INTRODUCTION TO POGS MDG COUNTDOWN
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Too many mothers and newborns are dying.
o 600,000 women die from preventable deaths worldwide (WHO 1996)
o 162 women die for every 100,000 live births (Philippines FPS 2006)
o Many of maternal deaths occur at home and are never recorded
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Most maternal deaths occur during labor, delivery and the immediate postpartum
period indicating that proper care during labor and delivery are critical.
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The five major direct causes of maternal mortality:
1. Hemorrhage. Bleeding in a pregnant woman can happen at any time
during pregnancy. However, it is the hemorrhage that occurs after
childbirth that is a main cause of maternal death. Postpartum bleeding is
most often due to failure of the uterus to contract effectively (uterine
atony). Lacerations and tear in the birth canal and retained placental
tissues are other causes of postpartum hemorrhage.
2. Hypertension. Women can develop hypertension during pregnancy and if
uncontrolled and untreated may develop convulsion that can lead to
death.
3. Infection. Failure to observe clean birth protocols can result to infections
that adversely affect the health of the mother and baby.
4. Obstructed labor. This is often due to mismanaged labor and
cephalopelvic disproportion. Women who have prolonged or obstructed
labor can develop vesicovaginal or rectovaginal fistulas. They are also
likely to develop postpartum bleeding.
5. Complications of abortion. Women with unplanned pregnancies may often
resort to induced abortion. This can be prevented if women have access
to family planning information and services and safe post abortion care.
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As to child health, The Philippines is one of the 42 countries that account for 90%
of global under-five mortality. Neonatal deaths account for almost 40% of all
child mortality. The leading causes of neonatal deaths are prematurity, sepsis or
pneumonia, and asphyxia.
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Reasons for high maternal and neonatal mortality:
1. Young age at marriage & first pregnancy
2. Domestic violence and gender inequality
3. Poor maternal health
4. Poor hygiene during and after delivery
5. Lack of/poor newborn care
6. The three delays
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THE THREE DELAYS: Barriers in accessing care on time
1. Delay in deciding to seek medical care
a. Failure to recognize danger signs
b. Lack of money
c. Unplanned/unwanted pregnancy
d. Lack of companion in going to health facility
e. No person to take care of children/home.
f. Fear of being ill treated in health facility
2. Delay in identifying and reaching the appropriate facility
a. Distance from a woman’s home to health facility/provider
b. Lack of/poor condition of roads
c. Lack of emergency transportation
d. Lack of awareness of existing services
e. Lack of community support
3. Delay in receiving appropriate and adequate care at the health facility
a. Lack of health care providers
b. Shortage of supplies
c. Lack of equipments
d. Lack of competence of health providers
e. Weak referral system
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MILLENIUM DEVELOPMENT GOALS
In December 2000, 189 Heads of States or Governments jointly endorsed the
Millennium Declaration which committed signatories to achieving, by 2015, 8
millenium development goals. The Philippines is one of the signatories to this
declaration. Of the 8 goals, Goals 4 and 5 relate to reduction of child mortality
and improvement of maternal health.
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
MDG 4 REDUCE CHILD MORTALITY
1. Reduce Under 5-mortality rate from 80.0 to 26.7 (per 1,000 LB)
2. Reduce Infant mortality rate from 57.0 to 19.0 (per 1,000 LB)
MDG 5 IMPROVE MATERNAL HEALTH
Reduce maternal mortality by 75% by 2015
(for the Philippines the target is to reduce MMR from 209 to 52 deaths per
100,000 live births).
The current maternal mortality rate is 162 per 100,000 livebirths (2006 FHS)
How will we make it happen?
1. A skilled health care professional attends every childbirth
2. Every woman has access to Emergency Obstetric and Newborn Care
(EmONC)
3. Family planning services to help women space their pregnancies
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A SKILLED ATTENDANT is an accredited health professional (a midwife,
nurse or doctor) who has been educated and trained to proficiency in the skills
needed to manage normal pregnancies, childbirth and the immediate postnatal
period, and in the identification, management and referral of complications
in women and newborns.
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EMERGENCY OBSTETRIC AND NEWBORN CARE refers to the elements of
obstetric & newborn care needed for the management of normal and complicated
pregnancy, delivery, postpartum periods and the newborn.
1. Early detection and treatment of problem pregnancies to prevent
progression to an emergency.
2. Management of emergency complications (for the mother – hemorrhage,
obstructed labor, pre-eclampsia/eclampsia, infection. For the newborn –
infection, asphyxia, hypothermia.)
There are 2 levels: Basic (BEMONC) and Comprehensive (CEMONC)
Basic emergency obstetric and newborn care – signal functions
1. Parenteral (IV or IM) administration of Antibiotics
2. Oxytocin
3. Anticonvulsants
4. Manual Removal of Placenta
5. Removal of Retained Products of conception
6. Assisted Vaginal Delivery
7. Administration of corticosteroids in preterm labor
8. Essential Newborn Care
Comprehensive emergency obstetric care signal functions – all of BEMONC +
1. Surgery (Cesarean Section)
2. Blood Transfusion
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Philippine midwifery practice is guided by the Midwifery Act of 1992 (R.A.7392).
Aside from providing care to the woman during normal pregnancy and childbirth,
the law has provided added skills that the midwife must learn to do her task
competently. These include:
1. Repair of first and second degree perineal lacerations to control
bleeding
2. Internal examination except when the woman has antepartum
bleeding
3. Intravenous fluid infusion during obstetric emergencies
4. Giving oxytocic drugs after delivery of placenta
5. Giving vitamin K to the newborn
The midwife must adhere to her scope of work and training to protect the safety
of those who seek her care. As a health professional, she is duty bound to
improve and continuously update and enhance her knowledge, skills and practice
by attending and participating in continuing professional education (midwifery)
activities.
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ANTENATAL CARE
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Focused antenatal care is based on the premise that every pregnancy is at risk
for complications. All women should receive the same basic care including
identifying complications. This model of antenatal care involves a minimum of 4
visits in normal or uncomplicated pregnancies. It stresses quality rather than
number of visits and has essential goal-directed elements including screening for
diseases that complicate pregnancy like pre-eclampsia and anemia. It also
reduces cost, lessens workload and provides more time to interact with patients
thereby improving quality of care.
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Focused Antenatal Care components:
1. General Assessment of the Pregnant Woman
2. Screening for diseases that complicate pregnancy: hypertension, anemia,
syphilis
3. Preventive measures: tetanus immunization, iron and folic acid
supplementation
4. Health Education: Self Care, Nutrition and Danger Signs during Pregnancy
5. Birth Plan
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Objectives of Prenatal Care
1.
Detection of diseases which may complicate pregnancy
2.
Education of women on danger and emergency signs & symptoms
3.
Preparation of the woman and her family for childbirth
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Steps to follow in Prenatal Care
1. IMMEDIATE ASSESSMENT for emergency signs: (QUICK CHECK)
 Unconscious/Convulsing
 Vaginal bleeding
 Severe abdominal pain
 Looks very ill
 Severe headache with visual disturbance
 Severe difficulty in breathing
 Fever
 Severe vomiting
*Attend to sick woman quickly,
2. Make the woman comfortable.
 Greet her, make sure she is comfortable and ask how she is feeling.
 If first visit, register the woman and issue a Mother and Child
Book/Home Based Maternal Record
3. Assess the pregnant woman
FIRST visit:
 How old is patient? Past Medical History
 Obstetric History: Gravidity? LMP? AOG?
 Ask about or check record for prior pregnancies:
o Convulsions
o Stillbirth or death in the first day
o Heavy bleeding during or after delivery
o Prior cesarean section, forceps or abortion
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ON ALL VISITS:
 Check duration of pregnancy (AOG)
 Ask for bleeding/danger signs during this pregnancy
 Check record for previous treatments received during this pregnancy
 Prepare birth and emergency plan
 Ask patient if she has other concerns
 Give education and counseling on family planning
THIRD TRIMESTER
 Leopold’s exam, fetal heart beat
 Give education & counseling on family planning
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Do not perform vaginal exam as a routine prenatal care procedure.
