sweden and the United Kingdom of Great Britain and Northern Ireland.

Acknowledgements

AcknOWledgemenTs

International Pediatric Association

International Confederation of Midwives

International Federation of Gynecology and Obstetrics

Table of contents

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A InTrOducTIOn

IntroductionHow to read the guide Acronyms Content Structure and presentation Assumptions underlying the guide

A PrIncIPles OF gOOd cAre

A2 CommunicationA3 Workplace and administrative proceduresA4 Standard precautions and cleanlinessA5 Organising a visit

b QuIck cHeck, rAPId AssessmenT And mAnAgemenT OF WOmen OF cHIldbeArIng Age

b2 Quick checkb3-b7 Rapid assessment and management b3 Airway and breathing b3 Circulation (shock) b4-b5 Vaginal bleeding b6 Convulsions or unconscious b6 Severe abdominal pain b6 Dangerous fever b7 Labour b7 Other danger signs or symptoms b7 If no emergency or priority signs, non urgent

B emergency TreATmenTs FOr THe WOmAn

b9 Airway, breathing and circulation b9 Manage the airway and breathing b9 Insert IV line and give fluids b9 If intravenous access not possibleb10-b12 Bleeding b10 Massage uterus and expel clots b10 Apply bimanual uterine compression b10 Apply aortic compression b10 Give oxytocin b10 Give ergometrine b11 Remove placenta and fragments manually b11 After manual removal of placenta b12 Repair the tear and empty bladder b12 Repair the tear or episiotomyb13-b14 Important considerations in caring for a woman with eclampsia or pre-eclampsia b13 Give magnesium sulphate b13 Important considerations in caring for a woman with eclampsia b14 Give diazepam b14 Give appropriate antihypertensive drugb15 Infection b15 Give appropriate IV/IM antibioticsb16 Malaria b16 Give arthemether or quinine IM b16 Give glucose IVb17 Refer the woman urgently to the hospital b17 Essential emergency drugs and supplies for transport and home delivery

b bleedIng In eArly PregnAncy And POsT-AbOrTIOn cAre

b19 Examination of the woman with bleeding in early pregnancy and post-abortion careb20 Give preventive measuresb21 Advise and counsel on post-abortion care b21 Advise on self-care b21 Advise and counsel on family planning b21 Provide information and support after abortion b21 Advise and counsel during follow-up visits

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c2 Assess the pregnant woman: pregnancy status, birth and emergency plan c3 Check for pre-eclampsia c4 Check for anaemia c5 Check for syphilis c6 Check for HIV statusc7 Respond to observed signs or volunteered problems

c7 If no fetal movement c7 If ruptured membranes and no labour c8 If fever or burning on urination c9 If vaginal discharge c10 If signs suggesting HIV infection c10 If smoking, alcohol or drug abuse, or history of violence c11 If cough or breathing difficulty c11 If taking antituberculosis drugsc12 Give preventive measuresc13 Advise and counsel on nutrition and self-carec14-c15 Develop a birth and emergency plan c14 Facility delivery c14 Home delivery with a skilled attendant c15 Advise on labour signs c15 Advise on danger signs c15 Discuss how to prepare for an emergency in pregnancyc16 Advise and counsel on family planning c16 Counsel on the importance of family planning c16 Special consideration for family planning counselling during pregnancyc17 Advise on routine and follow-up visitsc18 Home delivery without a skilled attendantc19 Assess eligibility of ARV for HIV-positive pregnant woman

d cHIldbIrTH – lAbOur, delIvery And ImmedIATe POsTPArTum cAre

d2 Examine the woman in labour or with ruptured membranesd3 Decide stage of labourd4-d5 Respond to obstetrical problems on admissiond6-d7 Give supportive care throughout labour d6 Communication d6 Cleanliness d6 Mobility d6 Urination d6 Eating, drinking d6 Breathing technique d6 Pain and discomfort relief d7 Birth companiond8-d9 First stage of labour d8 Not in active labour d9 In active labourd10-d11 Second stage of labour: deliver the baby and give immediate newborn cared12-d13 Third stage of labour: deliver the placentad14-d18 Respond to problems during labour and delivery d14 If fetal heart rate <120 or >160 beats per minute d15 If prolapsed cord d16 If breech presentation d17 If stuck shoulders (Shoulder dystocia) d18 If multiple birthsd19 Care of the mother and newborn within first hour of delivery of placentad20 Care of the mother one hour after delivery of placentad21 Assess the mother after deliveryd22-d25 Respond to problems immediately postpartum d22 If vaginal bleeding d22 If fever (temperature >38°C) d22 If perineal tear or episiotomy (done for lifesaving circumstances) d23 If elevated diastolic blood pressure d24 If pallor on screening, check for anaemia d24 If mother severely ill or separated from the child d24 If baby stillborn or deadd25 Give preventive measures

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d26 Advise on postpartum care d26 Advise on postpartum care and hygiene d26 Counsel on nutritiond27 Counsel on birth spacing and family planning d27 Counsel on the importance of family planning d27 Lactation amenorrhea method (LAM)d28 Advise on when to return d28 Routine postpartum visits d28 Follow-up visits for problems d28 Advise on danger signs d28 Discuss how to prepare for an emergency in postpartumd29 Home delivery by skilled attendant d29 Preparation for home delivery d29 Delivery care d29 Immediate postpartum care of mother d29 Postpartum care of newborn

e POsTPArTum cAre

e2 Postpartum examination of the mother (up to 6 weeks)e3-e10 Respond to observed signs or volunteered problems e3 If elevated diastolic blood pressure e4 If pallor, check for anaemia e5 Check for HIV status e6 If heavy vaginal bleeding e6 If fever or foul-smelling lochia e7 If dribbling urine e7 If pus or perineal pain e7 If feeling unhappy or crying easily e8 If vaginal discharge 4 weeks after delivery e8 If breast problem e9 If cough or breathing difficulty e9 If taking anti-tuberculosis drugs e10 If signs suggesting HIV infection

F PrevenTIve meAsures And AddITIOnAl TreATmenTs FOr THe WOmAn

F2–F4 Preventive measures F2 Give tetanus toxoid F2 Give vitamin A postpartum F3 Give iron and folic acid F3 Give mebendazole F3 Motivate on compliance with iron treatment F4 Give preventive intermittent treatment for falciparum malaria F4 Advise to use insecticide-treated bednet F4 Give appropriate oral antimalarial treatment F4 Give paracetamolF5–F6 Additional treatments for the woman

F5 Give appropriate oral antibiotics F6 Give benzathine penicillin IM F6 Observe for signs of allergy

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G2 Provide key information on HIV G2 What is HIV and how is HIV transmitted? G2 Advantage of knowing the HIV status in pregnancy G2 Counsel on safer sex including use of condomsG3 HIV testing and counselling

G3 HIV testing and counselling G3 Discuss confidentiality of HIV infection G3 Counsel on implications of the HIV test result G3 Benefits of disclosure (involving) and testing the male partner(s)G4 Care and counselling for the HIV -positive woman

G4 Additional care for the HIV -positive woman G4 Counsel the HIV -positive woman on family planningG5 Support to the HIV-positive woman

G5 Provide emotional support to the woman G5 How to provide supportG6 Give antiretroviral (ARV) medicine(s) to treat HIV infection

G6 Support the initiation of ARV G6 Support adherence to ARVG7 Counsel on infant feeding options

G7 Explain the risks of HIV transmission through breastfeeding and not breastfeeding G7 If a woman does not know her HIV status G7 If a woman knows that she is HIV positiveG8 Support the mothers choice of newborn feeding

G8 If mother chooses replacement feeding : teach her replacement feeding G8 Explain the risks of replacement feeding G8 Follow-up for replacement feeding G8 Give special counselling to the mother who is HIV-positive and chooses breastfeedingG9 Give appropriate antiretroviral to HIV- positive woman and the newborn

G10 Respond to observed signs and volunteered problems G10 If a woman is taking Antiretroviral medicines and develop new signs/symptoms, respond to

her problemsG11 Prevent HIV infection in health care workers after accidental exposure with body fluids (post

exposure prophylaxis) G11 If a health care worker is exposed to body fluids by cuts/pricks/ splashes, give him

appropriate care.

H THe WOmAn WITH sPecIAl needs

H2 Emotional support for the woman with special needs H2 Sources of support H2 Emotional supportH3 Special considerations in managing the pregnant adolescent

H3 When interacting with the adolescent H3 Help the girl consider her options and to make decisions which best suit her needsH4 Special considerations for supporting the woman living with violence

H4 Support the woman living with violence H4 Support the health service response to needs of women living with violence

I cOmmunITy suPPOrT FOr mATernAl And neWbOrn HeAlTH

I2 Establish links I2 Coordinate with other health care providers and community groups I2 Establish links with traditional birth attendants and traditional healers

I3 Involve the community in quality of services

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J2 Examine the newborn J3 If preterm, birth weight <2500 g or twin J4 Assess breastfeeding J5 Check for special treatment needs J6 Look for signs of jaundice and local infection J7 If danger signs J8 If swelling, bruises or malformation J9 Assess the mother’s breasts if complaining of nipple or breast painJ10 Care of the newbornJ11 Additional care of a small baby (or twin)J12 Assess replacement feeding

k breAsTFeedIng, cAre, PrevenTIve meAsures And TreATmenT FOr THe neWbOrn

K2 Counsel on breastfeeding K2 Counsel on importance of exclusive breastfeeding K2 Help the mother to initiate breastfeeding K3 Support exclusive breastfeeding K3 Teach correct positioning and attachment for breastfeeding K4 Give special support to breastfeed the small baby (preterm and/or low birth weight) K4 Give special support to breastfeed twinsK5 Alternative feeding methods

K5 Express breast milk K5 Hand express breast milk directly into the baby’s mouth K6 Cup feeding expressed breast milk K6 Quantity to feed by cup K6 Signs that baby is receiving adequate amount of milkK7 Weigh and assess weight gain

K7 Weigh baby in the first month of life K7 Assess weight gain K7 Scale maintenance

K8 Other breastfeeding support K8 Give special support to the mother who is not yet breastfeeding K8 If the baby does not have a mother K8 Advise the mother who is not breastfeeding at all on how to relieve engorgementK9 Ensure warmth for the baby

K9 Keep the baby warm K9 Keep a small baby warm K9 Rewarm the baby skin-to-skinK10 Other baby care K10 Cord care K10 Sleeping K10 HygieneK11 Newborn resuscitation K11 Keep the baby warm K11 Open the airway K11 If still not breathing, ventilate K11 If breathing less than 30 breaths per minute or severe chest in-drawing, stop ventilating K11 If not breathing or gasping at all after 20 minutes of ventilationK12 Treat and immunize the baby K12 Treat the baby K12 Give 2 IM antibiotics (first week of life) K12 Give IM benzathine penicillin to baby (single dose) if mother tested RPR-positive K12 Give IM antibiotic for possible gonococcal eye infection (single dose) K13 Treat local infection K13 Give isoniazid (INH) prophylaxis to newborn K13 Immunize the newborn K13 Give antiretroviral (ARV) medicine to newborn K14 Advise when to return with the baby K14 Routine visits K14 Follow-up visits K14 Advise the mother to seek care for the baby K14 Refer baby urgently to hospital

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l eQuIPmenT, suPPlIes, drugs And lAbOrATOry TesTs

L2 Equipment, supplies, drugs and tests for pregnancy and postpartum careL3 Equipment, supplies and drugs for childbirth careL4 Laboratory tests

L4 Check urine for protein L4 Check haemoglobinL5 Perform rapid plamareagin (RPR) test for syphilis

L5 Interpreting resultsL6 Perform rapid test for HIV

m InFOrmATIOn And cOunsellIng sHeeTs

M2 Care during pregnancyM3 Preparing a birth and emergency planM4 Care for the mother after birthM5 Care after an abortionM6 Care for the baby after birthM7 BreastfeedingM8-M9 Clean home delivery

n recOrds And FOrms

N2 Referral recordN3 Feedback recordN4 Labour recordN5 PartographN6 Postpartum recordN7 International form of medical certificate of cause of death

O glOssAry And AcrOnyms

The aim of Pregnancy, childbirth, postpartum and newborn care guide for essential practice (PCPNC) is to provide evidence-based recommendations to guide health care professionals in the management of women during pregnancy, childbirth and postpartum, and post abortion, and newborns during their first week of life, including management of endemic diseases like malaria, HIV/AIDS, TB and anaemia.

All recommendations are for skilled attendants working at the primary level of health care, either at the facility or in the community. They apply to all women attending antenatal care, in delivery, postpartum or post abortion care, or who come for emergency care, and to all newborns at birth and during the first week of life (or later) for routine and emergency care.

The PCPNC is a guide for clinical decision-making. It facilitates the collection, analysis, classification and use of relevant information by suggesting key questions, essential observations and/or examinations, and recommending appropriate research-based interventions. It promotes the early detection of complications and the initiation of early and appropriate treatment, including timely referral, if necessary.

Correct use of this guide should help reduce the high maternal and perinatal mortality and morbidity rates prevalent in many parts of the developing world, thereby making pregnancy and childbirth safer.

The guide is not designed for immediate use. It is a generic guide and should first be adapted to local needs and resources. It should cover the most serious endemic conditions that the skilled birth attendant must be able to treat, and be made consistent with national treatment guidelines and other policies. It is accompanied by an adaptation guide to help countries prepare their own national guides and training and other supporting materials.

The first section, How to use the guide, describes how the guide is organized, the overall content and presentation. Each chapter begins with a short description of how to read and use it, to help the reader use the guide correctly.

The Guide has been developed by the Department of Reproductive Health and Research with contributions from the following WHO programmes:

■ Child and Adolesscent Health and Development■ HIV/AIDS■ Nutrition for Health and Development■ Essential drugs and Medicines Policy■ Vaccines and Biologicals■ Communicable Diseases Control, Prevention and Eradication (tuberculosis, malaria, helminthiasis)■ Gender and Women’s Health■ Mental Health and Substance Dependence■ Blindness and Deafness

InTrOducTIOn

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Introduction

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ContentThe Guide includes routine and emergency care for women and newborns during pregnancy, labour and delivery, postpartum and post abortion, as well as key preventive measures required to reduce the incidence of endemic and other diseases like malaria, anaemia, HIV/AIDS and TB, which add to maternal and perinatal morbidity and mortality.

Most women and newborns using the services described in the Guide are not ill and/or do not have complications. They are able to wait in line when they come for a scheduled visit. However, the small proportion of women/newborns who are ill, have complications or are in labour, need urgent attention and care.

The clinical content is divided into six sections which are as follows:

■ Quick check (triage), emergency management (called Rapid Assessment and Management or RAM) and referral, followed by a chapter on emergency treatments for the woman.

■ Post-abortion care.■ Antenatal care.■ Labour and delivery.■ Postpartum care.■ Newborn care.

In each of the six clinical sections listed above there is a series of flow, treatment and information charts which include:

■ Guidance on routine care, including monitoring the well-being of the mother and/or baby.

■ Early detection and management of complications.

■ Preventive measures. ■ Advice and counselling.

In addition to the clinical care outlined above, other sections in the guide include:

■ Advice on HIV, prevention and treatment.■ Support for women with special needs.■ Links with the community.■ Drugs, supplies, equipment, universal

precautions and laboratory tests.■ Examples of clinical records.■ Counselling and key messages for women and

families.

There is an important section at the beginning of the Guide entitled Principles of good care A1-A5 . This includes principles of good care for all women, including those with special needs. It explains the organization of each visit to a healthcare facility, which applies to overall care. The principles are not repeated for each visit.

Recommendations for the management of complications at secondary (referral) health care level can be found in the following guides for midwives and doctors:

■ Managing complications of pregnancy and childbirth (WHO/RHR/00.7)

■ Managing newborn problems.

Documents referred to in this Guide can be obtained from the Department of Making Pregnancy Safer, Family and Community Health, World Health Organization, Geneva, Switzerland. e-mail: mpspublications@who.int.

Other related WHO documents can be downloaded from the following links:

■ Medical Eligibility Criteria 3rd edition: http://www.who.int/reproductive-health/publications/mec/mec.pdf.

■ Selected Practice Recommendations 2nd edition: http://www.who.int/reproductive-health/publications/spr/spr.pdf.

■ Guidelines for the Management of Sexually Transmitted Infections: http://www.who.int/reproductive-health/publications/rhr_01_10_mngt_stis/guidelines_mngt_stis.pdf

■ Sexually Transmitted and other Reproductive Tract Infections: A Guide to Essential Practice: http://www.who.int/reproductive-health/publications/rtis_gep/rtis_gep.pdf

■ Antiretroviral treatment of HIV infection in infants and children in resource-limited settings, towards universal access: Recommendations for a public health approach Web-based public review, 3–12 November 2005 http://www.who.int/hiv/pub/prev_care/en

■ WHO consultation on technical and operational recommendations for scale-up of laboratory services and monitoring HIV antiretroviral therapy in resource-limited settings. http://www.who.int/hiv/pub/prev_care/en ISBN 92 4 159368 7

■ Malaria and HIV Interactions and their Implications for Public Health Policy. http://www.who.int/hiv/pub/prev_care/en: ISNB 92 4 159335 0

■ Interim WHO clinical staging of HIV/AIDS and HIV/AIDS case definitions for surveillance African Region. http://www.who.int/hiv/pub/prev_care/en Ref no:: WHO/HIV/2005.02

■ HIV and Infant Feeding. Guidelines for decision-makers http://www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159122_6.htm

■ HIV and Infant Feeding. A guide for health-care managers and supervisors http://www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159123_4.htm

■ Integrated Management of Adolescent and adult illness http://www.who.int/3by5/publications/documents/imai/en/index.html

HOW TO reAd THe guIde

Structure and presentation

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ASK, CHECK RECORD LOOK, LISTEN FEEL SIGNS TREAT AND ADVISECLASSIFY

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This Guide is a tool for clinical decision-making. The content is presented in a frame work of coloured flow charts supported by information and treatment charts which give further details of care.

The framework is based on a syndromic approach whereby the skilled attendant identifies a limited number of key clinical signs and symptoms, enabling her/him to classify the condition according to severity and give appropriate treatment. Severity is marked in colour: red for emergencies, yellow for less urgent conditions which nevertheless need attention, and green for normal care.

Flow chartsThe flow charts include the following information:1. Key questions to be asked.2. Important observations and examinations to

be made.3. Possible findings (signs) based on information

elicited from the questions, observations and, where appropriate, examinations.

4. Classification of the findings.5. Treatment and advice related to the signs and

classification.

“Treat, advise” means giving the treatment indicated (performing a procedure, prescribing drugs or other treatments, advising on possible side-effects and how to overcome them) and giving advice on other important practices. The treat and advise column is often cross-referenced to other treatment and/or information charts. Turn to these charts for more information.

Use of colourColour is used in the flow charts to indicate the severity of a condition.

6. Green usually indicates no abnormal condition and therefore normal care is given, as outlined in the guide, with appropriate advice for home care and follow up.

7. Yellow indicates that there is a problem that can be treated without referral.

8. Red highlights an emergency which requires immediate treatment and, in most cases, urgent referral to a higher level health facility.

Key sequential stepsThe charts for normal and abnormal deliveries are presented in a framework of key sequential steps for a clean safe delivery. The key sequential steps for delivery are in a column on the left side of the page, while the column on the right has interventions which may be required if problems arise during delivery. Interventions may be linked to relevant treatment and/or information pages, and are cross-referenced to other parts of the Guide.

Treatment and information pagesThe flow charts are linked (cross-referenced) to relevant treatment and/or information pages in other parts of the Guide. These pages include information which is too detailed to include in the flow charts:

■ Treatments.■ Advice and counselling.■ Preventive measures. ■ Relevant procedures.

Information and counselling sheetsThese contain appropriate advice and counselling messages to provide to the woman, her partner and family. In addition, a section is included at the back of the Guide to support the skilled attendant in this effort. Individual sheets are provided with simplified versions of the messages on care during pregnancy (preparing a birth and emergency plan, clean home delivery, care for the mother and baby after delivery, breastfeeding and care after an abortion) to be given to the mother, her partner and family at the appropriate stage of pregnancy and childbirth.

These sheets are presented in a generic format. They will require adaptation to local conditions and language, and the addition of illustrations to enhance understanding, acceptability and attractiveness. Different programmes may prefer a different format such as a booklet or flip chart.

sTrucTure And PresenTATIOn

Assumptions underlying the GuideHO

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Recommendations in the Guide are generic, made on many assumptions about the health characteristics of the population and the health care system (the setting, capacity and organization of services, resources and staffing).

Population and endemic conditions■ High maternal and perinatal mortality■ Many adolescent pregnancies■ High prevalence of endemic conditions:

→ Anaemia → Stable transmission of falciparum malaria → Hookworms (Necator americanus and

Ancylostoma duodenale) → Sexually transmitted infections, including

HIV/AIDS → Vitamin A and iron/folate deficiencies.

Health care systemThe Guide assumes that:■ Routine and emergency pregnancy, delivery and

postpartum care are provided at the primary level of the health care, e.g. at the facility near where the woman lives. This facility could be a health post, health centre or maternity clinic. It could also be a hospital with a delivery ward and outpatient clinic providing routine care to women from the neighbourhood.

■ A single skilled attendant is providing care. She may work at the health care centre, a maternity unit of a hospital or she may go

to the woman's home, if necessary. However there may be other health workers who receive the woman or support the skilled attendant when emergency complications occur.

■ Human resources, infrastructure, equipment, supplies and drugs are limited. However, essential drugs, IV fluids, supplies, gloves and essential equipment are available.

■ If a health worker with higher levels of skill (at the facility or a referral hospital) is providing pregnancy, childbirth and postpartum care to women other than those referred, she follows the recommendations described in this Guide.

■ Routine visits and follow-up visits are “scheduled” during office hours.

■ Emergency services (“unscheduled” visits) for labour and delivery, complications, or severe illness or deterioration are provided 24/24 hours, 7 days a week.

■ Women and babies with complications or expected complications are referred for further care to the secondary level of care, a referral hospital.

■ Referral and transportation are appropriate for the distance and other circumstances. They must be safe for the mother and the baby.

■ Some deliveries are conducted at home, attended by traditional birth attendants (TBAs) or relatives, or the woman delivers alone (but home delivery without a skilled attendant is not recommended).

■ Links with the community and traditional providers are established. Primary health care

services and the community are involved in maternal and newborn health issues.

■ Other programme activities, such as management of malaria, tuberculosis and other lung diseases, treatment for HIV, and infant feeding counselling, that require specific training, are delivered by a different provider, at the same facility or at the referral hospital. Detection, initial treatment and referral are done by the skilled attendant.

■ All pregnant woman are routinely offered HIV testing and counselling at the first contact with the health worker, which could be during the antenatal visits, in early labour or in the postpartum period. Women who are first seen by the health worker in late labour are offered the test after the childbirth. Health workers are trained to provide HIV testing and counselling. HIV testing kits and ARV medicines are available at the Primary health-care

Knowledge and skills of care providersThis Guide assumes that professionals using it have the knowledge and skills in providing the care it describes. Other training materials must be used to bring the skills up to the level assumed by the Guide.

Adaptation of the GuideIt is essential that this generic Guide is adapted to national and local situations, not only within the context of existing health priorities and resources, but also within the context of respect and sensitivity to the needs of women, newborns and the communities to which they belong.

An adaptation guide is available to assist national experts in modifying the Guide according to national needs, for different demographic and epidemiological conditions, resources and settings. The adaptation guide offers some alternatives. It includes guidance on developing information and counselling tools so that each programme manager can develop a format which is most comfortable for her/him.

AssumPTIOns underlyIng THe guIde

A�Principles of good care

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Communicating with the woman (and her companion)■ Make the woman (and her companion) feel

welcome.■ Be friendly, respectful and non-judgmental at

all times.■ Use simple and clear language.■ Encourage her to ask questions.■ Ask and provide information related to her

needs. ■ Support her in understanding her options and

making decisions.■ At any examination or before any procedure:

→ seek her permission and→ inform her of what you are doing.

■ Summarize the most important information, including the information on routine laboratory tests and treatments.

Verify that she understands emergency signs, treatment instructions, and whenand where to return. Check for understanding by asking her to explain or demonstrate treatment instructions.

Privacy and confidentialityIn all contacts with the woman and her partner: ■ Ensure a private place for the examination

and counselling. ■ Ensure, when discussing sensitive subjects,

that you cannot be overheard. ■ Make sure you have the woman’s consent

before discussing with her partner or family.■ Never discuss confidential information about

clients with other providers, or outside the health facility.

■ Organize the examination area so that, during examination, the woman is protected from the view of other people (curtain, screen, wall).

■ Ensure all records are confidential and kept locked away.

■ Limit access to logbooks and registers to responsible providers only.

Prescribing and recommending treatments and preventive measures for the woman and/or her babyWhen giving a treatment (drug, vaccine, bednet, condom) at the clinic, or prescribing measures to be followed at home:■ Explain to the woman what the treatment is

and why it should be given. ■ Explain to her that the treatment will not harm

her or her baby, and that not taking it may be more dangerous.

■ Give clear and helpful advice on how to take the drug regularly:→ for example: take 2 tablets 3 times a

day, thus every 8 hours, in the morning, afternoon and evening with some water and after a meal, for 5 days.

■ Demonstrate the procedure.■ Explain how the treatment is given to the baby.

Watch her as she does the first treatment in the clinic.

■ Explain the side-effects to her. Explain that they are not serious, and tell her how to manage them.

■ Advise her to return if she has any problems or concerns about taking the drugs.

■ Explore any barriers she or her family may have, or have heard from others, about using the treatment, where possible:→ Has she or anyone she knows used the

treatment or preventive measure before?→ Were there problems?→ Reinforce the correct information that

she has, and try to clarify the incorrect information.

■ Discuss with her the importance of buying and taking the prescribed amount. Help her to think about how she will be able to purchase this.

communicAtion

A3Workplace and administrative procedures

Prin

ciPl

es o

f go

od c

Are

Workplace■ Service hours should be clearly posted.■ Be on time with appointments or inform the

woman/women if she/they need to wait.■ Before beginning the services, check that

equipment is clean and functioning and that supplies and drugs are in place.

■ Keep the facility clean by regular cleaning.■ At the end of the service:

→ discard litter and sharps safely→ prepare for disinfection; clean and disinfect

equipment and supplies → replace linen, prepare for washing→ replenish supplies and drugs→ ensure routine cleaning of all areas.

■ Hand over essential information to the colleague who follows on duty.

Daily and occasional administrative activities■ Keep records of equipment, supplies, drugs

and vaccines.■ Check availability and functioning of essential

equipment (order stocks of supplies, drugs, vaccines and contraceptives before they run out).

■ Establish staffing lists and schedules.■ Complete periodic reports on births, deaths

and other indicators as required, according to instructions.

Record keeping■ Always record findings on a clinical

record and home-based record. Record treatments, reasons for referral, and follow-up recommendations at the time the observation is made.

■ Do not record confidential information on the home-based record if the woman is unwilling.

■ Maintain and file appropriately: → all clinical records→ all other documentation.

International conventionsThe health facility should not allow distribution of free or low-cost suplies or products within the scope of the International Code of Marketing of Breast Milk Substitutes. It should also be tobacco free and support a tobacco-free environment.

WorkPlAce And AdministrAtive Procedures

Standard precautions and cleanliness

Prin

ciPl

es o

f go

od c

Are

A4

observe these precautions to protect the woman and her baby, and you as the health provider, from infections with bacteria and viruses, including Hiv.

Wash hands■ Wash hands with soap and water:

→ Before and after caring for a woman or newborn, and before any treatment procedure

→ Whenever the hands (or any other skin area) are contaminated with blood or other body fluids

→ After removing the gloves, because they may have holes

→ After changing soiled bedsheets or clothing.■ Keep nails short.

Wear gloves■ Wear sterile or highly disinfected gloves when

performing vaginal examination, delivery, cord cutting, repair of episiotomy or tear, blood drawing.

■ Wear long sterile or highly disinfected gloves for manual removal of placenta.

■ Wear clean gloves when:→ Handling and cleaning instruments→ Handling contaminated waste→ Cleaning blood and body fluid spills

■ Drawing blood.

Protect yourself from blood and other body fluids during deliveries

→ Wear gloves; cover any cuts, abrasions or broken skin with a waterproof bandage; take care when handling any sharp instruments (use good light); and practice safe sharps disposal.

→ Wear a long apron made from plastic or other fluid resistant material, and shoes.

→ If possible, protect your eyes from splashes of blood.

Practice safe sharps disposal■ Keep a puncture resistant container nearby. ■ Use each needle and syringe only once.■ Do not recap, bend or break needles after

giving an injection.■ Drop all used (disposable) needles, plastic

syringes and blades directly into this container, without recapping, and without passing to another person.

■ Empty or send for incineration when the container is three-quarters full.

Practice safe waste disposal■ Dispose of placenta or blood, or body fluid

contaminated items, in leak-proof containers.■ Burn or bury contaminated solid waste.■ Wash hands, gloves and containers after

disposal of infectious waste.■ Pour liquid waste down a drain or flushable toilet.■ Wash hands after disposal of infectious waste.

Deal with contaminated laundry■ Collect clothing or sheets stained with blood

or body fluids and keep them separately from other laundry, wearing gloves or use a plastic bag. do not touch them directly.

■ Rinse off blood or other body fluids before washing with soap.

Sterilize and clean contaminated equipment■ Make sure that instruments which penetrate

the skin (such as needles) are adequately sterilized, or that single-use instruments are disposed of after one use.

■ Thoroughly clean or disinfect any equipment which comes into contact with intact skin (according to instructions).

■ Use bleach for cleaning bowls and buckets, and for blood or body fluid spills.

Clean and disinfect gloves■ Wash the gloves in soap and water.■ Check for damage: Blow gloves full of air, twist

the cuff closed, then hold under clean water and look for air leaks. Discard if damaged.

■ Soak overnight in bleach solution with 0.5% available chlorine (made by adding 90 ml water to 10 ml bleach containing 5% available chlorine).

■ Dry away from direct sunlight.■ Dust inside with talcum powder or starch.

This produces disinfected gloves. They are not sterile.

Good quality latex gloves can be disinfected 5 or more times.

Sterilize gloves■ Sterilize by autoclaving or highly disinfect by

steaming or boiling.

universAl PrecAutions And cleAnliness

A5Organizing a visit

Prin

ciPl

es o

f go

od c

Are

Receive and respond immediatelyreceive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). ■ Perform Quick Check on all new incoming

women and babies and those in the waiting room, especially if no-one is receiving them B2 .

■ At the first emergency sign on Quick Check, begin emergency assessment and management (RAM) B�-B7 for the woman, or examine the newborn J�-J�� .

■ If she is in labour, accompany her to an appropriate place and follow the steps as in Childbirth: labour, delivery and immediate postpartum care d�-d29 .

■ If she has priority signs, examine her immediately using Antenatal care,

Postpartum or Post-abortion care charts c�-c�8 e�-e�0 B�8-B22.

■ If no emergency or priority sign on RAM or not in labour, invite her to wait in the waiting room.

■ If baby is newly born, looks small, examine immediately. Do not let the mother wait in the queue.

Begin each emergency care visit■ Introduce yourself.■ Ask the name of the woman.■ Encourage the companion to stay with the woman.■ Explain all procedures, ask permission,

and keep the woman informed as much as

you can about what you are doing. If she is unconscious, talk to the companion.

■ Ensure and respect privacy during examination and discussion.

■ If she came with a baby and the baby is well, ask the companion to take care of the baby during the maternal examination and treatment.

Care of woman or baby referred for special care to secondary level facility■ When a woman or baby is referred to a

secondary level care facility because of a specific problem or complications, the underlying assumption of the Guide is that, at referral level, the woman/baby will be assessed, treated, counselled and advised on follow-up for that particular condition/ complication.

■ Follow-up for that specific condition will be either:→ organized by the referral facility or→ written instructions will be given to the

woman/baby for the skilled attendant at the primary level who referred the woman/baby.

→ the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition.

■ Routine care continues at the primary care level where it was initiated.

Begin each routine visit (for the woman and/or the baby)■ Greet the woman and offer her a seat.■ Introduce yourself.■ Ask her name (and the name of the baby).■ Ask her:

→ Why did you come? For yourself or for your baby?

→ For a scheduled (routine) visit? → For specific complaints about you or your

baby?→ First or follow-up visit?→ Do you want to include your companion or

other family member (parent if adolescent) in the examination and discussion?

■ If the woman is recently delivered, assess the baby or ask to see the baby if not with the mother.

■ If antenatal care, always revise the birth plan at the end of the visit after completing the chart.

■ For a postpartum visit, if she came with the baby, also examine the baby:→ Follow the appropriate charts according

to pregnancy status/age of the baby and purpose of visit.

→ Follow all steps on the chart and in relevant boxes.

■ Unless the condition of the woman or the baby requires urgent referral to hospital, give preventive measures if due even if the woman has a condition "in yellow" that requires special treatment.

■ If follow-up visit is within a week, and if no other complaints:→ Assess the woman for the specific condition

requiring follow-up only→ Compare with earlier assessment and re-

classify.■ If a follow-up visit is more than a week after

the initial examination (but not the next scheduled visit):→ Repeat the whole assessment as required

for an antenatal, post-abortion, postpartum or newborn visit according to the schedule

→ If antenatal visit, revise the birth plan.

During the visit■ Explain all procedures, ■ Ask permission before undertaking an

examination or test.■ Keep the woman informed throughout.

Discuss findings with her (and her partner).■ Ensure privacy during the examination and

discussion.

At the end of the visit■ Ask the woman if she has any questions.■ Summarize the most important messages with her.■ Encourage her to return for a routine visit (tell

her when) and if she has any concerns.■ Fill the Home-Based Maternal Record (HBMR)

and give her the appropriate information sheet.■ Ask her if there are any points which need to be

discussed and would she like support for this.

orgAnizing A visit

A2 communicAtion

A3 WorkPlAce And AdministrAtive Procedures

A4 stAndArd PrecAutions And cleAnliness

A5 orgAnizing A visit

These principles of good care apply to all contacts between the skilled attendant and all women and their babies; they are not repeated in each section. Care-givers should therefore familiarize themselves with the following principles before using the Guide. The principles concern:

■ Communication A2 .■ Workplace and administrative procedures A3 .■ Standard precautions and cleanliness A4 .■ Organizing a visit A5 .

CommunicationPr

inci

Ples

of

good

cAr

eA2

Communicating with the woman (and her companion)■ Make the woman (and her companion) feel

welcome.■ Be friendly, respectful and non-judgmental at

all times.■ Use simple and clear language.■ Encourage her to ask questions.■ Ask and provide information related to her

needs. ■ Support her in understanding her options and

making decisions.■ At any examination or before any procedure:

→ seek her permission and→ inform her of what you are doing.

■ Summarize the most important information, including the information on routine laboratory tests and treatments.

Verify that she understands emergency signs, treatment instructions, and whenand where to return. Check for understanding by asking her to explain or demonstrate treatment instructions.

Privacy and confidentialityIn all contacts with the woman and her partner: ■ Ensure a private place for the examination

and counselling. ■ Ensure, when discussing sensitive subjects,

that you cannot be overheard. ■ Make sure you have the woman’s consent

before discussing with her partner or family.■ Never discuss confidential information about

clients with other providers, or outside the health facility.

■ Organize the examination area so that, during examination, the woman is protected from the view of other people (curtain, screen, wall).

■ Ensure all records are confidential and kept locked away.

■ Limit access to logbooks and registers to responsible providers only.

Prescribing and recommending treatments and preventive measures for the woman and/or her babyWhen giving a treatment (drug, vaccine, bednet, condom) at the clinic, or prescribing measures to be followed at home:■ Explain to the woman what the treatment is

and why it should be given. ■ Explain to her that the treatment will not harm

her or her baby, and that not taking it may be more dangerous.

■ Give clear and helpful advice on how to take the drug regularly:→ for example: take 2 tablets 3 times a

day, thus every 8 hours, in the morning, afternoon and evening with some water and after a meal, for 5 days.

■ Demonstrate the procedure.■ Explain how the treatment is given to the baby.

Watch her as she does the first treatment in the clinic.

■ Explain the side-effects to her. Explain that they are not serious, and tell her how to manage them.

■ Advise her to return if she has any problems or concerns about taking the drugs.

■ Explore any barriers she or her family may have, or have heard from others, about using the treatment, where possible:→ Has she or anyone she knows used the

treatment or preventive measure before?→ Were there problems?→ Reinforce the correct information that

she has, and try to clarify the incorrect information.

■ Discuss with her the importance of buying and taking the prescribed amount. Help her to think about how she will be able to purchase this.

communicAtion

A3Workplace and administrative procedures

Prin

ciPl

es o

f go

od c

Are

Workplace■ Service hours should be clearly posted.■ Be on time with appointments or inform the

woman/women if she/they need to wait.■ Before beginning the services, check that

equipment is clean and functioning and that supplies and drugs are in place.

■ Keep the facility clean by regular cleaning.■ At the end of the service:

→ discard litter and sharps safely→ prepare for disinfection; clean and disinfect

equipment and supplies → replace linen, prepare for washing→ replenish supplies and drugs→ ensure routine cleaning of all areas.

■ Hand over essential information to the colleague who follows on duty.

Daily and occasional administrative activities■ Keep records of equipment, supplies, drugs

and vaccines.■ Check availability and functioning of essential

equipment (order stocks of supplies, drugs, vaccines and contraceptives before they run out).

■ Establish staffing lists and schedules.■ Complete periodic reports on births, deaths

and other indicators as required, according to instructions.

Record keeping■ Always record findings on a clinical

record and home-based record. Record treatments, reasons for referral, and follow-up recommendations at the time the observation is made.

■ Do not record confidential information on the home-based record if the woman is unwilling.

■ Maintain and file appropriately: → all clinical records→ all other documentation.

International conventionsThe health facility should not allow distribution of free or low-cost suplies or products within the scope of the International Code of Marketing of Breast Milk Substitutes. It should also be tobacco free and support a tobacco-free environment.

WorkPlAce And AdministrAtive Procedures

Standard precautions and cleanlinessPr

inci

Ples

of

good

cAr

eA4

observe these precautions to protect the woman and her baby, and you as the health provider, from infections with bacteria and viruses, including Hiv.

Wash hands■ Wash hands with soap and water:

→ Before and after caring for a woman or newborn, and before any treatment procedure

→ Whenever the hands (or any other skin area) are contaminated with blood or other body fluids

→ After removing the gloves, because they may have holes

→ After changing soiled bedsheets or clothing.■ Keep nails short.

Wear gloves■ Wear sterile or highly disinfected gloves when

performing vaginal examination, delivery, cord cutting, repair of episiotomy or tear, blood drawing.

■ Wear long sterile or highly disinfected gloves for manual removal of placenta.

■ Wear clean gloves when:→ Handling and cleaning instruments→ Handling contaminated waste→ Cleaning blood and body fluid spills

■ Drawing blood.

Protect yourself from blood and other body fluids during deliveries

→ Wear gloves; cover any cuts, abrasions or broken skin with a waterproof bandage; take care when handling any sharp instruments (use good light); and practice safe sharps disposal.

→ Wear a long apron made from plastic or other fluid resistant material, and shoes.

→ If possible, protect your eyes from splashes of blood.

Practice safe sharps disposal■ Keep a puncture resistant container nearby. ■ Use each needle and syringe only once.■ Do not recap, bend or break needles after

giving an injection.■ Drop all used (disposable) needles, plastic

syringes and blades directly into this container, without recapping, and without passing to another person.

■ Empty or send for incineration when the container is three-quarters full.

Practice safe waste disposal■ Dispose of placenta or blood, or body fluid

contaminated items, in leak-proof containers.■ Burn or bury contaminated solid waste.■ Wash hands, gloves and containers after

disposal of infectious waste.■ Pour liquid waste down a drain or flushable toilet.■ Wash hands after disposal of infectious waste.

Deal with contaminated laundry■ Collect clothing or sheets stained with blood

or body fluids and keep them separately from other laundry, wearing gloves or use a plastic bag. do not touch them directly.

■ Rinse off blood or other body fluids before washing with soap.

Sterilize and clean contaminated equipment■ Make sure that instruments which penetrate

the skin (such as needles) are adequately sterilized, or that single-use instruments are disposed of after one use.

■ Thoroughly clean or disinfect any equipment which comes into contact with intact skin (according to instructions).

■ Use bleach for cleaning bowls and buckets, and for blood or body fluid spills.

Clean and disinfect gloves■ Wash the gloves in soap and water.■ Check for damage: Blow gloves full of air, twist

the cuff closed, then hold under clean water and look for air leaks. Discard if damaged.

■ Soak overnight in bleach solution with 0.5% available chlorine (made by adding 90 ml water to 10 ml bleach containing 5% available chlorine).

■ Dry away from direct sunlight.■ Dust inside with talcum powder or starch.

This produces disinfected gloves. They are not sterile.

Good quality latex gloves can be disinfected 5 or more times.

Sterilize gloves■ Sterilize by autoclaving or highly disinfect by

steaming or boiling.

stAndArd PrecAutions And cleAnliness

A5Organizing a visit

Prin

ciPl

es o

f go

od c

Are

Receive and respond immediatelyreceive every woman and newborn baby seeking care immediately after arrival (or organize reception by another provider). ■ Perform Quick Check on all new incoming

women and babies and those in the waiting room, especially if no-one is receiving them B2 .

■ At the first emergency sign on Quick Check, begin emergency assessment and management (RAM) B�-B7 for the woman, or examine the newborn J�-J�� .

■ If she is in labour, accompany her to an appropriate place and follow the steps as in Childbirth: labour, delivery and immediate postpartum care d�-d29 .

■ If she has priority signs, examine her immediately using Antenatal care,

Postpartum or Post-abortion care charts c�-c�9 e�-e�0 B�8-B22.

■ If no emergency or priority sign on RAM or not in labour, invite her to wait in the waiting room.

■ If baby is newly born, looks small, examine immediately. Do not let the mother wait in the queue.

Begin each emergency care visit■ Introduce yourself.■ Ask the name of the woman.■ Encourage the companion to stay with the woman.■ Explain all procedures, ask permission,

and keep the woman informed as much as

you can about what you are doing. If she is unconscious, talk to the companion.

■ Ensure and respect privacy during examination and discussion.

■ If she came with a baby and the baby is well, ask the companion to take care of the baby during the maternal examination and treatment.

Care of woman or baby referred for special care to secondary level facility■ When a woman or baby is referred to a

secondary level care facility because of a specific problem or complications, the underlying assumption of the Guide is that, at referral level, the woman/baby will be assessed, treated, counselled and advised on follow-up for that particular condition/ complication.

■ Follow-up for that specific condition will be either:→ organized by the referral facility or→ written instructions will be given to the

woman/baby for the skilled attendant at the primary level who referred the woman/baby.

→ the woman/baby will be advised to go for a follow-up visit within 2 weeks according to severity of the condition.

■ Routine care continues at the primary care level where it was initiated.

Begin each routine visit (for the woman and/or the baby)■ Greet the woman and offer her a seat.■ Introduce yourself.■ Ask her name (and the name of the baby).■ Ask her:

→ Why did you come? For yourself or for your baby?

→ For a scheduled (routine) visit? → For specific complaints about you or your

baby?→ First or follow-up visit?→ Do you want to include your companion or

other family member (parent if adolescent) in the examination and discussion?

■ If the woman is recently delivered, assess the baby or ask to see the baby if not with the mother.

■ If antenatal care, always revise the birth plan at the end of the visit after completing the chart.

■ For a postpartum visit, if she came with the baby, also examine the baby:→ Follow the appropriate charts according

to pregnancy status/age of the baby and purpose of visit.

→ Follow all steps on the chart and in relevant boxes.

■ Unless the condition of the woman or the baby requires urgent referral to hospital, give preventive measures if due even if the woman has a condition "in yellow" that requires special treatment.

■ If follow-up visit is within a week, and if no other complaints:→ Assess the woman for the specific condition

requiring follow-up only→ Compare with earlier assessment and re-

classify.■ If a follow-up visit is more than a week after

the initial examination (but not the next scheduled visit):→ Repeat the whole assessment as required

for an antenatal, post-abortion, postpartum or newborn visit according to the schedule

→ If antenatal visit, revise the birth plan.

During the visit■ Explain all procedures, ■ Ask permission before undertaking an

examination or test.■ Keep the woman informed throughout.

Discuss findings with her (and her partner).■ Ensure privacy during the examination and

discussion.

At the end of the visit■ Ask the woman if she has any questions.■ Summarize the most important messages with her.■ Encourage her to return for a routine visit (tell

her when) and if she has any concerns.■ Fill the Home-Based Maternal Record (HBMR)

and give her the appropriate information sheet.■ Ask her if there are any points which need to be

discussed and would she like support for this.

orgAnizing A visit

Quick check, rapid assessment and management of women of childbearing age

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Quick check, rapid assessment and management of women of childbearing ageQuick check

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ASK,CHECKRECORD■Whydidyoucome?

→foryourself? → forthebaby?■Howoldisthebaby?■Whatistheconcern?

LOOK,LISTEN,FEELis the woman being wheeled or carried in or:■bleedingvaginally■convulsing■ lookingveryill■unconscious■ inseverepain■ inlabour■deliveryisimminent

check if baby is or has:■verysmall■convulsing■breathingdifficulty

SIGNSIfthewomanisorhas:■unconscious(doesnotanswer)■convulsing■bleeding■severeabdominalpainorlooksveryill■headacheandvisualdisturbance■severedifficultybreathing■ fever■severevomiting.

■ Imminentdeliveryor■Labour

Ifthebabyisorhas:■verysmall■convulsions■difficultbreathing■ justborn■anymaternalconcern.

■Pregnantwoman,orafterdelivery,withnodangersigns

■Anewbornwithnodangersignsormaternalcomplaints.

TREAT■TransferwomantoatreatmentroomforRapid

assessmentandmanagement b3-b7 .■Callforhelpifneeded.■Reassurethewomanthatshewillbetakencareof

immediately.■Askhercompaniontostay.

■Transferthewomantothelabourward.■Callforimmediateassessment.

■TransferthebabytothetreatmentroomforimmediateNewborncare J�-J�� .

■Askthemothertostay.

■Keepthewomanandbabyinthewaitingroomforroutinecare.

CLASSIFYemergency for woman

labour

emergency for baby

routine care

ifemergencyforwomanorbabyorlabour,goto b3 .ifnoemergency,gotorelevantsection

Quick checka person responsible for initial reception of women of childbearing age and newborns seeking care should:■ assessthegeneralconditionofthecareseeker(s)immediatelyonarrival■ periodicallyrepeatthisprocedureifthelineislong.if a woman is very sick, talk to her companion.

b2

�

Rapid assessment and management (RAM) Airway and breathing, circulation (shock)

next:VaginalbleedingQuic

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This may be pneumonia, severe

anaemia with heart failure,

obstructed breathing, asthma.

This may be haemorrhagic shock,

septic shock.

TREATMENT

■Manageairwayandbreathing b9 .■refer woman urgently to hospital* b�7 .

Measurebloodpressure.IfsystolicBP<90mmHgorpulse>110perminute:■Positionthewomanonherleftsidewithlegshigherthanchest.■ InsertanIVline b9 .■Givefluidsrapidly b9 .■ IfnotabletoinsertperipheralIV,usealternative b9 .■Keepherwarm(coverher).■refer her urgently to hospital* b�7 .

*Butifbirthisimminent(bulging,thinperineumduringcontractions,visiblefetalhead),transferwomantolabourroomandproceedasond�-d28 .

rapid assessment and management (ram)use this chart for rapid assessment and management (ram) of all women of childbearing age, and also for women in labour, on first arrival and periodically throughout labour, delivery and the postpartum period. assess for all emergency and priority signs and give appropriate treatments, then refer the woman to hospital.-

first assess

EMERGENCYSIGNSdo all emergency steps before referral

airway and breathing■Verydifficultbreathingor■Centralcyanosis

circulation (shock)■Coldmoistskinor■Weakandfastpulse

MEASuRE

■Measurebloodpressure■Countpulse

�

Rapid assessment and management (RAM) Vaginal bleeding

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PREGNANCYSTATuSearly pregnancynotawareofpregnancy,ornotpregnant(uterusNOTaboveumbilicus)

late pregnancy(uterusaboveumbilicus)

during labour beforedeliveryofbaby

BLEEDINGheavy bleedingPadorclothsoakedin<5minutes.

light bleeding

any bleeding is dangerous

bleeding more than �00 ml since labour began

This may be abortion,

menorrhagia, ectopic pregnancy.

This may be placenta previa,

abruptio placentae, ruptured

uterus.

This may be

placenta previa, abruptio

placenta, ruptured uterus.

TREATMENT■ InsertanIVline b9 .■Givefluidsrapidly b9 .■Give0.2mgergometrineIM b�0 .■Repeat0.2mgergometrineIM/IVifbleedingcontinues.■ Ifsuspectpossiblecomplicatedabortion,giveappropriateIM/IVantibioticsb�5 .■refer woman urgently to hospital b�7 .

■Examinewomanason b�9 .■ Ifpregnancynotlikely,refertootherclinicalguidelines.

do not do vaginal examination, but:■ InsertanIVline b9 .■Givefluidsrapidlyifheavybleedingorshock b3 .■refer woman urgently to hospital* b�7 .

do not do vaginal examination, but:■ InsertanIVline b9 .■Givefluidsrapidlyifheavybleedingorshock b3 .■refer woman urgently to hospital* b�7 .

*Butifbirthisimminent(bulging,thinperineumduringcontractions,visiblefetalhead),transferwomantolabourroomandproceedasond�-d28 .

vaginal bleeding■ assess pregnancy status ■ assess amount of bleeding

next:Vaginalbleedinginpostpartum�

Rapid assessment and management (RAM) Vaginal bleeding: postpartum

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PREGNANCYSTATuSpostpartum(babyisborn)

check and ask if placenta is delivered

check for perineal and lower vaginal tears

check if still bleeding

BLEEDINGheavy bleeding■Padorclothsoakedin<5

minutes■Constanttricklingofblood■ Bleeding>250mlordelivered

outsidehealthcentreandstillbleeding

placenta not delivered

placenta delivered

check placenta b��

if present

heavy bleeding

controlled bleeding

This may be uterine atony,

retained placenta, ruptured

uterus, vaginal or cervical tear.

TREATMENT■Callforextrahelp.■Massageuterusuntilitishardandgiveoxytocin10IuIM b�0 .■ InsertanIVline b9 andgiveIVfluidswith20Iuoxytocinat60drops/minute.■Emptybladder.Catheterizeifnecessary b�2 .■CheckandrecordBPandpulseevery15minutesandtreatason b3 .

■Whenuterusishard,deliverplacentabycontrolledcordtractiond�2 .■ Ifunsuccessfulandbleedingcontinues,removeplacentamanuallyandcheckplacenta b�� .■GiveappropriateIM/IVantibiotics b�5 .■ Ifunabletoremoveplacenta,referwomanurgentlytohospital b�7 .

Duringtransfer,continueIVfluidswith20Iuofoxytocinat30drops/minute.

if placenta is complete:■Massageuterustoexpressanyclots b�0 .■ Ifuterusremainssoft,giveergometrine0.2mgIV b�0 .

do notgiveergometrinetowomenwitheclampsia,pre-eclampsiaorknownhypertension.■ContinueIVfluidswith20Iuoxytocin/litreat30drops/minute.■Continuemassaginguterustillitishard.if placenta is incomplete (or not available for inspection): ■Removeplacentalfragments b�� .■GiveappropriateIM/IVantibiotics b�5 .■ Ifunabletoremove,referwomanurgentlytohospital b�7 .

■Examinethetearanddeterminethedegree b�2 .Ifthirddegreetear(involvingrectumoranus),referwomanurgentlytohospital b�7 .

■ Forothertears:applypressureoverthetearwithasterilepadorgauzeandputlegstogether.Donotcrossankles.■Checkafter5minutes,ifbleedingpersistsrepairthetear b�2 .

■ContinueIVfluidswith20unitsofoxytocinat30drops/minute.InsertsecondIVline.■Applybimanualuterineoraorticcompression b�0 .■GiveappropriateIM/IVantibiotics b�5 .■ refer woman urgently to hospital b�7 .

■Continueoxytocininfusionwith20Iu/litreofIVfluidsat20drops/minforatleastonehourafterbleedingstopsb�0 .

■Observeclosely(every30minutes)for4hours.Keepnearbyfor24hours.Ifseverepallor,refertohealthcentre.■ExaminethewomanusingAssess the mother after delivery d�2 .

�

Rapid assessment and management (RAM) Emergency signs

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EMERGENCYSIGNS

■Convulsing(noworrecently),or■unconscious Ifunconscious,askrelative “hastherebeenarecentconvulsion?”

■Severeabdominalpain(notnormallabour)

Fever(temperaturemorethan38ºC)andanyof:■Veryfastbreathing■Stiffneck■Lethargy■Veryweak/notabletostand

This may be eclampsia.

This may be ruptured uterus,

obstructed labour, abruptio

placenta, puerperal or post-

abortion sepsis, ectopic

pregnancy.

This may be malaria,

meningitis, pneumonia,

septicemia.

convulsions or unconscious

severe abdominal pain

dangerous fever

TREATMENT

■Protectwomanfromfallandinjury.Gethelp.■Manageairway b9 .■Afterconvulsionends,helpwomanontoherleftside.■ InsertanIVlineandgivefluidsslowly(30drops/min) b9 .■Givemagnesiumsulphate b�3 .■ Ifearlypregnancy,givediazepamIVorrectally b�4 .■ IfdiastolicBP>110mmofHg,giveantihypertensive b�4 .■ Iftemperature>38ºC,orhistoryoffever,alsogivetreatmentfordangerous

fever(below).■ refer woman urgently to hospital* b�7 .

measure bp and temperature■ IfdiastolicBP>110mmofHg,giveantihypertensive b�4 .■ Iftemperature>38ºC,orhistoryoffever,alsogivetreatmentfordangerous

fever(below).■refer woman urgently to hospital* b�7 .

■ InsertanIVlineandgivefluids b9 .■ Iftemperaturemorethan38ºC,givefirstdoseofappropriateIM/IV

antiobiotics b�5 .■refer woman urgently to hospital* b�7 .■ IfsystolicBP<90mmHgsee b3 .

■ InsertanIVline b9 .■Givefluidsslowly b9 .■GivefirstdoseofappropriateIM/IVantibiotics b�5 .■GiveartemetherIM(ifnotavailable,givequinineIM)andglucose b�6 .■refer woman urgently to hospital* b�7 .

*Butifbirthisimminent(bulging,thinperineumduringcontractions,visiblefetalhead),transferwomantolabourroomandproceedasond�-d28 .

MEASuRE

■Measurebloodpressure■Measuretemperature■Assesspregnancystatus

■Measurebloodpressure■Measuretemperature

■Measuretemperature

next:Prioritysigns�

Rapid assessment and management (RAM) Priority signs

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PRIORITYSIGNS

■Labourpainsor■Rupturedmembranes

Ifanyof:■Severepallor■Epigastricorabdominalpain■Severeheadache■Blurredvision■Fever(temperaturemorethan38ºC)■Breathingdifficulty

■Noemergencysignsor■Noprioritysigns

TREATMENT

■ManageasforChildbirthd�-d28 .

■ Ifpregnant(andnotinlabour),provideantenatalcarec�-c�8 .■ Ifrecentlygivenbirth,providepostpartumcare d2� .and e�-e�0 .■ Ifrecentabortion,providepost-abortioncareb20-b2�.■ Ifearlypregnancy,ornotawareofpregnancy,checkforectopicpregnancyb�9 .

■ Ifpregnant(andnotinlabour),provideantenatalcarec�-c�8 .■ Ifrecentlygivenbirth,providepostpartumcare e�-e�0 .

labour

other danger signs or symptoms

if no emergency or priority signs, non urgent

MEASuRE

■Measurebloodpressure■Measuretemperature

B2 Quick check

B3 rapid assessment and management (ram) (�)

Airwayandbreathing Circulationandshock

B4 rapid assessment and management (ram) (2)

Vaginalbleeding

B5 rapid assessment and management (ram) (3)

Vaginalbleeding:postpartum

B6 rapid assessment and management (ram) (4)

Convulsions Severeabdominalpain Dangerousfever

B7 rapid assessment and management (ram) (5)

prioritysigns Labour Otherdangersignsorsymptoms Non-urgent

■PerformQuickcheckimmediatelyafterthewomanarrives b2 .Ifanydangersignisseen,helpthewomanandsendherquicklytotheemergencyroom.

■AlwaysbeginaclinicalvisitwithRapidassessmentandmanagement(RAM) b3-b7 :→Checkforemergencysignsfirst b3-b6 .

Ifpresent,provideemergencytreatmentandreferthewomanurgentlytohospital.Completethereferralform n2 .

→Checkforprioritysigns.Ifpresent,manageaccordingtocharts b7 .→Ifnoemergencyorprioritysigns,allowthewomantowaitinlineforroutinecare,accordingtopregnancystatus.

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ASK,CHECKRECORD■Whydidyoucome?

→foryourself? → forthebaby?■Howoldisthebaby?■Whatistheconcern?

LOOK,LISTEN,FEELis the woman being wheeled or carried in or:■bleedingvaginally■convulsing■ lookingveryill■unconscious■ inseverepain■ inlabour■deliveryisimminent

check if baby is or has:■verysmall■convulsing■breathingdifficulty

SIGNSIfthewomanisorhas:■unconscious(doesnotanswer)■convulsing■bleeding■severeabdominalpainorlooksveryill■headacheandvisualdisturbance■severedifficultybreathing■ fever■severevomiting.

■ Imminentdeliveryor■Labour

Ifthebabyisorhas:■verysmall■convulsions■difficultbreathing■ justborn■anymaternalconcern.

■Pregnantwoman,orafterdelivery,withnodangersigns

■Anewbornwithnodangersignsormaternalcomplaints.

TREAT■TransferwomantoatreatmentroomforRapid

assessmentandmanagement b3-b7 .■Callforhelpifneeded.■Reassurethewomanthatshewillbetakencareof

immediately.■Askhercompaniontostay.

■Transferthewomantothelabourward.■Callforimmediateassessment.

■TransferthebabytothetreatmentroomforimmediateNewborncare J�-J�� .

■Askthemothertostay.

■Keepthewomanandbabyinthewaitingroomforroutinecare.

CLASSIFYemergency for woman

labour

emergency for baby

routine care

ifemergencyforwomanorbabyorlabour,goto b3 .ifnoemergency,gotorelevantsection

Quick checka person responsible for initial reception of women of childbearing age and newborns seeking care should:■ assessthegeneralconditionofthecareseeker(s)immediatelyonarrival■ periodicallyrepeatthisprocedureifthelineislong.if a woman is very sick, talk to her companion.

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This may be pneumonia, severe

anaemia with heart failure,

obstructed breathing, asthma.

This may be haemorrhagic shock,

septic shock.

TREATMENT

■Manageairwayandbreathing b9 .■refer woman urgently to hospital* b�7 .

Measurebloodpressure.IfsystolicBP<90mmHgorpulse>110perminute:■Positionthewomanonherleftsidewithlegshigherthanchest.■ InsertanIVline b9 .■Givefluidsrapidly b9 .■ IfnotabletoinsertperipheralIV,usealternative b9 .■Keepherwarm(coverher).■refer her urgently to hospital* b�7 .

*Butifbirthisimminent(bulging,thinperineumduringcontractions,visiblefetalhead),transferwomantolabourroomandproceedasond�-d28 .

rapid assessment and management (ram)use this chart for rapid assessment and management (ram) of all women of childbearing age, and also for women in labour, on first arrival and periodically throughout labour, delivery and the postpartum period. assess for all emergency and priority signs and give appropriate treatments, then refer the woman to hospital.-

first assess

EMERGENCYSIGNSdo all emergency steps before referral

airway and breathing■Verydifficultbreathingor■Centralcyanosis

circulation (shock)■Coldmoistskinor■Weakandfastpulse

MEASuRE

■Measurebloodpressure■Countpulse

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PREGNANCYSTATuSearly pregnancynotawareofpregnancy,ornotpregnant(uterusNOTaboveumbilicus)

late pregnancy(uterusaboveumbilicus)

during labour beforedeliveryofbaby

BLEEDINGheavy bleedingPadorclothsoakedin<5minutes.

light bleeding

any bleeding is dangerous

bleeding more than �00 ml since labour began

This may be abortion,

menorrhagia, ectopic pregnancy.

This may be placenta previa,

abruptio placentae, ruptured

uterus.

This may be

placenta previa, abruptio

placenta, ruptured uterus.

TREATMENT■ InsertanIVline b9 .■Givefluidsrapidly b9 .■Give0.2mgergometrineIM b�0 .■Repeat0.2mgergometrineIM/IVifbleedingcontinues.■ Ifsuspectpossiblecomplicatedabortion,giveappropriateIM/IVantibioticsb�5 .■refer woman urgently to hospital b�7 .

■Examinewomanason b�9 .■ Ifpregnancynotlikely,refertootherclinicalguidelines.

do not do vaginal examination, but:■ InsertanIVline b9 .■Givefluidsrapidlyifheavybleedingorshock b3 .■refer woman urgently to hospital* b�7 .

do not do vaginal examination, but:■ InsertanIVline b9 .■Givefluidsrapidlyifheavybleedingorshock b3 .■refer woman urgently to hospital* b�7 .

*Butifbirthisimminent(bulging,thinperineumduringcontractions,visiblefetalhead),transferwomantolabourroomandproceedasond�-d28 .

vaginal bleeding■ assess pregnancy status ■ assess amount of bleeding

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Rapid assessment and management (RAM) Vaginal bleeding: postpartum

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PREGNANCYSTATuSpostpartum(babyisborn)

check and ask if placenta is delivered

check for perineal and lower vaginal tears

check if still bleeding

BLEEDINGheavy bleeding■Padorclothsoakedin<5minutes■Constanttricklingofblood■ Bleeding>250mlordeliveredoutside

healthcentreandstillbleeding

placenta not delivered

placenta delivered

check placenta b��

if present

heavy bleeding

controlled bleeding

This may be uterine atony,

retained placenta, ruptured

uterus, vaginal or cervical tear.

TREATMENT■Callforextrahelp.■Massageuterusuntilitishardandgiveoxytocin10IuIM b�0 .■ InsertanIVline b9 andgiveIVfluidswith20Iuoxytocinat60drops/minute.■Emptybladder.Catheterizeifnecessary b�2 .■CheckandrecordBPandpulseevery15minutesandtreatason b3 .

■Whenuterusishard,deliverplacentabycontrolledcordtractiond�2 .■ Ifunsuccessfulandbleedingcontinues,removeplacentamanuallyandcheckplacenta b�� .■GiveappropriateIM/IVantibiotics b�5 .■ Ifunabletoremoveplacenta,referwomanurgentlytohospital b�7 .

Duringtransfer,continueIVfluidswith20Iuofoxytocinat30drops/minute.

if placenta is complete:■Massageuterustoexpressanyclots b�0 .■ Ifuterusremainssoft,giveergometrine0.2mgIV b�0 .

do notgiveergometrinetowomenwitheclampsia,pre-eclampsiaorknownhypertension.■ContinueIVfluidswith20Iuoxytocin/litreat30drops/minute.■Continuemassaginguterustillitishard.if placenta is incomplete (or not available for inspection): ■Removeplacentalfragments b�� .■GiveappropriateIM/IVantibiotics b�5 .■ Ifunabletoremove,referwomanurgentlytohospital b�7 .

■Examinethetearanddeterminethedegree b�2 .Ifthirddegreetear(involvingrectumoranus),referwomanurgentlytohospital b�7 .

■ Forothertears:applypressureoverthetearwithasterilepadorgauzeandputlegstogether.Donotcrossankles.■Checkafter5minutes,ifbleedingpersistsrepairthetear b�2 .

■ContinueIVfluidswith20unitsofoxytocinat30drops/minute.InsertsecondIVline.■Applybimanualuterineoraorticcompression b�0 .■GiveappropriateIM/IVantibiotics b�5 .■ refer woman urgently to hospital b�7 .

■Continueoxytocininfusionwith20Iu/litreofIVfluidsat20drops/minforatleastonehourafterbleedingstops b�0 .■Observeclosely(every30minutes)for4hours.Keepnearbyfor24hours.Ifseverepallor,refertohealthcentre.■ExaminethewomanusingAssess the mother after delivery d�2 .

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EMERGENCYSIGNS

■Convulsing(noworrecently),or■unconscious Ifunconscious,askrelative “hastherebeenarecentconvulsion?”

■Severeabdominalpain(notnormallabour)

Fever(temperaturemorethan38ºC)andanyof:■Veryfastbreathing■Stiffneck■Lethargy■Veryweak/notabletostand

This may be eclampsia.

This may be ruptured uterus,

obstructed labour, abruptio

placenta, puerperal or post-

abortion sepsis, ectopic

pregnancy.

This may be malaria,

meningitis, pneumonia,

septicemia.

convulsions or unconscious

severe abdominal pain

dangerous fever

TREATMENT

■Protectwomanfromfallandinjury.Gethelp.■Manageairway b9 .■Afterconvulsionends,helpwomanontoherleftside.■ InsertanIVlineandgivefluidsslowly(30drops/min) b9 .■Givemagnesiumsulphate b�3 .■ Ifearlypregnancy,givediazepamIVorrectally b�4 .■ IfdiastolicBP>110mmofHg,giveantihypertensive b�4 .■ Iftemperature>38ºC,orhistoryoffever,alsogivetreatmentfordangerous

fever(below).■ refer woman urgently to hospital* b�7 .

measure bp and temperature■ IfdiastolicBP>110mmofHg,giveantihypertensive b�4 .■ Iftemperature>38ºC,orhistoryoffever,alsogivetreatmentfordangerous

fever(below).■refer woman urgently to hospital* b�7 .

■ InsertanIVlineandgivefluids b9 .■ Iftemperaturemorethan38ºC,givefirstdoseofappropriateIM/IV

antiobiotics b�5 .■refer woman urgently to hospital* b�7 .■ IfsystolicBP<90mmHgsee b3 .

■ InsertanIVline b9 .■Givefluidsslowly b9 .■GivefirstdoseofappropriateIM/IVantibiotics b�5 .■GiveartemetherIM(ifnotavailable,givequinineIM)andglucose b�6 .■refer woman urgently to hospital* b�7 .

*Butifbirthisimminent(bulging,thinperineumduringcontractions,visiblefetalhead),transferwomantolabourroomandproceedasond�-d28 .

MEASuRE

■Measurebloodpressure■Measuretemperature■Assesspregnancystatus

■Measurebloodpressure■Measuretemperature

■Measuretemperature

next:Prioritysignst

Rapid assessment and management (RAM) Priority signs

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PRIORITYSIGNS

■Labourpainsor■Rupturedmembranes

Ifanyof:■Severepallor■Epigastricorabdominalpain■Severeheadache■Blurredvision■Fever(temperaturemorethan38ºC)■Breathingdifficulty

■Noemergencysignsor■Noprioritysigns

TREATMENT

■ManageasforChildbirthd�-d28 .

■ Ifpregnant(andnotinlabour),provideantenatalcarec�-c�9 .■ Ifrecentlygivenbirth,providepostpartumcare d2� .and e�-e�0 .■ Ifrecentabortion,providepost-abortioncareb20-b2�.■ Ifearlypregnancy,ornotawareofpregnancy,checkforectopicpregnancyb�9 .

■ Ifpregnant(andnotinlabour),provideantenatalcarec�-c�9 .■ Ifrecentlygivenbirth,providepostpartumcare e�-e�0 .

labour

other danger signs or symptoms

if no emergency or priority signs, non urgent

MEASuRE

■Measurebloodpressure■Measuretemperature

Emergency treatments for the womanEm

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airway, BrEathing and circulation

Airway, breathing and circulation

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ManagetheairwayandbreathingIfthewomanhasgreatdifficultybreathingand:■ Ifyoususpectobstruction:

→Trytocleartheairwayanddislodgeobstruction→Helpthewomantofindthebestpositionforbreathing→urgently refer the woman to hospital.

■ Ifthewomanisunconscious:→Keepheronherback,armsattheside→Tiltherheadbackwards(unlesstraumaissuspected)→Liftherchintoopenairway→Inspecthermouthforforeignbody;removeiffound→Clearsecretionsfromthroat.

■ Ifthewomanisnotbreathing:→Ventilatewithbagandmaskuntilshestartsbreathingspontaneously

■ Ifwomanstillhasgreatdifficultybreathing,keepherproppedup,and■refer the woman urgently to hospital.

InsertIVlineandgivefluids■Washhandswithsoapandwaterandputongloves.■Cleanwoman’sskinwithspiritatsiteforIVline.■ Insertanintravenousline(IVline)usinga16-18gaugeneedle.■AttachRinger’slactateornormalsaline.Ensureinfusionisrunningwell.

Givefluidsatrapid rateifshock,systolicBP<90mmHg,pulse>110/minute,orheavyvaginalbleeding:■ Infuse1litrein15-20minutes(asrapidaspossible).■ Infuse1litrein30minutesat30ml/minute.Repeatifnecessary.■Monitorevery15minutesfor:

→bloodpressure(BP)andpulse→shortnessofbreathorpuffiness.

■Reducetheinfusionrateto3ml/minute(1litrein6-8hours)whenpulseslowstolessthan100/minute,systolicBPincreasesto100mmHgorhigher.

■Reducetheinfusionrateto0.5ml/minuteifbreathingdifficultyorpuffinessdevelops.■Monitorurineoutput.■Recordtimeandamountoffluidsgiven.

Givefluidsatmoderate rateifsevereabdominalpain,obstructedlabour,ectopicpregnancy,dangerousfeverordehydration:■ Infuse1litrein2-3hours.

Givefluidsatslow rateifsevereanaemia/severepre-eclampsiaoreclampsia:■ Infuse1litrein6-8hours.

Ifintravenousaccessnotpossible■Giveoralrehydrationsolution(ORS)bymouthifabletodrink,orbynasogastric(NG)tube.■QuantityofORS:300to500mlin1hour.

do notgiveORStoawomanwhoisunconsciousorhasconvulsions.

BlEEding

Bleeding (1)

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MassageuterusandexpelclotsIfheavypostpartumbleedingpersistsafterplacentaisdelivered,oruterusisnotwellcontracted(issoft):■Placecuppedpalmonuterinefundusandfeelforstateofcontraction.■Massagefundusinacircularmotionwithcuppedpalmuntiluterusiswellcontracted.■Whenwellcontracted,placefingersbehindfundusandpushdowninoneswiftactiontoexpelclots.■Collectbloodinacontainerplacedclosetothevulva.Measureorestimatebloodloss,andrecord.

ApplybimanualuterinecompressionIfheavypostpartumbleedingpersistsdespiteuterinemassage,oxytocin/ergometrinetreatmentandremovalofplacenta:■Wearsterileorcleangloves.■ Introducetherighthandintothevagina,clenchedfist,withthebackofthehanddirectedposteriorly

andtheknucklesintheanteriorfornix.■Placetheotherhandontheabdomenbehindtheuterusandsqueezetheuterusfirmlybetweenthe

twohands.■Continuecompressionuntilbleedingstops(nobleedingifthecompressionisreleased).■ Ifbleedingpersists,applyaorticcompressionandtransportwomantohospital.

ApplyaorticcompressionIfheavypostpartumbleedingpersistsdespiteuterinemassage,oxytocin/ergometrinetreatmentandremovalofplacenta:

■ Feelforfemoralpulse.

■ Applypressureabovetheumbilicustostopbleeding.Applysufficientpressureuntilfemoralpulseisnotfelt.

■ Afterfindingcorrectsite,showassistantorrelativehowtoapplypressure,ifnecessary.

■ Continuepressureuntilbleedingstops.Ifbleedingpersists,keepapplyingpressurewhiletransportingwomantohospital.

GiveoxytocinIfheavypostpartumbleeding

initial dose continuing dose maximum doseIM/IV:10IU IM/IV:repeat10IU after20minutes Notmorethan3litres ifheavybleedingpersists ofIVfluidscontainingIVinfusion: IVinfusion: oxytocin20IUin1litre 10IUin1litreat60drops/min at30drops/min

GiveergometrineIfheavybleedinginearlypregnancyor postpartumbleeding(afteroxytocin)butdo not give if eclampsia, pre-eclampsia, or hypertension

initial dose continuing dose maximum doseIM/IV:0.2mg IM:repeat0.2mg Notmorethanslowly IMafter15minutesifheavy 5doses(total1.0mg) bleedingpersists

Bleeding (2)

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Removeplacentaandfragmentsmanually■ Ifplacentanotdelivered1hourafterdeliveryofthebaby,OR■ Ifheavyvaginalbleedingcontinuesdespitemassageandoxytocinandplacentacannotbedelivered

bycontrolledcordtraction,orifplacentaisincompleteandbleedingcontinues.

preparation■Explaintothewomantheneedformanualremovaloftheplacentaandobtainherconsent.■ InsertanIVline.Ifbleeding,givefluidsrapidly.Ifnotbleeding,givefluidsslowly B� .■Assistwomantogetontoherback.■Givediazepam(10-mgIM/IV).■Cleanvulvaandperinealarea.■Ensurethebladderisempty.Catheterizeifnecessary B12 .■Washhandsandforearmswellandputonlongsterilegloves(andanapronorgownifavailable).

technique■Withthelefthand,holdtheumbilicalcordwiththeclamp.Thenpullthecordgentlyuntilitis

horizontal.■ Insertrighthandintothevaginaandupintotheuterus.■Leavethecordandholdthefunduswiththelefthandinordertosupportthefundusoftheuterus

andtoprovidecounter-tractionduringremoval.■Movethefingersoftherighthandsidewaysuntiledgeoftheplacentaislocated.■Detachtheplacentafromtheimplantationsitebykeepingthefingerstightlytogetherandusingthe

edgeofthehandtograduallymakeaspacebetweentheplacentaandtheuterinewall.■Proceedgraduallyallaroundtheplacentalbeduntilthewholeplacentaisdetachedfromtheuterine

wall.■Withdrawtherighthandfromtheuterusgradually,bringingtheplacentawithit.■Exploretheinsideoftheuterinecavitytoensureallplacentaltissuehasbeenremoved.■Withthelefthand,providecounter-tractiontothefundusthroughtheabdomenbypushingitinthe

oppositedirectionofthehandthatisbeingwithdrawn.Thispreventsinversionoftheuterus.■Examinetheuterinesurfaceoftheplacentatoensurethatlobesandmembranesarecomplete.If

anyplacentallobeortissuefragmentsaremissing,exploreagaintheuterinecavitytoremovethem.

if hours or days have passed since delivery, or if the placenta is retained due to constriction ring or closed cervix, it may not be possible to put the hand into the uterus. do not persist. refer urgently to hospital B17 .

if the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage, suspect placenta accreta. do not persist in efforts to remove placenta. refer urgently to hospital B17 .

Aftermanualremovaloftheplacenta■Repeatoxytocin10-IUIM/IV.■Massagethefundusoftheuterustoencourageatonicuterinecontraction.■Giveampicillin2gIV/IM B15 .■ Iffever>38.5°C,foul-smellinglochiaorhistoryofruptureofmembranesfor18ormorehours,also

givegentamicin80mgIM B15 .■ Ifbleedingstops:

→givefluidsslowlyforatleast1hourafterremovalofplacenta.■ Ifheavybleedingcontinues:

→giveergometrine0.2 mgIM→give20IUoxytocinineachlitreofIVfluidsandinfuserapidly→refer urgently to hospital B17 .

■Duringtransportation,feelcontinuouslywhetheruterusiswellcontracted(hardandround).Ifnot,massageandrepeatoxytocin10IUIM/IV.

■Providebimanualoraorticcompressionifseverebleedingbeforeandduringtransportation B10 .

rEpair thE tEar and Empty BladdEr

Bleeding (3)

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Repairthetearorepisiotomy■ Examinethetearanddeterminethedegree:

→Thetearissmallandinvolvedonlyvaginalmucosaandconnectivetissuesandunderlyingmuscles(firstorseconddegreetear).Ifthetearisnotbleeding,leavethewoundopen.

→Thetearislonganddeepthroughtheperineumandinvolvestheanalsphincterandrectalmucosa(thirdandfourthdegreetear).Coveritwithacleanpadandrefer the woman urgently to hospitalB17 .

■ Iffirstorseconddegreetearandheavybleedingpersistsafterapplyingpressureoverthewound:→Suturethetearorreferforsuturingifnooneisavailablewithsuturingskills.→Suturethetearusinguniversalprecautions,aseptictechniqueandsterileequipment.→Useaneedleholderanda21gauge,4cm,curvedneedle.→Useabsorbablepolyglyconsuturematerial.→Makesurethattheapexofthetearisreachedbeforeyoubeginsuturing.→Ensurethatedgesofthetearmatchupwell.do notsutureifmorethan12hourssincedelivery.refer woman to hospital.

EmptybladderIfbladderisdistendedandthewomanisunabletopassurine:■ Encouragethewomantourinate.■ Ifsheisunabletourinate,catheterizethebladder:

→Washhands→Cleanurethralareawithantiseptic→Putoncleangloves→Spreadlabia.Cleanareaagain→Insertcatheterupto4cm→Measureurineandrecordamount→Removecatheter.

Eclampsia and prE-Eclampsia (1)

Eclampsia and pre-eclampsia (1)

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GivemagnesiumsulphateIfseverepre-eclampsiaandeclampsia

iV/im combined dose (loading dose)■ InsertIVlineandgivefluidsslowly(normalsalineorRinger’slactate)—

1litrein6-8hours(3-ml/minute) B� .■Give4-gofmagnesiumsulphate(20mlof20%solution)IVslowlyover20minutes

(womanmayfeelwarmduringinjection). and:■Give10gofmagnesiumsulphateIM:give5g(10mlof50%solution)IMdeepinupperouter

quadrantofeachbuttockwith1mlof2%lignocaineinthesamesyringe.

if unable to give iV, give im only (loading dose)■Give10gofmagnesiumsulphateIM:give5g(10mlof50%solution)IMdeepinupperouter

quadrantofeachbuttockwith1mlof2%lignocaineinthesamesyringe.

if convulsions recur ■After15minutes,giveanadditional2gofmagnesiumsulphate(10mlof20%solution)IV

over20minutes.Ifconvulsionsstillcontinue,givediazepam B14 .

if referral delayed for long, or the woman is in late labour, continue treatment:■Give5gof50%magnesiumsulphatesolutionIMwith1mlof2%lignocaineevery4hoursin

alternatebuttocksuntil24hoursafterbirthorafterlastconvulsion(whicheverislater).■Monitorurineoutput:collecturineandmeasurethequantity.■Beforegivingthenextdoseofmagnesiumsulphate,ensure:

→kneejerkispresent→urineoutput>100ml/4hrs→respiratoryrate>16/min.

■do notgivethenextdoseifanyofthesesigns:→kneejerkabsent→urineoutput<100ml/4hrs→respiratoryrate<16/min.

■Recordfindingsanddrugsgiven.

Importantconsiderationsincaringforawomanwitheclampsiaorpre-eclampsia■Donotleavethewomanonherown.

→Helpherintotheleftsidepositionandprotectherfromfallandinjury→Placepaddedtonguebladesbetweenherteethtopreventatonguebite,andsecureittoprevent

aspiration(do notattemptthisduringaconvulsion).■GiveIV20%magnesiumsulphateslowlyover20minutes.Rapidinjectioncancauserespiratory

failureordeath.→Ifrespiratorydepression(breathinglessthan16/minute)occursaftermagnesiumsulphate,do

notgiveanymoremagnesiumsulphate.Givetheantidote:calciumgluconate1gIV(10mlof10%solution)over10minutes.

