Basic Maternal and Newborn Care: A guide for skilled providers

Publication date: 2004

authors Barbara Kinzie Patricia Gomez editor Rebecca Chase Basic Maternal and Newborn Care: A Guide for Skilled Providers authors Barbara Kinzie Patricia Gomez editor Rebecca Chase Basic Maternal and Newborn Care: A Guide for Skilled Providers The Maternal and Neonatal Health (MNH) Program is committed to saving mothers’ and newborns’ lives by increasing the timely use of key maternal and neonatal health and nutrition practices. The MNH Program is jointly implemented by JHPIEGO, the Johns Hopkins University/Center for Communication Programs, the Centre for Development and Population Activities, and the Program for Appropriate Technology in Health. JHPIEGO, an affiliate of Johns Hopkins University, builds global and local partnerships to enhance the quality of health care services for women and families around the world. JHPIEGO is a global leader in the creation of innovative and effective approaches to developing human resources for health. www.jhpiego.org Copyright © 2004 by JHPIEGO. All rights reserved. First published February 2004. Reprinted September 2004 with additional information and modified cross-referencing. Reprinted May 2006. For information: The ACCESS Program JHPIEGO Brown’s Wharf 1615 Thames Street Baltimore, Maryland 21231-3492, USA Tel: 410.537.1845 www.accesstohealth.org Authors: Barbara Kinzie Patricia Gomez Editor: Rebecca Chase Editorial Assistance: Melissa McCormick Erin Wagner Katrin DeCamp Roxana C. Del Barco Dana Lewison Ann Blouse Illustrator: Kimberly M. Battista Graphic Assistance and Layout: Deborah Raynor Youngae Kim Cover Design: Youngae Kim Cover Photos: Upper left “Women and newborn waiting to be seen by a skilled provider” Taken by Erwin Ochoa (Hospital de Area Roberto Suazo Cordova, La Paz, Comayagua, Honduras; 2003) Lower left “Kader (community volunteer) counseling a couple on prevention of postpartum hemorrhage” Taken by Harshad Sanghvi (Baleh Endah, Bandung, Indonesia; 2003) Center “Young mother smiling at her newborn” Taken by Susheela Engelbrecht (Ghana; 2000) Right “Family in Suami SIAGA village” Taken by Sereen Thaddeus (East Java, Indonesia; 1999) All photos are from the JHPIEGO/MNH Program photo archives. ISBN 0-929817-82-6 TRADEMARKS: All brand names and product names are trademarks or registered trademarks of their respective companies. Printed in the United States of America JHPIEGO/Maternal and Neonatal Health Program iii TABLE OF CONTENTS List of Figures. vi List of Tables . viii List of Textboxes . x Preface and Acknowledgments. xiii User Evaluation Form. xv How to Use This Manual . xix List of Abbreviations. xxii SECTION ONE: FUNDAMENTALS OF BASIC CARE Chapter 1: Introduction to Basic Care What Is Basic Care? .1-1 General Principles of Basic Care .1-5 The Care Provision System .1-9 Chapter 2: Rationales for Components of Basic Care Overview .1-13 Core Components of Basic Care.1-13 Additional Care Provision .1-29 Chapter 3: Key Tools in Basic Care Overview .1-41 Clinical Decision-Making.1-41 Interpersonal Skills .1-42 Infection Prevention.1-47 Record Keeping.1-57 SECTION TWO: CORE COMPONENTS OF BASIC CARE Chapter 4: Conducting the Basic Maternal and Newborn Care Visit Essential Pre-Visit Activities .2-1 Welcoming the Woman and Her Family .2-1 Conducting Basic Assessment .2-2 Providing Basic Care .2-3 Scheduling a Return Visit .2-3 Chapter 5: Antenatal Care Overview .2-5 Antenatal Assessment .2-6 History .2-6 Physical Examination .2-14 Testing.2-24 Antenatal Care Provision.2-26 Nutritional Support.2-26 Birth and Complication Readiness Plan .2-26 Self-Care and Other Healthy Practices .2-29 HIV Counseling and Testing.2-33 Immunizations and Other Preventive Measures.2-34 iv JHPIEGO/Maternal and Neonatal Health Program Chapter 6: Labor/Childbirth Care Overview .2-37 Ongoing Assessment and Supportive Care .2-38 Labor/Childbirth Assessment .2-50 History .2-50 Physical Examination .2-55 Testing.2-69 Labor/Childbirth Care Provision.2-70 Key Actions for the 1st Stage of Labor .2-70 Key Actions for the 2nd and 3rd Stages of Labor.2-71 Key Actions for the 4th Stage of Labor.2-79 Chapter 7: Postpartum Care Overview .2-83 Ongoing Assessment and Supportive Care .2-84 Postpartum Assessment.2-87 History .2-87 Physical Examination .2-95 Testing. 2-101 Postpartum Care Provision . 2-102 Breastfeeding and Breast Care . 2-102 Complication Readiness Plan . 2-103 Support for Mother-Baby-Family Relationships. 2-103 Family Planning . 2-104 Nutritional Support. 2-105 Self-Care and Other Healthy Practices . 2-105 HIV Counseling and Testing. 2-107 Immunizations and Other Preventive Measures. 2-107 Chapter 8: Newborn Care Overview . 2-109 Ongoing Assessment and Supportive Care . 2-110 Newborn Assessment. 2-113 History . 2-113 Physical Examination/Observation . 2-120 Newborn Care Provision. 2-130 Early and Exclusive Breastfeeding . 2-130 Complication Readiness Plan . 2-130 Newborn Care and Other Healthy Practices . 2-131 Immunizations and Other Preventive Measures. 2-135 SECTION THREE: ADDITIONAL CARE Chapter 9: Common Discomforts and Concerns Overview .3-1 Common Discomforts during Pregnancy, Labor and Birth, and the Postpartum Period .3-3 Common Concerns during the Newborn Period .3-25 Chapter 10: Special Needs Overview .3-35 Special Needs during Pregnancy, Labor and Birth, and the Postpartum Period.3-37 Special Needs of the Newborn Period .3-83 JHPIEGO/Maternal and Neonatal Health Program v Chapter 11: Life-Threatening Complications Overview .3-89 Maternal Rapid Initial Assessment.3-90 Stabilization of the Woman.3-92 Newborn Rapid Initial Assessment.3-96 Newborn Resuscitation.3-99 Maternal Life-Threatening Complications. 3-102 Life-Threatening Complications during the Newborn Period . 3-122 SECTION FOUR: ANNEXES Annex 1: Preparation of the Care Site General Cleanliness, Comfort, and Order .4-1 Clean Water Supply .4-1 Light Source.4-1 Furnishings.4-2 Annex 2: Essential Equipment and Supplies.4-3 Annex 3: The Partograph Using the Partograph.4-7 Annex 4: Additional Procedures Artificial Rupture of Membranes .4-11 Breech Birth (in Emergency Situations Only).4-11 Correcting Uterine Inversion .4-15 Defibulation .4-17 Episiotomy.4-18 Examination of the Vagina, Perineum, and Cervix for Tears .4-20 Manual Removal of the Placenta or Placental Fragments.4-22 Multiple Pregnancy Birth .4-25 Pelvic Examination.4-26 Speculum Examination .4-27 Bimanual Examination .4-30 Repair of Cervical Tears.4-36 Repair of Episiotomy .4-37 Repair of 1st and 2nd Degree Vaginal and Perineal Tears.4-38 Shoulder Dystocia (Stuck Shoulders) .4-40 Testing .4-41 Urine Test for Protein .4-41 Measuring Hemoglobin.4-43 Rapid Plasma Reagent Test .4-44 Vacuum Extraction.4-45 Annex 5: Additional Health Messages and Counseling Breastfeeding Support.4-47 Breastfeeding Versus Using a Breastmilk Substitute.4-49 Using a Breastmilk Substitute .4-51 Feeding by Cup, Cup and Spoon, or Other Device.4-52 Postpartum Contraception .4-53 Annex 6: Quick Check .4-61 Annex 7: Guidelines for Referral/Transfer .4-63 vi JHPIEGO/Maternal and Neonatal Health Program LIST OF FIGURES 1-1. Scope of Basic Care .1-5 1-2. Making Elbow-Length Gloves from Previously Used Surgical Gloves.1-52 1-3. Putting on Fingerless (A) and Surgical (B) Gloves.1-52 2-1. Antenatal Fundal Height Measurement .2-20 2-2. Fundal Palpation .2-21 2-3. Lateral Palpation .2-21 2-4. Pelvic Palpation (Supra-Pubic) .2-21 2-5. Checking the Skene’s Gland.2-24 2-6. Checking the Bartholin’s Gland .2-24 2-7. Abdominal Palpation for Descent of the Fetal Head .2-62 2-8. Dilation of Cervix in Centimeters .2-66 2-9. Landmarks of the Normal Fetal Skull .2-67 2-10. Apposing Bones (Bones Touching Each Other) in the Fetal Skull .2-67 2-11. Pushing Positions: Semi-Sitting/Reclining .2-73 2-12. Pushing Positions: Squatting.2-73 2-13. Pushing Positions: Hands and Knees .2-73 2-14. Pushing Positions: Lying on Side .2-73 2-15. Perineal Support during Normal Vaginal Birth.2-75 2-16. Pulling Gently Downward to Deliver the Anterior Shoulder during Normal Vaginal Birth .2-76 2-17. Pulling Gently Upward to Deliver the Posterior Shoulder during Normal Vaginal Birth.2-76 2-18. Supporting the Baby during Normal Vaginal Birth.2-76 2-19. Placing the Baby on the Woman’s Abdomen Immediately after Normal Vaginal Birth .2-77 2-20. Postpartum Fundal Height: Involution .2-99 2-21. Spasms (A) and Opisthotonos (B) . 2-125 2-22. Facial Palsy . 2-125 2-23. Erb’s Palsy. 2-125 2-24. Abdominal Distention. 2-127 2-25. Correct (A) and Incorrect (B) Attachment of the Newborn to the Breast . 2-129 3-1. Type I Area Cut (Left) and Healed (Right).3-50 3-2. Type II Area Cut (Left) and Healed (Right) .3-50 3-3. Type III Area Cut (Left) and Healed (Right) .3-50 3-4. Correct Position of the Head for Ventilation .3-99 3-5. Positioning the Mask and Checking the Seal. 3-100 3-6. Bimanual Compression of the Uterus . 3-105 3-7. Compression of the Abdominal Aorta and Palpation of the Femoral Pulse . 3-105 4-1. Fetal Descent by Abdominal Palpation.4-7 4-2. The Modified WHO Partograph.4-9 4-3. Breech Presentation: Frank (Left) and Complete (Right) .4-12 JHPIEGO/Maternal and Neonatal Health Program vii 4-4. Holding the Baby at the Hips .4-13 4-5. Lovset’s Maneuver.4-13 4-6. Delivery of the Shoulder That Is Posterior .4-14 4-7. Mauriceau-Smellie-Veit Maneuver .4-15 4-8. Manual Replacement of the Inverted Uterus .4-16 4-9. Infiltration of Perineal Tissue with Local Anesthetic .4-19 4-10. Making Incision while Inserting Two Fingers to Protect the Baby’s Head.4-20 4-11. Introducing One Hand into the Vagina along the Cord .4-23 4-12. Supporting the Uterus while Detaching the Placenta .4-23 4-13. Withdrawing the Hand from the Uterus.4-24 4-14. Inserting the Speculum (Left and Right).4-27 4-15. Rotating the Speculum.4-28 4-16. Opening the Speculum Blades.4-28 4-17. Speculum in Place with Blades Open .4-28 4-18. Removing the Speculum.4-29 4-19. Inserting the Fingers into the Vagina .4-31 4-20. Palpation of an Anteverted Uterus .4-31 4-21. Palpation of a Retroverted Uterus .4-32 4-22. Checking Cervical Movement (Left and Right) .4-32 4-23. Locating the Ovaries .4-35 4-24. Repair of a Cervical Tear .4-36 4-25. Repair of Episiotomy (Steps 1, 2, and 3) .4-38 4-26. Flexed Knees Pushed Firmly toward Chest .4-41 4-27. Vacuum Extractor.4-45 4-28. Applying Traction with the Malmstrom Cup.4-46 4-29. Breastfeeding: Cradle Position.4-47 4-30. Breastfeeding: Cross-Cradle Position .4-47 4-31. Breastfeeding: Football/Clutch Position .4-47 4-32. Breastfeeding: Side-Lying Position.4-47 4-33. Expressing Breastmilk.4-49 4-34. Alternative Feeding Methods: Cup (A), Paladai (B), Spoon (C) .4-53 4-35. Recommended Time to Start Contraceptives for Breastfeeding Women .4-55 4-36. Recommended Time to Start Contraceptives for Nonbreastfeeding Women .4-55 viii JHPIEGO/Maternal and Neonatal Health Program LIST OF TABLES 1-1. Rationales for Elements of Maternal History.1-14 1-2. Rationales for Elements of Newborn History .1-17 1-3. Rationales for Elements of Maternal Physical Examination.1-18 1-4. Rationales for Elements of Newborn Physical Examination/Observation.1-20 1-5. Rationales for Elements of Maternal Testing.1-21 1-6. Rationales for Elements of Maternal Basic Care Provision .1-22 1-7. Rationales for Elements of Newborn Basic Care Provision.1-24 1-8. Rationales for Ongoing Assessment during the Four Stages of Labor.1-25 1-9. Rationales for Ongoing Supportive Care Measures during the Four Stages of Labor .1-26 1-10. Rationales for Key Actions for the Woman and Baby during the 2nd and 3rd Stages of Labor .1-28 1-11. Rationales for Key Actions for the Woman and Baby during the 4th Stage of Labor .1-29 1-12. Rationales for Additional Care for Maternal and Fetal/Newborn Special Needs .1-31 1-13. Possible Diagnoses Associated with Maternal Life-Threatening Complications .1-38 1-14. Possible Diagnoses Associated with Newborn Life-Threatening Complications .1-40 1-15. Glove Requirements for Common Medical and Surgical Procedures .1-51 2-1. Scheduling for Basic Care Visits.2-4 2-2. Schedule and Overview of Antenatal Care .2-5 2-3. Tetanus Toxoid Immunization Schedule.2-34 2-4. Schedule and Overview of Labor/Childbirth Care.2-37 2-5. Ongoing Assessment of the Woman during Labor and Childbirth .2-39 2-6. Ongoing Assessment of the Baby during Labor and Childbirth.2-46 2-7. Ongoing Supportive Care Measures for Labor and Childbirth.2-47 2-8. Confirming True Labor and Assessing Stage/Phase of Labor.2-68 2-9. Summary of 1st Stage of Labor .2-70 2-10. Summary of 2nd and 3rd Stages of Labor .2-71 2-11. Summary of 4th Stage of Labor.2-80 2-12. Schedule and Overview of Postpartum Care .2-83 2-13. Ongoing Assessment of the Woman during the First 2–6 Hours after Birth.2-85 2-14. Ongoing Supportive Care of the Woman until Discharge from the Healthcare Facility or in the Home.2-86 2-15. Schedule and Overview of Newborn Care . 2-109 2-16. Ongoing Assessment of the Newborn during the First 2–6 Hours after Birth. 2-111 2-17. Ongoing Supportive Care for the Newborn until Discharge from the Healthcare Facility or in the Home. 2-112 2-18. Newborn Stool Descriptions . 2-118 2-19. Appropriate Followup Actions for Congenital Malformations. 2-119 2-20. Newborn Immunization Schedule . 2-135 3-1. Antiretroviral (ARV) Prophylaxis Regimens for Prevention of Mother-to-Child Transmission of HIV .3-54 JHPIEGO/Maternal and Neonatal Health Program ix 3-2. Guidelines for the Use of Nevirapine (NVP) for Prevention of Mother-to-Child Transmission of HIV in Different Scenarios . 3-55 3-3. Uterotonic Drugs . 3-106 3-4. Antibiotic Treatment for Fever during Pregnancy, Labor, or Postpartum . 3-116 4-1. Essential Equipment and Supplies: Routine Care (Section 2) .4-3 4-2. Essential Equipment and Supplies: Infection Prevention.4-4 4-3. Essential Equipment and Supplies: Emergency/Special Care (Section 3) .4-5 4-4. Essential Equipment and Supplies: Drugs/Vaccines (Sections 2 and 3).4-6 4-5. WHO Medical Eligibility Criteria Programmatic Classification .4-56 4-6. Counseling Outline for Postpartum Contraceptive Use.4-56 4-7. Danger Signs or Signs/Symptoms of Advanced Labor to Observe for/Ask about at Every Quick Check.4-62 x JHPIEGO/Maternal and Neonatal Health Program LIST OF TEXTBOXES 1-1. Birth Preparedness and Complication Readiness: A Shared Responsibility.1-4 1-2. Emergency Response in the Home Setting .1-12 1-3. Working with Traditional Birth Attendants.1-12 1-4. The Partograph: An Aid in Clinical Decision-Making.1-27 1-5. Interpersonal Skills during Labor/Childbirth and the Postpartum/Newborn Period .1-44 1-6. Individualizing Health Messages and Counseling.1-46 1-7. Tips for Conducting an Effective Group Education Session .1-47 1-8. Safety Tips for Using Hypodermic Needles and Syringes.1-53 1-9. Tips for Processing Linen.1-57 2-1. Following Up on Abnormal/Potentially Abnormal Findings .2-3 2-2. Preparing for Transfer to Continued Postpartum/Newborn Care .2-4 2-3. General Followup Questions .2-7 2-4. Common Discomforts of Pregnancy .2-8 2-5. Symptoms of Pregnancy .2-9 2-6. Methods for Calculating Estimated Date of Childbirth .2-9 2-7. Preparing for Further Examination .2-16 2-8. Checking Protractility of Nipples that Appear Inverted .2-17 2-9. Procedure for Fundal Height Measurement.2-19 2-10. Procedure for Determining Fetal Lie and Presentation .2-20 2-11. Procedure for Determining Fetal Heart Rate (after 20 weeks’ gestation).2-21 2-12. Procedure for Genital/Vaginal Examination .2-23 2-13. Post-Examination Steps.2-24 2-14. Why Side-Lying Is Important for the Pregnant Woman.2-31 2-15. Proper Body Mechanics.2-31 2-16. Common Discomforts of Labor/Childbirth.2-51 2-17. Essential Components of Complication Readiness during Labor and Childbirth .2-51 2-18. Following Up on Unknown Estimated Date of Childbirth.2-51 2-19. Determining Fetal Descent through Abdominal Palpation .2-61 2-20. Evaluating the Effectiveness of Contractions.2-62 2-21. Assessing Cervical Dilation .2-66 2-22. Assessing the Condition of Amniotic Fluid and Membranes.2-67 2-23. Assessing Presentation and Position of the Fetus and Molding .2-67 2-24. Breathing Techniques during Labor .2-73 2-25. Danger Signs during the Immediate Postpartum/Newborn Period .2-81 2-26. Procedure for Newborn Eye Treatment.2-82 2-27. Common Discomforts of the Postpartum Period.2-88 2-28. Danger Signs during the Postpartum/Newborn Period . 2-103 2-29. Important Considerations for Women Using LAM. 2-105 JHPIEGO/Maternal and Neonatal Health Program xi 2-30. General Followup Questions (Newborn) . 2-114 2-31. Common Concerns during the Newborn Period . 2-114 2-32. Preparing for the Physical Examination (Newborn). 2-120 2-33. Examining the Palate. 2-125 2-34. Post-Examination Steps (Newborn) . 2-127 2-35. Danger Signs during the Newborn Period . 2-131 2-36. Procedure for Newborn Bathing. 2-133 3-1. Index of Common Discomforts during Pregnancy, Labor and Birth, and the Postpartum Period .3-2 3-2. Index of Common Concerns during the Newborn Period.3-2 3-3. Index of Special Needs during Pregnancy, Labor and Birth, and the Postpartum Period .3-36 3-4. Index of Special Needs during the Newborn Period.3-36 3-5. Interpersonal Skills to Focus on with the Adolescent Woman.3-38 3-6. Assisting the Adolescent Woman in Identifying Her Support System .3-38 3-7. Nutritional Support for the Adolescent Woman.3-39 3-8. Health Messages and Counseling for the Adolescent Woman.3-39 3-9. Facilitating Linkages to Appropriate Local Sources of Support .3-40 3-10. Possible Causes of Anemia and Appropriate Followup Actions .3-42 3-11. Additional Care for Ineffective Attachment/Sucking .3-44 3-12. Additional Care for Engorged Breasts/Blocked Ducts.3-44 3-13. Additional Care for Sore/Cracked Nipples .3-45 3-14. Additional Care for Mastitis .3-45 3-15. Additional Care for Maternal Concerns about Insufficient Milk Supply.3-46 3-16. Additional Care for Inadequate Intake.3-46 3-17. Signs/Symptoms of Coexistant Conditions and Opportunistic Infections in the HIV-Positive Woman.3-53 3-18. Post-Test Counseling for an HIV-Positive Result .3-53 3-19. Newborn Feeding Options for the HIV-Positive Woman .3-56 3-20. Additional Nutritional Support for the HIV-Positive Woman .3-56 3-21. Health Messages and Counseling to Focus on with the HIV-Positive Woman.3-57 3-22. Health Messages and Counseling for Women Living in Malaria-Endemic Areas.3-60 3-23. Additional Assessment/Followup for Convulsions in Previous Pregnancy, Labor/Birth, or Postpartum Period.3-65 3-24. Additional Assessment/Followup for Three or More Spontaneous Abortions in Previous Pregnancy .3-65 3-25. Additional Assessment/Followup for Cesarean Section or Other Uterine Surgery in Previous Pregnancy or Birth .3-66 3-26. Additional Assessment/Followup for 3rd or 4th Degree Tear in Previous Birth .3-66 3-27. Additional Assessment/Followup for Previous Newborn Complications or Death .3-67 3-28. Methods for Confirming Rupture of Membranes .3-71 3-29. Interpersonal Skills for Use with a Woman and Family with a Stillbirth or Newborn Death .3-75 3-30. Additional Interpersonal Skills for Women Suffering from Violence.3-82 3-31. Safety Action Plan for Women Suffering from Violence.3-82 xii JHPIEGO/Maternal and Neonatal Health Program 3-32. Index of Life-Threatening Complications .3-90 3-33. Loading Dose and Maintenance Dose Schedule for Magnesium Sulfate .3-94 3-34. Loading Dose and Maintenance Dose Schedule for Diazepam.3-95 3-35. Guidelines for Starting an IV Infusion or Giving ORS.3-96 3-36. How to Make ORS .3-96 3-37. Distinguishing between Jitteriness and Convulsions/Spasms.3-98 3-38. Care after Newborn Resuscitation . 3-101 3-39. Management of Uterine Atony . 3-105 3-40. Management of Retained Placenta or Placental Fragments. 3-107 3-41. Management of Delayed Postpartum Hemorrhage (more than 24 hours after birth). 3-107 3-42. Management of Meconium-Stained Amniotic Fluid. 3-111 3-43. Management of Decreased or Absent Fetal Movements . 3-111 3-44. Management of Absent Fetal Heart Tones . 3-112 3-45. Management of Abnormal Fetal Heart Rate . 3-113 3-46. Management of Newborn Axillary Temperature Less than 36.5°C . 3-123 3-47. Management of Newborn Axillary Temperature More than 37.5°C . 3-123 3-48. Management of Fewer than 10 Skin Lesions or Lesions That Cover Less than Half the Body. 3-128 3-49. Management of White Patches in Mouth or Diaper/Napkin Area. 3-128 4-1. Additional Guidance for Women with Inverted Nipples.4-48 4-2. Expressing Breastmilk.4-49 4-3. Assessing the Feasibility of Using a Breastmilk Substitute .4-51 4-4. Guidelines for Referral/Transfer of the Woman or Newborn .4-64 JHPIEGO/Maternal and Neonatal Health Program xiii PREFACE Basic Maternal and Newborn Care: A Guide for Skilled Providers (BMNC) is based on the premise that provision of quality basic care to women experiencing normal pregnancies, births, and postpartum periods, as well as to their normal newborns, not only improves the health of mother and baby, but also can help save lives. Basic maternal and newborn care includes the healthcare services that all childbearing women and newborns should receive. Healthcare systems often focus their resources on caring for women and newborns who have complications, not recognizing that providing quality basic care services to all women and newborns can support and help maintain normal processes, as well as prevent many complications and/or identify and treat them before they become life-threatening. Basic care provision also emphasizes the importance of providing health messages and counseling to women and their families to empower them to become active participants in their own healthcare. The BMNC manual is intended for use by skilled providers (including midwives, doctors, and nurses) who care for women and newborns in low-resource settings. Basic care can be given in a variety of sites, including the woman’s home, the peripheral health center, and the district referral hospital. It is assumed that the skilled provider will furnish all basic care services, identify and manage common complications, and stabilize (if necessary) and refer/transfer women and newborns needing additional interventions. It is recognized, however, that some skilled providers will also be capable of treating more complex conditions and so will not need to refer/transfer the woman or her newborn to another facility or provider for that care. For further information about complications, this manual refers the user to Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors1 and Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives2, which are part of the World Health Organization’s (WHO) Integrated Management of Pregnancy and Childbirth (IMPAC) series. Although the manual is intended primarily as a reference for the skilled provider, the care described herein is based on current scientific evidence and/or expert opinion, and thus will be of use in both inservice training and preservice education programs. In inservice programs, the manual will serve as a reference to providers as they are updated in specific areas of basic maternal and newborn care. In preservice education programs, it will complement basic science materials as learners become proficient in recognizing and supporting normal pregnancy, labor and birth, and postpartum and newborn periods, while they learn how to identify and manage common complications. The manual is designed to be used with the BMNC Learning Resource Package, also published by JHPIEGO/Maternal and Neonatal Health Program, which contains all of the materials needed to conduct a competency-based training course (e.g., class schedules, course outlines, pre- and post-tests, skills checklists, role plays, case studies). Because this is a “field-test” manual, we encourage feedback on its structure and contents from users throughout the world, working in as many settings as possible. (See the User Evaluation, page xv.) We hope that this manual will serve as a foundation for the provision of basic care to women and newborns all around the world, both to maintain and promote their health, and to help ensure their survival. 1 WHO. 2000. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. WHO: Geneva. 2 WHO. 2003. Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives. WHO: Geneva. xiv JHPIEGO/Maternal and Neonatal Health Program ACKNOWLEDGMENTS The authors would like to acknowledge the following individuals and organizations, whose time, expertise, and other valuable contributions helped in the development of this manual. Contributors: Frances Ganges Elena Kehoe Harshad Sanghvi The special contribution of Susheela Engelbrecht, whose manuscript helped inform the development of this manual, is gratefully acknowledged. Reviewers∗: Jean Anderson Luc de Bernis Annie Clark Annie Davenport Sylvia Deganus Susheela Engelbrecht Frances Ganges Kamlesh Giri Anne Hyre Rajshree Jha Robert Johnson Joy Lawn Pamela Lynam Matthews Mathai Melissa McCormick Gloria Metcalfe Asmuyeni Muchtar Indira Narayanan Judith O’Heir Emmanuel Otolorin Harshad Sanghvi Ilse Santizo Della R. Sherratt Jeffrey Smith Mary Ellen Stanton Patricia Stephenson Betty Sweet Jelka Zupan Special thanks: Selected text/graphics presented in this document have been adapted/reprinted from: • Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. World Health Organization (WHO): Geneva, 2000; and • Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives. WHO: Geneva, 2003. This publication was made possible through support provided by the Maternal and Child Health Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, U.S. Agency for International Development, under the terms of Award No. HRN-00-98-00043-00. Reprinting in 2006 was made possible through support provided by the Maternal and Child Health Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, U.S. Agency for International Development, under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-04-00002-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. ∗ These individuals reviewed all or, according to area of expertise, part of the manual. JHPIEGO/Maternal and Neonatal Health Program xv USER EVALUATION Because Basic Maternal and Newborn Care: A Guide for Skilled Providers is a “field-test” manual, feedback on its structure and contents—from users throughout the world, working in as many settings as possible—is encouraged. After filling out this form (attaching pages as needed), please return it to: Patricia Gomez Director for Midwifery, MNH JHPIEGO 1615 Thames Street Baltimore, MD 21231 USA Email: pgomez@jhpiego.net Tel: 410.537.1862 Fax: 410.537.1479 A. User Information 1. Name ________________________________________________________ Date__________ 2. What type of health professional are you? (check only one) Physician/Surgeon Nurse/Midwife Nurse Midwife Medical Student Nursing/Midwifery Student Intern/Resident (or equivalent) Other (specify) _________________________________________________________________ 3. What is your area of specialty? Ob/Gyn Midwifery Nursing Nursing/Midwifery Pediatrics Other (specify) _________________________________________________________________ 4. Name and address of institution where you provide maternal and newborn healthcare Institution name ___________________________________________________________________ Address _________________________________________________________________________ City ______________________________________________ Country _____________________ 5. Type of institution Health Dispensary Private Clinic/Hospital Health Center Nursing/Midwifery Teaching Institution District Hospital Other (specify) ______________________________________ Regional Hospital ___________________________________________________ 6. What is your primary job responsibility? Healthcare provider Clinical training supervisor Teacher/Educator/Instructor Other (specify) _________________________________________________________________ Basic Maternal and Newborn Care: A Guide for Skilled Providers xvi JHPIEGO/Maternal and Neonatal Health Program 7. Please estimate the percentage of your professional time each week spent in the following activities. (Total should add up to 100%.) Patient/Client Care ______% Clinical Training ______% Teaching/Educating/Instructing ______% (not in clinical setting) Other (specify) _____________________ ______% TOTAL 100 % 8. How do you use Basic Maternal and Newborn Care: A Guide for Skilled Providers? (check all that apply) Client care provision Preservice education Inservice training 9. Is the manual appropriate for the cadre and/or the level at which you work? Yes No Don’t know xv ii JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am B . Pl ea se in di ca te y ou r o pi ni on o f t he m an ua l u si ng th e fo llo w in g 1– 5 sc al e: 5- E xc el le nt 4 -V er y G oo d 3- Sa tis fa ct or y 2- N ee ds Im pr ov em en t* 1- U ns at isf ac to ry * CO NT EN TS CO M PL ET EN ES S (co nta in s al l n e e d- to - kn ow in fo rm a tio n) A CC UR A CY (co nte n t i s co rr e ct a n d up -to - da te US ER -F RI EN DL IN ES S (ea sy to re a d, u n de rs ta nd , a nd u se ) US EF UL NE SS (in pr ob lem so lvi ng a n d de ci si on -m ak in g) H EL PF UL NE SS (of fig ure s, ta bl es , a n d te xt bo xe s) Ch ap te r 1: In tro du ct io n to B as ic Ca re Ch ap te r 2 : R at io n a le s fo r Co m po ne nt s of B as ic Ca re Ch ap te r 3 : K ey T oo ls in B as ic Ca re Ch ap te r 4 : C on du ct in g th e Ba si c M at er na l a nd N ew bo rn C ar e Vi si t Ch ap te r 5 : A nt e n a ta l C ar e— As se ss m en t a n d Ca re Pr ov is io n Ch ap te r 6 : L ab or /C hi ld bi rth C ar e— As se ss m en t a n d Ca re Pr ov is io n Ch ap te r 7 : P os tp ar tu m C ar e— As se ss m en t a n d Ca re Pr ov is io n Ch ap te r 8 : N ew bo rn C a re — As se ss m en t a n d Ca re Pr ov is io n Ch ap te r 9 : C om m o n D is co m fo rts / Co nc er n s Ch ap te r 1 0: Sp ec ia l N ee ds Ch ap te r 1 1: Li fe -T hr ea te ni ng Co m pl ic a tio n s An ne x 1 : P re pa ra tio n of th e Ca re S ite A nn ex 2 : E ss en tia l E qu ip m e n t a n d Su pp lie s A nn ex 3 : T he P ar to gr ap h A nn ex 4 : A dd itio na l P ro ce du re s A nn ex 5 : A dd itio na l H ea lth M es sa ge s a n d Co un se lin g A nn ex 6 : Q uic k C he ck A nn ex 7 : G ui de lin es fo r R ef er ra l/T ra ns fe r O ve ra ll (th e m an ua l a s a w ho le ) * P le as e c o m m e n t o n th e ba ck (un de r D ) if yo u r ate d an y ch ap te r o r a n n e x le ss th an s at is fa ct or y. Basic Maternal and Newborn Care: A Guide for Skilled Providers xviii JHPIEGO/Maternal and Neonatal Health Program C. Please answer any or all of the following questions: 1. In Section 1 (Chapters 1–3): What topics (if any) should be added or described in more detail? What topics (if any) should be omitted or described in less detail? 2. Are there any other global/basic care recommendations for assessing and caring for the woman and newborn that should be included to Section 2 to make the following chapters more useful? If so, what? Chapter 4: Conducting the Basic Maternal and Newborn Care Visit Chapter 5: Antenatal Care Chapter 6: Labor/Childbirth Care Chapter 7: Postpartum Care Chapter 8: Newborn Care 3. Are there any other changes that should be made to Section 2 (e.g., to the organization/layout or content)? 4. Are there Common Discomforts/Concerns that should be included (or deleted) to make Chapter 9 more useful? If so, what? 5. Are there Special Needs that should be included (or deleted) to make Chapter 10 more useful? If so, what? 6. Are there Life-Threatening Complications that should be included (or deleted) to make Chapter 11 more useful? If so, what? 7. Are there any other changes that should be made to Section 3 (e.g., to the organization/layout or content)? 8. In Section 4 (Annexes 1–7): What topics (if any) should be added or described in more detail? What topics (if any) should be omitted or described in less detail? 9. Are there any other changes that should be made to Section 4 (e.g., to the organization/layout or content)? 10. Are there specific job aids that would complement the manual or make it easier to use? If so, please describe. 11. Are there additional figures, tables, or textboxes (or changes to existing graphics) that would complement the text or make it easier to understand? If so, please describe. D. Additional Comments Thank you! JHPIEGO/Maternal and Neonatal Health Program xix HOW TO USE THIS MANUAL Different parts of this manual may be used by a wide range of people in the healthcare community in a variety of ways, depending on their individual objectives. Facility supervisors, for example, may focus on certain sections for guidance on integrating the use of the manual into current practice, as well as on assessing and improving existing practices/systems and even developing new ones where needed. Policymakers may focus on other sections when advocating for necessary changes in community, regional, or national healthcare protocols. This manual may provide a useful starting point, a basis for valuable thought and discussion, in these and many other efforts aimed at reducing maternal and newborn morbidity and mortality in developing countries. The primary user, however, is the skilled provider (page 1-6) who is caring for women at any point during the childbearing cycle and for newborn babies during the first 6 days of life. The following guidelines are intended to assist the skilled provider in using this manual to provide that care in the most effective and efficient manner possible. The manual comprises four sections, each numbered separately and designated with a number code. Cross-referencing is used extensively throughout the text to allow the user to quickly find the relevant information in all sections of the manual. These sections are described below. Section One: Fundamentals of Basic Care (designated by the number “1” preceding page, figure, table, and textbox numbers) contains information on cross-cutting issues, concepts, and skills that form the foundation of basic care during pregnancy, labor and childbirth, and the postpartum and newborn periods. z Chapter 1 describes the general principles and scope of basic care, as well as the context in which it is best carried out—issues that may need to be addressed at a facility/community level before the skilled provider is able to use the manual most effectively in caring for women and newborns. z Chapter 2 contains the rationales for all components of basic care, the assumption being that care will be more “focused” (and thus, more efficient and effective) if the provider understands the purpose for each element of assessment and care provision. z Chapter 3 provides a general review of key skills (in which the skilled provider should already be proficient) that are fundamental to the safe and effective provision of all basic care. Note: Although the provider may not need to access this section on a day-to-day or ongoing basis, s/he should know, understand, and—where appropriate—be able to apply its contents before using the technical sections. Section Two: Core Components of Basic Care (designated by the number “2” preceding page, figure, table, and textbox numbers) may be considered the primary text of the manual in that it provides practical guidance on caring for women whose pregnancies, labor/childbirths, and postpartum periods are progressing normally, and for normal newborn babies. Because any woman or newborn can develop a life-threatening complication at any time or have a condition that may pose a threat to health and survival, this section is linked to sections (Sections 3 and 4) that provide practical guidance on recognizing and responding appropriately to a wide range of problems and potential problems that may adversely affect the woman or newborn. z Chapter 4 provides general guidance on conducting the maternal or newborn healthcare visit. z Chapter 4 also acts as an easy-to-use, practical supplement to this piece (How to Use This Manual) by showing exactly how the provider navigates among different sections of the manual during the course of a visit. z Chapters 5 through 8 provide step-by-step guidance on caring for a woman during a normal pregnancy, labor and childbirth, and postpartum period, or for a normal newborn, respectively. z Each of the technical chapters (i.e., Chapters 5–8) begins with the appropriate overview/schedule of care. Basic Maternal and Newborn Care: A Guide for Skilled Providers xx JHPIEGO/Maternal and Neonatal Health Program z Following the overview are basic assessment tables that guide the provider through each component of assessment (history, physical examination, testing)—in the order in which it is generally conducted. The tables summarize normal findings where appropriate and indicate findings that may indicate a problem and/or a need for additional assessment and care. Integrated throughout the assessment tables, followup actions may simply highlight the element of basic care provision that is most relevant to a given element of assessment (e.g., the provider is directed to use information gathered about a woman’s dietary intake to individualize nutritional support); or—when findings may indicate a problem or potential problem—they generally direct the provider to Section 3 or 4, where there is further guidance on additional assessment and care provision, or Annex 7, which provides guidelines for urgent referral/transfer. Note: Whether the provider treats or refers/transfers the woman or newborn after stabilization (if necessary) depends on the provider’s/facility’s level of competency/capability and available resources—a matter which should be discussed/decided beforehand. z Following the assessment tables is basic care provision, detailed information on health messages and counseling, immunizations and other preventive measures, and other care components to be individualized for each woman and baby based on their unique needs and situations. Note: Because the provider may need to access this section on a day-to-day or ongoing basis, s/he may become familiar enough with its contents that the schedule/overview at the beginning of each technical chapter can eventually be used as a quick guide. Section Three: Additional Care (designated by the number “3” preceding page, figure, table, and textbox numbers) provides practical guidance on additional assessment and care provision that a woman or newborn with certain problems or potential problems (as detected/identified in Section Two) requires. Integrated throughout, follow-up actions generally direct the provider to other parts of Section 3 or to Section 4, where there is further guidance on additional assessment and care provision, or Annex 7, which provides guidelines for urgent referral/transfer. z Chapter 9 provides practical guidance on caring for women with common discomforts (signs/symptoms that sometimes arise during pregnancy, labor and childbirth, and the postpartum period), which are always or usually normal but may cause women anxiety or discomfort. Guidance is also provided for dealing with common concerns of the newborn period, which are also always or usually normal but may cause the mother anxiety. The provider accesses this chapter as directed in Section 2. Instructions for using this chapter are given on page 3-1. z Chapter 10 provides practical guidance for caring for women and newborns with special needs, which are conditions, situations, or factors that require special consideration, assessment, or care in addition to the core components of basic care. Additional assessment, together with the core components of assessment (Section Two), helps the provider distinguish between conditions that can and cannot be adequately managed within the scope of this manual. If no such conditions are identified, additional care provision, together with the core components of care provision (Section Two), helps to restore or maintain “normalcy.” The provider accesses this chapter as directed in Section 2. Instructions for using this chapter are given on page 3-35. z Chapter 11 provides practical guidance on initial specialized care (which may include life-saving measures) of the most commonly encountered complications, which may be life-threatening. Additional assessment, together with the core components of assessment (Section Two), helps the provider distinguish between conditions that can and cannot be adequately managed within the scope of this manual. If no such conditions are identified, additional care provision, together with the core components of care provision (Section Two), helps to restore or maintain “normalcy.” The provider accesses this chapter as directed in Section 2 or the quick check (Annex 6). Instructions for using this chapter are given on page 3-89. How to Use This Manual JHPIEGO/Maternal and Neonatal Health Program xxi Note: Because the care in this section is generally provided in addition to—not instead of—that in Section Two, the provider should be as familiar as possible with its contents and organization before using this manual. Knowing the overall approach of this section and how the two sections fit together can help the provider integrate them more smoothly in caring for a woman or newborn. Section Four: Annexes (designated by the number “4” preceding page, figure, table, and textbox numbers) contains the following annexes. Although some are supplemental in nature (e.g., Breastfeeding Support in Annex 5), others are an essential component of care for all women and newborns (e.g., the Quick Check, Annex 6). z Annex 1 describes preparation of the care site, which should be addressed at a facility/community level in order for the skilled provider to use the manual most effectively in caring for women and babies. z Annex 2 covers essential equipment, supplies, and drugs, which should be addressed at a facility/community level in order for the skilled provider to use the manual most effectively in caring for women and babies. z Annex 3 provides instructions for using the partograph as well as a sample partograph that can be copied and filled out by the provider while caring for a woman during labor and childbirth. z Annex 4 provides guidance on additional procedures that a woman or baby may require during the course of basic care. The provider should not bypass Section Two or Three to access this annex (or any of the individual entries therein) directly. Section Two or Three provides a necessary context to this annex, which is not intended, or designed, to be used as a stand-alone document. z Annex 5 provides guidance on additional health messages and counseling that a woman or baby may require during the course of basic care. Although the provider may bypass earlier sections to access this annex (or any of the individual entries therein) directly, Section Two or Three provides a helpful context for each of the topics covered. z Annex 6, which immediately follows the red divider, is the quick check that every woman or baby should undergo as the first step in basic care. Exactly how this is used and by whom should be addressed at a facility/community level in order for the skilled provider to able to use the manual most effectively in caring for women and babies. Use of this annex should be fully integrated into facility procedure in order for the skilled provider to use the manual most effectively in caring for women and babies. z Annex 7 provides guidelines for referral/transfer of the woman or newborn. The provider should not bypass Section Two or Three or Annex 6 to access this annex directly. Section Two or Three or Annex 6 provides a necessary context to this annex, which is not intended, or designed, to be used as a stand-alone document. Use of this annex should be fully integrated into facility procedure in order for the skilled provider to use the manual most effectively in caring for women and babies. xxii JHPIEGO/Maternal and Neonatal Health Program LIST OF ABBREVIATIONS 3TC Lamivudine AIDS Acquired immunodeficiency syndrome ANC Antenatal care ARV Antiretroviral AZT Zidovudine BCG bacille Calmette-Guérin (for immunization against tuberculosis) BMS Breastmilk substitute BP Blood pressure CBC Childbirth care CEOC Comprehensive essential obstetric care CIC Combined injectable contraceptive cm centimeter COC Combined oral contraceptive Cont. Continually dL deciliter DPT diphtheria, pertussis, and tetanus vaccine EDC Estimated date of childbirth FGC Female genital cutting g gram G6PD Glucose-6-phosphate dehydrogenase HBV Hepatitis B virus HIV Human immunodeficiency virus HIV/AIDS Human immunodeficiency virus/Acquired immunodeficiency syndrome HLD High-level disinfected IM Intramuscular IP Infection prevention IPPF International Planned Parenthood Federation IPT Intermittent preventive treatment ITN Insecticide-treated (bed)nets IUD Intrauterine device IV Intravenous kg kilogram kPa kiloPascal L liter LAM Lactational amenorrhea method LMP Last menstrual period mcg microgram MCPC Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors List of Abbreviations JHPIEGO/Maternal and Neonatal Health Program xxiii mg milligram min minute mL milliliter mmHg millimeter mercury MNP Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives MTCT Mother-to-child transmission of HIV N/A Not applicable NBC Newborn care NVP Nevirapine OPV Oral polio vaccine ORS Oral rehydration solution PLWHA People living with HIV/AIDS PMTCT Preventing mother-to-child transmission of HIV POC Progestin-only contraceptive POP Progestin-only pill PPC Postpartum care PPE Personal protective equipment PPH Postpartum hemorrhage psi pounds per square inch Rh Rhesus RPR/VDRL Rapid plasma reagent/ Venereal disease research laboratory test STI Sexually transmitted infection TB Tuberculosis TBA Traditional birth attendant TT Tetanus toxoid WHO World Health Organization ZDV Zidovudine Basic Maternal and Newborn Care: A Guide for Skilled Providers xxiv JHPIEGO/Maternal and Neonatal Health Program JHPIEGO/Maternal and Neonatal Health Program 1-1 CHAPTER ONE INTRODUCTION TO BASIC CARE WHAT IS BASIC CARE? The reduction of maternal and newborn mortality and morbidity continues to be a great challenge to human development. Each year, more than 500,000 women die from complications of pregnancy or childbirth, and more than 3 million babies die during the first week of life. It is not surprising, then, that many manuals related to maternal and newborn health focus on problems and complications that arise during the childbearing cycle (i.e., pregnancy, labor and childbirth, and the postpartum period) and the newborn period (i.e., the first 28 days of life). However, most women and babies progress through the childbearing cycle and newborn period without complications; thus, basic maternal and newborn care is sufficient for the majority of women and newborn babies. Basic maternal and newborn care consists of healthcare services that all pregnant women and newborn babies should receive. The services described in this manual are: z Appropriate for use in low-resource settings; z Based on evidence—that is, proven to be effective in promoting the health and survival of women and newborn babies—and firm rationales, rather than on habit or tradition; and z Focused, through targeted assessment and individualized care provision, on the most prevalent health issues affecting women and their babies. One key practice in basic care is the attendance of a skilled provider at every birth, which is a critical intervention that can save the lives of women and newborn babies. In addition, because every childbearing woman and newborn is at risk of developing a life-threatening complication at any time, basic care must be linked to a full range of services, including emergency care. Goals of Basic Care The major goal of basic care is to maintain a normal childbearing cycle and newborn period in an attempt to ensure a healthy outcome for the woman and baby. The childbearing cycle and newborn period usually progress normally, without complications. Therefore, basic care should not be an overly “medicalized” experience, focusing solely on the problems that may occur. The focus, rather, is on ensuring, supporting, and maintaining maternal and fetal/newborn well-being. To achieve the main goal of basic care, the skilled provider works toward accomplishing the following supporting goals, which are outlined in the four sections that follow: z Promotion of health and prevention of disease z Detection of existing diseases and treatment z Early detection and management of complications z Birth preparedness and complication readiness Promotion of Health and Prevention of Disease Integrated throughout basic care, health messages and counseling promote health by empowering women to take good care of themselves and their babies, and helping them prevent potential problems. The skilled provider should ensure that the woman and her family have the information they need to make healthy decisions during pregnancy, childbirth, and the postpartum/newborn period, as well as sufficient guidance in Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-2 JHPIEGO/Maternal and Neonatal Health Program applying that information in their particular situation. Some topics that may be included in health