Always record findings.
All pregnancies are at risk. Encourage all pregnant women to deliver in the
health facility.
Refer patients with abnormal findings to doctor or to higher facility.
4. Get baseline laboratory information of the woman on the first or following the first
visit.
 Hemoglobin, blood type
 Urinalysis
 If not available, refer to the nearest RHU or hospital for the tests.
5. Screen for diseases that may complicate pregnancy: Check for pallor or anemia
Ask about getting tired easily or shortness of breath during routine work,
drowsiness, palpitations, headaches – these may indicate anemia.
On 1st visit, check hemoglobin & blood type. The normal hemoglobin (Hb)
cut-off level for a pregnant woman is 11g/dl. If Hb is <8 g/dl, refer to doctor for
work-up and treatment of anemia.
On subsequent visits;
1) Look for conjunctival pallor.
2) Look for palmar pallor. If pallor: Is it severe pallor? Some pallor?
3) Count number of breaths in one minute.
6. Check for hypertension/pre-eclampsia
 Measure BP in sitting position. If blood pressure is above 140/90 early in
pregnancy, she is suffering from chronic hypertension and should be
referred to a doctor.
 If diastolic BP is 90 mm Hg or higher repeat measurement after 1 hour rest.
 If diastolic BP is still 90 mm Hg or higher ask the woman if she has:
1) Severe headache 2) Blurred vision 3) epigastric pain
 Check urine for protein.
 Diastolic BP>90 mm Hg, especially if with severe headache, blurred vision
and epigastric pain and ++ urine protein are signs of severe pre-eclampsia –
REFER immediately!
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7. Screen for diseases that may complicate pregnancy: Check for gestational
diabetes
ASK ABOUT
– Family history (first degree) of diabetes & history of obesity.
– Past pregnancy for difficult labor, large babies, congenital malformations
and previous unexplained fetal death.
LOOK FOR
Refer for glucose test:
– signs of maternal overweight or obesity
at 24-28 wks for low risk or
– Polyhydramnios
immediately if high risk
– Signs of large baby or fetal abnormality
– Vaginal infection.
8. Check for fever, burning sensation on urination and abnormal vaginal discharge.
• Ask about episodes of fever or chills and take temperature.
• Ask about pain or burning sensation on urination.
• Ask about presence of abnormal vaginal discharge, itching at the vulva or
if partner has a urinary problem.
9. Give preventive measures: Immunize against tetanus.
Tetanus Toxoid Immunization Schedule
Vaccine
Minimum Interval
Duration of Protection
TT1
at first contact with woman NIL – no protection
15-49 yrs or at first
antenatal care visit
TT2
at least 4 weeks after TT1
• Infants born to the mother will be
protected from neonatal tetanus
• 3 years of protection for the
mother
TT3
At least 6 weeks after TT2 • Infants born to the mother will be
protected from neonatal tetanus
• 5 years of protection for the
mother
TT4
At least 1 year after TT3
• Infants born to the mother will be
protected from neonatal tetanus
• 10 years of protection for the
mother
TT5
At least 1 year after TT4
• Infants born to the mother will be
protected from neonatal tetanus
• Lifetime protection for the
mother
To be protected, a pregnant mother must receive at least 2 doses of tetanus
toxoid. The last dose should be at least two weeks before delivery.
10. Give preventive measures Give MEBENDAZOLE to treat for intestinal parasites.
500 mg single dose once in six months (after 1st trimester)
11. Give iron and folate supplementation to prevent anemia and neural tube defects:
Ferrous sulfate 320 mg (60 mg elemental iron) & 250 mcg Folate
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If Hgb <80 gm/dl→ double the dose of iron. Refer to doctor for work-up of
anemia.
12. Give preventive intermittent treatment for falcifarum malaria (if area is endemic)
13. Provide health information, advice. Counsel on danger signals
HEALTH INFORMATION
 Nutrition
 Self-care during pregnancy
 Effect of tobacco, alcohol & drugs
 Breastfeeding
 Birth & Emergency situations
 Schedule of appointment
DANGER SIGNS
 Vaginal bleeding
 Convulsions
 Severe headache
 Severe abdominal pain
 Fast or difficult breathing
 Fever or burning urination
14. Encourage the woman to come back for return visits.
At least 4 routine antenatal visits
1st visit: before 4 months
2nd visit: 6 months
3rd visit: 8 months
4th visit: 9 months – return if undelivered within 2 weeks after the EDC.
Pregnant women who do not come for prenatal care should be visited at home.
THE BIRTH AND EMERGENCY PLAN
What is a birth plan?
• A written document prepared during the first prenatal consultation. Plan may
change anytime during pregnancy if an abnormality develops.
• Discussed by the patient with the skilled birth attendant.
• Contains information on:
– the woman’s condition during pregnancy
– preferences for her place of delivery and choice of birth attendant.
Discuss why facility delivery vs home delivery with skilled attendant is
recommended
– available resources (transportation, companion, money) for her childbirth
and newborn baby
– preparations needed (blood donor, referral center) should an emergency
situation arise during pregnancy, childbirth and postpartum.
Emergency Plan
• Discuss how to prepare for an emergency in pregnancy
 Advise on danger signs, signs of labor
 Where to go?
 How to go?
 What to bring?
 With whom will you go?
 How much will it cost? Who will pay? How will you pay?
 Start saving for these possible costs now.
 Who will care for your home and other children when you are away?
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Birth and Emergency Plan
I know that any complication can develop during delivery. I know that I should
delivery in a health
facility.
I will be attended at delivery by ___________________________________
I plan to deliver at _____________________________________________
This is a Philhealth accredited facility _____ Yes ____ No
The estimated cost of the maternity package in this facility is P___________
(inclusive of newborn care)
The mode of payment is ________________________________________
The available transport is _______________________________________
I have contacted ____________________________________ to bring me to
the hospital/health center.
I will be accompanied by ________________________________________
_____________________________ will take care of my children/home while
I am in the health facility.
In case of a need for blood transfusion, my possible donors are;
____________________________________________________________
_____________________________________________________________
In case of complications, I will be referred right away to:
______________________________________
Contact Person _______________________________________________
Address: ____________________________________________________
Tel No.:
____________________________________________________________
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PROVIDING CARE DURING LABOR, CHILDBIRTH
AND IMMEDIATE POSTPARTUM
STEPS TO FOLLOW IN INTRAPARTAL CARE
1. Examine the woman for emergency signs.
• Unconscious, Convulsing
• Vomiting
• Severe headache with blurring of vision
• Vaginal bleeding
• Severe abdominal pain
• Looks very ill
• Fever
• Severe breathing difficulty
** Do NOT make a very sick woman wait, attend to her quickly!
2. Greet the woman and make her comfortable.
 Ask for informed consent before examination or any procedure
 Respect her privacy
 Inform her of results of examination
 Reassure
3. Assess the woman in labor.
o Take the history of labor and record on the labor form.
o Review Home Based Maternal Record (HBMR)/ Mother and Child Book
 When is delivery expected? Preterm or term?
 Prior pregnancies
 Birth plan
o Assess uterine contractions: intensity, duration, and interval
o Observe the woman’s response to contractions.
o Perform abdominal exam: (Leopold’s maneuver, FHT) between
contractions
4. Determine the stage of labor.
 Explain to the woman that you will perform a vaginal examination and ask for her
consent.
 Respect her privacy
 Observe standard precautions (wash hands, wear gloves, ..)
 Inspect the vulva for:
o Bulging perineum
o Any visible fetal parts
o Vaginal bleeding
o Leaking amniotic fluid; if yes, is it meconium stained, foul smelling?
o Warts, keloid tissue or scars that may interfere with delivery
 Perform gentle vaginal examination (do not start during contraction).
 Explain findings to the woman. Reassure her.
 Record findings in labor record or partograph.
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SIGNS
Bulging thin perineum
Vagina gaping and head
visible
• Full cervical dilation
Cervical dilatation
- Multigravida >5 cm
- Primigravida >6 cm
CLASSIFY
Imminent Delivery
Cervical dilatation at >4cm
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•
Cervical dilatation at 0-3 cm
Contractions weak and <2 in
10 minutes
•
MANAGE
Manage 2nd stage of
labor
Record in partograph
Late Active Labor
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Manage 1st stage of labor
Record in partograph
Record in labor record
Early Active Labor
•
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•
Manage 1st stage of labor
Record in partograph
Record in labor record
Record in labor record
Not in Labor
•
5. Decide if the woman can safely deliver. If there is indication for referral …
•