■do notgiveintravenousfluidsrapidly.■do notgiveintravenously50%magnesiumsulphatewithoutdillutingitto20%.■refer urgently to hospitalunlessdeliveryisimminent.

→Ifdeliveryimminent,manageasinChildbirthd1-d2� andaccompanythewomanduringtransport

→Keepherintheleftsideposition→Ifaconvulsionoccursduringthejourney,givemagnesiumsulphateandprotectherfromfalland

injury.

formulation of magnesium sulphate 50% solution: 20% solution:tomake10mlof20%solution, vialcontaining5gin10ml(1g/2ml) add4mlof50%solutionto6mlsterilewater

im 5g 10mland1ml2%lignocaine NotapplicableiV 4g 8ml 20ml 2g 4ml 10ml

Afterreceivingmagnesiumsulphateawomanfeelflushing,thirst,headache,nauseaormayvomit.

B9 airway, BrEathing and circulation

Managetheairwayandbreathing InsertIVlineandgivefluids

B10 BlEEding (1) Massageuterusandexpelclots

Applybimanualuterinecompression Applyaorticcompression Giveoxytocin Giveergometrine

B11 BlEEding (2) Removeplacentaandfragmentsmanually

Aftermanualremovaloftheplacenta

B12 BlEEding (3) Repairthetear

Emptybladder

B13 Eclampsia and prE-Eclampsia (1)

Importantconsiderationsincaringforawomanwitheclampsiaandpre-eclampsia

Givemagnesiumsulphate

Eclampsia and prE-Eclampsia (2)

Eclampsia and pre-eclampsia (2)

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B14

GivediazepamIfconvulsionsoccurinearlypregnancyorIfmagnesiumsulphatetoxicityoccursormagnesiumsulphateisnotavailable.

loading dose iV■Givediazepam10mgIVslowlyover2minutes.■ Ifconvulsionsrecur,repeat10mg.

maintenance dose■Givediazepam40mgin500mlIVfluids(normalsalineorRinger’slactate)titratedover6-8hours

tokeepthewomansedatedbutrousable.■Stopthemaintenancedoseifbreathing<16breaths/minute.■Assistventilationifnecessarywithmaskandbag.■Donotgivemorethan100mgin24hours.■ IfIVaccessisnotpossible(e.g.duringconvulsion),givediazepamrectally.

loading dose rectally■Give20mg(4ml)ina10mlsyringe(orurinarycatheter):

→Removetheneedle,lubricatethebarrelandinsertthesyringeintotherectumtohalfitslength.→Dischargethecontentsandleavethesyringeinplace,holdingthebuttockstogetherfor10

minutestopreventexpulsionofthedrug.■ Ifconvulsionsrecur,repeat10mg.

maintenance dose■Giveadditional10mg(2ml)everyhourduringtransport.

diazepam:vialcontaining10mgin2ml iV rectallyinitial dose 10mg=2ml 20mg=4mlsecond dose 10mg=2ml 10mg=2ml

GiveappropriateantihypertensivedrugIfdiastolicbloodpressureis>110-mmHg:■Givehydralazine5mgIVslowly(3-4minutes).IfIVnotpossiblegiveIM.■ Ifdiastolicbloodpressureremains>90mmHg,repeatthedoseat30minuteintervalsuntil

diastolicBPisaround90mmHg.■Donotgivemorethan20mgintotal.

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GiveappropriateIV/IMantibiotics■Givethefirstdoseofantibiotic(s)beforereferral.Ifreferralisdelayedornotpossible,continue

antibioticsIM/IVfor48hoursafterwomanisfeverfree.Thengiveamoxicillinorally500mg3timesdailyuntil7daysoftreatmentcompleted.

■ Ifsignspersistormotherbecomesweakorhasabdominalpainpostpartum,refer urgently to hospitalB17 .

condition antiBiotics■Severeabdominalpain 3 antibiotics■Dangerousfever/veryseverefebriledisease ■Ampicillin■Complicatedabortion ■Gentamicin■Uterineandfetalinfection ■Metronidazole■Postpartumbleeding 2 antibiotics: →lasting>24hours ■Ampicillin →occurring>24hoursafterdelivery ■Gentamicin■Upperurinarytractinfection■Pneumonia■Manualremovalofplacenta/fragments 1 antibiotic:■Riskofuterineandfetalinfection ■Ampicillin■ Inlabour>24hours

antibiotic preparation dosage/route frequencyampicillin Vialcontaining500mgaspowder: First2gIV/IMthen1g every6hours

tobemixedwith2.5mlsterilewater gentamicin Vialcontaining40mg/mlin2ml 80mgIM every8hoursmetronidazole Vialcontaining500mgin100ml 500mgor100mlIVinfusion every8hours do not giVE im

Erythromycin Vialcontaining500mgaspowder 500mgIV/IM every6hours (ifallergytoampicillin)

malaria

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B16

GivearthemeterorquinineIMIfdangerousfeverorveryseverefebriledisease

arthemeter Quinine* 1mlvialcontaining80mg/ml 2mlvialcontaining300mg/mlleading dose for 3.2mg/kg 20mg/kg assumed weight 50-60 kg 2ml 4mlcontinue treatment 1.6mg/kg 10mg/kg if unable to refer 1mloncedailyfor3days** 2ml/8hoursforatotalof7days**

■Givetheloadingdoseofthemosteffectivedrug,accordingtothenationalpolicy.■ Ifquinine:

→dividetherequireddoseequallyinto2injectionsandgive1ineachanteriorthigh→alwaysgiveglucosewithquinine.

■ReferurgentlytohospitalB17 .■ Ifdeliveryimminentorunabletoreferimmediately,continuetreatmentasaboveandreferafter

delivery.

* Thesedosagesareforquininedihydrochloride.Ifquininebase,give8.2mg/kgevery8hours.**Discontinueparenteraltreatmentassoonaswomanisconsciousandabletoswallow.Beginoral

treatmentaccordingtonationalguidelines.

GiveglucoseIVIfdangerousfeverorveryseverefebrilediseasetreatedwithquinine

50% glucose solution* 25% glucose solution 10% glucose solution (5 ml/kg)25-50ml 50-100ml 125-250ml

■MakesureIVdripisrunningwell.GiveglucosebyslowIVpush.■ IfnoIVglucoseisavailable,givesugarwaterbymouthornasogastrictube.■Tomakesugarwater,dissolve4levelteaspoonsofsugar(20g)ina200mlcupofcleanwater.

* 50%glucosesolutionisthesameas50%dextrosesolutionorD50.Thissolutionisirritatingtoveins.Diluteitwithanequalquantityofsterilewaterorsalinetoproduce25%glucosesolution.

rEfEr thE woman urgEntly to thE hospital

Refer the woman urgently to hospital

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Referthewomanurgentlytohospital■Afteremergencymanagement,discussdecisionwithwomanandrelatives.■Quicklyorganizetransportandpossiblefinancialaid.■ Informthereferralcentreifpossiblebyradioorphone.■Accompanythewomanifatallpossible,orsend:

→ahealthworkertrainedindeliverycare→arelativewhocandonateblood→babywiththemother,ifpossible→essentialemergencydrugsandsuppliesB17 .→referralnote n2 .

■Duringjourney:→watchIVinfusion→ifjourneyislong,giveappropriatetreatmentontheway→keeprecordofallIVfluids,medicationsgiven,timeofadministrationandthewoman’scondition.

Essentialemergencydrugsandsuppliesfortransportandhomedelivery

Emergency drugs strength and form Quantity for carryOxytocin 10IUvial 6Ergometrine 0.2mgvial 2Magnesiumsulphate 5gvials(20g) 4Diazepam(parenteral) 10mgvial 3Calciumgluconate 1gvial 1Ampicillin 500mgvial 4Gentamicin 80mgvial 3Metronidazole 500mgvial 2Ringer’slactate 1litrebottle 4(ifdistantreferral)

Emergency supplies IVcathetersandtubing 2setsGloves 2pairs,atleast,onepairsterileSterilesyringesandneedles 5setsUrinarycatheter 1Antisepticsolution 1smallbottleContainerforsharps 1Bagfortrash 1Torchandextrabattery 1

if delivery is anticipated on the way Soap,towels 2setsDisposabledeliverykit(blade,3ties) 2setsCleancloths(3)forreceiving,dryingandwrappingthebaby 1setCleanclothesforthebaby 1setPlasticbagforplacenta 1setResuscitationbagandmaskforthebaby 1set

B14 Eclampsia and prE-Eclampsia (2)

Givediazepam Giveappropriateantihypertensive

B15 infEction GiveappropriateIV/IMantibiotics

B16 malaria GiveartemetherorquinineIM

GiveglucoseIV

B17 rEfEr thE woman urgEntly to thE hospital

Referthewomanurgentlytothehospital Essentialemergencydrugsandsupplies

fortransportandhomedelivery

■ThissectionhasdetailsonemergencytreatmentsidentifiedduringRapidassessmentandmanagement(RAM) B3-B6 tobegivenbeforereferral.

■GivethetreatmentandreferthewomanurgentlytohospitalB17.

■ Ifdrugtreatment,givethefirstdoseofthedrugsbeforereferral.Donotdelayreferralbygivingnon-urgenttreatments.

airway, BrEathing and circulation

Airway, breathing and circulation

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ManagetheairwayandbreathingIfthewomanhasgreatdifficultybreathingand:■ Ifyoususpectobstruction:

→Trytocleartheairwayanddislodgeobstruction→Helpthewomantofindthebestpositionforbreathing→urgently refer the woman to hospital.

■ Ifthewomanisunconscious:→Keepheronherback,armsattheside→Tiltherheadbackwards(unlesstraumaissuspected)→Liftherchintoopenairway→Inspecthermouthforforeignbody;removeiffound→Clearsecretionsfromthroat.

■ Ifthewomanisnotbreathing:→Ventilatewithbagandmaskuntilshestartsbreathingspontaneously

■ Ifwomanstillhasgreatdifficultybreathing,keepherproppedup,and■refer the woman urgently to hospital.

InsertIVlineandgivefluids■Washhandswithsoapandwaterandputongloves.■Cleanwoman’sskinwithspiritatsiteforIVline.■ Insertanintravenousline(IVline)usinga16-18gaugeneedle.■AttachRinger’slactateornormalsaline.Ensureinfusionisrunningwell.

Givefluidsatrapid rateifshock,systolicBP<90mmHg,pulse>110/minute,orheavyvaginalbleeding:■ Infuse1litrein15-20minutes(asrapidaspossible).■ Infuse1litrein30minutesat30ml/minute.Repeatifnecessary.■Monitorevery15minutesfor:

→bloodpressure(BP)andpulse→shortnessofbreathorpuffiness.

■Reducetheinfusionrateto3ml/minute(1litrein6-8hours)whenpulseslowstolessthan100/minute,systolicBPincreasesto100mmHgorhigher.

■Reducetheinfusionrateto0.5ml/minuteifbreathingdifficultyorpuffinessdevelops.■Monitorurineoutput.■Recordtimeandamountoffluidsgiven.

Givefluidsatmoderate rateifsevereabdominalpain,obstructedlabour,ectopicpregnancy,dangerousfeverordehydration:■ Infuse1litrein2-3hours.

Givefluidsatslow rateifsevereanaemia/severepre-eclampsiaoreclampsia:■ Infuse1litrein6-8hours.

Ifintravenousaccessnotpossible■Giveoralrehydrationsolution(ORS)bymouthifabletodrink,orbynasogastric(NG)tube.■QuantityofORS:300to500mlin1hour.

do notgiveORStoawomanwhoisunconsciousorhasconvulsions.

BlEEding

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MassageuterusandexpelclotsIfheavypostpartumbleedingpersistsafterplacentaisdelivered,oruterusisnotwellcontracted(issoft):■Placecuppedpalmonuterinefundusandfeelforstateofcontraction.■Massagefundusinacircularmotionwithcuppedpalmuntiluterusiswellcontracted.■Whenwellcontracted,placefingersbehindfundusandpushdowninoneswiftactiontoexpelclots.■Collectbloodinacontainerplacedclosetothevulva.Measureorestimatebloodloss,andrecord.

ApplybimanualuterinecompressionIfheavypostpartumbleedingpersistsdespiteuterinemassage,oxytocin/ergometrinetreatmentandremovalofplacenta:■Wearsterileorcleangloves.■ Introducetherighthandintothevagina,clenchedfist,withthebackofthehanddirectedposteriorly

andtheknucklesintheanteriorfornix.■Placetheotherhandontheabdomenbehindtheuterusandsqueezetheuterusfirmlybetweenthe

twohands.■Continuecompressionuntilbleedingstops(nobleedingifthecompressionisreleased).■ Ifbleedingpersists,applyaorticcompressionandtransportwomantohospital.

ApplyaorticcompressionIfheavypostpartumbleedingpersistsdespiteuterinemassage,oxytocin/ergometrinetreatmentandremovalofplacenta:

■ Feelforfemoralpulse.

■ Applypressureabovetheumbilicustostopbleeding.Applysufficientpressureuntilfemoralpulseisnotfelt.

■ Afterfindingcorrectsite,showassistantorrelativehowtoapplypressure,ifnecessary.

■ Continuepressureuntilbleedingstops.Ifbleedingpersists,keepapplyingpressurewhiletransportingwomantohospital.

GiveoxytocinIfheavypostpartumbleeding

initial dose continuing dose maximum doseIM/IV:10IU IM/IV:repeat10IU after20minutes Notmorethan3litres ifheavybleedingpersists ofIVfluidscontainingIVinfusion: IVinfusion: oxytocin20IUin1litre 10IUin1litre at60drops/min at30drops/min

GiveergometrineIfheavybleedinginearlypregnancyor postpartumbleeding(afteroxytocin)butdo not give if eclampsia, pre-eclampsia, or hypertension

initial dose continuing dose maximum doseIM/IV:0.2mg IM:repeat0.2mg Notmorethanslowly IMafter15minutesifheavy 5doses(total1.0mg) bleedingpersists

Bleeding (2)

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B11

Removeplacentaandfragmentsmanually■ Ifplacentanotdelivered1hourafterdeliveryofthebaby,OR■ Ifheavyvaginalbleedingcontinuesdespitemassageandoxytocinandplacentacannotbedelivered

bycontrolledcordtraction,orifplacentaisincompleteandbleedingcontinues.

preparation■Explaintothewomantheneedformanualremovaloftheplacentaandobtainherconsent.■ InsertanIVline.Ifbleeding,givefluidsrapidly.Ifnotbleeding,givefluidsslowly B� .■Assistwomantogetontoherback.■Givediazepam(10-mgIM/IV).■Cleanvulvaandperinealarea.■Ensurethebladderisempty.Catheterizeifnecessary B12 .■Washhandsandforearmswellandputonlongsterilegloves(andanapronorgownifavailable).

technique■Withthelefthand,holdtheumbilicalcordwiththeclamp.Thenpullthecordgentlyuntilitis

horizontal.■ Insertrighthandintothevaginaandupintotheuterus.■Leavethecordandholdthefunduswiththelefthandinordertosupportthefundusoftheuterus

andtoprovidecounter-tractionduringremoval.■Movethefingersoftherighthandsidewaysuntiledgeoftheplacentaislocated.■Detachtheplacentafromtheimplantationsitebykeepingthefingerstightlytogetherandusingthe

edgeofthehandtograduallymakeaspacebetweentheplacentaandtheuterinewall.■Proceedgraduallyallaroundtheplacentalbeduntilthewholeplacentaisdetachedfromtheuterine

wall.■Withdrawtherighthandfromtheuterusgradually,bringingtheplacentawithit.■Exploretheinsideoftheuterinecavitytoensureallplacentaltissuehasbeenremoved.■Withthelefthand,providecounter-tractiontothefundusthroughtheabdomenbypushingitinthe

oppositedirectionofthehandthatisbeingwithdrawn.Thispreventsinversionoftheuterus.■Examinetheuterinesurfaceoftheplacentatoensurethatlobesandmembranesarecomplete.If

anyplacentallobeortissuefragmentsaremissing,exploreagaintheuterinecavitytoremovethem.

if hours or days have passed since delivery, or if the placenta is retained due to constriction ring or closed cervix, it may not be possible to put the hand into the uterus. do not persist. refer urgently to hospital B17 .

if the placenta does not separate from the uterine surface by gentle sideways movement of the fingertips at the line of cleavage, suspect placenta accreta. do not persist in efforts to remove placenta. refer urgently to hospital B17 .

Aftermanualremovaloftheplacenta■Repeatoxytocin10-IUIM/IV.■Massagethefundusoftheuterustoencourageatonicuterinecontraction.■Giveampicillin2gIV/IM B15 .■ Iffever>38.5°C,foul-smellinglochiaorhistoryofruptureofmembranesfor18ormorehours,also

givegentamicin80mgIM B15 .■ Ifbleedingstops:

→givefluidsslowlyforatleast1hourafterremovalofplacenta.■ Ifheavybleedingcontinues:

→giveergometrine0.2 mgIM→give20IUoxytocinineachlitreofIVfluidsandinfuserapidly→refer urgently to hospital B17 .

■Duringtransportation,feelcontinuouslywhetheruterusiswellcontracted(hardandround).Ifnot,massageandrepeatoxytocin10IUIM/IV.

■Providebimanualoraorticcompressionifseverebleedingbeforeandduringtransportation B10 .

rEpair thE tEar and Empty BladdEr

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Repairthetearorepisiotomy■ Examinethetearanddeterminethedegree:

→Thetearissmallandinvolvedonlyvaginalmucosaandconnectivetissuesandunderlyingmuscles(firstorseconddegreetear).Ifthetearisnotbleeding,leavethewoundopen.

→Thetearislonganddeepthroughtheperineumandinvolvestheanalsphincterandrectalmucosa(thirdandfourthdegreetear).Coveritwithacleanpadandrefer the woman urgently to hospitalB17 .

■ Iffirstorseconddegreetearandheavybleedingpersistsafterapplyingpressureoverthewound:→Suturethetearorreferforsuturingifnooneisavailablewithsuturingskills.→Suturethetearusinguniversalprecautions,aseptictechniqueandsterileequipment.→Useaneedleholderanda21gauge,4cm,curvedneedle.→Useabsorbablepolyglyconsuturematerial.→Makesurethattheapexofthetearisreachedbeforeyoubeginsuturing.→Ensurethatedgesofthetearmatchupwell.do notsutureifmorethan12hourssincedelivery.refer woman to hospital.

EmptybladderIfbladderisdistendedandthewomanisunabletopassurine:■ Encouragethewomantourinate.■ Ifsheisunabletourinate,catheterizethebladder:

→Washhands→Cleanurethralareawithantiseptic→Putoncleangloves→Spreadlabia.Cleanareaagain→Insertcatheterupto4cm→Measureurineandrecordamount→Removecatheter.

Eclampsia and prE-Eclampsia (1)

Eclampsia and pre-eclampsia (1)

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B13

GivemagnesiumsulphateIfseverepre-eclampsiaandeclampsia

iV/im combined dose (loading dose)■ InsertIVlineandgivefluidsslowly(normalsalineorRinger’slactate)—

1litrein6-8hours(3-ml/minute) B� .■Give4-gofmagnesiumsulphate(20mlof20%solution)IVslowlyover20minutes

(womanmayfeelwarmduringinjection). and:■Give10gofmagnesiumsulphateIM:give5g(10mlof50%solution)IMdeepinupperouter

quadrantofeachbuttockwith1mlof2%lignocaineinthesamesyringe.

if unable to give iV, give im only (loading dose)■Give10gofmagnesiumsulphateIM:give5g(10mlof50%solution)IMdeepinupperouter

quadrantofeachbuttockwith1mlof2%lignocaineinthesamesyringe.

if convulsions recur ■After15minutes,giveanadditional2gofmagnesiumsulphate(10mlof20%solution)IV

over20minutes.Ifconvulsionsstillcontinue,givediazepam B14 .

if referral delayed for long, or the woman is in late labour, continue treatment:■Give5gof50%magnesiumsulphatesolutionIMwith1mlof2%lignocaineevery4hoursin

alternatebuttocksuntil24hoursafterbirthorafterlastconvulsion(whicheverislater).■Monitorurineoutput:collecturineandmeasurethequantity.■Beforegivingthenextdoseofmagnesiumsulphate,ensure:

→kneejerkispresent→urineoutput>100ml/4hrs→respiratoryrate>16/min.

■do notgivethenextdoseifanyofthesesigns:→kneejerkabsent→urineoutput<100ml/4hrs→respiratoryrate<16/min.

■Recordfindingsanddrugsgiven.

Importantconsiderationsincaringforawomanwitheclampsiaorpre-eclampsia■Donotleavethewomanonherown.

→Helpherintotheleftsidepositionandprotectherfromfallandinjury→Placepaddedtonguebladesbetweenherteethtopreventatonguebite,andsecureittoprevent

aspiration(do notattemptthisduringaconvulsion).■GiveIV20%magnesiumsulphateslowlyover20minutes.Rapidinjectioncancauserespiratory

failureordeath.→Ifrespiratorydepression(breathinglessthan16/minute)occursaftermagnesiumsulphate,do

notgiveanymoremagnesiumsulphate.Givetheantidote:calciumgluconate1gIV(10mlof10%solution)over10minutes.

■do notgiveintravenousfluidsrapidly.■do notgiveintravenously50%magnesiumsulphatewithoutdillutingitto20%.■refer urgently to hospitalunlessdeliveryisimminent.

→Ifdeliveryimminent,manageasinChildbirthd1-d2� andaccompanythewomanduringtransport

→Keepherintheleftsideposition→Ifaconvulsionoccursduringthejourney,givemagnesiumsulphateandprotectherfromfalland

injury.

formulation of magnesium sulphate 50% solution: 20% solution:tomake10mlof20%solution, vialcontaining5gin10ml(1g/2ml) add4mlof50%solutionto6mlsterilewater

im 5g 10mland1ml2%lignocaine NotapplicableiV 4g 8ml 20ml 2g 4ml 10ml

Afterreceivingmagnesiumsulphateawomanfeelflushing,thirst,headache,nauseaormayvomit.

Eclampsia and prE-Eclampsia (2)

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B14

GivediazepamIfconvulsionsoccurinearlypregnancyorIfmagnesiumsulphatetoxicityoccursormagnesiumsulphateisnotavailable.

loading dose iV■Givediazepam10mgIVslowlyover2minutes.■ Ifconvulsionsrecur,repeat10mg.

maintenance dose■Givediazepam40mgin500mlIVfluids(normalsalineorRinger’slactate)titratedover6-8hours

tokeepthewomansedatedbutrousable.■Stopthemaintenancedoseifbreathing<16breaths/minute.■Assistventilationifnecessarywithmaskandbag.■Donotgivemorethan100mgin24hours.■ IfIVaccessisnotpossible(e.g.duringconvulsion),givediazepamrectally.

loading dose rectally■Give20mg(4ml)ina10mlsyringe(orurinarycatheter):

→Removetheneedle,lubricatethebarrelandinsertthesyringeintotherectumtohalfitslength.→Dischargethecontentsandleavethesyringeinplace,holdingthebuttockstogetherfor10

minutestopreventexpulsionofthedrug.■ Ifconvulsionsrecur,repeat10mg.

maintenance dose■Giveadditional10mg(2ml)everyhourduringtransport.

diazepam:vialcontaining10mgin2ml iV rectallyinitial dose 10mg=2ml 20mg=4mlsecond dose 10mg=2ml 10mg=2ml

GiveappropriateantihypertensivedrugIfdiastolicbloodpressureis>110-mmHg:■Givehydralazine5mgIVslowly(3-4minutes).IfIVnotpossiblegiveIM.■ Ifdiastolicbloodpressureremains>90mmHg,repeatthedoseat30minuteintervalsuntil

diastolicBPisaround90mmHg.■Donotgivemorethan20mgintotal.

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GiveappropriateIV/IMantibiotics■Givethefirstdoseofantibiotic(s)beforereferral.Ifreferralisdelayedornotpossible,continue

antibioticsIM/IVfor48hoursafterwomanisfeverfree.Thengiveamoxicillinorally500mg3timesdailyuntil7daysoftreatmentcompleted.

■ Ifsignspersistormotherbecomesweakorhasabdominalpainpostpartum,refer urgently to hospitalB17 .

condition antiBiotics■Severeabdominalpain 3 antibiotics■Dangerousfever/veryseverefebriledisease ■Ampicillin■Complicatedabortion ■Gentamicin■Uterineandfetalinfection ■Metronidazole■Postpartumbleeding 2 antibiotics: →lasting>24hours ■Ampicillin →occurring>24hoursafterdelivery ■Gentamicin■Upperurinarytractinfection■Pneumonia■Manualremovalofplacenta/fragments 1 antibiotic:■Riskofuterineandfetalinfection ■Ampicillin■ Inlabour>24hours

antibiotic preparation dosage/route frequencyampicillin Vialcontaining500mgaspowder: First2gIV/IMthen1g every6hours

tobemixedwith2.5mlsterilewater gentamicin Vialcontaining40mg/mlin2ml 80mgIM every8hoursmetronidazole Vialcontaining500mgin100ml 500mgor100mlIVinfusion every8hours do not giVE im

Erythromycin Vialcontaining500mgaspowder 500mgIV/IM every6hours (ifallergytoampicillin)

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GivearthemeterorquinineIMIfdangerousfeverorveryseverefebriledisease

arthemeter Quinine* 1mlvialcontaining80mg/ml 2mlvialcontaining300mg/mlleading dose for 3.2mg/kg 20mg/kg assumed weight 50-60 kg 2ml 4mlcontinue treatment 1.6mg/kg 10mg/kg if unable to refer 1mloncedailyfor3days** 2ml/8hoursforatotalof7days**

■Givetheloadingdoseofthemosteffectivedrug,accordingtothenationalpolicy.■ Ifquinine:

→dividetherequireddoseequallyinto2injectionsandgive1ineachanteriorthigh→alwaysgiveglucosewithquinine.

■ReferurgentlytohospitalB17 .■ Ifdeliveryimminentorunabletoreferimmediately,continuetreatmentasaboveandreferafter

delivery.

* Thesedosagesareforquininedihydrochloride.Ifquininebase,give8.2mg/kgevery8hours.**Discontinueparenteraltreatmentassoonaswomanisconsciousandabletoswallow.Beginoral

treatmentaccordingtonationalguidelines.

GiveglucoseIVIfdangerousfeverorveryseverefebrilediseasetreatedwithquinine

50% glucose solution* 25% glucose solution 10% glucose solution (5 ml/kg)25-50ml 50-100ml 125-250ml

■MakesureIVdripisrunningwell.GiveglucosebyslowIVpush.■ IfnoIVglucoseisavailable,givesugarwaterbymouthornasogastrictube.■Tomakesugarwater,dissolve4levelteaspoonsofsugar(20g)ina200mlcupofcleanwater.

* 50%glucosesolutionisthesameas50%dextrosesolutionorD50.Thissolutionisirritatingtoveins.Diluteitwithanequalquantityofsterilewaterorsalinetoproduce25%glucosesolution.

rEfEr thE woman urgEntly to thE hospital

Refer the woman urgently to hospital

EmEr

gEnc

y tr

Eatm

Ents

for

thE

wom

an

B17

Referthewomanurgentlytohospital■Afteremergencymanagement,discussdecisionwithwomanandrelatives.■Quicklyorganizetransportandpossiblefinancialaid.■ Informthereferralcentreifpossiblebyradioorphone.■Accompanythewomanifatallpossible,orsend:

→ahealthworkertrainedindeliverycare→arelativewhocandonateblood→babywiththemother,ifpossible→essentialemergencydrugsandsuppliesB17 .→referralnote n2 .

■Duringjourney:→watchIVinfusion→ifjourneyislong,giveappropriatetreatmentontheway→keeprecordofallIVfluids,medicationsgiven,timeofadministrationandthewoman’scondition.

Essentialemergencydrugsandsuppliesfortransportandhomedelivery

Emergency drugs strength and form Quantity for carryOxytocin 10IUvial 6Ergometrine 0.2mgvial 2Magnesiumsulphate 5gvials(20g) 4Diazepam(parenteral) 10mgvial 3Calciumgluconate 1gvial 1Ampicillin 500mgvial 4Gentamicin 80mgvial 3Metronidazole 500mgvial 2Ringer’slactate 1litrebottle 4(ifdistantreferral)

Emergency supplies IVcathetersandtubing 2setsGloves 2pairs,atleast,onepairsterileSterilesyringesandneedles 5setsUrinarycatheter 1Antisepticsolution 1smallbottleContainerforsharps 1Bagfortrash 1Torchandextrabattery 1

if delivery is anticipated on the way Soap,towels 2setsDisposabledeliverykit(blade,3ties) 2setsCleancloths(3)forreceiving,dryingandwrappingthebaby 1setCleanclothesforthebaby 1setPlasticbagforplacenta 1setResuscitationbagandmaskforthebaby 1set

Bleeding in early pregnancy and post-abortion careBl

eedi

ng in

ear

ly p

regn

ancy

and

pos

t-aB

orti

on c

are

B18

Bleeding in early pregnancy and post-aBortion care

Bleeding in early pregnancy and post-abortion care

Blee

ding

in e

arly

pre

gnan

cy a

nd p

ost-

aBor

tion

car

e

B19

ASK,CHECKRECORD■Whendidbleedingstart?■Howmuchbloodhaveyoulost?■Areyoustillbleeding?■ Isthebleedingincreasingor

decreasing?■Couldyoubepregnant?■Whenwasyourlastperiod?■Haveyouhadarecentabortion?■Didyouoranyoneelsedoanything

toinduceanabortion?■Haveyoufaintedrecently?■Doyouhaveabdominalpain?■Doyouhaveanyotherconcernsto

discuss?

LOOK,LISTEN,FEEL■Lookatamountofbleeding.■Noteifthereisfoul-smellingvaginal

discharge.■Feelforlowerabdominalpain.■Feelforfever.Ifhot,measure

temperature.■Lookforpallor.

SIGNS■Vaginalbleedingandanyof:

→Foul-smellingvaginaldischarge→Abortionwithuterine

manipulation→Abdominalpain/tenderness→Temperature>38°C.

■Lightvaginalbleeding

■Historyofheavybleedingbut:→nowdecreasing,or→nobleedingatpresent.

■Twoormoreofthefollowingsigns:→abdominalpain→fainting→pale→veryweak

TREATANDADVISE■ InsertanIVlineandgivefluids B9 .■Giveparacetamolforpain f4 .■GiveappropriateIM/IVantibiotics B15 .■refer urgently to hospital B17 .

■Observebleedingfor4-6hours:→Ifnodecrease,refer to hospital.→Ifdecrease,letthewomangohome.→Advisethewomantoreturnimmediatelyif

bleedingincreases.■Followupin2days B21 .

■Checkpreventivemeasures B20 .■Adviseonself-care B21 .■Adviseandcounselonfamilyplanning B21 .■Advisetoreturnifbleedingdoesnotstopwithin

2days.

■ InsertanIVlineandgivefluids B9 .■refer urgentlyto hospital B17 .

CLASSIFYcomplicated aBortion

threatenedaBortion

complete aBortion

ectopic pregnancy

next:Givepreventivemeasures

examination of the woman with Bleeding in early pregnancy, and post-aBortion careuse this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods

�

give preventive measures

Give preventive measures

Blee

ding

in e

arly

pre

gnan

cy a

nd p

ost-

aBor

tion

car

e

B20

ASSESS,CHECKRECORDS■Checktetanustoxoid(TT)immunizationstatus.

■Checkwoman’ssupplyoftheprescribeddoseofiron/folate.

■CheckHIVstatus c6 .

■CheckRPRstatusinrecords c5 .■ IfnoRPRresults,dotheRPRtest l5 .

TREATANDADVISE■Givetetanustoxoidifdue f2 .

■Give3month’ssupplyofironandcounseloncompliance f3 .

■ IfHIVstatusisunknown,counselonHIVtesting g3 .■ IfknownHIV-positive:

→refertoHIVservicesforfurtherassessmentandtreatment.→givesupport g4 .→adviseonopportunisticinfectionandneedtoseekmedicalhelp c10 .→counselonsafersexincludinguseofcondoms g2 .

■ IfHIV-negative,counseloncorrectandconsistentuseofcondoms g4 .

IfRapidplasmareagin(RPR)positive:■Treatthewomanforsyphiliswithbenzathinepenicillin f6 .■Adviseontreatingherpartner.■EncourageHIVtestingandcounselling g3 .■Reinforceuseofcondoms g2 .

advise and counsel on post-aBortion care

Advise and counsel on post-abortion care

Blee

ding

in e

arly

pre

gnan

cy a

nd p

ost-

aBor

tion

car

e

B21

Adviseonself-care■Restforafewdays,especiallyiffeelingtired.■Adviseonhygiene

→changepadsevery4to6hours→washtheperineumdaily→avoidsexualrelationsuntilbleedingstops.

■Advisewomantoreturnimmediatelyifshehasanyofthefollowingdangersigns:→increasedbleeding→continuedbleedingfor2days→foul-smellingvaginaldischarge→abdominalpain→fever,feelingill,weakness→dizzinessorfainting.

■Advisewomantoreturninifdelay(6weeksormore)inresumingmenstrualperiods.

Adviseandcounselonfamilyplanning■Explaintothewomanthatshecanbecomepregnantsoonaftertheabortion-assoonasshehas

sexualintercourse—ifshedoesnotuseacontraceptive:→Anyfamilyplanningmethodcanbeusedimmediatelyafteranuncomplicatedfirsttrimester

abortion.→Ifthewomanhasaninfectionorinjury:delayIUDinsertionorfemalesterilizationuntilhealed.For

informationonoptions,seeMethodsfornon-breastfeedingwomenon d27 .■Makearrangementsforhertoseeafamilyplanningcounsellorassoonaspossible,orcounselher

directly.(seeThedecision-makingtoolforfamilyplanningclientsandprovidersforinformationonmethodsandonthecounsellingprocess).

■Adviseonsafersexincludinguseofcondomifsheorherpartnerareatriskofsexuallytransmittedinfection(STI)orHIV g2 .

ProvideinformationandsupportafterabortionAwomanmayexperiencedifferentemotionsafteranabortion,andmaybenefitfromsupport:■Allowthewomantotalkaboutherworries,feelings,healthandpersonalsituation.Askifshehas

anyquestionsorconcerns.■Facilitatefamilyandcommunitysupport,ifsheisinterested(dependingonthecircumstances,she

maynotwishtoinvolveothers).→Speaktothemabouthowtheycanbestsupporther,bysharingorreducingherworkload,helping

outwithchildren,orsimplybeingavailabletolisten.→Informthemthatpost-abortioncomplicationscanhavegraveconsequencesforthewoman’s

health.Informthemofthedangersignsandtheimportanceofthewomanreturningtothehealthworkerifsheexperiencesany.

→Informthemabouttheimportanceoffamilyplanningifanotherpregnancyisnotdesired.■ Ifthewomanisinterested,linkhertoapeersupportgrouporotherwomen’sgroupsorcommunity

serviceswhichcanprovideherwithadditionalsupport.■ Ifthewomandisclosesviolenceoryouseeunexplainedbruisesandotherinjurieswhichmakeyou

suspectshemaybesufferingabuse,see h4 .■AdviseonsafersexincludinguseofcondomsifsheorherpartnerareatriskforSTIorHIV g2 .

Adviseandcounselduringfollow-upvisitsIfthreatenedabortionandbleedingstops:■Reassurethewomanthatitissafetocontinuepregnancy.■Provideantenatalcarec1-c18 .

Ifbleedingcontinues:■AssessandmanageasinBleedinginearlypregnancy/post-abortioncareB18-B22.

→Iffever,foul-smellingvaginaldischarge,orabdominalpain,givefirstdoseofappropriateIV/IMantibiotics B15 .

→Referwomantohospital.

B19 examination of the woman with Bleeding in early pregnancy and post-aBortion care

B20 give preventive measures

B21 advise and counsel on post-aBortion care

Adviseonself-care Adviseandcounselonfamilyplanning Provideinformationandsupportafter

abortion Adviseandcounselduringfollow-upvisits

■AlwaysbeginwithRapidassessmentandmanagement(RAM) B3-B7 .

■NextusetheBleedinginearlypregnancy/postabortioncareB19 toassessthewomanwithlightvaginalbleedingorahistoryofmissedperiods.

■UsechartonPreventivemeasures B20 toprovidepreventivemeasuresduetoallwomen.

■UseAdviseandCounselonpost-abortioncare B21 toadviseonselfcare,dangersigns,follow-upvisit,familyplanning.

■Recordalltreatmentgiven,positivefindings,andtheschedulednextvisitinthehome-basedandclinicrecordingforms.

■ IfthewomanisHIVpositive,adolescentorhasspecialneeds,useg1-g11 h1-h4 ..

Bleeding in early pregnancy and post-abortion care

Blee

ding

in e

arly

pre

gnan

cy a

nd p

ost-

aBor

tion

car

e

B19

ASK,CHECKRECORD■Whendidbleedingstart?■Howmuchbloodhaveyoulost?■Areyoustillbleeding?■ Isthebleedingincreasingor

decreasing?■Couldyoubepregnant?■Whenwasyourlastperiod?■Haveyouhadarecentabortion?■Didyouoranyoneelsedoanything

toinduceanabortion?■Haveyoufaintedrecently?■Doyouhaveabdominalpain?■Doyouhaveanyotherconcernsto

discuss?

LOOK,LISTEN,FEEL■Lookatamountofbleeding.■Noteifthereisfoul-smellingvaginal

discharge.■Feelforlowerabdominalpain.■Feelforfever.Ifhot,measure

temperature.■Lookforpallor.

SIGNS■Vaginalbleedingandanyof:

→Foul-smellingvaginaldischarge→Abortionwithuterine

manipulation→Abdominalpain/tenderness→Temperature>38°C.

■Lightvaginalbleeding

■Historyofheavybleedingbut:→nowdecreasing,or→nobleedingatpresent.

■Twoormoreofthefollowingsigns:→abdominalpain→fainting→pale→veryweak

TREATANDADVISE■ InsertanIVlineandgivefluids B9 .■Giveparacetamolforpain f4 .■GiveappropriateIM/IVantibiotics B15 .■refer urgently to hospital B17 .

■Observebleedingfor4-6hours:→Ifnodecrease,refer to hospital.→Ifdecrease,letthewomangohome.→Advisethewomantoreturnimmediatelyif

bleedingincreases.■Followupin2days B21 .

■Checkpreventivemeasures B20 .■Adviseonself-care B21 .■Adviseandcounselonfamilyplanning B21 .■Advisetoreturnifbleedingdoesnotstopwithin

2days.

■ InsertanIVlineandgivefluids B9 .■refer urgentlyto hospital B17 .

CLASSIFYcomplicated aBortion

threatenedaBortion

complete aBortion

ectopic pregnancy

next:Givepreventivemeasures

examination of the woman with Bleeding in early pregnancy, and post-aBortion careuse this chart if a woman has vaginal bleeding in early pregnancy or a history of missed periods

t

give preventive measures

Give preventive measuresBl

eedi

ng in

ear

ly p

regn

ancy

and

pos

t-aB

orti

on c

are

B20

ASSESS,CHECKRECORDS■Checktetanustoxoid(TT)immunizationstatus.

■Checkwoman’ssupplyoftheprescribeddoseofiron/folate.

■CheckHIVstatus c6 .

■CheckRPRstatusinrecords c5 .■ IfnoRPRresults,dotheRPRtest l5 .

TREATANDADVISE■Givetetanustoxoidifdue f2 .

■Give3month’ssupplyofironandcounseloncompliance f3 .

■ IfHIVstatusisunknown,counselonHIVtesting g3 .■ IfHIV-positive:

→refertoHIVservicesforfurtherassessmentandtreatment.→givesupport g4 .→adviseonopportunisticinfectionandneedtoseekmedicalhelp c10 .→counselonsafersexincludinguseofcondoms g2 .

■ IfHIV-negative,counselonsafersexincludinguseofcondoms g4 .

IfRapidplasmareagin(RPR)positive:■Treatthewomanforsyphiliswithbenzathinepenicillin f6 .■Adviseontreatingherpartner.■EncourageHIVtestingandcounselling g3 .■Reinforceuseofcondoms g2 .

advise and counsel on post-aBortion care

Advise and counsel on post-abortion care

Blee

ding

in e

arly

pre

gnan

cy a

nd p

ost-

aBor

tion

car

e

B21

Adviseonself-care■Restforafewdays,especiallyiffeelingtired.■Adviseonhygiene

→changepadsevery4to6hours→washtheperineumdaily→avoidsexualrelationsuntilbleedingstops.

■Advisewomantoreturnimmediatelyifshehasanyofthefollowingdangersigns:→increasedbleeding→continuedbleedingfor2days→foul-smellingvaginaldischarge→abdominalpain→fever,feelingill,weakness→dizzinessorfainting.

■Advisewomantoreturninifdelay(6weeksormore)inresumingmenstrualperiods.

Adviseandcounselonfamilyplanning■Explaintothewomanthatshecanbecomepregnantsoonaftertheabortion-assoonasshehas

sexualintercourse—ifshedoesnotuseacontraceptive:→Anyfamilyplanningmethodcanbeusedimmediatelyafteranuncomplicatedfirsttrimester

abortion.→Ifthewomanhasaninfectionorinjury:delayIUDinsertionorfemalesterilizationuntilhealed.For

informationonoptions,seeMethodsfornon-breastfeedingwomenon d27 .■Makearrangementsforhertoseeafamilyplanningcounsellorassoonaspossible,orcounselher

directly.(seeThedecision-makingtoolforfamilyplanningclientsandprovidersforinformationonmethodsandonthecounsellingprocess).

■Counselonsafersexincludinguseofcondomifsheorherpartnerareatriskofsexuallytransmittedinfection(STI)orHIV g2 .

ProvideinformationandsupportafterabortionAwomanmayexperiencedifferentemotionsafteranabortion,andmaybenefitfromsupport:■Allowthewomantotalkaboutherworries,feelings,healthandpersonalsituation.Askifshehas

anyquestionsorconcerns.■Facilitatefamilyandcommunitysupport,ifsheisinterested(dependingonthecircumstances,she

maynotwishtoinvolveothers).→Speaktothemabouthowtheycanbestsupporther,bysharingorreducingherworkload,helping

outwithchildren,orsimplybeingavailabletolisten.→Informthemthatpost-abortioncomplicationscanhavegraveconsequencesforthewoman’s

health.Informthemofthedangersignsandtheimportanceofthewomanreturningtothehealthworkerifsheexperiencesany.

→Informthemabouttheimportanceoffamilyplanningifanotherpregnancyisnotdesired.■ Ifthewomanisinterested,linkhertoapeersupportgrouporotherwomen’sgroupsorcommunity

serviceswhichcanprovideherwithadditionalsupport.■ Ifthewomandisclosesviolenceoryouseeunexplainedbruisesandotherinjurieswhichmakeyou

suspectshemaybesufferingabuse,see h4 .■CounselonsafersexincludinguseofcondomsifsheorherpartnerareatriskforSTIorHIV g2 .

Adviseandcounselduringfollow-upvisitsIfthreatenedabortionandbleedingstops:■Reassurethewomanthatitissafetocontinuepregnancy.■Provideantenatalcarec1-c18 .

Ifbleedingcontinues:■AssessandmanageasinBleedinginearlypregnancy/post-abortioncareB18-B22.

→Iffever,foul-smellingvaginaldischarge,orabdominalpain,givefirstdoseofappropriateIV/IMantibiotics B15 .

→Referwomantohospital.

Antenatal careAn

tenA

tAl

cAre

■Alwaysbeginwithrapid assessment and management (rAM) B3-B7 .Ifthewomanhasnoemergencyorprioritysignsandhascomeforantenatalcare,usethissectionforfurthercare.

■NextusethePregnancy status and birth plan chart C2 toaskthewomanaboutherpresentpregnancystatus,historyofpreviouspregancies,andcheckherforgeneraldangersigns.Decideonanappropriateplaceofbirthforthewomanusingthischartandpreparethebirthandemergencyplan.Thebirthplanshouldbereviewedduringeveryfollow-upvisit.

■Checkallwomenforpre-eclampsia,anaemia,syphilisandHIVstatusaccordingtothecharts c3-c6 .

■ Incaseswhereanabnormalsignisidentified(volunteeredorobserved),usethechartsrespond to observed signs or volunteered problems c7-c11 toclassifytheconditionandidentifyappropriatetreatment(s).

■Givepreventive measuresduec12 .

■Developabirth and emergency plan c14-c15 .

■Adviseandcounselonnutrition c13 ,familyplanning c16 ,laboursigns,dangersigns c15 ,routineandfollow-upvisitsc17 usingInformation and counselling sheetsM1-M19 .

■Recordallpositivefindings,birthplan,treatmentsgivenandthenextscheduledvisitinthehome-basedmaternalcard/clinicrecordingform.

■AssesseligibilityofARVforHIV-positivewomanc19 .

■ IfthewomanisHIVpositive,adolescentorhasspecialneeds,seeG1-G11 H1-H4 .

AntenAtAl cAre

Antenatal care

Ante

nAtA

l cA

re

c1

Assess the pregnant woman Pregancy status, birth and emergency plan

Ante

nAtA

l cA

re

ASk,CHeCk,ReCoRDAll vIsIts■Checkdurationofpregnancy.■Wheredoyouplantodeliver?■Anyvaginalbleedingsincelastvisit?■ Isthebabymoving?(after4months)■Checkrecordforpreviouscomplicationsand

treatmentsreceivedduringthispregnancy.■Doyouhaveanyconcerns?

fIrst vIsIt ■Howmanymonthspregnantareyou?■Whenwasyourlastperiod?■Whendoyouexpecttodeliver?■Howoldareyou?■Haveyouhadababybefore?Ifyes:■Checkrecordforpriorpregnanciesorif

thereisnorecordaskabout:→Numberofpriorpregnancies/deliveries→Priorcaesareansection,forceps,orvacuum→Priorthirddegreetear→Heavybleedingduringorafterdelivery→Convulsions→Stillbirthordeathinfirstday.→Doyousmoke,drinkalcoholor

useanydrugs?

tHIrd trIMesterHasshebeencounselledonfamilyplanning?Ifyes,doesshewanttuballigationorIUD A15 .

Look,LISTeN,FeeL■Feelfortrimesterofpregnancy.

■Lookforcaesareanscar

■Feelforobviousmultiplepregnancy.

■Feelfortransverselie.■Listentofetalheart.

INDICATIoNS■Priordeliverybycaesarean.■Agelessthan14years.■Transverselieorotherobvious

malpresentationwithinonemonthofexpecteddelivery.

■obviousmultiplepregnancy.■TuballigationorIUDdesired

immediatelyafterdelivery.■Documentedthirddegreetear.■Historyoforcurrentvaginal

bleedingorothercomplicationduringthispregnancy.

■Firstbirth.■ Lastbabyborndeadordiedinfirst

day.■Agelessthan16years.■Morethansixpreviousbirths.■Priordeliverywithheavybleeding.■Priordeliverywithconvulsions.■Priordeliverybyforcepsorvacuum.■HIV-positivewoman.

■Noneoftheabove.

ADVISe■explainwhydeliveryneedstobeatreferrallevel c14 .■Developthebirthandemergencyplan c14 .

■explainwhydeliveryneedstobeatprimaryhealthcarelevel c14 .

■Developthebirthandemergencyplan c14 .

■explainwhydeliveryneedstobewithaskilledbirthattendant,preferablyatafacility.

■Developthebirthandemergencyplan c14 .

PLACeoFDeLIVeRY

referrAl level

PrIMAry HeAltH cAre level

AccordInG to woMAn’s Preference

next:Checkforpre-eclampsia

Assess tHe PreGnAnt woMAn: PreGnAncy stAtus, BIrtH And eMerGency PlAnuse this chart to assess the pregnant woman at each of the four antenatal care visits. during first antenatal visit, prepare a birth and emergency plan using this chart and review them during following visits. Modify the birth plan if any complications arise.

c2

�

Assess the pregnant woman Check for pre-eclampsia

ASk,CHeCkReCoRD■ Bloodpressureatthelastvisit?

Look,LISTeN,FeeL■Measurebloodpressureinsitting

position.■ Ifdiastolicbloodpressureis≥90

mmHg,repeatafter1hourrest.■ Ifdiastolicbloodpressureisstill≥90

mmHg,askthewomanifshehas:→severeheadache→blurredvision→epigastricpainand→checkproteininurine.

SIGNS■Diastolicbloodpressure≥110 mmHgand3+proteinuria,or

■Diastolicbloodpressure≥90-mmHgontworeadingsand2+proteinuria,andanyof:→severeheadache→blurredvision→epigastricpain.

■Diastolicbloodpressure90-110-mmHgontworeadingsand2+proteinuria.

■Diastolicbloodpressure≥90mmHgon2readings.

■Noneoftheabove.

TReATANDADVISe■Givemagnesiumsulphate B13 .■Giveappropriateanti-hypertensives B14 .■Revisethebirthplan c2 .■refer urgently to hospital B17 .

■Revisethebirthplan c2 .■Refertohospital.

■Advisetoreduceworkloadandtorest.■Adviseondangersigns c15 .■Reassessatthenextantenatalvisitorin1weekif

>8monthspregnant.■ Ifhypertensionpersistsafter1weekoratnextvisit,

refertohospitalordiscusscasewiththedoctorormidwife,ifavailable.

Notreatmentrequired.

CLASSIFYseverePre-eclAMPsIA

Pre-eclAMPsIA

HyPertensIon

no HyPertensIon

next:Checkforanaemia

cHeck for Pre-eclAMPsIAscreen all pregnant women at every visit.

Ante

nAtA

l cA

re

c3

�

Assess the pregnant woman Check for anaemia

Ante

nAtA

l cA

re

ASk,CHeCkReCoRD■Doyoutireeasily?■Areyoubreathless(shortofbreath)

duringroutinehouseholdwork?

Look,LISTeN,FeeLon first visit:■Measurehaemoglobin

on subsequent visits:■Lookforconjunctivalpallor.■Lookforpalmarpallor.Ifpallor:

→Isitseverepallor?→Somepallor?→Countnumberofbreathsin1

minute.

SIGNS■Haemoglobin<7-g/dl. And/or■Severepalmarandconjunctival

palloror

■Anypallorwithanyof→>30breathsperminute→tireseasily→breathlessnessatrest

■Haemoglobin7-11-g/dl. or ■Palmarorconjunctivalpallor.

■Haemoglobin>11-g/dl.■Nopallor.

TReATANDADVISe■Revisebirthplansoastodeliverinafacilitywith

bloodtransfusionservices c2 .■Givedoubledoseofiron(1tablettwicedaily)

for3months f3 .■Counseloncompliancewithtreatment f3 .■Giveappropriateoralantimalarial f4 .■Followupin2weekstocheckclinicalprogress,test

results,andcompliancewithtreatment.■refer urgently to hospital B17 .

■Givedoubledoseofiron(1tablettwicedaily)for3months f3 .

■Counseloncompliancewithtreatment f3 .■Giveappropriateoralantimalarialifnotgiveninthe

pastmonth f4 .■Reassessatnextantenatalvisit(4-6weeks).If

anaemiapersists,refertohospital.

■Giveiron1tabletoncedailyfor3months f3 .■Counseloncompliancewithtreatment f4 .

CLASSIFYsevereAnAeMIA

ModerAte AnAeMIA

no clInIcAl AnAeMIA

next:Checkforsyphilis

cHeck for AnAeMIAscreen all pregnant women at every visit.

c4

�

Assess the pregnant woman Check for syphilis

ASk,CHeCkReCoRD■Haveyoubeentestedforsyphilis

duringthispregnancy?→Ifnot,performtherapidplasma

reagin(RPR)test l5 .■ Iftestwaspositive,haveyouand

yourpartnerbeentreatedforsyphilis?→Ifnot,andtestispositive,ask

“Areyouallergictopenicillin?”

Look,LISTeN,FeeL TeSTReSULT■RPRtestpositive.

■RPRtestnegative.

TReATANDADVISe■ GivebenzathinebenzylpenicillinIM.Ifallergy,give

erythromycin f6 .■Plantotreatthenewborn k12 .■encouragewomantobringhersexualpartnerfor

treatment.■Counselonsafersexincludinguseofcondomsto

preventnewinfection G2 .

■Counselonsafersexincludinguseofcondomstopreventinfection G2 .

CLASSIFYPossIBle syPHIlIs

no syPHIlIs

next:CheckforHIVstatus

cHeck for syPHIlIstest all pregnant women at first visit. check status at every visit.

Ante

nAtA

l cA

re

c5

�

Assess the pregnant woman Check for HIV status

Ante

nAtA

l cA

re

ASk,CHeCkReCoRDProvide key information on HIv G2 . ■WhatisHIVandhowisHIVtransmit-

ted G2 ?■AdvantageofknowingtheHIVstatus

inpregnancy G2 .■explainaboutHIVtestingand

counsellingincludingconfidentialityoftheresult G3 .

Ask the woman:■HaveyoubeentestedforHIV? →Ifnot: tellher thatshewillbe

testedforHIV,unlesssherefuses. →Ifyes:Checkresult.(explainto

herthatshehasarightnottodisclosetheresult.)

→AreyoutakinganyARV? →CheckARVtreatmentplan.■Hasthepartnerbeentested?

Look,LISTeN,FeeL■ PerformtheRapidHIVtestifnot

performedinthispregnancy l6 .

SIGNS■PositiveHIV-positive.

■NegativeHIVtest.

■Sherefusesthetestorisnotwillingtodisclosetheresultofprevioustestornotestresultsavailable.

TReATANDADVISe■Counselonimplicationsofapositivetest G3 .If HIv services available:■Refer the woman to HIV services for further

assessment.■Askhertoreturnin2weekswithherdocuments.If HIv services are not available:■Determinetheseverityofthediseaseandassess

eligibilityforARVs c19 .■GiveherappropriateARV G6 , G9 .for all women: ■SupportadherencetoARV G6 .■Counseloninfantfeedingoptions G7 .■ProvideadditionalcareforHIV-positivewoman G4 .■Counselonfamilyplanning G4 .■Counselonsafersexincludinguseofcondoms G2 .■Counselonbenefitsofdisclosure(involving)and

testingherpartner G3 .■ProvidesupporttotheHIV-positivewoman G5 .

counsel on implications of a negative test G3 . ■Counselontheimportanceofstayingnegativeby

practisingsafersex,includinguseofcondoms G2 .■Counselonbenefitsofinvolvingandtestingthe

partner G3 .

■Counselonsafersexincludinguseofcondoms G2 .■Counselonbenefitsofinvolvingandtestingthe

partner G3 .

CLASSIFYHIv-PosItIve

HIv-neGAtIve

unknown HIv stAtus

next: Respondtoobservedsignsorvolunteeredproblems Ifnoproblem,gotopagec12 .

cHeck for HIv stAtustest and counsel all pregnant women for HIv at the first antenatal visit. check status at every visit. Inform the women that HIV test will be done routinely and that she may refuse the HIV test.

c6

�

If ruPtured MeMBrAnes And no lABour

Respond to observed signs or volunteered problems (1)

ASk,CHeCkReCoRD

■Whendidthebabylastmove?■ Ifnomovementfelt,askwoman

tomovearoundforsometime,reassessfetalmovement.

■Whendidthemembranesrupture?■Whenisyourbabydue?

Look,LISTeN,FeeL

■Feelforfetalmovements.■Listenforfetalheartafter6months

ofpregnancy d2 .■ Ifnoheartbeat,repeatafter1hour.

■Lookatpadorunderwearforevidenceof:→amnioticfluid→foul-smellingvaginaldischarge

■ Ifnoevidence,askhertowearapad.Checkagainin1hour.

■Measuretemperature.

SIGNS

■Nofetalmovement.■Nofetalheartbeat.

■Nofetalmovementbutfetalheartbeatpresent.

■Fever38ºC.■Foul-smellingvaginaldischarge.

■Ruptureofmembranesat<8monthsofpregnancy.

■Ruptureofmembranesat>8monthsofpregnancy.

TReATANDADVISe

■ Informthewomanandpartneraboutthepossibilityofdeadbaby.

■Refertohospital.

■ Informthewomanthatbabyisfineandlikelytobewellbuttoreturnifproblempersists.

■GiveappropriateIM/IVantibiotics B15 .■refer urgently to hospital B17 .

■GiveappropriateIM/IVantibiotic B15 .■refer urgently to hospital B17 .

■ManageasWomaninchildbirthd1-d28 .

CLASSIFY

ProBABly deAd BABy

well BABy

uterIne And fetAl InfectIon

rIsk of uterIne And fetAl InfectIon

ruPture of MeMBrAnes

next:Iffeverorburningonurination

resPond to oBserved sIGns or volunteered ProBleMs

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If no fetAl MoveMent

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C2 Assess tHe PreGnAnt woMAn: PreGnAncy stAtus, BIrtH And eMerGency PlAn

C3 cHeck for Pre-eclAMPsIA

C4 cHeck for AnAeMIA

C5 cHeck for syPHIlIs

C6 cHeck for HIv stAtus

C7 resPond to oBserved sIGns or volunteered ProBleMs (1)

Ifnofetalmovement Ifrupturedmembraneandnolabour

Respond to observed signs or volunteered problems (2)

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ASk,CHeCkReCoRD

■Haveyouhadfever?■Doyouhaveburningonurination?

Look,LISTeN,FeeL

■ Ifhistoryoffeverorfeelshot:→Measureaxillary

temperature.→Lookorfeelforstiffneck.→Lookforlethargy.

■Percussflanksfortenderness.

SIGNS

■Fever>38°Candanyof:→veryfastbreathingor→stiffneck→lethargy→veryweak/notabletostand.

■Fever>38°Candanyof:→Flankpain→Burningonurination.

■Fever>38°Corhistoryoffever(inlast48hours).

■Burningonurination.

TReATANDADVISe

■ InsertIVlineandgivefluidsslowly B9 .■GiveappropriateIM/IVantibiotics B15 .■Giveartemether/quinineIM B16 .■Giveglucose B16 .■refer urgently to hospital B17 .

■GiveappropriateIM/IVantibiotics B15 .■Giveappropriateoralantimalarial f4 .■refer urgently to hospital B17 .

■Giveappropriateoralantimalarial f4 .■ Ifnoimprovementin2daysorconditionisworse,

refertohospital.

■Giveappropriateoralantibiotics f5 .■encouragehertodrinkmorefluids.■ Ifnoimprovementin2daysorconditionisworse,

refertohospital.

CLASSIFY

very severe feBrIle dIseAse

uPPer urInAry trAct InfectIon

MAlArIA

lower urInAry trAct InfectIon

next:Ifvaginaldischarge

If fever or BurnInG on urInAtIon

c8

�

Respond to observed signs or volunteered problems (3)

ASk,CHeCkReCoRD

■Haveyounoticedchangesinyourvaginaldischarge?

■Doyouhaveitchingatthevulva?■Hasyourpartnerhadaurinary

problem?

Ifpartnerispresentintheclinic,askthewomanifshefeelscomfortableifyouaskhimsimilarquestions.Ifyes,askhimifhehas:■urethraldischargeorpus.■burningonpassingurine.

Ifpartnercouldnotbeapproached,explainimportanceofpartnerassessmentandtreatmenttoavoidreinfection.Schedulefollow-upappointmentforwomanandpartner(ifpossible).

Look,LISTeN,FeeL

■Separatethelabiaandlookforabnormalvaginaldischarge:→amount→colour→odour/smell.

■ Ifnodischargeisseen,examinewithaglovedfingerandlookatthedischargeontheglove.

SIGNS

■Abnormalvaginaldischarge.■Partnerhasurethraldischargeor

burningonpassingurine.

■Curdlikevaginaldischarge.■ Intensevulvalitching.

■Abnormalvaginaldischarge

TReATANDADVISe

■Giveappropriateoralantibioticstowoman f5 .■Treatpartnerwithappropriateoralantibiotics f5 .■Counselonsafersexincludinguseofcondoms G2 .

■Giveclotrimazole f5 .■Counselonsafersexincludinguseofcondoms G2 .

■Givemetronidazoletowoman f5 .■Counselonsafersexincludinguseofcondoms G2 .

CLASSIFY

PossIBle GonorrHoeA or cHlAMydIA InfectIon

PossIBle cAndIdA InfectIon

PossIBle BActerIAl ortrIcHoMonAsInfectIon

next:IfsignssuggestingHIVinfection

If vAGInAl dIscHArGe

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Respond to observed signs or volunteered problems (4)

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ASk,CHeCkReCoRD

■Haveyoulostweight?■Doyouhavefever?

Howlong(>1month)?■Haveyougotdiarrhoea(continuous

orintermittent)?Howlong,>1month?

■Haveyouhadcough?Howlong,>1month?

Assess if in high risk group:■occupationalexposure?■Multiplesexualpartner?■ Intravenousdrugabuse?■Historyofbloodtransfusion?■ IllnessordeathfromAIDSina

sexualpartner?■Historyofforcedsex?

Look,LISTeN,FeeL

■Lookforvisiblewasting.■Lookforulcersandwhitepatchesin

themouth(thrush).■Lookattheskin:

→Istherearash?→Arethereblistersalongtheribs

ononesideofthebody?

SIGNS

■Twoofthesesigns:→weightloss→fever>1month→diarrhoea>1month.

or■oneoftheabovesignsand

→oneormoreothersignsor→fromariskgroup.

TReATANDADVISe

■ReinforcetheneedtoknowHIVstatusandadviseonHIVtestingandcounsellingG2-G3 .

■Counselonthebenefitsoftestingthepartner G3 .■Counselonsafersexincludinguseofcondoms G2 .■RefertoTBcentreifcough.

■Counselonstoppingsmoking■Foralcohol/drugabuse,refertospecializedcare

providers.■Forcounsellingonviolence,see H4 .

CLASSIFY

stronG lIkelIHood of HIv InfectIon

next:Ifcoughorbreathingdifficulty

If sIGns suGGestInG HIv InfectIon (HIv status unknown)

c10

If sMokInG, AlcoHol or druG ABuse, or HIstory of vIolence

�

If tAkInG AntI-tuBerculosIs druGs

Respond to observed signs or volunteered problems (5)

ASk,CHeCkReCoRD

■Howlonghaveyoubeencoughing?■Howlonghaveyouhaddifficultyin

breathing?■Doyouhavechestpain?■Doyouhaveanybloodinsputum?■Doyousmoke?

■Areyoutakinganti-tuberculosisdrugs?Ifyes,sincewhen?

■Doesthetreatmentincludeinjection(streptomycin)?

Look,LISTeN,FeeL

■Lookforbreathlessness.■Listenforwheezing.■Measuretemperature.

SIGNS

At least 2 of the following signs:■Fever>38ºC.■Breathlessness.■Chestpain.

At least 1 of the following signs:■Coughorbreathingdifficulty

for>3weeks■Bloodinsputum■Wheezing

■Fever<38ºC,and■Cough<3weeks.

■Takinganti-tuberculosisdrugs.■Receivinginjectableanti-

tuberculosisdrugs.

TReATANDADVISe

■GivefirstdoseofappropriateIM/IVantibioticsB15 .■refer urgently to hospitalB17 .

■Refertohospitalforassessment.■ Ifseverewheezing,referurgentlytohospital.

■Advisesafe,soothingremedy.■ Ifsmoking,counseltostopsmoking.

■ Ifanti-tuberculartreatmentincludesstreptomycin(injection),referthewomantodistricthospitalforrevisionoftreatmentasstreptomycinisototoxictothefetus.

■ Iftreatmentdoesnotincludestreptomycin,assurethewomanthatthedrugsarenotharmfultoherbaby,andurgehertocontinuetreatmentforasuccessfuloutcomeofpregnancy.

■ IfhersputumisTBpositivewithin2monthsofdelivery,plantogiveINHprophylaxistothenewborn k13 .

■ReinforceadviceonHIVtestingandcounsellingG2-G3 .

■ Ifsmoking,counseltostopsmoking.■Advisetoscreenimmediatefamilymembersand

closecontactsfortuberculosis.

CLASSIFY

PossIBle PneuMonIA

PossIBle cHronIc lunG dIseAse

uPPerresPIrAtory trActInfectIon

tuBerculosIs

next:Givepreventivemeasures

If couGH or BreAtHInG dIffIcultyAn

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Antenatal care

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c12Give preventive measures

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GIve PreventIve MeAsuresAdvise and counsel all pregnant women at every antenatal care visit.

ASSeSS,CHeCkReCoRD■Checktetanustoxoid(TT)immunizationstatus.

■Checkwoman’ssupplyoftheprescribeddoseofiron/folate

■Checkwhenlastdoseofmebendazolegiven.

■Checkwhenlastdoseofanantimalarialgiven.■Askifshe(andchildren)aresleepingunderinsecticidetreatedbednets.

■Recordallvisitsandtreatmentsgiven.

TReATANDADVISe■Givetetanustoxoidifdue f2 .■ IfTT1,plantogiveTT2atnextvisit.

■Give3month’ssupplyofironandcounseloncomplianceandsafety f3 .

■Givemebendazoleonceinsecondorthirdtrimester f3 .

■Giveintermittentpreventivetreatmentinsecondandthirdtrimesters f4 .■encouragesleepingunderinsecticidetreatedbednets.

first visit■Developabirthandemergencyplanc14 .■Counselonnutritionc13 .■Counselonimportanceofexclusivebreastfeeding k2 .■Counselonstoppingsmokingandalcoholanddrugabuse.■Counselonsafersexincludinguseofcondoms.

All visits■Reviewandupdatethebirthandemergencyplanaccordingtonewfindingsc14-c15.■Adviseonwhentoseekcare: c17

→routinevisits→follow-upvisits→dangersigns.

third trimester■Counselonfamilyplanningc16 .

Advise and counsel on nutrition and self-care

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AdvIse And counsel on nutrItIon And self-cAreuse the information and counselling sheet to support your interaction with the woman, her partner and family.

Counselonnutrition■Advisethewomantoeatagreateramountandvarietyofhealthyfoods,suchasmeat,fish,oils,nuts,

seeds,cereals,beans,vegetables,cheese,milk,tohelpherfeelwellandstrong(giveexamplesoftypesoffoodandhowmuchtoeat).

■Spendmoretimeonnutritioncounsellingwithverythin,adolescentandHIV-positivewoman.■Determineifthereareimportanttaboosaboutfoodswhicharenutritionallyimportantforgood

health.Advisethewomanagainstthesetaboos.■Talktofamilymemberssuchasthepartnerandmother-in-law,toencouragethemtohelpensurethe

womaneatsenoughandavoidshardphysicalwork.

Adviseonself-careduringpregnancyAdvise the woman to:■Takeirontablets(p.T3).■Restandavoidliftingheavyobjects.■Sleepunderaninsecticideimpregnatedbednet.■Counselonsafersexincludinguseofcondoms,ifatriskforSTIorHIV G2 .■Avoidalcoholandsmokingduringpregnancy.■NoTtotakemedicationunlessprescribedatthehealthcentre/hospital.

C8 resPond to oBserved sIGns or volunteered ProBleMs (2)

Iffeverorburningonurination

C9 resPond to oBserved sIGns or volunteered ProBleMs (3)

Ifvaginaldischarge

C10 resPond to oBserved sIGns or volunteered ProBleMs (4)

IfsignssuggestingHIVinfection Ifsmoking,alcoholordrugabuse,

orhistoryofviolence

C11 resPond to oBserved sIGns or volunteered ProBleMs (5)

Ifcoughorbreathingdifficulty Iftakinganti-tuberculosisdrugs

C12 GIve PreventIve MeAsures

C13 AdvIse And counsel on nutrItIon And self-cAre

Counselonnutrition Adviseonself-careduringpregnancy

Develop a birth and emergency plan (1)

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develoP A BIrtH And eMerGency PlAn use the information and counselling sheet to support your interaction with the woman, her partner and family.

Facilitydeliveryexplain why birth in a facility is recommended■Anycomplicationcandevelopduringdelivery-theyarenotalwayspredictable.■Afacilityhasstaff,equipment,suppliesanddrugsavailabletoprovidebestcareifneeded,anda

referralsystem.■AIfHIV-positiveshewillneedappropriateARVtreatmentforherselfandherbabyduringchildbirth.■ComplicationsaremorecommoninHIV-positivewomenandhernewborns.Womenshoulddeliverin

afacility.

Advise how to prepare Reviewthearrangementsfordelivery:■Howwillshegetthere?Willshehavetopayfortransport?■Howmuchwillitcosttodeliveratthefacility?Howwillshepay?■Canshestartsavingstraightaway?■Whowillgowithherforsupportduringlabouranddelivery?■Whowillhelpwhilesheisawaytocareforherhomeandotherchildren?

Advise when to go■ Ifthewomanlivesnearthefacility,sheshouldgoatthefirstsignsoflabour.■ Iflivingfarfromthefacility,sheshouldgo2-3weeksbeforebabyduedateandstayeitheratthe

maternitywaitinghomeorwithfamilyorfriendsnearthefacility.■Advisetoaskforhelpfromthecommunity,ifneeded I2 .

Advise what to bring■Home-basedmaternalrecord.■Cleanclothsforwashing,dryingandwrappingthebaby.■Additionalcleanclothstouseassanitarypadsafterbirth.■Clothesformotherandbaby.■Foodandwaterforwomanandsupportperson.

HomedeliverywithaskilledattendantAdvise how to prepare Reviewthefollowingwithher:■Whowillbethecompanionduringlabouranddelivery?■Whowillbeclosebyforatleast24hoursafterdelivery?■Whowillhelptocareforherhomeandotherchildren?■Advisetocalltheskilledattendantatthefirstsignsoflabour.■Advisetohaveherhome-basedmaternalrecordready.■Advisetoaskforhelpfromthecommunity,ifneeded I2 .

explain supplies needed for home delivery■Warmspotforthebirthwithacleansurfaceoracleancloth.■Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,forcleaningthebaby’s

eyes,forthebirthattendanttowashanddryherhands,foruseassanitarypads.■Blankets.■Bucketsofcleanwaterandsomewaytoheatthiswater.■Soap.■Bowls:2forwashingand1fortheplacenta.■Plasticforwrappingtheplacenta.

AdviseonlaboursignsAdvisetogotothefacilityorcontacttheskilledbirthattendantifanyofthefollowingsigns:■abloodystickydischarge.■painfulcontractionsevery20minutesorless.■watershavebroken.

AdviseondangersignsAdvisetogotothehospital/healthcentreimmediately, day or night, wItHout waitingifanyofthefollowingsigns:■vaginalbleeding.■convulsions.■severeheadacheswithblurredvision.■ feverandtooweaktogetoutofbed.■severeabdominalpain.■ fastordifficultbreathing.

Sheshouldgotothehealthcentreas soon as possibleifanyofthefollowingsigns:■ fever.■abdominalpain.■ feelsill.■swellingoffingers,face,legs.

Discusshowtoprepareforanemergencyinpregnancy■Discussemergencyissueswiththewomanandherpartner/family:

→wherewillshego?→howwilltheygetthere?→howmuchitwillcostforservicesandtransport?→canshestartsavingstraightaway?→whowillgowithherforsupportduringlabouranddelivery?→whowillcareforherhomeandotherchildren?

■Advisethewomantoaskforhelpfromthecommunity,ifneeded I1–I3 .■Advisehertobringherhome-basedmaternalrecordtothehealthcentre,evenforanemergencyvisit.

Develop a birth and emergency plan (2)

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Advise and counsel on family planning

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AdvIse And counsel on fAMIly PlAnnInG

Counselontheimportanceoffamilyplanning■ Ifappropriate,askthewomanifshewouldlikeherpartneroranotherfamilymembertobeincluded

inthecounsellingsession.■explainthatafterbirth,ifshehassexandisnotexclusivelybreastfeeding,shecanbecomepregnant

assoonasfourweeksafterdelivery.Thereforeitisimportanttostartthinkingearlyonaboutwhatfamilyplanningmethodtheywilluse.→Askaboutplansforhavingmorechildren.Ifshe(andherpartner)wantmorechildren,advisethat

waitingatleast2-3yearsbetweenpregnanciesishealthierforthemotherandchild.→Informationonwhentostartamethodafterdeliverywillvarydependingwhetherawomanis

breastfeedingornot.→Makearrangementsforthewomantoseeafamilyplanningcounsellor,orcounselherdirectly

(seetheDecision-makingtoolforfamilyplanningprovidersandclientsforinformationonmethodsandonthecounsellingprocess).

■Counselonsafersexincludinguseofcondomsfordualprotectionfromsexuallytransmittedinfections(STI)orHIVandpregnancy.PromoteespeciallyifatriskforSTIorHIV G4 .

■ForHIV-positivewomen,see G5 forfamilyplanningconsiderations■Herpartnercandecidetohaveavasectomy(malesterilization)atanytime.

Method options for the non-breastfeeding womancan be used immediately postpartum Condoms Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implant Spermicide Femalesterilization(within7daysordelay6weeks) CopperIUD(immediatelyfollowingexpulsionof

placentaorwithin48hours)delay 3 weeks Combinedoralcontraceptives Combinedinjectables Diaphragm Fertilityawarenessmethods

Specialconsiderationsforfamilyplanningcounsellingduringpregnancycounselling should be given during the third trimester of pregnancy.■ Ifthewomanchoosesfemalesterilization:

→canbeperformedimmediatelypostpartumifnosignofinfection(ideallywithin7days,ordelayfor6weeks).

→planfordeliveryinhospitalorhealthcentrewheretheyaretrainedtocarryouttheprocedure.→ensurecounsellingandinformedconsentpriortolabouranddelivery.

■ Ifthewomanchoosesanintrauterinedevice(IUD):→canbeinsertedimmediatelypostpartumifnosignofinfection(upto48hours,ordelay4weeks)→planfordeliveryinhospitalorhealthcentrewheretheyaretrainedtoinserttheIUD.

Method options for the breastfeeding woman can be used immediately postpartum Lactationalamenorrhoeamethod(LAM) Condoms Spermicide Femalesterilization(within7daysor

delay6weeks) CopperIUD(within48hoursordelay4weeks)delay 6 weeks Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implants Diaphragmdelay 6 months Combinedoralcontraceptives Combinedinjectables Fertilityawarenessmethods

AdvIse on routIne And follow-uP vIsItsencourage the woman to bring her partner or family member to at least 1 visit.

Antenatal care

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Routineantenatalcarevisits1st visit Before4months 12-16weeks2nd visit 6months 24-28weeks3rd visit 8months 30-32weeks4th visit 9months 36-38weeks

■Allpregnantwomenshouldhave4routineantenatalvisits.■Firstantenatalcontactshouldbeasearlyinpregnancyaspossible.■Duringthelastvisit,informthewomantoreturnifshedoesnotdeliverwithin2weeksafterthe

expecteddateofdelivery.■MorefrequentvisitsordifferentschedulesmayberequiredaccordingtonationalmalariaorHIV

policies.■ IfwomenareHIV-positiveensureavisitbetween26-28weeks.

Follow-upvisitsIf the problem was: return in:Hypertension 1weekif>8monthspregnantSevereanaemia 2weeksHIV-positive 2weeksafterHIVtesting

Antenatal care

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HoMe delIvery wItHout A skIlled AttendAntreinforce the importance of delivery with a skilled birth attendant

InstructmotherandfamilyoncleanandsaferdeliveryathomeIfthewomanhaschosentodeliverathomewithoutaskilledattendant,reviewthesesimpleinstructionswiththewomanandfamilymembers.■Givethemadisposabledeliverykitandexplainhowtouseit.

tell her/them:■Toensureacleandeliverysurfaceforthebirth.■Toensurethattheattendantshouldwashherhandswithcleanwaterandsoapbefore/after

touchingmother/baby.Sheshouldalsokeephernailsclean.■To,afterdelivery,placethebabyonthemother’schestwithskin-to-skincontactandwipethebaby’s

eyesusingacleanclothforeacheye.■Tocoverthemotherandthebaby.■Tousethetiesandrazorbladefromthedisposabledeliverykittotieandcutthecord.Thecordiscut

whenitstopspulsating.■Todrythebabyaftercuttingthecord.Towipecleanbutnotbathethebabyuntilafter6hours.■Towaitfortheplacentatodeliveronitsown.■Tostartbreastfeedingwhenthebabyshowssignsofreadiness,withinthefirsthourafterbirth.■ToNoTleavethemotheraloneforthefirst24hours.■Tokeepthemotherandbabywarm.Todressorwrapthebaby,includingthebaby’shead.■ Todisposeoftheplacentainacorrect,safeandculturallyappropriatemanner(burnorburry).

AdvisetoavoidharmfulpracticesForexample:nottouselocalmedicationstohastenlabour.nottowaitforwaterstostopbeforegoingtohealthfacility.nottoinsertanysubstancesintothevaginaduringlabourorafterdelivery.nottopushontheabdomenduringlabourordelivery.nottopullonthecordtodelivertheplacenta.nottoputashes,cowdungorothersubstanceonumbilicalcord/stump.

encouragehelpfultraditionalpractices:

✎____________________________________________________________________

✎____________________________________________________________________

AdviseondangersignsIfthemotherorbabyhasanyofthesesigns,she/theymustgotothehealthcentreimmediately, day or night, wItHout waiting

Mother■Watersbreakandnotinlabourafter6hours.■Labourpains/contractionscontinueformorethan12hours.■Heavybleedingafterdelivery(pad/clothsoakedinlessthan5minutes).■Bleedingincreases.■Placentanotexpelled1hourafterbirthofthebaby.

Baby■Verysmall.■Difficultyinbreathing.■Fits.■Fever.■Feelscold.■Bleeding.■Notabletofeed.

Assesses eligibility of ARV for HIV-positive pregnant woman

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ASk,CHeCkReCoRD■Haveyoulostweight?■Haveyougotdiarrhoea(continuousorintermittent)?■ Doyouhavefever?

Howlong(>1month)?■ Haveyouhadcough?

Howlong(>1month)?■ Haveyouanydifficultyinbreathing?

Howlong(>1month)?■Have younoticedany change in

vaginaldischarge?

Look,LISTeN,FeeL■ Lookforulcersandwhitepatchesin

themouth(thrush).■ Lookattheskin: →Istherearash? →Arethereblistersalongtheribs

ononesideofthebody?■ Lookforvisiblewasting.■ Feelthehead,neck,andunderarm

forenlargedlymphnodes.■ Lookforanyabnormalvaginal

discharge c9 .

SIGNSHIV-positiveandanyofthefollowing:■Weightlossornoweightgain■Visiblewasting■Diarrhoea>1month■Fever>1month■Cough>1monthordifficult

breathing■Cracks/ulcersaroundlips/mouth■ Itchingrash■Blistersalongtheribsononeside

ofthebody■enlargedlymphnodes■Abnormalvaginaldischarge

HIV-positiveandnoneoftheabovesigns

TReATANDADVISe■Refertohospitalforfurtherassessment.

■GiveappropriateARVs G9 .■SupportinitiationofARV G6 .■ReviseANCvisitaccordingly.

CLASSIFYHIv-PosItIve wItH HIv-relAted sIGns And syMPtoMs

HIv-PosItIve wItHout HIv-relAted sIGns And syMPtoMs

Assess elIGIBIlIty of Arv for HIv-PosItIve PreGnAnt woMAnuse this chart to assess HIv-related signs and symptoms and to determine Arv needs for HIv-positive woman and her baby when appropriate HIv services and cd4 count are not available.

