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 properly cleaned. Instrument Processing Soiled instruments, used surgical gloves, and other reusable items can transmit disease if IP procedures are not properly followed. The IP practices for decontamination, cleaning, sterilization, high-level disinfection (HLD), and proper storage are summarized below. z Decontamination: This process makes inanimate objects safer to handle before cleaning. z Immediately after use, soak soiled items in 0.5% chlorine solution for 10 minutes. Do not soak metal instruments for more than 1 hour; prolonged soaking may cause rusting. z Use a plastic container for decontamination. This prevents dulling of sharp instruments and rusting of metal instruments. z After decontamination, rinse instruments immediately with cool water to prevent corrosion and remove visible organic material. z Larger surfaces, such as examination tables, should be wiped carefully with 0.5% chlorine solution after each use. z Cleaning: After instruments and other reusable items have been decontaminated, they need to be cleaned. z Cleaning removes visible soil and debris, including blood or body fluids. z Cleaning is the most effective way to reduce the number of microorganisms on soiled instruments and equipment. z Neither sterilization nor HLD procedures are effective without cleaning. z Cleaning is the best way to kill endospores, which also cause tetanus and gangrene. If sterilization is not available, thorough cleaning is the only way to effectively reduce the number of endospores. z Follow the steps below to properly clean instruments and other items. − Thoroughly wash items to be cleaned with soap and water. Use a liquid soap and soft brush (an old toothbrush works well) if available. Do not use abrasive cleaners or steel wool, especially on metal. − After washing, rinse items with clean water to remove any soap residue. − After rinsing, dry the items thoroughly, regardless of whether or not they will be sterilized or high-level disinfected. − If instruments will be sterilized, individually wrap and package them after cleaning. − Pay special attention to instruments with teeth, joints, or screws. − Wear utility gloves, protective eyewear, and a plastic apron while cleaning instruments and equipment. Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-55 − Wash surgical gloves on the inside and outside. To test gloves for holes, inflate them and hold them under water. If there are holes, air bubbles will appear. Do not reuse gloves that have holes. − Never mix oral and rectal thermometers, even if they are clean. z Sterilization: Sterilization destroys all microorganisms, including bacterial endospores, that are present on instruments or equipment. Use sterilization for instruments, surgical gloves, and other items that come in direct contact with the blood stream or other sterile tissues. Do not overload the sterilizer. Follow the guidelines below to achieve sterilization. z Autoclaving (high-pressure steam) for 20 minutes (for unwrapped items) or 30 minutes (for wrapped items) at 121°C (250°F) and 106 kPa (15 psi). Allow items to dry before removing them from the sterilizer. z Dry heat (oven) at 170°C (340°F) for 1 hour or 160°C (320°F) for 2 hours. z Chemical sterilization by allowing instruments to soak: − For 10 hours in a 2–4% glutaraldehyde solution (check specific product instructions); or − At least 24 hours in 8% formaldehyde. z High-Level Disinfection (HLD): HLD destroys all microorganisms except some bacterial endospores on instruments or objects. It is the only acceptable alternative to sterilization. HLD may be achieved by doing any of the actions below. z Boiling the items in water for 20 minutes. Always remove the items immediately, and if they will not be used promptly, place them in an HLD container. z Steaming the items for 20 minutes and then allowing the items to dry for 1–2 hours before using them. z Soaking the items in a 0.5% chlorine solution, 8% formaldehyde solution, glutaraldehyde solution, or 6% hydrogen peroxide solution for 20 minutes. Remove items using HLD or sterile forceps or gloves, and rinse well with boiled and filtered water three times. Allow items to air dry. Use items promptly, or store them in a HLD container. z Storage: Sterilized and HLD items must be stored carefully. Sterilized items will not remain sterile unless they are properly stored. z Keep the storage area clean, dry, dust-free, and lint-free. z Control temperature and humidity when possible. Keep the temperature at approximately 24°C and the relative humidity less than 70%. z Store sterile packs and containers 20–25 cm (8–10 inches) off the floor, 45–50 cm (18–20 inches) from the ceiling, and 15–20 cm (6–8 inches) from an outside wall. z Do not use cardboard boxes for storage. These shed dust and debris and may harbor insects. z Date and rotate the supplies. Use a “first in, first out” guideline for using instruments. z Wrapped packages that remain dry and intact may be used up to 1 week. z Wrapped packages sealed in plastic that remain dry and intact may be used up to 1 month. Housekeeping and Waste Disposal Housekeeping refers to the general cleaning of hospitals and clinics, including the floors, walls, equipment, tables, and other surfaces. In addition to reducing the number of microorganisms that may come into contact with clients, visitors, facility staff, and the community, regular and thorough housekeeping helps provide a clean and pleasant atmosphere for clients and facility staff. Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-56 JHPIEGO/Maternal and Neonatal Health Program Most waste (e.g., paper, trash, food, boxes) produced by hospitals and clinics is noncontaminated and poses no risk of infection to the people who handle it. These items can be disposed of by the usual methods or sent to the local landfill or dumpsite. Some waste, however, is contaminated and, if not disposed of properly, may carry microorganisms that can infect people who come into contact with it as well as the community at large. Contaminated waste includes blood and other body fluids, and items that come in contact with them, such as used dressings. To protect the people who handle waste items from accidental injury, and to prevent the spread of infection, contaminated waste should be properly handled and disposed of. Use the guidelines below for housekeeping and waste disposal. z Each care site should have and consistently follow a housekeeping schedule for regular maintenance and clean-up after procedures. z Post the cleaning schedule in a visible area. z Provide details on exactly what needs to be done and how often. z Educate facility staff regarding cleaning, and delegate responsibility. z Follow general guidelines for housekeeping: z Clean from the top to the bottom (e.g., of walls and window coverings) so that the dirt that falls during cleaning is removed. z Ensure that a fresh bucket containing disinfectant solution is available at all times. z Immediately clean up spills of blood or body fluids using disinfectant solutions. z Store and process soiled linens as shown in Textbox 1-9 (page 1-57); wrap or cover clean linens and store them in an enclosed cart or cabinet to prevent contamination with dust. z After each use, wipe off beds, tables, and procedure trolleys using disinfectant solution. z Decontaminate cleaning equipment that has been contaminated with blood or body fluids by soaking it for 10 minutes in a 0.5% chlorine solution. z Wash cleaning buckets, cloths, brushes, and mops with detergent and water daily, or sooner if visibly dirty. Rinse in clean water and dry completely before reuse. z Always wear utility gloves while cleaning, laundering linens, or handling waste. z Separate contaminated waste (e.g., items soiled by blood and other body fluids) from non-contaminated waste. z Dispose of the placenta in a safe and culturally appropriate way. z Wear gloves when handling the placenta. z Carry the placenta in a leakproof container. z Burn the placenta or bury it in a pit at least 2 meters deep. z Use a puncture-resistant container for contaminated sharps, and destroy the container when it is two-thirds full. z Follow the steps below to destroy containers of contaminated waste and sharps. z Add a small amount of kerosene to burn the container of contaminated waste or used syringes and needles. z Burn contaminated waste in an open area downwind from the care site. z Dispose of waste at least 50 meters away from water sources. Chapter Three: Key Tools in Basic Care JHPIEGO/Maternal and Neonatal Health Program 1-57 Textbox 1-9. Tips for Processing Linen z Linen should be collected in cloth or plastic bags or containers with lids. z Always wear utility gloves and a plastic or rubber apron when handling soiled linen. z Linen should be sorted carefully because soiled linen frequently contains needles, sharps, soiled dressings, or other infectious items. z All linen items used in the direct care of clients must be thoroughly washed before reuse. z Decontamination prior to washing is not necessary, unless linen is heavily soiled and will be handwashed. RECORD KEEPING Accurate record keeping is necessary for adequate monitoring of the woman’s or newborn’s condition, for providing continuity of care (over time and across healthcare workers), for planning and evaluating the client’s care, and for communication between healthcare workers and between care sites. The healthcare facility establishes and maintains a record for every woman and newborn who receive care, and the healthcare worker refers to and updates this record at each visit. Types of information noted in each client’s record include the following: z Personal information (e.g., client’s name, age, address, contact information) z Chief complaint (client’s reason for coming) z Findings from the history, physical examination, screening, and other diagnostic tests and procedures z Interpretation of findings/assessment, including identification of problems z Details of the care plan, including birth preparedness and complication readiness plans, and any changes in these plans z Care provided, including prophylaxis, advice and counseling, and treatments for specific problems z Referrals made z Outcomes (of care provided, referrals/transfers made) z Plans for followup/return visit Below are practical guidelines for taking clear, concise, and accurate records. z Prepare/update client records as soon as possible (during or immediately after the visit). Information not recorded in a timely manner may be forgotten or remembered incorrectly. z Record all signs/symptoms that contribute to an interpretation of findings/assessment (e.g., “hemoglobin 9 g/dL, moderate lethargy and fatigue, respirations 26/min, pale conjunctiva—assessment: mild to moderate anemia”). z Note the absence of any signs/symptoms that may be expected given an interpretation of findings/assessment (e.g., “hemoglobin 10 g/dL, mild lethargy and fatigue, normal respirations [16/min], pink conjunctiva—assessment: mild to moderate anemia”). z Note exact values and measurements where appropriate (e.g., “blood pressure: 120/95” rather than “blood pressure slightly elevated”). z Clearly distinguish between clinical observations and the client’s subjective experience (e.g., “woman feels hot to the touch” versus “woman reports feeling feverish”). z Present findings as objectively and nonjudgmentally as possible, as statements of fact rather than opinion (e.g., “woman has not taken medication” rather than “woman is uncooperative”). Basic Maternal and Newborn Care: A Guide for Skilled Providers 1-58 JHPIEGO/Maternal and Neonatal Health Program z Use neat handwriting and avoid unnecessary abbreviations/shorthand. Information should be legible/understandable to other healthcare workers, who may need to consult the client’s record. z Store records in a secure location, where only authorized personnel can access them. JHPIEGO/Maternal and Neonatal Health Program 2-1 CHAPTER FOUR CONDUCTING THE BASIC MATERNAL AND NEWBORN CARE VISIT ESSENTIAL PRE-VISIT ACTIVITIES Before the skilled provider conducts a basic maternal and newborn care visit, the following activities should be completed: z The woman and/or newborn undergo a quick check (Annex 6, page 4-61) to ensure that they do not have danger signs that may indicate a life-threatening complication or—for the pregnant woman—signs of labor. z If the woman has signs of labor but no danger signs, she should receive basic labor/childbirth care as described in Chapter 6. z If the woman and/or newborn has any danger signs, the woman and/or newborn should receive emergency attention and care, as indicated. z If there are no danger signs or signs of labor, the woman and/or newborn should wait to be seen by the skilled provider. z Before the woman (and newborn, if applicable) and her family enter the client care area, the skilled provider completes the following tasks: z Reviews the woman’s and/or newborn’s medical records, if available. (It is important to gather as much information as possible from existing records and charts.) z Ensures that the client care area is adequately prepared, including: − Placing waste products and contaminated objects (from the previous visit) into the appropriate containers; − Wiping down surfaces with 0.5% chlorine solution; − Checking that essential equipment and supplies (Annex 2, page 4-3) are available, easily accessible, and ready for use; and − Tidying the area if necessary. z Uses an antiseptic rub or washes her/his hands. (For more information, see Preparation of the Care Site [Annex 1, page 4-1] and Infection Prevention [Chapter 3, page 1-47].) WELCOMING THE WOMAN AND HER FAMILY As soon as the woman (and newborn, if applicable) and her family enter the client care area, the skilled provider welcomes them as follows. z Greet them in a manner appropriate to their culture. z During the postpartum/newborn period, acknowledge the newborn in a friendly manner as well. z If this is the first time you have met them, ask their names and introduce yourself. Continue to use their names as appropriate from this point on. z Offer seating to the woman and, if she desires, a companion (see Note, page 2-2). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-2 JHPIEGO/Maternal and Neonatal Health Program z Confirm that the woman and/or newborn have undergone the quick check. z Inform the woman, in general terms, what is going to happen during the visit. z Answer any questions she may have. (For more information about Interpersonal Skills, see page 1-42.) Note: The woman’s companion can help her feel more comfortable during the visit, as well as assist and support her in many practical ways during the childbearing cycle. During labor and childbirth, the companion has an especially important role in encouraging the woman, tending to her comfort, and helping to care for the baby after the birth. There may be times, however, when the presence of another person—even a close friend or family member—may cause the woman to avoid certain topics of discussion (e.g., violence against women, HIV status) or withhold important information. If you suspect that this is happening, use your best judgment in deciding how to address the situation. You may need to: z Politely ask the companion to wait outside during certain parts of the visit; or z Make a note on the woman’s records to address certain issues again, when the companion is not present (e.g., at a later visit). CONDUCTING BASIC ASSESSMENT z At every visit, conduct basic assessment (history, physical examination, testing) according to the care schedule/overview shown at the beginning of the appropriate chapter. During labor and within the first 6 hours after birth (pre-discharge), the woman and/or newborn should also receive ongoing assessment and supportive care, as indicated, while undergoing assessment. Throughout basic assessment: z Adhere to the general principles of basic care as outlined in Chapter 1 (page 1-5). z Take all of the findings gathered through each part of the assessment into consideration during other parts of the assessment. This approach can help you: − target assessment; and − make a more accurate diagnosis, as each finding should be viewed in relation to other findings, rather than as an isolated fact. (For more information on Clinical Decision-Making, see Chapter 3, page 1-41.) z If abnormal and potentially abnormal signs/symptoms are detected, conduct additional assessment as indicated (Textbox 2-1, page 2-3). z At return visits, also compare present findings with previous findings to: z ensure continued normal progress; z identify changes, both positive and negative; and z determine whether treatments and other aspects of basic care provision have been effective or require modification. Chapter Four: Conducting the Basic Maternal and Newborn Care Visit JHPIEGO/Maternal and Neonatal Health Program 2-3 Textbox 2-1. Following Up on Abnormal/Potentially Abnormal Findings z If sign/symptoms of conditions requiring urgent referral/transfer are detected, facilitate referral/transfer immediately, as indicated. − During labor/childbirth, urgent referral/transfer should be facilitated only after careful consideration and then only when the woman and newborn are in stable condition. z If signs/symptoms of common discomforts or concerns, special needs, or life-threatening complications are detected, conduct additional assessment and provide additional care, as indicated. z If sign/symptoms of conditions requiring nonurgent referral/transfer are detected, facilitate referral/transfer after providing basic care, as indicated. − During labor/childbirth, nonurgent referral/transfer should not be facilitated until a minimum of 6 hours after birth and then only when the woman and newborn are in stable condition. PROVIDING BASIC CARE z At every visit, provide basic care according to the care schedule/overview shown at the beginning of the appropriate chapter. During labor and within the first 6 hours after birth (pre-discharge), the woman and/or newborn should receive ongoing assessment and supportive care, as indicated, while the skilled provider performs key actions. Throughout basic care provision: z Adhere to the general principles of basic care as outlined in Chapter 1 (page 1-5). z Take all of the findings gathered through basic assessment into consideration during basic care provision. This approach can help you individualize health messages/counseling and other aspects of the basic care provision to best fit the woman’s or newborn’s needs. (For more information on clinical decision-making, see page 1-41.) z If abnormal and potentially abnormal signs/symptoms are detected, provide additional care as indicated (Textbox 2-1, above). z At return visits, make any necessary changes to the plan of care, replenish supplies of supplements and other drugs/medications, continue development of and/or review the birth and complication readiness plan, and reinforce key health messages and counseling. SCHEDULING A RETURN VISIT Note: Appropriate scheduling of basic care visits depends on the point at which the woman is in the childbearing cycle (e.g., 28 weeks’ gestation, 4 days’ postpartum) and/or the newborn is in the newborn period (e.g., 24 hours of age, 4 days of age), as well as their individual needs and situations. Women and newborn babies with common discomforts/concerns, special needs, complications, or other problems may require additional visits. z Before the woman and/or newborn leave, schedule a time for the next antenatal, postpartum, or newborn visit (Table 2-1, page 2-4). z Immediately after childbirth, if transferring the woman and/or newborn to a separate ward for continued postpartum/newborn care, see Textbox 2-2 (page 2-4). z Ensure that the woman knows when and where the next visit will be and why the next visit is important. z Provide contact information for the healthcare facility or skilled provider. z Address any additional questions or concerns. z Advise her to bring any records with her to each visit. z Advise her to bring her partner or other companion with her if possible (to at least one visit). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-4 JHPIEGO/Maternal and Neonatal Health Program z Ensure that she understands that she should not wait for the next appointment if she is having problems or experiencing any of the danger signs. z Review the danger signs and key points of the complication readiness plan. z Thank the woman and her family for coming. Table 2-1. Scheduling for Basic Care Visits* FIRST VISIT SECOND VISIT THIRD VISIT FOURTH VISIT COMMENTS Antenatal Care 16 weeks (by the end of 4 months) 24–28 weeks (6–7 months) 32 weeks (8 months) 36 weeks (9 months) For women whose pregnancies are progressing normally, a minimum of four antenatal care visits—scheduled as shown—is sufficient. Childbirth Care – – – – Ideally, childbirth care by a skilled provider is initiated when labor begins and continues into the immediate postpartum/newborn period (2 hours after childbirth). Postpartum Care 6 hours 6 days 6 weeks – For women whose postpartum periods are progressing normally, a minimum of three postpartum care visits—scheduled as shown—may be sufficient. Newborn Care 6 hours 6 days – – For babies whose newborn periods are progressing normally, a minimum of two newborn care visits—scheduled as shown— may be sufficient. * Visits should take place on or around the times listed. Textbox 2-2. Preparing for Transfer to Continued Postpartum/Newborn Care Before the woman and her newborn are transferred to continued postpartum/newborn care: z Address any additional questions or concerns. z Review the danger signs and key points of the complication readiness plan. z Ensure communication of all relevant information about the woman, labor and childbirth, and newborn to the skilled postpartum/newborn care provider(s). z Ensure that the woman and baby receive ongoing assessment and care in the interim period until 6 hours after birth (or pre-discharge): − Ongoing assessment according to the schedules shown in Chapters 7 and 8 (for the woman: Table 2-13 [page 2-85]; for the newborn: Table 2-16 [page 2-111]); and − Ongoing supportive care according to the schedules shown in Chapters 7 and 8 (for the woman: Table 2-14 [page 2-86]; for the newborn: Table 2-17 [page 2-112]). JHPIEGO/Maternal and Neonatal Health Program 2-5 CHAPTER FIVE ANTENATAL CARE OVERVIEW After the woman has undergone the quick check (Annex 6, page 4-61), the antenatal care visit should be conducted according to the guidelines shown in Chapter 4 (page 2-1) and the schedule shown below (Table 2-2). Table 2-2. Schedule and Overview of Antenatal Care COMPONENTS/ELEMENTS 1 ST VISIT SUBSEQUENT VISITS ASSESSMENT History H-1. Personal information, page 2-6 9 − H-2. Menstrual history, contraceptive history/plans, page 2-8 9 − H-3. Present pregnancy, page 2-10 9 9 H-4. Daily habits and lifestyle, page 2-10 9 − H-5. Obstetric history, page 2-11 9 − H-6. Medical history, page 2-12 9 − H-7. Interim history, page 2-13 − 9 Physical Examination PE-1. General well-being, page 2-14 9 9 PE-2. Blood pressure, page 2-15 9 9 PE-3. Breasts, page 2-15 9 As needed PE-4. Abdomen, page 2-17 9 9 PE-5. Genitals, page 2-22 9 As needed Testing T-1. Hemoglobin levels, page 2-25 9 As needed T-2. RPR (or VDRL), page 2-25 9 − T-3. HIV, page 2-25 91 As needed1 T-4. Blood group and Rh, page 2-25 9 As needed CARE PROVISION C-1. Nutritional Support, page 2-26 9 Reinforce key messages C-2. Birth and Complication Readiness Plan, page 2-26 9 Continue to develop as needed; reinforce key messages Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-6 JHPIEGO/Maternal and Neonatal Health Program Table 2-2. Schedule and Overview of Antenatal Care (continued) COMPONENTS/ELEMENTS 1 ST VISIT SUBSEQUENT VISITS CARE PROVISION (CONTINUED) C-3. Self-Care and Other Healthy Practices, page 2-29 C-3.1. Use of potentially harmful substances, page 2-29 C-3.2. Prevention of infection/hygiene, page 2-29 C-3.3. Rest and activity, page 2-30 C-3.4. Sexual relations and safer sex, page 2-31 C-3.5. Early and exclusive breastfeeding, page 2-32 C-3.6. Family planning, page 2-33 9 Reinforce key messages C-4. HIV Counseling and Testing, page 2-33 C-4.1. Pretest counseling, page 2-33 C-4.2. Post-test counseling, page 2-34 9 As needed C-5. Immunizations and Other Preventive Measures, page 2-34 C-5.1. Tetanus toxoid (TT) immunization, page 2-34 C-5.2. Iron/folate, page 2-35 Intermittent preventive treatment and insecticide-treated bednets (for malaria)2, page 3-59 Presumptive treatment (for hookworm infection)2, page 3-58 Vitamin A supplementation2, page 3-62 Iodine supplementation2, page 3-61 9 Reinforce key messages; replenish drugs as needed 1 If woman “opts out” of HIV testing at one visit, she should be offered testing at subsequent visits. 2 According to region/population-specific recommendations ANTENATAL ASSESSMENT History (H) Once you have welcomed the woman and her companion, take the woman’s history. Be sure to record all findings in the woman’s chart. ¨ If this is the first visit, take a complete history (elements H-1 through H-6). ¨ If this is a return visit, a shortened history (elements H-3 and H-7) may be sufficient. H-1. Personal Information (First Visit) Question Use of Information/Followup Action z What is the woman’s name? z Use this information to: z Identify the woman, and z Help establish rapport. z What is her age (her date of birth, if available)? ¨ If the woman is 19 years of age or under, see Adolescence (page 3-37) for additional information about assessment and care provision. z What is her phone number (if available)? z Where does she live (her address, if available)? z Use this information to: z Contact the woman, and z Guide development of the birth and complication readiness plan. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-7 Question Use of Information/Followup Action z Does she have reliable transportation? z What sources of income/financial support does she/her family have? z Use this information to guide development of the birth and complication readiness plan. z How many previous pregnancies (gravida) and childbirths (para) has she had? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z Is she currently having a medical, obstetric, social, or personal problem or other concerns? z Has she had any problems during this pregnancy? ¨ If YES: z Ask general followup questions (Textbox 2-3, below) to assess the nature of her problem; and z Consider this information in the context of further assessment. ¨ If the woman reports signs or symptoms shown in Textbox 2-4 (page 2-8), see the corresponding entry for additional information about assessment and care provision. z Has she received care from another caregiver (including a TBA, herbalist, traditional healer) during this pregnancy? ¨ If YES, why did she seek care? ¨ If because of a problem, ask the general followup questions in Set A (Textbox 2-3, below) to assess the nature of her problem. ¨ If not because of a problem, ask the general followup questions in Set B (Textbox 2-3, below) to assess the nature of care received. z Consider this information in the context of further assessment. Textbox 2-3. General Followup Questions Set A: Questions to ask if the woman has (or recently had) a problem: z What is the problem, exactly? z When did it first occur? z Did it occur suddenly or develop gradually? z When and how often does the problem occur? z What may have caused the problem? Did anything unusual occur before its onset? z How is the woman affected by the problem? Is she eating, sleeping, and behaving normally? z Has the problem become more or less severe? z Are there accompanying signs/symptoms or conditions? If YES, what are they? z Has she received care/treatment from another caregiver for this problem? If YES, proceed to Set B. Set B: Questions to ask if the woman has received care/treatment from another caregiver: z Who (or what healthcare facility) provided this care? z What did this care involve (drugs/medications, treatments, etc.)? z What was the outcome of this care (i.e., Was it effective? If for a problem, did it eliminate the problem?)? Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-8 JHPIEGO/Maternal and Neonatal Health Program Textbox 2-4. Common Discomforts of Pregnancy Abdomen, Breasts, and Legs Abdominal (or groin) pain, page 3-3 Breast changes, page 3-4 Leg cramps, page 3-5 Swelling (edema) of ankles and feet, page 3-5 Digestion and Elimination Bowel function changes— constipation or diarrhea, page 3-6 Food cravings or eating nonfood substances (pica), page 3-7 Gas, bloating, or loss of appetite, page 3-7 Heartburn or indigestion, page 3-8 Nausea or vomiting, page 3-9 Salivation, increased, page 3-9 Urination, increased, page 3-10 Genitals Vaginal discharge, page 3-11 Skin Itchiness, page 3-11 Perspiration, increased, page 3-12 Skin changes, page 3-12 Spider nevi, page 3-12 Stretch marks, page 3-13 Varicose veins, page 3-13 Sleep and Mental State Dreams (vivid) or nightmares, page 3-14 Fatigue or sleepiness, page 3-14 Feelings of worry or fear about pregnancy and labor, page 3-16 Insomnia, page 3-16 Mood swings, page 3-17 Miscellaneous Back pain, page 3-18 Bleeding or painful gums, page 3-19 Difficulty getting up/down, page 3-19 Dizziness or fainting, page 3-20 Hair loss, page 3-20 Headache, page 3-21 Heart palpitations, page 3-21 Hemorrhoids, page 3-22 Hip pain, page 3-22 Hyperventilation or shortness of breath, page 3-23 Nasal stuffiness or nasal bleeding, page 3-23 Numbness/tingling of fingers and toes, page 3-24 Walking awkwardly (waddling) or clumsiness, page 3-24 H-2. Menstrual History, Contraceptive History/Plans (First Visit) Question Use of Information/Followup Action z When was the first day of her last menstrual period (LMP)? ¨ If the woman does not know the first day of her LMP, confirm pregnancy and/or calculate gestational age based on further assessment, for example: z Symptoms of pregnancy (Textbox 2-5, page 2-9), as found through additional history z Signs of pregnancy, as found through physical examination or testing (abdominal examination, vaginal examination, urine pregnancy test, or ultrasound) ¨ If the woman knows the first day of her LMP, ask these followup questions: z Was her LMP abnormal in terms of onset, flow, and duration? z Was she using a hormonal contraceptive or breastfeeding when she became pregnant? ¨ If NO to BOTH followup questions, calculate estimated date of childbirth (EDC) using one of the methods shown in Textbox 2-6 (page 2-9). ¨ If YES to EITHER followup question, confirm pregnancy and/or calculate gestational age based on further assessment, for example: z Symptoms of pregnancy (Textbox 2-5, page 2-9), as found through additional history z Signs of pregnancy, as found through physical examination or testing (abdominal examination, vaginal examination, urine pregnancy test, or ultrasound) z How many more children does she plan to have? z Use this information to guide individualization of family planning and other aspects of basic care provision. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-9 Question Use of Information/Followup Action z Has she used a family planning method before? ¨ If YES, ask these followup questions: z Which family planning method(s) did she use? z If one method: Did she like it? Why/why not? z If more than one method: Which did she like most? Which did she like least? Why? z Use this information to guide individualization of family planning and other aspects of basic care provision. z Does she plan to use a family planning method after this baby is born? ¨ If YES, ask these followup questions: z Which method does she want to use? z Would she like information on additional methods? z Use this information to guide individualization of family planning and other aspects of basic care provision. Textbox 2-5. Symptoms of Pregnancy A woman may seek care to confirm that she is pregnant, having noticed the following symptoms: z No menses—she may have missed one or more menstrual periods z Breast changes—she may notice an increase in size, as well as tenderness or a tingling sensation z Nausea and/or vomiting—she may experience these symptoms at any time during the day/night, most commonly in the 1st trimester z Increased urinary frequency—she may notice that she has to urinate more frequently than usual z Quickening—she may feel the baby move Textbox 2-6. Methods for Calculating Estimated Date of Childbirth The following methods can be used to calculate EDC: z Gestational age calculator, such as the pregnancy wheel z Calendar method, based on the following formula: the date of the first day of the LMP + 7 days – 3 months = EDC for example: 9 May + 7 days – 3 months = 16 February z Moon method (if her periods are usually 1 moon, or 4 weeks, apart): If a woman’s period starts on a full moon, the baby is due 10 full moons later. If her period starts on a new moon, the baby is due 10 new moons later. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-10 JHPIEGO/Maternal and Neonatal Health Program H-3. Present Pregnancy (Every Visit) Question Use of Information/Followup Action z Has she felt fetal movements? ¨ If NO and the woman is/may be beyond 22 weeks’ gestation, ACT NOW!—see Management of Decreased or Absent Fetal Movements (Textbox 3-43, page 3-111) before proceeding. ¨ If YES, ask these followup questions: z When did the fetal movements begin? z Has she felt any in the last day? ¨ If the woman has felt fetal movements but not in the last day, ACT NOW!—see Management of Decreased or Absent Fetal Movements (Textbox 3-43, page 3-111) before proceeding. z What are her feelings about the pregnancy? z What are her partner’s/ family’s feelings about it? z Use this information to guide individualization of Support for Mother- Baby-Family Relationships and other aspects of basic care provision. ¨ If she reports mood swings (page 3-17) or worry or fear (page 3-16), see Chapter 9 for additional information about assessment and care provision. H-4. Daily Habits and Lifestyle (First Visit) Question Use of Information/Followup Action z Does the woman work outside the home? Is her daily workload strenuous (i.e., how much does she walk, carry heavy loads, engage in physical labor)? z Does she get adequate sleep/rest? z Is her dietary intake adequate (ask what she eats in a typical day, or what she has eaten in the past 2 days)? Does she eat any nonfood substances such as dirt or clay? z Has she given birth within the last year? z Is she currently breastfeeding another child? z Use this information to: z Determine whether there is a balance between the physical demands of the woman’s daily life and her dietary intake; and z Guide individualization of Nutritional Support and other aspects of basic care provision. ¨ If eating nonfood substances (pica) is reported, see page 3-7 for additional information about assessment and care provision. z Does she smoke, drink alcohol, or use any other potentially harmful substances? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z With whom does she live (partner, children, other household members)? z Use this information to guide development of the birth and complication readiness plan. Note: If the woman knows when the fetal movements began, use this information to help confirm/calculate gestational age. Fetal movements are usually first felt between 16 and 20 weeks’ gestation. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-11 Question Use of Information/Followup Action z Inform the woman that you are going to ask her some questions of a personal nature, and that you ask these questions of all clients. z Has anyone ever kept her from seeing family or friends, not allowed her to leave the house, or threatened her life? z Has she ever been injured, hit, or forced to have sex by someone? z Is she frightened of anyone? ¨ If NO to ALL questions OR the woman does not want to discuss this issue, inform her that she can discuss it with you at any time. ¨ If YES to ANY question OR you suspect abuse, see Violence against Women (page 3-81) for additional information about assessment and care provision. H-5. Obstetric History (First Visit) Note: Although a woman with a poor obstetric history does not necessarily require additional/specialized care, knowing about past complications helps you understand any concerns she may have during this pregnancy/ childbirth. In addition, discussing past complications provides an opportunity to emphasize the importance of having a birth and complication readiness plan. Question Use of Information/Followup Action z If this is not the woman’s first pregnancy/ childbirth, has she had any of the following previous complications: z Convulsions (pre-eclampsia/eclampsia) during pregnancy or childbirth? z Cesarean section, uterine rupture, or any uterine surgery during a previous childbirth? z Tears through the sphincter (3rd degree tear) and/or rectum (4th degree tear) during childbirth? z Postpartum hemorrhage? z Stillbirths; preterm or low birthweight babies; babies who died before 1 month of age? z Three or more spontaneous abortions? ¨ If YES, see Maternal, Fetal, or Newborn Complications of Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) for additional information about assessment and care provision. z If this is not the woman’s first child, has she breastfed before? ¨ If NO, explore the reasons why. z What prevented her from breastfeeding? z Did she stop because she had problems breastfeeding? ¨ If YES, ask these followup questions: z For how long did she breastfeed previous babies? z Did she have problems breastfeeding? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. Note: Violence against women is a difficult topic to address, especially if it is not clearly condemned in the woman’s culture. To encourage the woman to discuss this issue with you: z Ensure complete confidentiality by asking these questions when she is alone (i.e., when no family members or friends are present). z Make it clear that no one deserves to be hit or abused by anyone and that it should never happen, even though some people may think there is nothing wrong with it. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-12 JHPIEGO/Maternal and Neonatal Health Program H-6. Medical History (First Visit) Question Use of Information/Followup Action z Does the woman have any allergies? ¨ If YES, avoid use of any known allergens. z Has the woman been diagnosed with HIV? ¨ If YES, see HIV (page 3-51) for additional information about assessment and care provision. z Has she been recently (within the last 3 months) diagnosed with anemia? ¨ If YES, see Anemia (page 3-41) for additional information about assessment and care provision. z Has the woman been diagnosed with syphilis? ¨ If YES, see Syphilis (page 3-76) for additional information about assessment and care provision. z Has the woman been diagnosed with hepatitis, tuberculosis, heart disease, kidney disease, sickle cell disease, diabetes, goiter, or another serious chronic illness? ¨ If YES, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. z Has she had any previous hospitalizations or surgeries? ¨ If YES, ask these followup questions: z What was the reason for the hospitalization or surgery? z When was it? z What was the outcome? ¨ If the condition is unresolved or has the potential to complicate the pregnancy or childbirth, consider this information in the context of further assessment. z Is she taking any drugs/medications—including traditional/local preparations, herbal remedies, over-the-counter drugs, vitamins, and dietary supplements? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z Has she had a complete series of five tetanus toxoid (TT) immunizations to date? z Has it been less than 10 years since her last booster? z Use this information to assess the woman’s need for TT, according to the recommended TT schedule (Table 2-3, page 2-34). ¨ If NO to EITHER question OR the woman does not have a written record of prior TT immunizations, proceed according to the recommended TT schedule (Table 2-3, page 2-34). Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-13 H-7. Interim History (Return Visits) Question Use of Information/Followup Action z Is she having a medical, obstetric, social, or personal problem or other concerns currently? z Has she had any problems (or significant changes) since the last visit? ¨ If YES: z Ask general followup questions (Textbox 2-3, page 2-7) to assess the nature of the problem (or change); and z Consider this information in the context of further assessment. ¨ If the woman reports signs or symptoms shown in Textbox 2-4 (page 2-8), see the corresponding entry for additional information about assessment and care provision. z Use this information to determine changes that need to be made in the current plan of care. z Has she received care from another caregiver (including a TBA, herbalist, traditional healer) since the last visit? ¨ If YES, why did she seek care? ¨ If because of a problem, ask the general followup questions in Set A (Textbox 2-3, page 2-7) to assess the nature of her problem. ¨ If not because of a problem, ask the general followup questions in Set B (Textbox 2-3, page 2-7) to assess the nature of care received. z Consider this information in the context of further assessment. z Has there been a change in the woman’s personal information (phone number, address, etc.) since the last visit? z Has there been a change in her daily habits or lifestyle (increase in workload, decrease in rest/sleep or dietary intake, etc.) since the last visit? z Has there been a change in her medical history since the last visit? For example, new or recent: z Diagnoses z Injuries z Hospitalizations z Drugs/medications z Use this information to: z Maintain accuracy of the woman’s medical records, and z Determine changes that need to be made in the current plan of care. Note: The questions below, together with those in H-3, represent the minimum that you would ask a woman upon a return visit. Additional history may be necessary depending on the woman’s individual needs. Remember: The questions in element H-3 (Present Pregnancy) should be asked at every antenatal care visit. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-14 JHPIEGO/Maternal and Neonatal Health Program Question Use of Information/Followup Action z Has she been unable to carry out any part of the plan of care (e.g., taking drugs/medications as prescribed, following dietary recommendations)? z Has she had any reactions or side effects to immunizations or drugs/medications given at last visit? ¨ If YES to EITHER question: z Consider this information in the context of further assessment. z Use this information to determine changes that need to be made in the current plan of care. Physical Examination (PE) When you have finished taking the woman’s history, perform a physical examination. Be sure to record all findings in the woman’s chart. ¨ If this is the first visit, perform a complete physical examination (elements PE-1 through PE-5). ¨ If this is a return visit, a shortened physical examination may be sufficient: z Always assess general well-being, examine conjunctiva, measure blood pressure, and examine the abdomen (elements PE-1, PE-2, PE-4). z Perform visual inspection of the breasts and genital examination (elements PE-3, PE-5) as needed. PE-1. Assessment of General Well-Being (Every Visit) Element Normal Abnormal/Followup action Gait and movements Facial expression z The woman walks without a limp. z Her gait and movements are steady and moderately paced. z Her facial expression is alert and responsive, yet calm. ¨ If findings are not within normal range, ask these followup questions: z Has she been without food or fluids for a prolonged period? z Has she been taking drugs/medications, herbs, etc.? z Does she have an injury? ¨ If YES to ANY of the above questions, consider the findings during further assessment and when planning/implementing care. ¨ If NO to ALL of the above questions: z Ask general followup questions to assess the nature of her problem (Textbox 2-3, page 2-7); and z Consider this information in the context of further assessment. General cleanliness z The woman is generally clean (i.e., there is no visible dirt, no odor, etc.). ¨ If the woman appears unclean, consider when individualizing health messages and counseling and other aspects of basic care provision. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-15 Element Normal Abnormal/Followup action Skin z The woman’s skin is free from lesions and bruises. ¨ If there are lesions and bruises on the woman’s skin OR you suspect abuse, see Violence against Women (page 3-81) for additional information about assessment and care provision. ¨ If there are lesions and bruises on the woman’s skin AND you do not suspect abuse, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Conjunctiva (mucous membrane on insides of eyelids) z The woman’s conjunctiva is pink (not white or very pale pink) in color. ¨ If her conjunctiva appears white or very pale rather than pink, see Anemia (page 3-41) for additional information about assessment and care provision. PE-2. Blood Pressure Measurement (Every Visit) z Have the woman remain seated or lying down with the knees slightly bent, ensuring that she is comfortable and relaxed. z Measure her blood pressure (BP). Normal Abnormal/Followup Action z Systolic BP (top number) is 90–140 mmHg, and z Diastolic BP (bottom number) is less than 90 mmHg ¨ If the systolic BP is less than 90 mmHg, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. ¨ If the diastolic BP is 90–110 mmHg, ACT NOW!— see Severe Headache, Blurred Vision, or Elevated Blood Pressure (page 3-108) before proceeding. ¨ If the diastolic BP is more than 110 mmHg, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. PE-3. Visual Inspection of the Breasts (First Visit/As Needed) z Help the woman prepare for further examination (follow the steps shown in Textbox 2-7 [page 2-16]). z Ask the woman to uncover her body from the waist up. z Have her remain seated with her arms at her sides. z Visually inspect the overall appearance of the woman’s breasts, such as contours, skin, and nipples; note any abnormalities. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-16 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Contours Skin z Contours are regular with no dimpling or visible lumps. z Skin is smooth with no puckering; no areas of scaliness, thickening, or redness; and no lesions, sores, or rashes. z Normal variations: z Breasts may be larger (and more tender) than usual. z Veins may be larger and darker, more visible beneath the skin. z Areolas may be larger and darker than usual, with tiny bumps on them. ¨ If findings are not within normal range, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Nipples z There is no abnormal nipple discharge. z Nipples are not inverted. z Normal variations: z Nipples may be larger, darker, and more erectile than usual. z Colostrum (a clear, yellowish, watery fluid) may leak spontaneously from nipples after 6 weeks’ gestation. ¨ If there is abnormal nipple discharge, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. ¨ If nipples appear to be inverted, test for protractility (Textbox 2-8, page 2-17). ¨ If the nipples are inverted, be alert for potential breastfeeding problems (e.g., problems with attachment of the newborn to the breast, suckling). Textbox 2-7. Preparing for Further Examination Complete the steps below before performing the rest of the physical examination. Before asking the woman to undress: z Explain the next steps in the physical examination and obtain her permission/consent before proceeding. z Ask her to empty her bladder. − During pregnancy: At the first visit and as indicated, have the woman provide a urine sample at this time if you (or your healthcare facility) are equipped to conduct urine testing. z Have the woman undress in private. − During pregnancy and the postpartum period: Ask her to remove only enough clothing to complete the examination. For example: − For the breast inspection, she should remove her upper garments. − For the genital examination, she should remove her lower garments. − For the abdominal examination, she should remove or loosen upper and lower garments as needed. − During labor/childbirth: If possible, give her a clean gown to wear (instead of having her remove or loosen individual items of clothing). z Provide her with a drape or blanket (if available) to cover parts of her body that are not being examined. z Help her onto the examination surface and assist her in assuming a comfortable position. Use a pillow, if available, to support her head. If necessary, ask her to take a few deep breaths to help her relax. z Wash your hands thoroughly with soap and water and dry them with a clean, dry cloth or allow them to air dry. z Put new or high level-disinfected examination gloves on both hands. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-17 Textbox 2-8. Checking Protractility of Nipples that Appear Inverted z Place the thumb and fingers on either side of the areola and gently squeeze. z If the nipple goes in when it is gently squeezed, then it is inverted. (Truly inverted nipples are rare.) PE-4. Abdominal Examination (Every Visit) z If you have not already done so, help the woman prepare for further examination (follow the steps shown in Textbox 2-7 [page 2-16]). z Ask the woman to uncover her abdomen. z Have her lie on her back with her knees slightly bent. Element Normal Abnormal/Followup Action Surface of the abdomen (First Visit) z There are no scars (from previous cesarean section, uterine rupture, or other uterine surgeries) on the surface of the abdomen. ¨ If there is a scar from a cesarean section, uterine rupture, or other uterine surgery, see Maternal, Fetal, or Newborn Complications of Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) for additional information about assessment and care provision. Fundal height (between 12 and 22 weeks’ gestation) (After 16 weeks’ gestation, see also Fetal parts and movement [page 2-18].) z The uterus feels firm. z Fundal height increases, and does not decrease, between visits. z Fundal height is consistent with the gestational age, as previously calculated. z At 12 weeks, the uterus rises out of the pelvis and is palpable just above the symphysis pubis. z At 16 weeks, the uterus is about halfway between the symphysis pubis and umbilicus. z At 18–20 weeks, the uterus measures about 20 cm above the symphysis pubis, just below the umbilicus. z At 22 weeks, the uterus is at the level of the umbilicus. (See also Figure 2-1 [page 2-20].) ¨ If any of the following signs is present, see Size-Date Discrepancy through 22 Weeks’ Gestation (page 3-72) for additional information about assessment and care provision: z Uterus is soft and boggy, z Uterus has decreased in size since the last visit, or z Uterus is too small or large for dates. For the procedure, see Textbox 2-9 (page 2-19). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-18 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Fundal height (after 22 weeks’ gestation) (See also Fetal parts and movement [below].) z Fundal height increases, and does not decrease, between visits. z Fundal height is consistent (within 2 cm+/-, per local standards) with the gestational age, as previously calculated. z At 22–24 weeks, the uterus measures about 24 cm above the symphysis pubis, at the upper margin of the umbilicus. z At 26–30 weeks, the uterus measures about 28 cm above the symphysis pubis, midway between the umbilicus and the xiphoid process. z At 30–34 weeks, the uterus measures about 30 to 32 cm in length, closer to the xiphoid process than the umbilicus. z At 34–38 weeks, the uterus measures about 32 to 34 cm above the symphysis pubis and extends to the xiphoid process. z At 39–40 weeks, the uterus measures about 32 to 34 cm above the symphysis pubis, as the presenting part of the fetus settles into the pelvis. (See also Figure 2-1 [page 2-20].) ¨ If either of the following signs is present, see Size-Date Discrepancy after 22 Weeks’ Gestation (page 3-73) for additional information about assessment and care provision: z Uterus has decreased in size since the last visit, or z Uterus is too small or large for dates. Fetal parts and movement (between 20 weeks’ and term gestation) (At/after 36 weeks’ gestation, see also Fetal lie and presentation, [below].) z At 24+ weeks, fetal parts are palpable. z After 22+ weeks, fetal movements may be felt. ¨ If a fetus is not palpable and the likelihood of pregnancy is in doubt, confirm pregnancy by performing a pelvic examination (page 4-26) or conducting a urine pregnancy test. Fetal lie and presentation (at/after 36 weeks’ gestation) z At 36 weeks, the fetus is longitudinal in lie and cephalic in presentation. z After 36 weeks, the head may be: z Fixed, engaged z Dipping into the pelvis z Free and floating ¨ If the fetus is in breech presentation or transverse lie and you do not suspect labor, facilitate nonurgent referral/ transfer (Annex 7, page 4-63) after providing basic care. For the procedure, see Textbox 2-10 (page 2-20). For the procedure, see Textbox 2-9 (page 2-19). Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-19 Element Normal Abnormal/Followup Action Fetal heart tones (after 20 weeks’ gestation) z By 12 weeks, fetal heart tones are heard with a Doppler stethoscope or electronic fetal stethoscope (fetoscope). z At 20+ weeks, fetal heart tones are heard with a Pinard fetoscope. z Fetal heart rate is from 120 to 160 beats per minute (during pregnancy only, not when the woman is in labor). ¨ If fetal heart tones are present but not within normal range, ACT NOW!—see Management of Abnormal Fetal Heart Rate (Textbox 3-45, page 3-113) before proceeding. ¨ If fetal heart tones are not present, ACT NOW!—see Management of Absent Fetal Heart Tones (Textbox 3-44, page 3-112) before proceeding. Textbox 2-9. Procedure for Fundal Height Measurement Procedure for 12–22 weeks: z Gently palpate the abdomen above the symphysis pubis. z Estimate the weeks of gestation by determining the distance between the top of the fundus and the symphysis pubis (Figure 2-1, page 2-20). Procedure for more than 22 weeks: z Check the fundal height with a tape measure. z Place the zero line of the tape measure on the upper edge of the symphysis pubis. z Stretch the tape measure across the contour of the abdomen to the top of the fundus. Use the abdominal midline as the line of measurement (Figure 2-1, page 2-20). z Alternatively, place the zero line of the tape measure at the top of the fundus and stretch to the upper edge of the symphysis pubis. Note: When comparing actual fundal height measurements to those listed in the assessment table, be aware that there is variation among different populations in what is considered a “normal” fundal height at each gestational stage. Refer to local standards to determine appropriate fundal height measurements for your client population. For the procedure, see Textbox 2-11 (page 2-21). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-20 JHPIEGO/Maternal and Neonatal Health Program Figure 2-1. Antenatal Fundal Height Measurement Textbox 2-10. Procedure for Determining Fetal Lie and Presentation Before performing the following three maneuvers: z Be sure your hands are clean and warm. z Stand at the woman’s side, facing her head. STEP 1: Fundal Palpation (Figure 2-2, page 2-21): z Using the flat part (pads), not the tips, of your fingers, place both hands on the sides of the fundus at the top of the abdomen. z Determine which part of the fetus is at the top of the uterus. To do this, gently but firmly use the flat part (pads) of the fingers to assess the consistency and mobility of the fetal part: − The buttocks will be softer and more irregularly shaped than the head, and cannot be moved independently of the body. − The head will be harder than the buttocks, and can be moved back and forth between both hands. STEP 2: Lateral Palpation (Figure 2-3, page 2-21): z Move your hands smoothly down the sides of the uterus to feel for the fetal back; it will feel firm and smooth in contrast to the small parts, which will feel knobby and easily moveable. z Keep your dominant hand steady against the side of the uterus, while using the palms of your nondominant hand to apply gentle but deep pressure to explore the opposite side of the uterus. z Repeat the maneuver, palpating with the dominant hand and steadying with the nondominant hand. STEP 3: Pelvic Palpation (Supra-Pubic) (Figure 2-4, page 2-21): z Turn and face the woman’s feet. (Her knees should already be bent slightly to relax the abdominal muscles.) z Place your hands on the sides of the uterus with the palms of your hands below the level of the umbilicus and your fingers pointing toward the symphysis pubis. Grasp the fetal part snugly between the hands. (The thumbs will be at the approximate level of the umbilicus.) z If this fetal part is palpable at or above the symphysis, feel it for shape, size, consistency, and mobility. If the head is presenting, a hard mass with a distinctive round surface will be felt. If the breech is presenting, a larger, softer mass will be felt. Observe the woman’s face for signs of pain/tenderness during palpation. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-21 Figure 2-2. Fundal Palpation Figure 2-3. Lateral Palpation Figure 2-4. Pelvic Palpation (Supra-Pubic) Textbox 2-11. Procedure for Determining Fetal Heart Rate (after 20 weeks’ gestation) z Place the fetal stethoscope (fetoscope) on the woman’s abdomen at right angles to it (on the same side on which you palpated the fetal back). Note: If a Pinard fetoscope is not available, you may use a regular stethoscope, headscope, or toilet paper roll. z Place your ear in close, firm contact with the fetal stethoscope. z Move the fetal stethoscope around to where the fetal heart is heard most clearly. z Remove your hands from the fetal stethoscope and listen to the fetal heart. z Listen for a full minute, counting the beats against the second hand of a clock. − During active labor: Also listen through a contraction and for at least 15 seconds afterwards. Note: Feel the woman’s pulse at her wrist, simultaneously, to ensure that you are measuring fetal heart tones and not maternal pulse. The maternal pulse will be slower than the fetal heart rate. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-22 JHPIEGO/Maternal and Neonatal Health Program PE-5. Genital Examination (First Visit/As Needed) z If you have not already done so, help the woman prepare for further examination (follow the steps shown in Textbox 2-7 [page 2-16]). z Perform a genital/vaginal examination (Textbox 2-12, page 2-23). z After the examination, perform the Post-Examination Steps (Textbox 2-13, page 2-24). Element Normal Abnormal/Followup Action Vaginal opening Skin Labia z There are no signs of female genital cutting. z The genital skin is free from sores, ulcers, warts, nits, or lice. z The labia are soft and not painful. ¨ If signs of genital cutting are present, see Female Genital Cutting during Pregnancy or Labor (page 3-49) for additional information about assessment and care provision. ¨ If findings (other than signs of genital cutting) are not within normal range, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Vaginal secretions z There is no blood or foul- smelling, yellow, or greenish discharge coming from the vaginal opening. z There is no urine or stool coming from the vaginal opening. z Normal variations: There may be increased vaginal secretions, but they are white or clear and odorless. ¨ If there is vaginal bleeding, ACT NOW!—see Vaginal Bleeding in Early Pregnancy (through 22 weeks’ gestation) (page 3-102) or Vaginal Bleeding in Later Pregnancy (after 22 weeks’ gestation) or Labor (page 3-102) before proceeding. ¨ If other findings are not within normal range, facilitate nonurgent referral/ transfer (Annex 7, page 4-63) after providing basic care. Skene’s and Bartholin’s glands z The Skene’s and Bartholin’s glands are not painful and do not exude any discharge when milked or pressed. ¨ If findings are not within normal range, facilitate nonurgent referral/ transfer (Annex 7, page 4-63) after providing basic care. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-23 Textbox 2-12. Procedure for Genital/Vaginal Examination z Before you begin: − Inform the woman of what you are going to do before each step of the examination. − Ask the woman to uncover her genital area. Cover or drape her to preserve her privacy and respect her modesty. − Ask the woman to separate her legs while continuing to bend her knees slightly. − Turn on the light and direct it toward the genital area. − Wash your hands thoroughly with soap and water and dry them with a clean, dry cloth or allow them to air dry. − Put new or high-level disinfected examination gloves on both hands. z Before cleansing the vulva, inspect the external genitalia. z Touch the inside of the woman’s thigh before touching any part of her genital area. z Separating the labia majora with two fingers, check the labia minora, clitoris, urethral opening, and vaginal opening. z Palpate the labia minora. Look for swelling, discharge, tenderness, ulcers, and fistulas. Feel for any irregularities or nodules. z Look at the perineum. Check for any scars, lesions, inflammation, or skin integrity/cracks in the skin. z During the antenatal period: − Check the Skene’s gland for discharge and tenderness (Figure 2-5, page 2-24). With the palm facing upward, insert the index finger into the vagina and gently push upward toward the urethra; milk the gland on each side of the urethra, and then milk gently directly over the urethra. − Check the Bartholin’s gland for discharge and tenderness (Figure 2-6, page 2-24). Insert the index finger into the vagina at the lower edge of the opening and feel at base of each of the labia majora. Using your finger and thumb, palpate each side for any swelling or tenderness. − Ask the woman to bear down while you hold the labia open. Check for any bulging of the anterior or posterior vaginal walls. z During labor/childbirth: − Observe the introitus for visible bulging of membranes or fetal head/parts. − Perform a vaginal examination: Gently insert the index and middle finger of the examination hand into the vagina, maintaining light, downward pressure as you move your fingers toward the cervix. Continue with the cervical examination. z During the postpartum period: Note bruising of the perineum and characteristics of lochia (by looking at the perineum and the woman’s perineal pads). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-24 JHPIEGO/Maternal and Neonatal Health Program Figure 2-5. Checking the Skene’s Gland Figure 2-6. Checking the Bartholin’s Gland Textbox 2-13. Post-Examination Steps Complete the following steps after examining the woman: z Immerse both gloved hands in 0.5% chlorine solution. z Remove gloves by turning them inside out. z If disposing of gloves, place in leakproof container or plastic bag. z If reusing gloves, submerge in 0.5% chlorine solution for 10 minutes to decontaminate. z Wash hands thoroughly. z Assist the woman in getting off the table. − During labor/childbirth: Assist her in assuming the position of her choice. z Share your findings with her. Testing (T) When you have finished performing a physical examination, conduct testing. Be sure to record all findings in the woman’s chart. ¨ If this is the woman’s first visit, conduct all of the tests listed (elements T-1 through T-4), but remember that the woman may “opt out” of HIV testing (see Note [page 2-25]). ¨ If this is a return visit, conduct tests only as indicated or needed. z Test hemoglobin levels (element T-1) as needed based on signs and symptoms. z Conduct an HIV test (element T-3) whenever the woman chooses to have it done (see Note, page 2-25). Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-25 Element Normal Abnormal/Followup Action T-1. Hemoglobin levels z Hemoglobin level is 11 g/dL or more ¨ If her hemoglobin level is less than 7 g/dL, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If her hemoglobin level is 7–11 g/dL, see Anemia (page 3-41) for additional information about assessment and care provision. T-2. RPR1 z Negative ¨ If the test is positive for syphilis, see Syphilis (page 3-76) for additional information about assessment and care provision. T-3. HIV (See Note [below].) z Negative ¨ If the test is positive for HIV, see HIV (page 3-51) for additional information about assessment and care provision. T-4. Blood group and Rh, if available z Blood group is A, B, AB, or O. z Rh is positive. ¨ If Rh is negative, the woman is a candidate for anti-D immune globulin. 1 Use VDRL if RPR is not available. Note: The woman should be informed that HIV testing is recommended for all pregnant women, but that she may “opt out” of being tested if she desires. If she opts out, be sure to offer testing at all subsequent visits. A woman who chooses not to be tested during the first visit may change her mind and choose to be tested after she has received counseling, considered the benefits of testing, and/or discussed testing with her partner. Assure the woman that “opting out” will not result in her being denied services, and will not affect the care she receives. For the procedure, see page 4-43. For the procedure, see page 4-44. Note: Always adhere to national guidelines for HIV testing. In general: z If the test is positive for HIV, test again with a different type/preparation of test. z If the second test is positive, see HIV (page 3-51). z If the second test is negative, do a third test for discordant test results. z If the third test is positive, see HIV (page 3-51). z If the third test is negative, inform the woman that she is HIV-negative during post-test counseling (page 2-34). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-26 JHPIEGO/Maternal and Neonatal Health Program Region/Population-Specific Testing: Urine for Glucose (first visit/as needed) If the woman lives in an area with a high prevalence of diabetes/gestational diabetes or has a history of this disease, test her urine for glucose. Normal Abnormal/Followup Action Negative ¨ If her urine is negative for glucose BUT the woman lives in an area with a high prevalence of diabetes/gestational diabetes or has a history of this disease, repeat the test early in the 3rd trimester (around 28 weeks). ¨ If her urine is positive for glucose, the woman has a condition beyond the scope of basic care; facilitate appropriate care and/or referral/transfer to a specialist, higher level of care, or supportive services. ANTENATAL CARE PROVISION C-1. Nutritional Support Based on the woman’s dietary history, the resources available to the woman and her family, and any other relevant findings or discussion, individualize the following key nutrition messages. All women should: z Eat a balanced diet consisting of beans and nuts, starchy foods (e.g., potatoes, cassava, maize, cereals, rice), animal products (meat, milk, eggs, fish, yogurt, cheese), and fruits and vegetables. z Eat a variety of foods each day, including foods rich in: z Iron: red meat, liver, eggs, peanuts, lentils, dark green leafy vegetables, and shellfish. Substances that inhibit iron absorption, such as coffee or tea and calcium supplements, should be avoided or taken 2 hours after meals. z Vitamin A: liver, milk products, eggs, sweet potatoes, pumpkin, carrots, and papaya. z Calcium: milk, dark green leafy vegetables, shrimp, dried fish, beans, lentils, whole-grain millet, and oil seeds. z Magnesium: cereal, dark green leafy vegetables, seafood, nuts, legumes, and groundnuts. z Vitamin C: oranges or other citrus fruits, tomatoes, and potatoes. Pregnant women should also: z Eat at least one additional serving of staple food per day. z Eat smaller, more frequent meals if unable to consume larger amounts in fewer meals. z Take micronutrient supplements as directed. C-2. Birth and Complication Readiness Plan Assist the woman in developing a birth plan that includes both birth preparedness (all the arrangements that should be made for a normal birth) and complication readiness (an exact plan for what to do if a danger sign arises). The woman’s family, partner, or other key decision makers in her life should be involved in this process; if she permits, invite them to join in this discussion. Honor the woman’s choices except when doing Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-27 so may put her or her newborn at risk. Also, be sensitive to cultural beliefs or social norms (e.g., superstitions that urge against buying items for a baby not yet born) that may impede the planning process. Note: Although this section 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. In order for an individual birth plan to be effective in saving a woman’s life, it must also have support—in the form of actions, resources, skills, and attitudes—from policymakers, healthcare facilities, and individual community members. z On the first visit, introduce the concept of a birth plan (including complication readiness): z Ensure that the woman and her family understand that they should address each of the items well before the estimated date of childbirth (EDC). z On each return visit, review and update the birth plan: z What arrangements have been made since the last visit? z Has anything changed? z Have any obstacles or problems been encountered? z By 32 weeks, finalize the birth plan. The woman and her family should have made all of the arrangements by now. If needed, provide additional assistance at this time to complete the plan. Components of the Birth and Complication Readiness Plan Note: Items to be included in the complication readiness plan, which should be discussed/reviewed at every encounter/visit with the woman during the entire childbearing cycle, are indicated with an asterisk (*). Skilled Provider Assist the woman in arranging for a skilled provider to attend the birth; this person should be trained in supporting normal labor/childbirth and managing complications, if they arise. Items Needed for Clean and Safe Birth and the Newborn Make sure the woman has gathered necessary items for a clean and safe birth. Discuss the importance of keeping items together for easy retrieval when needed. z Items needed for the birth include: perineal pads/cloths; soap; clean bed cloths; placenta receptacle; clean, unused razor blade; waterproof/plastic cover; clean cord ties. z Items needed for the newborn include: blankets, diapers/napkins, hat, clothes, etc. that have been washed and dried in the sun. Appropriate Setting/ Healthcare Facility* Ensure that the woman has an appropriate place for the birth to take place based on her individual needs. For complication readiness, assist the woman in choosing the appropriate healthcare facility (e.g., district hospital, health center) to go to if danger signs arise. Note: Items needed depend on the individual requirements of the intended place of birth, whether in a healthcare facility or in the home. Note: Ensure that the woman knows how to contact the skilled provider or healthcare facility at the appropriate time. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-28 JHPIEGO/Maternal and Neonatal Health Program Transportation* Ensure that the woman is familiar with local transportation systems and has transportation to an appropriate place for the birth based on her individual needs. For complication readiness, assist the woman in choosing emergency transportation to an appropriate healthcare facility if danger signs arise. Funds* Assist the woman in planning to have funds available when needed to pay for care during normal birth. For example, putting aside even a small amount on a weekly basis can result in savings. For complication readiness, discuss emergency funds that are available through the community and/or healthcare facility if danger signs arise. Decision-Making* Discuss how decisions are made in the woman’s family (who usually makes decisions?), and decide the following: z How decisions will be made when labor begins or if danger signs arise (who is the key decision maker?) z Who else can make decisions if that person is not present Support* Assist the woman in deciding on/making arrangements for necessary support, including the following: z Companion of her choice to stay with her during labor and childbirth, and accompany her during transport if needed z Someone to care for her house and children during her absence Blood Donor* Ensure that the woman has identified an appropriate blood donor and that this person will be available in case of emergency. Danger Signs* and Signs of Labor Ensure that the woman knows the danger signs which indicate a need to enact the complication readiness plan: z Vaginal bleeding z Breathing difficulty z Fever z Severe abdominal pain z Severe headache/blurred vision z Convulsions/loss of consciousness z Foul-smelling discharge/fluid from vagina z Decreased/absent fetal movements z Leaking of greenish/brownish (meconium-stained) fluid from the vagina Also ensure that she knows the signs of labor, which indicate a need to contact the skilled provider and enact the birth preparedness plan: z Regular, progressively painful contractions Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-29 z Lower back pain radiating from uterus z Bloody show z Rupture of membranes C-3. Self-Care and Other Healthy Practices Based on the woman’s history and any other relevant findings or discussion, individualize health messages and counseling on the topics addressed below. Although these issues should be addressed at the earliest opportunity, other topics—such as support for mother-baby-family relationships, breastfeeding support, and the basics of newborn care—may be more relevant later in the pregnancy or can be included according to individual need. Ideally, the woman’s partner would be present during these discussions. Note: Women who have common discomforts of pregnancy require additional care, which consists mainly of health messages and counseling. Chapter 9 (page 3-1) contains information on additional care for women with common discomforts. C-3.1. Use of Potentially Harmful Substances z Smoking, drinking alcohol, and taking any drugs/medications—including certain prescribed and over- the-counter drugs, vitamins and dietary supplements, and herbal/traditional preparations or remedies— may be especially harmful to a pregnant woman and her unborn baby. z A pregnant woman should inform her skilled provider about any drugs/medications she is currently taking; her skilled provider will decide whether they should be discontinued or the dosage should be adjusted during pregnancy. z A pregnant woman should talk to her skilled provider before taking any drugs/medications during the course of the pregnancy. z The skilled provider should prescribe only drugs/medications that are necessary and safe. C-3.2. Prevention of Infection/Hygiene General hygiene: z Hands should be washed before the following activities: z Eating or drinking z Preparing food z Feeding a baby z Hands should be washed after the following activities: z Using the toilet z Changing a baby’s diaper/napkin z Safe water should be used for drinking to avoid infections and diarrhea, which may compromise nutritional status. To prepare safe drinking water, do the following: z Boil water for 10 minutes before use if it is not clean. z Store clean water in a container with a lid. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-30 JHPIEGO/Maternal and Neonatal Health Program z Food should be handled and stored safely by doing the following: z Clean surfaces on which food is prepared or served. z Cover food to avoid flies and contamination. z Store food for no more than 12 hours without refrigeration. z The woman’s body, clothing, bedding, and environment should be kept clean; this means: z Bathing regularly z Changing bedding and clothing regularly z Cleaning regularly Hygiene during pregnancy: In addition to practicing good general hygiene (above), the pregnant woman should be advised of the following: z During pregnancy, the pregnant woman should be especially careful about hygiene to prevent disease and infection—pregnant women sweat more and have more vaginal discharge than nonpregnant women (due to hormonal changes), and may be more vulnerable to germs. z Dental hygiene is especially important during pregnancy because increased estrogen levels can cause swelling and increased sensitivity in gum tissues. Whether she cleans her teeth with a dental stick or a toothbrush and toothpaste, the pregnant woman should do so regularly. C-3.3. Rest and Activity Based on the woman’s history and any other relevant findings and discussion, individualize the following key messages: z A pregnant woman should try to decrease the amount of heavy work and increase rest time. z A pregnant woman needs additional rest. In early pregnancy, the woman will feel tired as her body becomes accustomed to being pregnant. In later pregnancy, the growing fetus uses more of the woman’s energy and causes greater strains on her body. As the pregnancy progresses, she will need more and more rest. z A pregnant woman should have periodic rest periods during the day, in addition to whatever amount of sleep she normally needs. Note: In most cultures, women do not get permission to rest during pregnancy. It may be your role to play advocate for the woman, and help her find creative ways to reduce her workload and find more time for rest. z A pregnant woman should avoid lying on her back. The best resting position for a pregnant woman is lying on her left side with her feet elevated. (See also Textbox 2-14 [page 2-31]). z Pregnant women should avoid sitting or standing for long periods during the day. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-31 Textbox 2-14. Why Side-Lying Is Important for the Pregnant Woman When a pregnant woman lies flat on her back (such as when she is resting or sleeping), the enlarged uterus puts pressure on the major vessels of her circulatory system, which: z Decreases blood flow from the lower half of the body, which in turn: − Reduces the amount of blood filling the heart; − Lowers cardiac output; − Restricts blood flow to the fetus; and − May result in low blood pressure, which may cause the woman to faint when she gets up. z The woman can alleviate this syndrome by sitting up or lying on her side. z During pregnancy, hormonal changes cause softening of cartilage in some joints and relaxation in other joints. This means that the pregnant woman is much more susceptible to injuries. She should therefore: z Avoid overexertion; z Avoid carrying heavy loads; and z Use proper body mechanics (Textbox 2-15, below), especially when lifting anything such as a small child. z The pregnant woman has increased caloric needs. She should consider decreasing her workload and/or avoiding heavy physical labor, especially if she: z Appears to be getting thinner; z Has unsatisfied hunger or work-related fatigue; or z Cannot increase her dietary intake enough to meet the caloric requirements of pregnancy or the physical demands of her daily life. Textbox 2-15. Proper Body Mechanics z Use proper body mechanics for lifting: − Squat (keeping the spine erect), rather than bend, to lift anything so that the legs (thighs), rather than the back, bear the weight and strain. − When squatting or rising from a squatting position, spread the feet apart and place one foot slightly in front of the other, so that there is a broad base for balance. z Practice good posture when standing or sitting. z Do not cross the legs when sitting. C-3.4. Sexual Relations and Safer Sex Practicing safer sex can reduce the risk of HIV and other sexually transmitted infections (STIs): z Abstinence or mutually monogamous sex with a partner who is free from HIV or STIs is the only sure protection. z Consistent use of condoms is important, even during pregnancy. z Sexual practices that may further increase risk of infection (such as anal sex, “dry” sex, etc.) should be avoided. z A decrease or increase in the woman’s desire for sex is normal during pregnancy. z Intercourse during a pregnancy that is progressing normally will not harm the woman or the fetus. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-32 JHPIEGO/Maternal and Neonatal Health Program z Intercourse should be avoided, however, if she experiences the following: z Leaking watery fluid z Vaginal bleeding z Signs of premature labor z As the pregnancy progresses, changes in sexual position may be needed to accommodate the woman’s enlarged abdomen or satisfy both partners’ sexual needs. z Having or contracting an STI—such as HIV, syphilis, gonorrhea, or chlamydia—while pregnant is dangerous to the woman, her partner, and the unborn baby. C-3.5. Early and Exclusive Breastfeeding Note: If the woman is HIV-negative, exclusive breastfeeding for the first 6 months of life should be strongly encouraged. The following health messages and counseling should be provided to all women during pregnancy unless they are HIV-positive or have said that they do not wish to breastfeed. Based on the woman’s history and any other relevant findings and discussion, individualize the key messages below. Benefits of breastfeeding: Breastfeeding has many benefits for the woman and newborn, including the following: z Provides the best nutrition for the newborn: z Is easily digested and efficiently used by the baby’s body z Protects against infection and other illnesses z Offers some protection against allergies z Is cost-effective/affordable z Promotes mother-baby bonding z Provides the woman with contraceptive protection until menses return (as long as she is exclusively breastfeeding) General principles of early and exclusive breastfeeding: The basic principles of early and exclusive breastfeeding are as follows: z Babies should begin breastfeeding as soon as possible after birth (preferably within the first hour) and continue for the first 6 months of life. z Colostrum, the first milk, should be given to the baby, not thrown away. z The baby should be breastfed exclusively for the first 6 months of life. This means that nothing else should be given to the baby to drink or eat during that time. z The baby should be breastfed whenever s/he wants, day and night (on demand), which stimulates the breasts to produce an adequate supply of breastmilk. Note: For more specific breastfeeding guidelines, see page 2-102. For information on proper positioning for good attachment, see page 4-47. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-33 C-3.6. Family Planning During the antenatal period, discussion should begin concerning postpartum contraception options. It should be based on the woman’s history and other relevant findings together with her and, if appropriate, her partner’s preference for desired family size and child spacing. Appropriate birth spacing is also a crucial element of family health and should be discussed. z Intervals of at least 3 years have health benefits for both the woman and baby. Appropriate birth spacing lowers the risk of: z Maternal mortality z Anemia (woman) z Premature rupture of membranes (woman) z Postpartum endometritis (woman) z Malnutrition (woman) z Fetal death z Preterm birth z Small-for-gestational-age baby z Newborn death z Intrauterine growth retardation and low birthweight baby z Numerous safe methods of contraception are available for the breastfeeding woman (page 4-53). z The return of fertility after birth is not entirely predictable, and conception can occur before the woman resumes her menstrual periods. C-4. HIV Counseling and Testing (First Visit/As Needed) If the woman does not know her HIV status or has not been tested for HIV, provide HIV counseling and testing. C-4.1. Pretest Counseling z Inform her that testing is recommended for all pregnant (and postpartum) women, but that she may “opt out” (chose not to be tested) if she desires. z Explain that: z HIV counseling and testing is confidential and private. z The woman can receive HIV counseling and testing at any visit, even if she has opted out in the past. z Help the woman assess her individual risk factors for HIV/AIDS, such as unprotected sex, multiple partners (more than one partner in the last 3 months), nonmonogamous partner or one with a mobile job (military position, long-distance truck driver), new or casual partner, sexual assault, and injection drug use. z Provide information about HIV/AIDS: how the virus is transmitted (e.g., unprotected sex, reusing needles), how it can affect the body (e.g., decreases the body’s ability to fight infections), and how the risk of transmission can be reduced (e.g., mutual monogamy, abstinence, condom use for dual protection). z Address local myths and false rumors about HIV/AIDS, for example, about what it is, how it is transmitted, and who is at risk. z Provide information about the test (its confidentiality, how it is conducted, when the results will be available). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-34 JHPIEGO/Maternal and Neonatal Health Program z Provide information about the results: z A positive result indicates HIV infection. z A negative result indicates the absence of HIV infection, but because there is a “window period” between infection and a positive test result, the test may need to be repeated in cases of recent possible infection. z Emphasize the importance of returning for her test results and continuing basic care. C-4.2. Post-Test Counseling Arrange to see the woman in person to give her the test results. Do not give results over the telephone. z For a negative result: z Provide the result. z Review the woman’s individual risk factors and counsel accordingly. z Reinforce risk reduction practices, including skill-building exercises (e.g., demonstrating proper use of condoms; role playing to practice negotiation skills, such as for using condoms or abstaining from sex). z Identify support for risk reduction (e.g., accessible source of condoms). z For a positive result, see Textbox 3-18 (page 3-53) for guidance on appropriate post-test counseling, as well as HIV (page 3-51) for additional information about assessment and care provision. C-5. Immunizations and Other Preventive Measures C-5.1. Tetanus Toxoid (TT) Immunization ¨ If the woman is due for her next TT vaccination (according to her written record, history, or the schedule below [Table 2-3]): z Give tetanus toxoid 0.5 mL IM in the woman’s upper arm. z Update her card (provide her with one if needed) and inform her when the next vaccination is due. ¨ If the woman is not due for a TT vaccination, inform her when the next one is due. Table 2-3. Tetanus Toxoid Immunization Schedule TT INJECTION DUE TT1 At first contact with a woman of childbearing age or as early as possible during pregnancy (at first postpartum visit) TT2 At least 4 weeks after TT1 TT3 At least 6 months after TT2 TT4 At least 1 year after TT3 TT5 At least 1 year after TT4 z Counsel and provide health messages about the following: z TT immunization is the best protection against tetanus for the woman and her baby. Therefore, it is very important for her to be immunized according to the schedule on her card, and to bring her card to every healthcare visit. z The woman and her family should plan/prepare for a clean and safe childbirth with a skilled provider. z To prevent tetanus in the newborn, the newborn’s cord should be kept clean and dry after birth and until it falls off. Chapter Five: Antenatal Care JHPIEGO/Maternal and Neonatal Health Program 2-35 C-5.2. Iron/Folate z To prevent anemia, prescribe iron 60 mg + folate 400 mcg to be taken by mouth once daily throughout the pregnancy. z Dispense sufficient supply to last until the next visit. z Provide health messages and counseling as follows: z Eat foods rich in vitamin C, as these help the body absorb iron. Sources of vitamin C include citrus fruits (oranges, grapefruit, lemons, limes), tomatoes, peppers, potatoes, cassava leaves, and yams. z Avoid tea, coffee, and colas, as these inhibit iron absorption. z Possible side effects of the iron/folate tablets include black stools, constipation, and nausea. Lessen side effects by doing the following: − Drinking more fluids (an additional 2–4 cups per day) − Eating more fruits and vegetables − Getting adequate exercise (such as walking) − Taking tablets with meals or at night Region/Population-Specific Preventive Measures z For women in areas with a high prevalence of malaria, see guidelines for prevention (page 3-59). z For women in areas with a high prevalence of hookworm infection, see guidelines for prevention (page 3-58). z For women in areas with a high prevalence of vitamin A deficiency, see guidelines for additional supplementation (page 3-62). z For women in areas with a high prevalence of iodine deficiency, see guidelines for additional supplementation (page 3-61). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-36 JHPIEGO/Maternal and Neonatal Health Program JHPIEGO/Maternal and Neonatal Health Program 2-37 CHAPTER SIX LABOR/CHILDBIRTH CARE OVERVIEW After the woman has undergone the quick check (Annex 6, page 4-61), care during labor and childbirth should be provided according to the guidelines shown in Chapter 4 (page 2-1) and the schedule shown below (Table 2-4). Table 2-4. Schedule and Overview of Labor/Childbirth Care COMPONENTS/ELEMENTS INITIAL ASSESSMENT 1 ST STAGE 2 ND & 3RD STAGES 4TH STAGE ASSESSMENT Ongoing Assessment, page 2-38 9 9 9 9 History H-1. Personal information, page 2-50 9 − − − H-2. Estimated date of childbirth/menstrual history, page 2-51 9 − − − H-3. Present pregnancy and labor/childbirth, page 2-52 9 − − − H-4. Obstetric history, page 2-53 9 − − − H-5. Medical history, page 2-54 9 − − − Physical Examination PE-1. General well-being, page 2-55 9 − − − PE-2. Vital signs, page 2-56 9 1 1 1 PE-3. Breasts, page 2-57 92 − − − PE-4. Abdomen, page 2-58 9 1 1 1 PE-5. Genitals, page 2-63 9 1 1 1 PE-6. Cervix, page 2-64 9 1 1 1 Testing T-1. RPR (or VDRL), page 2-69 9 − − − T-2. HIV, page 2-69 93 − − − T-3. Blood group and Rh, page 2-70 9 − − − CARE PROVISION Ongoing Supportive Care, page 2-38 9 9 9 9 C-1. Key Actions for 1st Stage, page 2-70 C-1.1. Start a partograph, page 2-71 − 9 − − Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-38 JHPIEGO/Maternal and Neonatal Health Program Table 2-4. Schedule and Overview of Labor/Childbirth Care (continued) COMPONENTS/ELEMENTS INITIAL ASSESSMENT 1 ST STAGE 2 ND & 3RD STAGES 4TH STAGE CARE PROVISION (CONTINUED) C-2. Key Actions for 2nd and 3rd Stages, page 2-71 C-2.1. Assist the woman in pushing, page 2-72 C-2.2. Assist in normal birth, page 2-74 C-2.3. Initiate immediate newborn care, page 2-77 C-2.4. Perform active management of 3rd stage, page 2-78 − − 9 − C-3. Key Actions for 4th Stage, page 2-79 C-3.1. Provide immediate postpartum care for the woman, page 2-80 C-3.2. Continue immediate newborn care, page 2-82 − − − 9 1 Element is also part of ongoing assessment. 2 Element can be postponed to 4th stage. 3 Woman may “opt out” of HIV testing. ONGOING ASSESSMENT AND SUPPORTIVE CARE Throughout the four stages of labor, the woman (and newborn, when applicable) should receive: z Ongoing assessment, according to the schedule shown in Table 2-5 (page 2-39) (for guidance on ongoing assessment of the newborn, see Table 2-6 [page 2-46]); and z Ongoing supportive care, as shown in Table 2-7 (page 2-47). Remember: To respect and maintain the mother-baby dyad, keep them together as much as possible throughout the immediate 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. 2- 39 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 2- 5. O ng oi ng A ss es sm en t o f t he W om an d ur in g La bo r a n d Ch ild bi rth ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E1 2N D 4T H 2 N O RM AL AB NO RM AL /F O LL O W UP A CT IO N M at er na l B lo od Pr es su re * Ev er y 4 ho ur s Ev er y 4 ho ur s (at le as t) O nc e (at le as t) Ev er y 15 m in ut es z Sy st ol ic BP (to p n um be r) is 90 –1 40 m m H g. z D ia st ol ic B P (bo tto m nu mb er) is le ss th an 9 0 m m H g. ¨ If th e sy st ol ic B P is le ss th an 9 0 m m Hg , AC T N O W !— pe rfo rm R ap id In itia l A ss es sm en t (p ag e 3- 90 ) b e fo re p ro ce e di ng . ¨ If th e di as to lic B P is 9 0– 11 0 m m H g, AC T N O W !— se e S ev er e He a da ch e, Bl ur re d Vi sio n , o r El ev at ed B lo od P re ss ur e (pa ge 3 -1 08 ) b efo re pr oc ee di n g. ¨ If th e di as to lic B P is m or e th an 1 10 m m H g, AC T NO W !— pe rfo rm R ap id In itia l A ss e ss m e n t (p ag e 3- 90 ) b efo re p ro ce e di n g. M at er na l Te m pe ra tu re * Ev er y 4 ho ur s Ev er y 2 ho ur s O nc e (at le as t) (O nc e) z Te m pe ra tu re is le ss th an 3 8° C. ¨ If te m pe ra tu re is 3 8° C or m or e, AC T NO W !— se e F ev er o r F ou l-S m el lin g Va gi na l D is ch ar ge (p ag e 3- 11 5) be fo re p ro ce e di n g. M at er na l Pu ls e* Ev er y 4 ho ur s Ev er y 30 m in u te s Ev er y 30 m in u te s Ev er y 15 m in ut es z Pu ls e is le ss th an 1 10 b ea ts p er m in ut e. ¨ If pu ls e is 1 10 o r m o re b ea ts p er m in ut e, AC T N O W !— pe rfo rm R ap id In itia l A ss es sm en t (p ag e 3- 90 ) b e fo re p ro ce e di ng . Fe ta l H ea rt To ne s* Ev er y 4 ho ur s Ev er y 30 m in u te s Ev er y 5 m in ut es − z D ur in g 1s t st ag e/ la te nt p ha se : F et al he ar t r at e is fr om 12 0 to 1 60 b e a ts p er m in ut e. z O nc e th e w om an g oe s in to a ct iv e la bo r: fe ta l h ea rt ra te is fr om 1 00 to 18 0 be a ts p er m in ut e. ¨ If fe ta l h ea rt to ne s ar e ab se n t, AC T NO W !— se e M an ag em en t o f A bs en t F et al H ea rt To ne s (T ex tb ox 3 -4 4, pa ge 3 -1 12 ) b ef or e pr oc e e di n g. ¨ If fe ta l h ea rt to ne s ar e no t w ith in n o rm al ra ng e, AC T NO W !— se e M an a ge m e n t o f A bn or m al F et al H ea rt R at e (Te x tb ox 3 -4 5, p ag e 3- 11 3) be for e pr oc ee di n g. * O nc e ac tiv e la bo r b eg in s, th is e le m en t i s re co rd ed o n a p a rto gr ap h an d in te rp re te d ac co rd in gl y. 1 Fr om th is p oi nt u p to c hi ld bi rth , a ll el em e n ts fo llo w e d by a n a st er is k (*) ar e r e co rd ed o n a p ar to gr a ph a n d in te rp re te d ac co rd in gl y. 2 Co ns ta n t v ig ila n ce o f t he w om a n a n d ba by is c rit ica l d ur in g th e 3rd st ag e of la bo r, al th o u gh n o t a fo rm al c om po ne n t o f t hi s ta bl e. If th e wo m an a n d ba by a re s ta bl e, o n go in g m o n ito rin g co n tin ue s w ith th e 4th st ag e of la bo r a t t he ti m es in di ca te d in th is ta bl e. 2- 40 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 2- 5. O ng oi ng A ss es sm en t o f t he W om an d ur in g La bo r a nd C hi ld bi rth (c on tin u ed ) ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E1 2N D 4T H 2 N O RM AL AB NO RM AL /F O LL O W UP A CT IO N M em br an es an d Am ni ot ic Fl ui d* W he n do in g va gi na l e xa m o r w he n le ak in g of flu id fr om th e va gi n a is ob se rv ed or r ep or te d W he n do in g a va gi na l e xa m o r w he n le ak in g of flu id fr om th e va gi n a is ob se rv ed o r re po rte d W he n do in g a v a gi n a l e xa m o r w he n le ak in g of flu id fr om th e va gi n a is o bs er ve d or re po rte d − z M em br an es r u pt ur e sp on ta ne o u sl y du rin g la bo r o r b irt h. z Am ni ot ic fl ui d is cl ea r a nd h as a d ist in ct , bu t n ot fo ul , m ild o do r. N ot e: D o no t r ou tin e ly ru pt ur e th e m e m br an es . ¨ If th e flu id is re d, AC T NO W !— se e Va gi n a l Bl ee di ng in La te r Pr eg na n cy o r La bo r (pa ge 3- 10 2) be fo re p ro ce e di ng . ¨ If th e flu id is g re en is h/ br ow ni sh , AC T N O W !— se e M an a ge m e n t o f M ec on iu m -S ta in ed Am ni ot ic Fl ui d (T ex tb ox 3- 42 , p ag e 3- 11 1) be for e pr oc ee di n g. ¨ If th e flu id is fo u l-s m el lin g, AC T N O W !— se e Fe ve r o r F ou l-S m e llin g Va gi na l D is ch a rg e (p ag e 3- 11 5) be fo re p ro ce e di n g. ¨ If it ha s be en m or e th an 1 8 ho ur s si nc e m em br an es h av e ru pt ur ed , se e P re la bo r R up tu re o f M em br an es o r R up tu re o f M em br a n e s fo r M or e th an 1 8 H ou rs b e fo re Bi rth (p ag e 3- 70 ) fo r a dd itio n a l i nf or m at io n ab ou t a ss es sm en t a n d ca re p ro vis io n . M ol di n g of Fe ta l H ea d W he n do in g a va gi na l e xa m W he n do in g a va gi na l e xa m W he n do in g a v a gi n a l e xa m z Bo ne s ar e s e pa ra te d or ju st to uc h ea ch o th er . (S ee al so Fi gu re s 2- 9 an d 2- 10 [pa ge 2 -6 7]. ) ¨ If th e bo ne s ov er la p, co n si de r in th e co nt ex t o f fu rth er a ss es sm e n t: − Be a le rt fo r s ig n s/ sy m pt om s of u n sa tis fa ct or y pr og re ss o f l ab o r (e. g., fe tal de sc en t o r ce rv ic al d ila tio n is n ot p ro gr e ss in g, co n tra ct io n s be co m e m o re ir re gu la r). Fe ta l D es ce n t* O nc e Ev er y 4 ho ur s Ev er y 15 m in u te s − z D es ce nt p ro gr e ss e s co n tin u a lly in a ct iv e ph a se o f l ab or . ¨ If de sc en t i s no t p ro gr es si ng c on tin ua lly , co n si de r in th e co n te xt o f f ur th er a ss es sm en t: − Be a le rt fo r s ig n s/ sy m pt om s of u n sa tis fa ct or y pr og re ss o f l ab o r (e. g., ce rvi ca l d ila tio n is n ot pr og re ss in g, co n tra ct io n s be co m e m o re irr eg ul ar ). * O nc e ac tiv e la bo r b eg in s, th is e le m en t i s re co rd ed o n a p a rto gr ap h an d in te rp re te d ac co rd in gl y. 1 Fr om th is p oi nt u p to c hi ld bi rth , a ll el em e n ts fo llo w e d by a n a st er is k (*) ar e r e co rd ed o n a p ar to gr a ph a n d in te rp re te d ac co rd in gl y. 2 Co ns ta n t v ig ila n ce o f t he w om a n a n d ba by is c rit ica l d ur in g th e 3rd st ag e of la bo r, al th o u gh n o t a fo rm al c om po ne n t o f t hi s ta bl e. If th e wo m an a n d ba by a re s ta bl e, o n go in g m o n ito rin g co n tin ue s w ith th e 4th st ag e of la bo r a t t he ti m es in di ca te d in th is ta bl e. 2- 41 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 2- 5. O ng oi ng A ss es sm en t o f t he W om an d ur in g La bo r a nd C hi ld bi rth (c on tin u ed ) ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E1 2N D 4T H 2 N O RM AL AB NO RM AL /F O LL O W UP A CT IO N Co nt ra ct io ns Fr eq ue n cy * a n d Du ra tio n * Ev er y 4 ho ur s Ev er y 30 m in u te s Ev er y 30 m in u te s − z 1s t st ag e/ la te nt p ha se : C on tra ct io ns a re in cr ea si n g in st re ng th , f re qu e n cy , a n d du ra tio n . z 1s t st ag e/ ac tiv e ph as e: − Fr eq ue n cy : t hr ee to fi ve p er 10 m in u te s − D ur at io n : m o re th an 4 0 se co n ds − Co m pl et e re la xa tio n be tw ee n co n tra ct io n s z 2n d st ag e: − Fr eq ue n cy : t hr ee to fi ve p er 10 m in u te s − D ur at io n : m o re th an 4 0 se co n ds − Co m pl et e re la xa tio n be tw ee n co n tra ct io n s ¨ If th er e ar e co n tin uo us u te rin e co nt ra ct io ns th at d o n o t a llo w th e u te ru s to re la x, AC T N O W !— se e V ag in a l B le e di ng in L at er P re gn a n cy o r La bo r (pa ge 3 -1 02 ) b ef or e pr oc ee di n g. ¨ If th er e is c on st an t p ai n th at p er si st s be tw ee n co n tr ac tio ns o r i s su dd en in o n se t ( or if co n tr ac tio ns c ea se a lto ge th er ), A CT N O W !— se e S ev er e Ab do m in a l P ai n in La te r P re gn a n cy o r La bo r (p ag e 3- 11 9) be fo re p ro ce e di ng . z 1s t st ag e/ la te nt p ha se : ¨ If co nt ra ct io ns a re d ec re a si n g in fre qu en cy /d ur at io n, a ss e ss th e w om a n fo r fa lse la bo r ( Ta bl e 2- 8, p ag e 2- 68 ). ¨ If fa ls e la bo r i s su sp ec te d, se e F al se L a bo r (p ag e 3- 48 ) fo r a dd itio n a l i nf or m a tio n ab ou t a ss e ss m e n t a nd c ar e pr ov is io n . z 1s t st ag e/ ac tiv e ph as e: ¨ If co nt ra ct io ns a re d ec re a si n g in fre qu en cy /d ur at io n, AC T NO W !— se e Un sa tis fa ct or y Pr og re ss o f L ab or (p ag e 3- 10 9) be fo re p ro ce e di ng . z 2n d st ag e: ¨ If co nt ra ct io ns a re in cr ea si n g in fre qu en cy /d ur at io n an d fe ta l h ea d is n ot de sc en di ng c on tin ua lly , AC T N O W !— se e Un sa tis fa ct or y Pr og re ss o f L ab or (p ag e 3- 10 9) be fo re p ro ce e di ng . ¨ If co nt ra ct io ns a re d ec re a si n g in fre qu en cy /d ur at io n, co n si de r i n th e co nt ex t o f f ur th er a ss es sm e n t: − Be a le rt fo r s ig ns /s ym pt om s of u n sa tis fa ct or y pr og re ss o f l ab o r (e. g., fe ta l d es ce n t i s no t p ro gr es sin g). * O nc e ac tiv e la bo r b eg in s, th is e le m en t i s re co rd ed o n a p a rto gr ap h an d in te rp re te d ac co rd in gl y. 1 Fr om th is p oi nt u p to c hi ld bi rth , a ll el em e n ts fo llo w e d by a n a st er is k (*) ar e r e co rd ed o n a p ar to gr a ph a n d in te rp re te d ac co rd in gl y. 2 Co ns ta n t v ig ila n ce o f t he w om a n a n d ba by is c rit ica l d ur in g th e 3rd st ag e of la bo r, al th o u gh n o t a fo rm al c om po ne n t o f t hi s ta bl e. If th e wo m an a n d ba by a re s ta bl e, o n go in g m o n ito rin g co n tin ue s w ith th e 4th st ag e of la bo r a t t he ti m es in di ca te d in th is ta bl e. 2- 42 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 2- 5. O ng oi ng A ss es sm en t o f t he W om an d ur in g La bo r a nd C hi ld bi rth (c on tin u ed ) ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E1 2N D 4T H 2 N O RM AL AB NO RM AL /F O LL O W UP A CT IO N Ce rv ix D ila tio n * a n d Pr es en ta tio n Ev er y 4 ho ur s Ev er y 4 ho ur s − − z 1s t st ag e/ la te nt p ha se : − D ila tio n is 1 – 3 cm . − D ila tio n is p ro gr e ss in g slo w ly. − Pr es en ta tio n is ce ph al ic . z 1s t st ag e/ ac tiv e ph as e: − D ila tio n is 4 – 10 cm . − D ila tio n is in cr e as in g by 1 c m p er ho ur a t l ea st . − Pr es en ta tio n is ce ph al ic . z O n th e pa rto gr ap h: Pl ot te d lin e s ta ys o n o r to th e le ft o f t he a le rt lin e . ¨ If th e fe tu s is in b re ec h pr es en ta tio n, se e Br ee ch P re se n ta tio n in L a bo r (p ag e 3- 47 ) fo r a dd itio n a l i nf or m a tio n ab ou t a ss e ss m e n t a nd ca re pr ov isi o n . z 1s t st ag e/ la te nt p ha se : ¨ If di la tio n ha s no t i n cr ea s ed fo r m or e th an 8 ho ur s an d co n tr ac tio ns a re re gu la r, AC T N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). ¨ If di la tio n ha s re ac he d 1 to 3 c m , b ut th en p ro gr es si ve d ila tio n st op s, se e Un sa tis fa ct or y Pr og re ss o f L ab or (p ag e 3- 10 9) fo r i nf or m at io n a bo u t a dd itio n a l a ss es sm e n t a n d ca re pr ov isi on . z 1s t st ag e/ ac tiv e ph as e: ¨ If di la tio n ha s no t i nc re as ed a t l ea st 4 c m in 4 h ou rs a nd c on tra ct io ns a re re gu la r, AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). z O n th e pa rto gr ap h ¨ If th e pl ot te d lin e m ov es to th e rig ht o f t he al er t l in e, AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). * O nc e ac tiv e la bo r b eg in s, th is e le m en t i s re co rd ed o n a p a rto gr ap h an d in te rp re te d ac co rd in gl y. 1 Fr om th is p oi nt u p to c hi ld bi rth , a ll el em e n ts fo llo w e d by a n a st er is k (*) ar e r e co rd ed o n a p ar to gr a ph a n d in te rp re te d ac co rd in gl y. 2 Co ns ta n t v ig ila n ce o f t he w om a n a n d ba by is c rit ica l d ur in g th e 3rd st ag e of la bo r, al th o u gh n o t a fo rm al c om po ne n t o f t hi s ta bl e. If th e wo m an a n d ba by a re s ta bl e, o n go in g m o n ito rin g co n tin ue s w ith th e 4th st ag e of la bo r a t t he ti m es in di ca te d in th is ta bl e. 2- 43 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 2- 5. O ng oi ng A ss es sm en t o f t he W om an d ur in g La bo r a nd C hi ld bi rth (c on tin u ed ) ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E1 2N D 4T H 2 N O RM AL AB NO RM AL /F O LL O W UP A CT IO N Va gi na l Se cr et io ns o r B le ed in g Ev er y 4 ho ur s (or w he n in cr ea se d se cr e tio ns / bl ee di n g a re re po rte d) Ev er y 4 ho ur s (or w he n in cr ea se d se cr e tio ns / bl ee di n g a re re po rte d) Co nt in u a lly Ev er y 15 m in ut es z Th er e is n o bl o o d, fo ul -s m el lin g o r ye llo w /g re en is h di sc ha rg e, u rin e, o r st oo l c om in g fro m th e va gi n a l o pe n in g. z N or m al v ar ia tio ns : m u co u s pl u g, bl oo dy s ho w , a m n io tic fl ui ds (If am n io tic fl ui ds , se e M em br an e s a n d Am ni ot ic F lu id , p ag e 2- 65 . ) z 4t h st ag e: Am ou n t o f b le ed in g is s im ila r to h ea vy m en se s. − N or m al v ar ia tio ns : C lo ts n o la rg er th an le m o n s m a y be p as se d. z 1s t /2 n d st ag e: ¨ If bl o o d (as op po se d to n o rm al b lo od y sh ow ) is co mi n g fro m th e va gi na , AC T N O W !— se e V ag in a l B le e di ng in L at er Pr eg na n cy o r L a bo r ( pa ge 3 -1 02 ) b efo re pr oc ee di n g. z 4t h st ag e: ¨ If th er e is fr an k, h ea vy b le ed in g; a s te ad y sl ow tr ic kl e of bl oo d; in te rm itt en t g us he s o f b lo o d; o r b lo o d cl o ts la rg er th an le m on s, AC T N O W !— se e V ag in al B le e di ng a fte r C hi ld bi rth (p ag e 3- 10 3) be for e pr oc ee di n g. ¨ If ot he r f in di n gs a re n o t w ith in n o rm al ra ng e, fa cil ita te p o st pa rtu m re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3) aft er pro vid in g ba si c ca re . B la dd er Ev er y 4 ho ur s Ev er y 2 ho ur s Ev er y ho ur Ev er y 15 m in ut es z Bl ad de r i s no t p al pa bl e . z Th e w om an is a bl e to u rin at e w he n th e u rg e is fe lt. ¨ If th e bl ad de r i s pa lp ab le o r t he w om an is u n ab le to u rin at e w he n th e u rg e is fe lt, se e Ur in ar y Re te nt io n d ur in g La bo r a n d th e Po st pa rtu m P er io d (p ag e 3- 79 ) fo r a dd itio n a l in fo rm at io n a bo u t a ss es sm en t a n d ca re p ro vis io n. 1 Fr om th is p oi nt u p to c hi ld bi rth , a ll el em e n ts fo llo w e d by a n a st er is k (*) ar e r e co rd ed o n a p ar to gr a ph a n d in te rp re te d ac co rd in gl y. 2 Co ns ta n t v ig ila n ce o f t he w om a n a n d ba by is c rit ica l d ur in g th e 3rd st ag e of la bo r, al th o u gh n o t a fo rm al c om po ne n t o f t hi s ta bl e. If th e wo m an a n d ba by a re s ta bl e, o n go in g m o n ito rin g co n tin ue s w ith th e 4th st ag e of la bo r a t t he ti m es in di ca te d in th is ta bl e. 2- 44 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 2- 5. O ng oi ng A ss es sm en t o f t he W om an d ur in g La bo r a nd C hi ld bi rth (c on tin u ed ) ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E1 2N D 4T H 2 N O RM AL AB NO RM AL /F O LL O W UP A CT IO N M at er na l A bi lit y to Co pe / R es po ns e to L ab or a nd Ch ild bi rt h Co nt . Co nt . Co nt . Co nt . R em in de r: N or m a l r es po n se is h ig hl y va ria bl e an d of te n cu ltu ra lly s pe cif ic. z 1s t st ag e/ la te nt p ha se : T he w om an is be ha vi ng lik e he r “u su a l s el f” (le ve l o f di sc om fo rt an d e ffo rt re qu ire d a re m in im al ). z 1s t st ag e/ ac tiv e ph as e: Th e w om an is re a ct in g to p ai n a n d un ce rta in ty w ith so m e d ist re ss , b ut is a bl e to co m m u n ic at e an d st ill in c o n tro l o f h er be ha vi or (le ve l o f d isc om fo rt an d ef fo rt re qu ire d ar e m o de ra te ). z 2n d st ag e: Th e w om an is re a ct in g to gr ow in g in te ns ity o f p ai n an d u n ce rta in ty w ith s om e di st re ss , a n d m u st fo cu s al m o st a ll of h er e n e rg y an d a tte nt io n on co n tra ct io ns fi rs t a nd la te r o n p us hi ng (le ve l o f d isc om fo rt a n d e ffo rt re qu ire d ar e in te n se ). ¨ If th e w o m an ’s a bi lit y to c op e is n ot w ith in n o rm al ra ng e, co n si de r in th e co n te xt o f f ur th er a ss e ss m e n t. ¨ If th e w om an is e xp er ie nc in g an y of th e si gn s/ sy m pt om s sh ow n in Te xt bo x 2- 16 (p ag e 2- 51 ), s ee th e c orr es po n di n g en try fo r a dd itio n a l i nf or m a tio n ab ou t a ss e ss m e n t a nd ca re pr ov isi o n . Ut er us − − − Ev er y 15 m in ut es z Ut er us re m ai n s fir m ; f ee ls lik e a fir m ba ll a t o r b el ow th e um bi lic u s. ¨ If ut er us re m ai ns s of t o r q ui ck ly b ec om es so ft af te r u te rin e m as sa ge , AC T N O W !— se e V ag in a l Bl ee di ng a fte r C hi ld bi rth (p ag e 3- 10 3) be for e pr oc ee di n g. 1 Fr om th is p oi nt u p to c hi ld bi rth , a ll el em e n ts fo llo w e d by a n a st er is k (*) ar e r e co rd ed o n a p ar to gr a ph a n d in te rp re te d ac co rd in gl y. 2 Co ns ta n t v ig ila n ce o f t he w om a n a n d ba by is c rit ica l d ur in g th e 3rd st ag e of la bo r, al th o u gh n o t a fo rm al c om po ne n t o f t hi s ta bl e. If th e wo m an a n d ba by a re s ta bl e, o n go in g m o n ito rin g co n tin ue s w ith th e 4th st ag e of la bo r a t t he ti m es in di ca te d in th is ta bl e. 2- 45 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 2- 5. O ng oi ng A ss es sm en t o f t he W om an d ur in g La bo r a nd C hi ld bi rth (c on tin u ed ) ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E1 2N D 4T H 2 N O RM AL AB NO RM AL /F O LL O W UP A CT IO N B re as tfe ed in g − − − W he ne ve r n e w bo rn n u rs e s z Th e w om an is p os itio n e d an d ho ld s th e ba by p ro pe rly . z Th e w om an s e e m s co m fo rta bl e . z At ta ch m en t o f t he n ew bo rn to th e br ea st a nd s uc kl in g ar e e ffe ct ive . z Th e ba by s ee m s sa tis fie d af te r f ee di n g. ¨ If fin di ng s ar e no t w ith in n o rm al ra ng e an d at ta ch m en t o r s u ck lin g do es n ot a pp ea r ef fe ct iv e, se e B re as t a nd B re as tfe ed in g Pr ob le m s (p ag e 3- 43 ) fo r a dd itio n a l i nf or m a tio n on a ss e ss m e n t a nd c ar e pr ov is io n . ¨ If th e w om an h as n ot y et d ec id ed w he th er s he w an ts to b re as tfe ed o r u se a b re as tm ilk su bs tit ut e, se e B re as tfe ed in g ve rs us U sin g a Br ea st m ilk S ub st itu te (p ag e 4- 49 ). ¨ If th e w om an h as c ho se n to u se a b re as tm ilk su bs tit ut e, se e U sin g a B re as tm ilk S ub st itu te (p ag e 4- 51 ). M ot he r- B ab y B on di ng – – – Co nt . z Th e w om an a pp ea rs to e njo y p hy sic al co n ta ct w ith h er n e w bo rn a n d ap pe a rs co n te nt ed w ith th e ne w bo rn . z Sh e ca re ss e s, ta lk s to , a nd m ak es e ye co n ta ct w ith th e n e w bo rn . z W he n ho ld in g o r fe ed in g th e n e w bo rn , sh e an d th e ne w bo rn a re tu rn e d to wa rd e a ch o th er . z Sh e re sp o n ds w ith a ct iv e co n ce rn to th e ne w bo rn ’s c ry in g or n e e d fo r a tte nt io n. ¨ If fin di ng s ar e no t w ith in n o rm al ra ng e, a sk w he th er s he is e xp er ie n ci ng fe e lin gs o f s ad ne ss , gu ilt, w or th le ss n e ss , a n xi e ty , b ei ng o ve rw he lm e d, o r di st ur ba n ce s in s le ep o r a pp et ite ; c ry in g m o re th an u su a l; an d/ or is m or e irr ita bl e th an u su a l. ¨ If YE S, se e P os tp ar tu m S ad ne ss (p ag e 3- 69 ) fo r a dd itio n a l i nf or m at io n ab ou t a ss es sm en t a n d ca re pr ov isi on . 1 Fr om th is p oi nt u p to c hi ld bi rth , a ll el em e n ts fo llo w e d by a n a st er is k (*) ar e r e co rd ed o n a p ar to gr a ph a n d in te rp re te d ac co rd in gl y. 2 Co ns ta n t v ig ila n ce o f t he w om a n a n d ba by is c rit ica l d ur in g th e 3rd st ag e of la bo r, al th o u gh n o t a fo rm al c om po ne n t o f t hi s ta bl e. If th e wo m an a n d ba by a re s ta bl e, o n go in g m o n ito rin g co n tin ue s w ith th e 4th st ag e of la bo r a t t he ti m es in di ca te d in th is ta bl e. 2- 46 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 2- 6. O ng oi ng A ss es sm en t o f t he B ab y du rin g La bo r a nd C hi ld bi rth ST AG E, P HA SE O F LA B O R/ H O W O FT EN T O A SS ES S W H A T TO A SS ES S 1S T , LA TE N T 1S T , A CT IV E 2N D 4T H N O RM AL AB NO RM AL /F O LL O W UP A CT IO N Fe ta l W el l-b ei ng As in T ab le 2- 5 As in T ab le 2- 5 As in T ab le 2- 5 z As in T ab le 2 -5 ¨ As in T ab le 2 -5 N ew bo rn R es pi ra tio n − − − Ev er y 15 m in ut es z R es pi ra to ry ra te is 3 0– 60 b re at hs p er m in ut e. z Th er e is n o ga sp in g, g ru n tin g o n e xp ira tio n , o r ch es t i nd ra w in g. ¨ If re sp ira tio ns a re n ot w ith in n o rm al ra ng e, AC T N O W !— se e N ew bo rn R ap id In itia l A ss e ss m e n t (p ag e 3- 96 ) b efo re p ro ce e di n g. N ew bo rn Te m pe ra tu re − − − Ev er y 15 m in ut es z Fe et a re n ot c ol d to th e to uc h. z Fe et a re n ot v er y wa rm to th e to uc h. ¨ If fe et a re c ol d or v er y w ar m to th e to uc h, m e a su re a xi lla ry te m pe ra tu re . ¨ If ax ill ar y te m pe ra tu re is le ss th an 3 6. 5° C O R m o re th an 3 7. 5° C, AC T NO W !— se e A bn or m a l Bo dy T em pe ra tu re (p ag e 3- 12 2) be for e pr oc ee di n g. N ew bo rn Co lo r − − − Ev er y 15 m in ut es z Ba by ’s lip s, to ng ue , a nd n ai lb e ds a re p in k z N o ce nt ra l c ya n o si s (bl u e to ng ue a n d lip s) z N o jau n di ce (y e llo w n e ss ) z N o pa llo r z H an ds a n d fe e t a re s om et im es “ bl ui sh ”/ cy an ot ic ¨ If th er e is c en tra l c ya no si s or p al lo r, AC T N O W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). ¨ If th er e is ja un di ce , AC T NO W !— se e J au nd ice (p ag e 3- 12 4) be fo re p ro ce e di n g. 2- 47 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 2- 7. O ng oi ng Su pp or tiv e Ca re M ea su re s fo r L ab or a nd C hi ld bi rt h EL EM EN T 1S T ST AG E/ LA TE N T PH A SE 1S T ST AG E/ AC TI VE P HA SE 2N D A N D 3 R D ST AG ES 4T H ST AG E Co m m un ic at io n/ A tte nd an ce z Co ns ta n t v ig ila n ce is n ot y et n e ce ss a ry . A tte nd to th e w o m a n a s n e e de d, a t l ea st e ve ry 4 h ou rs . If sh e liv es c lo se by , s he c an re tu rn w he n co n tra ct io n s be co m e s tro ng e r. z Pe rio di ca lly e ng ag e h er in co n ve rs a tio n, e ve n if b rie fly . z En co ur a ge th e b irt h co m pa n io n to s ta y wi th h er . z N ev er le a ve th e w o m a n a lo n e fo r m or e th an 3 0 m in ut es , e ve n if bi rth c om pa n io n is w ith h e r. Cl os er a tte n da n ce m a y be n e ce ss a ry if w om an is h a vi ng di ffi cu lty c op in g, c om pa ni on is n o t a tte nt iv e, o r fe ta l o r m a te rn al c o n di tio n re qu ire s cl os er m on ito rin g. z Pe rio di ca lly e ng ag e h er in co n ve rs a tio n, e ve n if b rie fly . z Pr ov id e co n tin u a l i nf o rm a tio n a n d re a ss u ra n ce a bo u t t he w o m a n ’s p ro gr e ss a n d th e w e ll- be in g of th e b ab y. z N ev er m ak e fa ls e p ro m ise s. z En co ur a ge th e b irt h co m pa n io n to s ta y wi th h er . z N ev er le a ve th e w o m a n a lo n e du rin g 2n d o r 3rd st ag e. z Fo cu s on w om a n ; l oo k fo r n o n ve rb al c ue s o f h er n ee ds a n d pr e fe re nc e s. z Us e an d ex pe ct m in im al v er ba l in te ra ct io n s. B e di re ct a nd c le a r. z G ive h er v er ba l e n co u ra ge m e n t a n d pr a is e. z Pr ov id e co n tin u a l i nf o rm a tio n a n d re a ss u ra n ce a bo u t h er pr og re ss a n d th e w el l-b e in g o f th e ba by . z N ev er m ak e fa ls e p ro m ise s. z En co ur a ge b irt h co m pa n io n in su pp o rt of th e wo m an . z Th e sk ille d pr ov id er s ho u ld a tte nd to th e wo m a n a t l ea st e ve ry 1 5 m in u te s, w he n vi ta l si gn s ar e c he ck ed , a nd : − Fo cu s on th e w o m a n ; l oo k fo r n on ve rb al c u e s o f h er n e e ds a nd p re fe re n ce s. − G ive h er v er ba l e n co u ra ge m e n t a n d pr ai se . − Pr ov id e co n tin u a l in fo rm at io n an d re a ss u ra n ce a bo ut h er co n di tio n a n d th e w el l- be in g o f t he b ab y. − En co ur a ge h e r to a sk qu es tio n s a n d e xp re ss h er fe el in gs . − Ad vis e th e bi rth c om pa n io n to re m ai n w ith th e w om a n du rin g th is tim e. (S ee al so M ot he r- Ba by B on di n g [pa ge 2 -4 9]. ) R es t a nd A ct iv ity / Po si tio ns z Al lo w th e w o m a n to re m ai n a s a ct iv e as s he d es ire s. z En co ur a ge re st o r sl ee p, a s sh e de sir es , s o th at sh e is w el l re st ed w he n a ct iv e la bo r be gi ns . z Al lo w th e w o m a n fr ee do m to ch oo se fr om a v ar ie ty o f po sit io n s, w hi le gu id in g he r to fin d a po sit io n th at e as es h e r di sc om fo rt an d pr om ot es la bo r. z As si st h er in re la xi ng be tw e e n co n tra ct io n s in o rd er to co n se rv e he r e n e rg y. z En co ur a ge p o si tio n ch a n ge s (e. g., si ttin g, sq ua ttin g, sid e- lyi ng , h a n ds a n d kn ee s), as w e ll a s w a lk in g, p ac in g, s ta nd in g, ro ck in g, le a n in g ov er a c ha ir— th es e m ay a ll b e he lp fu l a t va rio us ti m es th ro u gh ou t t he la bo r p ro ce ss . z Al lo w th e w o m a n fr ee do m to ch oo se fr om a v ar ie ty o f po sit io n s, w hi le gu id in g he r to fin d a po sit io n th at e as es h e r di sc om fo rt an d pr om ot es la bo r. z As si st h er in re la xi ng be tw e e n co n tra ct io n s in o rd er to co n se rv e he r e n e rg y. z If a po sit io n is tir in g, a ss ist th e w o m a n in ch an gi ng p os itio n s be tw ee n c o n tra ct io ns to fa cil ita te p ro gr e ss a n d to pr ov id e s o m e r el ie f o f di sc om fo rt. z En co ur a ge p o si tio n ch a n ge s (e. g., si ttin g, sq ua ttin g, sid e- lyi ng , h a n ds a n d kn ee s). z En su re th at th e w o m a n h a s e n o u gh b la n ke ts to m ai nt ai n w a rm th . z M ai nt ai n a c a lm e n vi ro nm e n t co n du ci ve to re st fo r t he w om an th at fa cil ita te s bo nd in g w ith h e r ba by a n d in itia tio n of br ea st fe ed in g. (S ee al so M ot he r- Ba by B on di n g [pa ge 2 -4 9]. ) 2- 48 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 2- 7. O ng oi ng Su pp or tiv e Ca re M ea su re s fo r L ab or a nd C hi ld bi rt h (co nt inu ed ) EL EM EN T 1S T ST AG E/ LA TE N T PH A SE 1S T ST AG E/ AC TI VE P HA SE 2N D A N D 3 R D ST AG ES 4T H ST AG E Co m fo rt z G ive th e wo m an a b ac k ru b or m a ss a ge . z Te ac h he r t o br e a th e ou t m or e sl ow ly th an u su a l d u rin g co n tra ct io n s a n d re la x wi th e a ch br ea th . z Li gh tly m as sa ge , ru b he r b ac k, o r a pp ly pr es su re to th e lo w e r ba ck , a s sh e de sir es . z Pr ov id e a c o o l c lo th fo r t he fa ce a n d ch e st , a s sh e de sir es . z Co nt in u e to c oa ch h er to br ea th e th ro ug h he r m ou th du rin g co nt ra ct io n in d el ib er a te sl ow b re a th s. (F or mo re in fo rm at io n a bo u t b re at hi n g te ch ni qu es , s ee T ex tb ox 2 -2 4 [pa ge 2 -7 3]. ) z Li gh tly m as sa ge o r ru b he r ba ck , a s sh e de sir es . z Ap pl y lo we r b ac k pr es su re to he lp re lie ve b ac k pa in . z St re tc h le gs o ut a nd fl ex fo ot u pw ar ds to re lie ve m u sc le cr a m ps in le gs a n d fe et . z Pr ov id e a c o o l c lo th fo r t he fa ce a n d ch e st , a s sh e de sir es . z Co nt in u e to c oa ch h er to br ea th e du rin g co n tra ct io n s u n til sh e ha s th e u rg e to p us h; th en co a ch h e r to p us h wh e n s he ha s th e ur ge , a ck no w le dg in g he r g oo d ef fo rts . (F or mo re in fo rm at io n a bo u t b re at hi n g te ch ni qu es , s ee T ex tb ox 2 -2 4 [pa ge 2 -7 3]. ) z D o no t e nc o u ra ge h e r to p us h w he n sh e ha s n o u rg e n o r to su st ai n pu sh in g lo ng er th an s he de sir es . z En su re th at th e w o m a n a n d ba by h a ve e n o u gh b la n ke ts to st ay w ar m . z M ai nt ai n a c a lm e n vi ro nm e n t co n du ci ve to re st fo r t he w om an th at fa cil ita te s bo nd in g w ith h e r ba by a n d in itia tio n of br ea st fe ed in g. (S ee al so M ot he r- Ba by B on di n g [pa ge 2 -4 9]. ) N ut rit io n z En co ur a ge fo o ds a s to le ra te d. Th er e ar e no re st ric tio ns o n in ta ke a s lo n g a s th e w om an ha s no n a u se a a n d/ or v om itin g. z Pr ov id e th e w o m a n w ith n u tri tio us d rin ks to m ai nt ai n hy dr at io n . Tw o lit er s of o ra l flu id s pe r 24 -h o u r pe rio d is a m in im um a m o u n t. z En co ur a ge lig ht m ea ls /fo od a s to le ra te d. T he re a re n o re st ric tio ns o n in ta ke a s lo n g as th e w om an h as n o n a u se a a n d/ or v om iti ng . z Pr ov id e th e w o m a n w ith n u tri tio us d rin ks to m ai nt ai n hy dr at io n . Tw o lit er s of o ra l flu id s pe r 24 -h o u r pe rio d is a m in im um a m o u n t. N ot e: So m e wo m e n e xp er ie n ce n a u se a a n d/ or v om itin g as la bo r pr og re ss e s; it is e sp ec ia lly im po rta nt in th es e ca se s to o ffe r s m al l s ip s of flu id s as to le ra te d to m ai nt ai n hy dr at io n . z O ffe r s ip s of c oo l, sw ee te ne d flu id s be tw ee n c o n tra ct io n s. N ot e: Th e w om a n w ill pr ob a bl y no t w a n t f oo d du rin g th is tim e. S om e w o m e n e xp er ie n ce n a u se a a n d/ or vo m iti ng in th e 2n d st ag e; o ffe r f lu id s a s to le ra te d to m ai nt ai n hy dr a tio n. z En co ur a ge th e w o m a n to e at a n d dr in k, a s sh e de sir es . 2- 49 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 2- 7. O ng oi ng Su pp or tiv e Ca re M ea su re s fo r L ab or a nd C hi ld bi rt h (co nt inu ed ) EL EM EN T 1S T ST AG E/ LA TE N T PH A SE 1S T ST AG E/ AC TI VE P HA SE 2N D A N D 3 R D ST AG ES 4T H ST AG E El im in at io n z En co ur a ge th e w o m a n to e m pt y he r b la dd e r e ve ry 2 h ou rs a n d e m pt y he r b ow el s as n ee de d. z D o N O T gi ve th e wo m a n a n e n e m a . z En co u ra ge th e w om an to em pt y he r b la dd e r e ve ry 2 h ou rs a n d e m pt y he r b ow el s as n ee de d. z R ec or d u rin e o u tp ut o n pa rto gr a ph . z D o N O T gi ve th e wo m a n a n e n e m a . z H av e he r e m pt y he r b la dd er be fo re o n se t o f p us hi n g. z R ea ss ur e he r t ha t i t i s no rm al to u rin at e d ur in g th e fo rc e of a co n tra ct io n , o r e m pt y he r bo we ls a s th e ba by ’s he ad pr es se s on th e re ct um . z En co ur a ge th e w o m a n to p a ss u rin e w he n th e u rg e is fe lt or if bl ad de r i s pa lp a bl e. H yg ie ne / In fe ct io n Pr ev en tio n z M ai nt ai n cl ea n lin es s of th e w o m a n a n d he r e n vi ro nm e n t: − En co ur a ge h e r to b at he be fo re a ct ive la bo r b eg in s. − Cl ea n se th e ge n ita l a re a if n e ce ss a ry b ef or e e a ch e xa m in a tio n . − D o N O T sh av e th e vu lv a. − Be fo re a nd a fte r e ac h e xa m in a tio n , w a sh y ou r ha nd s (w ith so a p an d w a te r) an d dr y wi th a c le a n to w el o r a ir dr y. − Cl ea n u p sp ills im m ed ia te ly. − R ep la ce s o ile d cl ot hs /b la n ke ts w ith c le an a n d dr y clo th s/ bl an ke ts . z M ai nt ai n cl ea n lin es s of th e w o m a n a n d he r e n vi ro nm e n t: − En co ur a ge h e r to b at he be fo re a ct ive la bo r b eg in s. − Cl ea n se th e ge n ita l a re a if n e ce ss a ry b ef or e e a ch e xa m in a tio n . − D o N O T sh av e th e vu lv a. − Be fo re a nd a fte r e ac h e xa m in a tio n , w a sh y ou r ha nd s (w ith so a p an d w a te r) an d dr y wi th a c le a n to w el o r a ir dr y. − Cl ea n u p sp ills im m ed ia te ly. − R ep la ce s o ile d cl ot hs /b la n ke ts w ith c le an a n d dr y clo th s/ bl an ke ts . z D is po se o f t he s oi le d lin e n in a bu ck et , p la st ic ba g, o r o th e r co n ta in e r th at c an b e clo se d fo r tra ns po rt to w as hi ng fa cil ity . z Ke ep th e wo m a n c le a n b y w ip in g fe ce s an d se cr et io n s im m ed ia te ly fro m th e pe rin e u m . z R ep la ce s o ile d a n d we t c lo th in g a n d be dd in g. z D is po se o f t he s oi le d lin e n in a bu ck et , p la st ic ba g, o r o th e r co n ta in e r th at c an b e clo se d fo r tra ns po rt to a w as hi n g fa cil ity . z Ke ep c le a n p a ds /c lo th s ag a in st th e pe rin e u m . M ot he r- B ab y B on di ng N /A N/ A N /A z En su re th at th e w o m a n a n d n e w bo rn a re k ep t t og et he r a s m u ch a s po ss ib le ; f ac ilit a te ro o m in g- in fo r t he w om a n a n d n e w bo rn . z M ai nt ai n sk in -to - sk in c on ta ct be tw ee n th e w o m a n a n d ba by a s m u ch a s po ss ib le . z En co ur a ge th e w o m a n to h o ld a n d ex pl or e h er b ab y fre el y. z En co ur a ge th e w o m a n a n d fa m ily to c ud dl e a n d ta lk to th e n e w bo rn a s m u ch a s th ey w ish ; giv e th em ti m e al on e if po ss ib le . z H el p bu ild th e w o m a n ’s co n fid e n ce b y ve rb al a nd n o n ve rb al m es sa ge s of e n co u ra ge m e n t a n d pr ai se . z En co ur a ge e a rly a nd e xc lu si ve br ea st fe ed in g. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-50 JHPIEGO/Maternal and Neonatal Health Program LABOR/CHILDBIRTH ASSESSMENT History (H) Once you have welcomed the woman and her companion, review the woman’s antenatal records, if available. If not, take the woman’s history. Be sure to record all findings in the woman’s chart. Note that at the beginning of the active phase of 1st stage of labor, when the cervix is 4 cm dilated, you should start a partograph (Annex 3, page 4-7). From that point through childbirth, you should record findings (those marked with an asterisk [*] in this chapter) on the partograph. After the baby is born, resume the woman’s chart and start a chart for the newborn. H-1. Personal Information Question Use of Information/Followup Action z What is the woman’s name? z Use this information to: z Identify the woman, and z Help establish rapport. z What is her age (her date of birth, if available)? ¨ If the woman is 19 years of age or under, see Adolescence (page 3-37) for additional information about assessment and care provision. z What is her phone number (if available)? z Where does she live (her address, if available)? z Use this information to: z Contact the woman, and z Guide development of the complication readiness plan. z How many previous pregnancies (gravida) and childbirths (para) has she had? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z Does she have a complication readiness plan that can be enacted if problems arise during labor or childbirth? ¨ If YES, confirm that arrangements have been made for all essential components of complication readiness, as shown in Textbox 2-17 (page 2-51). ¨ f NO, arrange—or assist the woman and her family in arranging—for all essential components of complication readiness, as shown in Textbox 2-17 (page 2-51). z Is she currently having a medical, obstetric, social, or personal problem or other concerns? z Has she had any problems during this labor/childbirth? ¨ If YES: z Ask general followup questions (Textbox 2-3, page 2-7) to assess the nature of her problem; and z Consider this information in the context of further assessment. ¨ If the woman reports signs or symptoms shown in Textbox 2-16 (page 2-51), see the corresponding entry for additional information about assessment and care provision. z Has she received care from another caregiver (including a TBA, herbalist, traditional healer) during this labor/childbirth? ¨ If YES, ask why did she seek care? ¨ If because of a problem, ask the general followup questions in Set A (Textbox 2-3, page 2-7) to assess the nature of her problem. ¨ If not because of a problem, ask the general followup questions in Set B (Textbox 2-3, page 2-7) to assess the nature of care received. z Consider this information in the context of further assessment. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-51 Textbox 2-16. Common Discomforts of Labor/Childbirth Abdomen, Breasts, and Legs Abdominal (or groin) pain, page 3-3 Afterpains, page 3-4 Leg cramps, page 3-5 Swelling (edema) of ankles and feet, page 3-5 Digestion and Elimination Nausea or vomiting, page 3-9 Urination, increased, page 3-10 Genitals Vaginal discharge, page 3-11 Skin Varicose veins, page 3-13 Sleep and Mental State Mood swings, page 3-17 Feelings of worry or fear about labor, page 3-16 Miscellaneous Back pain, page 3-18 Feeling hot, page 3-20 Headache, page 3-21 Hemorrhoids, page 3-22 Hyperventilation or shortness of breath, page 3-23 Nasal stuffiness or nasal bleeding, page 3-23 Numbness/tingling of fingers and toes, page 3-24 Shivering/quivering, page 3-24 Walking awkwardly (waddling) or clumsiness, page 3-24 Textbox 2-17. Essential Components of Complication Readiness during Labor and Childbirth z Danger signs: the woman and her family are aware of signs/symptoms that indicate a need to enact the complication readiness plan z Emergency transportation: they have arranged for transfer to appropriate skilled provider/healthcare facility if danger signs arise z Emergency funds: they have access to funds to pay for emergency care if needed z Decision-making: they have discussed how decisions will be made if an emergency arises z Support: support people have been identified to accompany the woman in transfer and to take care of the house/family in her absence, if needed z Blood donor: an appropriate donor has been identified and is available, if needed (Complete information about Complication Readiness is provided on page 2-26.) H-2. Estimated Date of Childbirth/Menstrual History Question Use of Information/Followup Action z What is her estimated date of childbirth (EDC)? ¨ If less than 37 weeks’ gestation (according to the EDC) and onset of labor is apparent, ACT NOW!—see Contractions before 37 Weeks’ Gestation (page 3-120) before proceeding. ¨ If the woman does not know her EDC, estimate gestational age based on guidelines in Textbox 2-18 (below). Textbox 2-18. Following Up on Unknown Estimated Date of Childbirth If the woman does not know her EDC, estimate gestational age based on further assessment, for example: Last menstrual period (LMP): If the woman knows the first day of her LMP, ask these followup questions: z Was her LMP abnormal in terms of onset, flow, and duration? z Was she using a hormonal contraceptive or breastfeeding when she became pregnant? ¨ If NO to BOTH followup questions, calculate EDC using one of the methods shown in Textbox 2-6 (page 2-9). ¨ If YES to EITHER followup question, estimate gestational age based on further assessment, for example: − Woman’s report of first fetal movement (below) − Fundal height measurement (below) − Ultrasound, if available First fetal movement: If she knows when she first felt the baby move, estimate the EDC by adding 20 weeks to this date if this is her first baby, and by adding up to 24 weeks if she has had at least one baby. Fundal height measurement: During abdominal examination, compare fundal height measurement with any findings from the history to confirm EDC or identify potential size-date discrepancy. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-52 JHPIEGO/Maternal and Neonatal Health Program H-3. Present Pregnancy and Labor/Childbirth Question Use of Information/Followup Action z Did she receive antenatal care during this pregnancy? ¨ If YES, ask these followup questions and consider findings in the context of further assessment: z From what provider/healthcare facility did she receive antenatal care? z How many antenatal care visits did she have? z What did the antenatal care include (e.g., testing, immunizations, drugs/medications, counseling)? ¨ If NO or the care was not adequate, consider findings in the context of further assessment: z Be alert for signs/symptoms of conditions or complications that may not have been adequately addressed during pregnancy. z Have her membranes ruptured? ¨ If NO, reassure the woman that her membranes should rupture spontaneously during labor or birth. ¨ If YES, ask these followup questions: z When did they rupture? z What is/was the color of the amniotic fluid? z Is/was the fluid foul-smelling? z Normal/normal variations: z Amniotic fluid is clear and has a distinct, but not foul-smelling, mild odor. z Membranes rupture spontaneously during labor or birth. ¨ If fluid is/was red, ACT NOW!—see Vaginal Bleeding in Later Pregnancy or Labor (page 3-102) before proceeding. ¨ If fluid is/was greenish/brownish, ACT NOW!—see Management of Meconium-Stained Amniotic Fluid (Textbox 3-42, page 3-111) before proceeding. ¨ If fluid is/was foul-smelling, ACT NOW!—see Fever or Foul- Smelling Vaginal Discharge (page 3-115) before proceeding. ¨ If it has been more than 18 hours since membranes have ruptured, and you suspect labor has begun, see Prelabor Rupture of Membranes or Membranes Ruptured for More than 18 Hours before Birth (page 3-70) for additional information about assessment and care provision. ¨ If it has been 4 hours or more since membranes have ruptured, and you suspect labor has not begun, see Prelabor Rupture of Membranes or Membranes Ruptured for More than 18 Hours before Birth (page 3-70) for additional information about assessment and care provision. z Have regular contractions begun (i.e., are they occurring at regular intervals)? ¨ If NO, assess the woman for false labor (Table 2-8, page 2-68). ¨ If false labor is suspected, see False Labor (page 3-48) for additional information on assessment and care provision. ¨ If YES, when did they begin? ¨ If it has been more than 12 hours since regular contractions began, consider this finding in the context of further assessment: z Be alert for other signs of unsatisfactory progress of labor (e.g., fetal descent or cervical dilation is not progressing, contractions become more irregular). Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-53 Question Use of Information/Followup Action z What are the frequency and duration of contractions? z Use this information in: z Evaluating the effectiveness of contractions (Textbox 2-20, page 2-62). z Assessing stage and phase of labor (Table 2-8, page 2-68), which will be confirmed in the physical examination. z Establishing a baseline against which later findings can be evaluated. ¨ If false labor is suspected, see False Labor (page 3-48) for additional information on assessment and care provision. z Has she felt fetal movements in the last 24 hours? ¨ If she has not felt fetal movements in the last 24 hours, ACT NOW!—see Management of Decreased or Absent Fetal Movements (Textbox 3-43, page 3-111) before proceeding. z Has she drunk alcohol or used any drugs/ medications, herbs, or other potentially harmful substances in the last 24 hours? ¨ If YES, consider this finding in the context of further assessment. z Be alert for signs of toxicity (e.g., altered mental state, nausea, vomiting), rapid or slowed labor, and/or fetal distress. z When did she last eat and/or drink? ¨ If it has been more than 8 hours since she has eaten food or taken fluids, consider this finding in the context of further assessment: z Be alert for signs of dehydration (e.g., pulse more than 100 beats per minute, dry mouth and tongue, sunken eyes, thirst). H-4. Obstetric History Note: Although a woman with a poor obstetric history does not necessarily require additional/specialized care, knowing about past complications helps you understand any concerns she may have during this childbirth. In addition, discussing past complications provides an opportunity to emphasize the importance of having a complication readiness plan. Question Use of Information/Followup Action z If this is not the woman’s first childbirth, has she had a previous cesarean section, uterine rupture, or any uterine surgery? ¨ If YES, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Note: During labor, the woman should be provided nutritious drinks to maintain hydration. Two liters of oral fluids per 24-hour period is a minimum amount. Women should also be encouraged to have light meals/food as tolerated. There are no restrictions on intake as long as the woman has no nausea and/or vomiting. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-54 JHPIEGO/Maternal and Neonatal Health Program Question Use of Information/Followup Action z If this is not the woman’s first pregnancy/ childbirth, has she had any of the other following previous complications: z Convulsions (pre-eclampsia/eclampsia) during pregnancy or childbirth? z Tears through the sphincter (3rd degree tear) and/or rectum (4th degree tear) during childbirth? z Postpartum hemorrhage? z Stillbirths; preterm or low birthweight babies; babies who died before 1 month of age? ¨ If YES, see Maternal, Fetal, or Newborn Complications of Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) for additional information about assessment and care provision. z If this is not the woman’s first child, has she breastfed before? ¨ If NO, explore the reasons why. z What prevented her from breastfeeding? z Did she stop because she had problems breastfeeding? ¨ If YES, ask these followup questions: z For how long did she breastfeed previous babies? z Did she have problems breastfeeding? ¨ If she has had problems breastfeeding in the past, consider this finding in the context of further assessment: z Be alert for signs of breast and breastfeeding problems (e.g., breast pain, ineffective positioning or attachment). z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. H-5. Medical History Question Use of Information/Followup Action z Does the woman have any allergies? ¨ If YES, avoid use of any known allergens. z Has the woman been diagnosed with HIV? ¨ If YES, see HIV (page 3-51) for additional information about assessment and care provision. z Has she been recently (within the last 3 months) diagnosed with anemia? ¨ If YES, see Anemia (page 3-41) for additional information about assessment and care provision. z Has the woman been diagnosed with syphilis? ¨ If YES, see Syphilis (page 3-76) for additional information about assessment and care provision. z Has the woman been diagnosed with hepatitis, tuberculosis, heart disease, kidney disease, sickle cell disease, diabetes, goiter, or another serious chronic illness? ¨ If YES, facilitate nonurgent referral/transfer (Annex 7, page 4-63) during the postpartum period. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-55 Question Use of Information/Followup Action z Has she had any previous hospitalizations or surgeries? ¨ If YES, ask these followup questions: z What was the reason for the hospitalization or surgery? z When was it? z What was the outcome? ¨ If the condition is unresolved or has the potential to complicate childbirth, consider this information in the context of further assessment. z Is she taking any drugs/ medications—including traditional/local preparations, herbal remedies, over-the- counter drugs, vitamins, and dietary supplements? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z Has she had a complete series of five tetanus toxoid (TT) immunizations to date? z Has it been less than 10 years since her last booster? z Use this information to assess the woman’s need for TT, according to the recommended TT schedule (Table 2-3, page 2-34). ¨ If NO to EITHER question OR the woman does not have a written record of prior TT immunizations, facilitate postpartum followup. Physical Examination (PE) When you have finished taking the woman’s history, perform a physical examination. Be sure to record all findings in the woman’s chart. Note that at the beginning of the active phase of the 1st stage of labor, when the cervix is 4 cm dilated, you should start a partograph (Annex 3, page 4-7). From that point through childbirth, you should record findings (those marked with an asterisk [*] in this chapter) on the partograph. After the baby is born, resume the woman’s chart and start a chart for the newborn. PE-1. Assessment of General Well-Being Element Normal Abnormal/Followup action Gait and movements Behavior and vocalizations z The woman walks without a limp. z Her gait and movements are steady and moderately paced. z Her behavior and vocalizations are appropriate to her culture. (See Note, page 2-56.) ¨ If findings are not within normal range, ask these followup questions: z Has she been without food or fluids for a prolonged period? z Has she been taking drugs/medications, herbs, etc.? z Does she have an injury? z Is she in the middle of a contraction? ¨ If YES to ANY of the above questions, consider the findings during further assessment and when planning/implementing care. ¨ If NO to ALL of the above questions: z Ask general followup questions to assess the nature of her problem (Textbox 2-3, page 2-7); and z Consider this information in the context of further assessment. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-56 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup action Skin z The woman’s skin is free from lesions and bruises. ¨ If there are lesions and bruises on the woman’s skin OR you suspect abuse, see Violence against Women (page 3-81) for additional information about assessment and care provision. ¨ If there are lesions and bruises on the woman’s skin AND you do not suspect abuse, facilitate nonurgent referral/transfer (Annex 7, page 4-63) during the postpartum period. Conjunctiva (mucous membrane on insides of eyelids) z The woman’s conjunctiva is pink (not white or very pale pink) in color. ¨ If her conjunctiva appears white or very pale rather than pink, test the woman’s hemoglobin levels (page 4-43). ¨ If her hemoglobin level is less than 7 g/dL, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If her hemoglobin level is 7–11 g/dL, see Anemia (page 3-41) for additional information about assessment and care provision. Note: Each woman responds differently to the discomfort that is a normal part of labor and childbirth. Moreover, what is considered an appropriate response to pain is, to a certain extent, culturally specific. In some cultures, it is acceptable for women to cry out; in others, they are expected to remain quiet/unexpressive. Thus, it is important to observe the woman for coping behaviors that: z Are clearly unusual or extreme for her culture; z Pose a threat to herself or others; or z Interfere with your ability to care for her (e.g., flailing, inability to communicate, incoherence). Such behaviors may indicate imminent birth or an abnormal level of pain or other potential problem that requires prompt attention. PE-2. Vital Signs Measurement z Have the woman remain seated or lying down with the knees slightly bent, ensuring that she is comfortable and relaxed. z Assess her respirations. z While taking her temperature, measure her blood pressure (BP) and check her pulse. z Plot all elements marked with an asterisk (*) on the partograph once the active phase of the 1st stage of labor has begun (i.e., when the cervix is 4 cm dilated). Element Normal Abnormal/Followup Action Respirations z Her breathing is regular, not rapid. z No gasping, wheezing, or rales. ¨ If findings are not within normal range, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-57 Element Normal Abnormal/Followup Action Blood Pressure* z Systolic BP (top number) is 90–140 mmHg. z Diastolic BP (bottom number) is less than 90 mmHg. ¨ If the systolic BP is less than 90 mmHg, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. ¨ If the diastolic BP is 90–110 mmHg, ACT NOW!—see Severe Headache, Blurred Vision, or Elevated Blood Pressure (page 3-108) before proceeding. ¨ If the diastolic BP is more than 110 mmHg, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. Temperature* z Temperature is less than 38°C. ¨ If temperature is 38°C or more, ACT NOW!—see Fever or Foul- Smelling Vaginal Discharge (page 3-115) before proceeding. Pulse* z Pulse is less than 110 beats per minute. ¨ If pulse is 110 or more beats per minute, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. *Once active labor begins, this element is recorded on a partograph and interpreted accordingly. PE-3. Visual Inspection of the Breasts Note: In general, this part of the examination should be performed immediately postpartum. It should only be performed at this point if the woman is in the latent (or early active) phase of the 1st stage of labor and is not in acute distress. z Help the woman prepare for further examination; follow the steps shown in Textbox 2-7 (page 2-16) with the following modification. If possible, give her a clean gown to wear (instead of having her remove or loosen individual items of clothing). z Ask the woman to uncover her body from the waist up. z Have her remain seated with her arms at her sides. z Visually inspect the overall appearance of the woman’s breasts, such as contours, skin, and nipples; note any abnormalities. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-58 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Contours Skin z Contours are regular with no dimpling or visible lumps. z Skin is smooth with no puckering; no areas of scaliness, thickening, or redness; and no lesions, sores, or rashes. z Normal variations: z Breasts may be larger (and more tender) than usual. z Veins may be larger and darker, more visible beneath the skin. z Areolas may be larger and darker than usual, with tiny bumps on them. ¨ If findings are not within normal range, facilitate nonurgent referral/ transfer (Annex 7, page 4-63) during the postpartum period. Nipples z There is no abnormal nipple discharge. z Nipples are not inverted. z Normal variations: z Nipples may be larger, darker, and more erectile than usual. z Colostrum (a clear, yellowish, watery fluid) may leak spontaneously from nipples after 6 weeks’ gestation. ¨ If there is abnormal nipple discharge, facilitate nonurgent referral/transfer (Annex 7, page 4-63) during the postpartum period. ¨ If nipples appear to be inverted, test for protractility (Textbox 2-8, page 2-17). ¨ If the nipples are inverted, be alert for potential breastfeeding problems (e.g., problems with attachment of the newborn to the breast, suckling). PE-4. Abdominal Examination Note: The abdominal examination during labor is carried out between contractions. The abdomen becomes very hard during a contraction, making it difficult to feel the fetal parts or hear the fetal heart tones. In addition, it may be uncomfortable for the woman to remain still or have her abdomen palpated during a contraction. She should be encouraged to move, if necessary, during contractions. z If you have not already done so, help the woman prepare for further examination; follow the steps shown in Textbox 2-7 (page 2-16) with the following modification. If possible, give her a clean gown to wear (instead of having her remove or loosen individual items of clothing). z Ask the woman to uncover her abdomen. z Have her lie on her back with her knees slightly bent. Element Normal Abnormal/Followup Action Surface of the abdomen z There are no scars (from previous cesarean section, uterine rupture, or other uterine surgeries) on the surface of the abdomen. ¨ If there is a scar from a cesarean section, uterine rupture, or other uterine surgery, ACT NOW!— facilitate urgent referral/transfer (Annex 7, page 4-63). Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-59 Element Normal Abnormal/Followup Action Uterine shape z The uterus is oval-shaped (longer vertically than horizontally). ¨ If the uterus is longer horizontally than vertically, consider in the context of further assessment z Be alert for signs/ symptoms of transverse lie. Fundal height z Fundal height is consistent (within 2 cm+/-, per local standards) with the gestational age, as previously calculated. z At 34–38 weeks, the uterus measures about 32 to 34 cm above the symphysis pubis and extends to the xiphoid process. z At 39–40 weeks, the uterus measures about 32 to 34 cm above the symphysis pubis, as the presenting part of the fetus settles into the pelvis. (See also Figure 2-1 [page 2-20].) ¨ If fundal height suggests less than 37 weeks’ gestation and the onset of labor is apparent, ACT NOW!—see Contractions before 37 Weeks’ Gestation (page 3-120) before proceeding. ¨ If the fundal height is more than would normally be expected for a term birth, see Size-Date Discrepancy after 22 Weeks’ Gestation (page 3-73) for additional information about assessment and care provision. Fetal parts (and movement) z The fetus is palpable within the uterus. z The buttocks are palpable in the uterine fundus, are softer and more irregularly shaped than the head, and cannot be moved independently of the body. z The head is palpable in the lower uterine segment, is harder than the buttocks, and can be moved back and forth between both hands. z Normal variations: z Fetal movements may or may not be felt by the skilled provider during the abdominal examination. z Multiple pregnancy may be suspected if: z Multiple fetal poles and parts are palpated on abdominal examination. z Fetal head is small in relation to the size of the uterus. z The uterus is larger than expected for gestational age. z More than one fetal heart can be heard with the fetoscope. ¨ If more than one fetus is suspected/confirmed, see Multiple Pregnancy (page 3-68) for additional information about assessment and care provision. For the procedure, see Textbox 2-9 (page 2-19). For the procedure, see Textbox 2-10 (page 2-20). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-60 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Fetal lie and presentation z The fetus is longitudinal in lie and cephalic in presentation. z The head may be: z Fixed, engaged z Dipping into the pelvis z Free and floating ¨ If the fetus is in transverse lie, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the fetus is in breech presentation, ACT NOW!— see Breech Presentation in Labor (page 3-47) for additional information about assessment and care provision. Descent* z Descent should progress continually throughout labor until childbirth. z Use this information to: z Establish a baseline against which later findings can be evaluated z Help evaluate progress of labor Fetal heart tones* z Fetal heart rate is from 120 to 160 beats per minute before the woman is in the active phase of labor. z Fetal heart rate is from 100 to 180 beats per minute when the woman is in the active phase of labor. z Normal variation: In the active phase of labor, the fetal heart rate may slow during the peak of a strong contraction, but should return to normal within seconds of uterus relaxing. ¨ If fetal heart tones are absent, ACT NOW!—see Management of Absent Fetal Heart Tones (Textbox 3-44, page 3-112) before proceeding. ¨ If fetal heart tones are not within normal range, ACT NOW!—see Management of Abnormal Fetal Heart Rate (Textbox 3-45, page 3-113) before proceeding. Bladder z Bladder is not palpable. z The woman is able to urinate when the urge is felt. ¨ If the bladder is palpable or the woman is unable to urinate when the urge is felt, see Urinary Retention during Labor and the Postpartum Period (page 3-79) for additional information about assessment and care provision. *Once active labor begins, this element is recorded on a partograph and interpreted accordingly. For the procedure, see Textbox 2-10 (page 2-20). Note: Do not perform this assessment while the woman is having a contraction. Follow the procedure shown in Textbox 2-11 (page 2-21). Note: Fetal heart tones are easily audible between contractions in a term fetus. For the procedure, see Textbox 2-19 (page 2-61). Note: Palpate above the symphysis pubis. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-61 Element Normal Abnormal/Followup Action Contractions* (frequency and duration) z Effective contractions occur at regular intervals and continuously increase in strength, frequency, and duration. z 1st stage/latent phase: Contractions occur irregularly and last less than 20 seconds each. z 1st stage/active phase: Two to three contractions occur every 10 minutes and last 20–40 seconds each; as active phase progresses, contractions become more frequent and longer in duration, with three to five occurring every 10 minutes, lasting more than 40 seconds each. z The uterus completely relaxes between contractions. z Use this information to: z Distinguish between true and false labor (Table 2-8, page 2-68). z Evaluate the effectiveness of contractions (Textbox 2-20, page 2-62). z Help assess stage and phase of labor (Table 2-8, page 2-68), which will be confirmed in the cervical examination. z Establish a baseline against which later findings can be evaluated. ¨ If there are continuous uterine contractions that do not allow the uterus to relax, ACT NOW!—see Vaginal Bleeding in Later Pregnancy or Labor (page 3-102) before proceeding. ¨ If there is constant pain that persists between contractions or is sudden in onset (or if contractions cease altogether), ACT NOW!—see Severe Abdominal Pain in Later Pregnancy or Labor (page 3-119) before proceeding. *Once active labor begins, this element is recorded on a partograph and interpreted accordingly. Textbox 2-19. Determining Fetal Descent through Abdominal Palpation z Stand at the woman’s side. z Palpate the head above the symphysis pubis. z By abdominal palpation, assess descent in terms of fifths of fetal head palpable above the symphysis pubis (Figure 2-7, page 2-62): − A head that is entirely above the symphysis pubis accommodates five fingers and is five-fifths (5/5) palpable (Figure 2-7, page 2-62, Top Right and Left); − A head that is two-fifths (2/5) above the symphysis pubis accommodates two fingers above the symphysis (Figure 2-7, page 2-62, Bottom Right and Left); − A head that is entirely below the symphysis pubis is zero-fifths (0/5) palpable and engaged. For the procedure, see Textbox 2-20 (page 2-62). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-62 JHPIEGO/Maternal and Neonatal Health Program Figure 2-7. Abdominal Palpation for Descent of the Fetal Head Textbox 2-20. Evaluating the Effectiveness of Contractions Contractions provide the power to dilate the cervix and cause descent of the presenting part of the baby. They should be evaluated every 2 hours during the latent phase, every 30 minutes during the active phase, and every 15 minutes in the 2nd stage of labor. To evaluate contractions: z Place a hand on the woman’s abdomen (at the upper portion of the uterus) and palpate the contractions from the start of one contraction until the start of the next contraction. z Using a clock or watch while palpating, calculate frequency and duration of the contractions. − Frequency of contractions is the number of contractions in 10 minutes. − Duration of contractions is the number of seconds from the beginning of a contraction to the end of the contraction. In general, effective contractions: z Occur at regular intervals, and become more frequent and longer as labor progresses z Start in back and move to the front z Are increased in intensity by walking z Cause cervical dilation and fetal descent z Occur between periods of complete uterine relaxation Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-63 PE-5. Genital Examination Note: A speculum examination is not recommended as a routine part of assessment of labor. It may be done for certain indications such as confirming rupture of membranes. For the procedure, see page 4-27. z If you have not already done so, help the woman prepare for further examination; follow the steps shown in Textbox 2-7 (page 2-16) with the following modification. If possible, give her a clean gown to wear (instead of having her remove or loosen individual items of clothing). z Perform a genital/vaginal examination (for the procedure, see Textbox 2-12 [page 2-23]). z After the examination, perform the Post-Examination Steps (Textbox 2-13, page 2-24). Element Normal Abnormal/Followup Action Vaginal opening Skin Labia z Nothing is protruding from the vagina. z There are no signs of female genital cutting. z The genital skin is free from sores, ulcers, warts, nits, or lice. z The labia are soft and not painful. ¨ If there is a foot or hand protruding from the vagina, ACT NOW!—see Fetal Hand or Foot Presenting (page 3-114) before proceeding. ¨ If there is a cord protruding from the vagina, ACT NOW!—see Prolapsed Cord (page 3-114) before proceeding. ¨ If signs of female genital cutting are present, see Female Genital Cutting during Pregnancy or Labor (page 3-49) for additional information about assessment and care provision. ¨ If findings (other than signs of genital cutting) are not within normal range, facilitate nonurgent referral/transfer (Annex 7, page 4-63) during the postpartum period. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-64 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Vaginal secretions z There is no blood, foul-smelling or yellow/greenish discharge, urine, or stool coming from the vaginal opening. z Normal variations: z There may be discharge of the gel- like “mucous plug,” which is released from the cervix in latent phase or active labor; it may be pinkish or streaked with blood. z There may be “bloody show,” a pinkish-red discharge caused by broken capillaries during cervical dilation. z There may be amniotic fluid coming from the vagina; it should be clear and may have a distinct (but not foul-smelling) mild odor. (See Membranes and amniotic fluid [page 2-65].) ¨ If blood (as opposed to normal bloody show) is coming from the vagina, ACT NOW!—see Vaginal Bleeding in Later Pregnancy or Labor (page 3-102) before proceeding. ¨ If other findings are not within normal range, facilitate nonurgent referral/transfer (Annex 7, page 4-63) during the postpartum period. PE-6. Cervical Examination Element Normal Abnormal/Followup Action Dilation* z Dilation progresses continually during normal labor. (See also Figure 2-8 [page 2-66].) Note: If 4 cm or more, start the partograph. Initial cervical dilation in active phase of labor is plotted on the alert line; cervical dilation should remain on or to the left of the alert line of the partograph as labor progresses. z Use this information to: z Distinguish between true and false labor (Table 2-8, page 2-68). z Evaluate the effectiveness of contractions (Textbox 2-20, page 2-62). z Help assess stage and phase of labor (Table 2-8, page 2-68). z Establish a baseline against which later findings can be evaluated. *Once active labor begins, this element is recorded on a partograph and interpreted accordingly. For the procedure, see Textbox 2-21 (page 2-66). Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-65 Element Normal Abnormal/Followup Action Membranes and amniotic fluid* z Membranes rupture spontaneously during labor or birth. z Amniotic fluid is clear and has a distinct, but not foul-smelling, mild odor. z Normal variations: z The presence of a smooth membrane palpated over the presenting part indicates the presence of the intact bag of waters. The membrane may be closely applied to the presenting part, or filled with amniotic fluid forming forewaters. z If the bag of waters is ruptured, the presenting part will be felt directly. Pooling of fluid in the vagina or fluid flowing out of the vagina also confirms ruptured membranes. ¨ If the fluid is red, ACT NOW!—see Vaginal Bleeding in Later Pregnancy or Labor (page 3-102) before proceeding. ¨ If the fluid is greenish/brownish, ACT NOW!—see Meconium-Stained Amniotic Fluid (Textbox 3-42, page 3-111) before proceeding. ¨ If the fluid is foul-smelling, ACT NOW!—see Fever or Foul-Smelling Vaginal Discharge (page 3-115) before proceeding. ¨ If it has been more than 18 hours since membranes have ruptured, see Prelabor Rupture of Membranes or Membranes Ruptured for More than 18 Hours before Birth (page 3-70) for additional information about assessment and care provision. Presentation z In active labor, presentation is cephalic (i.e., the top of the head is palpated). ¨ If the presentation is not cephalic, ACT NOW!—see Breech Presentation in Labor (page 3-47) for additional information about assessment and care provision. ¨ If the presentation is cephalic and anything other than the top of the head is palpated (i.e., a brow, face, or chin are palpated), ACT NOW!— facilitate urgent referral/transfer (Annex 7, page 4-63). *Once active labor begins, this element is recorded on a partograph and interpreted accordingly. For the procedure, see Textbox 2-22 (page 2-67). For the procedure, see Textbox 2-23 (page 2-67). Note: This is most easily done after the rupture of membranes. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-66 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Molding* z Bones of the fetal skull are separated or just touch each other. (See also Figures 2-9 and 2-10 [page 2-67].) ¨ If the bones overlap, consider in the context of further assessment z Be alert for signs/symptoms of unsatisfactory progress of labor (e.g., fetal descent or cervical dilation is not progressing, contractions become more irregular). *Once active labor begins, this element is recorded on a partograph and interpreted accordingly. Textbox 2-21. Assessing Cervical Dilation Insert the middle and index fingers into the open cervix and gently open them to the cervical rim. The distance between the outer aspects of both fingers is the dilation in centimeters (Figure 2-8, below). Figure 2-8. Dilation of the Cervix in Centimeters For the procedure, see Textbox 2-23 (page 2-67). Note: This is most easily done after the rupture of membranes. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-67 Textbox 2-22. Assessing the Condition of Amniotic Fluid and Membranes z With your middle and index fingers still inserted into the cervix, evaluate whether the bag of waters is still intact or has ruptured. − The presence of a smooth membrane palpated over the presenting part indicates the presence of the intact bag of waters. The membrane may be closely applied to the presenting part, or filled with amniotic fluid forming forewaters. − If the bag of waters is ruptured, the presenting part will be felt directly. Pooling of fluid in the vagina or fluid flowing out of the vagina also confirms ruptured membranes. Textbox 2-23. Assessing Presentation and Position of the Fetus and Molding With your fingers still inserted: z Feel the fetal skull to confirm cephalic presentation of the fetus. z Assess molding, noting whether the bones touch each other or overlap. (Figure 2-9 [below] shows the landmarks of a normal fetal skull; Figure 2-10 [below] shows apposing bones in the fetal skull.) z As you withdraw your examination hand, inspect your gloves for blood and/or meconium, as well as odor of fluid. z After withdrawing fingers, note the color and odor of the fluid. Figure 2-9. Landmarks of the Normal Fetal Skull Figure 2-10. Apposing Bones (Bones Touching Each Other) in the Fetal Skull Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-68 JHPIEGO/Maternal and Neonatal Health Program Table 2-8. Confirming True Labor and Assessing Stage/Phase of Labor CERVIX CONTRACTIONS VAGINAL SECRETIONS DESCENT OTHER SIGNS False labor z No dilation or dilation is not progressive z Irregular z Frequency: fewer than three per 10 minutes z Duration: less than 20 seconds z Not progressively more frequent or longer in duration z Felt mainly in the front z No bloody show z No progressive descent of presenting part z The woman is comfort- able, is able to walk, and can eat and drink fluids. 1st stage of labor/ latent phase z Dilation less than 4 cm z Irregular z Frequency: variable, from one per 20 minutes to four per 10 minutes z Duration: less than 20 seconds z Progressively more frequent or longer in duration z Possibly bloody show z Possibly mucous plug z Possibly ruptured membranes z No progressive descent of presenting part z The woman is relatively comfortable, is able to walk, and can eat lightly and drink fluids. 1st stage of labor/ active phase z Increases from 4 cm to 10 cm z Rate: approximate- ly 1 cm per hour z Regular z Frequency: increases to at least three per 10 minutes z Duration: increases to more than 40 seconds each z Possibly bloody show z Possibly ruptured membranes z Presenting part is usually engaged in primiparas; may not be engaged in multiparas. z Descent through the birth canal begins. z The woman is uncom- fortable and needs support. z She finds it helpful to breathe in and out slowly during contractions. z She is focused on what is happening to her body. z She can walk but will need frequent rest periods. z She can drink fluids. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-69 Table 2-8. Confirming True Labor and Assessing Stage/Phase of Labor (continued) CERVIX CONTRACTIONS VAGINAL SECRETIONS DESCENT OTHER SIGNS 2nd stage of labor z Dilation is 10 cm. z Regular z Frequency: at least three per 10 minutes z Duration: at least 40 seconds each z Increase in bloody show z Membranes are usually ruptured (but if not may still rupture spon- taneously) z Descent is steady. z More and more of presenting part is seen at introitus during pushing. z The woman feels increasing rectal pressure. z She wants to bear down and gives short, involuntary pushes. z She may appear to be holding her breath. z The woman feels a progressively intense urge to push. Testing (T) When you have finished performing a physical examination, conduct testing; remember that the woman may “opt out” of HIV testing (see Note, below). Be sure to record all findings in the woman’s chart. Element Normal Abnormal/Followup Action T-1. RPR1 z Negative ¨ If the test is positive for syphilis, see Syphilis (page 3-76) for additional information about assessment and care provision. T-2. HIV (See Note [page 2-70].) z Negative ¨ If the test is positive for HIV, see HIV (page 3-51) for additional information about assessment and care provision. 1 Use VDRL if RPR is not available. For the procedure, see page 4-44. Note: Always adhere to national guidelines for HIV testing. In general: z If the test is positive for HIV, test again with a different type/preparation of test. z If the second test is positive, see HIV (page 3-51). z If the second test is negative, do a third test for discordant test results. z If the third test is positive, see HIV (page 3-51). z If the third test is negative, inform the woman that she is HIV-negative during post-test counseling (page 2-34). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-70 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action T-3. Blood group and Rh, if available z Blood group is A, B, AB, or O. z Rh is positive. ¨ If Rh is negative, the woman is a candidate for anti-D immune globulin. Notes: z If the woman presents to the healthcare facility for the first time in labor and does not know her HIV status, she should be offered HIV counseling (page 2-33) and rapid testing at this time. z The woman should be informed that HIV testing is recommended for all women during the childbearing cycle, but that she may “opt out” of being tested if she desires. If she opts out, be sure to offer testing at all subsequent visits. A woman who chooses not to be tested during the first visit may change her mind and choose to be tested after she has received counseling, considered the benefits of testing, and/or discussed testing with her partner. LABOR/CHILDBIRTH CARE PROVISION C-1. Key Actions for the 1st Stage of Labor If the woman is in the 1st stage of labor (according to the diagnostic criteria shown in Table 2-8 [page 2-68]), provide care as shown below. z Throughout the 1st stage of labor, perform ongoing assessment (Table 2-5, page 2-39) and ongoing supportive care (Table 2-7, page 2-47). z When the active phase begins (i.e., the cervix has dilated to 4 cm), start a partograph (C-1.1, page 2-70). Table 2-9. Summary of 1st Stage of Labor STAGE/PHASE DIAGNOSTIC CRITERIA COMMENTS 1st stage/ latent phase z Cervix: Dilation is 1–3 cm. z Contractions: − Irregular − Frequency: variable, irregular − Duration: less than 20 seconds z Descent: Not progressive z The latent phase begins with regular contractions and initial cervical dilation and continues until 4 cm dilated. This is the 1st stage/latent phase of labor, and cervical dilation may proceed slowly. It is variable in length and can last up to 20 hours in primiparas and 14 hours in multiparas. During this time, contractions are becoming coordinated and more frequent, last longer and are more efficient, and are causing the cervix to soften. z The woman may walk, sit, or lie down, as she desires. She should drink plenty of fluids and can eat small meals, if desired. She does not yet require constant attendance by a skilled provider. 1st stage/ active phase z Cervix: − Dilation is 4–10 cm. − Rate of dilation is approximately 1 cm per hour. z Contractions: − Regular − Frequency: increases to three to five per 10 minutes − Duration: increases to more than 40 seconds z Descent: − Fetal descent begins. − Presenting part is usually engaged by this time in primiparous women. z Active phase begins when the cervix reaches 4 cm dilation and lasts until it reaches 10 cm dilation. z With the onset of the active phase of labor (cervix dilated at least 4 cm), the skilled provider uses a partograph (C-1.1) to record information and make clinical decisions about the progress of the woman’s labor. z The woman’s care needs will increase (compared with the latent phase of labor); she will require more supportive care as her discomfort and anxiety increase with the increasing frequency and duration of contractions. The woman should not be left alone from this point on. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-71 C-1.1. Start a Partograph At the beginning of the active phase of the 1st stage of labor, when the dilation of the cervix reaches 4 cm, start a partograph (Annex 3, page 4-7) to evaluate fetal and maternal well-being as well as the progress of labor. From that point through childbirth, you should record findings (those marked with an asterisk [*] in this chapter) on the partograph. Be sure to record all other elements of assessment and care provision in the woman’s chart. Note: As a woman enters the late active phase of labor (or transition), she may need more intensive help managing the pain and discomfort as the experience of labor intensifies. Fear and anxiety may cause tension and increased pain. The laboring woman must cope with the contractions more purposefully; she may feel hot and sweaty, have increasing pelvic pressure and backache. She may become anxious, worried, and withdrawn, and feel as though she cannot go on. Labor support and comfort measures are critical during this phase of labor. C-2. Key Actions for the 2nd and 3rd Stages of Labor If the woman is in the 2nd or 3rd stage of labor (according to the diagnostic criteria shown in Table 2-8 [page 2-68]), provide care as shown below. z Throughout the 2nd and 3rd stages of labor, perform ongoing assessment (Table 2-5, page 2-39) and ongoing supportive care (Table 2-7, page 2-47). z During the 2nd stage/pushing phase: z Assist the woman in pushing (C-2.1, page 2-72). z Continue recording appropriate information on the partograph; use this information to evaluate the progress of the woman’s labor and make decisions about her care. z During the 2nd stage/expulsive phase, assist in normal birth (C-2.2, page 2-74). z Immediately after the baby is born, initiate immediate newborn care (C-2.3, page 2-77). z During 3rd stage, perform active management (C-2.4, page 2-78). Table 2-10. Summary of 2nd and 3rd Stages of Labor STAGE/PHASE DIAGNOSTIC CRITERIA COMMENTS 2nd stage/ pushing and expulsive phases z Cervix: Dilation is 10 cm. z Contractions: Urge to push becomes progressively stronger. z Descent: Progresses until presenting part of fetus reaches the pelvic floor z The early (pushing) phase of the 2nd stage of labor begins with complete dilation and ends when the head reaches the pelvic floor, causing a spontaneous urge to push. The early phase of 2nd stage can last from a few minutes to up to an hour. It is a transition phase, during which contractions may become less frequent and of shorter duration. The woman may rest or fall into a light sleep. There may be no spontaneous desire to bear down. As the fetal head descends, the contractions continue to become more frequent and last longer. z The late (expulsive) phase of the 2nd stage of labor begins when the presenting part of the fetus has descended to the pelvic floor and triggers the bearing- down reflex; it ends with the complete birth of the baby. The contractions become more forceful, and the woman begins pushing spontaneously. The pushing phase can last from 1–2.5 hours in a primigravida, and from a few minutes to 1 hour in a multigravida. The descent that began in the 1st stage accelerates in the 2nd stage of labor. Steady descent of the fetus during the 2nd stage is the most accurate indicator of normal progress. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-72 JHPIEGO/Maternal and Neonatal Health Program Table 2-10. Summary of 2nd and 3rd Stages of Labor (continued) STAGE/PHASE DIAGNOSTIC CRITERIA COMMENTS 3rd stage z The 3rd stage of labor begins with the birth of the baby and ends with the delivery of the placenta. z The 3rd stage of labor begins with the birth of the baby and ends with the delivery of the placenta. Although the 3rd stage usually lasts less than 30 minutes, constant vigilance is especially important throughout because of the woman’s increased risk of blood loss. A key action during this period is active management of the 3rd stage of labor, which has been demonstrated to significantly reduce the incidence of postpartum hemorrhage. z During this time, continue to observe the baby’s breathing and general condition—the baby is making many adjustments to life outside the uterus, and her/his condition can change suddenly. Also, provide constant vigilance for the woman—she can start to bleed suddenly. C-2.1. Assist the Woman in Pushing z Encourage the woman to assume a position for pushing that is comfortable for her and aids in the descent of the fetus, such as semi-sitting/reclining (Figure 2-11, page 2-73), squatting (Figure 2-12, page 2-73), hands and knees (Figure 2-13, page 2-73), or lying on side (Figure 2-14, page 2-73). z Help her rest between contractions by assisting her into resting positions (lying down, sitting, leaning over a chair or other stable piece of furniture) or encouraging her to stand or walk. z Have the woman push in response to her natural bearing-down reflex. Do NOT urge her to push! z Encourage her to focus her attention inward on the movement of the presenting part as it moves down the birth canal with every push. z Coach her to exhale as she bears down, rather than hold her breath throughout the contraction. (For more information about breathing techniques, see Textbox 2-24 [page 2-73].) z Encourage her to maintain pushing efforts only as long as she feels the urge. z Encourage her to relax her legs, jaw, and perineum while pushing. z Help her try different positions if descent is slow or her efforts are ineffective. z Offer encouraging feedback after each push and praise her effort. z Be patient. Slow steady progress is good. z Wipe her brow between pushes and offer her sips of water. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-73 Figure 2-11. Pushing Positions: Semi-Sitting/Reclining Figure 2-12. Pushing Positions: Squatting Figure 2-13. Pushing Positions: Hands and Knees Figure 2-14. Pushing Positions: Lying on Side Textbox 2-24. Breathing Techniques during Labor Based on the woman’s individual needs, advise her as follows: 1st stage/latent phase: During this part of labor, contractions are not very regular and are short in duration, so it is best for you to use your natural, normal breathing patterns at this time. 1st stage/active phase: 1. Early active phase (4–7 cm) Use abdominal breathing: take slow, deep breaths during contractions, making sure that the abdomen, not the chest, goes up and down with each breath. After each contraction, take a deep breath and let it out slowly, relaxing the entire body and letting yourself go loose all over. 2. Late active phase (8–10 cm) Use superficial chest breathing: breathe in and out more rapidly than in early active phase, taking shallower breaths. Now the chest should go up and down with each breath. You can use a pattern such as “pant-pant- blow” or “pant-blow-blow-pant” in which a shallow breath is followed by a quick blowing out before taking another shallow breath. Using this pattern helps you to concentrate more on breathing than on the contraction. If possible, have your birth companion do this breathing with you so that you have someone to concentrate on and “copy” when the contraction is very intense. After each contraction is over, take a deep breath and let it out slowly, relax the entire body, and let yourself go loose all over. (continued on next page) Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-74 JHPIEGO/Maternal and Neonatal Health Program Textbox 2-24. Breathing Techniques during Labor (continued) 2nd stage/pushing phase: 1. It is important to push only when you feel the urge, even if the cervix is completely open. The contractions will help the baby to descend to the point where you feel as though you want to push. 2. When you feel like pushing, it is important that you do not hold your breath, close off your throat, or push hard for a long time. Rather, push in the manner most natural and comfortable for you. Making noises while pushing is good, because this helps keep the throat open. Pushing for 5–10 seconds and then taking several breaths before pushing again helps ensure that the baby gets plenty of oxygen. 3. After each contraction is over, take a deep breath and let it out slowly, relaxing the entire body and letting yourself go loose all over. It may be necessary to stop pushing so the baby can be born slowly. In order not to push, start panting: breathe rapidly through your mouth and throat while your chest goes up and down. C-2.2. Assist in Normal Birth z Once the cervix is fully dilated and the woman is in the 2nd stage, encourage the woman to assume the position she prefers (above) and encourage her to push when the urge is felt. Note: The urge to push is very strong at this point and it is not always easy for a woman to control her pushing. Each small push will help stretch the perineum as the head crowns. Maintaining control during crowning and emergence of the head helps prevent tears. z Continually assess the speed at which the baby is descending through the birth canal. Have the woman continue spontaneous bearing-down efforts until the baby’s head crowns. z Coach the woman to push and/or breathe so that the birth of the head will be slow, steady, and controlled. ¨ If the baby is coming very fast, help the woman stop pushing by asking her to blow repeatedly or breathe steadily, which makes it easier to refrain from pushing. Note: Episiotomy is no longer recommended as a routine procedure. There is no evidence that routine episiotomy decreases perineal damage, future uterine prolapse, or urinary incontinence. In fact, routine episiotomy is associated with an increase of 3rd and 4th degree tears and subsequent anal sphincter muscle dysfunction. Episiotomy (page 4-18) should be considered only in the following cases: z Complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum extraction) z Scarring from female genital mutilation or poorly healed 3rd or 4th degree tears z Fetal distress Birth of the head: z Clean the woman’s perineum with a cloth or compress, wet with antiseptic or soap and water, wiping from front to back. z Ask the woman to pant or give only small pushes with contractions as the baby’s head is born. z As the pressure of the head thins out the perineum, one way to control the birth of the head is with the fingers of one hand applying a firm, gentle downward (but not restrictive) pressure to maintain flexion, allow natural stretching of perineal tissue, and prevent tears (Figure 2-15, page 2-75). Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-75 Figure 2-15. Perineal Support during Normal Vaginal Birth z Use the other hand to support the perineum using a compress or cloth, and allow the head to crown slowly and be born spontaneously. Do not manipulate the labia or perineum over the baby’s head because this increases the risk of tears. z Wipe the mucus (and membranes, if needed) from the baby’s mouth and nose with a clean cloth. z Feel around the baby’s neck to ensure that the umbilical cord is not around it: ¨ If the cord is around the neck but is loose, slip it over the baby’s head. ¨ If the cord is loose but cannot reach over the head, slip it backwards over the shoulders. ¨ If the cord is tight around the neck: − Tie or clamp the cord in two places 2 cm apart. − Cut the cord between the ties/clamps. − Unwind the cord from around the baby’s neck and proceed. Completion of birth: z Allow the baby’s head to turn spontaneously. z After the head turns, place a hand on each side of the baby’s head, over the ears, avoiding pressure around the neck with the fingers. Advise the woman to push gently with the next contraction. z Then, apply slow, gentle pressure downward (toward the woman’s spine) and outward until the anterior shoulder slips under the pubic bone (Figure 2-16, page 2-76). ¨ If there is difficulty delivering the shoulders, ACT NOW!—perform the procedure for shoulder dystocia (page 4-40) before proceeding. z When the axilla (arm fold) is seen, guide the head upward toward the woman’s abdomen as the posterior shoulder is born over the perineum (Figure 2-17, page 2-76). z Support the baby’s head with one hand and the rest of the baby’s body with the other hand as it slides out (Figure 2-18, page 2-76), and place the baby on the woman’s abdomen (Figure 2-19, page 2-77). ¨ If the woman is unable to hold the baby, ask her companion or an assistant to care for the baby. Note: The woman represented in Figures 2-15 to 2-19 is shown in supine position for ease in illustrating the skilled provider’s hand maneuvers recommended for assisting in normal vaginal birth. Other birth positions, as the woman desires, may be equally appropriate. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-76 JHPIEGO/Maternal and Neonatal Health Program Figure 2-16. Pulling Gently Downward to Deliver the Anterior Shoulder during Normal Vaginal Birth Figure 2-17. Pulling Gently Upward to Deliver the Posterior Shoulder during Normal Vaginal Birth Figure 2-18. Supporting the Baby during Normal Vaginal Birth Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-77 Figure 2-19. Placing the Baby on the Woman’s Abdomen Immediately after Normal Vaginal Birth C-2.3. Initiate Immediate Newborn Care After placing the baby on the woman’s abdomen: z Thoroughly dry the baby (removing maternal blood and other secretions) and cover with a clean, dry cloth, WHILE wiping the baby’s eyes (using a separate clean swab or cloth for each eye) and assessing breathing. ¨ If the baby does not start breathing immediately, ACT NOW!—perform newborn resuscitation (page 3-99) before proceeding. ¨ If the baby is crying or breathing (chest rising at least 30 times per minute), leave the baby with the woman. z Tie or clamp the umbilical cord in two places (at about 3 cm and 5 cm from the umbilicus) and cut the cord between the ties/clamps. z Ensure that the baby is kept warm and in skin-to-skin contact on the woman’s chest, and encourage breastfeeding. z Cover the baby with a cloth or blanket; ensure that the head is covered to prevent heat loss. z Palpate the abdomen to rule out the presence of an additional baby(s) and proceed with active management of the 3rd stage. Remember: Immediate skin-to-skin contact and breastfeeding of the baby: z Provide warmth for the baby (thermoregulation) z Provide nourishment for the baby (prevents hypoglycemia) z Facilitate mother-baby bonding z Stimulate the production of oxytocin which promotes uterine contraction after delivery of the placenta Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-78 JHPIEGO/Maternal and Neonatal Health Program C-2.4. Perform Active Management of 3rd Stage of Labor Administer oxytocin: z Within 1 minute of birth of the baby, palpate the abdomen to rule out the presence of an additional baby (or babies) and give oxytocin 10 units IM. Note: Oxytocin is preferred because it is effective 2–3 minutes after injection, has minimal side effects, and can be used in all women. If oxytocin is not available, give ergometrine* 0.2 mg IM or misoprostol 600 mcg by mouth. * Do NOT give ergometrine to women with pre-eclampsia, eclampsia, or high blood pressure because it increases the risk of convulsions and cerebrovascular accidents. Perform controlled cord traction: z Clamp the cord close to the perineum. Hold the clamped cord and the end of the clamp in one hand. z Place the other hand just above the pubic bone and gently apply countertraction (push upward on the uterus) to stabilize the uterus and prevent uterine inversion. z Keep light tension on the cord and await a strong uterine contraction (2–3 minutes). z When the uterus becomes rounded or the cord lengthens, very gently pull downward on the cord to deliver the placenta. Do not jerk on the cord or pull on it between contractions. Do not wait for a gush of blood before applying traction on the cord. z Continue to apply countertraction (push upward on the uterus) with the other hand. ¨ If the placenta does not descend during 30–40 seconds of controlled cord traction, relax the tension and repeat with the next contraction. (Normally the placenta will separate with 3 or 4 contractions when active management is used.) ¨ If the placenta does not deliver in 30 minutes, ACT NOW!—perform manual removal of the placenta (page 4-22) before proceeding. NEVER apply cord traction (pull) without applying countertraction (pushing) above the pubic bone with the other hand at the same time. Deliver and inspect the placenta: z As the placenta delivers, hold it with both hands and twist it slowly so that the membranes are expelled intact. ¨ If the membranes do not slip out spontaneously, gently twist them into a rope and move them up and down to assist separation without tearing them. ¨ If the cord is pulled off, ACT NOW!—perform manual removal of placental fragments (page 4- 22) before proceeding. z Rapidly inspect the placenta, cord, and membranes for general completeness. ¨ If a portion of the maternal surface is missing or if there are torn membranes with vessels, ACT NOW!—perform manual removal of placental fragments (page 4-22) before proceeding. z Slowly pull to complete the delivery. ¨ If the membranes tear, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. ¨ If uterine inversion occurs, ACT NOW!—perform correction of uterine inversion (page 4-15) before proceeding. Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-79 Massage the uterus: z Immediately massage the uterus through the woman’s abdomen until it is contracted. Show the woman how to massage her fundus to maintain contraction. z Repeat uterine massage every 15 minutes for the first 2 hours. z Ensure that the uterus does not become relaxed (soft) after you stop uterine massage. ¨ If the uterus becomes soft, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. Examine the placenta, cord, and membranes. Inspect for tears: z Inspect the vagina and perineum for tears: z With your gloved nondominant hand, separate the labia and look carefully at the vaginal opening and perineum for any tears or hematomas (collection of blood under the tissue). z Press firmly on the back wall of the vagina with your gloved dominant fingers so that you can look deep into the vagina. Bleeding from a tear may ooze slowly or spurt from an artery. z Slowly press against the vaginal wall and move your fingers up the side wall of the vagina, one side at a time. Be sure to feel all the way up the vagina to the cervix. Assess findings, as shown below. ¨ If there are tears or you are not sure whether there are tears, see Examination of the Vagina, Perineum, and Cervix for Tears (page 4-20) before proceeding. z Continually assess for bleeding. ¨ If there is a continuous trickle of blood, a sudden gush of blood, or clots of blood larger than small lemons, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. z Gently cleanse the perineum with warm water and a clean cloth. z Apply a clean pad/cloth to the vulva. z Remove all wet and soiled bed linens and dispose of them appropriately. z Ensure that the woman is comfortable and cover her with a blanket. C-3. Key Actions for the 4th Stage of Labor If you have determined that the woman is in the 4th stage of labor (according to the diagnostic criteria shown in Table 2-11 [page 2-80]), provide care as shown below. z Throughout the 4th stage of labor, perform ongoing assessment (Table 2-5, page 2-39) and ongoing supportive care (Table 2-7, page 2-47). z Provide immediate postpartum care for the woman (C-3.1) and continue immediate newborn care (C-3.2). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-80 JHPIEGO/Maternal and Neonatal Health Program Table 2-11. Summary of 4th Stage of Labor STAGE/PHASE DIAGNOSTIC CRITERIA COMMENTS 4th stage z The 4th stage of labor is the first 2 hours after childbirth. z During this time, the woman is undergoing an intense period of recovery and the newborn is adjusting to life outside the uterus. It is very important to keep the woman and newborn together as much as possible during this time (preferably in skin-to-skin contact) to maintain warmth of the newborn, facilitate bonding, and promote breastfeeding. The skilled provider must also continue to monitor them both closely for signs of problems and conduct an initial assessment of the newborn. z Continue recording all elements of assessment and care provision for the woman in her chart. In addition, begin a chart for the newborn at this time. C-3.1. Provide Immediate Postpartum Care for the Woman Note: Vigilant monitoring of the postpartum woman is vital to averting maternal death from postpartum hemorrhage. Measure the woman’s temperature: ¨ If temperature is 38°C or more, ACT NOW!—see Fever or Foul-Smelling Vaginal Discharge (page 3-115) before proceeding. Continue uterine massage: z Repeat uterine massage every 15 minutes for the first 2 hours. z Use the palm of one hand to massage the uterus. z Ensure that the uterus remains firm and does not become relaxed (soft) after uterine massage. ¨ If uterus remains soft or quickly becomes soft after uterine massage, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. ¨ If there is frank heavy bleeding, a steady slow trickle of blood, intermittent gushes of blood, or blood clots larger than lemons, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. Help initiate early breastfeeding: z Encourage the first feeding within the first hour of birth by leaving the newborn in skin-to-skin contact with woman. ¨ If the woman has not yet decided whether she wants to breastfeed or use a breastmilk substitute, see Breastfeeding versus Using a Breastmilk Substitute (page 4-49). ¨ If the woman cannot breastfeed (for whatever reason) or has chosen to use a breastmilk substitute, see Using a Breastmilk Substitute (page 4-51). z Give assistance at the first feed, if required, to ensure that the newborn is correctly positioned and attached to the breast. ¨ If the woman requires additional guidance (i.e., the newborn is having problems attaching, or the woman is having problems with positions or holds), see Breastfeeding Support (page 4-47). z Allow unrestricted time at the breast once the baby starts to suckle. Review the complication readiness plan: Chapter Six: Labor/Childbirth Care JHPIEGO/Maternal and Neonatal Health Program 2-81 z Review the woman’s complication readiness plan, updating it to reflect postpartum/newborn needs. If she and her family have not yet developed a complication readiness plan, assist them in developing one according to the guidelines shown on page 2-26. z Advise the woman and her family to enact the complication readiness plan if any of the danger signs shown in Textbox 2-25 (below) arises. Textbox 2-25. Danger Signs during the Immediate Postpartum/Newborn Period Maternal danger signs: z Vaginal bleeding (heavy or sudden increase) z Breathing difficulty z Fever (feeling of hotness) z Severe abdominal pain z Severe headache/blurred vision z Convulsions/loss of consciousness z Foul-smelling discharge from vagina z Pain in calf, with or without swelling z Verbalization/behavior that indicates she may hurt the baby or herself, or hallucinations Newborn danger signs: z Breathing difficulty z Convulsions, spasms, loss of consciousness, or back arching (opisthotonos) z Cyanosis (blueness) z Hot to touch/fever z Cold to touch z Bleeding z Jaundice (yellowness) z Pallor z Diarrhea z Persistent vomiting or abdominal distention z Not feeding or poor suckling (feeding difficulties) z Pus or redness of the umbilicus, eyes, or skin z Swollen limb or joint z Floppiness z Lethargy Provide health messages and counseling: z Based on the woman’s history and any other relevant findings or discussion, individualize the following key messages: z Maintain the warmth of the newborn: − Keep the baby dry and covered with a clean, warm cloth. − Maintain skin-to-skin contact with the baby. − Do not bathe the baby for the first 6–24 hours. − If the baby’s feet are cold, add a blanket/covering. z Continue uterine massage: − Repeat uterine massage every 15 minutes for the first 2 hours. − Use the palm of one hand to massage the uterus. − Inform the skilled provider immediately if the uterus remains soft or quickly becomes soft after uterine massage, and/or there is excessive vaginal bleeding. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-82 JHPIEGO/Maternal and Neonatal Health Program C-3.2. Continue Immediate Newborn Care Note: Although the following care measures should be provided in the early newborn period, usually within 1 or 2 hours of birth, continuing to protect the newborn from hypothermia is critical. z Be sure to keep the newborn in skin-to-skin contact with the woman OR covered as much as possible during this time. z Do not bathe the baby during the first 6 hours after birth as this can greatly increase the risk of hypothermia. Ideally, bathing should be delayed for 24 hours. z Help initiate early breastfeeding. z Securely attach an identification label to the baby’s wrist or ankle. z Provide eye treatment: z Immediately after birth, the baby’s eyes should have been wiped using a separate clean swab or cloth for each eye. z Instill an antimicrobial into each eye within an hour of birth following the procedure shown in Textbox 2-26 (below): − 2.5% polyvidone-iodine solution, one drop into each eye, OR − 1% silver nitrate solution, one drop into each eye, OR − 1% tetracycline ointment, which is applied on the inside of the lower lid. Textbox 2-26. Procedure for Newborn Eye Treatment z Wash hands thoroughly with soap and water and dry with a clean, dry cloth or allow them to air dry. z Place the baby on her/his back. z Wipe each eye with a separate clean swab or cloth, wiping from the inner eye outward. z Place the thumb below the lower eyelid and the forefinger above the upper eyelid and gently open the eye. z Apply a small amount of ointment to the inside of the lower lid, from the inside corner out, taking care not to contaminate the tip of the tube of ointment, OR drop one drop of solution onto the eye, being careful not to contaminate the tip of the container/dropper. z Repeat the procedure on the other eye. z Replace cap on tube/container. z Wash hands thoroughly with soap and water and dry with a clean, dry cloth or allow them to air dry. z Record procedure on birth record. z Give vitamin K1 1 mg IM in the anterolateral aspect of the thigh. z Prepare for the newborn physical examination: z Inform the woman of what you are going to do, encourage her to ask questions, and listen to what she has to say. z Wash hands thoroughly with soap and water and dry them with a clean, dry cloth or allow them to air dry. z Place the baby on a clean warm surface or examine the baby in the woman’s arms. z Conduct the first complete newborn physical examination. (For the procedure, see page 2-120.) Note: The first physical examination of the newborn is a form of screening to detect any abnormalities that may be present. It should be delayed for at least an hour or two after birth and longer if the newborn is unable to maintain a stable body temperature of 36.5–37.5°C. By this time, it is most likely that the woman will have carefully inspected her newborn and, if she is worried about anything, will have raised her concerns with the skilled provider. JHPIEGO/Maternal and Neonatal Health Program 2-83 CHAPTER SEVEN POSTPARTUM CARE OVERVIEW After the woman has undergone the quick check (Annex 6, page 4-61), the postpartum care visit should be conducted according to the guidelines shown in Chapter 4 (page 2-1) and the schedule shown below (Table 2-12). Table 2-12. Schedule and Overview of Postpartum Care COMPONENTS/ELEMENTS 1 ST VISIT SUBSEQUENT VISITS ASSESSMENT Ongoing Assessment, page 2-84 Up to 6 hours after birth − History H-1. Personal information, page 2-87 9 − H-2. Daily habits and lifestyle, page 2-88 9 − H-3. Present pregnancy and labor/childbirth, page 2-89 9 − H-4. Present postpartum period, page 2-90 9 9 H-5. Obstetric history, page 2-92 9 − H-6. Contraceptive history/plans, page 2-93 9 − H-7. Medical history, page 2-93 9 − H-8. Interim history, page 2-94 − 9 Physical Examination PE-1. General well-being, page 2-95 9 9 PE-2. Vital signs, page 2-96 9 9 PE-3. Breasts, page 2-97 9 9 PE-4. Abdomen, page 2-98 9 9 PE-5. Legs, page 2-99 9 9 PE-6. Genitals, page 2-101 9 9 Testing T-1. HIV, page 2-101 91 As needed1 CARE PROVISION Ongoing Supportive Care, page 2-84 Up to discharge − C-1. Breastfeeding and Breast Care, page 2-102 C-1.1. Breastfeeding guidelines, page 2-102 C-1.2. Additional advice for the woman, page 2-102 C-1.3. Breast care, page 2-102 9 Reinforce key messages Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-84 JHPIEGO/Maternal and Neonatal Health Program Table 2-12. Schedule and Overview of Postpartum Care (continued) COMPONENTS/ELEMENTS 1 ST VISIT SUBSEQUENT VISITS CARE PROVISION (CONT.) C-2. Complication Readiness Plan, page 2-103 9 Continue to develop as needed; reinforce key messages C-3. Support for Mother-Baby-Family Relationships, page 2-103 9 Reinforce key messages C-4. Family Planning, page 2-104 9 Reinforce key messages C-5. Nutritional Support, page 2-105 9 Reinforce key messages C-6. Self-Care and Other Healthy Practices, page 2-105 C-6.1. Prevention of infection/hygiene, page 2-106 C-6.2. Rest and activity, page 2-106 C-6.3. Sexual relations and safer sex, page 2-107 9 Reinforce key messages C-7. HIV Counseling, page 2-107 9 As needed C-8. Immunizations and Other Preventive Measures, page 2-107 C-8.1. Tetanus toxoid (TT) immunization, page 2-107 C-8.2. Iron/folate, page 2-107 Intermittent preventive treatment and insecticide-treated bednets (for malaria)2, page 3-59 Presumptive treatment (for hookworm infection)2, page 3-59 Vitamin A supplementation2, page 3-62 Iodine supplementation2, page 3-61 9 Reinforce key messages; replenish drugs as needed 1 If woman “opts out” of HIV testing at one visit, she should be offered testing at subsequent visits. 2 According to region/population specific recommendations ONGOING ASSESSMENT AND SUPPORTIVE CARE ¨ If within the first 6 hours after birth (or pre-discharge), the woman (and newborn) should be receiving: z Ongoing assessment, according to the schedule shown in Table 2-13 (page 2-85) (for guidance on ongoing assessment of the newborn, see Table 2-16 [page 2-111]); and z Ongoing supportive care, as shown in Table 2-14 (page 2-86) (for guidance on ongoing supportive care of the newborn, see Table 2-17 [page 2-112]). 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. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-85 Table 2-13. Ongoing Assessment of the Woman during the First 2–6 Hours after Birth WHAT TO ASSESS WHEN TO ASSESS NORMAL ABNORMAL/FOLLOWUP ACTION Blood Pressure z Every 2 hours z Systolic BP (top number) is 90–140 mmHg. z Diastolic BP (bottom number) is less than 90 mmHg. ¨ If the systolic BP is less than 90 mmHg, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding with ongoing assessment. ¨ If the diastolic BP is 90–110 mmHg, ACT NOW!—see Severe Headache, Blurred Vision, or Elevated Blood Pressure (page 3-108) before proceeding with ongoing assessment. ¨ If the diastolic BP is more than 110 mmHg, perform Rapid Initial Assessment (page 3-90) before proceeding. Pulse z Every 2 hours z Pulse is less than 110 beats per minute. ¨ If pulse is 110 or more beats per minute, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding with ongoing assessment. Temperature z Once z Temperature is less than 38°C. ¨ If temperature is 38°C or more, ACT NOW!—see Fever or Foul-Smelling Vaginal Discharge (page 3-115) before proceeding with ongoing assessment. Uterus Note: The uterus should be massaged every 15 minutes during the first 2 hours after birth. z Every hour z Uterus remains firm; feels like a firm ball at or below the umbilicus. ¨ If uterus remains soft or quickly becomes soft after uterine massage, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding with ongoing assessment. Vaginal Bleeding z Every hour z Amount of bleeding is similar to heavy menses. z Normal variations: Clots smaller than lemons may be passed. ¨ If there is frank heavy bleeding, a steady slow trickle of blood, intermittent gushes of blood, or blood clots larger than lemons, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding with ongoing assessment. Bladder z Every hour z Bladder is not palpable. z The woman is able to urinate when the urge is felt. ¨ If the bladder is palpable or the woman is unable to urinate when the urge is felt, see Urinary Retention during Labor and the Postpartum Period (page 3-79) for additional information about assessment and care provision. Breastfeeding Note: At least once during the first 6 hours after birth. z Whenever newborn nurses z Woman and baby are positioned well; baby is correctly attached to the breast and feeds well. ¨ If observations are not within normal range and attachment or suckling do not appear effective, see Breast and Breastfeeding Problems (page 3-43) for additional guidance. ¨ If the woman has not yet decided whether she wants to breastfeed or use a breastmilk substitute, see Breastmilk versus Breastmilk Substitute (page 4-49). ¨ If the woman has chosen to use a breastmilk substitute, see Using a Breastmilk Substitute (page 4-51). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-86 JHPIEGO/Maternal and Neonatal Health Program Table 2-14. Ongoing Supportive Care of the Woman until Discharge from the Healthcare Facility or in the Home ELEMENT MEASURE/RECOMMENDATION Attendance/ Communication z The skilled provider should attend to the woman at least every hour, and: − Focus on the woman; look for nonverbal cues of her needs and preferences. − Give her verbal encouragement and praise. − Provide continual information and reassurance about her condition and the well-being of the baby. − Encourage her to ask questions and express her feelings. − Advise the birth companion to remain with the woman during this time. Mother-Baby Bonding z Ensure that the woman and newborn are kept together as much as possible; facilitate rooming-in for the woman and newborn. z Maintain skin-to-skin contact between the woman and baby as much as possible. z Encourage the woman to hold and explore her baby freely. z Encourage the woman and family to cuddle and talk to the newborn as much as they wish; give them time alone if possible. z Help build the woman’s confidence by verbal and nonverbal messages of encouragement and praise. z Encourage early and exclusive breastfeeding. Comfort z Ensure that the woman has a clean bed and enough blankets to maintain warmth. z Maintain a calm environment conducive to rest for the woman that facilitates bonding with her baby and initiation of breastfeeding. Nutrition z Encourage the woman to eat and drink, as she desires. z Encourage the woman to breastfeed on demand and exclusively as soon as possible after birth. ¨ If the woman has not yet decided whether she wants to breastfeed or use a breastmilk substitute, see Breastmilk versus Breastmilk Substitute (page 4-49). ¨ If the woman has chosen to use a breastmilk substitute, see Using a Breastmilk Substitute (page 4-51). Elimination z Encourage the woman to pass urine when the urge is felt or if the bladder is palpable. z Encourage sufficient fluids and culturally appropriate food to prevent constipation and soften stool. Hygiene/Infection Prevention z Replace soiled and wet clothing and bedding. z Dispose of the soiled/wet linen in a bucket, plastic bag, or other container that can be closed for transport to a washing facility. z Keep clean pads/cloths against the perineum. Parenting Support z Observe the parents’ actions and behaviors; use this information to guide individualization of health messages and counseling and other elements of basic care provision. z Provide continual information and reassurance to the parents about the well- being of the baby. z Encourage them to ask questions and express their feelings. z Again, help build the parents’ confidence by verbal and nonverbal messages of encouragement and praise, as appropriate. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-87 POSTPARTUM ASSESSMENT History (H) Once you have welcomed the woman and her companion, and acknowledged the newborn, review the antenatal and birth records, if available. If not, take the woman’s history. Be sure to record all findings in the woman’s chart. ¨ If this is the first encounter/visit, take a complete history (elements H-1 through H-7). ¨ If this is a return visit, a shortened history (elements H-4 and H-8) may be sufficient. H-1. Personal Information (First Visit) Question Use of Information/Followup Action z What is the woman’s name? z What is the baby’s name? z Use this information to: z Identify the woman, z Show her that the baby is important to you, and z Help establish rapport. ¨ If there is no baby with the woman and you determine that the baby has died, see Stillbirth or Newborn Death (page 3-74) for additional information about assessment. z What is her age (her date of birth, if available)? ¨ If the woman is 19 years of age or under, see Adolescence (page 3-37) for additional information about assessment and care provision. z What is her phone number (if available)? z Where does she live (her address, if available)? z Use this information to: z Contact the woman, and z Guide development of the complication readiness plan. z Does she have reliable transportation? z What sources of income/financial support does she/her family have? z Use this information to guide development of the complication readiness plan. z How many previous pregnancies (gravida) and childbirths (para) has she had? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z Is she currently having a medical, obstetric, social, or personal problem or other concerns? z Has she had any problems during this postpartum period? ¨ If YES: z Ask general followup questions to assess the nature of her problem (Textbox 2-3, page 2-7); and z Consider this information in the context of further assessment. ¨ If the woman reports signs or symptoms shown in Textbox 2-27 (page 2-88), see the corresponding entry for additional information about assessment and care provision. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-88 JHPIEGO/Maternal and Neonatal Health Program Question Use of Information/Followup Action z Has she received care from another caregiver (including a TBA, herbalist, traditional healer) during this postpartum period? ¨ If YES, why did she seek care? ¨ If because of a problem, ask the general followup questions in Set A (Textbox 2-3, page 2-7) to assess the nature of her problem. ¨ If not because of a problem, ask the general followup questions in Set B (Textbox 2-3, page 2-7) to assess the nature of care received. z Consider this information in the context of further assessment. Textbox 2-27. Common Discomforts of the Postpartum Period Abdomen, Breasts, and Legs Afterpains, page 3-4 Digestion and Elimination Bowel function changes, page 3-6 Genitals Perineal pain, page 3-10 Skin Stretch marks (striae gravidarum), page 3-13 Sleep and Mental State Fatigue or sleepiness, page 3-14 Feelings of inadequacy, worry, or fear during the postpartum period, page 3-15 Insomnia, page 3-16 Miscellaneous Back pain, page 3-18 Hair loss, page 3-20 Headache, page 3-21 Hemorrhoids, page 3-22 H-2. Daily Habits and Lifestyle (First Visit) Question Use of Information/Followup Action z Does the woman work outside the home? Is her daily workload strenuous (i.e., how much does she walk, carry heavy loads, engage in physical labor)? z Does she get adequate sleep/rest? z Is her dietary intake adequate (ask what she eats in a typical day, or what she has eaten in the past 2 days)? z Has she given birth within the last year? z Is she currently breastfeeding another child? z Use this information to: z Determine whether there is a balance between the physical demands of the woman’s daily life and her dietary intake; and z Guide individualization of Nutritional Support and other aspects of basic care provision. z Does she smoke, drink alcohol, or use any other potentially harmful substances? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z With whom does she live (husband, partner, children, other household members)? z Use this information to guide development of the complication readiness plan. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-89 Question Use of Information/Followup Action z Inform the woman that you are going to ask her some questions of a personal nature, and that you ask these questions of all clients: z Has anyone ever kept her from seeing family or friends, not allowed her to leave the house, or threatened her life? z Has she ever been injured, hit, or forced to have sex by someone? z Is she frightened of anyone? ¨ If NO to ALL questions OR the woman does not want to discuss this issue, inform her that she can discuss it with you at any time. ¨ If YES to ANY question OR you suspect abuse, see Violence against Women (page 3-81) for additional information about assessment and care provision. H-3. Present Pregnancy and Labor/Childbirth (First Visit) Question Use of Information/Followup Action z When was the birth (exact date and time, if possible)? z Use this information to guide further assessment and care provision—the clinical significance of findings and the care the woman requires vary depending on how much time has elapsed since the birth. z Where did the birth take place, and was it attended by a skilled provider? ¨ If the birth took place in a healthcare facility and was attended by a skilled provider, ask these followup questions and consider findings in the context of further assessment: z From what provider/healthcare facility did she receive labor/childbirth care? z What did the labor/childbirth care include (e.g., testing, immunizations, drugs/medications, counseling)? ¨ If the birth took place at home, was not attended by a skilled provider, and/or the care was not adequate, consider findings in the context of further assessment: z Be alert for signs of conditions or complications that may not have been adequately addressed during labor and childbirth. z Did she have vaginal bleeding (or hemorrhage) during this pregnancy? ¨ If YES, see Anemia (page 3-41) for additional information about assessment and care provision. z Did she have convulsions (or pre-eclampsia/ eclampsia) during this pregnancy or childbirth? ¨ If YES, see Maternal, Fetal, or Newborn Complications of Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) for additional information about assessment and care provision. Note: Violence against women is a difficult topic to address, especially if it is not clearly condemned in the woman’s culture. To encourage the woman to discuss this issue with you: z Ensure complete confidentiality by asking these questions when she is alone (i.e., when no family members or friends are present). z Make it clear that no one deserves to be hit or abused by anyone and that it should never happen, even though some people may think there is nothing wrong with it. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-90 JHPIEGO/Maternal and Neonatal Health Program Question Use of Information/Followup Action z Did she have any of the following complications during this childbirth: z Cesarean section (or other uterine surgery)? z Vaginal or perineal tears? z Episiotomy? z Defibulation? ¨ If YES, see Tears and Incisions during the Postpartum Period (page 3-78) for additional information about assessment and care provision. z Were there any newborn complications during this childbirth? ¨ If there were newborn complications during this birth, see Maternal, Fetal, or Newborn Complications of Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) for additional information about assessment and care provision. H-4. Present Postpartum Period (Every Visit) Question Use of Information/Followup Action z Has she had heavy vaginal bleeding (or hemorrhage) during this postpartum period? z Normal/normal variations: z Day 1 postpartum: z Amount of bleeding is similar to heavy menses. z Clots smaller than lemons may be passed. z Day 2–week 6 postpartum: z Lochia (see below) z No bleeding ¨ If the woman presently has frank heavy bleeding, a steady slow trickle of blood, intermittent gushes of blood, or blood clots larger than lemons, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. ¨ If the woman no longer has abnormal vaginal bleeding but had heavy vaginal bleeding (or hemorrhage) during this postpartum period, see Anemia (page 3-41) for additional information about assessment and care provision. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-91 Question Use of Information/Followup Action z What is the color and amount of her lochia (vaginal discharge)? z Normal/normal variations: z Day 1 postpartum: bleeding similar to heavy menses (see above) z Days 2–4 postpartum (approximately): red lochia (lochia rubra)—the discharge is dark red or brownish with a fleshy odor (similar to that of menses); woman is changing pad/cloth every 2–4 hours z Days 5–14 postpartum (approximately): pink lochia (lochia serosa)—discharge contains less blood and is pinkish brown with a musty, stale odor z Day 11–week 3 or 4 postpartum (approximately): white lochia (lochia alba)—discharge becomes creamy white/yellowish z Lochia may last for up to 6 weeks’ postpartum. z An increase in the amount of lochia may occur as the woman becomes more active. ¨ If lochia is foul-smelling, ACT NOW!—see Fever or Foul- Smelling Vaginal Discharge (page 3-115) before proceeding. ¨ If color and amount of lochia are not within normal range for time frame, see Uterine Subinvolution (page 3-80) for additional information about assessment and care provision. z Has she had any problems with bowel and bladder function since childbirth, such as: z Incontinence? z Leakage of urine/feces from the vagina? z Burning on urination? z Inability to urinate when the urge is felt? z Constipation? ¨ If there is incontinence or leakage of urine/feces from the vagina, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. ¨ If she has burning on urination, see Burning on Urination (page 3-47) for additional information about assessment and care provision. ¨ If she is unable to urinate when the urge is felt, see Urinary Retention during Labor and the Postpartum Period (page 3-79) for additional information about assessment and care provision. ¨ If she has constipation, see Bowel Function Changes— Constipation or Diarrhea (page 3-6) for additional information about assessment and care provision. z What are her feelings about the baby and about her ability to care for her/him? z Use this information to guide individualization of Support for Mother-Baby-Family Relationships and other aspects of basic care provision. ¨ If she reports feelings of inadequacy, worry, or fear, see page 3-15 for additional information about assessment and care provision. ¨ If she reports crying, feelings of sadness or of being overwhelmed, or irritability, see Postpartum Sadness (page 3-69) for additional information about assessment and care provision. z What are her partner/family’s feelings about the baby? z Use this information to guide individualization of Support for Mother-Baby-Family Relationships and other aspects of basic care provision. z Does she feel that breastfeeding is going well? ¨ If NO, consider this finding in the context of further assessment: z Be alert for signs of breast and breastfeeding problems (e.g., breast pain, ineffective positioning or attachment). ¨ If the woman has not yet decided whether she wants to breastfeed or use a breastmilk substitute, see Breastmilk versus Breastmilk Substitute (page 4-49). ¨ If the woman has chosen to use a breastmilk substitute, see Using a Breastmilk Substitute (page 4-51). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-92 JHPIEGO/Maternal and Neonatal Health Program H-5. Obstetric History: Previous Postpartum/Newborn Period (First Visit) Note: Although a woman with previous postpartum/newborn complications does not necessarily require additional/specialized care, knowing about past complications helps you understand any concerns she may have during this postpartum/newborn period. In addition, discussing past complications provides an opportunity to emphasize the importance of having a complication readiness plan. Question Use of Information/Followup Action z If this is not the woman’s first child, are all children still living? ¨ If NO, ask whether any of them died within the first month of life. ¨ If any died within the first month of life, see Maternal, Fetal, or Newborn Complications of Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) for additional information about assessment and care provision. z If this is not the woman’s first child, has she breastfed before? ¨ If NO, explore the reasons why. z What prevented her from breastfeeding? z Did she stop because she had problems breastfeeding? ¨ If YES, ask these followup questions: z For how long did she breastfeed previous babies? z Did she have problems breastfeeding? ¨ If she has had problems breastfeeding in the past, consider this finding in the context of further assessment: z Be alert for signs of breast and breastfeeding problems (e.g., breast pain, ineffective positioning or attachment). z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z If this is not the woman’s first childbirth, has she had convulsions (pre-eclampsia/ eclampsia) during previous postpartum periods? ¨ If YES, consider this finding in the context of further assessment: z Be alert for signs of pre-eclampsia/eclampsia (e.g., elevated blood pressure, proteinuria, headache/blurred vision). z If this is not the woman’s first childbirth, has she vaginal bleeding (hemorrhage) during previous postpartum periods? ¨ If YES, consider this finding in the context of further assessment: z Be alert for vaginal bleeding. z If this is not the woman’s first childbirth, has she had postpartum depression/ psychosis during previous postpartum periods? ¨ If she has had previous postpartum psychosis/depression, consider this finding in the context of further assessment: z Be alert for signs of postpartum depression/psychosis (e.g., severe anxiety or depression that lasts more than 2 weeks, desire to hurt or inability to care for self or baby, hallucinations or delusions). Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-93 H-6. Contraceptive History/Plans (First Visit) Question Use of Information/Followup Action z How many more children does she plan to have? z Use this information to guide individualization of Family Planning and other aspects of basic care provision. z Has she used a family planning method before? ¨ If YES, ask these followup questions: z Which family planning method(s) did she use? z If one method: Did she like it? Why/why not? z If more than one method: Which did she like most? Which did she like least? Why? z Use this information to guide individualization of Family Planning and other aspects of basic care provision. z Does she plan to start using a family planning method? ¨ If YES, ask these followup questions: z Which method does she want to use? z Would she like information on additional methods? z Use this information to guide individualization of Family Planning and other aspects of basic care provision. H-7. Medical History (First Visit) Question Use of Information/Followup Action z Does the woman have any allergies? ¨ If YES, avoid use of any known allergens. z Has the woman been diagnosed with HIV? ¨ If YES, see HIV (page 3-51) for additional information about assessment and care provision. z Has she been recently (within the last 3 months) diagnosed with anemia? ¨ If YES, see Anemia (page 3-41) for additional information about assessment and care provision. z Has the woman been diagnosed with syphilis? ¨ If YES, see Syphilis (page 3-76) for additional information about assessment and care provision. z Has the woman been diagnosed with hepatitis, tuberculosis, heart disease, kidney disease, sickle cell disease, diabetes, goiter, or another serious chronic illness? ¨ If YES, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. z Has she had any previous hospitalizations or surgeries? ¨ If YES, ask these followup questions: z What was the reason for the hospitalization or surgery? z When was it? z What was the outcome? ¨ If the condition is unresolved or has the potential to complicate the postpartum period, consider this information in the context of further assessment. z Is she taking any drugs/ medications—including traditional/local preparations, herbal remedies, over-the-counter drugs, vitamins, and dietary supplements? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-94 JHPIEGO/Maternal and Neonatal Health Program Question Use of Information/Followup Action z Has she had a complete series of five tetanus toxoid (TT) immunizations to date? z Has it been less than 10 years since her last booster? z Use this information to assess the woman’s need for TT, according to the recommended TT schedule (Table 2-3, page 2-34). ¨ If NO to EITHER question OR the woman does not have a written record of prior TT immunizations, proceed according to the recommended TT schedule (Table 2-3, page 2-34). H-8. Interim History (Return Visits) Note: The questions below, together with those in H-4, represent the minimum that you would ask a woman upon a return visit. Additional history may be necessary depending on the woman’s individual needs. Question Use of Information/Followup Action z Is she having a medical, obstetric, social, or personal problem or other concerns currently? z Has she had any problems (or significant changes) since the last visit? ¨ If YES: z Ask general followup questions (Textbox 2-3, page 2-7) to assess the nature of the problem (or change); and z Consider this information in the context of further assessment. ¨ If the woman reports signs or symptoms shown in Textbox 2-27 (page 2-88), see the corresponding entry for additional information about assessment and care provision. z Use this information to determine changes that need to be made in the current plan of care. z Has she received care from another caregiver (including a TBA, herbalist, traditional healer) since the last visit? ¨ If YES, why did she seek care? ¨ If because of a problem, ask the general followup questions in Set A (Textbox 2-3, page 2-7) to assess the nature of her problem. ¨ If not because of a problem, ask the general followup questions in Set B (Textbox 2-3, page 2-7) to assess the nature of care received. z Consider this information in the context of further assessment. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-95 Question Use of Information/Followup Action z Has there been a change in the woman’s personal information (phone number, address, etc.) since the last visit? z Has there been a change in her daily habits or lifestyle (increase in workload, decrease in rest/sleep or dietary intake, etc.) since the last visit? z Has there been a change in her medical history since the last visit? For example, new or recent: z Diagnoses z Injuries z Hospitalizations z Drugs/medications z Use this information to: z Maintain accuracy of the woman’s medical records, and z Determine changes that need to be made in the current plan of care. z Has she been unable to carry out any part of the plan of care (e.g., taking drugs/medications as prescribed, following dietary recommendations)? z Has she had any reactions or side effects to immunizations or drugs/medications given at last visit? ¨ If YES to EITHER question: z Consider this information in the context of further assessment. z Use this information to determine changes that need to be made in the current plan of care. Physical Examination (PE) When you have finished taking the woman’s history, perform a physical examination. Be sure to record all findings in the woman’s chart. Whether this is the first encounter/visit or a return visit, perform a complete physical examination (elements PE-1 through PE-6). PE-1. Assessment of General Well-Being (Every Visit) Element Normal Abnormal/Followup Action Gait and movements Facial expression Behavior z The woman walks without a limp. z Her gait and movements are steady and moderately paced. z Her facial expression is alert and responsive, yet calm. z Her behavior is appropriate to her culture. ¨ If findings are not within normal range, ask these followup questions: z Has she been without food or fluids for a prolonged period? z Has she been taking drugs/medications, herbs, etc.? z Does she have an injury? ¨ If YES to ANY of the above questions, consider the findings during further assessment and when planning/implementing care. ¨ If NO to ALL of the above questions: z Ask general followup questions to assess the nature of her problem (Textbox 2-3, page 2-7); and z Consider this information in the context of further assessment. Remember: The questions in element H-4 (Present Postpartum Period) should be asked at every postpartum care visit. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-96 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action General cleanliness z The woman is generally clean (i.e., there is no visible dirt, no odor, etc.). ¨ If the woman appears unclean, consider when individualizing health messages and counseling and other aspects of basic care provision. ¨ If a foul odor is present, consider this finding in the context of further assessment (e.g., vaginal examination): z Be alert for other signs of infection (e.g., foul-smelling lochia, fever). Skin z The woman’s skin is free from lesions and bruises. ¨ If there are lesions and bruises on the woman’s skin OR you suspect abuse, see Violence against Women (page 3-81) for additional information about assessment and care provision. ¨ If there are lesions and bruises on the woman’s skin AND you do not suspect abuse, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Conjunctiva (mucous membrane on insides of eyelids) z The woman’s conjunctiva is pink (not white or very pale pink) in color. ¨ If her conjunctiva appears white or very pale rather than pink, see Anemia (page 3-41) for additional information about assessment and care provision. PE-2. Vital Signs Measurement (Every Visit) z Have the woman remain seated or lying down with the knees slightly bent, ensuring that she is comfortable and relaxed. z While taking her temperature, measure her blood pressure (BP) and check her pulse. Element Normal Abnormal/Followup Action Blood pressure z Systolic BP (top number) is 90–140 mmHg. z Diastolic BP (bottom number) is less than 90 mmHg. ¨ If the systolic BP is less than 90 mmHg, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. ¨ If the diastolic BP is 90–110 mmHg, ACT NOW!— see Severe Headache, Blurred Vision, or Elevated Blood Pressure (page 3-108) before proceeding. ¨ If the diastolic BP is more than 110 mmHg, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. Temperature z Temperature is less than 38°C. ¨ If temperature is 38°C or more, ACT NOW!—see Fever or Foul-Smelling Vaginal Discharge (page 3-115) before proceeding. Pulse z Pulse is less than 110 beats per minute. ¨ If pulse is 110 or more beats per minute, ACT NOW!—perform Rapid Initial Assessment (page 3-90) before proceeding. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-97 PE-3. Breast Examination (Every Visit) z Help the woman prepare for further examination (follow the steps shown in Textbox 2-7 [page 2-16]). z Ask the woman to uncover her body from the waist up. z Have her lie comfortably on her back. z Visually inspect the overall appearance of the woman’s breasts, such as contours, skin, and nipples; note any abnormalities. z Gently palpate the breasts; note any abnormalities. Element Normal Abnormal/Followup Action Breast inspection (Contours and skin) z Contours are regular with no dimpling or visible lumps. z Skin is smooth with no puckering; no areas of scaliness, thickening, or redness; and no lesions, sores, or rashes. z Normal variations: z If breastfeeding, breasts may look “lumpy” or irregular depending on emptying of milk ducts/lobes. z Breasts may be larger (and more tender) than usual. z Veins may be larger and darker, more visible beneath the skin. z Areolas may be larger and darker than usual, with tiny bumps on them. ¨ If findings are not within normal range, facilitate nonurgent referral/ transfer (Annex 7, page 4-63) after providing basic care. Breast palpation z Soft and nontender. z No localized areas that are red or feel hot or are extremely tender. z Normal variations: z If breastfeeding, breasts may feel “lumpy” or irregular depending on emptying of milk ducts/lobes. z On Days 2 to 4, breasts may become swollen, hard/tense; usually resolves within 24 to 48 hours. ¨ If there are swollen, hard/tense, or general or localized areas of redness, heat, or tenderness, see Breast and Breastfeeding Problems (page 3-43) for additional information about assessment and care provision. Nipples z There is no abnormal nipple discharge. z No pus is coming from nipples. z Only colostrum (on Days 1 or 2 postpartum) or milk is coming from nipples. z No cracks, fissures, or other lesions. z Nipples are not inverted. z Normal variations: z Nipples may be taut and shiny when breasts become engorged (on Days 2 to 4 postpartum). z Nipples may be sore. ¨ If there is abnormal nipple discharge or nipples develop cracks, fissures, or other lesions, see Breast and Breastfeeding Problems (page 3-43) for additional information about assessment and care provision. ¨ If nipples appear to be inverted, test for protractility (Textbox 2-8, page 2-17). ¨ If the nipples are inverted, be alert for potential breastfeeding problems (e.g., problems with attachment of the newborn to the breast, suckling). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-98 JHPIEGO/Maternal and Neonatal Health Program PE-4. Abdominal Examination (Every Visit) z If you have not already done so, help the woman prepare for further examination (follow the steps shown in Textbox 2-7 [page 2-16]). z Ask the woman to uncover her abdomen. z Have her lie on her back with her knees slightly bent. Element Normal Abnormal/Followup Action Surface of the abdomen z There is no incision (sutures)—from cesarean section, uterine rupture, or other uterine surgeries during this birth (as opposed to old scars)—on the surface of the abdomen. ¨ If there is an incision (sutures) from cesarean section, uterine rupture, or other uterine surgeries during this birth, see Tears and Incisions during the Postpartum Period (page 3-78) for additional information about assessment and care provision. Uterus/ involution z The uterus feels firm. z The uterus is not tender. z Fundal height decreases about 1 cm per day for the first 9–10 days postpartum. (See also Figure 2-20 [page 2-99].) z Immediately after completion of 3rd stage of labor, the uterus is usually one fingerbreadth below the umbilicus. z At 24 hours after birth, the uterus may be at the level of the umbilicus or slightly above the umbilicus. z At 6 days’ postpartum, the uterus is approximately midway between the umbilicus and the symphysis pubis. z At 6 weeks’ postpartum, the uterus is no longer palpable abdominally. z Normal variation: z Involution may be slower in women who are multiparous or following multiple gestation, polyhydramnios, the birth of a large baby, or infection. z Although the rate of involution (decrease in uterine size) may vary in different women, the size should progressively decrease. ¨ If the uterus is severely tender, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-80) before proceeding. ¨ If the uterus has increased or has not decreased in size since the last visit, see Uterine Subinvolution (page 3-80) for additional information about assessment and care provision. Bladder Note: Palpate just above the symphysis pubis. z Bladder is not palpable. z Woman is able to urinate when the urge is felt. ¨ If the bladder is palpable and the woman is unable to urinate when the urge is felt, see Urinary Retention during Labor and the Postpartum Period (page 3-79) for additional information about assessment and care provision. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-99 Figure 2-20. Postpartum Fundal Height: Involution PE-5. Leg Examination (Every Visit) Element Normal Abnormal/Followup action Calves z No pain in calf of leg when foot is forcibly dorsiflexed. ¨ If pain in calf, ACT NOW!—see Pain in Calf (page 3-118) before proceeding. PE-6. External Genital Examination (Every Visit) z If you have not already done so, help the woman prepare for further examination (follow the steps shown in Textbox 2-7 [page 2-16]). z Perform a genital/vaginal examination (for the procedure, see Textbox 2-12 [page 2-23]). z After the examination, perform the Post-Examination Steps (Textbox 2-13 [page 2-24]). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-100 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Overall appearance (vaginal opening, skin, and labia) z Nothing is protruding from the vagina. z There is no urine or stool coming from the vagina. z There is no swelling. z There is no incision (sutures) from tears, episiotomy, or defibulation. z The genital skin is free from sores, ulcers, warts, nits, or lice. z The labia are soft and not painful. ¨ If a purplish swelling appears in the vulva or is protruding from the vagina, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If there is an incision (sutures), see Tears and Incisions during the Postpartum Period (page 3-78) for additional information about assessment and care provision. ¨ If other findings are not within normal range, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Lochia (color and amount) z Day 1 postpartum: bright red blood (see Vaginal Bleeding, below) z Days 2–4 postpartum (approximately): red lochia (lochia rubra)—discharge is dark red or brownish with a fleshy odor (similar to that of menses); woman is changing pad/cloth every 2–4 hours z Days 5–14 postpartum (approximately): pink lochia (lochia serosa)—discharge contains less blood and is pinkish brown with a musty, stale odor z Day 11–week 3 or 4 postpartum (approximately): white lochia (lochia alba)—discharge becomes creamy white/yellowish z Normal variations: z Lochia may last for up to 6 weeks’ postpartum. z An increase in the amount of lochia may occur as the woman becomes more active. ¨ If lochia is foul-smelling, ACT NOW!—see Fever or Foul-Smelling Vaginal Discharge (page 3-115) before proceeding. ¨ If lochia rubra persists for 2 weeks or more, see Uterine Subinvolution (page 3-80) for additional information about assessment and care provision. Vaginal bleeding z Day 1 postpartum: amount of bleeding is similar to heavy menses. z Day 2–week 6 postpartum: z Lochia (see Lochia, above) z No bleeding z Normal variation: Clots smaller than lemons may be passed. ¨ If the woman presently has frank heavy bleeding, a steady slow trickle of blood, intermittent gushes of blood, or blood clots larger than lemons, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. ¨ If the woman no longer has abnormal vaginal bleeding but had heavy vaginal bleeding (or postpartum hemorrhage) during this postpartum period, see Anemia (page 3-41) for additional information about assessment and care provision. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-101 Element Normal Abnormal/Followup Action Perineum z No localized pain/tenderness, persistent swelling. z There is no urine or feces leaking from the vaginal opening. z There is no incision (sutures) from tears, episiotomy, or defibulation z Normal variations: ¨ If a slightly tender perineum is reported, see page 3-10 for additional information about assessment and care provision. z If normal childbirth, bruising, swelling, and discomfort may last up to Day 3 or 4 postpartum. z Healing may be slower if there was prolonged pushing, an episiotomy or tear, or trauma of instruments during childbirth. ¨ If perineum is severely tender, ACT NOW!—see Pus, Redness, or Pulling apart of Skin Edges of Perineal Suture Line; Pus or Drainage from Unrepaired Tear; Severe Pain from Tear or Episiotomy (page 3-118) before proceeding. ¨ If there is an incision (sutures) or tears, see Tears and Incisions during the Postpartum Period (page 3-78) for additional information about assessment and care provision. ¨ If there is incontinence or leakage of urine/feces from the vagina, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Woman-Newborn Observation z For assessment of breastfeeding, see page 2-127. z For assessment of mother-baby bonding, see page 2-129. Testing (T) When you have finished performing a physical examination, conduct testing. Be sure to record all findings in the woman’s chart. ¨ If this is the first encounter/visit or a return visit, conduct an HIV test if the woman has not yet been tested and she does not “opt out” of testing (see Note, below). Element Normal Abnormal/Followup Action T-1. HIV (See Note [below].) z Negative ¨ If the test is positive for HIV, see HIV (page 3-51) for additional information about assessment and care provision. Note: The woman should be informed that HIV testing is recommended for all women in their reproductive years, but that she may “opt out” of being tested if she desires. If she opts out, be sure to offer testing at all subsequent visits. A woman who chooses not to be tested during the first visit may change her mind and choose to be tested after she has received counseling, considered the benefits of testing, and/or discussed testing with her partner. Note: Always adhere to national guidelines for HIV testing. In general: z If the test is positive for HIV, test again with a different type/preparation of test. z If the second test is positive, see HIV (page 3-51). z If the second test is negative, do a third test for discordant test results. z If the third test is positive, see HIV (page 3-51). z If the third test is negative, inform the woman that she is HIV- negative during post-test counseling (page 2-34). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-102 JHPIEGO/Maternal and Neonatal Health Program POSTPARTUM CARE PROVISION C-1. Breastfeeding and Breast Care Note: If the woman is HIV-negative, exclusive breastfeeding for the first 6 months of life should be strongly encouraged. The following health messages and counseling should be provided to all women during the postpartum period unless they are HIV-positive or have said that they do not wish to breastfeed. Based on the woman’s breastfeeding history and any other relevant findings or discussion, individualize the key messages below. C-1.1. Breastfeeding Guidelines z The woman should breastfeed her baby exclusively for the first 6 months of life. This means that the baby should not be given anything else to drink or eat during that time—no water, juice, formula, rice, or any other drink or food. z The baby should be breastfed whenever s/he wants, day and night (on demand), which should be about every 2–3 hours (or 8–12 times per 24 hours) during the first weeks of life. z To ensure that the baby is getting enough to eat, the woman should note how often the baby urinates: at least 6 times per day during the first 2–7 days after birth indicates adequate intake. C-1.2. Additional Advice for the Woman z The woman should breastfeed in positions that are comfortable for her and that help to ensure successful breastfeeding. (For additional information about positioning, holding, attachment, etc., see Breastfeeding Support [page 4-47].) z She should try to use both breasts during each feed if possible. The amount of time the baby sucks at either breast should not be limited. Instead, the baby should be allowed to continue feeding at a breast for as long as s/he wants and then offered the other breast. z The breastfeeding woman needs adequate rest and sleep. Because the baby may wake during the night to be fed, the woman may become overtired during the day. It may help to rest or take naps during the day, whenever the baby is sleeping. z The breastfeeding woman needs extra fluid and food intake. She should drink at least one glass of fluids every time the baby breastfeeds and eat the equivalent of one extra meal per day. C-1.3. Breast Care z To prevent engorgement, breastfeed at least every 2–3 hours on demand (including during the night) and use both breasts at each feeding. z Wear a cotton bra or breast binder that is supportive but not tight/constrictive. z Keep the nipples clean and dry. z Wash nipples with a clean cloth and warm water only, no soap. Wash no more than once per day. z After breastfeeding or washing the nipples, leave some breastmilk on the nipples and allow them to dry by exposing them to air. Note: For information on the following related topics, see the page indicated: benefits of breastfeeding for the woman and newborn, page 2-32; general principles of early and exclusive breastfeeding, page 2-32; proper positioning for good attachment, page 4-47. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-103 C-2. Complication Readiness Plan Advise the woman and her family to enact the complication readiness plan if any of the danger signs shown in Textbox 2-28 (below) arise. z As soon as possible after birth: Review the woman’s complication readiness plan, updating it to reflect postpartum/newborn needs. If she and her family have not yet developed a complication readiness plan, assist them in developing one according to the guidelines shown on page 2-26. z On each return visit, review and update the plan: z What arrangements have been made since the last visit? z Has anything changed? z Have any obstacles or problems been encountered? Textbox 2-28. Danger Signs during the Postpartum/Newborn Period Maternal danger signs: z Vaginal bleeding (heavy or sudden increase) z Breathing difficulty z Fever z Severe abdominal pain z Severe headache/blurred vision z Convulsions/loss of consciousness z Foul-smelling discharge from vagina or tears/incisions z Pain in calf, with or without swelling z Verbalization/behavior that indicates she may hurt the baby or herself, or hallucinations Newborn danger signs: z Breathing difficulty z Convulsions, spasms, loss of consciousness, or back arching (opisthotonos) z Cyanosis (blueness) z Hot to touch/fever z Cold to touch z Bleeding z Jaundice (yellowness) z Pallor z Diarrhea z Persistent vomiting or abdominal distention z Not feeding or poor suckling (feeding difficulties) z Pus or redness of the umbilicus, eyes, or skin z Swollen limb or joint z Floppiness z Lethargy C-3. Support for Mother-Baby-Family Relationships As soon as possible after the birth, discuss the following issues with the woman and, if she permits, her partner, her family, or other key decision makers in her life. On each return visit, assess the family’s success in supporting the woman through the early postpartum period and integrating care of the newborn into their daily lives. Bonding z Encourage the family to touch, hold, and explore the newborn as much as they wish. z Encourage rooming-in for the woman and newborn. Challenges z Assist the family in identifying any unique challenges they may face, especially in the immediate postpartum/newborn period, such as: z Woman’s increased need for rest (and intake of food/fluids, if breastfeeding) z Increased workload and less time/energy available for other things, including other children and chores Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-104 JHPIEGO/Maternal and Neonatal Health Program Support z Assist the family in devising strategies for overcoming these obstacles, such as having someone else care for the newborn when the woman is in need of rest. Information z In addition to ensuring complication readiness: z Discuss the key aspects of newborn care (as shown in Chapter 8, page 2-131) and postpartum care clearly and carefully. z Encourage the woman/partner/family to ask questions and express concerns. z Repeat explanations as often as they desire. Encouragement and praise z Help build the woman’s confidence by verbal and non-verbal messages. z Assure her that she is capable of caring for her newborn. C-4. Family Planning z Introduce the concepts of birthspacing and family planning. z Intervals of at least 3 years between births have health benefits for both the woman and the baby. Appropriate birth spacing lowers the risk of: − Maternal mortality − Anemia (woman) − Premature rupture of membranes (woman) − Postpartum endometritis (woman) − Malnutrition (woman) − Fetal death − Preterm birth − Small-for-gestational-age baby − Newborn death − Intrauterine growth retardation and low birthweight baby z Discuss the woman’s previous experience with and beliefs about contraception, as well as her preferences. z Based on the woman’s history and any other relevant findings and discussion, individualize the following key messages: z Women who do not breastfeed can become pregnant again very quickly. On average, women who do not breastfeed will begin: − Menstruating by 6 or 8 weeks, and − Ovulating by 11 weeks (sometimes even sooner). z Women who breastfeed exclusively may be protected from becoming pregnant for up to 4–6 months, because breastfeeding can inhibit ovulation (which is known as the lactational amenorrhea method, LAM). On average, women who breastfeed begin: − Menstruating at 7.5–9 months, depending on how often and how much they are breastfeeding − Ovulating by 4–5 months if they breastfeed for 3 months, and by 7 months if they breastfeed for 6 months. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-105 ¨ If the woman is going to rely on LAM to prevent pregnancy during the postpartum period, advise her on other important considerations shown in Textbox 2-29 (below). z Some women can ovulate, and even become pregnant, as early as 35 days after childbirth. z Many postpartum women will ovulate before their menstrual periods resume. Once a woman begins ovulating, she can become pregnant. This means a woman can become pregnant even if she has not resumed menstrual periods. Textbox 2-29. Important Considerations for Women Using LAM z Risk of ovulating and becoming pregnant is higher if the baby is given fluids/food other than breastmilk. z Consider another family planning method whenever the baby decreases the frequency or amount of feeding, or when you begin adding other foods to the baby’s diet. z Do not discontinue breastfeeding solely to begin use of a contraceptive method. z Discuss the benefits and limitations of different methods, including LAM and dual protection with condoms. z Advise on the availability/accessibility of family planning services and methods. z If the woman desires to begin/resume family planning, assist her in choosing a contraceptive method that best meets her needs. (For additional information on Postpartum Contraception, see page 4-53.) C-5. Nutritional Support Based on the woman’s dietary history, the resources available to the woman and her family, and any other relevant findings or discussion, individualize the following key nutrition messages. All women should: Eat a balanced diet including a wide variety of foods. For more information about nutritional support for all women, see page 2-26. Women who are breastfeeding should also: z Eat at least two additional servings of staple food per day to supply the extra 300–500 extra calories needed. z Eat at least three additional servings of calcium-rich foods (e.g., dark green leafy vegetables, rice, tofu, salmon/sardines, or milk/dairy products) to supply the extra 1200 mg of calcium needed. z Drink at least 8 glasses of fluid (2 liters) each day; drinking a cup of fluids each time she breastfeeds is a good way to ensure enough fluid intake. z Include a variety of fluids such as milk, water, and juices. z Eat smaller, more frequent meals if unable to consume larger amounts in fewer meals. z Avoid alcohol and tobacco, which can decrease milk production. z Take micronutrient supplements as directed. z Try to decrease the amount of heavy work and increase rest time. C-6. Self-Care and Other Healthy Practices Based on the woman’s history and any other relevant findings or discussion, individualize health messages and counseling on the topics addressed below. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-106 JHPIEGO/Maternal and Neonatal Health Program Although these issues should be addressed at the earliest opportunity, other topics—such as breastfeeding support and the basics of newborn care—can be included according to individual need. Ideally, the woman’s partner would be present during these discussions. Note: Women who have common discomforts of the postpartum period require additional care, which consists mainly of health messages and counseling. Chapter 9 (page 3-1) contains information on additional care for women with common discomforts. C-6.1. Prevention of Infection/Hygiene In addition to practicing good general hygiene (page 2-29), the postpartum woman should be advised as follows: z During the postpartum period, the woman may be more susceptible to infection and should be especially careful to practice good genital hygiene, including: z Keeping the vulvar and vaginal area as clean and dry as possible. z Wash hands before and after washing the genitals. z Use a clean cloth to wash and another to dry the genital area. z Wash the genital area with soap and water after using the toilet. z Wash/wipe genitals from front to back, starting with the vulva and ending with the anus. Note: Before use, any basin or tub used for a sitz bath should be: z Rinsed with chlorine solution; z Washed with soap; and z Rinsed with water. z Change perineal pads or cloths at least 6 times per day during the first week, and at least twice per day thereafter. (Cloths may be reused if washed thoroughly, boiled, and dried in the sun between uses.) z Wear cotton underpants and comfortable, loose-fitting clothing. Avoid nylon underpants and pantyhose. z Avoid douching, having sex, and inserting tampons or anything else into the vagina for at least 2 weeks after birth or until: z There is no longer any lochia rubra or serosa, and z The lochia alba has diminished or ceased. Note: Advise the woman to return for care if lochia rubra persists for more than 2 weeks or becomes foul-smelling. C-6.2. Rest and Activity Based on the woman’s history and any other relevant findings and discussion, individualize the following key messages: z During the postpartum period, a woman needs plenty of rest to facilitate healing after birth. Adequate rest will help the postpartum woman regain her strength and recover more quickly. z A breastfeeding woman needs even more time to rest. Because she is breastfeeding, and her sleep at night will be interrupted, advise her to have periodic rest periods during the day when the newborn is sleeping. During the night, her partner or other family member may be able to care for the newborn when s/he is not feeding. Chapter Seven: Postpartum Care JHPIEGO/Maternal and Neonatal Health Program 2-107 z Traditionally, women have been advised to delay returning to work for 6 weeks. Many will feel able to resume all activities by 4 or 5 weeks. Each woman is different. Advise the woman to start back into her usual routine gradually, and to pay attention to her body for signs that she may be overdoing it or may need more rest. Note: In most cultures, women do not get permission to rest during the postpartum period. It may be your role to play advocate for the woman, and help her find creative ways to reduce her workload and find more time for rest. C-6.3. Sexual Relations and Safer Sex Based on the woman’s history and any other relevant findings or discussion, individualize the following key messages: z A woman should avoid having sexual intercourse for at least 2 weeks after birth or until: z There is no longer any lochia rubra or serosa, and z The lochia alba has diminished or ceased. Note: Advise the woman to return for care if lochia rubra persists for more than 2 weeks or becomes foul-smelling. z After that, the woman can decide when she is ready to resume sexual relations. Healing of episiotomy/tears and type/amount of lochia may influence her level of comfort with intercourse. Intercourse should be avoided, however, if she experiences: z Vaginal bleeding z Perineal pain z A woman is more susceptible to sexually transmitted infections—such as HIV, syphilis, gonorrhea, or chlamydia—during the postpartum period while the reproductive tract is still healing and returning to its prepregnancy condition. z Practicing safer sex can reduce the risk of HIV and other sexually transmitted infections (STIs): z Abstinence or mutually monogamous sex with a partner who is free from HIV or STIs is the only sure protection. z Consistent use of condoms is important, even during lactational amenorrhea. z Sexual practices that may further increase risk of infection (such as anal sex, “dry” sex, etc.) should be avoided. C-7. HIV Counseling and Testing (First Visit/As Needed) If the woman does not know her HIV status or has not been tested for HIV, provide HIV counseling and testing. (For more information, see page 2-33.) C-8. Immunizations and Other Preventive Measures C-8.1. Tetanus Toxoid (TT) Immunization Provide TT vaccination as needed. (For more information, see page 2-34.) C-8.2. Iron/Folate z To prevent anemia, prescribe iron 60 mg + folate 400 mcg to be taken by mouth once daily for 3 months. z Dispense a sufficient supply to last until the next visit. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-108 JHPIEGO/Maternal and Neonatal Health Program z Provide health messages and counseling as follows: z Eat foods rich in vitamin C, as these help the body absorb iron. Sources of vitamin C include citrus fruits (oranges, grapefruit, lemons, limes), tomatoes, peppers, potatoes, cassava leaves, and yams. z Avoid tea, coffee, and colas, as these inhibit iron absorption. z Possible side effects of the iron/folate tablets include black stools, constipation, and nausea. Lessen side effects by: − Drinking more fluids (an additional 2–4 cups per day) − Eating more fruits and vegetables − Getting adequate exercise (such as walking) − Taking tablets with meals or at night Region/Population-Specific Preventive Measures z For women in areas with a high prevalence of malaria, see guidelines for prevention (page 3-59). z For women in areas with a high prevalence of hookworm infection, see guidelines for prevention (page 3-58). z For women in areas with a high prevalence of vitamin A deficiency, see guidelines for additional supplementation (page 3-62). z For women in areas with a high prevalence of iodine deficiency, see guidelines for additional supplementation (page 3-61). JHPIEGO/Maternal and Neonatal Health Program 2-109 CHAPTER EIGHT NEWBORN CARE OVERVIEW After the newborn has undergone the quick check (Annex 6, page 4-63), the newborn care visit should be conducted according to the guidelines shown in Chapter 4 (page 2-1) and the schedule shown below (Table 2-15). Table 2-15. Schedule and Overview of Newborn Care COMPONENTS/ELEMENTS 1ST VISIT SUBSEQUENT VISITS ASSESSMENT Ongoing Assessment, page 2-110 Up to 6 hours after birth − History H-1. Personal information, page 2-113 9 − H-2. Present labor/childbirth, page 2-115 9 − H-3. Maternal obstetric history, page 2-116 9 − H-4. Maternal medical history, page 2-116 9 − H-5. Present newborn period, page 2-117 9 − H-6. Interim history, page 2-119 − 9 Physical Examination/Observation PE/O-1. Overall appearance/general well-being, page 2-120 Weight, page 2-121 Respiration, page 2-121 Temperature, page 2-121 Color, page 2-121 Movements and posture, page 2-122 Level of alertness and muscle tone, page 2-122 Skin, page 2-123 9 9 PE/O-2. Head, face and mouth, eyes, page 2-124 9 9 PE/O-3. Chest, abdomen and cord, and external genitalia, page 2-126 9 9 PE/O-4. Back and limbs, page 2-127 9 − PE/O-5. Breastfeeding, page 2-127 9 9 PE/O-6. Mother-baby bonding, page 2-129 9 9 CARE PROVISION Ongoing Supportive Care, page 2-110 Up to discharge − C-1. Early and Exclusive Breastfeeding, page 2-130 9 Reinforce key messages Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-110 JHPIEGO/Maternal and Neonatal Health Program Table 2-15. Schedule and Overview of Newborn Care (continued) COMPONENTS/ELEMENTS 1ST VISIT SUBSEQUENT VISITS CARE PROVISION (CONTINUED) C-2. Complication Readiness Plan, page 2-130 9 Continue to develop as needed; reinforce key messages C-3. Newborn Care and Other Healthy Practices, page 2-131 C-3.1. Maintaining warmth, page 2-131 C-3.2. Prevention of infection/hygiene, page 2-132 C-3.3. Washing and bathing, page 2-132 C-3.4. Cord care, page 2-134 C-3.5. Sleep and other behaviors/needs, page 2-134 9 Reinforce key messages C-4. Immunizations and Other Preventive Measures, page 2-135 C-4.1. Immunization, page 2-135 C-4.2. Vitamin K1, page 2-135 Intermittent preventive treatment and insecticide-treated bednets (for malaria)* 9 Reinforce key messages; replenish drugs as needed * According to region/population-specific recommendations ONGOING ASSESSMENT AND SUPPORTIVE CARE ¨ If within the first 6 hours after birth (or pre-discharge), the newborn (and woman) should be receiving: z Ongoing assessment, according to the schedule shown in Table 2-16 (page 2-111) (for guidance on ongoing assessment of the woman, see Table 2-13 [page 2-85]); and z Ongoing supportive care, as shown in Table 2-17 (page 2-112) (for guidance on ongoing supportive care of the woman, see Table 2-14 [page 2-86]). 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. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-111 Table 2-16. Ongoing Assessment of the Newborn during the First 2–6 Hours after Birth WHAT TO ASSESS WHEN TO ASSESS NORMAL ABNORMAL/FOLLOWUP ACTION Respiration z Every hour z Respiratory rate is 30–60 breaths per minute z No gasping z No grunting on expiration z No chest indrawing ¨ If respiration is not within normal range, ACT NOW!—perform Newborn Rapid Initial Assessment (page 3-96) before proceeding. Color z Every hour z Baby’s lips, tongue, and nailbeds are pink z No central cyanosis (blue tongue and lips) z No jaundice (yellowness) z No pallor z Hands and feet are sometimes “bluish”/ cyanotic ¨ If there is central cyanosis or pallor, facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If there is jaundice, ACT NOW!— see Jaundice (page 3-124) before proceeding. Cord stump z Once z Cord stump is not bleeding ¨ If the cord stump is bleeding, retie the cord. ¨ If bleeding continues after 15 minutes, ACT NOW!—see Bleeding (page 3-126) before proceeding. Breastfeeding z Whenever newborn nurses z Woman and baby are positioned well; baby is correctly attached to the breast and feeds well ¨ If observations are not within normal range and attachment or suckling do not appear effective, see Breast and Breastfeeding Problems (page 3-43) for additional information on assessment and care provision. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-112 JHPIEGO/Maternal and Neonatal Health Program Table 2-17. Ongoing Supportive Care for the Newborn until Discharge from the Healthcare Facility or in the Home ELEMENT MEASURE/RECOMMENDATION Warmth z Keep the woman and baby in skin-to-skin contact, covered with a clean, dry blanket/covering, as much as possible. ¨ If the baby cannot be in immediate skin-to-skin contact with the woman or after 6 hours, dress her/him in an extra layer or two (in addition to what is comfortable for adults) of clothing or blankets/coverings. z Avoid dressing the baby in tight, restrictive clothing or blankets/coverings because they reduce the retention of heat. z Cover the baby’s head with a hat. z Keep the room warm (25°C or more) and free from drafts. z Do not bathe the baby for at least the first 6 hours after birth, and preferably not in the first 24 hours, and not until the baby’s temperature is stable. Nutrition z Encourage the woman to breastfeed on demand and exclusively as soon as possible after birth. ¨ If the woman has not yet decided whether she wants to breastfeed or use a breastmilk substitute, see Breastmilk versus Breastmilk Substitute (page 4-49). ¨ If the woman has chosen to use a breastmilk substitute, see Using a Breastmilk Substitute (page 4-51). Hygiene/Infection Prevention z Replace soiled and wet clothing and bedding; dispose of soiled/wet linen in a bucket, plastic bag, or other container that can be closed for transport to a washing facility. z Keep the baby’s cord stump clean and dry. z Encourage the woman to care for her own newborn as much as possible. z Avoid sharing baby equipment and supplies, or disinfect shared equipment and supplies before/after use if sharing is necessary. z Ensure that all facility staff wash their hands before and after caring for each newborn. z Advise the woman, her partner, and other people to wash their hands before and after touching the newborn. z Keep sick children and adults away from the newborn because of the risk of cross-infection. Mother-Baby Bonding z Ensure that the woman and baby are kept together as much as possible; facilitate rooming-in for them. z Encourage the parents to hold and explore their baby freely. z Encourage the parents to cuddle and talk to the newborn as much as they wish; give them time alone if possible. z Help build the parents’ confidence by verbal and nonverbal messages of encouragement and praise, as appropriate. z Again, keep the woman and baby in skin-to-skin contact, covered with a clean, dry blanket/covering, as much as possible for the first 6 hours at least. z Again, encourage the woman to breastfeed on demand and exclusively as soon as possible after birth. Parenting Support z Observe the parents’ actions and behaviors; use this information to guide individualization of health messages and counseling and other elements of basic care provision. z Provide continual information and reassurance to the parents about the well-being of the baby. z Encourage them to ask questions and express their feelings. z Again, help build the parents’ confidence by verbal and nonverbal messages of encouragement and praise, as appropriate. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-113 NEWBORN ASSESSMENT History (H) Once you have welcomed the woman and her companion, and acknowledged the newborn, take the newborn’s history. Be sure to record all findings in the newborn’s chart. ¨ If this is the first encounter/visit, take a complete history (elements H-1 through H-5). ¨ If this is a return visit, a shortened history (elements H-5 and H-6) may be sufficient. H-1. Personal Information (First Visit) Question Use of Information/Followup Action z What is the woman’s name? z What is the newborn’s name and sex? z Use this information to: z Identify the newborn, and z Help establish rapport with the woman. z When was the baby born (time and date of birth, if available)? z Use this information to guide: z Further assessment, because the clinical significance of many findings varies depending on the age of the baby; and z Individualization of health messages and counseling and other aspects of basic care provision. z What is the woman’s phone number (if available)? z Where does she live (her address, if available)? z Use this information to: z Contact the woman, and z Guide development of the complication readiness plan. z Does the woman have reliable transportation? z What sources of income/financial support does she/her family have? z Use this information to guide: z Development of the complication readiness plan. z Individualization of health messages and counseling and other aspects of basic care provision. z How many previous pregnancies (gravida) and childbirths (para) has she had? z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z Is the newborn having a problem currently? z Has s/he had any problems during this newborn period? ¨ If YES: z Ask general followup questions to assess the nature of her/his problem (Textbox 2-30, page 2-114); and z Consider this information in the context of further assessment. ¨ If the woman has concerns or reports newborn signs shown in Textbox 2-31 (page 2-114), see the corresponding entry for additional information about assessment and care provision. z Has the newborn received care from another caregiver (including a TBA, herbalist, traditional healer) during this newborn period? ¨ If YES, why did the woman seek care for the newborn? ¨ If because of a problem, ask the general followup questions in Set A (Textbox 2-30, page 2-114) to assess the nature of the problem. ¨ If not because of a problem, ask the general followup questions in Set B (Textbox 2-30, page 2-114) to assess the nature of care received. z Consider this information in the context of further assessment. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-114 JHPIEGO/Maternal and Neonatal Health Program Textbox 2-30. General Followup Questions (Newborn) Set A: Questions to ask if the newborn has (or recently had) a problem: z What is the problem, exactly? z When did it first occur? z Did it occur suddenly or develop gradually? z When and how often does the problem occur? z What may have caused the problem? Did anything unusual occur before its onset? z How is the newborn affected by the problem? Is s/he eating, sleeping, and behaving normally? z Has the problem become more or less severe? z Are there accompanying signs/symptoms or conditions? If YES, what are they? z Has s/he received care/treatment from another caregiver for this problem? If YES, proceed to Set B. Set B: Questions to ask if the newborn has received care/treatment from another caregiver: z Who (or what healthcare facility) provided this care? z What did this care involve (drugs/medications, treatments, etc.)? z What was the outcome of this care (i.e., Was it effective? If for a problem, did it eliminate the problem?)? Textbox 2-31. Common Concerns during the Newborn Period Chest, Abdomen, Cord Stump, and External Genitalia Mucoid or bloody vaginal discharge, page 3-25 Swollen breasts, page 3-25 Swollen labia, page 3-25 Swollen scrotal sac, page 3-26 Tight foreskin, page 3-26 Umbilical hernia, page 3-26 Head, Face, Mouth, and Eyes Caput succedaneum, page 3-27 Cephalohematoma, page 3-27 Epithelial “pearls”, page 3-27 Molding or chignon, page 3-28 Subconjunctival hemorrhage, page 3-28 Swollen or red eyelids, page 3-28 Tongue tie, page 3-29 Skin Acne, page 3-29 Diaper/napkin rash, page 3-30 Erythema toxicum, page 3-30 Milia, page 3-31 Mongolian spots, page 3-31 Port wine stains, page 3-31 “Stork bites”, page 3-32 Miscellaneous Crying, increased, page 3-32 Irregular breathing, page 3-32 Startle reflex, page 3-33 Vomiting, page 3-33 Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-115 H-2. Present Labor/Childbirth (First Visit) Question Use of Information/Followup Action z Where did the birth take place, and was it attended by a skilled provider? ¨ If the birth took place in a healthcare facility and was attended by a skilled provider, ask these followup questions and consider findings in the context of further assessment: z From what provider/healthcare facility did the woman receive labor/childbirth care? z What did the labor/childbirth care include (e.g., testing, immunizations, drugs/medications, counseling)? ¨ If the birth took place at home, was not attended by a skilled provider, and/or the care was not adequate, consider findings in the context of further assessment: z Be alert for signs of conditions or complications that may not have been adequately addressed during labor and childbirth. z Did the woman have a uterine infection or fever during labor or after birth? ¨ If YES and the baby is less than 3 days of age, see Mother with History of Rupture of Membranes for More than 18 Hours before Birth and/or Uterine Infection or Fever during Labor or Birth (page 3-86) for additional information about assessment and care provision. z Did the woman have rupture of membranes for more than 18 hours before birth? ¨ If YES and the baby is less than 3 days of age, see Mother with History of Rupture of Membranes More than 18 Hours before Birth and/or Uterine Infection or Fever during Labor or Birth (page 3-86) for additional information about assessment and care provision. z Were there any complications that may have caused injury, such as shoulder dystocia, breech birth, large baby, or instrument assistance (vacuum extraction, forceps)? ¨ If YES, consider this finding in the context of further assessment: z Be alert for signs of birth injury (e.g., cuts or scrapes, bruises, swelling or tenderness of limbs or joints, asymmetrical movements of limbs). z Did the baby require resuscitation at birth? ¨ If YES, consider this finding in the context of further assessment: z Be alert for signs of breathing difficulty (e.g., abnormal respirations, chest indrawing, grunting on expiration, gasping). z What was the baby’s weight at birth? z Normal: Birthweight is 2.5–4.0 kg ¨ If the birthweight was less than 2 kg, ACT NOW!— facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the birthweight was more than 4.0 kg, see Large Baby (page 3-84) for additional information about assessment and care provision. ¨ If the birthweight was 2–2.5 kg, see Low Birthweight Baby (page 3-85) for additional information about assessment and care provision. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-116 JHPIEGO/Maternal and Neonatal Health Program H-3. Maternal Obstetric History: Previous Newborn Period (First Visit) Note: Although the baby of a woman who has had previous postpartum/newborn complications does not necessarily require additional/specialized care, knowing about past complications helps you understand any concerns she may have during this postpartum/newborn period. Also, discussing past complications provides an opportunity to emphasize the importance of having a complication readiness plan. Question Use of Information/Followup Action z If this is not the woman’s first child, are all children still living? ¨ If NO, ask whether any of them died before birth or within the first month of life. ¨ If YES, see Maternal, Fetal, or Newborn Complications during Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) for additional information about assessment and care provision. z If this is not the woman’s first child, has she breastfed before? ¨ If NO, explore the reasons why. z What prevented her from breastfeeding? z Did she stop because she had problems breastfeeding? ¨ If YES, ask these followup questions: z For how long did she breastfeed previous babies? z Did she have problems breastfeeding? ¨ If she has had problems breastfeeding in the past, consider this finding in the context of further assessment: z Be alert for signs of breast and breastfeeding problems (e.g., breast pain, ineffective positioning or attachment). z Use this information to guide individualization of health messages and counseling and other aspects of basic care provision. H-4. Maternal Medical History (First Visit) Question Use of Information/Followup Action z Has the woman been diagnosed with diabetes? ¨ If YES, and the baby is less than 3 days of age, facilitate urgent referral/transfer (Annex 7, page 4-63). z Has the woman been diagnosed with any of the following infectious diseases? z Hepatitis B z HIV z Syphilis z Tuberculosis ¨ If YES, see the corresponding entries for additional information about assessment and care provision: z Mother with Hepatitis B (page 3-85) z Mother with HIV (page 3-87) z Mother with Syphilis (page 3-87) z Mother with Tuberculosis (page 3-87) Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-117 Question Use of Information/Followup Action z What are her feelings about the baby and about her ability to care for her/him? z Use this information to guide individualization of Support for Mother-Baby-Family Relationships and other aspects of basic care provision. ¨ If she reports feelings of inadequacy, worry, or fear, see page 3-15, for additional information about assessment and care provision. ¨ If she reports crying, feelings of sadness or of being overwhelmed, or irritability, see Postpartum Sadness (page 3-69) for additional information about assessment and care provision. z What are her partner/family’s feelings about the baby? ¨ Use this information to guide individualization of Support for Mother-Baby-Family Relationships and other aspects of basic care provision. H-5. Present Newborn Period (Every Visit) Question Use of Information/Followup Action z Does she feel that breastfeeding is going well? ¨ If NO, consider this finding in the context of further assessment: z Be alert for signs of breast and breastfeeding problems (e.g., breast pain, ineffective positioning or attachment). ¨ If the woman has not yet decided whether she wants to breastfeed or use a breastmilk substitute, see Breastmilk versus Breastmilk Substitute (page 4-49). ¨ If the woman has chosen to use a breastmilk substitute, see Using a Breastmilk Substitute (page 4-51). z How often does the baby feed? z Does the baby seem satisfied after feeding? z Normal/normal variations: z The baby wakes every 2–3 hours to feed (but may sleep 4 hours between feeds at night). z The baby feeds at least 8 times per day. z The baby seems satisfied after feeding. ¨ If the baby’s feeding habits are not within normal range, consider the findings during further assessment to identify other signs of inadequate intake (e.g., urinating or passing stool too few times per day, dehydration). z How often does the baby urinate? z Normal/normal variations: z The baby urinates at least once in the first 24 hours. z After the first 48 hours after birth, the baby urinates at least 6 times per day. ¨ If the baby has not urinated within the first 24 hours or is urinating fewer than 6 times per day after the first 48 hours of life, see Breast and Breastfeeding Problems (page 3-43) for additional information about assessment and care provision. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-118 JHPIEGO/Maternal and Neonatal Health Program Question Use of Information/Followup Action z Has the baby passed the first stool? z When was the last time the baby passed stool? z How often does the baby pass stool? z What is its color/consistency? z Normal/normal variations (Table 2-18, below): z The first stool is typically passed within the first 2 days after birth. This is the “meconium” stool and is thick, tarry, and dark green. z From 3–7 days after birth: z Stools change in color and consistency. z The breastfed baby passes stool at least 4–10 times per day (approximately once per feeding). z The breastmilk substitute (BMS)-fed baby passes stool at least 2–4 times per day. ¨ If the baby has not passed stool within the first 48 hours of life, facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the baby has or recently had diarrhea (i.e., an increase in number of stools, watery stools), ACT NOW!—see Diarrhea (page 3-125) before proceeding. ¨ If, from 3–7 days after birth, the breastfed baby is passing stool fewer than 4 times per day or the BMS-fed baby is passing stool fewer than 2 times per day, see Breast and Breastfeeding Problems (page 3-43) for additional information about assessment and care provision. z Has the baby been diagnosed with a congenital malformation? ¨ If YES and it has not yet been adequately addressed, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care OR urgent referral/transfer (Annex 7, page 4-63) as indicated in Table 2-19 (page 2-119). z Has the baby received all required vaccines to date (e.g., OPV, BCG, HBV)? z Use this information to assess the baby’s need for vaccines during this visit; proceed according to the recommended Newborn Immunization Schedule (Table 2-20, page 2-135). Table 2-18. Newborn Stool Descriptions STOOL TYPE WHEN PASSED COLOR CONSISTENCY Meconium Within 1–2 days after birth Tarry, black/dark green Thick, sticky Transitional Within 3–5 days after birth Brown to green Thin Breastmilk After 5 days Yellow Watery, soft/mushy Breastmilk substitute After 5 days Pale yellow Formed, pasty Note: A written record of immunization is best, but if none is available, try to ascertain which vaccines the baby has received. If the woman does not remember whether the baby received immunizations or you suspect that the baby has not been immunized, provide OPV, BCG, and HBV vaccines according to the recommended Newborn Immunization Schedule (Table 2-20, page 2-135). Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-119 Table 2-19. Appropriate Followup Action for Congenital Malformations CONGENITAL MALFORMATION FOLLOWUP ACTION Skin tags and extra digits (if no bony attachment) Tie off; nonurgent referral Cleft lip or palate Nonurgent referral Club foot Nonurgent referral Down syndrome or other genetic birth defect (may appear as abnormal facial features) Link parents to support; nonurgent referral Hydrocephalus Nonurgent referral Spina bifida/meningomyelocele (may appear as spinal malformations) Urgent referral Gastroschisis/omphalocele (may appear as abdominal malformations) Urgent referral Imperforate anus Urgent referral Congenital heart abnormality Urgent referral H-6. Interim History (Return Visits) Note: The questions below, together with those in H-5, represent the minimum that you would ask the woman upon a return visit. Additional history may be necessary depending on the newborn’s individual needs. Question Use of Information/Followup Action z Is the newborn having a problem? z Has the newborn had any problems (or significant changes) since the last visit? ¨ If YES: z Ask general followup questions to assess the nature of the problem (or change) (Textbox 2-30, page 2-114); and z Consider this information in the context of further assessment. ¨ If the woman has concerns or reports newborn signs shown in Textbox 2-31 (page 2-114), see the corresponding entry for additional information about assessment and care provision. z Use this information to determine changes that need to be made in the current plan of care. z Has the newborn received care from another caregiver (including a TBA, herbalist, traditional healer) since the last visit? ¨ If YES, why did the woman seek care for the newborn? ¨ If because of a problem, ask the general followup questions in Set A (Textbox 2-30, page 2-114) to assess the nature of the problem. ¨ If not because of a problem, ask the general followup questions in Set B (Textbox 2-30, page 2-114) to assess the nature of care received. z Consider this information in the context of further assessment. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-120 JHPIEGO/Maternal and Neonatal Health Program Question Use of Information/Followup Action z Has there been a change in the woman’s personal information (phone number, address, etc.) since the last visit? z Has there been a change in the baby’s habits or behaviors (e.g., decrease in feeding, urinating) since the last visit? z Has there been a change in the baby’s medical history since the last visit? For example, new or recent: z Diagnoses z Injuries z Hospitalizations z Drugs/medications z Use this information to: z Maintain accuracy of the newborn’s medical records, and z Determine changes that need to be made in the current plan of care. z Has the woman been unable to carry out any part of the newborn’s plan of care (e.g., breastfeeding, keeping clean, keeping warm)? z Has the newborn had any adverse reactions to immunizations or drugs/ medications or any care provided? ¨ If YES to EITHER question: z Consider this information in the context of further assessment. z Use this information to determine changes that need to be made in the current plan of care. Physical Examination/Observation (PE/O) When you have finished taking the newborn’s history, perform a physical examination/observation. Be sure to record all findings in the newborn’s chart. ¨ If this is the first encounter/visit, perform a complete physical examination (elements PE/O-1 through PE/O-6). ¨ If this is a return visit, a shortened physical examination may be sufficient (elements PE/O-1 through PE/O-3, PE/O-5, and PE/O-6). PE/O-1. Assessment of Overall Appearance/General Well-Being (Every Visit) Before examining the baby, perform the steps shown in Textbox 2-32 (below). Textbox 2-32. Preparing for the Physical Examination (Newborn) Complete the following steps before performing the physical examination: z Inform the woman what you are going to do. Encourage her to ask questions, and listen to what she has to say. z Wash hands thoroughly with soap and water and dry them with a clean, dry cloth or allow them to air-dry. z Wear examination gloves if the baby has not been bathed since birth, if the cord is touched, or if there is blood, urine, and/or stool present. z Place the baby on a clean, warm surface or examine her/him in the woman’s arms. z Have clean clothes or blankets/coverings ready to dress the baby immediately after the examination. Remember: The questions in element H-5 (Present Newborn Period) should be asked at every newborn care visit. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-121 Element Normal Abnormal/Followup Action Weight z Birthweight is 2.5–4.0 kg. z Most babies lose up to 10% of their birthweight in the first few days after birth. z The full term baby regains her/his birthweight by approximately 7 days of age. z The low birthweight baby regains her/his birthweight by approximately 10 days of age. ¨ If birthweight is/was less than 2 kg, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If birthweight is/was more than 4.0 kg, see Large Baby (page 3-84) for additional information about assessment and care provision. ¨ If birthweight is/was 2–2.5 kg, see Low Birthweight Baby (page 3-85) for additional information about assessment and care provision. Respiration z Respiratory rate is 30–60 breaths per minute z No gasping z No chest indrawing z No grunting on expiration ¨ If respiration is not within normal range, ACT NOW!—perform a Newborn Rapid Initial Assessment (page 3-96) before proceeding. Temperature (axillary) z Temperature is 36.5–37.5°C ¨ If axillary temperature is more than 37.5°C, or less than 36.5°C, ACT NOW!—see Abnormal Body Temperature (page 3-122) before proceeding. Color z The baby’s lips, tongue, nailbeds, palms of hands, and soles of feet are pink. z No central cyanosis (blue tongue and lips). z No jaundice (yellowness). z No pallor. z Normal variation: Cyanosis (blueness) of hands or feet in the first 12 hours ¨ If there is pallor or central cyanosis, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If there is any jaundice within the first 24 hours or jaundice on arms, legs, hands, and feet on days 2–7, ACT NOW!—see Jaundice (page 3-124) before proceeding. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-122 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Movements and posture z Movements are regular and symmetrical (equal on both sides of the body). z No convulsions (repetitive jerking movements of limbs or face; tonic extension or flexion of arms and legs, either synchronous or asynchronous; baby may be awake or unresponsive). z No spasms (involuntary contraction of muscles that lasts a few seconds to several minutes; may be triggered by light, touch, or sound; baby is conscious and often crying with pain; jaw and fists are tightly clenched). (See Figure 2-21A [page 2-125].) z No opisthotonos (extreme hyperextension of the body, with the head and heels bent backward and the body arched forward). (See Figure 2-21B [page 2-125].) z Common concern: ¨ If the startle reflex (rapid, symmetrical “stiffening” of the body in response to a sudden noise or touch) is observed, see page 3-33 for additional information about assessment and care provision. ¨ If there are convulsions, spasms, or back arching (opisthotonos), ACT NOW!—perform a Newborn Rapid Initial Assessment (page 3-96) before proceeding. ¨ If there are irregular or asymmetrical arm or leg movements, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Level of alertness and muscle tone z Responds actively to handling and other stimuli z Can easily be roused from sleep z Not floppy or lethargic z Can be consoled when upset; not overly irritable ¨ If the baby is nonresponsive, floppy or lethargic, or inconsolable, ACT NOW!— facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If there is loss of consciousness, ACT NOW!—perform a Newborn Rapid Initial Assessment (page 3-96) before proceeding. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-123 Element Normal Abnormal/Followup Action Skin z The skin is clear and free from bruises and cuts or abrasions. z Common concerns: If any of the following signs are observed, see the corresponding page number for additional information about assessment and care provision: z Tiny white cysts on gums or roof of mouth at birth (epithelial “pearls”) (page 3-27) z Purplish-gray, flat marks on the lower back/buttock area at birth (Mongolian spots) (page 3-31) z Red or purple flat marks on the face or neck at birth (Port wine stains) (page 3-31) z Pink/light red marks on the nose, eyelids, or back of neck at birth (“stork bites”) (page 3-32) z Patchy red rash, with tiny white area in middle, all over body (except palm and soles) at 2 to 3 days after birth (erythema toxicum) (page 3-30) z Tiny white bumps (“whiteheads”) on the nose, cheeks, forehead, and/or chin in the first weeks of life (milia) (page 3-31) z Diffuse redness/irritation of groin area during first weeks of life (diaper/napkin rash) (page 3-30) z Pinpoint red bumps on face, back, and/or chest at 2 weeks of age (acne) (page 3-29) ¨ If bruises appear spontaneously within 2 to 3 days after birth, but there is no evidence of trauma at birth, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If there are cuts or abrasions and they are bleeding, press on the bleeding site. ¨ If bleeding continues after 15 minutes, ACT NOW!— see Bleeding (page 3-126) before proceeding. ¨ If there are cuts or abrasions and they are not bleeding, see Cuts or Abrasions that Are Not Bleeding (page 3-83) for additional information about assessment and care provision. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-124 JHPIEGO/Maternal and Neonatal Health Program PE/O-2. Head, Face and Mouth, Eyes (Every Visit) Element Normal Abnormal/Followup Action Head z The head is symmetrical in shape. z Fontanelles are soft and flat. z The distance between sutures is within normal range (i.e., they are not widely separated). z The size of the head is proportionate to the body. z Common concerns: If any of the following signs are observed, see the corresponding page number for additional information about assessment and care provision: z Swelling on the head that does not cross suture lines and feels firm to the touch (cephalohematoma); may take 12 weeks to resolve (page 3-27) z Edematous swelling (caput succedaneum) over the part of the head that came first through the birth canal; unless excessive, usually resolves within 24 hours (page 3-27) z Misshapen head caused by molding; usually resolves within 2 to 3 days (page 3-28) ¨ If any of the following signs are observed, ACT NOW!— facilitate urgent referral/transfer (Annex 7, page 4-63): z Anterior fontanelle is bulging z Sutures are abnormally wide z Swelling on the head crosses suture lines z Circumference of head appears to be increasing z Edematous swelling or misshapen head (caused by birth/molding) that is not resolved by 72 hours after birth ¨ If the head is very large or very small in proportion to the body, facilitate nonurgent referral/ transfer (Annex 7, page 4-63) after providing basic care. Face and Mouth (First Visit) z Facial features and movements are regular and symmetrical. z The lips, gums, and palate are intact. z Common concern: If tongue tie (a band of tissue between the underside of the tongue and floor of mouth seems short and tight) is observed, see page 3-29 for additional information about assessment and care provision. ¨ If any of the following signs are observed, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care: z Cleft lip (split in lip) or cleft palate (hole in upper palate connecting mouth and nasal passages) z Unable to wrinkle forehead or close eye on one side z Angle of mouth is pulled to one side z Other features/movements are not within normal range Eyes z The baby’s eyes have no swelling, redness, or pus draining from them. z Common Concern: If there is a bright red spot on sclera at birth (subconjunctival hemorrhage), see page 3-28 for additional information about assessment and care provision. ¨ If there is swelling, redness, or pus draining from the eyes, ACT NOW!—see Pus or Redness of Eyes (page 3-129) before proceeding. For the procedure, see Textbox 2-33 (page 2-125). Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-125 Textbox 2-33. Examining the Palate z Put a clean glove on the examining hand. z Use the little finger to feel the palate for any submucous cleft. z A normal newborn will respond by sucking the finger. Figure 2-21. Spasms (A) and Opisthotonos (B)∗ Figure 2-22. Facial Palsy* Figure 2-23. Erb’s Palsy* ∗ Figures 2-21A and B through 2-25 are reprinted with permission from: World Health Organization (WHO). 2003. Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives. WHO: Geneva. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-126 JHPIEGO/Maternal and Neonatal Health Program PE/O-3. Chest, Abdomen and Cord, and External Genitalia (Every Visit) Element Normal Abnormal/Followup Action Chest z The chest movements are regular and symmetrical. z No chest indrawing z Common concern: If swollen breasts are observed, see page 3-25 for additional information about assessment and care provision. ¨ If chest movements are not within normal range, ACT NOW!—facilitate urgent referral/ transfer (Annex 7, page 4-63). Abdomen and cord stump z The abdomen should be rounded, but not distended (Figure 2-24, page 2-127), with no protrusions. z The stump is dry. z No blood or pus oozing from the cord stump z No red, inflamed, swollen, or hardened skin around the umbilicus z No offensive smell z Common concern: If an umbilical hernia (protrusion at the base of the cord that is covered by skin) is observed, see page 3-26 for additional information about assessment and care provision. ¨ If there is a distended abdomen or any abnormal protrusion, particularly from the base of the cord or through a defect in the abdominal wall, ACT NOW!— cover exposed protrusion with clean, moist cloth (if applicable) and facilitate urgent referral/ transfer (Annex 7, page 4-63). ¨ If the cord stump is bleeding, retie the cord. ¨ If bleeding continues after 15 minutes, ACT NOW!— see Bleeding (page 3-126) before proceeding. ¨ If there is swelling, redness, a foul smell, or pus draining from the umbilicus, ACT NOW!—see Redness or Foul Smell of Umbilicus (page 3-130) before proceeding. External genitalia and anus Note: Do not insert anything into the anus to confirm patency. Patency of the anus is confirmed when meconium is passed. z Genitals are regular and symmetrical. z In boys, the urethral orifice is at the end of the penis. z The anus appears patent/intact. z Common concerns: If any of the following signs are observed, see the corresponding page number for additional information about assessment and care provision: z Swollen labia at birth (page 3-25) z Swollen scrotal sac at birth (page 3-26) z Tight foreskin at birth (page 3-26) z Mucoid or bloody vaginal discharge during first week of life (page 3-25) ¨ If anus appears imperforate, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the genitals are not within normal range, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-127 Figure 2-24. Abdominal Distention PE/O-4. Back and Limbs (First Visit) Element Normal Abnormal/Followup Action Back z The spine should be free of swelling, lesions, dimples, or hairy patches. ¨ If the spine is not within normal range, ACT NOW!— facilitate urgent referral/transfer (Annex 7, page 4-63). Limbs z Position and appearance of limbs, hands, and feet are normal and symmetrical. z Movement of limbs is regular and symmetrical. z No swelling over any bone. z No crying when arm, shoulder, or leg is touched. ¨ If limbs are not within normal range, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. PE/O-5. Breastfeeding (Every Visit) After examining the baby and before observing breastfeeding, perform the steps shown in Textbox 2-34 (below). Textbox 2-34. Post-Examination Steps (Newborn) Complete the following steps after examining the baby: z If gloves have been worn: − Immerse both gloved hands in 0.5% chlorine solution. − Remove gloves by turning them inside out. − If disposing of gloves, place in leakproof container or plastic bag. − If reusing gloves, submerge in 0.5% chlorine solution for 10 minutes to decontaminate. z Wash hands thoroughly. z Assist the woman with the baby as necessary. z Help the woman feel relaxed and confident throughout the observation. z Reinforce, through words and nonverbal behavior, that you are present to provide help and support, not to judge the woman or her newborn in any way. z Do not hurry the woman and her newborn. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-128 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Positioning z The woman is comfortable with back and arms supported. z Baby’s head and body are aligned; baby’s abdomen is turned toward the woman. z Baby’s face is facing the breast with nose opposite nipple. z Baby’s body is held close to the woman. z Baby’s whole body is supported. z The baby is brought to the nipple height. ¨ If positioning is not within normal range, take this finding into consideration during the further assessment of breastfeeding: z Be alert for signs of ineffective attachment to the breast/suckling. z See Breastfeeding Support (page 4-47) for additional guidance on positioning. Holding z The woman may support the weight of her breast with her hand and shape her breast by putting her thumb on the upper part, so that the nipple and areola are pointing toward the baby’s mouth; OR z She may support the breast by placing her fingers flat against the chest wall, while bringing the baby to her breast to suckle. ¨ If holding is not within normal range, take this finding into consideration during the further assessment of breastfeeding z Be alert for signs of ineffective attachment to the breast/suckling. z See Breastfeeding Support (page 4-47) for additional guidance. Attachment and suckling z Nipple and areola are drawn into the baby’s mouth rather than only the nipple into the mouth. z The baby’s mouth is wide open; lower lip is curled back below base of nipple. z The baby takes slow, deep sucks, often with visible or audible swallowing. z The baby pauses from time to time. z The baby may make “smacking” sounds. z See Figure 2-25 (page 2-129). ¨ If attachment does not appear effective, see Breast and Breastfeeding Problems (page 3-43) for additional information about assessment and care provision. Woman’s comfort z Woman does not complain of, or appear to have, nipple/breast pain during the breastfeed. ¨ If the woman has pain during the breastfeed, see Breast and Breastfeeding Problems (page 3-43) for additional information about assessment and care provision. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-129 Element Normal Abnormal/Followup Action Finishing the breastfeed z The newborn should release the breast her/himself rather than being pulled from the breast. z Feeding may vary in length, anywhere from 4 to 40 minutes per breast. z Breasts are softer at the end of the feed compared to full and firm at the beginning. z Newborn looks sleepy and satisfied at the end of a feed. ¨ If observations are not within normal range but attachment/ suckling appear effective and there have been no signs of inadequate intake, use this information to guide individualization of health messages and counseling and other aspects of basic care provision. z See Breastfeeding Support (page 4-47) for additional guidance on positioning. Figure 2-25. Correct (A) and Incorrect (B) Attachment of the Newborn to the Breast PE/O-6. Mother-Baby Bonding Note: The mother-child relationship begins during pregnancy and develops rapidly after the birth of the baby. Normal maternal feelings vary, from the rush of affection that some women feel immediately after birth, to less dramatic, more gradually developing feelings that other women experience. In a healthy relationship, however, the woman will begin to demonstrate some degree of concern/nurturing toward her baby immediately after birth. Through careful observation, you may detect early problems in this area and help uncover the underlying reasons, so that appropriate action can be taken to allow a healthy mother-baby bond to develop. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-130 JHPIEGO/Maternal and Neonatal Health Program Element Normal Abnormal/Followup Action Physical contact Communication Empathy z The woman appears to enjoy physical contact with her newborn and appears contented with the newborn. z She caresses, talks to, and makes eye contact with the newborn. z When holding or feeding the newborn, she and the newborn are turned toward each other. z She responds with active concern to the newborn’s crying or need for attention. ¨ If findings are not within normal range for this cultural context, ask her how she is/has been feeling (emotionally). ¨ If she reports feelings of inadequacy, worry, or fear, see page 3-15 for additional information about assessment and care provision. ¨ If she reports crying, feelings of sadness or of being overwhelmed, or irritability, see Postpartum Sadness (page 3-69) for additional information about assessment and care provision. z Use this information to guide individualization of Support for Mother- Baby-Family Relationships and other aspects of basic care provision. NEWBORN CARE PROVISION C-1. Early and Exclusive Breastfeeding Note: If the woman is HIV-negative, exclusive breastfeeding for the first 6 months of life should be strongly encouraged. The following health messages and counseling should be provided to all women during the postpartum period unless they are HIV-positive or have said that they do not wish to breastfeed. Based on the woman’s breastfeeding history and any other relevant findings or discussion, individualize health messages and counseling: z The woman should give her colostrum (first milk) to her baby before her next milk “comes in.” Colostrum is the perfect first food for a baby and contains important ingredients that boost immunity and provide all essential nutrients. z The woman should breastfeed her baby exclusively for the first 6 months of life. This means that the baby should not be given anything else to drink or eat during that time—no water, juice, formula, rice, or any other drink or food. z The baby should be breastfed whenever s/he wants, day and night (on demand), which should be about every 2–3 hours (or 8–12 times per 24 hours) during the first weeks of life. z To ensure that the baby is getting enough to eat, the woman should note how often the baby urinates: at least 6 times per day during the first 2–7 days after birth indicates adequate intake. Note: For information on the following related topics, see the page indicated: benefits of breastfeeding for the woman and newborn, page 2-32; general principles of early and exclusive breastfeeding, page 2-32; additional advice for the woman on breastfeeding (page 2-102) and breast care (page 2-102); proper positioning for good attachment, page 4-47. C-2. Complication Readiness Plan Advise the woman and her family to enact the complication readiness plan if any of the danger signs shown in Textbox 2-35 (page 2-131) arise. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-131 z As soon as possible after birth: Review the woman’s complication readiness plan, updating it to reflect newborn needs. If she and her family have not yet developed a complication readiness plan, assist them in developing one according to the guidelines shown on page 2-26. z On each return visit, review and update the plan: z What arrangements have been made since the last visit? z Has anything changed? z Have any obstacles or problems been encountered? Textbox 2-35. Danger Signs during the Newborn Period z Breathing difficulty z Convulsions, spasms, loss of consciousness, or arching of the back (opisthotonos) z Cyanosis (blueness) z Hot to touch/fever z Cold to touch z Bleeding z Jaundice (yellowness) z Pallor z Diarrhea z Persistent vomiting or abdominal distention z Not feeding or poor suckling (feeding difficulties) z Pus or redness of the umbilicus, eyes, or skin z Swollen limb or joint z Floppiness z Lethargy C-3. Newborn Care and Other Healthy Practices Based on the newborn’s history and any other relevant findings or discussion, individualize health messages and counseling on the topics addressed below. Although all of the issues that follow should be addressed at the earliest opportunity, other topics—such as breastfeeding support or using a breastmilk substitute—can be included according to individual need. Ideally, the woman’s partner would be present during these discussions. Remember: A woman who has common concerns during the newborn period requires additional care, which consists mainly of health messages and counseling. Chapter 9 (page 3-1) contains information on additional care for women with common concerns. C-3.1. Maintaining Warmth Based on the woman’s/baby’s history and any other relevant findings or discussion, individualize the following key messages: z The woman and baby should be kept in skin-to-skin contact, covered with a clean, dry blanket/covering, as much as possible for the first 6 hours after birth at least. ¨ If the baby cannot be in immediate skin-to-skin contact with the woman or after 6 hours, dress her/him in an extra layer or two (in addition to what is comfortable for adults) of clothing or blankets/ coverings. z Do not bathe the baby for at least the first 6 hours after birth, and preferably not in the first 24 hours, and not until the baby’s temperature is stable. z Avoid dressing the baby in tight, restrictive clothing or blankets/coverings because they reduce the retention of heat. z Cover the baby’s head with a hat. z Keep the room warm (25°C or more) and free from drafts. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-132 JHPIEGO/Maternal and Neonatal Health Program z Check the newborn’s feet at least every 4 hours for the first 24 hours or until the temperature is stable. ¨ If the feet feel cold in comparison to normal adult skin, extra warmth is required immediately: add a layer of clothing and blankets/coverings. ¨ If the feet feel hot in comparison to normal adult skin, remove a layer of clothing and blankets/coverings. ¨ If the feet remain cold or hot for 1 hour after the above changes are made, enact the complication readiness plan. z Other practices that help maintain warmth include early and exclusive breastfeeding (page 2-130). C-3.2. Prevention of Infection/Hygiene Based on the woman’s/baby’s history and any other relevant findings or discussion, individualize the following key messages: z The following practices are especially important in the first months of life because the baby’s immune system is still developing and may be more susceptible to infection. z In general, the woman, partner, and other people should wash their hands before touching or caring for the baby. They should also wash their hands after cleaning the baby or changing her/his diaper/napkin. (For more information about good general hygiene, see page 2-29.) z When the baby’s diaper/napkin is soiled/wet, the following actions should immediately be carried out: z Remove the diaper/napkin and properly dispose of it in a bucket, plastic bag, or other container that can be closed. z Wash the baby’s bottom, from the groin/genitals toward the buttocks. z Dry the baby’s bottom, from the groin/genitals toward the buttocks. z Until the cord falls off, place the cord outside the diaper/napkin to prevent contamination with urine and feces. z Put no lotions, powders, or other products on the baby’s skin. z Put a clean diaper/napkin on the baby. z The woman should care for her own baby as much as possible. z Sharing of baby equipment and supplies with other babies and children should be avoided. z Sick children and adults should be kept away from the baby because of the risk of cross-infection. z The baby should be protected from smoke, which can result in respiratory problems. z The woman should remain vigilant for signs of infection and other newborn danger signs. If any of these signs are seen, she should immediately enact the complication readiness plan. z Other practices that help protect the baby from infection include the following: z Breastfeeding z Proper cord care z Getting the recommended immunizations z Sleeping under an insecticide-treated (bed)net in malaria-endemic areas C-3.3. Washing and Bathing z Show the woman how to bathe the baby before she leaves the healthcare facility (according to the guidelines shown in Textbox 2-36 [page 2-133]). Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-133 z Based on the woman’s/baby’s history and any other relevant findings or discussion, individualize the following key messages: z The baby should not be bathed for at least the first 6 hours after birth, and preferably not the first 24 hours, and not until the baby’s temperature is stable. z After 6 hours (preferably 24 hours) and once the baby’s temperature is stable (36.5–37.5°C), the baby can be bathed according to the guidelines shown in Textbox 2-36 (below). z Soap is not necessary and should never be used on a baby’s face; mild soap can be used on the rest of the baby’s body. z While bathing the newborn, the woman should remain vigilant for signs of infection and other danger signs, especially in skin fold areas behind ears, around neck, and in groin. ¨ If any of these signs are seen, she should immediately enact the complication readiness plan. z It is not necessary to bathe the newborn daily, especially if it is difficult to ensure a warm environment for the bath; however, the baby’s groin/genitals and buttocks should be washed and dried each time the diaper/napkin is soiled/wet. Textbox 2-36. Procedure for Newborn Bathing Before bathing and before the baby is undressed: z Prepare equipment and supplies. z Ensure that the room is warm (25°C or more) and free from drafts. z Ensure that the water is warm, but not hot, to touch. Until the cord has fallen off and the stump is completely healed, bathe the baby according to the following guidelines to ensure that the cord is kept dry: z Lay the baby on a clean towel on a flat surface, or have somebody else hold the baby. z First, undress the baby’s head and upper body. z Bathe the baby’s head and upper body (remember: do not use soap on the baby’s face): − Begin by washing the baby’s head and face, using clean water and clean cloths. − Clean the eyes using separate clean cloths or cotton balls, wiping each eye from the inside to the outside edge. − Then wash the neck, arms, and rest of upper body. Note: Wash around the cord and do not immerse it in water! z Immediately dry and dress the baby’s head and upper body, including a hat. z Next, undress the baby’s lower body (remember: properly dispose of the diaper/napkin). z Bathe the baby’s lower body: − Begin by washing the baby’s legs. − Then wash the baby’s bottom, from the groin/genitals toward the buttocks. z Immediately dry and dress the baby’s lower body (remember: fold the diaper/napkin so that it does not cover the cord). After the cord has fallen off and the stump is completely healed, the baby can be bathed in a shallow pan of water while being held upright, and the upper body and lower body do not have to be bathed, dried, and clothed separately. z Immediately after bathing, the baby should be: − Thoroughly dried; − Dressed and/or wrapped in a clean, dry blanket/covering; and − Put in close contact with the woman. ¨ If the baby becomes chilled during bathing, rewarm the baby by placing her/him in skin-to-skin contact with the woman and covering with a clean, dry blanket. z Put no lotions, powders, or other products on the baby’s skin. Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-134 JHPIEGO/Maternal and Neonatal Health Program C-3.4. Cord Care Based on the woman’s/baby’s history and any other relevant findings or discussion, individualize the following key messages: z Wash hands before giving cord care. z The cord should be kept dry, even while the baby is being bathed (as shown in Textbox 2-36 [page 2-133]). ¨ If the cord becomes wet, it should be gently dried. z No dressings or substances of any kind should be applied to the cord stump. z The cord should be carefully placed outside of the diaper/napkin (with the front of the diaper/napkin folded down) to prevent contamination with urine and feces. ¨ If the cord becomes contaminated, it should be washed with soap and water, gently dried, and carefully placed outside of the diaper/napkin. z The cord usually falls off 4–7 days after birth. z After the cord falls off, the umbilicus should be kept clean. No dressings or substances of any kind should be applied to the umbilicus. z Reinforce the importance of early recognition and appropriate response to the following danger signs. ¨ If the cord bleeds, retie the cord. ¨ If bleeding does not stop within 15 minutes of being retied, immediately enact the complication readiness plan. ¨ If there is swelling, redness, or pus draining from the cord, immediately enact the complication readiness plan. ¨ If there is delayed separation of the cord, immediately enact the complication readiness plan. C-3.5. Sleep and Other Behaviors/Needs Based on the woman’s/baby’s history and any other relevant findings or discussion, individualize the following key messages: z The baby should be placed on her/his back or side to sleep or rest when not in skin-to-skin contact with the woman. z Keep the baby from where s/he could roll over an edge and fall to the ground; be reached/harmed by another child or animal; or become covered by a pillow, other object, or person. z Babies generally sleep about 20 hours per day and wake only for feeding. They do not distinguish day from night and therefore wake for night feeds. z During the weeks following birth, the baby usually starts sleeping for longer periods at night and staying awake more during the day. z The baby signals her/his need for attention by crying. The woman should respond by: z Picking up her baby; z Talking to her/him; z Establishing eye-to-eye contact; and z Addressing the cause of the crying (dirty diaper/napkin, hunger, other discomfort). − The baby will usually stop crying and gaze at her/his mother. This interaction promotes bonding between the woman and baby. Chapter Eight: Newborn Care JHPIEGO/Maternal and Neonatal Health Program 2-135 z In addition to the basic physical requirements of nutrition, warmth, sleep, and a clean and safe environment, the baby needs comfort and expressions of security and love (e.g., cuddling, talking, eye-to-eye contact). Note: Caring for the newborn can be a joyful experience, but it can also be very challenging—requiring major adjustments on the part of all family members. The woman and her family may need help in integrating care of the newborn into their daily lives. For more information on support for mother-baby-family relationships, see page 2-104. C-4. Immunizations and Other Preventive Measures C-4.1. Immunization (First Visit) z Before discharge, the newborn should be given the following vaccines (Table 2-20, below). z These should be recorded on an immunization card, which is given to the woman, and the newborn’s chart. z Advise the woman to return for the additional newborn vaccines at 6, 10, and 14 weeks of age. Table 2-20. Newborn Immunization Schedule VACCINE DUE BCG to protect against tuberculosis After birth, before discharge from healthcare facility OPV-0 to protect against poliomyelitis After birth, before discharge from healthcare facility HB-1 to protect against hepatitis B After birth, before discharge from healthcare facility C-4.2. Vitamin K1 Injection (less than 6 hours of age) z Give vitamin K1 1 mg IM in the anterolateral aspect of the thigh. Region/Population-Specific Preventive Measures For newborns in areas with a high prevalence of malaria, see guidelines for prevention (page 3-59). Basic Maternal and Newborn Care: A Guide for Skilled Providers 2-136 JHPIEGO/Maternal and Neonatal Health Program JHPIEGO/Maternal and Neonatal Health Program 3-1 CHAPTER NINE COMMON DISCOMFORTS AND CONCERNS OVERVIEW This chapter contains guidance for skilled providers on how to respond to common discomforts and concerns (as described on page 1-30) that may be identified when caring for women and their newborn babies during pregnancy, labor and childbirth, and the postpartum/newborn period. Women and babies with common discomforts or concerns require care in addition to the core components of basic care (as shown in Chapters 4–8). General guidelines for providing this additional care are presented below. (For an index of common discomforts during pregnancy, labor and childbirth, and the postpartum period, see Textbox 3-1 [page 3-2]; for an index of common concerns during the newborn period, see Textbox 3-2 [page 3-2].) During Assessment Consider the relevant information in the following table (based on presenting sign/symptom, first column) to confirm that what the woman is experiencing or the newborn’s physical examination findings are within the range of normal. Accompanying alert signs that may indicate a problem are listed in the fourth column. During Care Provision Once you have confirmed that the woman is experiencing a common discomfort or that the newborn has a common concern and not an abnormal condition: z Reassure the woman that what she or her baby is experiencing is normal and does not pose a threat to her or the baby; z Explain the anatomic/physiologic basis (second column) as appropriate; z Counsel the woman on prevention and relief measures (third column) when appropriate; and z Advise her to return for care or facilitate appropriate care and/or referral to a specialist if: z Signs or symptoms worsen; z Danger signs (page 4-61) arise; OR z Alert signs that may indicate a problem (fourth column) arise. Note: If the woman or newborn presents with any of the alert signs that may indicate a problem (fourth column), see the relevant section in this manual or facilitate referral/transfer as necessary. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-2 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-1. Index of Common Discomforts during Pregnancy, Labor and Birth, and the Postpartum Period Woman’s Abdomen, Breasts, and Legs Abdominal (or groin) pain, page 3-3 Afterpains, page 3-4 Breast changes, page 3-4 Leg cramps, page 3-5 Swelling (edema) of ankles and feet, page 3-5 Woman’s Digestion and Elimination Bowel function changes—constipation or diarrhea, page 3-6 Food cravings or eating nonfood substances, page 3-7 Gas, bloating, or loss of appetite, page 3-7 Heartburn or indigestion, page 3-8 Nausea or vomiting, page 3-9 Salivation, increased, page 3-9 Urination, increased, page 3-10 Woman’s Genitals Perineal pain, page 3-10 Vaginal discharge, page 3-11 Woman’s Skin Itchiness, page 3-11 Perspiration, increased, page 3-12 Skin changes, page 3-12 Spider nevi, page 3-12 Stretch marks (striae gravidarum), page 3-13 Varicose veins, page 3-13 Woman’s Sleep and Mental State Dreams (vivid) or nightmares, page 3-14 Fatigue or sleepiness, page 3-14 Feelings of inadequacy, worry, or fear during the postpartum period, page 3-15 Feelings of worry or fear about pregnancy and labor, page 3-16 Insomnia, page 3-16 Mood swings, page 3-17 Miscellaneous (Woman) Back pain, page 3-18 Bleeding or painful gums, page 3-19 Difficulty getting up and down, page 3-19 Dizziness or fainting, page 3-20 Feeling hot, page 3-20 Hair loss, page 3-20 Headache, page 3-21 Heart palpitations, page 3-21 Hemorrhoids, page 3-22 Hip pain, page 3-22 Hyperventilation or shortness of breath, page 3-23 Nasal stuffiness or nasal bleeding, page 3-23 Numbness/tingling of fingers and toes, page 3-24 Shivering/quivering, page 3-24 Walking awkwardly (waddling) or clumsiness, page 3-24 Textbox 3-2. Index of Common Concerns during the Newborn Period Newborn’s Chest, Abdomen, Cord Stump, and External Genitalia Mucoid or bloody vaginal discharge, page 3-25 Swollen breasts, page 3-25 Swollen labia, page 3-25 Swollen scrotal sac, page 3-26 Tight foreskin, page 3-26 Umbilical hernia, page 3-26 Newborn’s Head, Face, Mouth, and Eyes Caput succedaneum, page 3-27 Cephalohematoma, page 3-27 Epithelial “pearls,” page 3-27 Molding or chignon, page 3-28 Subconjunctival hemorrhage, page 3-28 Swollen or red eyelids, page 3-28 Tongue tie, page 3-29 Newborn’s Skin Acne, page 3-29 Diaper/napkin rash, page 3-30 Erythema toxicum, page 3-30 Milia, page 3-31 Mongolian spots, page 3-31 Port wine stains, page 3-31 “Stork bites,” page 3-32 Miscellaneous (Newborn) Crying, increased, page 3-32 Irregular breathing, page 3-32 Startle reflex, page 3-33 Vomiting, page 3-33 3- 3 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N D IS CO M FO R TS D UR IN G PR EG NA N CY , L AB O R AN D B IR TH , A N D T H E PO ST PA R TU M PE R IO D SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S A BD O M EN , B RE AS TS , A ND L EG S A bd om in al (o r gr oi n) pa in — Cr am ps , tw in ge s, p u llin g se n sa tio n s, o r su dd e n pa in o n th e si de s o f th e lo w e r a bd o m e n (or gr oin ) M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r a nd th e 1s t – 2n d st ag e of la bo r a nd s u bs id es a fte r t he b irt h of th e ba by . z En la rg e d ut er u s st re tc he s su rr o u n di n g lig a m e n ts a nd m u sc le s. z D ur in g la bo r a n d bi rth : − Po si tio n s in la bo r a n d bi rth s tra in m us cl es a nd lig am e n ts . − Ut er in e co n tra ct io ns R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z W he n lyi ng d ow n : − Li e on th e si de w ith th e kn ee s a n d hi ps b en t; an d − Pl ac e a pi llo w b et we e n th e kn e e s a n d an o th e r pi llo w u n de r t he a bd o m e n . z If th e pa in b ec o m e s bo th e rs o m e , try a ny o f t he fo llo w in g: − G en tly m as sa ge o r a pp ly fir m p re ss ur e o ve r th e pa in fu l a re a . − Ap pl y a wa rm c lo th o r h ea tin g pa d or ta ke w a rm b at hs . − Si t o r l ie d ow n . − Fl ex th e kn ee s o n to th e ab do m e n . Du rin g la bo r an d bi rth , a dv is e th e w o m an a n d/ or b irt h co m pa ni on a s fo llo w s: z Ch an ge p o si tio n s fre qu en tly d u rin g la bo r, fo r e xa m pl e : − W al k in te rm itt en tly . − Si t o r s qu at . − Be nd o ve r be d. − G et o n ha nd s an d kn e e s. − Li e on o n e s id e a n d th en th e o th er . z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Lo ss o f a pp e tit e — w hi ch m ay in di ca te a pp en di ci tis Up pe r a bd o m in a l p a in th at m a y be re lie ve d by fo od b u t re cu rs 2 –3 h ou rs la te r, lo ss o f a pp e tit e, n au se a o r vo m iti n g, an d in to le ra n ce to fa tty fo od s— w hi ch m ay in di ca te g al lb la dd e r di se as e o r pe pt ic u lc er Fa in tin g, sh ou ld er p ai n— w hi ch m ay in di ca te e ct op ic pr eg n a n cy (N ot e: Th is is a n u n lik e ly di a gn o si s af te r t he e a rly 2 n d tri m es te r.) Ut er in e te n de rn e ss , a bd o m in a l di st en tio n , si gn s o f f et al di st re ss — wh ich m a y in di ca te u te rin e in fe ct io n o r u te rin e ru pt ur e Fl an k/ lo in p ai n, in cr ea se in fre qu en cy a nd u rg en cy o f u rin at io n , bu rn in g on u rin at io n — w hi ch m ay in di ca te u rin ar y tra ct in fe ct io n 3- 4 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S A BD O M EN , B RE AS TS , A ND L EG S (C ON TIN UE D ) A fte rp ai ns — Cr am ps , co n tra ct io n s a s in la bo r M os t c om m on ly o cc u rs d ur in g th e 4th st ag e of la bo r a n d da ys 2 –4 p os tp a rtu m . Es pe cia lly c om m o n in th e m ul tip a ra . z Ut er us c on tra ct s in te rm itt en tly a fte r c hi ld bi rth . z Br ea st fe ed in g st im ul at es pr od u ct io n of h o rm o n e s th a t in cr ea se u te rin e co n tra ct io n s. z A fu ll b la dd er d is pl ac e s th e u te ru s an d ca us e s in cr ea se d u te rin e c o n tra ct io ns . R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Li e fa ce d o w n w ith a p illo w u n de r t he a bd om e n . (T his m ay be un co m fo rta bl e a t f irs t, bu t t he p ai n wi ll le ss e n a n d m ay d isa pp ea r.) z If th e pa in b ec o m e s bo th er so m e : − G en tly m as sa ge o r a pp ly fir m p re ss ur e o ve r th e pa in fu l a re a . − Ap pl y a wa rm c lo th o r h ea tin g pa d to th e pa in fu l a re a . − W a lk a ro un d or ch an ge p os itio n . − Em pt y bl ad de r f re qu en tly . z Af te r b irt h, if n on ph a rm a co lo gi c tre at m e n ts d o no t p ro vid e re lie f, pa ra ce ta m o l (ac eta mi no ph e n ) 5 00 m g m a y be u se d 30 m in u te s be fo re b re a st fe ed in g, a s n e e de d. D ur in g la bo r a nd b irt h, a dv is e th e w o m an a n d/ or b irt h co m pa ni on as fo llo w s: z Ur in at e fre qu en tly ; a fu ll b la dd er in cr ea se s u te rin e c o n tra ct io ns . z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n o r do n ot d im in is h 3– 4 da ys a fte r b irt h; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Ut er in e te n de rn e ss , a bd o m in a l di st en tio n — w hi ch m ay in di ca te u te rin e in fe ct io n or u te rin e r u pt ur e Fl an k/ lo in p ai n, in cr ea se in fre qu en cy a nd u rg en cy o f u rin at io n , bu rn in g on u rin at io n — w hi ch m ay in di ca te u rin ar y tra ct in fe ct io n Lo ss o f a pp e tit e — w hi ch m ay in di ca te a pp en di ci tis B re as t c ha ng es — Bi la te ra l i nc re a se in si ze ; t en de rn e ss o r tin gl in g; th in , c le a r/ ye llo w is h ni pp le di sc ha rg e M os t c om m on ly o cc u rs d ur in g th e 1s t tri m es te r. z H or m on a l c ha n ge s ca us e va rio us b re as t c ha ng es in pr ep a ra tio n fo r br ea st fe ed in g. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z W e a r a w e ll- fit tin g, s up po rti ve b ra . z W e a r a b ra w hi le s le ep in g. z Ke ep n ip pl es d ry a nd c le a n to pr ot ec t f ro m in fe ct io n. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. A lu m p; d im pl in g/ pu ck e rin g; a re a s o f s ca lin e ss , re dn es s, o r th ic kn es s; o r l es io ns , s or es , o r ra sh es — w hi ch m ay in di ca te ca rc in om a 3- 5 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S A BD O M EN , B RE AS TS , A ND L EG S (C ON TIN UE D ) Le g cr am ps — Su dd e n in o ns e t a nd o f s ho rt du ra tio n M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r a nd 1s t – 2n d st ag e of la bo r. z Un cl e ar c au se z O cc as io na lly fr om p re ss ur e o f f et us ’s he ad o n ne rv es a s he ad d es ce n ds du rin g la bo r R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z If th e pa in b ec o m e s bo th e rs o m e , try a ny o f t he fo llo w in g: − G en tly m as sa ge o r a pp ly fir m p re ss ur e o ve r th e pa in fu l a re a . − Ap pl y a wa rm c lo th o r h ea tin g pa d to th e pa in fu l a re a . − St ra ig ht en kn ee a n d fle x fo o t u pw ar d; s ta nd o n to es o f a ffe ct ed le g an d pr es s he e l t ow a rd th e flo or . − W e a r su pp o rt ho se , e sp ec ia lly if st an di ng fo r l on g pe rio ds d u rin g th e da y. − Ta ke fr eq ue n t b re ak s fro m s itt in g or s ta nd in g fo r l on g pe rio ds . − Ch an ge p o si tio n s fre qu en tly d u rin g la bo r (se e e xa m pl e s u n de r Ab do m in a l [o r g roi n] pa in [p ag e 3- 3]) . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Lo ca liz ed pa in o ve r a v e in , sw e llin g of th e a ffe ct ed lim b— w hi ch m ay in di ca te s up er fic ia l th ro m bo ph le bi tis Ca lf m us cle te n de rn e ss , sw e llin g of th e a ffe ct ed lim b— w hi ch m ay in di ca te d ee p ve in th ro m bo sis N um bn es s/ tin gl in g of fi ng er s a n d to es , f oo td ro p pe rs ist in g a fte r l ab or — w hi ch m ay in di ca te n er ve da m ag e Sw el lin g (ed em a) of an kl es a nd fe et — Ap pe a rs a t t he e nd o f th e da y, a fte r s itt in g or st an di n g fo r a lo n g tim e; d isa pp ea rs a fte r re st o r e le va tin g fe et . M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r a nd 1s t – 2n d st ag e of la bo r. z H or m on a l c ha n ge s ca us e : − In cr ea se in le ve ls o f so di um ; − Co ng e st io n in v e in s in lo w er le gs ; a nd − Ea si er fl ui d le a ka ge fro m c ap illa rie s. z En la rg e d ut er u s pu ts pr es su re o n v e in s w he n th e w o m a n is s itt in g a n d lyi ng do wn , l e a di ng to : − Bl oo d po ol in g in le g ve in s, a nd − Va ric os e ve in s be co m in g sw o lle n an d tw is tin g. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z W he n lyi ng d ow n , lie o n yo ur le ft si de w ith le gs s lig ht ly e le va te d. z W he n si tti ng , s lig ht ly el e va te y o u r fe et /le gs . z A vo id : − Cr os sin g th e le gs w he n sit tin g; − Ti gh t g ar te rs o r r e st ric tiv e ba nd s ar ou n d le gs ; a nd − Si tti ng o r s ta nd in g fo r l on g pe rio ds . z In cr ea se in ta ke o f f lu id s (2– 3 l ite rs p er d ay ). z W e a r su pp o rt ho se if o th er re m e di es h av e no t b ee n su cc e ss fu l. D ur in g la bo r/b irt h, a dv is e th e w om an a nd /o r b irt h co m pa n io n as fo llo w s: z Ch an ge p o si tio n s fre qu en tly d u rin g la bo r (se e e xa m pl e s u n de r A bd o m in al [o r gr oi n] pa in [p ag e 3- 3]) . z D rin k pl e n ty o f f lu id s du rin g la bo r. z If th e sy m pt om s wo rs en , l et th e s ki lle d pr ov id e r kn ow . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. H ea da ch e, bl ur re d vis io n , n a u se a o r vo m itin g, e pi ga st ric pa in — w hi ch m ay in di ca te p re - e cl am ps ia /e cla m ps ia Fa tig ue o r s le e pi ne ss , di zz in e ss o r fa in tin g, p al lo r, br ea th le ss n e ss , a n d ra pi d he ar t b ea t— w hi ch m ay in di ca te s ev er e a n e m ia Lo ca liz ed pa in o ve r a v e in , sw e llin g of th e a ffe ct ed lim b— w hi ch m ay in di ca te s up er fic ia l th ro m bo ph le bi tis Ca lf m us cle te n de rn e ss , sw e llin g of th e a ffe ct ed lim b— w hi ch m ay in di ca te d ee p ve in th ro m bo sis 3- 6 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S D IG ES TI O N AN D E LI M IN A TI O N B ow el fu nc tio n ch an ge s— Co ns tip at io n o r di ar rh ea M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r a nd th ro ug ho ut p o st pa rtu m pe rio d. Co ns tip at io n: z H or m on al c ha n ge s re la x sm o o th m us cl e s, sl ow in g di ge st io n a n d el im in a tio n. z Sl ow ed di ge st io n in cr e a se s w a te r a bs o rb ed fr om c ol on . z D ur in g pr eg na n cy a nd la bo r, e n la rg ed u te ru s pu ts pr es su re o n th e lo w er b ow e l, sl ow in g m ov em e n t t hr ou gh in te st in e s. z Br ea st fe ed in g re qu ire s a lo t o f w at er a nd c a n le a d to de hy dr at io n . z If th e wo m an h a d an e pi sio to m y, te ar , o r o th er pe rin e a l t ra um a , sh e m ay re fra in fr om b ow e l m o ve m e n ts b e ca u se o f t he pa in o f d ef ec at io n . z O th er p os sib le ca u se s/ fa ct or s in clu de : − Po or d ie t; − In ad eq ua te in ta ke o f flu id s; a nd − La ck o f e xe rc ise . D ia rr he a: z Un cle a r ca u se d ur in g pr eg n a n cy z D ur in g la bo r a n d bi rth , ho rm on e s th at c au se u te rin e co n tra ct io n s a ls o s tim ul at e th e bo we l. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z En su re a g o o d di et : − In cr ea se in ta ke o f f re sh fr ui ts a n d ve ge ta bl es a n d wh o le g ra in s. − Ad d pr un e s o r pr un e ju ice to d ie t. − In cr ea se in ta ke o f f lu id s (2– 3 l ite rs p er d ay ). I f b rea stf ee din g, dr in k a gl as s of fl ui d ea ch ti m e th e ba by fe ed s. − D rin k ho t o r c ol d flu id s (es pe cia lly o n a n e m pt y st om ac h). z D ef ec at e wh en th e ur ge is fe lt. z A vo id la xa tiv es , m in er al o il, lu br ica n ts , st im ul an ts , s al in e , hy pe ro sm o tic s, di ph e n ylm et ha n e , a n d ca st o r o il. z Us e a st oo l s of te n e r if th e ab o ve m e a su re s do n o t w or k. z Be gi n w a lk in g wi th in 6 h ou rs o f c hi ld bi rth (if no rm al no n -o pe ra tiv e bi rth ) a n d in cr ea se a m o u n t o f e xe rc ise e a ch d ay . Fo r d ia rr he a, a ls o: z En su re a de qu a te in ta ke o f e le ct ro lyt e s (e. g., ric e w ate r w ith sa lt, b an an a s, o ra l r eh yd ra tio n s o lu tio n s). z A vo id o pi at es , b ism ut h su bs a lic yla te , ka o pe ct at e, a nd a ds o rb en ts . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. R ap id ly pr og re ss in g di ffi cu lty in d ef ec a tin g, g a s, v o m iti ng , ris in g pu ls e ra te , a nd w o rs e n in g ge ne ra l c on di tio n — w hi ch m ay in di ca te b ow e l o bs tru ct io n D ia rrh e a , cr a m pi ng , b lo a tin g, lo ss o f a pp e tit e— w hi ch m ay in di ca te b ac te ria l o r p ar a si tic in fe ct io n 3- 7 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S D IG ES TI O N AN D E LI M IN A TI O N (C ON TIN UE D) Fo od cr av in gs o r ea tin g no n fo od su bs ta nc es (pi ca ) M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r, an d is m o st s ev er e in 1s t tri m es te r. z Un cle ar c a u se , po ss ib ly in flu en ce d by tr ad itio n N ot e: Fo od c ra vi ng s ar e o f n o co n ce rn a s lo ng a s th e di et is n u tri tio n a lly a de qu a te a n d cr a vi ng s a re n o t f or u nh ea lth y fo od s or u nh ea lth y no nf oo d su bs ta nc e s. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Ea t a b al an ce d di et . z A vo id e a tin g un he a lth y fo od s (e. g., ca nd y) an d un he al th y no n fo od su bs ta nc e s (e. g., di rt, ch alk , c lay ). S ug ge st a n al te rn a tiv e ac tiv ity o r su bs tit ut in g he a lth y fo od s. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . G as , b lo at in g, o r lo ss o f a pp et ite M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r. z H or m on al c ha n ge s re la x sm o o th m us cl e s, sl ow in g di ge st io n a n d el im in a tio n. z En la rg e d ut er u s pu ts pr es su re o n lo w e r bo we l, sl ow in g m ov em e n t t hr ou gh in te st in e s. z R es pi ra to ry c ha n ge s ca u se in cr ea se d sw a llo w in g of a ir. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Ea t a b al an ce d di et . z A vo id ga s- fo rm in g fo od s. z G et d ai ly ex er cis e a n d ad eq ua te re st . z Ch ew fo o d th or o u gh ly. z D ef ec at e wh en th e ur ge is fe lt. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Fa tig ue o r s le e pi ne ss , l o ss o f a pp e tit e, w ea kn e ss , w a st in g, a n d po o r ge n e ra l c on di tio n — w hi ch m ay in di ca te m al n u tri tio n o r a n o th e r ch ro n ic co n di tio n /ill ne ss D ia rrh e a o r cr a m pi ng — w hi ch m a y in di ca te b ac te ria l o r pa ra sit ic in fe ct io n 3- 8 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S D IG ES TI O N AN D E LI M IN A TI O N (C ON TIN UE D) H ea rt bu rn o r in di ge st io n M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r. z En la rg e d ut er u s pu sh es st om ac h hi gh er a n d co m pr es se s it, p us hi n g ga st ric a cid s in to lo w er e so ph ag u s. z H or m on a l c ha n ge s ca us e a de cr ea se in to n e a n d fu nc tio n of s to m a ch a nd in te st in e s, a n d re la xa tio n o f th e va lv e be tw e e n th e st om ac h an d es o ph a gu s. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e go o d bo dy m e ch an ic s (se e gu id el in es u n de r B ac k pa in [p ag e 3- 18 ]). z Ad jus t d iet a s ne ce ss a ry : − Ea t a b al an ce d di et . − Ea t s m al le r, m or e fre qu e n t m ea ls . − D rin k flu id s be tw e e n m e a ls ra th er th an w ith m ea ls . − In cr ea se in ta ke o f h ig h- fib e r fo od s (e. g., fre sh fru its an d v eg e ta bl e s). z A vo id : − O ve re at in g; − Ea tin g fa tty , f rie d, a nd s pi cy fo od s; − Sm ok in g, c of fe e , a lc oh o l, an d ch oc ol a te ; − Ta ki ng c al ci um , so di um b ica rb o n a te , a n d bi sm u th s ub sa lic yla te ; a nd − Ly in g do wn im m e di at e ly af te r e a tin g. z R es t a nd s le e p w ith h ea d hi gh e r th an s to m ac h. z If no np ha rm a co lo gi c tre at m en ts d o no t p ro vid e re lie f, lo w- so di um a n ta ci ds , ci m et id in e , o r ra n iti di n e m a y be u se d, b ut th en o n ly fo r s ho rt co u rs e a n d e xa ct ly as d ire ct ed . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Ep ig a st ric p ai n , he ad ac he , bl ur re d vis io n , n a u se a o r vo m itin g— w hi ch m ay in di ca te pr e- ec la m ps ia o r e cl am ps ia Up pe r a bd o m in a l p ai n th at is u su a lly re lie ve d by fo od b u t re cu rs 2 –3 h ou rs la te r— wh ic h m a y in di ca te p e pt ic ul ce r 3- 9 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S D IG ES TI O N AN D E LI M IN A TI O N (C ON TIN UE D) N au se a or v om iti ng M os t c om m on ly o cc u rs d ur in g th e 1s t tri m es te r, 1s t st ag e of la bo r, a n d tra ns itio n. z H or m on a l c ha n ge s z Sm oo th m us cle r e la xa tio n z Ch an ge s in ca rb oh yd ra te m e ta bo lis m z Sl ow er e m pt yin g of th e st om ac h du rin g la bo r z Fa tig ue R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Ad jus t d iet a s ne ce ss a ry : − Ea t c ra ck er s, d ry b re ad , d ry to rti lla s, d ry c ha pa tti s, o r o th er g ra in fo od . − Ea t s m al le r, m or e fre qu e n t m ea ls . − A vo id o ve re a tin g an d ea tin g fa tty , f rie d, a nd s pi cy fo od s. − D rin k flu id s be tw e e n m e a ls ra th er th an w ith m ea ls . − D rin k he rb al , g in ge r, or c in n a m o n te as . z Si t u pr ig ht a fte r m ea ls. z G et p le nt y of fr es h ai r: ta ke s ho rt w a lk s, s le ep w ith w in do w o pe n , e tc . z Us e ac up re ss u re o ve r a pp ro pr ia te p oi nt o n th e pa lm ar s id e o f t he w ris t. z If se ve re , t ak e vit am in B 6 ca ps u le s (on e 5 0- m g ca ps ul e 2 ti m e s pe r d ay ). z If no np ha rm ac o lo gi c tre at m en ts d o no t p ro vid e re lie f, th e fo llo w in g m e di ca tio n s m a y be u se d, bu t t he n on ly as d ire ct ed : − M et oc lo pr a m id e hy dr oc hl or id e − Ph en o th ia zi ne s (pr om eth az ine h yd ro ch lo rid e , pr oc hl o rp er a zi ne , ch lo rp ro m a zi ne ) z A vo id : − Ly in g do wn im m e di at e ly af te r e a tin g. − O do rs o r o th er fa ct or s lik el y to in du ce v o m iti ng . − Br us hi ng th e te e th o r c le an in g th e to ng ue r ig ht a fte r m ea ls. z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Ep ig a st ric p ai n , he ad ac he , bl ur re d vis io n — w hi ch m ay in di ca te p re -e cl a m ps ia o r e cl am ps ia Lo ss o f a pp e tit e — w hi ch m ay in di ca te a pp en di ci tis Lo ss o f a pp e tit e , in to le ra n ce to fa tty fo od s— wh ich m ay in di ca te g al lb la dd er d is ea se Ba ck p ai n , de hy dr at io n , a n d po or g e n e ra l c o n di tio n — w hi ch m a y in di ca te p a n cr e a tit is Ex ce ss iv e vo m itin g wi th de hy dr at io n a n d ke to sis — w hi ch m ay in di ca te hy pe re m e si s Fe ve r o r c hi lls — w hi ch m ay in di ca te m al ar ia o r u rin a ry tra ct in fe ct io n Sa liv at io n, in cr ea se d M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r. z Un cle ar c a u se , bu t m ay b e re la te d to e at in g st ar ch y fo od s R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Li m it in ta ke o f f oo ds c on ta in in g st ar ch . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . 3- 10 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S D IG ES TI O N AN D E LI M IN A TI O N (C ON TIN UE D) Ur in at io n, in cr ea se d— In cr ea se in fre qu en cy , e sp ec ia lly a t n ig ht (no ctu ria ); l ea ki ng o f u rin e w he n sn e e zi ng , co u gh in g, o r la u gh in g M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r a nd 1s t – 2n d st ag e of la bo r. z En la rg e d ut er u s pu ts pr es su re o n th e b la dd er . z D ur in g th e da y, th e lo w er le gs a n d fe et b ec o m e sw o lle n ; w he n th e w om an re st s w ith h er fe et u p, th e flu id is re a bs or be d an d e xc re te d by th e k id ne ys . z O th er p os sib le ca u se s/ fa ct or s in clu de : − In cr ea se d vo lu m e o f flu id in b od y; − In cr ea se d blo od flo w to kid ne ys ; a nd − In cr ea se d e xc re tio n of so di um a nd w a te r. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Vo id w he n th e u rg e is fe lt. z Le an fo rw ar d w he n vo id in g to he lp e m pt y th e bl a dd e r co m pl et el y. z Li m it in ta ke o f f lu id s co n ta in in g n a tu ra l d iu re tic s (e. g., co ffe e, tea , c ola w ith ca ffe in e) bu t d o n o t r e st ric t f lu id in ta ke . z D o n o t d ec re as e flu id in ta ke in th e ev en in g to d ec re a se n o ct ur ia , e xc ep t i f n o ct ur ia is p re ve n tin g sle ep a nd c au sin g fa tig u e . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Fl an k/ lo in p ai n, bu rn in g on u rin at io n — w hi ch m ay in di ca te u rin ar y tra ct in fe ct io n In cr ea se d th irs t— w hi ch m ay in di ca te d ia be te s W O M AN ’S G EN IT AL S Pe rin ea l p ai n M os t c om m on ly o cc u rs d ur in g w e e ks 1– 2 po st pa rtu m . z Ti ss ue tr au m a fro m e pi sio to m y/ te ar s o r br ui sin g o f t iss ue d ur in g bi rth R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z En su re g o o d pe rin ea l h yg ie n e (se e p ag e 2- 10 6). z So ak a re a in w a rm tu b or s itz b at h in tu b o r bo w l t ha t h as b e e n d isi n fe ct ed be fo re u se . z Be tw ee n s itz b at hs : − Ke ep th e pe rin e u m d ry if th er e a re s u tu re s or te ar s. − Us e an ic e p ac k or a na lg es ic cr e a m . (P lac e a p ie ce o f g au ze o r th in cl ot h be tw e e n ic e a n d pe rin e u m to a vo id e xc e ss iv e ch illi n g o f t he tis su es .) z Us e an a lg es ic s su ch a s pa ra ce ta m ol (a ce ta m in op he n ) o r ib up ro fe n. z Br ea st fe ed w hi le ly in g do w n r at he r t ha n si tti n g. z Si t o n a cu sh io n w ith a n in de n ta tio n or h ol e in th e m id dl e of it. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Sl ou gh in g, re dd en e d su tu re lin e, o r p u s is s ee n on th e pe rin e a l p ad o r c o m in g fro m th e w ou n d— wh ic h m ay in di ca te a n in fe ct io n A pu rp le s w e llin g th at a pp ea rs in th e vu lv a o r pr ot ru de s fro m th e va gi n a — w hi ch m ay in di ca te a v ul va r he m at om a 3- 11 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S G EN IT AL S (C ON TIN UE D) Va gi na l d is ch ar ge M os t c om m on ly oc cu rs du rin g th e 1s t – 3rd tri m es te r a nd th e 1s t – 4th st ag e of la bo r. (D uri ng th e po st pa rtu m p e rio d, se e p ag e 2- 91 fo r in fo rm at io n ab ou t a ss e ss m e n t a nd c ar e re la te d to n or m al lo ch ia a n d va gi n a l di sc ha rg e. ) z In cr ea se d va sc u la rit y of ge ni ta l t ra ct in cr e a se s m u cu s pr od u ct io n. z As th e ce rv ix s ta rts to th in a n d di la te b e fo re la bo r o r in e a rly la bo r, a m u co u s pl u g m a y be e xp el le d. z As la bo r a dv a n ce s, b lo od y sh ow m ay a pp e a r. z Af te r b irt h, th e lin in g of th e u te ru s is s he d a n d lig ht bl ee di n g (lo ch ia r u br a) o cc u rs . R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z En su re g o o d hy gi en e : − Ke ep th e vu lv ar a re a a s cl ea n a n d dr y as p os si bl e. − D ur in g la bo r, us e a p er in e a l p a d/ cl ot h if ne e de d wh e n o u t o f b ed . − Ch an ge p a ds /c lo th s as n ee de d du rin g th e po st pa rtu m p er io d. z R es um e n o rm a l a ct iv iti es s lo w ly ov er s ev er a l w ee ks p os tp a rtu m , o r t he a m o u n t o f b le ed in g m a y su dd e n ly in cr e a se . z A vo id : − N ylo n un de rp an ts a nd p an ty ho se (w ea r co tto n un de rp a n ts a n d co m fo rta bl e , lo o se -fi tti ng c lo th in g); an d − D o u ch in g. z If th e sig n/ sy m pt om w or se n s, le t t he s ki lle d pr o vi de r k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pr of us e, w at er y, fr ot hy , f ou l- sm e llin g, o r y el lo w o r gr ee n is h di sc ha rg e; s or e s, u lc er s, o r w a rts o n ge n ita ls ; o r a ny o f th es e si gn s in th e w om a n ’s pa rtn er (s) — wh ic h m ay in di ca te s ex ua lly tr an sm itt ed in fe ct io n Itc hi ng , o do ro u s di sc ha rg e— w hi ch m ay in di ca te v ag in iti s A gu sh o r p er sis te nt tr ic kl e of flu id p rio r to th e on se t o f la bo r— w hi ch m a y in di ca te pr el ab or ru pt ur e o f m e m br an es w ith in cr ea se d ris k of a m ni on iti s W O M AN ’S S KI N Itc hi ne ss M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r. z En la rg e d ut er u s ca u se s st re tc hi ng a n d tig ht en in g of sk in a cr os s th e a bd om e n . z Fa m ilia l t en de n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e to pi ca l a nt ip ru rit ics a n d m o is tu riz in g cr ea m . z If to pi ca l m ed ica tio ns d o n o t p ro vi de re lie f, an tih is ta m in e s (di ph e n hy dr am in e , do xy la m in e s u cc in at e) ma y b e u se d, b ut th en o n ly fo r s ho rt co u rs e a n d e xa ct ly as d ire ct ed . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Sk in le sio n s su ch a s pa pu le s, m a cu le s, o r p us tu le s— wh ich m a y in di ca te d er m at itis Lo ss o f a pp e tit e , n a u se a o r vo m iti ng , i nt o le ra nc e to fa tty fo od s— wh ic h m ay in di ca te ga llb la dd e r di se a se 3- 12 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S S KI N (C ON TIN UE D) Pe rs pi ra tio n, in cr ea se d M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r, in cr ea si ng th ro u gh o u t pr eg n a n cy . z An in cr ea se in s w e a t g la n d a ct iv ity , p os sib ly ca us ed b y: − H or m on a l c ha n ge s − In cr ea se in th yr oi d a ct iv ity − In cr ea se in bo dy w ei gh t a n d m et ab ol ic a ct iv ity R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z W e a r lig ht , l oo se -fi tti ng c lo th in g. z In cr ea se in ta ke o f f lu id s (2– 3 l ite rs p er d ay ) a n d dr in k pl en ty o f f lu id s du rin g la bo r. z Ba th e m or e fre qu en tly o r s po n ge w ith c oo l w a sh cl o th . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. R ap id h ea rt be a t, tre m or , hy pe ra ct iv ity , w ei gh t l os s, a n d/ or h e a t i nt o le ra n ce — w hi ch m ay in di ca te hy pe rth yr o id is m Pa lp ita tio ns , n e rv o u sn e ss /tr e m bl in g, fe el in g o f i m pe nd in g do o m , tig ht ne ss in th e ch es t, dr y m ou th — wh ich m a y in di ca te s e ve re a n xi et y Sk in c ha ng es — Ac ne ; b lo tc hi ne ss o r da rk en in g o f s kin o n th e fa ce , b re as ts , a nd a bd o m e n (c hlo as m a ); dr yn es s or re d/ itc hy pa lm s of h an ds o r so le s of fe et M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r. z H or m on a l c ha n ge s in cr e a se bl oo d flo w to s ki n. z Ac ne m ay b e ca u se d by a n in cr ea se in o il gl an d ac tiv ity . z Ch lo a sm a m a y be c au se d by a n in cr e a se in m e la ni n de po si tio n in s ki n. z Fa m ilia l t en de n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z To a vo id s kin d ar ke ni n g, c ov er s ki n or u se n o n a lle rg en ic s un -b lo ck in g cr e a m w he n in th e su n . z Fo r d ry ne ss , u se to pi ca l a nt ip ru rit ic s an d m oi st ur iz in g cr ea m . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Sk in le sio n s su ch a s pa pu le s, m a cu le s, o r p us tu le s— wh ich m a y in di ca te d er m at itis G en er al iz ed ra sh es a ss o ci at e d wi th fe ve r Sp id er n ev i— Va sc ul ar “s pi de rs ” (tin y, red , ra ise d lin es th at b ra nc h ou t f ro m a fl at o r s lig ht ly ra is ed ce n te r), m os t pr om in e n t a ro u n d e ye s, n ec k, th ro at , a n d ar m s M os t c om m on ly o cc u rs d ur in g th e 1s t – 2n d tri m es te r, in cr ea si ng w ith pr eg n a n cy a n d fa di ng a fte r c hi ld bi rth . z H or m on a l c ha n ge s in cr e a se bl oo d flo w to s ki n, d ila tin g ve in s an d sm al l a rte rie s. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w o m an a n d ad vi se h er to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . 3- 13 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S S KI N (C ON TIN UE D) St re tc h m ar ks (st ria e gr av id ar u m )— R ed di sh o r w hi tis h st re ak s on b re as ts , a bd o m e n , o r u pp er th ig hs M os t c om m on ly oc cu rs du rin g 2n d – 3rd tri m es te r, fa di ng a fte r c hi ld bi rth (pe rm an en t to so me de gr e e ). z H or m on a l c ha n ge s z Pr od uc tio n o f s te ro id ho rm on e s by th e ad re n a l gl an ds z Fa m ilia l t en de n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z W e a r w e ll- fit tin g, su pp or tiv e ga rm e n ts fo r t he br ea st s an d ab do m e n . z If itc hi ng is s ev e re , u se to pi ca l e m o llie n ts o r a n tip ru rit ics . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . Va ric os e ve in s— Sw ol le n b lu e ve in s on th e le gs o r g e n ita ls ; m a y be p ai nf ul M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r a nd 1s t – 3rd st ag e of la bo r. z Pr es su re o f e nl a rg ed u te ru s ca u se s ve n o u s co n ge st io n in lo w er v ei ns . z H or m on al c ha n ge s re la x sm o o th m us cl e s a n d we a ke n sm a ll ve in s. z Fa m ilia l t en de n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e go o d bo dy m e ch an ic s (se e gu id el in es u n de r B ac k pa in [p ag e 3- 18 ]): − W he n si tti ng , s lig ht ly el e va te th e fe et /le gs . − W he n lyi ng d ow n , lie o n th e le ft sid e an d sli gh tly e le va te th e fe et /le gs . z G et d ai ly ex er cis e. z W e a r su pp o rt ho se . z A vo id : − St an di n g or s itt in g fo r l on g pe rio ds ; − Ti gh t c lo th in g or gi rd le s; a n d − Cr os sin g th e le gs w he n sit tin g. D ur in g la bo r/b irt h, a dv is e th e w om an a nd /o r b irt h co m pa n io n as fo llo w s: z Ch an ge p o si tio n s fre qu en tly d u rin g la bo r (se e e xa m pl e s u n de r A bd o m in al [o r gr oi n] pa in [p ag e 3- 3]) . z Us e ph ys io lo gi c pu sh in g (pu sh in g wi th c on tra ct io ns w he n sh e ha s th e u rg e to pu sh ) d u rin g 2n d st ag e of la bo r t o de cr ea se c o n ge st io n of v ul va r v ar ic os iti es . z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Lo ca liz ed pa in o ve r a v e in , sw e llin g of th e a ffe ct ed lim b— w hi ch m ay in di ca te s up er fic ia l th ro m bo ph le bi tis Ca lf m us cle te n de rn e ss , sw e llin g of th e a ffe ct ed lim b— w hi ch m ay in di ca te d ee p ve in th ro m bo sis H em at om a of v u lv ar va ric os ity — wh ich m ay in di ca te ru pt ur e of v ar ico si ty 3- 14 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S S LE EP A ND M EN TA L ST AT E D re am s (vi vid ) o r n ig ht m ar es M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r. z H or m on a l c ha n ge s R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z A vo id e a tin g jus t b ef or e be dt im e. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . Fa tig ue o r sl ee pi ne ss M os t c om m on ly o cc u rs d ur in g th e 1s t tri m es te r a nd w ee k 1 po st pa rtu m . N or m al /n or m al v ar ia tio n: M ay p er sis t if wo m an is n o t g et tin g e n o u gh s le e p z D ec re as e d m et a bo lis m in e a rly p re gn a n cy z In cr ea se in bl oo d vo lu m e a n d flo w , w hi ch c au se h e a rt to w or k ha rd er z Em ot io na l s tre ss z N or m al re a ct io n to th e ha rd w o rk o f l ab o r a n d bi rth z En or m ou s a m o u n t o f e ne rg y e xp en de d in la bo r a nd b irt h z Em ot io na l a nd p hy sic al st re ss o f h av in g to c ar e fo r ba by in a dd iti on to p re vio u s re sp on si bi lit ie s z In te rru pt ed s le e p to fe ed a n d ca re fo r b ab y R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z En su re a g o o d di et : − Ea t a b al an ce d di et . − Ta ke m ic ro nu tri e n t s up pl em e n ts a s di re ct ed . z G et d ai ly ex er cis e. z M as sa ge th e ba ck a nd /o r a bd o m e n . z D ur in g th e po st pa rtu m p er io d, g et a de qu a te re st a nd s le e p, ta kin g a n a p w he n th e b ab y sle ep s wh e n e ve r po ss ib le . z A vo id : − O ve re xe rti on ; a nd − Sm ok in g an d a lc oh ol . Su gg es t t ha t t he w om an ’s p ar tn er /fa m ily : z En su re th at th e w o m a n h a s tim e fo r r es t a nd sl ee p. z Av oi d m ak in g u n re a so n a bl e d em an ds o n he r. z Sh ar e so m e o f t he re sp on si bi lit ie s of n ew bo rn ca re . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. D iz zi ne ss o r fa in tin g, p al lo r, br ea th le ss n e ss , ra pi d he a rt be at , s we llin g of lim bs — wh ic h m a y in di ca te s ev e re a n e m ia Ch an ge in st at e of co n sc io us ne ss — w hi ch m ay in di ca te im pe n di ng co n vu ls io n s du e to e cl am ps ia o r m a la ria G as , b lo at in g, lo ss o f a pp et ite , w e a kn es s, w a st in g, p oo r ge ne ra l c on di tio n — w hi ch m ay in di ca te m al n u tri tio n or a n o th e r ch ro ni c co n di tio n /ill ne ss In so m ni a, e xc es si ve o r in ap pr op ria te s a dn e ss o r gu ilt, fe el in gs o f w or th le ss ne ss a n d/ or a n xi ou sn e ss la st in g fo r m o re th an 1 w e e k— w hi ch m ay in di ca te p os tp a rtu m de pr e ss io n H al lu ci na tio n s, d el us io n s, m o rb id o r s ui ci da l t ho u gh ts — w hi ch m ay in di ca te po st pa rtu m ps yc ho sis 3- 15 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S S LE EP A ND M EN TA L ST AT E (C ON TIN UE D) Fe el in gs o f in ad eq ua cy , w or ry , o r fe ar d ur in g th e po st pa rtu m p er io d M os t c om m on ly o cc u rs d ur in g w e e ks 1– 2 po st pa rtu m . N ot e: Es pe cia lly co m m o n a m o n g a do le sc e n ts a nd pr im ip a ra s z Es pe cia lly c om m o n in fi rs t pr eg n a n ci es a s th e w om an co n fro nt s th e: − R ea lit y of a n ew a n d ve ry d ep e n de n t l ife in he r c ar e − Ch al le ng e of le a rn in g a bo u t c hi ld c ar e w he n sh e is fe el in g ph ys ica lly vu ln er a bl e R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w o m an a n d re as su re he r th ro ug h yo ur w o rd s as w el l a s yo ur a ct io ns : z As su re h er th at sh e is o f i ne st im a bl e wo rth in h er b ab y’s w el l-b ei ng a n d th at n o o n e e ls e ca n c a re fo r h er b a by a s we ll as s he c an . z Po in t o ut th in gs sh e is d oi n g w e ll/r ig ht , e ve n if th ey a re s m al l t hi ng s. z G ive h er c le a r a n d ca re fu l a dv ic e/ co un se lin g on n ew bo rn c a re a n d se lf- ca re . z Al lo w h e r to a sk q ue st io n s a n d di sc us s he r a n xi et ie s. D o n o t o ve rw he lm h er w ith to o m uc h in fo rm at io n a t o ne ti m e. A dv is e th e w om an a nd /o r h er c om pa ni on a s fo llo w s: z Ea t a b al an ce d di et a nd g e t d a ily e xe rc is e . z Ta ke ti m e fo r h er se lf an d re su m e s oc ia l c o n ta ct s as s oo n as fe as ib le . z Av oi d un re a lis tic e xp ec ta tio n s fo r h er se lf. z Ta ke a n ap w he n th e ba by s le e ps w he n e ve r po ss ib le . Su gg es t t ha t t he w om an ’s p ar tn er /fa m ily : z En su re th at th e w o m a n h a s tim e fo r r es t a nd sl ee p. z Av oi d m ak in g u n re a so n a bl e d em an ds o n he r. z Al lo w h er ti m e al on e w ith h er p ar tn er (if c ul tu ra lly a pp ro pr ia te , su gg es t t ha t th e pa rtn er ta ke he r o ut ). z Be s en si tiv e to th e w om an ’s n e e ds . z Ca re fo r t he w o m a n in a n a tte nt iv e an d co m pa ss io n a te w a y. z Sh ar e so m e o f t he re sp on si bi lit ie s of n ew bo rn ca re . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Cr yin g, fe el in gs o f s ad ne ss o r o f b ei ng o ve rw he lm ed , irr ita bi lity b et we e n 3 a n d 6 da ys a fte r b irt h— w hi ch m ay in di ca te p os tp a rtu m s ad ne ss (“b lue s”) . In so m ni a, e xc es si ve o r in ap pr op ria te s a dn e ss o r gu ilt, fe el in gs o f w or th le ss ne ss a n d/ or a n xi ou sn e ss la st in g fo r m o re th an 1 w e e k— w hi ch m ay in di ca te p os tp a rtu m de pr e ss io n H al lu ci na tio n s, d el us io n s, m o rb id o r s ui ci da l t ho u gh ts — w hi ch m ay in di ca te po st pa rtu m p sy ch os is 3- 16 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S S LE EP A ND M EN TA L ST AT E (C ON TIN UE D) Fe el in gs o f w o rr y o r fe ar a bo ut pr eg na nc y an d la bo r M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r a nd 1s t – 2n d st ag e of la bo r. z H or m on a l c ha n ge s z An xi et y ab o u t l a bo r a n d bi rth z N or m al re a ct io n to th e ha rd w o rk /p ai n o f l ab or a nd b irt h R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z D is cu ss th e no rm a lc y of w or ry a nd fe ar d ur in g la bo r a nd b irt h an d wa ys to po sit ive ly m an a ge e m o tio ns ; i n vo lv e pa rtn er a n d fa m ily in d isc u ss io ns a bo u t n o rm a lc y of w o rr y an d fe ar d ur in g pr eg n a n cy , a s a pp ro pr ia te . z D is cu ss w a ys to p os itiv el y m an ag e wo rry a n d fe ar . z In vo lv e th e bi rth c om pa n io n , pa rtn er , a nd /o r f am ily in h el pi n g th e wo m a n co pe w ith la bo r th ro ug h br e a th in g an d re la xa tio n te ch ni qu e s a n d co m m u n ic a tio n /e n co u ra ge m e n t. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pe rs pi ra tio n , pa lp ita tio n s, n e rv o u sn e ss /tr e m bl in g, fe el in g o f i m pe nd in g do o m , tig ht ne ss in th e ch es t, dr y m ou th — wh ich m a y in di ca te s e ve re a n xi et y In so m ni a M os t c om m on ly o cc u rs d ur in g th e 2n d tri m es te r a nd w e e k 1 po st pa rtu m . N or m al /n or m al v ar ia tio n: M ay p er sis t if no re lie f m ea su re s z An xi et y z In cr ea se d R EM (r ap id ey e m o ve m e n t) p ha se o f s le ep , w hi ch is le ss r e st fu l z D is co m fo rt ca us e d by e n la rg ed u te ru s a n d ot he r pr eg n a n cy -re la te d ch an ge s z Fe ar o f s le ep in g th ro ug h n ew bo rn ’s cr y or n ee d fo r he r z D is co m fo rt ca us e d by pe rin e a l t ra um a R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e re la xa tio n te ch ni qu es b ef o re tr yin g to s le e p. z W he n lyi ng d ow n : − Li e on th e si de w ith th e kn ee s a n d hi ps b en t; an d − Pl ac e a pi llo w b et we e n th e kn e e s a n d an o th e r pi llo w u n de r t he a bd o m e n . z A vo id ca ffe in e, a lc oh ol , a nd s le e p m e di ca tio n s, e sp ec ia lly lo n g- te rm u se o f be nz o di a ze pi ne s. Su gg es t t ha t t he w om an ’s p ar tn er /fa m ily : z En su re th at th e w o m a n h a s tim e fo r r es t a nd sl ee p. z Sh ar e so m e o f t he re sp on si bi lit ie s of n ew bo rn ca re (e .g. , th e p art ne r c an lis te n fo r b ab y du rin g th e ni gh t). A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Ex ce ss iv e or in a pp ro pr ia te sa dn e ss o r gu ilt, fe el in gs o f w o rth le ss n e ss a n d/ or a n xi ou sn es s la st in g fo r m or e th an 1 w ee k— w hi ch m ay in di ca te p os tp a rtu m de pr e ss io n H al lu ci na tio n s, d el us io n s, m o rb id o r s ui ci da l t ho u gh ts — w hi ch m ay in di ca te po st pa rtu m p sy ch os is 3- 17 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM W O M AN ’S S LE EP A ND M EN TA L ST AT E (C ON TIN UE D) M oo d sw in gs — M ay fe el h ap py /c ha tty in e a rly la bo r; m ay w an t n o o n e to b e ne a r o r to uc h he r d u rin g tra ns iti on M os t c om m on ly o cc u rs d ur in g th e 1s t tri m es te r a nd 1s t – 2n d st ag e of la bo r. z H or m on a l c ha n ge s z St re ss , f at ig ue z N or m al re a ct io n to th e ha rd w o rk /p ai n o f l ab or a nd b irt h R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z D is cu ss w a ys to p os itiv el y m an ag e m oo d sw in gs ; i nv o lv e p ar tn er a n d fa m ily in d isc us sio n s a bo u t n or m al cy o f m oo d sw in gs . z D is cu ss th e no rm a l m oo d sw in gs d u rin g la bo r a n d bi rth a nd w ay s to po sit ive ly m an a ge e m o tio ns . z In vo lv e th e bi rth c om pa n io n , pa rtn er , a nd /o r f am ily in h el pi n g th e wo m a n co pe w ith la bo r th ro ug h br e a th in g an d re la xa tio n te ch ni qu e s a n d co m m u n ic a tio n /e n co u ra ge m e n t. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. M oo d sw in gs la st in g m or e th an 1 w ee k w ith d ep re ss io n , su ic id a l t ho u gh ts , h yp er ac tiv ity a n d/ or g ra n di os e id ea s— w hi ch m ay in di ca te b ip o la r a ffe ct ive d iso rd e r In so m ni a, e xc es si ve o r in ap pr op ria te s a dn e ss o r gu ilt, fe el in gs o f w or th le ss ne ss a n d/ or a n xi ou sn e ss la st in g fo r m o re th an 1 w e e k— w hi ch m ay in di ca te p os tp a rtu m de pr e ss io n H al lu ci na tio n s, d el us io n s, m o rb id o r s ui ci da l t ho u gh ts — w hi ch m ay in di ca te po st pa rtu m ps yc ho sis 3- 18 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM M IS CE LL AN EO US (W OM AN ) B ac k pa in M os t c om m on ly oc cu rs du rin g th e 2n d – 3rd tri m es te r, 1s t – 2n d st ag e o f l ab or , a nd w e e k 1 po st pa rtu m . N or m al /n or m al v ar ia tio n: M ay p er sis t du e to p oo r bo dy m e ch an ic s or p oo r po st ur e, e sp e ci a lly w hi le b re a st fe ed in g z H or m on a l c ha n ge s ca us e co n n e ct iv e tis su e to b ec om e so fte r a nd lo o se r; joi nts in pe lvi s re la x. z A sh ift in w om an ’s c e n te r o f gr av ity c au se s co m pe ns at io ns in p os tu re a n d m ov e m e n t. z M us cl es a lo n g th e fro nt o f th e ab do m e n s e pa ra te . z O th er p os sib le ca u se s/ fa ct or s in clu de : − In cr ea se in b re as t s ize ; − Fa tig ue ; − Po or b od y m ec ha ni cs ; − Pr es su re o f t he fe tu s’s he ad o n th e ne rv e s a s th e he ad d es ce n ds du rin g la bo r; an d − Po or p os tu re w he n br ea st fe ed in g ba by . R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z R ei nf or ce th e im po rta nc e o f u sin g go o d bo dy m ec ha ni cs : − W he n sq ua tti ng o r ris in g fro m sq ua tti ng p o si tio n , sp re a d fe et a pa rt an d pl ac e o n e fo o t s lig ht ly in fro nt o f t he o th er , s o th er e is a b ro ad b as e fo r ba la n ce . − W he n lift in g, sq ua t (k ee pi ng th e sp in e e re ct ), r a th er th an b en d, s o th at th e le gs (th igh s) be ar the w eig ht a nd s tra in . − D o no t l ift a ny th in g he av ie r t ha n th e ba by fo r t he fi rs t f ew w ee ks po st pa rtu m . − A vo id u n co m fo rta bl e w o rk in g he ig ht s, li fti ng h ea vy lo a ds , a n d o ve re xe rti on . − Pr ac tic e go o d po st ur e wh en s ta n di n g or s itt in g. − D o no t c ro ss le gs w he n sit tin g. z W he n lyi ng d ow n : − Li e on th e si de w ith th e kn ee s a n d hi ps b en t; − Pl ac e a pi llo w b et we e n th e kn e e s a n d an o th e r pi llo w u n de r t he a bd o m e n ; a nd − Sl ig ht ly e le va te th e fe et /le gs . z Pr ac tic e th e “a n gr y ca t” ex er cis e : ge t o n yo u r ha nd s an d kn e e s w ith b a ck fl at , pu sh th e lo w e r ba ck u p, re tu rn to fl at b ac k, a nd re pe a t. z W e a r a w e ll- fit tin g, s up po rti ve b ra . z Sl ee p on a fi rm m a ttr es s or s ur fa ce . z If th e pa in b ec o m e s bo th e rs o m e , try a ny o f t he fo llo w in g: − Ap pl y an ic e pa ck a nd /o r a w ar m c lo th o r h ea tin g pa d to th e p ai n fu l a re a. − G en tly m as sa ge o r a pp ly fir m p re ss ur e o ve r th e pa in fu l a re a . z If no np ha rm ac o lo gi c tre at m en ts d o no t p ro vid e re lie f, pa ra ce ta m ol (ac eta mi no ph e n ) 5 00 m g m ay be u se d as n e e de d. D ur in g la bo r/b irt h, a dv is e th e w om an a nd /o r b irt h co m pa n io n as fo llo w s: z As su m e th e ha n ds a nd k ne es o r kn ee -c he st p os itio n to a id in ro ta tio n an d de sc en t o f t he fe ta l h ea d. z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Ut er in e co n tra ct io ns th at a re pr og re ss iv e ly lo n ge r/f re qu en t a n d ce rv ic al d ila tio n— w hi ch m a y in di ca te la bo r Fl an k/ lo in p ai n, bu rn in g on u rin at io n — w hi ch m ay in di ca te u rin ar y tra ct in fe ct io n N um bn es s, m us cu la r w e a kn e ss o r w a st in g, d iff icu lty u rin at in g or d ef ec at in g— w hi ch m a y in di ca te n e u ro lo gi c di se as e Lo w er a bd o m in a l t en de rn es s, u te rin e te nd er n e ss , a bd om in al di st en tio n — w hi ch m ay in di ca te u te rin e in fe ct io n 3- 19 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM M IS CE LL AN EO US (W OM AN ) ( CO NT IN UE D) B le ed in g or p ai nf ul gu m s Ty pi ca lly m os t s e ve re du rin g th e 2n d tri m es te r. z H or m on a l c ha n ge s ca us e a n in cr ea se in b lo o d flo w to th e m o u th , w hi ch re su lts in : − In cr ea se in gr ow th o f sm a ll bl o o d ve ss e ls a nd sw e llin g of g u m s; − R ap id tu rn ov e r o f c el ls th at li ne g u m s; − D ec re as e in th ic kn es s of gu m ti ss ue , m ak in g it m o re fr ag ile ; a n d − Ed em a in co n n e ct iv e tis su es . R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z R in se m ou th w ith w ar m s al t w a te r. z Pr ac tic e go o d de nt al hy gi e n e . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Lo ca liz ed sw e llin g of th e gu m s th at m ay o r m ay n ot b le ed — w hi ch m ay in di ca te g in gi vi tis D iff ic ul ty g et tin g up an d do w n M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r. z H or m on a l c ha n ge s ca us e co n n e ct iv e tis su e to b ec om e so fte r a nd lo o se r; joi nts in pe lvi s re la x. z O th er p os sib le ca u se s/ fa ct or s in clu de : − Ch an ge s in po st ur e du e to e nl ar ge d ut e ru s; a nd − Fa tig ue . R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z W he n ge tti ng u p fro m a ly in g po sit io n : − R ol l t o on e s id e; − Pu sh u p on th e kn ee s; a nd − Th en s ta nd u p. z W he n si tti ng , p ro p a pi llo w a ga in st th e ba ck a n d pl ac e a pi llo w u n de r t he kn ee s; o r e le va te th e fe et . z W he n lyi ng d ow n : − Pr op a p illo w a ga in st th e ba ck a n d pl a ce a p illo w u n de r t he k n e e s; O R − Li e on th e le ft sid e wi th th e k ne e s a n d hi ps b e n t, an d pl a ce a p illo w be tw ee n th e kn e e s a n d an o th e r pi llo w u n de r t he a bd o m e n ; a n d − Sl ig ht ly e le va te th e fe et /le gs . z A vo id lyi ng fl at o n th e ba ck . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. N um bn es s, m us cu la r w e a kn e ss o r w a st in g, d iff icu lty u rin at in g or d ef ec at in g— w hi ch m a y in di ca te n e u ro lo gi c di se as e Se ve re lo w e r ba ck p ai n th at ra di at e s in to th e le gs 3- 20 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM M IS CE LL AN EO US (W OM AN ) ( CO NT IN UE D) D iz zi ne ss o r f ai nt in g M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd tri m es te r. z D ro p in b lo o d pr e ss u re ca u se d by c ha n ge s in po sit ion z Bl oo d po ol s in v e ss e ls in lo w er le gs a n d fe et z O th er p os sib le ca u se s/ fa ct or s in clu de : − St re ss ; − Fa tig ue ; − H un ge r; an d − H yp er ve n til at io n . R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z G et u p slo wl y fro m a s itt in g or lyi ng p o si tio n . z W he n lyi ng d ow n , lie o n th e le ft sid e. z Ea t s m al le r, m or e fre qu e n t m ea ls . z A vo id st an di ng in w ar m o r s tu ffy p la ce s fo r l o n g pe rio ds . z A vo id lyi ng fl at o n th e ba ck . z A vo id h yp er ve n til at io n by p la ci ng h a n ds in fro nt o f t he m ou th a nd b re a th in g in to th em o r b y br ea th in g in to a s m a ll pa pe r o r pl as tic s ac k. z If th e di sc om fo rt wo rs en s, le t t he s kil le d pr o vi de r k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Fa tig ue o r s le e pi ne ss , p a llo r, br ea th le ss n e ss , ra pi d he a rt be at , s we llin g of lim bs — wh ic h m a y in di ca te s ev e re a n e m ia Sh ou ld er p ai n— w hi ch m ay in di ca te e ct op ic p re gn a n cy (N ot e: Th is is a n un lik el y di ag n o si s af te r t he e ar ly 2n d tri m es te r.) Fe el in g ho t M os t c om m on ly o cc u rs d ur in g th e 1s t – 3rd st ag e of la bo r. z M us cu la r a ct iv ity o f l ab or ca u se s se n sa tio n o f h ea t. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e co ol d rin ks , co o l c om pr es se s, a n d ge n tle fa nn in g. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . H ai r l os s M os t c om m on ly o cc u rs d ur in g th e 3rd tri m es te r a nd is m o re li ke ly du rin g th e po st pa rtu m p e rio d. z H or m on al c ha n ge s al te r n o rm a l h ai r-g ro w th p ro ce ss . R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w o m an a n d ad vi se h er to re tu rn fo r c ar e if da ng e r si gn s (pa ge 4 -6 1) a ris e. 3- 21 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM M IS CE LL AN EO US (W OM AN ) ( CO NT IN UE D) H ea da ch e M os t c om m on ly oc cu rs du rin g th e 1s t – 3r d tri m es te r, 1s t – 3rd st ag e o f l ab or , a nd d ay s 1– 2 po st pa rtu m . z H or m on al c ha n ge s m ay ca u se : − N as al c on ge st io n ; − M ild in cr e a se in o xy ge n le ve ls ; a n d − Sw el lin g of e ye ba ll, w hi ch c an r e su lt in e ye st ra in . z O th er p os sib le ca u se s/ fa ct or s in clu de : − M us cl e sp as m s; − Em ot io na l s tre ss ; − Fa tig ue ; − Lo w b lo o d su ga r; − D eh yd ra tio n ; − Po or p os tu re w hi le ho ld in g a n d br ea st fe ed in g ba by ; a nd − In ab ilit y to re st , r el ax , o r sl ee p du rin g la bo r. z D eh yd ra tio n im m e di at e ly a fte r b irt h du e to : − Fl ui d lo st d u rin g la bo r/c hi ld bi rth − In cr ea se d u rin a tio n po st pa rtu m to ri d bo dy o f f lu id a cc um u la te d du rin g pr eg na n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Ea t a b al an ce d di et (in clu di n g a de qu at e flu id in ta ke ) a nd g et a de qu at e re st . z Ap pl y he a t o r i ce to th e ne ck , o r t ak e w ar m b a th s. z M as sa ge th e ne ck a nd s ho u ld e r m u sc le s. z If no np ha rm ac o lo gi c tre at m en ts d o no t p ro vid e re lie f, pa ra ce ta m ol (ac eta mi no ph e n ) 5 00 m g m a y be u se d as n e e de d. z A vo id a sp iri n, ib up ro fe n, n ar co tic s, s e da tiv es , o r hy pn ot ics . D ur in g la bo r/b irt h, a dv is e th e w om an a nd /o r b irt h co m pa n io n as fo llo w s: z R es t a s m uc h a s po ss ib le in e a rly la bo r a n d be tw ee n co n tra ct io ns . z D rin k pl e n ty o f f lu id s an d ea t s m a ll m ea ls d ur in g la bo r. z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pa in w ith b lu rre d vis io n , n a u se a o r vo m itin g, e pi ga st ric pa in — w hi ch m ay in di ca te p re - e cl am ps ia o r e cl am ps ia Un ila te ra l p a in w ith n au se a , vo m iti ng , o r v isu a l di st ur ba n ce s— w hi ch m ay in di ca te m ig ra in e Pa in o ve r th e si nu se s w ith pu ru le n t n as a l d isc ha rg e, n a sa l s tu ffi ne ss o r bl ee di ng — w hi ch m ay in di ca te a cu te si nu si tis H ea rt p al pi ta tio ns — Fl ut te rin g or p o u n di n g se n sa tio n a ro u n d th e he ar t, as th ou gh it ha s sk ip pe d a be a t M os t c om m on ly o cc u rs d ur in g th e 1s t tri m es te r. z In cr ea se in bl oo d flo w to a nd fro m h ea rt du rin g pr eg na n cy z An xi et y ab o u t p os sib le h e a rt di se as e (b ec a u se o f sy m pt om s) R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Sh or tn es s of b re a th th at w o rs e n s o n e xe rti on , c he st pa in — w hi ch m ay in di ca te he ar t d ise a se Pe rs pi ra tio n , n e rv o u sn e ss / tre m bl in g, fe el in g of im pe n di n g do om , t ig ht ne ss in c he st , d ry m o u th — w hi ch m ay in di ca te se ve re a n xi et y 3- 22 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM M IS CE LL AN EO US (W OM AN ) ( CO NT IN UE D) H em or rh oi ds — Sw ol le n v e in s in a n d a ro u n d th e re ct u m , a ss o ci at e d wi th p ai n , itc hi ng , a n d bl e e di ng M os t c om m on ly oc cu rs du rin g th e 2n d – 3rd tri m es te r, 1s t – 3rd st ag e o f l ab or , a nd w e e k 1 po st pa rtu m . z H or m on a l c ha n ge s ca us e e n la rg em e n t a n d co ng es tio n o f r ec ta l v ei ns . z En la rg e d ut er u s pu ts pr es su re o n r e ct al v ei ns . z Co ns tip at io n z Ve no u s co n ge st io n oc cu rs w ith fe ta l d es ce n t a nd pu sh in g du rin g la bo r, ca u si ng o r a gg ra va tin g e xi st in g he m or rh oi ds . z Ex tre m e pr es su re e xe rte d on re ct al v ei n s du rin g pu sh in g in la bo r R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z En su re a g o o d di et : − Ea t a b al an ce d di et (in clu di n g a de qu at e flu id in ta ke ). − In cr ea se in ta ke o f h ig h- fib e r fo od s (e. g., fre sh fru its an d v eg e ta bl e s). z So ak a ffe ct ed a re a in a w a rm tu b or s itz b at h. z If th e he m or rh oi d is pr ot ru di ng , a pp ly ice p ac ks to th e ar ea a nd g e n tly re in se rt th e he m o rr ho id in to th e re ct um . z Us e to pi ca l a ne st he tic o in tm en ts , i f n ec es sa ry . z A vo id : − Be co m in g co ns tip at ed (s ee B ow el fu nc tio n ch an ge s— co n st ip at io n or di ar rh e a [p ag e 3- 6]) ; − St ra in in g du rin g bo we l m ov em e n ts ; a nd − Si tti ng fo r l on g pe rio ds , e sp ec ia lly o n ha rd s ur fa ce s. D ur in g la bo r/b irt h, a dv is e th e w om an a nd /o r b irt h co m pa n io n as fo llo w s: z Us e po sit io n s th at ta ke p re ss u re o ff th e pe rin e u m a n d an u s (e. g., ha nd s a n d kn e e s). z Us e ph ys io lo gi c pu sh in g (pu sh in g wi th c on tra ct io ns w he n sh e ha s th e u rg e to p us h) du rin g th e 2n d st ag e of la bo r. z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Co ns tip a tio n w ith a na l p a in , bl ee di n g on d ef ec at io n— w hi ch m a y in di ca te a n a n a l f iss ur e H ip p ai n— Us ua lly o n o n e s id e on ly M os t c om m on ly o cc u rs d ur in g th e 3rd tri m es te r. z H or m on a l c ha n ge s ca us e co n n e ct iv e tis su e to b ec om e so fte r a nd lo o se r; joi nts in pe lvi s re la x. z Ch an ge in po st u re d ue to e n la rg ed u te ru s R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Pr ac tic e ex er ci se s to s tre ng th e n th e ba ck a n d ab do m e n , su ch a s: − R ai si n g le gs fr om a ly in g- do w n po sit io n − Ab do m in a l s tre ng th en in g e xe rc is es − Th e “a ng ry c at ” e xe rc is e (se e gu id e lin e s u n de r Ba ck p ai n [p ag e 3- 18 ]) z If th e pa in b ec o m e s bo th er so m e , a pp ly a wa rm c lo th o r h ea tin g pa d. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. N um bn es s, m us cu la r w e a kn e ss o r w a st in g, d iff icu lty u rin at in g or d ef ec at in g— w hi ch m a y in di ca te n e u ro lo gi c di se as e Se ve re w a dd lin g, h ip /p el vi s in st ab ilit y— wh ich m ay in di ca te se pa ra tio n of th e sy m ph ys is pu bi s (sp on ta n e o u s sy m ph ys io to m y) or of on e o f th e sa cr oi lia c joi n ts d ur in g la bo r 3- 23 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM M IS CE LL AN EO US (W OM AN ) ( CO NT IN UE D) H yp er ve nt ila tio n or sh or tn es s of b re at h M os t c om m on ly o cc u rs d ur in g th e 3rd tri m es te r a nd 1s t – 2n d st ag e of la bo r. z H or m on a l c ha n ge s ca us e lo w er le ve ls o f c a rb on di ox id e an d hi gh er le ve ls o f o xy ge n ; h yp er ve n til at io n he lp s m ai nt ai n n o rm a l l ev e ls . z En la rg e d ut er u s pu sh es di ap hr ag m o u t o f p la ce , de cr ea si ng lu ng ca pa cit y an d ca u si ng s ho rtn e ss o f b re at h. z R ap id , s ha llo w b re at hi ng du rin g co nt ra ct io ns R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e go o d bo dy m e ch an ic s (se e gu id el in es u n de r B ac k pa in [p ag e 3- 18 ]). z W he n lyi ng d ow n : − Li e on th e le ft sid e wi th th e k ne e s a n d hi ps b e n t; an d − Pl ac e a pi llo w b et we e n th e kn e e s a n d an o th e r pi llo w u n de r t he a bd o m e n . z A vo id h yp er ve n til at io n by p la ci ng h a n ds in fro nt o f t he m ou th a nd b re a th in g in to th em o r b y br ea th in g in to a s m a ll pa pe r o r pl as tic s ac k. z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . D ur in g la bo r/b irt h, a dv is e th e w om an a nd /o r b irt h co m pa n io n as fo llo w s: z Tr y to u se s lo w, re gu la r b re a th in g du rin g co n tra ct io ns . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Co ug h, p ro du ct io n of s pu tu m , w he ez in g— wh ic h m ay in di ca te a r e sp ira to ry d iso rd er (e .g. , in fe ct io n, a st hm a) Sh or tn es s of b re a th th at w o rs e n s o n e xe rti on , c he st pa in , h e a rt pa lp ita tio n s— w hi ch m a y in di ca te h e a rt di se a se D iz zi ne ss o r f ai nt in g, fa tig ue o r sl ee pi ne ss , pa llo r, ra pi d he ar t be at , s we llin g of lim bs — wh ic h m a y in di ca te s ev e re a n e m ia R ap id h ea rt be a t; co ug h, pr od u ct io n of p in k, fr ot hy sp ut um — wh ich m a y in di ca te pu lm on a ry e de m a N as al s tu ffi ne ss o r n as al b le ed in g M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r a nd 1s t – 3rd st ag e of la bo r. z H or m on a l c ha n ge s ca us e : − In cr ea se in bl oo d flo w to th e ca pi lla rie s; a nd − D ila tio n o f v ei n s. z In cr ea se d bl oo d flo w to m u co u s m e m br a n e s, ca u si ng in cr e a se d m uc us pr od u ct io n z N as al b le ed in g m ay re su lt fro m lo ca l t ra um a (e. g., no se pi ck in g) or na sa l p ol yp s. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z To s to p a no se bl ee d: − Si t u p (do no t li e d ow n o r til t h ea d ba ck ); − G en tly p in ch n o st ril s sh ut fo r a fe w m in ut es a n d th en re le a se ; a nd − R ep ea t s ev er al tim es u nt il bl e e di ng st op s. z Fo r s tu ffi ne ss , u se n or m a l s al in e d ro ps . z If to pi ca l m ed ica tio ns d o n o t p ro vi de re lie f, an tih is ta m in e s (di ph e n hy dr am in e , do xy la m in e s u cc in at e) ma y b e u se d, b ut th en o n ly fo r s ho rt co u rs e a n d e xa ct ly as d ire ct ed . z A vo id s ys te m ic de co ng es ta n ts a nd c om bi na tio n dr u gs . z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pa in o ve r th e si nu se s w ith pu ru le n t n as a l d isc ha rg e, he ad ac he — w hi ch m ay in di ca te a cu te s in us iti s St uf fin es s wi th h ea da ch es , w a te rin g e ye s— w hi ch m ay in di ca te a lle rg ie s 3- 24 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N DI SC O M FO RT S DU RI NG P RE G NA NC Y, L AB O R A N D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SI G N/ SY M PT O M A N A TO M IC /P HY SI O LO G IC B A SI S PR EV EN TI O N AN D RE LI EF M EA SU RE S— PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A PR O BL EM M IS CE LL AN EO US (W OM AN ) ( CO NT IN UE D) N um bn es s/ tin gl in g o f f in ge rs an d to es — M ay a lso o cc u r in b ut to ck s, hi ps , a nd th ig hs M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r, in cr ea si ng th ro u gh o u t pr eg n a n cy , a nd th e 1s t – 2n d st ag es o f l ab or . z Sh ift in w om an ’s c e n te r o f gr av ity c au se s co m pe ns at io ns in p os tu re , pu tti ng p re ss u re o n s pi n a l n e rv e s. z O th er p os sib le ca u se s/ fa ct or s in clu de : − Sw el lin g/ e de m a co m pr es se s su rr o u n di ng n e rv e s; a nd − H yp er ve n til at io n du rin g co n tra ct io n s. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e go o d bo dy m e ch an ic s (se e gu id el in es u n de r B ac k pa in [p ag e 3- 18 ]). z W he n nu m bn es s/ tin gl in g be co m e s bo th e rs o m e , try th e fo llo wi ng : − Ly in g do wn (o n t he u na ffe ct ed si de ); a nd − So ak in g in a w ar m tu b. z If th e pa in /d isc o m fo rt wo rs en s, le t t he s ki lle d pr ov id er k no w . D ur in g la bo r/b irt h, a dv is e th e w om an a nd /o r b irt h co m pa n io n as fo llo w s: z Us e slo w, re gu la r br ea th in g du rin g co n tra ct io n s. z A vo id h yp er ve n til at io n by p la ci ng h a n ds in fro nt o f t he m ou th a nd b re a th in g in to th em o r b y br ea th in g in to s m a ll pa pe r o r p la st ic sa ck . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. N um bn e ss a n d pa in in fin ge rs — wh ic h m a y in di ca te ca rp al tu n n e l s yn dr om e M us cu la r w e a kn e ss o r w a st in g, d iff icu lty u rin at in g or de fe ca tin g— wh ic h m ay in di ca te n eu ro lo gi c di se a se Fo ot dr op p e rs is tin g af te r la bo r— w hi ch m a y in di ca te n e rv e da m a ge Sh iv er in g/ qu iv er in g M os t c om m on ly o cc u rs d ur in g th e 4th st ag e of la bo r. z Ce ss at io n o f i nt en se m u sc u la r a ct iv ity a nd de cr ea se in c al o ric co n su m pt io n R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z R ea ss ur e th at th is is a n or m a l r e sp on se a fte r l ab or a n d bi rth . z Pr ov id e bl an ke ts /c ov er in gs , a n d el im in a te d ra fts . A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . Fe ve r— w hi ch m ay in di ca te m a la ria o r a n o th er in fe ct io n W al ki ng a w kw ar dl y (w ad dli n g) or cl um si ne ss M os t c om m on ly o cc u rs d ur in g th e 2n d – 3rd tri m es te r a nd 1 st st ag e of la bo r. z H or m on a l c ha n ge s ca us e co n n e ct iv e tis su e to b ec om e so fte r a nd lo o se r; joi nts in pe lvi s re la x. z En la rg e d ut er u s til ts p el vis fo rw ar d, s hi fti ng th e w om an ’s ce n te r o f g ra vit y. z D ec re as e d to ne o f a bd o m in a l m us cl es R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se h er an d/ or c om pa n io n as fo llo w s: z Us e go o d bo dy m e ch an ic s (se e gu id el in es u n de r B ac k pa in [p ag e 3- 18 ]). z W e a r su pp o rti ve sh oe s w ith fl at h ee ls. A dv is e th e w om an to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. N um bn es s, m us cu la r w e a kn e ss o r w a st in g, d iff icu lty u rin at in g or d ef ec at in g— w hi ch m ay in di ca te n eu ro lo gic d ise as e Se ve re w a dd lin g, h ip /p el vi s in st ab ilit y— wh ich m ay in di ca te se pa ra tio n of th e sy m ph ys is pu bi s (sp on ta n e o u s sy m ph ys io to m y) or of on e o f th e sa cr oi lia c joi n ts d ur in g la bo r 3- 25 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER N S D UR IN G T HE N EW B O RN P ER IO D SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S C HE ST , A BD O M EN , C O RD S TU M P, A ND E XT ER NA L G EN IT AL IA M uc oi d or b lo o dy v ag in al d is ch ar ge O ns et m os t c om m on ly in fi rs t w ee k of lif e. z Ca us ed by b ab y’s e xp os u re to th e w om an ’s ho rm on es du rin g pr eg na n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Va gi n a l d is ch ar ge s ho u ld d is a pp ea r w ith in 7 d ay s af te r b irt h. z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Sw ol le n br ea st s O ns et m os t c om m on ly in fi rs t w ee k of lif e. N or m al /n or m al v ar ia tio n: M ay pr od u ce a ti ny qu an tit y of m ilk z Ca us ed by b ab y’s e xp os u re to th e w om an ’s ho rm on es du rin g pr eg na n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Th e br ea st s m a y st ay s wo lle n fo r u p to 6 m on th s. z N o sp ec ia l c ar e is n ee de d. z N ev er s qu e e ze o r m a n ip u la te th e br ea st s. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. R ed ne ss , s tre ak in g, te nd er ne ss — wh ich m a y in di ca te in fe ct io n Sw ol le n la bi a N ot ed m os t c om m o n ly a t b irt h. z Ca us ed by b ab y’s e xp os u re to th e w om an ’s ho rm on es du rin g pr eg na n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Th e sw ol le n la bi a sh ou ld re tu rn to n or m al w ith in 2– 4 w ee ks a fte r bi rth . z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . 3- 26 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S C HE ST , A BD O M EN , C O RD S TU M P, A N D E XT ER N A L G EN IT AL IA (C ON TIN UE D) Sw ol le n sc ro ta l s ac — Ed em a or h yd ro ce le N ot ed m os t c om m o n ly a t b irt h. N or m al /n or m al v ar ia tio n: Sw el lin g fro m a h yd ro ce le m a y in cr ea se w he n th e ba by is u pr ig ht o r cr ie s, a nd d ec re a se w he n th e b ab y lie s do wn a n d is at re st . z Ed em a of th e sc ro ta l s ac m a y be c au se d by p re ss ur e du rin g la bo r a nd b irt h, e sp ec ia lly if b re e ch . z H yd ro ce le is c a u se d by flu id le a ki n g in to th e sc ro ta l sa c fro m th e pe rit on e a l ca vi ty w he n a s m a ll ho le co n n e ct in g th e p er ito n e a l ca vi ty a nd s cr ot u m h as n ot ye t c lo se d. R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Ed em a of th e sc ro ta l s ac w ill di sa pp e a r w ith in 7 da ys a fte r b irt h. z H yd ro ce le w ill di sa pp e a r w ith in 6 –1 2 m on th s. z N o sp ec ia l c ar e is n ee de d fo r e ith er c on di tio n . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. A lu m p in th e gr o in w he n th e ba by c rie s, pe rs ist en t s w el lin g ex te n di ng fr o m th e gr oi n to th e sc ro tu m — w hi ch m a y in di ca te in gu in a l h er n ia Ti gh t f or es ki n N ot ed m os t c om m o n ly a t b irt h. N ot e: M os t m al es a re bo rn w ith fo re sk in s th at c an no t b e re tra ct ed to v ie w th e he ad o f t he p en is . z Ca us e un kn o w n A dv is e th e w om an a nd fa m ily a s fo llo w s: z Ti gh t f or es kin w ill us u a lly re so lv e by 1 y ea r o f a ge . z N o sp ec ia l c ar e is n ee de d. z D o no t r et ra ct th e fo re sk in . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Sw el lin g o f t he p en is, in a bi lit y to p as s u rin e— w hi ch m ay in di ca te in fe ct io n or a n a to m ic a bn o rm a lit y Um bi lic al h er ni a— Pr ot ru si on a t b as e of u m bi lic u s th at is co ve re d by s kin N ot ed m os t c om m o n ly a t b irt h. N or m al /n or m al v ar ia tio n: M ay b e m o re p ro n o u n ce d w he n th e b ab y cr ie s z Ca us ed by fl ui d fro m th e a bd o m e n o r by a lo op o f bo we l t ha t e m er ge s th ro ug h th e m us cl es o f t he a bd o m e n R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Th e u m bi lic a l h e rn ia u su al ly di sa pp e a rs b y 1 ye ar o f a ge . z N o sp ec ia l c ar e is n ee de d. z D o no t b in d th e ba by ’s ab do m e n to “f la tte n” th e bu lg e. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pe rs is te nt v om iti ng , a bn o rm a l b ow el m o ve m e n ts — w hi ch m ay in di ca te b ow e l o bs tru ct io n 3- 27 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S H EA D, F AC E, M O UT H, A ND E YE S Ca pu t su cc ed an eu m — Ed em at ou s sw e llin g o ve r th e pa rt of th e he ad th at c am e fir st th ro ug h th e bi rth c an al O ns et m os t c om m on ly a t b irt h. z Ca us ed by p re ss u re o n th e he ad d ur in g bi rth R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Ca pu t u su a lly d isa pp e ar s w ith in 2 – 3 da ys a fte r b irt h. z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Fa ilu re o f t he h e a d to re ga in n o rm a l sh ap e w ith in 7 2 ho ur s— w hi ch m ay in di ca te b ra in o r sk ul l m al fo rm at io n La rg e he ad w ith w id e su tu re s— w hi ch m a y in di ca te h yd ro ce ph al us Sw el lin g u n de r th e en tir e sc al p (no t lim ite d by s ut u re lin es ) th a t m ay fe el sp on gy a nd b ab y cr ie s wh e n to uc he d; a n d in cr e a se in ci rc um fe re nc e o f h ea d a fte r b irt h— wh ic h m ay in di ca te su bg a le al h em o rr ha ge Ce ph al oh em at om a— Sw el lin g o n th e he ad th at d oe s no t c ro ss su tu re li n e s a n d fe el s fir m to th e to uc h; u su a lly o nl y on o n e si de o f t he h ea d O ns et m os t c om m on ly a t b irt h or w ith in fi rs t 24 h ou rs a fte r b irt h. z Ca us ed by b le e di ng be tw ee n th e ou te r s ur fa ce o f t he s ku ll b on e s a n d th e sc a lp d ue to p re ss u re o n th e he ad d ur in g bi rth R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Th e si ze o f t he ce ph al oh em a to m a m a y in cr ea se s lig ht ly 3– 5 da ys a fte r b irt h, o r i t m ay re m ai n st a bl e. z It m ay ta ke u p to 1 2 we ek s to di sa pp e a r co m pl et el y. z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Fa ilu re o f t he h e a d to re ga in n o rm a l sh ap e by 1 2 we ek s— wh ich m a y in di ca te b ra in o r sk ul l m al fo rm at io n Sw el lin g u n de r th e en tir e sc al p (no t lim ite d by s ut u re lin es ) th a t m ay fe el sp on gy a nd b ab y cr ie s wh e n to uc he d; a n d in cr e a se in ci rc um fe re nc e o f h ea d a fte r b irt h— wh ic h m ay in di ca te su bg a le al h em o rr ha ge Bl ue n e ss o f m ou th , t on gu e , a n d/ or lim bs — wh ic h m a y in di ca te c ya n o si s Ye llo w ne ss o f s kin – wh ich m a y in di ca te jau nd ice Ep ith el ia l “ pe ar ls ”— Ti ny w hi te c ys ts o n gu m s or ro of o f m o u th N ot ed m os t c om m o n ly a t b irt h. z Ca us e un kn o w n A dv is e th e w om an a nd fa m ily a s fo llo w s: z Th e cy st s sh ou ld d isa pp ea r w ith in 1 –2 m on th s. z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Th ic k w hi te a re as in m ou th — w hi ch m ay in di ca te fu ng a l i nf ec tio n (th rus h) 3- 28 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S H EA D, F AC E, M O UT H, A ND E YE S (C ON TIN UE D) M ol di n g or ch ig no n — M is sh ap e n he ad , a rti fic ia l c a pu t fro m v ac uu m e xt ra ct or cu p O ns et m os t c om m on ly a t b irt h. z Ca us ed by th e bo ne s o f t he sk ul l a da pt in g to th e pe lvi s du rin g la bo r a nd b irt h R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z M ol di n g or c hi gn o n s ho u ld d isa pp e a r w ith in 2 – 3 da ys a fte r b irt h. z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Fa ilu re o f t he h e a d to re ga in n o rm a l sh ap e w ith in 7 2 ho ur s— w hi ch m ay in di ca te b ra in o r sk ul l m al fo rm at io n La rg e he ad w ith w id e su tu re s— w hi ch m a y in di ca te h yd ro ce ph al us Ve ry s m al l h ea d— wh ich m a y in di ca te br ai n m al fo rm at io n Sw el lin g u n de r th e en tir e sc al p (no t lim ite d by s ut u re lin es ) th a t m ay fe el sp on gy a nd b ab y cr ie s wh e n to uc he d; a n d in cr e a se in ci rc um fe re nc e o f h ea d a fte r b irt h— wh ic h m ay in di ca te su bg a le al h em o rr ha ge Su bc on jun ct iv al he m or rh ag e— Br ig ht re d sp ot o n sc le ra O ns et m os t c om m on ly a t b irt h. z Ca us ed by b le e di ng fro m ca pi lla rie s in s cl er a du e to pr es su re o n th e h ea d an d e ye s du rin g la bo r a n d bi rth R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Su bc on jun ct iv al h em or rh a ge s ho ul d di sa pp e a r w ith in 2 – 3 we e ks . z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Re dn es s do es n ot d isa pp ea r by 3 w ee ks o f a ge — wh ic h m a y in di ca te tr au m a or a n o th er a bn o rm a l c on di tio n (e .g. , in fe ct io n , he m or rh ag ic co n jun ct iv iti s, co n ge n ita l a no m a ly) Sw ol le n or re d ey el id s O ns et m os t c om m on ly a t b irt h. z Ca us ed by p re ss u re o n th e fa ce a nd e ye s du rin g la bo r a n d bi rth z M ay a lso b e du e to te m po ra ry lo ca l i rri ta tio n fro m a nt ib io tic d ro ps o r o in tm en ts R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Sw el lin g a n d irr ita tio n sh o u ld d isa pp e a r w ith in 4 8 ho u rs . z Cl ea n se e ye s w ith s te ril e sa lin e o r bo ile d, c oo le d w a te r 4 ti m e s da ily u n til re dn es s/ sw e llin g di sa pp e a rs . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Sw el lin g/ irr ita tio n d oe s n o t i m pr ov e, p us o r w a te ry d isc ha rg e ap pe a rs — w hi ch m a y in di ca te in fe ct io n 3- 29 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S H EA D, F AC E, M O UT H, A ND E YE S (C ON TIN UE D) To ng u e tie — Ba nd o f tis su e be tw e e n th e u n de rs id e o f t he to ng ue a n d flo o r o f m o u th s ee m s sh or t a n d tig ht . N ot ed m os t c om m o n ly a t b irt h. z Ca us e un kn o w n A dv is e th e w om an a nd fa m ily a s fo llo w s: z Th e ba nd w ill lo o se n a n d st re tc h as th e ba by gr ow s. z Th e ba nd s ho u ld n ev e r be “c lip pe d. ” z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . N EW B O RN ’S S KI N A cn e— Pi np oi nt re d bu m ps o n fa ce , ba ck , a n d/ or c he st O ns et m os t c om m on ly by 2 w ee ks o f a ge . z Ca us ed by b ab y’s e xp os u re to th e m ot he r’s ho rm on e s du rin g pr eg na n cy R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z Ac ne s ho u ld la st o nl y a fe w we e ks b ut m ay n o t d isa pp ea r u n til 6 m o n th s of a ge . z N o sp ec ia l c ar e is n ee de d. z D o no t u se s pe ci al s oa ps o r a pp ly cr ea m s o r o in tm en ts ; t he se w ill n o t h el p an d m ay m ak e th e ac n e w o rs e . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pu st ul es o r b lis te rs w ith c le ar fl u id — w hi ch m ay in di ca te s ki n in fe ct io n 3- 30 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S S KI N (C ON TIN UE D) D ia pe r/n ap ki n ra sh — D iff us e re dn es s/ irr ita tio n of g ro in a re a O ns et m os t c om m on ly in fi rs t w ee ks o f l ife . z Us ua lly c au se d by pr ol on ge d ex po su re to w et a n d di rty d ia pe rs /n ap kin s R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z D ia pe r/n ap kin ra sh w ill re so lv e e ith er w he n th e b ab y st op s we a rin g di ap e rs /n ap kin s o r w he n th e di ap e r/n ap ki n is ch an ge d m or e o fte n or is le ft op en s o th e ar ea ca n d ry . z Cl ea n se a n d dr y th e gr oi n ar e a th or ou gh ly ea ch ti m e th e di ap e r/n ap ki n is ch an ge d. z Ch an ge th e di ap er /n ap ki n m or e fre qu en tly . z Le av e th e di a pe r/n ap kin a re a e xp os e d to a ir if e n vi ro nm e n t i s w a rm e n o u gh . z If di ap er s/ na pk in s/ clo th s ar e re u sa bl e, ri ns e th em th or ou gh ly a fte r w a sh in g to a vo id ir rit at io n fro m s oa ps . z D o no t u se s pe ci al s oa ps o r a pp ly cr ea m s o r o in tm en ts ; t he se w ill n o t h el p an d m ay m ak e th e ra sh w or se . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. W hi te p at ch es in d ia pe r/n a pk in a re a — w hi ch m ay in di ca te fu ng al in fe ct io n (th rus h) G en er al iz ed e de m a (b od y sw el lin g), bl ist er in g sk in ra sh o n pa lm s an d so le s, pr of us e ru n n y n o se (“ sn u ffl es ” ), a bd o m in a l d ist e n tio n (fr om en la rg ed liv er a nd /o r s pl e e n , o r fro m fl ui d in th e a bd o m e n )— w hi ch m ay in di ca te co n ge n ita l s yp hi lis Er yt he m a to xi cu m — Pa tc hy re d ra sh , w ith tin y wh ite a re a in m id dl e , a ll ov e r bo dy e xc e pt p al m s an d so le s O ns et m os t c om m on ly a t 2 –3 d ay s o f a ge . z Ca us e un kn o w n A dv is e th e w om an a nd fa m ily a s fo llo w s: z Er yt he m a to xic u m u su a lly d isa pp e a rs s po n ta ne o u sl y in th e fir st 2 –4 w e e ks o f l ife . z N o sp ec ia l c ar e is n ee de d. z D o no t u se s pe ci al s oa ps o r a pp ly cr ea m s o r o in tm en ts ; t he se w ill n o t h el p an d m ay m ak e th e ra sh w or se . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pu st ul es o r b lis te rs w ith c le ar fl u id — w hi ch m ay in di ca te s ki n in fe ct io n 3- 31 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S S KI N (C ON TIN UE D) M ili a— Ti ny w hi te bu m ps (“ wh ite he ad s” ) o n n o se , ch ee ks , fo re he a d, a nd /o r c hi n O ns et m os t c om m on ly in fi rs t w ee ks o f l ife . z Ca us ed by b lo ck ag e of th e o il gl a n ds R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z M ilia s ho u ld d isa pp e a r w ith in 1 –2 m on th s of a ge . z N o sp ec ia l c ar e is n ee de d. z D o no t u se s pe ci al s oa ps o r a pp ly cr ea m s o r o in tm en ts ; t he se w ill n o t h el p an d m ay m ak e th e m ilia w or se . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Pu st ul es o r b lis te rs w ith c le ar fl u id — w hi ch m ay in di ca te s ki n in fe ct io n M on go lia n sp o ts — Pu rp lis h- gr ay , f la t m a rk s on lo w er ba ck /b ut to ck a re a N ot ed m os t c om m o n ly a t b irt h. N ot e: M or e co m m on in A si an , H is pa n ic , a n d Af ric an b ab ie s z Ca us e un kn o w n A dv is e th e w om an a nd fa m ily a s fo llo w s: z M on go lia n s po ts m a y fa de a wa y by 2 –3 y ea rs o f a ge . z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . Po rt w in e st ai ns — R ed o r p u rp le fla t m a rk s on th e fa ce o r n e ck N ot ed m os t c om m o n ly a t b irt h. z Ca us e un kn o w n A dv is e th e w om an a nd fa m ily a s fo llo w s: z Po rt w in e st ai n s w ill no t d isa pp ea r s po n ta ne o u sl y. z N o sp ec ia l c ar e is n ee de d. z Tr ea tm en t c an b e in itia te d w he n th e ch ild is o ld er . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . 3- 32 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM N EW B O RN ’S S KI N (C ON TIN UE D) “ St or k bi te s” — Pi nk /lig ht re d m a rk s o n th e no se , e ye lid s, o r ba ck o f n ec k N ot ed m os t c om m o n ly a t b irt h. z Ca us e un kn o w n A dv is e th e w om an a nd fa m ily a s fo llo w s: z “ St or k bi te s” u su a lly d is a pp ea r by 1 –2 y ea rs o f a ge . z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . M IS CE LL AN EO US (N EW BO RN ) Cr yi ng , i nc re as ed M os t c om m on ly o cc u rs in fi rs t w ee ks o f l ife . N or m al /n or m al v ar ia tio n: O fte n o cc u rs fo r a fe w ho ur s a ro u n d th e sa m e ti m e e ve ry d ay . z M ay b e ca us e d by h un ge r, fa tig ue , o r c ol ic (a co mm on in te st in a l c on di tio n) R ev ie w th e an at om ic /p hy si ol og ic b as is w ith th e w om an a n d ad vi se he r a nd /o r t he fa m ily a s fo llo w s: z In cr ea se d cr yin g u su a lly d isa pp ea rs b y 2– 3 m o n th s of a ge . z Tr y to fi nd th e ca us e of th e cr yin g: fe ed a n d bu rp th e ba by ; c ha ng e w e t d ia pe rs /n ap kin s; m ak e su re th er e ar e no pi ns th at c ou ld be st ic ki ng th e ba by . z So ot he th e b ab y by h ol di n g/ cu dd lin g, w ra pp in g in b la n ke ts , r oc ki ng , ta lk in g ge nt ly, a nd b a th in g. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. In co ns ol a bl e cr yin g an d/ or fe ed in g di ffi cu ltie s, fe ve r, c ha ng e in b o w e l m o ve m e n ts — w hi ch m ay in di ca te in fe ct io n o r a cu te c o n di tio n s su ch a s bo we l o bs tru ct io n H ig h- pi tc he d, p er si st en t c ry in g— w hi ch m a y in di ca te b ra in tr au m a /d am a ge Irr eg ul ar b re at hi ng — R es pi ra tio ns b e tw ee n 20 a nd 6 0 br e a th s pe r m in ut e w ith o cc a si on a l pa us e s la st in g le ss th an 6 s ec on ds M os t c om m on ly oc cu rs in fi rs t w ee ks o f l ife . z D ue to th e im m at ur ity o f ba by ’s ce n tra l n e rv o u s sy st em A dv is e th e w om an a nd fa m ily a s fo llo w s: z Th e irr eg u la r b re a th in g sh ou ld im pr ov e in th e fi rs t m on th a s th e ba by m at ur e s. z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s wo rs e n ; O R z D an ge r si gn s (p ag e 4- 61 ) a ris e . 