messages and counseling include the following: z Nutritional support z Danger signs and complication readiness z Care for common discomforts during pregnancy, labor/childbirth, and the postpartum period z Counseling and testing for HIV z Hygiene and infection prevention z Breastfeeding and breast care z Sexual relations and safer sex z Family planning z Newborn care z Prevention of tetanus and anemia z Discouraging harmful traditional practices while encouraging beneficial traditional practices Health messages and counseling should be built into every basic care visit, but some topics may be more efficiently addressed in a group setting. For example, an entire community may need, but lack, information on topics such as nutrition and HIV/AIDS. Conducting a group education session on a healthcare facility/ community level can allow the skilled provider to focus more on counseling—which should be a one-on-one activity—during visits. Although the childbearing cycle and newborn period usually progress normally, an important goal of basic care is the promotion of safe, simple, and cost-effective interventions to prevent certain conditions. Some key interventions that have proven effective in reducing maternal and newborn mortality and morbidity include the following: z Tetanus toxoid immunization z Iron/folate supplementation z Intermittent preventive treatment of malaria z Use of infection prevention practices z Prevention of mother-to-child transmission of HIV z Use of the partograph z Restricted use of episiotomy z Active management of the 3rd stage of labor z Early and exclusive breastfeeding z Immediate warming of the newborn z Newborn immunizations z Family planning services Detection of Existing Diseases and Treatment In addition to health promotion and the prevention of diseases and other problems, a goal of basic care is the detection of existing diseases/conditions that can complicate the childbearing cycle and newborn period. Basic care also includes providing or facilitating appropriate treatment of any problems detected. Through targeted assessment, which is based on individual needs, the skilled provider interviews the woman and Chapter One: Introduction to Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-3 examines her or the newborn to detect signs and symptoms of chronic or infectious diseases/conditions that are endemic among the population being served, congenital problems, and other problems that may harm the health of the woman or newborn, such as: z Syphilis and other sexually transmitted infections (STIs) z HIV/AIDS z Malaria z Tuberculosis z Anemia z Heart disease z Diabetes z Malnutrition Early Detection and Management of Complications To achieve another, closely related goal of basic care, the skilled provider looks for signs and symptoms of maternal and newborn complications. Basic care also includes performing life-saving measures, if necessary, and managing or facilitating management of any complications detected. The following complications are the major causes of maternal and newborn mortality and morbidity: z Hemorrhage (woman) z Obstructed labor (woman and fetus) z Pre-eclampsia/eclampsia (woman) z Sepsis/infection (woman and newborn) z Asphyxia (newborn) z Hypothermia (newborn) Birth Preparedness and Complication Readiness If the woman and her family are well prepared for normal childbirth as well as any possible maternal or newborn complications, the woman or baby is more likely to receive the skilled and timely care needed to preserve health and ensure survival. Although the manual focuses on what the skilled provider, the woman, and her family can do to prepare for birth and possible complications, birth preparedness/complication readiness is actually a community-wide issue, as shown in Textbox 1-1 (page 1-4). As part of focused antenatal care, the woman and her family develop a birth plan to ensure that necessary preparations are made well in advance of the estimated date of childbirth. This plan includes arrangements for normal childbirth and the postpartum/newborn period, such as: z Skilled provider to attend the birth and care for the woman and newborn during the immediate postpartum/newborn period z Appropriate place of birth (home, healthcare facility, or referral center) z Transportation of/to the skilled provider z Funds z Support/birth companion z Items needed for a clean and safe birth and for the newborn z Assistance at home with other children Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-4 JHPIEGO/Maternal and Neonatal Health Program In addition, because every woman and newborn is at risk of developing a complication, and most of these complications cannot be predicted, the plan includes complication readiness to ensure an appropriate and timely response to any complication that may arise. Preparing for complications can help prevent life- threatening delays in recognizing and responding to complications. In some cases, the time required to make arrangements—which could have been made before the emergency—defines the line between survival and death for the woman and/or child. Factors to consider when preparing a complication readiness plan include the following: z Knowledge of possible danger signs and appropriate responses z How to access emergency funds z How to access emergency transportation z Where to go in an emergency z Possible blood donors Textbox 1-1. Birth Preparedness and Complication Readiness: A Shared Responsibility Birth preparedness and complications readiness are shared responsibilities. Women, families, communities, policymakers, and healthcare facility staff should work individually and together to build an enabling environment for birth preparedness and complication readiness by doing the following: z Identifying and knowing how to reach a skilled provider z Funding (including personal, communal, and reimbursement schemes) to pay for expenses incurred z Establishing communal transportation schemes that can be accessed should life-threatening complications occur z Advocating for skilled providers, 24-hour services, and improved roads and communications systems Scope of Basic Care Although some women and newborn babies require specialized care because of complications or other potentially dangerous conditions, the vast majority of them—whose pregnancies, births, and postpartum/ newborn periods progress normally—require only basic care services. The core components of basic care are the services that all women and newborn babies should receive to ensure, support, and maintain a normal childbearing cycle and newborn period (Figure 1-1, page 1-5). At a minimum, basic care includes the following: z Targeted assessment to facilitate the early detection of complications, chronic conditions, and other problems/potential problems z Individualized care provision, consisting of preventive measures, health messages and counseling, and birth preparedness and complication readiness planning Basic care also encompasses the following care scenarios: z Additional care: for women and newborn babies who have common discomforts/concerns or special needs z Common discomforts/concerns (Chapter 9, page 3-1): normal changes, signs and symptoms, and physical and emotional behaviors that may occur during the childbearing cycle (e.g., back pain, breast tenderness, vivid dreams) and newborn period (e.g., misshapen head, increased crying) z Special needs (Chapter 10, page 3-35): conditions or social/personal factors that should be taken into consideration when planning and implementing care z Initial specialized care (Chapter 11, page 3-89): for women and newborn babies with potentially life-threatening complications and other conditions whose diagnosis and management may lie beyond the scope of this manual Chapter One: Introduction to Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-5 Figure 1-1. Scope of Basic Care GENERAL PRINCIPLES OF BASIC CARE Overview In order for basic maternal and newborn healthcare to be effective in reducing mortality and morbidity among women and babies, services must be consistently delivered in accordance with certain general principles. In addition to being based on evidence and firm rationales, high-quality maternal and newborn healthcare should be: z Delivered by a skilled provider (page 1-6) in the context of a care provision system (page 1-9) that includes a clean, safe client care area and an emergency-response system z Provided in a manner that is respectful of and sensitive to the woman, her newborn and family (page 1-7), and their culture (page 1-8) z Individualized to meet the unique needs of the woman and her newborn and family (page 1-7) Most women and newborn babies require only these services. Some women and newborn babies also require these services. Fewer women and newborn babies require these services (stabilization, facilitation of referral/ transfer). Additional Care for women and newborn babies with common discomforts/concerns (Chapter 9) or special needs (Chapter 10) Core Components of Basic Care including targeted assessment and individualized care provision to maintain a normal childbearing cycle and newborn period, for all women and newborn babies (Chapters 4–8) Initial Specialized Care for women and newborn babies with life-threatening complications and conditions (Chapter 11) Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-6 JHPIEGO/Maternal and Neonatal Health Program z Incorporated with the following key skills: z Clinical decision-making (page 1-41) z Interpersonal skills (page 1-42) z Infection prevention (page 1-47) z Record keeping (page 1-57) The Skilled Provider The presence of a skilled provider during childbirth and the immediate postpartum/newborn period is a critical aspect in saving the lives of women and newborn babies. The skilled provider has the knowledge, skills, and qualifications1 necessary to deliver essential maternal and newborn care in any setting—including the home, community health post, healthcare facility, and district hospital. The term skilled provider is not specific to any one profession; rather, it designates a person (e.g., midwife, doctor, nurse, or other qualified healthcare worker) with certain core competencies. These core competencies include basic and life-saving skills and reflect the minimum skill set of the skilled provider. The skilled provider also has responsibilities in helping to establish and maintain safe and effective healthcare services. This section outlines the core competencies and responsibilities of the skilled provider (as defined in the context of this manual) in managing the normal childbearing cycle and newborn period. The skilled provider is capable of: z Gathering relevant information about the woman or newborn through targeted history taking, physical examination, and testing to ensure that the childbearing cycle or newborn period is progressing normally z Analyzing information gathered in a logical and systematic manner to make clinical decisions about care z Caring for a woman and baby during a normal childbearing cycle and newborn period by: z Providing ongoing advice and counseling z Providing preventive measures (e.g., immunizations, drugs, and micronutrient supplementation) z Assisting in birth preparedness and complication readiness planning z Assisting in normal labor and childbirth, including continuous monitoring during labor and childbirth using the partograph, clean and safe childbirth, and active management of the 3rd stage of labor z Providing immediate support to the newborn after birth to make sure s/he is breathing, is warm, receives proper cord and eye care, and is immunized z Vigilantly monitoring the woman and baby through the first 6 hours postpartum and then at 6 days, and the woman again at 6 weeks, to ensure early detection and management of problems z Providing encouragement and guidance in early and exclusive breastfeeding and other key self- and newborn-care measures z Providing family planning and other key reproductive health services z Anticipating and recognizing potential problems by: z Noting any deviations from normal z Detecting signs/symptoms of the major causes of maternal and newborn morbidity and mortality z Checking for signs/symptoms of other conditions that may adversely affect the woman and newborn z Identifying factors that are associated with complications 1 The qualifications necessary to be considered a skilled provider differ from country to country. Chapter One: Introduction to Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-7 z Responding appropriately to major complications/conditions by: z Performing life-saving measures, if needed z Managing the problem or facilitating referral/transfer of a woman or newborn to a higher level of care, as appropriate z Using all available and appropriate means to: z Protect and promote the health/survival of the woman and newborn z Detect complications/conditions z Manage and/or refer/transfer for complications/conditions z Continuing to learn and to develop her/his knowledge base and skill set z Providing care that is in accordance with national policies and standards, clinical care guidelines, and local resources z Continually assessing existing services in order to: z Build on strengths z Identify gaps z Work on practical solutions to fill gaps z Supporting activities that advocate or facilitate linkages among healthcare workers, facilities, communities, and other key stakeholders in the care provision system Woman- and Newborn-Friendly Care In woman- and newborn-friendly care, the woman’s and newborn’s health and survival, basic human rights, and comfort are given clear priority. The woman’s personal desires and preferences are also regarded as important. Providing woman- and newborn-friendly care means: z Making services acceptable to the woman and her family: z The beliefs and traditions of their culture (page 1-8), as well as gender roles and relations, are respected. z Family members or other support people are included in the care of the woman and newborn, as the woman desires. z Health messages and recommendations are relevant and feasible given the woman’s resources, capabilities, and limitations. z Empowering the woman and her family to become active participants in their healthcare, and supporting them in overcoming obstacles to maintaining or improving their health: z The woman is given the information she needs to plan for birth, survive an emergency, and take good care of herself and her newborn. z The woman and her family are assisted in solving problems and making decisions regarding her and her newborn’s health. z Ensuring that skilled providers and other healthcare workers demonstrate knowledge of the rights of women: z Information about her health and the health of her baby is shared with the woman. z The woman is continually informed about what will happen next during the visit. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-8 JHPIEGO/Maternal and Neonatal Health Program z The woman’s permission/consent is obtained throughout the physical examination and testing (before proceeding to the next element), as well as before performing any special procedures. z The woman is encouraged to express her views about the services received. z Ensuring that all healthcare facility staff use good interpersonal skills (page 1-42) z Keeping the woman and her newborn together as much as possible to encourage bonding, as well as to honor and maintain the mother-baby dyad Remember: To respect and maintain the mother-baby dyad, keep them together as much as possible throughout the postpartum/newborn period. z Avoid separating the woman and newborn, even while individually assessing and caring for them. z Place the baby in skin-to-skin contact immediately at birth, and facilitate immediate breastfeeding. z Encourage and facilitate “rooming in”—keeping the baby with the woman day and night. z Allow and encourage the woman’s participation in examination and care of the baby. z Considering the emotional, psychological, and social well-being of the woman and newborn to be as important as their physical well-being Male Involvement There is growing recognition that male partners should be actively involved in the care of women and newborns. Communication, participation, and partnership within/by the couple in seeking and making decisions about care help to ensure a fuller and safer reproductive health experience for the woman, her newborn, and her family. Some ways that skilled providers can encourage and facilitate involvement of male partners in the care of women and newborns during pregnancy, childbirth, and the postpartum/newborn period—when appropriate and as the woman desires—include the following: z Recognizing and working to decrease skilled provider bias against the involvement of male partners z Helping the male partner feel comfortable participating in antenatal, childbirth, and postpartum/newborn care z Making a special effort to include the male partner in planning for birth preparedness and complication readiness z Targeting the couple during health counseling around topics that are especially pertinent to the male partner (e.g., family planning, sexual relations and safer sex, mother-baby-family relationships) Culturally Appropriate Care Pregnancy and childbirth are individual, family, and community events, rich in spiritual significance and power. Every culture has its own rituals, taboos, and proscriptions surrounding pregnancy and childbirth. These beliefs and practices are deeply held, are passed from generation to generation, and may even be institutionalized in law and religion. They define what a culture regards as acceptable or unacceptable conduct on the part of the pregnant woman, her partner and family, and others who are caring for her. Cultural awareness, competency, and openness are, therefore, essential in entering into a care relationship with a woman during this important time in her life. The skilled provider cooperates and coordinates with traditional health systems whenever possible. Both skilled providers and traditional birth attendants view their knowledge as important and legitimate. If a skilled provider’s recommendations do not fit within a woman’s cultural context, the woman or her family may not consider them to be as important, valuable, or authoritative as advice from people within the community, and therefore dismiss them. Chapter One: Introduction to Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-9 The skilled provider can demonstrate cultural sensitivity when interacting with the woman and her family by doing the following: z Speaking to the woman in her own language or arranging to have someone in attendance who can z Observing the rules and norms of the culture of the woman and newborn as appropriate z Understanding who makes the decisions in the lives of the woman and newborn and, when appropriate, involving that person in the decision-making process z Working with traditional birth attendants when possible (For more information, see Healthcare Facility- Community Linkages, page 1-12.) z Showing respect for traditional practices by doing the following: z Striving to understand the details of the traditional practices and the reasons for them z Promoting and building upon positive or “neutral” traditional practices z Offering alternatives to practices that are potentially harmful or that detract from beneficial practices z Showing sensitivity and acknowledging that change can be a difficult process when the elimination of a traditional practice is necessary Note: When a specific cultural practice has been identified as a violation of human rights, skilled providers must carefully assess the use of the practice in their area and—with other skilled providers and local, influential people—develop a plan to advocate change. Individualization of Care This manual proposes a standard package of basic services that all women and babies should receive during the childbearing cycle and newborn period. However, it also recognizes the importance of developing a plan of care that meets the individual needs of each woman and newborn. By taking into consideration all of the information known about a woman and newborn—e.g., current health, medical history, daily habits and lifestyle, cultural beliefs and customs, and any other unique circumstances—the skilled provider can individualize both assessment and care provision components of the care plan. For example, if the woman reveals during her history that she has had gestational diabetes in the past, the skilled provider would include a urine test for glucose. Or, if a newborn has problems attaching to the breast, the skilled provider may emphasize techniques for successful breastfeeding. THE CARE PROVISION SYSTEM Skilled care is a critical component in reducing maternal and newborn mortality and morbidity. However, for skilled providers to do their jobs effectively, they must be supported by an adequate care provision system. The care provision system actually comprises many smaller systems that must work together to function as a whole and, in accordance with national policies and standards, ensure positive health outcomes for women and newborn babies. An adequate care provision system has the following features: z Necessary infrastructure that includes: z Facilities that are adequately built and with reliable sources of power and clean, running water z Essential supplies, equipment, and drugs available at all levels of the care provision system, as well as a system for re-supply and maintenance of these resources z Health finance systems for assisting clients in saving funds, for covering or sharing the cost of services, and for reimbursing the skilled providers z Roads that connect communities, even in remote regions, with healthcare facilities at all levels of the healthcare system Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-10 JHPIEGO/Maternal and Neonatal Health Program z Human resources (i.e., skilled providers, medical and nonmedical support staff) available in sufficient numbers and in the places where they are needed z A functioning system for referral/transfer z Every skilled provider, healthcare facility, and community has a complication readiness plan and can access the referral/transfer system when an emergency arises z A quality assurance system that includes: z Service delivery guidelines that have been developed and disseminated to all levels of the care provision system z Mechanisms for ongoing quality assessment and improvement of healthcare services that have been developed and implemented z Systems for developing and maintaining clinical competence that include: z Preservice education programs to equip skilled providers with the knowledge, skills, and qualifications necessary to provide high-quality maternal and newborn care z Inservice training programs to update and expand the knowledge base and skill set of skilled providers already on the job, to help them improve the quality of services provided Healthcare Site Preparation/Preparedness Before safe and effective services can be provided to women and newborn babies on a consistent basis, the healthcare site itself must be adequately prepared. Whether the woman and newborn come to a healthcare facility for care or receive care in a home setting, it is the skilled provider’s responsibility to ensure that: z The client care area is clean and organized (Annex 1, page 4-1), z Essential equipment and supplies are available and ready for use (Annex 2, page 4-3), and z An emergency-response system is in place (below). Emergency Response System All healthcare facility staff should be trained both to recognize danger signs, which indicate that the woman or newborn may be experiencing a life-threatening complication, or signs of advanced labor, and to respond in an agreed-upon fashion. This training forms the basis of effective emergency response. Having an emergency response system in place ensures that a woman or newborn with an emergent condition will be identified, stabilized (if necessary), and treated as quickly as possible. This system helps to ensure appropriate response because, in the event of an emergency, healthcare facility staff know exactly what to do (i.e., the exact procedures and protocols) and the necessary resources are available and accessible (e.g., emergency transport, supplies, drugs). (For information on emergency response in the home setting, see Textbox 1-2, page 1-12.) In general, an emergency response system should include provision for the following elements: z Identification z Initial response z Management or referral/transfer Identification To eliminate delay in obtaining life-saving attention for a woman or newborn who presents with an emergency condition, a designated member of the healthcare facility staff—who is trained/equipped to identify danger signs and signs of advanced labor, and to mobilize emergency care—performs a quick check Chapter One: Introduction to Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-11 (Annex 6, page 4-61). The quick check is performed immediately upon the woman’s or newborn’s arrival at the healthcare facility (or to a different part of the same healthcare facility, e.g., a postpartum or newborn ward). Initial Response If any danger sign is (or was recently) present, the person who performed the quick check immediately initiates the designated emergency response procedures. (This should include notifying the skilled provider as soon as possible, if an individual other than the skilled provider performed the quick check.) The skilled provider then performs a rapid initial assessment to assess the general nature of the woman’s or newborn’s problem and need for stabilization. Appropriate care for a woman presenting with signs of advanced labor would also be initiated at this time. Management or Referral/Transfer Once the woman or newborn has been stabilized (if necessary), the skilled provider either manages the complication/condition (if qualified and equipped to do so) or urgently refers/transfers the woman or newborn to a healthcare facility that has the following comprehensive essential obstetric care (CEOC) services: z Anesthesia z Blood transfusion z Surgical obstetrics, including: z Cesarean section z Repair of 3rd and 4th degree vaginal tears and extensive cervical tears z Laparotomy (e.g., surgical treatment of sepsis, hysterectomy, removal of ectopic pregnancy)2 z Care for sick or low birthweight newborns If the woman or newborn is not in need of stabilization/resuscitation, the skilled provider should treat her or the newborn according to guidelines provided for the presenting danger sign, which may involve the following: z Provision of basic care with certain additions and/or emphases z Referral/transfer to a specialist or higher level of care if appropriate Facilitating the referral/transfer process includes the following tasks: z Obtaining, or assisting the woman in obtaining, reliable transportation to the referral site z Arranging for the woman to receive appropriate care and support during transfer z Sending complete documentation of the woman’s condition to the referral site, including all relevant findings and interventions z Communicating with the referral site as needed to ensure continuity of care and appropriate followup for the woman 2 Adapted from: World Health Organization. 