C14 develoP A BIrtH And eMerGency PlAn

Facilitydelivery Homedeliverywithaskilledattendant

C15 Adviseonlaboursigns Adviseondangersigns

Discusshowtoprepareforanemergencyinpregnancy

C16 AdvIse And counsel on fAMIly PlAnnInG

Counselontheimportanceoffamilyplanning Specialconsiderationsforfamilyplanning

counsellingduringpregnancy

C17 AdvIse on routIne And follow-uP vIsIts

C18 HoMe delIvery wItHout A skIlled AttendAnt

Instructmotherandfamilyoncleanandsaferdeliveryathome

Advisetoavoidharmfulpractices AdviseondangersignsC19 Assess elIGIBIlIty of Arv for

HIv-PosItIve woMAn

Assess the pregnant woman Pregnancy status, birth and emergency planAn

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ASk,CHeCk,ReCoRDAll vIsIts■Checkdurationofpregnancy.■Wheredoyouplantodeliver?■Anyvaginalbleedingsincelastvisit?■ Isthebabymoving?(after4months)■Checkrecordforpreviouscomplicationsand

treatmentsreceivedduringthispregnancy.■Doyouhaveanyconcerns?

fIrst vIsIt ■Howmanymonthspregnantareyou?■Whenwasyourlastperiod?■Whendoyouexpecttodeliver?■Howoldareyou?■Haveyouhadababybefore?Ifyes:■Checkrecordforpriorpregnanciesorif

thereisnorecordaskabout:→Numberofpriorpregnancies/deliveries→Priorcaesareansection,forceps,orvacuum→Priorthirddegreetear→Heavybleedingduringorafterdelivery→Convulsions→Stillbirthordeathinfirstday.→Doyousmoke,drinkalcoholor

useanydrugs?

tHIrd trIMesterHasshebeencounselledonfamilyplanning?Ifyes,doesshewanttuballigationorIUD A15 .

Look,LISTeN,FeeL■Feelfortrimesterofpregnancy.

■Lookforcaesareanscar

■Feelforobviousmultiplepregnancy.

■Feelfortransverselie.■Listentofetalheart.

INDICATIoNS■Priordeliverybycaesarean.■Agelessthan14years.■Transverselieorotherobvious

malpresentationwithinonemonthofexpecteddelivery.

■obviousmultiplepregnancy.■TuballigationorIUDdesired

immediatelyafterdelivery.■Documentedthirddegreetear.■Historyoforcurrentvaginal

bleedingorothercomplicationduringthispregnancy.

■Firstbirth.■ Lastbabyborndeadordiedinfirst

day.■Agelessthan16years.■Morethansixpreviousbirths.■Priordeliverywithheavybleeding.■Priordeliverywithconvulsions.■Priordeliverybyforcepsorvacuum.■HIV-positivewoman.

■Noneoftheabove.

ADVISe■explainwhydeliveryneedstobeatreferrallevel c14 .■Developthebirthandemergencyplan c14 .

■explainwhydeliveryneedstobeatprimaryhealthcarelevel c14 .

■Developthebirthandemergencyplan c14 .

■explainwhydeliveryneedstobewithaskilledbirthattendant,preferablyatafacility.

■Developthebirthandemergencyplan c14 .

PLACeoFDeLIVeRY

referrAl level

PrIMAry HeAltH cAre level

AccordInG to woMAn’s Preference

next:Checkforpre-eclampsia

Assess tHe PreGnAnt woMAn: PreGnAncy stAtus, BIrtH And eMerGency PlAnuse this chart to assess the pregnant woman at each of the four antenatal care visits. during first antenatal visit, prepare a birth and emergency plan using this chart and review them during following visits. Modify the birth plan if any complications arise.

c2

t

Assess the pregnant woman Check for pre-eclampsia

ASk,CHeCkReCoRD■ Bloodpressureatthelastvisit?

Look,LISTeN,FeeL■Measurebloodpressureinsitting

position.■ Ifdiastolicbloodpressureis≥90

mmHg,repeatafter1hourrest.■ Ifdiastolicbloodpressureisstill≥90

mmHg,askthewomanifshehas:→severeheadache→blurredvision→epigastricpainand→checkproteininurine.

SIGNS■Diastolicbloodpressure≥110 mmHgand3+proteinuria,or

■Diastolicbloodpressure≥90-mmHgontworeadingsand2+proteinuria,andanyof:→severeheadache→blurredvision→epigastricpain.

■Diastolicbloodpressure90-110-mmHgontworeadingsand2+proteinuria.

■Diastolicbloodpressure≥90mmHgon2readings.

■Noneoftheabove.

TReATANDADVISe■Givemagnesiumsulphate B13 .■Giveappropriateanti-hypertensives B14 .■Revisethebirthplan c2 .■refer urgently to hospital B17 .

■Revisethebirthplan c2 .■Refertohospital.

■Advisetoreduceworkloadandtorest.■Adviseondangersigns c15 .■Reassessatthenextantenatalvisitorin1weekif

>8monthspregnant.■ Ifhypertensionpersistsafter1weekoratnextvisit,

refertohospitalordiscusscasewiththedoctorormidwife,ifavailable.

Notreatmentrequired.

CLASSIFYseverePre-eclAMPsIA

Pre-eclAMPsIA

HyPertensIon

no HyPertensIon

next:Checkforanaemia

cHeck for Pre-eclAMPsIAscreen all pregnant women at every visit.

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Assess the pregnant woman Check for anaemiaAn

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ASk,CHeCkReCoRD■Doyoutireeasily?■Areyoubreathless(shortofbreath)

duringroutinehouseholdwork?

Look,LISTeN,FeeLon first visit:■Measurehaemoglobin

on subsequent visits:■Lookforconjunctivalpallor.■Lookforpalmarpallor.Ifpallor:

→Isitseverepallor?→Somepallor?→Countnumberofbreathsin1

minute.

SIGNS■Haemoglobin<7-g/dl. And/or■Severepalmarandconjunctival

palloror

■Anypallorwithanyof→>30breathsperminute→tireseasily→breathlessnessatrest

■Haemoglobin7-11-g/dl. or ■Palmarorconjunctivalpallor.

■Haemoglobin>11-g/dl.■Nopallor.

TReATANDADVISe■Revisebirthplansoastodeliverinafacilitywith

bloodtransfusionservices c2 .■Givedoubledoseofiron(1tablettwicedaily)

for3months f3 .■Counseloncompliancewithtreatment f3 .■Giveappropriateoralantimalarial f4 .■Followupin2weekstocheckclinicalprogress,test

results,andcompliancewithtreatment.■refer urgently to hospital B17 .

■Givedoubledoseofiron(1tablettwicedaily)for3months f3 .

■Counseloncompliancewithtreatment f3 .■Giveappropriateoralantimalarialifnotgiveninthe

pastmonth f4 .■Reassessatnextantenatalvisit(4-6weeks).If

anaemiapersists,refertohospital.

■Giveiron1tabletoncedailyfor3months f3 .■Counseloncompliancewithtreatment f4 .

CLASSIFYsevereAnAeMIA

ModerAte AnAeMIA

no clInIcAl AnAeMIA

next:Checkforsyphilis

cHeck for AnAeMIAscreen all pregnant women at every visit.

c4

t

Assess the pregnant woman Check for syphilis

ASk,CHeCkReCoRD■Haveyoubeentestedforsyphilis

duringthispregnancy?→Ifnot,performtherapidplasma

reagin(RPR)test l5 .■ Iftestwaspositive,haveyouand

yourpartnerbeentreatedforsyphilis?→Ifnot,andtestispositive,ask

“Areyouallergictopenicillin?”

Look,LISTeN,FeeL TeSTReSULT■RPRtestpositive.

■RPRtestnegative.

TReATANDADVISe■ GivebenzathinebenzylpenicillinIM.Ifallergy,give

erythromycin f6 .■Plantotreatthenewborn k12 .■encouragewomantobringhersexualpartnerfor

treatment.■Counselonsafersexincludinguseofcondomsto

preventnewinfection G2 .

■Counselonsafersexincludinguseofcondomstopreventinfection G2 .

CLASSIFYPossIBle syPHIlIs

no syPHIlIs

next:CheckforHIVstatus

cHeck for syPHIlIstest all pregnant women at first visit. check status at every visit.

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Assess the pregnant woman Check for HIV statusAn

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ASk,CHeCkReCoRDProvide key information on HIv G2 . ■WhatisHIVandhowisHIVtransmit-

ted G2 ?■AdvantageofknowingtheHIVstatus

inpregnancy G2 .■explainaboutHIVtestingand

counsellingincludingconfidentialityoftheresult G3 .

Ask the woman:■HaveyoubeentestedforHIV? →Ifnot: tellher thatshewillbe

testedforHIV,unlesssherefuses. →Ifyes:Checkresult.(explainto

herthatshehasarightnottodisclosetheresult.)

→AreyoutakinganyARV? →CheckARVtreatmentplan.■Hasthepartnerbeentested?

Look,LISTeN,FeeL

■ PerformtheRapidHIVtestifnotperformedinthispregnancy l6 .

SIGNS■PositiveHIVtest.

■NegativeHIVtest.

■Sherefusesthetestorisnotwillingtodisclosetheresultofprevioustestornotestresultsavailable.

TReATANDADVISe■Counselonimplicationsofapositivetest G3 .If HIv services available:■ReferthewomantoHIVservicesforfurtherasses-

sment.■Askhertoreturnin2weekswithherdocuments.If HIv services are not available:■Determinetheseverityofthediseaseandassess

eligibilityforARVs c19 .■GiveherappropriateARV G6 , G9 .for all women: ■SupportadherencetoARV G6 .■Counseloninfantfeedingoptions G7 .■ProvideadditionalcareforHIV-positivewoman G4 .■Counselonfamilyplanning G4 .■Counselonsafersexincludinguseofcondoms G2 .■Counselonbenefitsofdisclosure(involving)and

testingherpartner G3 .■ProvidesupporttotheHIV-positivewoman G5 .

■Counselonimplicationsofanegativetest G3 . ■Counselontheimportanceofstayingnegativeby

practisingsafersex,includinguseofcondoms G2 .■Counselonbenefitsofinvolvingandtestingthe

partner G3 .

■Counselonsafersexincludinguseofcondoms G2 .■Counselonbenefitsofinvolvingandtestingthe

partner G3 .

CLASSIFYHIv-PosItIve

HIv-neGAtIve

unknown HIv stAtus

next: Respondtoobservedsignsorvolunteeredproblems Ifnoproblem,gotopagec12 .

cHeck for HIv stAtustest and counsel all pregnant women for HIv at the first antenatal visit. check status at every visit. Inform the women that HIV test will be done routinely and that she may refuse the HIV test.

c6

t

If ruPtured MeMBrAnes And no lABour

Respond to observed signs or volunteered problems (1)

ASk,CHeCkReCoRD

■Whendidthebabylastmove?■ Ifnomovementfelt,askwoman

tomovearoundforsometime,reassessfetalmovement.

■Whendidthemembranesrupture?■Whenisyourbabydue?

Look,LISTeN,FeeL

■Feelforfetalmovements.■Listenforfetalheartafter6months

ofpregnancy d2 .■ Ifnoheartbeat,repeatafter1hour.

■Lookatpadorunderwearforevidenceof:→amnioticfluid→foul-smellingvaginaldischarge

■ Ifnoevidence,askhertowearapad.Checkagainin1hour.

■Measuretemperature.

SIGNS

■Nofetalmovement.■Nofetalheartbeat.

■Nofetalmovementbutfetalheartbeatpresent.

■Fever38ºC.■Foul-smellingvaginaldischarge.

■Ruptureofmembranesat<8monthsofpregnancy.

■Ruptureofmembranesat>8monthsofpregnancy.

TReATANDADVISe

■ Informthewomanandpartneraboutthepossibilityofdeadbaby.

■Refertohospital.

■ Informthewomanthatbabyisfineandlikelytobewellbuttoreturnifproblempersists.

■GiveappropriateIM/IVantibiotics B15 .■refer urgently to hospital B17 .

■GiveappropriateIM/IVantibiotic B15 .■refer urgently to hospital B17 .

■ManageasWomaninchildbirthd1-d28 .

CLASSIFY

ProBABly deAd BABy

well BABy

uterIne And fetAl InfectIon

rIsk of uterIne And fetAl InfectIon

ruPture of MeMBrAnes

next:Iffeverorburningonurination

resPond to oBserved sIGns or volunteered ProBleMs

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Respond to observed signs or volunteered problems (2)An

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ASk,CHeCkReCoRD

■Haveyouhadfever?■Doyouhaveburningonurination?

Look,LISTeN,FeeL

■ Ifhistoryoffeverorfeelshot:→Measureaxillary

temperature.→Lookorfeelforstiffneck.→Lookforlethargy.

■Percussflanksfortenderness.

SIGNS

■Fever>38°Candanyof:→veryfastbreathingor→stiffneck→lethargy→veryweak/notabletostand.

■Fever>38°Candanyof:→Flankpain→Burningonurination.

■Fever>38°Corhistoryoffever(inlast48hours).

■Burningonurination.

TReATANDADVISe

■ InsertIVlineandgivefluidsslowly B9 .■GiveappropriateIM/IVantibiotics B15 .■Giveartemether/quinineIM B16 .■Giveglucose B16 .■refer urgently to hospital B17 .

■GiveappropriateIM/IVantibiotics B15 .■Giveappropriateoralantimalarial f4 .■refer urgently to hospital B17 .

■Giveappropriateoralantimalarial f4 .■ Ifnoimprovementin2daysorconditionisworse,

refertohospital.

■Giveappropriateoralantibiotics f5 .■encouragehertodrinkmorefluids.■ Ifnoimprovementin2daysorconditionisworse,

refertohospital.

CLASSIFY

very severe feBrIle dIseAse

uPPer urInAry trAct InfectIon

MAlArIA

lower urInAry trAct InfectIon

next:Ifvaginaldischarge

If fever or BurnInG on urInAtIon

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t

Respond to observed signs or volunteered problems (3)

ASk,CHeCkReCoRD

■Haveyounoticedchangesinyourvaginaldischarge?

■Doyouhaveitchingatthevulva?■Hasyourpartnerhadaurinary

problem?

Ifpartnerispresentintheclinic,askthewomanifshefeelscomfortableifyouaskhimsimilarquestions.Ifyes,askhimifhehas:■urethraldischargeorpus.■burningonpassingurine.

Ifpartnercouldnotbeapproached,explainimportanceofpartnerassessmentandtreatmenttoavoidreinfection.Schedulefollow-upappointmentforwomanandpartner(ifpossible).

Look,LISTeN,FeeL

■Separatethelabiaandlookforabnormalvaginaldischarge:→amount→colour→odour/smell.

■ Ifnodischargeisseen,examinewithaglovedfingerandlookatthedischargeontheglove.

SIGNS

■Abnormalvaginaldischarge.■Partnerhasurethraldischargeor

burningonpassingurine.

■Curdlikevaginaldischarge.■ Intensevulvalitching.

■Abnormalvaginaldischarge

TReATANDADVISe

■Giveappropriateoralantibioticstowoman f5 .■Treatpartnerwithappropriateoralantibiotics f5 .■Counselonsafersexincludinguseofcondoms G2 .

■Giveclotrimazole f5 .■Counselonsafersexincludinguseofcondoms G2 .

■Givemetronidazoletowoman f5 .■Counselonsafersexincludinguseofcondoms G2 .

CLASSIFY

PossIBle GonorrHoeA or cHlAMydIA InfectIon

PossIBle cAndIdA InfectIon

PossIBle BActerIAl ortrIcHoMonAsInfectIon

next:IfsignssuggestingHIVinfection

If vAGInAl dIscHArGe

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Respond to observed signs or volunteered problems (4)An

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ASk,CHeCkReCoRD

■Haveyoulostweight?■Doyouhavefever?

Howlong(>1month)?■Haveyougotdiarrhoea(continuous

orintermittent)?Howlong,>1month?

■Haveyouhadcough?Howlong,>1month?

Assess if in high risk group:■occupationalexposure?■Multiplesexualpartner?■ Intravenousdrugabuse?■Historyofbloodtransfusion?■ IllnessordeathfromAIDSina

sexualpartner?■Historyofforcedsex?

Look,LISTeN,FeeL

■Lookforvisiblewasting.■Lookforulcersandwhitepatchesin

themouth(thrush).■Lookattheskin:

→Istherearash?→Arethereblistersalongtheribs

ononesideofthebody?

SIGNS

■Twoofthesesigns:→weightloss→fever>1month→diarrhoea>1month.

or■oneoftheabovesignsand

→oneormoreothersignsor→fromariskgroup.

TReATANDADVISe

■ReinforcetheneedtoknowHIVstatusandadviseonHIVtestingandcounsellingG2-G3 .

■Counselonthebenefitsoftestingthepartner G3 .■Counselonsafersexincludinguseofcondoms G2 .■RefertoTBcentreifcough.

■Counselonstoppingsmoking■Foralcohol/drugabuse,refertospecializedcare

providers.■Forcounsellingonviolence,see H4 .

CLASSIFY

stronG lIkelIHood of HIv InfectIon

next:Ifcoughorbreathingdifficulty

If sIGns suGGestInG HIv InfectIon (HIv status unknown)

c10

If sMokInG, AlcoHol or druG ABuse, or HIstory of vIolence

t

If tAkInG AntI-tuBerculosIs druGs

Respond to observed signs or volunteered problems (5)

ASk,CHeCkReCoRD

■Howlonghaveyoubeencoughing?■Howlonghaveyouhaddifficultyin

breathing?■Doyouhavechestpain?■Doyouhaveanybloodinsputum?■Doyousmoke?

■Areyoutakinganti-tuberculosisdrugs?Ifyes,sincewhen?

■Doesthetreatmentincludeinjection(streptomycin)?

Look,LISTeN,FeeL

■Lookforbreathlessness.■Listenforwheezing.■Measuretemperature.

SIGNS

At least 2 of the following signs:■Fever>38ºC.■Breathlessness.■Chestpain.

At least 1 of the following signs:■Coughorbreathingdifficulty

for>3weeks■Bloodinsputum■Wheezing

■Fever<38ºC,and■Cough<3weeks.

■Takinganti-tuberculosisdrugs.■Receivinginjectableanti-

tuberculosisdrugs.

TReATANDADVISe

■GivefirstdoseofappropriateIM/IVantibioticsB15 .■refer urgently to hospitalB17 .

■Refertohospitalforassessment.■ Ifseverewheezing,referurgentlytohospital.

■Advisesafe,soothingremedy.■ Ifsmoking,counseltostopsmoking.

■ Ifanti-tuberculartreatmentincludesstreptomycin(injection),referthewomantodistricthospitalforrevisionoftreatmentasstreptomycinisototoxictothefetus.

■ Iftreatmentdoesnotincludestreptomycin,assurethewomanthatthedrugsarenotharmfultoherbaby,andurgehertocontinuetreatmentforasuccessfuloutcomeofpregnancy.

■ IfhersputumisTBpositivewithin2monthsofdelivery,plantogiveINHprophylaxistothenewborn k13 .

■ReinforceadviceonHIVtestingandcounsellingG2-G3 .

■ Ifsmoking,counseltostopsmoking.■Advisetoscreenimmediatefamilymembersand

closecontactsfortuberculosis.

CLASSIFY

PossIBle PneuMonIA

PossIBle cHronIc lunG dIseAse

uPPerresPIrAtory trActInfectIon

tuBerculosIs

next:Givepreventivemeasures

If couGH or BreAtHInG dIffIculty

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Antenatal careAn

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c12Give preventive measuresAn

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GIve PreventIve MeAsuresAdvise and counsel all pregnant women at every antenatal care visit.

ASSeSS,CHeCkReCoRD■Checktetanustoxoid(TT)immunizationstatus.

■Checkwoman’ssupplyoftheprescribeddoseofiron/folate

■Checkwhenlastdoseofmebendazolegiven.

■Checkwhenlastdoseofanantimalarialgiven.■Askifshe(andchildren)aresleepingunderinsecticidetreatedbednets.

■Recordallvisitsandtreatmentsgiven.

TReATANDADVISe■Givetetanustoxoidifdue f2 .■ IfTT1,plantogiveTT2atnextvisit.

■Give3month’ssupplyofironandcounseloncomplianceandsafety f3 .

■Givemebendazoleonceinsecondorthirdtrimester f3 .

■Giveintermittentpreventivetreatmentinsecondandthirdtrimesters f4 .■encouragesleepingunderinsecticidetreatedbednets.

first visit■Developabirthandemergencyplanc14 .■Counselonnutritionc13 .■Counselonimportanceofexclusivebreastfeeding k2 .■Counselonstoppingsmokingandalcoholanddrugabuse.■Counselonsafersexincludinguseofcondoms.

All visits■Reviewandupdatethebirthandemergencyplanaccordingtonewfindingsc14-c15.■Adviseonwhentoseekcare: c17

→routinevisits→follow-upvisits→dangersigns.

third trimester■Counselonfamilyplanningc16 .

Advise and counsel on nutrition and self-care

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AdvIse And counsel on nutrItIon And self-cAreuse the information and counselling sheet to support your interaction with the woman, her partner and family.

Counselonnutrition■Advisethewomantoeatagreateramountandvarietyofhealthyfoods,suchasmeat,fish,oils,nuts,

seeds,cereals,beans,vegetables,cheese,milk,tohelpherfeelwellandstrong(giveexamplesoftypesoffoodandhowmuchtoeat).

■Spendmoretimeonnutritioncounsellingwithverythin,adolescentandHIV-positivewoman.■Determineifthereareimportanttaboosaboutfoodswhicharenutritionallyimportantforgood

health.Advisethewomanagainstthesetaboos.■Talktofamilymemberssuchasthepartnerandmother-in-law,toencouragethemtohelpensurethe

womaneatsenoughandavoidshardphysicalwork.

Adviseonself-careduringpregnancyAdvise the woman to:■Takeirontablets(p.T3).■Restandavoidliftingheavyobjects.■Sleepunderaninsecticideimpregnatedbednet.■Counselonsafersexincludinguseofcondoms,ifatriskforSTIorHIV G2 .■Avoidalcoholandsmokingduringpregnancy.■NoTtotakemedicationunlessprescribedatthehealthcentre/hospital.

Develop a birth and emergency plan (1)An

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c14

develoP A BIrtH And eMerGency PlAn use the information and counselling sheet to support your interaction with the woman, her partner and family.

Facilitydeliveryexplain why birth in a facility is recommended■Anycomplicationcandevelopduringdelivery-theyarenotalwayspredictable.■Afacilityhasstaff,equipment,suppliesanddrugsavailabletoprovidebestcareifneeded,anda

referralsystem.■ IfHIV-positiveshewillneedappropriateARVtreatmentforherselfandherbabyduringchildbirth.■ComplicationsaremorecommoninHIV-positivewomenandhernewborns.HIV-positivewomen

shoulddeliverinafacility.

Advise how to prepare Reviewthearrangementsfordelivery:■Howwillshegetthere?Willshehavetopayfortransport?■Howmuchwillitcosttodeliveratthefacility?Howwillshepay?■Canshestartsavingstraightaway?■Whowillgowithherforsupportduringlabouranddelivery?■Whowillhelpwhilesheisawaytocareforherhomeandotherchildren?

Advise when to go■ Ifthewomanlivesnearthefacility,sheshouldgoatthefirstsignsoflabour.■ Iflivingfarfromthefacility,sheshouldgo2-3weeksbeforebabyduedateandstayeitheratthe

maternitywaitinghomeorwithfamilyorfriendsnearthefacility.■Advisetoaskforhelpfromthecommunity,ifneeded I2 .

Advise what to bring■Home-basedmaternalrecord.■Cleanclothsforwashing,dryingandwrappingthebaby.■Additionalcleanclothstouseassanitarypadsafterbirth.■Clothesformotherandbaby.■Foodandwaterforwomanandsupportperson.

HomedeliverywithaskilledattendantAdvise how to prepare Reviewthefollowingwithher:■Whowillbethecompanionduringlabouranddelivery?■Whowillbeclosebyforatleast24hoursafterdelivery?■Whowillhelptocareforherhomeandotherchildren?■Advisetocalltheskilledattendantatthefirstsignsoflabour.■Advisetohaveherhome-basedmaternalrecordready.■Advisetoaskforhelpfromthecommunity,ifneeded I2 .

explain supplies needed for home delivery■Warmspotforthebirthwithacleansurfaceoracleancloth.■Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,forcleaningthebaby’s

eyes,forthebirthattendanttowashanddryherhands,foruseassanitarypads.■Blankets.■Bucketsofcleanwaterandsomewaytoheatthiswater.■Soap.■Bowls:2forwashingand1fortheplacenta.■Plasticforwrappingtheplacenta.

AdviseonlaboursignsAdvisetogotothefacilityorcontacttheskilledbirthattendantifanyofthefollowingsigns:■abloodystickydischarge.■painfulcontractionsevery20minutesorless.■watershavebroken.

AdviseondangersignsAdvisetogotothehospital/healthcentreimmediately, day or night, wItHout waitingifanyofthefollowingsigns:■vaginalbleeding.■convulsions.■severeheadacheswithblurredvision.■ feverandtooweaktogetoutofbed.■severeabdominalpain.■ fastordifficultbreathing.

Sheshouldgotothehealthcentreas soon as possibleifanyofthefollowingsigns:■ fever.■abdominalpain.■ feelsill.■swellingoffingers,face,legs.

Discusshowtoprepareforanemergencyinpregnancy■Discussemergencyissueswiththewomanandherpartner/family:

→wherewillshego?→howwilltheygetthere?→howmuchitwillcostforservicesandtransport?→canshestartsavingstraightaway?→whowillgowithherforsupportduringlabouranddelivery?→whowillcareforherhomeandotherchildren?

■Advisethewomantoaskforhelpfromthecommunity,ifneeded I1–I3 .■Advisehertobringherhome-basedmaternalrecordtothehealthcentre,evenforanemergencyvisit.

Develop a birth and emergency plan (2)

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Advise and counsel on family planningAn

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AdvIse And counsel on fAMIly PlAnnInG

Counselontheimportanceoffamilyplanning■ Ifappropriate,askthewomanifshewouldlikeherpartneroranotherfamilymembertobeincluded

inthecounsellingsession.■explainthatafterbirth,ifshehassexandisnotexclusivelybreastfeeding,shecanbecomepregnant

assoonasfourweeksafterdelivery.Thereforeitisimportanttostartthinkingearlyonaboutwhatfamilyplanningmethodtheywilluse.→Askaboutplansforhavingmorechildren.Ifshe(andherpartner)wantmorechildren,advisethat

waitingatleast2-3yearsbetweenpregnanciesishealthierforthemotherandchild.→Informationonwhentostartamethodafterdeliverywillvarydependingwhetherawomanis

breastfeedingornot.→Makearrangementsforthewomantoseeafamilyplanningcounsellor,orcounselherdirectly

(seetheDecision-makingtoolforfamilyplanningprovidersandclientsforinformationonmethodsandonthecounsellingprocess).

■Counselonsafersexincludinguseofcondomsfordualprotectionfromsexuallytransmittedinfections(STI)orHIVandpregnancy.PromoteespeciallyifatriskforSTIorHIV G4 .

■ForHIV-positivewomen,see G5 forfamilyplanningconsiderations■Herpartnercandecidetohaveavasectomy(malesterilization)atanytime.

Method options for the non-breastfeeding womancan be used immediately postpartum Condoms Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implant Spermicide Femalesterilization(within7daysordelay6weeks) CopperIUD(immediatelyfollowingexpulsionof

placentaorwithin48hours)delay 3 weeks Combinedoralcontraceptives Combinedinjectables Diaphragm Fertilityawarenessmethods

Specialconsiderationsforfamilyplanningcounsellingduringpregnancycounselling should be given during the third trimester of pregnancy.■ Ifthewomanchoosesfemalesterilization:

→canbeperformedimmediatelypostpartumifnosignofinfection(ideallywithin7days,ordelayfor6weeks).

→planfordeliveryinhospitalorhealthcentrewheretheyaretrainedtocarryouttheprocedure.→ensurecounsellingandinformedconsentpriortolabouranddelivery.

■ Ifthewomanchoosesanintrauterinedevice(IUD):→canbeinsertedimmediatelypostpartumifnosignofinfection(upto48hours,ordelay4weeks)→planfordeliveryinhospitalorhealthcentrewheretheyaretrainedtoinserttheIUD.

Method options for the breastfeeding woman can be used immediately postpartum Lactationalamenorrhoeamethod(LAM) Condoms Spermicide Femalesterilization(within7daysor

delay6weeks) CopperIUD(within48hoursordelay4weeks)delay 6 weeks Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implants Diaphragmdelay 6 months Combinedoralcontraceptives Combinedinjectables Fertilityawarenessmethods

AdvIse on routIne And follow-uP vIsItsencourage the woman to bring her partner or family member to at least 1 visit.

Antenatal care

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c17Advise on routine and follow-up visits

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Routineantenatalcarevisits1st visit Before4months Before16weeks2nd visit 6months 24-28weeks3rd visit 8months 30-32weeks4th visit 9months 36-38weeks

■Allpregnantwomenshouldhave4routineantenatalvisits.■Firstantenatalcontactshouldbeasearlyinpregnancyaspossible.■Duringthelastvisit,informthewomantoreturnifshedoesnotdeliverwithin2weeksafterthe

expecteddateofdelivery.■MorefrequentvisitsordifferentschedulesmayberequiredaccordingtonationalmalariaorHIV

policies.■ IfwomenisHIV-positiveensureavisitbetween26-28weeks.

Follow-upvisitsIf the problem was: return in:Hypertension 1weekif>8monthspregnantSevereanaemia 2weeksHIV-positive 2weeksafterHIVtesting

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HoMe delIvery wItHout A skIlled AttendAntreinforce the importance of delivery with a skilled birth attendant

InstructmotherandfamilyoncleanandsaferdeliveryathomeIfthewomanhaschosentodeliverathomewithoutaskilledattendant,reviewthesesimpleinstructionswiththewomanandfamilymembers.■Givethemadisposabledeliverykitandexplainhowtouseit.

tell her/them:■Toensureacleandeliverysurfaceforthebirth.■Toensurethattheattendantshouldwashherhandswithcleanwaterandsoapbefore/after

touchingmother/baby.Sheshouldalsokeephernailsclean.■To,afterdelivery,placethebabyonthemother’schestwithskin-to-skincontactandwipethebaby’s

eyesusingacleanclothforeacheye.■Tocoverthemotherandthebaby.■Tousethetiesandrazorbladefromthedisposabledeliverykittotieandcutthecord.Thecordiscut

whenitstopspulsating.■Todrythebabyaftercuttingthecord.Towipecleanbutnotbathethebabyuntilafter6hours.■Towaitfortheplacentatodeliveronitsown.■Tostartbreastfeedingwhenthebabyshowssignsofreadiness,withinthefirsthourafterbirth.■ToNoTleavethemotheraloneforthefirst24hours.■Tokeepthemotherandbabywarm.Todressorwrapthebaby,includingthebaby’shead.■ Todisposeoftheplacentainacorrect,safeandculturallyappropriatemanner(burnorburry).

AdvisetoavoidharmfulpracticesForexample:nottouselocalmedicationstohastenlabour.nottowaitforwaterstostopbeforegoingtohealthfacility.nottoinsertanysubstancesintothevaginaduringlabourorafterdelivery.nottopushontheabdomenduringlabourordelivery.nottopullonthecordtodelivertheplacenta.nottoputashes,cowdungorothersubstanceonumbilicalcord/stump.

encouragehelpfultraditionalpractices:

✎____________________________________________________________________

✎____________________________________________________________________

AdviseondangersignsIfthemotherorbabyhasanyofthesesigns,she/theymustgotothehealthcentreimmediately, day or night, wItHout waiting

Mother■Watersbreakandnotinlabourafter6hours.■Labourpains/contractionscontinueformorethan12hours.■Heavybleedingafterdelivery(pad/clothsoakedinlessthan5minutes).■Bleedingincreases.■Placentanotexpelled1hourafterbirthofthebaby.

Baby■Verysmall.■Difficultyinbreathing.■Fits.■Fever.■Feelscold.■Bleeding.■Notabletofeed.

Assesses eligibility of ARV for HIV-positive pregnant woman

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ASk,CHeCkReCoRD■Haveyoulostweight?■Haveyougotdiarrhoea(continuousorintermittent)?■ Doyouhavefever?

Howlong(>1month)?■ Haveyouhadcough?

Howlong(>1month)?■ Haveyouanydifficultyinbreathing?

Howlong(>1month)?■Have younoticedany change in

vaginaldischarge?

Look,LISTeN,FeeL■ Lookforulcersandwhitepatchesin

themouth(thrush).■ Lookattheskin: →Istherearash? →Arethereblistersalongtheribs

ononesideofthebody?■ Lookforvisiblewasting.■ Feelthehead,neck,andunderarm

forenlargedlymphnodes.■ Lookforanyabnormalvaginal

discharge c9 .

SIGNSHIV-positiveandanyofthefollowing:■Weightlossornoweightgain■Visiblewasting■Diarrhoea>1month■Fever>1month■Cough>1monthordifficult

breathing■Cracks/ulcersaroundlips/mouth■ Itchingrash■Blistersalongtheribsononeside

ofthebody■enlargedlymphnodes■Abnormalvaginaldischarge

HIV-positiveandnoneoftheabovesigns

TReATANDADVISe■Refertohospitalforfurtherassessment.

■GiveappropriateARVs G9 .■SupportinitiationofARV G6 .■ReviseANCvisitaccordinglyc17 .

CLASSIFYHIv-PosItIve wItH HIv-relAted sIGns And syMPtoMs

HIv-PosItIve wItHout HIv-relAted sIGns And syMPtoMs

Assess elIGIBIlIty of Arv for HIv-PosItIve PreGnAnt woMAnuse this chart to determine Arv needs for HIv-positive woman and her baby when appropriate HIv services and cd4 count are not available.

Childbirth: labour, delivery and immediate postpartum careCh

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Childbirth: labour, delivery and immediate postpartum CareExamine the woman in labour or with ruptured membranes

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ASK,CHECKRECORDhistory of this labour:■Whendidcontractionsbegin?■Howfrequentarecontractions?

Howstrong?■Haveyourwatersbroken?Ifyes,

when?Weretheyclearorgreen?■Haveyouhadanybleeding?

Ifyes,when?Howmuch?■ Isthebabymoving?■Doyouhaveanyconcern?Check record, or if no record: ■Askwhenthedeliveryisexpected.■Determineifpreterm

(lessthan8monthspregnant).■Reviewthebirthplan.if prior pregnancies: ■Numberofpriorpregnancies/

deliveries.■Anypriorcaesareansection,

forceps,orvacuum,orothercomplicationsuchaspostpartumhaemorhage?

■Anypriorthirddegreetear?Current pregnancy:■RPRstatus C5 .■Hbresults C4 .■Tetanusimmunizationstatus f2 .■HIVstatus C6 .■ Infantfeedingplan g7-g8 .

LOOK,LISTEN,FEEL■Observethewoman’sresponseto

contractions:→Isshecopingwellorisshe

distressed?→Isshepushingorgrunting?

■Checkabdomenfor:→caesareansectionscar.→horizontalridgeacrosslower

abdomen(ifpresent,emptybladderb12 andobserveagain).

■ Feelabdomenfor:→contractionsfrequency,duration,

anycontinuouscontractions?→fetallie—longitudinalor

transverse?→fetalpresentation—head,breech,

other?→morethanonefetus?→fetalmovement.

■Listentothefetalheartbeat:→Countnumberofbeatsin1minute.→Iflessthan100beatsper

minute,ormorethan180,turnwomanonherleftsideandcountagain.

■Measurebloodpressure.■Measuretemperature.■Lookforpallor.■Lookforsunkeneyes,drymouth.■Pinchtheskinoftheforearm:does

itgobackquickly?

next:Performvaginalexaminationanddecidestageoflabour

examine the woman in labour or with ruptured membranesfirst do rapid assessment and management b3-b7 . then use this chart to assess the woman’s and fetal status and decide stage of labour.

d2

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Decide stage of labour

ASK,CHECKRECORD

■Explaintothewomanthatyouwillgiveheravaginalexaminationandaskforherconsent.

LOOK,LISTEN,FEEL■Lookat vulvafor:

→ bulgingperineum → anyvisiblefetalparts → vaginalbleeding → leakingamnioticfluid;ifyes,isit

meconiumstained,foul-smelling? → warts,keloidtissueorscarsthatmay

interferewithdelivery.

perform vaginal examination■do notshavetheperinealarea.■Prepare:

→ cleangloves → swabs,pads.

■Washhandswithsoapbeforeandaftereachexamination.

■Washvulvaandperinealareas.■Putongloves.■Positionthewomanwithlegsflexedandapart.

do notperformvaginalexaminationifbleedingnoworatanytimeafter7monthsofpregnancy.

■Performgentlevaginalexamination(donotstartduringacontraction): → Determinecervicaldilatationin

centimetres. → Feelforpresentingpart.Isithard,round

andsmooth(thehead)?Ifnot,identifythepresentingpart.

→ Feelformembranes–aretheyintact? → Feelforcord–isitfelt?Isitpulsating?If

so,actimmediatelyason d15 .

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deCide stage of labour

SIGNS■Bulgingthinperineum,vagina

gapingandheadvisible,fullcervicaldilatation.

■Cervicaldilatation:→multigravida≥5cm→primigravida≥6cm

■Cervicaldilatation≥4cm.

■Cervicaldilatation:0-3cm;contractionsweakand<2in10minutes.

MANAGE■Seesecondstageoflabourd10-d11.■Recordinpartograph n5 .

■Seefirststageoflabour–activelabour d9 .■Startplottingpartograph n5 .■Recordinlabourrecord n5 .

■Seefirststageoflabour—notactivelabour d8 .■Recordinlabourrecord n4 .

CLASSIFYimminent delivery

late aCtive labour

early aCtive labour

not yet in aCtive labour

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Respond to obstetrical problems on admission

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SIGNS■Transverselie.■Continuouscontractions.■Constantpainbetweencontractions.■Suddenandsevereabdominalpain.■Horizontalridgeacrosslower

abdomen.■Labour>24hours.

■Ruptureofmembranesandanyof:→Fever>38˚C→Foul-smellingvaginaldischarge.

■Ruptureofmembranesat<8-monthsofpregnancy.

■Diastolicbloodpressure>90mmHg.

■Severepalmarandconjunctivalpallorand/orhaemoglobin<7-g/dl.

■Breechorothermalpresentationd16 .■Multiplepregnancyd18 .■Fetaldistressd14 .■Prolapsedcordd15 .

TREATANDADVISE■ Ifdistressed,insertanIVlineandgivefluids b9 .■ Ifinlabour>24hours,giveappropriateIM/IV

antibiotics b15 .■refer urgently to hospital b17 .

■GiveappropriateIM/IVantibiotics b15 .■ Iflatelabour,deliverandrefertohospital

afterdelivery b17 .■Plantotreatnewborn J5 .

■GiveappropriateIM/IVantibiotics b15 .■ Iflatelabour,deliverd10-d28.■Discontinueantibioticformotherafterdeliveryifno

signsofinfection.■Plantotreatnewborn J5 .

■Assessfurtherandmanageason d23 .

■Manageason d24 .

■Followspecificinstructions(seepagenumbersinleftcolumn).

CLASSIFYobstruCted labour

uterine and fetal infeCtion

risk of uterine and fetal infeCtion

pre-eClampsia

severe anaemia

obstetriCal CompliCation

respond to obstetriCal problems on admissionuse this chart if abnormal findings on assessing pregnancy and fetal status d2-d3 .

FORALLSITUATIONSINREDBELOW,refer urgently to hospital if in early labour,MANAGEONLYIFINLATELABOUR

d4

Respond to obstetrical problems on admission

SIGNS■Warts,keloidtissuethatmay

interferewithdelivery.■Priorthirddegreetear.

■Bleedinganytimeinthirdtrimester.■Priordeliveryby:

→caesareansection→forcepsorvacuumdelivery.

■Agelessthan14years.

■Labourbefore8completedmonthsofpregnancy(morethanonemonthbeforeestimateddateofdelivery).

■Fetalheartrate<120or>160beatsperminute.

■Ruptureofmembranesattermandbeforelabour.

■ Iftwoormoreofthefollowingsigns:→thirsty→sunkeneyes→drymouth→skinpinchgoesbackslowly.

■HIVtestpositive.■TakingARVtreatmentorprophylaxis

andinfantfeeding.

■Nofetalmovement,and■Nofetalheartbeaton

repeatedexamination

TREATANDADVISE■Doagenerousepisiotomyandcarefullycontrol

deliveryofthehead d10-d11 .

■ Iflatelabour,deliver d10-d28 .■Havehelpavailableduringdelivery.

■Reassessfetalpresentation(breechmorecommon).■ Ifwomanislying,encouragehertolieonherleftside.■Callforhelpduringdelivery.■Conductdeliveryverycarefullyassmallbabymaypop

outsuddenly.Inparticular,controldeliveryofthehead.■Prepareequipmentforresuscitationofnewborn k11 .

■Manageason d14 .

■GiveappropriateIM/IVantibioticsifruptureofmembrane>18hours b15 .

■Plantotreatthenewborn J5 .

■Giveoralfluids.■ Ifnotabletodrink,give1litreIVfluidsover3hours b9 .

■EnsurethatthewomantakesARVdrugsprescribedg9 .

■Supportherchoiceofinfantfeeding g7-g8 .

■Explaintotheparentsthatthebabyisnotdoingwell.

CLASSIFYrisk of obstetriCal CompliCation

preterm labour

possible fetal distress

rupture of membranes

dehydration

hiv-positive

possible fetal death

next:GivesupportivecarethroughoutlabourChil

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Communication■Explainallprocedures,seekpermission,anddiscussfindingswiththewoman.■Keepherinformedabouttheprogressoflabour.■Praiseher,encourageandreassureherthatthingsaregoingwell.■Ensureandrespectprivacyduringexaminationsanddiscussions.■ IfknownHIVpositive,findoutwhatshehastoldthecompanion.Respectherwishes.

Cleanliness■Encouragethewomantobatheorshowerorwashherselfandgenitalsattheonsetoflabour.■Washthevulvaandperinealareasbeforeeachexamination.■Washyourhandswithsoapbeforeandaftereachexamination.Usecleanglovesforvaginal

examination.■Ensurecleanlinessoflabourandbirthingarea(s).■Cleanupspillsimmediately.■do notgiveenema.

Mobility■Encouragethewomantowalkaroundfreelyduringthefirststageoflabour.■Supportthewoman’schoiceofposition(leftlateral,squating,kneeling,standingsupportedbythe

companion)foreachstageoflabouranddelivery.

Urination■Encouragethewomantoemptyherbladderfrequently.Remindherevery2hours.

Eating,drinking■Encouragethewomantoeatanddrinkasshewishesthroughoutlabour.■Nutritiousliquiddrinksareimportant,eveninlatelabour.■ Ifthewomanhasvisibleseverewastingortiresduringlabour,makesuresheeatsanddrinks.

Breathingtechnique■Teachhertonoticehernormalbreathing.■Encouragehertobreatheoutmoreslowly,makingasighingnoise,andtorelaxwitheachbreath.■ Ifshefeelsdizzy,unwell,isfeelingpins-and-needles(tingling)inherface,handsandfeet,

encouragehertobreathemoreslowly.■Topreventpushingattheendoffirststageoflabour,teachhertopant,tobreathewithanopen

mouth,totakein2shortbreathsfollowedbyalongbreathout.■Duringdeliveryofthehead,askhernottopushbuttobreathesteadilyortopant.

Painanddiscomfortrelief■Suggestchangeofposition.■Encouragemobility,ascomfortableforher.■Encouragecompanionto:

→massagethewoman’sbackifshefindsthishelpful.→holdthewoman’shandandspongeherfacebetweencontractions.

■Encouragehertousethebreathingtechnique.■Encouragewarmbathorshower,ifavailable.

■ if woman is distressed or anxious, investigate the cause d2-d3 .■ if pain is constant (persisting between contractions) and very severe or sudden in onset d4 .

give supportive Care throughout labouruse this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman’s wishes.

Give supportive care throughout labour

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Birth companion

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Birthcompanion■Encouragesupportfromthechosenbirthcompanionthroughoutlabour.■Describetothebirthcompanionwhatsheorheshoulddo:

→Alwaysbewiththewoman.→Encourageher.→Helphertobreatheandrelax.→Rubherback,wipeherbrowwithawetcloth,doothersupportiveactions.→Givesupportusinglocalpracticeswhichdonotdisturblabourordelivery.→Encouragewomantomovearoundfreelyasshewishesandtoadoptthepositionofherchoice.→Encouragehertodrinkfluidsandeatasshewishes.→Assisthertothetoiletwhenneeded.

■Askthebirthcompaniontocallforhelpif:→Thewomanisbearingdownwithcontractions.→Thereisvaginalbleeding.→Sheissuddenlyinmuchmorepain.→Shelosesconsciousnessorhasfits.→Thereisanyotherconcern.

■Tellthebirthcompanionwhatsheorheshouldnot doandexplainwhy: do notencouragewomantopush. do notgiveadviceotherthanthatgivenbythehealthworker. do notkeepwomaninbedifshewantstomovearound.

D2 examine the woman in labour or with ruptured membres

D3 deCide stage of labour

D4 respond to obstetriCal problems on admission (1)

D5 respond to obstetriCal problems on admission (2)

D6 give supportive Care throughout labour

D7 birth Companion

d8

MONITOREVERYHOUR:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Frequency,intensityanddurationofcontractions.■Fetalheartrated14 .■Moodandbehaviour(distressed,anxious) d6 .

■RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .■Recordtimeofruptureofmembranesandcolourofamnioticfluid.■GiveSupportivecare d6-d7 .■never leave the woman alone.

ASSESSPROGRESSOFLABOUR■After8hoursif:

→Contractionsstrongerandmorefrequentbut→Noprogressincervicaldilatationwithorwithoutmembranesruptured.

■After8hoursif:→noincreaseincontractions,and→membranesarenotruptured,and→noprogressincervicaldilatation.

■Cervicaldilatation4cmorgreater.

MONITOREVERY4HOURS:■Cervicaldilatation d3 d15 . Unlessindicated,do notdovaginalexaminationmorefrequentlythanevery4hours.■Temperature.■Pulse b3 .■Bloodpressured23 .

TREATANDADVISE,IFREqUIRED■refer the woman urgently to hospitalb17 .

■Dischargethewomanandadvisehertoreturnif:→pain/discomfortincreases→vaginalbleeding→membranesrupture.

■Beginplottingthepartograph n5 andmanagethewomanasinActivelabour d9 .

first stage of labour: not in aCtive labouruse this chart for care of the woman when not in aCtive labour, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes.

First stage of labour (1): when the woman is not in active labour

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MONITOREVERY30MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Frequency,intensityanddurationofcontractions.■Fetalheartrated14 .■Moodandbehaviour(distressed,anxious) d6 .

■RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .■Recordtimeofruptureofmembranesandcolourofamnioticfluid.■GiveSupportivecare d6-d7 .■never leave the woman alone.

ASSESSPROGRESSOFLABOUR■PartographpassestotherightofALERTLINE.

■PartographpassestotherightofACTIONLINE.

■Cervixdilated10cmorbulgingperineum.

MONITOREVERY4HOURS:■Cervicaldilatation d3 d15 . Unlessindicated,do not dovaginalexaminationmorefrequentlythanevery4hours.■Temperature.■Pulse b3 .■Bloodpressured23 .

TREATANDADVISE,IFREqUIRED■Reassesswomanandconsidercriteriaforreferral.■Callseniorpersonifavailable.Alertemergencytransportservices.■Encouragewomantoemptybladder.■Ensureadequatehydrationbutomitsolidfoods.■Encourageuprightpositionandwalkingifwomanwishes.■Monitorintensively.Reassessin2hoursandreferifnoprogress.Ifreferraltakesalongtime,refer

immediately(DONOTwaittocrossactionline).

■refer urgently to hospital b17 unlessbirthisimminent.

■ManageasinSecond stage of labourd10-d11.

first stage of labour: in aCtive labouruse this chart when the woman is in aCtive labour, when cervix dilated 4 cm or more.

First stage of labour (2): when the woman is in active labour

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MONITOREVERY5MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Frequency,intensityanddurationofcontractions.■Fetalheartrated14 .■Perineumthinningandbulging.■Visibledescentoffetalheadorduringcontraction.■Moodandbehaviour(distressed,anxious) d6 .■RecordfindingsregularlyinLabourrecordandPartograph(pp.N4-N6).■GiveSupportivecare d6-d7 .■Neverleavethewomanalone.

DELIVERTHEBABY■Ensurealldeliveryequipmentandsupplies,includingnewbornresuscitationequipment,are

available,andplaceofdeliveryiscleanandwarm(25°C) l3 .

■Ensurebladderisempty.■Assistthewomanintoacomfortablepositionofherchoice,asuprightaspossible.■Staywithherandofferheremotionalandphysicalsupportd10-d11.

■Allowhertopushasshewisheswithcontractions.

■Waituntilheadvisibleandperineumdistending.■Washhandswithcleanwaterandsoap.Putonglovesjustbeforedelivery.■SeeUniversalprecautionsduringlabouranddelivery a4 .

TREATANDADVISEIFREqUIRED

■ Ifunabletopassurineandbladderisfull,emptybladder b12 .■do notletherlieflat(horizontally)onherback.■ Ifthewomanisdistressed,encouragepaindiscomfortrelief d6 .

do not urgehertopush.■ If,after30minutesofspontaneousexpulsiveefforts,theperineumdoesnotbegintothinand

stretchwithcontractions,doavaginalexaminationtoconfirmfulldilatationofcervix.■ Ifcervixisnotfullydilated,awaitsecondstage.Placewomanonherleftsideanddiscourage

pushing.Encouragebreathingtechnique d6 .

■ Ifsecondstagelastsfor2hoursormorewithoutvisiblesteadydescentofthehead,callforstafftrainedtousevacuumextractororrefer urgently to hospital b17 .

■ Ifobviousobstructiontoprogress(warts/scarring/keloidtissue/previousthirddegreetear),doagenerousepisiotomy.do notperformepisiotomyroutinely.

■ Ifbreechorothermalpresentation,manageason d16 .

seCond stage of labour: deliver the baby and give immediate newborn Careuse this chart when cervix dilated 10 cm or bulging thin perineum and head visible.

Second stage of labour: deliver the baby and give immediate newborn care (1)

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Second stage of labour: deliver the baby and give immediate newborn care (2)

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DELIVERTHEBABY■Ensurecontrolleddeliveryofthehead:

→Keeponehandgentlyontheheadasitadvanceswithcontractions.→Supportperineumwithotherhandandcoveranuswithpadheldinpositionbysideofhandduringdelivery.→Leavetheperineumvisible(betweenthumbandfirstfinger).→Askthemothertobreathesteadilyandnottopushduringdeliveryofthehead.→Encouragerapidbreathingwithmouthopen.

■Feelgentlyaroundbaby’sneckforthecord.■Checkifthefaceisclearofmucusandmembranes.

■Awaitspontaneousrotationofshouldersanddelivery(within1-2minutes).■Applygentledownwardpressuretodelivertopshoulder.■Thenliftbabyup,towardsthemother’sabdomentodeliverlowershoulder.■Placebabyonabdomenorinmother’sarms.■Notetimeofdelivery.

■Thoroughlydrythebabyimmediately.Wipeeyes.Discardwetcloth.■Assessbaby’sbreathingwhiledrying.■ Ifthebabyisnotcrying,observebreathing:

→breathingwell(chestrising)?→notbreathingorgasping?

■Excludesecondbaby.■Palpatemother’sabdomen.■Give10IUoxytocinIMtothemother.■Watchforvaginalbleeding.

■Changegloves.Ifnotpossible,washglovedhands.■Clampandcutthecord.

→puttiestightlyaroundthecordat2cmand5cmfrombaby’sabdomen.→cutbetweentieswithsterileinstrument.→observeforoozingblood.

■Leavebabyonthemother’schestinskin-to-skincontact.Placeidentificationlabel.■Coverthebaby,covertheheadwithahat.

■Encourageinitiationofbreastfeeding k2 .

TREATANDADVISE,IFREqUIRED■ Ifpotentiallydamagingexpulsiveefforts, exertmorepressureonperineum.■Discardsoiledpadtopreventinfection.

■ Ifcordpresentandloose,deliverthebabythroughtheloopofcordorslipthecordoverthebaby’shead;ifcordistight,clampandcutcord,thenunwind.

■Gentlywipefacecleanwithgauzeorcloth,ifnecessary.

■ Ifdelayindeliveryofshoulders: →do not panicbutcallforhelpandaskcompaniontoassist →ManageasinStuck shoulders d17 .■ Ifplacingnewbornonabdomenisnotacceptable,orthemothercannotholdthebaby,placethebabyin

aclean,warm,safeplaceclosetothemother.

do notleavethebabywet-she/hewillbecomecold.■ Ifthebabyisnotbreathingorgasping (unlessbabyisdead,macerated,severelymalformed):

→Cutcordquickly:transfertoafirm,warmsurface;startNewbornresuscitation k11 .■CALLFORHELP-onepersonshouldcareforthemother.

■ Ifsecondbaby,do notgiveoxytocinnow.get help.■Deliverthesecondbaby.ManageasinMultiple pregnancy d18 .■ Ifheavybleeding,repeatoxytocin10-IU-IM.

■ Ifbloodoozing,placeasecondtiebetweentheskinandthefirsttie.

do not applyanysubstancetothestump.do notbandageorbindthestump.

■ Ifroomcool(lessthan25°C),useadditionalblankettocoverthemotherandbaby.

■ IfHIV-positivemotherhaschosenreplacementfeeding,feedaccordingly.■CheckARVtreatmentneeded g9 .

d12

MONITORMOTHEREVERY5MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Feelifuterusiswellcontracted.■Moodandbehaviour(distressed,anxious) d6 .■Timesincethirdstagebegan(timesincebirth).

■Recordfindings,treatmentsandproceduresinLabour record andPartograph (pp.N4-N6).■GiveSupportive care d6-d7 .■never leave the woman alone.

DELIVERTHEPLACENTA■Ensure10-IUoxytocinIMisgiven d11 .■Awaitstronguterinecontraction (2-3minutes)anddeliverplacenta bycontrolled cord

traction:→Placesideofonehand(usuallyleft)abovesymphysispubiswithpalmfacingtowardsthe

mother’sumbilicus.Thisappliescountertractiontotheuterusduringcontrolledcordtraction.Atthesametime,applysteady,sustainedcontrolledcordtraction.

→Ifplacentadoesnotdescendduring30-40secondsofcontrolledcordtraction,releasebothcordtractionandcountertractionontheabdomenandwaituntiltheuterusiswellcontractedagain.Thenrepeatcontrolledcordtractionwithcountertraction.

→Astheplacentaiscomingout,catchinbothhandstopreventtearingofthemembranes.→Ifthemembranesdonotslipoutspontaneously,gentlytwistthemintoaropeandmovethemup

anddowntoassistseparationwithouttearingthem.

■Checkthatplacentaandmembranesarecomplete.

MONITORBABYEVERY15MINUTES:■Breathing:listenforgrunting,lookforchestin-drawingandfastbreathing J2 .■Warmth:checktoseeiffeetarecoldtotouch J2 .

TREATANDADVISEIFREqUIRED■ If,after30minutesofgivingoxytocin,theplacentaisnotdeliveredandthewomanisNOTbleeding:

→Emptybladder b12

→Encouragebreastfeeding→Repeatcontrolledcordtraction.

■ Ifwomanisbleeding,manageason b5

■ Ifplacentaisnotdeliveredinanother30minutes(1hourafterdelivery):→Removeplacentamanually b11

→GiveappropriateIM/IVantibiotic b15 .■ Ifin1hourunabletoremoveplacenta:

→Referthewomantohospital b17

→InsertanIVlineandgivefluidswith20IUofoxytocinat30dropsperminute duringtransfer b9 .

do notexertexcessivetractiononthecord.do notsqueezeorpushtheuterustodelivertheplacenta.

■ Ifplacentaisincomplete:→Removeplacentalfragmentsmanually b11 .→GiveappropriateIM/IVantibiotic b15 .

third stage of labour: deliver the plaCentause this chart for care of the woman between birth of the baby and delivery of placenta.

Third stage of labour: deliver the placenta

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Third stage of labour: deliver the placenta

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DELIVERTHEPLACENTA■Checkthatuterusiswellcontractedandthereisnoheavybleeding.■Repeatcheckevery5minutes.

■Examineperineum,lowervaginaandvulvafortears.

■Collect,estimateandrecordbloodlossthroughoutthirdstageandimmediatelyafterwards.

■Cleanthewomanandtheareabeneathher.Putsanitarypadorfoldedcleanclothunderherbuttockstocollectblood.Helphertochangeclothesifnecessary.

■Keepthemotherandbabyindeliveryroomforaminimumofonehourafterdeliveryofplacenta.

■Disposeofplacentainthecorrect,safeandculturallyappropriatemanner.

TREATANDADVISE,IFREqUIRED■ Ifheavybleeding:

→Massageuterustoexpelclotsifany,untilitishard b10 .→Giveoxytocin10IUIM b10 .→Callforhelp.→StartanIVline b9 ,add20IUofoxytocintoIVfluidsandgiveat60dropsperminute n9 .→Emptythebladder b12 .

■ Ifbleedingpersistsanduterusissoft:→Continuemassaginguterusuntilitishard.→Applybimanualoraorticcompression b10 .→ContinueIVfluidswith20IUofoxytocinat30dropsperminute.→refer woman urgently to hospital b17 .

■ Ifthirddegreetear(involvingrectumoranus),refer urgently to hospital b17 .■Forothertears:applypressureoverthetearwithasterilepadorgauzeandputlegstogether.

do notcrossankles.■Checkafter5minutes.Ifbleedingpersists,repairthetear b12 .

■ Ifbloodloss≈250-ml,butbleedinghasstopped:→Plantokeepthewomaninthefacilityfor24hours.→Monitorintensively(every30minutes)for4hours: →BP,pulse →vaginalbleeding →uterus,tomakesureitiswellcontracted.→Assistthewomanwhenshefirstwalksafterrestingandrecovering.→Ifnotpossibletoobserveatthefacility,refer to hospital b17 .

■ Ifdisposingplacenta:→Usegloveswhenhandlingplacenta.→Putplacentaintoabagandplaceitintoaleak-proofcontainer.→Alwayscarryplacentainaleak-proofcontainer.→Incineratetheplacentaorburyitatleast10mawayfromawatersource,ina2mdeeppit.

D8 first stage of labour (1): when the woman is not in aCtive labour

D9 first stage of labour (2): in aCtive labour

D10 seCond stage of labour: deliver the baby and give immediate newborn Care (1)

D11 seCond stage of labour: deliver the baby and give immediate newborn Care (2)

D12 third stage of labour: deliver the plaCenta (1)

D13 third stage of labour: deliver the plaCenta (2)

next:Ifprolapsedcord

respond to problems during labour and delivery

d14Respond to problems during labour and delivery (1) If FHR <120 or >160 bpm

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ASK,CHECKRECORD LOOK,LISTEN,FEEL

■Positionthewomanonherleftside.■ Ifmembraneshaveruptured,lookat

vulvaforprolapsedcord.■Seeifliquorwasmeconiumstained.■RepeatFHRcountafter

15 minutes.

SIGNS

■Cordseenatvulva.

■FHRremains>160or<120after30minutesobservation.

■FHRreturnstonormal.

TREATANDADVISE

■Manageurgentlyason d15 .

■ Ifearlylabour:→refer the woman urgently to hospital b17

→Keepherlyingonherleftside.■ Iflatelabour:

→Callforhelpduringdelivery→Monitoraftereverycontraction.IfFHRdoesnot

returntonormalin15minutesexplaintothewoman(andhercompanion)thatthebabymaynotbewell.

→Preparefornewbornresuscitation k11 .

■MonitorFHRevery15minutes.

CLASSIFY

prolapsed Cord

baby not well

baby well

if fetal heart rate (fhr) <120 or >160 beats per minute

�

if prolapsed Cordthe cord is visible outside the vagina or can be felt in the vagina below the presenting part.

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d15Respond to problems during labour and delivery (2) If prolapsed cord

ASK,CHECKRECORD LOOK,LISTEN,FEEL■Lookatorfeelthecordgentlyfor

pulsations.■Feelfortransverselie.■Dovaginalexaminationto

determinestatusoflabour.

SIGNS■Transverselie

■Cordispulsating

■Cordisnotpulsating

TREAT■refer urgently to hospital b17 .

if early labour:■Pushtheheadorpresentingpartoutofthepelvis

andholditabovethebrim/pelviswithyourhandontheabdomenuntilcaesareansectionisperformed.

■ Instructassistant(family,staff)topositionthewoman’sbuttockshigherthantheshoulder.

■refer urgently to hospital b17 .■ Iftransfernotpossible,allowlabourtocontinue.

if late labour:■Callforadditionalhelpifpossible(formotherandbaby).■PrepareforNewbornresuscitation k11 .■Askthewomantoassumeanuprightorsquatting

positiontohelpprogress.■Expeditedeliverybyencouragingwomantopush

withcontraction.

■Explaintotheparentsthatbabymaynotbewell.

CLASSIFYobstruCted labour

fetus alive

fetusprobably dead

next:Ifbreechpresentation�

Respond to problems during labour and delivery (3) If breech presentation

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SIGN■ Ifearlylabour

■ Iflatelabour

■ Iftheheaddoesnotdeliver afterseveralcontractions

■ Iftrappedarmsorshoulders

■ Iftrappedhead(andbabyisdead)

next:Ifstuckshoulders

if breeCh presentation

d16

TREAT■refer urgently to hospital b17 .

■Callforadditionalhelp.■Confirmfulldilatationofthecervixbyvaginalexamination d3 .■Ensurebladderisempty.IfunabletoemptybladderseeEmptybladder b12 .■Preparefornewbornresuscitation k11 .■Deliverthebaby:

→Assistthewomanintoapositionthatwillallowthebabytohangdownduringdelivery,forexample,proppedupwithbuttocksatedgeofbedorontoherhandsandknees(allfoursposition).

→Whenbuttocksaredistending,makeanepisiotomy.→Allowbuttocks,trunkandshoulderstodeliverspontaneouslyduringcontractions.→Afterdeliveryoftheshouldersallowthebabytohanguntilnextcontraction.

■Placethebabyastrideyourleftforearmwithlimbshangingoneachside.■Placethemiddleandindexfingersofthelefthandoverthemalarcheekbonesoneithersidetoapply

gentledownwardspressuretoaidflexionofhead.■Keepingthelefthandasdescribed,placetheindexandringfingersoftherighthandoverthebaby’s

shouldersandthemiddlefingeronthebaby’sheadtogentlyaidflexionuntilthehairlineisvisible.■Whenthehairlineisvisible,raisethebabyinupwardandforwarddirectiontowardsthemother’sabdomenuntil

thenoseandmoutharefree.Theassistantgivessuprapubicpressureduringtheperiodtomaintainflexion.

■Feelthebaby’schestforarms.Ifnotfelt:■Holdthebabygentlywithhandsaroundeachthighandthumbsonsacrum.■Gentlyguidingthebabydown,turnthebaby,keepingthebackuppermostuntiltheshoulderwhichwas

posterior(below)isnowanterior(atthetop)andthearmisreleased.■Thenturnthebabyback,againkeepingthebackuppermosttodelivertheotherarm.■Thenproceedwithdeliveryofheadasdescribedabove.

■Tiea1kgweighttothebaby’sfeetandawaitfulldilatation.■Thenproceedwithdeliveryofheadasdescribedabove.neverpullonthebreechdo notallowthewomantopushuntilthecervixisfullydilated.Pushingtoosoonmaycausetheheadtobetrapped.

LOOK,LISTEN,FEEL■Onexternalexaminationfetalheadfelt

infundus.■Softbodypart(legorbuttocks)

feltonvaginalexamination.■Legsorbuttockspresentingat

perineum.

�

Respond to problems during labour and delivery (4) If stuck shoulders

SIGN■Fetalheadisdelivered,but

shouldersarestuckandcannotbedelivered.

■ Iftheshouldersarestillnotdeliveredandsurgicalhelpisnotavailableimmediately.

TREAT■Callforadditionalhelp.■Preparefornewbornresuscitation.■Explaintheproblemtothewomanandhercompanion.■Askthewomantolieonherbackwhilegrippingherlegstightlyflexedagainsther

chest,withkneeswideapart.Askthecompanionorotherhelpertokeepthelegsinthatposition.

■Performanadequateepisiotomy.■Askanassistanttoapplycontinuouspressuredownwards,withthepalmofthe

handontheabdomendirectlyabovethepubicarea,whileyoumaintaincontinuousdownwardtractiononthefetalhead.

■Remaincalmandexplaintothewomanthatyouneedhercooperationtotryanotherposition.

■Assisthertoadoptakneelingon“allfours”positionandaskhercompaniontoholdhersteady-thissimplechangeofpositionissometimessufficienttodislodgetheimpactedshoulderandachievedelivery.

■ Introducetherighthandintothevaginaalongtheposteriorcurveofthesacrum.■Attempttodelivertheposteriorshoulderorarmusingpressurefromthefingerof

therighthandtohooktheposteriorshoulderandarmdownwardsandforwardsthroughthevagina.

■Completetherestofdeliveryasnormal.■ Ifnotsuccessful,refer urgently to hospital b17 .

do notpullexcessivelyonthehead.

next:Ifmultiplebirths

if stuCk shoulders (shoulder dystoCia)

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d17

�

Respond to problems during labour and delivery (5) If multiple births

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SIGN■Preparefordelivery

■Secondstageoflabour

■Thirdstageoflabour

■ Immediatepostpartumcare

TREAT■Preparedeliveryroomandequipmentforbirthof2ormorebabies.Include:

→morewarmcloths→twosetsofcordtiesandrazorblades→resuscitationequipmentfor2babies.

■Arrangeforahelpertoassistyouwiththebirthsandcareofthebabies.

■Deliverthefirstbabyfollowingtheusualprocedure.Resuscitateifnecessary.Labelher/himTwin1.■Askhelpertoattendtothefirstbaby.■Palpateuterusimmediatelytodeterminethelieofthesecondbaby.Iftransverseorobliquelie,gentlyturnthebabybyabdominalmanipulationtoheadorbreechpresentation.■Checkthepresentationbyvaginalexamination.Checkthefetalheartrate.■Awaitthereturnofstrongcontractionsandspontaneousruptureofthesecondbagofmembranes,usuallywithin1hourofbirthoffirstbaby,butmaybelonger.■Staywiththewomanandcontinuemonitoringherandthefetalheartrateintensively.■Removewetclothsfromunderneathher.Iffeelingchilled,coverher.■Whenthemembranesrupture,performvaginalexamination d3 tocheckforprolapsedcord.Ifpresent,seeProlapsedcord d15 .■Whenstrongcontractionsrestart,askthemothertobeardownwhenshefeelsready.■Deliverthesecondbaby.Resuscitateifnecessary.Labelher/himTwin2.■Aftercuttingthecord,askthehelpertoattendtothesecondbaby.■Palpatetheuterusforathirdbaby.Ifathirdbabyisfelt,proceedasdescribedabove.Ifnothirdbabyisfelt,gotothirdstageoflabour.do notattempttodelivertheplacentauntilallthebabiesareborn.do notgivethemotheroxytocinuntilafterthebirthofallbabies.

■Giveoxytocin10IUIMaftermakingsurethereisnotanotherbaby.■Whentheuterusiswellcontracted,delivertheplacentaandmembranesbycontrolledcordtraction,applyingtractiontoallcordstogether d12-d23.■Beforeandafterdeliveryoftheplacentaandmembranes,observecloselyforvaginalbleedingbecausethiswomanisatgreaterriskofpostpartumhaemorrhage.If

bleeding,see b5 .■Examinetheplacentaandmembranesforcompleteness.Theremaybeonelargeplacentawith2umbilicalcords,oraseparateplacentawithanumbilicalcordforeachbaby.

■Monitorintensivelyasriskofbleedingisincreased.■ProvideimmediatePostpartumcare d19-d20.■ Inaddition:

→Keepmotherinhealthcentreforlongerobservation→Plantomeasurehaemoglobinpostpartumifpossible→Givespecialsupportforcareandfeedingofbabies J11 and k4 .

next:Careofthemotherandnewbornwithinfirsthourofdeliveryofplacenta

if multiple births

d18

�

d19

MONITORMOTHEREVERY15MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Feelifuterusishardandround.

■Recordfindings,treatmentsandproceduresinLabour recordandPartograph n4-n6 .■Keepmotherandbabyindeliveryroom-do not separate them.■never leave the woman and newborn alone.

CAREOFMOTHERANDNEWBORNwoman■Assesstheamountofvaginalbleeding.■Encouragethewomantoeatanddrink.■Askthecompaniontostaywiththemother.■Encouragethewomantopassurine.

newborn■Wipetheeyes.■Applyanantimicrobialwithin1hourofbirth.

→either1%silvernitratedropsor2.5%povidoneiodinedropsor1%tetracyclineointment.■DONOTwashawaytheeyeantimicrobial.■ Ifbloodormeconium,wipeoffwithwetclothanddry.■DONOTremovevernixorbathethebaby.■Continuekeepingthebabywarmandinskin-to-skincontactwiththemother.■Encouragethemothertoinitiatebreastfeedingwhenbabyshowssignsofreadiness.Offerherhelp.■DONOTgiveartificialteatsorpre-lactealfeedstothenewborn:nowater,sugarwater,orlocalfeeds.■Examinethemotherandnewbornonehourafterdeliveryofplacenta. UseAssess the mother after delivery d21 andExaminethenewborn J2-J8 .

MONITORBABYEVERY15MINUTES:■Breathing:listenforgrunting,lookforchestin-drawingandfastbreathing J2 .■Warmth:checktoseeiffeetarecoldtotouch J2 .

INTERVENTIONS,IFREqUIRED■ Ifpadsoakedinlessthan5minutes,orconstanttrickleofblood,manageason d22 ..■ Ifuterussoft,manageason b10 .■ Ifbleedingfromaperinealtear,repairifrequired b12 orrefer to hospital b17 .

■ Ifbreathingwithdifficulty—grunting,chestin-drawingorfastbreathing,examinethebabyason J2-J8 .■ Iffeetarecoldtotouchormotherandbabyareseparated: →Ensuretheroomiswarm.Covermotherandbabywithablanket

→Reassessin1hour.Ifstillcold,measuretemperature.Iflessthan36.50C,manageason k9 .■ Ifunabletoinitiatebreastfeeding(motherhascomplications):

→Planforalternativefeedingmethod k5-k6 . →IfmotherHIV-positive:givetreatmenttothenewborn g9 . →Supportthemother'schoiceofnewbornfeeding g8 .

■Ifbabyisstillbornordead,givesupportivecaretomotherandherfamily d24 .

■refer to hospitalnowifwomanhadseriouscomplicationsatadmissionorduringdeliverybutwasinlatelabour.

Care of the mother and newborn within first hour of delivery of plaCentause this chart for woman and newborn during the first hour after complete delivery of placenta.

Care of the mother within first hour of delivery of placenta

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D14 respond to problems during labour and delivery (1)

Iffetalheartrate<120or>160bpm

D15 respond to problems during labour and delivery (2)

Ifprolapsedcord

D16 respond to problems during labour and delivery (3)

Ifbreechpresentation

D17 respond to problems during labour and delivery (4)

Ifstuckshoulders

D18 respond to problems during labour and delivery (5)

Ifmultiplebirths

D19 Care of the mother and newborn within first hour of delivery of plaCenta

Childbirth: labour, delivery and immediate postpartum care

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d1

d20

MONITORMOTHERAT2,3AND4HOURS,THENEVERY4HOURS:■Foremergencysigns,usingrapidassessment(RAM).■Feeluterusifhardandround.

■Recordfindings,treatmentsandproceduresinLabour record andPartograph n4-n6 .■Keepthemotherandbabytogether.■never leave the woman and newborn alone.■do not dischargebefore12hours.

CAREOFMOTHER■Accompanythemotherandbabytoward.■Adviseon Postpartum care and hygiene d26 .■Ensurethemotherhassanitarynapkinsorcleanmaterialtocollectvaginalblood.■Encouragethemothertoeat,drinkandrest.■Ensuretheroomiswarm(25°C).

■Askthemother’scompaniontowatchherandcallforhelpifbleedingorpainincreases,ifmotherfeelsdizzyorhassevereheadaches,visualdisturbanceorepigastricdistress.

■Encouragethemothertoemptyherbladderandensurethatshehas passedurine.

■Checkrecordandgiveanytreatmentorprophylaxiswhichisdue.■Advisethemotheronpostpartumcareandnutrition d26 .■Advisewhentoseekcare d28 .■Counselonbirthspacingandotherfamilyplanningmethods d27 .■RepeatexaminationofthemotherbeforedischargeusingAssess the mother after delivery d21 .For

baby,see J2-J8 .

INTERVENTIONS,IFREqUIRED■Makesurethewomanhassomeonewithherandtheyknowwhentocallforhelp.■ IfHIV-positive:giveherappropriatetreatment g6 , g9 .

■ Ifheavyvaginalbleeding,palpatetheuterus.→Ifuterusnotfirm,massagethefundustomakeitcontractandexpelanyclots b6 .→Ifpadissoakedinlessthan5minutes,manageason b5 .→Ifbleedingisfromperinealtear,repairorrefertohospital b17 .

■ Ifthemothercannotpassurineorthebladderisfull(swellingoverlowerabdomen)andsheisuncomfortable,helpherbygentlypouringwateronvulva.

do not catheterizeunlessyouhaveto.

■ IftuballigationorIUDdesired,makeplansbeforedischarge.■ Ifmotherisonantibioticsbecauseofruptureofmembranes>18hoursbutshowsnosignsof

infectionnow,discontinueantibiotics.

Care of the mother one hour after delivery of plaCentause this chart for continuous care of the mother until discharge. see J10 for care of the baby.

Care of the mother one hour after delivery of placenta

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assess the mother after delivery use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge. for examining the newborn use the chart on J2-J8 .

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d21Assess the mother after delivery

ASK,CHECKRECORD■Checkrecord:

→bleedingmorethan250ml?→completenessofplacentaand

membranes?→complicationsduringdeliveryor

postpartum?→specialtreatmentneeds?→needstuballigationorIUD?

■Howareyoufeeling?■Doyouhaveanypains?■Doyouhaveanyconcerns?■Howisyourbaby?■Howdoyourbreastsfeel?

LOOK,LISTEN,FEEL■Measuretemperature.■Feeltheuterus.Isithardand

round?■Lookforvaginalbleeding■Lookatperineum.

→Isthereatearorcut?→Isitred,swollenordrainingpus?

■Lookforconjunctivalpallor.■Lookforpalmarpallor.

SIGNS■Uterushard.■Littlebleeding.■Noperinealproblem.■Nopallor.■Nofever.■Bloodpressurenormal.■Pulsenormal.

TREATANDADVISE■Keepthemotheratthefacilityfor12hoursafter

delivery.■Ensurepreventivemeasures d25 .■Adviseonpostpartumcareandhygiene d26 .■Counselonnutrition d26 .■Counselonbirthspacingandfamilyplanning d27 .■Adviseonwhentoseekcareandnextroutine

postpartumvisit d28 .■Reassessfordischarge d21 .■Continueanytreatmentsinitiatedearlier.■ Iftuballigationdesired,refertohospitalwithin7

daysofdelivery.IfIUDdesired,refertoappropriateserviceswithin48hours.

CLASSIFYmother well

next:Respondtoproblemsimmediatelypostpartum Ifnoproblems,gotopage d25 .

�

Respond to problems immediately postpartum (1)

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ASK,CHECKRECORD

■Timesinceruptureofmembranes■Abdominalpain■Chills

LOOK,LISTEN,FEEL

■Apadissoakedinlessthan5minutes.

■Repeattemperaturemeasurementafter2hours

■Iftemperatureisstill>38ºC→Lookforabnormalvaginal

discharge.→Listentofetalheartrate→feellowerabdomenfor

tenderness

■Istherebleedingfromthetearorepisiotomy

■Doesitextendtoanusorrectum?

SIGNS

■Morethan1padsoakedin5minutes

■Uterusnothardandnotround

■Temperaturestill>380Candanyof:→Chills→Foul-smellingvaginaldischarge→Lowabdomentenderness→FHRremains>160after30

minutesofobservation→ruptureofmembranes>18hours

■Temperaturestill>380C

■Tearextendingtoanusorrectum.

■Perinealtear■Episiotomy

TREATANDADVISE

■See b5 fortreatment.■refer urgently to hospital b17 .

■InsertanIVlineandgivefluidsrapidly b9 .■GiveappropriateIM/IVantibiotics b15 .■Ifbabyandplacentadelivered:

→Giveoxytocin10IUIM b10 .■refer woman urgently to hospital b17 .■Assessthenewborn J2-J8 .

Treatifanysignofinfection.

■Encouragewomantodrinkplentyoffluids.■Measuretemperatureevery4hours.■Iftemperaturepersistsfor>12hours,isveryhighor

risesrapidly,giveappropriateantibioticandrefer to hospital b15 .

■refer woman urgently to hospital b15 .

■Ifbleedingpersists,repairthetearorepisiotomy b12

.

CLASSIFY

heavy bleeding

uterine and fetal infeCtion

risk of uterine and fetal infeCtion

third degree tear

small perineal tear

next:Ifelevateddiastolicbloodpressure

if vaginal bleeding

if fever (temperature >38ºC)

if perineal tear or episiotomy (done for lifesaving CirCumstanCes)

d22

�

if elevated diastoliC blood pressure

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d23Respond to problems immediately postpartum (2)

ASK,CHECKRECORD LOOK,LISTEN,FEEL■Ifdiastolicbloodpressureis≥90mmHg,repeatafter1hourrest.

■Ifdiastolicbloodpressureisstill≥90-mmHg,askthewomanifshehas:→severeheadache→blurredvision→epigastricpainand→checkproteininurine.

SIGNS■Diastolicbloodpressure≥110 mmHgOR

■Diastolicbloodpressure≥90 mmHgand2+proteinuriaandanyof:→severeheadache→blurredvision→epigastricpain.

■Diastolicbloodpressure90-110mmHgontworeadings.

■2+proteinuria(onadmission).

■Diastolicbloodpressure≥90 mmHgon2readings.

TREATANDADVISE■Givemagnesiumsulphate b13 .■Ifinearlylabourorpostpartum,

refer urgently to hospital b17 .■if late labour:

→continuemagnesiumsulphatetreatment b13

→monitorbloodpressureeveryhour.→do notgiveergometrineafterdelivery.

■refer urgently to hospital after delivery b17 .

■Ifearlylabour, refer urgently to hospital e17 .■Iflatelabour:

→monitorbloodpressureeveryhour→do notgiveergometrineafterdelivery.

■IfBPremainselevatedafterdelivery,refer to hospital e17 .

■Monitorbloodpressureeveryhour.■do notgiveergometrineafterdelivery.■Ifbloodpressureremainselevatedafterdelivery,

refer woman to hospital e17 .

CLASSIFYseverepre-eClampsia

pre-eClampsia

hypertension

next:Ifpalloronscreening,checkforanaemia�

Respond to problems immediately postpartum (3)

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ASK,CHECKRECORD

■ Bleedingduringlabour,deliveryorpostpartum.

LOOK,LISTEN,FEEL

■ Measurehaemoglobin,ifpossible.■Lookforconjunctivalpallor.■Lookforpalmarpallor.Ifpallor:

→Isitseverepallor?→Somepallor?→Countnumberofbreathsin

1-minute

SIGNS

■ Haemoglobin<7g/dl. and/or■ Severepalmarandconjunctivalpalloror■ Anypallorwith>30breathsperminute.