in early labor & the referral hospital can be timely reached: → Refer urgently
• in late active labor:
 Monitor progress of labor and deliver the baby
 Prepare for immediate referral if still necessary
• If the woman or her family refuses referral
 Explain the possible consequences
 Continue to take care of her
6. Give supportive care throughout the labor.
 Explain procedures, seek permission and discuss findings with the woman and
her family.
 Examine the woman in a place where she is not exposed to people other than
the examining person and her choice of companion
 NEVER LEAVE a woman in labor alone.
Encourage woman to:
 wash from her waist down or take a bath at the onset of labor.
 empty her bladder and bowels. Remind her to empty her bladder every 2
hours. (A full bladder may prolong the labor)
 move freely (if BOW is not ruptured). Respect and support her choice of a
birthing position
 drink as she wishes. Contractions will make her thirsty and the sugar will give
her energy for her labor. Do not give solid foods – this may make her vomit.
7. Monitor and manage labor.
 First stage: not yet in active labor, cervix is dilated 0-3 cm., contractions are
weak, <2 in 10 minutes
 Every hour: check for emergency signs, frequency, intensity & duration of
contractions, FHR, mood and behavior.
 Every 4 hours: check vital signs and cervical dilatation.
 Record findings in Labor record
 Assess progress of labor: After 8 hrs, if contractions are stronger & more
frequent but no progress in cervical dilatation: REFER
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First stage: in active labor, cervix is dilated at 4 cm or more
 Check every 30 mins for emergency signs, frequency and duration of
contractions, FHR, mood and behavior.
 Check every 4 hours: fever, PR, BP, cervical dilatation.
 Record time of rupture of membranes and color of the amniotic fluid.
 Record findings in partograph.
RELIEF OF PAIN AND DISCOMFORT
1. Suggest change of position
2. Encourage mobility as comfortable for her
3. Encourage proper breathing: breath more slowly, make a sighing noise,
make 2 short breaths followed by a long breath out.
4. Massage her lower back if she finds it helpful
CAUTION
1. DO NOT do IE more frequently than every 4 hours.
2. DO NOT allow the woman to push unless delivery is imminent → pushing
does not speed up labor, mother will become tired, cervix will swell.
3. DO NOT give medications to speed up labor → DANGEROUS: may
cause trauma to the mother and baby.
4. Do not do fundal pressure may cause uterine rupture, fetal death
 Second stage: from full dilatation (10cm) of the cervix until birth of baby.
How to tell if a woman is in the 2nd stage of laor
 On IE, cervix is fully dilated
 Woman wants to bear down
 Strong uterine contractions every 2-3 minutes
 Bulging thin perineum, fetal head visible during contractions.
 BOW will rupture
MONITORING THE SECOND STAGE
 Check uterine contractions, fetal heart rate, mood and behavior
 Continue recording in the partograph
REMINDERS:
 Massaging or stretching the perineum have not been shown to be
beneficial.
 DO NOT apply fundal pressure to help deliver the baby → may harm
mother and baby.
8. DELIVER THE BABY
 Implement the 3 CLEANS
1. Clean hands. Wear double gloves.
2. Clean delivery surface
3. Clean cutting and care of the cord
 Stay with the woman and encourage her. Make her comfortable.
 Encourage the mother to bear down when the baby’s head is coming down.
 When the birth opening is stretching, support the perineum and anus with a clean
swab to prevent lacerations
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 Ensure controlled delivery of the head
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9.
Keep one hand on the head as it advances during
contractions. Keep the head from coming out too
quickly
Support the perineum with other hand.
Discard pad and replace when soiled to prevent
infection
During delivery of the head, encourage
woman to stop pushing and breathe rapidly
with mouth open.
Gently feel if the cord is around the neck
o If it is loosely around the neck, slip it over the shoulders or head
o If it is tight, place a finger under the cord, clamp and cut the cord, and
unwind it from around the neck.
Gently wipe the baby’s nose and mouth with a clean gauze or cloth.
Wait for external rotation (within 1-2 min), head will turn sideways bringing one
shoulder just below the symphysis pubis and other facing the perineum
Apply gentle downward pressure to deliver top shoulder then lift baby up to
deliver lower shoulder. Gently deliver the rest of the baby. Note the time baby is
delivered.
Put baby on mother’s abdomen in prone position. Cover with dry towel.
Thoroughly dry the baby immediately. Wipe eyes.
Discard wet cloth.
Put baby prone on mother’s abdomen, in skin-to-skin contact. Keep the baby
warm.
Exclude 2nd baby by palpating mother’s abdomen.
Give 10 units oxytocin IM to the mother. (Active management of the 3rd stage of
labor). *May be done by midwife under supervision of doctor.
Watch for vaginal bleeding.
Remove first set of gloves.
CLAMP AND CUT THE CORD
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Feel the cord. When no more cord pulsation
is felt on the cord (usually within 3 mins.),
clamp the cord 2cm from the base using
sterile plastic cord clamp
Sweep the cord and apply a Kelly forceps
5cm from the base and then cut in-between.
Observe stump for blood oozing. Do not
bandage or bind the stump. Leave it open
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THIRD STAGE: between birth of the baby and delivery of the placenta.
o Deliver the placenta by controlled cord
traction (with counter traction on the uterus
above the symphysis pubis).
o Massage the uterus over the fundus.
o Inject oxytocin.10 U IM (if not yet given as
part of active management)
o Encourage initiation of breastfeeding. Keep
the baby on mother’s abdomen for 60-90
min.
o Check that the placenta and membranes
are complete. Put the placenta into a
container for disposal.
ACTIVE MANAGEMENT of the third stage of labor (under supervision of
doctor)
o Cord is clamped after cord pulsations have stopped.
o Oxytocin is given within 2 minutes of delivery of the baby.
o Placenta is delivered by controlled cord traction with countertraction on the
uterus above the symphysis pubis.
o Massage fundus.
10. Monitor closely within 1-hour after delivery (Immediate postpartum period)
and give supportive care.
 Check for vaginal tears and bleeding.
 Clean the woman and make her comfortable.
 Check BP, PR, emergency signs & uterine contraction every 15 minutes.
 Initiate breastfeeding within 1-hour when the baby is ready.
11. Continue care after 1 hour postpartum. Keep watch closely for at least 2 hours.
 Temperature, BP and pulse every 30 minutes
 Check at 2, 3 and 4 hours, then every 4 hours:
o emergency signs
o hardness of the uterus
 Check for bladder distension if unable to void.
 Advise clean cloth/napkin to collect vaginal blood.
 Eat and drink high-energy foods that are easily digestible.
** Companion: to watch her and to call you for bleeding or pain, dizzy or for any
other
problem
For the baby
 Keep the baby in the room with the mother, in her bed or within easy reach.
 Support exclusive breastfeeding on demand, day and night, as often and as long
as the baby wants.
 Immunize according to the EPI schedule.
 Mother and companion to watch the baby:
 breastfeeding difficulty
 difficulty of breathing
 cold feet
 bleeding from the cord
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 Check baby at around 4 and 8 hours and then daily:
 cold feet, breastfeeding and breathing difficulty.
12. Educate and counsel on family planning and provide the family planning
method if available.
 Ask what are the couple’s plans regarding having more children.
 Give relevant information and advice.
 Advice that exclusive breastfeeding is the best contraceptive in the 1st six
months.
 Help her to choose the most appropriate method for her and her partner.
13. Inform, teach and counsel the woman on important MCH messages.
 Talk to the woman when she is rested and comfortable.
 Also give important information and advice to her companion.
 Take time to explain, use visual aids, and demonstrate important lessons.
 Encourage them to participate actively in discussions and to ask questions.
13. Discharge the woman and her baby.
 The woman and her baby may be discharged 24 hours after delivery.
 Ensure that the woman is able to breastfeed successfully before discharge.
 Repeat important health information.
 Check understanding and arrange follow-up.
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THE PARTOGRAPH
The partograph is a useful tool for monitoring the progress of labor. Use it to avoid
unnecessary interventions so maternal and neonatal morbidity are not needlessly
increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or
mortality and to ensure close monitoring of the woman in labor.
USES OF THE PARTOGRAPH
► Assessment of progress of labor
 Cervical dilatation
 Contractions
 Alert and action lines
► Assessment of maternal well being
 Pulse, temperature, blood pressure
 Urine voided
► Assessment of fetal well being
 Fetal heart rate and pattern
 Color of amniotic fluid
Parts of the Partograph
The upper colored portion is
where progress of labor.is
plotted.
Progress of
Labor
The lower portion is where
observations of the maternal
and fetal well-being are written.
Maternal & Fetal
well being
ALERT LINE