2000. Fact Sheet No. 245 (June). Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-12 JHPIEGO/Maternal and Neonatal Health Program Textbox 1-2. Emergency Response in the Home Setting z The quick check (Annex 6, page 4-61) is the first action a designated member of the healthcare facility staff should take upon entering the woman’s home, just as it is the first action taken when a woman or newborn arrives at a healthcare facility. z If danger signs are found, appropriate action should be taken by proceeding to rapid initial assessment, stabilization (if necessary), and treatment or referral/transfer of the woman to the appropriate healthcare facility. − The woman’s complication readiness plan (page 2-26) will specify arrangements previously made for complication readiness, including emergency transportation and funds, decision-making, blood donors, and support. This plan will enable the skilled provider and family members to respond appropriately and without delay—even in the home setting. − If there is no complication readiness plan, address the above issues with the woman and her family, and take action in as timely a manner as possible. Healthcare Facility-Community Linkages Skilled providers, healthcare facilities, and the care provision system have the final responsibility in providing high-quality maternal and newborn care, but the communities they serve also have an important role in maintaining that quality. Healthcare facilities and healthcare workers should continually work with women, families, and communities to improve awareness of, demand for, and access to high-quality services. The skilled provider can help organize activities to strengthen linkages between the healthcare facility and the community it serves, such as: z Inviting the community to learn about the healthcare facility’s role, function, constraints, and limitations, and to be part of the healthcare services development committee z Including members of the community in the development, evaluation, and shaping of services through constructive dialogue about mutual needs, issues, and accountability z Learning about “traditional care” services existing in the community and facilitating their integration, when appropriate, with those offered by the healthcare facility (e.g., working with traditional birth attendants; Textbox 1-3, below) z Collaborating with the community in developing transportation, funding, and referral systems to reduce delays for women and newborn babies in obtaining care z Organizing open-door events to celebrate pregnancy and safe motherhood with the community Textbox 1-3. Working with Traditional Birth Attendants Traditional birth attendants (TBAs), female relatives, neighbors, and other community birth assistants are part of the childbirth process throughout the developing world. Because TBAs generally hold positions of respect and influence within their communities, they are in a key position to inform and assist women and their families in preparing for birth. Facilities and skilled providers should respect TBAs as part of the informal healthcare system by: z Including TBAs in supporting women and their families throughout the childbearing cycle and newborn period z Enlisting the support of TBAs in conveying vital health messages and information to families and communities in a culturally appropriate way, such as: − Ensuring that TBAs have correct information and are supported in their understanding of safe motherhood messages − Supporting, rather than competing with, the inherent role that TBAs have in giving advice and information to communities and families − Equipping TBAs to provide health education on such topics as nutrition, STIs (including HIV), breastfeeding, newborn care, danger signs, and where to go for help in the event of an emergency z Partnering with TBAs in identifying pregnant women in the community who need healthcare services and helping them access services z Responding respectfully and promptly to TBAs who bring a woman to a healthcare facility or skilled provider z Allowing and working with TBAs to provide emotional and social support to women during labor and childbirth, whether in the healthcare facility or the home JHPIEGO/Maternal and Neonatal Health Program 1-13 CHAPTER TWO RATIONALES FOR COMPONENTS OF BASIC CARE OVERVIEW The basic maternal and newborn care practices recommended in this manual are based on evidence and firm rationales. This chapter describes the core components of basic care and the rationales for their inclusion in this manual. With a greater understanding of the purpose of each core component, skilled providers will be able to focus their care more effectively. CORE COMPONENTS OF BASIC CARE The core components of basic care are the services that all women and newborn babies should receive to ensure, support, and maintain a normal childbearing cycle and newborn period. At a minimum, basic care includes the following: z Targeted assessment to ensure normal progress of the childbearing cycle and newborn period and facilitate the early detection of complications, chronic conditions, and other problems/potential problems; and z Individualized care provision to help maintain normal progress, consisting of preventive measures, supportive care, health messages and counseling, and birth preparedness and complication readiness planning. Quick Check The quick check ensures that a woman or newborn in need of immediate medical attention is identified, stabilized (if necessary), and treated or referred/transferred as quickly as possible. Every woman or newborn who comes to the healthcare facility for care (or is cared for at home) undergoes a quick check immediately upon arrival. All healthcare facility staff should be trained and equipped to recognize and respond appropriately to potentially life-threatening conditions. If danger signs are identified, the skilled provider performs a rapid initial assessment to determine the degree of illness (if any) and the need for stabilization or emergency care before proceeding. The quick check is also used to recognize and respond appropriately to signs of advanced labor in the pregnant woman, and to danger signs in the newborn. Basic Assessment If it is determined through the quick check that the woman or newborn does not have an emergent condition, the skilled provider may proceed to the assessment. Through the assessment process, the skilled provider works to: z Ensure maternal or newborn well-being and/or normal pregnancy z Gather information that can be used to individualize a plan of care to best meet the woman’s or newborn’s needs z Identify common discomforts/concerns and special needs z Detect conditions beyond the scope of basic care, including life-threatening complications z Establish a trusting and respectful relationship with the woman and her companion/partner/family During the assessment, the skilled provider takes the woman’s or newborn’s history, performs a physical examination, and conducts any necessary tests. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-14 JHPIEGO/Maternal and Neonatal Health Program History The woman’s or newborn’s history provides information that helps the skilled provider target the physical examination and testing, and individualize the plan of care. History taking also facilitates identification of common discomforts/concerns and special needs, and detection of abnormal signs and symptoms to help focus the additional care required. A rationale for each element of the history is described in Table 1-1 (below) and Table 1-2 (page 1-17). Table 1-1. Rationales for Elements of Maternal History ELEMENT* RATIONALE Personal information z Used to: − Identify and contact the woman. − Help establish rapport. − Gain a general idea of who she is and her living situation. − Guide development of the birth preparedness/complication readiness plan. − Guide further assessment and individualization of care, health messages, and counseling. − Identify the adolescent, who may have special needs and requires additional care. Daily habits and lifestyle z Helps guide individualization of health messages and counseling. z Helps address other concerns, such as: − Daily workload, rest, and dietary intake: Helps determine whether there is a balance between the physical demands of the woman’s daily life and her rest and dietary intake. − Use of potentially harmful substances: Helps to individualize health messages and counseling on use of alcohol, tobacco, and drugs/medications. − Household members: Helps guide development of the birth preparedness/complication readiness plan. z Can help identify women who are subjected to violence, a special need that requires additional care. Menstrual and contraceptive history z Helps calculate the gestational age of the pregnancy as well as the estimated date of childbirth (EDC). The EDC can help gauge whether the fetus is developing normally. z Guides individualization of health messages and counseling about family planning. z Asking about previous family planning methods and plans for using family planning methods in the future helps guide individualization of care, health messages, and counseling. Obstetric history z A woman who has had complications or problems during a previous pregnancy, labor/childbirth, or postpartum period may require additional care, even if it involves nothing more than emotional support and reassurance. Similar complications or problems may occur during the present pregnancy, labor/childbirth, or postpartum period depending on the underlying cause, and some previous complications or problems may require referral/transfer to a higher level of care. In particular, the skilled provider should ask about the following complications and problems to guide individualization of care, health messages, and counseling: − Convulsions − Cesarean section − Uterine rupture − Perineal tear − Stillbirths − Preterm or low birthweight baby − Babies who died before 1 month of age − Three or more spontaneous abortions − Pre-eclampsia/eclampsia − Postpartum depression/psychosis − Problems with breastfeeding * Unless otherwise indicated, each element should be assessed in each part of the childbearing cycle. Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-15 Table 1-1. Rationales for Elements of Maternal History (continued) ELEMENT* RATIONALE Present pregnancy (ANC and CBC only) z Guides further assessment, individualization of care, health messages, and counseling. − Reports of convulsions or vaginal bleeding during this pregnancy help the skilled provider develop and implement a care plan that will adequately address the woman’s needs and prevent related complications during the postpartum period. z Helps to assess for: − Fetal movements: Calculate/confirm gestational age and provide a baseline observation against which to evaluate later reports of a decrease in or lack of fetal movement, which is a special need that requires additional care. − Common discomforts: Determine the need for additional care, which may include assessing the woman further to confirm that there is not a more serious cause, reassuring her, and advising her on ways to relieve her anxiety and discomfort. − Emotional distress/unwanted pregnancy: Guide individualization of counseling and referral (e.g., mental health services). Present labor/childbirth (CBC only) z Rupture of membranes helps determine the need for additional care to prevent infection of woman and baby. The character (i.e., color, odor) of the amniotic fluid provides additional information about possible complications for the woman or fetus, including amnionitis and fetal distress. z Frequency and duration of contractions provide further information needed to determine the onset and assess the progress of labor. − Fetal movements: Provide an indication of fetal well-being. Reported decrease or absence of fetal movement in the last 24 hours may be the first indication of fetal distress. − Use of potentially harmful substances: Indicate a need to be especially vigilant for signs of toxicity, rapid or slowed labor, and/or fetal distress. − Food and fluids: If the woman has not eaten or taken fluids in the last 8 hours, the skilled provider needs to be vigilant for signs of dehydration, exhaustion, and ketosis, which can interfere with the normal progress of labor. Present pregnancy and labor/childbirth (PPC only) z Helps guide further assessment and individualization of care, health messages, and counseling: − When birth occurred: Clinical significance of many findings and the care the woman needs vary depending on how much time has elapsed since the birth. − Birth setting and attendance: If a birth occurred at home and/or was not attended by a skilled provider, the postpartum care skilled provider should be alert for signs and symptoms indicating problems that may not have been identified or adequately addressed during childbirth (e.g., sepsis). − Present pregnancy: Reports of convulsions or vaginal bleeding during this pregnancy help the skilled provider develop and implement a care plan that will adequately address the woman’s needs and prevent related complications during the postpartum period. − Present childbirth: Reports of cesarean section or other operative/Instrument- assisted birth, ruptured uterus, perineal tear or episiotomy, or convulsions during this childbirth will guide further assessment and care provision. This ensures the development and implementation of a care plan that will adequately address the woman’s needs and prevent related complications during the postpartum period. * Unless otherwise indicated, each element should be assessed in each part of the childbearing cycle. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-16 JHPIEGO/Maternal and Neonatal Health Program Table 1-1. Rationales for Elements of Maternal History (continued) ELEMENT* RATIONALE Present postpartum period (PPC only) z Helps guide further assessment and care provision for problems or complications that may be ongoing: − Vaginal bleeding: Heavy or prolonged bleeding may indicate potentially life- threatening complications. A history of vaginal bleeding will guide further assessment to detect anemia or other problems. − Lochia: Abnormalities in the color, quality, or amount of lochia guide further assessment to detect other signs and symptoms of sepsis or subinvolution. − Bowel/bladder function: Reported bowel or bladder dysfunction will guide further assessment to detect vesico-vaginal or recto-vaginal fistulas, urinary tract infection, urinary retention, or constipation. − Breastfeeding: Breastfeeding problems require prompt attention so that the woman will not become discouraged and stop breastfeeding. − Emotional response to the baby: Emotional distress, psychotic symptoms, postpartum sadness (“blues”), or depression may interfere with the woman’s ability to practice good self-care and care for her baby, and may indicate a need for referral to support resources or mental health services. − Adjustment of the family to the baby: If the partner or other family members are not adjusting to the baby, the woman/family may need to receive additional counseling or be linked to support groups or other organizations that can help facilitate a more harmonious family dynamic. Interim history (ANC and PPC only) z A history of any problems or issues that have developed since the last visit helps the skilled provider evaluate the effectiveness of the woman’s plan of care, targeted assessment, and focused care provision, and screen for problems that may require treatment/referral. Findings also will guide the skilled provider in adjusting the care plan, if necessary, to better meet the woman’s needs. * Unless otherwise indicated, each element should be assessed in each part of the childbearing cycle. Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-17 Table 1-2. Rationales for Elements of Newborn History ELEMENT RATIONALE Personal information z Used to do the following: − Identify the newborn and contact the woman. − Help establish rapport with the woman and show that the skilled provider thinks the baby is important. − Guide further assessment—the clinical significance of many findings varies depending on the age of the newborn. − Guide individualization of care, health messages, and counseling. − Guide development of the complication readiness plan. Baby’s birth z Helps guide further assessment of the newborn. − Birth setting and attendance: If the birth occurred at home and/or was not attended by a skilled provider, the skilled provider should be alert for signs of conditions/complications that may not have been adequately addressed. − Maternal complications: The woman’s report of rupture of membranes for more than 18 hours before birth, or a uterine infection or fever during labor or after birth, will guide further assessment and care provision. − Newborn complications: Report of complications that may have caused injury, such as shoulder dystocia, breech birth, large baby, or instrument assistance (e.g., vacuum extraction, forceps) indicates a need for further assessment for signs of birth injury. − Asphyxia at birth: Be alert for signs of respiratory distress/breathing difficulty. − Birthweight: Low or high birthweight will guide further assessment and care provision. Birthweight less than 2 kg is a life-threatening condition beyond the scope of basic care. Birthweight of 2.0–2.5 kg or greater than 4 kg is a special need. − Birth less than 24 months since the previous birth: Higher incidence of newborn mortality. Present newborn period z Helps skilled providers understand the current condition of the newborn and plan appropriate care, including counseling of the woman/caregiver. − Baby’s feeding habits: Guides further assessment if intakes seem inadequate. − Breastfeeding: Guides further assessment, health messages, and counseling. − Passage of stool and urine: Knowledge of the frequency of urination of the newborn helps determine if the newborn is receiving sufficient milk, and guides counseling and health messages. The frequency and consistency of the newborn’s stools will also help determine if feeding is adequate, or if s/he has a problem (e.g., diarrhea or blood in stool). − Congenital malformation: Indicates that the baby has a condition beyond the scope of basic care that does not require immediate attention. − Newborn immunizations: Guides further care provision. Maternal medical history z Gathering information about any maternal infections at the time of the birth will guide further assessment, individualization of care, health messages, and counseling. z Woman with diabetes: Indicates that a baby less than 3 days of age has a condition beyond the scope of basic care. z Woman with hepatitis B (HBV), HIV, syphilis, or tuberculosis (TB): Guides further assessment and care provision. z Woman’s feelings toward baby: If the woman feels sad or overwhelmed, or feels negatively toward the baby, further assessment of the woman may be necessary. Interim history z Information about problems that may have developed since the last visit, and information about treatment or care of the newborn, will guide the skilled provider in planning and implementing care, including referral/transfer (if necessary). This information will also guide the counseling of the woman/caregiver. Any problems that would cause a woman/caregiver to bring her newborn for treatment must be addressed as a priority in order to gain or maintain the woman’s trust, and to encourage the woman to continue to be vigilant in observations and care of her newborn. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-18 JHPIEGO/Maternal and Neonatal Health Program Physical Examination Physical examination helps the skilled provider detect and identify abnormal signs, special needs, and other potential problems that should be considered during further assessment and when planning and implementing care. A rationale for each element of the physical examination is described in Table 1-3 (below) and Table 1-4 (page 1-20). Table 1-3. Rationales for Elements of Maternal Physical Examination ELEMENT* RATIONALE Gait and movements z Limping or unsteadiness may indicate prolonged lack of food or drink, use of drugs/medications/herbal treatments, injury, or another potentially serious condition (e.g., postpartum depression/psychosis). z During labor: Abnormal gait and movements may also indicate that the woman is in the middle of a contraction. Behavior, vocalizations, and facial expression(s) z Unresponsiveness, anxiousness, or culturally inappropriate behavior may indicate emotional distress, prolonged lack of food or drink, use of drugs/medications, or a potentially serious condition (e.g., postpartum depression/psychosis). z During labor: Abnormal findings may also indicate that the woman is in the middle of a contraction. General hygiene z Visible dirt may indicate the need for messages and counseling on hygiene/infection prevention. z A foul odor may indicate the need for messages and counseling about hygiene/infection prevention; the skilled provider should be alert for signs of a more serious problem (e.g., infection). Skin z Bruises or lesions may indicate gender violence, injury from another source, or another serious condition. Conjunctiva z Pallor may be a sign of anemia; further testing may be needed. Breathing z Labored or audible breathing may indicate breathing difficulty. Blood pressure z Elevated blood pressure may indicate pre-eclampsia/eclampsia; further assessment may be needed. z Low blood pressure may be a sign of shock. Temperature z Fever (38°C or more) indicates infection. Pulse z Rapid rate (110 beats per minute or more) may indicate dehydration, anxiousness, overexertion, or another, more serious problem (e.g., anemia, shock, infection, heart disease). Breasts z Gross abnormalities (e.g., skin puckering or scaliness, dimpling, irregular contours) may indicate cancer. z During the postpartum period: − Localized areas of redness, heat, or pain; pus/blood coming from the nipples; or red, warm, painful breasts may indicate infection (abscess or mastitis). − Swollen, hard, tense breasts may indicate engorgement. − Cracked/sore nipples may indicate breast or breastfeeding problems. − Inverted nipples may indicate the need for breastfeeding support. * Unless otherwise indicated, each element should be assessed in each part of the childbearing cycle. Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-19 Table 1-3. Rationales for Elements of Maternal Physical Examination (continued) ELEMENT* RATIONALE Abdominal examination z Scar may indicate previous surgery or trauma. z Fundal height can help calculate gestational age (after 12 weeks) and determine fetal position (after 36 weeks). z Palpation of uterus for fetal parts (after 24 weeks) and movement (after 22 weeks) and listening to fetal heart tones (after 20 weeks) provide evidence of fetal life. z Helps identify size-date discrepancy and lack of fetal heart tones, as well as malpresentation of the fetus (after 36 weeks). z During labor and childbirth: − Monitoring fetal descent helps evaluate progress of labor. − Uterus that does not relax between contractions indicates a need for further assessment. z During the postpartum period: − The following may indicate infection: abdominal incision (sutures) that is draining pus/discharge or has edges that are red or pulled apart; or severely tender uterus. − Soft or boggy uterus, or uterus that has increased or not decreased since the last visit, may indicate subinvolution. − Palpable bladder may indicate urinary retention. Genital examination z Sores, ulcers, warts, and painful labia may indicate an STI. z Foul-smelling vaginal discharge may indicate infection. z Leakage of urine/feces from the vagina may indicate a fistula. z During pregnancy: bleeding may indicate hemorrhage. z During the postpartum period: − The following may indicate infection: perineal incision (sutures) that is draining pus/discharge or has edges that are red or pulled apart; or foul-smelling lochia. − Incision (sutures) from perineal tear or episiotomy indicates a need for additional care. − Heavy bleeding may indicate hemorrhage. − Abnormal color or amount of lochia may indicate hemorrhage and/or subinvolution. − Swelling, edema, or severely tender perineum indicate a need for additional care. Cervical examination (CBC only) z Presentation of the fetus can be confirmed. z Degree of cervical dilation helps determine the stage, phase, and progress of labor. z Rupture of membranes for more than 18 hours before birth increases the risk of infection. z Degree of molding of the fetal head may indicate obstructed labor. z Red/greenish/brownish and/or foul-smelling amniotic fluid may indicate the presence of meconium or signs of infection. z Palpation of cord indicates cord prolapse. Leg examination (PPC only) z Pain in the calf when the foot is forcibly dorsiflexed may indicate deep vein thrombosis. * Unless otherwise indicated, each element should be assessed in each part of the childbearing cycle. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-20 JHPIEGO/Maternal and Neonatal Health Program Table 1-4. Rationales for Elements of Newborn Physical Examination/Observation ELEMENT RATIONALE Weight z Birthweight less than 2.5 kg (less than 2.0 kg in some populations) or more than 4 kg indicates a special need and a potentially serious condition. Temperature z Fever (more than 37.5°C axillary) or hypothermia (less than 36.5°C axillary) may indicate infection, environmental danger, or another serious condition. Chest/Respirations z Abnormal respirations, grunting on expiration, gasping, indrawing, or irregular/asymmetrical movements of the chest wall may indicate respiratory distress, other breathing problems, or another serious condition. Color z Central cyanosis may indicate respiratory distress. z Jaundice/yellowness may indicate sepsis, blood incompatibility, or another serious condition. z Pallor may indicate anemia, internal bleeding, a blood abnormality, or another serious condition (e.g., a heart defect). Movements and posture z Convulsions or extreme jitteriness may indicate central nervous system damage or another serious condition (e.g., hypoglycemia). z Spasms and/or extreme hyperextension may indicate tetanus. Level of alertness and muscle tone z Floppiness or lethargy may indicate damage to central nervous system, sepsis, drug withdrawal, hypoglycemia, or another serious condition. z Irregular/asymmetric movements may indicate birth injury or another, more serious condition. Skin z Bruises may indicate birth injury or another, more serious condition (e.g., blood clotting disorder). z Lesions may indicate congenital syphilis or another serious condition. z Cuts and abrasions may indicate birth injury. Head z Disproportionate size, bulging anterior fontanelle, or abnormally wide sutures may indicate hydrocephalus, a congenital malformation, or another serious condition. Face and mouth z Irregular/asymmetrical features (e.g., cleft lip or palate), facial movements, or paralysis may indicate a congenital malformation or another serious condition. Eyes z Redness, swelling, or pus may indicate infection. Abdomen z Distention may indicate infection or bowel obstruction. z Abnormal protrusions not covered by skin (e.g., omphalocele/gastroschisis) may indicate a congenital malformation. Cord stump/ umbilicus z Bleeding may indicate a need to retie the cord or another, more serious condition. z Redness, swelling, or pus may indicate infection. z Protrusions at the base may indicate an umbilical hernia or another, more serious condition (e.g., omphalocele/gastroschisis). External genitalia and anus z Irregularity of genitalia or imperforate anus may indicate a congenital malformation. Back z Dent or opening over the spine may indicate a serious malformation (e.g., spina bifida). Limbs z Swelling over a bone or joint, or irregular/asymmetrical movements may indicate birth injury. z Birth defects (e.g., club foot) may indicate a serious condition. Breastfeeding z Problems with holding, positioning, or newborn attaching/suckling may indicate a lack of technique (and a need for breastfeeding support), breast problems (e.g., sore/cracked nipples), or another, more serious condition (e.g., the inability of the baby to suck). Mother-baby bonding z Problems with physical contact, “communication,” or empathy between the woman and newborn may indicate postpartum sadness (“blues”) or another, more serious condition (e.g., postpartum depression/psychosis). Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-21 Maternal Testing Testing reveals abnormalities that may not have been apparent during history taking or physical examination. A rationale for each element of testing is described in Table 1-5 (below). Table 1-5. Rationales for Elements of Maternal Testing ELEMENT* RATIONALE Hemoglobin levels (ANC only; CBC and PPC as indicated) Used to screen for anemia. This test should be repeated if the woman presents with signs or symptoms of anemia. Rapid Plasma Reagent (RPR) or VDRL (ANC and CBC only) Used to test for syphilis, a special need. HIV Used to detect the presence of HIV antibodies, which indicate HIV infection. HIV testing should be done as early as possible during the pregnancy, but any woman can benefit from learning her HIV status. Normally, combined with pretest and post-test counseling. A positive (reactive) HIV test allows the woman to receive additional care to keep her as healthy as possible, prevent transmission to her baby and partner, and help her make decisions about the future. The skilled provider can counsel HIV-negative women on ways to stay uninfected. Blood group, Rh (ANC and CBC only) Used to determine blood group or Rh so that blood donors can be identified as part of the complication readiness plan (in case transfusion is needed), as well as to identify Rh-negative women who could benefit from injection of anti-D immune globulin. Urine for glucose (ANC only in areas/ populations where there is a high prevalence of diabetes) Used to test for diabetes. Other tests for STIs in accordance with local guidelines Used to ensure adequate identification and treatment of STIs. * Unless otherwise indicated, each element should be assessed in each part of the childbearing cycle. Basic Care Provision General Elements If all findings of the assessment are normal, the woman or newborn is a suitable candidate for basic care provision. All of the components of basic care provision should be addressed during the first visit, if possible, and reinforced or addressed as needed during subsequent visits. During this part of the basic care visit, the skilled provider helps support and maintain a normal childbearing cycle and newborn period by doing the following: z Helping to prevent conditions that can adversely affect the woman, fetus, or newborn through preventive measures z Assisting the woman and her family in preparing for normal birth and possible complications z Empowering the woman with information that promotes her overall health and protects her life, as well as the health and life of her baby z Continuing to build a trusting and respectful relationship with the woman and her companion/partner/ family A rationale for each element of basic care provision is described in Table 1-6 (page 1-22) and Table 1-7 (page 1-24). Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-22 JHPIEGO/Maternal and Neonatal Health Program Table 1-6. Rationales for Elements of Maternal Basic Care Provision ELEMENT1 RATIONALE Birth preparedness and complication readiness planning z The birth preparedness plan helps ensure that all arrangements for a clean and safe birth, including the presence of a skilled provider, are made well in advance of the estimated date of childbirth. z Because all women are at risk of complications during the childbearing cycle, and most complications cannot be predicted, the woman and her family should be prepared to respond appropriately in an emergency situation. Such preparation can help prevent life-threatening delays in recognizing and responding to complications. In some cases, the time required to make arrangements—which could have been made before the emergency—may easily define the line between survival and death for woman and child. Breastfeeding and breast care z Breastfeeding has many health benefits for the newborn and promotes bonding between the woman and baby. The woman should learn about the importance of breastfeeding during the antenatal period so that she will expect—and demand—that her baby be put to the breast immediately after birth. Many breastfeeding problems can be prevented if the woman understands the basic principles of milk production, is skilled at effective breastfeeding techniques and practices, and practices simple self- care measures. Counseling and testing for HIV z Counseling and testing for HIV is offered to all women. − Women who test negative for HIV can learn how to remain uninfected. − A woman who tests positive for HIV can take appropriate measures to optimize her health, make informed decisions about the future, help protect her partner, and decrease the risk of transmission to her baby. Family planning z During the childbearing cycle, women and their families think more and become more aware of the demands of a growing family—making this a good time to discuss family planning. Birth spacing and choosing the most appropriate family planning method for the woman offer many health benefits for her, her baby, and her partner. Family planning is a key component of basic postpartum care because a woman’s fertility will likely return by the end of the postpartum period if she is not breastfeeding exclusively. Health messages and counseling z Use of potentially harmful substances: Use of alcohol, tobacco, and certain drugs/medications during pregnancy can cause fetal malformation, central nervous system problems, and intrauterine growth restriction; during breastfeeding, it can decrease milk production and cause problems in the newborn. z Hygiene/infection prevention: Good hygiene and infection prevention practices (e.g., handwashing) can help the woman protect herself and her baby from local and systemic infection. z Rest and activity: Women need additional rest throughout the childbearing cycle because of the high energy that pregnancy, postpartum healing/recovery, and breastmilk production require. There also needs to be a balance among the woman’s level of activity, daily workload, and dietary intake. z Sexual relations and safer sex: The woman needs to know how sexual relations may fit into the childbearing cycle. She also needs to know how to protect herself from STIs, which can have many damaging effects on the woman and child, especially when acquired during pregnancy. z Consider the following during postpartum care: − Newborn care: Information on newborn care may help build the confidence of the first-time mother and help ensure that the newborn gets the care that s/he needs to remain healthy. − Woman-newborn and family relationships: As the woman and her family adjust their pattern of living to meet the needs of a new and very dependent life, health messages and counseling can help alleviate stress, facilitate bonding, and anticipate and address problems that may develop. 1 Elements are listed in alphabetical order. Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-23 Table 1-6. Rationales for Elements of Maternal Basic Care Provision (continued) ELEMENT1 RATIONALE Immunization and other preventive measures z Tetanus toxoid immunization: TT is a safe and stable vaccine that, when given according to the recommended schedule, protects both woman and child against tetanus. z Iron/folate supplementation: Daily iron/folate supplements have been shown to reduce incidence of anemia, which can lead to maternal and fetal morbidity and mortality. z Malaria2 prevention: Intermittent preventive treatment (IPT) has been shown to reduce the incidence of malaria in pregnancy. Insecticide-treated (bed)nets (ITNs), when used as directed by the skilled provider, can help protect against malaria by killing and repelling mosquitoes that carry the infection. z Hookworm infection2 prevention: Presumptive treatment prevents hookworm infection, a major cause of iron-deficiency anemia. z Vitamin A2 supplementation: After the first 60 days after conception, vitamin A supplements can help reduce the incidence of maternal mortality and night blindness. z Iodine2 supplementation: Iodine deficiency is associated with an increase in newborn deaths, cognitive and motor performance impairment, and perinatal morbidity and mortality. Nutritional support z Health messages and counseling should be provided on the importance of sufficient caloric, protein, and nutrient intake (based on the woman’s individual needs). A pregnant woman requires an additional 200 calories per day (e.g., 12 groundnuts or 1 serving of maize porridge) or more if her nonpregnant weight was low. A lactating woman requires an additional 500 calories per day. z The consequences of malnutrition for the woman include increased infections and anemia, compromised immune function, weakness, lethargy, and lower productivity. For the fetus/baby, maternal malnutrition may result in problems such as an increased risk of perinatal mortality, intrauterine growth restriction, preterm birth, low birthweight, compromised immune function, birth defects, and delays in mental and physical development. 1 Elements are listed in alphabetical order. 2 In areas/populations where there is a high prevalence of the condition or deficiency Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-24 JHPIEGO/Maternal and Neonatal Health Program Table 1-7. Rationales for Elements of Newborn Basic Care Provision ELEMENT* RATIONALE Breastfeeding z Breastfeeding provides the newborn with the ideal nutrition, provides antibodies to protect the baby from infection, promotes bonding between the newborn and woman, and provides protection against allergies even later in life. Complication readiness z Because all babies are at risk of complications, and most complications cannot be predicted, the woman and her family should be prepared to respond appropriately in an emergency situation. The woman and her family must be familiar with danger signs that indicate a problem, as well as where to find help. Such preparation can help prevent life-threatening delays in recognizing and responding to complications. In some cases, the time required to make decisions and arrangements—which could have been made prior to the emergency—may easily define the line between survival and death. Cord care z Keeping the cord clean and dry helps protect the newborn from tetanus. Application of alcohol, tinctures, powders, ointments, and other substances to the cord stump may increase the risk of infection. Hygiene z Almost one quarter of newborn deaths are due to infection. Because handwashing is the most effective means of preventing infection, each person who handles the newborn must wash her/his hands before and after handling the newborn. Immunizations z Administering the following vaccines protects the newborn against certain diseases: − BCG: tuberculosis − Hepatitis-1 and Hepatitis-2: hepatitis B virus − Oral polio-0 and Oral polio-1: poliomyelitis − DPT-1: diphtheria, whooping cough (pertussis), and tetanus Maintaining warmth z Hypothermia requires the baby’s body to expend energy to keep warm, rather than to grow, and adds stress to the fragile organ systems. Hypothermia and hyperthermia (fever) can be signs of sepsis. Sleep and other needs/behaviors z Understanding the normal sleeping, eating, and crying behaviors of the newborn helps the woman avoid becoming needlessly anxious. Washing and bathing z If the baby is not dried quickly and thoroughly and dressed warmly after a bath, the evaporation of water causes a decrease in body temperature. The baby’s first bath should be delayed until s/he is at least 6 hours old—preferably 24 hours old—to protect her/him from hypothermia. * Elements are listed in alphabetical order. Elements Unique to Labor/Childbirth Although findings from the quick check and basic assessment may be normal, the condition of the woman or baby can change very suddenly during labor, childbirth, and the immediate postpartum/newborn period. Therefore, ongoing monitoring of the condition of the woman and baby at a frequency appropriate to the stage and phase of labor is essential to ensuring the continued well-being of the woman and baby, as well as early detection of any abnormalities. (Note: From the 1st stage/active phase of labor until childbirth, assessment of progress of labor is facilitated by use of a partograph. See Table 1-8 [page 1-25] for more details.) Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-25 Table 1-8. Rationales for Ongoing Assessment during the Four Stages of Labor ELEMENT RATIONALE Maternal blood pressure Pre-eclampsia/eclampsia and shock Maternal temperature Fever (38°C or more) and infection Maternal pulse Maternal distress and shock Fetal heart tones Abnormal fetal heart tones or lack of fetal heart tones (which may indicate fetal distress) Membranes and amniotic fluid Rupture of membranes for more than 18 hours before birth, meconium (which may indicate fetal distress), and infection Frequency and duration of contractions Unsatisfactory progress of labor Dilation of the cervix Unsatisfactory progress of labor Presentation of the fetus Malpresentation Fetal descent Unsatisfactory progress of labor Uterus Postpartum hemorrhage Vaginal secretions or bleeding Hemorrhage Bladder Urinary retention Maternal ability to cope/response to labor and childbirth Problems coping and extreme pain Newborn respiration Respiratory distress Newborn temperature Fever (more than 37.5°C axillary), which may indicate infection, or hypothermia (less than 36.5°C axillary) Newborn color Central cyanosis (which may indicate respiratory distress) Continuous emotional and physical support during labor is associated with shorter labor, the use of less medication (including epidural analgesia), and fewer operative deliveries. Even when progressing normally, labor and childbirth can be stressful and exhausting for the woman. Therefore, it is important that the skilled provider, birth companion, and healthcare facility staff remain encouraging and supportive throughout, considering the woman’s emotional well-being, comfort, and desires, as well as her physical requirements. As labor progresses, an increase in the level of physical and emotional support provided may be necessary, as the growing intensity of labor places greater demands on the woman. See Table 1-9 (page 1-26) for more details. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-26 JHPIEGO/Maternal and Neonatal Health Program Table 1-9. Rationales for Ongoing Supportive Care Measures during the Four Stages of Labor ELEMENT RATIONALE Attendance/communication z Continuous care by the same skilled provider throughout the childbirth event, rather than several different skilled providers, is associated with better outcomes for the woman and baby. The presence of a birth companion throughout labor has been associated with decreased need for pain medication, cesarean sections and other operative deliveries, amniotomy, and other medical interventions. Facilitating effective communication among all present—focused on listening and answering questions—helps create an environment in which the woman feels safe, secure, and of value. Rest and activity/positions z Facilitating a balance between activity and rest will help the woman be rested as she enters the 2nd stage of labor, when she needs the most energy and strength. Allowing the woman to choose the position that is most comfortable for her is an important part of culturally sensitive, woman-friendly care. Nonsupine positions have many advantages over supine or dorsal lithotomy positions. Comfort measures z Physical and emotional comfort measures (e.g., massage, cold cloth on the forehead, relaxation techniques) help the woman cope with labor and are associated with: − Reduced need for analgesia − Fewer operative vaginal deliveries − Less incidence of postpartum depression at 6 weeks Nutrition z Current literature supports allowing women to eat and drink as desired in normal labor. (In women deprived of food and fluid, the amount of ketones in the blood increases, while the amount of essential amino acids decreases.) Higher intake of fluids helps prevent dehydration and is associated with shorter duration of labor and reduced need for augmentation of labor with oxytocin infusion. Elimination z Encouraging the woman to empty her bladder at least every 2 hours and her bowels as needed helps prevent obstruction of labor and inefficient uterine activity. Enemas are no longer recommended as they are uncomfortable, can damage the bowel, and do not shorten labor or decrease newborn and perineal wound infection. Routine catheterization should be avoided as it may increase the incidence of infection. Hygiene/infection prevention z Infection prevention practices during labor and childbirth help protect the woman and newborn from sepsis and transmission of HIV, hepatitis B, and other infectious diseases. Mother-baby bonding (4th stage of labor) z Bonding between the woman and baby is a crucial early connection that fosters maternal nurturing, care, and protection of the baby; can reduce risk of infection in the baby; can help maintain the baby’s warmth; and promotes successful breastfeeding. Key Actions during the Four Stages of Labor During each stage/phase of labor, the skilled provider performs specific key actions appropriate to the stage/phase of labor while also performing the ongoing assessment and supportive care measures listed above. 1st Stage/Active Phase of Labor Prolonged labor is a leading cause of death among pregnant women and newborn babies in the developing world. It is most likely to occur if a woman’s pelvis is not large enough to accommodate her baby’s head or if a woman’s uterus does not contract sufficiently. If her labor does not progress normally, the woman may experience serious complications such as obstructed labor, dehydration, exhaustion, or rupture of the uterus. Prolonged labor may also contribute to maternal infection and hemorrhage, as well as to newborn infection. Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-27 The partograph (Textbox 1-4, below)—a simple chart for recording information about the progress of labor and the condition of the woman and her baby during labor—gives objective data on which to base clinical decisions during the 1st stage/active phase of labor and enhances communication among members of the team of skilled providers who are caring for the woman, so that decisions can be made in a timely manner. Skilled management of labor using a partograph is key to the appropriate prevention and management of prolonged labor and its complications. The World Health Organization (WHO) promotes use of the partograph to improve the management of labor and support decision-making regarding the need for interventions. When used appropriately, the partograph helps skilled providers identify prolonged labor and determine when to take appropriate actions. Textbox 1-4. The Partograph: An Aid in Clinical Decision-Making The partograph helps the skilled provider make decisions about a woman’s care by furnishing a visual representation of the conditions of both woman and fetus. The information given helps the skilled provider determine whether and when to intervene if labor is not progressing normally. Each time the skilled provider plots data on the graph, s/he should consider, “Is this what should be happening at this point?” z If the answer is yes, the skilled provider should then consider what s/he expects to happen in the next 2–4 hours if labor progresses normally. This sets the standard to which the progress of the woman’s labor as well as the status of the fetus should be compared. z If the answer is no, the skilled provider must consider what to do to address the condition of the woman or fetus. For example, if cervical dilation is plotted to the right of the “alert line,” s/he knows that progress is abnormal and the woman will require additional care and possibly management or urgent referral/transfer for complications. Used in this way, the partograph helps to ensure that women and fetuses are carefully monitored during labor, unnecessary interventions are avoided, and complications are recognized and responded to in a timely manner. 2nd and 3rd Stages of Labor The 2nd stage of labor begins with complete cervical dilation and ends with the birth of the baby. Steady descent of the fetus during the 2nd stage is the most accurate indicator of normal progress. During this period, support of the woman’s efforts and practical assistance are critical. The 3rd stage of labor begins with the birth of the baby and ends with the delivery of the placenta, a process the skilled provider actively manages to reduce the amount of blood the woman loses. A rationale for each key action for the woman and baby during the 2nd and 3rd stages of labor is described in Table 1-10 (page 1-28). Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-28 JHPIEGO/Maternal and Neonatal Health Program Table 1-10. Rationales for Key Actions for the Woman and Baby during the 2nd and 3rd Stages of Labor ELEMENT RATIONALE Assisting in pushing z The woman is encouraged to push when she feels the urge and to rest between contractions. She is not encouraged to push when she does not feel the urge because this does not decrease the length of the 2nd stage and may in fact contribute to maternal exhaustion and discouragement. The skilled provider advises the woman on the amount of effort to put forth and helps the woman control pushing while the baby’s head is coming to help prevent tearing. Facilitating the position of choice z It is important to allow the woman to choose a position that is comfortable for her. However, nonsupine (upright or lateral) positions have many advantages over supine or dorsal lithotomy positions and should be encouraged. These positions are associated with the following: − Shorter 2nd stage of labor − Fewer instrument-assisted births − Fewer episiotomies − Fewer reports of severe pain − Fewer abnormal fetal heart rate patterns Assisting in vaginal birth z Hand movements used in assisting in vaginal birth facilitate smooth passage of the baby through the birth canal, help protect the woman from tears, and protect the baby from trauma and oxygen deprivation. Controlled birth of the head can help prevent tearing and the need for episiotomy. Episiotomies are not performed routinely because they have been associated with higher incidence of tears in the anus and rectum, increased postpartum perineal pain, and increased risk of rectal incontinence. Initiating immediate newborn care z Thoroughly drying and covering the baby with a dry cloth and placing the baby on the woman’s abdomen help prevent heat loss. Heat loss results in additional oxygen requirements in the newborn and stress on vital organs. z Immediate assessment of breathing helps ensure that the baby’s oxygen requirements are met. z Clamping and cutting the cord helps prevent blood loss, and standard infection prevention measures help prevent cord infection, which can be fatal. z Wiping the newborn’s eyes with a clean swab or cloth removes transient organisms that may harm the baby’s eyes. Active management of the 3rd stage of labor z Because of the risk of postpartum hemorrhage, delivery of the placenta and membranes is potentially the most hazardous part of childbirth. Several definitive studies have found that women who received active management had a shorter 3rd stage of labor and reduced need for blood transfusion and uterotonic drugs. − Giving uterotonic drugs within 1 minute of the birth of the baby helps the uterus contract and the placenta separate. − Controlled cord traction with supra-pubic countertraction during a contraction helps the placenta descend. − Uterine massage helps the uterus stay contracted. − Inspection of the placenta and membranes for completeness helps assess for possible hemorrhage. − Examination of the vagina and perineum for tears helps prevent further bleeding. 4th Stage of Labor During the 4th stage of labor (the first 2 hours after delivery of the placenta), the skilled provider facilitates mother-baby bonding, promotes breastfeeding, and performs other tasks to assist the woman in recovering from labor, and the newborn in adjusting to life outside the uterus. A rationale for each key action for the woman and baby during the 4th stage of labor is described in Table 1-11 (page 1-29). Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-29 Table 1-11. Rationales for Key Actions for the Woman and Baby during the 4th Stage of Labor RATIONALE ELEMENT WOMAN NEWBORN Close monitoring of vital signs, vaginal bleeding, and uterine fundus z This detects hemorrhage to allow intervention in a timely fashion. Helping to initiate early and exclusive breastfeeding z Early breastfeeding helps stimulate the woman’s uterus to contract, decreasing blood loss. z Early breastfeeding helps establish a successful pattern for breastfeeding, prevent newborn hypothermia and hypoglycemia, provide energy that the baby needs for adjusting to life outside the uterus, and promote mother-baby bonding. Reviewing the complication readiness plan z This helps ensure that the woman and her family are prepared for a possible emergency. Providing health messages and counseling z These should be limited to the essentials (below) and the woman’s questions and concerns as the woman may be focused on her baby or too exhausted or excited to absorb the new information. − Hygiene: Good hygiene practices, especially perineal hygiene and newborn care, prevent local and systemic infection. − Newborn warmth: Prevents newborn hypothermia. − Uterine massage: Helps maintain firmness and prevent postpartum hemorrhage. Attaching an identification label (newborn) z This measure ensures correct identification of the baby by facility staff and family. Providing eye treatment (newborn) z Placing an antimicrobial in the eyes of the newborn can kill organisms introduced during labor that can cause serious infection. Conducting a complete initial physical examination (newborn) z See Table 1-4 (page 1-20). ADDITIONAL CARE PROVISION Basic care also includes additional care, as needed, for women with normal pregnancies who also have common discomforts and special needs, as well as initial care for women and newborn babies with life-threatening complications. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-30 JHPIEGO/Maternal and Neonatal Health Program Common Discomforts/Concerns Common discomforts/concerns are normal changes, signs, and physical and emotional behaviors that may occur during the childbearing cycle and newborn period. Examples of common maternal discomforts include back pain, stretch marks, and nausea or vomiting. Some examples of common concerns during the newborn period are diaper/napkin rash, misshapen head (molding), and swollen or red eyelids. Although common discomforts/concerns do not usually pose a threat to the health of the woman or newborn, the woman or newborn may require care in addition to the core components of basic care. Once the skilled provider has ruled out more serious possible causes of the woman’s or newborn’s symptoms, the woman should be provided with reassurance and practical guidance, if available, on how to address the discomforts/concerns. She should also be advised on key alert signs that may indicate a more serious problem. Chapter 9 (page 3-1) provides guidance on additional care for women and babies with common discomforts/concerns. Special Needs Some women and babies have a condition that requires a specific course of management or have abnormal signs and symptoms that require further assessment. Others have social or personal factors that should be taken into consideration when planning and implementing care. Still others require additional preventive measures because they live in an area endemic for certain diseases or deficiencies. Women and newborn babies with special needs require care in addition to the core components of basic care. Chapter 10 (page 3-35) provides guidance on additional care for women and newborn babies with special needs. Table 1-12 (page 1-31) describes the special needs covered in this manual and the possible effects on women and babies. 1- 31 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am Ta bl e 1- 12 . R at io na le s fo r A dd iti o n al C ar e fo r M at er na l a nd F et al /N ew bo rn S pe ci al N ee ds FA CT O R/ CA US E D ES CR IP TI O N/ B A CK G RO UN D IN FO RM AT IO N PO SS IB LE E FF EC TS O N W O M AN PO SS IB LE E FF EC TS O N FE TU S/ NE W BO RN Ad ol e sc e n ce (1 9 y ea rs o f a ge a nd u nd e r) In m an y cu ltu re s, th e ad ol e sc e n t w om an is c on si de re d a n “ a du lt, ” is s om et im es m a rr ie d, a nd m a y be e ag er to b ec om e p re gn a n t— e ve n a t a v er y e a rly a ge — to p ro ve h er fe rti lit y an d ga in th e re sp ec t o f h er fa m ily , i n- la w s, o r t he c om m u n ity . I n ot he r c ul tu re s, h ow ev er , pr eg n a n cy d u rin g ad o le sc e n ce is c le ar ly di sc o u ra ge d. In e ith er ca se , th e pr eg n a n t a do le sc en t m a y be liv in g wi th m an y ba rr ie rs to ca re , a s w e ll a s ci rc um st an ce s th at m ay p os e a th re at to h er h ea lth a n d su rv iv al a n d th e ou tc om e o f t he p re gn a n cy . z Th e ad ol es ce n t w o m a n m a y be e xp er ie n ci ng p o w e rle ss n e ss in th e fo llo w in g wa ys : − La ck o f a cc es s to b as ic he al th ca re a n d a n te na ta l ca re s e rv ic es − La ck o f a s up po rt sy st em − La ck o f r es ou rc e s (e. g., fu nd in g, tr an sp o rta tio n) − Li m ite d a bi lity to p ro vid e ba sic s el f-c a re o r n e w bo rn ca re z Em ot io na l t ra um a (e. g., fe eli ng s o f f ea r, sh am e, a nd g ui lt) z Th re at o f g en de r vi ol en ce z Ex po su re to S TI s Vi ol en ce a ga in st w o m e n Al th ou gh fr ee do m fr om v io le nc e is a b as ic hu m a n r ig ht , t he re is a ge ne ra l t ol er a n ce o f a bu se in m a n y so cie tie s. Fr om 1 0 to 5 0% o f w o m e n a ro u n d th e w or ld a re e st im at ed to h a ve s u ffe re d ph ys ica l vi ol en ce a t s om e ti m e du rin g th ei r l iv es . M an y pr eg na n t w om en fa ce s u ch v io le n ce , w hi ch th re a te ns th ei r he al th a n d su rv iv al a s w el l a s th e ou tc om e of th e pr eg na n cy . Pr eg na n cy m ay b e a pr ec ip ita tin g fa ct or o f v io le nc e , w hi ch be co m e s “p un is hm en t” fo r b ec o m in g pr eg n a n t. Vi ol en ce in th e fo rm o f r ap e m ay re su lt in p re gn an cy . z W o m e n w ho s u ffe r f ro m g en de r vi ol en ce a t t he h an ds o f a p ar tn e r, fa m ily m em be r, o r a n o th er p e rs o n m a y be liv in g w ith th e fo llo w in g: − Th e on go in g th re a t o f i nju ry a n d de a th − Po w er le ss n e ss a n d e m o tio n a l t ra um a (e .g. , fe el in gs o f f ea r, sh am e, a nd gu ilt) − Ex po su re to S TI s − La ck o f a cc es s to b as ic he al th ca re a n d a n te na ta l ca re s e rv ic es − La ck o f a s up po rt sy st em − Im pa ire d a bi lity to p ro vid e ba sic s el f-c a re o r n e w bo rn ca re z Vi ol en ce m ay c o n tri bu te to pr eg n a n cy lo ss o r o th er p ro bl em s th at c an c om pl ic a te la bo r a n d ch ild bi rth . 1- 32 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am Ta bl e 1- 12 . R at io na le s fo r A dd iti o n al C ar e fo r M at er na l a nd F et al /N ew bo rn S pe ci al N ee ds (c on tin ue d) FA CT O R/ CA US E D ES CR IP TI O N/ B A CK G RO UN D IN FO RM AT IO N PO SS IB LE E FF EC TS O N W O M AN PO SS IB LE E FF EC TS O N FE TU S/ NE W BO RN Po or o bs te tri c hi st or y A hi st or y of c om pl ic at io ns d ur in g th e ch ild be ar in g cy cle m ay in di ca te a n un de rly in g m e di ca l o r o bs te tri c co n di tio n th at m ay a lso ca u se a p ro bl e m du rin g th e c u rr e n t p re gn an cy . Th e fo llo w in g ar e p re vio u s co m pl ica tio n s th at m a y re qu ire a dd itio n a l c ar e: z An te na ta l c o n vu ls io n s z Ce sa re a n s e ct io n o r o th er u te rin e su rg e ry z 3rd o r 4th de gr ee pe rin e a l t ea rs z Th re e or m or e sp on ta n e o u s a bo rti on s z Fe ta l o r n ew bo rn c o m pl ica tio n s z Po st pa rtu m h em o rr ha ge z An xi et y; n ee d fo r r ea ss ur a n ce z Si m ila r p ro bl e m s du rin g th is ch ild be ar in g cy cle d ep en di ng o n u n de rly in g ca us e (e .g. , co m pl ica tio ns d ue to e le va te d bl oo d pr es su re ) z Po ss ib ly a n e e d fo r c ar e wi th sp ec ia lis t o r a t h ig he r le ve l f ac ilit y du rin g th is ch ild be ar in g cy cle (e. g., pr ev iou s c e sa re a n s e ct io n ) z Si m ila r p ro bl em s m ay o cc ur du rin g th is ch ild be ar in g cy cle de pe n di ng o n un de rly in g ca u se (e. g., pr ev iou s f et al c om pl ica tio n s du e to p re -e cl am ps ia /e cla m ps ia ) Fe m al e ge ni ta l c ut tin g (F GC ) FG C is a co m m on p ra ct ice in so m e c u ltu re s. z So m e ty pe s of F G C m ay d o th e fo llo wi n g: − O bs tru ct th e va gi na l o pe n in g − Ca us e la rg e k el oi ds o r de rm oi d cy st s − Ca us e in fe ct ed m u co sa l u lc er s or c ys ts An em ia An em ia re su lts w he n th e he m o gl ob in le ve l f al ls be lo w 11 g /d L. T he m a in c au se is ir on /fo la te d ef ici en cy . W he n a w om a n is p re gn a n t o r br ea st fe ed in g, he r b od y re qu ire s m o re ir on th a n u su a l. Fo r w om e n in d ev e lo pi n g co u n tri es , i t m a y be e sp e ci al ly di ffi cu lt to m ee t t hi s in cr ea se d ne e d fo r i ro n be ca u se th ei r d ie ts a re o fte n la ck in g in iro n- ric h fo od s. In a dd itio n, a n e m ia is o fte n ag gr a va te d by p ar a si te s (e. g., ho ok wo rm ) a nd , in en de m ic a re a s, m a la ria . z H ig he r ris k of d is e a se a n d in fe ct io n z Sh oc k z Ca rd ia c fa ilu re z Lo w b irt hw ei gh t z In fe ct io ns z In cr ea se d ris k of d ea th 1- 33 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am Ta bl e 1- 12 . R at io na le s fo r A dd iti o n al C ar e fo r M at er na l a nd F et al /N ew bo rn S pe ci al N ee ds (c on tin ue d) FA CT O R/ CA US E D ES CR IP TI O N/ B A CK G RO UN D IN FO RM AT IO N PO SS IB LE E FF EC TS O N W O M AN PO SS IB LE E FF EC TS O N FE TU S/ NE W BO RN H IV Th e hu m an im m u n o de fic ie n cy v iru s (H IV ) c au se s A ID S. Th e v iru s w e a ke n s th e im m u n e s ys te m , m a ki ng th e in fe ct ed p er so n su sc e pt ib le to o pp o rtu ni st ic in fe ct io ns . H IV c an b e ac ce le ra te d by pr eg n a n cy , a nd H IV c an c on tri bu te to m at er n a l c om pl ic at io n s. In a dd itio n , H IV c an b e tra ns m itt ed fr o m th e w om a n to h er b ab y du rin g pr eg na n cy a nd c hi ld bi rth , a nd w hi le b re a st fe ed in g. M o re th an 9 0% o f p ed ia tri c HI V/ AI DS c a se s a re c a u se d by m ot he r- to - ch ild tr an sm is si o n o f H IV . z R is k of o pp o rtu n is tic in fe ct io n s su ch a s tu be rc u lo si s or o ra l o r va gi na l c an di di a si s z H ig h ris k of o th e r co e xi st en t co n di tio n s a n d po st pa rtu m in fe ct io n s z In cr ea se d ris k of d ep re ss io n , a n xi et y, a nd o th er e m ot io n a l di ffi cu ltie s z In cr ea se d ris k of a ba nd on m e n t a n d ab us e z La ck o f s oc ia l s u pp o rt be ca us e o f st ig m a an d di sc rim in at io n su rr o u n di n g HI V in fe ct io n z In cr ea se d ris k of p er in a ta l m o rta lit y z H IV in fe ct io n (w hi le in th e w o m b, du rin g bi rth , a nd w hi le br ea st fe ed in g) − In fe ct io n in cr e a se s ris k of pe rin a ta l m or ta lit y, p re te rm bi rth , o pp o rtu ni st ic in fe ct io ns , lo w b irt hw e ig ht , in tra ut er in e gr ow th re st ric tio n , a n d vi ta m in d ef ici en cie s H BV H ep at itis B v iru s (H BV ) is a vir u s th at c an b e tra ns m itt ed s ex u a lly , th ro ug h ne e dl e s, o r by s ha rin g to ot hb ru sh es a n d ra zo rs w ith a n in fe ct ed p e rs o n . H BV m ay b e th e ca us e of 8 0% o f l ive r c an ce r in th e w or ld . A w om an w ith h ep a tit is B c an tr an sm it th e vi ru s to th e fe tu s. z Ch ro ni c he pa tit is z Ci rrh os is z Li ve r c an ce r z In fe ct io n wi th H BV , p os sib ly le ad in g to c hr on ic h ep at itis , ci rrh os is , o r l iv e r ca n ce r Sy ph ilis Sy ph ilis is a n ST I c au se d by th e sp iro ch et e Tr ep on e m a p al lid um . If le ft u n tre at ed d u rin g pr eg n a n cy , i t c a n b e tra ns m itt ed to th e fe tu s th ro ug h th e pl a ce n ta . z So ft tis su e tu m or s z Le si on s in th e bl oo d ve ss el s, he ar t, sp in a l c or d, a nd b ra in z In cr ea se d ris k of s po nt an e o u s a bo rti o n z Co ng e n ita l s yp hi lis z Sp on ta n e o u s a bo rti on z St illb irt h z In cr ea se d ris k of m or ta lity Tu be rc ul o si s (T B) TB is a b ac te ria l i nf ec tio n th at ca n b e tra ns m itt ed to th e fe tu s. It is a ss o ci at e d wi th H IV in m an y pa rts o f t he w or ld . z In fe ct io n in th e lu ng s, c en tra l n e rv o u s sy st em , o r o rg an s z G en er al iz ed sy st em ic in fe ct io n z In fe ct io n in th e n e w bo rn , re su lti ng in fa ilu re to th riv e o r de at h M al ar ia M al ar ia is a p ar a si tic in fe ct io n tra ns m itt ed b y m o sq ui to e s. A s m a n y a s 30 0 to 5 00 m illi on c as es o f m al ar ia , a nd 1 m illi on d ea th s fro m m a la ria , o cc ur e a ch y ea r. Fo rty p er ce nt o f t he w o rld ’s po pu la tio n is a t r is k fo r m al ar ia . P re ve nt io n , e a rly d et ec tio n, a n d tre at m en t o f m a la ria in th e a n te na ta l a nd p os tp ar tu m p er io ds c an h el p to re du ce b ot h th e nu m be r o f d ea th s an d th e de a th ra te s of w o m e n a n d ch ild re n. M al ar ia d ur in g pr eg na nc y af fe ct s th e he al th o f b ot h n e w bo rn a nd w o m a n . In a re a s o f s ta bl e tra n sm is si on , m al a ria in fe ct io n in w om en is o fte n a sy m pt om at ic; th e ha rm fu l co n se qu en ce s to th e w om an a n d n e w bo rn m a y oc cu r b ef or e th e di se as e is re co gn ize d. z Sp on ta n e o u s a bo rti on z Se ve re a n e m ia z R en al fa ilu re z Pu lm on a ry e de m a z H ig h fe ve r z St illb irt h z Lo w b irt hw ei gh t z Co ng e n ita l m al a ria 1- 34 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am Ta bl e 1- 12 . R at io na le s fo r A dd iti o n al C ar e fo r M at er na l a nd F et al /N ew bo rn S pe ci al N ee ds (c on tin ue d) FA CT O R/ CA US E D ES CR IP TI O N/ B A CK G RO UN D IN FO RM AT IO N PO SS IB LE E FF EC TS O N W O M AN PO SS IB LE E FF EC TS O N FE TU S/ NE W BO RN H oo kw o rm in fe ct io n H oo kw o rm is a pa ra sit ic in fe ct io n tra ns m itt ed th ro ug h th e s ki n fro m so il th at c on ta in s ho ok w o rm la rv a e . Ho ok w or m is an in te st in al pa ra sit e th at in fe ct s ab ou t 1 b illi on pe op le , o r on e fif th o f t he w or ld ’s po pu la tio n . Al th ou gh ho ok w or m is ra re ly fo un d in dr y cli m at es , ho ok wo rm c an in fe st u p to 80 % of th e po pu la tio n in s om e tro pi ca l an d su bt ro pi ca l a re as . z An em ia z Pr ot ei n de fic ie n cy Vi ta m in A d ef ici en cy D ur in g pr eg na n cy , v ita m in A is n e e de d in in cr e a se d a m o u n ts to su pp o rt m at er na l r ep ro du ct ive pr oc es se s, in clu di n g fe ta l g ro w th a n d de ve lo pm e n t. Vi ta m in A d ef ici en cy is a m a jor pu bl ic he a lth pr ob le m in A fri ca , So ut he a st A si a, a n d th e W e st er n Pa ci fic , a n d is th e m os t c om m on c au se o f p re ve n ta bl e c hi ld ho o d bl in dn e ss . Vi ta m in A is n ee de d in in cr e a se d am ou n ts d ur in g pr eg n a n cy a n d w hi le b re as tfe ed in g to s up po rt m at er na l r ep ro du ct ive p ro ce ss e s a n d pr e ve n t d e fic ie nc y. V ita m in A d ef ici en cy in th e w om an r e su lts in re du ce d tra ns fe r o f v ita m in A to th e fe tu s. A lth ou gh a b ro a d, lif e- cy cle a pp ro ac h to v ita m in A d ef ici en cy b y fo rti fy in g fo od a n d im pr ov in g di e t m ay b e m os t a pp ro pr ia te , i nd ivi du al su pp le m e n ta tio n (ca ps ule s a n d di et ar y) ma y b e ne e de d. B ec a u se hi gh d os es o f v ita m in A s ho u ld be a vo id ed in pr eg na n t w om e n , th e sa fe st ti m e to b ui ld u p vi ta m in A re se rv e s in w om en o f r e pr o du ct ive a ge is d u rin g th e fir st 6 w ee ks a fte r c hi ld bi rth (i. e., be for e f ert ilit y re tu rn s). z N ig ht b lin dn es s z Po ss ib le in cr e a se d ris k of m o rta lit y z R ed uc e d tra ns fe r o f v ita m in A to th e fe tu s z Po ss ib le in cr e a se d ris k of m ot he r- to -c hi ld tr an sm iss io n of H IV (if th e w o m a n is in fe ct e d) Io di ne de fic ie n cy Th is d ef ici en cy re su lts fr om a la ck o f i od in e in th e di et . I od in e de fic ie n cy is a m a jor ris k f ac tor fo r b ot h ph ys ica l a nd m en ta l de ve lo pm e n ta l d iso rd e rs o f a n e st im at ed 1 .6 b illi on p e o pl e liv in g in io di n e -d ef ici e n t e n vi ro n m e n ts . I de al ly, n at io n w id e io di za tio n w o u ld re du ce d ef ici e n cy . F or tif yin g sa lt a n d im pr ov in g di e t m ay b e m o st a pp ro pr ia te . I n th e m ea nt im e , in di vid ua l s up pl em en ta tio n m a y be n e e de d. z G oi te r z D ur in g pr eg na n cy : m en ta l re ta rd at io n o r br a in d am a ge o f t he ba by , a s we ll as st illb irt h, sp on ta n e o u s a bo rti on s, a n d in cr ea se d ne o n a ta l m or ta lit y z M en ta l r et ar da tio n z Br ai n da m a ge z St illb irt h z Sp on ta n e o u s a bo rti on z In cr ea se d ris k of n ew bo rn m o rta lit y D ia be te s D ia be te s oc cu rs w he n th e pa n cr e a s do e s n o t p ro du ce e n o u gh in su lin , a h or m o n e th at h el ps th e bo dy s to re a n d us e th e su ga r a nd fa t f ro m fo od . D ia be te s in th e w o m a n c a n b e ch ro ni c or re su lt fro m pr eg n a n cy . z Ca n re su lt in in cr e a se d ris k of m a te rn al m or bi di ty a nd m or ta lit y w he n un co n tro lle d z La rg er s iz e of b ab ie s bo rn to di ab e tic w om e n m a y co nt rib u te to ce ph a lo pe lvi c di sp ro po rti o n a n d o bs tru ct ed la bo r z H ig h ris k of d e ve lo pi ng lo w bl o o d su ga r d u rin g fir st 3 d ay s of lif e. Lo w b lo o d su ga r ca n r e su lt in da m ag e to m ajo r o rga n s ys tem s, co n vu ls io n s, u n co n sc io u sn e ss , a n d ev e n d e a th z In cr ea se d ris k (th ree tim es hi gh er ) o f h av in g a co ng en ita l m a lfo rm at io n z In cr ea se d ris k of ja un di ce 1- 35 