■ Anybleeding.■ Haemoglobin7-11-g/dl.■ Palmarorconjunctivalpallor.

■ Haemoglobin>11-g/dl■ Nopallor.

CLASSIFY

severeanaemia

moderateanaemia

no anaemia

next:Givepreventivemeasures

if pallor on sCreening, CheCk for anaemia

if mother severely ill or separated from the baby

if baby stillborn or dead

d24

TREATANDADVISE

■ if early labour orpostpartum,refer urgently to hospital b17 .

■ if late labour:→monitorintensively→minimizebloodloss→refer urgently to hospital after delivery b17 .

■ do notdischargebefore24hours.■ Checkhaemoglobinafter3days.■ Givedoubledoseofironfor3months f3 .■Followupin4weeks.

■ Giveiron/folatefor3months f3 .

■ Teachmothertoexpressbreastmilkevery3hours k5 .■ Helphertoexpressbreastmilkifnecessary.Ensurebaby

receivesmother’smilk k8 .■ Helphertoestablishorre-establishbreastfeedingassoonas

possible.See k2-k3 .

■ Givesupportivecare:→Informtheparentsassoonaspossibleafterthebaby’s

death.→Showthebabytothemother,givethebabytothemotherto

hold,whereculturallyappropriate.→Offertheparentsandfamilytobewiththedeadbabyin

privacyaslongastheyneed.→Discusswiththemtheeventsbeforethedeathandthe

possiblecausesofdeath.■ Advisethemotheronbreastcare k8 .■ Counselonappropriatefamilyplanningmethod d27 .

�

d25

ASSESS,CHECKRECORDS■CheckRPRstatusinrecords.■IfnoRPRduringthispregnancy,dotheRPRtest l5 .

■Checktetanustoxoid(TT)immunizationstatus.■Checkwhenlastdoseofmebendazolewasgiven.

■Checkwoman’ssupplyofprescribeddoseofiron/folate.■CheckifvitaminAgiven.

■Askwhetherwomanandbabyaresleepingunderinsecticidetreatedbednet.■Counselandadviseallwomen.

■Recordalltreatmentsgiven n6 .

■CheckHIVstatusinrecords.

TREATANDADVISE■IfRPRpositive:

→Treatwomanandthepartnerwithbenzathinepenicillin f6 .→Treatthenewborn k12 .

■Givetetanustoxoidifdue f2 .■Givemebendazoleoncein6months f3 .

■Give3month’ssupplyofironandcounseloncompliance f3 .■GivevitaminAifdue f2 .

■Encouragesleepingunderinsecticidetreatedbednet f4 .■Adviseonpostpartumcare d26 .■Counselonnutrition d26 .■Counselonbirthspacingandfamilyplanning d27 .■Counselonbreastfeeding k2 .■Counselonsafersexincludinguseofcondoms g2 .■Adviseonroutineandfollow-uppostpartumvisits d28 .■Adviseondangersigns d28 .■Discusshowtoprepareforanemergencyinpostpartum d28 .

■IfHIV-positive:→SupportadherencetoARV g6 .→Treatthenewborn g9 .

■IfHIVtestnotdone,offerherthetest e5 .

give preventive measuresensure that all are given before discharge.

Give preventive measures

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D20 Care of the mother one hour after delivery of plaCenta

D21 assess the mother after delivery

D22 respond to problems immediately postpartum (1)

Ifvaginalbleeding Iffever Ifperinealtearorepisiotomy

D23 respond to problems immediately postpartum (2)

Ifelevateddiastolicbloodpressure

D24 respond to problems immediately postpartum (3)

Ifpalloronscreening,checkforanaemia Ifmotherseverelyillorseparatedfrombaby Ifbabystillbornordead

D25 give preventive measures

d26

AdviseonpostpartumcareandhygieneAdviseandexplaintothewoman:■Toalwayshavesomeonenearherforthefirst24hourstorespondtoanychangeinhercondition.■Nottoinsertanythingintothevagina.■Tohaveenoughrestandsleep.■Theimportanceofwashingtopreventinfectionofthemotherandherbaby:

→washhandsbeforehandlingbaby→washperineumdailyandafterfaecalexcretion→changeperinealpadsevery4to6hours,ormorefrequentlyifheavylochia→washusedpadsordisposeofthemsafely→washthebodydaily.

■Toavoidsexualintercourseuntiltheperinealwoundheals.

Counselonnutrition■Advisethewomantoeatagreateramountandvarietyofhealthyfoods,suchasmeat,fish,oils,

nuts,seeds,cereals,beans,vegetables,cheese,milk,tohelpherfeelwellandstrong(giveexamplesoftypesoffoodandhowmuchtoeat).

■Reassurethemotherthatshecaneatanynormalfoods–thesewillnotharmthebreastfeedingbaby.■Spendmoretimeonnutritioncounsellingwithverythinwomenandadolescents.■Determineifthereareimportanttaboosaboutfoodswhicharenutritionallyhealthy.

Advisethewomanagainstthesetaboos.■Talktofamilymemberssuchaspartnerandmother-in-law,toencouragethemtohelpensurethe

womaneatsenoughandavoidshardphysicalwork.

advise on postpartum Care

Advise on postpartum care

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Counselontheimportanceoffamilyplanning■Ifappropriate,askthewomanifshewouldlikeherpartneroranotherfamilymembertobeincluded

inthecounsellingsession.■Explainthatafterbirth,ifshehassexandisnotexclusivelybreastfeeding,shecanbecomepregnant

assoonas4weeksafterdelivery.Thereforeitisimportanttostartthinkingearlyaboutwhatfamilyplanningmethodtheywilluse.→Askaboutplansforhavingmorechildren.Ifshe(andherpartner)wantmorechildren,advisethat

waitingatleast2-3yearsbetweenpregnanciesishealthierforthemotherandchild.→Informationonwhentostartamethodafterdeliverywillvarydependingonwhetherawomanis

breastfeedingornot.→Makearrangementsforthewomantoseeafamilyplanningcounsellor,orcounselherdirectly

(seetheDecision-making tool for family planning providers and clientsforinformationonmethodsandonthecounsellingprocess).

■Councelonsafersexincludinguseofcondomsfordualprotectionfromsexuallytransmittedinfection(STI)orHIVandpregnancy.Promotetheiruse,especiallyifatriskforsexuallytransmittedinfection(STI)orHIV g2 .

■ForHIV-positivewomen,see g4 forfamilyplanningconsiderations■Herpartnercandecidetohaveavasectomy(malesterilization)atanytime.

method options for the non-breastfeeding woman Can be used immediately postpartum Condoms Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implant Spermicide Femalesterilization(within7daysordelay6weeks) copperIUD(immediatelyfollowingexpulsionof

placentaorwithin48hours)delay 3 weeks Combinedoralcontraceptives Combinedinjectables Fertilityawarenessmethods

Lactationalamenorrhoeamethod(LAM)■Abreastfeedingwomanisprotectedfrompregnancyonlyif:

→sheisnomorethan6monthspostpartum,and→sheisbreastfeedingexclusively(8ormoretimesaday,includingatleastonceatnight:no

daytimefeedingsmorethan4hoursapartandnonightfeedingsmorethan6hoursapart;nocomplementaryfoodsorfluids),and

→hermenstrualcyclehasnotreturned.

■Abreastfeedingwomancanalsochooseanyotherfamilyplanningmethod,eithertousealoneortogetherwithLAM.

method options for the breastfeeding woman Can be used immediately postpartum Lactationalamenorrhoeamethod(LAM) Condoms Spermicide Femalesterilisation(within7daysordelay6weeks) copperIUD(within48hoursordelay4weeks)delay 6 weeks Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implants Diaphragmdelay 6 months Combinedoralcontraceptives Combinedinjectables Fertilityawarenessmethods

Counsel on birth spaCing and family planning

Counsel on birth spacing and family planning

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Routinepostpartumcarevisits

first visit d19 Withinthefirstweek,preferablywithin2-3days

seCond visit e2 4-6weeks

Follow-upvisitsforproblems

if the problem was: return in: Fever 2daysLowerurinarytractinfection 2daysPerinealinfectionorpain 2daysHypertension 1weekUrinaryincontinence 1weekSevereanaemia 2weeksPostpartumblues 2weeksHIV-positive 2weeksModerateanaemia 4weeksIftreatedinhospital Accordingtohospitalinstructionsoraccordingtonational foranycomplication guidelines,butnolaterthanin2weeks.

Adviseondangersignsadvise to go to a hospital or health centre immediately, day or night, without waiting, if any of the following signs:■vaginalbleeding:

→morethan2or3padssoakedin20-30minutesafterdeliveryor→bleedingincreasesratherthandecreasesafterdelivery.

■convulsions.■ fastordifficultbreathing.■ feverandtooweaktogetoutofbed.■severeabdominalpain.

Gotohealthcentreas soon as possibleifanyofthefollowingsigns:■ fever■abdominalpain■ feelsill■breastsswollen,redortenderbreasts,orsorenipple■urinedribblingorpainonmicturition■painintheperineumordrainingpus■ foul-smellinglochia

Discusshowtoprepareforanemergencyinpostpartum■Advisetoalwayshavesomeonenearforatleast24hoursafterdeliverytorespondtoanychangein

condition.■Discusswithwomanandherpartnerandfamilyaboutemergencyissues:

→wheretogoifdangersigns→howtoreachthehospital→costsinvolved→familyandcommunitysupport.

■Advisethewomantoaskforhelpfromthecommunity,ifneededi1-i3.■Advisethewomantobringherhome-basedmaternalrecordtothehealthcentre,evenforan

emergencyvisit.

advise on when to returnuse this chart for advising on postpartum care on d21 or e2 . for newborn babies see the schedule on k14 .encourage woman to bring her partner or family member to at least one visit.

Advise on when to return

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Preparationforhomedelivery■Checkemergencyarrangements.■Keepemergencytransportarrangementsup-to-date.■Carrywithyouallessentialdrugs b17 ,records,andthedeliverykit.■Ensurethatthefamilyprepares,ason C18 .

Deliverycare■Followthelabouranddeliveryproceduresd2-d28 k11 .■Observeuniversalprecautions a4 .■Givesupportive care.Involvethecompanionincareandsupport d6-d7 .■Maintainthepartographandlabourrecord n4-n6 .■Providenewborncare J2-J8 .■refer to facility as soon as possible if any abnormal finding in mother or baby b17 k14 .

Immediatepostpartumcareofmother■Staywiththewomanforfirsttwohoursafterdeliveryofplacenta C2 C13-C14.■Examinethemotherbeforeleavingher d21 .■Adviseonpostpartumcare,nutritionandfamilyplanningd26-d27.■Ensurethatsomeonewillstaywiththemotherforthefirst24hours.

Postpartumcareofnewborn■Stayuntilbabyhashadthefirstbreastfeedandhelpthemothergoodpositioningandattachment b2 .■Adviseonbreastfeedingandbreastcare b3 .■Examinethebabybeforeleaving n2-n8 .■ Immunizethebabyifpossible b13 .■Adviseonnewborncare b9-b10 .■Advisethefamilyaboutdangersignsandwhenandwheretoseekcare b14 .■ Ifpossible,returnwithinadaytocheckthemotherandbaby.■Adviseapostpartumvisitforthemotherandbabywithinthefirstweek b14 .

home delivery by skilled attendantuse these instructions if you are attending delivery at home.

Home delivery by skilled attendant

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D26 advise on postpartum Care Adviseonpostpartumcareandhygiene

Counselonnutrition

D27 Counsel on birth spaCing and family planning

Counselonimportanceoffamilyplanning Lactationandamenorrhoeamethod(LAM)

D28 advise on when to return Routinepostpartumvisits

Adviseondangersigns Discusshowtoprepareforanemergency

postpartum

D29 home delivery by skilled attendant

Preparationforhomedelivery Deliverycare Immediatepostpartumcareofthemother Postpartumcareofthenewborn

■Alwaysbeginwith rapid assessment and management (ram) b3-b7 .

■Next,usethechartonexamine the woman in labour or with ruptured membranes d2-d3 toassesstheclinicalsituationandobstetricalhistory,anddecidethestageoflabour.

■ Ifanabnormalsignisidentified,usethechartsonrespond to obstetrical problems onadmission d4-d5 .

■Careforthewomanaccordingtothestageoflabour d8-d13 andrespondtoproblemsduringlabouranddeliveryason d14-d18.

■Usegive supportive care throughout labour d6-d7 toprovidesupportandcarethroughoutlabouranddelivery.

■Recordfindingscontinuallyonlabourrecordandpartograph n4-n6 .

■KeepmotherandbabyinlabourroomforonehourafterdeliveryandusechartsCare of the mother and newborn within first hour of delivery placentaon d19 .

■Nextuse Care of the mother after the first hour following delivery of placenta d20 toprovidecareuntildischarge.Usecharton d25 toprovidepreventive measuresandadvise on postpartum care d26-d28toadviseoncare,dangersigns,whentoseekroutineoremergencycare,andfamilyplanning.

■Examinethemotherfordischargeusingcharton d21 .

■do notdischargemotherfromthefacilitybefore12hours.

■ IfthemotherisHIV-positiveoradolescent,orhasspecialneeds,seeg1-g11 h1-h4 .

■ Ifattendingadeliveryatthewoman’shome,see d29 .

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ASK,CHECKRECORDhistory of this labour:■Whendidcontractionsbegin?■Howfrequentarecontractions?

Howstrong?■Haveyourwatersbroken?Ifyes,

when?Weretheyclearorgreen?■Haveyouhadanybleeding?

Ifyes,when?Howmuch?■ Isthebabymoving?■Doyouhaveanyconcern?Check record, or if no record: ■Askwhenthedeliveryisexpected.■Determineifpreterm

(lessthan8monthspregnant).■Reviewthebirthplan.if prior pregnancies: ■Numberofpriorpregnancies/

deliveries.■Anypriorcaesareansection,

forceps,orvacuum,orothercomplicationsuchaspostpartumhaemorhage?

■Anypriorthirddegreetear?Current pregnancy:■RPRstatus C5 .■Hbresults C4 .■Tetanusimmunizationstatus f2 .■HIVstatus C6 .■ Infantfeedingplan g7-g8 .■Receivinganymedicine.

LOOK,LISTEN,FEEL■Observethewoman’sresponseto

contractions:→Isshecopingwellorisshe

distressed?→Isshepushingorgrunting?

■Checkabdomenfor:→caesareansectionscar.→horizontalridgeacrosslower

abdomen(ifpresent,emptybladderb12 andobserveagain).

■ Feelabdomenfor:→contractionsfrequency,duration,

anycontinuouscontractions?→fetallie—longitudinalor

transverse?→fetalpresentation—head,breech,

other?→morethanonefetus?→fetalmovement.

■Listentothefetalheartbeat:→Countnumberofbeatsin1minute.→Iflessthan100beatsper

minute,ormorethan180,turnwomanonherleftsideandcountagain.

■Measurebloodpressure.■Measuretemperature.■Lookforpallor.■Lookforsunkeneyes,drymouth.■Pinchtheskinoftheforearm:does

itgobackquickly?

next:Performvaginalexaminationanddecidestageoflabour

examine the woman in labour or with ruptured membranesfirst do rapid assessment and management b3-b7 . then use this chart to assess the woman’s and fetal status and decide stage of labour.

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Decide stage of labour

ASK,CHECKRECORD

■Explaintothewomanthatyouwillgiveheravaginalexaminationandaskforherconsent.

LOOK,LISTEN,FEEL■Lookat vulvafor:

→ bulgingperineum → anyvisiblefetalparts → vaginalbleeding → leakingamnioticfluid;ifyes,isit

meconiumstained,foul-smelling? → warts,keloidtissueorscarsthatmay

interferewithdelivery.

perform vaginal examination■do notshavetheperinealarea.■Prepare:

→ cleangloves → swabs,pads.

■Washhandswithsoapbeforeandaftereachexamination.

■Washvulvaandperinealareas.■Putongloves.■Positionthewomanwithlegsflexedandapart.

do notperformvaginalexaminationifbleedingnoworatanytimeafter7monthsofpregnancy.

■Performgentlevaginalexamination(donotstartduringacontraction): → Determinecervicaldilatationin

centimetres. → Feelforpresentingpart.Isithard,round

andsmooth(thehead)?Ifnot,identifythepresentingpart.

→ Feelformembranes–aretheyintact? → Feelforcord–isitfelt?Isitpulsating?If

so,actimmediatelyason d15 .

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deCide stage of labour

SIGNS■Bulgingthinperineum,vagina

gapingandheadvisible,fullcervicaldilatation.

■Cervicaldilatation:→multigravida≥5cm→primigravida≥6cm

■Cervicaldilatation≥4cm.

■Cervicaldilatation:0-3cm;contractionsweakand<2in10minutes.

MANAGE■Seesecondstageoflabourd10-d11.■Recordinpartograph n5 .

■Seefirststageoflabour–activelabour d9 .■Startplottingpartograph n5 .■Recordinlabourrecord n5 .

■Seefirststageoflabour—notactivelabour d8 .■Recordinlabourrecord n4 .

CLASSIFYimminent delivery

late aCtive labour

early aCtive labour

not yet in aCtive labour

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SIGNS■Transverselie.■Continuouscontractions.■Constantpainbetweencontractions.■Suddenandsevereabdominalpain.■Horizontalridgeacrosslower

abdomen.■Labour>24hours.

■Ruptureofmembranesandanyof:→Fever>38˚C→Foul-smellingvaginaldischarge.

■Ruptureofmembranesat<8-monthsofpregnancy.

■Diastolicbloodpressure>90mmHg.

■Severepalmarandconjunctivalpallorand/orhaemoglobin<7-g/dl.

■Breechorothermalpresentationd16 .■Multiplepregnancyd18 .■Fetaldistressd14 .■Prolapsedcordd15 .

TREATANDADVISE■ Ifdistressed,insertanIVlineandgivefluids b9 .■ Ifinlabour>24hours,giveappropriateIM/IV

antibiotics b15 .■refer urgently to hospital b17 .

■GiveappropriateIM/IVantibiotics b15 .■ Iflatelabour,deliverandrefertohospital

afterdelivery b17 .■Plantotreatnewborn J5 .

■GiveappropriateIM/IVantibiotics b15 .■ Iflatelabour,deliverd10-d28.■Discontinueantibioticformotherafterdeliveryifno

signsofinfection.■Plantotreatnewborn J5 .

■Assessfurtherandmanageason d23 .

■Manageason d24 .

■Followspecificinstructions(seepagenumbersinleftcolumn).

CLASSIFYobstruCted labour

uterine and fetal infeCtion

risk of uterine and fetal infeCtion

pre-eClampsia

severe anaemia

obstetriCal CompliCation

respond to obstetriCal problems on admissionuse this chart if abnormal findings on assessing pregnancy and fetal status d2-d3 .

FORALLSITUATIONSINREDBELOW,refer urgently to hospital if in early labour,MANAGEONLYIFINLATELABOUR

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Respond to obstetrical problems on admission

SIGNS■Warts,keloidtissuethatmay

interferewithdelivery.■Priorthirddegreetear.

■Bleedinganytimeinthirdtrimester.■Priordeliveryby:

→caesareansection→forcepsorvacuumdelivery.

■Agelessthan14years.

■Labourbefore8completedmonthsofpregnancy(morethanonemonthbeforeestimateddateofdelivery).

■Fetalheartrate<120or>160beatsperminute.

■Ruptureofmembranesattermandbeforelabour.

■ Iftwoormoreofthefollowingsigns:→thirsty→sunkeneyes→drymouth→skinpinchgoesbackslowly.

■HIVtestpositive.■TakingARVtreatmentorprophylaxis.

■Nofetalmovement,and■Nofetalheartbeaton

repeatedexamination

TREATANDADVISE■Doagenerousepisiotomyandcarefullycontrol

deliveryofthehead d10-d11 .

■ Iflatelabour,deliver d10-d28 .■Havehelpavailableduringdelivery.

■Reassessfetalpresentation(breechmorecommon).■ Ifwomanislying,encouragehertolieonherleftside.■Callforhelpduringdelivery.■Conductdeliveryverycarefullyassmallbabymaypop

outsuddenly.Inparticular,controldeliveryofthehead.■Prepareequipmentforresuscitationofnewborn k11 .

■Manageason d14 .

■GiveappropriateIM/IVantibioticsifruptureofmembrane>18hours b15 .

■Plantotreatthenewborn J5 .

■Giveoralfluids.■ Ifnotabletodrink,give1litreIVfluidsover3hours b9 .

■EnsurethatthewomantakesARVdrugsasprescribed g6 , g9 .

■Supportherchoiceofinfantfeeding g7-g8 .

■Explaintotheparentsthatthebabyisnotdoingwell.

CLASSIFYrisk of obstetriCal CompliCation

preterm labour

possible fetal distress

rupture of membranes

dehydration

hiv-positive

possible fetal death

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Communication■Explainallprocedures,seekpermission,anddiscussfindingswiththewoman.■Keepherinformedabouttheprogressoflabour.■Praiseher,encourageandreassureherthatthingsaregoingwell.■Ensureandrespectprivacyduringexaminationsanddiscussions.■ IfknownHIVpositive,findoutwhatshehastoldthecompanion.Respectherwishes.

Cleanliness■Encouragethewomantobatheorshowerorwashherselfandgenitalsattheonsetoflabour.■Washthevulvaandperinealareasbeforeeachexamination.■Washyourhandswithsoapbeforeandaftereachexamination.Usecleanglovesforvaginal

examination.■Ensurecleanlinessoflabourandbirthingarea(s).■Cleanupspillsimmediately.■do notgiveenema.

Mobility■Encouragethewomantowalkaroundfreelyduringthefirststageoflabour.■Supportthewoman’schoiceofposition(leftlateral,squating,kneeling,standingsupportedbythe

companion)foreachstageoflabouranddelivery.

Urination■Encouragethewomantoemptyherbladderfrequently.Remindherevery2hours.

Eating,drinking■Encouragethewomantoeatanddrinkasshewishesthroughoutlabour.■Nutritiousliquiddrinksareimportant,eveninlatelabour.■ Ifthewomanhasvisibleseverewastingortiresduringlabour,makesuresheeatsanddrinks.

Breathingtechnique■Teachhertonoticehernormalbreathing.■Encouragehertobreatheoutmoreslowly,makingasighingnoise,andtorelaxwitheachbreath.■ Ifshefeelsdizzy,unwell,isfeelingpins-and-needles(tingling)inherface,handsandfeet,

encouragehertobreathemoreslowly.■Topreventpushingattheendoffirststageoflabour,teachhertopant,tobreathewithanopen

mouth,totakein2shortbreathsfollowedbyalongbreathout.■Duringdeliveryofthehead,askhernottopushbuttobreathesteadilyortopant.

Painanddiscomfortrelief■Suggestchangeofposition.■Encouragemobility,ascomfortableforher.■Encouragecompanionto:

→massagethewoman’sbackifshefindsthishelpful.→holdthewoman’shandandspongeherfacebetweencontractions.

■Encouragehertousethebreathingtechnique.■Encouragewarmbathorshower,ifavailable.

■ if woman is distressed or anxious, investigate the cause d2-d3 .■ if pain is constant (persisting between contractions) and very severe or sudden in onset d4 .

give supportive Care throughout labouruse this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman’s wishes.

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Birthcompanion■Encouragesupportfromthechosenbirthcompanionthroughoutlabour.■Describetothebirthcompanionwhatsheorheshoulddo:

→Alwaysbewiththewoman.→Encourageher.→Helphertobreatheandrelax.→Rubherback,wipeherbrowwithawetcloth,doothersupportiveactions.→Givesupportusinglocalpracticeswhichdonotdisturblabourordelivery.→Encouragewomantomovearoundfreelyasshewishesandtoadoptthepositionofherchoice.→Encouragehertodrinkfluidsandeatasshewishes.→Assisthertothetoiletwhenneeded.

■Askthebirthcompaniontocallforhelpif:→Thewomanisbearingdownwithcontractions.→Thereisvaginalbleeding.→Sheissuddenlyinmuchmorepain.→Shelosesconsciousnessorhasfits.→Thereisanyotherconcern.

■Tellthebirthcompanionwhatsheorheshouldnot doandexplainwhy: do notencouragewomantopush. do notgiveadviceotherthanthatgivenbythehealthworker. do notkeepwomaninbedifshewantstomovearound.

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MONITOREVERYHOUR:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Frequency,intensityanddurationofcontractions.■Fetalheartrated14 .■Moodandbehaviour(distressed,anxious) d6 .

■RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .■Recordtimeofruptureofmembranesandcolourofamnioticfluid.■GiveSupportivecare d6-d7 .■never leave the woman alone.

ASSESSPROGRESSOFLABOUR■After8hoursif:

→Contractionsstrongerandmorefrequentbut→Noprogressincervicaldilatationwithorwithoutmembranesruptured.

■After8hoursif:→noincreaseincontractions,and→membranesarenotruptured,and→noprogressincervicaldilatation.

■Cervicaldilatation4cmorgreater.

MONITOREVERY4HOURS:■Cervicaldilatation d3 d15 . Unlessindicated,do notdovaginalexaminationmorefrequentlythanevery4hours.■Temperature.■Pulse b3 .■Bloodpressured23 .

TREATANDADVISE,IFREqUIRED■refer the woman urgently to hospitalb17 .

■Dischargethewomanandadvisehertoreturnif:→pain/discomfortincreases→vaginalbleeding→membranesrupture.

■Beginplottingthepartograph n5 andmanagethewomanasinActivelabour d9 .

first stage of labour: not in aCtive labouruse this chart for care of the woman when not in aCtive labour, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes.

First stage of labour (1): when the woman is not in active labourCh

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MONITOREVERY30MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Frequency,intensityanddurationofcontractions.■Fetalheartrated14 .■Moodandbehaviour(distressed,anxious) d6 .

■RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .■Recordtimeofruptureofmembranesandcolourofamnioticfluid.■GiveSupportivecare d6-d7 .■never leave the woman alone.

ASSESSPROGRESSOFLABOUR■PartographpassestotherightofALERTLINE.

■PartographpassestotherightofACTIONLINE.

■Cervixdilated10cmorbulgingperineum.

MONITOREVERY4HOURS:■Cervicaldilatation d3 d15 . Unlessindicated,do not dovaginalexaminationmorefrequentlythanevery4hours.■Temperature.■Pulse b3 .■Bloodpressured23 .

TREATANDADVISE,IFREqUIRED■Reassesswomanandconsidercriteriaforreferral.■Callseniorpersonifavailable.Alertemergencytransportservices.■Encouragewomantoemptybladder.■Ensureadequatehydrationbutomitsolidfoods.■Encourageuprightpositionandwalkingifwomanwishes.■Monitorintensively.Reassessin2hoursandreferifnoprogress.Ifreferraltakesalongtime,refer

immediately(DONOTwaittocrossactionline).

■refer urgently to hospital b17 unlessbirthisimminent.

■ManageasinSecond stage of labourd10-d11.

first stage of labour: in aCtive labouruse this chart when the woman is in aCtive labour, when cervix dilated 4 cm or more.

First stage of labour (2): when the woman is in active labour

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MONITOREVERY5MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Frequency,intensityanddurationofcontractions.■Fetalheartrated14 .■Perineumthinningandbulging.■Visibledescentoffetalheadorduringcontraction.■Moodandbehaviour(distressed,anxious) d6 .■RecordfindingsregularlyinLabourrecordandPartograph n4-n6 .■GiveSupportivecare d6-d7 .■Neverleavethewomanalone.

DELIVERTHEBABY■Ensurealldeliveryequipmentandsupplies,includingnewbornresuscitationequipment,are

available,andplaceofdeliveryiscleanandwarm(25°C) l3 .

■Ensurebladderisempty.■Assistthewomanintoacomfortablepositionofherchoice,asuprightaspossible.■Staywithherandofferheremotionalandphysicalsupportd10-d11.

■Allowhertopushasshewisheswithcontractions.

■Waituntilheadvisibleandperineumdistending.■Washhandswithcleanwaterandsoap.Putonglovesjustbeforedelivery.■SeeUniversalprecautionsduringlabouranddelivery a4 .

TREATANDADVISEIFREqUIRED

■ Ifunabletopassurineandbladderisfull,emptybladder b12 .■do notletherlieflat(horizontally)onherback.■ Ifthewomanisdistressed,encouragepaindiscomfortrelief d6 .

do not urgehertopush.■ If,after30minutesofspontaneousexpulsiveefforts,theperineumdoesnotbegintothinand

stretchwithcontractions,doavaginalexaminationtoconfirmfulldilatationofcervix.■ Ifcervixisnotfullydilated,awaitsecondstage.Placewomanonherleftsideanddiscourage

pushing.Encouragebreathingtechnique d6 .

■ Ifsecondstagelastsfor2hoursormorewithoutvisiblesteadydescentofthehead,callforstafftrainedtousevacuumextractororrefer urgently to hospital b17 .

■ Ifobviousobstructiontoprogress(warts/scarring/keloidtissue/previousthirddegreetear),doagenerousepisiotomy.do notperformepisiotomyroutinely.

■ Ifbreechorothermalpresentation,manageason d16 .

seCond stage of labour: deliver the baby and give immediate newborn Careuse this chart when cervix dilated 10 cm or bulging thin perineum and head visible.

Second stage of labour: deliver the baby and give immediate newborn care (1)Ch

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Second stage of labour: deliver the baby and give immediate newborn care (2)

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DELIVERTHEBABY■Ensurecontrolleddeliveryofthehead:

→Keeponehandgentlyontheheadasitadvanceswithcontractions.→Supportperineumwithotherhandandcoveranuswithpadheldinpositionbysideofhandduringdelivery.→Leavetheperineumvisible(betweenthumbandfirstfinger).→Askthemothertobreathesteadilyandnottopushduringdeliveryofthehead.→Encouragerapidbreathingwithmouthopen.

■Feelgentlyaroundbaby’sneckforthecord.■Checkifthefaceisclearofmucusandmembranes.

■Awaitspontaneousrotationofshouldersanddelivery(within1-2minutes).■Applygentledownwardpressuretodelivertopshoulder.■Thenliftbabyup,towardsthemother’sabdomentodeliverlowershoulder.■Placebabyonabdomenorinmother’sarms.■Notetimeofdelivery.

■Thoroughlydrythebabyimmediately.Wipeeyes.Discardwetcloth.■Assessbaby’sbreathingwhiledrying.■ Ifthebabyisnotcrying,observebreathing:

→breathingwell(chestrising)?→notbreathingorgasping?

■Excludesecondbaby.■Palpatemother’sabdomen.■Give10IUoxytocinIMtothemother.■Watchforvaginalbleeding.

■Changegloves.Ifnotpossible,washglovedhands.■Clampandcutthecord.

→puttiestightlyaroundthecordat2cmand5cmfrombaby’sabdomen.→cutbetweentieswithsterileinstrument.→observeforoozingblood.

■Leavebabyonthemother’schestinskin-to-skincontact.Placeidentificationlabel.■Coverthebaby,covertheheadwithahat.

■Encourageinitiationofbreastfeeding k2 .

TREATANDADVISE,IFREqUIRED■ Ifpotentiallydamagingexpulsiveefforts, exertmorepressureonperineum.■Discardsoiledpadtopreventinfection.

■ Ifcordpresentandloose,deliverthebabythroughtheloopofcordorslipthecordoverthebaby’shead;ifcordistight,clampandcutcord,thenunwind.

■Gentlywipefacecleanwithgauzeorcloth,ifnecessary.

■ Ifdelayindeliveryofshoulders: →do not panicbutcallforhelpandaskcompaniontoassist →ManageasinStuck shoulders d17 .■ Ifplacingnewbornonabdomenisnotacceptable,orthemothercannotholdthebaby,placethebabyin

aclean,warm,safeplaceclosetothemother.

do notleavethebabywet-she/hewillbecomecold.■ Ifthebabyisnotbreathingorgasping (unlessbabyisdead,macerated,severelymalformed):

→Cutcordquickly:transfertoafirm,warmsurface;startNewbornresuscitation k11 .■CALLFORHELP-onepersonshouldcareforthemother.

■ Ifsecondbaby,do notgiveoxytocinnow.get help.■Deliverthesecondbaby.ManageasinMultiple pregnancy d18 .■ Ifheavybleeding,repeatoxytocin10-IU-IM.

■ Ifbloodoozing,placeasecondtiebetweentheskinandthefirsttie.

do not applyanysubstancetothestump.do notbandageorbindthestump.

■ Ifroomcool(lessthan25°C),useadditionalblankettocoverthemotherandbaby.

■ IfHIV-positivemotherhaschosenreplacementfeeding,feedaccordingly.■CheckARVtreatmentneeded g6 , g9 .

d12

MONITORMOTHEREVERY5MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Feelifuterusiswellcontracted.■Moodandbehaviour(distressed,anxious) d6 .■Timesincethirdstagebegan(timesincebirth).

■Recordfindings,treatmentsandproceduresinLabour record andPartograph (pp.N4-N6).■GiveSupportive care d6-d7 .■never leave the woman alone.

DELIVERTHEPLACENTA■Ensure10-IUoxytocinIMisgiven d11 .■Awaitstronguterinecontraction (2-3minutes)anddeliverplacenta bycontrolled cord

traction:→Placesideofonehand(usuallyleft)abovesymphysispubiswithpalmfacingtowardsthe

mother’sumbilicus.Thisappliescountertractiontotheuterusduringcontrolledcordtraction.Atthesametime,applysteady,sustainedcontrolledcordtraction.

→Ifplacentadoesnotdescendduring30-40secondsofcontrolledcordtraction,releasebothcordtractionandcountertractionontheabdomenandwaituntiltheuterusiswellcontractedagain.Thenrepeatcontrolledcordtractionwithcountertraction.

→Astheplacentaiscomingout,catchinbothhandstopreventtearingofthemembranes.→Ifthemembranesdonotslipoutspontaneously,gentlytwistthemintoaropeandmovethemup

anddowntoassistseparationwithouttearingthem.

■Checkthatplacentaandmembranesarecomplete.

MONITORBABYEVERY15MINUTES:■Breathing:listenforgrunting,lookforchestin-drawingandfastbreathing J2 .■Warmth:checktoseeiffeetarecoldtotouch J2 .

TREATANDADVISEIFREqUIRED■ If,after30minutesofgivingoxytocin,theplacentaisnotdeliveredandthewomanisNOTbleeding:

→Emptybladder b12

→Encouragebreastfeeding→Repeatcontrolledcordtraction.

■ Ifwomanisbleeding,manageason b5

■ Ifplacentaisnotdeliveredinanother30minutes(1hourafterdelivery):→Removeplacentamanually b11

→GiveappropriateIM/IVantibiotic b15 .■ Ifin1hourunabletoremoveplacenta:

→Referthewomantohospital b17

→InsertanIVlineandgivefluidswith20IUofoxytocinat30dropsperminute duringtransfer b9 .

do notexertexcessivetractiononthecord.do notsqueezeorpushtheuterustodelivertheplacenta.

■ Ifplacentaisincomplete:→Removeplacentalfragmentsmanually b11 .→GiveappropriateIM/IVantibiotic b15 .

third stage of labour: deliver the plaCentause this chart for care of the woman between birth of the baby and delivery of placenta.

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Third stage of labour: deliver the placenta

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d13

DELIVERTHEPLACENTA■Checkthatuterusiswellcontractedandthereisnoheavybleeding.■Repeatcheckevery5minutes.

■Examineperineum,lowervaginaandvulvafortears.

■Collect,estimateandrecordbloodlossthroughoutthirdstageandimmediatelyafterwards.

■Cleanthewomanandtheareabeneathher.Putsanitarypadorfoldedcleanclothunderherbuttockstocollectblood.Helphertochangeclothesifnecessary.

■Keepthemotherandbabyindeliveryroomforaminimumofonehourafterdeliveryofplacenta.

■Disposeofplacentainthecorrect,safeandculturallyappropriatemanner.

TREATANDADVISE,IFREqUIRED■ Ifheavybleeding:

→Massageuterustoexpelclotsifany,untilitishard b10 .→Giveoxytocin10IUIM b10 .→Callforhelp.→StartanIVline b9 ,add20IUofoxytocintoIVfluidsandgiveat60dropsperminute n9 .→Emptythebladder b12 .

■ Ifbleedingpersistsanduterusissoft:→Continuemassaginguterusuntilitishard.→Applybimanualoraorticcompression b10 .→ContinueIVfluidswith20IUofoxytocinat30dropsperminute.→refer woman urgently to hospital b17 .

■ Ifthirddegreetear(involvingrectumoranus),refer urgently to hospital b17 .■Forothertears:applypressureoverthetearwithasterilepadorgauzeandputlegstogether.

do notcrossankles.■Checkafter5minutes.Ifbleedingpersists,repairthetear b12 .

■ Ifbloodloss≈250-ml,butbleedinghasstopped:→Plantokeepthewomaninthefacilityfor24hours.→Monitorintensively(every30minutes)for4hours: →BP,pulse →vaginalbleeding →uterus,tomakesureitiswellcontracted.→Assistthewomanwhenshefirstwalksafterrestingandrecovering.→Ifnotpossibletoobserveatthefacility,refer to hospital b17 .

■ Ifdisposingplacenta:→Usegloveswhenhandlingplacenta.→Putplacentaintoabagandplaceitintoaleak-proofcontainer.→Alwayscarryplacentainaleak-proofcontainer.→Incineratetheplacentaorburyitatleast10mawayfromawatersource,ina2mdeeppit.

next:Ifprolapsedcord

respond to problems during labour and delivery

d14Respond to problems during labour and delivery (1) If FHR <120 or >160 bpmCh

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ASK,CHECKRECORD LOOK,LISTEN,FEEL

■Positionthewomanonherleftside.■ Ifmembraneshaveruptured,lookat

vulvaforprolapsedcord.■Seeifliquorwasmeconiumstained.■RepeatFHRcountafter

15 minutes.

SIGNS

■Cordseenatvulva.

■FHRremains>160or<120after30minutesobservation.

■FHRreturnstonormal.

TREATANDADVISE

■Manageurgentlyason d15 .

■ Ifearlylabour:→refer the woman urgently to hospital b17

→Keepherlyingonherleftside.■ Iflatelabour:

→Callforhelpduringdelivery→Monitoraftereverycontraction.IfFHRdoesnot

returntonormalin15minutesexplaintothewoman(andhercompanion)thatthebabymaynotbewell.

→Preparefornewbornresuscitation k11 .

■MonitorFHRevery15minutes.

CLASSIFY

prolapsed Cord

baby not well

baby well

if fetal heart rate (fhr) <120 or >160 beats per minute

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if prolapsed Cordthe cord is visible outside the vagina or can be felt in the vagina below the presenting part.

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d15Respond to problems during labour and delivery (2) If prolapsed cord

ASK,CHECKRECORD LOOK,LISTEN,FEEL■Lookatorfeelthecordgentlyfor

pulsations.■Feelfortransverselie.■Dovaginalexaminationto

determinestatusoflabour.

SIGNS■Transverselie

■Cordispulsating

■Cordisnotpulsating

TREAT■refer urgently to hospital b17 .

if early labour:■Pushtheheadorpresentingpartoutofthepelvis

andholditabovethebrim/pelviswithyourhandontheabdomenuntilcaesareansectionisperformed.

■ Instructassistant(family,staff)topositionthewoman’sbuttockshigherthantheshoulder.

■refer urgently to hospital b17 .■ Iftransfernotpossible,allowlabourtocontinue.

if late labour:■Callforadditionalhelpifpossible(formotherandbaby).■PrepareforNewbornresuscitation k11 .■Askthewomantoassumeanuprightorsquatting

positiontohelpprogress.■Expeditedeliverybyencouragingwomantopush

withcontraction.

■Explaintotheparentsthatbabymaynotbewell.

CLASSIFYobstruCted labour

fetus alive

fetusprobably dead

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SIGN■ Ifearlylabour

■ Iflatelabour

■ Iftheheaddoesnotdeliver afterseveralcontractions

■ Iftrappedarmsorshoulders

■ Iftrappedhead(andbabyisdead)

next:Ifstuckshoulders

if breeCh presentation

d16

TREAT■refer urgently to hospital b17 .

■Callforadditionalhelp.■Confirmfulldilatationofthecervixbyvaginalexamination d3 .■Ensurebladderisempty.IfunabletoemptybladderseeEmptybladder b12 .■Preparefornewbornresuscitation k11 .■Deliverthebaby:

→Assistthewomanintoapositionthatwillallowthebabytohangdownduringdelivery,forexample,proppedupwithbuttocksatedgeofbedorontoherhandsandknees(allfoursposition).

→Whenbuttocksaredistending,makeanepisiotomy.→Allowbuttocks,trunkandshoulderstodeliverspontaneouslyduringcontractions.→Afterdeliveryoftheshouldersallowthebabytohanguntilnextcontraction.

■Placethebabyastrideyourleftforearmwithlimbshangingoneachside.■Placethemiddleandindexfingersofthelefthandoverthemalarcheekbonesoneithersidetoapply

gentledownwardspressuretoaidflexionofhead.■Keepingthelefthandasdescribed,placetheindexandringfingersoftherighthandoverthebaby’s

shouldersandthemiddlefingeronthebaby’sheadtogentlyaidflexionuntilthehairlineisvisible.■Whenthehairlineisvisible,raisethebabyinupwardandforwarddirectiontowardsthemother’sabdomenuntil

thenoseandmoutharefree.Theassistantgivessuprapubicpressureduringtheperiodtomaintainflexion.

■Feelthebaby’schestforarms.Ifnotfelt:■Holdthebabygentlywithhandsaroundeachthighandthumbsonsacrum.■Gentlyguidingthebabydown,turnthebaby,keepingthebackuppermostuntiltheshoulderwhichwas

posterior(below)isnowanterior(atthetop)andthearmisreleased.■Thenturnthebabyback,againkeepingthebackuppermosttodelivertheotherarm.■Thenproceedwithdeliveryofheadasdescribedabove.

■Tiea1kgweighttothebaby’sfeetandawaitfulldilatation.■Thenproceedwithdeliveryofheadasdescribedabove.neverpullonthebreechdo notallowthewomantopushuntilthecervixisfullydilated.Pushingtoosoonmaycausetheheadtobetrapped.

LOOK,LISTEN,FEEL■Onexternalexaminationfetalheadfelt

infundus.■Softbodypart(legorbuttocks)

feltonvaginalexamination.■Legsorbuttockspresentingat

perineum.

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Respond to problems during labour and delivery (4) If stuck shoulders

SIGN■Fetalheadisdelivered,but

shouldersarestuckandcannotbedelivered.

■ Iftheshouldersarestillnotdeliveredandsurgicalhelpisnotavailableimmediately.

TREAT■Callforadditionalhelp.■Preparefornewbornresuscitation.■Explaintheproblemtothewomanandhercompanion.■Askthewomantolieonherbackwhilegrippingherlegstightlyflexedagainsther

chest,withkneeswideapart.Askthecompanionorotherhelpertokeepthelegsinthatposition.

■Performanadequateepisiotomy.■Askanassistanttoapplycontinuouspressuredownwards,withthepalmofthe

handontheabdomendirectlyabovethepubicarea,whileyoumaintaincontinuousdownwardtractiononthefetalhead.

■Remaincalmandexplaintothewomanthatyouneedhercooperationtotryanotherposition.

■Assisthertoadoptakneelingon“allfours”positionandaskhercompaniontoholdhersteady-thissimplechangeofpositionissometimessufficienttodislodgetheimpactedshoulderandachievedelivery.

■ Introducetherighthandintothevaginaalongtheposteriorcurveofthesacrum.■Attempttodelivertheposteriorshoulderorarmusingpressurefromthefingerof

therighthandtohooktheposteriorshoulderandarmdownwardsandforwardsthroughthevagina.

■Completetherestofdeliveryasnormal.■ Ifnotsuccessful,refer urgently to hospital b17 .

do notpullexcessivelyonthehead.

next:Ifmultiplebirths

if stuCk shoulders (shoulder dystoCia)

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SIGN■Preparefordelivery

■Secondstageoflabour

■Thirdstageoflabour

■ Immediatepostpartumcare

TREAT■Preparedeliveryroomandequipmentforbirthof2ormorebabies.Include:

→morewarmcloths→twosetsofcordtiesandrazorblades→resuscitationequipmentfor2babies.

■Arrangeforahelpertoassistyouwiththebirthsandcareofthebabies.

■Deliverthefirstbabyfollowingtheusualprocedure.Resuscitateifnecessary.Labelher/himTwin1.■Askhelpertoattendtothefirstbaby.■Palpateuterusimmediatelytodeterminethelieofthesecondbaby.Iftransverseorobliquelie,gentlyturnthebabybyabdominalmanipulationtoheadorbreechpresentation.■Checkthepresentationbyvaginalexamination.Checkthefetalheartrate.■Awaitthereturnofstrongcontractionsandspontaneousruptureofthesecondbagofmembranes,usuallywithin1hourofbirthoffirstbaby,butmaybelonger.■Staywiththewomanandcontinuemonitoringherandthefetalheartrateintensively.■Removewetclothsfromunderneathher.Iffeelingchilled,coverher.■Whenthemembranesrupture,performvaginalexamination d3 tocheckforprolapsedcord.Ifpresent,seeProlapsedcord d15 .■Whenstrongcontractionsrestart,askthemothertobeardownwhenshefeelsready.■Deliverthesecondbaby.Resuscitateifnecessary.Labelher/himTwin2.■Aftercuttingthecord,askthehelpertoattendtothesecondbaby.■Palpatetheuterusforathirdbaby.Ifathirdbabyisfelt,proceedasdescribedabove.Ifnothirdbabyisfelt,gotothirdstageoflabour.do notattempttodelivertheplacentauntilallthebabiesareborn.do notgivethemotheroxytocinuntilafterthebirthofallbabies.

■Giveoxytocin10IUIMaftermakingsurethereisnotanotherbaby.■Whentheuterusiswellcontracted,delivertheplacentaandmembranesbycontrolledcordtraction,applyingtractiontoallcordstogether d12-d23.■Beforeandafterdeliveryoftheplacentaandmembranes,observecloselyforvaginalbleedingbecausethiswomanisatgreaterriskofpostpartumhaemorrhage.If

bleeding,see b5 .■Examinetheplacentaandmembranesforcompleteness.Theremaybeonelargeplacentawith2umbilicalcords,oraseparateplacentawithanumbilicalcordforeachbaby.

■Monitorintensivelyasriskofbleedingisincreased.■ProvideimmediatePostpartumcare d19-d20.■ Inaddition:

→Keepmotherinhealthcentreforlongerobservation→Plantomeasurehaemoglobinpostpartumifpossible→Givespecialsupportforcareandfeedingofbabies J11 and k4 .

next:Careofthemotherandnewbornwithinfirsthourofdeliveryofplacenta

if multiple births

d18

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d19

MONITORMOTHEREVERY15MINUTES:■Foremergencysigns,usingrapidassessment(RAM) b3-b7 .■Feelifuterusishardandround.

■Recordfindings,treatmentsandproceduresinLabour recordandPartograph n4-n6 .■Keepmotherandbabyindeliveryroom-do not separate them.■never leave the woman and newborn alone.

CAREOFMOTHERANDNEWBORNwoman■Assesstheamountofvaginalbleeding.■Encouragethewomantoeatanddrink.■Askthecompaniontostaywiththemother.■Encouragethewomantopassurine.

newborn■Wipetheeyes.■Applyanantimicrobialwithin1hourofbirth.

→either1%silvernitratedropsor2.5%povidoneiodinedropsor1%tetracyclineointment.■DONOTwashawaytheeyeantimicrobial.■ Ifbloodormeconium,wipeoffwithwetclothanddry.■DONOTremovevernixorbathethebaby.■Continuekeepingthebabywarmandinskin-to-skincontactwiththemother.■Encouragethemothertoinitiatebreastfeedingwhenbabyshowssignsofreadiness.Offerherhelp.■DONOTgiveartificialteatsorpre-lactealfeedstothenewborn:nowater,sugarwater,orlocalfeeds.■Examinethemotherandnewbornonehourafterdeliveryofplacenta. UseAssess the mother after delivery d21 andExaminethenewborn J2-J8 .

MONITORBABYEVERY15MINUTES:■Breathing:listenforgrunting,lookforchestin-drawingandfastbreathing J2 .■Warmth:checktoseeiffeetarecoldtotouch J2 .

INTERVENTIONS,IFREqUIRED■ Ifpadsoakedinlessthan5minutes,orconstanttrickleofblood,manageason d22 ..■ Ifuterussoft,manageason b10 .■ Ifbleedingfromaperinealtear,repairifrequired b12 orrefer to hospital b17 .

■ Ifbreathingwithdifficulty—grunting,chestin-drawingorfastbreathing,examinethebabyason J2-J8 .■ Iffeetarecoldtotouchormotherandbabyareseparated: →Ensuretheroomiswarm.Covermotherandbabywithablanket

→Reassessin1hour.Ifstillcold,measuretemperature.Iflessthan36.50C,manageason k9 .■ Ifunabletoinitiatebreastfeeding(motherhascomplications):

→Planforalternativefeedingmethod k5-k6 . →IfmotherHIV-positive:givetreatmenttothenewborn g9 . →Supportthemother'schoiceofnewbornfeeding g8 .

■Ifbabyisstillbornordead,givesupportivecaretomotherandherfamily d24 .

■refer to hospitalnowifwomanhadseriouscomplicationsatadmissionorduringdeliverybutwasinlatelabour.

Care of the mother and newborn within first hour of delivery of plaCentause this chart for woman and newborn during the first hour after complete delivery of placenta.

Care of the mother and newborn within first hour of delivery of placenta

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MONITORMOTHERAT2,3AND4HOURS,THENEVERY4HOURS:■Foremergencysigns,usingrapidassessment(RAM).■Feeluterusifhardandround.

■Recordfindings,treatmentsandproceduresinLabour record andPartograph n4-n6 .■Keepthemotherandbabytogether.■never leave the woman and newborn alone.■do not dischargebefore12hours.

CAREOFMOTHER■Accompanythemotherandbabytoward.■Adviseon Postpartum care and hygiene d26 .■Ensurethemotherhassanitarynapkinsorcleanmaterialtocollectvaginalblood.■Encouragethemothertoeat,drinkandrest.■Ensuretheroomiswarm(25°C).

■Askthemother’scompaniontowatchherandcallforhelpifbleedingorpainincreases,ifmotherfeelsdizzyorhassevereheadaches,visualdisturbanceorepigastricdistress.

■Encouragethemothertoemptyherbladderandensurethatshehas passedurine.

■Checkrecordandgiveanytreatmentorprophylaxiswhichisdue.■Advisethemotheronpostpartumcareandnutrition d26 .■Advisewhentoseekcare d28 .■Counselonbirthspacingandotherfamilyplanningmethods d27 .■RepeatexaminationofthemotherbeforedischargeusingAssess the mother after delivery d21 .For

baby,see J2-J8 .

INTERVENTIONS,IFREqUIRED■Makesurethewomanhassomeonewithherandtheyknowwhentocallforhelp.■ IfHIV-positive:giveherappropriatetreatment g6 , g9 .

■ Ifheavyvaginalbleeding,palpatetheuterus.→Ifuterusnotfirm,massagethefundustomakeitcontractandexpelanyclots b6 .→Ifpadissoakedinlessthan5minutes,manageason b5 .→Ifbleedingisfromperinealtear,repairorrefertohospital b17 .

■ Ifthemothercannotpassurineorthebladderisfull(swellingoverlowerabdomen)andsheisuncomfortable,helpherbygentlypouringwateronvulva.

do not catheterizeunlessyouhaveto.

■ IftuballigationorIUDdesired,makeplansbeforedischarge.■ Ifmotherisonantibioticsbecauseofruptureofmembranes>18hoursbutshowsnosignsof

infectionnow,discontinueantibiotics.

Care of the mother one hour after delivery of plaCentause this chart for continuous care of the mother until discharge. see J10 for care of the baby.

Care of the mother one hour after delivery of placentaCh

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assess the mother after delivery use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge. for examining the newborn use the chart on J2-J8 .

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d21Assess the mother after delivery

ASK,CHECKRECORD■Checkrecord:

→bleedingmorethan250ml?→completenessofplacentaand

membranes?→complicationsduringdeliveryor

postpartum?→specialtreatmentneeds?→needstuballigationorIUD?

■Howareyoufeeling?■Doyouhaveanypains?■Doyouhaveanyconcerns?■Howisyourbaby?■Howdoyourbreastsfeel?

LOOK,LISTEN,FEEL■Measuretemperature.■Feeltheuterus.Isithardand

round?■Lookforvaginalbleeding■Lookatperineum.

→Isthereatearorcut?→Isitred,swollenordrainingpus?

■Lookforconjunctivalpallor.■Lookforpalmarpallor.

SIGNS■Uterushard.■Littlebleeding.■Noperinealproblem.■Nopallor.■Nofever.■Bloodpressurenormal.■Pulsenormal.

TREATANDADVISE■Keepthemotheratthefacilityfor12hoursafter

delivery.■Ensurepreventivemeasures d25 .■Adviseonpostpartumcareandhygiene d26 .■Counselonnutrition d26 .■Counselonbirthspacingandfamilyplanning d27 .■Adviseonwhentoseekcareandnextroutine

postpartumvisit d28 .■Reassessfordischarge d21 .■Continueanytreatmentsinitiatedearlier.■ Iftuballigationdesired,refertohospitalwithin7

daysofdelivery.IfIUDdesired,refertoappropriateserviceswithin48hours.

CLASSIFYmother well

next:Respondtoproblemsimmediatelypostpartum Ifnoproblems,gotopage d25 .

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ASK,CHECKRECORD

■Timesinceruptureofmembranes■Abdominalpain■Chills

LOOK,LISTEN,FEEL

■Apadissoakedinlessthan5minutes.

■Repeattemperaturemeasurementafter2hours

■Iftemperatureisstill>38ºC→Lookforabnormalvaginal

discharge.→Listentofetalheartrate→feellowerabdomenfor

tenderness

■Istherebleedingfromthetearorepisiotomy

■Doesitextendtoanusorrectum?

SIGNS

■Morethan1padsoakedin5minutes

■Uterusnothardandnotround

■Temperaturestill>380Candanyof:→Chills→Foul-smellingvaginaldischarge→Lowabdomentenderness→FHRremains>160after30

minutesofobservation→ruptureofmembranes>18hours

■Temperaturestill>380C

■Tearextendingtoanusorrectum.

■Perinealtear■Episiotomy

TREATANDADVISE

■See b5 fortreatment.■refer urgently to hospital b17 .

■InsertanIVlineandgivefluidsrapidly b9 .■GiveappropriateIM/IVantibiotics b15 .■Ifbabyandplacentadelivered:

→Giveoxytocin10IUIM b10 .■refer woman urgently to hospital b17 .■Assessthenewborn J2-J8 .

Treatifanysignofinfection.

■Encouragewomantodrinkplentyoffluids.■Measuretemperatureevery4hours.■Iftemperaturepersistsfor>12hours,isveryhighor

risesrapidly,giveappropriateantibioticandrefer to hospital b15 .

■refer woman urgently to hospital b15 .

■Ifbleedingpersists,repairthetearorepisiotomy b12

.

CLASSIFY

heavy bleeding

uterine and fetal infeCtion

risk of uterine and fetal infeCtion

third degree tear

small perineal tear

next:Ifelevateddiastolicbloodpressure

if vaginal bleeding

if fever (temperature >38ºC)

if perineal tear or episiotomy (done for lifesaving CirCumstanCes)

d22

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if elevated diastoliC blood pressure

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d23Respond to problems immediately postpartum (2)

ASK,CHECKRECORD LOOK,LISTEN,FEEL■Ifdiastolicbloodpressureis≥90mmHg,repeatafter1hourrest.

■Ifdiastolicbloodpressureisstill≥90-mmHg,askthewomanifshehas:→severeheadache→blurredvision→epigastricpainand→checkproteininurine.

SIGNS■Diastolicbloodpressure≥110 mmHgOR

■Diastolicbloodpressure≥90 mmHgand2+proteinuriaandanyof:→severeheadache→blurredvision→epigastricpain.

■Diastolicbloodpressure90-110mmHgontworeadings.

■2+proteinuria(onadmission).

■Diastolicbloodpressure≥90 mmHgon2readings.

TREATANDADVISE■Givemagnesiumsulphate b13 .■Ifinearlylabourorpostpartum,

refer urgently to hospital b17 .■if late labour:

→continuemagnesiumsulphatetreatment b13

→monitorbloodpressureeveryhour.→do notgiveergometrineafterdelivery.

■refer urgently to hospital after delivery b17 .

■Ifearlylabour, refer urgently to hospital e17 .■Iflatelabour:

→monitorbloodpressureeveryhour→do notgiveergometrineafterdelivery.

■IfBPremainselevatedafterdelivery,refer to hospital e17 .

■Monitorbloodpressureeveryhour.■do notgiveergometrineafterdelivery.■Ifbloodpressureremainselevatedafterdelivery,

refer woman to hospital e17 .

CLASSIFYseverepre-eClampsia

pre-eClampsia

hypertension

next:Ifpalloronscreening,checkforanaemiat

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■ Bleedingduringlabour,deliveryorpostpartum.

LOOK,LISTEN,FEEL

■ Measurehaemoglobin,ifpossible.■Lookforconjunctivalpallor.■Lookforpalmarpallor.Ifpallor:

→Isitseverepallor?→Somepallor?→Countnumberofbreathsin

1-minute

SIGNS

■ Haemoglobin<7g/dl. and/or■ Severepalmarandconjunctivalpalloror■ Anypallorwith>30breathsperminute.

■ Anybleeding.■ Haemoglobin7-11-g/dl.■ Palmarorconjunctivalpallor.

■ Haemoglobin>11-g/dl■ Nopallor.

CLASSIFY

severeanaemia

moderateanaemia

no anaemia

next:Givepreventivemeasures

if pallor on sCreening, CheCk for anaemia

if mother severely ill or separated from the baby

if baby stillborn or dead

d24

TREATANDADVISE

■ if early labour orpostpartum,refer urgently to hospital b17 .

■ if late labour:→monitorintensively→minimizebloodloss→refer urgently to hospital after delivery b17 .

■ do notdischargebefore24hours.■ Checkhaemoglobinafter3days.■ Givedoubledoseofironfor3months f3 .■Followupin4weeks.

■ Giveiron/folatefor3months f3 .

■ Teachmothertoexpressbreastmilkevery3hours k5 .■ Helphertoexpressbreastmilkifnecessary.Ensurebaby

receivesmother’smilk k8 .■ Helphertoestablishorre-establishbreastfeedingassoonas

possible.See k2-k3 .

■ Givesupportivecare:→Informtheparentsassoonaspossibleafterthebaby’s

death.→Showthebabytothemother,givethebabytothemotherto

hold,whereculturallyappropriate.→Offertheparentsandfamilytobewiththedeadbabyin

privacyaslongastheyneed.→Discusswiththemtheeventsbeforethedeathandthe

possiblecausesofdeath.■ Advisethemotheronbreastcare k8 .■ Counselonappropriatefamilyplanningmethod d27 .

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d25

ASSESS,CHECKRECORDS■CheckRPRstatusinrecords.■IfnoRPRduringthispregnancy,dotheRPRtest l5 .

■Checktetanustoxoid(TT)immunizationstatus.■Checkwhenlastdoseofmebendazolewasgiven.

■Checkwoman’ssupplyofprescribeddoseofiron/folate.■CheckifvitaminAgiven.

■Askwhetherwomanandbabyaresleepingunderinsecticidetreatedbednet.■Counselandadviseallwomen.

■Recordalltreatmentsgiven n6 .

■CheckHIVstatusinrecords.

TREATANDADVISE■IfRPRpositive:

→Treatwomanandthepartnerwithbenzathinepenicillin f6 .→Treatthenewborn k12 .

■Givetetanustoxoidifdue f2 .■Givemebendazoleoncein6months f3 .

■Give3month’ssupplyofironandcounseloncompliance f3 .■GivevitaminAifdue f2 .

■Encouragesleepingunderinsecticidetreatedbednet f4 .■Adviseonpostpartumcare d26 .■Counselonnutrition d26 .■Counselonbirthspacingandfamilyplanning d27 .■Counselonbreastfeeding k2 .■Counselonsafersexincludinguseofcondoms g2 .■Adviseonroutineandfollow-uppostpartumvisits d28 .■Adviseondangersigns d28 .■Discusshowtoprepareforanemergencyinpostpartum d28 .

■IfHIV-positive:→SupportadherencetoARV g6 .→Treatthenewborn g9 .

■IfHIVtestnotdone,offerherthetest e5 .

give preventive measuresensure that all are given before discharge.

Give preventive measures

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AdviseonpostpartumcareandhygieneAdviseandexplaintothewoman:■Toalwayshavesomeonenearherforthefirst24hourstorespondtoanychangeinhercondition.■Nottoinsertanythingintothevagina.■Tohaveenoughrestandsleep.■Theimportanceofwashingtopreventinfectionofthemotherandherbaby:

→washhandsbeforehandlingbaby→washperineumdailyandafterfaecalexcretion→changeperinealpadsevery4to6hours,ormorefrequentlyifheavylochia→washusedpadsordisposeofthemsafely→washthebodydaily.

■Toavoidsexualintercourseuntiltheperinealwoundheals.

Counselonnutrition■Advisethewomantoeatagreateramountandvarietyofhealthyfoods,suchasmeat,fish,oils,

nuts,seeds,cereals,beans,vegetables,cheese,milk,tohelpherfeelwellandstrong(giveexamplesoftypesoffoodandhowmuchtoeat).

■Reassurethemotherthatshecaneatanynormalfoods–thesewillnotharmthebreastfeedingbaby.■Spendmoretimeonnutritioncounsellingwithverythinwomenandadolescents.■Determineifthereareimportanttaboosaboutfoodswhicharenutritionallyhealthy.

Advisethewomanagainstthesetaboos.■Talktofamilymemberssuchaspartnerandmother-in-law,toencouragethemtohelpensurethe

womaneatsenoughandavoidshardphysicalwork.

advise on postpartum Care

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Counselontheimportanceoffamilyplanning■Ifappropriate,askthewomanifshewouldlikeherpartneroranotherfamilymembertobeincluded

inthecounsellingsession.■Explainthatafterbirth,ifshehassexandisnotexclusivelybreastfeeding,shecanbecomepregnant

assoonas4weeksafterdelivery.Thereforeitisimportanttostartthinkingearlyaboutwhatfamilyplanningmethodtheywilluse.→Askaboutplansforhavingmorechildren.Ifshe(andherpartner)wantmorechildren,advisethat

waitingatleast2-3yearsbetweenpregnanciesishealthierforthemotherandchild.→Informationonwhentostartamethodafterdeliverywillvarydependingonwhetherawomanis

breastfeedingornot.→Makearrangementsforthewomantoseeafamilyplanningcounsellor,orcounselherdirectly

(seetheDecision-making tool for family planning providers and clientsforinformationonmethodsandonthecounsellingprocess).

■Councelonsafersexincludinguseofcondomsfordualprotectionfromsexuallytransmittedinfection(STI)orHIVandpregnancy.Promotetheiruse,especiallyifatriskforsexuallytransmittedinfection(STI)orHIV g2 .

■ForHIV-positivewomen,see g4 forfamilyplanningconsiderations■Herpartnercandecidetohaveavasectomy(malesterilization)atanytime.

method options for the non-breastfeeding woman Can be used immediately postpartum Condoms Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implant Spermicide Femalesterilization(within7daysordelay6weeks) copperIUD(immediatelyfollowingexpulsionof

placentaorwithin48hours)delay 3 weeks Combinedoralcontraceptives Combinedinjectables Fertilityawarenessmethods

Lactationalamenorrhoeamethod(LAM)■Abreastfeedingwomanisprotectedfrompregnancyonlyif:

→sheisnomorethan6monthspostpartum,and→sheisbreastfeedingexclusively(8ormoretimesaday,includingatleastonceatnight:no

daytimefeedingsmorethan4hoursapartandnonightfeedingsmorethan6hoursapart;nocomplementaryfoodsorfluids),and

→hermenstrualcyclehasnotreturned.

■Abreastfeedingwomancanalsochooseanyotherfamilyplanningmethod,eithertousealoneortogetherwithLAM.

method options for the breastfeeding woman Can be used immediately postpartum Lactationalamenorrhoeamethod(LAM) Condoms Spermicide Femalesterilisation(within7daysordelay6weeks) copperIUD(within48hoursordelay4weeks)delay 6 weeks Progestogen-onlyoralcontraceptives Progestogen-onlyinjectables Implants Diaphragmdelay 6 months Combinedoralcontraceptives Combinedinjectables Fertilityawarenessmethods

Counsel on birth spaCing and family planning

Counsel on birth spacing and family planning

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Routinepostpartumcarevisits

first visit d19 Withinthefirstweek,preferablywithin2-3days

seCond visit e2 4-6weeks

Follow-upvisitsforproblems

if the problem was: return in: Fever 2daysLowerurinarytractinfection 2daysPerinealinfectionorpain 2daysHypertension 1weekUrinaryincontinence 1weekSevereanaemia 2weeksPostpartumblues 2weeksHIV-positive 2weeksModerateanaemia 4weeksIftreatedinhospital Accordingtohospitalinstructionsoraccordingtonational foranycomplication guidelines,butnolaterthanin2weeks.

Adviseondangersignsadvise to go to a hospital or health centre immediately, day or night, without waiting, if any of the following signs:■vaginalbleeding:

→morethan2or3padssoakedin20-30minutesafterdeliveryor→bleedingincreasesratherthandecreasesafterdelivery.

■convulsions.■ fastordifficultbreathing.■ feverandtooweaktogetoutofbed.■severeabdominalpain.

Gotohealthcentreas soon as possibleifanyofthefollowingsigns:■ fever■abdominalpain■ feelsill■breastsswollen,redortenderbreasts,orsorenipple■urinedribblingorpainonmicturition■painintheperineumordrainingpus■ foul-smellinglochia

Discusshowtoprepareforanemergencyinpostpartum■Advisetoalwayshavesomeonenearforatleast24hoursafterdeliverytorespondtoanychangein

condition.■Discusswithwomanandherpartnerandfamilyaboutemergencyissues:

→wheretogoifdangersigns→howtoreachthehospital→costsinvolved→familyandcommunitysupport.

■Advisethewomantoaskforhelpfromthecommunity,ifneededi1-i3.■Advisethewomantobringherhome-basedmaternalrecordtothehealthcentre,evenforan

emergencyvisit.

advise on when to returnuse this chart for advising on postpartum care on d21 or e2 . for newborn babies see the schedule on k14 .encourage woman to bring her partner or family member to at least one visit.

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Preparationforhomedelivery■Checkemergencyarrangements.■Keepemergencytransportarrangementsup-to-date.■Carrywithyouallessentialdrugs b17 ,records,andthedeliverykit.■Ensurethatthefamilyprepares,ason C18 .

Deliverycare■Followthelabouranddeliveryproceduresd2-d28 k11 .■Observeuniversalprecautions a4 .■Givesupportive care.Involvethecompanionincareandsupport d6-d7 .■Maintainthepartographandlabourrecord n4-n6 .■Providenewborncare J2-J8 .■refer to facility as soon as possible if any abnormal finding in mother or baby b17 k14 .

Immediatepostpartumcareofmother■Staywiththewomanforfirsttwohoursafterdeliveryofplacenta C2 C13-C14.■Examinethemotherbeforeleavingher d21 .■Adviseonpostpartumcare,nutritionandfamilyplanningd26-d27.■Ensurethatsomeonewillstaywiththemotherforthefirst24hours.

Postpartumcareofnewborn■Stayuntilbabyhashadthefirstbreastfeedandhelpthemothergoodpositioningandattachment b2 .■Adviseonbreastfeedingandbreastcare b3 .■Examinethebabybeforeleaving n2-n8 .■ Immunizethebabyifpossible b13 .■Adviseonnewborncare b9-b10 .■Advisethefamilyaboutdangersignsandwhenandwheretoseekcare b14 .■ Ifpossible,returnwithinadaytocheckthemotherandbaby.■Adviseapostpartumvisitforthemotherandbabywithinthefirstweek b14 .

home delivery by skilled attendantuse these instructions if you are attending delivery at home.

Home delivery by skilled attendant

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postpartum Carepo

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ASK,CHECKRECORD■Whenandwheredidyoudeliver?■Howareyoufeeling?■Haveyouhadanypainorfeveror

bleedingsincedelivery?■Doyouhaveanyproblemwith

passingurine?■Haveyoudecidedonany

contraception?■Howdoyourbreastsfeel?■Doyouhaveanyotherconcerns?■Checkrecords:

→Anycomplicationsduringdelivery?

→Receivinganytreatments?→HIVstatus.

LOOK,LISTEN,FEEL■Measurebloodpressureand

temperature.■Feeluterus.Isithardandround?■Lookatvulvaandperineumfor:

→tear→swelling→pus.

■Lookatpadforbleedingandlochia.→Doesitsmell?→Isitprofuse?

■Lookforpallor.

SIGNS■Motherfeelingwell.■Didnotbleed>250 ml.■Uteruswellcontractedandhard.■Noperinealswelling.■Bloodpressure,pulseand

temperaturenormal.■Nopallor.■Nobreastproblem,

isbreastfeedingwell.■Nofeverorpainorconcern.■Noproblemwithurination.

TREATANDADVISE■Makesurewomanandfamilyknowwhattowatch

forandwhentoseekcare d28 .■AdviseonPostpartumcareandhygiene,

andcounselonnutrition d26 .■Counselontheimportanceofbirthspacingand

familyplanning d27 .Referforfamilyplanningcounselling.

■Dispense3monthsironsupplyandcounseloncompliance F3 .

■Giveanytreatmentorprophylaxisdue:→tetanusimmunizationifshehasnothad

fullcourse F2 .■Promoteuseofimpregnated bednetforthemotherandbaby.■Recordonthemother’shome-basedmaternal

record.■Advisetoreturntohealthcentrewithin4-6weeks.

CLASSIFYnormal postpartum

next:Respondtoobservedsignsorvolunteeredproblems

postpartum examination oF the mother (up to 6 weeks)use this chart for examining the mother after discharge from a facility or after home deliveryif she delivered less than a week ago without a skilled attendant, use the chart assess the mother after delivery d2� .

to examine the baby see J2-J8 .

if breast problem see J9 .

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next:Ifpallor,checkforanaemia

Respond to observed signs or volunteered problems (1) If elevated diastolic blood pressure

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ASK,CHECKRECORD

■Historyofpre-eclampsiaoreclampsiainpregnancy,deliveryorafterdelivery?

LOOK,LISTEN,FEEL

■ Ifdiastolicbloodpressureis≥90mmHg,repeataftera1hourrest.

SIGNS

■Diastolicbloodpressure≥110 mmHg.

■Diastolicbloodpressure≥90 mmHgon2readings.

■Diastolicbloodpressure<90 mmHgafter2readings.

TREATANDADVISE

■Giveappropriateantihypertensive b�4 .■refer urgently to hospital b�7 .

■Reassessin1week.Ifhypertensionpersists,refertohospital.

■Noadditionaltreatment.

CLASSIFY

severe hypertension

moderate hypertension

blood pressure normal

respond to observed signs or volunteered problems

iF elevated diastoliC blood pressure

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e4Respond to observed signs or volunteered problems (2) If pallor, check for anaemia

ASK,CHECKRECORD■Checkrecordforbleedingin

pregnancy,deliveryorpostpartum.■Haveyouhadheavybleedingsince

delivery?■Doyoutireeasily?■Areyoubreathless(shortofbreath)

duringroutinehousework?

LOOK,LISTEN,FEEL■Measurehaemoglobinifhistoryof

bleeding.■Lookforconjunctivalpallor.■Lookforpalmarpallor. Ifpallor:

→isitseverepallor?→somepallor?

■Countnumberofbreathsin1minute.

SIGNS■Haemoglobin<7-g/dl and/or■Severepalmarandconjunctival

palloror■Anypallorandanyof: →>30breathsperminute →tireseasily →breathlessnessatrest.

■Haemoglobin7-11-g/dl or■Palmarorconjunctivalpallor.

■Haemoglobin>11-g/dl.■Nopallor.

TREATANDADVISE■Givedoubledoseofiron

(1tablet60mgtwicedailyfor3months) F3 .■refer urgently to hospital b�7 .■Followupin2weekstocheckclinicalprogressand

compliancewithtreatment.

■Givedoubledoseofironfor3months F3 .■Reassessatnextpostnatalvisit(in4weeks).

Ifanaemiapersists,refertohospital.

■Continuetreatmentwithironfor3monthsaltogether F3 .

CLASSIFYsevereanaemia

moderate anaemia

no anaemia

next:CheckforHIVstatus

iF pallor, CheCk For anaemia

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Respond to observed signs or volunteered problems (3) Check for HIV status

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ASK,CHECKRECORDprovide key information on hiv g2 .■WhatisHIVandhowisHIV

transmitted g2 ?

■AdvantageofknowingtheHIVstatus g2 .

■ExplainaboutHIVtestingandcounsellingincludingconfidentialityoftheresult g3 .

ask the woman:■HaveyoubeentestedforHIV? →Ifnot:tellherthatshewillbe

testedforHIV,unlesssherefuses. →Ifyes:checkresult.(Explainto

herthatshehasarightnottodisclosetheresult.)

→AreyoutakinganyARVtreatment?

→Checktreatmentplan.■Hasthepartnerbeentested?

LOOK,LISTEN,FEEL■PerformtheRapidHIVtestifnot

performedinthispregnancy l6 .

SIGNS■PositiveHIVtest

■NegativeHIVtest

■Sherefusesthetestorisnotwillingtodisclosetheresultofprevioustestornotestresultsavailable

TREATANDADVISE■Counselonimplicationsofapositivetest g3 .■ReferthewomantoHIVservicesforfurther

assessment. →Counseloninfantfeedingoptions g7 . →ProvideadditionalcareforHIV-positivewoman g4 . →Counselonfamilyplanning g4 . →Counselonsafersexincludinguseofcondoms g2 . →Counselonbenefitsofdisclosure(involving)and

testingherpartne g3 . →ProvidesupporttotheHIV-positivewoman g5 .■Followupin2weeks.

■Counselonimplicationsofanegativetest g3 .■Counselontheimportanceofstayingnegativeby

practisingsafersex,includinguseofcondoms g2 .■Counselonbenefitsofinvolvingandtestingthe

partner g3 .

■Counselonsafersexincludinguseofcondoms g2 .■Counselonbenefitsofinvolvingandtestingthe

partner g3 .

CLASSIFYhiv-positive

hiv-negative

unknownhiv status

next:Ifheavyvaginalbleeding

CheCk For hiv statususe this chart for hiv testing and counselling during postpartum visit if the woman is not previously tested.IfthewomenhastakenARVduringpregnancyorchildbirthreferhertoHIVservicesforfurtherassessment.

�

iF heavy vaginal bleeding

Respond to observed signs or volunteered problems (4)

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ASK,CHECKRECORD

■Haveyouhad:→heavybleeding?→foul-smellinglochia?→burningonurination?

LOOK,LISTEN,FEEL

■Feellowerabdomenandflanksfortenderness.

■Lookforabnormallochia.■Measuretemperature.■Lookorfeelforstiffneck.■Lookforlethargy.

SIGNS

■Morethan1padsoakedin5minutes.

■Temperature>38°Candanyof:→veryweak→abdominaltenderness→foul-smellinglochia→profuselochia→uterusnotwellcontracted→lowerabdominalpain→historyofheavyvaginalbleeding.

■Fever>38ºCandanyof:→burningonurination→flankpain.

■Burningonurination.

■Temperature>38°Candanyof:→stiffneck→lethargy.

■Fever>38°C.

TREATANDADVISE

■Give0.2mgergometrineIM b�0 .■GiveappropriateIM/IVantibiotics b�5 .■Manageasin

Rapid assessment and management b3-b7 .■refer urgently to hospital b�7 .

■ InsertanIVlineandgivefluidsrapidly b9 .■GiveappropriateIM/IVantibiotics b�5 .■refer urgently to hospital b�7 .

■GiveappropriateIM/IVantibiotics b�5 .■refer urgently to hospital b�7 .

■Giveappropriateoralantibiotic F5 .■Encouragehertodrinkmorefluids.■Followupin2days.

Ifnoimprovement,refertohospital.

■ InsertanIVline b9 .■GiveappropriateIM/IVantibiotics b�5 .■GiveartemetherIM(orquinineIMifartemethernot

available)andglucose b�6 .■refer urgently to hospital b�7 .

■Giveoralantimalarial F4 .■Followupin2days.

Ifnoimprovement,refertohospital.

CLASSIFY

postpartum bleeding

uterine inFeCtion

upper urinary traCt inFeCtion

lower urinary traCt inFeCtion

very severe Febrile disease

malaria

next:Ifdribblingurine

iF Fever or Foul-smelling loChia

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Respond to observed signs or volunteered problems (5)

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ASK,CHECKRECORD

■Howhaveyoubeenfeelingrecently?■Haveyoubeeninlowspirits?■Haveyoubeenabletoenjoythe

thingsyouusuallyenjoy?■Haveyouhadyourusuallevelof

energy,orhaveyoubeenfeelingtired?■Howhasyoursleepbeen?■Haveyoubeenabletoconcentrate

(forexampleonnewspaperarticlesoryourfavouriteradioprogrammes)?

LOOK,LISTEN,FEEL SIGNS

■Dribblingorleakingurine.

■Excessiveswellingofvulvaorperineum.

■Pusinperineum.■Paininperineum.

Twoormoreofthefollowingsymptomsduringthesame2weekperiodrepresentingachangefromnormal:■ Inappropriateguiltornegative

feelingtowardsself.■Crieseasily.■Decreasedinterestorpleasure.■Feelstired,agitatedallthetime.■Disturbedsleep(sleepingtoomuch

ortoolittle,wakingearly).■Diminishedabilitytothinkor

concentrate.■Markedlossofappetite.

■Anyoftheabove,forlessthan2weeks.

TREAT

■Checkperinealtrauma.■Giveappropriateoralantibioticsforlowerurinary

tractinfection F5 .■ Ifconditionspersistsmorethan1week,referthe

womantohospital.

■Referthewomantohospital.

■Removesutures,ifpresent.■Cleanwound.Counseloncareandhygiene d26 .■Giveparacetamolforpain F4 .■Followupin2days.Ifnoimprovement,refertohospital.

■Provideemotionalsupport.■refer urgently the woman to hospital b7 .

■Assurethewomanthatthisisverycommon.■Listentoherconcerns.Giveemotional

encouragementandsupport.■Counselpartnerandfamilytoprovideassistanceto

thewoman.■Followupin2weeks,andreferifnoimprovement.

CLASSIFY

urinaryinContinenCe

perineal trauma

perineal inFeCtion or pain

postpartum depression(usually aFter First week)

postpartum blues(usually in First week)

next:Ifvaginaldischarge4weeksafterdelivery

iF dribbling urine

iF pus or perineal pain

iF Feeling unhappy or Crying easily

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e2 postpartum examination oF the mother (up to 6 weeks)

e3 respond to observed signs or volunteered problems (�)

Ifelevateddiastolicpressure

e4 respond to observed signs or volunteered problems (2)

Ifpallor,checkforanaemia

e5 respond to observed signs or volunteered problems (3)

CheckforHIVstatus

e6 respond to observed signs or volunteered problems (4)

Ifheavyvaginalbleeding Iffeverorfoul-smellinglochia

e7 respond to observed signs or volunteered problems (5)

Ifdribblingurine Ifpussorperinealpain Iffeelingunhappyorcryingeasily

Respond to observed signs or volunteered problems (6)

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next:Ifcoughorbreathingdifficulty

ASK,CHECKRECORD

■Doyouhaveitchingatthevulva?■Hasyourpartnerhadaurinary

problem?