ACTION LINE
This is an enlarged picture of upper
portion of the partograph. It is divided
evenly into small boxes by gridlines
vertically and horizontally.
Each horizontal gridline corresponds
to the cervical dilatation in centimeter
from 4 to 10.
While the vertical gridlines indicate the
time, in hours, the patient is in active
labor.
The upper portion is also divided into
3 colors – green, yellow, and red..
The boundary between the green and yellow parts forms a diagonal line called the alert
line which starts at 4 cm. up to 10 cm At the alert line, the onset of the active phase of
labor (4 cm), the patient is expected to reach full dilation at the rate of 1 cm/hour.
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Parallel and 4 hours to the right of the alert line is another line formed by the boundary
between the yellow and red part which is again highlighted here. This is the action line.
Note that it too starts at 4 cm and ends in 10 cm.
The following are examples of risk factors which may have been identified during
prenatal and before the start of labor where the use of the partograph is not
recommended. These patients should be referred to higher facility.
 Very short stature
 Anemia, severe
 Antepartum hemorrhage
 Multiple pregnancy
 Severe pre-eclampsia and eclampsia
 Malpresentation
 Fetal distress
 Very premature labor
 Previous cesarean section
 Obvious obstructed labor
PARTOGRAPH AND CRITERIA FOR ACTIVE LABOR
 Start the partograph only when the woman is in ACTIVE labor (4 cm or more) and
is contracting enough (3-4 contractions in 10 min)
 Label with patient identifying information
THE PROGRESS OF LABOR
 Plot CERVICAL DILATATION
- This is plotted or recorded using “X”
- Perform the internal examination (IE) every 4 hours, or more frequently if
necessary.
 If the woman is admitted in labor in the latent phase (less than 4 cm dilated ) –
use the LABOR RECORD to record your findings (BP, FHT etc).
 If she remains in the latent phase for the next 8 hours, labor is prolonged and she
must be transferred to the hospital.
PLOTTING CERVICAL DILATATION WHEN LABOR IS IN THE ACTIVE PHASE
 Plot or record cervical dilatation on the alert line whenever woman is admitted in
the active phase of labor.
 The plotting of the cervical dilatation will remain on or to the left of the alert line
when there is a satisfactory progress in labor
MONITOR EVERY 4 HOURS (or more frequently if necessary): Vital signs: BP,
Temperature, PR and cervical dilatation.
MONITOR EVERY HOUR: FHT, frequency, intensity and duration of contractions,
woman’s mood and behavior.
OTHER FINDINGS TO RECORD
 Vaginal bleeding (0, +, ++, +++)
 Time membranes ruptured
 “ I ” if membranes are intact
 Color of amniotic fluid
 “ C ” membranes are ruptured and amniotic fluid is clear
 “ M ” amniotic fluid is stained
 “ A ” Amniotic fluid is absent
 “B” Amniotic fluid is bloody
 Urine voided (yes, no)
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IF PARTOGRAPH PASSES THE ALERT LINE:
 Reassess woman and consider criteria for referral.
 Alert transport services.
 Empty bladder.
 Ensure adequate hydration but omit solid foods.
 Encourage upright position and walking if woman wishes.
 Monitor intensively. If referral long, reassess in 2 hours and refer if no progress.
If partograph passes action line…
refer urgently to an EmOC facility unless delivery is imminent.
ABDOMINAL EXAMINATION DURING PREGNANCY
1. Inspection
• Check if there are any scars. If the scar was from CS → REFER
• Is abdomen normal shape and size?
→ twins
→ transverse lie
→ breech
2. Palpation
• Checking the fundic height
• Estimation of fetal weight
• Leopold’s maneuver
Why measure the fundic height?
1) To determine if the uterine size is compatible with the age of gestation
Fundic height coincides with the age of gestation from 18-30 weeks
2) To aid in the estimation of fetal weight
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HOW TO MEASURE THE FUNDIC HEIGHT
1. Bladder must be empty
2. Apply the tape with the calibration
hidden to avoid bias
3. Measure from upper edge of
symphysis pubis to top of the fundus
(do not push the fundus down)
POSSIBLE PROBLEMS WITH FUNDIC HEIGHT
Fundic height is too large
Fundic height is too small
• Computed AOG is wrong
• Computed AOG is wrong
• Multiple pregnancy
• Baby is not growing well (IUGR)
• Polyhydramnios
↓
• Molar Pregnancy
→
REFER!
• Pregnancy with Myoma or Ovarian
Tumor
LEOPOLD’S MANEUVER
First Maneuver:
WHAT OCCUPIES THE FUNDUS?
• Face the woman’s head with both hands,
feel the height of the fundus.
•
Which part of the fetus do you feel?
2nd Maneuver:
• Feel the sides of the uterus to find the
position of the baby’s back and
extremities.
– Back feels smooth
– Extremeties feel irregular
3rd Maneuver:
IDENTIFY PRESENTING PART
• Grasp area immediately above the
symphysis between thumb and fingers
– HEAD: hard and round, movable
if not engaged
– BREECH: feels softer and
irregular
4th Maneuver
• Face the woman’s feet. Place fingers on
both sides of the lower abdomen and
press downwards and inwards
• Determine fetal occipital prominence
• Helps to identify the presenting part and
whether it is engaged
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INTERNAL EXAMINATION DURING LABOR
WHEN TO DO AN INTERNAL EXAMINATION
• ONLY DURING LABOR
• When the BOW ruptures (to rule out cord prolapse)
• If malpresentation is suspected on abdominal examination
• Before transferring a woman to another facility to ensure she is not likely to
deliver on the journey.
• In the 3rd stage, if there is postpartum hemorrhage, caused by retained placenta
or suspected laceration.
If the woman has had vaginal bleeding after 5th month of pregnancy: DO NOT
PROCEED.
NEVER do an I.E. unless you have a good indication for doing so. Every I.E. may
bring INFECTION to the woman and her baby.
PROCEDURE FOR INTERNAL EXAMINATION
1. Explain to the woman what you are going to do.
2. Take full aseptic precautions
3. Rinse the vulva with clean water.
4. Wear clean gloves
5. INSPECT THE VULVA:
a. Is there amniotic fluid? Is it clear or meconium stained?
b. Is there any abnormal discharge, blood or pus?
6. Feel inside the vagina with the middle and index fingers.
WHAT TO NOTE DURING INTERNAL EXAMINATION
1. Cervical Dilatation
2. Bag of waters
3. Presenting part
4. Pelvis (architecture, adequacy of diameters)
WHAT IS CERVICAL DILATATION
•
•
•
•
Gradual opening of the cervix
Measured in centimeters
Feel with your 2 fingers
The fully dilated cervix is 10 cm open.
Assessing Cervical Dilatation
Insert the middle and index finger into the
open cervix and gently open them to the
cervical rim. The distance between the
outer rim of both fingers is the cervical
dilatation
1 finger = 1.25 cm
2 fingers = 3 cm
3 fingers = 4.5 cm
4 fingers = 5.5 cm
5 fingers = 7 cm
6 fingers = 8.5 cm
7 fingers = 9.5 cm
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DETERMINE STATUS OF BAG OF WATERS (BOW)
• Is BOW intact or ruptured?
•
Is there amniotic fluid leaking? Clear or meconium stained?
• Is BOW intact or ruptured?
**BE CAREFUL NOT TO RUPTURE THE BAG OF WATER IF THE PRESENTING
PART IS FLOATING OR NOT ACCESSIBLE
DETERMINE THE PRESENTING PART
• What is the presentation?
– Cephalic: Feels hard. Sutures and fontanelles of the baby’s head are felt
– Malpresentation: Hardness of the baby’s head is not felt but soft buttocks
or extremeties (foot or hand).
• Is the cord palpable?
• What is the level of the presenting part?
PELVIC ARCHITECTURE
Assess the following:
1. Sacral curvature : hollow (deep), average (normal), or flat (shallow)
2. Sacrosciatic notch – wide or narrow
3. Ischial spines – sharp/prominent
4. Pubic arch – estimate the angle of the rami at the pubis: narrow ( <), medium (about
90°) or wide (>90°)
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5. The diagonal conjugate (from the lower border of the symphysis pubis to the
promontory of the sacrum)
The pelvis in UNLIKELY to be contracted when:
• The diagonal conjugate is ≥ 11.5 – 12
• The sacrum is not flat
cm.
• The subpubic angle is not narrow
• The pelvic sidewalls are parallel
• The ischial spines are not prominent
INTRAVENOUS FLUID (IVF) INSERTION
1. PREPARE MATERIALS TO BE USED
a. Bottle or bag of IV fluid: D5LR or NSS
b. IV needle/cannula/catheter: Gauge 18 or G20
c. IV tubing or administration set
d. Tourniquet
e. Cotton balls with alcohol
f. Tape
g. Disposable gloves
2. PREPARE FOR IVF INSERTION
a. Check the patient identification
b. Explain in simple terms the procedure to the patient and make her
comfortable
c. Organize correct and adequate lighting
d. Wash hands to prevent infection or cross-contamination
e. Wear protective gloves
f. Place yourself in a comfortable position; sitting, if possible
3. PREPARE IV ADMINISTRATION SET
a. Check the type, clarity, and expiration of fluid.
b. Remove the plug or protective covering from the bottom of the bag/bottle.
Close the flow regulator, remove protective covering from the spike of
tubing set, and insert the spike into the port of fluid bag or bottle.
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c. Place the fluid bag or bottle higher, squeeze the drip chamber to fill 1/3 of
it, open the flow regulator to flush the air (and bubbles) from the rest of
the tubing, and close the flow regulator.
d. Hang the bag on an IV pole. Care should be taken not to contaminate the
end of the tubing.
4. CHOOSE THE SITE OF INSERTION
Alternate:
Forearm veins
Preferred: Hand veins