3- 33 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am CO M M O N CO NC ER NS D UR IN G T HE N EW BO RN P ER IO D (C ON TIN UE D) SI G N O R FI N D IN G A N A TO M IC /P HY SI O LO G IC B A SI S CO UN SE LI NG P O IN TS — PR O VI DE R EA SS UR AN CE A N D : A LE R T SI G NS T HA T M AY IN D IC AT E A P R O BL EM M IS CE LL AN EO US (N EW BO RN ) ( CO NT IN UE D) St ar tle re fle x — R ap id , s ym m et ric al “ st iff en in g” o f t he b od y in re sp o n se to s u dd e n n o is e or to uc h N ot ed m os t c om m o n ly a t b irt h. N or m al /n or m al v ar ia tio n: Th e ar m s cu rv e o u tw a rd th en re tu rn to w ar ds th e bo dy in o n e s m o o th m o ve m e n t. A dv is e th e w om an a nd fa m ily a s fo llo w s: z Th e st ar tle re fle x is a n or m al re fle x in m at ur e n e w bo rn b ab ie s a n d do es n o t i nd ica te d an ge r o f c on vu ls io n s o r o th er b ra in p ro bl e m s. z Th is re fle x wi ll d isa pp e a r by 2 – 4 m on th s of a ge . z N o sp ec ia l c ar e is n ee de d. A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Co nt in u o u s jitt eri ne ss (s ym me tri ca l r ap id m o ve m e n ts a n d ra pi d, is ol at ed jer kin g of th e lim bs )— wh ic h m ay in di ca te lo w bl oo d gl u co se o r se ps is As ym m et ric al m ov em en ts o f a rm s a n d/ or le gs — wh ic h m ay in di ca te b irt h in jur y Vo m iti ng M os t c om m on ly oc cu rs in fi rs t w ee k of lif e. N or m al /n or m al v ar ia tio n: O cc u rs a fte r s om e or a ll fe ed in gs a nd /o r du rin g bu rp in g wh en a s m a ll a m o u n t o f m ilk c om es ba ck u p. A dv is e th e w om an a nd fa m ily a s fo llo w s: z Co nt in u e to fe ed th e ba by o n d em an d. If th e wo m an is fe e di n g th e ba by u sin g a cu p or c up a n d sp oo n , be s ur e th at s he is n ot o ve rfe ed in g th e ba by . E nc o u ra ge m or e fre qu e n t, sm al l f ee ds . z En co ur a ge th e w o m a n to h o ld o r la y th e ba by w ith th e he ad h ig he r th an th e st om ac h im m ed ia te ly a fte r f ee di ng s. z W he n th e ba by fin ish es o n e b re a st , g en tly s it he r/h im u p to b ur p to rid th e st om ac h of e xc es s ai r b ef or e of fe rin g th e se co nd br ea st . z H an dl e th e ba by ge nt ly af te r f ee di n gs . A dv is e th e w om an a nd fa m ily to re tu rn fo r c ar e if: z Si gn s/ sy m pt om s w o rs e n ; z D an ge r si gn s (p ag e 4- 61 ) a ris e ; O R z Ke y al er t s ig n s (ne xt co lum n) a ris e. Fe ed in g di ffi cu lti es , f or ce fu l v om iti ng — w hi ch m ay in di ca te g as tri c irr ita tio n or ga st ro in te st in al m a lfo rm at io n o r o bs tru ct io n La ck o f w ei gh t g ai n, fe ed in g di ffi cu ltie s, fe ve r, ch an ge s in b ow e l m ov em e n ts — w hi ch m ay in di ca te in fe ct io n a n d/ or in te st in a l p ro bl e m s Bl oo d or b ile in vo m it— w hi ch m a y in di ca te n ec ro tiz in g en te ro co lit is o r ga st ro in te st in al m a lfo rm at io n o r o bs tru ct io n Pe rs is te nt v om itin g— wh ic h is a d an ge r si gn re qu iri n g re fe rra l/t ra ns fe r Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-34 JHPIEGO/Maternal and Neonatal Health Program JHPIEGO/Maternal and Neonatal Health Program 3-35 CHAPTER TEN SPECIAL NEEDS OVERVIEW This chapter contains guidance on how to respond to special needs (as described on page 1-30) that a skilled provider may identify when caring for women and their newborn babies during pregnancy, labor and childbirth (see Note, below), and the postpartum/newborn period. Women and babies with special needs require care in addition to the core components of basic care (as shown in Chapters 4–8). General guidelines for providing this additional care are presented below. (For an index of maternal special needs, see Textbox 3-3 [page 3-36]; for an index of newborn special needs, see Textbox 3-4 [page 3-36].) Note: An important goal in caring for the woman with special needs during labor and childbirth is to determine whether her needs require additional care during labor and birth or are more appropriately addressed during the postpartum period. It is the childbirth care skilled provider’s responsibility to ensure that all relevant information is made available to the skilled provider(s) giving care after the immediate postpartum period through the time of discharge. This may include: z Providing all information related to special needs identified z Making special recommendations about the woman’s care during the early postpartum period, for example, regarding complication readiness or referral to a specialist, higher level of care, or supportive services z Facilitating linkage during the postpartum period to appropriate local sources of support (women’s advocacy groups, public health agencies, peer support groups, community service organizations) During Assessment Consider the relevant information in the following table (based on presenting special need, first column) to confirm that the woman or newborn does not have a condition beyond the scope of basic care and to assess the exact nature (related factors, severity, etc.) of the need(s). This assessment may include: z Focusing on various elements of basic assessment, as described in Chapters 4–8; and z Conducting additional assessments (e.g., additional questions, tests). During Care Provision Once you have completed the additional assessment and confirmed that the woman’s pregnancy, labor and birth, or postpartum period is progressing normally or that the newborn does not have a life-threatening condition and that basic care can adequately address the special need(s)— z Talk to the woman about how addressing her special need(s) can improve the outcome of her pregnancy, labor and birth, or postpartum period, as well as her overall health; z Talk to the woman, partner, and/or other caregiver about how addressing the newborn’s special need(s) can protect or improve her/his overall health; and z Consider the relevant information (based on presenting special need) in this chapter when planning and implementing the woman’s or newborn’s plan of care, which may include one or many of the following interventions: z Reinforcing various elements of basic care provision, as described in Chapter 4 (page 2-1) z Adding special health messages and counseling and other elements of care provision z Making special recommendations regarding birth preparedness and complication readiness (e.g., a particular healthcare facility as the place of birth) Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-36 JHPIEGO/Maternal and Neonatal Health Program z Scheduling additional antenatal care or postpartum care visits to monitor the woman more closely, or additional newborn care visits to monitor the baby more closely z Providing treatment (e.g., drugs/medications) to cure, alleviate, or manage the condition z Advising any other providers involved in the woman’s or newborn’s care about problems identified, as well as appropriate action to take to address these problems z Ensuring that any other providers involved in the woman’s or newborn’s care are given all information relevant to the health and survival of the woman or newborn z Linking the woman to appropriate local sources of support (women’s advocacy groups, public health agencies, peer support groups, community service organizations) Note: A woman who is pregnant, in labor, or in the postpartum period or a newborn who presents with any of the special needs described in this chapter may also present with abnormal signs/symptoms that indicate a condition whose diagnosis or treatment lies beyond the scope of basic care. Or, the woman’s or baby’s needs may be so complex that basic services cannot adequately address them. In either case, the skilled provider should facilitate appropriate care and/or referral/transfer to a specialist, higher level of care, or supportive services. Textbox 3-3. Index of Special Needs during Pregnancy, Labor and Birth, and the Postpartum Period Adolescence (19 years of age and under), page 3-37 Anemia, page 3-41 Breast and breastfeeding problems, page 3-43 Breech presentation in labor, page 3-47 Burning on urination, page 3-47 False labor, page 3-48 Female genital cutting during pregnancy or labor, page 3-49 HIV, page 3-51 Living in an area of endemic hookworm infection, page 3-58 Living in an area of endemic malaria infection, page 3-59 Living in an area of endemic iodine deficiency, page 3-61 Living in an area of endemic vitamin A deficiency, page 3-62 Living in an area of high prevalence of diabetes during pregnancy, page 3-63 Maternal, fetal, or newborn complications of previous pregnancy, labor/childbirth, or the postpartum/ newborn period, page 3-64 Multiple pregnancy, page 3-68 Postpartum sadness (“blues”), page 3-69 Prelabor rupture of membranes or membranes ruptured for more than 18 hours before birth, page 3-70 Size-date discrepancy through 22 weeks’ gestation, page 3-72 Size-date discrepancy after 22 weeks’ gestation, page 3-73 Stillbirth or newborn death, page 3-74 Syphilis, page 3-76 Tears and incisions during the postpartum period, page 3-78 Urinary retention during labor and the postpartum period, page 3-79 Uterine subinvolution, page 3-80 Violence against women, page 3-81 Textbox 3-4. Index of Special Needs during the Newborn Period Cuts or abrasions that are not bleeding, page 3-83 Large baby (4 kg or more), page 3-84 Low birthweight baby (less than 2.5 kg), page 3-85 Mother with hepatitis B, page 3-85 Mother with history of rupture of membranes for more than 18 hours before birth and/or uterine infection or fever during labor or birth, page 3-86 Mother with HIV, page 3-87 Mother with syphilis, page 3-87 Mother with tuberculosis, page 3-87 3- 37 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L N EE D S D UR IN G P R EG NA N CY , L A B O R A N D B IR TH , A N D T H E PO ST PA R TU M PE R IO D SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N A do le sc en ce (1 9 ye ar s o f a ge a nd u n de r) (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) N ot e: W hi le a ss e ss in g a n d ca rin g fo r t he a do le sc e n t w om a n , fo cu s on th e in te rp er so na l s kil ls ou tlin ed in Te xt bo x 3- 5 (p ag e 3- 38 ). G en er al c on si de ra tio ns : Im po rta nt g oa ls in p ro vid in g ca re to th e a do le sc e n t w om a n a re to : z Pr ov id e he r w ith th e in fo rm at io n s he n e e ds to m ee t i m m ed ia te c ha lle ng e s; fo r e xa m pl e , sh e m ay n ot h av e c a re d fo r a n ew bo rn b ef or e an d m ay la ck ba sic p a re n tin g sk ills . z Id en tif y an d he lp h er o ve rc o m e o bs ta cle s in h er o w n li fe ; f or e xa m pl e , sh e m a y ne ed e xt ra a ss is ta nc e in o bt ai ni n g ne ce ss a ry re so u rc e s (e. g. , f un di ng , tra ns po rta tio n , so ci al s up po rt) to pu t he r b irt h pr e pa re dn e ss /c om pl ic a tio n re a di n e ss p la n in to a ct io n . z H e lp he r re co gn iz e he r rig ht to hi gh -q ua lit y ca re ; f or e xa m pl e, be su re th at s he fe el s we lc om e, k no w s w ha t s er vi ce s a re a va ila bl e, a n d u n de rs ta nd s ho w to a cc es s th es e se rv ic es . Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. z D et er m in e th e ci rc um st an ce s su rr o u n di n g th e p re gn a n cy , w hi ch m a y be th e re su lt of a n ab u si ve o r u n sa fe re la tio ns hi p (e. g., u n pr o te ct ed s ex o r m u lti pl e pa rtn er s; in ce st , s ex ua l a bu se , ra pe , o r fo rc ed s ex ; s ex ua l e xp lo ita tio n, p ro st itu tio n , o r fo rc ed m a rr ia ge ). ¨ If th e pr eg na nc y is th e re su lt of a ny fo rm o f s ex ua l ab us e, se e V io le n ce a ga in st W o m e n (p ag e 3- 81 ) fo r a dd itio n a l i nf or m a tio n ab ou t a ss e ss m e n t a nd ca re p ro vis io n . z Fo cu s on id e n tif yin g ba rri e rs to c ar e, a s w el l a s ha rm fu l be ha vi or s an d pr ac tic es . z D ur in g pr eg na n cy : − Co nf irm p re gn a n cy , i f n ee de d, th ro ug h ph ys ica l e xa m in a tio n o r te st in g. − An a do le sc en t w ho p re se n ts w ith s ig ns /s ym pt om s of pr eg n a n cy m ay n ot k no w th at sh e is p re gn a n t. − An a do le sc en t m ay b ec om e p re gn a n t b ef or e m e n st ru at io n s ta rts o r h er m en st ru al p e rio ds be co m e re gu la r. − D et er m in e w he th er s he fe el s w o rr ie d o r a fra id a bo u t pr eg n a n cy o r l a bo r. ¨ If YE S, se e F ee lin gs o f W o rr y or F ea r a bo ut P re gn a n cy a n d La bo r ( pa ge 3 -1 6) for ad di tio na l i n fo rm at io n ab o u t a ss e ss m e n t a nd c ar e pr ov is io n . z D ur in g la bo r an d bi rt h: D et er m in e w he th er s he re ce iv ed a de qu at e an te n a ta l c a re . z D ur in g th e po st pa rtu m p er io d: − D et er m in e w he th er s he re ce iv e d ad e qu a te a n te na ta l o r ch ild bi rth c ar e. − D et er m in e w he th er s he fe el s in se cu re in te rm s o f h er a bi lity to c ar e fo r h er n ew bo rn . ¨ If YE S, se e F ee lin gs o f I na de qu ac y, W o rr y, o r F ea r du rin g th e Po st pa rtu m P er io d (p ag e 3- 15 ) fo r a dd itio n a l in fo rm at io n a bo u t a ss es sm en t a n d ca re p ro vis io n. If th e wo m an is in g oo d he a lth a n d he r p re gn a n cy , l ab o r, o r po st pa rtu m p e rio d is pr o gr es sin g no rm a lly , p ro vi de b as ic ca re a s sh ow n in S ec tio n 2, w ith th e fo llo w in g ad di tio ns a n d/ or e m ph as e s. z H el p he r id e n tif y he r “ pe rs on a l s u pp or t s ys te m ” (T ex tb ox 3 -6 , p ag e 3- 38 ). z Pr ov id e a pp ro pr ia te n ut rit io n a l s u pp or t (T ex tb ox 3 -7 , pa ge 3 -3 9). z As si st in d ev el o pm en t o f t he b irt h pr ep ar ed n e ss a n d co m pl ica tio n re a di ne ss p la n , e n su rin g th at s he : − Un de rs ta n ds a n d pa rti cip at es in fo rm ul at in g th e pl an . − Is s up po rte d in se cu rin g th e re so ur ce s sh e ne e ds to p ut h er b irt h pr ep a re dn e ss / co m pl ica tio n re a di ne ss p la n in to a ct io n. z Pr ov id e he al th m es sa ge s a n d co u n se lin g wi th a pp ro pr ia te e m ph as e s (T ex tb ox 3 -8 , p ag e 3- 39 ). z Fa ci lit at e lin ka ge to a pp ro pr ia te lo ca l s ou rc e s o f s up po rt (T ex tb ox 3 -9 , p ag e 3- 40 ) w ith th e fo llo w in g ad di tio n s, a s a pp ro pr ia te : − O th er y ou ng m o th er s, w ho c an d em on st ra te th e ba sic s of n ew bo rn c a re (b a th in g, fe ed in g, d re ss in g) a n d ot he r pa re n tin g sk ills to a fir st -ti m e m ot he r − Sc ho ol o r v oc at io na l c e n te rs (fo r co n tin ui n g he r e du ca tio n) Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-38 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-5. Interpersonal Skills to Focus on with the Adolescent Woman When providing basic care to the adolescent woman: z Use a kind, direct, honest, and matter-of-fact approach to communication. Adolescents’ discomfort or shyness in talking to adults (especially embarrassment about sexual issues and their own body) requires such an approach. z Ensure that she is heard/listened to by all in attendance. z Avoid treating her as a child. Treat her with respect, foster her self-esteem, and build trust so that she can feel safe in addressing any issue during the birth process. z Ensure complete confidentiality and privacy during her visits. z Answer any questions she has, and encourage her to ask questions. z Encourage her to bring a companion of choice to each visit. z Involve family decision makers and other influential people as much as possible (with her permission/consent) when planning and implementing her care or if complications arise. z Respect her right to make decisions about her care and her own life and the life of her newborn. Allow her the time she needs to make important decisions. If complications arise, ensure that she understands the situation and allow her the time she needs to make important decisions. z If a pelvic examination is necessary, keep in mind that this may be the woman’s first gynecologic examination and she may be very anxious about it. It is especially important, therefore, to explain to her what to expect, obtain her permission/consent, listen to her concerns, and answer her questions before proceeding. z The adolescent woman may be very anxious about being examined. It is especially important, therefore, to explain to her what to expect, obtain her permission/consent, listen to her concerns, and answer her questions before proceeding. z If she needs information about the process of pregnancy or labor and birth, explain these topics to her in language that she understands and in a way that is not overwhelming to her. For more information on Interpersonal Skills, see page 1-42. Textbox 3-6. Assisting the Adolescent Woman in Identifying Her Support System The woman’s support system should include people with whom she has positive relationships who can: z Accompany her to basic care visits; z Encourage her during the birth process; z Assist her in planning for the birth and securing resources, such as reliable transportation and adequate funds for possible complications; z Support her in adhering to the plan of care, especially during the postpartum/newborn period; and z Assist her in caring for herself and her newborn. Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-39 Textbox 3-7. Nutritional Support for the Adolescent Woman The adolescent woman may still be growing and developing, possibly intensifying her nutritional needs. The following measures, in addition to those covered in Section 2, can help address these needs: z Involve family decision makers and other influential people as much as possible (with her permission/consent) in ensuring that the physical demands of the woman’s daily life are balanced with her dietary intake; that is, that she: − Has access to food when she is hungry, − Can avoid heavy physical labor, and − Is able to get adequate rest. z Counsel the woman to: − Eat and drink more frequently (extra servings and snacks), especially if she is very young. The younger the adolescent, the greater the nutritional requirements for her own growth. Remember, her own development is competing with that of the fetus or production of breastmilk for nutrients. − Avoid skipping meals. The adolescent may be especially concerned about her body image and therefore tempted to reduce her dietary intake to avoid gaining weight during pregnancy or to quickly lose pregnancy weight. Reassure her that she will be able to lose the weight after pregnancy, and emphasize the importance of adequate nutrition to her baby and herself, especially when breastfeeding. z Reinforce the importance of: − Increasing her dietary intake of iron and taking her iron/folate supplements as directed (anemia is common during the adolescent growth spurt, even without pregnancy); − Increasing her dietary intake of calcium to help meet the demands of her continuing skeletal development, in addition to those of pregnancy and breastmilk production; and − Drinking fluids each time she breastfeeds her baby. Note: If the adolescent woman has difficulty swallowing pills, advise her to crush them and/or take them in pureed fruit or some other food product. Textbox 3-8. Health Messages and Counseling for the Adolescent Woman Discussing the following issues may be of special importance to the adolescent woman: z Early and consistent attendance to all healthcare visits z Self-care z Pregnancy and birth processes z Safer sex, as well as negotiation skills, such as for using condoms or abstaining from sex z Family planning z Mother-baby-family relationships z Techniques for successful breastfeeding (Annex 5, page 4-47)—in particular, helping the adolescent mother get familiar with her baby and feel comfortable and confident in breastfeeding z Newborn care z Benefits of continuing her formal education and possibilities for doing so Note: Use simple visual aids—such as placental and pelvic models or diagrams—when teaching about fetal development and other issues relating to pregnancy. When discussing what will happen during labor and childbirth, use whatever simple visual aids (diagrams, wall charts, etc.) may be available. Use simple hands-on demonstrations of newborn care as well as self-care. Adolescents are typically concrete, rather than abstract, thinkers. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-40 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-9. Facilitating Linkages to Appropriate Local Sources of Support Based on specific areas of need that you have identified in the woman’s life, encourage and/or facilitate linkages to appropriate local sources of support/assistance, for example: z Women’s service and advocacy groups z Public health agencies z Peer support groups z Community service organizations z Religious leaders, organizations, churches z Local leaders and elders z Appropriate legal agencies z International relief and donor organizations z Workers groups and cooperatives z Various sources of support she can access to assist her in caring for the baby after birth Note: It is important to maintain an up-to-date list of local sources of support/assistance, so that you can quickly and effectively link the woman to the appropriate services. 3- 41 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N A ne m ia (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : A fu nd am en ta l g oa l o f c ar in g fo r a w o m a n w ith a ne m ia d u rin g pr eg n a n cy o r th e po st pa rtu m p er io d is th e pr e ve n tio n of se ve re a n e m ia th ro ug h nu tri tio n a l co u n se lin g; p re ve n tio n a n d tre at m en t o f in fe ct io n s ca u si ng a n e m ia , su ch a s m a la ria a n d ho o kw or m ; a nd ir on /fo la te su pp le m e n ta tio n . D ur in g la bo r a n d bi rth , th e go al o f c ar e is to u se m ea su re s th at pr ev en t b lo od lo ss (s uc h a s a ct iv e m a n a ge m en t o f t he 3 rd st ag e of la bo r) an d m a n a ge c on di tio n s a ss o ci a te d w ith he m or rh a ge (s uc h a s u ter ine a to ny ). (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M CP C. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. z D et er m in e w he th er th e w om an w a s di a gn o se d wi th a n e m ia in th e la st 3 m on th s. z R ec og n iz e th e si gn s an d sy m pt om s of a ne m ia . − W o m a n r e po rts s ym pt om s of a ne m ia , su ch a s w e a kn e ss , tir ed ne ss , sh or tn es s of b re at h (es pe cia lly w ith e xe rc is e), di zz in e ss , a n d fa in tin g. − Yo u ob se rv e s ig ns o f a ne m ia , s u ch a s pa llo r o f t he co n jun ct iv a. ¨ If th er e ar e si gn s/ sy m pt om s of an em ia o r t he w om an h as be en d ia gn os ed w ith a ne m ia in th e la st 3 m o n th s, te st th e w o m a n ’s h e m o gl o bi n le ve l (p ag e 4- 43 ) b efo re pr oc ee di n g: ¨ If th e w om an ’s h em og lo bi n le ve l i s le ss th an 7 g /d L, AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , pa ge 4 -6 3). ¨ If th e w om an ’s h em og lo bi n le ve l i s 7– 11 g /d L, pr oc ee d w ith a dd itio n a l a ss e ss m e n t. z Tr y to d et er m in e th e po ss ib le c a u se o f a ne m ia ba se d o n th e w o m a n ’s h is to ry o r m ed ica l r ec o rd s (if av ail a bl e) (Te xt bo x 3- 10 , pa ge 3 -4 2). If th e wo m an is in g oo d he a lth (ex ce pt for th e p res en ce o f m ild /m od e ra te a ne m ia : he m og lo bi n is 7 – 11 g /d L), an d h er pr eg n a n cy , l ab o r, o r po st pa rtu m p er io d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e as sh ow n in Se ct io n 2, w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. z Ad dr es s an y po ss ib le c a u se s o f a ne m ia (T ex tb ox 3 -1 0, pa ge 3 -4 2). z R ei nf or ce th e fo llo w in g nu tri tio n a l s u pp o rt m es sa ge s: − Ea t f oo ds c on ta in in g iro n w ith fo od s th at a re ri ch in vi ta m in C (e .g. , c itr us fr ui ts , t om a to es , p ot at oe s) to e n ha n ce a bs o rp tio n. − Av oi d ea tin g iro n -r ic h fo o ds w ith fo od s th at in hi bi t iro n ab so rp tio n (e. g., te a, co ffe e, bra n). − Av oi d ea tin g un he a lth y no n fo o d su bs ta n ce s su ch a s cl ay (p ica ). z Co un se l t he w o m a n o n th e im po rta nc e o f t ak in g iro n/ fo la te (a s d ire cte d i n S ec tio n 2) da ily . − D is cu ss a ny c o n ce rn s o r m is co n ce pt io ns th e w o m a n h as a bo u t t ak in g iro n . − Ad dr es s sid e ef fe ct s: − Bl ac k st oo ls , w hi ch a re n o rm a l − Co ns tip a tio n , w hi ch is a c o m m o n d isc o m fo rt (p ag e 3- 6) − Ad vis e he r to re tu rn if s he h as p ro bl e m s ta ki n g iro n ta bl et s. z R et es t t he w om a n ’s h em o gl o bi n le ve l i n 1 m on th to e n su re th at s he is re sp on di n g to ir on th er ap y. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-42 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-10. Possible Causes of Anemia and Appropriate Followup Actions z Determine whether the woman has a history of vaginal bleeding/hemorrhage during pregnancy or after birth. − During pregnancy, ask the following questions: Did she bleed heavily after her last pregnancy? How long ago was her last pregnancy? ¨ If she bled heavily after her last pregnancy and her last pregnancy was within the last 2–3 years, see Maternal, Fetal, or Newborn Complications of Previous Pregnancy, Labor/Childbirth, or the Postpartum/Newborn Period (page 3-64) before proceeding with additional care provision. − During the postpartum period, ask the following questions: Did she bleed heavily before, during, or after this birth? ¨ If YES but the woman is no longer bleeding, take this finding into consideration during further assessment. ¨ If YES and the woman is still bleeding, ACT NOW!—see Vaginal Bleeding after Childbirth (page 3-103) before proceeding. z Does the woman live in an area endemic for malaria or hookworm infection? ¨ If YES, see Living in an Area of Endemic Malaria (page 3-59) or Hookworm Infection (page 3-58) before proceeding with additional care provision. z Is she HIV-positive? ¨ If YES, see HIV (page 3-51) for additional information about assessment and care provision. z Does she have a chronic infection such as tuberculosis, malaria, syphilis, or another infectious disease; a genetic disorder such as sickle cell disease or thalassemia major; or is she losing blood in her urine or stool? ¨ If YES OR if the cause of anemia is unknown, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. 3- 43 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N B re as t a nd B re as tfe ed in g Pr ob le m s: z In ef fe ct ive a tta ch m en t/ su ck lin g z Im pr op er te ch n iq ue (h ol di ng , po sit io n in g) z Pa in o r d is co m fo rt du e to e ng o rg ed br ea st s, b lo ck e d du ct s, s or e/ cr ac ke d n ip pl es , o r m as tit is * z Fl at o r i nv er te d n ip pl e s z M at er na l c o n ce rn a bo u t i ns uf fic ie nt m ilk s up pl y z Si gn s of in a de qu at e in ta ke (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) * (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M CP C. ) Pe rfo rm b as ic a ss e ss m e n t (i nc lu di n g ob se rv a tio n of b re a st fe ed in g), a s sh ow n in S ec tio n 2, w ith th e fo llo wi n g a dd iti on s an d/ or e m ph as e s ba se d o n p re se n tin g sig ns /s ym pt om s or c on di tio n. z Lo ok fo r s ig n s o f i na de qu a te in ta ke (th e b ab y is u rin at in g le ss th an 6 ti m es p e r da y af te r t he fir st 4 8 ho ur s). ¨ If th er e ar e si gn s of in ad eq ua te in ta ke , a ss e ss fo r po ss ib le c a u se s: − Ba by o r w om a n is il l (a cc ord in g to b as ic as se ss m e n t a s sh ow n in Ch ap te r 7 o r 8 [pa ge 2 -8 3 or 2 -1 09 ]). − Ba by h as a c le ft pa la te o r l ip . − Ba by is p re te rm o r lo w b irt hw e ig ht . − In ef fe ct ive a tta ch m en t/s uc kli ng . z O bs er ve th e wo m a n a n d he r b ab y wh ile b re a st fe ed in g to e n su re e ffe ct ive a tta ch m e n t/s uc kli n g. ¨ If th er e ar e si gn s of in ef fe ct iv e at ta ch m en t/s uc kl in g, a ss e ss fo r p os si bl e ca u se s: − Im pr op er te ch n iq ue (h ol di ng , po sit io n in g). − Ba by o r w om a n is il l (a cc ord in g to b as ic as se ss m e n t a s sh ow n in Ch ap te r 7 o r 8 [pa ge 2 -8 3 or 2 -1 09 ]). − Ba by h as a c le ft pa la te o r l ip . − W o m a n h as p a in o r di sc o m fo rt du e to b re as t p ro bl e m s (e. g., en go rge d br ea st s, b lo ck e d du ct s, s or e/ cr a ck ed n ip pl es , m as tit is) . − W o m a n h as fl at o r in ve rte d ni pp le s. ¨ If th e ba by a nd /o r w om an a re il l (a cc or din g t o b as ic as se ss m en t) bu t h av e n o d an ge r s ign s, or if th e b ab y ha s a cl ef t p al at e or li p, fa cil ita te n on u rg en t r ef er ra l/tr an sf er (A nn ex 7 , pa ge 4 -6 3) aft er pro vid in g ba si c ca re . ¨ If th e ba by a nd /o r w om an a re n o t i ll (ac co rd ing to ba sic as s es s m en t) an d t he ba by do es n ot h av e a cl ef t p al at e or lip , pr ov id e ad di tio na l c ar e , a s sh ow n in th e ne xt c ol um n , ba se d o n th e pr es e n tin g sig n s/ sy m pt om s or c on di tio n . ¨ If an a bs ce ss (h ar d l um p o r re d, fl uc tu an t l es io n) de ve lop s in th e br ea st , s e e F ev er o r F ou l-S m el lin g Va gi na l D is ch ar ge (p ag e 3- 11 5) be fo re p ro ce e di n g. If th e po st pa rtu m /n ew bo rn p er io d is pr o gr es sin g no rm al ly (ex ce pt for br ea st /b re as tfe ed in g pr ob le m s), pr ov id e b as ic ca re a s sh ow n in S ec tio n 2, w ith th e fo llo w in g ad di tio ns a n d/ or e m ph as e s. z En co ur a ge th e w o m a n to c on tin u e e xc lu si ve br ea st fe ed in g. (F or ad dit ion a l i nf or m at io n a bo u t t he be ne fit s of b re as tfe ed in g, s e e Br ea st fe ed in g Ve rs us Us in g a Br e a st m ilk S ub st itu te [p ag e 4- 49 ].) z Fo llo w th e g ui da n ce b e lo w a s a pp ro pr ia te : − Fo r i ne ffe ct ive a tta ch m en t/s uc kli n g, s ee Te xt bo x 3- 11 (p ag e 3- 44 ). − Fo r i m pr op er te ch ni qu e : − Pr ov id e br ea st fe e di n g su pp o rt (p ag e 4- 47 ). − Ad vis e he r t o re tu rn fo r c ar e if di ffi cu ltie s pe rs ist o r w or se n . − R ev ie w th e da n ge r s ig ns a nd th e w om an ’s co m pl ica tio n re a di ne ss p la n : − En su re th at e m e rg en cy tr an sp o rta tio n an d fu nd s ar e im m e di at e ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r he lp if a d an ge r si gn a ris es . − Fo r e ng or ge d br ea st s/ bl o ck ed d uc ts , s ee Te xt bo x 3- 12 (p ag e 3- 44 ). − Fo r s or e/ cr ac ke d ni pp le s, s e e Te xt bo x 3- 13 (p ag e 3- 45 ). − Fo r m as tit is , s ee T ex tb ox 3 -1 4 (p ag e 3- 45 ). − Fo r f la t o r i nv er te d ni pp le s, s ee T ex tb ox 4 -1 (p ag e 4- 48 ). − Fo r m at er na l c o n ce rn a bo u t i ns uf fic ie n t m ilk su pp ly, s ee T ex tb ox 3 -1 5 (p ag e 3- 46 ). − Fo r i na de qu a te in ta ke , s ee T ex tb ox 3 -1 6 (p ag e 3- 46 ). Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-44 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-11. Additional Care for Ineffective Attachment/Suckling z Encourage skin-to-skin contact so that the baby can explore the woman’s breasts, find the areola and nipple, and attach on her/his own, in a relaxed (for woman and baby) manner. z Help the woman position her baby in the way that is most comfortable for her and her baby. − The underarm position may give the woman more control of the baby’s head. − Leaning over the baby so that the breast is allowed to drop into the baby’s mouth may help the baby to take more of the breast into the mouth. − For more information on positioning, see Breastfeeding Support (page 4-47). z Help the woman position the baby close to her with hips flexed, so that the baby does not have to turn her/his head to reach the breast. Her/his mouth and nose should be facing the nipple. Have the woman: − Aim the baby’s bottom lip toward the underside of the areola, and the top lip at the same level as the nipple. Bring the baby to the height of the nipple. Pull the baby close by supporting the back rather than the back of the head. − Support the breast so it is not pressing on the baby’s chin. The baby’s chin should drive into the breast. − For more information on supporting the breast, see Breastfeeding Support (page 4-47). ¨ If the position is appropriate and the baby still does not suckle well, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). z Advise her to return for care if difficulties persist or worsen. z Review the danger signs and the woman’s complication readiness plan. − Ensure that emergency transportation and funds are immediately accessible. − Ensure that she knows where to go for help if a danger sign arises. Textbox 3-12. Additional Care for Engorged Breasts/Blocked Ducts z Explain to the woman that breast engorgement is normal when the milk starts to come in around 2–3 days after birth. Explain that although it is painful, it should get better with time. z Advise the woman to use the following method to empty the breasts: − Use warm water or compresses 5–10 minutes before feeding and gently massage the breast to allow milk to flow more easily. − Express a small amount of milk (Textbox 4-2, page 4-49) before feeding to soften the breast and make it easier for the baby to latch on. − Feed the baby as frequently as every 2 hours around the clock. − Let the baby suckle as long as s/he wants on each breast. − Change her position each time the baby nurses so that all ducts will be emptied. z Also advise her as follows: − To relieve pain, apply cool compresses between feeds. − If nonpharmacologic treatments do not provide relief, paracetamol (acetaminophen) 500 mg may be taken 30 minutes before breastfeeding, as needed. − Wear a well-fitting, supportive bra. − Avoid wearing a tight bra, which can press on a duct and cause it to block. z Advise her to return for care if the pain or discomfort persists or if the breasts become red, warm, more painful, or if she develops fever and chills. z Review the danger signs and the woman’s complication readiness plan. − Ensure that emergency transportation and funds are immediately accessible. − Ensure that she knows where to go for help if a danger sign arises. Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-45 Textbox 3-13. Additional Care for Sore/Cracked Nipples Note: Do NOT perform the steps shown in this textbox until AFTER all relevant steps in the additional assessment and care provision columns are completed. z Advise the woman as follows: − Be sure that the baby is well attached when feeding and that the baby’s mouth encircles the whole areola. − Start feeding on the side that is less sore. ¨ If cracking is severe on only one nipple, breastfeed using only the other breast for 2 or more days while the affected nipple heals, or feed the baby expressed breastmilk. Express milk regularly from the breast not used to ensure continued breastmilk production. − When removing the baby from the breast, break the suction gently by: − Pulling on the baby’s chin or corner of the mouth; OR − Placing one finger in the corner of the baby’s mouth. − Rub breast milk on the nipple and areola after each feed, and allow it to dry. − Apply pure lanolin to the nipples between feeds. − Wash breasts only once per day, and do not use soaps or alcohol on the breasts. − If nonpharmacologic treatments do not provide relief, paracetamol (acetaminophen) 500 mg may be taken 30 minutes before breastfeeding, as needed. − Wear a well-fitting, supportive bra. − Avoid wearing a tight bra, which can irritate nipples. z Advise her to return for care if the pain or discomfort persists or worsens. z Review the danger signs and the woman’s complication readiness plan. − Ensure that emergency transportation and funds are immediately accessible. − Ensure that she knows where to go for help if a danger sign arises. Textbox 3-14. Additional Care for Mastitis Note: Do NOT perform the steps shown in this textbox until AFTER all relevant steps in the additional assessment and care provision columns are completed. z Treat the woman with: − cloxacillin 500 mg by mouth 4 times per day for 10 days; OR − erythromycin 250 mg by mouth 3 times per day for 10 days. z Encourage the woman to: − Continue breastfeeding − Wear a well-fitting, supportive bra − Apply cool compresses to the breasts between feedings to reduce pain and swelling − Drink at least 12 glasses of fluid each day − Wash her hands as frequently as possible prior to touching her breast(s) z Give paracetamol (acetaminophen) 500 mg 3 times per day by mouth as needed. z Advise her to return in 3 days to ensure response, or earlier if the pain or discomfort persists or worsens or if a hard lump or red, fluctuant lesion develops in the breast. z Review the danger signs and the woman’s complication readiness plan. − Ensure that emergency transportation and funds are immediately accessible. − Ensure that she knows where to go for help if a danger sign arises. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-46 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-15. Additional Care for Maternal Concerns about Insufficient Milk Supply Most concern about insufficient milk is anxiety rather than insufficient milk supply. If the baby is urinating at least 6 times per day (after the first 48 hours), the baby is getting enough milk. ¨ If the baby is urinating less than 6 times per day (after the first 48 hours), see Inadequate Intake (Textbox 3-16, below). z Help the woman to relax in confidence that the baby will get enough milk. If a woman is very worried or upset, her let-down reflex may temporarily not work well and it may seem as if there is not enough milk. ¨ If the woman’s milk has not yet come in (before day 2 or 3), reassure the woman that the colostrum she is producing is sufficient for the needs of the baby at this time. z Remind the woman that almost all women produce enough milk for one or more babies, and if the baby is not getting enough milk it is usually because s/he is not suckling often enough or long enough, not because the woman is not producing enough milk. z Explain to the woman that as the baby’s intake increases, the breasts are emptied at each feed, giving the woman the impression that there is not enough milk. z Ensure that the woman has enough to eat and is able to rest and sleep when her baby sleeps. z The woman should drink a sufficient amount of fluids to satisfy her thirst (and about one glass per breastfeed, or 2 liters per day), but she does not need to force herself to drink fluids in order to produce enough breastmilk. The woman should limit her intake of caffeine-containing drinks that increase urination. z The woman should not use the combined oral contraceptive pill (COC) during the first 6 months after birth as this may decrease the milk supply. Also, alcohol and smoking may decrease the milk supply. z Advise her to return for care if difficulties persist or worsen. z Review the danger signs and the woman’s complication readiness plan. − Ensure that emergency transportation and funds are immediately accessible. − Ensure that she knows where to go for help if a danger sign arises. Textbox 3-16. Additional Care for Inadequate Intake Note: Do NOT perform the steps shown in this textbox until AFTER all relevant steps in the additional assessment and care provision columns are completed. If the baby has inadequate intake, as evidenced by the baby urinating less than 6 times per day after the first 48 hours: z Have the woman supplement breastfeeding by expressing breastmilk between feedings and giving the expressed breastmilk to the baby, using a cup/spoon, immediately after breastfeeding (page 4-52). z Ensure that the woman is allowing the baby to suckle often and on demand to sustain adequate milk production: − Feed the baby as frequently as s/he wants—as much as every 2 hours around the clock. Awaken the baby every 3 hours for feeding if s/he sleeps for longer periods of time. − Let the baby suckle as long as s/he wants on each breast. − Manually empty breasts by expressing milk (Textbox 4-2, page 4-49) if the baby stops feeding when the breasts still feel full. z Advise her to return for care if difficulties persist or worsen. z Review the danger signs and the woman’s complication readiness plan. − Ensure that emergency transportation and funds are immediately accessible. − Ensure that she knows where to go for help if a danger sign arises. 3- 47 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N B re ec h Pr es en ta tio n in L ab or (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M CP C. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. z D et er m in e th e w o m a n ’s s ta ge /p ha se o f l ab or (T ab le 2 -8 , pa ge 2 -6 8) if n o t a lre ad y do ne . ¨ If th e w o m an is in th e 1s t st ag e o f l ab or , AC T N O W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). ¨ If th e w o m an is in th e 2n d st ag e o f l ab or , pe rfo rm a va gi na l e xa m in a tio n, if n ot a lre a dy d o n e , to d et er m in e th e ty pe o f b re ec h (F ig ur e 4- 3, p ag e 4- 12 ): f ran k, co mp let e, or fo ot lin g. ¨ If fo ot lin g br ee ch , AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). ¨ If fra nk o r c om pl et e br ee ch , pr oc ee d wi th a dd itio n a l ca re p ro vis io n (n ex t c olu mn ). If th e wo m an is in g oo d he a lth a n d he r l a bo r i s pr og re ss in g n o rm a lly (e xc ep t f or th e br ee ch p re se n ta tio n), pr ov id e ba si c ca re a s sh ow n in S ec tio n 2, w ith th e fo llo w in g ad di tio ns a n d/ or e m ph as e s. ¨ If th e w o m an is in th e 2n d st ag e o f l ab or a nd th e fe tu s is in fr an k or c om pl et e br ee ch p re se n ta tio n, se e p ag e 4- 11 fo r t he p ro ce du re fo r b re ec h bi rth . B ur ni ng o n Ur in at io n (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M CP C. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. ¨ If th e w o m an is in th e po st pa rt um p er io d, co n fir m th at b ur n in g is n ot “e xt er na l,” ca u se d by u rin e pa ss in g o ve r a n in jur ed pe rin e u m (te ar o r e pi sio to m y), be for e p roc e e di ng . ¨ If th e bu rn in g is e xt er na l, se e T ea rs a nd In ci si on s du rin g th e Po st pa rtu m Pe rio d (p ag e 3- 78 ). ¨ If th e bu rn in g is n ot e xt er na l, co n tin ue w ith a dd itio n a l a ss e ss m e n t. z Pe rfo rm c ul tu re a n d se n si tiv ity o n a c le an -c a tc h ur in e sp e ci m e n , if fa cil itie s/ st af f a re a va ila bl e. z As se ss th e w om a n fo r f ev er (te mp era tur e o f 3 8° C or m or e) a n d fla nk /lo in p ai n. ¨ If th e w om an h as a fe ve r o r fla nk /lo in p ai n, AC T NO W !— se e F ev er o r F ou l-S m el lin g Va gi na l D is ch ar ge (p ag e 3- 11 5) be fo re p ro ce e di ng . ¨ If th e w om an d oe s no t h av e a fe ve r o r f la n k/ lo in p ai n, pr oc ee d wi th a dd itio n a l c a re p ro vi si on (n ex t c o lu m n). If th e wo m an is in g oo d he a lth (ex ce pt for bu rni ng o n u rin at io n ), a nd h er p re gn an cy , l ab or , o r p os tp a rtu m p er io d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e a s sh ow n in Se ct io n 2, w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph as e s. z Be gi n tre at m en t f or c ys tit is wh ile a w ai tin g th e re su lts o f cu ltu re a n d se n si tiv ity . C ha n ge tre at m en t a cc o rd in g to se n si tiv ity , i f n ec es sa ry . G ive : − a m o xi ci llin 1 ta bl et (5 00 m g) ev e ry 8 h ou rs fo r 3 da ys ; O R − tri m et ho pr im /s u lfa m et ho xa zo le (1 60 m g/8 00 m g) 1 ta bl et e ve ry 1 2 ho u rs fo r 3 d ay s. z En co ur a ge h er to in cr ea se h e r in ta ke o f f lu id s. z Ad vis e he r t o re tu rn fo r c ar e if sy m pt om s pe rs ist o r w o rs e n , O R if sh e no tic e s fe ve r o r f la nk /lo in p ai n— w hi ch m ay in di ca te a cu te p ye lo n e ph rit is. z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s c o m pl ica tio n re a di n e ss p la n. − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a da ng er s ig n a ris e s o r if he r c on di tio n do e s n o t be gi n to im pr ov e a fte r 2 d ay s. 3- 48 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Fa ls e La bo r (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : Ev en w he n a w o m a n p re se n ts w ith co n tra ct io n s, s he m ay b e ex pe rie nc in g fa lse la bo r. If fa lse la bo r i s su sp ec te d, ba se d o n th e di a gn o st ic c rit er ia sh ow n in Ta bl e 2- 8 (p ag e 2- 68 ), t he w om a n s ho u ld re ce iv e a dd itio n a l a ss e ss m e n t a nd c ar e a s sh ow n . ¨ If th e w om an is e xp er ie nc in g co nt ra ct io ns an d is le ss th an 37 w ee ks ’ g es ta tio n, fa cil ita te u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). z Co nt in u e to m on ito r t he w om a n ’s v ita l s ig n s a n d th e fe ta l h e ar t r at e. ¨ If m or e th an 3 7 w ee ks ’ g es ta tio n, e n co u ra ge h er to w al k an d m ov e a ro u n d. z R e- ex am in e th e w o m a n a fte r 4 h ou rs to a ss e ss fo r s ig ns /s ym pt om s (ce rvi ca l d ila tio n , co n tra ct io ns , v a gi na l s ec re tio n s) of the on se t o f la bo r: − Pr og re ss ive c er vic al d ila tio n is di ag no sti c of th e on se t o f l ab or . − Co nt ra ct io n s th a t b ec om e pr o gr e ss iv el y m or e fre qu en t a nd /o r lo ng e r in d u ra tio n (w ith or w ith o u t b lo o dy s ho w , m u co u s pl u g, a n d ru pt ur ed m em br an es ) o fte n h er al d th e on se t— bu t a re n o t di ag n o st ic o f t he o n se t— of la bo r. ¨ If th e ce rv ix h as d ila te d si n ce th e la st e xa m in at io n, pr oc ee d w ith b as ic ca re du rin g la bo r a n d bi rth (C ha pt er 6 , p ag e 2- 37 ). ¨ If th e co nt ra ct io ns h av e be co m e pr og re ss iv el y m or e fre qu en t a nd /o r lo ng er in d u ra tio n (w ith o r w ith o u t b lo o dy sh ow , m uc ou s pl ug , an d ru pt ur ed m em br an es ), b ut th e ce rv ix h as N O T di la te d si n ce th e la st e xa m in at io n: − En co ur a ge th e w o m a n to c on tin u e to w al k an d m ov e a ro u n d. R e- ex am in e he r a fte r 4 h ou rs to a ss es s fo r si gn s/ sy m pt om s (ce rvi ca l d ila tio n , co n tra ct io n s, va gi na l se cr e tio n s) of the on se t o f l ab o r. ¨ If ce rv ic al d ila tio n ha s re ac he d 1– 3 cm , b ut th en pr og re ss iv e di la tio n st op s, se e U ns at isf ac to ry Pr og re ss o f L ab or (p ag e 3- 10 9) for in for ma tio n a bo u t a dd itio n a l a ss es sm e n t a nd c ar e . ¨ If th er e is n o ch an ge in ce rv ic al d ila tio n, co n tr ac tio ns , o r th e pr es en ce o f b lo od y sh ow , a m u co u s pl ug , o r ru pt ur ed m em br an es , a n d al l o th er p ar am et er s ar e n o rm al , th e w om an is n o t i n la bo r a n d sh o u ld n ot b e ad m itt e d to th e la bo r w a rd (o r pr ep a re d fo r c hi ld bi rth ) a t th is tim e. Pr oc ee d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). ¨ If th e ce rv ix h as d ila te d si n ce th e la st e xa m in at io n, pr oc ee d wi th b as ic c ar e du rin g la bo r a n d bi rth (C ha pt er 6 , p ag e 2- 37 ). z Pr ov id e su pp o rt an d en co u ra ge m e n t, th an k th e w o m a n fo r c om in g in , a n d pr o vi de h ea lth m e ss a ge s a n d co u n se lin g on th e fo llo w in g: − Im po rta nc e of a de qu at e re st a nd fo od /fl ui d in ta ke − D iff er en ce s be tw e e n tr ue a n d fa lse la bo r − W he n to re tu rn to th e fa cil ity o r c al l t he s kil le d pr ov id e r z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s b irt h pr ep a re dn e ss a n d co m pl ic a tio n r e a di ne ss p la n : − En su re th at e m e rg en cy tr an sp o rta tio n an d fu nd s ar e im m e di at e ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a d an ge r s ig n a ris es . 3- 49 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Fe m al e G en ita l C ut tin g (F GC ) d ur ing Pr eg na nc y or L ab or (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : T he g oa l i n pr ov id in g ca re fo r t he w om an w ith F G C sh ou ld b e on pr e ve n tin g it, o r i ts co m pl ica tio ns , f ro m a dv er se ly a ffe ct in g th e ou tc om e of th e pr eg na n cy a n d th e w o m a n a n d he r ba by d ur in g la bo r a n d bi rth . Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. z D et er m in e th e ty pe o f F G C th a t t he w om an h as . T he re a re th re e co m m o n ty pe s o f F G C: − Cl ito rid ec to m y (T yp e I ), i n w hic h p ar t o r a ll o f t he c lit or is h as be en r e m o ve d (F ig ur e 3- 1, p ag e 3- 50 ). − Ex ci si on (T yp e I I), in wh ich pa rt or a ll of th e cli to ris a nd pr ep u ce h as b e e n r e m o ve d, a lo ng w ith th e pa rti al o r to ta l e xc is io n o f t he la bi a m in o ra (F ig ur e 3- 2, p ag e 3- 50 ). − In fib ul at io n (T yp e I II), in w hic h t he c lit or is a nd la bi a m in or a ha ve b e e n r e m o ve d an d th e in ci se d sid es o f t he la bi a m a jor a h a ve b e e n s tit ch ed to ge th er , c re at in g a ho od o f s kin o ve r th e ur et hr a a n d an te rio r p ar t o f t he v ag in a l o rif ice (F ig ur e 3- 3, p ag e 3- 50 ). − A nu m be r o f o th er u nc la ss ifie d pr oc ed ur es m a y al so b e e n co u n te re d, su ch a s: − Pi er ci ng , in ci si n g, o r s tre tc hi ng th e cl ito ris a n d/ or la bi a − Ca ut er izi ng th e cl ito ris a nd s u rr o u n di ng tis su e − Sc ra pi ng o r cu tti ng th e va gi n a o r in tro du ci ng c or ro siv e su bs ta nc e s in to th e va gi n a z D et er m in e w he th er th e sc ar is co m pl ica te d by o th er fa ct or s (e. g., la rg e ke lo id s or de rm oi d cy st s, w hi ch m ay o bs tru ct th e va gi na l o pe n in g; in fe ct e d m uc os al u lc er s; b en ig n cy st s). ¨ If th e w o m an h as F G C Ty pe I or II a nd th e sc ar is n ot co m pl ic at ed b y ot he r f ac to rs , pr oc ee d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). ¨ If th e w om an h as F G C Ty pe II I a nd th e sc ar is n ot co m pl ic at ed b y ot he r f ac to rs , pr oc ee d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n), w hic h m u st in cl ud e d ef ib ul a tio n . ¨ If th e FG C sc ar is c om pl ic at ed b y ot he r f ac to rs , fa cil ita te n o n u rg en t r ef er ra l/t ra ns fe r ( A n n ex 7 , p ag e 4- 63 ) a fte r pr ov id in g ba sic ca re . − D ur in g la bo r: ¨ If th e FG C sc ar is c om pl ic at ed b y ot he r f ac to rs th at o bs tru ct th e va gi na l o pe ni ng , fa cil ita te u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ) a fte r pr ov id in g ba sic ca re . If th e wo m an is in g oo d he a lth a n d he r p re gn a n cy o r l ab or a n d bi rth is p ro gr e ss in g n o rm al ly, p ro vid e ba si c ca re a s sh ow n in Se ct io n 2 , w ith th e fo llo w in g ad di tio n s a n d/ or e m ph a se s. Un co m pl ic at ed T yp e I o r II FG C: z B ef or e ch ild bi rt h: R ea ss ur e th e w om a n th at th e cu tti ng w ill no t c o m pl ica te c hi ld bi rth . I f t hi s ty pe o f F G C is c om m on in h e r cu ltu re , s he w ill pr o ba bl y un de rs ta n d th at s he w ill no t n ee d an y sp e ci al p ro ce du re in o rd er to gi ve b irt h, b ut re as su ra n ce is o fte n he lp fu l. z A t a ny p oi nt in th e ch ild be ar in g cy cl e: Co u n se l t he w o m a n a n d he r pa rtn er o n th e p ot en tia lly h a rm fu l e ffe ct s of F G C du rin g pr eg na n cy , l ab or a nd c hi ld bi rth , a n d th e po st pa rtu m p er io d, e sp ec ia lly if th e ne w bo rn is a g irl . Un co m pl ic at ed T yp e III F G C: z D ef ib ul at io n is n ec es sa ry to re m ov e th e ob st ru ct io n to th e va gi n a l o pe n in g be fo re th e bi rth . S ee p ag e 4- 17 fo r th e de fib u la tio n pr oc ed u re . Al th ou gh d ef ib u la tio n ca n be pe rfo rm ed d ur in g th e 2n d st ag e o f l ab or , a s th e ba by ’s he ad is c ro wn in g, th e op tim al tim e is d ur in g th e 2n d tri m es te r o f p re gn an cy — to a vo id s ub jec tin g t he w om a n to a n in cr ea se d ch an ce o f i nf e ct io n an d bl e e di ng d ur in g ch ild bi rth . z B ef or e de fib ul at io n: Co un se l t he w om an a n d he r pa rtn er a bo ut th e pr oc e du re a s w e ll as th e im po rta nc e o f n ot a tte m pt in g to re -in fib ul a te a fte r c hi ld bi rth . D ep en di ng o n th e cu ltu re , th e w om an ’s p ar tn e r o r o th er de cis io n m a ke r m a y ne ed to b e in cl ud e d in th is co u n se lin g. T he c ou pl e sh ou ld u n de rs ta nd th at re - in fib ul at io n is n o t n ec es sa ry a n d is as so cia te d w ith m a n y m ed ica l r is ks . A llo w th e w o m a n ti m e to a bs or b th e in fo rm at io n a n d an sw e r he r qu es tio n s. z A t a ny p oi nt in th e ch ild be ar in g cy cl e: Co u n se l t he w o m a n a n d he r pa rtn er o n th e h ar m fu l e ffe ct s o f F G C du rin g pr eg na n cy , l ab or a nd c hi ld bi rth , a nd th e po st pa rtu m p er io d, e sp ec ia lly if th e ne w bo rn is a g irl . Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-50 JHPIEGO/Maternal and Neonatal Health Program Figure 3-1. Type I Area Cut (Left) and Healed (Right) Figure 3-2. Type II Area Cut (Left) and Healed (Right) Figure 3-3. Type III Area Cut (Left) and Healed (Right) 3- 51 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L A SS ES SM EN T A D D IT IO NA L CA R E PR O VI SI O N H IV (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) N ot e: Th ro ug ho u t a ss es si n g a n d ca rin g fo r t he H IV -p os iti ve w om an , fo cu s on th e fo llo wi n g in te rp e rs o n al s ki lls : z Al w ay s re sp e ct th e co nf id en tia lit y of th e w om an a n d fa m ily . z Pr ov id e re a ss u ra n ce a n d e n co u ra ge m e n t. z Be e m pa th e tic a nd n o n jud gm en ta l. Pr og ra m m at ic C o n si de ra tio n s W H O h as a fo ur -p ro ng s tra te gy fo r pr ev en tin g m ot he r-t o- ch ild tra ns m is si on (M TC T) of H IV : z Pr ev en tio n o f H IV in w om en z Pr ev en tio n o f u n in te n de d pr eg n a n ci es in H IV -in fe ct ed w o m e n z Pr ev en tio n o f M TC T of H IV z Su pp o rt fo r t he H IV -p os itiv e w o m a n a n d he r fa m ily Th e sk ille d pr ov id er s ho u ld c on si de r th is s tra te gy w he n pr o vi di ng c ar e to a ll w om e n o f r ep ro du ct iv e ag e . G en er al c on si de ra tio ns : T he w om an w ith H IV s ho ul d re ce iv e th e sa m e ba sic ca re p ro vid e d to a ll w om e n p lu s a dd iti on a l ca re , a s de sc rib ed in th is s ec tio n. T he he al th a n d we ll- be in g o f t he w o m a n sh ou ld n ev e r be ig no re d in a n e ffo rt to pr ev en t m ot he r-t o- ch ild tr an sm is si on o f H IV . S om e of th e m ai n go al s of c ar e fo r th e H IV -p os itiv e w o m a n a re to : Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. z En su re th at th e w o m a n (a n d ne w bo rn , if ap pl ic a bl e) is re ce iv in g ca re fro m a n HI V sp e ci al is t f or m an a ge m e n t o f h er d ise a se , a dd itio n a l t es tin g, p ro ph yla ct ic dr ug s a ga in st o pp o rtu ni st ic in fe ct io n s, a n d an tir e tro vi ra l (A RV ) th er ap y (as av a ila bl e a n d ap pr o pr ia te ). ¨ If no t r ec ei vi ng c ar e fro m a n H IV s pe ci al is t, lin k th e w om an (a nd n e w bo rn , i f a pp lic a bl e ) to an H IV sp ec ia lis t a fte r p ro vid in g ba sic ca re . z As se ss th e qu a lit y of th e wo m a n ’s s u pp or t s ys te m s an d he r r is k of a ba n do n m e n t o r a bu se . z D et er m in e w he th er th e w om an (o r n ew bo rn , i f a pp lic ab le ) h as re ce iv ed AR V th er ap y. z Id en tif y co ex ist e n t c on di tio ns a n d sig ns /s ym pt om s of ot he r op po rtu nis tic in fe ct io ns (T ex tb ox 3 -1 7, p ag e 3- 53 ). ¨ If th e w o m an h as tu be rc ul os is , a dv ise h e r to in iti at e/ co n tin u e ca re w ith a n a pp ro pr ia te s pe ci al is t. (S ee al so M ot he r w ith T ub er cu lo si s [pa ge 3 -8 7], fo r i nf or m at io n a bo u t a dd itio n a l a ss es sm e n t a nd ca re o f t he n ew bo rn .) ¨ If th e w om an h as a ny s ig ns / sy m pt om s of c oe xi st en t c on di tio ns a nd o pp or tu n is tic in fe ct io ns , fa cil ita te n o n u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ) a fte r pr ov id in g ba sic ca re . ¨ If th e w om an d oe s no t h av e an y si gn s/ sy m pt om s of c oe xi st en t c on di tio n s an d o pp or tu n is tic in fe ct io ns , fa cil ita te n o n u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ) a fte r pr ov id in g ba sic ca re . If th e wo m an is in g oo d he a lth (ex ce pt for H IV st atu s) an d h e r pr eg n a n cy , l ab o r, o r po st pa rtu m p er io d is pr og re ss in g n o rm a lly , pr ov id e ba sic c ar e as sh ow n in Se ct io n 2, w ith th e fo llo w in g ad di tio n s a n d/ or e m ph as e s. W A R N IN G : I nv as iv e pr o ce du re s (e. g., ex ter na l v ers ion , a m n io ce n te si s, a rti fic ia l r up tu re o f m em br an e s, u se o f f et al s ca lp el ec tro de s, e pi sio to m y) sh o u ld be av oi de d in ca rin g fo r th e HI V- po sit ive w o m a n . ¨ If th e w om an h as n ot y et re ce iv ed h er te st re su lt an d he r te st re su lt is p os iti ve , pr ov id e p os t-t es t c ou n se lin g ac co rd in g to th e gu id el in es in Te xt bo x 3- 18 (p ag e 3- 53 ). z H el p th e w o m a n id en tif y he r “ pe rs on a l s up po rt sy st em ”: pe op le in h er li fe — fri en ds , f am ily m em be rs , o th er H IV -p os itiv e pe o pl e— w ith w ho m s he ha s po sit ive r e la tio ns hi ps , w ho c a n : − Pr ov id e e m o tio n a l a n d pr ac tic a l s up po rt, a nd − H el p he r se cu re re so u rc e s a n d pl an fo r t he fu tu re . z As si st th e w om a n in p la n n in g fo r t he fu tu re , a dd re ss in g th e fo llo wi n g iss u e s: − W ho w ill ca re fo r t he w om an a n d he r ch ild re n if sh e be co m e s ill? − W ill he r c hi ld re n be a t r isk o f n eg le ct , a bu se , o r a ba n do n m e n t? − D oe s sh e h av e a cc e ss to h ea lth ca re s er vi ce s a n d dr ug s/ m ed ic at io n s sp ec ific al ly fo r H IV -p os itiv e pe op le ? z D is cu ss a nt ire tro vi ra l (A RV ) th er ap y tre at m en t o pt io ns : ¨ If th e w om an is a lre ad y on A RV th er ap y, a dv ise h er to co n tin u e w ith th er ap y in c on su lta tio n w ith h er H IV s pe cia lis t. ¨ If th e ba by is a lre ad y on A RV th er ap y, a dv is e th e w om a n to c on tin ue th e ba by ’s th er a py in c on su lta tio n w ith th e ba by ’s HI V sp e ci al is t, or fo llo w lo ca l g u id e lin e s. If no lo ca l gu id e lin e s a re in pl ac e , pr ov id e A R V th er ap y a cc o rd in g to th e gu id el in es s ho w n in Ta bl es 3 -1 (p ag e 3- 54 ) a nd 3 -2 (p ag e 3- 55 ). ¨ If th e pr eg na nt o r l ab or in g w o m an o r th e n ew bo rn is n ot al re ad y on A RV th er ap y, fo llo w lo ca l g ui de lin e s fo r A RV th er ap y. If n o lo ca l g u id e lin e s a re in p la ce , pr o vi de A RV th er ap y ac co rd in g to th e gu id e lin e s sh ow n in Ta bl es 3 -1 (p ag e 3- 54 ) a nd 3 -2 (p ag e 3- 55 ). 3- 52 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED A D D IT IO NA L A SS ES SM EN T A D D IT IO NA L CA R E PR O VI SI O N H IV , c o n tin u ed z M ax im iz e an d m a in ta in th e he a lth o f th e w om an a n d ne wb or n. z Pr ev en t m ot he r- to -c hi ld tr an sm is si on o f H IV . z As si st th e w om a n in id en tif yin g/ bu ild in g he r p er so n a l su pp or t s ys te m . z R ef er o r l in k th e w o m a n a n d n e w bo rn to a pp ro pr ia te h ea lth ca re o r su pp o rt se rv ic es . z Pr ev en t H IV tr an sm is si o n to u n in fe ct ed p ar tn er (s) . z Pr ov id e e m o tio n a l s up po rt an d co u n se lin g du rin g pr eg na n cy , l ab or a n d bi rth , a nd th e po st pa rtu m p er io d, a n d in pl an n in g fo r t he fu tu re . z En su re th at th e w o m a n h as th e ca re a n d su pp or t s he n e e ds to p ro vi de a de qu at e ca re fo r h er n ew bo rn . (S ee pa ge 2 -3 3 fo r f ur th er in fo rm at io n a bo u t H IV c ou ns el in g an d te st in g. ) z Co un se l t he w om an ab ou t h er n ew bo rn fe ed in g op tio ns — ex clu siv e br ea st fe ed in g or re pl ac e m e n t f ee di ng (T ex tb ox 3 -1 9, p ag e 3- 56 ). z R ei nf or ce th e im po rta nc e o f c om pl ica tio n re a di ne ss : T he w o m a n is m o re p ro n e to in fe ct io n an d sh o u ld s e e k he lp a s so o n a s po ss ib le if sh e ha s an y si gn s/ sy m pt om s o f c oe xis te nt c on di tio n s o r o pp o rtu ni st ic in fe ct io ns (T ex tb o x 3 -1 7, p ag e 3- 53 ) o r a n y of th e da ng er s ig n s lis te d on p ag e 4- 61 . z En co ur a ge re fe rr a l f or te st in g fo r s ex ua lly tr an sm itt ed in fe ct io n s a n d sc re e n in g fo r c er vic al c an ce r. z D is cu ss fa m ily p la nn in g (p ag e 4- 53 ): − Th e us e of co nd om s f or d ua l p ro te ct io n ag ain st b ot h pr eg na nc y a n d tra ns m is si o n o f H IV a nd o th er ST Is is re co m m en de d. − Fe rti lit y aw ar en es s- ba se d m et ho ds m ay n o t b e ap pr op ria te du e to c ha n ge s in m en st ru al c yc le a nd te m pe ra tu re d u e to H IV o r t re at m en t. z Pr ov id e th e a pp ro pr ia te p re ve n tiv e m ea su re s: ¨ If th e w om an li ve s in a n ar ea e n de m ic fo r a ny o f t he fo llo w in g di se as es o r de fic ie nc ie s, se e th e p ag e (s) in di ca te d: − M al ar ia (p ag e 3- 59 ) − H oo kw o rm in fe ct io n (p ag e 3- 58 ) − Vi ta m in A d ef ici en cy (p ag e 3- 62 ) − Io di ne de fic ie n cy (p ag e 3- 61 ) z Pr ov id e n u tri tio n a l s up po rt (Te x tb ox 3 -2 0, p ag e 3- 56 ). z Pr ov id e he al th m es sa ge s a n d co u n se lin g (T ex tb ox 3 -2 1, pa ge 3 -5 7). z Fa ci lit at e lin ka ge to a pp ro pr ia te lo ca l s ou rc e s o f s up po rt (T ex tb ox 3 -9 , p ag e 3- 40 ) w ith th e fo llo w in g ad di tio n s: p ee r a n d co m m u n ity s up po rt gr ou ps fo r p eo pl e liv in g w ith H IV /A ID S (P LW H A) , a nd ot he r H IV p ro gr a m s. z D ur in g pr eg na n cy : − R ei nf or ce th e im po rta nc e o f a rra ng in g fo r a s ki lle d pr ov id er to a tte nd th e bi rth . − R ec om m en d gi vi ng b irt h at a s ite w he re th e w o m a n a n d n e w bo rn c a n b e gi ve n A R V th er ap y be fo re a n d af te r b irt h, if fe as ib le , t o re du ce th e ris k of M TC T. z D ur in g la bo r an d ch ild bi rth : − Di sc u ss m ea su re s yo u w ill ta ke to de cr ea se th e ris k of M TC T. − En co ur a ge re la xa tio n te ch n iq u e s a n d ad e qu at e in ta ke o f flu id s/ fo od to a vo id e xh au st io n . − W ip e m at er na l b lo od a nd b od y se cr e tio ns fr om th e ne w bo rn w ith a c le a n c lo th . Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-53 Textbox 3-17. Signs/Symptoms of Coexistent Conditions and Opportunistic Infections in the HIV-Positive Woman The following signs/symptoms may indicate coexistent conditions and opportunistic infections: z Signs/symptoms of respiratory infections (cough, breathing difficulties) z Signs/symptoms of tuberculosis (cough, bloody sputum, fever) z Signs/symptoms of urinary tract infection (burning on urination, increased urgency/frequency of urination, fever) z Signs/symptoms of anemia (pallor, fatigue) z Signs/symptoms of malaria (fever, chills, joint pains, headache, anorexia) z Persistent diarrhea z Enlarged lymph nodes z Oral or vaginal candidiasis z Skin eruptions, lesions, rashes, and infections z Sexually transmitted infections z Weakness/numbness of the lower extremities z Difficulty swallowing z Severe weight loss Textbox 3-18. Post-Test Counseling for an HIV-Positive Result If the woman has chosen counseling and testing for HIV, has had her test, and her test result is positive, provide the following post-test counseling and care. z Provide the results, reassuring the woman that they are confidential. z Provide emotional support: − Recognize and deal with her immediate emotional response, such as denial, anger, or sadness. Be alert for signs of self-destructive behavior and threats of suicide. − Ensure that she will not be alone and that she will have support during the next hours and days. − Be understanding and reassuring in response to her uncertainty/anxiety about her baby’s well-being. For example, the slightest illness in her newborn may be evidence to her that she has infected her baby and may cause intense feelings of guilt. z Assess the risk of abandonment or abuse. − Ask about the partner’s typical expression of anger and fear: − Does the partner resort to physical violence or withdrawal? − Is the partner able to discuss problems in a helpful way? − Ask about her sense of the stability of the relationship: − How have she and her partner dealt with problems in the past? ¨ If you suspect abuse, see Violence against Women (page 3-81) for additional information about assessment and care provision before proceeding with additional care provision. z Discuss the following issues, as appropriate: − Referral for care—depending on locally available resources such as an HIV program, specialist, or community support group − Disclosure of HIV status to family and friends, including issues such as timing, approach, and to whom it may or may not be safe/appropriate to disclose this information (Role-play disclosure techniques if the woman desires.) − The impact of HIV on pregnancy and breastfeeding (e.g., risk of low birthweight, MTCT) − The need to use condoms throughout pregnancy, the postpartum period, and after the postpartum period to reduce the risk of transmission of HIV − How she plans on spending the next few hours or days − The conditions of other household members who may be HIV-positive − Partner referral for HIV counseling and testing Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-54 JHPIEGO/Maternal and Neonatal Health Program Table 3-1. Antiretroviral (ARV) Prophylaxis Regimens for Prevention of Mother-to-Child Transmission of HIV1 COURSE ANTENATAL (WOMAN) INTRAPARTUM (WOMAN) POSTNATAL (NEWBORN) COMMENT NEVIRAPINE Nevirapine (NVP)a None 200 mg by mouth oral tablet at onset of labor 1 dose of 2 mg/kg body weight syrup within 72 hours of birth b z Oral regimen z Can be directly observed z Treatment expensive ZIDOVUDINE c Short course of Zidovudine (ZDV, AZT, Retrovir) d 300 mg by mouth twice per day from 36 weeks’ gestation 300 mg by mouth every 3 hours from onset of labor to birth None z Requires adherence by woman z Oral regimen z No newborn dosing required Long course of Zidovudine (ZDV, AZT, Retrovir) d from 14–34 weeks’ gestation and continuing until the onset of labor give either: 100 mg by mouth 5 times per day OR 300 mg every 12 hours OR 200 mg every 8 hours OR 200 mg by mouth every 8 hours 2 mg/kg body weight IV for first hour, then 1 mg/kg body weight per hour IV until birth 2 mg/kg body weight ZDV syrup every 6 hours for 6 weeks b z Requires intravenous ZDV formulation and administration z Requires ongoing adherence by woman and newborn z Mild reversible anemia can occur with newborn regimen ZIDOVUDINE + LAMIVUDINE Zidovudine (ZDV, AZT, Retrovir) and Lamivudine (3TC) None ZDV 600 mg by mouth at onset of labor and 300 mg every 3 hours until birth PLUS 3TC 150 mg by mouth at onset of labor and 150 mg every 12 hours until birth ZDV 4 mg/kg body weight PLUS 3TC 2 mg/kg body weight by mouth every 12 hours for 7 days b z Oral regimen z Requires administration of two drugs z Requires adherence by woman and newborn a For guidelines on using NVP in additional scenarios, see Table 3-2. b The newborn should receive ARV in addition to—not in place of—the dose given to the woman. c Zidovudine, AZT, ZDV, and Retrovir are all different names for the same drug. d The woman should receive both the antenatal and intrapartum doses of ZDV. 1 Adapted from: World Health Organization (WHO)/Centers for Disease Control (CDC). Mother-to-Child Transmission of HIV Prevention: Generic Training Course. September 2003 (Draft). Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-55 Table 3-2. Guidelines for the Use of Nevirapine (NVP) for Prevention of Mother-to-Child Transmission of HIV in Different Scenarios2 SCENARIO GUIDELINE No Antenatal Care If the woman presents to the healthcare facility for the first time in labor: z Give the woman 1 dose of NVP (200-mg tablet) by mouth as soon as possible after labor begins (to improve efficacy, NVP should be given at least 2 hours before childbirth). z Give the baby 1 dose of NVP syrup (2 mg/kg body weight) within 72 hours of birth. False Labor If the woman receives NVP in labor, but it turns out to be false labor: z Give a repeat dose of NVP (200-mg tablet) when labor is established. ¨ If the woman is still not in active labor after a second dose of NVP, facilitate nonurgent referral/transfer. Childbirth Less than 2 Hours after Receiving NVP If the woman gives birth less than 2 hours after receiving NVP: z Give the baby 1 dose of NVP syrup (2 mg/kg body weight) immediately after birth. z Give the baby a second dose of NVP syrup (2 mg/kg body weight) within 72 hours after birth or at discharge. Cesarean Section If the woman requires an emergency cesarean section, give the woman 1 dose of NVP (200-mg tablet) by mouth before urgent referral/transfer. If the woman will have an elective cesarean section, ensure that woman receives 1 dose of NVP (200-mg tablet) at least 3 hours before surgery. Home Birth If the woman is likely to give birth at home: z Give the woman 1 dose of NVP (200-mg tablet) at 28–32 weeks’ gestation, and instruct her to take it when she goes into labor or when her membranes rupture. z Give the woman 1 dose of NVP for the baby (6 mg syrup), and instruct her to give it to the baby within 72 hours after birth. z Advise the woman to return to the healthcare facility as soon as possible after the baby’s birth. 2 Adapted from: World Health Organization (WHO)/Centers for Disease Control (CDC). Mother-to-Child Transmission of HIV Prevention: Generic Training Course. September 2003 (Draft). Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-56 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-19. Newborn Feeding Options for the HIV-Positive Woman Counsel the woman about her feeding options—breastfeeding or replacement feeding: z The woman’s decision to breastfeed or use replacement feedings must be made after careful consideration of the risks and benefits. Support the woman in making an informed choice of feeding method. See Breastfeeding Versus Using a Breastmilk Substitute (page 4-49) for information on breastfeeding versus using a breastmilk substitute. z Emphasize that breastfeeding increases the risk of MTCT, and the decision to breastfeed should be made after careful consideration of the options. z In areas where use of breastmilk substitutes is feasible, acceptable, safe, affordable, and available/ accessible, avoidance of all breastfeeding is recommended—but it is still the woman’s decision to make. z Whatever the woman decides, support her decision and provide her with information to help reduce the risk of MTCT and other potential problems. Note: “Mixed feeding” (alternating breastfeeding with anything else, including breastmilk substitute, local porridges, tea, water, etc.) may carry a higher risk of MTCT than either exclusive breastfeeding or exclusive replacement feeding. z Counsel to discontinue breastfeeding as early as possible, between 4 and 6 months after childbirth, to minimize the risk of MTCT. Weaning should be abrupt, not gradual, and followed by exclusive replacement feeding. z Teach proper latch-on/attachment techniques and recommend on-demand feeding to prevent damage to nipples or breast engorgement. Lesions of the breast are associated with an increased risk of MTCT. (As needed: see Breastfeeding Support [page 4-47]; or Breast and Breastfeeding Problems [page 3-43].) z Advise her to seek prompt medical attention for conditions such as mastitis, breast abscess, and fungal infection (thrush) of the nipples, as well as oral thrush in the newborn, which are associated with an increased risk of MTCT. Textbox 3-20. Additional Nutritional Support for the HIV-Positive Woman The HIV-positive woman may be undergoing many physical processes and changes that intensify her nutritional needs. The following measures, in addition to those covered in Section 2, can help address these needs: z Explain how HIV/AIDS affects nutrition through three, sometimes overlapping, processes: − By causing a loss of appetite and therefore a decrease in food intake; − By impairing the digestion and absorption of nutrients consumed; and − By altering metabolism—or the way the body transports, uses, stores, and excretes nutrients. z Reinforce the importance of: − Eating an adequate amount and variety of food − Taking micronutrient supplementation as directed − Practicing safe food-handling to prevent food-borne illness − Using safe drinking water to prevent diarrhea • Also recommend the following practices: − Eat four meals per day that include protein (e.g., yogurt, meat/fish, nuts, milk). − Increase intake of calories, protein, and micronutrients each day. − Increase intake of antioxidant-rich foods from food sources (e.g., vegetables, nuts, meats, legumes, grains, fruits) and multivitamin supplements. − Increase intake of foods rich in Omega-3 fatty acids (e.g., fish, nuts, seeds). z Provide specific instructions on maintaining dietary intake during periods of decreased appetite, diarrhea, or infection. z Facilitate linkage to food support programs where possible. Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-57 Textbox 3-21. Health Messages and Counseling to Focus on with the HIV-Positive Woman Discuss the importance of the following issues: z Avoiding alcohol, tobacco, and drugs z Reducing her workload and increasing periods of rest z Practicing good hygiene/infection prevention z Practicing safer sex (e.g., consistent condom use to prevent infection of her partner(s) and transmission of other STIs) z Having a skilled provider attend the birth z Future family planning options (page 4-53; see also, above) z Adhering to the plan of care z Receiving consistent care for herself (and her newborn, if applicable) from an HIV specialist 3- 58 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Li vi ng in an A re a o f E nd em ic H oo kw or m In fe ct io n (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : T he fu nd am e n ta l g o a l o f p ro vid in g ca re fo r w o m e n li vi ng in a n a re a o f e nd em ic ho ok w o rm in fe ct io n is to p re ve n t t he in fe ct io n o r its c om pl ica tio ns fr o m de ve lo pi ng . A p re gn a n t w om a n li vi n g in a n e n de m ic ar e a m a y be a w a re o f t he ri sk o f h oo kw o rm in fe ct io n— sh e m a y ev en ha ve it ; w ha t s he m ig ht n ot k no w is th at it ca n le a d to a ne m ia o r p ro te in de fic ie n cy du rin g pr eg na n cy o r p os tp ar tu m . In a dd itio n to p ro vi di ng p re ve n tiv e m e a su re s, th e sk ille d pr ov id er sh ou ld fo cu s on in cr e a si ng th e wo m a n ’s a w a re n e ss w ith h ea lth m es sa ge s an d co u n se lin g ab o u t t he ri sk s to h er se lf an d he r b ab y, a s we ll a s pr a ct ic al in fo rm at io n o n h ow to re du ce th es e ris ks . (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M CP C. ) W he n pe rfo rm in g ba sic a ss es sm e n t, a s sh ow n in S ec tio n 2, fo cu s o n id en tif ica tio n o f s ig ns /s ym pt om s o f e n de m ic h oo kw o rm in fe ct io n (e .g. , itc hi ng a n d ra sh a t s ite w he re s ki n to uc he s so il, u su a lly fe e t; di ar rh ea ; a n e m ia ; w ei gh t l os s; a no re xi a). If th e wo m an is in g oo d he a lth a n d he r p re gn a n cy o r p os tp a rtu m p er io d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e as sh ow n in Se ct io n 2, w ith th e fo llo wi n g ad di tio ns a n d/ or e m ph a se s. z Ca re fo r w om en in a re as e n de m ic fo r h oo kw or m in fe ct io n m u st in cl ud e th e fo llo wi n g in te rv en tio ns (a s de sc rib ed in m o re d et ai l b el ow ): − Pr es um pt ive a n tih el m in th ic tr e a tm en t; an d − H ea lth m e ss a ge s a n d co u n se lin g ab ou t o th e r pr ev en tiv e m e a su re s. z Pr ov id e pr es u m pt iv e an tih el m in th ic tr ea tm en t: − In re gi on s w he re h oo kw o rm is e n de m ic (p rev a le nc e o f 2 0% o r m o re ), i f th e w om an ha s no t r ec ei ve d tre at m en t w ith in th e pa st 6 m on th s, o r i s fo un d by la bo ra to ry te st in g to h av e h oo kw o rm in fe ct io n: − G ive m eb en da zo le 5 00 m g by m o u th o nc e, O R − Pr es cr ib e m eb e n da zo le 1 00 m g by m o u th tw ic e da ily fo r 3 da ys , O R − G ive a lb e n da zo le 4 00 m g by m o u th o nc e . − In re gi on s w ith a h ig h pr ev al e n ce o f h oo kw o rm in fe ct io n, p ro vi de a n a dd itio n a l do se a fte r 1 2 w e e ks . N ot e: D o N O T gi ve p re gn a n t w om en m eb en da zo le o r a lb en da zo le d u rin g th e 1s t tri m es te r. z Pr ov id e he al th m es sa ge s an d co un se lin g a bo u t o th er p re ve n tiv e m ea su re s to h el p th e w om an fu rth er re du ce h er ri sk o f h oo kw o rm in fe ct io n. E nc o u ra ge h er to a sk qu es tio n s if th er e is s om et hi n g sh e do es n o t u nd e rs ta nd . − H oo kw o rm is tr an sm itt ed th ro u gh th e sk in fr om so il th at c on ta in s ho o kw o rm la rv ae . − H oo kw o rm in fe ct io n ca n ca u se m a te rn al a n e m ia a nd p ro te in d ef ici e n cy . − So m e wa ys to a vo id h oo kw o rm in fe ct io n ar e a s fo llo ws : − W e a r sh oe s ou td oo rs . D o no t w a lk b ar e fo ot . − D is po se o f f ec es c ar ef ul ly (e. g., us ing a pit la tri ne ). − D o no t t ou ch s o il w ith b ar e h a n ds , e sp ec ia lly so il th at is li ke ly to c on ta in fe ce s. − Us e go o d hy gi e n e a n d in fe ct io n p re ve n tio n p ra ct ice s. 3- 59 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Li vi ng in a n Ar ea o f E nd em ic M al ar ia In fe ct io n (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : T he fu nd am e n ta l g o a l o f p ro vid in g ca re fo r w o m e n li vi ng in a n a re a o f e nd em ic m a la ria in fe ct io n is to p re ve nt th e co n di tio n , o r co m pl ica tio n s o f t he co n di tio n , fro m de ve lo pi n g. A p re gn a n t w o m a n li vi ng in a n e n de m ic a re a m a y be a w a re o f h er ri sk o f d ev el op in g th e di se as e — sh e m a y ev en h av e it; w ha t s he m ig ht n ot k no w is th at th e co ns e qu e n ce s o f t he d ise as e m a y be m or e de tri m en ta l du rin g pr eg na n cy o r p os tp ar tu m . In a dd itio n to p ro vi di ng p re ve n tiv e m e a su re s, th e sk ille d pr ov id er sh ou ld fo cu s on in cr e a si ng th e wo m a n ’s a w a re n e ss w ith h ea lth m es sa ge s an d co u n se lin g ab o u t t he ri sk s to h er se lf an d he r b ab y, a s we ll a s pr a ct ic al in fo rm at io n o n h ow to re du ce th es e ris ks . (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M CP C. ) W he n pe rfo rm in g ba sic a ss es sm e n t, a s sh ow n in S ec tio n 2, fo cu s o n id en tif ica tio n o f s ig ns /s ym pt om s o f e n de m ic m al ar ia in fe ct io n (e. g., fe ve r, ch ills /ri go rs , h ea da ch e, m us cl e /jo int pa in , a n e m ia , co m a /c on vu ls io n s). ¨ If th e w om an p re se nt s w ith si gn s/ sy m pt om s of m al ar ia ill ne ss , tre at a cc or di ng to lo ca l gu id e lin e s/ pr o to co ls o r fa cil ita te u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7, p ag e 4- 63 ). If th e wo m an is in g oo d he a lth a n d he r p re gn a n cy o r p os tp a rtu m p er io d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e as sh ow n in Se ct io n 2, w ith th e fo llo wi n g ad di tio ns a n d/ or e m ph a se s: z Ca re fo r w om en in a re as e n de m ic fo r m al ar ia m u st in cl ud e th e fo llo w in g in te rv en tio n s (as de sc rib e d in m o re d et ai l b el ow ): − In te rm itt en t p re ve n tiv e tre at m e n t, − Us e of in se ct ici de -tr ea te d (be d)n ets , − H ea lth m e ss a ge s a n d co u n se lin g ab ou t o th e r pr ev en tiv e m e a su re s, − Ea rly d et ec tio n a n d tre at m en t (a cc ord ing to lo ca l g u id e lin e s), an d − Ca se m an a ge m e n t o f m al ar ia il ln e ss . z In te rm itt en t p re ve nt iv e tre at m en t ( IP T) w ith S P (su lfa do xin e + py rim et ha m in e): Al l pr eg n a n t w om e n in a re a s o f s ta bl e tra ns m is sio n (an d, w he re r e co m m e n de d, in a re as o f u n st ab le tr an sm is si on ) s ho u ld re ce ive th re e do se s of IP T (a sin gle d os e o f S P is 3 ta bl et s of s ul fa do xin e 5 00 m g + py rim et ha m in e 2 5 m g) ac co rd in g to n at io n a l p ro to co l o r th e fo llo w in g gu id el in e s: − G ive a d os e at th e fir st a nt en at al c ar e vi si t a fte r f et al m ov em e n t (q uic ke n in g) be gi n s, a n d − G ive a d os e at th e ne xt tw o an te na ta l c ar e vi si ts — bu t n ot m or e o fte n th an m o n th ly. − D o N O T gi ve IP T to w om en w ho a re le ss th a n 1 6 w e e ks (4 m o n th s) pre gn a n t. − D o N O T gi ve S P to w om en w ho a re a lle rg ic to s ul fa d ru gs . F ol lo w n at io n a l gu id el in e s fo r m a la ria p re ve n tio n fo r s ul fa -a lle rg ic wo m e n . N ot e: Be s ur e to g ive th e wo m a n a c u p of c le a n w at er a nd d ire ct ly ob se rv e h er sw a llo w in g th e ta bl et s. z Us e o f i ns ec tic id e- tre at ed (b ed )n ets (IT Ns ): − Th e w om an s ho u ld s le e p be n e a th a n IT N (w ith h er b ab y) co n si st en tly (e ve ry n ig ht ), ke ep in g it tu ck e d we ll a ro u n d th e sl ee pi ng m a t o r m at tre ss to p re ve n t e nt ry o f m o sq ui to e s. − Th e ne t s ho ul d be re -d ip pe d in in se ct ic id e ev e ry 6 m on th s (or ac co rdi n g to lo ca l gu id e lin e s) to rem a in e ffe ct ive a ga in st m os qu ito es . z H ea lth m es sa ge s an d co un se lin g a bo ut o th er p re ve n tiv e m e a su re s (Te x tb ox 3 -2 2, pa ge 3 -6 0). Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-60 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-22. Health Messages and Counseling for Women Living in Malaria-Endemic Areas Provide the woman with the following additional health messages and counseling to help her further reduce her risk of malaria. Encourage her to ask questions if there is something she does not understand. z Malaria is a parasitic infection that can cause spontaneous abortion, severe anemia, renal failure, pulmonary edema, and high fever in the pregnant woman, and stillbirth, low birthweight, or congenital malaria in the fetus or newborn. z The drugs (and doses) that are prescribed to prevent and treat malaria during pregnancy are safe for both the woman and the fetus. z Malaria is transmitted through a mosquito bite. Some ways to avoid mosquitoes are as follows: − Sleep every night under an ITN, starting as early as possible in pregnancy and continuing throughout the postpartum period. − Get rid of standing water, thick foliage, and other potential mosquito-breeding areas around the house. − Cover arms and legs around twilight and sunrise. − Use a repellant if available. z Emphasize the importance of taking iron/folate (ferrous sulfate or ferrous fumarate 60 mg plus folate 400 mcg) daily as malaria contributes to anemia. z If signs of malaria illness develop (such as fever, chills, joint pains, headaches, and anorexia), seek medical attention. (Advise the woman exactly where to go.) z A woman’s immunity to malaria may be compromised by HIV, so be especially alert to signs of malaria in HIV-positive women. z It is very important to get all of the recommended doses of IPT. (Inform the woman when her next dose of IPT is due and where to go for it.) 3- 61 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Li vi ng in an A re a o f E nd em ic Io di n e D ef ic ie nc y (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : T he fu nd am e n ta l g o a l o f p ro vid in g ca re fo r w o m e n li vi ng in a n a re a o f e nd em ic io di ne de fic ie n cy is to pr ev en t t he d e fic ie nc y, o r co m pl ica tio ns o f t he d ef ici en cy , f ro m de ve lo pi ng . A p re gn a n t w om a n li vi n g in a n e n de m ic ar e a m a y be a w a re o f h er ri sk o f d ev el o pi n g th e de fic ie nc y— sh e m ay e ve n h a ve it ; w ha t s he m ig ht n ot k no w is th at th e co ns eq ue n ce s o f t he de fic ie n cy m a y be m or e de tri m en ta l d ur in g pr eg n a n cy o r p o st pa rtu m . I n ad di tio n to pr ov id in g pr ev e n tiv e m ea su re s, th e sk ille d pr ov id e r sh ou ld fo cu s on in cr e a si ng th e w om an ’s a w ar en es s w ith he al th m es sa ge s a n d co u n se lin g a bo ut th e ris ks to h er se lf a n d he r ba by , a s we ll a s pr ac tic al in fo rm at io n on h ow to re du ce th es e ris ks . W he n pe rfo rm in g ba sic a ss es sm e n t, a s sh ow n in S ec tio n 2, fo cu s o n id en tif ica tio n o f s ig ns /s ym pt om s o f io di n e d e fic ie n cy . ¨ If th e w om an h as a s ig ni fic an t go ite r o r o th er s ig ns /s ym pt om s o f i od in e de fic ie nc y, fa cil ita te n o n u rg en t r ef er ra l/t ra ns fe r a fte r pr ov id in g ba sic ca re . If th e wo m an is in g oo d he a lth a n d he r p re gn a n cy o r p os tp a rtu m p er io d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e as sh ow n in Se ct io n 2, w ith th e fo llo wi n g ad di tio ns a n d/ or e m ph a se s: z M ic ro nu tri en t s up pl em en ta tio n: Ca re fo r w om en in a re a s e n de m ic fo r i od in e de fic ie n cy m us t i nc lu de io di n e su pp le m e n ta tio n : − As e ar ly as p os si bl e in pr eg n a n cy : − G ive a o ne -ti m e do se o f 2 – 3 ca ps ul e s o f i od in e 4 00 –6 00 m g by m ou th , O R − In jec t a on e-t im e d os e of io di n e 2 40 m g (0. 