Ifpartnerispresentintheclinic,askthewomanifshefeelscomfortableifyouaskhimsimilarquestions.Ifyes,askhimifhehas:■urethraldischargeorpus■burningonpassingurine.

Ifpartnercouldnotbeapproached,explainimportanceofpartnerassessmentandtreatmenttoavoidreinfection.

LOOK,LISTEN,FEEL

■Separatethelabiaandlookforabnormalvaginaldischarge:→amount→colour→odour/smell.

■ Ifnodischargeisseen,examinewithaglovedfingerandlookatthedischargeontheglove.

SIGNS

■Abnormalvaginaldischarge,andpartnerhasurethraldischargeorburningonpassingurine.

■Curd-likevaginaldischargeand/or■ Intensevulvalitching.

■Abnormalvaginaldischarge.

TREATANDADVISE

■Giveappropriateoralantibioticstowoman F5 .■Treatpartnerwithappropriateoralantibiotics F5 .■Counselonsafersexincludinguseofcondoms g2 .

■Giveclotrimazole F5 .■Counselonsafersexincludinguseofcondoms F4 .■ Ifnoimprovement,referthewomantohospital.

■Givemetronidazoletowoman F5 .■Counselonsafersexincludinguseofcondoms g2 .

CLASSIFY

possible gonorrhoea or Chlamydia inFeCtion

possible Candida inFeCtion

possible baCterial ortriChomonasinFeCtion

iF vaginal disCharge 4 weeks aFter delivery

iF breast problemsee J9 .

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Respond to observed signs or volunteered problems (7)

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next:IfsignssuggestingHIVinfection

ASK,CHECKRECORD

■Howlonghaveyoubeencoughing?■Howlonghaveyouhaddifficultyin

breathing?■Doyouhavechestpain?■Doyouhaveanybloodinsputum?■Doyousmoke?

■Areyoutakinganti-tuberculosisdrugs?Ifyes,sincewhen?

LOOK,LISTEN,FEEL

■Lookforbreathlessness.■Listenforwheezing.■Measuretemperature.

SIGNS

Atleast2ofthefollowing:■Temperature>38ºC.■Breathlessness.■Chestpain.

Atleast1ofthefollowing:■Coughorbreathingdifficultyfor

>3 weeks.■Bloodinsputum.■Wheezing.

■Temperature<38ºC.■Coughfor<3weeks.

■Takinganti-tuberculosisdrugs.

TREATANDADVISE

■GivefirstdoseofappropriateIM/IVantibiotics b�5 .■refer urgently to hospital b�7 .

■Refertohospitalforassessment.■ Ifseverewheezing,referurgentlytohospital.■UsePractical Approach to Lunghealthguidelines

(PAL)forfurthermanagement.

■Advisesafe,soothingremedy.■ Ifsmoking,counseltostopsmoking.

■Assurethewomanthatthedrugsarenotharmfultoherbaby,andoftheneedtocontinuetreatment.

■ IfhersputumisTB-positivewithin2monthsofdelivery,plantogiveINHprophylaxistothenewborn k�3 .

■ReinforceadviceforHIVtesting g3 .■ Ifsmoking,counseltostopsmoking.■Advisetoscreenimmediatefamilymembersand

closecontactsfortuberculosis.

CLASSIFY

possible pneumonia

possible ChroniC lung disease

upper respiratory traCt inFeCtion

tuberCulosis

iF Cough or breathing diFFiCulty

iF taking anti-tuberCulosis drugs

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Respond to observed signs or volunteered problems (8) If signs suggesting HIV infection

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ASK,CHECKRECORD■Haveyoulostweight?■Doyouhavefever?

Howlong(>1month)?■Haveyougotdiarrhoea

(continuousorintermittent)?Howlong(>1month)?

■Haveyouhadcough?Howlong(>1month)?

LOOK,LISTEN,FEEL■Lookforvisiblewasting.■Lookforulcersandwhitepatchesin

themouth(thrush).■Lookattheskin:

→Istherearash?→Arethereblistersalongtheribs

ononesideofthebody?

SIGNS■Twoofthefollowing:

→weightloss→fever>1month→diarrhoea>1month.

or■Oneoftheabovesignsand

→oneormoreothersignor→fromahigh-riskgroup.

TREATANDADVISE■ReinforcetheneedtoknowHIVstatusandcounsel

forHIVtesting g3 .■Counselonthebenefitsoftestingherpartner g3 .■Counselonsafersexincludinguseofcondoms g2 .■Examinefurtherandmanageaccordingtonational

HIVguidelinesorrefertoappropriateHIVservices.■RefertoTBcentreifcough.

CLASSIFYstrong likelihood oF hiv inFeCtion

iF signs suggesting hiv inFeCtionhiv status unknown or known hiv-positive.

e8 respond to observed signs or volunteered problems (6)

Ifvaginaldischarge4weeksafterdelivery Ifbreastproblem J9

e9 respond to observed signs or volunteered problems (7)

Ifcoughorbreathingdifficulty Iftakinganti-tuberculosisdrugs

e�0 respond to observed signs or volunteered problems (8)

IfsignssuggestingHIVinfection

■AlwaysbeginwithRapidassessmentandmanagement(RAM) b2-b7 .

■NextusethePostpartumexaminationofthemother e2 .

■ Ifanabnormalsignisidentified(volunteeredorobserved),usethechartsRespondtoobservedsignsorvolunteeredproblems e3-e�0 .

■Recordalltreatmentgiven,positivefindings,andtheschedulednextvisitinthehome-basedandclinicrecordingform.

■Forthefirstorsecondpostpartumvisitduringthefirstweekafterdelivery,usethePostpartumexaminationchart d2� andAdviseandcounsellingsection d26 toexamineandadvisethemother.

■ IfthewomanisHIVpositive,adolescentorhasspecialneeds,use g�-g�� h�-h4 .

post

part

um C

are

e2Postpartum care

ASK,CHECKRECORD■Whenandwheredidyoudeliver?■Howareyoufeeling?■Haveyouhadanypainorfeveror

bleedingsincedelivery?■Doyouhaveanyproblemwith

passingurine?■Haveyoudecidedonany

contraception?■Howdoyourbreastsfeel?■Doyouhaveanyotherconcerns?■Checkrecords:

→Anycomplicationsduringdelivery?

→Receivinganytreatments?→HIVstatus.

LOOK,LISTEN,FEEL■Measurebloodpressureand

temperature.■Feeluterus.Isithardandround?■Lookatvulvaandperineumfor:

→tear→swelling→pus.

■Lookatpadforbleedingandlochia.→Doesitsmell?→Isitprofuse?

■Lookforpallor.

SIGNS■Motherfeelingwell.■Didnotbleed>250 ml.■Uteruswellcontractedandhard.■Noperinealswelling.■Bloodpressure,pulseand

temperaturenormal.■Nopallor.■Nobreastproblem,

isbreastfeedingwell.■Nofeverorpainorconcern.■Noproblemwithurination.

TREATANDADVISE■Makesurewomanandfamilyknowwhattowatch

forandwhentoseekcare d28 .■AdviseonPostpartumcareandhygiene,

andcounselonnutrition d26 .■Counselontheimportanceofbirthspacingand

familyplanning d27 .Referforfamilyplanningcounselling.

■Dispense3monthsironsupplyandcounseloncompliance F3 .

■Giveanytreatmentorprophylaxisdue:→tetanusimmunizationifshehasnothad

fullcourse F2 .■Promoteuseofimpregnated bednetforthemotherandbaby.■Recordonthemother’shome-basedmaternal

record.■Advisetoreturntohealthcentrewithin4-6weeks.

CLASSIFYnormal postpartum

next:Respondtoobservedsignsorvolunteeredproblems

postpartum examination oF the mother (up to 6 weeks)use this chart for examining the mother after discharge from a facility or after home deliveryif she delivered less than a week ago without a skilled attendant, use the chart assess the mother after delivery d2� .

to examine the baby see J2-J8 .

if breast problem see J9 .

t

next:Ifpallor,checkforanaemia

Respond to observed signs or volunteered problems (1) If elevated diastolic blood pressure

post

part

um C

are

e3

ASK,CHECKRECORD

■Historyofpre-eclampsiaoreclampsiainpregnancy,deliveryorafterdelivery?

LOOK,LISTEN,FEEL

■ Ifdiastolicbloodpressureis≥90mmHg,repeataftera1hourrest.

SIGNS

■Diastolicbloodpressure≥110 mmHg.

■Diastolicbloodpressure≥90 mmHgon2readings.

■Diastolicbloodpressure<90 mmHgafter2readings.

TREATANDADVISE

■Giveappropriateantihypertensive b�4 .■refer urgently to hospital b�7 .

■Reassessin1week.Ifhypertensionpersists,refertohospital.

■Noadditionaltreatment.

CLASSIFY

severe hypertension

moderate hypertension

blood pressure normal

respond to observed signs or volunteered problems

iF elevated diastoliC blood pressure

t

post

part

um C

are

e4Respond to observed signs or volunteered problems (2) If pallor, check for anaemia

ASK,CHECKRECORD■Checkrecordforbleedingin

pregnancy,deliveryorpostpartum.■Haveyouhadheavybleedingsince

delivery?■Doyoutireeasily?■Areyoubreathless(shortofbreath)

duringroutinehousework?

LOOK,LISTEN,FEEL■Measurehaemoglobinifhistoryof

bleeding.■Lookforconjunctivalpallor.■Lookforpalmarpallor. Ifpallor:

→isitseverepallor?→somepallor?

■Countnumberofbreathsin1minute.

SIGNS■Haemoglobin<7-g/dl and/or■Severepalmarandconjunctival

palloror■Anypallorandanyof: →>30breathsperminute →tireseasily →breathlessnessatrest.

■Haemoglobin7-11-g/dl or■Palmarorconjunctivalpallor.

■Haemoglobin>11-g/dl.■Nopallor.

TREATANDADVISE■Givedoubledoseofiron

(1tablet60mgtwicedailyfor3months) F3 .■refer urgently to hospital b�7 .■Followupin2weekstocheckclinicalprogressand

compliancewithtreatment.

■Givedoubledoseofironfor3months F3 .■Reassessatnextpostnatalvisit(in4weeks).

Ifanaemiapersists,refertohospital.

■Continuetreatmentwithironfor3monthsaltogether F3 .

CLASSIFYsevereanaemia

moderate anaemia

no anaemia

next:CheckforHIVstatus

iF pallor, CheCk For anaemia

t

Respond to observed signs or volunteered problems (3) Check for HIV status

post

part

um C

are

e5

ASK,CHECKRECORDprovide key information on hiv g2 .■WhatisHIVandhowisHIV

transmitted g2 ?

■AdvantageofknowingtheHIVstatus g2 .

■ExplainaboutHIVtestingandcounsellingincludingconfidentialityoftheresult g3 .

ask the woman:■HaveyoubeentestedforHIV? →Ifnot:tellherthatshewillbe

testedforHIV,unlesssherefuses. →Ifyes:checkresult.(Explainto

herthatshehasarightnottodisclosetheresult.)

→AreyoutakinganyARVtreatment?

→Checktreatmentplan.■Hasthepartnerbeentested?

LOOK,LISTEN,FEEL

■PerformtheRapidHIVtestifnotperformedinthispregnancy l6 .

SIGNS■PositiveHIVtest

■NegativeHIVtest

■Sherefusesthetestorisnotwillingtodisclosetheresultofprevioustestornotestresultsavailable

TREATANDADVISE■Counselonimplicationsofapositivetest g3 .■ReferthewomantoHIVservicesforfurther

assessment. →Counseloninfantfeedingoptions g7 . →ProvideadditionalcareforHIV-positivewoman g4 . →Counselonfamilyplanning g4 . →Counselonsafersexincludinguseofcondoms g2 . →Counselonbenefitsofdisclosure(involving)and

testingherpartne g3 . →ProvidesupporttotheHIV-positivewoman g5 .■Followupin2weeks.

■Counselonimplicationsofanegativetest g3 .■Counselontheimportanceofstayingnegativeby

practisingsafersex,includinguseofcondoms g2 .■Counselonbenefitsofinvolvingandtestingthe

partner g3 .

■Counselonsafersexincludinguseofcondoms g2 .■Counselonbenefitsofinvolvingandtestingthe

partner g3 .

CLASSIFYhiv-positive

hiv-negative

unknownhiv status

next:Ifheavyvaginalbleeding

CheCk For hiv statususe this chart for hiv testing and counselling during postpartum visit if the woman is not previously tested.IfthewomenhastakenARVduringpregnancyorchildbirthreferhertoHIVservicesforfurtherassessment.

t

iF heavy vaginal bleeding

Respond to observed signs or volunteered problems (4)po

stpa

rtum

Car

ee6

ASK,CHECKRECORD

■Haveyouhad:→heavybleeding?→foul-smellinglochia?→burningonurination?

LOOK,LISTEN,FEEL

■Feellowerabdomenandflanksfortenderness.

■Lookforabnormallochia.■Measuretemperature.■Lookorfeelforstiffneck.■Lookforlethargy.

SIGNS

■Morethan1padsoakedin5minutes.

■Temperature>38°Candanyof:→veryweak→abdominaltenderness→foul-smellinglochia→profuselochia→uterusnotwellcontracted→lowerabdominalpain→historyofheavyvaginalbleeding.

■Fever>38ºCandanyof:→burningonurination→flankpain.

■Burningonurination.

■Temperature>38°Candanyof:→stiffneck→lethargy.

■Fever>38°C.

TREATANDADVISE

■Give0.2mgergometrineIM b�0 .■GiveappropriateIM/IVantibiotics b�5 .■Manageasin

Rapid assessment and management b3-b7 .■refer urgently to hospital b�7 .

■ InsertanIVlineandgivefluidsrapidly b9 .■GiveappropriateIM/IVantibiotics b�5 .■refer urgently to hospital b�7 .

■GiveappropriateIM/IVantibiotics b�5 .■refer urgently to hospital b�7 .

■Giveappropriateoralantibiotic F5 .■Encouragehertodrinkmorefluids.■Followupin2days.

Ifnoimprovement,refertohospital.

■ InsertanIVline b9 .■GiveappropriateIM/IVantibiotics b�5 .■GiveartemetherIM(orquinineIMifartemethernot

available)andglucose b�6 .■refer urgently to hospital b�7 .

■Giveoralantimalarial F4 .■Followupin2days.

Ifnoimprovement,refertohospital.

CLASSIFY

postpartum bleeding

uterine inFeCtion

upper urinary traCt inFeCtion

lower urinary traCt inFeCtion

very severe Febrile disease

malaria

next:Ifdribblingurine

iF Fever or Foul-smelling loChia

t

Respond to observed signs or volunteered problems (5)

post

part

um C

are

e7

ASK,CHECKRECORD

■Howhaveyoubeenfeelingrecently?■Haveyoubeeninlowspirits?■Haveyoubeenabletoenjoythe

thingsyouusuallyenjoy?■Haveyouhadyourusuallevelof

energy,orhaveyoubeenfeelingtired?■Howhasyoursleepbeen?■Haveyoubeenabletoconcentrate

(forexampleonnewspaperarticlesoryourfavouriteradioprogrammes)?

LOOK,LISTEN,FEEL SIGNS

■Dribblingorleakingurine.

■Excessiveswellingofvulvaorperineum.

■Pusinperineum.■Paininperineum.

Twoormoreofthefollowingsymptomsduringthesame2weekperiodrepresentingachangefromnormal:■ Inappropriateguiltornegative

feelingtowardsself.■Crieseasily.■Decreasedinterestorpleasure.■Feelstired,agitatedallthetime.■Disturbedsleep(sleepingtoomuch

ortoolittle,wakingearly).■Diminishedabilitytothinkor

concentrate.■Markedlossofappetite.

■Anyoftheabove,forlessthan2weeks.

TREAT

■Checkperinealtrauma.■Giveappropriateoralantibioticsforlowerurinary

tractinfection F5 .■ Ifconditionspersistsmorethan1week,referthe

womantohospital.

■Referthewomantohospital.

■Removesutures,ifpresent.■Cleanwound.Counseloncareandhygiene d26 .■Giveparacetamolforpain F4 .■Followupin2days.Ifnoimprovement,refertohospital.

■Provideemotionalsupport.■refer urgently the woman to hospital b7 .

■Assurethewomanthatthisisverycommon.■Listentoherconcerns.Giveemotional

encouragementandsupport.■Counselpartnerandfamilytoprovideassistanceto

thewoman.■Followupin2weeks,andreferifnoimprovement.

CLASSIFY

urinaryinContinenCe

perineal trauma

perineal inFeCtion or pain

postpartum depression(usually aFter First week)

postpartum blues(usually in First week)

next:Ifvaginaldischarge4weeksafterdelivery

iF dribbling urine

iF pus or perineal pain

iF Feeling unhappy or Crying easily

t

Respond to observed signs or volunteered problems (6)po

stpa

rtum

Car

ee8

next:Ifcoughorbreathingdifficulty

ASK,CHECKRECORD

■Doyouhaveitchingatthevulva?■Hasyourpartnerhadaurinary

problem?

Ifpartnerispresentintheclinic,askthewomanifshefeelscomfortableifyouaskhimsimilarquestions.Ifyes,askhimifhehas:■urethraldischargeorpus■burningonpassingurine.

Ifpartnercouldnotbeapproached,explainimportanceofpartnerassessmentandtreatmenttoavoidreinfection.

LOOK,LISTEN,FEEL

■Separatethelabiaandlookforabnormalvaginaldischarge:→amount→colour→odour/smell.

■ Ifnodischargeisseen,examinewithaglovedfingerandlookatthedischargeontheglove.

SIGNS

■Abnormalvaginaldischarge,andpartnerhasurethraldischargeorburningonpassingurine.

■Curd-likevaginaldischargeand/or■ Intensevulvalitching.

■Abnormalvaginaldischarge.

TREATANDADVISE

■Giveappropriateoralantibioticstowoman F5 .■Treatpartnerwithappropriateoralantibiotics F5 .■Counselonsafersexincludinguseofcondoms g2 .

■Giveclotrimazole F5 .■Counselonsafersexincludinguseofcondoms g2 .■ Ifnoimprovement,referthewomantohospital.

■Givemetronidazoletowoman F5 .■Counselonsafersexincludinguseofcondoms g2 .

CLASSIFY

possible gonorrhoea or Chlamydia inFeCtion

possible Candida inFeCtion

possible baCterial ortriChomonasinFeCtion

iF vaginal disCharge 4 weeks aFter delivery

iF breast problemsee J9 .

t

Respond to observed signs or volunteered problems (7)

post

part

um C

are

e9

next:IfsignssuggestingHIVinfection

ASK,CHECKRECORD

■Howlonghaveyoubeencoughing?■Howlonghaveyouhaddifficultyin

breathing?■Doyouhavechestpain?■Doyouhaveanybloodinsputum?■Doyousmoke?

■Areyoutakinganti-tuberculosisdrugs?Ifyes,sincewhen?

LOOK,LISTEN,FEEL

■Lookforbreathlessness.■Listenforwheezing.■Measuretemperature.

SIGNS

Atleast2ofthefollowing:■Temperature>38ºC.■Breathlessness.■Chestpain.

Atleast1ofthefollowing:■Coughorbreathingdifficultyfor

>3 weeks.■Bloodinsputum.■Wheezing.

■Temperature<38ºC.■Coughfor<3weeks.

■Takinganti-tuberculosisdrugs.

TREATANDADVISE

■GivefirstdoseofappropriateIM/IVantibiotics b�5 .■refer urgently to hospital b�7 .

■Refertohospitalforassessment.■ Ifseverewheezing,referurgentlytohospital.

■Advisesafe,soothingremedy.■ Ifsmoking,counseltostopsmoking.

■Assurethewomanthatthedrugsarenotharmfultoherbaby,andoftheneedtocontinuetreatment.

■ IfhersputumisTB-positivewithin2monthsofdelivery,plantogiveINHprophylaxistothenewborn k�3 .

■ReinforceadviceforHIVtesting g3 .■ Ifsmoking,counseltostopsmoking.■Advisetoscreenimmediatefamilymembersand

closecontactsfortuberculosis.

CLASSIFY

possible pneumonia

possible ChroniC lung disease

upper respiratory traCt inFeCtion

tuberCulosis

iF Cough or breathing diFFiCulty

iF taking anti-tuberCulosis drugs

t

Respond to observed signs or volunteered problems (8) If signs suggesting HIV infectionpo

stpa

rtum

Car

ee�0

ASK,CHECKRECORD■Haveyoulostweight?■Doyouhavefever?

Howlong(>1month)?■Haveyougotdiarrhoea

(continuousorintermittent)?Howlong(>1month)?

■Haveyouhadcough?Howlong(>1month)?

LOOK,LISTEN,FEEL■Lookforvisiblewasting.■Lookforulcersandwhitepatchesin

themouth(thrush).■Lookattheskin:

→Istherearash?→Arethereblistersalongtheribs

ononesideofthebody?

SIGNS■Twoofthefollowing:

→weightloss→fever>1month→diarrhoea>1month.

or■Oneoftheabovesignsand

→oneormoreothersignor→fromahigh-riskgroup.

TREATANDADVISE■ReinforcetheneedtoknowHIVstatusandcounsel

forHIVtesting g3 .■Counselonthebenefitsoftestingherpartner g3 .■Counselonsafersexincludinguseofcondoms g2 .■Examinefurtherandmanageaccordingtonational

HIVguidelinesorrefertoappropriateHIVservices.■RefertoTBcentreifcough.

CLASSIFYstrong likelihood oF hiv inFeCtion

iF signs suggesting hiv inFeCtionhiv status unknown or known hiv-positive.

Preventive measures and additional treatments for the woman

Prev

enti

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and

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eatm

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for

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wom

an

f1

Preventive measures and additional treatments for the womanf2

Givetetanustoxoid■ Immunizeallwomen■Checkthewoman’stetanustoxoid(TT)immunizationstatus:

→WhenwasTTlastgiven?→WhichdoseofTTwasthis?

■ Ifimmunizationstatusunknown,giveTT1.PlantogiveTT2in4weeks.

if due:■Explaintothewomanthatthevaccineissafetobegiveninpregnancy;itwillnotharmthebaby.■Theinjectionsitemaybecomealittleswollen,redandpainful,butthiswillgoawayinafewdays.■ Ifshehasheardthattheinjectionhascontraceptiveeffects,assureheritdoesnot,thatitonly

protectsherfromdisease.■Give0.5mlTTIM,upperarm.■Advisewomanwhennextdoseisdue.■Recordonmother’scard.

tetanus toxoid scheduleAtfirstcontactwithwomanofchildbearingageoratfirstantenatalcarevisit,asearlyaspossible. TT1Atleast4weeksafterTT1(atnextantenatalcarevisit). TT2Atleast6monthsafterTT2. TT3Atleast1yearafterTT3. TT4Atleast1yearafterTT4. TT5

GivevitaminApostpartum■Give200-000-IUvitaminAcapsulesafterdeliveryorwithin6weeksofdelivery:■ExplaintothewomanthatthecapsulewithvitaminAwillhelphertorecoverbetter,andthatthe

babywillreceivethevitaminthroughherbreastmilk.→askhertoswallowthecapsuleinyourpresence.→explaintoherthatifshefeelsnauseatedorhasaheadache,itshouldpassinacoupleofdays.

■do notgivecapsuleswithhighdoseofvitaminAduringpregnancy.

vitamin a1capsule 200-000 1capsuleafterdeliveryorwithin6weeksofdelivery

Preventive measures

Preventive measures (1)

Prev

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Preventive measures (2) Iron and mebendazole f3

Giveironandfolicacid■Toallpregnant,postpartumandpost-abortionwomen:

→Routinelyoncedailyinpregnancyanduntil3monthsafterdeliveryorabortion.→Twicedailyastreatmentforanaemia(doubledose).

■Checkwoman’ssupplyofironandfolicacidateachvisitanddispense3monthssupply.■Advisetostoreironsafely:

→Wherechildrencannotgetit→Inadryplace.

iron and folate1tablet=60-mg,folicacid=400-µg all women women with anaemia 1tablet 2tabletsin pregnancy Throughoutthepregnancy 3monthsPostpartum and 3months 3monthspost-abortion

Givemebendazole■Give500mgtoeverywomanoncein6months.■do notgiveitinthefirsttrimester.

mebendazole500mgtablet 100mgtablet1tablet 5tablets

MotivateoncompliancewithirontreatmentExplorelocalperceptionsaboutirontreatment(examplesofincorrectperceptions:makingmorebloodwillmakebleedingworse,ironwillcausetoolargeababy).■Explaintomotherandherfamily:

→Ironisessentialforherhealthduringpregnancyandafterdelivery→Thedangerofanaemiaandneedforsupplementation.

■Discussanyincorrectperceptions.■Explorethemother’sconcernsaboutthemedication:

→Hassheusedthetabletsbefore?→Werethereproblems?→Anyotherconcerns?

■Adviseonhowtotakethetablets→Withmealsor,ifoncedaily,atnight→Irontabletsmayhelpthepatientfeellesstired.Donotstoptreatmentifthisoccurs→Donotworryaboutblackstools.Thisisnormal.

■Giveadviceonhowtomanageside-effects:→Ifconstipated,drinkmorewater→Taketabletsafterfoodoratnighttoavoidnausea→Explainthatthesesideeffectsarenotserious→Advisehertoreturnifshehasproblemstakingtheirontablets.

■ Ifnecessary,discusswithfamilymember,TBA,othercommunity-basedhealthworkersorotherwomen,howtohelpinpromotingtheuseofironandfolatetablets.

■Counseloneatingiron-richfoods–see C16 d26 .

Prev

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f4

Givepreventiveintermittenttreatmentforfalciparummalaria■Givesulfadoxine-pyrimethamineatthebeginningofthesecondandthirdtrimestertoallwomen

accordingtonationalpolicy.■Checkwhenlastdoseofsulfadoxine-pyrimethaminegiven:

→Ifnodoseinlastmonth,givesulfadoxine-pyrimethamine,3tabletsinclinic.■Advisewomanwhennextdoseisdue.■Monitorthebabyforjaundiceifgivenjustbeforedelivery.■Recordonhome-basedrecord.

sulfadoxine pyrimethamine1tablet=500mg+25mgpyrimethaminesulfadoxine second trimester third trimester 3tablets 3tablets

Advisetouseinsecticide-treatedbednet■Askwhetherwomanandnewbornwillbesleepingunderabednet.■ Ifyes,

→Hasitbeendippedininsecticide?→When?→Advisetodipevery6months.

■ Ifnot,advisetouseinsecticide-treatedbednet,andprovideinformationtohelpherdothis.

GiveappropriateoralantimalarialtreatmentAhighlyeffectiveantimalarial(evenifsecond-line)ispreferredduringpregnancy

Chloroquine sulfadoxine + Pyrimethamine

Givedailyfor3days Givesingledoseinclinic Tablet Tablet Tablet (150mgbase) (100mgbase) 500mgsulfadoxine+

25mgpyrimethaminePregnantwoman Day1 Day2 Day3 Day1 Day2 Day3(forweightaround50kg) 4 4 2 6 6 3 3

GiveparacetamolIfseverepain

Paracetamol dose frequency1tablet=500mg 1-2tablets every4-6hours

antimalarial treatment and ParaCetamol

Additional treatments for the woman (1) Antimalarial treatment and paracetamol

Prev

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Additional treatments for the woman (2) Give appropriate oral antibiotics

COMMEnT

Avoidinlatepregnancyandtwoweeksafterdeliverywhenbreastfeeding.

notsafeforpregnantorlactatingwomen.

notsafeforpregnantorlactatingwoman.

Donotuseinthefirsttrimesterofpregnancy.

Teachthewomanhowtoinsertapessaryintovaginaandtowashhandsbeforeandaftereachapplication.

Give aPProPriate oral antiBiotiCs

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f5

AnTIBIOTICCloxaCillin1capsule(500mg)

amoxyCillin1tablet(500mg)ORtrimethoPrim+sulPhamethoxaZole1tablet(80mg+400mg)

Ceftriaxone(Vial=250mg)

CiProfloxaCin(1tablet=250mg)

erythromyCin(1tablet=250mg)

tetraCyCline(1tablet=250mg)ORdoxyCyCline(1tablet=100mg)

metronidaZole(1tablet=500mg)

ClotrimaZole1pessary200mgor500mg

InDICATIOnmastitis

lower urinary tract infection

Gonorrhoea Woman

Partneronly

Chlamydia Woman

Partneronly

trichomonas or bacterial vaginal infection

vaginal candida infection

DOsE500mg

500mg

80mgtrimethoprim+400mgsulphamethoxazole

250mgIMinjection

500mg(2tablets)

500mg(2tablets)

500mg(2tablets)

100mg

2gor500mg

200mg

500mg

FREqUEnCyevery6hours

every8hours

twotabletsevery12hours

onceonly

onceonly

every6hours

every6hours

every12hours

onceonlyevery12hours

everynight

onceonly

DURATIOn10days

3days

3days

onceonly

onceonly

7days

7days

7days

onceonly7days

3days

onceonly

Additional treatments for the woman (3) Give benzathine penicillin IM

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f6

COMMEnTGiveastwoIMinjectionsatseparatesites.Plantotreatnewborn K12 .Counseloncorrectandconsistentuseofcondoms G2 .

notsafeforpregnantorlactatingwoman.

AnTIBIOTICBenZathine PeniCillin im(2.4millionunitsin5ml)

erythromyCin(1tablet=250mg)

tetraCyCline(1tablet=250mg)ORdoxyCyCline(1tablet=100mg)

InDICATIOnsyphilis rPr test positive

if woman has allergy to penicillin

if partner has allergy to penicillin

DOsE2.4millionunitsIMinjection

500mg(2tablets)

500mg(2tablets)

100mg

FREqUEnCyonceonly

every6hours

every6hours

every12hours

DURATIOnonceonly

15days

15days

15days

Give BenZathine PeniCillin imtreat the partner. rule out history of allergy to antibiotics.

oBserve for siGns of allerGyafter giving penicillin injection, keep the woman for a few minutes and observe for signs of allergy.

Ask,CHECkRECORD■Howareyoufeeling?■Doyoufeeltightnessinthechest

andthroat?■Doyoufeeldizzyandconfused?

LOOk,LIsTEn,FEEL■Lookattheface,neckandtongue

forswelling.■Lookattheskinforrashorhives.■Lookattheinjectionsiteforswelling

andredness.■Lookfordifficultbreathing.■Listenforwheezing.

sIGnsAnyofthesesigns:■Tightnessinthechestandthroat.■Feelingdizzyandconfused.■swellingoftheface,neckand

tongue.■ Injectionsiteswollenandred.■Rashorhives.■Difficultbreathingorwheezing.

TREAT■Opentheairway B9 .■ InsertIVlineandgivefluids B9 .■Give0.5mladrenaline1:1000in10mlsaline

solutionIVslowly.Repeatin5-15minutes,ifrequired.

■DOnOTleavethewomanonherown.■refer urgently to hospital B17 .

CLAssIFyallerGy toPeniCillin

f2 Preventive measures (1)Givetetanustoxoid

GivevitaminApostpartum

f3 Preventive measures (2)Giveironandfolicacid

Motivateoncompliancewithirontreatment Givemebendazole

f4 additional treatments for the woman (1)

Givepreventiveintermittenttreatmentforfalciparummalaria

Advisetouseinsecticide-treatedbednet Giveparacetamol

f5 additional treatments for the woman (2)

Giveappropriateoralantibiotics

f6 additional treatments for the woman (3)

GivebenzathinepenicillinIM Observeforsignsofallergy

■Thissectionhasdetailsonpreventivemeasuresandtreatmentsprescribedinpregnancyandpostpartum.

■Generalprinciplesarefoundinthesectionongoodpractice a2 .

■ForemergencytreatmentforthewomanseeB8-B17 .

■FortreatmentforthenewbornseeK9-K13 .

f2

Givetetanustoxoid■ Immunizeallwomen■Checkthewoman’stetanustoxoid(TT)immunizationstatus:

→WhenwasTTlastgiven?→WhichdoseofTTwasthis?

■ Ifimmunizationstatusunknown,giveTT1.PlantogiveTT2in4weeks.

if due:■Explaintothewomanthatthevaccineissafetobegiveninpregnancy;itwillnotharmthebaby.■Theinjectionsitemaybecomealittleswollen,redandpainful,butthiswillgoawayinafewdays.■ Ifshehasheardthattheinjectionhascontraceptiveeffects,assureheritdoesnot,thatitonly

protectsherfromdisease.■Give0.5mlTTIM,upperarm.■Advisewomanwhennextdoseisdue.■Recordonmother’scard.

tetanus toxoid scheduleAtfirstcontactwithwomanofchildbearingageoratfirstantenatalcarevisit,asearlyaspossible. TT1Atleast4weeksafterTT1(atnextantenatalcarevisit). TT2Atleast6monthsafterTT2. TT3Atleast1yearafterTT3. TT4Atleast1yearafterTT4. TT5

GivevitaminApostpartum■Give200-000-IUvitaminAcapsulesafterdeliveryorwithin6weeksofdelivery:■ExplaintothewomanthatthecapsulewithvitaminAwillhelphertorecoverbetter,andthatthe

babywillreceivethevitaminthroughherbreastmilk.→askhertoswallowthecapsuleinyourpresence.→explaintoherthatifshefeelsnauseatedorhasaheadache,itshouldpassinacoupleofdays.

■do notgivecapsuleswithhighdoseofvitaminAduringpregnancy.

vitamin a1capsule 200-000IU 1capsuleafterdeliveryorwithin6weeksofdelivery

Preventive measures

Preventive measures (1)Pr

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Preventive measures (2) Iron and mebendazole f3

Giveironandfolicacid■Toallpregnant,postpartumandpost-abortionwomen:

→Routinelyoncedailyinpregnancyanduntil3monthsafterdeliveryorabortion.→Twicedailyastreatmentforanaemia(doubledose).

■Checkwoman’ssupplyofironandfolicacidateachvisitanddispense3monthssupply.■Advisetostoreironsafely:

→Wherechildrencannotgetit→Inadryplace.

iron and folate1tablet=60-mg,folicacid=400-µg all women women with anaemia 1tablet 2tabletsin pregnancy Throughoutthepregnancy 3monthsPostpartum and 3months 3monthspost-abortion

Givemebendazole■Give500mgtoeverywomanoncein6months.■do notgiveitinthefirsttrimester.

mebendazole500mgtablet 100mgtablet1tablet 5tablets

MotivateoncompliancewithirontreatmentExplorelocalperceptionsaboutirontreatment(examplesofincorrectperceptions:makingmorebloodwillmakebleedingworse,ironwillcausetoolargeababy).■Explaintomotherandherfamily:

→Ironisessentialforherhealthduringpregnancyandafterdelivery→Thedangerofanaemiaandneedforsupplementation.

■Discussanyincorrectperceptions.■Explorethemother’sconcernsaboutthemedication:

→Hassheusedthetabletsbefore?→Werethereproblems?→Anyotherconcerns?

■Adviseonhowtotakethetablets→Withmealsor,ifoncedaily,atnight→Irontabletsmayhelpthepatientfeellesstired.Donotstoptreatmentifthisoccurs→Donotworryaboutblackstools.Thisisnormal.

■Giveadviceonhowtomanageside-effects:→Ifconstipated,drinkmorewater→Taketabletsafterfoodoratnighttoavoidnausea→Explainthatthesesideeffectsarenotserious→Advisehertoreturnifshehasproblemstakingtheirontablets.

■ Ifnecessary,discusswithfamilymember,TBA,othercommunity-basedhealthworkersorotherwomen,howtohelpinpromotingtheuseofironandfolatetablets.

■Counseloneatingiron-richfoods–see C16 d26 .

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Givepreventiveintermittenttreatmentforfalciparummalaria■Givesulfadoxine-pyrimethamineatthebeginningofthesecondandthirdtrimestertoallwomen

accordingtonationalpolicy.■Checkwhenlastdoseofsulfadoxine-pyrimethaminegiven:

→Ifnodoseinlastmonth,givesulfadoxine-pyrimethamine,3tabletsinclinic.■Advisewomanwhennextdoseisdue.■Monitorthebabyforjaundiceifgivenjustbeforedelivery.■Recordonhome-basedrecord.

sulfadoxine pyrimethamine1tablet=500mg+25mgpyrimethaminesulfadoxine second trimester third trimester 3tablets 3tablets

Advisetouseinsecticide-treatedbednet■Askwhetherwomanandnewbornwillbesleepingunderabednet.■ Ifyes,

→Hasitbeendippedininsecticide?→When?→Advisetodipevery6months.

■ Ifnot,advisetouseinsecticide-treatedbednet,andprovideinformationtohelpherdothis.

GiveappropriateoralantimalarialtreatmentAhighlyeffectiveantimalarial(evenifsecond-line)ispreferredduringpregnancy

Chloroquine sulfadoxine + Pyrimethamine

Givedailyfor3days Givesingledoseinclinic Tablet Tablet Tablet (150mgbase) (100mgbase) 500mgsulfadoxine+

25mgpyrimethaminePregnantwoman Day1 Day2 Day3 Day1 Day2 Day3(forweightaround50kg) 4 4 2 6 6 3 3

GiveparacetamolIfseverepain

Paracetamol dose frequency1tablet=500mg 1-2tablets every4-6hours

antimalarial treatment and ParaCetamol

Additional treatments for the woman (1) Antimalarial treatment and paracetamolPr

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Additional treatments for the woman (2) Give appropriate oral antibiotics

COMMEnT

Avoidinlatepregnancyandtwoweeksafterdeliverywhenbreastfeeding.

notsafeforpregnantorlactatingwomen.

notsafeforpregnantorlactatingwoman.

Donotuseinthefirsttrimesterofpregnancy.

Teachthewomanhowtoinsertapessaryintovaginaandtowashhandsbeforeandaftereachapplication.

Give aPProPriate oral antiBiotiCs

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AnTIBIOTICCloxaCillin1capsule(500mg)

amoxyCillin1tablet(500mg)ORtrimethoPrim+sulPhamethoxaZole1tablet(80mg+400mg)

Ceftriaxone(Vial=250mg)

CiProfloxaCin(1tablet=250mg)

erythromyCin(1tablet=250mg)

tetraCyCline(1tablet=250mg)ORdoxyCyCline(1tablet=100mg)

metronidaZole(1tablet=500mg)

ClotrimaZole1pessary200mgor500mg

InDICATIOnmastitis

lower urinary tract infection

Gonorrhoea Woman

Partneronly

Chlamydia Woman

Partneronly

trichomonas or bacterial vaginal infection

vaginal candida infection

DOsE500mg

500mg

80mgtrimethoprim+400mgsulphamethoxazole

250mgIMinjection

500mg(2tablets)

500mg(2tablets)

500mg(2tablets)

100mg

2gor500mg

200mg

500mg

FREqUEnCyevery6hours

every8hours

twotabletsevery12hours

onceonly

onceonly

every6hours

every6hours

every12hours

onceonlyevery12hours

everynight

onceonly

DURATIOn10days

3days

3days

onceonly

onceonly

7days

7days

7days

onceonly7days

3days

onceonly

Additional treatments for the woman (3) Give benzathine penicillin IMPr

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COMMEnTGiveastwoIMinjectionsatseparatesites.Plantotreatnewborn K12 .Counseloncorrectandconsistentuseofcondoms G2 .

notsafeforpregnantorlactatingwoman.

AnTIBIOTICBenZathine PeniCillin im(2.4millionunitsin5ml)

erythromyCin(1tablet=250mg)

tetraCyCline(1tablet=250mg)ORdoxyCyCline(1tablet=100mg)

InDICATIOnsyphilis rPr test positive

if woman has allergy to penicillin

if partner has allergy to penicillin

DOsE2.4millionunitsIMinjection

500mg(2tablets)

500mg(2tablets)

100mg

FREqUEnCyonceonly

every6hours

every6hours

every12hours

DURATIOnonceonly

15days

15days

15days

Give BenZathine PeniCillin imtreat the partner. rule out history of allergy to antibiotics.

oBserve for siGns of allerGyafter giving penicillin injection, keep the woman for a few minutes and observe for signs of allergy.

Ask,CHECkRECORD■Howareyoufeeling?■Doyoufeeltightnessinthechest

andthroat?■Doyoufeeldizzyandconfused?

LOOk,LIsTEn,FEEL■Lookattheface,neckandtongue

forswelling.■Lookattheskinforrashorhives.■Lookattheinjectionsiteforswelling

andredness.■Lookfordifficultbreathing.■Listenforwheezing.

sIGnsAnyofthesesigns:■Tightnessinthechestandthroat.■Feelingdizzyandconfused.■swellingoftheface,neckand

tongue.■ Injectionsiteswollenandred.■Rashorhives.■Difficultbreathingorwheezing.

TREAT■Opentheairway B9 .■ InsertIVlineandgivefluids B9 .■Give0.5mladrenaline1:1000in10mlsaline

solutionIVslowly.Repeatin5-15minutes,ifrequired.

■DOnOTleavethewomanonherown.■refer urgently to hospital B17 .

CLAssIFyallerGy toPeniCillin

Inform and counsel on HIV

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Inform and counsel on HIVProVIde key InformatIon on HIV

Provide key information on HIV

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WhatisHIV(humanimmunodeficiencyvirus)andhowisHIVtransmitted?■HIVisavirusthatdestroyspartsofthebody’simmunesystem.ApersoninfectedwithHIVmaynot

feelsickatfirst,butslowlythebody’simmunesystemisdestroyed.Thepersonbecomesillandunabletofightinfection.OnceapersonisinfectedwithHIV,sheorhecangivethevirustoothers.

■HIVcanbetransmittedthrough: →ExchangeofHIV-infectedbodyfluidssuchassemen,vaginalfluidorbloodduringunprotected

sexualintercourse. →HIV-infectedbloodtransfusionsorcontaminatedneedles. →Fromaninfectedmothertoherchild(MTCT)during: →pregnancy →labouranddelivery →postpartumthroughbreastfeeding.■Almostfouroutof20babiesborntoHIVpositivewomenmaybeinfectedwithoutanyintervention.■HIVcannotbetransmittedthroughhuggingormosquitobites.■AbloodtestisdonetofindoutifthepersonisinfectedwithHIV.■Allpregnantwomenareofferedthistest.Theycanrefusethetest.

AdvantageofknowingtheHIVstatusinpregnancyknowing the HIV status during pregnancy is important so that the woman can:■ thewomanknowsherHIVstatus■canshareinformationwithherpartner■encourageherpartnertobetestedIfthewomanisHIV-positiveshecan:■getappropriatemedicalcaretotreatand/orpreventHIV-associatedillnesses.■ reducetheriskoftransmissionofinfectiontothebaby: →bytakingantiretroviraldrugsinpregnancy,andduringlabour G6 , G9

→bypracticingsaferinfantfeedingoptions G9

→byadaptingbirthandemergencyplananddeliverypractices G4 .■protectherselfandhersexualpartner(s)frominfectionorreinfection.■makeachoiceaboutfuturepregnancies.IfthewomanisHIV-negativeshecan:■ learnhowtoremainnegative.

Counselonsafersexincludinguseofcondomssafer seX Is any seXual PractIce tHat reduces tHe rIsk of transmIttInG HIV and

seXually transmItted InfectIons (stIs) from one Person to anotHer

tHe Best ProtectIon Is oBtaIned By:■Correctandconsistentuseofcondomsduringeverysexualact.■Choosingsexualactivitiesthatdonotallowsemen,fluidfromthevagina,orbloodtoenterthe

mouth,anusorvaginaofthepartner.■Reducingthenumberofpartners. → IfthewomanisHIV-negativeexplaintoherthatsheisatriskofHIVinfectionandthatitis

importanttoremainnegativeduringpregnancyandbreastfeeding.Theriskofinfectingthebabyishigherifthemotherisnewlyinfected.

→ IfthewomanisHIV-positiveexplaintoherthatcondomuseduringeverysexualactduringpregnancyandbreastfeedingwillprotectherandherbabyfromsexuallytransmittedinfections,orreinfectionwithanotherHIVstrainandwillpreventthetransmissionofHIVinfectiontoherpartner.

→ Makesurethewomanknowshowtousecondomsandwheretogetthem.

HIV testInG and counsellInG

HIV testing and counselling

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Voluntarycounsellingandtesting(VCT)servicesexplain about HIV testing:■HIVtestisusedtodetermineifthewomanisinfectedwithHIV.■ Itincludesbloodtestingandcounselling.■Resultisavailableonthesamedayoratthenextvisit.■Thetestisofferedroutinelytoeverywomanateverypregnancytohelpprotectherandherbaby’s

health.Shemaydeclinethetest.

If HIV testing is not available in your setting, inform the woman about:■Pre-testcounselling.■Post-testcounselling.■ Infantfeedingcounselling.

If Vct is not available in your setting, inform the woman about:■Wheretogo.■Howthetestisperformed.■Howconfidentialityismaintained(seebelow).■Whenandhowresultsaregiven.■Whensheshouldcomebacktotheclinicwiththetestresult■Costsinvolved.■ProvidetheaddressofHIVtestinginyourarea’snearestsite:

✎____________________________________________________________________

✎____________________________________________________________________

DiscussconfidentialityofHIVinfection■Assurethewomanthathertestresultisconfidentialandwillbesharedonlywithherselfandany

personchosenbyher.■EnsureconfidentialitywhendiscussingHIVresults,status,treatmentandcarerelatedtoHIV,

opportunisticinfections,additionalvisitsandinfantfeedingoptions.A2■Ensureallrecordsareconfidentialandkeptlockedawayandonlyhealthcareworkerstakingcareof

herhaveaccesstotherecords.■do notlabelrecordsasHIV-positive.

CounselonimplicationsoftheHIVtestresult■DiscusstheHIVresultswhenthewomanisaloneorwiththepersonofherchoice.■Statetestresultsinaneutraltone.■Givethewomantimetoexpressanyemotions.

If test result Is neGatIVe:■ExplaintothewomanthatanegativeresultcanmeaneitherthatsheisnotinfectedwithHIVorthat

sheisinfectedwithHIVbuthasnotyetmadeantibodiesagainstthevirus(thisissometimescalledthe“window”period).

■Counselontheimportanceofstayingnegativebysafersexincludinguseofcondoms G2 .

If test result Is PosItIVe:■Explaintothewomanthatapositivetestresultmeansthatsheiscarryingtheinfectionandhasthe

possibilityoftransmittingtheinfectiontoherunbornchildwithoutanyintervention.■Lethertalkaboutherfeelings.Respondtoherimmediateconcerns.■ Informherthatshewillneedfurtherassessmenttodeterminetheseverityoftheinfection,

appropriatecareandtreatmentneededforherselfandherbaby.TreatmentwillslowdowntheprogressionofherHIVinfectionandwillreducetheriskofinfectiontothebaby.

■ProvideinformationonhowtopreventHIVre-infection.■ Informherthatsupportandcounsellingisavailableifneeded,tocopeonlivingwithHIVinfection.■Discussdisclosureandpartnertesting.■Askthewomanifshehasanyconcerns.

Benefitsofdisclosure(involving)andtestingthemalepartner(s)EncouragethewomentodisclosetheHIVresultstoherpartneroranotherpersonshetrusts.BydisclosingherHIVstatustoherpartnerandfamily,thewomanmaybeinabetterpositionto:■EncouragepartnertobetestedforHIV.■PreventthetransmissionofHIVtoherpartner(s).■PreventtransmissionofHIVtoherbaby.■ProtectherselffromHIVreinfection.■AccessHIVtreatment,careandsupportservices.■Receivesupportfromherpartner(s)andfamilywhenaccessingantenatalcareandHIVtreatment,

careandsupportservices.■Helptodecreasetheriskofsuspicionandviolence.

care and counsellInG for tHe HIV-PosItIVe woman

Care and counselling for the HIV-positive woman

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AdditionalcarefortheHIV-positivewoman■Determinehowmuchthewomanhastoldherpartner,labourcompanionandfamily,then

respectthisconfidentiality.■Besensitivetoherspecialconcernsandfears.Giveheradditionalsupport G5 .■AdviseontheimportanceofgoodnutritionC13D26.■Usestandardprecautionsasforallwomen A4 .■Adviseherthatsheismorepronetoinfectionsandshouldseekmedicalhelp

assoonaspossibleifshehas: →fever →persistentdiarrhoea →coldandcough—respiratoryinfections →burningurination →vaginalitching/foul-smellingdischarge →noweightgain →skininfections →foul-smellinglochia.

durInG PreGnancy:■Revisethebirthplan C2 C13. →Advisehertodeliverinafacility. →Advisehertogotoafacilityassoonashermembranesruptureorlabourstarts. →TellhertotakeARVmedicineattheonsetoflabourasinstructed G6 .■Discusstheinfantfeedingoptions G8-G9 .■Modifypreventivetreatmentformalaria,accordingtonationalstrategy F4 .

durInG cHIldBIrtH:■Checkifnevirapineistakenatonsetoflabour.■GiveARVmedicinesasprescribed G6 , G9 .■Adheretostandardpracticeforlabouranddelivery.■RespectconfidentialitywhengivingARVtothemotherandbaby.■RecordallARVmedicinesgivenonlabourrecord,postpartumrecordandonreferralrecord,if

womanisreferred.

durInG tHe PostPartum PerIod:■Tellherthatlochiacancauseinfectioninotherpeopleandthereforesheshoulddisposeofblood

stainedsanitarypadssafely(listlocaloptions).■Counselheronfamilyplanning G4 .■ Ifnotbreastfeeding,adviseheronbreastcare K8 .■VisitHIVservices2weeksafterdeliveryforfurtherassessment.

CounseltheHIV-positivewomanonfamilyplanning

■UsetheadviceandcounsellingsectionsonC15duringantenatalcareandD27duringpostpartumvisits.Thefollowingadviceshouldbehighlighted:

→Explaintothewomanthatfuturepregnanciescanhavesignificanthealthrisksforherandherbaby.Theseinclude:transmissionofHIVtothebaby(duringpregnancy,deliveryorbreastfeeding),miscarriage,pretermlabour,stillbirth,lowbirthweight,ectopicpregnancyandothercomplications.

→Ifshewantsmorechildren,adviseherthatwaitingatleast2-3yearsbetweenpregnanciesishealthierforherandthebaby.

→DiscussheroptionsforpreventingbothpregnancyandinfectionwithothersexuallytransmittedinfectionsorHIVreinfection.

■CondomsmaybethebestoptionforthewomanwithHIV.Counselthewomanonsafersexincludingtheuseofcondoms G2 .

■ Ifthewomanthinkthatherpartnerwillnotusecondoms,shemaywishtouseanadditionalmethodforpregnancyprotection.

■However,notallmethodsareappropriatefortheHIV-positivewoman: →Giventhewoman’sHIVstatus,shemaynotchoosetobreastfeedandlactationalamenorrhoea

method(LAM)maynotbeasuitablemethod. →SpermicidesarenotrecommendedforHIV-positivewomen. →Intrauterinedevice(IUD)useisnotrecommendedforwomenwithAIDSwhoarenotonARV

therapy. →Duetochangesinthemenstrualcycleandelevatedtemperaturesfertilityawarenessmethods

maybedifficultifthewomanhasAIDSorisontreatmentforHIVinfections. →Ifthewomanistakingpillsfortuberculosis(rifampin),sheusuallycannotusecontraceptivepills,

monthlyinjectablesorimplants.

Thefamilyplanningcounsellorwillprovidemoreinformation.

suPPort to tHe HIV-PosItIVe womanPregnant women who are HIV- positive benefit greatly from the following support after the first impact of the test result has been overcome.

Support to the HIV-positive woman

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Provideemotionalsupporttothewoman■Empathizewithherconcernsandfears.■Usegoodcounsellingskills A2 .■Helphertoassesshersituationanddecidewhichisthebestoptionforher,her(unborn)childand

hersexualpartner.Supportherchoice.■Connectherwithotherexistingsupportservicesincludingsupportgroups,income-

generatingactivities,religioussupportgroups,orphancare,homecare.■Helphertofindwaystoinvolveherpartnerand/orextendedfamilymembersinsharing

responsibility,toidentifyafigurefromthecommunitywhowillsupportandcareforher.■Discusshowtoprovidefortheotherchildrenandhelpheridentifyafigurefromtheextendedfamily

orcommunitywhowillsupportherchildren.■ConfirmandsupportinformationgivenduringHIVtestingandcounselling,thepossibilityofARV

treatment,safesex,infantfeedingandfamilyplanningadvice(helphertoabsorbtheinformationandapplyitinherowncase).

■ IfthewomanhassignsofAIDSand/orofotherillness,referhertoappropriateservices.

Howtoprovidesupport■ConductpeersupportgroupsforwomenwhohaveHIV-infectionandcouplesaffectedbyHIV/AIDS: →Ledbyasocialworkerand/orwomanwhohascometotermswithherownHIVinfection.■Establishandmaintainconstantlinkageswithotherhealth,socialandcommunityworkerssupport

services: →Toexchangeinformationforthecoordinationofinterventions →Tomakeaplanforeachfamilyinvolved.■Referindividualsorcouplesforcounsellingbycommunitycounsellors.

Give antiretroviral (ARV) medicine(s) to treat HIV infection

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GIVe antIretroVIral (arV) medIcIne(s) to treat HIV InfectIonuse these charts when starting arV medicine(s) and to support adherence to arV

SupporttheinitiationofARV■ IfthewomanisalreadyonARVtreatmentcontinuethetreatmentduringpregnancy,asprescribed.If

sheisinthefirsttrimesterofpregnancyandtreatmentincludesefavirenz,replaceitwithnevirapine.■ IfthewomanisnotonARVtreatmentandistestedHIV-positive,chooseappropriateARVregimens

C9 ,G10accordingtothestageofthedisease.■ IftreatmentwithZidovudine(AZT)isplanned:measurehaemoglobin;iflessthan8g/dl,referto

hospital C4 .■WritethetreatmentplanintheHomeBasedMaternalRecord.■Givewritteninstructionstothewomanonhowtotakethemedicines.■Giveprophylaxisforopportunisticinfectionsaccordingtonationalguidelines.■Modifypreventivetreatmentformalariaaccordingtonationalguidelines F4 .

ExplorelocalperceptionsaboutARVsexplain to the woman and family that:■ARVtreatmentwillimprovethewoman’shealthandwillgreatlyreducetheriskofinfectiontoher

baby.Thetreatmentwillnotcurethedisease.■ThechoiceofregimendependsonthestageofthediseaseC19. → IfsheisinearlystageofHIVinfection,shewillneedtotakemedicinesduringpregnancy,

childbirthandonlyforashortperiodafterdeliverytopreventmother-to-childtransmissionofHIVinfection(PMTCT).Progressofdiseasewillbemonitoredtodetermineifsheneedsadditionaltreatment.

→ Ifshehasmild-severeHIVdiseaseshewillneedtocontinuethetreatmentevenafterchildbirthandpostpartumperiod.

■Shemayhavesomesideeffectsbutnotallwomenhavethem.Commonsideeffectslikenausea,diarrohea,headacheorfeveroftenoccurinthebeginningbuttheyusuallydisappearwithin2–3weeks.Othersideeffectslikeyelloweyes,pallor,severeabdominalpain,shortnessofbreath,skinrash,painfulfeet,legsorhandsmayappearatanytime.Ifthesesignspersist,sheshouldcometotheclinic.

■GiveherenoughARVtabletsfor2weeksortillhernextANCvisit.■Askthewomanifshehasanyconcerns.Discussanyincorrectperceptions.

SupportadherencetoARV■ForARVmedicinetobeeffective:Advisewomanon:■ExplaintoherthattoreceiveARVprophylactictreatment,shemust: →whichtabletssheneedstotakeduringpregnancy,whenlabourbegins(painfulabdominal

contractionsand/ormembranesrupture)andafterchildbirth. →takingthemedicineregularly,everyday,attherighttime.Ifshechoosestostoptakingmedicines

duringpregnancy,herHIVdiseasecouldgetworseandshemaypasstheinfectiontoherchild. →ifsheforgetstotakeadose,sheshouldnotdoublethenextdose. →continuethetreatmentduringandafterthechildbirth(ifprescribed),evenifsheisbreastfeeding. →takingthemedicine(s)withmealsinordertominimizesideeffects.Fornewborn: →Givethefirstdoseofmedicinetothenewborn8–12hoursafterbirth. →Teachthemotherhowtogivetreatmenttothenewborn. →Tellthemotherthatthebabymustcompletethefullcourseoftreatmentandwillneedregular

visitsthroughouttheinfancy. →Ifthemotherreceivedlessthan4weeksofZidovudine(AZT)duringpregnancy,givethetreatment

tothenewbornfor4weeks.■Recordalltreatmentgiven.Ifthemotherorbabyisreferred,writethetreatmentgivenandthe

regimenprescribedonthereferralcard.

■do notlabelrecordsasHIV-Positive■do notsharedrugswithfamilyorfriends.

Counsel on infant feeding options

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counsel on Infant feedInG oPtIons

ExplaintherisksofHIVtransmissionthroughbreastfeedingandnotbreastfeeding■Fouroutof20babiesborntoknownHIV-positivemotherswillbeinfectedduringpregnancyand

deliverywithoutARVmedication.Threemoremaybeinfectedbybreastfeeding.■Theriskmaybereducedifthebabyisbreastfedexclusivelyusinggoodtechnique,sothatthe

breastsstayhealthy.■Mastitisandnipplefissuresincreasetheriskthatthebabywillbeinfected.■Theriskofnotbreastfeedingmaybemuchhigherbecausereplacementfeedingcarriesriskstoo: →diarrhoeabecauseofcontaminationfromuncleanwater,uncleanutensilsorbecausethemilkis

leftouttoolong. →malnutritionbecauseofinsufficientquantitygiventothebaby,themilkistoowatery,orbecause

ofrecurrentepisodesofdiarrhoea.■Mixedfeedingincreasestheriskofdiarrhoea.ItmayalsoincreasetheriskofHIVtransmission.

IfawomandoesnotknowherHIVstatus■Counselontheimportanceofexclusivebreastfeeding K2 .■Encourageexclusivebreastfeeding.■CounselontheneedtoknowtheHIVstatusandwheretogoforHIVtestingandcounselling G3 .■ExplaintohertherisksofHIVtransmission: →eveninareaswheremanywomenhaveHIV,mostwomenarenegative →theriskofinfectingthebabyishigherifthemotherisnewlyinfected →explainthatitisveryimportanttoavoidinfectionduringpregnancyandthebreastfeeding

period.

IfawomanknowsthatsheisHIV-positive■ Informherabouttheoptionsforfeeding,theadvantagesandrisks: →Ifacceptable,feasible,safeandsustainable(affordable),shemightchoosereplacementfeeding

withhome-preparedformulaorcommercialformula. →Exclusivebreastfeeding,stoppingassoonasreplacementfeedingispossible.Ifreplacement

feedingisintroducedearly,shemuststopbreastfeeding. →Exclusivebreastfeedingfor6months,thencontinuedbreastfeedingpluscomplementaryfeeding

after6monthsofage,asrecommendedforHIV-negativewomenandwomenwhodonotknowtheirstatus.

■ Insomesituationsadditionalpossibilitiesare: →expressingandheat-treatingherbreastmilk →wetnursingbyanHIV-negativewoman.■Helphertoassesshersituationanddecidewhichisthebestoptionforher,andsupportherchoice.■ Ifthemotherchoosesbreastfeeding,giveherspecialadvice.■Makesurethemotherunderstandsthatifshechoosesreplacementfeedingthisincludesenriched

complementaryfeedingupto2years. →Ifthiscannotbeensured,exclusivebreastfeeding,stoppingearlywhenreplacementfeedingis

feasible,isanalternative. →Allbabiesreceivingreplacementfeedingneedregularfollow-up,andtheirmothersneedsupport

toprovidecorrectreplacementfeeding.

G2 ProVIde key InformatIon on HIV WhatisHIVandhowisHIVtransmitted?

AdvantageofknowingtheHIVstatusinpregnancy

Counselonsafersexincludinguseofcondoms

G3 HIV testInG and counsellInG HIVtestingandcounselling

DiscussconfidentialityofHIVinfection CounselonimplicationsoftheHIVtestresult Benefitsofdisclosure(involving)andtestingthe

malepartner(s)

G4 care and counsellInG for tHe HIV-PostItIVe woman

AdditionalcarefortheHIV-positivewoman CounseltheHIV-positivewomanonfamily

planning

G5 suPPort to tHe HIV-PosItIVe woman

Provideemotionalsupporttothewoman Howtoprovidesupport

G6 GIVe antIretroVIral (arV) medIcIne(s) to treat HIV InfectIon

SupporttheinitiationofARV SupportadherencetoARV

G7 counsel on Infant feedInG oPtIons

ExplaintherisksofHIVtransmissionthroughbreastfeedingandnotbreastfeeding

IfawomandoesnotknowherHIVstatus IfawomanknowsthatsheisHIV-positive

Support the mothers choice of infant feeding

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suPPort tHe motHers cHoIce of Infant feedInG

Ifthemotherchoosesreplacementfeeding,teachherreplacementfeeding■Askthemotherwhatkindofreplacementfeedingshechose.Forthefirstfewfeedsafterdelivery,preparetheformulaforthemother,thenteachherhowtopreparetheformulaandfeedthebabybycup K9 : →Washhandswithwaterandsoap →Boilthewaterforfewminutes →Cleanthecupthoroughlywithwater,soapand,ifpossible,boilorpourboiledwaterinit →Decidehowmuchmilkthebabyneedsfromtheinstructions →Measurethemilkandwaterandmixthem →Teachthemotherhowtofeedthebabybycup →Letthemotherfeedthebaby8timesaday(inthefirstmonth).Teachhertobeflexibleand

respondtothebaby’sdemands →Ifthebabydoesnotfinishthefeedwithin1hourofpreparation,giveittoanolderchildoraddto

cooking.DONOTgivethemilktothebabyforthenextfeed →Washtheutensilswithwaterandsoapsoonafterfeedingthebaby →Makeanewfeedeverytime.■Giveherwritteninstructionsonsafepreparationofformula.■Explaintherisksofreplacementfeedingandhowtoavoidthem.■Advisewhentoseekcare.■Adviseaboutthefollow-upvisit.

Explaintherisksofreplacementfeeding■Herbabymaygetdiarrhoeaif: →hands,water,orutensilsarenotclean →themilkstandsouttoolong.■Herbabymaynotgrowwellif: →she/hereceivestoolittleformulaeachfeedortoofewfeeds →themilkistoowatery →she/hehasdiarrhoea.

Follow-upforreplacementfeeding■Ensureregularfollow-upvisitsforgrowthmonitoring.■Ensurethesupporttoprovidesafereplacementfeeding.■Advisethemothertoreturnif: →thebabyisfeedinglessthan6times,oristakingsmallerquantities K6

→thebabyhasdiarrhoea →thereareotherdangersigns.

GivespecialcounsellingtothemotherwhoisHIV-positiveandchoosesbreastfeeding■Supportthemotherinherchoiceofbreastfeeding.■Ensuregoodattachmentandsucklingtopreventmastitisandnippledamage K3 .■Advisethemothertoreturnimmediatelyif: →shehasanybreastsymptomsorsigns →thebabyhasanydifficultyfeeding.■Ensureavisitinthefirstweektoassessattachmentandpositioningandtheconditionofthe

mother’sbreasts.■Arrangeforfurthercounsellingtoprepareforthepossibilityofstoppingbreastfeedingearly.■Givepsychosocialsupport G6 .

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antIretroVIrals for HIV-PosItIVe woman and Her InfantBelow are examples of arV regimens. use national guidelines for local protocols.for longer regimens to further reduce the risk of transmission follow national guidelines.record the arV medicine prescribed and given in the appropriate records – facility and home-based. do not write HIV-positive.

Antiretrovirals for HIV-positive woman and her infant

woman newborn infant

Pregnancy labour, delivery Postpartum**

arVsBefore �� weeks

starting at �� weeks

at onset of labour*

until birth of the baby

after birth of the baby

arVsdose (syrup)

Give first dose

then give duration

HIV-positivewithHIV-AIDSrelatedsignsandsymptoms

Tripletherapy ContinuetheARVtreatmentprescribedbeforepregnancy.InthefirsttrimesterreplaceEfavirenzwithNevirapine(200mgoncedailyfor2weeks,thenevery12hours)

Zidovudine 4mg/kg 8–12hoursafterbirth

every12hours

7days***

HIV-positivewithoutHIV-relatedsignsandsymptoms

3TC 150mg every12hours 7days

Zidovudine 300mgevery12hours

300mg every3hours

every12hours

7days Zidovudine 4mg/kg 8–12hoursafterbirth

every12hours

7days***

Nevirapine 200mgonce Nevirapine 2mg/kg within72hours

once

ARVsduringlabour Zidovudine 300mg every3hours

Zidovudine 4mg/kg 8–12hoursafterbirth

every12hours

4weeks

Or600mg

Nevirapine 200mgonce Nevirapine 2mg/kg within72hours

once

OnlyminimalrangeofARVtreatment

Nevirapine 200mgonce Nevirapine 2mg/kg within72hours

once

*Atonsetofcontractionsorruptureofmembranes,regardlessofthepreviousschedule**Arrangefollow-upforfurtherassessmentandtreatmentwithin2weeksafterdelivery ***TreatthenewborninfantwithZidovudinefor4weeksifmotherreceivedZidovudineforlessthan4weeksduringpregnancy,

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resPond to oBserVed sIGns or Volunteered ProBlemsuse this chart to manage the woman who has a problem while taking arV medicines. these problems may be side effects of arV medicines or of an underlying disease. rule out serious pregnancy-related diseases before assuming that these are side effects of the drugs. follow up in � weeks or earlier if condition worsens. In no improve-ment, refer the woman to hospital for further management.

SIGNSHeadache

nausea or vomiting

fever

diarrhoea

rash or blisters/ulcers

yellow eyes or mucus membrane

ADVISEANDTREAT■Measurebloodpressureandmanageasin C2 and E3 .■ IfDBPʺ 90mmgiveparacetamolforheadache F4 .

■Measurebloodpressureandmanageasin C2 and E3 .■Advisetotakemedicineswithfood.■ Ifinthefirst3monthsofpregnancy,reassurethatthemorningnauseaandvomitingwill

disappearafterafewweeks.■Refertohospitalifnotpassingurine.

■Measuretemperature.■Manageaccordingto C7-C8 ,C10-C11ifduringpregnancy,and E6-E8 ifinpostpartumperiod.

■Advisetodrinkonecupoffluidaftereverystool.■Refertohospitalifbloodinstool,notpassingurineorfever>38ºC.

■ Ifrashislimitedtoskin,followupin2weeks.■ Ifsevererash,blistersandulcersonskin,andmouthandfever>38ºCrefertohospitalfor

furtherassessmentandtreatment.

■Refertohospitalforfurtherassessmentandtreatment.

IFWOMANHASANyPROBLEM

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G��Prevent HIV infection in health-care workers after accidental exposure with body fluids (Post exposure prophylaxis)

PreVent HIV InfectIon In HealtH-care workers after accIdental eXPosure wItH Body fluIds (Post eXPosure ProPHylaXIs)

Ifyouareaccidentallyexposedtobloodorbodyfluidsbycutsorpricksorsplashesonface/eyesdothefollowingsteps:■ Ifbloodorbloodyfluidsplashesonintactskin,immediatelywashtheareawithsoapandwater.■ Ifthegloveisdamaged,washtheareawithsoapandwaterandchangetheglove.■ Ifsplashedintheface(eye,nose,mouth)washwithwateronly.■ Ifafingerprickoracutoccurredduringproceduressuchassuturing,allowthewoundtobleedforafewseconds,

donotsqueezeouttheblood.Washwithsoapandwater.Useregularwoundcare.Topicalantisepticsmaybeused.■CheckrecordsfortheHIVstatusofthepregnantwoman.* → IfwomanisHIV-negativenofurtheractionisrequired. →IfwomanisHIV-positivetakeARVmedicineswithin2hours(seenationalguidelinesforchoiceanddurationof

medicine). →IftheHIVstatusofthepregnantwomanisunknown: →StarttheARVmedicinewithin2hours(seenationalguidelinesforchoiceanddurationofmedicine). →ExplaintothewomanwhathashappenedandseekherconsentforrapidHIVtest.DONOTtestthewoman

withoutherconsent.Maintainconfidentiality A2 . →PerformtheHIVtestL6. →Ifthewoman’sHIVtestisnegative,discontinuetheARVmedicines. →Ifthewoman’sHIVtestispositive,managethewomanasin C2 / E3 andhealthworker(yourself)should

completetheARVandbetestedafter6weeks.■ Informthesupervisoroftheexposuretypeandtheactiontakenforthehealth-careworker(yourself).Retestthe

health-careworker6weeksaftertheexposure.

*Ifthehealth-careworker(yourself)isHIV-positivenoPEPisrequired.do nottestthewoman.

G8 suPPort tHe motHer’s cHoIce of Infant feedInG

Ifmotherchoosesreplacementfeeding:Teachherreplacementfeeding.

Explaintherisksofreplacementfeeding Follow-upforreplacementfeeding Givespecialcounsellingtothemotherwhois

HIV-positiveandchoosesbreastfeeding

G9 GIVe aPProPrIate antIretroVIral to HIV-PosItIVe woman and tHe newBorn

G10 resPond to oBserVed sIGns and Volunteered ProBlems

Ifawomanistakingantiretroviralmedicinesanddevelopsnewsigns/symptoms,respondtoherproblems

G11 PreVent HIV InfectIon In HealtH-care workers after accIdental eXPosure wItH Body fluIds (Post eXPosure ProPHylaXIs)

Ifahealth-careworkerisexposedtobodyfluidsbycuts/pricks/splashes,givehim/herappropriatecare

■UsethissectionwhenaccurateinformationonHIVmustbegiventothewomanandherfamily.

■ProvidekeyinformationonHIVtoallwomenandexplainatthefirstantenatalcarevisithowHIVtransmittedandtheadvantagesofknowingtheHIVstatusinpregnancy G2 .

■ExplainaboutHIVtestingandcounselling,theimplicationsofthetestresultandbenefitsofinvolvingandtestingthemalepartner(s).DiscussconfidentialityofHIVinfection G3 .

■ IfthewomanisHIV-positive: →provideadditionalcareduringpregnancy,childbirthand

postpartum G4 . →giveanyparticularsupportthatshemayrequire G5 . →Ifantiretroviraltreatmentisindicatedgiveappropriate

treatment G6 , G9 .

■Counselthewomanoninfantfeedingoptions G7 .

■Supportthemotherschoiceofinfantfeeding G8 .

■Counselallwomenonsafersexincludinguseofcondomsduringandafterpregnancy G2 .

■ Ifthewomantakingantiretroviraltreatmentishavingcomplaints,respondtoherproblemsG10.

■ Ifthehealth-careworkerisaccidentallyexposedtoHIVinfection,giveher/himappropriatecareG11.

ProVIde key InformatIon on HIV

Provide key information on HIVIn

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WhatisHIV(humanimmunodeficiencyvirus)andhowisHIVtransmitted?■HIVisavirusthatdestroyspartsofthebody’simmunesystem.ApersoninfectedwithHIVmaynot

feelsickatfirst,butslowlythebody’simmunesystemisdestroyed.Thepersonbecomesillandunabletofightinfection.OnceapersonisinfectedwithHIV,sheorhecangivethevirustoothers.

■HIVcanbetransmittedthrough: →ExchangeofHIV-infectedbodyfluidssuchassemen,vaginalfluidorbloodduringunprotected

sexualintercourse. →HIV-infectedbloodtransfusionsorcontaminatedneedles. →Fromaninfectedmothertoherchild(MTCT)during: →pregnancy →labouranddelivery →postpartumthroughbreastfeeding.■Almostfouroutof20babiesborntoHIVpositivewomenmaybeinfectedwithoutanyintervention.■HIVcannotbetransmittedthroughhuggingormosquitobites.■AbloodtestisdonetofindoutifthepersonisinfectedwithHIV.■Allpregnantwomenareofferedthistest.Theycanrefusethetest.

AdvantageofknowingtheHIVstatusinpregnancyknowing the HIV status during pregnancy is important so that:■ thewomanknowsherHIVstatus■canshareinformationwithherpartner■encourageherpartnertobetested

If the woman is HIV-positive she can:■getappropriatemedicalcaretotreatand/orpreventHIV-associatedillnesses.■ reducetheriskoftransmissionofinfectiontothebaby: →bytakingantiretroviraldrugsinpregnancy,andduringlabour G6 , G9

→bypracticingsaferinfantfeedingoptions G9

→byadaptingbirthandemergencyplananddeliverypractices G4 .■protectherselfandhersexualpartner(s)frominfectionorreinfection.■makeachoiceaboutfuturepregnancies.

If the woman is HIV- negative she can:■ learnhowtoremainnegative.

Counselonsafersexincludinguseofcondomssafer seX Is any seXual PractIce tHat reduces tHe rIsk of transmIttInG HIV and

seXually transmItted InfectIons (stIs) from one Person to anotHer

tHe Best ProtectIon Is oBtaIned By:■Correctandconsistentuseofcondomsduringeverysexualact.■Choosingsexualactivitiesthatdonotallowsemen,fluidfromthevagina,orbloodtoenterthe

mouth,anusorvaginaofthepartner.■Reducingthenumberofpartners. → IfthewomanisHIV-negativeexplaintoherthatsheisatriskofHIVinfectionandthatitis

importanttoremainnegativeduringpregnancyandbreastfeeding.Theriskofinfectingthebaby ishigherifthemotherisnewlyinfected.

→ IfthewomanisHIV-positiveexplaintoherthatcondomuseduringeverysexualactduring pregnancyandbreastfeedingwillprotectherandherbabyfromsexuallytransmittedinfections,or reinfectionwithanotherHIVstrainandwillpreventthetransmissionofHIVinfectiontoherpartner.

→ Makesurethewomanknowshowtousecondomsandwheretogetthem.

HIV testInG and counsellInG

HIV testing and counselling

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HIVtestingandCounsellingservicesexplain about HIV testing:■HIVtestisusedtodetermineifthewomanisinfectedwithHIV.■ Itincludesbloodtestingandcounselling.■Resultisavailableonthesamedayoratthenextvisit.■Thetestisofferedroutinelytoeverywomanateverypregnancytohelpprotectherandherbaby’s

health.Shemaydeclinethetest.

If HIV testing is not available in your setting, inform the woman about:■Wheretogo.■Howthetestisperformed.■Howconfidentialityismaintained(seebelow).■Whenandhowresultsaregiven.■Whensheshouldcomebacktotheclinicwiththetestresult■Costsinvolved.■ProvidetheaddressofHIVtestinginyourarea’snearestsite:

✎____________________________________________________________________

✎____________________________________________________________________

■Askherifshehasanyquestionsorconcerns.

DiscussconfidentialityofHIVinfection■Assurethewomanthathertestresultisconfidentialandwillbesharedonlywithherselfandany

personchosenbyher.■EnsureconfidentialitywhendiscussingHIVresults,status,treatmentandcarerelatedtoHIV,

opportunisticinfections,additionalvisitsandinfantfeedingoptions A2 .■Ensureallrecordsareconfidentialandkeptlockedawayandonlyhealthcareworkerstakingcareof

herhaveaccesstotherecords.■do notlabelrecordsasHIV-positive.

CounselonimplicationsoftheHIVtestresult■DiscusstheHIVresultswhenthewomanisaloneorwiththepersonofherchoice.■Statetestresultsinaneutraltone.■Givethewomantimetoexpressanyemotions.

If test result Is neGatIVe:■ExplaintothewomanthatanegativeresultcanmeaneitherthatsheisnotinfectedwithHIVorthat

sheisinfectedwithHIVbuthasnotyetmadeantibodiesagainstthevirus(thisissometimescalledthe“window”period).

■Counselontheimportanceofstayingnegativebysafersexincludinguseofcondoms G2 .

If test result Is PosItIVe:■Explaintothewomanthatapositivetestresultmeansthatsheiscarryingtheinfectionandhasthe

possibilityoftransmittingtheinfectiontoherunbornchildwithoutanyintervention.■Lethertalkaboutherfeelings.Respondtoherimmediateconcerns.■ Informherthatshewillneedfurtherassessmenttodeterminetheseverityoftheinfection,

appropriatecareandtreatmentneededforherselfandherbaby.TreatmentwillslowdowntheprogressionofherHIVinfectionandwillreducetheriskofinfectiontothebaby.

■ProvideinformationonhowtopreventHIVre-infection.■ Informherthatsupportandcounsellingisavailableifneeded,tocopeonlivingwithHIVinfection.■Discussdisclosureandpartnertesting.■Askthewomanifshehasanyconcerns.

Benefitsofdisclosure(involving)andtestingthemalepartner(s)EncouragethewomentodisclosetheHIVresultstoherpartneroranotherpersonshetrusts.BydisclosingherHIVstatustoherpartnerandfamily,thewomanmaybeinabetterpositionto:■EncouragepartnertobetestedforHIV.■PreventthetransmissionofHIVtoherpartner(s).■PreventtransmissionofHIVtoherbaby.■ProtectherselffromHIVreinfection.■AccessHIVtreatment,careandsupportservices.■Receivesupportfromherpartner(s)andfamilywhenaccessingantenatalcareandHIVtreatment,

careandsupportservices.■Helptodecreasetheriskofsuspicionandviolence.

care and counsellInG for tHe HIV-PosItIVe woman

Care and counselling for the HIV-positive womanIn

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AdditionalcarefortheHIV-positivewoman■Determinehowmuchthewomanhastoldherpartner,labourcompanionandfamily,then

respectthisconfidentiality.■Besensitivetoherspecialconcernsandfears.Giveheradditionalsupport G5 .■AdviseontheimportanceofgoodnutritionC13D26.■Usestandardprecautionsasforallwomen A4 .■Adviseherthatsheismorepronetoinfectionsandshouldseekmedicalhelp

assoonaspossibleifshehas: →fever →persistentdiarrhoea →coldandcough—respiratoryinfections →burningurination →vaginalitching/foul-smellingdischarge →noweightgain →skininfections →foul-smellinglochia.

durInG PreGnancy:■Revisethebirthplan C2 C13. →Advisehertodeliverinafacility. →Advisehertogotoafacilityassoonashermembranesruptureorlabourstarts. →TellhertotakeARVmedicineattheonsetoflabourasinstructed G6 .■Discusstheinfantfeedingoptions G8-G9 .■Modifypreventivetreatmentformalaria,accordingtonationalstrategy F4 .

durInG cHIldBIrtH:■Checkifnevirapineistakenatonsetoflabour.■GiveARVmedicinesasprescribed G6 G9 .■Adheretostandardpracticeforlabouranddelivery.■RespectconfidentialitywhengivingARVtothemotherandbaby.■RecordallARVmedicinesgivenonlabourrecord,postpartumrecordandonreferralrecord,if

womanisreferred.

durInG tHe PostPartum PerIod:■Tellherthatlochiacancauseinfectioninotherpeopleandthereforesheshoulddisposeofblood

stainedsanitarypadssafely(listlocaloptions).■Counselheronfamilyplanning G4 .■ Ifnotbreastfeeding,adviseheronbreastcare K8 .■VisitHIVservices2weeksafterdeliveryforfurtherassessment.