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am Ta bl e 1- 12 . R at io na le s fo r A dd iti o n al C ar e fo r M at er na l a nd F et al /N ew bo rn S pe ci al N ee ds (c on tin ue d) FA CT O R/ CA US E D ES CR IP TI O N/ B A CK G RO UN D IN FO RM AT IO N PO SS IB LE E FF EC TS O N W O M AN PO SS IB LE E FF EC TS O N FE TU S/ NE W BO RN Si ze -d at e d isc re pa n cy Fu nd al h ei gh t/u te rin e si ze is la rg er o r s m al le r th an e xp ec te d fo r ge st at io na l a ge . I t m a y in di ca te in co rre ct d at es , l ar ge fe tu s, in tra ut er in e g ro w th re st ric tio n, e ct op ic pr e gn a n cy , s po nt an e o u s a bo rti o n , o r m o la r p re gn a n cy . Bu rn in g on u rin a tio n Th e w om an fe el s a bu rn in g se n sa tio n w he n s he u rin a te s. z Pr ot ei nu ria z Ur in ar y tra ct in fe ct io n z Ki dn e y in fe ct io n Ur in ar y re te n tio n Th e pr es su re o f t he fe tu s’ s he a d on th e u re th ra a n d bl ad de r d ur in g pr ol on ge d la bo r ca n le ad to b ru isi ng , e de m a , a n d ev e n s pa sm o f th e in te rn a l s ph in ct er o f t he b la dd e r, w hi ch in tu rn m ay le ad to u rin ar y re te n tio n in th e po st pa rtu m p er io d. R up tu re o f m em br an es fo r m or e th an 1 8 ho ur s be fo re b irt h; u te rin e in fe ct io n o r fe ve r d ur in g la bo r o r b irt h In ta ct m em br an e s pr ot ec t t he fe tu s an d wo m a n fr om in fe ct io n . If m e m br an es r u pt ur e ea rly , d ise a se -c a u si n g or ga ni sm s m ay a sc e n d in to th e flu id a nd w al l o f t he u te ru s, c a u si n g fa ta l in fe ct io n o f t he n e w bo rn a n d/ or w o m a n . z Se ps is z Se ps is Br ea st a nd br ea st fe ed in g pr ob le m s Ex am pl es in cl u de p oo r a tta ch m e n t o f t he n ew bo rn to th e br e a st , m a te rn al c o n ce rn a bo u t i ns uf fic ie nt s up pl y of m ilk , f la t o r i nv er te d n ip pl es , a nd m as tit is. z D is co m fo rts , s uc h as b re as t e n go rg em e n t a n d cr ac ke d/ so re n ip pl es z D is co ur a ge m e n t, w hi ch c an le a d to m or e di ffi cu ltie s or di sc on tin u at io n o f b re as tfe ed in g a lto ge th er z Lo ss o f b en e fit s o f b re as tfe ed in g Po st pa rtu m s ad ne ss (“b lue s”) O fte n ex pe rie n ce d du rin g th e th ird to fi fth d ay a fte r b irt h, po st pa rtu m s ad ne ss (“ blu e s” ) m a y be c au se d by h or m on a l ch an ge s, s ud de n c e ss a tio n o f p hy sic al e xe rti o n o f l ab o r, p ea k e xp er ie n ce o f g ivi ng bi rth , e m o tio na l l et do w n a fte r a nx ie ty o f pr eg n a n cy a n d fe ar o f l ab or , p hy sic al d is co m fo rts o f t he po st pa rtu m p er io d, a nd la ck o f s le ep . z Cr yin g z Fe el in gs o f s ad n e ss z Fe el in g ov er w he lm ed z Irr ita bi lity 1s t , 2n d , o r 3rd de gr ee pe rin e a l t ea rs ; e pi sio to m y; d ef ib ul a tio n W o m e n w ho h a ve p er in ea l t ea rs o r w ho h a ve u n de rg on e e pi sio to m y or d ef ib ul a tio n m a y e xp er ie n ce d is co m fo rt an d ot he r si de e ffe ct s. z Pe rin ea l p a in z Bl ee di ng z In fe ct io n Ut er in e su bi n vo lu tio n Ut er us h as in cr e a se d, o r is n ot d ec re as in g, in si ze s in ce th e la st vi si t; in cr ea se in lo ch ia . z Fe ve r z Ab do m in a l p ai n z Bl ee di ng 1- 36 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am Ta bl e 1- 12 . R at io na le s fo r A dd iti o n al C ar e fo r M at er na l a nd F et al /N ew bo rn S pe ci al N ee ds (c on tin ue d) FA CT O R/ CA US E D ES CR IP TI O N/ B A CK G RO UN D IN FO RM AT IO N PO SS IB LE E FF EC TS O N W O M AN PO SS IB LE E FF EC TS O N FE TU S/ NE W BO RN Pr ev io us n ew bo rn co m pl ica tio ns o r d ea th s H is to ry o f n ew bo rn c om pl ic a tio n s o r de a th m ay in di ca te a n u n de rly in g m at e rn a l c o n di tio n th at m a y ca us e a p ro bl e m d ur in g th e ba by ’s fir st d ay s o f l ife . z St illb irt h z N ew bo rn d e a th N ew bo rn d e a th o r st illb or n Th e de at h o f a n ew bo rn is v er y di st ur bi n g fo r a ll co nc e rn e d an d e vo ke s a ra n ge o f e m ot io ns th at c an h av e s ig ni fic an t co n se qu en ce s. z Pa in a n d gr ie f z D ep re ss io n z D is or ie n ta tio n z Is ol at io n z An ge r z D en ia l Lo w b irt hw ei gh t b ab y Bi rth w ei gh t l es s th an 2 .5 k g (or le ss th an 2. 0 kg in s om e po pu la tio n s). z Br ea th in g pr ob le m s z Lo w b o dy te m pe ra tu re z Fe ed in g pr ob le m s La rg e ba by Bi rth w ei gh t o f 4 k g or m or e. z Tr au m a du rin g ch ild bi rth z Tr au m a or in jur y du rin g bi rth z Br ea th in g di ffi cu lti es d u e to m e co n iu m a sp ira tio n z Lo w b lo o d su ga r Ba by w ith c ut s a n d a br as io n s th at a re n o t bl ee di n g So m e eq u ip m e n t u se d an d pr o ce du re s pe rfo rm e d du rin g bi rth c an re su lt in c ut s an d ab ra si on s to th e ba by . z In cr ea se d ris k of in fe ct io n z M ay in di ca te a n in jur y t ha t a ffe ct ed th e ba by in o th er w ay s (e. g., br ok en bo n e s, d isl o ca tio n s, tra um a to o rg an s) Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-37 Life-Threatening Complications Introduction Some women and newborn babies may present with danger signs that indicate a life-threatening condition or one whose diagnosis or management lies beyond the scope of this manual. Identifying those who have such conditions is just as important as identifying women and newborn babies who are progressing normally through the childbearing cycle and newborn period. Initial care for these women and newborn babies, which is covered in Chapter 11 (page 3-89), includes the following: z Rapid initial assessment z Stabilization and other initial management measures, as needed z Urgent referral/transfer to a specialist or facility that has comprehensive essential obstetric care services Rapid Initial Assessment and Stabilization Procedures When danger signs are identified, the skilled provider immediately performs a rapid initial assessment to determine the degree of illness, need for emergency care/stabilization, and immediate course of action that must be taken. The skilled provider will assess the woman or newborn for signs of the following: z Respiratory distress z Shock z Convulsions or loss of consciousness (and, for newborn babies, spasms) If the woman or newborn is in need of stabilization, the skilled provider performs the designated life-saving measures to stabilize the woman or newborn before proceeding with care or urgent referral/transfer. If the woman or newborn is not in need of stabilization, the skilled provider should conduct a further assessment per presenting danger sign to determine whether the woman or newborn requires urgent referral/transfer or specialized care, or whether the woman or newborn can continue with basic care. Table 1-13 (page 1-38) and Table 1-14 (page 1-40) describe the life-threatening conditions that may be indicated by various danger signs. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-38 JHPIEGO/Maternal and Neonatal Health Program Table 1-13. Possible Diagnoses Associated with Maternal Life-Threatening Complications FACTOR POSSIBLE DIAGNOSES Vaginal bleeding in early pregnancy (through 22 weeks’ gestation) z Ectopic pregnancy z Threatened abortion z Inevitable abortion z Incomplete abortion z Complete abortion z Molar pregnancy Vaginal bleeding in later pregnancy (after 22 weeks’ gestation) or labor z Placental abruption z Placenta previa z Ruptured uterus Vaginal bleeding after childbirth z Uterine atony z Extensive tears of the cervix, vagina, perineum, and/or labia z Non-extensive tears of the cervix, vagina, perineum, and/or labia z Retained placenta or placenta fragments z Ruptured uterus z Inverted uterus z Delayed postpartum hemorrhage Severe headache, blurred vision, elevated blood pressure, convulsions z Pre-eclampsia/eclampsia z Epilepsy z Chronic hypertension z Meningitis or encephalitis z Tetanus z Malaria Breathing difficulty z Severe anemia z Heart failure due to anemia or heart disease z Pneumonia z Bronchial asthma z Pulmonary edema associated with heart failure or pre-eclampsia z Pulmonary embolism Fever z Amnionitis z Septic abortion z Acute pyelonephritis z Metritis z Abscess (pelvic, wound, breast) z Peritonitis z Deep vein thrombosis z Pneumonia z Malaria z Typhoid z Hepatitis Chapter Two: Rationales for Components of Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-39 Table 1-13. Possible Diagnoses Associated with Maternal Life-Threatening Complications (continued) FACTOR POSSIBLE DIAGNOSES Severe abdominal pain in early pregnancy (through 22 weeks’ gestation) z Ectopic pregnancy z Spontaneous abortion/septic abortion z Peritonitis z Appendicitis z Acute pyelonephritis z Ovarian cyst z Bowel obstruction or pancreatitis Severe abdominal pain in later pregnancy (after 22 weeks’ gestation) or labor z Preterm labor z Placental abruption z Ruptured uterus z Amnionitis z Appendicitis z Acute pyelonephritis z Peritonitis z Bowel obstruction or pancreatitis Severe abdominal pain after childbirth z Metritis z Ruptured uterus z Pelvic abscess z Peritonitis z Acute pyelonephritis z Ovarian cyst z Bowel obstruction or pancreatitis Contractions before 37 weeks’ gestation z Preterm labor Unsatisfactory progress of 1st or 2nd stage of labor z Cephalopelvic disproportion/obstructed labor z Inadequate uterine activity, possibly caused by amnionitis, inadequate caloric intake, inadequate fluid intake Inadequate uterine contractions z Inadequate uterine activity, possibly caused by amnionitis, inadequate caloric intake, inadequate fluid intake Meconium-stained amniotic fluid, absence of fetal movement or heart tones, abnormal fetal heart rate, prolapsed cord z Fetal distress or death Fetal part (e.g., hand, foot) protruding from vagina z Malpresentation/malposition Pain in calf z Deep vein thrombosis Pus, redness, or pulling apart of skin edges of the perineal suture line; pus or drainage from unrepaired tear; severe pain from tear or episiotomy z Necrotizing fasciitis z Cellulitis z Abscess z Fistula Verbalization/behavior that indicates the woman may hurt herself or her baby, and/or hallucinations z Postpartum psychosis z Postpartum depression Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-40 JHPIEGO/Maternal and Neonatal Health Program Table 1-14. Possible Diagnoses Associated with Newborn Life-Threatening Complications FACTOR POSSIBLE DIAGNOSES Abnormal body temperature (axillary temperature less than 36.5°C or more than 37.5°C) z Exposure to low or high environmental temperature z Sepsis Bleeding z Hemorrhagic disease z Coagulopathy Redness or foul smell of umbilicus z Infection of umbilicus z Sepsis Pus or redness of eyes z Gonoccocal ophthalmia/conjunctivitis z Chlamydial conjunctivitis z Staphylococcal conjunctivitis Pus or lesions of skin z Cellulitis/abscess z Sepsis z Congenital syphilis Jaundice z Sepsis z Glucose-6-phosphate dehydrogenase (G6PD) deficiency z Rhesus or ABO blood incompatibility z Obstructive disorders: intestinal atresia or stenosis, meconium ileus, Hirschsprung’s disease Abdominal distention z Sepsis z Necrotizing enterocolitis z Suspected gastrointestinal malformation or obstruction Diarrhea z Dehydration z Sepsis z Necrotizing enterocolitis z Dysentery/intestinal infection Swollen limb or joint z Fracture z Birth injury JHPIEGO/Maternal and Neonatal Health Program 1-41 CHAPTER THREE KEY TOOLS IN BASIC CARE OVERVIEW This chapter outlines the following four tools necessary to providing high-quality basic care: z Clinical decision-making z Interpersonal skills z Infection prevention z Record keeping These tools should be used in every component of basic care provision by all staff at the healthcare facility (as appropriate to their job duties). CLINICAL DECISION-MAKING To decide on the care a woman or newborn needs, the skilled provider engages in a purposeful and organized thinking process known as clinical decision-making. Although this process is ongoing and circular, it can be broken down into a series of linked steps, which often occur simultaneously. These steps help the skilled provider gather the information needed to form accurate judgments about a person’s condition, begin appropriate care, and evaluate the effectiveness of the care provided. In the course of caring for a woman or her baby, the skilled provider undertakes the process of clinical decision-making repeatedly as the clinical situation changes and different needs or problems emerge. The steps of clinical decision-making are as follows: z Gathering information z Interpreting information z Developing a care plan z Implementing the care plan z Evaluating the care plan Gathering Information This step includes obtaining information through targeted history taking, physical examination, and testing to determine individual needs and potential problems to be addressed. As the skilled provider progresses through the assessment, it is essential to consider the information gathered through each part (history, physical examination, testing) in the context of the other parts. This approach helps the skilled provider focus testing and make more accurate diagnoses as each finding is viewed in relation to other findings, rather than as an isolated fact. The information gathered includes both what the skilled provider observes and what the woman reports about herself or her baby. Interpreting Information The skilled provider must then interpret the information gathered in order to form a diagnosis. The interpretation process involves the following: z Comparing signs/symptoms and other findings to accepted standards of health and disease to judge whether they are normal or abnormal Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-42 JHPIEGO/Maternal and Neonatal Health Program z Considering all conditions known to produce any abnormal sign/symptom detected z Eliminating conditions that do not fit the whole clinical picture z Ruling out the most serious, if less likely, conditions z Investigating further each abnormal sign/symptom (e.g., when it began, how painful or severe it is, what other signs/symptoms go along with it, etc.) z Considering these signs/symptoms in the context of other factors, such as the woman’s or newborn’s age and history z Consulting other sources of reliable and up-to-date information, such as reference books and clinical specialists, for additional information when needed Developing a Care Plan Based on the assessment, the skilled provider and the woman work together to develop an appropriate plan of care that is also individualized to meet the woman’s and/or newborn’s unique needs (e.g., individual preferences, lifestyle, cultural beliefs, socioeconomic status). Implementing the Care Plan Once the care plan is developed, it is put into action. Implementing the care plan is a responsibility shared by both the skilled provider (e.g., providing tetanus toxoid immunization) and the woman and her family (e.g., practicing birth preparedness and complication readiness or keeping the newborn warm using skin-to-skin contact). Evaluating the Care Plan Evaluating the care plan is more than a step in clinical decision-making; it is an ongoing process. The skilled provider continuously monitors the woman’s response to treatment and is ready to change the care plan as necessary. If the plan has not achieved the desired result, additional information will need to be gathered and interpreted so that the plan can be revised. A care plan is effective when it has done the following: z Been carried out by the woman, her care support systems, and the skilled provider z Improved or maintained the woman’s or newborn’s general level of health z Restored any abnormal findings to the range of normal z Met the woman’s needs for information, guidance, and support z Been acknowledged as valuable by the woman and her family z Revealed new health needs to address or changes to be made INTERPERSONAL SKILLS Interpersonal skills allow people to interact successfully with others. Skilled providers who demonstrate good interpersonal skills are able to develop open communication with clients and establish mutual respect and trust. In general, skilled providers should do the following: z Provide a safe and comfortable healthcare environment in which the woman and her family feel welcome (Annex 1, page 4-1) z Promote continuity of care so that the woman sees the same skilled provider as often as possible Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-43 z Use effective communication skills when providing services to the woman and her newborn z Treat the woman and her newborn with respect and courtesy z Ensure privacy and confidentiality z Respond to the woman’s emotional needs, in addition to her physical needs z Display a professional attitude with clients and coworkers Effective Communication Good communication skills are an essential aspect of providing high-quality healthcare services to the woman and her newborn. Effective communication helps build a woman’s trust and confidence in the skilled provider, which makes her more likely to seek care for herself or her baby, follow recommendations, and return for followup visits. Listed below are ways in which the skilled provider can communicate effectively with women and their families throughout the childbearing cycle. Skills that are particular to labor/childbirth and the postpartum/newborn period are highlighted in Textbox 1-5 (page 1-44). z Use simple, clear, and locally understood language (or a translator, if necessary), as well as terminology that the woman understands. z Speak in a soft, gentle tone of voice. z Be sensitive to and show respect for social norms and cultural beliefs and practices (page 1-8). z Use culturally appropriate nonverbal communication (e.g., smiling, looking directly at the client, avoiding distracting movements, and allowing for pauses or moments of silence). z Highlight important information by summarizing or repeating it. z Encourage the woman to ask questions and express her concerns. z Listen carefully to what the woman has to say, avoid interrupting her, and take notes as necessary. z Answer the woman’s questions directly in a calm, reassuring manner. z Be honest with the woman, and do not be afraid to admit when you do not know something. z Ask the woman to repeat the key points or recommendations to ensure her understanding, or give her illustrations and written information (if available and appropriate) to remind her of instructions. z Respect the woman’s right to make decisions about her own or her baby’s life, and allow her the time she needs to make important decisions. z Be empathetic and reinforce through words and nonverbal communication that it is the skilled provider’s role to provide help and support, not to judge the woman and her family. z Thank the woman and her family for coming at the end of each visit. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-44 JHPIEGO/Maternal and Neonatal Health Program Textbox 1-5. Interpersonal Skills during Labor/Childbirth and the Postpartum/Newborn Period The general interpersonal skills recommended in this section should be used during all aspects of basic care provision. There are, however, some special recommendations for labor and childbirth, as well as the postpartum/newborn period. Labor and Childbirth z Remain sensitive to the woman’s physical discomfort and emotional state. z Keep the woman informed about the progress of her labor. z During a physical examination, allow the woman to move during a contraction if she desires. z Provide continuous emotional and physical support as appropriate during labor and childbirth. Consider the woman’s emotional well-being, comfort, and desires, as well as her physical requirements. (For more information on supportive care measures during labor and childbirth, see Table 2-7 [page 2-47].) z Give the woman verbal encouragement and praise, as well as reassurance about her condition and the well-being of the baby. Postpartum/Newborn Period z Allow the woman and newborn to remain together as much as possible. z Encourage the woman in her “mothering” abilities by doing the following: − Noting and praising her for what she is doing right − Helping to build her confidence by using verbal and non-verbal messages − Assuring her that she is capable of caring for her newborn − Substituting gentle, constructive suggestions for criticisms z Continually acknowledge the baby, referring to her/him by name when appropriate. z Ensure that someone is watching the baby or that s/he is in a safe place while the woman is undergoing a physical examination. z When observing breastfeeding, help the woman feel relaxed and confident; do not hurry the woman and her newborn. Reinforce through words and non-verbal communication that the skilled provider is present to help and support her, not to judge her or her newborn. z Work with the family to devise strategies for challenges that they may face during the immediate postpartum/newborn period (e.g., the woman’s increased need for rest). Privacy and Confidentiality An atmosphere of privacy and confidentiality helps to protect the woman’s security and dignity, and increases her willingness to communicate openly. Ideally, the client care area would be a separate room with a door that closes and locks, but other simple changes can make significant improvements in privacy during visits. For example, adding curtains or dividers can provide greater privacy for the woman during a physical examination. All information that the woman provides during her visit should be kept confidential. Confidentiality means that, without the woman’s consent, healthcare workers and facility staff do not discuss this information with the woman’s partner, family, person accompanying her to the healthcare facility, or any facility staff members not directly involved in her care and treatment (except when required in a life-threatening medical emergency). Use the measures listed below to help assure the woman that her right to privacy and confidentiality is being respected. z Arrange for the waiting area to be an adequate distance from the client care area, so that clients waiting for services do not hear information about the woman or newborn currently being seen. z Close and lock the doors to the client care area during the visit, and/or secure the curtains, ensuring that they completely block any view of the client care area. z If a separate room is not available for the woman’s or newborn’s visit, increase confidentiality by taking the history and discussing personal matters in an area where others cannot hear the conversation, and by limiting traffic of healthcare facility staff and visitors into and through the area. z Allow the woman to decide whether her companion is to be included in all or any parts of her visit. Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-45 z Speak in a low voice when discussing the history or present health status of the woman or her newborn. z Store medical records securely, where only authorized personnel can access them. When performing a physical examination, follow the steps below to ensure the woman’s privacy and confidentiality. z Have the woman remove and adjust clothing only as needed. z Remove upper garments for a breast inspection. z Remove lower garments for a genital examination. z Remove or loosen upper and lower garments as needed for an abdominal examination. z Provide the woman with a drape or blanket to cover parts of her body that are not being examined. z If the woman needs to undress before the physical examination, exit the client care area while she is doing so. z Ask the woman’s permission before re-entering the client care area to perform the physical examination. Follow the steps below to ensure the woman’s privacy and confidentiality in the home setting. z Allow the woman to choose the part of the house in which she wants to have the visit. z Be prepared to ask family members to leave the care area to ensure privacy. Physical Examination The woman may feel anxious about having a physical examination, or about having her newborn examined. The interpersonal skills listed below can help skilled providers make the woman feel more comfortable. z Explain to the woman what is going to happen, and why. z Be encouraging and supportive. z Preserve her privacy (page 1-44) and respect her modesty. z Ensure that the woman is comfortable on the examination surface (e.g., help her onto the examination surface, provide a pillow to support her head, ask her to take a few deep breaths to help her relax). z Be gentle and avoid sudden movements. z Encourage the woman to ask questions and voice concerns. z Obtain the woman’s permission/consent before proceeding with the examination or procedure. z Discuss findings as the examination progresses, making sure that the woman understands what they mean. z Respect social norms and cultural beliefs and practices. Counseling and Health Messages The purpose of counseling and health messages is to provide the woman with essential information for improving or maintaining her health or the health of her newborn, and to facilitate decision-making and, when necessary, behavior change. Providing counseling and health messages also empowers the woman to become an active participant in her healthcare and that of her newborn. Topics include: birth preparedness and complication readiness; common discomforts; danger signs; HIV pre- and post-test counseling; safer sex; family planning; and newborn feeding options. Health messages will vary throughout the process of care during the childbearing cycle and newborn period. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-46 JHPIEGO/Maternal and Neonatal Health Program When providing health messages, the skilled provider gives practical messages to help the woman, such as information on nutrition or how to recognize and respond to an emergency. When counseling, the skilled provider offers assistance and support to help the woman apply health messages to her life, adopt healthy practices, solve problems, and make informed decisions. The provision of effective health messages and counseling is based on the key principles listed below. z The skills required for providing health messages and counseling build on those used in effective communication (page 1-43). z Messages are most helpful to the woman and her family when they do the following: z Are based on locally available and financially feasible solutions z Emphasize what the woman should do and how to do it (rather than why) z Are easy for the woman to understand, remember, and implement z Advice and counseling should be integrated whenever possible with other components of the care plan (e.g., while dispensing iron/folate, the skilled provider should also advise the woman on how to take it, inform her about dietary sources of iron/folate, counsel her on relief of common side effects, and provide information on any other related issues). z As in other components of the care plan, health messages and counseling should be individualized to fit the woman’s needs and circumstances (Textbox 1-6, below). Textbox 1-6. Individualizing Health Messages and Counseling One way to individualize health messages and counseling is to prioritize the topics. Prioritizing means selecting topics to discuss and/or emphasize based on what is most important: (1) in different clinical situations; and (2) at different times during the childbearing cycle and newborn period. Prioritization is important because the skilled provider has a limited amount of time to spend with each woman and newborn, and there are limits on how much information the woman can retain at a single visit. z First, respond to the woman’s specific questions or concerns. − The woman is most likely to benefit from information that addresses self-identified needs. − Paying attention to existing issues, even if they are not life-threatening, is as important as preparing for potential problems. z Next, provide the woman with essential messages that may have a direct or immediate impact on the health or survival of the woman and her baby. Advice and counseling on these topics is an important part of every visit. Examples are birth preparedness and complication readiness. z Finally, deliver other messages that help the woman: (1) enhance or maintain her and her baby’s health; (2) understand and adhere to the care plan; (3) cope with the current emotional and physical aspects of her situation; and (4) prepare for the next phase of the childbearing cycle or newborn period. Examples are nutrition, rest, hygiene, family planning, and sexual relations. − Some messages can be prioritized according to when they are most relevant. For example, although family planning may be covered briefly in the antenatal period, it should be discussed in much more detail in the postpartum period. − Not all messages are routine or appropriate for all women. For example, some women may require a lot of advice/counseling on breastfeeding, while others require no guidance at all. It is the skilled provider’s job to continually assess the woman’s need for particular health messages. z Counseling and health messages should be respectful of the woman, her family, and their social norms and cultural beliefs/practices. z Counseling should be provided in a manner that empowers the woman to exercise informed choice (i.e., do not try to persuade the woman to make a particular decision or take a certain course of action). z The involvement of the woman’s support system is especially important in advice and counseling; her partner, companion, or family members can support her in following recommendations, carrying out plans, and making important decisions. z It is important to maintain an up-to-date list of local sources of support and assistance so that the skilled provider can quickly and effectively link the woman and her family to appropriate resources. Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-47 z Group education should be used to introduce or supplement (not replace) individual counseling and health messages (Textbox 1-7, below). Textbox 1-7. Tips for Conducting an Effective Group Education Session z Consider the local cultural needs. Choose appropriate topics and use words that the group can understand. z Encourage all clients to participate in the group education session. z Introduce the topic(s) clearly and state the objectives of the session. z Ask questions to find out what the group knows before providing all of the information. There is no need to give information the group already knows. z Use an interactive approach. Ask and answer questions and encourage group members to ask questions. z Praise group members when they participate. z Use client education materials as appropriate. z Maintain eye contact with the group. z Speak loudly enough that everyone can hear. z Summarize key points. z Even if the skilled provider does not facilitate the group education session, s/he should be familiar with the way group education sessions are conducted and which topics are covered at her/his healthcare facility. Encouragement and Support The childbearing cycle is a time of challenges and opportunities for women. The skilled provider should help the woman find strategies to solve problems and identify opportunities to increase her general knowledge and skills. z Whenever possible, note and praise the woman for things she is doing well. z Use gentle, constructive suggestions rather than judging or criticizing the woman. z Provide psychological support and practical help. z Show empathy for and understanding of the woman’s situation or concerns. z When appropriate, assure the woman that her struggles are common among women in her situation. z Take measures to provide physical comfort (e.g., a cool cloth during labor, a warm blanket after birth, etc.) as needed and appropriate. z When appropriate, let the woman’s partner, companion, or family know how they can help her. INFECTION PREVENTION1 One of the most significant causes of maternal death is postpartum infection (or puerperal sepsis), which accounts for 15% of all maternal deaths in developing countries.2 Unsafe abortion practices and related infections also contribute to many maternal deaths each year. Newborn babies are at increased risk of infection because their immune systems have not yet matured. Approximately 2.5 million newborn babies die of tetanus or other infections each year. Healthcare workers and support staff are also at risk of infection—in caring for women and newborn babies throughout the childbearing cycle, they can become infected through exposure to contaminated surgical instruments, blood or body fluids, and other infectious items. As bloodborne infectious diseases such as hepatitis B, C, and D, and HIV continue to spread, healthcare workers and clients are at increased risk of acquiring an infection during a routine healthcare visit or surgical procedure. 1 Much of the information in the Infection Prevention section was adapted from Infection Prevention Guidelines for Healthcare Facilities with Limited Resources. Tietjen L, D Bossemeyer, N McIntosh. 2003. JHPIEGO Corporation: Baltimore, MD. 2 World Health Organization. 1996. Puerperal Sepsis Module, Safe Motherhood. WHO: Geneva. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-48 JHPIEGO/Maternal and Neonatal Health Program Infection prevention (IP) practices3 focus on preventing infection and disease transmission in both clients and healthcare workers. When proper precautions are not taken, people can become very ill or die. Therefore, IP practices should be integrated in the following ways into every component of maternal and newborn care, as needed, to protect the woman, newborn, healthcare worker, and other healthcare facility staff: z Minimizing infections due to microorganisms z Decreasing the risk of transmitting life-threatening diseases such as hepatitis B, C, and D, and HIV to the woman and newborn and to healthcare workers and facility staff, including cleaning and housekeeping personnel In addition to incorporating IP practices during healthcare, healthcare workers should reduce the risk of infection by avoiding harmful traditional practices and talking to women and their families about healthy practices. How Infection Prevention Practices Work Microorganisms cannot be seen by the human eye. A surgical instrument may look clean but be contaminated by microorganisms. IP practices interrupt the cycle of transmission by either destroying microorganisms or preventing transmission from one source to another. For example, handwashing before a procedure and disinfection during housekeeping will interrupt the cycle at the reservoir stage. Also, handwashing, housekeeping, instrument processing, and safe handling of sharps will interrupt the cycle at the method of transmission level. Preventing injuries with sharps will interrupt the cycle at the place of entry stage. IP practices overlap and have a cumulative effect; by applying all IP practices correctly and consistently, the likelihood of causing an infection or transmitting disease is greatly decreased. Infection Prevention Principles IP practices are based on the principles listed below. z Every person (client or healthcare worker) is considered infectious because infections may be present but asymptomatic. z Every person is considered at risk of infection. z Handwashing (or using an alcohol-based handrub) is the most practical procedure for preventing infections. z Gloves are worn on both hands before touching anything wet—broken skin, mucous membranes, blood, or other body fluids (secretions or excretions)—or performing an invasive procedure. z Barriers (e.g., protective goggles, face masks, or aprons) are worn if splashes or spills of any body fluids are anticipated. z Antiseptic agents are used to clean the skin or mucous membranes before certain procedures, or for cleaning wounds. z All healthcare workers and facility staff follow safe work practices (e.g., not recapping or bending needles, proper instrument processing, and suturing with blunt needles when appropriate). z The care site is cleaned routinely, and waste is properly disposed of. z Facility staff who are in direct contact with clients receive as many of the following immunizations as possible: z Rubella z Measles 3 The terms “universal” or “standard precautions” refer to some of the IP practices that focus on protecting the healthcare worker. IP practices include, but are not limited to, universal or standard precautions. Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-49 z Hepatitis B virus z Mumps z Influenza (yearly) Infection Prevention Practices Handwashing Handwashing is the most practical procedure for preventing the spread of infection. Wash hands with soap and water (if hands are visibly clean and not contaminated with blood or body fluids, disinfect them using an antiseptic handrub) in the following situations: z Before and after examining a client z After contact with blood, other body fluids, or soiled instruments, even if gloves were worn z Before and after removing gloves because they may have invisible holes in them z Upon arriving at and before leaving the workplace To wash hands, do the following: z Thoroughly wet hands with clean water z Wash hands for 10–15 seconds with plain soap and running or poured water z Allow hands to air-dry or dry them with a clean paper or personal towel Unless the hands are visibly soiled, a waterless, alcohol-based antiseptic handrub is more effective in cleaning hands than handwashing. Antiseptic handrub can be made by adding 2 mL of glycerin (or other emollient) to 100 mL of 60–90% ethyl or isopropyl alcohol solution. Use the guidelines below to clean hands using an antiseptic handrub. z Apply enough antiseptic handrub to cover the entire surface of hands and fingers (about one teaspoonful). z Rub the solution vigorously into hands, especially between fingers and under nails, until dry. Antisepsis When combined with good hand hygiene and other IP practices, proper antisepsis can help prevent infection by reducing the number of microorganisms on the skin. Use the guidelines below for skin preparation for injections. z If the skin is clean, it is not necessary to use an antiseptic before giving a skin injection. z If the injection site appears dirty, wash it with soap and water. z Dry with a clean towel; then give the injection. When cleansing the genitals before and after birth, wash the external genital area with soap and water or antiseptic if visibly soiled. Note: If using an antiseptic, ask the client about allergic reactions. Use a water-based product (such as an iodophor or chlorhexidine), as alcohols or products containing alcohol may burn and irritate mucous membranes. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-50 JHPIEGO/Maternal and Neonatal Health Program Gloving Gloves are the most important physical barrier for preventing the spread of infection. They protect the hands of healthcare workers from infectious materials and protect clients from microorganisms on healthcare workers’ hands. Please note that the use of gloves does not replace hand hygiene. Gloves should be worn in the following situations: z If there is reasonable chance of hand contact with broken skin, mucous membranes, blood, or other body fluids (secretions or excretions) z When performing an invasive procedure z When handling soiled instruments, gloves, medical waste, or contaminated waste items, or when touching contaminated surfaces Adhere to the guidelines below for glove use. z A separate pair of gloves must be used for each woman and newborn to avoid spreading infection from client to client. z Properly dispose of gloves after contact with a client. Before removing gloves, dip hands in 0.5% chlorine solution and, if not re-using gloves, dispose of gloves in a leak-proof bag or container. z Wear high-level disinfected (HLD) or sterile gloves for any procedures that will involve contact with broken skin or tissue under the skin (e.g., pelvic examination, childbirth, or vaginal repair; see Table 1-15 [page 1-51]). z Wear clean examination gloves for starting an IV, drawing blood, or handling blood or body fluids. z Wear utility gloves for cleaning instruments, handling waste, and cleaning up blood and body fluids. z If the supply of gloves is limited, surgical gloves can be reused if they have been: z Decontaminated by soaking in 0.5% chlorine solution for 10 minutes; z Washed and rinsed; and z Sterilized or high-level disinfected. z If single-use disposable surgical gloves are reused, do not process them more than three times because invisible tears may occur. z Never use gloves that are cracked or peeling or that have visible holes or tears. z Always remove a used or contaminated glove by the cuff. z Place the used or contaminated glove in a waste container; if reusing the glove, place it in 0.5% chlorine solution. Listed below are some DOs and DON’Ts about glove use. z DO wear the correct size gloves, particularly surgical gloves. Poorly fitting gloves limit the healthcare worker’s ability to perform a task and may be torn or cut more easily. z DO keep fingernails short (no more than 3 mm [1/8 inch] beyond the fingertip) to reduce the risk of tears. z DO pull gloves up over the cuffs of the gown, if worn, to protect the wrists. z DO use water-soluble (non-oil containing) hand lotions and moisturizers often to prevent hands from drying, cracking, and chapping. z DON’T use oil-based hand lotions or creams. These damage latex rubber surgical and examination gloves. Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-51 z DON’T use hand lotions and moisturizers that are very fragrant or perfumed, as they irritate the skin under gloves. z DON’T store gloves in areas where there are extremes in temperature (e.g., in the sun, near a heater, by an air conditioner, etc.). These conditions may damage the gloves and reduce their effectiveness as a barrier. Table 1-15. Glove Requirements for Common Medical and Surgical Procedures TASK OR ACTIVITY ARE GLOVES NEEDED? PREFERRED GLOVES1 ACCEPTABLE GLOVES Blood pressure check No Temperature check No Injection No Blood drawing Yes Examination2 HLD Surgical4 Measuring hemoglobin Yes Examination2 HLD Surgical4 Urinalysis Yes Examination2 HLD Surgical4 RPR Test Yes Examination2 HLD Surgical4 Catheterization Yes Sterile Surgical3 HLD Surgical4 IV insertion and removal Yes Examination2 HLD Surgical4 Genital examination (including examination for tears) Yes Examination2 HLD Surgical Pelvic (speculum and bimanual) examination Yes Examination2 HLD Surgical4 Vaginal birth Yes Sterile Surgical3 Examination2 or HLD Surgical4 Management of prolapsed cord Yes Sterile Surgical3 HLD Surgical4 Artificial rupture of membranes Yes Sterile Surgical3 HLD Surgical4 Episiotomy Yes Sterile Surgical3 HLD Surgical4 Repair of episiotomy, cervical, vaginal, and perineal tears, and defibulation Yes Sterile Surgical3 HLD Surgical4 Manual removal of placenta or placental fragments, and correction of uterine inversion Yes Sterile Surgical3 (use elbow-length gloves, if possible) HLD Surgical4 (use elbow-length gloves, if possible) Vacuum extraction Yes Sterile Surgical3 Examination2 or HLD Surgical4 Bimanual compression of the uterus Yes Sterile Surgical3 HLD Surgical4 Handling and cleaning instruments Yes Utility5 Examination2 or HLD Surgical4 Handling contaminated waste Yes Utility5 Examination2 or HLD Surgical4 Cleaning blood or body fluid spills Yes Utility5 Examination2 or HLD Surgical4 1 Although sterile gloves may be used for any surgical procedure, they are not always required. In some cases, examination or HLD surgical gloves are equally safe and less expensive. 2 This includes new, never-used individual, or bulk-packaged examination gloves (as long as boxes are stored properly). 3 When sterilization equipment (autoclave) is not available, high-level disinfection is the only acceptable alternative. 4 Reprocessed surgical gloves. Reprocessing surgical gloves more than three times usually is not cost-effective. 5 Utility gloves are thick household gloves. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-52 JHPIEGO/Maternal and Neonatal Health Program Elbow-Length Gloves for Obstetric Procedures When the hand and forearm need to be inserted into the vagina (e.g., manual removal of the placenta or placental fragments), elbow-length—sometimes termed “gauntlet”— gloves help protect the healthcare worker from significant blood and amniotic fluid contamination and help protect the woman as well. If elbow-length gloves are not available, an inexpensive, effective alternative can be easily made from previously used surgical gloves that have been decontaminated, cleaned, and dried. Follow the steps below to make a pair of elbow-length gloves. z Cut the four fingers completely off each glove just below where all the fingers join the glove (Figure 1-2, below). z Sterilize or high-level disinfect two to three pairs of cut-off (fingerless) gloves according to the recommended process for each method and store the gloves after final processing in a sterile or HLD container until needed. Figure 1-2. Making Elbow-Length Gloves from Previously Used Surgical Gloves Follow the steps below if it is anticipated that the forearms need to be protected before starting the procedures. z Perform surgical handscrub, including the forearms up to the elbows, using an alcohol-based antiseptic agent. z Put fingerless sterile or HLD gloves on both hands and pull up onto the forearm(s) (Figure 1-3A, below). z Put intact sterile or HLD surgical gloves on both hands so that the lower (distal) end of the fingerless glove is completely covered (Figure 1-3B, below). Figure 1-3. Putting on Fingerless (A) and Surgical (B) Gloves A B Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-53 Follow the steps below if the need for protection of the forearm(s) occurs during a procedure or a sudden need to wear elbow-length gloves arises (e.g., correcting uterine inversion). z Remove the surgical glove from one or both hands. z Put on a fingerless sterile or HLD glove(s) and pull up onto the forearm(s). z Put a new sterile or HLD surgical glove on one or both hands. Safe Handling of Sharp Instruments Hypodermic (hollow bore) needles cause the most injuries to healthcare workers at all levels. Follow the safety guidelines below when handling and using (Textbox 1-8, below) sharp instruments, such as needles and syringes. z Never pass a sharp instrument from one hand directly to another person’s hand. z Use a pan such as a sterile kidney basin to carry and pass sharp instruments. z Always alert others by saying “sharp” or “blade” when placing an instrument in the “safe” basin or container. z Use caution when suturing to prevent accidental injuries with sharps. Always use a needle holder when suturing, and never hold the needle with fingers or use the fingers to guide the needle. z After use, decontaminate syringes and needles by flushing them with 0.5% chlorine three times. z Immediately dispose of sharps in a puncture-resistant container. Do not recap, bend, break, or disassemble needles before disposal. Textbox 1-8. Safety Tips for Using Hypodermic Needles and Syringes z Use each needle and syringe only once. z Do not disassemble the needle and syringe after use. z Do not recap, bend, or break needles before disposal. z Decontaminate the needle and syringe before disposal. z Dispose of the needle and syringe in a puncture-resistant container. Personal Protective Equipment (PPE) Personal protective equipment (PPE) is used to protect healthcare workers and clients from infectious microorganisms, especially when splashing of blood or other body fluids is likely. PPE includes: z Gloves (page 1-50) z Eyewear (face shields, goggles, or glasses) z Protects the healthcare worker’s eyes from accidental splashes of blood or body fluids z Should be worn (along with masks) when performing a task (e.g., artificial rupture of membranes [amniotomy], assisting a birth) during which an accidental splash into the face is likely z Aprons z Should be made of rubber or plastic to provide a fluid-resistant barrier that keeps contaminated fluids off the healthcare worker’s clothing and skin z Should be worn while cleaning, or during a procedure in which blood or other body fluid spills are anticipated Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-54 JHPIEGO/Maternal and Neonatal Health Program z Footwear z Protects the healthcare worker’s feet from injury by sharps or heavy items that may accidentally fall on them z Should be clean and cover the entire foot (do not go barefoot or wear sandals, thongs, or shoes made of soft materials); rubber boots and leather shoes provide the most protection but should be kept clean PPE can be made of paper, cloth (such as lightweight cotton), treated fabrics, or synthetic materials that do not allow liquids to penetrate them. When fabric is used, it should be light in color to show dirt and contamination easily. PPE made of paper should never be reused because it cannot be prope

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