5 m L Li pi o do l) I M. − If th e wo m an re ce ive d io di ne su pp le m e n ta tio n du rin g th e 1s t o r 2n d tri m es te r, gi ve he r a no th er d o se o f i od in e p o st pa rtu m . N ot e: In a re as w ith a h ig h pr ev a le nc e o f i od in e d ef ic ie nc y, it is a ct ua lly b es t t o st ar t io di n e su pp le m en ta tio n be fo re pr eg na nc y in or de r to n ot m iss th e ea rly , c rit ica l s ta ge of fe ta l b ra in d ev el op m en t; ho w ev er , t hi s pr ac tic e is n ot a lw ay s po ss ib le or fe as ib le . z H ea lth m es sa ge s an d co un se lin g: Ca re fo r w om en in a re as e n de m ic fo r i od in e de fic ie n cy m us t i nc lu de h ea lth m e ss a ge s an d co u n se lin g. P ro vid e th e w o m a n w ith th e fo llo wi n g in fo rm a tio n to h el p he r f ur th er re du ce h er ri sk o f i o di ne de fic ie nc y. E nc ou ra ge he r t o as k qu es tio ns if th er e is so m e th in g sh e d oe s no t u nd e rs ta nd . − Io di ne de fic ie n cy c an h av e m a n y ha rm fu l e ffe ct s on th e wo m a n ’s b a by , s uc h as m e n ta l r et ar da tio n. − Io di ne de fic ie n cy m ay b e pr ev e n te d by : − In cr ea si n g di e ta ry in ta ke o f l oc a lly a va ila bl e fo od s th at a re ri ch in io di ne , su ch a s fis h, s he llfi sh , a nd s ea w e e d; a nd − Us in g io di ze d sa lt in st ea d of re gu la r ta bl e s a lt. 3- 62 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Li vi ng in an A re a o f E nd em ic Vi ta m in A D ef ic ie nc y (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : T he fu nd am e n ta l g o a l o f p ro vid in g ca re fo r w o m e n li vi ng in a n a re a o f v ita m in A de fic ie n cy is to pr ev en t t he d e fic ie nc y, o r co m pl ica tio ns o f t he d ef ici en cy , f ro m de ve lo pi ng . A p re gn a n t w om a n li vi n g in a n e n de m ic ar e a m a y be a w a re o f h er ri sk o f d ev el o pi n g th e de fic ie nc y— sh e m ay e ve n h a ve it ; w ha t s he m ig ht n ot k no w is th at th e co ns eq ue n ce s o f t he de fic ie n cy m a y be m or e de tri m en ta l d ur in g pr eg n a n cy o r p o st pa rtu m . I n ad di tio n to pr ov id in g pr ev e n tiv e m ea su re s, th e sk ille d pr ov id e r sh ou ld fo cu s on in cr e a si ng th e w om an ’s a w ar en es s w ith he al th m es sa ge s a n d co u n se lin g a bo ut th e ris ks to h er se lf a n d he r ba by , a s we ll a s pr ac tic al in fo rm at io n on h ow to re du ce th es e ris ks . W he n pe rfo rm in g ba sic a ss es sm e n t, a s sh ow n in S ec tio n 2, fo cu s o n id en tif ica tio n o f s ig ns /s ym pt om s o f vi ta m in A d ef ici e n cy (e .g. , n ig ht -b lin dn e ss , se ru m r e tin ol co n ce n tra tio n le ss th an 2 0 m cg /d L). If th e wo m an is in g oo d he a lth a n d he r p re gn a n cy is p ro gr e ss in g no rm a lly , p ro vid e b as ic ca re a s sh ow n in S ec tio n 2, w ith th e fo llo w in g ad di tio ns a n d/ o r e m ph as e s: z M ic ro nu tri en t s up pl em en ta tio n: Ca re fo r w om en in a re a s e n de m ic fo r v ita m in A de fic ie n cy m us t i nc lu de m ic ro n u tri en t s up pl e m e n ta tio n : D ur in g pr eg na n cy : − Pr es cr ib e vit am in A s up pl em e n ts : − In th e 1s t– 3r d tri m es te rs — pr es cr ib e 10 , 00 0 IU o f v ita m in A o nc e pe r da y by m o u th ; O R − In th e 2n d a n d 3rd tri m es te rs — pr es cr ib e 25 , 00 0 IU o f v ita m in A o nc e pe r w e e k by m ou th . − D is pe n se a s u ffi ci en t q ua n tit y of ta bl et s to la st th e w om an u n til h er n e xt v is it. − Ad vis e th e wo m a n th at s he s ho ul d NO T ta ke m or e vi ta m in A th an is p re sc rib ed . D ur in g th e po st pa rtu m p er io d: − Pr es cr ib e vit am in A s up pl em e n ts : ¨ If th e w om an is b re as tfe ed in g, gi ve 2 00 ,0 00 IU o f v ita m in A in a s in gl e do se by m ou th im m e di at e ly po st pa rtu m u p to 8 w ee ks ’ p o st pa rtu m . ¨ If th e w om an is N O T br ea st fe ed in g, gi ve 2 00 ,0 00 IU o f v ita m in A in a s in gl e do se b y m ou th im m ed ia te ly po st pa rtu m u p to 6 we ek s’ po st pa rtu m . − Ad vis e th e wo m a n th at s he s ho ul d NO T ta ke m o re v ita m in A th an is p re sc rib ed o r ta ke it m or e th an 8 w ee ks a fte r b irt h. z H ea lth m es sa ge s an d co un se lin g: Ca re fo r w om en in a re as e n de m ic fo r v ita m in A de fic ie n cy m us t i nc lu de h ea lth m e ss a ge s an d co u n se lin g ab o u t i nc re as in g th e in ta ke o f fo od s ric h in vi ta m in A . P ro vi de th e w om an w ith th e fo llo w in g in fo rm at io n to h el p he r fu rth er re du ce h er ri sk o f v ita m in A d ef ici e n cy . E nc ou ra ge h e r to a sk q ue st io n s if th er e is s om et hi n g sh e do e s n o t u nd er st an d. − Vi ta m in A d ef ici en cy m ay b e pr e ve n te d by in cr e a si ng d ie ta ry in ta ke o f l oc al ly a va ila bl e fo od s th at a re ri ch in vi ta m in A , s uc h as y el lo w a n d or an ge fr ui ts a nd ve ge ta bl es (e .g. , ca rr o ts , m an go e s, p um pk in , sq ua sh ), r ed pa lm o il, an d da rk gr ee n le af y ve ge ta bl es . − In th e H IV -p os itiv e w om an , vi ta m in A d ef ici en cy c an in cr e a se th e ris k of m o th er -to -c hi ld tra ns m is si on (M TC T) of H IV . 3- 63 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Li vi ng in a n Ar ea o f H ig h Pr ev al en ce o f D ia be te s du rin g Pr eg na nc y (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : F or w om en liv in g in a n a re a w ith a h ig h pr e va le n ce o f di ab e te s or g es ta tio na l d ia be te s, o n e g oa l o f c ar e du rin g pr eg n a n cy is s cr e e n in g of a ll w om e n to d et ec t d ia be te s, w hi ch c an a ffe ct th e pr eg n a n cy a n d ca u se s e rio u s co m pl ica tio ns in th e ne w bo rn . Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in S ec tio n 2, w ith th e fo llo w in g a dd itio n s a n d/ or e m ph as e s. z Du rin g an an te na ta l c ar e vis it, te st th e w om an ’s u rin e fo r g lu co se . ¨ If th e w o m an ’s u rin e is po si tiv e fo r g lu co se , fa cil ita te n o n u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3) aft er pro vid in g ba sic c ar e . ¨ If th e w o m an ’s u rin e is n eg at iv e fo r g lu co se : − Co nt in u e w ith b as ic ca re , a n d − R ep ea t t he te st e ar ly in th e 3rd tri m es te r ( aro un d 28 w ee ks ’ g es ta tio n). N /A 3- 64 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N M at er na l, Fe ta l, or N ew bo rn Co m pl ic at io ns o f P re vi ou s Pr eg na nc y, La bo r/C hi ld bi rt h, o r th e Po st pa rtu m /N ew bo rn P er io d (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : I n so m e ca se s, a p oo r o bs te tri c hi st or y m ay in di ca te a n e e d fo r s pe cia liz ed ca re , in cl u di n g re fe rra l/t ra ns fe r to a h ig he r l e ve l o f c ar e. Si m ila r p ro bl e m s m a y oc cu r d ur in g th is ch ild be ar in g cy cle o r n e w bo rn p er io d. Us ua lly , h ow e ve r, n o s pe cia liz e d ca re is n e e de d. E ith e r w a y, k no wi n g a bo u t p as t co m pl ica tio ns h el ps y o u u n de rs ta nd co n ce rn s/ an xie tie s th e w om an m a y ha ve so th at y ou c an pr ov id e r e a ss u ra n ce ; a nd di sc us sin g pa st co m pl ica tio n s pr ov id e s a n o pp o rtu ni ty to re in fo rc e th e im po rta nc e o f ha vi ng a c om pl ic at io n re a di ne ss p la n an d a s ki lle d pr ov id e r a t e ve ry b irt h. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in S ec tio n 2, w ith th e fo llo w in g a dd itio n s a n d/ or e m ph as e s. z D et er m in e th e n a tu re o f t he pr ev io u s co m pl ic a tio ns . z Pe rfo rm a dd iti on a l a ss e ss m e n t a n d ap pr op ria te fo llo wu p, a s sh ow n in th e Te xt bo x in di ca te d, fo r t he fo llo wi ng co m pl ica tio n s: − Fo r p re vio us c o n vu ls io n s, se e Te x tb ox 3 -2 3 (pa ge 3- 65 ) − Fo r t hr ee o r m or e sp on ta n e o u s a bo rti on s, s e e Te xt bo x 3- 24 (p ag e 3- 65 ) − Fo r p re vio us c es a re a n se ct io n or o th e r u te rin e su rg er y, s ee T ex tb ox 3 -2 5 (p ag e 3- 66 ) − Fo r p re vio u s 3rd or 4 th de gr ee te ar , s ee T ex tb ox 3 -2 6 (p ag e 3- 66 ) − Fo r p re vio us n e w bo rn co m pl ica tio ns o r de at h, s ee Te xt bo x 3- 27 (p ag e 3- 67 ) ¨ If th e w o m an h ad a ny co m pl ic at io n no t m en tio n ed ab ov e, pr oc ee d wi th a dd itio n a l ca re p ro vis io n (n ex t c olu mn ). If th e wo m an is in g oo d he a lth a n d he r p re gn a nc y, la bo r a n d bi rth , o r p os tp ar tu m p er io d is pr og re ss in g n o rm a lly , n o sp e ci al c ar e is n ee de d. P ro vid e b as ic c ar e as s ho w n in S ec tio n 2, w ith th e fo llo w in g ad di tio n s a n d/ or e m ph a se s. z Li st en to th e w o m a n ’s s to ry a n d pr ov id e re a ss u ra n ce . z Pr ov id e a pp ro pr ia te fo llo w u p a s sh ow n in th e Te xt bo x in di ca te d, fo r s pe cif ie d co m pl ica tio ns (p re vi ou s co lu m n ). z Fo r a ll pr ev io us c o m pl ic at io ns , e m ph as ize th e im po rta n ce o f t he fo llo wi n g: − Pr ep ar in g fo r n o rm a l b irt h an d po ss ib le c o m pl ic at io n s − H av in g a s ki lle d pr ov id er to a tte nd th e bi rth − Ad he rin g to th e pl an o f c ar e z Fo r p re vi ou s pr eg na nc y co m pl ic at io ns , pr o vi de b as ic ca re w ith : e m ph a si s on th e im po rta nc e o f p ra ct ici ng go o d se lf- ca re a nd c o n tin u in g ba sic ca re fo r e ar ly de te ct io n of po ss ib le p ro bl e m s. z Fo r p re vi ou s la bo r/c hi ld bi rth c om pl ic at io n s, pr ov id e ba si c ca re w ith : s pe cia l a tte nt io n to o n go in g a ss e ss m e n t d ur in g la bo r a n d us in g a pa rto gr ap h to a ss e ss m a te rn al a n d fe ta l w el l-b ei ng a n d id en tif y un sa tis fa ct or y pr og re ss o f l ab o r. z Fo r p re vi ou s po st pa rtu m c om pl ic at io ns , pr ov id e b as ic c ar e w ith : s pe cia l a tte nt io n to pe rfo rm in g a ct iv e m a n a ge m en t o f t he 3 rd st ag e of la bo r a n d vi gi la n tly m on ito rin g th e w o m a n d ur in g th e im m e di a te p os tp ar tu m . z Fo r p re vi ou s n ew bo rn c om pl ic at io ns , pr ov id e ba si c ca re w ith : s pe cia l a tte nt io n to im m ed ia te n ew bo rn c ar e , in cl u di ng dr yin g th e b ab y; a nd e m ph as is o n th e im po rta nc e o f p ra ct ici ng go o d ne w bo rn c a re a n d co n tin ui n g ba sic c ar e fo r e ar ly de te ct io n o f po ss ib le p ro bl e m s. Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-65 Textbox 3-23. Additional Assessment/Followup for Convulsions in Previous Pregnancy, Labor/Birth, or Postpartum Period Determine the cause of convulsions based on the woman’s history or medical records, if available. Some causes of convulsions require specific treatment and management. ¨ If the convulsions were due to known malaria: − Reinforce the importance of receiving intermittent preventive treatment (IPT) for malaria and continued use of insecticide-treated (bed)nets (ITNs); − Be alert for early signs/symptoms of the disease; and − Proceed with additional care provision (third column, page 3-64). ¨ If the convulsions were due to known eclampsia: − Reinforce importance of regular antenatal and postpartum visits to have blood pressure checked; − Check blood pressure every 2 hours during labor; − Be alert for early signs/symptoms of the disease during pregnancy and up to 24 hours’ postpartum; and − Proceed with additional care provision (third column, page 3-64). ¨ If the convulsions were due to known tetanus: − Reinforce the importance of tetanus toxoid immunization (according to the schedule shown on page 2-34); and − Proceed with additional care provision (third column, page 3-64). ¨ If the convulsions were due to known epilepsy or an unknown cause, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Textbox 3-24. Additional Assessment/Followup for Three or More Spontaneous Abortions in Previous Pregnancy Determine when the abortions occurred (in terms of gestation): ¨ If the woman has had three or more spontaneous abortions, be especially alert to early pregnancy danger signs of vaginal bleeding or severe abdominal pain. ¨ If the woman has had three or more spontaneous abortions after 14 weeks, facilitate nonurgent referral/transfer (Annex 7, page 4-63), as she may need a cervical cerclage. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-66 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-25. Additional Assessment/Followup for Cesarean Section or Other Uterine Surgery in Previous Pregnancy or Birth Determine the cause of the uterine surgery based on the woman’s history or medical records, if available. There are several possible causes, some of which will have implications for this pregnancy and childbirth and can be used to guide development of the birth preparedness and complication readiness plan. Some possible causes include: z Ectopic pregnancy (excision of pregnancy in cornua) z Ruptured uterus z Previous cesarean section, due to: − Cephalopelvic disproportion − Complications requiring immediate delivery, such as placenta previa or placental abruption − Twin or breech delivery − Fetal distress During pregnancy: z Reinforce the importance of the following when assisting in the development of the birth plan: − Giving birth in the appropriate healthcare facility (every woman with a scarred uterus from a previous uterine surgery should give birth in a healthcare facility equipped to perform emergency obstetric surgery); − Getting to the facility in early labor (some scars may rupture before labor or during the latent phase); and − Having adequate finances available in case surgical intervention is needed. z Ensure that the woman gives birth in a healthcare facility equipped to perform emergency obstetric surgery (as part of her birth plan). ¨ If the woman has had one previous cesarean section with low transverse uterine incision, she may have a “trial of labor” in a healthcare facility if judged by a skilled provider to be safe. ¨ If the woman has had a previous uterine rupture or two or more cesarean sections, she must give birth by cesarean section. z Proceed with additional care provision (third column, page 3-64). During labor: ¨ If the woman has had a previous cesarean section or other uterine surgery, facilitate urgent referral (Annex 7, page 4-63). Textbox 3-26. Additional Assessment/Followup for 3rd or 4th Degree Tear in Previous Birth Determine whether the repair was adequate and if there were any related complications (e.g., fistula, rectal sphincter dysfunction). ¨ If the repair was inadequate, or a fistula or rectal-sphincter dysfunction is present, facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. ¨ If the repair was adequate and there were no related complications, proceed with additional care provision (third column, page 3-64). Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-67 Textbox 3-27. Additional Assessment/Followup for Previous Newborn Complications or Death z To determine the nature of the complication or death and possible cause (e.g., complications during pregnancy, childbirth, or the postpartum/newborn period, or other maternal/newborn problems), ask these followup questions: − What was the timing of the complication or death in relationship to labor and birth? − Were there complications during childbirth (e.g., malpresentation, instrument-assisted birth, cesarean section)? ¨ If the complication or death was associated with cesarean section or other uterine surgery, see Textbox 3-25 (page 3-66). − Did the baby have jaundice, feeding difficulties, or other problems, conditions, etc.? ¨ If there is a history of newborn jaundice, closely observe this newborn for the first 5 days after birth. ¨ If the newborn complication or death was apparently related to sepsis, diarrhea, feeding problems, birth injury, birth defect, preterm birth, or low birthweight, use this information to guide further assessment and individualization of health messages and counseling. − Are there aspects of the woman’s lifestyle (e.g., use of potentially harmful substances such as alcohol or local drugs) that may have contributed to the complication or death? ¨ If YES, use this information to guide individualization of health messages and counseling. − Did the woman have other problems, conditions, etc.? ¨ If the complication or death was associated with maternal convulsions, see Textbox 3-23 (page 3-65). ¨ If the complication or death was due to maternal disease or condition, facilitate nonurgent referral (Annex 7, page 4-63) after providing basic care. z Reinforce the importance of: − Continuing basic care; − Having a skilled provider attend the birth; and − Returning for postpartum/newborn care. z Proceed with additional care provision (third column, page 3-64). 3- 68 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N M ul tip le P re gn an cy (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M CP C. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. z Co nf irm m ul tip le pr eg n a n cy th ro u gh th e w om a n ’s h is to ry a nd ph ys ica l e xa m in a tio n : − As k if th e wo m an h as n o te d ei th er o f t he fo llo w in g du rin g he r p re gn an cy : − R ap id u te rin e g ro w th in th e 2n d a n d 3rd tri m es te rs − Co ns ta n t f et al m ov em en t − Ex am in e fo r: − Fu nd al h ei gh t l ar ge r t ha n e xp ec te d fo r g es ta tio na l a ge − Fe ta l h ea d sm al l in re la tio n to th e si ze o f t he u te ru s − Pa lp a tio n of th re e o r m o re fe ta l p ol es a n d m ul tip le s m al l pa rts − Au sc ul ta tio n o f m o re th an o ne fe ta l h ea rt wi th a di ffe re nc e o f a t l ea st 1 0 be a ts p er m in ut e , a n d di st in ct fro m th e m at er na l p u ls e z Pe rfo rm a n ul tra so u n d ex am in a tio n, if av ai la bl e , to c on fir m m u lti pl e pr eg n a n cy . ¨ If th e w o m an is in la bo r, de te rm in e th e w o m a n ’s s ta ge /p ha se o f l ab or (T ab le 2 -8 , p ag e 2- 68 ). ¨ If th e w o m an is in th e 1s t st ag e o f l ab or , AC T N O W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). ¨ If th e w o m an is in th e 2n d st ag e o f l ab or , pr oc ee d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). ¨ If th e w o m an is N O T in la bo r, fa cil ita te n on u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ) a fte r p rov idi ng b as ic ca re . If th e wo m an is in th e 2n d st ag e of la bo r a n d in go od h ea lth , n o s pe cia l c ar e is n ee de d. P ro vi de b a si c ca re a s sh ow n in Se ct io n 2, w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph as e s. z En su re th at a n a ss is ta nt is a va ila bl e to h el p du rin g th e bi rth a nd in th e im m ed ia te c a re o f t he b ab ie s. z St ar t a n IV in fu sio n an d slo w ly in fu se fl ui ds . z M on ito r t he fe tu se s by in te rm itt en t a us cu lta tio n o f t he fe ta l h ea rt to ne s. R ec or d fin di n gs o n th e pa rto gr ap h u si ng a d iff er en t c ol or to re pr e se n t e ac h fe tu s. z Ch ec k th e pr e se n ta tio n o f t he fi rs t f et us (p ag e 2- 60 ) if n o t a lre a dy d on e : ¨ If a ce ph al ic p re se n ta tio n, a llo w la bo r t o pr o gr es s a s fo r a s in gl e fe tu s, a nd m on ito r p ro gr es s in la bo r u si ng a p ar to gr a ph . ¨ If a br ee ch p re se nt at io n, a pp ly th e sa m e gu ide lin es a s f or a sin gle to n br ee ch b irt h (pa ge 4- 12 ). z Se e M ul tip le P re gn a n cy B irt h (p ag e 4- 25 ) fo r a dd itio n a l in fo rm at io n o n a ss is tin g in th e bi rth . 3- 69 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Po st pa rtu m S ad ne ss (“ Bl ue s” ) (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) N ot e: If th e wo m an is in s ev er e ps yc ho lo gi ca l/ e m o tio n a l d is tre ss , p ro vid e vi gi la n t e m ot io n a l s up po rt an d co m fo rt th ro ug ho ut y ou r a ss e ss m e n t a n d re fe rra l. G en er al c on si de ra tio ns : A lth ou gh th e bi rth o f a n ew b ab y is a ha pp y tim e fo r m o st w om en , s o m e e xp er ie nc e po st pa rtu m “b lu e s” o n d a ys 3 – 6 af te r bi rth — cr yin g, fe el in gs o f s ad n e ss o r o f be in g o ve rw he lm e d, o r i rri ta bi lit y. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 7 (p ag e 2- 83 ), w ith th e fo llo w in g ad di tio n s a n d/ or e m ph as e s. z As se ss th e w om a n fo r t he fo llo w in g sig n s/ sy m pt om s of po st pa rtu m d e pr e ss io n : − In so m ni a a n d ch an ge s in a pp et ite − Ex ce ss iv e or in a pp ro pr ia te s ad ne ss o r g u ilt − Fe el in gs o f w or th le ss ne ss o r a n xi ou sn e ss − Si gn s/ sy m pt om s la st in g m or e th an 1 w ee k − H is to ry o f p os tp ar tu m d ep re ss io n z As se ss th e w om a n fo r t he fo llo w in g sig n s/ sy m pt om s of po st pa rtu m p sy ch os is: − Vi su al o r a u di to ry h al lu ci na tio n s o r de lu si on s − M or bi d, s ui cid a l, o r fri gh te ni n g th ou gh ts − D es ire to , o r b e lie f t ha t s he w ill, h ur t h er se lf or th e ba by − Se ve re d e pr es si on la st in g m or e th an 2 w ee ks − H is to ry o f p os tp ar tu m p sy ch o si s z As k fa m ily m em be rs if th ey a re c o n ce rn e d ab ou t t he w om a n ’s e m o tio n a l h e a lth a n d he r a bi lit y to c ar e fo r h er se lf or h er b ab y. ¨ If AN Y of th e ab ov e si gn s/ sy m pt om s of p o st pa rtu m de pr es si on is p re se nt , fa cil ita te n on u rg e n t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ) a fte r p rov id in g ba si c ca re . ¨ If AN Y of th e ab ov e si gn s/ sy m pt om s of p o st pa rtu m ps yc ho si s is p re se nt , AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ) b efo re pr oc ee di n g. D o no t l ea ve th e w o m a n a lo n e a t a ny ti m e. ¨ If NO NE o f t he a bo ve s ig ns /s ym pt om s is p re se nt , pr oc ee d wi th a dd itio n a l c a re p ro vi si on (n ex t c o lu m n). If th e po st pa rtu m /n ew bo rn p er io d is pr o gr es sin g no rm al ly, pr ov id e b as ic c ar e as s ho w n in Ch ap te r 7 , w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. z Pr ov id e re a ss u ra n ce th at fe el in gs o f i na de qu a cy , w or ry , o r fe ar m ay b e n o rm a l (u p to 3 4% o f w om en e xp er ie n ce so m e d ep re ss io n d ur in g th e in iti al w e e k af te r bi rth ). F or m o re in fo rm at io n , se e F ee lin gs o f I na de qu ac y, W o rr y, o r Fe ar d ur in g th e Po st pa rtu m Pe rio d (p ag e 3- 15 ). z Ad vis e he r t o re tu rn fo r c ar e if sy m pt om s pe rs ist o r w o rs e n . z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s c o m pl ica tio n re a di n e ss p la n. − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a da ng er s ig n a ris e s. z Ar ra ng e to s ee th e w om an a n d n e w bo rn a ga in w ith in th e w ee k of d ia gn os is. 3- 70 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Pr el ab or R up tu re o f M em br an es o r M em br an es R up tu re d fo r M or e Th an 18 H ou rs b ef or e Bi rth (F or the ra tio na le fo r pr ov id in g ad di tio n a l ca re to a w om a n w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) G en er al co n si de ra tio ns : Pr el ab o r ru pt ur e o f m e m br an es is ru pt ur e o f t he m em br an e s be fo re th e on se t o f l ab or , a n d ca n o cc u r a t a ny tim e du rin g pr eg na n cy . It is im po rta nt to kn ow h o w lo n g th e m e m br an es h av e be en r u pt ur ed in o rd er to p ro vid e a pp ro pr ia te a n tib io tic tr ea tm e n t a n d/ or fa cil ita te re fe rra l/ tra ns fe r t o a hi gh e r le ve l o f c ar e. Pe rfo rm b as ic as se ss m en t, as s ho w n in Ch ap te r 6 (pa ge 2- 37 ), w ith th e fo llo w in g ad dit io ns a nd /o r em ph as es . z Be fo re p ro ce e di ng , c on fir m th at th e m em br a n e s ha ve r u pt u re d by a ss e ss in g th e od or o f t he fl ui ds . O r, if m em br an e ru pt ur e is no t r ec en t o r t he le a ka ge is g ra du a l, us e on e o f t he m et ho ds s ho w n in Te xt bo x 3- 28 (p ag e 3- 71 ). W ar ni ng : D o N O T pe rfo rm a d ig ita l v a gi n a l e xa m in a tio n a s th is w ill no t h e lp co n fir m ru pt ur e o f m e m br an e s a n d ca n in tro du ce in fe ct io n . ¨ If le ss th an 3 7 w ee ks ’ g es ta tio n, AC T NO W !— fa cil ita te u rg e n t r ef er ra l/t ra n sf er (A nn ex 7 , pa ge 4 -6 3). Se e be lo w to d et er m in e if th e w o m a n r e qu ire s a n tib io tic s be fo re re fe rra l. z As se ss th e w om a n fo r t he fo llo w in g ab n o rm a l s ig ns /s ym pt o m s: − Fe ve r − Fo ul -s m el lin g flu id − Te nd er a bd om e n − Fe ta l h ea rt ra te m o re th an 1 60 be at s pe r m in u te if n ot in la bo r o r m o re th an 18 0 be a ts p er m in ut e if in la bo r ¨ If th e w o m an h as a fe ve r o r f ou l-s m el lin g flu id , AC T NO W !— se e T ab le 3 -4 (p ag e 3- 11 6) to be gi n a n tib io tic tre at m en t a s fo r a m ni on iti s be fo re fa cil ita tin g u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). ¨ If AN Y of th e o th er a bo ve a bn or m al s ig ns /s ym pt om s is pr es en t, AC T N O W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). ¨ If la bo r h as b eg un a nd it ha s be en m or e th an 1 8 ho ur s si nc e th e m em br an es h av e ru pt ur ed , AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). C om pl et e th e fo llo w in g st ep in a dd itio n to th os e in A nn ex 7 : ¨ If le ss th an 3 7 w ee ks ’ g es ta tio n, gi ve th e wo m a n e ry th ro m yc in 2 50 m g by m o u th P LU S a m o xi ci llin 5 00 m g by m ou th e ve ry 8 h ou rs . ¨ If 37 w ee ks ’ g es ta tio n or m or e, gi ve th e wo m a n b e n za th in e b en zy lp e n ic illi n 2 m illi o n u n its IV O R a m pi cil lin 2 g IV e ve ry 6 h ou rs . ¨ If la bo r h as n ot b eg un a nd it h as b ee n m or e th an 4 h ou rs s in ce th e m em br an es h av e ru pt ur ed , AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). I f it is lik el y th at th e m e m br an es w ill be ru pt ur e d fo r m or e th an 1 8 ho u rs b y th e tim e th e w om a n r e a ch es th e re fe rra l c en te r, co m pl et e th e fo llo w in g st ep in a dd itio n to th os e in A nn ex 7 : ¨ If le ss th an 3 7 w ee ks ’ g es ta tio n, gi ve th e wo m a n e ry th ro m yc in 2 50 m g by m o u th P LU S a m o xi ci llin 5 00 m g by m ou th e ve ry 8 h ou rs . ¨ If 37 w ee ks ’ g es ta tio n or m or e, gi ve th e wo m a n b e n za th in e b en zy lp e n ic illi n 2 m illi o n u n its IV O R am pi cil lin 2 g IV e ve ry 6 h ou rs . ¨ If la bo r h as n ot b eg un , i t h as b ee n le ss th an 4 h ou rs s in ce th e m em br a n es h av e ru pt ur ed , a nd th er e ar e n o a bn or m al s ig ns /s ym pt om s, pr oc ee d wi th a dd itio n a l c a re (n e xt c ol um n ). If m or e th an 3 7 w e e ks ’ g e st at io n , la bo r ha s no t b eg un , it ha s be en le ss th an 4 ho ur s si n ce th e m em br a n e s ha ve ru pt ur ed , a n d th er e ar e n o o th e r a bn o rm a l s ig ns /s ym pt om s, p ro vid e ba sic c ar e a s sh ow n in Ch ap te r 6 (p ag e 2- 37 ), w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. z M on ito r f et al h e a rt an d m at er n a l vi ta l s ig ns h ou rly . z Pa lp a te a nd m on ito r c on tra ct io n s a s so o n a s th e w o m a n r e po rts o n se t o f c on tra ct io ns . z En su re th at th e w o m a n is d rin ki ng e n o u gh fl ui ds /w e ll hy dr at ed . z W hi le w ai tin g fo r la bo r to b eg in , do N O T pe rfo rm a ny v ag in a l e xa m in a tio n s. z O nc e co nt ra ct io n s a re o cc u rr in g at a fre qu en cy o f a t le as t t hr ee in 1 0 m in ut es a n d la st in g at le as t 4 0 se co n ds e a ch , a v a gi n a l e xa m in a tio n m a y be p er fo rm e d to de te rm in e if th e wo m an is in la bo r. A va gi na l e xa m in at io n m a y al so b e pe rfo rm ed if th er e ar e sig ns o f f et al di st re ss o r t he w o m a n h as th e u rg e to p us h. Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-71 Textbox 3-28. Methods for Confirming Rupture of Membranes z Place a perineal pad/cloth over the vulva and examine it 1 hour later visually and by odor. Amniotic fluid before labor will usually appear clear (or greenish, if meconium is present) and have a typical odor. Urine, by contrast, will be yellow in color and have a characteristic odor. z Use a high-level disinfected speculum for examination of the vagina and cervix: − Fluid may be seen coming from the cervix or forming a pool in the posterior vaginal fornix. − Ask the woman to cough. This may cause a gush of fluid from the cervix, which can be seen with the speculum. z Perform the following tests: − The nitrazine test works by detecting the alkalinity of amniotic fluid (vaginal secretions and urine are both acidic). Touch a piece of nitrazine paper against the fluid pooled on the speculum blade or taken by using a sterile cotton-tipped applicator. A change from yellow to blue indicates the presence of amniotic fluid. Blood and some vaginal infections may give false-positive results. − For the ferning test, obtain an amniotic fluid sample from the posterior vaginal fornix during a speculum examination using a sterile cotton-tipped applicator. Spread some fluid on a slide, let it dry, and examine it under a microscope. Amniotic fluid crystallizes and may leave a fern-leaf pattern. False negatives are frequent. 3- 72 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Si ze -D at e Di sc re pa nc y th ro ug h 22 W ee ks ’ G es ta tio n (F un da l he ig ht /u te rin e siz e is la rg e r o r sm a lle r t ha n e xp ec te d fo r ge st at io n a l a ge . ) (F or the ra tio na le fo r p ro vid in g a dd itio n a l c ar e to a w om an w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) N ot e: Us e lo ca lly a pp ro pr ia te fe ta l g ro wt h st an da rd s fo r f et al gr ow th a ss e ss m e n t. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 5 (p ag e 2- 5), w ith th e f oll ow in g ad di tio n s a n d/ or e m ph as e s. z Co nf irm m ea su re m e n t w ith a s e co n d sk ille d pr o vi de r, if po ss ib le a n d ap pr op ria te . z Co nf irm p re gn a n cy , b y ur in e o r se ru m p re gn a n cy te st , i f n ec es sa ry . z Co nf irm g es ta tio n a l a ge th ro u gh m en st ru a l a n d co n tra ce pt ive h is to ry , s ig ns /s ym pt om s of pr eg n a n cy , p re se n ce o f f et al m o ve m e n ts o r f et al h ea rt to ne s, a bd om in a l e xa m in at io n (fo r ge st at io n a l a ge “ la nd m ar ks ,” se e p ag e 2- 17 ), a n d/ or p el vi c ex a m in at io n . ¨ If an e rr or in c al cu la tio n o f d at es is fo un d, co rr e ct th e es tim a te d da te o f c hi ld bi rth a n d th e pr e se n t n u m be r o f w ee ks ’ g es ta tio n b as ed o n th e re vi se d da te . A dv ise th e w o m a n o f h er n ew d at es . P ro ce ed w ith b as ic ca re p ro vis io n . ¨ If an e rr or in c al cu la tio n o f d at es is N O T fo un d, qu es tio n a n d/ or e xa m in e th e w om an fo r t he fo llo wi n g si gn s/ sy m pt om s: − Va gi n a l b le ed in g − Ab do m in a l c ra m pi ng /p ai n /te nd er ne ss − D ila te d ce rv ix − Ce rv ica l m o tio n te nd er n e ss − Te nd er a dn ex a l m a ss − So ft, b og gy u te ru s la rg er th an e xp ec te d fo r d at es − R ec en t h is to ry o f m al ar ia o r o th er s e ve re di se a se th at c au se s fe ve r ¨ If AN Y of th e ab ov e si gn s/ sy m pt om s is p re se n t, AC T NO W !— pe rfo rm R ap id In iti al A ss es sm e n t (p ag e 3- 90 ) a nd th en pr ov id e ca re fo r V ag in al B le e di n g in Ea rly Pr eg na n cy (p ag e 3- 10 2) be fo re p ro ce e di n g. ¨ If NO NE o f t he a bo ve s ig ns /s ym pt om s is p re se nt a nd d at es a re c o rr ec t, pr oc ee d wi th a dd itio n a l c a re p ro vi si on (n ex t c o lu m n). If th e wo m an is in g oo d he a lth a n d he r pr eg n a n cy is p ro gr es sin g no rm a lly , p ro vid e ba sic c ar e as s ho w n in Ch ap te r 5 (pa ge 2- 5), w ith th e fo llo w in g ad di tio n s a n d/ or e m ph a se s. z Pr ov id e re a ss u ra n ce . z H av e th e w o m a n r e tu rn in 2 w ee ks to re -m e a su re u te rin e si ze . S om e w o m e n ha ve a g ro w th s pu rt be tw ee n 2 0 an d 24 w e e ks , s o yo u m a y no tic e th at sh e is la rg e fo r d at es a t o ne v is it, b ut th en th e gr ow th e ve n s o u t. ¨ If th er e is s til l m o re th an 2 c m di ffe re nc e in m ea su re m en t ( or m o re th an 2 w ee ks ’ d iff er en ce in u te rin e si ze ) a fte r 2 w ee ks , fa cil ita te n o n u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ) a fte r pr ov id in g ba sic ca re . 3- 73 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Si ze -D at e Di sc re pa nc y af te r 22 W ee ks ’ G es ta tio n (F un da l he ig ht /u te rin e siz e is la rg e r o r sm a lle r t ha n e xp ec te d fo r ge st at io n a l a ge . ) (F or the ra tio na le fo r p ro vid in g a dd itio n a l c ar e to a w om an w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) N ot e: Us e lo ca lly a pp ro pr ia te fe ta l g ro wt h st an da rd s fo r f et al gr ow th a ss e ss m e n t. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g ad di tio ns a n d/ or e m ph a se s: z Co nf irm m ea su re m e n t w ith a s e co n d sk ille d pr o vi de r, if po ss ib le a n d ap pr op ria te . ¨ If th er e is s til l m o re th an 2 c m d iff er en ce in m ea su re m en t ( or m or e t ha n 2 w ee ks ’ d iff er en ce in u te rin e si ze ), c o n tin ue a s fo llo ws . Sm al l f or d at es : z As se ss fo r t he fo llo wi n g co n di tio ns : − Fe ta l d ea th (e .g. , a bs en t f et al m o ve m e n ts , a bs e n t f et al h e a rt to ne s) ¨ If ab se nt fe ta l m ov em en ts , se e T ex tb ox 3 -4 3 (p ag e 3- 11 1) be for e p roc e e di ng . ¨ If ab se nt fe ta l h ea rt to ne s, se e T ex tb ox 3 -4 4 (p ag e 3- 11 2) be for e p roc e e di ng . − Tr an sv er se li e ¨ If th e ba by is in tr an sv er se li e an d th e w om an is g re at er th an 3 6 w ee ks ’ ge st at io n an d is N O T in la bo r, fa cil ita te n on u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). ¨ If th e ba by is in tr an sv er se li e an d th e w om an is g re at er th an 3 6 w ee ks ’ ge st at io n an d IS in la bo r, AC T N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). ¨ If th e ba by is in tr an sv er se li e an d th e w om an is le ss th an 3 6 w ee ks ’ ge st at io n an d is N O T in la bo r, pr oc ee d wi th a dd itio n a l c ar e pr ov isi on (n ex t co lu m n). ¨ If th e ba by is in tr an sv er se li e an d th e w om an is le ss th an 3 6 w ee ks ’ ge st at io n an d IS in la bo r, AC T N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). ¨ If NO NE o f t he a bo ve c on di tio n s ar e pr es en t, pr oc ee d wi th a dd itio na l c ar e pr ov isi o n (n e xt c ol um n). La rg e fo r d at es : z As se ss fo r t he fo llo wi n g sig ns : − Pa lp a tio n of m u lti pl e fe ta l p ar ts − Au sc ul ta tio n o f m o re th an o ne fe ta l h ea rt − Pa lp a tio n of a s in gl e la rg e fe tu s (i.e ., t oo la rge fo r p elv is ) − Pa lp a tio n of to o m u ch a m ni o tic flu id ¨ If AN Y of th e ab ov e si gn s is p re se nt a nd th e w om an IS in la bo r, AC T N O W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ) b efo re pr oc ee di n g. ¨ If th e w o m an is in a dv an ce d la bo r a nd it is lik el y th at s he w ill g iv e bi rth be fo re re fe rr al /tr an sf er c an o cc u r an d m ul tip le p re gn an cy is s us pe ct ed , se e M ul tip le P re gn a n cy (p ag e 3- 68 ). ¨ If NO NE o f t he a bo ve s ig ns a re p re se n t a nd th e w o m an is N O T in la bo r, pr oc ee d w ith a dd itio n a l c a re p ro vis io n (n ex t c olu mn ). If th e la bo r/c hi ld bi rth is p ro gr es si ng n o rm a lly , pr ov id e b as ic c ar e as s ho w n in Se ct io n 2, w ith th e fo llo w in g ad di tio n s a n d/ or e m ph as e s. Sm al l f or d at es : z Pr ov id e re a ss u ra n ce . z Be a le rt fo r s ig n s o f m at er na l a n d fe ta l di st re ss . z Be a le rt fo r a v er y lo w bi rth w e ig ht b ab y (le ss th an 2 kg ), w ho re qu ire s u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). z Be a le rt fo r a lo w bi rth we ig ht b ab y (2– 2.5 kg ), w ho h as s pe cia l n e e ds th at re qu ire a dd itio n a l c ar e (pa ge 3 -8 5). z If th e ba by is in tr an sv er se li e an d th e w o m an is le ss th an 3 6 w ee ks ’ ge st at io n an d is N O T in la bo r, fo llo wu p a fte r 3 6 we ek s to re ch ec k th e ba by ’s lie . La rg e fo r d at es : z Pr ov id e re a ss u ra n ce . z Us e a pa rto gr ap h fo r e ar ly de te ct io n of o bs tru ct ed la bo r. z Be a le rt fo r s ig n s o f m at er na l a n d fe ta l di st re ss . z Be a le rt fo r a la rg e ba by (m ore th an 4 k g), w ho h a s sp ec ia l n ee ds th at re qu ire a dd itio n a l c ar e (pa ge 3 -8 4). 3- 74 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N St ill bi rth o r N ew bo rn D ea th (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a w om a n w ith th is s pe ci al n ee d, se e T ab le 1 -1 2, p ag e 1- 31 . ) G en er al c on si de ra tio ns : S till bi rth o r t he de at h of a n e w bo rn is v er y di st u rb in g fo r a ll co nc e rn e d an d ev ok e s a r a n ge o f e m o tio n s th at c an h av e s ig ni fic a n t co n se qu en ce s. Th e w om an w ho se b a by is b or n de a d or w ho se n e w bo rn h as d ie d is o fte n pl ac e d in th e w ar d w ith o th er w o m e n a n d th e ir he a lth y ba bi e s. T hi s m a y wo rs en th e p ai n a n d gr ie f t he w om an a n d he r fa m ily a re e n du rin g. In a dd iti on , he al th ca re w o rk e rs o fte n te nd to a vo id th e w o m a n w ho h a s gi ve n bi rth to a s till bo rn o r to a b ab y wh o di e d at , o r a fte r, bi rth . At te nt io n is o fte n la vis he d u po n th e w o m a n w ith a h ea lth y ba by , w hi le th e w o m a n w ho se b ab y ha s di ed m a y be le ft to g rie ve a lo n e a n d wi th o u t b as ic re gu la r a ss e ss m e n t a nd c ar e. H ow th e w o m a n a n d ea ch m em be r o f t he fa m ily re a ct s to th e de at h o f a n ew bo rn m a y de pe n d on : z So cia l s itu a tio n o f t he w om an /c o u pl e a n d th ei r c ul tu ra l a nd re lig io u s pr ac tic es , b el ie fs , a nd e xp ec ta tio ns z Pe rs on a liti e s o f t he p eo pl e in vo lv ed a n d th e qu a lit y an d na tu re o f s o ci al , pr ac tic al , a n d em o tio na l s up po rt z M ar ita l s ta tu s of th e w om an a n d he r re la tio ns hi p to h er p ar tn er z Em ot io na l a nd p hy sic al s up po rt re ce iv ed fro m s kil le d pr ov id er s z Ca us e of d ea th Pe rfo rm b as ic a ss e ss m e n t ju st a s yo u wo ul d fo r a w om an w ho h as a liv in g ba by , a s sh ow n in Ch ap te r 7 (p ag e 2- 83 ), w ith th e f oll o w in g a dd itio n s a n d/ or e m ph as e s. z As se ss th e em o tio na l/p sy ch o lo gi ca l r ea ct io n s o f t he w om an a n d fa m ily . C om m on r e a ct io n s to n ew bo rn d e a th in cl ud e : − D en ia l (f ee lin gs o f “ it ca n’ t b e tru e” ) − G ui lt re ga rd in g pe rc ei ve d re sp on sib ilit y − An ge r ( wh ic h m a y be d ire ct ed to w ar d he a lth ca re w o rk er s bu t o fte n m as ks p ar en ts ’ a n ge r a t t he m se lv e s fo r “ fa ilu re ”) − D ep re ss io n a n d lo ss o f s el f-e st ee m , w hi ch m a y be lo n g- la st in g − Is ol at io n (fe eli n g of b ei ng di ffe re n t o r s ep ar a te fr om o th er s), w hi ch m ay b e re in fo rc e d by h e a lth ca re w o rk e rs if th ey a vo id pe op le w ho h a ve e xp er ie nc e d lo ss − D is or ie n ta tio n z Be a le rt to a ny s ig ns th at th e w o m a n m a y hu rt he rs el f. ¨ If si gn s/ sy m pt om s of p os tp ar tu m d ep re ss io n/ ps yc ho si s, fa cil ita te u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). z O bs er ve th e in te ra ct io n s be tw e e n th e w o m a n a n d he r pa rtn e r/ fa m ily to a ss es s th e su pp or t s he h as a n d to d et ec t a ny ha rm fu l/d e st ru ct iv e pa tte rn s th at m ay re qu ire in te rv en tio n. If th e wo m an is in g oo d he a lth a n d th e po st pa rtu m p er io d is pr og re ss in g n o rm a lly , p ro vid e th e sa m e ba si c ca re g iv en to th e w o m an w ith a li vi ng ba by a s sh ow n in Ch ap te r 6 , w ith th e fo llo w in g ad di tio n s a n d/ or e m ph a se s. z Fo llo w a dd itio n a l g ui de lin e s fo r i nt er pe rs on a l s ki lls (T ex tb ox 3 -2 9, pa ge 3 -7 5). z Pr ov id e he lp w ith th e gr ie vin g pr oc es s: − Al lo w th e p ar en ts to s ee a nd h ol d th e b ab y af te r de at h if th is is a pp ro pr ia te . Av oi d se pa ra tin g th e pa re n ts a nd b a by to o so on (b e fo re th ey in di ca te th ey a re re ad y), a s th is c an d el ay th e gr ie vi ng pr oc es s. − W he re it is a c us to m to n am e th e ba by a t b irt h, e n co u ra ge th e pa re n ts (a nd fa ci lit y st af f) t o c all th ei r b ab y by th e na m e th ey h av e ch o se n . − If cu ltu ra lly a pp ro pr ia te , o ffe r t he p ar e n ts s om e m e m e n to s of th e ba by , s uc h a s a n a m e ta g, a lo ck o f h ai r, or a p al m p rin t, as th is wi ll h e lp w ith th e gr ie vin g pr o ce ss . z As si st w ith fi na l a rra ng e m e n ts : − Ev en if th e ba by w ill no t b e bu rie d by th e fa m ily , a llo w th e w om a n /fa m ily to p re pa re th e ba by fo r t he bu ria l i f t he y wi sh . − En co ur a ge lo ca lly a cc ep te d bu ria l p ra ct ic es a n d e n su re th at m ed ica l p ro ce du re s (su ch as a u to ps ie s) ac co m m o da te th em . − H el p th e fa m ily a s m u ch a s po ss ib le w ith a ll pa pe rw o rk n ec es sa ry to re gi st e r th e ba by ’s b irt h a n d de a th . z Ar ra ng e to s ee th e fa m ily a fe w we ek s af te r t he d ea th to a n sw e r qu es tio n s a n d pr o vi de a n y ne ce ss ar y su pp or t i n th e gr ie vin g pr o ce ss . z Li nk th e fa m ily to s up po rt pr ov id ed b y a re lig io u s pe rs o n o r a c o m m u n ity su pp or t g ro u p if th e fa m ily d e si re s. Chapter Ten: Special Needs JHPIEGO/Maternal and Neonatal Health Program 3-75 Textbox 3-29. Interpersonal Skills for Use with a Woman and Family with a Stillbirth or Newborn Death Remember: Although the circumstances surrounding each newborn death are unique and there is no one method for approaching all families, communication and genuine empathy are the most important keys to effective care in such situations. When providing basic care to the woman whose baby has died: z Listen to the family’s concerns and questions and communicate clearly, keeping the family in mind. z Provide the necessary privacy when talking to the family and when they are talking with each other. z If you do not speak a language the family understands, use a sensitive translator. Give simple, honest information about the baby’s death and what has happened; understanding the situation can reduce their anxiety and guilt and help with the grieving process. z Ask open-ended questions to assess the parents’ need for more information. z Be honest. Do not hesitate to admit what you do not know. Maintaining trust matters more than appearing knowledgeable. z Use non-verbal communication techniques, such as nodding your head, to show the family that you are focusing on them and listening to their fears and sadness. z Show that you care about the woman and her family and that you respect them. z Express your feelings of concern for the family and encourage them to express their emotions, if culturally acceptable. z Respect traditional beliefs and customs and accommodate the family’s needs as much as possible. z Do not place blame on the family if there is a question of neglect or intervening too late. z Remember to care for other facility staff who themselves may experience guilt, grief, confusion, and other emotions. For more information on Interpersonal Skills, see page 1-42. 3- 76 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Sy ph ili s (F or the ra tio na le fo r p ro vid in g a dd itio n a l c ar e to a w om an w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) N ot e: A w om an w ho re po rts a po sit ive te st fo r s yp hi lis (w he the r o r n o t s he h as si gn s/ sy m pt om s o f s yp hi lis , a n d wh et he r o r n o t s he h as a re co rd o f t he te st ), a nd ha s re ce iv ed n o tr ea tm en t o r in ad e qu a te tr ea tm en t, M US T be tr ea te d a t t hi s tim e. He r ba by w ill al so n ee d e va lu a tio n a n d tre at m en t i m m ed ia te ly a fte r b irt h. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. W om an z D ur in g a ss e ss m e n t, id en tif y sig ns /s ym pt om s o f s yp hi lis in th e w om an : − Ch an cr e (ul ce ro u s le si o n ) a t th e s ite of in fec tio n, u su a lly a ro u n d th e ge n ita lia − R as h on th e pa lm s of th e ha nd s an d/ or s ol es o f t he fe et − Pa tc hy h ai r l o ss o n th e sc al p, e ye br o w s, a n d/ o r e ye la sh es − Lo w -g ra de fe ve r, so re th ro at , h ea da ch e , lo ss o f a pp et ite − Co nd ylo m a ta la ta (fl at, m ois t, w art -lik e l es io n s a ro u n d th e ge ni ta lia ) ¨ If th e w o m an h as s ig ns /s ym pt om s of s yp hi lis (b ut ha s no t be en d ia gn os ed ), p er fo rm a s er ol og ic te st fo r s yp hi lis (R PR /V DR L; pa ge 4 -4 4), ev en if sh e wa s te st ed e ar lie r in pr eg n a n cy . ¨ If th e w o m an te st s po si tiv e fo r s yp hi lis , pr oc ee d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). ¨ If th e w om an h as b ee n di ag n o se d w ith s yp hi lis , a sk w he th er s he re ce iv ed tr ea tm en t f or s yp hi lis a n d de te rm in e w he th e r tre at m en t w as a de qu a te (i. e., 2. 4 m illio n u n its o f pe ni cil lin a t l ea st 3 0 da ys b ef or e b irt h). ¨ If th e w om an h as b ee n di ag no se d w ith s yp hi lis a nd ha s no t b ee n ad eq ua te ly tr ea te d, pr oc ee d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). ¨ If th e w om an h as b ee n di ag n o se d w ith s yp hi lis b ut ha s be en a de qu at el y tre at ed , sh ow s no si gn s/ sy m pt om s of s yp hi lis , A N D h as a n eg at iv e R PR /V DR L, n o a dd itio n a l c ar e is n ee de d. If th e pr eg na n cy , l ab or , b irt h, a nd /o r p o st pa rtu m p er io d ar e pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e as sh ow n in Se ct io n 2, w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s. W om an z Pr ov id e tre at m en t a cc or di ng to th e fo llo w in g gu id el in e s. ¨ If th e w om an h as b ee n di ag no se d w ith s yp hi lis a n d ha s no t be en a de qu at el y tre at ed : ¨ If sh e ha s ne w ly a cq ui re d si gn s/ sy m pt om s of s yp hi lis , gi ve th e wo m a n b en za th in e be n zy lp e n ic illi n 2. 4 m illi o n u n its IM (1 .2 mi llio n u n its in e a ch bu tto ck a t t he s am e vi si t). ¨ If sh e ha s sig ns /s ym pt om s of s yp hi lis o f u nk n o w n d ur at io n , gi ve th e wo m a n b en za th in e be n zy lp e n ici llin 2 .4 m illi o n u n its IM o nc e pe r w e e k fo r 3 w ee ks (1 .2 mi llio n u n its in e ac h bu tto ck a t t he s am e vis it. ) − Fo llo w lo ca l c ou n try p ro to co ls fo r f ol lo wu p m an ag em en t o f t he w o m a n w ith a p os itiv e RP R /V D R L. (W H O re co m m en ds th a t a fte r tre at m en t, qu an tit at ed n on -tr ep on e m a l s er o lo gi c te st s sh ou ld b e pe rfo rm ed a t m on th ly in te rv al s u n til b irt h, a nd th e w om an re - tre at ed if th er e is s er ol og ic ev id en ce o f r e- in fe ct io n or re la ps e .) Be s ur e th at th e w o m a n k no w s th at s he s ho ul d ha ve h er a n tib o dy ti te rs fo llo w e d po st pa rtu m . z Ex ch an ge a ll i nf or m at io n in a p riv at e se tti ng , a n d re a ss u re th e w o m a n th a t t he c on ve rs a tio n w ill be ke pt c on fid en tia l. z G ive e m ot io n a l s u pp or t t o th e w o m a n a n d he lp he r d ea l w ith p os sib le e ffe ct s of s yp hi lis o n th e ne w bo rn . z Pr ov id e a dd itio n a l h e a lth m es sa ge s an d co u n se lin g on th e fo llo w in g: − M od e of tr an sm is si on a n d po ss ib le e ffe ct s of sy ph ilis o n th e w o m a n a n d he r ba by : − Un tre at ed sy ph ilis c an c au se th e w om a n to lo se h er b ab y du rin g th is or a su bs eq u e n t p re gn a n cy . − Th e ba by m ay b e bo rn s e rio u sl y ill wi th c on ge n ita l a n o m a lie s. − Im po rta nc e of c o n si st en t c on do m u se to p re ve n t S TI s − Im po rta nc e of h av in g se xu al pa rtn er s te st ed an d tre at ed fo r sy ph ilis z Te ac h th e w om a n to w at ch fo r d an ge r s ig n s in th e ba by th a t c ou ld in di ca te c on ge n ita l s yp hi lis (s e e b el ow ), a nd se e k m ed ica l c a re im m ed ia te ly if an y of th es e sig ns a pp ea r. 3- 77 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Sy ph ili s, co n tin u ed N ew bo rn ¨ If th e m ot he r w as d ia gn os ed w ith s yp hi lis a n d w as n ot tr ea te d, o r w as n ot tr ea te d ad eq ua te ly , o r h er tr ea tm en t st at us is u nk no w n o r u n ce rt ai n, co n du ct a dd itio n a l a ss e ss m e n t a s fo llo ws : − D ur in g ph ys ica l e xa m in a tio n , lo ok fo r s ig ns o f s yp hi lis : − G en er al iz ed e de m a (b od y sw el lin g) − Bl is te rin g sk in ra sh o n th e pa lm s a n d so le s − Pr of us e ru nn y no se (“ sn u ffl es ” ) − Ab do m in a l d ist e n tio n (fr om en la rg ed liv e r a n d/ or sp le en , o r fro m fl ui d in th e ab do m e n ) ¨ If th e ne w bo rn s ho w s si gn s o f s yp hi lis , AC T N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). ¨ If th e ne w bo rn s ho w s n o s ig ns o f s yp hi lis , pr oc ee d wi th a dd itio n a l c a re p ro vi si on (n ex t c o lu m n). ¨ If th e m ot he r w as a de qu at el y tr ea te d (2. 4 m ill io n u n its o f pe ni ci lli n at le as t 3 0 da ys b ef or e bi rth ) A ND th e n ew bo rn sh ow s si gn s n o o f s yp hi lis , n o a dd iti on a l c a re is n ee de d. N ew bo rn z Pr ov id e tre at m en t a cc or di ng to th e fo llo w in g gu id el in e s: − G ive th e ba by a n tib io tic s: − pr oc ai n e b e n zy lp en ic illi n 10 0 m g/ kg b od y we ig ht IM a s a si ng le in jec tio n , O R − be nz a th in e be n zy lp en ic illi n 7 5 m g/ kg b od y w e ig ht IM a s a si ng le in jec tio n . z Fo llo w u p in 4 w ee ks to e xa m in e th e ba by fo r si gn s of c on ge n ita l sy ph ilis . 3- 78 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Te ar s an d In ci si on s du rin g th e Po st pa rtu m P er io d: z Ab do m in a l i nc is io ns z Va gi n a l o r p e rin e a l t ea rs z Ep isi ot o m y z D ef ib ul at io n (F or the ra tio na le fo r p ro vid in g a dd itio n a l c ar e to a w om an w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 7 , w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. A bd om in al in ci si on : z In sp ec t t he in cis io n/ su tu re s fo r s ig ns o f i nf ec tio n. ¨ If th er e is p us , r ed ne ss , o r p ul lin g ap ar t o f t he s ki n ed ge s of th e su tu re li ne , AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). ¨ If th er e ar e no s ig ns o f i nf ec tio n, pr oc ee d w ith a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). Va gi na l o r p er in ea l t ea rs , e pi si ot om y, o r d ef ib ul at io n : z In s uf fic ie nt lig ht , i ns pe ct th e ge ni ta l a re a . ¨ If un re pa ire d 1s t o r 2n d de gr ee te ar o r e pi si ot om y: ¨ If le ss th an 2 4 ho ur s si nc e bi rth , se e R ep ai r o f 1s t o r 2n d D eg re e Va gi n a l a n d Pe rin ea l T ea rs (p ag e 4- 38 ) o r R ep ai r o f E pi sio to m y (pa ge 4 -3 7). ¨ If m or e th an 2 4 ho ur s si nc e bi rth , a llo w th e in ci si on o r te ar to h ea l u n re pa ire d an d pr oc ee d wi th a dd itio n a l a ss es sm e n t. ¨ If un re pa ire d 3r d o r 4t h de gr ee te ar , AC T NO W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). z In sp ec t t he g en ita l a re a fo r t he fo llo wi n g si gn s/ sy m pt om s: − Pu s, re dn es s, o r pu llin g a pa rt o f t he s kin e dg e s o f t he su tu re li ne − Pu s or d ra in a ge fr om u nr ep a ire d te ar , e pi sio to m y, o r de fib u la tio n − Se ve re p a in fr om te ar , e pi sio to m y, o r d ef ib ul a tio n ¨ If AN Y of th e ab ov e si gn s/ sy m pt om s is p re se n t, AC T N O W !— se e P us , R ed ne ss , o r Pu llin g Ap ar t o f S kin E dg es o f P er in ea l S ut u re L in e ; P us o r D ra in ag e fro m Un re pa ire d Te ar ; S ev er e Pa in fr om T ea r o r E pi sio to m y (pa ge 3 -1 18 ) be fo re p ro ce e di ng . ¨ If NO NE o f t he a bo ve s ig ns /s ym pt om s is p re se nt , pr oc ee d wi th a dd itio n a l c a re p ro vi si on (n ex t c o lu m n). If th e po st pa rtu m p er io d is pr og re ss in g n o rm a lly , p ro vid e ba si c ca re a s sh ow n in Ch ap te r 7 , w ith th e fo llo w in g ad di tio n s a n d/ or e m ph as e s. A bd om in al in ci si on : z Ad vis e th e wo m a n to fo llo w u p as d ire ct ed w ith th e sk ille d pr o vi de r w ho p e rfo rm ed th e pr oc ed u re . ¨ If th e w om an re po rts (o r t he re ar e o bv io us s ig ns o f) an y pr ob le m s re la te d to th e pr oc ed ur e, fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). Va gi na l o r p er in ea l t ea rs , e pi si ot om y, o r d ef ib ul at io n : z En su re g o o d pe rin ea l/g e n ita l h yg ie n e to p re ve n t i nf ec tio n (s ee pa ge 2 -2 9). z Ad vis e th e wo m a n a s fo llo w s: − Br ea st fe ed w hi le ly in g on h er s id e ra th er th an sit tin g (pa ge 4- 47 ). − W ai t t o re su m e se xu al in te rc ou rs e fo r a t l ea st 2 w ee ks a fte r b irt h o r u n til : t he re is n o lo ch ia ru br a o r se ro sa , lo ch ia a lb a ha s di m in is he d o r de cr e a se d, th e va gi na a n d pe rin eu m a re h ea le d, a n d th er e is n o pe rin e a l p a in . ¨ If th e w om an h as b ur ni ng o n u rin at io n du e to u rin e pa ss in g o ve r th e in jur ed p er in eu m , a dv ise h er th at th is w ill im pr o ve a s th e in ci si o n o r te a r he a ls . ¨ If th e w om an h as a re pa ire d 3r d o r 4t h de gr ee te ar o r ep is io to m y, a dv ise h e r to in cr e a se h e r in ta ke o f f lu id s (2– 3 lit er s pe r d ay ), f rui ts, ve ge tab le s, a nd w ho le g ra in s o r u se a s to ol so fte ne r t o pr ev e n t c on st ip a tio n o r pr ev e n t f ur th er d am a ge o r pa in fr om c on st ip at io n . z A LL te ar s an d in ci si on s: Ad vi se h er to re tu rn fo r c ar e if si gn s/ sy m pt om s pe rs ist o r w or se n , o r if sig ns /s ym pt om s of in fe ct io n de ve lo p. z Re vie w th e da ng er s ign s an d th e w om an ’s c om pl ica tio n re ad in es s pl an . − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly a cc e ss ib le . − En su re th at s he k no w s w he re to go fo r h el p if a da ng er s ign a ris es . 3- 79 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Ur in ar y Re te nt io n du rin g La bo r a nd th e Po st pa rtu m Pe rio d (F or the ra tio na le fo r p ro vid in g a dd itio n a l c ar e to a w om an w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) G en er al c on si de ra tio ns : T he pr es su re o f t he fe tu s’s h ea d o n th e ur et hr a a n d bl ad de r du rin g pr ol on ge d la bo r c an le ad to b ru is in g, e de m a, a nd e ve n s pa sm o f t he in te rn a l sp hi nc te r o f t he b la dd er . A ny o f t he se e ffe ct s ca n re su lt in u rin ar y re te n tio n in la bo r o r t he e a rly p o st pa rtu m p er io d. Pe rfo rm b as ic as se ss m en t, as s ho w n in Ch ap te r 6 or 7 (pa ge 2- 37 o r 2- 83 ), w ith th e f oll o w in g ad di tio ns a nd /o r e m ph a se s. z As se ss th e w om a n fo r f ev er (te mp era tur e 3 8° C or m or e). ¨ If th e w om an h as a fe ve r, AC T NO W !— se e F ev er o r Fo ul -S m el lin g Va gi n a l D is ch ar ge (p ag e 3- 11 5) be for e pr oc ee di n g. ¨ If th e w om an d oe s no t h av e a fe ve r, pr oc e e d wi th a dd itio n a l a ss es sm e n t. z As se ss th e w om a n (a sk ab o u t a nd o bs er ve ) fo r u rin e l e a ki n g fro m th e va gi na . ¨ If ur in e is le ak in g fro m h er v ag in a, fa cil ita te n on u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ) a fte r p rov idi ng ba sic c ar e . ¨ If th er e is n o u rin e le ak in g fro m h er v ag in a, th e pr ob a bl e di ag n o si s is u rin a ry re te nt io n . Pr oc ee d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). If la bo r o r t he p o st pa rtu m p er io d is pr og re ss in g no rm al ly, p ro vi de b as ic ca re a s sh ow n in C ha pt er 6 o r 7 (p ag e 2- 37 o r pa ge 2 -8 3), w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. z H el p th e w o m a n u rin a te . − As si st h er in fi nd in g a c o m fo rta bl e po sit io n — pe rh a ps o ut o f b ed . − Pr ov id e pr iva cy fo r h er . − R un ta p wa te r t ha t s he c an h ea r, a n d/ or p ou r w a rm w a te r o ve r he r v ul va to h el p he r u rin a te . ¨ If al l n o n in va si ve m et ho ds to he lp h er u rin at e ar e u n su cc es sf ul : − D ur in g la bo r, in se rt a st ra ig ht ca th et er u si ng a se pt ic te ch ni qu e, d ra in u rin e , a n d re m o ve c a th et er . − D ur in g th e po st pa rtu m p er io d: − In se rt a se lf- re ta in in g ca th e te r u si ng a se pt ic te ch ni qu e . ¨ If it ap pe ar s th at th e bl ad de r c on ta in s m or e th an o n e lit er o f u rin e, dr ai n th e ur in e a t i nt er va ls , n o m o re th an 1/ 2 lit er a t a ti m e. − Le av e th e ca th e te r i n fo r 2 4– 48 ho ur s, d ra in in g in to a cl os ed b ag o r c o n ta in e r. − G ive am ox ici llin 50 0 m g by m ou th e ve ry 8 h ou rs fo r 3 da ys O R tri m et ho pr im /s ul fa m et ho xa zo le (1 60 m g/ 80 0 m g) by m o u th e ve ry 1 2 ho ur s fo r 3 d a ys . N ot e: Th e w om a n m a y ne e d m u ch e nc ou ra ge m en t t o pa ss u rin e fre qu en tly b ec a u se d o in g so m a y be p ai nf ul . z En co ur a ge h e r to in cr ea se h e r flu id in ta ke . z Ad vis e he r t o re tu rn fo r c ar e if sy m pt om s pe rs ist o r w or se n, O R if sh e n o tic es b u rn in g o n u rin a tio n, fe ve r, or fl an k/ lo in p a in — w hi ch m a y in di ca te u rin a ry tra ct o r k id ne y in fe ct io n. z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s c o m pl ica tio n re a di ne ss pl an . − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly a cc e ss ib le . − En su re th at s he k no w s w he re to go fo r h el p if a da ng er s ign a ris es . 3- 80 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Ut er in e Su bi nv o lu tio n (F or the ra tio na le fo r p ro vid in g a dd itio n a l c ar e to a w om an w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) N ot e: Ut er in e su bi nv o lu tio n is de fin e d as a n in cr e a se in lo ch ia o r w he n th e ut er us ha s in cr e a se d, o r is n ot de cr ea si ng , i n siz e (as sh ow n in F ig ur e 2- 20 , p ag e 2- 99 ) si nc e th e la st p os tp ar tu m v isi t. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 7 , w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. z As se ss th e w om a n fo r f ev er (te mp era tur e o f 3 8° C or m or e). ¨ If th e w om an h as a fe ve r, AC T NO W !— pe rfo rm R ap id In iti al A ss es sm e n t (p ag e 3- 90 ) b efo re pro ce e di ng . ¨ If th e w om an d oe s no t h av e a fe ve r, co n tin u e w ith a dd itio n a l a ss es sm e n t. z As se ss th e w om a n fo r a bd o m in al p ai n . ¨ If th e w o m an h as a bd om in al p ai n, A CT N O W !— pe rfo rm R ap id In iti al A ss es sm e n t (p ag e 3- 90 ) b efo re pr oc ee di n g. ¨ If th e w o m an d oe s no t h av e ab do m in al pa in , co n tin ue w ith a dd itio n a l a ss e ss m e n t. z As se ss th e w om a n ’s lo ch ia /b le e di n g. ¨ If th er e is h ea vy b le ed in g, AC T NO W !— pe rfo rm R ap id In iti al A ss es sm e n t (p ag e 3- 90 ) b efo re pro ce e di ng . ¨ If th er e is n o m o re lo ch ia th an n or m al , pr o ce e d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). If th er e is no fe ve r, ab do m in al pa in , o r h ea vy bl ee di ng a n d he r p os tp a rtu m pe rio d is pr og re ss in g n o rm a lly e xc ep t t ha t t he u te ru s is s til l n o t de cr ea si ng in s iz e a n d/ or th e lo ch ia is n o t d ec re a si ng in a m o u n t, pr ov id e ba sic c ar e a s sh ow n in Ch ap te r 7 (p ag e 2- 83 ), w ith th e f oll o w in g a dd itio n s a n d/ or e m ph as e s. z G ive a u te ro to n ic d ru g (Ta bl e 3- 3, p ag e 3- 10 6), pr efe rab ly e rg om et rin e 2 m g by m ou th 3 tim es p er d ay fo r 3 d ay s. z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s c o m pl ica tio n re a di ne ss pl an : − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly a cc e ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a d an ge r s ig n a ris es . 3- 81 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S DU RI NG P RE G NA NC Y, L A B O R AN D B IR TH , A N D T H E PO ST PA RT UM P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Vi ol en ce a ga in st W o m en (F or the ra tio na le fo r p ro vid in g a dd itio n a l c ar e to a w om an w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) N ot e: W hi le a ss e ss in g a n d ca rin g fo r t he w o m a n w ho h a s su ffe re d fro m v io le n ce o r a bu se , fo cu s on th e in te rp e rs o n a l s ki lls o ut lin e d in Te xt bo x 3- 30 (p ag e 3- 82 ). G en er al c on si de ra tio ns : Vi ol en ce a ga in st w om en a ffe ct s bo th th ei r p hy sic a l a n d m e n ta l h e a lth . A lth ou gh y ou m a y no t h av e ha d tra in in g in ho w to d ea l w ith th es e pr ob le m s, y ou m a y co nf ro nt th em a s yo u co u n se l, as se ss , a n d ca re fo r w om en s ee ki ng ca re d ur in g pr e gn an cy , l ab or a n d bi rth , o r t he p os tp ar tu m pe rio d. Y ou r r ol e in re sp on di ng to v io le n ce a ga in st w om en is cr iti ca l b ut lim ite d. F ou r es pe cia lly im po rta nt g oa ls ar e to : z Id en tif y an y ab u se -r e la te d co n di tio n s o r in jur ies , z H el p he r re co gn iz e ab us e in h er o w n li fe a n d e n co u ra ge he r t o ta ke st ep s to p ro te ct h er se lf a n d he r ch ild re n , z En su re th at s he fe el s sa fe w hi le r e ce iv in g ca re , a n d z En co ur a ge a n d/ o r fa cil ita te li n ka ge to a pp ro pr ia te lo ca l s ou rc e s o f s up po rt. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Se ct io n 2, w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. z R ec og n iz e th e si gn s of v io le n ce a ga in st w om e n . Th e fir st s te p in re sp o n di ng to vi ol en ce a ga in st w om en is to id en tif y it. E ve n if th e wo m an d o e s n o t a dm it to a bu se w he n sp ec ific al ly as ke d, th er e ar e ot he r fa ct or s th at m ay s ug ge st a bu se , fo r e xa m pl e : − Th e w om an h as a h is to ry o f a bu se (a s s tat ed by h er o r a s n o te d on he r m e di ca l r ec or d). − Sh e ha s a hi st or y of d ep re ss io n a n d/ or s ui cid e at te m pt s. − H er e xp la n a tio n o f c au se is in co n si st en t w ith a n y in jur ie s o bs er ve d. − Sh e ha s wo u n ds , b ru ise s, a nd le sio n s o n th e a bd o m e n , ch es t, or g en ita l a re a . − Sh e is m al n o u ris he d, h a s u n e xp la in e d pa in , o r a pp e a rs to be in g e n e ra lly p oo r c on di tio n . − Sh e is of te n la te fo r v isi ts o r a tte nd s th em s po ra di ca lly , o r sh e m ay n ot h a ve r e ce iv ed c a re d ur in g pr e gn a n cy . z D et er m in e th e n a tu re o f t he a bu se b y as kin g a bo ut it : − W ha t h as b ee n do ne to h er ? − H ow lo n g ha s it be en g oi ng o n ? − H as it g ot te n wo rs e ? − H ow is it c ur re n tly a ffe ct in g he r life ? z Us e th is in fo rm a tio n to h el p in di vid u a liz e he a lth m es sa ge s a n d co u n se lin g an d o th er a sp ec ts o f b as ic ca re p ro vi si on . z Ke ep th e fo llo w in g in m in d: − Th e w om an m a y de ny a bu se e ve n if it is o cc u rr in g, a n d sh e m ay fe el u n co m fo rta bl e d is cu ss in g a bu se in fr on t o f he r c om pa n io n . It is v er y im po rta nt , t he re fo re , to ta lk w ith he r a lo n e (e .g. , a sk th e co m pa n io n to le a ve th e r o o m u n til yo u ha ve a dd re ss ed th is iss u e ). I f s he sa ys th at sh e i s n ot be in g a bu se d bu t y ou s tro ng ly su sp ec t s he is , le t h er kn ow th at “t he d oo r i s op en ” a n d th at s he c an ta lk to y ou a bo u t t hi s is su e a t a ny ti m e. − If th e wo m an is su ffe rin g fro m a bu se , be a wa re th at s he m a y fe el u nc o m fo rta bl e ta kin g he r c lo th e s o ff fo r t he ph ys ica l e xa m in a tio n o r be in g e xa m in e d du rin g la bo r. G ive h er e xt ra ti m e, if n ee de d, to u nd re ss , a nd e ns u re a de qu at e dr ap in g. B e es pe ci al ly ca re fu l t o as k he r pe rm iss io n/ co n se n t t o to u ch h er b ef or e ea ch ex am in at io n. If th e wo m an is in g oo d he a lth a n d he r p re gn a n cy , l ab o r a n d bi rth , o r po st pa rtu m p e rio d is pr o gr es sin g no rm a lly , p ro vi de b as ic ca re a s sh ow n in S ec tio n 2, w ith th e fo llo w in g ad di tio ns a n d/ o r e m ph as e s. H ea lth M es sa ge s an d Co un se lin g If th e wo m an re po rts a bu se , lis te n at te nt iv el y to h er a nd re sp on d in a sy m pa th et ic, s u pp o rti ve , a nd n o n jud gm en ta l m a n n e r: z Va lid a te h er e xp er ie n ce ; a vo id de ny in g or m in im iz in g th e ab u si ve e xp er ie n ce o r si tu at io n . z Ac kn ow le dg e th e in jus tic e of th e ab u se a n d e m ph a si ze th at it is n ot he r f au lt by m ak in g st at em en ts s uc h a s: “ So m et im es p eo pl e fe el it ’s o ka y if th ey a re hi t o r a bu se d. Bu t t hi s is s om et hi ng th at s ho u ld n o t ha pp en . N o o n e e ve r de se rv e s to b e hi t o r a bu se d in a ny w ay .” z H el p th e w o m a n to fe el th at s he is n ot a lo n e : − As ki ng a bo ut v io le nc e is a ls o a n in te rv e n tio n in re sp on di n g to vi ol en ce . W o m e n o fte n fe el a lo n e a n d iso la te d, so b ei ng a bl e to co n fid e in s om e o n e a bo u t t he vi ol en ce is o fte n a st ep to wa rd a dm itt in g th at th er e is a p ro bl e m , a s w e ll as s e e ki ng a nd a cc e pt in g he lp . − M ak e re as su rin g st at em en ts , s u ch a s, “ I’m g la d th at y ou h av e to ld m e th is. W e o fte n th in k we a re a lo n e , bu t a bu se h ap pe n s to m a n y wo m en .” z H el p he r to fe el e m po we re d by e n co u ra gi n g he r a nd s ha rin g in fo rm at io n wi th h er . Sa fe ty A ct io n Pl an H el p th e w o m a n d ev el o p a “s a fe ty a ct io n pl a n , ” w hi ch c an h el p he r to pr ot ec t h er se lf an d he r u n bo rn ch ild fr o m in ci de nt s of a bu se . Th is p la n m a y in clu de a ll ite m s sh ow n in Te xt bo x 3- 31 (p ag e 3- 82 ). Li nk ag e to A pp ro pr ia te L oc al S ou rc es o f S up po rt Fa ci lit at e lin ka ge to a pp ro pr ia te lo ca l s ou rc e s o f s up po rt (Te xt bo x 3- 9, pa ge 3 -4 0) wi th th e fo llo w in g ad di tio n : z Fa ith -b as e d or ga ni za tio n s a n d lo ca l n o n go ve rn m e n ta l o rg a n iz at io n s m a y pr ov id e s e rv ic es n ee de d by th e wo m an . Su ch o rg a n iz at io ns m ay a ls o be a m e ch a n is m fo r f ac ilit a tin g ad op tio n fo r v ict im s of ra pe o r o th er s w ith u n w a n te d ba bi es . Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-82 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-30. Additional Interpersonal Skills for Women Suffering from Violence When providing basic care to a pregnant woman or new mother who is suffering from violence: z Help her recognize her right to high-quality care: be sure that she feels welcome, knows what services are available, and understands how to access these services. z Demonstrate sympathy and understanding. z Help her feel safe by ensuring a pleasant environment and using a kind, nonjudgmental approach to communication. z Ensure complete confidentiality and privacy during her visits. z Respect her right to make decisions about the care she receives. Allow her the time she needs to make important decisions. z Be aware of, and gently responsive to, a possible fear of vaginal examinations or any invasive procedure. For more information on Interpersonal Skills, see page 1-42. Textbox 3-31. Safety Action Plan for Women Suffering from Violence Help the woman develop a “safety action plan,” which can help her to protect herself and her baby from incidents of abuse. This plan may include the following steps: z Identify neighbors, friends, or relatives who are willing to offer assistance or a “refuge.” z Tell a trusted neighbor about the violence, and ask that person to call the police or other trusted authority if loud noises are heard coming from the house. z Know the contact information for community agencies that can provide emergency assistance. z Keep a bag packed with money, clothes, and important papers in case it is necessary to leave home quickly. z Plan and rehearse an “escape route.” 3- 83 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L N EE D S O F TH E N EW B O RN P ER IO D SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Cu ts o r A br as io n s th at A re N ot B le ed in g (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M N P. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo w in g ad di tio n s a n d/ or e m ph a se s. ¨ If th e cu ts o r a br as io ns a re b le ed in g, se e Bl ee di ng (pa ge 3 -1 26 ) b e fo re p ro ce e di n g. z Be a le rt fo r s ig n s o f a m or e se rio us c o n di tio n : − Sw el lin g o r te nd er ne ss o ve r bo n e o r joi nt − Br ui se s − Pa llo r − In co ns ol a bl e cr yin g ¨ If AN Y of th e ab ov e si gn s is p re se nt , AC T NO W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ) be fo re p ro ce e di ng . ¨ If NO NE o f t he a bo ve s ig ns is p re se nt , pr oc e e d wi th a dd itio n a l c ar e pr ov isi o n (n e xt c ol um n). If th e ne wb or n is in g oo d he a lth a n d th e n e w bo rn p e rio d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e a s sh ow n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph a se s. z Cl ea n th e cu t o r a br as io n u si n g ga uz e s o a ke d in a n a n tis ep tic s ol ut io n (e .g. , 2 .5% po lyv id on e io di n e ; n ot e th at o th er a nt is e pt ic so lu tio ns m a y st in g). z Ke ep th e wo u n d cl ea n a n d dr y an d in st ru ct th e wo m a n ho w to d o so . ¨ If th e ba by h as a c ut , co ve r th e cu t w ith a s im pl e ba nd ag e to k ee p it cle an a n d dr y. ¨ If th e ed ge s of th e cu t a re o pe n, pu ll t he m cl os ed w ith a b u tte rfl y ba nd a ge . z As k th e w om an to b rin g th e ba by b ac k if sh e se e s si gn s o f l oc al in fe ct io n (e .g. , re dn es s, h ea t, sw el lin g o f s kin a ro u n d cu t o r a br a si on ). ¨ If si gn s o f l oc al in fe ct io n ar e se en , tre at w ith a to pi ca l a n tib io tic o in tm en t 3 ti m e s pe r d ay fo r 5 da ys , l ea vin g th e cu t o r a br as io n un co ve re d. z H el p th e w o m a n d et er m in e th e c a u se o f t he c u ts o r a br as io n s so th a t t he y ca n be p re ve n te d in th e fu tu re . z H av e th e w o m a n r e tu rn w ith th e ba by in 1 w e e k. If th er e is n o in fe ct io n , n o fu rth er fo llo w u p is ne e de d. 3- 84 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S O F TH E NE W B O RN P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N La rg e Ba by (4 kg or m or e) (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M N P. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 8 , w ith th e fo llo wi ng a dd itio n s a n d/ or e m ph as e s. z D et er m in e w he th er th e ba by ’s m o th er h as b ee n d ia gn o se d w ith di ab e te s. z O bs er ve th e ba by c lo se ly fo r t he fo llo w in g pr o bl em s, w hi ch a re m o re li ke ly to o cc u r in a la rg e ba by : − Bi rth in jur ie s— be s ur e th at th e b ab y is ab le to m o ve a ll lim bs a nd th at th er e ar e n o lu m ps o r k no ts o n a n y bo n e s. − Si gn s of lo w b lo o d gl u co se — be a le rt fo r e xt re m e le th a rg y (sl ee pin e ss ), a pn ea , co n vu ls io n s, o r jitt eri ne ss . − M ec on iu m a sp ira tio n— if th ick m e co n iu m is p re se n t i n th e a m n io tic fl ui d, b e al e rt fo r s ig ns o f b re at hi n g di ffi cu lty . − R es pi ra to ry d ist re ss — be a le rt fo r s ig ns o f b re at hi ng di ffi cu lty . ¨ If th e ba by ’s m o th er h as d ia be te s an d th e ba by is le ss th an 3 da ys o f a ge , O R th e ba by h as A N Y of th e ab ov e pr ob le m s, AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , pa ge 4 -6 3). ¨ If th e ba by ’s m o th er d oe s NO T ha ve d ia be te s, a nd th e ba by ha s N O NE o f t he a bo ve p ro bl em s, pr oc ee d wi th a dd itio n a l ca re p ro vis io n (n ex t c olu mn ). If th e ne wb or n is in g oo d he a lth a n d th e n e w bo rn p e rio d is pr og re ss in g n or m al ly, pr ov id e ba sic c ar e as s ho w n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo w in g ad di tio n s a n d/ or e m ph a se s. z Be s ur e th at th e b ab y st ar ts b re a st fe ed in g wi th in th e fir st ho ur a n d th at s /h e is a llo w e d to s uc kle a s lo n g a n d as fre qu en tly a s de si re d. 3- 85 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S O F TH E NE W B O RN P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N Lo w B irt hw ei gh t B ab y (le ss th an 2 .5 k g) (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) N ot e: A ba by w ho w ei gh s le ss th an 2 .5 kg a t b irt h is ge n e ra lly c on sid e re d lo w bi rth we ig ht , r eg ar dl e ss o f g es ta tio na l a ge . In s om e po pu la tio ns , h ow e ve r, s m a lle r ba bi e s a re n o t c on si de re d to b e lo w bi rth we ig ht , a nd lo ca l s ta n da rd s wi ll n e e d to b e es ta bl is he d. W ha te ve r t he c au se o f lo w b irt hw e ig ht o r th e m at ur ity o f t he lo w bi rth we ig ht b ab y, th e sm al l b ab y re qu ire s a dd itio n a l c ar e. Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo w in g ad di tio n s a n d/ or e m ph a se s. ¨ If th e ba by w ei gh s le ss th an 2 k g, A CT N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). ¨ If th e ba by w ei gh s 2– 2. 5 kg , o bs er ve th e ba by e ve ry 1 5 m in ut es d u rin g th e 4th st ag e an d be a le rt to th e fo llo w in g pr ob le m s, w hi ch a re m or e lik e ly to o cc ur in a lo w b irt hw e ig ht ba by : − Br ea th in g pr ob le m s— if th e ba by is p re te rm , t he lu n gs m ay n o t b e m at ur e. − Lo w b o dy te m pe ra tu re — th e lo w b irt hw ei gh t b a by h as lit tle o r n o fa t f or in su la tio n , a n d th e te m pe ra tu re r e gu la tin g sy st em o f t he p re te rm b ab y is im m at ur e. − Fe ed in g pr ob le m s— th e lo w b irt hw ei gh t b ab y m a y ha ve lit tle st re ng th to s uc kl e vi go ro u sl y a n d ha s a s m a ll st om ac h so m u st fe ed m or e fre qu en tly . ¨ If th e ba by ha s AN Y of th e ab o v e pr o bl em s, AC T NO W !— pe rfo rm N ew bo rn R ap id In itia l A ss es sm en t (p ag e 3- 96 ) be fo re p ro ce e di ng . N ot e: Th e ba by w ith a lo w bi rth w ei gh t i s m or e a t r is k of in fe ct io n a n d jau n di ce , b u t t he se p ro bl em s m a y no t b e e vi de n t d ur in g th e fir st 2 h ou rs a fte r b irt h. If th e ne wb or n is in g oo d he a lth a n d th e n e w bo rn p e rio d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e a s sh ow n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph a se s. z Ke ep th e ba by in s ki n- to -s ki n c o n ta ct b et we e n th e w o m a n ’s b re a st s. K ee p th e ba by ’s he a d co ve re d, a nd pl ac e a se cu re c o ve r o ve r th e w om an a nd b a by . z En su re th at th e ro o m is k ep t w a rm (a t le as t 2 5° C) . z En su re th at th e ba by s ta rts b re as tfe ed in g wi th in th e fir st ho ur a n d th at s /h e nu rs es a t l e a st e ve ry 2 –3 ho ur s. z En su re th at th e ba by re ce iv es v ita m in K 1 1 m g IM w ith in th e fir st 6 h ou rs a fte r b irt h. z Ke ep th e wo m a n w e ll- in fo rm e d of th e ba by ’s c o n di tio n a n d ex pl ai n th e re a so n s th e ba by m ay h av e s pe cia l pr ob le m s w ith b re at hi n g, fe ed in g, o r k ee pi ng w a rm . z To d et er m in e if th e ba by is m ai nt ai ni ng w ar m th , t he w o m a n c a n c he ck th e ba by ’s h an ds a nd fe e t e ac h tim e sh e br ea st fe ed s. If th ey a re c ol d, s he c an k ee p th e ba by in sk in -to -s ki n co nt ac t u nt il th e ne xt ti m e sh e br ea st fe ed s. T hi s co nt ac t a ls o he lp s to s ta bi liz e th e ba by ’s br ea th in g, pr ot ec ts th e ba by fr om in fe ct io n, a nd e n ha n ce s br e a st fe ed in g. M ot he r w ith H ep at iti s B (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M N P. ) N /A If th e ne wb or n pe rio d is pr og re ss in g n o rm a lly , p ro vid e ba si c ca re a s sh ow n in C ha pt er 8 (p ag e 2- 10 9), w ith th e f oll ow ing a dd itio n s a n d/ or e m ph as e s: z G ive th e fir st d os e of 0 .5 m L he pa tit is B v ac ci ne IM in th e up pe r th ig h a s so o n a s po ss ib le a fte r b irt h (pr efe rab ly wi th in 1 2 ho ur s af te r b irt h). z If av ai la bl e , gi ve he pa tit is im m u n e g lo bu lin 20 0 IU IM in th e ot he r t hi gh w ith in 2 4 ho u rs a fte r b irt h. z R ea ss ur e th e w o m a n th a t i t i s sa fe to b re as tfe ed . z Ad vis e th e wo m a n to in iti a te o r c on tin u e c a re fo r h er se lf w ith a n ap pr op ria te s pe cia lis t. 3- 86 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S O F TH E NE W B O RN P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N M ot he r w ith hi st or y of ru pt ur e 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 an d/ or u te rin e in fe ct io n or fe ve r d ur in g la bo r o r b irt h (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M N P. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s. B ab y 3 da ys o ld o r l es s: ¨ If th e m ot he r h ad ru pt ur e of m em br an es fo r m or e th an 1 8 ho ur s w ith ou t 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, a ss e ss th e ne w bo rn fo r th e fo llo wi n g si gn s of s ep si s: − Fo ul s m el l − Po or fe ed in g/ su ck lin g af te r h av in g fe d we ll − Br ea th in g di ffi cu lty (e .g. , re sp ira to ry ra te le ss th an 3 0 or m or e th an 6 0 br e a th s pe r m in ut e, g ru n tin g on e xp ira tio n, c he st in dr aw in g) − Se ve re v om iti ng − D ia rrh e a − Fl op pi n e ss o r le th ar gy − Un st ab le b od y te m pe ra tu re − Co nv ul sio ns /s pa sm s − Ab do m in a l d ist e n tio n ¨ If AN Y si gn s of n ew bo rn se ps is , AC T NO W !— fa cil ita te u rg en t re fe rr al /tr an sf er (A nn ex 7 , p ag e 4- 63 ) b ef or e pr oc ee di n g. Co m pl et e th e fo llo w in g st ep in a dd iti on to th o se in A nn e x 7: − G ive th e ba by a m pi cil lin 5 0 m g/ kg b od y we ig ht IM P LU S ge nt am ic in 5 m g/ kg b od y we ig ht IM (if 2 kg or m ore ) o r 4 m g/ kg b od y w e ig ht IM (if le ss th an 2 kg ). ¨ If NO s ig n s o f n ew bo rn s ep si s, pr oc ee d wi th a dd iti on a l c ar e pr ov isi o n (n e xt c ol um n). ¨ If th e m ot he r h ad u te rin e in fe ct io n or fe ve r d ur in g la bo r o r ch ild bi rt h, AC T N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A n n ex 7 , pa ge 4 -6 3) be for e p ro ce e di ng . Co m pl et e th e fo llo wi n g st ep in a dd itio n to th os e in A nn ex 7 : − G ive th e ba by a m pi cil lin 5 0 m g/ kg b od y we ig ht IM P LU S ge nt am ic in 5 m g/ kg b od y we ig ht IM (if 2 kg or m ore ) o r 4 m g/ kg b od y w e ig ht IM (if le ss th an 2 kg ). B ab y m or e th an 3 d ay s ol d: ¨ If AN Y si gn s of n ew bo rn s ep si s (se e l ist ab ov e), AC T NO W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ) b efo re pr oc ee di ng . Co m ple te th e fo llo wi n g st ep in ad di tio n to th os e in An n ex 7 : − G ive th e ba by a m pi cil lin 5 0 m g/ kg b od y we ig ht IM P LU S ge nt am ic in 5 m g/ kg b od y we ig ht IM (if 2 kg or m ore ) o r 4 m g/k g bo dy w e ig ht IM (if le ss th an 2 kg ). ¨ If NO s ig ns o f n ew bo rn s ep si s (se e l ist ab ov e), n o a dd iti o n a l c a re is n ec es sa ry . If th e ne wb or n is in g oo d he a lth a n d th e n e w bo rn p e rio d is p ro gr es sin g n o rm a lly , p ro vid e ba sic c ar e as sh ow n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph as e s. z O bs er ve th e ba by fo r s ig ns o f s e ps is ev er y 4 ho ur s fo r 5 d ay s. z Te ac h th e w om a n to w at ch fo r s ig ns o f s ep si s an d to s ee k m ed ica l c ar e im m ed ia te ly if an y of th es e si gn s ap pe a r. 3- 87 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am SP EC IA L NE ED S O F TH E NE W B O RN P ER IO D (C ON TIN UE D) SP EC IA L NE ED A D D IT IO NA L AS SE SS M EN T A D D IT IO NA L CA RE P RO VI SI O N M ot he r w ith H IV (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) Fo r i nf or m at io n o n a dd iti on al a ss e ss m e n t f or th e ba by o f a w o m a n w ho is H IV -p o si tiv e, s ee p ag e 3- 51 . Fo r i nf or m at io n o n a dd iti on al c ar e p ro vis io n fo r a b ab y of a w o m a n w ho is H IV -p os itiv e, s e e p ag e 3- 51 . M ot he r w ith Sy ph ili s (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M N P. ) Fo r i nf or m at io n o n a dd iti on al a ss e ss m e n t f or th e ba by o f a w o m a n w ith s yp hi lis (d iag no si s or si gn s/ sy m pt om s of ), s ee pa ge 3 -7 6. Fo r i nf or m at io n o n a dd iti on a l c a re p ro vis io n fo r t he b ab y of a w o m a n w ith s yp hi lis (d iag no si s o r si gn s/ sy m pt om s of ), s ee pa ge 3 -7 6. M ot he r w ith Tu be rc ul os is (F or the ra tio na le fo r p ro vid in g ad di tio na l ca re to a b ab y w ith th is s pe cia l n ee d, s ee Ta bl e 1- 12 , p ag e 1- 31 . ) (F or ad dit ion a l i nf or m at io n o n d iff er en tia l di ag n o si s an d tre a tm en t, se e M N P. ) Pe rfo rm b as ic a ss e ss m e n t, as s ho w n in Ch ap te r 8 , w ith th e fo llo wi ng a dd itio n s a n d/ or e m ph as e s. z D et er m in e w he th er th e w om an ’s in fe ct io n is a ct iv e (fe ve r; n igh t sw e a ts ; w ei gh t l os s; c hr on ic , p ro du ct iv e co ug h; p le ur isy ; p os itiv e sp ut um c ul tu re o r X- ra y). z D et er m in e w he th er s he w as d ia gn o se d (sp u tu m -p os itiv e ) w ith in 2 m on th s be fo re th e bi rth . z D et er m in e w he th er s he w as tr e a te d fo r l es s th an 2 m on th s be fo re th e bi rth . ¨ If th e m ot he r h as a ct iv e tu be rc u lo si s an d ha s no t b ee n tr ea te d or w as tr ea te d fo r l es s th an 2 m on th s be fo re b irt h, O R if th e m ot he r w as d ia gn o se d (sp ut um - po si tiv e) wi thi n 2 m on th s of th e ba by ’s b irt h, tre at a cc or di ng to lo ca l p ro to co l a n d pr o ce e d wi th a dd itio n a l c ar e p ro vis io n (n e xt c ol um n). If th e ne wb or n is in g oo d he a lth a n d th e n e w bo rn p e rio d is pr og re ss in g n o rm a lly , p ro vid e ba sic c ar e a s sh ow n in Ch ap te r 8 (p ag e 2- 10 9), w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph a se s. z Im m un iz at io n s a n d ot he r pr ev e n tiv e m ea su re s: − D o N O T gi ve B CG a t b irt h. − G ive th e ba by p ro ph yla ct ic iso n ia zi d 5 m g/ kg b od y w e ig ht d ai ly fo r 6 m on th s. z Fo llo w u p: − Co un se l t he w o m a n to h av e th e ba by re -e va lu at ed by a s pe cia lis t a t t he a ge o f 6 w e e ks to c he ck fo r si gn s/ sy m pt om s o f t ub er cu lo si s a n d to p er fo rm a n X- ra y of th e ch es t. − Tw o w ee ks a fte r th e 6- m o n th tr ea tm en t w ith is on ia zi d th e ra py , g ive B CG (if th er e ar e no s ig ns o f t ub er cu lo si s). − Ad vis e th e wo m a n to in iti a te o r c on tin u e c a re fo r he rs el f w ith a n ap pr o pr ia te s pe ci al is t. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-88 JHPIEGO/Maternal and Neonatal Health Program JHPIEGO/Maternal and Neonatal Health Program 3-89 CHAPTER ELEVEN LIFE-THREATENING COMPLICATIONS OVERVIEW This chapter contains guidance for skilled providers on how to respond to life-threatening complications (as described on page 1-37) that they may encounter when caring for women and their newborn babies during pregnancy, labor and childbirth, and the postpartum/newborn period. A woman or newborn who presents with a danger sign (a sign/symptom that may indicate a life-threatening complication) during the quick check (Annex 7, page 4-63)—or at any other point in the course of basic care during pregnancy, labor and childbirth, or the postpartum/newborn period (as shown in Chapters 4–8)—should immediately receive additional care by a skilled provider, according to the guidelines shown below. (For an index of life-threatening complications for the woman and newborn, see Textbox 3-32 [page 3-90].) Responding to Danger Signs Identified during the Quick Check z Every woman or newborn who presents with a danger sign during the quick check should immediately receive a Rapid Initial Assessment (for the woman: page 3-90; for the newborn: page 3-96), by a skilled provider, to determine the following: z Degree of illness z Need for emergency care/stabilization z Appropriate course of action to be taken ¨ If the woman IS in need of stabilization or the newborn IS in need of resuscitation, the skilled provider should follow the appropriate procedure (for the woman: page 3-92; for the newborn: page 3-99) before proceeding. ¨ If the woman or newborn IS NOT in need of stabilization/resuscitation or HAS BEEN stabilized/resuscitated, the skilled provider should treat her or the newborn according to guidelines under the presenting life-threatening complication, which may involve: z Referral/transfer to a specialist or higher level of care if appropriate (Annex 7, page 4-63); OR z Provision of basic care with certain additions and/or emphases. Responding to Danger Signs Identified in the Course of Basic Care1 z Every woman or newborn who presents with a danger sign at any other point in the course of basic care (i.e., after the quick check) should immediately receive additional care by a skilled provider, according to guidelines under the presenting danger sign, which may involve: z Referral/transfer to a specialist or higher level of care if appropriate (Annex 7, page 4-63); OR z Provision of basic care with certain additions and/or emphases. 1 Some danger signs identified in the course of basic care required Rapid Initial Assessment (and the steps that follow, as needed) by a skilled provider. These are clearly indicated as such throughout Section 2. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-90 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-32. Index of Life-Threatening Complications Maternal Rapid Initial Assessment, page 3-90 (breathing difficulty, convulsions, shock) Stabilization of the Woman, page 3-92 Newborn Rapid Initial Assessment, page 3-96 (breathing difficulty, shock, convulsions or spasms) Newborn Resuscitation, page 3-99 WOMAN NEWBORN Vaginal bleeding in early pregnancy (through 22 weeks’ gestation), page 3-102 Vaginal bleeding in later pregnancy (after 22 weeks’ gestation) or labor, page 3-102 Vaginal bleeding after childbirth, page 3-103 Severe headache, blurred vision, or elevated blood pressure, page 3-108 Unsatisfactory progress of labor, page 3-109 Inadequate uterine contractions, page 3-109 Meconium-stained amniotic fluid, decreased or absent fetal movements, absent fetal heart tones, or abnormal fetal heart rate, page 3-110 Prolapsed cord, page 3-114 Fetal hand or foot presenting, page 3-114 Fever (temperature 38°C or more) or foul-smelling vaginal discharge, page 3-115 Pain in calf, page 3-118 Pus, redness, or pulling apart of skin edges of perineal suture line; pus or drainage from unrepaired tear; severe pain from tear or episiotomy, page 3-118 Severe abdominal pain in early pregnancy (through 22 weeks’ gestation), page 3-119 Severe abdominal pain in later pregnancy (after 22 weeks’ gestation) or labor, page 3-119 Severe abdominal pain after childbirth, page 3-120 Contractions before 37 weeks’ gestation, page 3-120 Verbalization/behavior that indicates woman may hurt herself or the baby, or hallucinations, page 3-121 Abnormal body temperature, page 3-122 Jaundice, page 3-124 Diarrhea, page 3-125 Abdominal distention, page 3-125 Bleeding, page 3-126 Pus or lesions of skin, page 3-127 Pus or redness of eyes, page 3-129 Redness or foul smell of umbilicus, page 3-130 Swollen limb or joint, page 3-130 MATERNAL RAPID INITIAL ASSESSMENT Note: For Rapid Initial Assessment of the newborn, see page 3-96. When danger signs are identified, immediately perform this Rapid Initial Assessment to determine the woman’s degree of illness, her need for emergency care/stabilization, and the immediate course of action that must be taken. Note that many assessments can be conducted simultaneously. z Assess the woman for the following signs/symptoms of breathing difficulty: z Not breathing z Rapid breathing (30 breaths per minute or more) z Obstructed breathing or gasping z Wheezing or rales z Pallor or cyanosis (blueness) of skin ¨ If the woman HAS ANY signs/symptoms of breathing difficulty, call for help. Follow the stabilization procedure under Breathing Difficulty (page 3-92) before proceeding. Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-91 ¨ If the woman DOES NOT HAVE ANY signs/symptoms of breathing difficulty, proceed with this Rapid Initial Assessment. z Assess the woman for convulsions or loss of consciousness. ¨ If the woman IS convulsing or unconscious, follow the stabilization procedure under Convulsions, Unconsciousness, or Diastolic Blood Pressure More than 110 mmHg with Proteinuria 2+ or More (page 3-93) before proceeding. ¨ If the woman IS NOT convulsing or unconscious, proceed with this Rapid Initial Assessment. z Measure the woman’s blood pressure and take her temperature and pulse. ¨ If the woman has low blood pressure (systolic less than 90 mmHg) or a rapid pulse (110 beats per minute or more), assess for other signs/symptoms of shock, which may include: − Pallor of conjunctiva − Perspiration − Cool and clammy skin − Rapid breathing (30 breaths per minute or more) − Anxiousness or confusion − Unconscious or nearly unconscious − Scanty urine output (less than 30 mL per hour) ¨ If the woman IS in shock, call for help. Follow the stabilization procedure under Shock (page 3-95) before proceeding. ¨ If the woman IS NOT in shock, proceed with this Rapid Initial Assessment. Note: Even if the woman shows no evidence of shock at this time, this does not mean she will not go into shock; therefore, constant vigilance is necessary. Suspect or anticipate shock if ANY of the following has occurred/is present: z Vaginal bleeding z Infection z Trauma ¨ If the woman’s diastolic blood pressure is more than 110 mmHg, test her urine for protein (Annex 4, page 4-41). ¨ If the woman’s urine IS POSITIVE for protein 2+ or more, call for help. Follow the stabilization procedure under Convulsions, Unconsciousness, or Diastolic Blood Pressure More than 110 mmHg with Proteinuria 2+ or More (page 3-93) before proceeding. ¨ If the woman’s urine IS NEGATIVE for protein or is positive but less than 2+, proceed with this Rapid Initial Assessment. ¨ If the woman’s temperature is 38°C or more (fever), proceed to Presenting Danger Sign (below). Presenting Danger Sign ¨ If the woman presents with any single danger sign, proceed to the relevant information in this chapter according to life-threatening complication (page 3-92) to provide appropriate management. ¨ If the woman presents with more than one danger sign, proceed first to the entry for the life-threatening complication that is most severe, ensuring that management is provided for EACH of the woman’s life-threatening complications before referral/transfer or before returning to basic assessment and care Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-92 JHPIEGO/Maternal and Neonatal Health Program provision. If it is not clear which presenting life-threatening complication is most severe, proceed to the entry for each life-threatening complication based on the order in which they appear below. ¨ If determination of gestational age is necessary, see page 2-8 for the procedure. Life-Threatening Complications z Vaginal bleeding in early pregnancy (through 22 weeks’ gestation), page 3-102 z Vaginal bleeding in later pregnancy (after 22 weeks’ gestation) or labor, page 3-102 z Vaginal bleeding after childbirth, page 3-103 z Severe headache, blurred vision, or elevated blood pressure, page 3-108 z Unsatisfactory progress of labor, page 3-109 z Inadequate uterine contractions, page 3-109 z Meconium-stained amniotic fluid, decreased or absent fetal movements, absent fetal heart tones, or abnormal fetal heart rate, page 3-110 z Prolapsed cord, page 3-114 z Fetal hand or foot presenting, page 3-114 z Fever (temperature 38ºC or more) or foul-smelling vaginal discharge, page 3-115 z Pain in calf, page 3-118 z Pus, redness, or pulling apart of skin edges of perineal suture line; pus or drainage from unrepaired tear; severe pain from tear or episiotomy, page 3-118 z Severe abdominal pain in early pregnancy (through 22 weeks’ gestation), page 3-119 z Severe abdominal pain in later pregnancy (after 22 weeks’ gestation) or labor, page 3-119 z Severe abdominal pain after childbirth, page 3-120 z Contractions before 37 weeks’ gestation, page 3-120 z Verbalization/behavior that indicates woman may hurt herself or the baby, or hallucinations, page 3-121 STABILIZATION OF THE WOMAN Breathing Difficulty z Stabilize the woman according to the following guidelines before proceeding: ¨ If the woman IS NOT breathing: − Keep woman in supine position with her head tilted backwards. − Lift her chin to open the airway. − Inspect her mouth for foreign body and remove if found. − Clear secretions from her throat. − Ventilate with bag and mask until the woman starts breathing. ¨ If the woman IS breathing: − Rapidly evaluate vital signs (pulse, blood pressure, breathing) if not already done. − Prop the woman on her left side. Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-93 − Give oxygen at 6–8 L per minute. − Continually ensure that her airway is clear. z As soon as the Rapid Initial Assessment is complete and the woman is stabilized, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). (For complete differential diagnosis and management of breathing difficulty, see MCPC.) Convulsions, Unconsciousness, or Diastolic Blood Pressure More than 110 mmHg with Proteinuria 2+ or More z Rapidly evaluate vital signs (pulse, blood pressure, breathing) if not already done. z Stabilize the woman according to the following guidelines before proceeding: z Never leave her alone. z Protect her from injury, but do not actively restrain her. ¨ If the woman IS unconscious: z Check her airway; z Prop her on her left side; and z Check for neck rigidity. ¨ If her neck is rigid, use appropriate isolation precautions to protect facility staff and other patients in case the woman is found to have meningitis. ¨ If the woman IS convulsing, turn her on her side to minimize the risk of aspiration if she vomits and to ensure that an airway is open. z Give a loading dose of magnesium sulfate solution (Textbox 3-33, page 3-94). Note: If magnesium sulfate IS NOT available, use diazepam. For treatment guidelines, see Textbox 3-34 (page 3-95). (For complete differential diagnosis and management of headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure, see MCPC.) Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-94 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-33. Loading Dose and Maintenance Dose Schedule for Magnesium Sulfate z Give magnesium sulfate solution*, 4 g IV slowly over 5 minutes. Advise the woman that she will experience a feeling of warmth when magnesium sulfate is given. z Follow promptly with 10 g of magnesium sulfate solution, 5 g in each buttock as deep IM injection, with 1 mL of 2% lidocaine in the same syringe. Ensure that aseptic technique is used when giving a deep IM injection. ¨ If convulsions persist or recur after 15 minutes, give magnesium sulfate, 2 g IV over 5 minutes. z As soon as the Rapid Initial Assessment is complete and the woman is stabilized, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If referral/transfer is delayed or the woman is in advanced labor, continue to give magnesium sulfate according to the maintenance dose schedule (see warning, below): − Give magnesium sulfate 5 g IM plus 1 mL of 2% lidocaine (into alternate buttocks) every 4 hours. − Continue treatment for 24 hours after birth or after the last convulsion, whichever occurs last. WARNING! Before giving the woman another dose of magnesium sulfate, ensure that the woman’s: z Respiratory rate is at least 16 breaths per minute; ¨ If respiratory arrest occurs, assist ventilation with a mask and bag, and give calcium gluconate 1 g (10 mL of 10% solution) IV slowly over 10 minutes. z Patellar reflexes are present; and z Urinary output is at least 30 mL per hour over 4 hours. * Magnesium sulfate comes in different concentrations (e.g., 20%, 40%, 50%). When giving injections IM, it is best to use higher concentrations (e.g., 50%) to decrease the total volume required. Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-95 Textbox 3-34. Loading Dose and Maintenance Dose Schedule for Diazepam ONLY if magnesium sulfate IS NOT available, treat with diazepam as follows: Intravenous Administration z Give a loading dose of diazepam, 10 mg IV slowly over 2 minutes. ¨ If convulsions persist or recur, repeat loading dose. z As soon as the Rapid Initial Assessment is complete and the woman is stabilized, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If referral is delayed or the woman is in advanced labor, give a maintenance dose according to the following guidelines: − Give diazepam 40 mg in 500 mL IV fluids (Ringer’s lactate or normal saline) over 6–8 hours, titrated to keep the woman sedated but rousable. ¨ If respiratory rate drops below 16 breaths per minute, stop the maintenance dose. − Do not give more than 100 mg of diazepam in 24 hours. Rectal Administration z When IV access is not available, give diazepam rectally. z Give a loading dose of diazepam, 20 mg in a 10 mL syringe, according to the following guidelines: − Remove the needle, lubricate the barrel, and insert the syringe into the rectum to half its length. − Discharge the diazepam and leave the syringe in place, holding the buttocks together for 10 minutes to prevent expulsion of the drug. − Alternatively, the drug may be given through a catheter inserted into the rectum. ¨ If convulsions are not controlled within 10 minutes, administer an additional 10 mg or more, depending on the size of the woman and her clinical response. Be prepared to assist ventilation. z As soon as the Rapid Initial Assessment is complete and the woman is stabilized, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If referral is delayed or the woman is in advanced labor, give a maintenance dose according to the following guidelines: − Give diazepam 40 mg in 500 mL IV fluids (Ringer’s lactate or normal saline) over 6–8 hours, titrated to keep the woman sedated but rousable. ¨ If respiratory rate drops below 16 breaths per minute, stop the maintenance dose. − Do not give more than 100 mg of diazepam in 24 hours. Shock z Stabilize the woman according to the following guidelines before proceeding: z Turn the woman on her side to minimize the risk of aspiration if she vomits and to ensure that an airway is open. z Ensure that she is breathing. z Keep the woman warm, but do not overheat her. z Elevate her legs to increase the return of blood to the heart (if possible, raise the foot-end of the bed) before and during transfer. z Start an IV infusion or give oral rehydration solution (ORS) if the woman is fully conscious (see Textbox 3-35 [page 3-96]). z Monitor vital signs (pulse, blood pressure, breathing) and skin temperature every 15 minutes. z As soon as the Rapid Initial Assessment is complete and the woman is stabilized, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). (For further guidance on stabilization of the woman in shock, see MCPC.) Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-96 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-35. Guidelines for Starting an IV Infusion or Giving ORS Starting an IV infusion z Start two IV infusions, if possible. z Use a large-bore needle (16-gauge or largest available). z Rapidly infuse normal saline or Ringer’s lactate at the rate of 1 L per 15–20 minutes. z Give at least 2 L of fluid in the first hour. ¨ If managing shock or bleeding, infuse more rapidly, replacing 2–3 times the estimated fluid lost. ¨ ONLY if unable to start an IV infusion, give the woman ORS according to the guidelines below. Giving ORS z See Textbox 3-36 (below) for instructions on how to make ORS. ¨ If the woman IS ABLE to drink, IS conscious, and IS NOT having (and has not recently had) convulsions, give ORS 300–500 mL by mouth over a 1-hour period. Note: Unless the woman is fully conscious and alert, do NOT give the woman fluid by mouth. ¨ If the woman IS UNABLE to drink, IS NOT conscious, or IS having (or has recently had) convulsions, give ORS 500 mL rectally over a 20- to 30-minute period, according to the following guidelines: − Fill an enema bag/can with 500 mL of ORS. − Run the ORS to the end of the tube and clamp off. − Insert the lubricated tube about 10 cm (3–4 inches) into the rectum. − Run the ORS in slowly. Note: It will take 20–30 minutes for the ORS to run into the woman. If you run it in too rapidly, the woman will get abdominal cramps and push the ORS out. Textbox 3-36. How to Make ORS z Wash a 1-liter container and one teaspoon with soap and water, and rinse with boiled water. z Boil and cool 1 liter of clean (no visible particulate matter or cloudiness) water. z Add 8 level teaspoons sugar. z Add 1/2 level teaspoon salt. z Stir and store in the covered clean container. z Discard unused ORS after 24 hours. CAUTION: Before giving ORS, taste it and be sure it tastes no saltier than tears. NEWBORN RAPID INITIAL ASSESSMENT When danger signs are identified, immediately perform this Newborn Rapid Initial Assessment to determine the newborn’s degree of illness, her/his need for emergency care/stabilization, and the immediate course of action that must be taken. Note that many assessments can be conducted simultaneously. These guidelines assume that a provider skilled in establishing an intravenous line in a newborn is NOT available. z Place the baby on a warm surface that is adequately lit. z Assess the baby for the following signs of breathing difficulty: z Not breathing z Gasping z Abnormal breathing (less than 20 or more than 60 breaths per minute) Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-97 z Indrawing of the chest or grunting on expiration z Asymmetrical or irregular movement of the chest z Central cyanosis (blue tongue and lips) ¨ If the baby IS NOT breathing, IS gasping, or HAS a respiratory rate less than 20 breaths per minute, immediately perform resuscitation (page 3-99) before proceeding. ¨ If the baby HAS ANY other signs of breathing difficulty or has NO signs of breathing difficulty, proceed with this Newborn Rapid Initial Assessment. z Measure the baby’s heart beat. ¨ If the baby has a rapid heart beat (180 beats per minute or more), assess for other signs of shock, which may include: − Pallor − Central cyanosis (blue tongue and lips) − Cold to the touch − Rapid breathing (more than 60 breaths per minute) − Unconscious or nearly unconscious (baby is unresponsive to voice, touch, and light; cannot be awakened) ¨ If the baby IS in shock: − ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63) as soon as the Newborn Rapid Initial Assessment is complete. Complete the following steps in addition to those in Annex 7: − Assess the baby for bleeding. ¨ If the baby is bleeding, press on the bleeding site with a sterile compress, and continue compression before and during transfer. − Keep the baby warm throughout assessment and care. (For further guidance on stabilization of the newborn in shock, see MNP.) ¨ If the baby IS NOT in shock, proceed with this Newborn Rapid Initial Assessment. Note: Even if the baby shows no evidence of shock at this time, this does not mean s/he will not go into shock; therefore, constant vigilance is necessary. Suspect or anticipate shock if ANY of the following has occurred/is present: z Breathing difficulty z Bleeding z Loss of consciousness z Signs of sepsis (lethargy, floppiness, poor feeding, persistent vomiting, inconsolability, foul smell) z Assess the baby for convulsions or spasms: z Convulsions: Repetitive jerking movements of limbs or face; tonic extension or flexion of arms and legs, either synchronous or asynchronous; a straining look; “chomping” and “smacking” of lips; baby may be awake or unresponsive. ¨ If convulsions are suspected, see also Textbox 3-37 (page 3-98). Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-98 JHPIEGO/Maternal and Neonatal Health Program z Spasms: Involuntary contraction of muscles that lasts a few seconds to several minutes; may be triggered by light, touch, or sound; baby is conscious and often crying with pain; jaw and fists are tightly clenched. ¨ If spasms are suspected, see also Textbox 3-37 (below). Textbox 3-37. Distinguishing between Jitteriness and Convulsions/Spasms z Like convulsions, jitteriness is characterized by rapid, repetitive movements. z Unlike convulsions, movements associated with jitteriness are of the same amplitude and in the same direction. z Unlike spasms, jitteriness is usually stopped by cuddling, feeding, or flexing the baby’s limb. ¨ If the baby is having convulsions or spasms, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63) as soon as the Newborn Rapid Initial Assessment is complete. In addition to the steps in Annex 7, give a single dose of phenobarbital 20 mg/kg body weight IM. ¨ If the baby has arching of the back (opisthotonos) or is unconscious, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63) as soon as the Newborn Rapid Initial Assessment is complete. (For complete differential diagnosis and management of newborn convulsions or spasms, see MNP.) ¨ If the baby IS NOT having convulsions, spasms, arching of the back (opisthotonos), or loss of consciousness, proceed with this Newborn Rapid Initial Assessment. z Assess the baby for the following signs of sepsis: z Lethargy z Floppiness z Poor feeding z Persistent vomiting z Other signs such as inconsolability or foul smell ¨ If the baby DOES have signs of sepsis, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Complete the following steps in addition to those in Annex 7: − Give the baby antibiotics: − ampicillin 50 mg/kg body weight IM; PLUS − gentamicin 5 mg/kg body weight IM (if 2 kg or more) or 4 mg/kg body weight IM (if less than 2 kg). ¨ If the baby DOES NOT have signs of sepsis, proceed to Presenting Danger Sign (below). Presenting Danger Sign ¨ If the baby presents with any single danger sign, proceed to the relevant information in this chapter according to the life-threatening complication (page 3-99) to provide appropriate management. ¨ If the baby presents with more than one danger sign, proceed first to the entry for the life- threatening complication that is most severe, ensuring that management is provided for EACH of the baby’s life-threatening complications before referral/transfer or before returning to basic assessment and care provision. If it is not clear which presenting life-threatening complication is most severe, proceed to the entry for each life-threatening complication based on the order in which they appear below. Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-99 Life-Threatening Complications z Abnormal body temperature, page 3-122 z Jaundice, page 3-124 z Diarrhea, page 3-125 z Abdominal distention, page 3-125 z Bleeding, page 3-126 z Pus or lesions of skin, page 3-127 z Pus or redness of eyes, page 3-129 z Redness or foul smell of umbilicus, page 3-130 z Swollen limb or joint, page 3-130 NEWBORN RESUSCITATION ¨ If the baby is not breathing, is gasping, or respirations are less than 20 breaths per minute, immediately perform resuscitation as described below: z Dry the baby, remove the wet cloth, and wrap the baby in a dry, warm cloth. z Clamp and cut the cord, if not already done (page 2-79). z Place the newborn on her/his back on a clean, warm surface and keep covered except for the face and chest. z Position the head (Figure 3-4, below) so that it is slightly extended to open the airway (a rolled-up piece of cloth placed under the newborn’s shoulders may be used to extend the head). Figure 3-4. Correct Position of the Head for Ventilation z Clear the airways by suctioning the mouth first and then each nostril using a suction apparatus (e.g., DeLee mucus trap or rubber bulb syringe). z Insert suction tube 5 cm into the baby’s mouth and suction during withdrawal. z Insert suction tube 3 cm into each nostril and suction during withdrawal. ¨ If there is blood or meconium in the mouth or nose, be especially thorough with suctioning. Note: Do not suction deep in the throat as this may cause the baby’s heart to slow or the baby to stop breathing. Do not suction every baby at birth, but only if there is blood or meconium in the mouth or nose or if the baby requires resuscitation. Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-100 JHPIEGO/Maternal and Neonatal Health Program ¨ If the baby is not breathing well after the airway has been suctioned, begin ventilation. ¨ If the baby begins to breathe well after the airway has been suctioned, see Textbox 3-38 (page 3-101) for care after newborn resuscitation. Ventilation z Quickly recheck the position of the head to make sure that it is slightly extended. z Place the mask over the baby’s chin, mouth, and nose to form a seal (use mask size 1 for normal birthweight newborn and size 0 for low birthweight newborn). z Squeeze the Ambu bag (Figure 3-5, below) attached to the mask two or three times, using the whole hand if the bag is small, or using two fingers if the bag is large. Ventilate the baby with oxygen, if available; otherwise, use room air. Be sure the fingers holding the mask are not over the baby’s throat or in the baby’s eyes. z Observe the chest to determine whether it is rising: ¨ If the chest is rising, proceed with ventilation at about 40 breaths per minute. ¨ If the chest is not rising: − Check the position of the head to make sure that it is slightly extended. − If the seal with the face is not adequate, reposition the mask. − Increase ventilation pressure. − If the above measures are not successful, repeat suctioning of mouth and nose to remove mucus, blood, or meconium. Figure 3-5. Positioning the Mask and Checking the Seal z Ventilate for 1 minute or until the baby begins to cry or breathe spontaneously. Then stop to quickly assess the baby’s breathing. ¨ If the baby has a respiratory rate of at least 20 breaths per minute and there is no chest indrawing: − Stop ventilation. − Put the baby in skin-to-skin contact with the woman. − Explain to the woman what happened and what you did for the baby. − Provide appropriate followup care (Textbox 3-38, page 3-101), including vigilant observation of color and vital signs every 15 minutes for 2 hours. Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-101 ¨ If, after 20 minutes of ventilation, the baby is making some effort to breathe but has a respiratory rate of less than 30 breaths per minute or more than 60 breaths per minute and/or continues to have chest indrawing, central cyanosis (blue tongue and lips), or grunting on expiration: − ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Complete the following steps in addition to those in Annex 7: ¨ If respirations are less than 20 breaths per minute, continue to ventilate before and during transfer, giving oxygen at a moderate flow rate during transfer, if possible. ¨ If respirations are 20–30 or more than 60 breaths per minute, give oxygen at a moderate flow rate during transfer, if possible. − Provide emotional support to the woman and family. (For complete differential diagnosis and management of breathing difficulty, see MNP.) ¨ If there is no gasping or breathing at all after 20 minutes of ventilation: − Stop ventilating. − Provide emotional and psychological support to the family. − See Stillbirth or Newborn Death (Chapter 10, page 3-74) for additional information about assessment and care provision. Textbox 3-38. Care after Newborn Resuscitation z Leave the baby in skin-to-skin contact with the woman and cover with a warm, dry blanket. z Observe the newborn for at least 4 hours for: − Breathing problems (e.g., rapid breathing, indrawing of chest, or grunting on expiration); and − Changes in body temperature. z Encourage early breastfeeding to reduce the risk of low blood glucose. z Proceed with basic newborn care (Chapter 8, page 2-109). z Explain to the parents that there is a slight risk of complications such as feeding problems or convulsions. Emphasize the need to seek immediate medical help if any of these problems occur. 3- 10 2 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC A TI O NS SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Va gi na l b le ed in g in ea rly p re gn an cy (th rou gh 2 2 w ee ks ’ ge st at io n) (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) z Fa in tin g z H is to ry o f e xp ul si on o f t iss ue (pr od uc ts of co n ce pt io n ) z Cr am pi n g/ lo w e r a bd om in a l pa in z Te nd er u te ru s z Te nd er a dn ex a l m a ss o r ce rv ic al m ot io n te nd er ne ss (fo r th e pr oc ed ur e fo r Pe lv ic Ex am in at io n , se e A nn ex 4 , pa ge 4- 26 ) z Ut er us s of t a nd la rg er th an e xp ec te d fo r g es ta tio na l a ge AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , pa ge 4 -6 3). ¨ If th e w om an is b le ed in g HE AV IL Y an d ac ce ss to re fe rr al c ar e is n ot im m ed ia te , gi ve 0 .2 m g e rg om et rin e IM (re pe ate d a fte r 15 m in ut es if n e ce ss ar y) or mi so pro sto l 4 00 m cg b y m ou th (re pe ate d on ce a fte r 4 h ou rs if n ec es sa ry ). (F or co mp let e d iff er en tia l d ia gn o si s an d m an a ge m e n t o f va gi na l b le e di ng in e ar ly pr eg n a n cy , s ee M CP C. ) Pr oc ee d wi th b a si c ca re p ro vi si on w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s: z Pr ov id e re a ss u ra n ce a n d ex pl a in th at s he m a y be e xp er ie n ci ng th e ea rly s ta ge s of a n ab or tio n , bu t t ha t n o tre at m en t (e .g. , b ed res t, a dm in is tra tio n o f h or m on es ) h as b ee n fo un d to be b en e fic ia l. z En su re th at s he h as a s uf fic ie n t s up pl y of iro n/ fo la te ta bl e ts to la st u nt il he r n ex t s ch ed u le d a n te na ta l c ar e vi si t. z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s b irt h pr ep a re dn e ss a n d co m pl ic a tio n r e a di ne ss p la n : − En su re th at e m e rg en cy tr an sp o rta tio n an d fu nd s ar e im m e di at e ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a da ng e r si gn a ris es . − Ad vis e th e wo m a n to s ee k ca re a t a fa cil ity ca pa bl e of p ro vi di ng c om pr e he n si ve e ss e n tia l o bs te tri c ca re s er vic es (s ee pa ge 1 -9 ) if he r bl ee di ng in cr e a se s, ti ss ue is e xp el le d, o r s he h as c ra m pi n g. Va gi na l b le ed in g in la te r p re gn an cy (af ter 22 w ee ks ’ g es ta tio n) o r la bo r N ot e: D o N O T pe rfo rm a p el vic e xa m in a tio n o n a w o m a n in la te r pr eg n a n cy o r l a bo r w ho is e xp er ie n ci ng bl ee di n g or A NY o f t he si gn s/ sy m pt om s in th e n e xt c ol um n. (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) z M od er at e to h ea vy b le e di n g z Te nd er o r t en se u te ru s or a bd o m e n z Se ve re a bd om in a l p a in z In te rm itt en t o r c on st an t a bd o m in a l p ai n (no t co n tra ct io n s) z Co nt in u o u s co n tra ct io ns th at do n ot a llo w th e u te ru s to re la x z R el ax e d ut er u s (no co n tra ct io n s, n o t t en se ) z Ea si ly pa lp a bl e fe ta l p ar ts z D ec re as e d or a bs en t f et al m o ve m e n ts z Ab no rm a l o r a bs e n t f et al he ar t t on es z Fe ta l p re se nt in g pa rt no t in pe lvi s z Si gn ific an t b lo od in am n io tic flu id AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , pa ge 4 -6 3). z Co m pl et e th e fo llo w in g st ep s in a dd iti on to th o se in An ne x 7: − St ar t a n IV in fu sio n or g iv e o ra l r eh yd ra tio n so lu tio n (T ex tb o x 3 -3 5, p ag e 3- 96 ). (F or co mp let e d iff er en tia l d ia gn o si s an d m an a ge m e n t o f va gin al b le ed in g in la te r p re gn an cy o r la bo r, s ee M CP C. ) ¨ If th e bl ee di ng is li gh t, a ss e ss th e w om an fo r o n se t o f l ab o r (Ta bl e 2- 8, p ag e 2- 68 ). ¨ If th e w o m an IS N O T in la bo r, AC T N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , p ag e 4- 63 ). ¨ If th e w o m an IS in la bo r: ¨ If le ss th an 3 7 w ee ks ’ g es ta tio n, AC T N O W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). ¨ If 37 w ee ks ’ g es ta tio n or m or e, pr oc ee d wi th b as ic c ar e fo r n o rm a l la bo r a n d bi rth (C ha pt er 6 , p ag e 2- 37 ). 3- 10 3 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Va gi na l b le ed in g af te r c hi ld bi rth W A R N IN G : M or e th an h a lf of a ll m at er na l d e a th s oc cu r w ith in 2 4 ho ur s o f c hi ld bi rth , m os tly d ue to e xc es si ve b le e di n g. Po st pa rtu m h em o rr ha ge (P PH ) c au se s m ore th an o ne - qu ar te r o f a ll m at er na l d ea th s w o rld w id e , w ith u te rin e at on y be in g th e m ajo r fa ct or . R ap id a ct io n in re sp on se to P PH is th er ef or e cr iti ca l. Te ar s of th e bi rth c an a l a re th e se co nd m o st fr eq ue nt c a u se o f P PH . P PH w ith a c on tra ct ed u te ru s is u su al ly du e to a c er vi ca l o r va gi na l t ea r, bu t t ea rs m ay b e pr es en t a t t he s am e tim e as u te rin e at on y. Ch ec k th e ut er in e fu nd u s to d e te rm in e w he th er it is c on tra ct e d. ¨ If th e ut er us IS N O T w el l c on tra ct ed , pe rfo rm th e fo llo wi n g w hi le c o n tin u al ly m on ito rin g th e w om an ’s c o n di tio n : − M as sa ge th e ut e ru s to e xp el b lo od a nd b lo o d clo ts . − H av e an a ss is ta n t g ive o xy to cin 1 0 un its IM . − St ar t a n IV in fu sio n or g iv e o ra l r eh yd ra tio n s o lu tio n (Te xt bo x 3 -3 5, p ag e 3- 96 ). A dd ox yto ci n 20 u n its to 1 lit er o f I V flu id s an d ru n a t 6 0 dr op s pe r m in u te . − Ke ep th e wo m a n w a rm a n d el ev at e he r le gs . − H el p th e w o m a n u rin a te , o r c at he te riz e h e r bl a dd e r u si ng a se pt ic te ch ni qu e . ¨ If th e ut er us IS w el l c on tra ct ed , pe rfo rm th e fo llo wi n g w hi le co n tin u a lly m o n ito rin g th e wo m a n ’s c o n di tio n : − Ex am in e th e v a gi na , pe rin e u m , a n d ce rv ix fo r t ea rs (fo r th e p roc ed ur e, s e e A nn ex 4 , p ag e 4- 20 ). − St ar t a n IV in fu sio n or g iv e o ra l r eh yd ra tio n s o lu tio n (se e T ex tb ox 3 -3 5, p ag e 3- 96 ). − Ke ep th e wo m a n w a rm a n d el ev at e he r le gs . − H el p th e w o m a n u rin a te , o r c at he te riz e h e r bl a dd e r u si ng a se pt ic te ch ni qu e . z Ut er in e a to ny : u te ru s so ft an d n o t c on tra ct ed ¨ If th e ut er us is at on ic , m a n a ge a cc o rd in g to th e gu id e lin e s sh o w n in T ex tb ox 3 -3 9 (p ag e 3- 10 5). z Te ar s of th e va gi na , p e rin e u m , la bi a , a n d/ or c e rv ix ¨ If th e w om an h as e xt en si ve te ar s (3r d o r 4th de gr e e te ar s; e xt en si ve te a rs o f v ag in a , pe rin e u m , a n d/ or la bi a ; o r c er vi ca l t ea rs e xt en di ng in to lo w e r u te rin e s e gm en t), AC T N O W !— fa cil ita te u rg e n t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). ¨ If th er e ar e 1s t o r 2n d de gr ee te ar s, re pa ir a cc o rd in g to th e g ui de lin es s ho w n o n pa ge 4 -3 8. ¨ If th er e ar e ce rv ic al te ar s n o t e xt en di ng in to lo w er u te rin e se gm en t, re pa ir ac co rd in g to th e gu id e lin e s sh o w n o n p ag e 4- 36 . (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) z R et ai ne d pl a ce n ta : p la ce n ta n o t d el iv er ed by 30 m in ut es a fte r b irt h ¨ If th e pl ac en ta is re ta in ed , m a n a ge a cc or di n g to th e gu ide lin es sh ow n in T ex tb ox 3 -4 0 (pa ge 3- 10 7). Pr oc ee d wi th b a si c ca re p ro vi si on w ith th e fo llo wi n g a dd itio n s a n d/ or e m ph as e s: z Pr ov id e re a ss u ra n ce th at s om e bl ee di n g (si mi la r to h ea vy m en se s, w ith o r w ith o u t c lo ts ) a fte r ch ild bi rth is n o rm a l. Fo r m o re in fo rm at io n on lo ch ia ru br a , se e p ag e 2- 91 . z Pa lp a te th e ut er u s e ve ry 1 5 m in u te s fo r 4 h ou rs to e ns ur e it re m a in s co n tra ct ed . z O bs er ve th e wo m a n fo r a t l ea st 2 4 ho ur s be fo re a llo w in g he r t o go h om e . z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s co m pl ica tio n re a di ne ss p la n : − En su re th at e m e rg en cy tr an sp o rta tio n an d fu nd s ar e im m e di at e ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a da ng e r si gn a ris es . 3- 10 4 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T z R et ai ne d pl ac en ta l f ra gm en ts : po rti on o f m at er na l s ur fa ce o f pl ac en ta m is si n g, o r t or n m e m br an es a nd v es se ls ¨ If th er e ar e re ta in ed p la ce nt al fr ag m en ts , m a n a ge a cc or di ng to th e gu id el in e s sh o w n in Te xt bo x 3- 40 (p ag e 3- 10 7). z R up tu re d ut er us : PP H w ith in 1 ho ur o f b irt h, s e ve re a bd o m in a l p ai n th at m ay de cr ea se af te r ru pt u re , p os sib ly w ith s ho ck o r t e n de r a bd o m e n ¨ If th e w o m an h as a ru pt ur ed u te ru s, AC T N O W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). z In ve rte d ut er us : u te rin e fu nd u s n o t f el t o n ab do m in al e xa m in a tio n , sl ig ht o r i nt en se u te rin e p ai n , u te ru s po ss ib ly vi si bl e a t v ul va ¨ If th e ut er us is in ve rte d, m a n a ge a cc o rd in g to th e gu id e lin e s sh o w n o n p ag e 4- 15 . z D el ay e d PP H: b le ed in g be gi n n in g m or e th an 2 4 ho ur s a fte r b irt h ¨ If th er e is d el ay ed P PH , m a n a ge a cc o rd in g to th e gu id e lin e s sh o w n in T ex tb ox 3 -4 1 (p ag e 3- 10 7). Va gi na l b le ed in g af te r c hi ld bi rth , co n tin ue d N ot e: If th e bl ee di ng do e s n o t s to p a fte r u te rin e m as sa ge a n d o xy to cin , a n d th e pl a ce n ta is n ot a va ila bl e fo r in sp ec tio n , m a n a ge a s fo r r et ai ne d pl ac en ta l f ra gm e n ts . (F or co mp let e d iff er en tia l d ia gn o si s an d m an a ge m e n t o f va gi na l b le e di ng a fte r c hi ld bi rth , s ee M CP C. ) Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-105 Textbox 3-39. Management of Uterine Atony z Continue to massage the uterus through the abdominal wall to expel clots and cause uterine contractions. z Catheterize the bladder using aseptic technique, if not already done. z Give a uterotonic drug (Table 3-3, page 3-106). ¨ If bleeding continues: − Perform bimanual compression of the uterus (Figure 3-6, below): − Wearing high-level disinfected gloves, insert a hand into the vagina and form a fist. − Place fist into the anterior fornix and apply pressure against the anterior wall of the uterus. − With the other hand, press deeply into the abdomen behind the uterus, applying pressure against the posterior wall of the uterus. − Maintain compression until the bleeding is controlled and the uterus contracts. Figure 3-6. Bimanual Compression of the Uterus − Alternatively, perform compression of the abdominal aorta (Figure 3-7, below): − Apply downward pressure with closed fist over abdominal aorta directly through the abdominal wall: − The point of compression is just above the umbilicus and slightly to the left. − Aortic pulsations can be easily felt through the anterior abdominal wall in the immediate postpartum period. − With the other hand, palpate femoral pulse to check adequacy of compression: ¨ If pulse is palpable, pressure exerted by fist is inadequate. ¨ If pulse is not palpable, pressure exerted is adequate. − Maintain compression until bleeding is controlled. FIGURE 3-7. Compression of the Abdominal Aorta and Palpation of the Femoral Pulse Note: Packing the uterus is ineffective and wastes precious time. ¨ If the bleeding continues, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the bleeding stops, provide basic care as shown in Chapter 6 with the following addition: − Two to three hours after bleeding stops, measure the woman’s hemoglobin. ¨ If hemoglobin is less than 7 g/dL, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If hemoglobin is 7–11 g/dL, see Anemia (Chapter 10, page 3-41). Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-106 JHPIEGO/Maternal and Neonatal Health Program Table 3-3. Uterotonic Drugs OXYTOCIN ERGOMETRINE/ METHYL- ERGOMETRINE 15-METHYL PROSTAGLANDIN F2" MISOPROSTOL Dose and route IV: Infuse 20 units in 1 L IV fluids at 60 drops per minute IM: 10 units IM or IV (slowly): 0.2 mg IM: 0.25 mg Rectal, oral, or sublingual: 600 mcg Continuing dose IV: Infuse 20 units in 1 L IV fluids at 40 drops per minute* Repeat 0.2 mg IM after 15 minutes If required, give 0.2 mg IM or IV (slowly) every 4 hours 0.25 mg every 15 minutes Refer if an additional dose is needed. Maximum dose Not more than 3 L of IV fluids containing oxytocin 5 doses (total 1 mg) 8 doses (total 2 mg) Precautions/ Contraindications Do not give as an IV bolus Pre-eclampsia, hypertension, heart disease Asthma * If the woman is already receiving oxytocin 20 units in 1 L IV fluids at 40 drops per minute and the bleeding continues, give a different uterotonic drug. WARNING: Prostaglandins should NOT be given intravenously. They may be fatal. Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-107 Textbox 3-40. Management of Retained Placenta or Placental Fragments Retained Placenta ¨ If you can see the placenta, ask the woman to push it out. ¨ If you can feel the placenta in the vagina, remove it. ¨ If the placenta is still not delivered: − Give oxytocin 10 units IM, if not already done for active management of the 3rd stage of labor, and attempt controlled cord traction with the next uterine contraction (page 2-77). − Catheterize the bladder using aseptic technique, if not already done. ¨ If controlled cord traction is unsuccessful, attempt manual removal of the placenta (Annex 4, page 4-22). Notes: z Do NOT give ergometrine because it causes tonic uterine contraction, which may delay expulsion of the placenta. z Avoid forceful cord traction and fundal pressure as they may cause uterine inversion. ¨ If the bleeding continues, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the bleeding stops, provide basic care as shown in Chapter 6 with the following additions: − Two to three hours after bleeding stops, measure the woman’s hemoglobin. ¨ If hemoglobin is less than 7 g/dL, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If hemoglobin is 7–11 g/dL, see Anemia (Chapter 10, page 3-41). Retained Placental Fragments z Perform manual exploration of the uterus, which is similar to the procedure for manual removal of the placenta (Annex 4, page 4-22). z Remove placental fragments by hand. ¨ If the bleeding continues, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the bleeding stops, provide basic care as shown in Chapter 6 with the following additions: − Two to three hours after bleeding stops, measure the woman’s hemoglobin. ¨ If hemoglobin is less than 7 g/dL, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If hemoglobin is 7–11 g/dL, see Anemia (Chapter 10, page 3-41). Note: Very adherent tissue may be placenta accreta. Efforts to extract fragments that do not separate easily may result in heavy bleeding or uterine perforation, which usually requires hysterectomy. Textbox 3-41. Management of Delayed Postpartum Hemorrhage (more than 24 hours after birth) Note: Delayed PPH may be a sign of uterine infection. z Give a uterotonic drug (Table 3-3, page 3-106). ¨ If the cervix is not dilated, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the cervix is dilated, perform manual exploration of the uterus, which is similar to the procedure for manual removal of the placenta (Annex 4, page 4-22), to remove large clots and placental fragments. ¨ If the bleeding continues, perform bimanual compression of the uterus or compression of the abdominal aorta (Textbox 3-39, page 3-105). ¨ If the bleeding continues despite above measures, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If the bleeding stops, provide basic care as shown in Chapter 6 with the following addition: − Two to three hours after bleeding stops, measure the woman’s hemoglobin. ¨ If hemoglobin is less than 7 g/dL, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). ¨ If hemoglobin is 7–11 g/dL, see Anemia (Chapter 10, page 3-41). 3- 10 8 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Se ve re h ea da ch e, bl ur re d vi si on , o r el ev at ed b lo od pr es su re (B P) (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) ¨ If th e w om an H A S di as to lic B P 11 0 m m H g o r m o re w ith p ro te in ur ia 2 + or m o re , fo llo w th e st ab iliz a tio n p ro ce du re fo r c on vu ls io n s, u n co n sc io u sn e ss , o r di as to lic b lo od p re ss u re 11 0 m m Hg o r m o re w ith p ro te in ur ia 2 + o r m o re (p ag e 3- 93 ) b efo re p ro ce e di n g. ¨ If th e w o m an d oe s NO T HA VE d ia st ol ic B P 11 0 m m H g or m or e w ith p ro te in ur ia 2 + o r m o re , a ss e ss h er fo r t he fo llo w in g sig ns /s ym pt om s: − D ia st ol ic B P m or e th an 9 0 m m H g wi th pr ot ei n u ria (T o t es t th e w om an ’s u rin e fo r pr ot ei n , se e A n n ex 4 , p ag e 4- 41 . ) − D iff icu lty c he wi n g an d op e n in g th e m ou th − H is to ry o f c on vu ls io n s − Fe ve r/c hi lls /ri go rs − St iff n ec k − M us cl e/ joi nt p ai n − Sp as m s of fa ce , n ec k, tr un k − Ar ch ed b ac k − Bo ar d- lik e ab do m e n AC T N O W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). (Fo r co m pl et e di ffe re nt ia l d ia gn os is an d m an ag em en t o f h ea da ch e, bl ur re d vis io n , co n vu ls io n s o r lo ss o f c on sc io us ne ss , e le va te d bl oo d pr es su re , se e M CP C. ) ¨ If th e w o m an ’s B P is 9 0– 11 0 m m Hg w ith n o pr ot ei nu ria : − Al lo w th e w o m a n to s it co m fo rta bl y an d m e a su re h er b lo o d pr e ss u re a ga in a fte r 1 ho ur . ¨ If th e w om an ’s b lo od p re ss ur e re m ai ns 9 0 m m H g or m or e af te r 1 ho ur , AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). ¨ If th e w o m an ’s B P is w ith in n o rm al ra ng e, pr oc ee d wi th b a si c ca re p ro vi si on w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s: − Pr ov id e re a ss u ra n ce th at h ea da ch e du rin g pr eg n a n cy m ay b e no rm al . F or m or e in fo rm at io n a bo u t h ea da ch e a s a c o m m o n di sc om fo rt of p re gn a n cy a nd th e po st pa rtu m pe rio d, se e He ad ac he (C ha pt er 9 , p ag e 3- 21 ). − R ev ie w th e da n ge r s ig ns a nd th e w om an ’s bi rth p re pa re dn e ss a n d co m pl ic a tio n re a di n e ss p la n: − En su re th at e m e rg en cy tr an sp o rta tio n a n d fu nd s a re im m e di at el y ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r he lp if a d an ge r si gn a ris es . 3- 10 9 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Un sa tis fa ct or y pr og re ss o f l ab or (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , s ee Ta bl e 1- 13 [pa ge 1- 38 ].) z Fe ve r z Fo ul -s m el lin g am n io tic fl ui d/ va gi na l d isc ha rg e z Ab no rm al p ul se a n d bl oo d pr e ss u re z Ab no rm a l o r a bs e n t f et al h e a rt to ne s z D ec re as e d or a bs en t f et al m ov em en ts z Ba llo o n in g of lo w e r u te rin e s e gm en t (b etw ee n sy m ph ys is an d u m bi lic u s) or for ma tio n o f r et ra ct io n ba nd (tr an sv ers e o r o bl iq ue rid ge a cr o ss u te ru s be tw ee n s ym ph ys is an d um bi lic us ) z N o de sc e n t o f b ab y’s h ea d af te r 3 0 m in u te s of pu sh in g in n o n su pi ne po sit io n z Su tu re s of fe ta l h ea d ov e rla pp e d an d no t r ed u ci bl e , la rg e ca pu t AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). z Co m pl et e th e fo llo w in g st ep s in a dd itio n to th os e in A nn ex 7 : − M on ito r t he w o m a n ’s v ita l si gn s an d th e fe ta l h ea rt to ne s ev er y 15 m in ut es . (F or co mp let e d iff er en tia l d ia gn o si s a n d m an a ge m e n t o f u ns at isf ac to ry pr og re ss o f l ab o r, s e e M CP C. ) ¨ If th e w o m an is in th e 1s t st ag e o f l ab or , se e In ad eq ua te U te rin e Co n tra ct io n s (be lo w ) fo r a dd itio n a l i nf or m a tio n ab ou t a ss e ss m e n t a nd ca re p ro vis io n . ¨ If th e w o m an is in th e 2n d st ag e o f l ab or , pr oc ee d wi th b a si c ca re p ro vi si on w ith th e fo llo wi n g a dd iti o n s a n d/ or e m ph as e s: − R em ai n vi gi la nt fo r s ig ns o f m at er na l o r f et al di st re ss (a bn o rm a l p ul se a n d bl oo d pr es su re ; a bn or m a l o r a bs en t f et al h ea rt to ne s or d ec re a se d or a bs e n t f et al m o ve m e n ts ). − D o no t e nc o u ra ge p ro lo n ge d pu sh in g or ho ld in g o f b re at h. − Pr ov id e ph ys ica l c om fo rt an d e m o tio n a l su pp or t t o fa cil ita te re st b et we en co n tra ct io n s a n d to s up po rt th e w o m a n ’s a bi lity to c op e. − En su re a de qu a te h yd ra tio n a n d ca lo rie s. In ad eq ua te u te rin e co n tr ac tio ns (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , s ee Ta bl e 1- 13 [p ag e 1- 38 ].) z Fe ve r z Fo ul -s m el lin g am n io tic fl ui d/ va gi na l d isc ha rg e z Pu ls e 11 0 be a ts p er m in ut e or m o re z Sy st ol ic BP le ss th an 9 0 m m H g z D ia st ol ic B P 90 m m H g or m or e z Ab no rm a l o r a bs e n t f et al h e a rt to ne s z D ec re as e d or a bs en t f et al m ov em en ts z In la te nt p ha se , ce rv ic al d ila tio n d oe s n o t r ea ch 4 cm a fte r 8 h ou rs o f p ro gr es siv e ly m or e fre qu e n t a n d lo n ge r la st in g co nt ra ct io n s z In a ct iv e ph as e , ce rv ic al d ila tio n d oe s n o t p ro gr es s a t t he ra te o f a t l ea st 1 c m p er ho ur ; o n pa rto gr a ph , ce rv ic al d ila tio n is p lo tte d to ri gh t o f a le rt lin e AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). z Co m pl et e th e fo llo w in g st ep s in a dd itio n to th os e in A nn ex 7 : − M on ito r t he w o m a n ’s v ita l si gn s an d th e fe ta l h ea rt to ne s ev er y 15 m in ut es . (F or co mp let e d iff er en tia l d ia gn o si s a n d m an a ge m e n t o f u ns at isf ac to ry pr og re ss o f l ab o r, s e e M CP C. ) ¨ If co nt ra ct io ns o cc ur le ss th an th re e tim es in 10 m in ut es a n d la st le ss th an 40 se co n ds e ac h: − Te st th e w om an ’s u rin e fo r k et on es . ¨ If ke to ne s ar e pr es en t, gi ve a t l ea st 1 lit er o f ju ice o r o th er s w ee t f lu id b y m o u th . ¨ If ke to ne s ar e pr es en t a nd th e w o m an is u n ab le to d rin k flu id s, gi ve 1 lit er o f d ex tro se 5 % in ½ n or m a l sa lin e IV w ith in 1 ho ur . ¨ If th er e is n o im pr ov em en t i n co nt ra ct io ns w ith in 1 h o u r, A CT N O W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). 3- 11 0 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T M ec on iu m -s ta in ed am n io tic fl ui d, de cr ea se d or a bs en t fe ta l m ov em en ts , ab se nt fe ta l h ea rt to ne s, o r a bn or m al fe ta l h ea rt ra te (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) N /A (F or co mp let e d iff er en tia l d ia gn o si s a n d m an a ge m e n t o f f et al d ist re ss in la bo r, se e M CP C. ) ¨ If th er e is m ec on iu m -s ta in ed am n io tic fl u id , m a n a ge a cc or di ng to g u id e lin e s sh ow n in Te xt bo x 3- 42 (p ag e 3- 11 1). ¨ If fe ta l m ov em en ts a re d ec re as ed o r a bs en t, m a n a ge a cc or di ng to g u id e lin e s sh ow n in Te xt bo x 3- 43 (p ag e 3- 11 1). ¨ If fe ta l h ea rt to ne s ar e ab se n t, m a n a ge a cc o rd in g to g u id el in e s sh ow n in T ex tb ox 3 - 44 (p ag e 3- 11 2). ¨ If th e fe ta l h ea rt ra te is a bn or m al , m a n a ge a cc o rd in g to g u id el in e s sh ow n in T ex tb ox 3 - 45 (p ag e 3- 11 3). Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-111 Textbox 3-42. Management of Meconium-Stained Amniotic Fluid Slight Degree of Meconium z Prop the woman up or place her on her left side. z Listen to the fetal heart rate both during and between contractions at least once every 30 minutes. ¨ If fetal heart rate remains normal, the meconium staining may only be a sign of fetal maturing and not a sign of fetal distress. Proceed with basic care provision (Chapter 6, page 2-37). ¨ If fetal heart tones are absent, see Textbox 3-44 (page 3-112). ¨ If fetal heart rate is abnormal, see Textbox 3-45 (page 3-113). Thick Meconium ¨ If the woman is in the 1st stage of labor, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Give oxygen to the woman at 4–6 L per minute during preparation and transfer. ¨ If the woman is in the 2nd stage of labor: − Deliver the baby as quickly as possible, using episiotomy (Annex 4, page 4-18) and vacuum extraction (Annex 4, page 4-45), if necessary. In order to use vacuum extraction, the head must be at least at 0 station or no more than 2/5 palpable above the symphysis pubis. ¨ If these conditions are not met, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Give oxygen to the woman at 4–6 L per minute during preparation and transfer. − Prepare, or have assistant prepare, for resuscitation of the newborn (page 3-99). Textbox 3-43. Management of Decreased or Absent Fetal Movements z Palpate abdomen to feel for fetal movements. z Ask if the woman has had a sedative drug. Woman IS NOT in Labor ¨ If the woman has had a sedative drug, wait until the effect of the drug has worn off and then listen for fetal heart tones. ¨ If the woman has not had drugs, listen for fetal heart tones. ¨ If fetal heart tones are absent, see Textbox 3-44 (page 3-112). ¨ If fetal heart rate is heard and is normal, proceed with basic care provision (Chapter 6, page 2-37). ¨ If fetal heart rate is heard and is abnormal, see Textbox 3-45 (page 3-113). Woman IS in Labor z Listen for fetal heart tones. ¨ If fetal heart tones are absent, see Textbox 3-44 (page 3-112). ¨ If fetal heart rate is heard and is normal, proceed with basic care provision (Chapter 6, page 2-37). ¨ If fetal heart rate is heard and is abnormal, see Textbox 3-45 (page 3-113). Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-112 JHPIEGO/Maternal and Neonatal Health Program Textbox 3-44. Management of Absent Fetal Heart Tones Woman IS NOT in Labor z Ask several other persons to listen, use an electronic fetal stethoscope, or obtain an obstetric ultrasound, if available. ¨ If fetal heart tones are not detected on obstetric ultrasound, there is no need to refer/transfer the woman because the fetus is dead. Deliver the baby in a manner that is safest for the woman. See Stillbirth or Newborn Death (Chapter 10, page 3-74) for additional information about assessment and care provision. ¨ If still unable to hear fetal heart tones (using methods other than obstetric ultrasound), wait 1 hour and then repeat. ¨ If fetal heart rate is heard and is normal, proceed with basic care provision (Chapter 6, page 2-37). ¨ If fetal heart rate is heard and is abnormal, see Textbox 3-45 (page 3-113). ¨ If fetal heart tones are still not heard: − Inform the woman and her partner that the baby may be dead. See Stillbirth or Newborn Death (Chapter 10, page 3-74) for additional information about assessment and care provision. − Provide emotional support. − Facilitate nonurgent referral/transfer (Annex 7, page 4-63) after providing basic care. Woman IS in Labor z Ask several other persons to listen, use an electronic fetal stethoscope, or obtain an obstetric ultrasound if available. ¨ If fetal heart tones are not detected on obstetric ultrasound, there is no need to refer/transfer the woman because the fetus is dead. Deliver the baby in a manner that is safest for the woman. See Stillbirth or Newborn Death (Chapter 10, page 3-74) for additional information about assessment and care provision. ¨ If still unable to hear fetal heart tones (using methods other than obstetric ultrasound), wait for 15 minutes and then repeat. Place the woman on her left side and give her oxygen at 4–6 L per minute. ¨ If fetal heart rate is heard and is normal, proceed with basic care provision (Chapter 6, page 2-37). ¨ If fetal heart rate is heard and is abnormal, see Textbox 3-45 (page 3-113). ¨ If fetal heart tones are still not heard: ¨ If the woman is in the 1st stage of labor, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Complete the following steps in addition to those in Annex 7: − Inform the woman and her partner that the baby may be dead, and provide emotional support. − Continue giving oxygen to the woman at 4–6 L per minute during preparation and transfer. − Prop up the woman or place her on her left side during preparation and transfer. ¨ If the woman is in the 2nd stage of labor: − Inform the woman and her partner that the baby may be dead, and provide emotional support. − Give oxygen to the woman at 4–6 L per minute. − Prop up the woman or place her on her left side. − Deliver the baby as quickly as possible, using episiotomy (Annex 4, page 4-18) and vacuum extraction (Annex 4, page 4-45), if necessary. In order to use vacuum extraction, the head must be at least at 0 station or no more than 2/5 palpable above the symphysis pubis. ¨ If these conditions are not met, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Continue to give oxygen at 4–6 L per minute during preparation and transfer. − Prepare, or have assistant prepare, for resuscitation of the newborn (page 3-99). Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-113 Textbox 3-45. Management of Abnormal Fetal Heart Rate Note: A very slow fetal heart rate (less than 100) in the absence of contractions or persisting after contractions or a rapid fetal heart rate (more than 180) in the absence of a rapid maternal heart rate during labor should be considered a sign of fetal distress. Likewise, a fetal heart rate less than 120 or more than 160 when the woman is not in labor is a sign of fetal distress. Woman IS NOT in Labor z Try to identify a maternal cause (e.g., maternal fever, drugs). ¨ If a maternal cause is identified, initiate appropriate management. ¨ If a maternal cause is not identified, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Woman IS in Labor z Listen to the fetal heart rate throughout at least three contractions. ¨ If fetal heart rate remains abnormal throughout at least three contractions: ¨ If the woman is in the 1st stage of labor: − Place the woman on her left side and give her oxygen at 4–6 L per minute. Listen to the fetal heart rate throughout the next three contractions. ¨ If fetal heart rate remains abnormal throughout at least three contractions, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). Continue giving oxygen to the woman at 4–6 L per minute during preparation and transfer. ¨ If the woman is in the 2nd stage of labor: − Deliver as quickly as possible, using episiotomy (Annex 4, page 4-18) and vacuum extraction (Annex 4, page 4-45), if necessary. In order to use vacuum extraction, the head must be at least at 0 station or no more than 2/5 palpable above the symphysis pubis. ¨ If these conditions are not met, ACT NOW!—facilitate urgent referral/transfer (Annex 7, page 4-63). − Prepare, or have assistant prepare, for resuscitation of the newborn (page 3-99). ¨ If fetal heart rate is normal, proceed with basic care provision (Chapter 6, page 2-37). 3- 11 4 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Pr ol ap se d co rd z Co rd is p u ls at in g. W om an in 1s t St ag e of L ab or z AC T NO W !— fa cil ita te u rg en t r ef er ra l/tr an sf er (A n n ex 7 , pa ge 4 -6 3). C om ple te the fo llo w in g st ep s in a dd itio n to th os e in A nn e x 7: − W e a rin g hi gh - le ve l d isi n fe ct ed g lo ve s, in se rt a ha nd in to th e va gi na a n d pu sh th e pr es en tin g pa rt up to d ec re a se p re ss u re o n th e co rd a n d di slo dg e th e pr e se n tin g pa rt fro m th e pe lvi s. − Pl ac e th e ot he r ha nd a bo ve th e sy m ph ys is pu bi s to k ee p th e pr e se n tin g pa rt ou t o f t he p el vis , o r ha ve a n a ss is ta n t d o th is, a nd e le va te th e w o m a n ’s h ip s o n p illo w s o r ro lle d bl a n ke ts . − O nc e th e pr es e n tin g pa rt is fir m ly he ld a bo ve th e pe lvi c b rim , r em ov e th e ot he r h an d fro m th e va gin a. − Ke ep th e ha nd a bo ve th e sy m ph ys is pu bi s be fo re a n d du rin g tra ns fe r t o th e re fe rra l h ea lth ca re fa cil ity u n til a ce sa re an s ec tio n c an b e pe rfo rm ed . W om an in 2n d St ag e of L ab or z D el iv e r th e ba by a s qu ick ly as p os sib le , u si n g e pi sio to m y (A nn ex 4 , p ag e 4- 18 ) a nd va cu um e xt ra ct io n (A nn ex 4 , p ag e 4- 45 ), i f n ec es sa ry. In o rd er to u se v ac u u m e xt ra ct io n , th e he ad m us t b e at le a st a t 0 st a tio n o r n o m or e th an 2 /5 p al pa bl e ab ov e th e sy m ph ys is pu bi s. ¨ If th es e co nd iti o n s ar e n o t m et , AC T NO W !— fa cil ita te u rg en t r e fe rra l/t ra ns fe r (A nn ex 7 , pa ge 4 -6 3). z Pr ep ar e , o r ha ve a ss is ta nt p re pa re , fo r r es us cit at io n o f t he n ew bo rn (pa ge 3 -9 9). (F or co mp let e d iff er en tia l d ia gn o si s an d m an a ge m e n t o f pr ol ap se d co rd , se e M CP C. ) ¨ If th e co rd is n ot p u ls at in g, th er e is n o ne ed to re fe r/t ra ns fe r th e w om an b ec au se th e ba by is d ea d. − D el iv e r th e ba by in a m an ne r th at is s af es t fo r t he w om an . − Se e St illb irt h or N ew bo rn D ea th (C ha pt er 1 0, p ag e 3- 74 ) fo r a dd iti o n a l in fo rm at io n a bo u t a ss es sm en t a n d ca re pr ov isi o n . Fe ta l h an d or fo ot pr es en tin g (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , s ee Ta bl e 1- 13 [pa ge 1 -3 8]. ) AC T NO W !— fa cil ita te u rg en t r ef er ra l/t ra ns fe r (A nn ex 7 , pa ge 4 -6 3). (F or co mp let e d iff er en tia l d ia gn o si s an d m an a ge m e n t o f m a lp os iti on s a n d m al pr e se n ta tio ns , s ee M CP C. ) 3- 11 5 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Fe ve r ( tem pe ra tu re 38 °C o r m or e) o r fo ul -s m el lin g va gi na l di sc ha rg e (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) W o m an H as a F ev er ¨ If th e w om an is p os tp ar tu m a nd h as O NL Y a pa in fu l/t en de r b re as t w ith ou t a ny fl uc tu an t sw el lin g or p us , se e B re as t a n d Br ea st fe ed in g Pr ob le m s (C ha pt er 1 0, p ag e 3- 43 ). ¨ If th e w om an h as a fe ve r w ith o r w ith ou t A NY o th er si gn s/ sy m pt om s, AC T NO W !— fa cil ita te u rg e n t re fe rra l/t ra ns fe r ( A nn ex 7 , p ag e 4- 63 ). C om ple te the fo llo wi n g st ep s in a dd iti on to th os e in An ne x 7: − St ar t a n IV in fu sio n or g iv e o ra l r eh yd ra tio n so lu tio n (T ex tb o x 3 -3 5, p ag e 3- 96 ). − Pr ov id e a n tib io tic s as s ho w n in Ta bl e 3- 4 (p ag e 3- 11 6). − Pr ov id e su pp o rti ve c ar e, in cl u di ng u se o f a fa n or te pi d sp o n ge to re du ce te m pe ra tu re b e fo re re fe rra l/t ra ns fe r. W om an H as F ou l-S m el lin g Va gi na l D is ch ar ge z AC T NO W !— fa cil ita te u rg en t r ef er ra l/tr an sf er (A n n ex 7 , pa ge 4- 63 ). C om pl et e th e fo llo w in g st ep s in a dd itio n to th os e in A nn e x 7: − St ar t a n IV in fu sio n or g iv e o ra l r eh yd ra tio n so lu tio n (se e T ex tb ox 3 -3 5, p ag e 3- 96 ). − Pr ov id e a n tib io tic s as s ho w n in Ta bl e 3- 4 (p ag e 3- 11 6). − Pr ov id e su pp o rti ve c ar e, in cl u di ng u se o f a fa n or te pi d sp o n ge to re du ce te m pe ra tu re b e fo re re fe rra l/t ra ns fe r. (F or co mp let e d iff er en tia l d ia gn o si s an d m an a ge m e n t o f fe ve r d ur in g pr e gn a n cy a nd la bo r o r a fte r c hi ld bi rth , s ee M CP C. ) Basic Maternal and Newborn Care: A Guide for Skilled Providers 3-116 JHPIEGO/Maternal and Neonatal Health Program Table 3-4. Antibiotic Treatment for Fever during Pregnancy, Labor, or Postpartum SIGNS/SYMPTOMS TYPICALLY PRESENT IN ADDITION TO FEVER SIGNS/SYMPTOMS SOMETIMES PRESENT PROBABLE DIAGNOSIS ANTIBIOTIC OF CHOICE z Chills z Foul-smelling, watery vaginal discharge after 22 weeks’ gestation z Abdominal pain z History of loss of fluid z Tender uterus z Rapid fetal heart rate z Light vaginal bleeding Amnionitis Ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours until the woman is fever-free for 48 hours z Chills z Lower abdominal pain z Purulent, foul-smelling lochia z Tender uterus z Light vaginal bleeding z Shock Metritis Ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours until the woman is fever-free for 48 hours z Burning on urination z Spiking fever/chills z Increased urgency/frequency of urination z Abdominal pain z Retropubic/suprapubic pain z Flank/loin pain z Tenderness in rib cage z Anorexia z Nausea/vomiting Acute pyelonephritisa Ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours until the woman is fever-free for 48 hours z Lower abdominal pain and distention z Persistent spiking fever/chills z Tender uterus z Poor response to antibiotics z Swelling in adnexa or pouch of Douglas Pelvic abscess Ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours until the woman is fever-free for 48 hours z Fever/chills z Lower abdominal pain z Absent bowel sounds z Rebound tenderness z Abdominal distention z Anorexia z Nausea/vomiting z Shock Peritonitis Ampicillin 2 g IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours until the woman is fever-free for 48 hours z Firm, very tender breast z Overlying erythema z Fluctuant swelling in breast z Draining pus Breast abscess Cloxacillin 500 mg by mouth every 6 hours OR erythromycin 250 mg by mouth every 8 hours for 10 days a For treatment of cystitis, see Burning on Urination (Chapter 10, page 3-47). Chapter Eleven: Life-Threatening Complications JHPIEGO/Maternal and Neonatal Health Program 3-117 Table 3-4. Antibiotic Treatment for Fever During Pregnancy, Labor, or Postpartum (continued) SIGNS/SYMPTOMS TYPICALLY PRESENT IN ADDITION TO FEVER SIGNS/SYMPTOMS SOMETIMES PRESENT PROBABLE DIAGNOSIS ANTIBIOTIC OF CHOICE z Painful and tender wound z Erythema and edema beyond edge of incision z Hardened wound z Purulent discharge z Reddened area around wound Wound cellulitis or necrotizing fasciitis ¨ If superficial, give ampicillin 500 mg by mouth every 6 hours PLUS metronidazole 400 mg by mouth every 8 hours for 5 days ¨ If deep, involving muscles and causing necrosis, give penicillin G 2 million units IV every 6 hours PLUS gentamicin 5 mg/kg body weight IV every 24 hours PLUS metronidazole 500 mg IV every 8 hours until the woman is fever-free for 48 hours. Then, give ampicillin 500 mg by mouth every 6 hours PLUS metronidazole 400 mg by mouth every 8 hours for 5 days z Chills/rigors z Headache z Muscle/joint pain z Anemia (complicated malaria only) z Coma (complicated malaria only) z Enlarged spleen z Convulsions (complicated malaria only) z Jaundice (complicated malaria only) Malaria Follow national treatment guidelines z Breathing difficulty z Cough with expectoration z Chest pain z Consolidation z Congested throat z Rapid breathing z Ronchi/rales Pneumonia Erythromycin 500 mg by mouth every 6 hours for 7 days z Headache z Dry cough z Malaise z Anorexia z Enlarged spleen z Confusion z Stupor Typhoid Ampicillin 1 g by mouth every 6 hours OR amoxicillin 1 g by mouth every 8 hours for 14 days z Breast pain and tenderness z Reddened, wedge- shaped area on breast 3–4 weeks after birth z Inflammation preceded by engorgement z Usually only one breast affected Mastitisb Cloxacillin 500 mg by mouth every 6 hours for 10 days OR erythromycin 250 mg by mouth every 8 hours for 10 days b For additional information on care provision for mastitis, see Textbox 3-14 (page 3-45). 3- 11 8 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Pa in in c al f (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) z Sp iki ng fe ve r z Po si tiv e H o m a n s’ s ig n (pa in in ca lf m u sc le w he n fo o t i s fo rc ib ly fle xe d u pw ar d) z Sw el lin g o f o ne le g z H ar dn es s de ep in c al f m us cle AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). z In a dd itio n to th e st ep s in An ne x 7, b e fo re a n d du rin g tra ns fe r e ns ur e th at th e w om an do es n o t w al k a n d th at th e le g is n ot m as sa ge d o r m a n ip u la te d in a n y wa y. Pr oc ee d wi th b a si c ca re p ro vi si on w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph as e s a s a pp ro pr ia te : z Pr ov id e re a ss u ra n ce a n d ex pl a in th at th e sy m pt om s sh e is e xp er ie n ci ng m a y be n or m a l. Fo r m or e in fo rm a tio n ab ou t l e g cr a m ps a s a co m m o n d isc om fo rt du rin g pr eg n a n cy a n d th e po st pa rtu m p er io d, s ee L e g Cr a m ps (C ha pt er 9 , p ag e 3- 5). z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s c o m pl ica tio n re a di n e ss p la n. − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a d an ge r si gn a ris e s. Pu s, re dn es s, o r pu lli n g ap ar t o f s ki n ed ge s of p er in ea l su tu re li ne ; p us o r dr ai na ge fr om u n re pa ire d te ar ; se v er e pa in fr om te ar o r ep is io to m y (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) z Ex ce ss iv e sw el lin g of th e vu lva o r pe rin e u m z In fe ct io n in vo lv in g m us cle s o r de ep er la ye rs o f t iss ue z N ec ro tic ti ss ue z H ar de n e d w o u n d wi th re dn es s a n d sw e llin g be yo n d th e ed ge o f t he in ci si on z St oo l o r u rin e c o m in g fro m th e va gi na z Fe ve r z Ce llu liti s z N ec ro tiz in g fa sc iit is AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). C om ple te the fo llo wi ng st ep s in a dd itio n to th os e in An ne x 7: ¨ If th e w om an h as a ny o f t he fo llo w in g al er t s ig ns , st ar t a n IV in fu sio n or g iv e o ra l re hy dr at io n s o lu tio n (se e Te xt bo x 3- 35 [pa ge 3 -9 6]) an d pr ov id e a n tib io tic s a s sh ow n in Ta bl e 3- 4 (p ag e 3- 11 6): − In fe ct io n in vo lv in g m us cle s o r de ep er la ye rs o f t iss ue − N ec ro tic ti ss ue − H ar de n e d w o u n d wi th re dn e ss a n d sw e llin g be yo n d th e ed ge o f t he in ci si on − Fe ve r − Ce llu liti s − N ec ro tiz in g fa sc iit is (F or co mp let e d iff er en tia l d ia gn o si s a n d m an a ge m e n t o f i nf ec tio n o f pe rin e a l w ou n ds , se e M CP C. ) Pr oc ee d wi th b a si c ca re p ro vi si on w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph as e s a s a pp ro pr ia te : ¨ If pu s is d ra in in g or th er e is re dn es s or p ul lin g ap ar t o f pe rin ea l s ut ur e lin e, re m o ve s u tu re s an d de br id e th e w o u n d. z Cl ea n th e w ou n d fro m fr on t t o ba ck w ith a nt ise pt ic (or so ap ) a n d rin se w ith c le an w a te r. z In st ru ct th e w om an o n pe rin e a l h yg ie n e (p ag e 2- 10 6). z Fo r m or e in fo rm a tio n ab ou t p er in ea l p ai n as a c o m m o n di sc om fo rt of th e po st pa rtu m p er io d, s ee P er in e a l P ai n (C ha pt er 9 , p ag e 3- 10 ). z Ad vis e th e wo m a n to w ai t u nt il th e w ou n d ha s he al e d be fo re re su m in g se xu al in te rc o u rs e . z Ad vis e he r t o re tu rn fo r c ar e if sy m pt om s pe rs ist o r w or se n. z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s c o m pl ica tio n re a di n e ss p la n. − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a d an ge r si gn a ris e s. 3- 11 9 JH PI EG O /M at er na l a nd N eo na ta l H ea lth P ro gr am M A TE R N A L LI FE -T H R EA TE N IN G C O M PL IC AT IO NS (C ON TIN UE D) SI G N O R SY M PT O M A SS ES S FO R TH ES E AL ER T SI G NS /S YM PT O M S IF A N Y A LE R T SI G NS /S YM PT O M S PR ES EN T IF N O A LE RT S IG NS /S YM PT O M S PR ES EN T Se ve re a bd om in al pa in in ea rly pr eg na nc y (th rou gh 22 w ee ks ’ g es ta tio n) (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d wi th th is si gn /s ym pt om , se e T ab le 1 -1 3 [pa ge 1 -3 8]. ) z Va gi n a l b le ed in g z N au se a/ vo m itin g z Lo ss o f a pp e tit e z Fe ve r/c hi lls z R eb ou n d te nd e rn e ss z Si ze -d at e d isc re pa n cy z Te nd er a dn ex a l m a ss o r ce rv ic a l m o tio n te nd er ne ss (fo r th e p roc e du re fo r P el vic E xa m in at io n , se e A nn ex 4 , pa ge 4 -2 6) z Bu rn in g on u rin a tio n z In cr ea se d u rg en cy /fr eq ue n cy o f u rin at io n AC T NO W !— fa cil ita te u rg en t re fe rra l/t ra ns fe r ( A nn ex 7 , pa ge 4 -6 3). (F or co mp let e d iff er en tia l d ia gn o si s a n d m an a ge m e n t o f a bd o m in a l pa in in e a rly p re gn a n cy , s ee M CP C. ) Pr oc ee d wi th b a si c ca re p ro vi si on w ith th e fo llo wi n g ad di tio n s a n d/ or e m ph as e s: z Pr ov id e re a ss u ra n ce th at a bd o m in al p ai n m ay b e no rm al du rin g pr eg na n cy . F or m or e in fo rm at io n ab ou t a bd om in a l o r gr oi n pa in a s a co m m o n d isc o m fo rt of p re gn an cy , s ee Ab do m in a l (o r G roi n) Pa in (C ha pt er 9 , p ag e 3- 3). z R ev ie w th e da n ge r s ig ns a nd th e w om an ’s b irt h pr ep a re dn e ss a n d co m pl ic a tio n r e a di ne ss p la n : − En su re th at e m e rg en cy tr an sp o rta tio n an d fu n ds a re im m ed ia te ly ac ce ss ib le . − En su re th at s he k no w s w he re to g o fo r h el p if a d an ge r si gn a ris e s. Se ve re a bd om in al pa in in la te r pr eg na nc y (af ter 22 w ee ks ’ g es ta tio n) o r la bo r (F or inf orm ati on on po ss ib le di ag no se s a ss o ci at e d w