CounseltheHIV-positivewomanonfamilyplanning

■UsetheadviceandcounsellingsectionsonC15duringantenatalcareandD27duringpostpartumvisits.Thefollowingadviceshouldbehighlighted:

→Explaintothewomanthatfuturepregnanciescanhavesignificanthealthrisksforherandherbaby.Theseinclude:transmissionofHIVtothebaby(duringpregnancy,deliveryorbreastfeeding),miscarriage,pretermlabour,stillbirth,lowbirthweight,ectopicpregnancyandothercomplications.

→Ifshewantsmorechildren,adviseherthatwaitingatleast2-3yearsbetweenpregnanciesishealthierforherandthebaby.

→DiscussheroptionsforpreventingbothpregnancyandinfectionwithothersexuallytransmittedinfectionsorHIVreinfection.

■CondomsmaybethebestoptionforthewomanwithHIV.Counselthewomanonsafersexincludingtheuseofcondoms G2 .

■ Ifthewomanthinkthatherpartnerwillnotusecondoms,shemaywishtouseanadditionalmethodforpregnancyprotection.However,notallmethodsareappropriatefortheHIV-positivewoman:

→Giventhewoman’sHIVstatus,shemaynotchoosetobreastfeedandlactationalamenorrhoeamethod(LAM)maynotbeasuitablemethod.

→SpermicidesarenotrecommendedforHIV-positivewomen. →Intrauterinedevice(IUD)useisnotrecommendedforwomenwithAIDSwhoarenotonARV

therapy. →Duetochangesinthemenstrualcycleandelevatedtemperaturesfertilityawarenessmethods

maybedifficultifthewomanhasAIDSorisontreatmentforHIVinfections. →Ifthewomanistakingpillsfortuberculosis(rifampin),sheusuallycannotusecontraceptivepills,

monthlyinjectablesorimplants.

Thefamilyplanningcounsellorwillprovidemoreinformation.

suPPort to tHe HIV-PosItIVe womanPregnant women who are HIV- positive benefit greatly from the following support after the first impact of the test result has been overcome.

Support to the HIV-positive woman

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Provideemotionalsupporttothewoman■Empathizewithherconcernsandfears.■Usegoodcounsellingskills A2 .■Helphertoassesshersituationanddecidewhichisthebestoptionforher,her(unborn)childand

hersexualpartner.Supportherchoice.■Connectherwithotherexistingsupportservicesincludingsupportgroups,income-

generatingactivities,religioussupportgroups,orphancare,homecare.■Helphertofindwaystoinvolveherpartnerand/orextendedfamilymembersinsharing

responsibility,toidentifyafigurefromthecommunitywhowillsupportandcareforher.■Discusshowtoprovidefortheotherchildrenandhelpheridentifyafigurefromtheextendedfamily

orcommunitywhowillsupportherchildren.■ConfirmandsupportinformationgivenduringHIVtestingandcounselling,thepossibilityofARV

treatment,safesex,infantfeedingandfamilyplanningadvice(helphertoabsorbtheinformationandapplyitinherowncase).

■ IfthewomanhassignsofAIDSand/orofotherillness,referhertoappropriateservices.

Howtoprovidesupport■ConductpeersupportgroupsforwomenwhohaveHIV-infectionandcouplesaffectedbyHIV/AIDS: →Ledbyasocialworkerand/orwomanwhohascometotermswithherownHIVinfection.■Establishandmaintainconstantlinkageswithotherhealth,socialandcommunityworkerssupport

services: →Toexchangeinformationforthecoordinationofinterventions →Tomakeaplanforeachfamilyinvolved.■Referindividualsorcouplesforcounsellingbycommunitycounsellors.

Give antiretroviral (ARV) medicine(s) to treat HIV infectionIn

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GIVe antIretroVIral (arV) medIcIne(s) to treat HIV InfectIonuse these charts when starting arV medicine(s) and to support adherence to arV

SupporttheinitiationofARV■ IfthewomanisalreadyonARVtreatmentcontinuethetreatmentduringpregnancy,asprescribed.If

sheisinthefirsttrimesterofpregnancyandtreatmentincludesefavirenz,replaceitwithnevirapine.■ IfthewomanisnotonARVtreatmentandistestedHIV-positive,chooseappropriateARVregimens

C19, G9 accordingtothestageofthedisease.■ IftreatmentwithZidovudine(AZT)isplanned:measurehaemoglobin;iflessthan8g/dl,referto

hospital C4 .■WritethetreatmentplanintheHomeBasedMaternalRecord.■Givewritteninstructionstothewomanonhowtotakethemedicines.■Giveprophylaxisforopportunisticinfectionsaccordingtonationalguidelines.■Modifypreventivetreatmentformalariaaccordingtonationalguidelines F4 .

ExplorelocalperceptionsaboutARVsexplain to the woman and family that:■ARVtreatmentwillimprovethewoman’shealthandwillgreatlyreducetheriskofinfectiontoher

baby.Thetreatmentwillnotcurethedisease.■ThechoiceofregimendependsonthestageofthediseaseC19. → IfsheisinearlystageofHIVinfection,shewillneedtotakemedicinesduringpregnancy,

childbirthandonlyforashortperiodafterdeliverytopreventmother-to-childtransmissionofHIVinfection(PMTCT).Progressofdiseasewillbemonitoredtodetermineifsheneedsadditionaltreatment.

→ Ifshehasmild-severeHIVdiseaseshewillneedtocontinuethetreatmentevenafterchildbirthandpostpartumperiod.

■Shemayhavesomesideeffectsbutnotallwomenhavethem.Commonsideeffectslikenausea,diarrohea,headacheorfeveroftenoccurinthebeginningbuttheyusuallydisappearwithin2–3weeks.Othersideeffectslikeyelloweyes,pallor,severeabdominalpain,shortnessofbreath,skinrash,painfulfeet,legsorhandsmayappearatanytime.Ifthesesignspersist,sheshouldcometotheclinic.

■GiveherenoughARVtabletsfor2weeksortillhernextANCvisit.■Askthewomanifshehasanyconcerns.Discussanyincorrectperceptions.

SupportadherencetoARVForARVmedicinetobeeffective:■Advisewomanon: →whichtabletssheneedstotakeduringpregnancy,whenlabourbegins(painfulabdominal

contractionsand/ormembranesrupture)andafterchildbirth. →takingthemedicineregularly,everyday,attherighttime.Ifshechoosestostoptakingmedicines

duringpregnancy,herHIVdiseasecouldgetworseandshemaypasstheinfectiontoherchild. →ifsheforgetstotakeadose,sheshouldnotdoublethenextdose. →continuethetreatmentduringandafterthechildbirth(ifprescribed),evenifsheisbreastfeeding. →takingthemedicine(s)withmealsinordertominimizesideeffects.■Fornewborn: →Givethefirstdoseofmedicinetothenewborn8–12hoursafterbirth. →Teachthemotherhowtogivetreatmenttothenewborn. →Tellthemotherthatthebabymustcompletethefullcourseoftreatmentandwillneedregular

visitsthroughouttheinfancy. →Ifthemotherreceivedlessthan4weeksofZidovudine(AZT)duringpregnancy,givethetreatment

tothenewbornfor4weeks.■Recordalltreatmentgiven.Ifthemotherorbabyisreferred,writethetreatmentgivenandthe

regimenprescribedonthereferralcard.

■do notlabelrecordsasHIV-Positive■do notsharedrugswithfamilyorfriends.

Counsel on infant feeding options

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counsel on Infant feedInG oPtIons

ExplaintherisksofHIVtransmissionthroughbreastfeedingandnotbreastfeeding■Fouroutof20babiesborntoknownHIV-positivemotherswillbeinfectedduringpregnancyand

deliverywithoutARVmedication.Threemoremaybeinfectedbybreastfeeding.■Theriskmaybereducedifthebabyisbreastfedexclusivelyusinggoodtechnique,sothatthe

breastsstayhealthy.■Mastitisandnipplefissuresincreasetheriskthatthebabywillbeinfected.■Theriskofnotbreastfeedingmaybemuchhigherbecausereplacementfeedingcarriesriskstoo: →diarrhoeabecauseofcontaminationfromuncleanwater,uncleanutensilsorbecausethemilkis

leftouttoolong. →malnutritionbecauseofinsufficientquantitygiventothebaby,themilkistoowatery,orbecause

ofrecurrentepisodesofdiarrhoea.■Mixedfeedingincreasestheriskofdiarrhoea.ItmayalsoincreasetheriskofHIVtransmission.

IfawomandoesnotknowherHIVstatus■Counselontheimportanceofexclusivebreastfeeding K2 .■Encourageexclusivebreastfeeding.■CounselontheneedtoknowtheHIVstatusandwheretogoforHIVtestingandcounselling G3 .■ExplaintohertherisksofHIVtransmission: →eveninareaswheremanywomenhaveHIV,mostwomenarenegative →theriskofinfectingthebabyishigherifthemotherisnewlyinfected →explainthatitisveryimportanttoavoidinfectionduringpregnancyandthebreastfeeding

period.

IfawomanknowsthatsheisHIV-positive■ Informherabouttheoptionsforfeeding,theadvantagesandrisks: →Ifacceptable,feasible,safeandsustainable(affordable),shemightchoosereplacementfeeding

withhome-preparedformulaorcommercialformula. →Exclusivebreastfeeding,stoppingassoonasreplacementfeedingispossible.Ifreplacement

feedingisintroducedearly,shemuststopbreastfeeding. →Exclusivebreastfeedingfor6months,thencontinuedbreastfeedingpluscomplementaryfeeding

after6monthsofage,asrecommendedforHIV-negativewomenandwomenwhodonotknowtheirstatus.

■ Insomesituationsadditionalpossibilitiesare: →expressingandheat-treatingherbreastmilk →wetnursingbyanHIV-negativewoman.■Helphertoassesshersituationanddecidewhichisthebestoptionforher,andsupportherchoice.■ Ifthemotherchoosesbreastfeeding,giveherspecialadvice.■Makesurethemotherunderstandsthatifshechoosesreplacementfeedingthisincludesenriched

complementaryfeedingupto2years. →Ifthiscannotbeensured,exclusivebreastfeeding,stoppingearlywhenreplacementfeedingis

feasible,isanalternative. →Allbabiesreceivingreplacementfeedingneedregularfollow-up,andtheirmothersneedsupport

toprovidecorrectreplacementfeeding.

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suPPort tHe motHers cHoIce of Infant feedInG

Ifthemotherchoosesreplacementfeeding,teachherreplacementfeeding■Askthemotherwhatkindofreplacementfeedingshechose.■Forthefirstfewfeedsafterdelivery,preparetheformulaforthemother,thenteachherhowtopreparetheformulaandfeedthebabybycup K9 : →Washhandswithwaterandsoap →Boilthewaterforfewminutes →Cleanthecupthoroughlywithwater,soapand,ifpossible,boilorpourboiledwaterinit →Decidehowmuchmilkthebabyneedsfromtheinstructions →Measurethemilkandwaterandmixthem →Teachthemotherhowtofeedthebabybycup →Letthemotherfeedthebaby8timesaday(inthefirstmonth).Teachhertobeflexibleand

respondtothebaby’sdemands →Ifthebabydoesnotfinishthefeedwithin1hourofpreparation,giveittoanolderchildoraddto

cooking.DONOTgivethemilktothebabyforthenextfeed →Washtheutensilswithwaterandsoapsoonafterfeedingthebaby →Makeanewfeedeverytime.■Giveherwritteninstructionsonsafepreparationofformula.■Explaintherisksofreplacementfeedingandhowtoavoidthem.■Advisewhentoseekcare.■Adviseaboutthefollow-upvisit.

Explaintherisksofreplacementfeeding■Herbabymaygetdiarrhoeaif: →hands,water,orutensilsarenotclean →themilkstandsouttoolong.■Herbabymaynotgrowwellif: →she/hereceivestoolittleformulaeachfeedortoofewfeeds →themilkistoowatery →she/hehasdiarrhoea.

Follow-upforreplacementfeeding■Ensureregularfollow-upvisitsforgrowthmonitoring.■Ensurethesupporttoprovidesafereplacementfeeding.■Advisethemothertoreturnif: →thebabyisfeedinglessthan6times,oristakingsmallerquantities K6

→thebabyhasdiarrhoea →thereareotherdangersigns.

GivespecialcounsellingtothemotherwhoisHIV-positiveandchoosesbreastfeeding■Supportthemotherinherchoiceofbreastfeeding.■Ensuregoodattachmentandsucklingtopreventmastitisandnippledamage K3 .■Advisethemothertoreturnimmediatelyif: →shehasanybreastsymptomsorsigns →thebabyhasanydifficultyfeeding.■Ensureavisitinthefirstweektoassessattachmentandpositioningandtheconditionofthe

mother’sbreasts.■Arrangeforfurthercounsellingtoprepareforthepossibilityofstoppingbreastfeedingearly.■Givepsychosocialsupport G6 .

Info

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V

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antIretroVIrals for HIV-PosItIVe woman and Her InfantBelow are examples of arV regimens. use national guidelines for local protocols.for longer regimens to further reduce the risk of transmission follow national guidelines.record the arV medicine prescribed and given in the appropriate records – facility and home-based. do not write HIV-positive.

Antiretrovirals for HIV-positive woman and her infant

woman newborn infant

Pregnancy labour, delivery Postpartum**

arVsBefore �� weeks

starting at �� weeks

at onset of labour*

until birth of the baby

after birth of the baby

arVsdose (syrup)

Give first dose

then give duration

HIV-positivewithHIV-AIDSrelatedsignsandsymptoms

Tripletherapy ContinuetheARVtreatmentprescribedbeforepregnancy.InthefirsttrimesterreplaceEfavirenzwithNevirapine(200mgoncedailyfor2weeks,thenevery12hours)

Zidovudine 4mg/kg 8–12hoursafterbirth

every12hours

7days***

HIV-positivewithoutHIV-relatedsignsandsymptoms

3TC 150mg every12hours 7days

Zidovudine 300mgevery12hours

300mg every3hours

every12hours

7days Zidovudine 4mg/kg 8–12hoursafterbirth

every12hours

7days***

Nevirapine 200mgonce Nevirapine 2mg/kg within72hours

once

ARVsduringlabour Zidovudine 300mg every3hours

Zidovudine 4mg/kg 8–12hoursafterbirth

every12hours

4weeks

Or600mg

Nevirapine 200mgonce Nevirapine 2mg/kg within72hours

once

OnlyminimalrangeofARVtreatment

Nevirapine 200mgonce Nevirapine 2mg/kg within72hours

once

*Atonsetofcontractionsorruptureofmembranes,regardlessofthepreviousschedule**Arrangefollow-upforfurtherassessmentandtreatmentwithin2weeksafterdelivery ***TreatthenewborninfantwithZidovudinefor4weeksifmotherreceivedZidovudineforlessthan4weeksduringpregnancy,

Info

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VG�0Respond to observed signs or volunteered problems

resPond to oBserVed sIGns or Volunteered ProBlemsuse this chart to manage the woman who has a problem while taking arV medicines. these problems may be side effects of arV medicines or of an underlying disease. rule out serious pregnancy-related diseases before assuming that these are side effects of the drugs. follow up in � weeks or earlier if condition worsens. In no improve-ment, refer the woman to hospital for further management.

SIGNSHeadache

nausea or vomiting

fever

diarrhoea

rash or blisters/ulcers

yellow eyes or mucus membrane

ADVISEANDTREAT■Measurebloodpressureandmanageasin C2 and E3 .■ IfDBP≤ 90mmgiveparacetamolforheadache F4 .

■Measurebloodpressureandmanageasin C2 and E3 .■Advisetotakemedicineswithfood.■ Ifinthefirst3monthsofpregnancy,reassurethatthemorningnauseaandvomitingwill

disappearafterafewweeks.■Refertohospitalifnotpassingurine.

■Measuretemperature.■Manageaccordingto C7-C8 ,C10-C11ifduringpregnancy,and E6-E8 ifinpostpartumperiod.

■Advisetodrinkonecupoffluidaftereverystool.■Refertohospitalifbloodinstool,notpassingurineorfever>38ºC.

■ Ifrashislimitedtoskin,followupin2weeks.■ Ifsevererash,blistersandulcersonskin,andmouthandfever>38ºCrefertohospitalfor

furtherassessmentandtreatment.

■Refertohospitalforfurtherassessmentandtreatment.

IFWOMANHASANyPROBLEM

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G��Prevent HIV infection in health-care workers after accidental exposure with body fluids (Post exposure prophylaxis)

PreVent HIV InfectIon In HealtH-care workers after accIdental eXPosure wItH Body fluIds (Post eXPosure ProPHylaXIs)

Ifyouareaccidentallyexposedtobloodorbodyfluidsbycutsorpricksorsplashesonface/eyesdothefollowingsteps:■ Ifbloodorbloodyfluidsplashesonintactskin,immediatelywashtheareawithsoapandwater.■ Ifthegloveisdamaged,washtheareawithsoapandwaterandchangetheglove.■ Ifsplashedintheface(eye,nose,mouth)washwithwateronly.■ Ifafingerprickoracutoccurredduringproceduressuchassuturing,allowthewoundtobleedforafewseconds,

donotsqueezeouttheblood.Washwithsoapandwater.Useregularwoundcare.Topicalantisepticsmaybeused.■CheckrecordsfortheHIVstatusofthepregnantwoman.* → IfwomanisHIV-negativenofurtheractionisrequired. →IfwomanisHIV-positivetakeARVmedicineswithin2hours(seenationalguidelinesforchoiceanddurationof

medicine). →IftheHIVstatusofthepregnantwomanisunknown: →StarttheARVmedicinewithin2hours(seenationalguidelinesforchoiceanddurationofmedicine). →ExplaintothewomanwhathashappenedandseekherconsentforrapidHIVtest.DONOTtestthewoman

withoutherconsent.Maintainconfidentiality A2 . →PerformtheHIVtest L6 . →Ifthewoman’sHIVtestisnegative,discontinuetheARVmedicines. →Ifthewoman’sHIVtestispositive,managethewomanasin C2 and E3 .Thehealthworker(yourself)

shouldcompletetheARVtreatmentandbetestedafter6weeks.■ Informthesupervisoroftheexposuretypeandtheactiontakenforthehealth-careworker(yourself).Retestthe

health-careworker6weeksaftertheexposure.

*Ifthehealth-careworker(yourself)isHIV-positivenoPEPisrequired.do nottestthewoman.

The woman with special needs

the

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the Woman With special needsemotional support for the Woman With special needs You may need to refer many women to another level of care or to a support group. however, if such support is not available, or if the woman will not seek help, counsel her as follows. Your support and willingness to listen will help her to heal.

Emotional support for the woman with special needs

the

Wom

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spec

ial

need

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Sourcesofsupporta key role of the health worker includes linking the health services with the community and other support services available. maintain existing links and, when possible, explore needs and alternatives for support through the following:■Communitygroups,women’sgroups,leaders.■Peersupportgroups.■Otherhealthserviceproviders.■Communitycounsellors.■Traditionalproviders.

EmotionalsupportPrinciplesofgoodcare,includingsuggestionsoncommunicationwiththewomanandherfamily,areprovidedon a� .Whengivingemotionalsupporttothewomanwithspecialneedsitisparticularlyimportanttorememberthefollowing:■Createacomfortableenvironment:

→Beawareofyourattitude→Beopenandapproachable→Useagentle,reassuringtoneofvoice.

■Guaranteeconfidentialityandprivacy:→Communicateclearlyaboutconfidentiality.Tellthewomanthatyouwillnottellanyoneelseabout

thevisit,discussionorplan.→Ifbroughtbyapartner,parentorotherfamilymember,makesureyouhavetimeandspaceto

talkprivately.Askthewomanifshewouldliketoincludeherfamilymembersintheexaminationanddiscussion.Makesureyouseekherconsentfirst.

→Makesurethephysicalareaallowsprivacy.■Conveyrespect:

→Donotbejudgmental→Beunderstandingofhersituation→Overcomeyourowndiscomfortwithhersituation.

■Givesimple,directanswersinclearlanguage:→Verifythatsheunderstandsthemostimportantpoints.

■Provideinformationaccordingtohersituationwhichshecanusetomakedecisions.■Beagoodlistener:

→Bepatient.Womenwithspecialneedsmayneedtimetotellyoutheirproblemormakeadecision

→Payattentiontoherasshespeaks.■Follow-upvisitsmaybenecessary.

Special considerations in managing the pregnant adolescent

the

Wom

an W

ith

spec

ial

need

s

h�

Wheninteractingwiththeadolescent■Donotbejudgemental.Youshouldbeawareof,andovercome,yourowndiscomfortwithadolescent

sexuality.■Encouragethegirltoaskquestionsandtellherthatalltopicscanbediscussed.■Usesimpleandclearlanguage.■Repeatguaranteeofconfidentiality a� g� .■Understandadolescentdifficultiesincommunicatingabouttopicsrelatedtosexuality(fearsof

parentaldiscovery,adultdisapproval,socialstigma,etc).

Supportherwhendiscussinghersituationandaskifshehasanyparticularconcerns:■Doesshelivewithherparents,cansheconfideinthem?Doessheliveasacouple?Issheinalong-

termrelationship?Hasshebeensubjecttoviolenceorcoercion?■Determinewhoknowsaboutthispregnancy—shemaynothaverevealeditopenly.■Supportherconcernsrelatedtopuberty,socialacceptance,peerpressure,formingrelationships,

socialstigmasandviolence.

Helpthegirlconsiderheroptionsandtomakedecisionswhichbestsuitherneeds.■Birthplanning:deliveryinahospitalorhealthcentreishighlyrecommended.Sheneedsto

understandwhythisisimportant,sheneedstodecideifshewilldoitandandhowshewillarrangeit.■PreventionofSTIorHIV/AIDSisimportantforherandherbaby.Ifsheorherpartnerareatriskof

STIorHIV/AIDS,theyshoulduseacondominallsexualrelations.Shemayneedadviceonhowtodiscusscondomusewithherpartner.

■Spacingofthenextpregnancy—forboththewomanandbaby’shealth,itisrecommendedthatanynextpregnancybespacedbyatleast2or3years.Thegirl,withherpartnerifapplicable,needstodecideifandwhenasecondpregnancyisdesired,basedontheirplans.Healthyadolescentscansafelyuseanycontraceptivemethod.Thegirlneedssupportinknowingheroptionsandindecidingwhichisbestforher.Beactiveinprovidingfamilyplanningcounsellingandadvice.

special considerations in managing the pregnant adolescentspecial training is required to work with adolescent girls and this guide does not substitute for special training. however, when working with an adolescent, whether married or unmarried, it is particularly important to remember the following.

special considerations for supporting the Woman living With violenceviolence against women by their intimate partners affects women’s physical and mental health, including their reproductive health. While you may not have been trained to deal with this problem, women may disclose violence to you or you may see unexplained bruises and other injuries which make you suspect she may be suffering abuse. the following are some recommendations on how to respond and support her.

The woman living with violence

the

Wom

an W

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ial

need

s

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Supportthewomanlivingwithviolence■Provideaspacewherethewomancanspeaktoyouinprivacywhereherpartnerorotherscannot

hear.Doallyoucantoguaranteeconfidentiality,andreassureherofthis.■Gentlyencouragehertotellyouwhatishappeningtoher.Youmayaskindirectquestionstohelpher

tellherstory.■Listentoherinasympatheticmanner.Listeningcanoftenbeofgreatsupport.Donotblameheror

makeajokeofthesituation.Shemaydefendherpartner’saction.Reassureherthatshedoesnotdeservetobeabusedinanyway.

■Helphertoassessherpresentsituation.Ifshethinkssheorherchildrenareindanger,exploretogethertheoptionstoensureherimmediatesafety(e.g.canshestaywithherparentsorfriends?Doesshehave,orcouldsheborrow,money?)

■Exploreheroptionswithher.Helpheridentifylocalsourcesofsupport,eitherwithinherfamily,friends,andlocalcommunityorthroughNGOs,sheltersorsocialservices,ifavailable.Remindherthatshehaslegalrecourse,ifrelevant.

■Offerheranopportunitytoseeyouagain.Violencebypartnersiscomplex,andshemaybeunabletoresolvehersituationquickly.

■Documentanyformsofabuseidentifiedorconcernsyoumayhaveinthefile.

Supportthehealthserviceresponsetoneedsofwomenlivingwithviolence■Helpraiseawarenessamonghealthcarestaffaboutviolenceagainstwomenanditsprevalencein

thecommunitytheclinicserves.■Findoutwhatiftrainingisavailabletoimprovethesupportthathealthcarestaffcanprovideto

thosewomenwhomayneedit.■Displayposters,leafletsandotherinformationthatcondemnviolence,andinformationongroups

thatcanprovidesupport.■Makecontactwithorganizationsworkingtoaddressviolenceinyourarea.Identifythosethatcan

providesupportforwomeninabusiverelationships.Ifspecificservicesarenotavailable,contactothergroupssuchaschurches,women’sgroups,elders,orotherlocalgroupsanddiscusswiththemsupporttheycanprovideorotherwhatrolestheycanplay,likeresolvingdisputes.Ensureyouhavealistoftheseresourcesavailable.

H2 emotional support for the Woman With special needs

Sourcesofsupport Emotionalsupport

H3 special considerations in managing the pregnant adolescent

Wheninteractingwiththeadolescent Helpthegirlconsiderheroptionsandtomake

decisionswhichbestsuitherneeds

H4 special considerations for supporting the Woman living With violence

Supportthewomanlivingwithviolence Supportthehealthserviceresponsetothe

needsofwomenlivingwithviolence

■ Ifawomanisanadolescentorlivingwithviolence,sheneedsspecialconsideration.Duringinteractionwithsuchwomen,usethissectiontosupportthem.

emotional support for the Woman With special needs You may need to refer many women to another level of care or to a support group. however, if such support is not available, or if the woman will not seek help, counsel her as follows. Your support and willingness to listen will help her to heal.

Emotional support for the woman with special needsth

e W

oman

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Sourcesofsupporta key role of the health worker includes linking the health services with the community and other support services available. maintain existing links and, when possible, explore needs and alternatives for support through the following:■Communitygroups,women’sgroups,leaders.■Peersupportgroups.■Otherhealthserviceproviders.■Communitycounsellors.■Traditionalproviders.

EmotionalsupportPrinciplesofgoodcare,includingsuggestionsoncommunicationwiththewomanandherfamily,areprovidedon a� .Whengivingemotionalsupporttothewomanwithspecialneedsitisparticularlyimportanttorememberthefollowing:■Createacomfortableenvironment:

→Beawareofyourattitude→Beopenandapproachable→Useagentle,reassuringtoneofvoice.

■Guaranteeconfidentialityandprivacy:→Communicateclearlyaboutconfidentiality.Tellthewomanthatyouwillnottellanyoneelseabout

thevisit,discussionorplan.→Ifbroughtbyapartner,parentorotherfamilymember,makesureyouhavetimeandspaceto

talkprivately.Askthewomanifshewouldliketoincludeherfamilymembersintheexaminationanddiscussion.Makesureyouseekherconsentfirst.

→Makesurethephysicalareaallowsprivacy.■Conveyrespect:

→Donotbejudgmental→Beunderstandingofhersituation→Overcomeyourowndiscomfortwithhersituation.

■Givesimple,directanswersinclearlanguage:→Verifythatsheunderstandsthemostimportantpoints.

■Provideinformationaccordingtohersituationwhichshecanusetomakedecisions.■Beagoodlistener:

→Bepatient.Womenwithspecialneedsmayneedtimetotellyoutheirproblemormakeadecision

→Payattentiontoherasshespeaks.■Follow-upvisitsmaybenecessary.

Special considerations in managing the pregnant adolescent

the

Wom

an W

ith

spec

ial

need

s

h�

Wheninteractingwiththeadolescent■Donotbejudgemental.Youshouldbeawareof,andovercome,yourowndiscomfortwithadolescent

sexuality.■Encouragethegirltoaskquestionsandtellherthatalltopicscanbediscussed.■Usesimpleandclearlanguage.■Repeatguaranteeofconfidentiality a� g� .■Understandadolescentdifficultiesincommunicatingabouttopicsrelatedtosexuality(fearsof

parentaldiscovery,adultdisapproval,socialstigma,etc).

Supportherwhendiscussinghersituationandaskifshehasanyparticularconcerns:■Doesshelivewithherparents,cansheconfideinthem?Doessheliveasacouple?Issheinalong-

termrelationship?Hasshebeensubjecttoviolenceorcoercion?■Determinewhoknowsaboutthispregnancy—shemaynothaverevealeditopenly.■Supportherconcernsrelatedtopuberty,socialacceptance,peerpressure,formingrelationships,

socialstigmasandviolence.

Helpthegirlconsiderheroptionsandtomakedecisionswhichbestsuitherneeds.■Birthplanning:deliveryinahospitalorhealthcentreishighlyrecommended.Sheneedsto

understandwhythisisimportant,sheneedstodecideifshewilldoitandandhowshewillarrangeit.■PreventionofSTIorHIV/AIDSisimportantforherandherbaby.Ifsheorherpartnerareatriskof

STIorHIV/AIDS,theyshoulduseacondominallsexualrelations.Shemayneedadviceonhowtodiscusscondomusewithherpartner.

■Spacingofthenextpregnancy—forboththewomanandbaby’shealth,itisrecommendedthatanynextpregnancybespacedbyatleast2or3years.Thegirl,withherpartnerifapplicable,needstodecideifandwhenasecondpregnancyisdesired,basedontheirplans.Healthyadolescentscansafelyuseanycontraceptivemethod.Thegirlneedssupportinknowingheroptionsandindecidingwhichisbestforher.Beactiveinprovidingfamilyplanningcounsellingandadvice.

special considerations in managing the pregnant adolescentspecial training is required to work with adolescent girls and this guide does not substitute for special training. however, when working with an adolescent, whether married or unmarried, it is particularly important to remember the following.

special considerations for supporting the Woman living With violenceviolence against women by their intimate partners affects women’s physical and mental health, including their reproductive health. While you may not have been trained to deal with this problem, women may disclose violence to you or you may see unexplained bruises and other injuries which make you suspect she may be suffering abuse. the following are some recommendations on how to respond and support her.

The woman living with violenceth

e W

oman

Wit

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ecia

l ne

eds

h�

Supportthewomanlivingwithviolence■Provideaspacewherethewomancanspeaktoyouinprivacywhereherpartnerorotherscannot

hear.Doallyoucantoguaranteeconfidentiality,andreassureherofthis.■Gentlyencouragehertotellyouwhatishappeningtoher.Youmayaskindirectquestionstohelpher

tellherstory.■Listentoherinasympatheticmanner.Listeningcanoftenbeofgreatsupport.Donotblameheror

makeajokeofthesituation.Shemaydefendherpartner’saction.Reassureherthatshedoesnotdeservetobeabusedinanyway.

■Helphertoassessherpresentsituation.Ifshethinkssheorherchildrenareindanger,exploretogethertheoptionstoensureherimmediatesafety(e.g.canshestaywithherparentsorfriends?Doesshehave,orcouldsheborrow,money?)

■Exploreheroptionswithher.Helpheridentifylocalsourcesofsupport,eitherwithinherfamily,friends,andlocalcommunityorthroughNGOs,sheltersorsocialservices,ifavailable.Remindherthatshehaslegalrecourse,ifrelevant.

■Offerheranopportunitytoseeyouagain.Violencebypartnersiscomplex,andshemaybeunabletoresolvehersituationquickly.

■Documentanyformsofabuseidentifiedorconcernsyoumayhaveinthefile.

Supportthehealthserviceresponsetoneedsofwomenlivingwithviolence■Helpraiseawarenessamonghealthcarestaffaboutviolenceagainstwomenanditsprevalencein

thecommunitytheclinicserves.■Findoutwhatiftrainingisavailabletoimprovethesupportthathealthcarestaffcanprovideto

thosewomenwhomayneedit.■Displayposters,leafletsandotherinformationthatcondemnviolence,andinformationongroups

thatcanprovidesupport.■Makecontactwithorganizationsworkingtoaddressviolenceinyourarea.Identifythosethatcan

providesupportforwomeninabusiverelationships.Ifspecificservicesarenotavailable,contactothergroupssuchaschurches,women’sgroups,elders,orotherlocalgroupsanddiscusswiththemsupporttheycanprovideorotherwhatrolestheycanplay,likeresolvingdisputes.Ensureyouhavealistoftheseresourcesavailable.

Community support for maternal and newborn health

Com

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supp

ort

for

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Community support for maternal and newborn health

establish links

Establish links

Com

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nity

su

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t fo

r m

ater

nal

and

new

born

hea

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Coordinatewithotherhealthcareprovidersandcommunitygroups■Meetwithothersinthecommunitytodiscussandagreemessagesrelatedtopregnancy,delivery,

postpartumandpost-abortioncareofwomenandnewborns.■Worktogetherwithleadersandcommunitygroupstodiscussthemostcommonhealthproblems

andfindsolutions.Groupstocontactandestablishrelationswhichinclude:→otherhealthcareproviders→traditionalbirthattendantsandhealers→maternitywaitinghomes→adolescenthealthservices→schools→nongovernmentalorganizations→breastfeedingsupportgroups→districthealthcommittees→women’sgroups→agriculturalassociations→neighbourhoodcommittees→youthgroups→churchgroups.

■Establishlinkswithpeersupportgroupsandreferralsitesforwomenwithspecialneeds,includingwomenlivingwithHIV,adolescentsandwomenlivingwithviolence.Haveavailablethenamesandcontactinformationforthesegroupsandreferralsites,andencouragethewomantoseektheirsupport.

Establishlinkswithtraditionalbirthattendantsandtraditionalhealers

■Contacttraditionalbirthattendantsandhealerswhoareworkinginthehealthfacility’scatchmentarea.Discusshowyoucansupporteachother.

■Respecttheirknowledge,experienceandinfluenceinthecommunity.■Sharewiththemtheinformationyouhaveandlistentotheiropinionsonthis.Providecopiesof

healtheducationmaterialsthatyoudistributetocommunitymembersanddiscussthecontentwiththem.Havethemexplainknowledgethattheysharewiththecommunity.Togetheryoucancreatenewknowledgewhichismorelocallyappropriate.

■Reviewhowtogetheryoucanprovidesupporttowomen,familiesandgroupsformaternalandnewbornhealth.

■ InvolveTBAsandhealersincounsellingsessions inwhichadviceisgiventofamiliesandothercommunitymembers.IncludeTBAsinmeetingswithcommunityleadersandgroups.

■Discusstherecommendationthatalldeliveriesshouldbeperformedbyaskilledbirthattendant.Whennotpossibleornotpreferredbythewomanandherfamily,discusstherequirementsforsaferdeliveryathome,postpartumcare,andwhentoseekemergencycare.

■ InviteTBAstoactaslabourcompanionsforwomentheyhavefollowedduringpregnancy,ifthisisthewoman’swish.

■MakesureTBAsareincludedinthereferralsystem.■Clarifyhowandwhentorefer,andprovideTBAswithfeedbackonwomentheyhavereferred.

involve the Community in quality of serviCes

Involve the community in quality of services

Com

mun

ity

supp

ort

for

mat

erna

l an

d ne

wbo

rn h

ealt

h

i�

all in the community should be informed and involved in the process of improving the health of their members. ask the different groups to provide feedback and suggestions on how to improve the services the health facility provides.■Findoutwhatpeopleknowaboutmaternalandnewbornmortalityandmorbidityintheirlocality.

Sharedatayoumayhaveandreflecttogetheronwhythesedeathsandillnessesmayoccur.Discusswiththemwhatfamiliesandcommunitiescandotopreventthesedeathsandillnesses.Togetherprepareanactionplan,definingresponsibilities.

■Discussthedifferenthealthmessagesthatyouprovide.Havethecommunitymemberstalkabouttheirknowledgeinrelationtothesemessages.Togetherdeterminewhatfamiliesandcommunitiescandotosupportmaternalandnewbornhealth.

■Discusssomepracticalwaysinwhichfamiliesandothersinthecommunitycansupportwomenduringpregnancy,post-abortion,deliveryandpostpartumperiods:→Recognitionofandrapidresponsetoemergency/dangersignsduringpregnancy,deliveryand

postpartumperiods→Provisionoffoodandcareforchildrenandotherfamilymemberswhenthewomanneedstobe

awayfromhomeduringdelivery,orwhensheneedstorest→Accompanyingthewomanafterdelivery→Supportforpaymentoffeesandsupplies→Motivationofmalepartnerstohelpwiththeworkload,accompanythewomantotheclinic,allow

hertorestandensuresheeatsproperly.Motivatecommunicationbetweenmalesandtheirpartners,includingdiscussingpostpartumfamilyplanningneeds.

■Supportthecommunityinpreparinganactionplantorespondtoemergencies.Discussthefollowingwiththem:→Emergency/dangersigns-knowingwhentoseekcare→Importanceofrapidresponsetoemergenciestoreducemotherandnewborndeath,disabilityand

illness→Transportoptionsavailable,givingexamplesofhowtransportcanbeorganized→Reasonsfordelaysinseekingcareandpossibledifficulties,includingheavyrains→Whatservicesareavailableandwhere→Whatoptionsareavailable→Costsandoptionsforpayment→Aplanofactionforrespondinginemergencies,includingrolesandresponsibilities.

I2 establish links Coordinatewithotherhealthcareproviders

andcommunitygroups Establishlinkswithtraditionalbirthattendants

andtraditionalhealers

I3 involve the Community in quality of serviCes

■Everyoneinthecommunityshouldbeinformedandinvolvedintheprocessofimprovingthehealthoftheircommunitymembers.Thissectionprovidesguidanceonhowtheirinvolvementcanhelpimprovethehealthofwomenandnewborns.

■Differentgroupsshouldbeaskedtogivefeedbackandsuggestionsonhowtoimprovetheservicesthehealthfacilitiesprovide.

■Usethefollowingsuggestionswhenworkingwithfamiliesandcommunitiestosupportthecareofwomenandnewbornsduringpregnancy,delivery,post-abortionandpostpartumperiods.

establish links

Establish linksCo

mm

unit

y su

ppor

t fo

r m

ater

nal

and

new

born

hea

lth

i�

Coordinatewithotherhealthcareprovidersandcommunitygroups■Meetwithothersinthecommunitytodiscussandagreemessagesrelatedtopregnancy,delivery,

postpartumandpost-abortioncareofwomenandnewborns.■Worktogetherwithleadersandcommunitygroupstodiscussthemostcommonhealthproblems

andfindsolutions.Groupstocontactandestablishrelationswhichinclude:→otherhealthcareproviders→traditionalbirthattendantsandhealers→maternitywaitinghomes→adolescenthealthservices→schools→nongovernmentalorganizations→breastfeedingsupportgroups→districthealthcommittees→women’sgroups→agriculturalassociations→neighbourhoodcommittees→youthgroups→churchgroups.

■Establishlinkswithpeersupportgroupsandreferralsitesforwomenwithspecialneeds,includingwomenlivingwithHIV,adolescentsandwomenlivingwithviolence.Haveavailablethenamesandcontactinformationforthesegroupsandreferralsites,andencouragethewomantoseektheirsupport.

Establishlinkswithtraditionalbirthattendantsandtraditionalhealers

■Contacttraditionalbirthattendantsandhealerswhoareworkinginthehealthfacility’scatchmentarea.Discusshowyoucansupporteachother.

■Respecttheirknowledge,experienceandinfluenceinthecommunity.■Sharewiththemtheinformationyouhaveandlistentotheiropinionsonthis.Providecopiesof

healtheducationmaterialsthatyoudistributetocommunitymembersanddiscussthecontentwiththem.Havethemexplainknowledgethattheysharewiththecommunity.Togetheryoucancreatenewknowledgewhichismorelocallyappropriate.

■Reviewhowtogetheryoucanprovidesupporttowomen,familiesandgroupsformaternalandnewbornhealth.

■ InvolveTBAsandhealersincounsellingsessions inwhichadviceisgiventofamiliesandothercommunitymembers.IncludeTBAsinmeetingswithcommunityleadersandgroups.

■Discusstherecommendationthatalldeliveriesshouldbeperformedbyaskilledbirthattendant.Whennotpossibleornotpreferredbythewomanandherfamily,discusstherequirementsforsaferdeliveryathome,postpartumcare,andwhentoseekemergencycare.

■ InviteTBAstoactaslabourcompanionsforwomentheyhavefollowedduringpregnancy,ifthisisthewoman’swish.

■MakesureTBAsareincludedinthereferralsystem.■Clarifyhowandwhentorefer,andprovideTBAswithfeedbackonwomentheyhavereferred.

involve the Community in quality of serviCes

Involve the community in quality of services

Com

mun

ity

supp

ort

for

mat

erna

l an

d ne

wbo

rn h

ealt

h

i�

all in the community should be informed and involved in the process of improving the health of their members. ask the different groups to provide feedback and suggestions on how to improve the services the health facility provides.■Findoutwhatpeopleknowaboutmaternalandnewbornmortalityandmorbidityintheirlocality.

Sharedatayoumayhaveandreflecttogetheronwhythesedeathsandillnessesmayoccur.Discusswiththemwhatfamiliesandcommunitiescandotopreventthesedeathsandillnesses.Togetherprepareanactionplan,definingresponsibilities.

■Discussthedifferenthealthmessagesthatyouprovide.Havethecommunitymemberstalkabouttheirknowledgeinrelationtothesemessages.Togetherdeterminewhatfamiliesandcommunitiescandotosupportmaternalandnewbornhealth.

■Discusssomepracticalwaysinwhichfamiliesandothersinthecommunitycansupportwomenduringpregnancy,post-abortion,deliveryandpostpartumperiods:→Recognitionofandrapidresponsetoemergency/dangersignsduringpregnancy,deliveryand

postpartumperiods→Provisionoffoodandcareforchildrenandotherfamilymemberswhenthewomanneedstobe

awayfromhomeduringdelivery,orwhensheneedstorest→Accompanyingthewomanafterdelivery→Supportforpaymentoffeesandsupplies→Motivationofmalepartnerstohelpwiththeworkload,accompanythewomantotheclinic,allow

hertorestandensuresheeatsproperly.Motivatecommunicationbetweenmalesandtheirpartners,includingdiscussingpostpartumfamilyplanningneeds.

■Supportthecommunityinpreparinganactionplantorespondtoemergencies.Discussthefollowingwiththem:→Emergency/dangersigns-knowingwhentoseekcare→Importanceofrapidresponsetoemergenciestoreducemotherandnewborndeath,disabilityand

illness→Transportoptionsavailable,givingexamplesofhowtransportcanbeorganized→Reasonsfordelaysinseekingcareandpossibledifficulties,includingheavyrains→Whatservicesareavailableandwhere→Whatoptionsareavailable→Costsandoptionsforpayment→Aplanofactionforrespondinginemergencies,includingrolesandresponsibilities.

Newborn care

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NewborN careExamine the newborn

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ASK,CHECKRECORDcheck maternal andnewborn record or askthe mother:■Howoldisthebaby?■Preterm(lessthan37weeks

or1monthormoreearly)?■Breechbirth?■Difficultbirth?■Resuscitatedatbirth?■Hasbabyhadconvulsions?

ask the mother:■Doyouhaveconcerns?■Howisthebabyfeeding?

is the mother very ill or transferred?

LOOK,LISTEN,FEEL■Assessbreathing(babymustbe

calm)→ listenforgrunting→countbreaths:arethey60or

lessperminute?Repeatthecountifelevated

→lookatthechestforin-drawing.■Lookatthemovements:are theynormalandsymmetrical?■Lookatthepresentingpart— isthereswellingandbruises?■Lookatabdomenforpallor.■Lookformalformations.■Feelthetone:isitnormal?■Feelforwarmth.Ifcold,or verywarm,measuretemperature.■Weighthebaby.

SIGNS■Normalweightbaby

(2500-gormore).■Feedingwell—sucklingeffectively

8timesin24hours,dayandnight.■Nodangersigns.■Nospecialtreatmentneedsor

treatmentcompleted.■Smallbaby,feedingwellandgaining

weightadequately.

■Bodytemperature 35-36.4ºC.

■Mothernotabletobreastfeedduetoreceivingspecial

treatment.■Mothertransferred.

TREATANDADVISEif first examination:■Ensurecareforthenewborn J10 .■Examineagainfordischarge.

if pre-discharge examination:■ ImmunizeifdueK13.■Adviseonbabycare K2 K9-K10 .■Adviseonroutinevisitatage3-7daysK14.■Adviseonwhentoreturnifdanger signsK14.■Recordinhome-basedrecord.■ Iffurthervisits,repeatadvices.

■Re-warmthebabyskin-to-skin K9 .■ Iftemperaturenotrisingafter2hours,reassess

thebaby.

■Helpthemotherexpressbreastmilk K5 .■Consideralternativefeedingmethodsuntilmotheris

well K5-K6 .■Providecareforthebaby,ensurewarmth K9 .■Ensuremothercanseethebabyregularly.■Transferthebabywiththemotherifpossible.■Ensurecareforthebabyathome.

CLASSIFYwell baby

mildhypothermia

mother Not able to take care for baby

Next:Ifpreterm,birthweight<2500gortwin

examiNe the NewborNuse this chart to assess the newborn after birth, classify and treat, possibly around an hour; for discharge (not before �2 hours); and during the first week of life at rou-tine, follow-up, or sick newborn visit. record the findings on the postpartum record N6 . always examine the baby in the presence of the mother.

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If preterm, birth weight <2500 g or twin

ASK,CHECKRECORD■Babyjustborn.■Birthweight

→ <1500-g→ 1500-gto<2500-g.

■Preterm → <32weeks → 33-36weeks.■Twin.

LOOK,LISTEN,FEEL■ Ifthisisrepeatedvisit,

assessweightgain

SIGNS■Birthweight<1500-g.■Verypreterm<32weeks

or>2monthsearly).

■Birthweight1500-g-2500-g.■Pretermbaby(32-36weeks

or1-2monthsearly).■Severaldaysoldand

weightgaininadequate.■Feedingdifficulty.

■Twin

TREATANDADVISE■refer baby urgently to hospitalK14.■Ensureextrawarmthduringreferral.

■Givespecialsupporttobreastfeedthesmallbaby K4 .

■Ensureadditionalcareforasmallbaby J11 .■Reassessdaily J11 .■Donotdischargebeforefeedingwell,gainingweight

andbodytemperaturestable.■ Iffeedingdifficultiespersistfor3daysand

otherwisewell,referforbreastfeedingcounselling.

■Givespecialsupporttothemothertobreastfeedtwins K4 .

■Donotdischargeuntilbothtwinscangohome.

CLASSIFYVery small baby

small baby

twiN

if preterm, birth weight <2500-g or twiN

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Next:Assessbreastfeeding�

Assess breastfeeding

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ASK,CHECKRECORDask the mother■Howisthebreastfeedinggoing?■Hasyourbabyfedintheprevious

hour?■ Isthereanydifficulty?■ Isyourbabysatisfiedwiththefeed?■Haveyoufedyourbabyanyother

foodsordrinks?■Howdoyourbreastsfeel?■Doyouhaveanyconcerns?

if baby more than one day old:■Howmanytimeshasyourbabyfed

in24hours?

Toassessreplacementfeedingsee J12 .

LOOK,LISTEN,FEEL■ observe a breastfeed. Ifthebabyhasnotfedintheprevioushour,askthemothertoputthebabyonherbreastsandobservebreastfeedingforabout5minutes.

look■ Isthebabyabletoattachcorrectly?■ Isthebabywell-positioned?■ Isthebabysucklingeffectively?

Ifmotherhasfedinthelasthour,askhertotellyouwhenherbabyiswillingtofeedagain.

SIGNS■Sucklingeffectively.■Breastfeeding8timesin24hours

ondemanddayandnight

■Notyetbreastfed(firsthoursoflife).■Notwellattached.■Notsucklingeffectively.■Breastfeedinglessthan8timesper

24hours.■Receivingotherfoodsordrinks.■Severaldaysoldandinadequate

weightgain.

■Notsuckling(after6hoursofage).■Stoppedfeeding.

TREATANDADVISE■Encouragethemothertocontinuebreastfeedingon

demand K3 .

■Supportexclusivebreastfeeding K2-K3 .■Helpthemothertoinitiatebreastfeeding K3 .■Teachcorrectpositioningandattachment K3 .■Advisetofeedmorefrequently,dayandnight.

Reassureherthatshehasenoughmilk.■Advisethemothertostopfeedingthebabyother

foodsordrinks.■Reassessatthenextfeedorfollow-upvisitin2days.

■refer baby urgently to hospitalK14.

CLASSIFYfeediNg well

feediNg difficulty

Not able to feed

Next:Checkforspecialtreatmentneeds

assess breastfeediNgassess breastfeeding in every baby as part of the examination. if mother is complaining of nipple or breast pain, also assess the mother’s breasts J9 .

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Check for special treatment needs

ASK,CHECKRECORDcheck record for special treatment needs■Hasthemotherhad

within2daysofdelivery:→ fever>38ºC?→infectiontreatedwithantibiotics?

■Membranesruptured>18hoursbeforedelivery?

■MothertestedRPR-positive?■MothertestedHIV-positive?

→isorhasbeenonARV→hasshereceived

infantfeedingcounselling?■ IsthemotherreceivingTBtreatment

whichbegan<2monthsago?

LOOK,LISTEN,FEEL SIGNS■Baby<1dayoldandmembranes

ruptured>18hoursbeforedelivery,or

■Motherbeingtreatedwithantibioticsforinfection,

or■Motherhasfever>38ºC.

■MothertestedRPR-positive.

■MotherknowntobeHIV-positive.■Motherhasnotbeen

counselledoninfantfeeding.■Motherchosebreastfeeding.■Motherchosereplacementfeeding.

■MotherstartedTBtreatment<2monthsbeforedelivery.

TREATANDADVISE■Givebaby2IMantibioticsfor5daysK12.■Assessbabydaily J2-J7 .

■GivebabysingledoseofbenzathinepenicillinK12.■Ensuremotherandpartneraretreated F6 .■Followupin2weeks.

■GiveARVtothenewborn G9 .■ Informoninfantfeedingoptions G7 .■Givespecialcounsellingtomotherwhoisbreast

feeding G8 .■Teachthemotherreplacementfeeding.■Followupin2weeks G8 .

■Givebabyisoniazidpropylaxisfor6monthsK13.■GiveBCGvaccinationtothebabyonlywhenbaby’s

treatmentcompleted.■Followupin2weeks.

CLASSIFYrisk of bacterial iNfectioN

risk of coNgeNital syphilis

risk of hiV traNsmissioN

risk of tuberculosis

Next:Lookforsignsofjaundiceandlocalinfection

check for special treatmeNt Needs

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Look for signs of jaundice and local infection

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ASK,CHECKRECORD■Whathasbeenappliedtothe

umbilicus?

LOOK,LISTEN,FEEL■Lookattheskin,isityellow?

→ ifbabyislessthan24hoursold,lookatskinontheface

→ ifbabyis24hoursoldormore,lookatpalmsandsoles.

■Lookattheeyes.Aretheyswollenanddrainingpus?

■Lookattheskin,especiallyaroundtheneck,armpits,inguinalarea:→ Arethereskinpustules?→ Isthereswelling,hardnessor

largebullae?■Lookattheumbilicus:

→ Isitred?→ Drainingpus?→ Doesrednessextendtotheskin?

SIGNS■Yellowskinonfaceand

only≤24hoursold.■Yellowpalmsandsolesand

>24hoursold.

■Eyesswollenanddrainingpus.

■Redumbilicusorskinaroundit.

■Lessthan10pustules

TREATANDADVISE■refer baby urgently to hospitalK14.■Encouragebreastfeedingontheway.■ Iffeedingdifficulty,giveexpressedbreastmilkbycup K6 .

■GivesingledoseofappropriateantibioticforeyeinfectionK12.

■TeachmothertotreateyesK13.■Followupin2days.Ifnoimprovementorworse,

referurgentlytohospital.■Assessandtreatmotherandherpartnerforpossible

gonorrhea E8 .

■TeachmothertotreatumbilicalinfectionK13.■ Ifnoimprovementin2days,orifworse,refer

urgentlytohospital.

■TeachmothertotreatskininfectionK13.■Followupin2days.■ Ifnoimprovementofpustulesin2daysormore,

referurgentlytohospital.

CLASSIFYJauNdice

goNococcaleye iNfectioN

local umbilicaliNfectioN

local skiNiNfectioN

Next:Ifdangersigns

look for sigNs of JauNdice aNd local iNfectioN

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If danger signs

SIGNSany of the following signs:■Fastbreathing

(morethan60breathsperminute).■Slowbreathing

(lessthan30breathsperminute).■Severechestin-drawing■Grunting■Convulsions.■Floppyorstiff.■Fever(temperature>38ºC).■Temperature<35ºCornotrising

afterrewarming.■Umbilicusdrainingpusorumbilical

rednessextendingtoskin.■Morethan10skinpustules

orbullae,orswelling,redness,hardnessofskin.

■Bleedingfromstumporcut.

TREATANDADVISE■Givefirstdoseof2IMantibioticsK12.■ refer baby urgently to hospitalK14.

in addition:■Re-warmandkeepwarmduringreferral K9 .

■TreatlocalumbilicalinfectionbeforereferralK13.

■TreatskininfectionbeforereferralK13.

■Stopthebleeding.

CLASSIFYpossible serious illNess

Next:Ifswelling,bruisesormalformation

if daNger sigNs

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J2 examiNe the NewborN

J3 if preterm, birth weight <2500 g or twiN

J4 assess breastfeediNg

J5 check for special treatmeNt Needs

J6 look for sigNs of JauNdice aNd local iNfectioN

J7 if daNger sigNs

If swelling, bruises or malformation

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SIGNS■Bruises,swellingonbuttocks.■Swollenhead—bumpon

oneorbothsides.■Abnormalpositionoflegs

(afterbreechpresentation).■Asymmetricalarmmovement,

armdoesnotmove.

■Clubfoot

■Cleftpalateorlip

■Oddlooking,unusualappearance

■Opentissueonhead,abdomenorback

■Otherabnormalappearance.

TREATANDADVISE■Explaintoparentsthatitdoesnothurtthebaby,

itwilldisappearinaweekortwoandnospecialtreatmentisneeded.

■DONOTforcelegsintoadifferentposition.■Gentlyhandlethelimbthatisnotmoving,

donotpull.

■Referforspecialtreatmentifavailable.

■Helpmothertobreastfeed.Ifnotsuccessful,teachheralternativefeedingmethods K5-K6 .Plantofollowup.

■Adviseonsurgicalcorrectionatageofseveralmonths.

■Referforspecialevaluation.

■Coverwithsteriletissuessoakedwithsterilesalinesolutionbeforereferral.

■Referforspecialtreatmentifavailable.

■Manageaccordingtonationalguidelines.

CLASSIFYbirth iNJury

malformatioN

seVere malformatioN

Next:Assessthemother’sbreastsifcomplainingofnippleorbreastpain

if swelliNg, bruises or malformatioN

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Next:Careofthenewborn

Assess the mother’s breasts if complaining of nipple or breast pain

ASK,CHECKRECORD■Howdoyourbreastsfeel?

LOOK,LISTEN,FEEL■Lookatthenippleforfissure■Lookatthebreastsfor:

→ swelling→ shininess→ redness.

■Feelgentlyforpainfulpartofthebreast.

■Measuretemperature.■Observeabreastfeed

ifnotyetdone J4 .

SIGNS■Noswelling,rednessortenderness.■Normalbodytemperature.■Nipplenotsoreandnofissure

visible.■Babywellattached.

■Nipplesoreorfissured.■Babynotwellattached.

■Bothbreastsareswollen,shinyandpatchyred.

■Temperature<38ºC.■Babynotwellattached.■Notyetbreastfeeding.

■Partofbreastispainful,swollenandred.

■Temperature>38ºC■Feelsill.

TREATANDADVISE■Reassurethemother.

■Encouragethemothertocontinuebreastfeeding.■Teachcorrectpositioningandattachment K3 .■Reassessafter2feeds(or1day).Ifnotbetter,

teachthemotherhowtoexpressbreastmilkfromtheaffectedbreastandfeedbabybycup,andcontinuebreastfeedingonthehealthyside.

■Encouragethemothertocontinuebreastfeeding.■Teachcorrectpositioningandattachment K3 .■Advisetofeedmorefrequently.■Reassessafter2feeds(1day).Ifnotbetter,teach

motherhowtoexpressenoughbreastmilkbeforethefeedtorelievediscomfort K5 .

■Encouragemothertocontinuebreastfeeding.■Teachcorrectpositioningandattachment K3 .■Givecloxacillinfor10days F5 .■Reassessin2days.Ifnoimprovementorworse,

refertohospital.■ IfmotherisHIV+letherbreastfeedonthehealthy

breast.Expressmilkfromtheaffectedbreastanddiscarduntilnofever K5 .

■ Ifseverepain,giveparacetamol F4 .

CLASSIFYbreastshealthy

NipplesoreNessor fissure

breast eNgorgemeNt

mastitis

assess the mother’s breasts if complaiNiNg of Nipple or breast paiN

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care of the NewborNuse this chart for care of all babies until discharge.

Care of the newborn

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CAREANDMONITORING■Ensuretheroomiswarm(notlessthan25ºCandnodraught).■Keepthebabyintheroomwiththemother,inherbedorwithineasyreach.■Letthemotherandbabysleepunderabednet.

■Supportexclusivebreastfeedingondemanddayandnight.■Askthemothertoalertyouifbreastfeedingdifficulty.■Assessbreastfeedingineverybabybeforeplanningfordischarge.do Notdischargeifbabyisnotyetfeedingwell.

■Teachthemotherhowtocareforthebaby.→ Keepthebabywarm K9

→ GivecordcareK10

→ EnsurehygieneK10.do Notexposethebabyindirectsun.do Notputthebabyonanycoldsurface.do Notbaththebabybefore6hours.

■Askthemotherandcompaniontowatchthebabyandalertyouif→ Feetcold→ Breathingdifficulty:grunting,fastorslowbreathing,chestin-drawing→ Anybleeding.

■GiveprescribedtreatmentsaccordingtothescheduleK12.

■Examineeverybabybeforeplanningtodischargemotherandbaby J2-J9 . do Notdischargebeforebabyis12hoursold.

RESPONDTOABNORMALFINDINGS■ Ifthebabyisinacot,ensurebabyisdressedorwrappedandcoveredbyablanket.

Covertheheadwithahat.

■ Ifmotherreportsbreastfeedingdifficulty,assessbreastfeedingandhelpthemotherwithpositioningandattachment J3

■ Ifthemotherisunabletotakecareofthebaby,providecareorteachthecompanionK9-K10

■Washhandsbeforeandafterhandlingthebaby.

■ Iffeetarecold:→ Teachthemothertoputthebabyskin-to-skinK13.→ Reassessin1hour;iffeetstillcold,measuretemperatureandre-warmthebaby K9 .

■ Ifbleedingfromcord,checkiftieislooseandretiethecord.■ Ifotherbleeding,assessthebabyimmediately J2-J7 .■ Ifbreathingdifficultyormotherreportsanyotherabnormality,examinethebabyason J2-J7 .

Next:Additionalcareofasmallbaby(ortwin)�

additioNal care of a small baby (or twiN)use this chart for additional care of a small baby: preterm, �-2 months early or weighing �500g-<2500g. refer to hospital a very small baby: >2 months early, weighing <�500-g

Additional care of a small baby (twin)

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CAREANDMONITORING■Plantokeepthesmallbabylongerbeforedischarging.■Allowvisitstothemotherandbaby.

■Givespecialsupportforbreastfeedingthesmallbaby(ortwins) K4 :→ Encouragethemothertobreastfeedevery2-3hours.→ Assessbreastfeedingdaily:attachment,suckling,durationandfrequencyoffeeds,andbaby

satisfactionwiththefeed J4 K6 .→ Ifalternativefeedingmethodisused,assessthetotaldailyamountofmilkgiven.→ Weighdailyandassessweightgain K7 .

■Ensureadditionalwarmthforthesmallbaby K9 :→ Ensuretheroomisverywarm(25º–28ºC).→ Teachthemotherhowtokeepthesmallbabywarminskin-to-skincontact→ Provideextrablanketsformotherandbaby.

■Ensurehygiene K10 .do Notbaththesmallbaby.Washasneeded.

■Assessthesmallbabydaily:→ Measuretemperature→ Assessbreathing(babymustbequiet,notcrying):listenforgrunting;countbreathsperminute,

repeatthecountif>60or<30;lookforchestin-drawing→ Lookforjaundice(first10daysoflife):first24hoursontheabdomen,thenonpalmsandsoles.

■Plantodischargewhen:→ Breastfeedingwell→ Gainingweightadequatelyon3consecutivedays→ Bodytemperaturebetween36.5ºand37.5ºCon3consecutivedays→ Motherableandconfidentincaringforthebaby→ Nomaternalconcerns.

■Assessthebabyfordischarge.

RESPONSETOABNORMALFINDINGS

■ Ifthesmallbabyisnotsucklingeffectivelyanddoesnothaveotherdangersigns,consideralternativefeedingmethods K5-K6 .→ Teachthemotherhowtohandexpressbreastmilkdirectlyintothebaby’smouth K5 → Teachthemothertoexpressbreastmilkandcupfeedthebaby K5-K6

→ Determineappropriateamountfordailyfeedsbyage K6 .■ Iffeedingdifficultypersistsfor3days,orweightlossgreaterthan10%ofbirthweightand

nootherproblems,referforbreastfeedingcounsellingandmanagement.

■ Ifdifficulttokeepbodytemperaturewithinthenormalrange(36.5ºCto37.5ºC):→ Keepthebabyinskin-to-skincontactwiththemotherasmuchaspossible→ Ifbodytemperaturebelow36.5ºCpersistsfor2hoursdespiteskin-to-skincontactwithmother,

assessthebaby J2-J8 .■ Ifbreathingdifficulty,assessthebaby J2-J8 .■ Ifjaundice,referthebabyforphototherapy.■ Ifanymaternalconcern,assessthebabyandrespondtothemother J2-J8 .

■ Ifthemotherandbabyarenotabletostay,ensuredaily(home)visitsorsendtohospital.

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assess replacemeNt feediNgif mother chose replacement feeding assess the feeding in every baby as part of the examination.advise the mother on how to relieve engorgement K8 . if mother is complaining of breast pain, also assess the mother’s breasts J9 .

ASK,CHECKRECORDask the mother■Whatareyoufeedingthebaby?■Howareyoufeedingyourbaby?■Hasyourbabyfedintheprevious

hour?■ Isthereanydifficulty?■Howmuchmilkisbabytakingper

feed?■ Isyourbabysatisfiedwiththefeed?■Haveyoufedyourbabyanyother

foodsordrinks?■Doyouhaveanyconcerns?

if baby more than one day old:■Howmanytimeshasyourbabyfed

in24hours?■Howmuchmilkisbabytakingper

day?

■Howdoyourbreastsfeel?

LOOK,LISTEN,FEELobserve a feed■ Ifthebabyhasnotfedinthe

previoushour,askthemothertofeedthebabyandobservefeedingforabout5minutes.Askhertopreparethefeed.

look■ Issheholdingthecuptothebaby’s

lips?■ Isthebabyalert,openseyesand

mouth?■ Isthebabysuckingandswallowing

themilkeffectively,spillinglittle?

Ifmotherhasfedinthelasthour,askhertotellyouwhenherbabyiswillingtofeedagain.

SIGNS■Suckingandswallowingadequate

amountofmilk,spillinglittle.■Feeding8timesin24hourson

demanddayandnight.

■Notyetfed(first6hoursoflife).■Notfedbycup.■Notsuckingandswallowingeffectively,

spilling■Notfeedingadequateamountperday.■Feedinglessthan8timesper24

hours.■Receivingotherfoodsordrinks.■Severaldaysoldandinadequate

weightgain.

■Notsucking(after6hoursofage).■Stoppedfeeding.

TREATANDADVISE■Encouragethemothertocontinuefeedingbycupon

demand K6 .

■Teachthemotherreplacementfeeding G8 .■Teachthemothercupfeeding K6 .■Advisetofeedmorefrequently,ondemand,dayand

night.■Advisethemothertostopfeedingthebabyotherfoods

ordrinksorbybottle.■Reassessatthenextfeedorfollow-upvisitin2days.

■refer baby urgently to hospitalK14 .

CLASSIFYfeediNg well

feediNg difficulty

Not able to feed

J8 if swelliNg, bruises or malformatioN

J9 assess the mother’s breasts if complaiNiNg of Nipple or breast paiN

J10 care of the NewborN

J11 additioNal care of a small baby (or twiN)

J12 assess replacemeNt feediNg

■Examinineroutinelyallbabiesaroundanhourofbirth,fordischarge,atroutineandfollow-uppostnatalvisitsinthefirstweeksoflife,andwhentheproviderormotherobservesdangersigns.

■UsethechartAssessthemother’sbreastsifthemotheriscomplainingofnippleorbreastpain J9 .

■Duringthestayatthefacility,usetheCareofthenewbornchartJ10 .Ifthebabyissmallbutdoesnotneedreferral,alsousetheAdditionalcareforasmallbabyortwinchart J11 .

■UsetheBreastfeeding,care,preventivemeasuresandtreatmentforthenewbornsectionsfordetailsofcare,resuscitationandtreatments K1-K13 .

■UseAdviseonwhentoreturnwiththebabyK14foradvisingthemotherwhentoreturnwiththebabyforroutineandfollow-upvisitsandtoseekcareorreturnifbabyhasdangersigns.Useinformationandcounsellingsheets M5-M6 .

■Forcareatbirthandduringthefirsthoursoflife,useLabouranddeliveryD19.

also see:■CounselonchoicesofinfantfeedingandHIV-relatedissues G7-G8 .■Equipment,suppliesanddrugs L1-L5 .■Records N1-N7 .■BabydiedD24.

Examine the newbornNe

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are

ASK,CHECKRECORDcheck maternal andnewborn record or askthe mother:■Howoldisthebaby?■Preterm(lessthan37weeks

or1monthormoreearly)?■Breechbirth?■Difficultbirth?■Resuscitatedatbirth?■Hasbabyhadconvulsions?

ask the mother:■Doyouhaveconcerns?■Howisthebabyfeeding?

is the mother very ill or transferred?

LOOK,LISTEN,FEEL■Assessbreathing(babymustbe

calm)→ listenforgrunting→countbreaths:arethey30-60

perminute?Repeatthecountifelevated

→lookatthechestforin-drawing.■Lookatthemovements:are theynormalandsymmetrical?■Lookatthepresentingpart— isthereswellingandbruises?■Lookatabdomenforpallor.■Lookformalformations.■Feelthetone:isitnormal?■Feelforwarmth.Ifcold,or verywarm,measuretemperature.■Weighthebaby.

SIGNS■Normalweightbaby

(2500-gormore).■Feedingwell—sucklingeffectively

8timesin24hours,dayandnight.■Nodangersigns.■Nospecialtreatmentneedsor

treatmentcompleted.■Smallbaby,feedingwellandgaining

weightadequately.

■Bodytemperature 35-36.4ºC.

■Mothernotabletobreastfeedduetoreceivingspecial

treatment.■Mothertransferred.

TREATANDADVISEif first examination:■Ensurecareforthenewborn J10 .■Examineagainfordischarge.

if pre-discharge examination:■ ImmunizeifdueK13.■Adviseonbabycare K2 K9-K10 .■Adviseonroutinevisitatage3-7daysK14.■Adviseonwhentoreturnifdanger signsK14.■Recordinhome-basedrecord.■ Iffurthervisits,repeatadvices.

■Re-warmthebabyskin-to-skin K9 .■ Iftemperaturenotrisingafter2hours,reassess

thebaby.

■Helpthemotherexpressbreastmilk K5 .■Consideralternativefeedingmethodsuntilmotheris

well K5-K6 .■Providecareforthebaby,ensurewarmth K9 .■Ensuremothercanseethebabyregularly.■Transferthebabywiththemotherifpossible.■Ensurecareforthebabyathome.

CLASSIFYwell baby

mildhypothermia

mother Not able to take care for baby

Next:Ifpreterm,birthweight<2500gortwin

examiNe the NewborNuse this chart to assess the newborn after birth, classify and treat, possibly around an hour; for discharge (not before �2 hours); and during the first week of life at rou-tine, follow-up, or sick newborn visit. record the findings on the postpartum record N6 . always examine the baby in the presence of the mother.

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If preterm, birth weight <2500 g or twin

ASK,CHECKRECORD■Babyjustborn.■Birthweight

→ <1500-g→ 1500-gto<2500-g.

■Preterm → <32weeks → 33-36weeks.■Twin.

LOOK,LISTEN,FEEL■ Ifthisisrepeatedvisit,

assessweightgain

SIGNS■Birthweight<1500g.■Verypreterm<32weeks

or>2monthsearly).

■Birthweight1500g-<2500g.■Pretermbaby(32-36weeks

or1-2monthsearly).■Severaldaysoldand

weightgaininadequate.■Feedingdifficulty.

■Twin

TREATANDADVISE■refer baby urgently to hospitalK14.■Ensureextrawarmthduringreferral.

■Givespecialsupporttobreastfeedthesmallbaby K4 .

■Ensureadditionalcareforasmallbaby J11 .■Reassessdaily J11 .■Donotdischargebeforefeedingwell,gainingweight

andbodytemperaturestable.■ Iffeedingdifficultiespersistfor3daysand

otherwisewell,referforbreastfeedingcounselling.

■Givespecialsupporttothemothertobreastfeedtwins K4 .

■Donotdischargeuntilbothtwinscangohome.

CLASSIFYVery small baby

small baby

twiN

if preterm, birth weight <2500-g or twiN

New

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car

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Next:Assessbreastfeedingt

Assess breastfeedingNe

wbo

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are

ASK,CHECKRECORDask the mother■Howisthebreastfeedinggoing?■Hasyourbabyfedintheprevious

hour?■ Isthereanydifficulty?■ Isyourbabysatisfiedwiththefeed?■Haveyoufedyourbabyanyother

foodsordrinks?■Howdoyourbreastsfeel?■Doyouhaveanyconcerns?

if baby more than one day old:■Howmanytimeshasyourbabyfed

in24hours?

Toassessreplacementfeedingsee J12 .

LOOK,LISTEN,FEEL■ observe a breastfeed. Ifthebabyhasnotfedintheprevioushour,askthemothertoputthebabyonherbreastsandobservebreastfeedingforabout5minutes.

look■ Isthebabyabletoattachcorrectly?■ Isthebabywell-positioned?■ Isthebabysucklingeffectively?

Ifmotherhasfedinthelasthour,askhertotellyouwhenherbabyiswillingtofeedagain.

SIGNS■Sucklingeffectively.■Breastfeeding8timesin24hours

ondemanddayandnight

■Notyetbreastfed(firsthoursoflife).■Notwellattached.■Notsucklingeffectively.■Breastfeedinglessthan8timesper

24hours.■Receivingotherfoodsordrinks.■Severaldaysoldandinadequate

weightgain.

■Notsuckling(after6hoursofage).■Stoppedfeeding.

TREATANDADVISE■Encouragethemothertocontinuebreastfeedingon

demand K3 .

■Supportexclusivebreastfeeding K2-K3 .■Helpthemothertoinitiatebreastfeeding K3 .■Teachcorrectpositioningandattachment K3 .■Advisetofeedmorefrequently,dayandnight.

Reassureherthatshehasenoughmilk.■Advisethemothertostopfeedingthebabyother

foodsordrinks.■Reassessatthenextfeedorfollow-upvisitin2days.

■refer baby urgently to hospitalK14.

CLASSIFYfeediNg well

feediNg difficulty

Not able to feed

Next:Checkforspecialtreatmentneeds

assess breastfeediNgassess breastfeeding in every baby as part of the examination. if mother is complaining of nipple or breast pain, also assess the mother’s breasts J9 .

J�

t

Check for special treatment needs

ASK,CHECKRECORDcheck record for special treatment needs■Hasthemotherhad

within2daysofdelivery:→ fever>38ºC?→infectiontreatedwithantibiotics?

■Membranesruptured>18hoursbeforedelivery?

■MothertestedRPR-positive?■MothertestedHIV-positive?

→isorhasbeenonARV→hasshereceived

infantfeedingcounselling?■ IsthemotherreceivingTBtreatment

whichbegan<2monthsago?

LOOK,LISTEN,FEEL SIGNS■Baby<1dayoldandmembranes

ruptured>18hoursbeforedelivery,or

■Motherbeingtreatedwithantibioticsforinfection,

or■Motherhasfever>38ºC.

■MothertestedRPR-positive.

■MotherknowntobeHIV-positive.■Motherhasnotbeen

counselledoninfantfeeding.■Motherchosebreastfeeding.■Motherchosereplacementfeeding.

■MotherstartedTBtreatment<2monthsbeforedelivery.

TREATANDADVISE■Givebaby2IMantibioticsfor5daysK12.■Assessbabydaily J2-J7 .

■GivebabysingledoseofbenzathinepenicillinK12.■Ensuremotherandpartneraretreated F6 .■Followupin2weeks.

■GiveARVtothenewborn G9 .■Counseloninfantfeedingoptions G7 .■Givespecialcounsellingtomotherwhoisbreast

feeding G8 .■Teachthemotherreplacementfeeding.■Followupin2weeks G8 .

■Givebabyisoniazidpropylaxisfor6monthsK13.■GiveBCGvaccinationtothebabyonlywhenbaby’s

treatmentcompleted.■Followupin2weeks.

CLASSIFYrisk of bacterial iNfectioN

risk of coNgeNital syphilis

risk of hiV traNsmissioN

risk of tuberculosis

Next:Lookforsignsofjaundiceandlocalinfection

check for special treatmeNt Needs

New

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car

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J5

t

Look for signs of jaundice and local infectionNe

wbo

rN c

are

ASK,CHECKRECORD■Whathasbeenappliedtothe

umbilicus?

LOOK,LISTEN,FEEL■Lookattheskin,isityellow?

→ ifbabyislessthan24hoursold,lookatskinontheface

→ ifbabyis24hoursoldormore,lookatpalmsandsoles.

■Lookattheeyes.Aretheyswollenanddrainingpus?

■Lookattheskin,especiallyaroundtheneck,armpits,inguinalarea:→ Arethereskinpustules?→ Isthereswelling,hardnessor

largebullae?■Lookattheumbilicus:

→ Isitred?→ Drainingpus?→ Doesrednessextendtotheskin?

SIGNS■Yellowskinonfaceand

only<24hoursold.■Yellowpalmsandsolesand≥24hoursold.

■Eyesswollenanddrainingpus.

■Redumbilicusorskinaroundit.

■Lessthan10pustules

TREATANDADVISE■refer baby urgently to hospitalK14.■Encouragebreastfeedingontheway.■ Iffeedingdifficulty,giveexpressedbreastmilkbycup K6 .

■GivesingledoseofappropriateantibioticforeyeinfectionK12.

■TeachmothertotreateyesK13.■Followupin2days.Ifnoimprovementorworse,

referurgentlytohospital.■Assessandtreatmotherandherpartnerforpossible

gonorrhea E8 .

■TeachmothertotreatumbilicalinfectionK13.■ Ifnoimprovementin2days,orifworse,refer

urgentlytohospital.

■TeachmothertotreatskininfectionK13.■Followupin2days.■ Ifnoimprovementofpustulesin2daysormore,

referurgentlytohospital.

CLASSIFYJauNdice

goNococcaleye iNfectioN

local umbilicaliNfectioN

local skiNiNfectioN

Next:Ifdangersigns

look for sigNs of JauNdice aNd local iNfectioN

J�

t

If danger signs

SIGNSany of the following signs:■Fastbreathing

(morethan60breathsperminute).■Slowbreathing

(lessthan30breathsperminute).■Severechestin-drawing■Grunting■Convulsions.■Floppyorstiff.■Fever(temperature>38ºC).■Temperature<35ºCornotrising

afterrewarming.■Umbilicusdrainingpusorumbilical

rednessextendingtoskin.■Morethan10skinpustules

orbullae,orswelling,redness,hardnessofskin.

■Bleedingfromstumporcut.■Pallor.

TREATANDADVISE■Givefirstdoseof2IMantibioticsK12.■ refer baby urgently to hospitalK14.

in addition:■Re-warmandkeepwarmduringreferral K9 .

■TreatlocalumbilicalinfectionbeforereferralK13.

■TreatskininfectionbeforereferralK13.

■Stopthebleeding.

CLASSIFYpossible serious illNess

Next:Ifswelling,bruisesormalformation

if daNger sigNs

New

borN

car

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J�

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If swelling, bruises or malformationNe

wbo

rN c

are

SIGNS■Bruises,swellingonbuttocks.■Swollenhead—bumpon

oneorbothsides.■Abnormalpositionoflegs

(afterbreechpresentation).■Asymmetricalarmmovement,

armdoesnotmove.

■Clubfoot

■Cleftpalateorlip

■Oddlooking,unusualappearance

■Opentissueonhead,abdomenorback

■Otherabnormalappearance.

TREATANDADVISE■Explaintoparentsthatitdoesnothurtthebaby,

itwilldisappearinaweekortwoandnospecialtreatmentisneeded.

■DONOTforcelegsintoadifferentposition.■Gentlyhandlethelimbthatisnotmoving,

donotpull.

■Referforspecialtreatmentifavailable.

■Helpmothertobreastfeed.Ifnotsuccessful,teachheralternativefeedingmethods K5-K6 .Plantofollowup.

■Adviseonsurgicalcorrectionatageofseveralmonths.

■Referforspecialevaluation.

■Coverwithsteriletissuessoakedwithsterilesalinesolutionbeforereferral.

■Referforspecialtreatmentifavailable.

■Manageaccordingtonationalguidelines.

CLASSIFYbirth iNJury

malformatioN

seVere malformatioN

Next:Assessthemother’sbreastsifcomplainingofnippleorbreastpain

if swelliNg, bruises or malformatioN

J�

t

Next:Careofthenewborn

Assess the mother’s breasts if complaining of nipple or breast pain

ASK,CHECKRECORD■Howdoyourbreastsfeel?

LOOK,LISTEN,FEEL■Lookatthenippleforfissure■Lookatthebreastsfor:

→ swelling→ shininess→ redness.

■Feelgentlyforpainfulpartofthebreast.

■Measuretemperature.■Observeabreastfeed

ifnotyetdone J4 .

SIGNS■Noswelling,rednessortenderness.■Normalbodytemperature.■Nipplenotsoreandnofissure

visible.■Babywellattached.

■Nipplesoreorfissured.■Babynotwellattached.

■Bothbreastsareswollen,shinyandpatchyred.

■Temperature<38ºC.■Babynotwellattached.■Notyetbreastfeeding.

■Partofbreastispainful,swollenandred.

■Temperature>38ºC■Feelsill.

TREATANDADVISE■Reassurethemother.

■Encouragethemothertocontinuebreastfeeding.■Teachcorrectpositioningandattachment K3 .■Reassessafter2feeds(or1day).Ifnotbetter,

teachthemotherhowtoexpressbreastmilkfromtheaffectedbreastandfeedbabybycup,andcontinuebreastfeedingonthehealthyside.

■Encouragethemothertocontinuebreastfeeding.■Teachcorrectpositioningandattachment K3 .■Advisetofeedmorefrequently.■Reassessafter2feeds(1day).Ifnotbetter,teach

motherhowtoexpressenoughbreastmilkbeforethefeedtorelievediscomfort K5 .

■Encouragemothertocontinuebreastfeeding.■Teachcorrectpositioningandattachment K3 .■Givecloxacillinfor10days F5 .■Reassessin2days.Ifnoimprovementorworse,

refertohospital.■ IfmotherisHIV+letherbreastfeedonthehealthy

breast.Expressmilkfromtheaffectedbreastanddiscarduntilnofever K5 .