AVOID
o Areas of joint flexion
o Veins close to arteries and deep lying vessels
o Small, visible but impalpable superficial veins
o Veins irritated by previous use
Use distal veins first
Use vein on opposite side to the site of intended procedure
5. PERFORM THE VENIPUNCTURE
a. Apply a tourniquet above the chosen site
to create an adequate venous filling.
b. Ask patient to make a fist to maximize
vein engorgement.
c. Palpate the vein or tap it to help it dilate.
d. Clean the entry site with alcohol and
allow it to dry.
e. Do not repalpate
f.
Insert the IV catheter into the skin at 3045º angle with the bevel up and in the
direction of the vein.
g. Advance the catheter to enter the vein
until blood is seen in the “flash
chamber” of the catheter
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h. Advance the plastic catheter on into the
vein while leaving the needle stationary.
i. Apply gentle pressure over the vein just
proximal to the entry site to prevent
blood flow and remove the needle from
the plastic catheter.
j. Connect the plastic catheter to the
previously-prepared IV tubing set and open
the flow regulator
k. Tape the catheter in place and
adjust the flow rate.
6. COMPLICATIONS OF IV THERAPY
a. Hematoma
b. Infiltration (pain, swelling, pallor of site, IV flow rate decreases or stops,
absence of backflow of blood into the tubing)
c. Thromboembolism
d. Air embolism
e. Phlebitis and septicemia
f. Fluid overload
g. Hematoma
h. Infiltration (pain, swelling, pallor of site, IV flow rate decreases or stops,
absence of backflow of blood into the tubing)
i. Thromboembolism
j. Air embolism
k. Phlebitis and septicemia
l. Fluid overload
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PERINEAL REPAIR
Perineal tears or lacerations are injuries
or tears in the vaginal canal and the
outlet that occurs during delivery of the
baby. The areas affected by perineal
tears are the perineum, lateral vaginal
walls, areas adjacent to the clitoris,
lateral sulcus tear and others.
Basic Instruments and supplies
1. Needle holder
2. Tissue forcep
3. Scissors
4. Hemostat
5. Gloves
6. Suture material with needle
7. Lidocaine 1 or 2 %
8. Syringe with needle
9. Gauze sponge
10. Antiseptics
Basic Principles in Repairing Lacerations
1. Adequate hemostasis
3. Use minimum suture material
2. Anatomical restoration
4. Adequate anesthesia
Classification of Lacerations
1st degree – involving the fourchette,
perineal skin and vaginal mucous
membrane
2nd degree laceration fourchette, perineal skin and vaginal
mucous membrane PLUS the fascia
and muscles of the perineal body
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3rd degree laceration - fourchette, perineal
skin and vaginal mucous membrane, the
fascia and muscles of the perineal body PLUS
the anal sphincter
4th degree laceration
extends through the rectal mucosa
exposing the lumen of the rectum
Different Techniques of Suturing
1. Continuous suture technique – to repair
subcutaneous fascia
2. Interrupted suture – to repair fascia and
muscle
3. Lock suture – to repair vaginal wall
Choice of Suture Material
• Must be absorbable: Chromic 2-0, Polyglocolic derivative (Vicryl, Dexon)
• Preferably with needle attached to it (atraumatic)
Choice of Needle
1. Round – soft tissues like mucosa and muscles
2. Cutting – tougher tissues like fascia and skin
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Steps in Perineal Repair
1. Provide emotional support and encouragement.
2. Ask an assistant to massage the uterus and provide fundal pressure.
3. Carefully examine the vagina, perineum and cervix
4. If the tear is long and deep through the perineum, inspect to be sure there is no
third or fourth degree tear:
a. Place a gloved finger in the anus;
b. Gently lift the finger and identify the sphincter;
c. Feel for the tone or tightness of the sphincter.
d. Change to clean, high-level disinfected gloves.
e. If the sphincter is injured → REFER
f. If the sphincter is not injured, proceed with repair
5. Clean area with antiseptic solution.
6. Apply firm pressure on bleeding areas. Clamp and ligate bleeders
7. Infiltrate site with local anesthetic.
Technique of Infiltration with Local Anesthetic