■ Ifseverepain,giveparacetamol F4 .

CLASSIFYbreastshealthy

NipplesoreNessor fissure

breast eNgorgemeNt

mastitis

assess the mother’s breasts if complaiNiNg of Nipple or breast paiN

New

borN

car

e

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care of the NewborNuse this chart for care of all babies until discharge.

Care of the newbornNe

wbo

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J�0

CAREANDMONITORING■Ensuretheroomiswarm(notlessthan25ºCandnodraught).■Keepthebabyintheroomwiththemother,inherbedorwithineasyreach.■Letthemotherandbabysleepunderabednet.

■Supportexclusivebreastfeedingondemanddayandnight.■Askthemothertoalertyouifbreastfeedingdifficulty.■Assessbreastfeedingineverybabybeforeplanningfordischarge.do Notdischargeifbabyisnotyetfeedingwell.

■Teachthemotherhowtocareforthebaby.→ Keepthebabywarm K9

→ GivecordcareK10

→ EnsurehygieneK10.do Notexposethebabyindirectsun.do Notputthebabyonanycoldsurface.do Notbaththebabybefore6hours.

■Askthemotherandcompaniontowatchthebabyandalertyouif→ Feetcold→ Breathingdifficulty:grunting,fastorslowbreathing,chestin-drawing→ Anybleeding.

■GiveprescribedtreatmentsaccordingtothescheduleK12.

■Examineeverybabybeforeplanningtodischargemotherandbaby J2-J9 . do Notdischargebeforebabyis12hoursold.

RESPONDTOABNORMALFINDINGS■ Ifthebabyisinacot,ensurebabyisdressedorwrappedandcoveredbyablanket.

Covertheheadwithahat.

■ Ifmotherreportsbreastfeedingdifficulty,assessbreastfeedingandhelpthemotherwithpositioningandattachment J3

■ Ifthemotherisunabletotakecareofthebaby,providecareorteachthecompanionK9-K10

■Washhandsbeforeandafterhandlingthebaby.

■ Iffeetarecold:→ Teachthemothertoputthebabyskin-to-skinK13.→ Reassessin1hour;iffeetstillcold,measuretemperatureandre-warmthebaby K9 .

■ Ifbleedingfromcord,checkiftieislooseandretiethecord.■ Ifotherbleeding,assessthebabyimmediately J2-J7 .■ Ifbreathingdifficultyormotherreportsanyotherabnormality,examinethebabyason J2-J7 .

Next:Additionalcareofasmallbaby(ortwin)t

additioNal care of a small baby (or twiN)use this chart for additional care of a small baby: preterm, �-2 months early or weighing �500g-<2500g. refer to hospital a very small baby: >2 months early, weighing <�500g

Additional care of a small baby (twin)

New

borN

car

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CAREANDMONITORING■Plantokeepthesmallbabylongerbeforedischarging.■Allowvisitstothemotherandbaby.

■Givespecialsupportforbreastfeedingthesmallbaby(ortwins) K4 :→ Encouragethemothertobreastfeedevery2-3hours.→ Assessbreastfeedingdaily:attachment,suckling,durationandfrequencyoffeeds,andbaby

satisfactionwiththefeed J4 K6 .→ Ifalternativefeedingmethodisused,assessthetotaldailyamountofmilkgiven.→ Weighdailyandassessweightgain K7 .

■Ensureadditionalwarmthforthesmallbaby K9 :→ Ensuretheroomisverywarm(25º–28ºC).→ Teachthemotherhowtokeepthesmallbabywarminskin-to-skincontact→ Provideextrablanketsformotherandbaby.

■Ensurehygiene K10 .do Notbaththesmallbaby.Washasneeded.

■Assessthesmallbabydaily:→ Measuretemperature→ Assessbreathing(babymustbequiet,notcrying):listenforgrunting;countbreathsperminute,

repeatthecountif>60or<30;lookforchestin-drawing→ Lookforjaundice(first10daysoflife):first24hoursontheabdomen,thenonpalmsandsoles.

■Plantodischargewhen:→ Breastfeedingwell→ Gainingweightadequatelyon3consecutivedays→ Bodytemperaturebetween36.5ºand37.5ºCon3consecutivedays→ Motherableandconfidentincaringforthebaby→ Nomaternalconcerns.

■Assessthebabyfordischarge.

RESPONSETOABNORMALFINDINGS

■ Ifthesmallbabyisnotsucklingeffectivelyanddoesnothaveotherdangersigns,consideralternativefeedingmethods K5-K6 .→ Teachthemotherhowtohandexpressbreastmilkdirectlyintothebaby’smouth K5 → Teachthemothertoexpressbreastmilkandcupfeedthebaby K5-K6

→ Determineappropriateamountfordailyfeedsbyage K6 .■ Iffeedingdifficultypersistsfor3days,orweightlossgreaterthan10%ofbirthweightand

nootherproblems,referforbreastfeedingcounsellingandmanagement.

■ Ifdifficulttokeepbodytemperaturewithinthenormalrange(36.5ºCto37.5ºC):→ Keepthebabyinskin-to-skincontactwiththemotherasmuchaspossible→ Ifbodytemperaturebelow36.5ºCpersistsfor2hoursdespiteskin-to-skincontactwithmother,

assessthebaby J2-J8 .■ Ifbreathingdifficulty,assessthebaby J2-J8 .■ Ifjaundice,referthebabyforphototherapy.■ Ifanymaternalconcern,assessthebabyandrespondtothemother J2-J8 .

■ Ifthemotherandbabyarenotabletostay,ensuredaily(home)visitsorsendtohospital.

New

borN

car

eJ�2Assess replacement feeding

assess replacemeNt feediNgif mother chose replacement feeding assess the feeding in every baby as part of the examination.advise the mother on how to relieve engorgement K8 . if mother is complaining of breast pain, also assess the mother’s breasts J9 .

ASK,CHECKRECORDask the mother■Whatareyoufeedingthebaby?■Howareyoufeedingyourbaby?■Hasyourbabyfedintheprevious

hour?■ Isthereanydifficulty?■Howmuchmilkisbabytakingper

feed?■ Isyourbabysatisfiedwiththefeed?■Haveyoufedyourbabyanyother

foodsordrinks?■Doyouhaveanyconcerns?

if baby more than one day old:■Howmanytimeshasyourbabyfed

in24hours?■Howmuchmilkisbabytakingper

day?■Howdoyourbreastsfeel?

LOOK,LISTEN,FEELobserve a feed■ Ifthebabyhasnotfedinthe

previoushour,askthemothertofeedthebabyandobservefeedingforabout5minutes.Askhertopreparethefeed.

look■ Issheholdingthecuptothebaby’s

lips?■ Isthebabyalert,openseyesand

mouth?■ Isthebabysuckingandswallowing

themilkeffectively,spillinglittle?

Ifmotherhasfedinthelasthour,askhertotellyouwhenherbabyiswillingtofeedagain.

SIGNS■Suckingandswallowingadequate

amountofmilk,spillinglittle.■Feeding8timesin24hourson

demanddayandnight.

■Notyetfed(first6hoursoflife).■Notfedbycup.■Notsuckingandswallowingeffectively,

spilling■Notfeedingadequateamountperday.■Feedinglessthan8timesper24

hours.■Receivingotherfoodsordrinks.■Severaldaysoldandinadequate

weightgain.

■Notsucking(after6hoursofage).■Stoppedfeeding.

TREATANDADVISE■Encouragethemothertocontinuefeedingbycupon

demand K6 .

■Teachthemotherreplacementfeeding G8 .■Teachthemothercupfeeding K6 .■Advisetofeedmorefrequently,ondemand,dayand

night.■Advisethemothertostopfeedingthebabyotherfoods

ordrinksorbybottle.■Reassessatthenextfeedorfollow-upvisitin2days.

■refer baby urgently to hospitalK14 .

CLASSIFYfeediNg well

feediNg difficulty

Not able to feed

Breastfeeding, care, preventive measures and treatment for the newborn

Brea

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g, c

are,

pre

vent

ive

mea

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for

the

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K�

Breastfeeding, care, preventive measures and treatment for the newBorn Counsel on breastfeeding (1)

Brea

stfe

edin

g, c

are,

pre

vent

ive

mea

sure

s an

d tr

eatm

ent

for

the

new

Born

K2

counsel on Breastfeeding

Counselonimportanceofexclusivebreastfeedingduringpregnancyandafterbirthinclude partner or other family memBers if possiBle

explain to the mother that:■Breastmilkcontainsexactlythenutrientsababyneeds →iseasilydigestedandefficientlyusedbythebaby’sbody →protectsababyagainstinfection.■Babiesshouldstartbreastfeedingwithin1hourofbirth.Theyshouldnothaveanyotherfoodor

drinkbeforetheystarttobreastfeed.■Babiesshouldbeexclusivelybreastfedforthefirst6monthsoflife.

■Breastfeeding →helpsbaby’sdevelopmentandmother/babyattachment →canhelpdelayanewpregnancy(see d27 forbreastfeedingandfamilyplanning).

ForcounsellingifmotherHIV-positive,see g7 .

Helpthemothertoinitiatebreastfeedingwithin1hour,whenbabyisready■Afterbirth,letthebabyrestcomfortablyonthemother’schestinskin-to-skincontact.■ Tellthemothertohelpthebabytoherbreastwhenthebabyseemstobeready,usuallywithinthe

firsthour.Signsofreadinesstobreastfeedare: →babylookingaround/moving →mouthopen →searching.■ Checkthatpositionandattachmentarecorrectatthefirstfeed.Offertohelpthemotheratanytime K3 .■Letthebabyreleasethebreastbyher/himself;thenofferthesecondbreast.■ Ifthebabydoesnotfeedin1hour,examinethebabyJ2–J9 .Ifhealthy,leavethebabywiththe

mothertotrylater.Assessin3hours,orearlierifthebabyissmall J4 .■ Ifthemotherisillandunabletobreastfeed,helphertoexpressbreastmilkandfeedthebabyby

cup K6 .Onday1expressinaspoonandfeedbyspoon.■ Ifmothercannotbreastfeedatall,useoneofthefollowingoptions: →donatedheat-treatedbreastmilk. →Ifnotavailable,thencommercialinfantformula. →Ifnotavailable,thenhome-madeformulafrommodifiedanimalmilk.

Counsel on breastfeeding (2)

Brea

stfe

edin

g, c

are,

pre

vent

ive

mea

sure

s an

d tr

eatm

ent

for

the

new

Born

K3

Supportexclusivebreastfeeding■Keepthemotherandbabytogetherinbedorwithineasyreach.do notseparatethem.■Encouragebreastfeedingondemand,dayandnight,aslongasthebabywants. →Ababyneedstofeeddayandnight,8ormoretimesin24hoursfrombirth.Onlyonthefirstday

mayafull-termbabysleepmanyhoursafteragoodfeed. →Asmallbabyshouldbeencouragedtofeed,dayandnight,atleast8timesin24hoursfrom

birth.■Helpthemotherwhenevershewants,andespeciallyifsheisafirsttimeoradolescentmother.■Letbabyreleasethebreast,thenofferthesecondbreast.■ Ifmothermustbeabsent,letherexpressbreastmilkandletsomebodyelsefeedtheexpressed

breastmilktothebabybycup.

do notforcethebabytotakethebreast.do notinterruptfeedbeforebabywants.do notgiveanyotherfeedsorwater.do notuseartificialteatsorpacifiers.

■Advisethemotheronmedicationandbreastfeeding →Mostdrugsgiventothemotherinthisguidearesafeandthebabycanbebreastfed. →Ifmotheristakingcotrimoxazoleorfansidar,monitorbabyforjaundice.

Teachcorrectpositioningandattachmentforbreastfeeding■Showthemotherhowtoholdherbaby.Sheshould: →makesurethebaby’sheadandbodyareinastraightline →makesurethebabyisfacingthebreast,thebaby’snoseisoppositehernipple →holdthebaby’sbodyclosetoherbody →supportthebaby’swholebody,notjusttheneckandshoulders■Showthemotherhowtohelpherbabytoattach.Sheshould: →touchherbaby’slipswithhernipple →waituntilherbaby’smouthisopenedwide →moveherbabyquicklyontoherbreast,aimingtheinfant’slowerlipwellbelowthenipple.■Lookforsignsofgoodattachment: → moreofareolavisibleabovethebaby'smouth →mouthwideopen →lowerlipturnedoutwards →baby'schintouchingbreast■Lookforsignsofeffectivesuckling(thatis,slow,deepsucks,sometimespausing).■ Iftheattachmentorsucklingisnotgood,tryagain.Thenreassess.■ Ifbreastengorgement,expressasmallamountofbreastmilkbeforestartingbreastfeedingtosoften

nippleareasothatitiseasierforthebabytoattach.

if mother is hiv-positive, see g7 for special counselling to the mother who is hiv-positive and breastfeeding.

if mother chose replacement feedings, see g8 .

Counsel on breastfeeding (3)

Brea

stfe

edin

g, c

are,

pre

vent

ive

mea

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s an

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ent

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the

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Born

K4

counsel on Breastfeeding

Givespecialsupporttobreastfeedthesmallbaby(pretermand/orlowbirthweight)counsel the mother:■Reassurethemotherthatshecanbreastfeedhersmallbabyandshehasenoughmilk.■Explainthathermilkisthebestfoodforsuchasmallbaby.Feedingforher/himisevenmore

importantthanforabigbaby.■Explainhowthemilk’sappearancechanges:milkinthefirstdaysisthickandyellow,thenit

becomesthinnerandwhiter.Botharegoodforthebaby.■Asmallbabydoesnotfeedaswellasabigbabyinthefirstdays: →maytireeasilyandsuckweaklyatfirst →maysuckleforshorterperiodsbeforeresting →mayfallasleepduringfeeding →mayhavelongpausesbetweensucklingandmayfeedlonger →doesnotalwayswakeupforfeeds.■Explainthatbreastfeedingwillbecomeeasierifthebabysucklesandstimulatesthebreasther/

himselfandwhenthebabybecomesbigger.■Encourageskin-to-skincontactsinceitmakesbreastfeedingeasier.

help the mother:■ Initiatebreastfeedingwithin1hourofbirth.■Feedthebabyevery2-3hours.Wakethebabyforfeeding,evenifshe/hedoesnotwakeupalone,

2hoursafterthelastfeed.■Alwaysstartthefeedwithbreastfeedingbeforeofferingacup.Ifnecessary,improvethemilkflow

(letthemotherexpressalittlebreastmilkbeforeattachingthebabytothebreast).■Keepthebabylongeratthebreast.Allowlongpausesorlong,slowfeed.Donotinterruptfeedifthe

babyisstilltrying.■ Ifthebabyisnotyetsucklingwellandlongenough,dowhateverworksbetterinyoursetting: →Letthemotherexpressbreastmilkintobaby’smouth K5 . →Letthemotherexpressbreastmilkandfeedbabybycup K6 .Onthefirstdayexpressbreast

milkinto,andfeedcolostrumbyspoon.■ Teachthemothertoobserveswallowingifgivingexpressedbreastmilk.■Weighthebabydaily(ifaccurateandprecisescalesavailable),recordandassessweightgain K7 .

Givespecialsupporttobreastfeedtwins

counsel the mother:■Reassurethemotherthatshehasenoughbreastmilkfortwobabies.■Encourageherthattwinsmaytakelongertoestablishbreastfeedingsincetheyarefrequentlyborn

pretermandwithlowbirthweight.

help the mother:■Startfeedingonebabyatatimeuntilbreastfeedingiswellestablished.■Helpthemotherfindthebestmethodtofeedthetwins: →Ifoneisweaker,encouragehertomakesurethattheweakertwingetsenoughmilk. →Ifnecessary,shecanexpressmilkforher/himandfeedher/himbycupafterinitialbreastfeeding. →Dailyalternatethesideeachbabyisoffered.

Counsel on breastfeeding (3)

Brea

stfe

edin

g, c

are,

pre

vent

ive

mea

sure

s an

d tr

eatm

ent

for

the

new

Born

K4

counsel on Breastfeeding

Givespecialsupporttobreastfeedthesmallbaby(pretermand/orlowbirthweight)counsel the mother:■Reassurethemotherthatshecanbreastfeedhersmallbabyandshehasenoughmilk.■Explainthathermilkisthebestfoodforsuchasmallbaby.Feedingforher/himisevenmore

importantthanforabigbaby.■Explainhowthemilk’sappearancechanges:milkinthefirstdaysisthickandyellow,thenit

becomesthinnerandwhiter.Botharegoodforthebaby.■Asmallbabydoesnotfeedaswellasabigbabyinthefirstdays: →maytireeasilyandsuckweaklyatfirst →maysuckleforshorterperiodsbeforeresting →mayfallasleepduringfeeding →mayhavelongpausesbetweensucklingandmayfeedlonger →doesnotalwayswakeupforfeeds.■Explainthatbreastfeedingwillbecomeeasierifthebabysucklesandstimulatesthebreasther/

himselfandwhenthebabybecomesbigger.■Encourageskin-to-skincontactsinceitmakesbreastfeedingeasier.

help the mother:■ Initiatebreastfeedingwithin1hourofbirth.■Feedthebabyevery2-3hours.Wakethebabyforfeeding,evenifshe/hedoesnotwakeupalone,

2hoursafterthelastfeed.■Alwaysstartthefeedwithbreastfeedingbeforeofferingacup.Ifnecessary,improvethemilkflow

(letthemotherexpressalittlebreastmilkbeforeattachingthebabytothebreast).■Keepthebabylongeratthebreast.Allowlongpausesorlong,slowfeed.Donotinterruptfeedifthe

babyisstilltrying.■ Ifthebabyisnotyetsucklingwellandlongenough,dowhateverworksbetterinyoursetting: →Letthemotherexpressbreastmilkintobaby’smouth K5 . →Letthemotherexpressbreastmilkandfeedbabybycup K6 .Onthefirstdayexpressbreast

milkinto,andfeedcolostrumbyspoon.■ Teachthemothertoobserveswallowingifgivingexpressedbreastmilk.■Weighthebabydaily(ifaccurateandprecisescalesavailable),recordandassessweightgain K7 .

Givespecialsupporttobreastfeedtwins

counsel the mother:■Reassurethemotherthatshehasenoughbreastmilkfortwobabies.■Encourageherthattwinsmaytakelongertoestablishbreastfeedingsincetheyarefrequentlyborn

pretermandwithlowbirthweight.

help the mother:■Startfeedingonebabyatatimeuntilbreastfeedingiswellestablished.■Helpthemotherfindthebestmethodtofeedthetwins: →Ifoneisweaker,encouragehertomakesurethattheweakertwingetsenoughmilk. →Ifnecessary,shecanexpressmilkforher/himandfeedher/himbycupafterinitialbreastfeeding. →Dailyalternatethesideeachbabyisoffered.

Alternative feeding methods (2)

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Cupfeedingexpressedbreastmilk■ Teachthemothertofeedthebabywithacup.Donotfeedthebabyyourself.Themothershould:■Measurethequantityofmilkinthecup■Holdthebabysittingsemi-uprightonherlap■Holdthecupofmilktothebaby’slips: →restcuplightlyonlowerlip →touchedgeofcuptoouterpartofupperlip →tipcupsothatmilkjustreachesthebaby’slips →butdonotpourthemilkintothebaby’smouth.■Babybecomesalert,opensmouthandeyes,andstartstofeed.■ Thebabywillsuckthemilk,spillingsome.■Smallbabieswillstarttotakemilkintotheirmouthusingthetongue.■Babyswallowsthemilk.■Babyfinishesfeedingwhenmouthclosesorwhennotinterestedintakingmore.■ Ifthebabydoesnottakethecalculatedamount: →Feedforalongertimeorfeedmoreoften →Teachthemothertomeasurethebaby’sintakeover24hours,notjustateachfeed.■ Ifmotherdoesnotexpressenoughmilkinthefirstfewdays,orifthemothercannotbreastfeedat

all,useoneofthefollowingfeedingoptions: →donatedheat-treatedbreastmilk →home-madeorcommercialformula.■Feedthebabybycupifthemotherisnotavailabletodoso.■Babyiscupfeedingwellifrequiredamountofmilkisswallowed,spillinglittle,andweightgainis

maintained.

Quantitytofeedbycup■Startwith80ml/kgbodyweightperdayforday1.Increasetotalvolumeby10-20ml/kgperday,

untilbabytakes150ml/kg/day.Seetablebelow.■Dividetotalinto8feeds.Giveevery2-3hourstoasmallsizeorillbaby.■Checkthebaby’s24hourintake.Sizeofindividualfeedsmayvary.■Continueuntilbabytakestherequiredquantity.■Washthecupwithwaterandsoapaftereachfeed.

approximate quantity to feed By cup (in ml) every 2-3 hours from Birth (By weight)

weight (kg) day 0 � 2 3 4 5 6 7

�.5-�.9 15ml 17ml 19ml 21ml 23ml 25ml 27ml 27+ml

2.0-2.4 20ml 22ml 25ml 27ml 30ml 32ml 35ml 35+ml

2.5+ 25ml 28ml 30ml 35ml 35ml 40+ml 45+ml 50+ml

Signsthatbabyisreceivingadequateamountofmilk■Babyissatisfiedwiththefeed.■Weightlossislessthan10%inthefirstweekoflife.■Babygainsatleast160-ginthefollowingweeksoraminimum300-ginthefirstmonth.■Babywetseverydayasfrequentlyasbabyisfeeding.■Baby’sstoolischangingfromdarktolightbrownoryellowbyday3.

Weigh and assess weight gain

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Weighbabyinthefirstmonthoflife

weigh the BaBy■Monthlyifbirthweightnormalandbreastfeedingwell.Every2weeksifreplacementfeedingor

treatmentwithisoniazid.■Whenthebabyisbroughtforexaminationbecausenotfeedingwell,orill.

weigh the small BaBy■Everydayuntil3consecutivetimesgainingweight(atleast15-g/day).■Weeklyuntil4-6weeksofage(reachedterm).

Assessweightgainuse this table for guidance when assessing weight gain in the first month of life

age acceptable weight loss/gain in the first month of life

� week Lossupto10%

2-4 weeks Gainatleast160gperweek(atleast15g/day)

� month Gainatleast300ginthefirstmonth

if weighing daily with a precise and accurate scale

first week Noweightlossortotallessthan10%

afterward dailygaininsmallbabiesatleast20g

ScalemaintenanceDaily/weeklyweighingrequirespreciseandaccuratescale(10-gincrement): →Calibrateitdailyaccordingtoinstructions. →Checkitforaccuracyaccordingtoinstructions.

Simplespringscalesarenotpreciseenoughfordaily/weeklyweighing.

K2 counsel on Breastfeeding (�) Counselonimportanceofexclusivebreast

feeding Helpthemothertoinitiatebreastfeeding

K3 counsel on Breastfeeding (2) Supportexclusivebreastfeeding

Teachcorrectpositioningandattachmentforbreastfeeding

K4 counsel on Breastfeeding (3)Givespecialsupporttobreastfeedthesmallbaby(pretermand/orlowbirthweight)

Givespecialsupporttobreastfeedtwins

K5 alternative feeding methods (�)

Expressbreastmilk Handexpressbreastmilkdirectlyintothe

baby’smouth

K6 alternative feeding methods (2)

Cupfeedingexpressedbreastmilk Quantitytofeedbycup Signsthatbabyisreceivingadequateamount

ofmilk

K7 weigh and assess weight gain Weighbabyinthefirstmonthoflife

Assessweightgain Scalemaintenance

Other breastfeeding support

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other Breastfeeding support

Givespecialsupporttothemotherwhoisnotyetbreastfeeding(mother or baby ill, or baby too small to suckle)■ Teachthemothertoexpressbreastmilk K5 .Helpherifnecessary.■Usethemilktofeedthebabybycup.■ Ifmotherandbabyareseparated,helpthemothertoseethebabyorinformheraboutthebaby’s

conditionatleasttwicedaily.■ Ifthebabywasreferredtoanotherinstitution,ensurethebabygetsthemother’sexpressedbreast

milkifpossible.■Encouragethemothertobreastfeedwhensheorthebabyrecovers.

Ifthebabydoesnothaveamother■Givedonatedheattreatedbreastmilkorhome-basedorcommercialformulabycup.■ Teachthecarerhowtopreparemilkandfeedthebaby K6 .■Followupin2weeks;weighandassessweightgain.

Advisethemotherwhoisnotbreastfeedingatallonhowtorelieveengorgement(Baby died or stillborn, mother chose replacement feeding)■Breastsmaybeuncomfortableforawhile.■Avoidstimulatingthebreasts.■Supportbreastswithawell-fittingbraorcloth.Donotbindthebreaststightlyasthismayincrease

herdiscomfort.■Applyacompress.Warmthiscomfortableforsomemothers,otherspreferacoldcompressto

reduceswelling.■ Teachthemothertoexpressenoughmilktorelievediscomfort.Expressingcanbedoneafewtimes

adaywhenthebreastsareoverfull.Itdoesnotneedtobedoneifthemotherisuncomfortable.Itwillbelessthanherbabywouldtakeandwillnotstimulateincreasedmilkproduction.

■Relievepain.Ananalgesicsuchasibuprofen,orparacetamolmaybeused.Somewomenuseplantproductssuchasteasmadefromherbs,orplantssuchasrawcabbageleavesplaceddirectlyonthebreasttoreducepainandswelling.

■ Advisetoseekcareifbreastsbecomepainful,swollen,red,ifshefeelsillortemperaturegreaterthan38ºC.

pharmacological treatments to reduce milk supply are not recommended. Theabovemethodsareconsideredmoreeffectiveinthelongterm.

Ensure warmth for the baby

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ensure warmth for the BaBy

Keepthebabywarmat Birth and within the first hour(s)■Warmdeliveryroom:forthebirthofthebabytheroomtemperatureshouldbe25-28ºC,nodraught.■Drybaby:immediatelyafterbirth,placethebabyonthemother’sabdomenoronawarm,cleanand

drysurface.Drythewholebodyandhairthoroughly,withadrycloth.■Skin-to-skincontact:Leavethebabyonthemother’sabdomen(beforecordcut)orchest(aftercord

cut)afterbirthforatleast2hours.Coverthebabywithasoftdrycloth.■ Ifthemothercannotkeepthebabyskin-to-skinbecauseofcomplications,wrapthebabyinaclean,

dry,warmclothandplaceinacot.Coverwithablanket.Usearadiantwarmerifroomnotwarmorbabysmall.

suBsequently (first day)■ Explaintothemotherthatkeepingbabywarmisimportantforthebabytoremainhealthy.■ Dressthebabyorwrapinsoftdrycleancloth.Covertheheadwithacapforthefirstfewdays,especiallyif

babyissmall.■ Ensurethebabyisdressedorwrappedandcoveredwithablanket.■ Keepthebabywithineasyreachofthemother.Donotseparatethem(rooming-in).■ Ifthemotherandbabymustbeseparated,ensurebabyisdressedorwrappedandcoveredwitha

blanket.■ Assesswarmthevery4hoursbytouchingthebaby’sfeet:iffeetarecolduseskin-to-skincontact,add

extrablanketandreassess(seeRewarmthenewborn).■ Keeptheroomforthemotherandbabywarm.Iftheroomisnotwarmenough,alwayscoverthebaby

withablanketand/oruseskin-to-skincontact.

at home■ Explaintothemotherthatbabiesneedonemorelayerofclothesthanotherchildrenoradults.■ Keeptheroomorpartoftheroomwarm,especiallyinacoldclimate.■ Duringtheday,dressorwrapthebaby.■ Atnight,letthebabysleepwiththemotherorwithineasyreachtofacilitatebreastfeeding.

do notputthebabyonanycoldorwetsurface.do notbaththebabyatbirth.Waitatleast6hoursbeforebathing.do notswaddle–wraptootightly.Swaddlingmakesthemcold.do notleavethebabyindirectsun.

Keepasmallbabywarm■ Theroomforthebabyshouldbewarm(notlessthan25°C)withnodraught.■Explaintothemothertheimportanceofwarmthforasmallbaby.■Afterbirth,encouragethemothertokeepthebabyinskin-to-skincontactaslongaspossible.■Advisetouseextraclothes,socksandacap,blankets,tokeepthebabywarmorwhenthebabyis

notwiththemother.■Washorbathababyinaverywarmroom,inwarmwater.Afterbathing,dryimmediatelyand

thoroughly.Keepthebabywarmafterthebath.Avoidbathingsmallbabies.■Checkfrequentlyiffeetarewarm.Ifcold,rewarmthebaby(seebelow).■Seekcareifthebaby’sfeetremaincoldafterrewarming.

Rewarmthebabyskin-to-skin■Beforerewarming,removethebaby’scoldclothing.■Placethenewbornskin-to-skinonthemother’schestdressedinapre-warmedshirtopenatthe

front,anappy(diaper),hatandsocks.■Covertheinfantonthemother’schestwithherclothesandanadditional(pre-warmed)blanket.■Checkthetemperatureeveryhouruntilnormal.■Keepthebabywiththemotheruntilthebaby’sbodytemperatureisinnormalrange.■ Ifthebabyissmall,encouragethemothertokeepthebabyinskin-to-skincontactforaslongas

possible,dayandnight.■Besurethetemperatureoftheroomwheretherewarmingtakesplaceisatleast25°C.■ Ifthebaby’stemperatureisnot36.5ºCormoreafter2hoursofrewarming,reassessthebaby J2–J7 .■ Ifreferralneeded,keepthebabyinskin-to-skinposition/contactwiththemotherorotherperson

accompanyingthebaby.

Other baby care

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other BaBy carealways wash hands before and after taking care of the baby. do not share supplies with other babies.

Cordcare■Washhandsbeforeandaftercordcare.■Putnothingonthestump.■Foldnappy(diaper)belowstump.■Keepcordstumplooselycoveredwithcleanclothes.■ Ifstumpissoiled,washitwithcleanwaterandsoap.Dryitthoroughlywithcleancloth.■ Ifumbilicusisredordrainingpusorblood,examinethebabyandmanageaccordingly J2–J7 .■Explaintothemotherthatsheshouldseekcareiftheumbilicusisredordrainingpusorblood.

do notbandagethestumporabdomen. do notapplyanysubstancesormedicinetostump. Avoidtouchingthestumpunnecessarily.

Sleeping■Usethebednetdayandnightforasleepingbaby.■Letthebabysleeponher/hisbackorontheside.■Keepthebabyawayfromsmokeorpeoplesmoking.■Keepthebaby,especiallyasmallbaby,awayfromsickchildrenoradults.

Hygiene(washing,bathing)

at Birth:■Onlyremovebloodormeconium.

do notremovevernix. do notbathethebabyuntilatleast6hoursofage.

later and at home:■Washtheface,neck,underarmsdaily.■Washthebuttockswhensoiled.Drythoroughly.■Bathwhennecessary: →Ensuretheroomiswarm,nodraught →Usewarmwaterforbathing →Thoroughlydrythebaby,dressandcoverafterbath.

other BaBy care:■Useclothonbaby’sbottomtocollectstool.Disposeofthestoolasforwoman’spads.Washhands.

do notbathethebabybefore6hoursoldorifthebabyiscold. do notapplyanythinginthebaby’seyesexceptanantimicrobialatbirth.

small BaBies require more careful attention:■ Theroommustbewarmerwhenchanging,washing,bathingandexaminingasmallbaby.

Newborn resuscitation

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newBorn resuscitationstart resuscitation within � minute of birth if baby is not breathing or is gasping for breath.observe universal precautions to prevent infection a4 .

Keepthebabywarm■Clampandcutthecordifnecessary.■ Transferthebabytoadry,cleanandwarmsurface.■ Informthemotherthatthebabyhasdifficultyinitiatingbreathingandthatyouwillhelpthebabytobreathe.■Keepthebabywrappedandunderaradiantheaterifpossible.

Opentheairway■Positiontheheadsoitisslightlyextended.■Suctionfirstthemouthandthenthenose.■ Introducethesuctiontubeintothenewborn’smouth5-cmfromlipsandsuckwhilewithdrawing.■ Introducethesuctiontube3-cmintoeachnostrilandsuckwhilewithdrawinguntilnomucus.■Repeateachsuctionifnecessarybutnomorethantwiceandnomorethan20secondsintotal.

Ifstillnobreathing,VENTILATE:■Placemasktocoverchin,mouth,andnose.■Formseal.■Squeezebagattachedtothemaskwith2fingersorwholehand,accordingtobagsize,2or3times.■Observeriseofchest.Ifchestisnotrising: →repositionhead →checkmaskseal.■Squeezebagharderwithwholehand.■Oncegoodsealandchestrising,ventilateat40squeezesperminuteuntilnewbornstartscryingor

breathingspontaneously.

Ifbreathingorcrying,stopventilating■Lookatthechestforin-drawing.■Countbreathsperminute.■ Ifbreathingmorethan30breathsperminuteandnoseverechestin-drawing: →donotventilateanymore →putthebabyinskin-to-skincontactonmother’schestandcontinuecareason d�9

→monitorevery15minutesforbreathingandwarmth →tellthemotherthatthebabywillprobablybewell.

do notleavethebabyalone

Ifbreathinglessthan30breathsperminuteorseverechestin-drawing:■continueventilating■arrangeforimmediatereferral■explaintothemotherwhathappened,whatyouaredoingandwhy■ventilateduringreferral■ recordtheeventonthereferralformandlabourrecord.

Ifnobreathingorgaspingatallafter20minutesofventilation■Stopventilating.Thebabyisdead.■Explaintothemotherandgivesupportivecare d24 .■Recordtheevent.

Treat and immunize the baby (1)

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treat the BaBy

Treatthebaby■Determineappropriatedrugsanddosageforthebaby’sweight.■ Tellthemotherthereasonsforgivingthedrugtothebaby.■Giveintramuscularantibioticsinthigh.Useanewsyringeandneedleforeachantibiotic.

teach the mother to give treatment to the BaBy at home■Explaincarefullyhowtogivethetreatment.Labelandpackageeachdrugseparately.■Checkmother’sunderstandingbeforesheleavestheclinic.■Demonstratehowtomeasureadose.■Watchthemotherpracticemeasuringadosebyherself.■Watchthemothergivethefirstdosetothebaby.

Give2IMantibiotics(firstweekoflife)■GivefirstdoseofbothampicillinandgentamicinIMinthighbeforereferralforpossibleserious

illness,severeumbilicalinfectionorsevereskininfection.■GivebothampicillinandgentamicinIMfor5daysinasymptomaticbabiesclassifiedatriskof

infection.■Giveintramuscularantibioticsinthigh.Useanewsyringeandneedleforeachantibiotic.

ampicillin im gentamicin im dose:50mgperkg dose:5mgperkg every12hours every24hoursifterm; Add2.5mlsterilewater 4mgperkgevery24hoursifpreterm

weight to500mgvial=200mg/ml 20mgper2mlvial=10mg/ml

�.0 — �.4 kg 0.35ml 0.5ml �.5 — �.9 kg 0.5ml 0.7ml 2.0 — 2.4 kg 0.6ml 0.9ml 2.5 — 2.9 kg 0.75ml 1.35ml 3.0 — 3.4 kg 0.85ml 1.6ml 3.5 — 3.9 kg 1ml 1.85ml 4.0 — 4.4 kg 1.1ml 2.1ml

GiveIMbenzathinepenicillintobaby(singledose)ifmothertestedRPR-positive Benzathine penicillin im dose:50000units/kgonce Add5mlsterilewatertovial containing1.2millionunits =1.2millionunits/(6mltotalvolume) weight =200000units/ml �.0 - �.4 kg 0.35ml �.5 - �.9 kg 0.5ml 2.0 - 2.4 kg 0.6ml 2.5 - 2.9 kg 0.75ml 3.0 - 3.4 kg 0.85ml 3.5 - 3.9 kg 1.0ml 4.0 - 4.4 kg 1.1ml

GiveIMantibioticforpossiblegonococcaleyeinfection(singledose) ceftriaxone (�st choice) Kanamycin (2nd choice) dose:50mgperkgonce dose:25mgperkgonce,max75mg weight 250mgper5mlvial=mg/ml 75mgper2mlvial=37.5mg/ml

�.0 - �.4 kg 1ml 0.7ml �.5 - �.9 kg 1.5ml 1ml 2.0 - 2.4 kg 2ml 1.3ml 2.5 - 2.9 kg 2.5ml 1.7ml 3.0 - 3.4 kg 3ml 2ml 3.5 - 3.9 kg 3.5ml 2ml 4.0 - 4.4 kg 4ml 2ml

Treat and immunize the baby (2)

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Treatlocalinfectionteach mother to treat local infection■Explainandshowhowthetreatmentisgiven.■Watchherasshecarriesoutthefirsttreatment.■Askhertoletyouknowifthelocalinfectiongetsworseandtoreturntotheclinicifpossible.■ Treatfor5days.

treat sKin pustules or umBilical infectiondo the following 3 times daily:■Washhandswithcleanwaterandsoap.■Gentlywashoffpusandcrustswithboiledandcooledwaterandsoap.■Drytheareawithcleancloth.■Paintwithgentianviolet.■Washhands.

treat eye infection do the following 6-8 times daily:■Washhandswithcleanwaterandsoap.■Wetcleanclothwithboiledandcooledwater.■Usethewetclothtogentlywashoffpusfromthebaby’seyes.■Apply1%tetracyclineeyeointmentineacheye3timesdaily.■Washhands.

reassess in 2 days:■Assesstheskin,umbilicusoreyes.■ Ifpusorrednessremainsorisworse,refertohospital.■ Ifpusandrednesshaveimproved,tellthemothertocontinuetreatinglocalinfectionathome.

Giveisoniazid(INH)prophylaxistonewbornif the mother is diagnosed as having tuberculosis and started treatmentless than 2 months before delivery:■Give5-mg/kgisoniazid(INH)orallyonceadayfor6months(1tablet=200-mg).■DelayBCGvaccinationuntilINHtreatmentcompleted,orrepeatBCG.■Reassurethemotherthatitissafetobreastfeedthebaby.■Followupthebabyevery2weeks,oraccordingtonationalguidelines,toassessweightgain.

Immunizethenewborn■GiveBCG,OPV-0,HepatitisB(HB-1)vaccineinthefirstweekoflife,preferablybeforedischarge.■ Ifun-immunizednewbornfirstseen1-4weeksofage,giveBCGonly.■Recordonimmunizationcardandchildrecord.■Advisewhentoreturnfornextimmunization.

age vaccine

Birth < � week BCGOPV-0HB1 6 weeks DPTOPV-1HB-2

GiveARVmedicinetonewborn■GivethefirstdoseofARVmedicinestonewborn8–12hoursafterbirth: → GiveNevirapine2mg/kgonceonly. → GiveZidovudine4mg/kgevery12hours.■ Ifthenewbornspillsorvomitswithin30minutesrepeatthedose.

Teachmothertogiveoralarvmedicinesathome■Explainandshowhowthemedicineisgiven. → Washhands. → Demonstratehowtomeasurethedoseonthespoon. → Beginfeedingthebabybycup. → Givemedicinebyspoonbeforetheendofthefeed. → Completethefeed.■Watchherasshecarriesoutthenexttreatment.■ExplaintothemotherthatsheshouldwatchherbabyaftergivingadoseofZidovudine.Ifbaby

vomitsorspillswithin30minutes,sheshouldrepeatthedose.■GiveZidovudineevery12hoursfor7days.

K8 other Breastfeeding support Givespecialsupporttothemotherwhoisnot

yetbreastfeeding Advisethemotherwhoisnotbreastfeedingat

allonhowtorelieveengorgement Ifthebabydoesnothaveamother

K9 ensure warmth for the BaBy Keepthebabywarm

Keepasmallbabywarm Rewarmthebabyskin-to-skin

K10 other BaBy care Cordcare

Sleeping Hygiene

K11 newBorn resuscitation Keepthebabywarm

Opentheairway Ifstillnotbreathing,ventilate... Ifbreathingorcrying,stopventilating Ifnotbreathingorgaspingatallafter20

minutesofventilation

K12 treat and immunize the BaBy (�) Treatthebaby

Give2IMantibiotics(firstweekoflife) GiveIMbenzathinepenicillintobaby(single

dose)ifmothertestedRPRpositive GiveIMantibioticforpossiblegonococcaleye

infection(singledose)

K13 treat and immunize the BaBy (2) Treatlocalinfection

Giveisoniazid(INH)prophylaxistonewborn Immunizethenewborn

Advise when to return with the baby

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advise when to return with the BaByfor maternal visits see schedule on d28 .

Routinevisits returnpostnatal visit Withinthefirstweek,preferably

within2-3daysimmunization visit Atage6weeks

(IfBCG,OPV-0andHB-1giveninthefirstweekoflife)

Follow-upvisits

if the problem was: return inFeedingdifficulty 2daysRedumbilicus 2daysSkininfection 2daysEyeinfection 2daysThrush 2daysMotherhaseither: →breastengorgementor 2days →mastitis. 2daysLowbirthweight,andeither →firstweekoflifeor 2days →notadequatelygainingweight 2daysLowbirthweight,andeither →olderthan1weekor 7days →gainingweightadequately 7daysOrphanbaby 14daysINHprophylaxis 14daysTreatedforpossiblecongenitalsyphilis 14daysMotherHIV-positive 14days

AdvisethemothertoseekcareforthebabyUsethecounsellingsheettoadvisethemotherwhentoseekcare,orwhentoreturn,ifthebabyhasanyofthesedangersigns:

return or go to the hospital immediately if the BaBy has■difficultybreathing.■convulsions.■ feverorfeelscold.■bleeding.■diarrhoea.■verysmall,justborn.■notfeedingatall.

go to health centre as quicKly as possiBle if the BaBy has■difficultyfeeding.■pusfromeyes.■skinpustules.■yellowskin.■acordstumpwhichisredordrainingpus.■ feeds<5timesin24hours.

Referbabyurgentlytohospital■Afteremergencytreatment,explaintheneedforreferraltothemother/father.■Organizesafetransportation.■Alwayssendthemotherwiththebaby,ifpossible.■Sendreferralnotewiththebaby.■ Informthereferralcentreifpossiblebyradioortelephone.

during transportation■Keepthebabywarmbyskin-to-skincontactwithmotherorsomeoneelse.■Coverthebabywithablanketandcoverher/hisheadwithacap.■Protectthebabyfromdirectsunshine.■Encouragebreastfeedingduringthejourney.■ Ifthebabydoesnotbreastfeedandjourneyismorethan3hours,considergivingexpressedbreast

milkbycup K6 .

K14 advise when to return with the BaBy

Routinevisits Follow-upvisits Advisethemothertoseekcareforthebaby Referbabyurgentlytohospital

■Thissectionhasdetailsonbreastfeeding,careofthebaby,treatments,immunization,routineandfollow-upvisitsandurgentreferraltohospital.

■Generalprinciplesarefoundinthesectionongoodcare a�-a6 .

■ IfmotherHIV-positive,seealsog7-g�� .

Counsel on breastfeeding (1)Br

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counsel on Breastfeeding

Counselonimportanceofexclusivebreastfeedingduringpregnancyandafterbirthinclude partner or other family memBers if possiBle

explain to the mother that:■Breastmilkcontainsexactlythenutrientsababyneeds →iseasilydigestedandefficientlyusedbythebaby’sbody →protectsababyagainstinfection.■Babiesshouldstartbreastfeedingwithin1hourofbirth.Theyshouldnothaveanyotherfoodor

drinkbeforetheystarttobreastfeed.■Babiesshouldbeexclusivelybreastfedforthefirst6monthsoflife.

■Breastfeeding →helpsbaby’sdevelopmentandmother/babyattachment →canhelpdelayanewpregnancy(see d27 forbreastfeedingandfamilyplanning).

ForcounsellingifmotherHIV-positive,see g7 .

Helpthemothertoinitiatebreastfeedingwithin1hour,whenbabyisready■Afterbirth,letthebabyrestcomfortablyonthemother’schestinskin-to-skincontact.■ Tellthemothertohelpthebabytoherbreastwhenthebabyseemstobeready,usuallywithinthe

firsthour.Signsofreadinesstobreastfeedare: →babylookingaround/moving →mouthopen →searching.■ Checkthatpositionandattachmentarecorrectatthefirstfeed.Offertohelpthemotheratanytime K3 .■Letthebabyreleasethebreastbyher/himself;thenofferthesecondbreast.■ Ifthebabydoesnotfeedin1hour,examinethebabyJ2–J9 .Ifhealthy,leavethebabywiththe

mothertotrylater.Assessin3hours,orearlierifthebabyissmall J4 .■ Ifthemotherisillandunabletobreastfeed,helphertoexpressbreastmilkandfeedthebabyby

cup K6 .Onday1expressinaspoonandfeedbyspoon.■ Ifmothercannotbreastfeedatall,useoneofthefollowingoptions: →donatedheat-treatedbreastmilk. →Ifnotavailable,thencommercialinfantformula. →Ifnotavailable,thenhome-madeformulafrommodifiedanimalmilk.

Counsel on breastfeeding (2)

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Supportexclusivebreastfeeding■Keepthemotherandbabytogetherinbedorwithineasyreach.do notseparatethem.■Encouragebreastfeedingondemand,dayandnight,aslongasthebabywants. →Ababyneedstofeeddayandnight,8ormoretimesin24hoursfrombirth.Onlyonthefirstday

mayafull-termbabysleepmanyhoursafteragoodfeed. →Asmallbabyshouldbeencouragedtofeed,dayandnight,atleast8timesin24hoursfrom

birth.■Helpthemotherwhenevershewants,andespeciallyifsheisafirsttimeoradolescentmother.■Letbabyreleasethebreast,thenofferthesecondbreast.■ Ifmothermustbeabsent,letherexpressbreastmilkandletsomebodyelsefeedtheexpressed

breastmilktothebabybycup.

do notforcethebabytotakethebreast.do notinterruptfeedbeforebabywants.do notgiveanyotherfeedsorwater.do notuseartificialteatsorpacifiers.

■Advisethemotheronmedicationandbreastfeeding →Mostdrugsgiventothemotherinthisguidearesafeandthebabycanbebreastfed. →Ifmotheristakingcotrimoxazoleorfansidar,monitorbabyforjaundice.

Teachcorrectpositioningandattachmentforbreastfeeding■Showthemotherhowtoholdherbaby.Sheshould: →makesurethebaby’sheadandbodyareinastraightline →makesurethebabyisfacingthebreast,thebaby’snoseisoppositehernipple →holdthebaby’sbodyclosetoherbody →supportthebaby’swholebody,notjusttheneckandshoulders■Showthemotherhowtohelpherbabytoattach.Sheshould: →touchherbaby’slipswithhernipple →waituntilherbaby’smouthisopenedwide →moveherbabyquicklyontoherbreast,aimingtheinfant’slowerlipwellbelowthenipple.■Lookforsignsofgoodattachment: → moreofareolavisibleabovethebaby'smouth →mouthwideopen →lowerlipturnedoutwards →baby'schintouchingbreast■Lookforsignsofeffectivesuckling(thatis,slow,deepsucks,sometimespausing).■ Iftheattachmentorsucklingisnotgood,tryagain.Thenreassess.■ Ifbreastengorgement,expressasmallamountofbreastmilkbeforestartingbreastfeedingtosoften

nippleareasothatitiseasierforthebabytoattach.

if mother is hiv-positive, see g7 for special counselling to the mother who is hiv-positive and breastfeeding.

if mother chose replacement feedings, see g8 .

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counsel on Breastfeeding

Givespecialsupporttobreastfeedthesmallbaby(pretermand/orlowbirthweight)counsel the mother:■Reassurethemotherthatshecanbreastfeedhersmallbabyandshehasenoughmilk.■Explainthathermilkisthebestfoodforsuchasmallbaby.Feedingforher/himisevenmore

importantthanforabigbaby.■Explainhowthemilk’sappearancechanges:milkinthefirstdaysisthickandyellow,thenit

becomesthinnerandwhiter.Botharegoodforthebaby.■Asmallbabydoesnotfeedaswellasabigbabyinthefirstdays: →maytireeasilyandsuckweaklyatfirst →maysuckleforshorterperiodsbeforeresting →mayfallasleepduringfeeding →mayhavelongpausesbetweensucklingandmayfeedlonger →doesnotalwayswakeupforfeeds.■Explainthatbreastfeedingwillbecomeeasierifthebabysucklesandstimulatesthebreasther/

himselfandwhenthebabybecomesbigger.■Encourageskin-to-skincontactsinceitmakesbreastfeedingeasier.

help the mother:■ Initiatebreastfeedingwithin1hourofbirth.■Feedthebabyevery2-3hours.Wakethebabyforfeeding,evenifshe/hedoesnotwakeupalone,

2hoursafterthelastfeed.■Alwaysstartthefeedwithbreastfeedingbeforeofferingacup.Ifnecessary,improvethemilkflow

(letthemotherexpressalittlebreastmilkbeforeattachingthebabytothebreast).■Keepthebabylongeratthebreast.Allowlongpausesorlong,slowfeed.Donotinterruptfeedifthe

babyisstilltrying.■ Ifthebabyisnotyetsucklingwellandlongenough,dowhateverworksbetterinyoursetting: →Letthemotherexpressbreastmilkintobaby’smouth K5 . →Letthemotherexpressbreastmilkandfeedbabybycup K6 .Onthefirstdayexpressbreast

milkinto,andfeedcolostrumbyspoon.■ Teachthemothertoobserveswallowingifgivingexpressedbreastmilk.■Weighthebabydaily(ifaccurateandprecisescalesavailable),recordandassessweightgain K7 .

Givespecialsupporttobreastfeedtwins

counsel the mother:■Reassurethemotherthatshehasenoughbreastmilkfortwobabies.■Encourageherthattwinsmaytakelongertoestablishbreastfeedingsincetheyarefrequentlyborn

pretermandwithlowbirthweight.

help the mother:■Startfeedingonebabyatatimeuntilbreastfeedingiswellestablished.■Helpthemotherfindthebestmethodtofeedthetwins: →Ifoneisweaker,encouragehertomakesurethattheweakertwingetsenoughmilk. →Ifnecessary,shecanexpressmilkforher/himandfeedher/himbycupafterinitialbreastfeeding. →Dailyalternatethesideeachbabyisoffered.

Alternative feeding methods (1)

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Expressbreastmilk■ Themotherneedscleancontainerstocollectandstorethemilk.

Awideneckedjug,jar,bowlorcupcanbeused.■Onceexpressed,themilkshouldbestoredwithawell-fittinglidorcover.■ Teachthemothertoexpressbreastmilk: →Toprovidemilkforthebabywhensheisaway.Tofeedthebabyifthebabyis

smallandtooweaktosuckle →Torelieveengorgementandtohelpbabytoattach →Todrainthebreastwhenshehasseveremastitisorabscesses.■ Teachthemothertoexpresshermilkbyherself.do notdoitforher.■ Teachherhowto: →Washherhandsthoroughly. →Sitorstandcomfortablyandholdacleancontainerunderneathherbreast. →Putherfirstfingerandthumboneithersideoftheareola,behindthenipple. →Pressslightlyinwardstowardsthebreastbetweenherfingerandthumb. →Expressonesideuntilthemilkflowslows.Thenexpresstheotherside. →Continuealternatingsidesforatleast20-30minutes.■ Ifmilkdoesnotflowwell: →Applywarmcompresses. →Havesomeonemassageherbackandneckbeforeexpressing. →Teachthemotherbreastandnipplemassage. →Feedthebabybycupimmediately.Ifnot,storeexpressedmilkinacool,cleanandsafeplace.■ Ifnecessary,repeattheproceduretoexpressbreastmilkatleast8timesin24hours.Expressas

muchasthebabywouldtakeormore,every3 hours.■Whennotbreastfeedingatall,expressjustalittletorelievepain K5 .■ Ifmotherisveryill,helphertoexpressordoitforher.

Handexpressbreastmilkdirectlyintothebaby’smouth■ Teachthemothertoexpressbreastmilk.■Holdthebabyinskin-to-skincontact,themouthclosetothenipple.■Expressthebreastuntilsomedropsofbreastmilkappearonthenipple.■Waituntilthebabyisalertandopensmouthandeyes,orstimulatethebabylightlytoawakenher/him.■Letthebabysmellandlickthenipple,andattempttosuck.■Letsomebreastmilkfallintothebaby’smouth.■Waituntilthebabyswallowsbeforeexpressingmoredropsofbreastmilk.■Aftersometime,whenthebabyhashadenough,she/hewillcloseher/hismouthand

takenomorebreastmilk.■Askthemothertorepeatthisprocessevery1-2hoursifthebabyisverysmall

(orevery2-3hoursifthebabyisnotverysmall).■Beflexibleateachfeed,butmakesuretheintakeisadequatebycheckingdailyweightgain.

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Cupfeedingexpressedbreastmilk■ Teachthemothertofeedthebabywithacup.Donotfeedthebabyyourself.Themothershould:■Measurethequantityofmilkinthecup■Holdthebabysittingsemi-uprightonherlap■Holdthecupofmilktothebaby’slips: →restcuplightlyonlowerlip →touchedgeofcuptoouterpartofupperlip →tipcupsothatmilkjustreachesthebaby’slips →butdonotpourthemilkintothebaby’smouth.■Babybecomesalert,opensmouthandeyes,andstartstofeed.■ Thebabywillsuckthemilk,spillingsome.■Smallbabieswillstarttotakemilkintotheirmouthusingthetongue.■Babyswallowsthemilk.■Babyfinishesfeedingwhenmouthclosesorwhennotinterestedintakingmore.■ Ifthebabydoesnottakethecalculatedamount: →Feedforalongertimeorfeedmoreoften →Teachthemothertomeasurethebaby’sintakeover24hours,notjustateachfeed.■ Ifmotherdoesnotexpressenoughmilkinthefirstfewdays,orifthemothercannotbreastfeedat

all,useoneofthefollowingfeedingoptions: →donatedheat-treatedbreastmilk →home-madeorcommercialformula.■Feedthebabybycupifthemotherisnotavailabletodoso.■Babyiscupfeedingwellifrequiredamountofmilkisswallowed,spillinglittle,andweightgainis

maintained.

Quantitytofeedbycup■Startwith80ml/kgbodyweightperdayforday1.Increasetotalvolumeby10-20ml/kgperday,

untilbabytakes150ml/kg/day.Seetablebelow.■Dividetotalinto8feeds.Giveevery2-3hourstoasmallsizeorillbaby.■Checkthebaby’s24hourintake.Sizeofindividualfeedsmayvary.■Continueuntilbabytakestherequiredquantity.■Washthecupwithwaterandsoapaftereachfeed.

approximate quantity to feed By cup (in ml) every 2-3 hours from Birth (By weight)

weight (kg) day 0 � 2 3 4 5 6 7

�.5-�.9 15ml 17ml 19ml 21ml 23ml 25ml 27ml 27+ml

2.0-2.4 20ml 22ml 25ml 27ml 30ml 32ml 35ml 35+ml

2.5+ 25ml 28ml 30ml 35ml 35ml 40+ml 45+ml 50+ml

Signsthatbabyisreceivingadequateamountofmilk■Babyissatisfiedwiththefeed.■Weightlossislessthan10%inthefirstweekoflife.■Babygainsatleast160-ginthefollowingweeksoraminimum300-ginthefirstmonth.■Babywetseverydayasfrequentlyasbabyisfeeding.■Baby’sstoolischangingfromdarktolightbrownoryellowbyday3.

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Weighbabyinthefirstmonthoflife

weigh the BaBy■Monthlyifbirthweightnormalandbreastfeedingwell.Every2weeksifreplacementfeedingor

treatmentwithisoniazid.■Whenthebabyisbroughtforexaminationbecausenotfeedingwell,orill.

weigh the small BaBy■Everydayuntil3consecutivetimesgainingweight(atleast15-g/day).■Weeklyuntil4-6weeksofage(reachedterm).

Assessweightgainuse this table for guidance when assessing weight gain in the first month of life

age acceptable weight loss/gain in the first month of life

� week Lossupto10%

2-4 weeks Gainatleast160gperweek(atleast15g/day)

� month Gainatleast300ginthefirstmonth

if weighing daily with a precise and accurate scale

first week Noweightlossortotallessthan10%

afterward dailygaininsmallbabiesatleast20g

ScalemaintenanceDaily/weeklyweighingrequirespreciseandaccuratescale(10-gincrement): →Calibrateitdailyaccordingtoinstructions. →Checkitforaccuracyaccordingtoinstructions.

Simplespringscalesarenotpreciseenoughfordaily/weeklyweighing.

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other Breastfeeding support

Givespecialsupporttothemotherwhoisnotyetbreastfeeding(mother or baby ill, or baby too small to suckle)■ Teachthemothertoexpressbreastmilk K5 .Helpherifnecessary.■Usethemilktofeedthebabybycup.■ Ifmotherandbabyareseparated,helpthemothertoseethebabyorinformheraboutthebaby’s

conditionatleasttwicedaily.■ Ifthebabywasreferredtoanotherinstitution,ensurethebabygetsthemother’sexpressedbreast

milkifpossible.■Encouragethemothertobreastfeedwhensheorthebabyrecovers.

Ifthebabydoesnothaveamother■Givedonatedheattreatedbreastmilkorhome-basedorcommercialformulabycup.■ Teachthecarerhowtopreparemilkandfeedthebaby K6 .■Followupin2weeks;weighandassessweightgain.

Advisethemotherwhoisnotbreastfeedingatallonhowtorelieveengorgement(Baby died or stillborn, mother chose replacement feeding)■Breastsmaybeuncomfortableforawhile.■Avoidstimulatingthebreasts.■Supportbreastswithawell-fittingbraorcloth.Donotbindthebreaststightlyasthismayincrease

herdiscomfort.■Applyacompress.Warmthiscomfortableforsomemothers,otherspreferacoldcompressto

reduceswelling.■ Teachthemothertoexpressenoughmilktorelievediscomfort.Expressingcanbedoneafewtimes

adaywhenthebreastsareoverfull.Itdoesnotneedtobedoneifthemotherisuncomfortable.Itwillbelessthanherbabywouldtakeandwillnotstimulateincreasedmilkproduction.

■Relievepain.Ananalgesicsuchasibuprofen,orparacetamolmaybeused.Somewomenuseplantproductssuchasteasmadefromherbs,orplantssuchasrawcabbageleavesplaceddirectlyonthebreasttoreducepainandswelling.

■ Advisetoseekcareifbreastsbecomepainful,swollen,red,ifshefeelsillortemperaturegreaterthan38ºC.

pharmacological treatments to reduce milk supply are not recommended. Theabovemethodsareconsideredmoreeffectiveinthelongterm.

Ensure warmth for the baby

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ensure warmth for the BaBy

Keepthebabywarmat Birth and within the first hour(s)■Warmdeliveryroom:forthebirthofthebabytheroomtemperatureshouldbe25-28ºC,nodraught.■Drybaby:immediatelyafterbirth,placethebabyonthemother’sabdomenoronawarm,cleanand

drysurface.Drythewholebodyandhairthoroughly,withadrycloth.■Skin-to-skincontact:Leavethebabyonthemother’sabdomen(beforecordcut)orchest(aftercord

cut)afterbirthforatleast2hours.Coverthebabywithasoftdrycloth.■ Ifthemothercannotkeepthebabyskin-to-skinbecauseofcomplications,wrapthebabyinaclean,

dry,warmclothandplaceinacot.Coverwithablanket.Usearadiantwarmerifroomnotwarmorbabysmall.

suBsequently (first day)■ Explaintothemotherthatkeepingbabywarmisimportantforthebabytoremainhealthy.■ Dressthebabyorwrapinsoftdrycleancloth.Covertheheadwithacapforthefirstfewdays,especiallyif

babyissmall.■ Ensurethebabyisdressedorwrappedandcoveredwithablanket.■ Keepthebabywithineasyreachofthemother.Donotseparatethem(rooming-in).■ Ifthemotherandbabymustbeseparated,ensurebabyisdressedorwrappedandcoveredwitha

blanket.■ Assesswarmthevery4hoursbytouchingthebaby’sfeet:iffeetarecolduseskin-to-skincontact,add

extrablanketandreassess(seeRewarmthenewborn).■ Keeptheroomforthemotherandbabywarm.Iftheroomisnotwarmenough,alwayscoverthebaby

withablanketand/oruseskin-to-skincontact.

at home■ Explaintothemotherthatbabiesneedonemorelayerofclothesthanotherchildrenoradults.■ Keeptheroomorpartoftheroomwarm,especiallyinacoldclimate.■ Duringtheday,dressorwrapthebaby.■ Atnight,letthebabysleepwiththemotherorwithineasyreachtofacilitatebreastfeeding.

do notputthebabyonanycoldorwetsurface.do notbaththebabyatbirth.Waitatleast6hoursbeforebathing.do notswaddle–wraptootightly.Swaddlingmakesthemcold.do notleavethebabyindirectsun.

Keepasmallbabywarm■ Theroomforthebabyshouldbewarm(notlessthan25°C)withnodraught.■Explaintothemothertheimportanceofwarmthforasmallbaby.■Afterbirth,encouragethemothertokeepthebabyinskin-to-skincontactaslongaspossible.■Advisetouseextraclothes,socksandacap,blankets,tokeepthebabywarmorwhenthebabyis

notwiththemother.■Washorbathababyinaverywarmroom,inwarmwater.Afterbathing,dryimmediatelyand

thoroughly.Keepthebabywarmafterthebath.Avoidbathingsmallbabies.■Checkfrequentlyiffeetarewarm.Ifcold,rewarmthebaby(seebelow).■Seekcareifthebaby’sfeetremaincoldafterrewarming.

Rewarmthebabyskin-to-skin■Beforerewarming,removethebaby’scoldclothing.■Placethenewbornskin-to-skinonthemother’schestdressedinapre-warmedshirtopenatthe

front,anappy(diaper),hatandsocks.■Covertheinfantonthemother’schestwithherclothesandanadditional(pre-warmed)blanket.■Checkthetemperatureeveryhouruntilnormal.■Keepthebabywiththemotheruntilthebaby’sbodytemperatureisinnormalrange.■ Ifthebabyissmall,encouragethemothertokeepthebabyinskin-to-skincontactforaslongas

possible,dayandnight.■Besurethetemperatureoftheroomwheretherewarmingtakesplaceisatleast25°C.■ Ifthebaby’stemperatureisnot36.5ºCormoreafter2hoursofrewarming,reassessthebaby J2–J7 .■ Ifreferralneeded,keepthebabyinskin-to-skinposition/contactwiththemotherorotherperson

accompanyingthebaby.

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other BaBy carealways wash hands before and after taking care of the baby. do not share supplies with other babies.

Cordcare■Washhandsbeforeandaftercordcare.■Putnothingonthestump.■Foldnappy(diaper)belowstump.■Keepcordstumplooselycoveredwithcleanclothes.■ Ifstumpissoiled,washitwithcleanwaterandsoap.Dryitthoroughlywithcleancloth.■ Ifumbilicusisredordrainingpusorblood,examinethebabyandmanageaccordingly J2–J7 .■Explaintothemotherthatsheshouldseekcareiftheumbilicusisredordrainingpusorblood.

do notbandagethestumporabdomen. do notapplyanysubstancesormedicinetostump. Avoidtouchingthestumpunnecessarily.

Sleeping■Usethebednetdayandnightforasleepingbaby.■Letthebabysleeponher/hisbackorontheside.■Keepthebabyawayfromsmokeorpeoplesmoking.■Keepthebaby,especiallyasmallbaby,awayfromsickchildrenoradults.

Hygiene(washing,bathing)

at Birth:■Onlyremovebloodormeconium.

do notremovevernix. do notbathethebabyuntilatleast6hoursofage.

later and at home:■Washtheface,neck,underarmsdaily.■Washthebuttockswhensoiled.Drythoroughly.■Bathwhennecessary: →Ensuretheroomiswarm,nodraught →Usewarmwaterforbathing →Thoroughlydrythebaby,dressandcoverafterbath.

other BaBy care:■Useclothonbaby’sbottomtocollectstool.Disposeofthestoolasforwoman’spads.Washhands.

do notbathethebabybefore6hoursoldorifthebabyiscold. do notapplyanythinginthebaby’seyesexceptanantimicrobialatbirth.

small BaBies require more careful attention:■ Theroommustbewarmerwhenchanging,washing,bathingandexaminingasmallbaby.

Newborn resuscitation

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newBorn resuscitationstart resuscitation within � minute of birth if baby is not breathing or is gasping for breath.observe universal precautions to prevent infection a4 .

Keepthebabywarm■Clampandcutthecordifnecessary.■ Transferthebabytoadry,cleanandwarmsurface.■ Informthemotherthatthebabyhasdifficultyinitiatingbreathingandthatyouwillhelpthebabytobreathe.■Keepthebabywrappedandunderaradiantheaterifpossible.

Opentheairway■Positiontheheadsoitisslightlyextended.■Suctionfirstthemouthandthenthenose.■ Introducethesuctiontubeintothenewborn’smouth5-cmfromlipsandsuckwhilewithdrawing.■ Introducethesuctiontube3-cmintoeachnostrilandsuckwhilewithdrawinguntilnomucus.■Repeateachsuctionifnecessarybutnomorethantwiceandnomorethan20secondsintotal.

Ifstillnobreathing,VENTILATE:■Placemasktocoverchin,mouth,andnose.■Formseal.■Squeezebagattachedtothemaskwith2fingersorwholehand,accordingtobagsize,2or3times.■Observeriseofchest.Ifchestisnotrising: →repositionhead →checkmaskseal.■Squeezebagharderwithwholehand.■Oncegoodsealandchestrising,ventilateat40squeezesperminuteuntilnewbornstartscryingor

breathingspontaneously.

Ifbreathingorcrying,stopventilating■Lookatthechestforin-drawing.■Countbreathsperminute.■ Ifbreathingmorethan30breathsperminuteandnoseverechestin-drawing: →donotventilateanymore →putthebabyinskin-to-skincontactonmother’schestandcontinuecareason d�9

→monitorevery15minutesforbreathingandwarmth →tellthemotherthatthebabywillprobablybewell.

do notleavethebabyalone

Ifbreathinglessthan30breathsperminuteorseverechestin-drawing:■continueventilating■arrangeforimmediatereferral■explaintothemotherwhathappened,whatyouaredoingandwhy■ventilateduringreferral■ recordtheeventonthereferralformandlabourrecord.

Ifnobreathingorgaspingatallafter20minutesofventilation■Stopventilating.Thebabyisdead.■Explaintothemotherandgivesupportivecare d24 .■Recordtheevent.

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Treatthebaby■Determineappropriatedrugsanddosageforthebaby’sweight.■ Tellthemotherthereasonsforgivingthedrugtothebaby.■Giveintramuscularantibioticsinthigh.Useanewsyringeandneedleforeachantibiotic.

teach the mother to give treatment to the BaBy at home■Explaincarefullyhowtogivethetreatment.Labelandpackageeachdrugseparately.■Checkmother’sunderstandingbeforesheleavestheclinic.■Demonstratehowtomeasureadose.■Watchthemotherpracticemeasuringadosebyherself.■Watchthemothergivethefirstdosetothebaby.

Give2IMantibiotics(firstweekoflife)■GivefirstdoseofbothampicillinandgentamicinIMinthighbeforereferralforpossibleserious

illness,severeumbilicalinfectionorsevereskininfection.■GivebothampicillinandgentamicinIMfor5daysinasymptomaticbabiesclassifiedatriskof

infection.■Giveintramuscularantibioticsinthigh.Useanewsyringeandneedleforeachantibiotic.

ampicillin im gentamicin im dose:50mgperkg dose:5mgperkg every12hours every24hoursifterm; Add2.5mlsterilewater 4mgperkgevery24hoursifpreterm

weight to500mgvial=200mg/ml 20mgper2mlvial=10mg/ml

�.0 — �.4 kg 0.35ml 0.5ml �.5 — �.9 kg 0.5ml 0.7ml 2.0 — 2.4 kg 0.6ml 0.9ml 2.5 — 2.9 kg 0.75ml 1.35ml 3.0 — 3.4 kg 0.85ml 1.6ml 3.5 — 3.9 kg 1ml 1.85ml 4.0 — 4.4 kg 1.1ml 2.1ml

GiveIMbenzathinepenicillintobaby(singledose)ifmothertestedRPR-positive Benzathine penicillin im dose:50000units/kgonce Add5mlsterilewatertovial containing1.2millionunits =1.2millionunits/(6mltotalvolume) weight =200000units/ml �.0 - �.4 kg 0.35ml �.5 - �.9 kg 0.5ml 2.0 - 2.4 kg 0.6ml 2.5 - 2.9 kg 0.75ml 3.0 - 3.4 kg 0.85ml 3.5 - 3.9 kg 1.0ml 4.0 - 4.4 kg 1.1ml

GiveIMantibioticforpossiblegonococcaleyeinfection(singledose) ceftriaxone (�st choice) Kanamycin (2nd choice) dose:50mgperkgonce dose:25mgperkgonce,max75mg weight 250mgper5mlvial=mg/ml 75mgper2mlvial=37.5mg/ml

�.0 - �.4 kg 1ml 0.7ml �.5 - �.9 kg 1.5ml 1ml 2.0 - 2.4 kg 2ml 1.3ml 2.5 - 2.9 kg 2.5ml 1.7ml 3.0 - 3.4 kg 3ml 2ml 3.5 - 3.9 kg 3.5ml 2ml 4.0 - 4.4 kg 4ml 2ml

Treat and immunize the baby (2)

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Treatlocalinfectionteach mother to treat local infection■Explainandshowhowthetreatmentisgiven.■Watchherasshecarriesoutthefirsttreatment.■Askhertoletyouknowifthelocalinfectiongetsworseandtoreturntotheclinicifpossible.■ Treatfor5days.

treat sKin pustules or umBilical infectiondo the following 3 times daily:■Washhandswithcleanwaterandsoap.■Gentlywashoffpusandcrustswithboiledandcooledwaterandsoap.■Drytheareawithcleancloth.■Paintwithgentianviolet.■Washhands.

treat eye infection do the following 6-8 times daily:■Washhandswithcleanwaterandsoap.■Wetcleanclothwithboiledandcooledwater.■Usethewetclothtogentlywashoffpusfromthebaby’seyes.■Apply1%tetracyclineeyeointmentineacheye3timesdaily.■Washhands.

reassess in 2 days:■Assesstheskin,umbilicusoreyes.■ Ifpusorrednessremainsorisworse,refertohospital.■ Ifpusandrednesshaveimproved,tellthemothertocontinuetreatinglocalinfectionathome.

Giveisoniazid(INH)prophylaxistonewbornif the mother is diagnosed as having tuberculosis and started treatmentless than 2 months before delivery:■Give5-mg/kgisoniazid(INH)orallyonceadayfor6months(1tablet=200-mg).■DelayBCGvaccinationuntilINHtreatmentcompleted,orrepeatBCG.■Reassurethemotherthatitissafetobreastfeedthebaby.■Followupthebabyevery2weeks,oraccordingtonationalguidelines,toassessweightgain.

Immunizethenewborn■GiveBCG,OPV-0,HepatitisB(HB-1)vaccineinthefirstweekoflife,preferablybeforedischarge.■ Ifun-immunizednewbornfirstseen1-4weeksofage,giveBCGonly.■Recordonimmunizationcardandchildrecord.■Advisewhentoreturnfornextimmunization.

age vaccine

Birth < � week BCGOPV-0HB1 6 weeks DPTOPV-1HB-2

GiveARVmedicinetonewborn■GivethefirstdoseofARVmedicinestonewborn8–12hoursafterbirth: → GiveNevirapine2mg/kgonceonly. → GiveZidovudine4mg/kgevery12hours.■ Ifthenewbornspillsorvomitswithin30minutesrepeatthedose.

TeachmothertogiveoralARVmedicinesathome■Explainandshowhowthemedicineisgiven. → Washhands. → Demonstratehowtomeasurethedoseonthespoon. → Beginfeedingthebabybycup. → Givemedicinebyspoonbeforetheendofthefeed. → Completethefeed.■Watchherasshecarriesoutthenexttreatment.■ExplaintothemotherthatsheshouldwatchherbabyaftergivingadoseofZidovudine.Ifbaby

vomitsorspillswithin30minutes,sheshouldrepeatthedose.■GiveZidovudineevery12hoursfor7days.

Advise when to return with the baby Br

east

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advise when to return with the BaByfor maternal visits see schedule on d28 .

Routinevisits returnpostnatal visit Withinthefirstweek,preferably

within2-3daysimmunization visit Atage6weeks

(IfBCG,OPV-0andHB-1giveninthefirstweekoflife)

Follow-upvisits

if the problem was: return inFeedingdifficulty 2daysRedumbilicus 2daysSkininfection 2daysEyeinfection 2daysThrush 2daysMotherhaseither: →breastengorgementor 2days →mastitis. 2daysLowbirthweight,andeither →firstweekoflifeor 2days →notadequatelygainingweight 2daysLowbirthweight,andeither →olderthan1weekor 7days →gainingweightadequately 7daysOrphanbaby 14daysINHprophylaxis 14daysTreatedforpossiblecongenitalsyphilis 14daysMotherHIV-positive 14days

AdvisethemothertoseekcareforthebabyUsethecounsellingsheettoadvisethemotherwhentoseekcare,orwhentoreturn,ifthebabyhasanyofthesedangersigns:

return or go to the hospital immediately if the BaBy has■difficultybreathing.■convulsions.■ feverorfeelscold.■bleeding.■diarrhoea.■verysmall,justborn.■notfeedingatall.

go to health centre as quicKly as possiBle if the BaBy has■difficultyfeeding.■pusfromeyes.■skinpustules.■yellowskin.■acordstumpwhichisredordrainingpus.■ feeds<5timesin24hours.

Referbabyurgentlytohospital■Afteremergencytreatment,explaintheneedforreferraltothemother/father.■Organizesafetransportation.■Alwayssendthemotherwiththebaby,ifpossible.■Sendreferralnotewiththebaby.■ Informthereferralcentreifpossiblebyradioortelephone.

during transportation■Keepthebabywarmbyskin-to-skincontactwithmotherorsomeoneelse.■Coverthebabywithablanketandcoverher/hisheadwithacap.■Protectthebabyfromdirectsunshine.■Encouragebreastfeedingduringthejourney.■ Ifthebabydoesnotbreastfeedandjourneyismorethan3hours,considergivingexpressedbreast

milkbycup K6 .

Equipment, supplies, drugs and laboratory tests

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

L1

EQUIPMENT, SUPPLIES, DRUGS AND LABORATORY TESTSEquipment, supplies, drugs and tests for pregnancy and postpartum care

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

L2

EQUIPMENT, SUPPLIES, DRUGS AND TESTS fOR ROUTINE AND EMERGENcY PREGNANcY AND POSTPARTUM cARE

Warmandcleanroom■Examinationtableorbedwithcleanlinen■Lightsource■Heatsource

Handwashing■Cleanwatersupply■Soap■Nailbrushorstick■Cleantowels

Waste■Bucketforsoiledpadsandswabs■Receptacleforsoiledlinens■Containerforsharpsdisposal

Sterilization■ Instrumentsterilizer■Jarforforceps

Miscellaneous■Wallclock■Torchwithextrabatteriesandbulb■Logbook■Records■Refrigerator

Equipment■Bloodpressuremachineandstethoscope■Bodythermometer■Fetalstethoscope■Babyscale

Supplies■Gloves:

→utility→sterileorhighlydisinfected→longsterileformanualremovalofplacenta

■Urinarycatheter■Syringesandneedles■ IVtubing■Suturematerialfortearorepisiotomyrepair■Antisepticsolution(iodophorsorchlorhexidine)■Spirit(70%alcohol)■Swabs■Bleach(chlorinebasecompound)■ Impregnatedbednet■Condoms

Tests■RPRtestingkit■Proteinuriasticks■Containerforcatchingurine■HIVtestingkit(2types)■Haemoglobintestingkit

Disposabledeliverykit■Plasticsheettoplaceundermother■Cordties(sterile)■Sterileblade

Drugs■Oxytocin■Ergometrine■Magnesiumsulphate■Calciumgluconate■Diazepam■Hydralazine■Ampicillin■Gentamicin■Metronidazole■Benzathinepenicillin■Cloxacillin■Amoxycillin■Ceftriaxone■Trimethoprim+sulfamethoxazole■Clotrimazolevaginalpessary■Erythromycin■Ciprofloxacin■Tetracyclineordoxycycline■Arthemetherorquinine■Chloroquinetablet■Lignocaine■Adrenaline■Ringerlactate■Normalsaline0.9%■Glucose50%solution■Waterforinjection■Paracetamol■Gentianviolet■ Iron/folicacidtablet■Mebendazole■Sulphadoxine-pyrimethamine■Nevirapine(adult,infant)■Zidovudine(AZT)(adult,infant)■Lamivudine(3TC)

Vaccine■Tetanustoxoid

Laboratory tests (1)

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

L�

LABORATORY TESTS

Checkurineforprotein■Labelacleancontainer.■Givewomanthecleancontainerandexplainwhereshecanurinate.■Teachwomanhowtocollectaclean-catchurinesample.Askherto:

→Cleanvulvawithwater→Spreadlabiawithfingers→Urinatefreely(urineshouldnotdribbleovervulva;thiswillruinsample)→Catchthemiddlepartofthestreamofurineinthecup.Removecontainerbeforeurinestops.

■Analyseurineforproteinusingeitherdipstickorboilingmethod.

DIPSTIck METhOD■Dipcoatedendofpaperdipstickinurinesample.■Shakeoffexcessbytappingagainstsideofcontainer.■Waitspecifiedtime(seedipstickinstructions).■Comparewithcolourchartonlabel.Coloursrangefromyellow(negative)throughyellow-greenand

green-blueforpositive.

BOILING METhOD■Puturineintesttubeandboiltophalf.Boiledpartmaybecomecloudy.Afterboilingallowthetest

tubetostand.Athickprecipitateatthebottomofthetubeindicatesprotein.■Add2-3dropsof2-3%aceticacidafterboilingtheurine(evenifurineisnotcloudy)

→Iftheurineremainscloudy,proteinispresentintheurine.→Ifcloudyurinebecomesclear,proteinisnotpresent.→Ifboiledurinewasnotcloudytobeginwith,butbecomescloudywhenaceticacidisadded,

proteinispresent.

Checkhaemoglobin■Drawbloodwithsyringeandneedleorasterilelancet.■ Insertbelowinstructionsformethodusedlocally.

✎____________________________________________________________________

✎____________________________________________________________________

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

L�Perform Rapid HIV test (type of test use depends on the national policy)

PERfORM RAPID hIV TEST (TYPE Of TEST USE DEPENDS ON ThE NATIONAL POLIcY)

■Explaintheprocedureandseekconsentaccordingtothenationalpolicy.■Usetestkitsrecommendedbythenationaland/orinternationalbodiesandfollowtheinstructions

oftheHIVrapidtestselected.■Prepareyourworksheet,labelthetest,andindicatethetestbatchnumberandexpirydate.Check

thatexpirytimehasnotlapsed.■Weargloveswhendrawingbloodandfollowstandardsafetyprecautionsforwastedisposal.■ Informthewomenwhentoreturntotheclinicfortheirtestresults(samedayortheywillhaveto

comeagain).■Drawbloodforalltestsatthesametime(testsforHb,syphilisandHIVcanoftenbecoupledatthe

sametime).→Useasterileneedleandsyringewhendrawingbloodfromavein.→Usealancetwhendoingafingerprick.

■Performthetestfollowingmanufacturer’sinstructions.■ InterprettheresultsaspertheinstructionsoftheHIVrapidtestselected.