Make sure there are no known allergies to lidocaine
or related drugs.




Use 10 or 20cc syringe with gauge 22, 3 cm needle
Fill with lidocaine 2%
Insert the whole length of the needle below the skin
Aspirate (pull back on the plunger) to be sure that
no vessel has been penetrated. If blood is
returned in the syringe with aspiration, remove
the needle. Recheck the position carefully and try
again. Never inject if blood is aspirated. The
woman can suffer convulsions and death if IV
injection of lidoocaine occurs.
Inject evenly as you withdraw the syringe. Infiltrate
beneath the vaginal mucosa, beneath the skin of the
perineum and deeply into the perineal muscle using
about 10 mL 2% lidocaine solution.

Note:
At the conclusion of the set of injections, wait 2 minutes
and then pinch the area with forceps. If the woman
feels the pinch, wait 2 more minutes and then retest
8. Close the vaginal mucosa using continuous interlocking or simple interrupted 2-0
suture (Fig A):
 Start the repair about 1 cm above the apex (top) of the laceration. Place each
stitch about 1 to 1.5 cm from the last. Dark purple lines are blood vessels, avoid
these!
 Continue the suture to the level of the vaginal opening;
 At the opening of the vagina, bring together the cut edges of the vaginal opening;
 Bring the needle under the vaginal opening and out through the incision and tie.
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 Stitches should include the same amount of tissue from each side. If the edges
roll, this means that too much tissue has been taken into that stitch or that the
stitch is being pulled too tight. This can lead to a gaping scar if not corrected.
9. Close the perineal muscle using interrupted 2-0 sutures (Fig B).

The perineal muscles may be differentiated from the skin layers by feel. The
muscles are tougher and more resistant to touch. The color of muscles are
reddish hue.

Place the first muscular stitch close to the top of the vagina. At the level of the
hymenal ring, the separated ends of the bulbocavernousus muscle are reunited.
This muscle is rarely torn. It is almost always cut in giving an episiotomy. The
"figure of eight" suture may also be used to repair. If not done properly, the
mouth of the vagina will gape. If it is sewn tight, intercourse may be painful.

Check to be sure the plane of the needle is at right angles to the plane of the
holder. The needle holder must be held parallel with the wound edges, otherwise
a puncture of the rectum may occur.
10. Close the skin using interrupted (or subcuticular) 2-0 sutures (Fig C) starting at the
vaginal opening. If the tear was deep, perform a rectal examination. Make sure no
stitches are in the rectum.
Technique and Tips in Perineal Repair
1. Repair lacerations in layer.
2. Close the deeper perineal tissues with interrupted sutures.
3. Use small caliber sutures (Chromic 2-0)
4. Avoid tying the sutures too tight.
5. Check the rectal lumen after repair. A rectal exam should be performed to check
if any of these stitches have been accidently put through into the rectum. If so,
they must be removed. Removal will help prevent infection as well as a formation
of an open sinus tract from perineum to rectum.
6. Remove the gauze when finished.
7. Clean the area before and after repair.
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After Perineal Repair:

Wash the perineal area with antiseptic solution, pat dry the area, clean away all
soiled linen and position a sterile sanitary pad over the vulva and perineum.

Dispose of all bloody linens in a closed or closeable container for transport to
laundry

Gently lay the woman’s legs down together at the same time, and make her
comfortable. Make sure she is not wet or cold. Always maintain privacy and
modesty.
Postpartum Care of Wound
1. Advise the woman to clean the genital area including the suture line, with clean water
twice daily, and always after defecation. Change perineal pads/cloths frequently
enough to prevent unpleasant odor.
2. Provide pain relief: Give analgesics, Warm compress to lessen the edema, Hot sitz
bath, Medicinal / Herbal wash
3.
If a woman has excessive pain in the days after a repair, she should be examined
immediately because pain is a frequent sign of infection in the perineal area
At the Postpartum Visit
4. Examine the sutured perineum for healing and any signs of infection, e.g. marked
inflammation, excessive swelling, pus.
5. If the wound becomes infected: REFER
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POSTPARTUM CARE
STEPS TO FOLLOW IN POSTPARTUM CARE
1.
Assess for emergency signs.
– Vaginal bleeding
- Pallor
– Fever
- Looks very ill
* Do not make a very sick woman wait, attend to her immediately.
2.
Make the woman comfortable.
 Assess:
 When, where delivered
 How are you feeling?
 Pain, fever, bleeding since
delivery?
 Hard to void urine?
 Family Planning?
 Other concerns?
 Check records: complications,
treatment during delivery?
 HIV Status





Examine
BP, T°, Pulse rate
Check breast
Feel uterus: Is it hard, round?
Look at vulva & perineum for: tear,
swelling, pus
Look at pad for bleeding and lochia:
does it smell? Profuse?
Look for pallor


3. Assess breastfeeding
 Is there any difficulty breastfeeding?
 Observe how mother breastfeeds for at least 4 minutes.
- Is baby positioned well?
- Is baby able to attach to the nipples well?
- Is baby sucking effectively?
ROUTINE POSTPARTUM CARE
Mother feels well
BP, pulse & temperature normal
No breast problems, breastfeeding well
Uterus well contracted
No problem with urination
No pain or other concern
Give any treatment or prophylaxis due
Iron
Vitamin A
Tetanus
Advise and Counsel
Health education
Schedule return visit
ABNORMALITIES IN THE POSTPARTUM PERIOD
 Elevated BP

 Pallor

 Vaginal Bleeding

 Foul smelling lochia

 Dribbling Urine

REFER!
Pus or perineal pain
Feeling unhappy
Vaginal discharge
Breast Problem
 Infection/ Breast abscess
 Sore or cracked nipple
 Engorgement
 Insufficient milk
Cough or breathing difficulty
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TREATMENT AND PROPHYLAXIS
1. Prevent anemia with iron/folate supplementation.
2 tablets of iron/folate daily for 2 months (or more if mother is pale)
2. Give one capsule Vitamin A (200,000 IU) if none was given postpartum --- to protect
the baby from nutritional blindness and infections.
ADVISE AND COUNSEL
1. Postpartum care and hygiene
– Wash hands before handling baby
– Wash perineum daily
– Have enough rest and sleep
– Avoid sexual intercourse until perineal wound heals.
2. Nutrition
– Eat a greater amount and variety of healthy foods
– Spend more time on nutrition counseling with thin women and
adolescents.
ENCOURAGE BREASTFEEDING
– Importance, benefits and management of breastfeeding
– Teach correct positioning and attachment for breastfeeding
– Support exclusive breastfeeding for the first 6 months of life
– Encourage breastfeeding on demand. Avoid supplementary feeds
BIRTHSPACING AND FAMILY PLANNING
 Counsel on importance of family planning
 Inform about all contraceptive choices in postpartum period
 Facilitate free informed choice for all women
 Reinforce that non-hormonal methods (LAM, barrier methods, IUD and
sterilization) are best options for lactating mothers
 Discuss other method options for the breastfeeding & non-breastfeeding woman
IMPORTANCE OF FAMILY PLANNING
 A woman who is not exclusively breastfeeding can become pregnant as soon as
4 weeks after delivery if she has sex.
Method options for
non-breastfeeding woman
Immediately postpartum: Condoms,
IUD, BTL
Progestogen only OCP and injectables
Delay 3 weeks:
Combined OCP/injectables
Natural family planning
Method options for breastfeeding
woman
Immediately postpartum: LAM,
Condom, BTL, IUD
Delay 6 weeks: Progestogen only oral
contraceptives and injectables (DMPA)
Delay 6 months: combined OCP,
Natural family planning
SCHEDULE RETURN VISITS
All postpartum women should have at least 2 routine postpartum visits.
 1st visit: 1st week postpartum, preferably within 48 -72 hours.
 2nd visit 6 weeks postpartum
Women who do not return for postpartum visits should be visited at home.
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COMPLICATIONS OF PREGNANCY
OBSTETRIC EMERGENCIES
I. PRE-ECLAMPSIA
 Diagnostic criteria
1. Hypertension after 20 weeks (Diastolic BP more than 90 mm Hg)
2. Proteinuria 1+
1. Risk factors for pre-eclampsia
1. Primigravid
6. Women with
2. Young teens
Diabetes
3. Women > 35 years
H Mole
4. Obese
Essential or renal
HPN
5. Multiple Pregnancy
Family hx of HPN
2. Danger signals
1. Massive pitting pedal edema  (generalized swelling)
2. Severe headache
3. Epigastric pain
4. Vomiting
5. Visual disturbance or blurring of vision
3. Complications of severe pre-eclampsia
1. Small baby (IUGR)
2. Stillbirth
3. Abruptio Placenta
4. HELLP syndrome
5. Eclampsia
ECLAMPSIA
 Convulsions in a woman with pre-eclampsia
 Convulsions may occur
• in pregnancy after 20 weeks AOG,
• in labor
• during the first 48 hours postpartum.
 Effects on Mother
• Respiratory – pulmonary edema
• Heart Failure
• Cerebral vascular accidents
• Acute kidney failure
• Liver necrosis
• HELLP syndrome
• Visual disturbance
• Injuries during convulsion
Effects on fetus
Small babay
Stillbirth
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