→Ifthefirsttestresultisnegative,nofurthertestingisdone.Recordtheresultas–NegativeforHIV.→Ifthefirsttestresultispositive,performasecondHIVrapidtestusingadifferenttestkit.→Ifthesecondtestisalsopositive,recordtheresultas–PositiveforHIV.→Ifthefirsttestresultispositiveandsecondtestresultisnegative,recordtheresultas

inconclusive.Repeatthetestafter6weeksorreferthewomantohospitalforaconfirmatorytest.→Sendtheresultstothehealthworker.Respectconfidentiality A2 .

■Recordallresultsinthelogbook.

Equipment, suplies and drugs

Performrapidplasmareagin(RPR)testforsyphilis■Seekconsent.

■Explainprocedure.

■Useasterileneedleandsyringe.Drawup5mlbloodfromavein.Putinacleartesttube.

■Lettesttubesit20minutestoallowserumtoseparate(orcentrifuge3-5minutesat2000–3000-rpm).Intheseparatedsample,serumwillbeontop.

■Usesamplingpipettetowithdrawsomeoftheserum.Takecarenottoincludeanyredbloodcellsfromthelowerpartoftheseparatedsample.

■Holdthepipetteverticallyoveratestcardcircle.Squeezeteattoallowonedrop(50‑µl)ofserumtofallontoacircle.Spreadthedroptofillthecircleusingatoothpickorothercleanspreader.

Important: Several samples may be tested on one card. Be careful not to contaminate the remaining test circles. Use a clean spreader for every sample. carefully label each sample with a patient’s name or number.

■Attachdispensingneedletoasyringe.Shakeantigen.*Drawupenoughantigenforthenumberofteststobedone(onedroppertest).

■Holdingthesyringevertically,allowexactlyonedropofantigen(20‑µl)tofallontoeachtestsample.DO NOT stir.

■Rotatethetestcardsmoothlyonthepalmofthehandfor8minutes.**(Orrotateonamechanicalrotator.)

*Makesureantigenwasrefrigerated(notfrozen)andhasnotexpired.**Roomtemperatureshouldbe73º-85ºF(22.8º–29.3ºC).

Laboratory tests (2) Perform rapid plasmareagin (RPR) test for syphilis

EQUI

PMEN

T, SU

PPLI

ES A

ND D

RUGS

L�

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

PERfORM RAPID PLASMAREAGIN (RPR) TEST fOR SYPhILIS

Interpretingresults■After8minutesrotation,inspectthecardingoodlight.Turnorliftthecardtoseewhetherthere

isclumping(reactiveresult).Mosttestcardsincludenegativeandpositivecontrolcirclesforcomparison.

1. Non‑reactive(noclumpingoronlyslightroughness)–Negativeforsyphilis2. Reactive(highlyvisibleclumping)-Positiveforsyphilis3. Weakly reactive (minimalclumping)-Positiveforsyphilis

NOTE:Weaklyreactivecanalsobemorefinelygranulatedanddifficulttoseethaninthisillsutration.

ExAMPLE Of A TEST cARD

1 2 3

Equipment, suplies and drugs

Warmandcleanroom■Deliverybed:abedthatsupportsthewomaninasemi-sittingor

lyinginalateralposition,withremovablestirrups(onlyforrepairingtheperineumorinstrumentaldelivery)

■Cleanbedlinen■Curtainsifmorethanonebed■Cleansurface(foralternativedeliveryposition)■Worksurfaceforresuscitationofnewbornneardeliverybeds■Lightsource■Heatsource■Roomthermometer

Handwashing■Cleanwatersupply■Soap■Nailbrushorstick■Cleantowels

Waste■Containerforsharpsdisposal■Receptacleforsoiledlinens■Bucketforsoiledpadsandswabs■Bowlandplasticbagforplacenta

Sterilization■ Instrumentsterilizer■Jarforforceps

Miscellaneous■Wallclock■Torchwithextrabatteriesandbulb■Logbook

Equipment, supplies and drugs for childbirth care

EQUI

PMEN

T, SU

PPLI

ES A

ND D

RUGS

L3

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

EQUIPMENT, SUPPLIES AND DRUGS fOR chILDBIRTh cARE

Equipment■Bloodpressuremachineandstethoscope■Bodythermometer■Fetalstethoscope■Babyscale■Selfinflatingbagandmask-neonatalsize■Mucusextractorwithsuctiontube

Deliveryinstruments(sterile)■Scissors■Needleholder■Arteryforcepsorclamp■Dissectingforceps■Spongeforceps■Vaginalspeculum

Supplies■Gloves:

→utility→sterileorhighlydisinfected→longsterileformanualremovalofplacenta→Longplasticapron

■Urinarycatheter■Syringesandneedles■ IVtubing■Suturematerialfortearorepisiotomyrepair■Antisepticsolution(iodophorsorchlorhexidine)■Spirit(70%alcohol)■Swabs■Bleach(chlorine-basecompound)■Clean(plastic)sheettoplaceundermother■Sanitarypads■Cleantowelsfordryingandwrappingthebaby■Cordties(sterile)■Blanketforthebaby■Babyfeedingcup■ Impregnatedbednet

Drugs■Oxytocin■Ergometrine■Magnesiumsulphate■Calciumgluconate■Diazepam■Hydralazine■Ampicillin■Gentamicin■Metronidazole■Benzathinepenicillin■Lignocaine■Adrenaline■Ringerlactate■Normalsaline0.9%■Waterforinjection■Eyeantimicrobial(1%silvernitrateor2.5%povidoneiodine)■Tetracycline1%eyeointment■VitaminA■ Izoniazid■Nevirapine(adult,infant)■Zidovudine(AZT)(adult,infant)■Lamivudine(3TC)

Vaccine■BCG■OPV■HepatitisB

Contraceptives(seeDecision-making tool for family planning providers and

clients)

Test■RPRtestingkits■HIVtestingkits(2types)■Haemoglobintestingkit

L2 EQUIPMENT, SUPPLIES, DRUGS AND TESTS fOR ROUTINE AND EMERGENcY cARE

L3 EQUIPMENT, SUPPLIES AND DRUGS fOR chILDBIRTh cARE

L4 LABORATORY TESTS (1) Checkurineforprotein

Checkhaemoglobin

L5 LABORATORY TESTS (2) Performrapidplamareagin(RPR)testfor

syphilis

L6 LABORATORY TESTS (3) PerformrapidtestforHIV

Equipment, supplies, drugs and tests for pregnancy and postpartum careEQ

UIPM

ENT,

SUPP

LIES

, DRU

GS A

ND L

ABOR

ATOR

Y TE

STS

L2

EQUIPMENT, SUPPLIES, DRUGS AND TESTS fOR ROUTINE AND EMERGENcY PREGNANcY AND POSTPARTUM cARE

Warmandcleanroom■Examinationtableorbedwithcleanlinen■Lightsource■Heatsource

Handwashing■Cleanwatersupply■Soap■Nailbrushorstick■Cleantowels

Waste■Bucketforsoiledpadsandswabs■Receptacleforsoiledlinens■Containerforsharpsdisposal

Sterilization■ Instrumentsterilizer■Jarforforceps

Miscellaneous■Wallclock■Torchwithextrabatteriesandbulb■Logbook■Records■Refrigerator

Equipment■Bloodpressuremachineandstethoscope■Bodythermometer■Fetalstethoscope■Babyscale

Supplies■Gloves:

→utility→sterileorhighlydisinfected→longsterileformanualremovalofplacenta

■Urinarycatheter■Syringesandneedles■ IVtubing■Suturematerialfortearorepisiotomyrepair■Antisepticsolution(iodophorsorchlorhexidine)■Spirit(70%alcohol)■Swabs■Bleach(chlorinebasecompound)■ Impregnatedbednet■Condoms

Tests■RPRtestingkit■Proteinuriasticks■Containerforcatchingurine■HIVtestingkit(2types)■Haemoglobintestingkit

Disposabledeliverykit■Plasticsheettoplaceundermother■Cordties(sterile)■Sterileblade

Drugs■Oxytocin■Ergometrine■Magnesiumsulphate■Calciumgluconate■Diazepam■Hydralazine■Ampicillin■Gentamicin■Metronidazole■Benzathinepenicillin■Cloxacillin■Amoxycillin■Ceftriaxone■Trimethoprim+sulfamethoxazole■Clotrimazolevaginalpessary■Erythromycin■Ciprofloxacin■Tetracyclineordoxycycline■Arthemetherorquinine■Chloroquinetablet■Lignocaine■Adrenaline■Ringerlactate■Normalsaline0.9%■Glucose50%solution■Waterforinjection■Paracetamol■Gentianviolet■ Iron/folicacidtablet■Mebendazole■Sulphadoxine-pyrimethamine■Nevirapine(adult,infant)■Zidovudine(AZT)(adult,infant)■Lamivudine(3TC)

Vaccine■Tetanustoxoid

Equipment, suplies and drugs

Warmandcleanroom■Deliverybed:abedthatsupportsthewomaninasemi-sittingor

lyinginalateralposition,withremovablestirrups(onlyforrepairingtheperineumorinstrumentaldelivery)

■Cleanbedlinen■Curtainsifmorethanonebed■Cleansurface(foralternativedeliveryposition)■Worksurfaceforresuscitationofnewbornneardeliverybeds■Lightsource■Heatsource■Roomthermometer

Handwashing■Cleanwatersupply■Soap■Nailbrushorstick■Cleantowels

Waste■Containerforsharpsdisposal■Receptacleforsoiledlinens■Bucketforsoiledpadsandswabs■Bowlandplasticbagforplacenta

Sterilization■ Instrumentsterilizer■Jarforforceps

Miscellaneous■Wallclock■Torchwithextrabatteriesandbulb■Logbook

Equipment, supplies and drugs for childbirth care

EQUI

PMEN

T, SU

PPLI

ES A

ND D

RUGS

L3

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

EQUIPMENT, SUPPLIES AND DRUGS fOR chILDBIRTh cARE

Equipment■Bloodpressuremachineandstethoscope■Bodythermometer■Fetalstethoscope■Babyscale■Selfinflatingbagandmask-neonatalsize■Mucusextractorwithsuctiontube

Deliveryinstruments(sterile)■Scissors■Needleholder■Arteryforcepsorclamp■Dissectingforceps■Spongeforceps■Vaginalspeculum

Supplies■Gloves:

→utility→sterileorhighlydisinfected→longsterileformanualremovalofplacenta→Longplasticapron

■Urinarycatheter■Syringesandneedles■ IVtubing■Suturematerialfortearorepisiotomyrepair■Antisepticsolution(iodophorsorchlorhexidine)■Spirit(70%alcohol)■Swabs■Bleach(chlorine-basecompound)■Clean(plastic)sheettoplaceundermother■Sanitarypads■Cleantowelsfordryingandwrappingthebaby■Cordties(sterile)■Blanketforthebaby■Babyfeedingcup■ Impregnatedbednet

Drugs■Oxytocin■Ergometrine■Magnesiumsulphate■Calciumgluconate■Diazepam■Hydralazine■Ampicillin■Gentamicin■Metronidazole■Benzathinepenicillin■Lignocaine■Adrenaline■Ringerlactate■Normalsaline0.9%■Waterforinjection■Eyeantimicrobial(1%silvernitrateor2.5%povidoneiodine)■Tetracycline1%eyeointment■VitaminA■ Izoniazid■Nevirapine(adult,infant)■Zidovudine(AZT)(adult,infant)■Lamivudine(3TC)

Vaccine■BCG■OPV■HepatitisB

Contraceptives(seeDecision-making tool for family planning providers and

clients)

Test■RPRtestingkit■HIVtestingkits(2types)■Haemoglobintestingkit

Laboratory tests (1)EQ

UIPM

ENT,

SUPP

LIES

, DRU

GS A

ND L

ABOR

ATOR

Y TE

STS

L�

LABORATORY TESTS

Checkurineforprotein■Labelacleancontainer.■Givewomanthecleancontainerandexplainwhereshecanurinate.■Teachwomanhowtocollectaclean-catchurinesample.Askherto:

→Cleanvulvawithwater→Spreadlabiawithfingers→Urinatefreely(urineshouldnotdribbleovervulva;thiswillruinsample)→Catchthemiddlepartofthestreamofurineinthecup.Removecontainerbeforeurinestops.

■Analyseurineforproteinusingeitherdipstickorboilingmethod.

DIPSTIck METhOD■Dipcoatedendofpaperdipstickinurinesample.■Shakeoffexcessbytappingagainstsideofcontainer.■Waitspecifiedtime(seedipstickinstructions).■Comparewithcolourchartonlabel.Coloursrangefromyellow(negative)throughyellow-greenand

green-blueforpositive.

BOILING METhOD■Puturineintesttubeandboiltophalf.Boiledpartmaybecomecloudy.Afterboilingallowthetest

tubetostand.Athickprecipitateatthebottomofthetubeindicatesprotein.■Add2-3dropsof2-3%aceticacidafterboilingtheurine(evenifurineisnotcloudy)

→Iftheurineremainscloudy,proteinispresentintheurine.→Ifcloudyurinebecomesclear,proteinisnotpresent.→Ifboiledurinewasnotcloudytobeginwith,butbecomescloudywhenaceticacidisadded,

proteinispresent.

Checkhaemoglobin■Drawbloodwithsyringeandneedleorasterilelancet.■ Insertbelowinstructionsformethodusedlocally.

✎____________________________________________________________________

✎____________________________________________________________________

Equipment, suplies and drugs

Performrapidplasmareagin(RPR)testforsyphilis■Seekconsent.

■Explainprocedure.

■Useasterileneedleandsyringe.Drawup5mlbloodfromavein.Putinacleartesttube.

■Lettesttubesit20minutestoallowserumtoseparate(orcentrifuge3-5minutesat2000–3000-rpm).Intheseparatedsample,serumwillbeontop.

■Usesamplingpipettetowithdrawsomeoftheserum.Takecarenottoincludeanyredbloodcellsfromthelowerpartoftheseparatedsample.

■Holdthepipetteverticallyoveratestcardcircle.Squeezeteattoallowonedrop(50‑µl)ofserumtofallontoacircle.Spreadthedroptofillthecircleusingatoothpickorothercleanspreader.

Important: Several samples may be tested on one card. Be careful not to contaminate the remaining test circles. Use a clean spreader for every sample. carefully label each sample with a patient’s name or number.

■Attachdispensingneedletoasyringe.Shakeantigen.*Drawupenoughantigenforthenumberofteststobedone(onedroppertest).

■Holdingthesyringevertically,allowexactlyonedropofantigen(20‑µl)tofallontoeachtestsample.DO NOT stir.

■Rotatethetestcardsmoothlyonthepalmofthehandfor8minutes.**(Orrotateonamechanicalrotator.)

*Makesureantigenwasrefrigerated(notfrozen)andhasnotexpired.**Roomtemperatureshouldbe73º-85ºF(22.8º–29.3ºC).

Laboratory tests (2) Perform rapid plasmareagin (RPR) test for syphilis

EQUI

PMEN

T, SU

PPLI

ES A

ND D

RUGS

L�

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

S

PERfORM RAPID PLASMAREAGIN (RPR) TEST fOR SYPhILIS

Interpretingresults■After8minutesrotation,inspectthecardingoodlight.Turnorliftthecardtoseewhetherthere

isclumping(reactiveresult).Mosttestcardsincludenegativeandpositivecontrolcirclesforcomparison.

1. Non‑reactive(noclumpingoronlyslightroughness)–Negativeforsyphilis2. Reactive(highlyvisibleclumping)-Positiveforsyphilis3. Weakly reactive (minimalclumping)-Positiveforsyphilis

NOTE:Weaklyreactivecanalsobemorefinelygranulatedanddifficulttoseethaninthisillsutration.

ExAMPLE Of A TEST cARD

1 2 3

EQUI

PMEN

T, SU

PPLI

ES, D

RUGS

AND

LAB

ORAT

ORY

TEST

SL�Perform Rapid HIV test

PERfORM RAPID hIV TEST (TYPE Of TEST USE DEPENDS ON ThE NATIONAL POLIcY)

■Explaintheprocedureandseekconsentaccordingtothenationalpolicy.■Usetestkitsrecommendedbythenationaland/orinternationalbodiesandfollowtheinstructions

oftheHIVrapidtestselected.■Prepareyourworksheet,labelthetest,andindicatethetestbatchnumberandexpirydate.Check

thatexpirytimehasnotlapsed.■Weargloveswhendrawingbloodandfollowstandardsafetyprecautionsforwastedisposal.■ Informthewomenwhentoreturntotheclinicfortheirtestresults(samedayortheywillhaveto

comeagain).■Drawbloodforalltestsatthesametime(testsforHb,syphilisandHIVcanoftenbecoupledatthe

sametime).→Useasterileneedleandsyringewhendrawingbloodfromavein.→Usealancetwhendoingafingerprick.

■Performthetestfollowingmanufacturer’sinstructions.■ InterprettheresultsaspertheinstructionsoftheHIVrapidtestselected.

→Ifthefirsttestresultisnegative,nofurthertestingisdone.Recordtheresultas–NegativeforHIV.→Ifthefirsttestresultispositive,performasecondHIVrapidtestusingadifferenttestkit.→Ifthesecondtestisalsopositive,recordtheresultas–PositiveforHIV.→Ifthefirsttestresultispositiveandsecondtestresultisnegative,recordtheresultas

inconclusive.Repeatthetestafter6weeksorreferthewomantohospitalforaconfirmatorytest.→Sendtheresultstothehealthworker.Respectconfidentiality A2 .

■Recordallresultsinthelogbook.

Information and counselling sheets

Info

rmat

Ion

and

coun

sell

Ing

shee

ts

m�

InformatIon and counsellIng sheetscare durIng pregnancy

Care during pregnancy

Info

rmat

Ion

and

coun

sell

Ing

m2

Visitthehealthworkerduringpregnancy■Gotothehealthcentreifyouthinkyouarepregnant.Itisimportanttobegincareasearlyinyour

pregnancyaspossible.■Visitthehealthcentreatleast4timesduringyourpregnancy,evenifyoudonothaveanyproblems.

Thehealthworkerwilltellyouwhentoreturn.■ Ifatanytimeyouhaveanyconcernsaboutyouroryourbaby’shealth,gotothehealthcentre.■Duringyourvisitstothehealthcentre,thehealthworkerwill:

→ Checkyourhealthandtheprogressofthepregnancy → Helpyoumakeabirthplan → Answerquestionsorconcernsyoumayhave → Providetreatmentformalariaandanaemia → Giveyouatetanustoxoidimmunization → Adviseandcounselon: → breastfeeding → birthspacingafterdelivery → nutrition → HIVcounsellingandtesting → correctandconsistentcondomuse → laboratorytests → othermattersrelatedtoyourandyourbaby’shealth.

■Bringyourhome-basedmaternalrecordtoeveryvisit.

Careforyourselfduringpregnancy■Eatmoreandhealthierfoods,includingmorefruitsandvegetables,beans,meat,fish,eggs,cheese,milk.■Takeirontabletseverydayasexplainedbythehealthworker.■Restwhenyoucan.Avoidliftingheavyobjects.■Sleepunderabednettreatedwithinsecticide.■Donottakemedicationunlessprescribedatthehealthcentre.■Donotdrinkalcoholorsmoke.■Useacondomcorrectlyineverysexualrelationtopreventsexuallytransmittedinfection(STI)or

HIV/AIDSifyouoryourcompanionareatriskofinfection.

pregnancy Is a specIal tIme. care for yourself and your baby.

Routinevisitstothehealthcentre

�st visit Before4months2nd visit 6-7months3rd visit 8months4th visit 9months

KnowthesignsoflabourIfyouhaveanyofthesesigns,gotothehealthcentreassoonasyoucan.If these signs continue for �2 hours or more, you need to go immediately.■Painfulcontractionsevery20minutesorless.■Bagofwaterbreaks.■Bloodystickydischarge.

WhentoseekcareondangersignsGotothehospitalorhealthcentreimmediately, day or night,do not wait,ifanyofthefollowingsigns:■vaginalbleeding■convulsions/fits■severeheadacheswithblurredvision■ feverandtooweaktogetoutofbed■severeabdominalpain■ fastordifficultbreathing.

Gotothehealthcentreas soon as possibleifanyofthefollowingsigns:■ fever■abdominalpain■waterbreaksandnotinlabourafter6hours■ feelill■swollenfingers,faceandlegs.

preparIng a bIrth and emergency plan

Preparing a birth and emergency plan

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PreparingabirthplanThehealthworkerwillprovideyouwithinformationtohelpyouprepareabirthplan.Basedonyourhealthcondition,thehealthworkercanmakesuggestionsastowhereitwouldbebesttodeliver.Whetherinahospital,healthcentreorathome,itisimportanttodeliverwithaskilledattendant.

at every vIsIt to the health centre, revIeW and dIscuss your bIrth plan.the plan can change if complications develop.

Planningfordeliveryathome■Whodoyouchoosetobetheskilledattendantfordelivery?■Whowillsupportyouduringlabouranddelivery?■Whowillbeclosebyforatleast24hoursafterdelivery?■Whowillhelpyoutocareforyourhomeandotherchildren?■Organizethefollowing:

→Acleanandwarmroomorcornerofaroom.→Home-basedmaternalrecord.→Acleandeliverykitwhichincludessoap,asticktocleanunderthenails,anewrazorbladetocut

thebaby’scord,3piecesofstring(about20cm.each)totiethecord.→Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,forcleaningthe

baby’seyes,andforyoutouseassanitarypads.→Warmcoversforyouandthebaby.→Warmspotforthebirthwithacleansurfaceorcleancloth.→Bowls:twoforwashingandonefortheplacenta.→Plasticforwrappingtheplacenta.→Bucketsofcleanwaterandsomewaytoheatthiswater.→Forhandwashing,water,soapandatowelorclothfordryinghandsofthebirthattendant.→Freshdrinkingwater,fluidsandfoodforthemother.

Preparinganemergencyplan■Toplanforanemergency,consider:

→Whereshouldyougo?→Howwillyougetthere?→Willyouhavetopayfortransporttogetthere?Howmuchwillitcost?→Whatcostswillyouhavetopayatthehealthcentre?Howwillyoupayforthis?→Canyoustartsavingforthesepossiblecostsnow?→Whowillgowithyoutothehealthcentre?→Whowillhelptocareforyourhomeandotherchildrenwhileyouareaway?

Planningfordeliveryatthehospitalorhealthcentre■Howwillyougetthere?Willyouhavetopayfortransporttogetthere?■Howmuchwillitcosttodeliveratthefacility?Howwillyoupayforthis?■Canyoustartsavingforthesecostsnow?■Whowillgowithyouandsupportyouduringlabouranddelivery?■Whowillhelpyouwhileyouareawayandcareforyourhomeandotherchildren?■Bringthefollowing:

→Home-basedmaternalrecord.→Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,andforyoutouseas

sanitarypads.→Cleanclothesforyouandthebaby.→Foodandwaterforyouandthesupportperson.

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Care for the mother after birth

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Careofthemother■Eatmoreandhealthierfoods,includingmoremeat,fish,oils,coconut,nuts,cereals,beans,

vegetables,fruits,cheeseandmilk.■Takeirontabletsasexplainedbythehealthworker.■Restwhenyoucan.■Drinkplentyofclean,safewater.■Sleepunderabednettreatedwithinsecticide.■Donottakemedicationunlessprescribedatthehealthcentre.■Donotdrinkalcoholorsmoke.■Useacondomineverysexualrelation,ifyouoryourcompanionareatriskofsexuallytransmitted

infections(STI)orHIV/AIDS.■Washalloverdaily,particularlytheperineum.■Changepadevery4to6hours.Washpadordisposeofitsafely.

Familyplanning■Youcanbecomepregnantwithinseveralweeksafterdeliveryifyouhavesexualrelationsandarenot

breastfeedingexclusively.■Talktothehealthworkeraboutchoosingafamilyplanningmethodwhichbestmeetsyourandyour

partner’sneeds.

Routinevisitstothehealthcentre

Firstweekafterbirth:

✎____________________________________________________________________

✎____________________________________________________________________

6weeksafterbirth: ✎____________________________________________________________________

✎____________________________________________________________________

WhentoseekcarefordangersignsGotohospitalorhealthcentreimmediately, day or night, do notwait,ifanyofthefollowingsigns:■Vaginalbleedinghasincreased.■Fits.■Fastordifficultbreathing.■Feverandtooweaktogetoutofbed.■Severeheadacheswithblurredvision.

Gotohealthcentreas soon as possibleifanyofthefollowingsigns:■Swollen,redortenderbreastsornipples.■Problemsurinating,orleaking.■ Increasedpainorinfectionintheperineum.■ Infectionintheareaofthewound.■Smellyvaginaldischarge.

care after an abortIon

Care after an abortion

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Self-care■Restforafewdays,especiallyifyoufeeltired.■Changepadsevery4to6hours.Washusedpadordisposeofitsafely.Washperineum.■Donothavesexualintercourseuntilbleedingstops.■YouandyourpartnershoulduseacondomcorrectlyineveryactofsexualintercourseifatriskofSTI

orHIV.■Returntothehealthworkerasindicated.

Familyplanning■Rememberyoucanbecomepregnantassoonasyouhavesexualrelations.

Useafamilyplanningmethodtopreventanunwantedpregnancy.■Talktothehealthworkeraboutchoosingafamilyplanningmethodwhichbestmeetsyourandyour

partner’sneeds.

KnowthesedangersignsIfyouhaveanyofthesesigns,gotothehealthcentreimmediately, day or night. do not wait:■ Increasedbleedingorcontinuedbleedingfor2days.■Fever,feelingill.■Dizzinessorfainting.■Abdominalpain.■Backache.■Nausea,vomiting.■Foul-smellingvaginaldischarge.

Additionalsupport■Thehealthworkercanhelpyouidentifypersonsorgroupswhocanprovideyou

withadditionalsupportifyoushouldneedit.

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Care for the baby after birth

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Careofthenewborn

keep your neWborn clean■Washyourbaby’sfaceandneckdaily.Batheher/himwhennecessary.Afterbathing,thoroughlydry

yourbabyandthendressandkeepher/himwarm.■Washbaby’sbottomwhensoiledanddryitthoroughly.■Washyourhandswithsoapandwaterbeforeandafterhandlingyourbaby,especiallyaftertouching

her/hisbottom.

care for the neWborn’s umbIlIcal cord■Keepcordstumplooselycoveredwithacleancloth.Folddiaperandclothesbelowstump.■Donotputanythingonthestump.■ Ifstumpareaissoiled,washwithcleanwaterandsoap.Thendrycompletelywithcleancloth.■Washyourhandswithsoapandwaterbeforeandaftercare.

keep your neWborn Warm■ Incoldclimates,keepatleastanareaoftheroomwarm.■Newbornsneedmoreclothingthanotherchildrenoradults.■ Ifcold,putahatonthebaby’shead.Duringcoldnights,coverthebabywithanextrablanket.

other advIce■Letthebabysleeponher/hisbackorside.■Keepthebabyawayfromsmoke.

Routinevisitstothehealthcentre

first week after birth:

✎____________________________________________________________________

✎____________________________________________________________________

at � weeks :

✎____________________________________________________________________

✎____________________________________________________________________

Atthesevisitsyourbabywillbevaccinated.have your baby immunized.

WhentoseekcarefordangersignsGotohospitalorhealthcentreimmediately, day or night, do not wait,ifyourbabyhasanyofthefollowingsigns:■Difficultbreathing■Fits■Fever■Feelscold■Bleeding■Stopsfeeding■Diarrhoea.

Gotothehealthcentreas soon as possibleifyourbabyhasanyofthefollowingsigns:■Difficultyfeeding.■Feedslessthanevery5hours.■Puscomingfromtheeyes.■ Irritatedcordwithpusorblood.■Yelloweyesorskin.

breastfeedIng

Breastfeeding

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Breastfeedinghasmanyadvantagesfor the baby■Duringthefirst6monthsoflife,thebabyneedsnothingmorethanbreastmilk—notwater,not

othermilk,notcereals,notteas,notjuices.■Breastmilkcontainsexactlythewaterandnutrientsthatababy’sbodyneeds.Itiseasilydigested

andefficientlyusedbythebaby’sbody.Ithelpsprotectagainstinfectionsandallergiesandhelpsthebaby’sgrowthanddevelopment.

for the mother■Postpartumbleedingcanbereducedduetouterinecontractionscausedbythebaby’ssucking.■Breastfeedingcanhelpdelayanewpregnancy.

for the fIrst � months of lIfe, gIve only breast mIlk to your baby, day and nIght as often and as long as she/he Wants.

Suggestionsforsuccessfulbreastfeeding■ Immediatelyafterbirth,keepyourbabyinthebedwithyou,orwithineasyreach.■Startbreastfeedingwithin1hourofbirth.■Thebaby’ssuckstimulatesyourmilkproduction.Themorethebabyfeeds,themoremilkyouwill

produce.■Ateachfeeding,letthebabyfeedandreleaseyourbreast,andthenofferyoursecondbreast.Atthe

nextfeeding,alternateandbeginwiththesecondbreast.■Giveyourbabythefirstmilk(colostrum).Itisnutritiousandhasantibodiestohelpkeepyourbaby

healthy.■Atnight,letyourbabysleepwithyou,withineasyreach.■Whilebreastfeeding,youshoulddrinkplentyofclean,safewater.Youshouldeatmoreandhealthier

foodsandrestwhenyoucan.

Thehealthworkercansupportyouinstartingandmaintainingbreastfeeding■Thehealthworkercanhelpyoutocorrectlypositionthebabyandensureshe/heattachestothe

breast.Thiswillreducebreastproblemsforthemother.■Thehealthworkercanshowyouhowtoexpressmilkfromyourbreastwithyourhands.Ifyoushould

needtoleavethebabywithanothercaretakerforshortperiods,youcanleaveyourmilkanditcanbegiventothebabyinacup.

■Thehealthworkercanputyouincontactwithabreastfeedingsupportgroup.

If you have any difficulties with breastfeeding, see the health worker immediately.

Breastfeedingandfamilyplanning■Duringthefirst6monthsafterbirth,ifyoubreastfeedexclusively,dayandnight,andyour

menstruationhasnotreturned,youareprotectedagainstanotherpregnancy.■ Ifyoudonotmeettheserequirements,orifyouwishtouseanotherfamilyplanningmethodwhile

breastfeeding,discussthedifferentoptionsavailablewiththehealthworker.

M2 care durIng pregnancy Visitthehealthworkerduringpregnancy

Careforyourselfduringpregnancy Routinevisitstothehealthcentre Knowthesignsoflabour Whentoseekcareondangersigns

M3 preparIng a bIrth and emergency plan

Preparingabirthplan Planningfordeliveryathome Preparinganemergencyplan Planningfordeliveryatthehospitalorhealth

centre

M4 care for the mother after bIrth

Careofthemother Familyplanning Routinevisitstothehealthcentre Whentoseekcarefordangersigns

M5 care after an abortIon Self-care

Familyplanning KnowtheseDANGERsigns Additionalsupport

M6 care for the baby after bIrth

Careofthenewborn Routinevisitstothehealthcentre Whentoseekcarefordangersigns

M7 breastfeedIng Breastfeedinghasmanyadvantagesforthe

babyandthemother Suggestionsforsuccessfulbreastfeeding Healthworkersupport Breastfeedingandfamilyplanning

clean home delIvery regardless of the site of delivery, it is strongly recommended that all women deliver with a skilled attendant. for a woman who prefers to deliver at home the following recommendations are provided for a clean home delivery to be reviewed during antenatal care visits.

Clean home delivery (1)

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Deliveryathomewithanattendant■Ensuretheattendantandotherfamilymembersknowtheemergencyplanandareawareofdanger

signsforyourselfandyourbaby.■Arrangeforasupportpersontoassisttheattendantandtostaywithyouduringlabourandafter

delivery.→Havethesesuppliesorganizedforacleandelivery:newrazorblade,3piecesofstringabout

20-cmeachtotiethecord,andcleanclothstocoverthebirthplace.→Preparethehomeandthesuppliesindicatedforasafebirth: →Clean,warmbirthplacewithfreshairandasourceoflight →Cleanwarmblankettocoveryou→Cleancloths: →fordryingandwrappingthebaby →forcleaningthebaby’seyes →touseassanitarypadsafterbirth →todryyourbodyafterwashing →forbirthattendanttodryherhands.→Cleanclothesforyoutowearafterdelivery→Freshdrinkingwater,fluidsandfoodforyou→Bucketsofcleanwaterandsoapforwashing,foryouandtheskilledattendant→Meanstoheatwater→Threebowls,twoforwashingandonefortheplacenta→Plasticforwrappingtheplacenta→Bucketforyoutourinatein.

Instructionstomotherandfamilyforacleanandsaferdeliveryathome■Makesurethereisacleandeliverysurfaceforthebirthofthebaby.■Asktheattendanttowashherhandsbeforetouchingyouorthebaby.Thenailsoftheattendant

shouldbeshortandclean.■Whenthebabyisborn,placeher/himonyourabdomen/chestwhereitiswarmandclean.Drythe

babythoroughlyandwipethefacewithacleancloth.Thencoverwithacleandrycloth.■Cutthecordwhenitstopspulsating,usingthedisposabledeliverykit,accordingtoinstructions.■Waitfortheplacentatodeliveronitsown.■Makesureyouandyourbabyarewarm.Havethebabynearyou,dressedorwrappedandwithhead

coveredwithacap.■Startbreastfeedingwhenthebabyshowssignsofreadiness,withinthefirsthourofbirth.■Disposeofplacenta_____________________________________________

(describecorrect,safeculturallyacceptedwaytodisposeofplacenta)

do notbealoneforthe24hoursafterdelivery.do notbaththebabyonthefirstday.

Clean home delivery (2)

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Avoidharmfulpracticesfor example:do notuselocalmedicationstohastenlabour.do notwaitforwaterstostopbeforegoingtohealthfacility.do notinsertanysubstancesintothevaginaduringlabourorafterdelivery.do notpushontheabdomenduringlabourordelivery.do notpullonthecordtodelivertheplacenta.do notputashes,cowdungorothersubstanceonumbilicalcord/stump.

✎____________________________________________________________________

✎____________________________________________________________________

Encouragehelpfultraditionalpractices:

✎____________________________________________________________________

✎____________________________________________________________________

DangersignsduringdeliveryIfyouoryourbabyhasanyofthesesigns,go to the hospital or health centre immediately, day or night, do not wait.

mother■ Ifwatersbreakandnotinlabourafter6hours.■Labourpains(contractions)continueformorethan12hours.■Heavybleeding(soaksmorethan2-3padsin15minutes).■Placentanotexpelled1hourafterbirthofbaby.

baby■Verysmall.■Difficultyinbreathing.■Fits.■Fever.■Feelscold.■Bleeding.■Notabletofeed.

Routinevisitstothehealthcentre■Gotothehealthcentreorarrangeahomevisitbyaskilledattendantassoonaspossibleafter

delivery,preferablywithinthefirstdays,fortheexaminationofyouandyourbabyandtoreceivepreventivemeasures.

■Goforaroutinepostpartumvisitat6weeks.

M8 clean home delIvery (�) Deliveryathomewithanattendant

Instructionstomotherandfamilyforacleanandsaferdeliveryathome

M9 clean home delIvery (2) Avoidharmfulpractices

Encouragehelpfultraditionalpractices Dangersignsduringdelivery Routinevisitstothehealthcentre

■Theseindividualsheetshavekeyinformationforthemother,herpartnerandfamilyoncareduringpregnancy,preparingabirthandemergencyplan,cleanhomedelivery,careforthemotherandbabyafterdelivery,breastfeedingandcareafteranabortion.

■ Individualsheetsareusedsothatthewomancanbegiventherelevantsheetattheappropriatestageofpregnancyandchildbirth.

care durIng pregnancy

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Visitthehealthworkerduringpregnancy■Gotothehealthcentreifyouthinkyouarepregnant.Itisimportanttobegincareasearlyinyour

pregnancyaspossible.■Visitthehealthcentreatleast4timesduringyourpregnancy,evenifyoudonothaveanyproblems.

Thehealthworkerwilltellyouwhentoreturn.■ Ifatanytimeyouhaveanyconcernsaboutyouroryourbaby’shealth,gotothehealthcentre.■Duringyourvisitstothehealthcentre,thehealthworkerwill:

→ Checkyourhealthandtheprogressofthepregnancy → Helpyoumakeabirthplan → Answerquestionsorconcernsyoumayhave → Providetreatmentformalariaandanaemia → Giveyouatetanustoxoidimmunization → Adviseandcounselon: → breastfeeding → birthspacingafterdelivery → nutrition → HIVcounsellingandtesting → correctandconsistentcondomuse → laboratorytests → othermattersrelatedtoyourandyourbaby’shealth.

■Bringyourhome-basedmaternalrecordtoeveryvisit.

Careforyourselfduringpregnancy■Eatmoreandhealthierfoods,includingmorefruitsandvegetables,beans,meat,fish,eggs,cheese,milk.■Takeirontabletseverydayasexplainedbythehealthworker.■Restwhenyoucan.Avoidliftingheavyobjects.■Sleepunderabednettreatedwithinsecticide.■Donottakemedicationunlessprescribedatthehealthcentre.■Donotdrinkalcoholorsmoke.■Useacondomcorrectlyineverysexualrelationtopreventsexuallytransmittedinfection(STI)or

HIV/AIDSifyouoryourcompanionareatriskofinfection.

pregnancy Is a specIal tIme. care for yourself and your baby.

Routinevisitstothehealthcentre

�st visit Before4months2nd visit 6-7months3rd visit 8months4th visit 9months

KnowthesignsoflabourIfyouhaveanyofthesesigns,gotothehealthcentreassoonasyoucan.If these signs continue for �2 hours or more, you need to go immediately.■Painfulcontractionsevery20minutesorless.■Bagofwaterbreaks.■Bloodystickydischarge.

WhentoseekcareondangersignsGotothehospitalorhealthcentreimmediately, day or night,do not wait,ifanyofthefollowingsigns:■vaginalbleeding■convulsions/fits■severeheadacheswithblurredvision■ feverandtooweaktogetoutofbed■severeabdominalpain■ fastordifficultbreathing.

Gotothehealthcentreas soon as possibleifanyofthefollowingsigns:■ fever■abdominalpain■waterbreaksandnotinlabourafter6hours■ feelill■swollenfingers,faceandlegs.

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Preparing a birth and emergency plan

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PreparingabirthplanThehealthworkerwillprovideyouwithinformationtohelpyouprepareabirthplan.Basedonyourhealthcondition,thehealthworkercanmakesuggestionsastowhereitwouldbebesttodeliver.Whetherinahospital,healthcentreorathome,itisimportanttodeliverwithaskilledattendant.

at every vIsIt to the health centre, revIeW and dIscuss your bIrth plan.the plan can change if complications develop.

Planningfordeliveryathome■Whodoyouchoosetobetheskilledattendantfordelivery?■Whowillsupportyouduringlabouranddelivery?■Whowillbeclosebyforatleast24hoursafterdelivery?■Whowillhelpyoutocareforyourhomeandotherchildren?■Organizethefollowing:

→Acleanandwarmroomorcornerofaroom.→Home-basedmaternalrecord.→Acleandeliverykitwhichincludessoap,asticktocleanunderthenails,anewrazorbladetocut

thebaby’scord,3piecesofstring(about20cm.each)totiethecord.→Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,forcleaningthe

baby’seyes,andforyoutouseassanitarypads.→Warmcoversforyouandthebaby.→Warmspotforthebirthwithacleansurfaceorcleancloth.→Bowls:twoforwashingandonefortheplacenta.→Plasticforwrappingtheplacenta.→Bucketsofcleanwaterandsomewaytoheatthiswater.→Forhandwashing,water,soapandatowelorclothfordryinghandsofthebirthattendant.→Freshdrinkingwater,fluidsandfoodforthemother.

Preparinganemergencyplan■Toplanforanemergency,consider:

→Whereshouldyougo?→Howwillyougetthere?→Willyouhavetopayfortransporttogetthere?Howmuchwillitcost?→Whatcostswillyouhavetopayatthehealthcentre?Howwillyoupayforthis?→Canyoustartsavingforthesepossiblecostsnow?→Whowillgowithyoutothehealthcentre?→Whowillhelptocareforyourhomeandotherchildrenwhileyouareaway?

Planningfordeliveryatthehospitalorhealthcentre■Howwillyougetthere?Willyouhavetopayfortransporttogetthere?■Howmuchwillitcosttodeliveratthefacility?Howwillyoupayforthis?■Canyoustartsavingforthesecostsnow?■Whowillgowithyouandsupportyouduringlabouranddelivery?■Whowillhelpyouwhileyouareawayandcareforyourhomeandotherchildren?■Bringthefollowing:

→Home-basedmaternalrecord.→Cleanclothsofdifferentsizes:forthebed,fordryingandwrappingthebaby,andforyoutouseas

sanitarypads.→Cleanclothesforyouandthebaby.→Foodandwaterforyouandthesupportperson.

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Careofthemother■Eatmoreandhealthierfoods,includingmoremeat,fish,oils,coconut,nuts,cereals,beans,

vegetables,fruits,cheeseandmilk.■Takeirontabletsasexplainedbythehealthworker.■Restwhenyoucan.■Drinkplentyofclean,safewater.■Sleepunderabednettreatedwithinsecticide.■Donottakemedicationunlessprescribedatthehealthcentre.■Donotdrinkalcoholorsmoke.■Useacondomineverysexualrelation,ifyouoryourcompanionareatriskofsexuallytransmitted

infections(STI)orHIV/AIDS.■Washalloverdaily,particularlytheperineum.■Changepadevery4to6hours.Washpadordisposeofitsafely.

Familyplanning■Youcanbecomepregnantwithinseveralweeksafterdeliveryifyouhavesexualrelationsandarenot

breastfeedingexclusively.■Talktothehealthworkeraboutchoosingafamilyplanningmethodwhichbestmeetsyourandyour

partner’sneeds.

Routinevisitstothehealthcentre

Firstweekafterbirth:

✎____________________________________________________________________

✎____________________________________________________________________

6weeksafterbirth: ✎____________________________________________________________________

✎____________________________________________________________________

WhentoseekcarefordangersignsGotohospitalorhealthcentreimmediately, day or night, do notwait,ifanyofthefollowingsigns:■Vaginalbleedinghasincreased.■Fits.■Fastordifficultbreathing.■Feverandtooweaktogetoutofbed.■Severeheadacheswithblurredvision.

Gotohealthcentreas soon as possibleifanyofthefollowingsigns:■Swollen,redortenderbreastsornipples.■Problemsurinating,orleaking.■ Increasedpainorinfectionintheperineum.■ Infectionintheareaofthewound.■Smellyvaginaldischarge.

care after an abortIon

Care after an abortion

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Self-care■Restforafewdays,especiallyifyoufeeltired.■Changepadsevery4to6hours.Washusedpadordisposeofitsafely.Washperineum.■Donothavesexualintercourseuntilbleedingstops.■YouandyourpartnershoulduseacondomcorrectlyineveryactofsexualintercourseifatriskofSTI

orHIV.■Returntothehealthworkerasindicated.

Familyplanning■Rememberyoucanbecomepregnantassoonasyouhavesexualrelations.

Useafamilyplanningmethodtopreventanunwantedpregnancy.■Talktothehealthworkeraboutchoosingafamilyplanningmethodwhichbestmeetsyourandyour

partner’sneeds.

KnowthesedangersignsIfyouhaveanyofthesesigns,gotothehealthcentreimmediately, day or night. do not wait:■ Increasedbleedingorcontinuedbleedingfor2days.■Fever,feelingill.■Dizzinessorfainting.■Abdominalpain.■Backache.■Nausea,vomiting.■Foul-smellingvaginaldischarge.

Additionalsupport■Thehealthworkercanhelpyouidentifypersonsorgroupswhocanprovideyou

withadditionalsupportifyoushouldneedit.

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Careofthenewborn

keep your neWborn clean■Washyourbaby’sfaceandneckdaily.Batheher/himwhennecessary.Afterbathing,thoroughlydry

yourbabyandthendressandkeepher/himwarm.■Washbaby’sbottomwhensoiledanddryitthoroughly.■Washyourhandswithsoapandwaterbeforeandafterhandlingyourbaby,especiallyaftertouching

her/hisbottom.

care for the neWborn’s umbIlIcal cord■Keepcordstumplooselycoveredwithacleancloth.Folddiaperandclothesbelowstump.■Donotputanythingonthestump.■ Ifstumpareaissoiled,washwithcleanwaterandsoap.Thendrycompletelywithcleancloth.■Washyourhandswithsoapandwaterbeforeandaftercare.

keep your neWborn Warm■ Incoldclimates,keepatleastanareaoftheroomwarm.■Newbornsneedmoreclothingthanotherchildrenoradults.■ Ifcold,putahatonthebaby’shead.Duringcoldnights,coverthebabywithanextrablanket.

other advIce■Letthebabysleeponher/hisbackorside.■Keepthebabyawayfromsmoke.

Routinevisitstothehealthcentre

first week after birth:

✎____________________________________________________________________

✎____________________________________________________________________

at � weeks :

✎____________________________________________________________________

✎____________________________________________________________________

Atthesevisitsyourbabywillbevaccinated.have your baby immunized.

WhentoseekcarefordangersignsGotohospitalorhealthcentreimmediately, day or night, do not wait,ifyourbabyhasanyofthefollowingsigns:■Difficultybreathing■Fits■Fever■Feelscold■Bleeding■Stopsfeeding■Diarrhoea.

Gotothehealthcentreas soon as possibleifyourbabyhasanyofthefollowingsigns:■Difficultyfeeding.■Feedslessthanevery5hours.■Puscomingfromtheeyes.■ Irritatedcordwithpusorblood.■Yelloweyesorskin.

breastfeedIng

Breastfeeding

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Breastfeedinghasmanyadvantagesfor the baby■Duringthefirst6monthsoflife,thebabyneedsnothingmorethanbreastmilk—notwater,not

othermilk,notcereals,notteas,notjuices.■Breastmilkcontainsexactlythewaterandnutrientsthatababy’sbodyneeds.Itiseasilydigested

andefficientlyusedbythebaby’sbody.Ithelpsprotectagainstinfectionsandallergiesandhelpsthebaby’sgrowthanddevelopment.

for the mother■Postpartumbleedingcanbereducedduetouterinecontractionscausedbythebaby’ssucking.■Breastfeedingcanhelpdelayanewpregnancy.

for the fIrst � months of lIfe, gIve only breast mIlk to your baby, day and nIght as often and as long as she/he Wants.

Suggestionsforsuccessfulbreastfeeding■ Immediatelyafterbirth,keepyourbabyinthebedwithyou,orwithineasyreach.■Startbreastfeedingwithin1hourofbirth.■Thebaby’ssuckstimulatesyourmilkproduction.Themorethebabyfeeds,themoremilkyouwill

produce.■Ateachfeeding,letthebabyfeedandreleaseyourbreast,andthenofferyoursecondbreast.Atthe

nextfeeding,alternateandbeginwiththesecondbreast.■Giveyourbabythefirstmilk(colostrum).Itisnutritiousandhasantibodiestohelpkeepyourbaby

healthy.■Atnight,letyourbabysleepwithyou,withineasyreach.■Whilebreastfeeding,youshoulddrinkplentyofclean,safewater.Youshouldeatmoreandhealthier

foodsandrestwhenyoucan.

Thehealthworkercansupportyouinstartingandmaintainingbreastfeeding■Thehealthworkercanhelpyoutocorrectlypositionthebabyandensureshe/heattachestothe

breast.Thiswillreducebreastproblemsforthemother.■Thehealthworkercanshowyouhowtoexpressmilkfromyourbreastwithyourhands.Ifyoushould

needtoleavethebabywithanothercaretakerforshortperiods,youcanleaveyourmilkanditcanbegiventothebabyinacup.

■Thehealthworkercanputyouincontactwithabreastfeedingsupportgroup.

If you have any difficulties with breastfeeding, see the health worker immediately.

Breastfeedingandfamilyplanning■Duringthefirst6monthsafterbirth,ifyoubreastfeedexclusively,dayandnight,andyour

menstruationhasnotreturned,youareprotectedagainstanotherpregnancy.■ Ifyoudonotmeettheserequirements,orifyouwishtouseanotherfamilyplanningmethodwhile

breastfeeding,discussthedifferentoptionsavailablewiththehealthworker.

clean home delIvery regardless of the site of delivery, it is strongly recommended that all women deliver with a skilled attendant. for a woman who prefers to deliver at home the following recommendations are provided for a clean home delivery to be reviewed during antenatal care visits.

Clean home delivery (1)In

form

atIo

n an

d co

unse

llIn

g sh

eets

m�

Deliveryathomewithanattendant■Ensuretheattendantandotherfamilymembersknowtheemergencyplanandareawareofdanger

signsforyourselfandyourbaby.■Arrangeforasupportpersontoassisttheattendantandtostaywithyouduringlabourandafter

delivery.→Havethesesuppliesorganizedforacleandelivery:newrazorblade,3piecesofstringabout

20-cmeachtotiethecord,andcleanclothstocoverthebirthplace.→Preparethehomeandthesuppliesindicatedforasafebirth: →Clean,warmbirthplacewithfreshairandasourceoflight →Cleanwarmblankettocoveryou→Cleancloths: →fordryingandwrappingthebaby →forcleaningthebaby’seyes →touseassanitarypadsafterbirth →todryyourbodyafterwashing →forbirthattendanttodryherhands.→Cleanclothesforyoutowearafterdelivery→Freshdrinkingwater,fluidsandfoodforyou→Bucketsofcleanwaterandsoapforwashing,foryouandtheskilledattendant→Meanstoheatwater→Threebowls,twoforwashingandonefortheplacenta→Plasticforwrappingtheplacenta→Bucketforyoutourinatein.

Instructionstomotherandfamilyforacleanandsaferdeliveryathome■Makesurethereisacleandeliverysurfaceforthebirthofthebaby.■Asktheattendanttowashherhandsbeforetouchingyouorthebaby.Thenailsoftheattendant

shouldbeshortandclean.■Whenthebabyisborn,placeher/himonyourabdomen/chestwhereitiswarmandclean.Drythe

babythoroughlyandwipethefacewithacleancloth.Thencoverwithacleandrycloth.■Cutthecordwhenitstopspulsating,usingthedisposabledeliverykit,accordingtoinstructions.■Waitfortheplacentatodeliveronitsown.■Makesureyouandyourbabyarewarm.Havethebabynearyou,dressedorwrappedandwithhead

coveredwithacap.■Startbreastfeedingwhenthebabyshowssignsofreadiness,withinthefirsthourofbirth.■Disposeofplacenta_____________________________________________

(describecorrect,safeculturallyacceptedwaytodisposeofplacenta)

do notbealoneforthe24hoursafterdelivery.do notbaththebabyonthefirstday.

Clean home delivery (2)

Info

rmat

Ion

and

coun

sell

Ing

shee

ts

m�

Avoidharmfulpracticesfor example:do notuselocalmedicationstohastenlabour.do notwaitforwaterstostopbeforegoingtohealthfacility.do notinsertanysubstancesintothevaginaduringlabourorafterdelivery.do notpushontheabdomenduringlabourordelivery.do notpullonthecordtodelivertheplacenta.do notputashes,cowdungorothersubstanceonumbilicalcord/stump.

✎____________________________________________________________________

✎____________________________________________________________________

Encouragehelpfultraditionalpractices:

✎____________________________________________________________________

✎____________________________________________________________________

DangersignsduringdeliveryIfyouoryourbabyhasanyofthesesigns,go to the hospital or health centre immediately, day or night, do not wait.

mother■ Ifwatersbreakandnotinlabourafter6hours.■Labourpains(contractions)continueformorethan12hours.■Heavybleeding(soaksmorethan2-3padsin15minutes).■Placentanotexpelled1hourafterbirthofbaby.

baby■Verysmall.■Difficultyinbreathing.■Fits.■Fever.■Feelscold.■Bleeding.■Notabletofeed.

Routinevisitstothehealthcentre■Gotothehealthcentreorarrangeahomevisitbyaskilledattendantassoonaspossibleafter

delivery,preferablywithinthefirstdays,fortheexaminationofyouandyourbabyandtoreceivepreventivemeasures.

■Goforaroutinepostpartumvisitat6weeks.

Records and forms

Reco

Rds

and

foRm

s

n�

Referral record

Reco

Rds

and

foRm

s

n�

ReFeRRalRecoRdWhoisReFeRRiNG RecoRdNuMbeR ReFeRReddaTe TiMe

NaMe aRRivaldaTe TiMe

FaciliTy

accoMpaNiedbyThehealThWoRkeR

WoMaNNaMe aGe

addRess

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythebaby

MajoRFiNdiNGs(cliNicaaNdbp,TeMp.,lab.)

lasT(bReasT)Feed(TiMe)

TReaTMeNTsGiveNaNdTiMe

beFoReReFeRRal

duRiNGTRaNspoRT

iNFoRMaTioNGiveNToTheWoMaNaNdcoMpaNioNabouTTheReasoNsFoRReFeRRal

babyNaMe daTeaNdhouRoFbiRTh

biRThWeiGhT GesTaTioNalaGe

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythemother

MajoRFiNdiNGs(cliNicaaNdTeMp.)

lasT(bReasT)Feed(TiMe)

TReaTMeNTsGiveNaNdTiMe

beFoReReFeRRal

duRiNGTRaNspoRT

iNFoRMaTioNGiveNToTheWoMaNaNdcoMpaNioNabouTTheReasoNsFoRReFeRRal

sampleformtobeadapted.Revisedon13june2003.

Feedback record

Reco

Rds

and

foRm

s

n�

FeedbackRecoRdWhoisReFeRRiNG RecoRdNuMbeR adMissioNdaTe TiMe

NaMe dischaRGedaTe TiMe

FaciliTy

WoMaNNaMe aGe

addRess

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythebaby

diaGNoses

TReaTMeNTsGiveNaNdTiMe

TReaTMeNTsaNdRecoMMeNdaTioNsoNFuRTheRcaRe

FolloW-upvisiT WheN WheRe

pReveNTiveMeasuRes

iFdeaTh:daTe

causes

babyNaMe daTeoFbiRTh

biRThWeiGhT aGeaTdischaRGe(days)

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythemother

diaGNoses

TReaTMeNTsGiveNaNdTiMe

TReaTMeNTsaNdRecoMMeNdaTioNsoNFuRTheRcaRe

FolloW-upvisiT WheN WheRe

pReveNTiveMeasuRes

iFdeaTh:daTe

causes

sampleformtobeadapted.Revisedon25august2003.

Labour record

Reco

Rds

and

foRm

s

n�

labouRRecoRduse thIs RecoRd foR monItoRIng duRIng labouR, delIveRy and PostPaRtum RecoRdNuMbeR

NaMe aGe paRiTy

addRess

duRIng labouR at oR afteR bIRth – motheR at oR afteR bIRth – newboRn Planned newboRn tReatment

adMissioNdaTe biRThTiMe livebiRTh■sTillbiRTh:FResh■MaceRaTed■

adMissioNTiMe oxyTociN–TiMeGiveN ResusciTaTioNNo■yes■

TiMeacTivelabouRsTaRTed placeNTacoMpleTeNo■yes■ biRThWeiGhT

TiMeMeMbRaNesRupTuRed TiMedeliveRed GesT.aGe----------oRpReTeRMNo■yes■

TiMesecoNdsTaGesTaRTs esTiMaTedbloodloss secoNdbaby

entRy examInatIon

stage of labouR NoTiNacTivelabouR■ acTivelabouR■

not In actIve labouR Planned mateRnal tReatment

houRssiNceaRRival 1 2 3 4 5 6 7 8 9 10 11 12

houRssiNceRupTuRedMeMbRaNes

vaGiNalbleediNG(0+++)

sTRoNGcoNTRacTioNsiN10MiNuTes

FeTalheaRTRaTe(beaTspeRMiNuTe)

T(axillaRy)

pulse(beaTs/MiNuTe)

bloodpRessuRe(sysTolic/diasTolic)

uRiNevoided

ceRvicaldilaTaTioN(cM)

PRoblem tIme onset tReatments otheR than noRmal suPPoRtIve caRe

0

0

If motheR RefeRRed duRIng labouR oR delIveRy, RecoRd tIme and exPlaIn

0

sampleformtobeadapted.Revisedon13june2003.

Partograph

Reco

Rds

and

foRm

s

n�

fIndIngs tIme

hours in active labour � � � � � 6 7 8 9 �0 �� ��

hourssincerupturedmembranes

Rapidassessment b3-b7

vaginalbleeding(0+++)

amnioticfluid(meconiumstained)

contractionsin10minutes

Fetalheartrate(beats/minute)

urinevoided

T(axillary)

pulse(beats/minute)

bloodpressure(systolic/diastolic)

cervicaldilatation(cm)

deliveryofplacenta(time)

oxytocin(time/given)

problem-noteonset/describebelow

paRToGRaphuse thIs foRm foR monItoRIng actIve labouR

�0 cm

9 cm

8 cm

7 cm

6 cm

� cm

� cm

sam

ple

form

tob

ead

apte

d.R

evis

edo

n13

june

200

3.

Postpartum record

Reco

Rds

and

foRm

s

n6

posTpaRTuMRecoRdmonItoRIng afteR bIRth eveRy �-�� mIn foR �st houR � hR � hR � hR 8 hR �� hR �6 hR �0 hR �� hR

TiMe

RapidassessMeNT

bleediNG(0+++)

uTeRushaRd/RouNd?

mateRnal:bloodpRessuRe

pulse

uRiNevoided

vulva

newboRn:bReaThiNG

WaRMTh

newboRn abnoRmal sIgns (lIst)

0

tIme feedIng obseRved ■FeediNGWell ■diFFiculTy

coMMeNTs

0

Planned tReatment tIme tReatment gIven

MoTheR

0

0

NeWboRN

0

iFReFeRRed(MoTheRoRNeWboRN),RecoRdTiMeaNdexplaiN:

0

iFdeaTh(MoTheRoRNeWboRN),daTe,TiMeaNdcause:

advIse and counselmotheR

■ postpartumcareandhygiene

■ Nutrition

■ birthspacingandfamilyplanning

■ dangersigns

■ Follow-upvisits

baby

■ exclusivebreastfeeding

■ hygiene,cordcareandwarmth

■ specialadviceiflowbirthweight

■ dangersigns

■ Follow-upvisits

PReventIve measuResfoR motheR

■ iron/folate

■ vitamina

■ Mebendazole

■ sulphadoxine-pyrimethamine

■ Tetanustoxoidimmunization

■ RpRtestresultandtreatment

■ aRv

foR baby

■ Riskofbacterialinfectionandtreatment

■ bcG,opv-0,hep-0

■ RpRresultandtreatment

■ Tbtestresultandprophylaxis

■ aRv

sampleformtobeadapted.Revisedon25august2003.

International form of medical certificate of cause of death

Reco

Rds

and

foRm

s

n7

iNTeRNaTioNalFoRMoFMedicalceRTiFicaTeoFcauseoFdeaTh aPPRoxImate InteRval cause of death between onset and death

I (a) ................................ ......................diseaseorconditiondirectly dueto(orasconsequenceof)...........leadingtodeath* (b)................................ ......................

antecedent causes dueto(orasconsequenceof) ......................Morbidconditions,ifany,giving (c)................................risetotheabovecause,stating dueto(orasconsequenceof) ...................... (d)................................ ......................

II ......................othersignificantconditionscontributingto ..................................thedeath,butnotrelatedtothedisease ..................................orconditioncausingit. ..................................

*Thisdoesnotmeanthemodeofdying,e.g.heartfailure,respiratoryfailure.itmeansthedisease,injuryorcomplicationthatcauseddeath.

consIdeR collectIng the followIng InfoRmatIonIIIifthedeceasedisafemale,wasshe ■ Notpregnant ■ Notpregnant,butpregnantwithin42daysofdeath ■ pregnantatthetimeofdeath ■ unknownifpregnantorwaspregnantwithin42daysofdeath

0Ivifthedeceasedisaninfantandlessthanonemonthold Whatwasthebirthweight:......... g ifexactbirthweightnotknown,wasbabyweighing: ■ 2500gormore ■ lessthan2500g

N2 RefeRRal RecoRd

N3 feedback RecoRd

N4 labouR RecoRd

N5 PaRtogRaPh

N6 PostPaRtum RecoRd

N7 InteRnatIonal foRm of medIcal ceRtIfIcate of cause of death

■Recordsaresuggestednotsomuchfortheformatasforthecontent.ThecontentoftherecordsisadjustedtothecontentoftheGuide.

■Modifynationalorlocalrecordstoincludealltherelevantsectionsneededtorecordimportantinformationfortheprovider,thewomanandherfamily,forthepurposesofmonitoringandsurveillanceandofficialreporting.

■Filloutotherrequiredrecordssuchasimmunizationcardsforthemotherandbaby.

RecoRds and foRms

Referral recordRe

coRd

s an

d fo

Rms

n�

ReFeRRalRecoRdWhoisReFeRRiNG RecoRdNuMbeR ReFeRReddaTe TiMe

NaMe aRRivaldaTe TiMe

FaciliTy

accoMpaNiedbyThehealThWoRkeR

WoMaNNaMe aGe

addRess

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythebaby

MajoRFiNdiNGs(cliNicaaNdbp,TeMp.,lab.)

lasT(bReasT)Feed(TiMe)

TReaTMeNTsGiveNaNdTiMe

beFoReReFeRRal

duRiNGTRaNspoRT

iNFoRMaTioNGiveNToTheWoMaNaNdcoMpaNioNabouTTheReasoNsFoRReFeRRal

babyNaMe daTeaNdhouRoFbiRTh

biRThWeiGhT GesTaTioNalaGe

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythemother

MajoRFiNdiNGs(cliNicaaNdTeMp.)

lasT(bReasT)Feed(TiMe)

TReaTMeNTsGiveNaNdTiMe

beFoReReFeRRal

duRiNGTRaNspoRT

iNFoRMaTioNGiveNToTheWoMaNaNdcoMpaNioNabouTTheReasoNsFoRReFeRRal

sampleformtobeadapted.Revisedon13june2003.

Feedback record

Reco

Rds

and

foRm

s

n�

FeedbackRecoRdWhoisReFeRRiNG RecoRdNuMbeR adMissioNdaTe TiMe

NaMe dischaRGedaTe TiMe

FaciliTy

WoMaNNaMe aGe

addRess

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythebaby

diaGNoses

TReaTMeNTsGiveNaNdTiMe

TReaTMeNTsaNdRecoMMeNdaTioNsoNFuRTheRcaRe

FolloW-upvisiT WheN WheRe

pReveNTiveMeasuRes

iFdeaTh:daTe

causes

babyNaMe daTeoFbiRTh

biRThWeiGhT aGeaTdischaRGe(days)

MaiNReasoNsFoRReFeRRal ■emergency■ Non-emergency■ Toaccompanythemother

diaGNoses

TReaTMeNTsGiveNaNdTiMe

TReaTMeNTsaNdRecoMMeNdaTioNsoNFuRTheRcaRe

FolloW-upvisiT WheN WheRe

pReveNTiveMeasuRes

iFdeaTh:daTe

causes

sampleformtobeadapted.Revisedon25august2003.

Labour recordRe

coRd

s an

d fo

Rms

n�

labouRRecoRduse thIs RecoRd foR monItoRIng duRIng labouR, delIveRy and PostPaRtum RecoRdNuMbeR

NaMe aGe paRiTy

addRess

duRIng labouR at oR afteR bIRth – motheR at oR afteR bIRth – newboRn Planned newboRn tReatment

adMissioNdaTe biRThTiMe livebiRTh■sTillbiRTh:FResh■MaceRaTed■

adMissioNTiMe oxyTociN–TiMeGiveN ResusciTaTioNNo■yes■

TiMeacTivelabouRsTaRTed placeNTacoMpleTeNo■yes■ biRThWeiGhT

TiMeMeMbRaNesRupTuRed TiMedeliveRed GesT.aGe----------oRpReTeRMNo■yes■

TiMesecoNdsTaGesTaRTs esTiMaTedbloodloss secoNdbaby

entRy examInatIon

stage of labouR NoTiNacTivelabouR■ acTivelabouR■

not In actIve labouR Planned mateRnal tReatment

houRssiNceaRRival 1 2 3 4 5 6 7 8 9 10 11 12

houRssiNceRupTuRedMeMbRaNes

vaGiNalbleediNG(0+++)

sTRoNGcoNTRacTioNsiN10MiNuTes

FeTalheaRTRaTe(beaTspeRMiNuTe)

T(axillaRy)

pulse(beaTs/MiNuTe)

bloodpRessuRe(sysTolic/diasTolic)

uRiNevoided

ceRvicaldilaTaTioN(cM)

PRoblem tIme onset tReatments otheR than noRmal suPPoRtIve caRe

0

0

If motheR RefeRRed duRIng labouR oR delIveRy, RecoRd tIme and exPlaIn

0

sampleformtobeadapted.Revisedon13june2003.

Partograph

Reco

Rds

and

foRm

s

n�

fIndIngs tIme

hours in active labour � � � � � 6 7 8 9 �0 �� ��

hourssincerupturedmembranes

Rapidassessment b3-b7

vaginalbleeding(0+++)

amnioticfluid(meconiumstained)

contractionsin10minutes

Fetalheartrate(beats/minute)

urinevoided

T(axillary)

pulse(beats/minute)

bloodpressure(systolic/diastolic)

cervicaldilatation(cm)

deliveryofplacenta(time)

oxytocin(time/given)

problem-noteonset/describebelow

paRToGRaphuse thIs foRm foR monItoRIng actIve labouR

�0 cm

9 cm

8 cm

7 cm

6 cm

� cm

� cm

sam

ple

form

tob

ead

apte

d.R

evis

edo

n13

june

200

3.

Postpartum recordRe

coRd

s an

d fo

Rms

n6

posTpaRTuMRecoRdmonItoRIng afteR bIRth eveRy �-�� mIn foR �st houR � hR � hR � hR 8 hR �� hR �6 hR �0 hR �� hR

TiMe

RapidassessMeNT

bleediNG(0+++)

uTeRushaRd/RouNd?

mateRnal:bloodpRessuRe

pulse

uRiNevoided

vulva

newboRn:bReaThiNG

WaRMTh

newboRn abnoRmal sIgns (lIst)

0

tIme feedIng obseRved ■FeediNGWell ■diFFiculTy

coMMeNTs

0

Planned tReatment tIme tReatment gIven

MoTheR

0

0

NeWboRN

0

iFReFeRRed(MoTheRoRNeWboRN),RecoRdTiMeaNdexplaiN:

0

iFdeaTh(MoTheRoRNeWboRN),daTe,TiMeaNdcause:

advIse and counselmotheR

■ postpartumcareandhygiene

■ Nutrition

■ birthspacingandfamilyplanning

■ dangersigns

■ Follow-upvisits

baby

■ exclusivebreastfeeding

■ hygiene,cordcareandwarmth

■ specialadviceiflowbirthweight

■ dangersigns

■ Follow-upvisits

PReventIve measuResfoR motheR

■ iron/folate

■ vitamina

■ Mebendazole

■ sulphadoxine-pyrimethamine

■ Tetanustoxoidimmunization

■ RpRtestresultandtreatment

■ aRv

foR baby

■ Riskofbacterialinfectionandtreatment

■ bcG,opv-0,hep-0

■ RpRresultandtreatment

■ Tbtestresultandprophylaxis

■ aRv

sampleformtobeadapted.Revisedon25august2003.

International form of medical certificate of cause of death

Reco

Rds

and

foRm

s

n7

iNTeRNaTioNalFoRMoFMedicalceRTiFicaTeoFcauseoFdeaTh aPPRoxImate InteRval cause of death between onset and death

I (a) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .diseaseorconditiondirectly dueto(orasconsequenceof). . . . . . . . . . .leadingtodeath* (b). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

antecedent causes dueto(orasconsequenceof) . . . . . . . . . . . . . . . . . . . . . .Morbidconditions,ifany,giving (c). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . risetotheabovecause,stating dueto(orasconsequenceof) . . . . . . . . . . . . . . . . . . . . . . (d). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II . . . . . . . . . . . . . . . . . . . . . .othersignificantconditionscontributingto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . thedeath,butnotrelatedtothedisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . orconditioncausingit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

*Thisdoesnotmeanthemodeofdying,e.g.heartfailure,respiratoryfailure.itmeansthedisease,injuryorcomplicationthatcauseddeath.

consIdeR collectIng the followIng InfoRmatIonIIIifthedeceasedisafemale,wasshe ■ Notpregnant ■ Notpregnant,butpregnantwithin42daysofdeath ■ pregnantatthetimeofdeath ■ unknownifpregnantorwaspregnantwithin42daysofdeath

0Ivifthedeceasedisaninfantandlessthanonemonthold Whatwasthebirthweight:. . . . . . . . . g ifexactbirthweightnotknown,wasbabyweighing: ■ 2500gormore ■ lessthan2500g

Glossary and acronymsgl

ossa

ry a

nd a

cron

yms

abortionTermination of pregnancy from whatever cause before the fetus is capable of extrauterine life.

adolescentYoung person 10–19 years old.

advise To give information and suggest to someone a course of action.

antenatal care Care for the woman and fetus during pregnancy.

assess To consider the relevant information and make a judgement. As used in this guide, to examine a woman or baby and identify signs of illness.

baby A very young boy or girl in the first week(s) of life.

birth Expulsion or extraction of the baby (regardless of whether the cord has been cut).

birth and emergency plan A plan for safe childbirth developed in antenatal care visit which considers the woman’s condition, preferences and available resources. A plan to seek care for danger signs during pregnancy, childbirth and postpartum period, for the woman and newborn.

birth weightThe first of the fetus or newborn obtained after birth.

For live births, birth weight should preferably be measured within the first hour of life before significant postnatal weight loss has occurred, recorded to the degree of accuracy to which it is measured.

chartAs used in this guide, a sheet presenting information in the form of a table.

childbirth Giving birth to a baby or babies and placenta.

classifyTo select a category of illness and severity based on a woman’s or baby’s signs and symptoms.

clinic As used in this guide, any first-level outpatient health facility such as a dispensary, rural health post, health centre or outpatient department of a hospital.

communityAs used in this guide, a group of people sometimes living in a defined geographical area, who share common culture, values and norms. Economic and social differences need to be taken into account when determining needs and establishing links within a given community.

birth companion Partner, other family member or friend who accompanies the woman during labour and delivery.

childbearing age (woman)15-49 years. As used in this guide, also a girl 10-14 years, or a woman more than 49 years, when pregnant, after abortion, after delivery.

complaintAs described in this guide, the concerns or symptoms of illness or complication need to be assessed and classified in order to select treatment.

concern A worry or an anxiety that the woman may have about herself or the baby(ies).

complicationA condition occurring during pregnancy or aggravating it. This classification includes conditions such as obstructed labour or bleeding.

confidenceA feeling of being able to succeed.

contraindicationA condition occurring during another disease or aggravating it. This classification includes conditions such as obstructed labour or bleeding.

counsellingAs used in this guide, interaction with a woman to support her in solving actual or anticipated problems, reviewing options, and making decisions. It places emphasis on provider support for helping the woman make decisions.

danger signsTerminology used to explain to the woman the signs of life-threatening and other serious conditions which require immediate intervention.

emergency signs Signs of life-threatening conditions which require immediate intervention.

essential Basic, indispensable, necessary.

facility A place where organized care is provided: a health post, health centre, hospital maternity or emergency unit, or ward.

family Includes relationships based on blood, marriage, sexual partnership, and adoption, and a broad range of groups whose bonds are based on feelings of trust mutual support, and a shared destiny.

follow-up visit A return visit requested by a health worker to see if further treatment or referral is needed.

gestational ageDuration of pregnancy from the last menstrual period. In this guide, duration of pregnancy (gestational age) is expressed in 3 different ways:

trimester months weeksFirst less than 4 months less than 16 weeksSecond 4-6 months 16-28 weeksThird 7-9+ months 29-40+ weeks

gruntingSoft short sounds that a baby makes when breathing out. Grunting occurs when a baby is having difficulty breathing.

Glossary

home deliveryDelivery at home (with a skilled attendant, a traditional birth attendant, a family member, or by the woman herself).

hospital As used in this guide, any health facility with inpatient beds, supplies and expertise to treat a woman or newborn with complications.

integrated management A process of caring for the woman in pregnancy, during and after childbirth, and for her newborn, that includes considering all necessary elements: care to ensure they remain healthy, and prevention, detection and management of complications in the context of her environment and according to her wishes.

labourAs used in this guide, a period from the onset of regular contractions to complete delivery of the placenta.

low birth weight babyWeighing less than 2500-g at birth.

maternity clinicHealth centre with beds or a hospital where women and their newborns receive care during childbirth and delivery, and emergency first aid.

miscarriagePremature expulsion of a non-viable fetus from the uterus.

monitoringFrequently repeated measurements of vital signs or observations of danger signs.

newborn Recently born infant. In this guide used interchangeable with baby.

partner As used in this guide, the male companion of the pregnant woman (husband, “free union”) who is the father of the baby or the actual sexual partner.

postnatal careCare for the baby after birth. For the purposes of this guide, up to two weeks.

postpartum careCare for the woman provided in the postpartum period, e.g. from complete delivery of the placenta to 42 days after delivery.

pre-referralBefore referral to a hospital.

pregnancyPeriod from when the woman misses her menstrual period or the uterus can be felt, to the onset of labour/elective caesarian section or abortion.

prematureBefore 37 completed weeks of pregnancy.

preterm babyBorn early, before 37 completed weeks of pregnancy. If number of weeks not known, 1 month early.

primary health care*Essential health care accessible at a cost the country and community can afford, with methods that are practical, scientifically sound and socially acceptable. (Among the essential activities are maternal and child health care, including family planning; immunization; appropriate treatment of common diseases and injuries; and the provision of essential drugs).

primary health care levelHealth post, health centre or maternity clinic; a hospital providing care for normal pregnancy and childbirth.

priority signsSigns of serious conditions which require interventions as soon as possible, before they become life-threatening.

Quick checkA quick check assessment of the health status of the woman or her baby at the first contact with the health provider or services in order to assess if emergency care is required.

rapid assessment and managementSystematic assessment of vital functions of the woman and the most severe presenting signs and symptoms; immediate initial management of the life-threatening conditions; and urgent and safe referral to the next level of care.

reassessmentAs used in this guide, to examine the woman or baby again for signs of a specific illness or condition to see if she or the newborn are improving.

recommendationAdvice. Instruction that should be followed.

referral, urgentAs used in this guide, sending a woman or baby, or both, for further assessment and care to a higher level of care; including arranging for transport and care during transport, preparing written information (referral form), and communicating with the referral institution.

referral hospitalA hospital with a full range of obstetric services including surgery and blood transfusion and care for newborns with problems.

reinfectionInfection with same or a different strain of HIV virus.

replacement feedingThe process of feeding a baby who is not receiving breast milk with a diet that provides all the nutrients she/he needs until able to feed entirely on family foods.

secondary health careMore specialized care offered at the most peripheral level, for example radiographic diagnostic, general surgery, care of women with complications of pregnancy and childbirth, and diagnosis and treatment of uncommon and severe diseases. (This kind of care is provided by trained staff at such institutions as district or provincial hospitals).

shock A dangerous condition with severe weakness, lethargy, or unconsciousness, cold extremeties, and fast, weak pulse. It is caused by severe bleeding, severe infection, or obstructed labour.

sign As used in this guide, physical evidence of a health problem which the health worker observes by looking, listening, feeling or measuring. Examples of signs: bleeding, convulsions, hypertension, anaemia, fast breathing.

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skilled attendantRefers exclusively to people with midwifery skills (for example, midwives, doctors and nurses) who have been trained to proficiency in the skills necessary to manage normal deliveries and diagnose or refer obstetric complications.

For the purposes of this guide, a person with midwifery skills who:■ has acquired the requisite

qualifications to be registered and/or legally licensed to practice training and licensing requirements are country-specific;

■ May practice in hospitals, clinics, health units, in the home, or in any other service setting.

■ Is able to do the following:→ give necessary care and advice

to women during pregnancy and postpartum and for their newborn infants;

→ conduct deliveries on her/his own and care for the mother and newborn; this includes provision of preventive care, and detection and appropriate referral of abnormal conditions.

→ provide emergency care for the woman and newborn; perform selected obstetrical procedures such as manual removal of placenta and newborn resuscitation; prescribe and give drugs (IM/IV) and infusions to the mother and baby as needed, including for post-abortion care.

→ provide health information and counselling for the woman, her family and community.

small babyA newly born infant born preterm and/or with low birth weight.

stableStaying the same rather than getting worse.

stillbirthBirth of a baby that shows no signs of life at birth (no gasping, breathing or heart beat).

surveillance, permanentContinuous presence and observation of a woman in labour.

symptomAs used in this guide, a health problem reported by a woman, such as pain or headache.

term, full-termWord used to describe a baby born after 37 completed weeks of pregnancy.

trimester of pregnancySee Gestational age.

very small babyBaby with birth weight less than 1500-g or gestational age less than 32 weeks.

WHO definitions have been used where possible but, for the purposes of this guide, have been modified where necessary to be more appropriate to clinical care (reasons for modification are given). For conditions where there are no official WHO definitions, operational terms are proposed, again only for the purposes of this guide.

Acronyms

aids Acquired immunodeficiency syndrome, caused by infection with human immunodeficiency virus (HIV). AIDS is the final and most severe phase of HIV infection.

anc Care for the woman and fetus during pregnancy.

arv Antiretroviral drug, a drug to treat HIV infection, or to prevent mother-to-child transmission of HIV.

bcg An immunization to prevent tuberculosis, given at birth.

bp Blood pressure.bpm Beats per minute.fhr Fetal heart rate.hb Haemoglobin.hb-1 Vaccine given at birth to prevent

hepatitis B.hmbr Home-based maternal record:

pregnancy, delivery and inter-pregnancy record for the woman and some information about the newborn.

hiv Human immunodeficiency virus. HIV is the virus that causes AIDS.

inh Isoniazid, a drug to treat tuberculosis.

iv Intravenous (injection or infusion).im Intramuscular injection.iu International unit.iud Intrauterine device.lam Lactation amenorrhea.

lbw Low birth weight: birth weight less than 2500 g.

lmp Last menstrual period: a date from which the date of delivery is estimated.

mtct Mother-to-child transmission of HIV.ng Naso-gastric tube, a feeding tube

put into the stomach through the nose.

ors Oral rehydration solution.opv-0 Oral polio vaccine. To prevent

poliomyelitis, OPV-0 is given at birth.Qc A quick check assessment of the

health status of the woman or her baby at the first contact with the health provider or services in order to assess if emergency care is required.

ram Systematic assessment of vital functions of the woman and the most severe presenting signs and symptoms; immediate initial management of the life-threatening conditions; and urgent and safe referral to the next level of care.

rpr Rapid plasma reagin, a rapid test for syphilis. It can be performed in the clinic.

sti Sexually transmitted infection.

tba A person who assists the mother during childbirth. In general, a TBA would initially acquire skills by delivering babies herself or through apprenticeship to other TBAs.

tt An immunization against tetanus> More than≥ Equal or more than< Less than≤ Equal or less than

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For more information, please contact:

Department of Making Pregnancy Safer

Family and Community Health, World Health Organization

Avenue Appia 20, CH-1211 Geneva 27, Switzerland

Tel: +41 22 791 4447 / 3346

Fax: +41 22 791 5853

Email: MPSinfo@who.int

For updates to this publication, please visit:www.who.int/making_pregnancy_safer