Reducing the Risk of Eclampsia
• Pregnant women should come for ANC early – take baseline BP
• Regular antenatal visits especially in the 3rd trimester
• Measure BP at each ANC visit and check urine for protein if
diastolic BP>90 mm Hg.
• REFER if proteinuria develops
• Counsel woman and family about danger signals of severe preeclampsia
What to do when seizures occur
• Call for medical help
• As soon as possible, clear airway and or give oxygen at 4–6
L/min.
• Position the woman on her left side to reduce the risk of aspiration
of secretions, vomit and blood
• Stay with woman and protect her from injury but do not restrain
her
Immediately after the convulsion
• Set up IVF – run at slow rate
• Monitor BP, pulse, respiration, level of consciousness. Record.
• Insert urinary catheter to monitor urine output and test for protein.
• Arrange for referral
During the transport
• Put mother in any flat or low surface to prevent from falling during
ambulation.
• Observe proper maternal positioning and least stimulation during
transport.
• Never leave alone
II. VAGINAL BLEEDING IN DURING PREGNANCY
 Assess the PREGNANCY STATUS
i. EARLY PREGNANCY – uterus is below the umbilicus
ii. LATE PREGNANCY – uterus above umbilicus
 Assess the AMOUNT OF BLEEDING
i. HEAVY – pad or cloth is soaked in less than 5 minutes
ii. LIGHT
 Assess for alert signs and symptoms REFER!
1. Fainting
2. History of expulsion of tissues
3. Cramping/lower abdominal pain
4. Tender uterus
5. Tender mass
6. Uterus soft and larger than expected for AOG
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 Provide initial treatment
Pregnancy Status
Amount of Bleeding
Early pregnancy – uterus
below umbilicus
HEAVY (pad soaked in 5
minutes or less), or with
alert signs
This may be abortion,
ectopic pregnancy or
molar pregnancy.
LIGHT, no alert signs
Late – uterus above the
umbilicus
This may be placenta
previa or abruptio placenta
Any bleeding is
dangerous!
Assess for alert
symptoms:
Treatment
•
•
•
•
•
•
Reassure the woman
Insert IV line
IV fluids
Monitor vital signs
REFER
If the woman is bleeding HEAVILY
and referral center is far, give 0.2
mg ergometrine IM
•
•
•
•
Reassure
Give iron/folate
Review emergency plan
Follow up after 2 weeks
•
•
•
•
DO NOT perform IE!
Insert IV line
Monitor vital signs
Reassure the woman, make her
comfortable
REFER
•
PLACENTA PREVIA
Abnormal implantation of the placenta at the
lower uterine segment
Classic Sign:
Painless vaginal bleeding
Uterus is soft, non-tender, with or without contractions,
fetus is palpable.
RISK FACTORS
1. Maternal age > 35 years old
2. Previous cesarean section
3. Multiparity
4. Previous placenta previa
5. History of uterine surgery, multiple abortions, D&C
6. Cigarette smoking
7. Large placenta in multiple gestation
ABRUPTIO PLACENTA
Separation of a normally implanted
placenta from the uterus before
childbirth.
UTERUS is HYPERTONIC or TENSE
and TENDER on PALPATION
ABDOMEN –
“BOARD-LIKE RIGIDITY“
1. Maternal Hypertension,
Pre-eclampsia, Chronic
hypertension
2. Maternal age
3. Multiparity
4. Cigarette smoking.
5. Maternal trauma
6. Polyhydramnios
7. Poor nutrition
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III.
PRE-LABOR RUPTURE OF MEMBRANES
Rupture of the bag of water prior to the onset of labor
a. PROM when fetus is > 37 weeks
b. Preterm PROM (PPROM) when fetus is less than 37 weeks
•
•
•
•
Diagnosis:
ASK when did membranes rupture?
LOOK at pad for evidence of amniotic fluid or foul smelling vaginal discharge.
• If no evidence, ask her to wear a pad and check again in one hour.
Measure temperature
Routine vaginal examination is NOT recommended – increase risk of infection
WHAT TO DO
 If (+) fever >38°C
 Foul smelling vaginal discharge
 No labor
 Rupture membranes at <8
months of pregnancy


IV.




Rupture of membranes at >8
months pregnancy

Manage as woman in childbirth
Give antibiotic (Ampicillin 2
grams)
REFER to hospital
PRETERM LABOR
Definition
Labor before 8 completed months of pregnancy ;
more than 1 month before estimated date of birth
between 24 – 34 weeks gestation
Signs and symptoms
1. Contractions
2. Watery vaginal discharge
3. Vaginal bleeding
4. Low dull backache
What to do
1. Establish AOG
2. Evaluate contractions
3. Assess cervix
 Sterile speculum examination
 Digital examination*
4. Stabilize woman and fetus
5. If woman is lying, encourage her to lie on her left side
6. Check vital signs especially BP
7. If BP is normal and no heart problem:
 Give Nifedipine 10mg tablet orally (not under the tongue) every 6
hours until she reaches a CEmONC facility
 Give Dexamethasone 6mg intramuscularly every 12 hours until she
reaches a CemONC facility ( up to a total of 4 doses)
8. Facilitate transfer the hospital with neonatal and obstetrical care
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V.


PROLONGED LABOR
Causes of prolonged labor
1. Cephalopelvic disproportion: small or contracted pelvis or large fetus
2. Abnormal presentations (e.g. brow, shoulder associated with transverse
lie)
3. Malposition of the fetus
4. Fetal abnormalities, e.g. hydrocephalus, encephalocele, locked twins
5. Abnormalities of the reproductive tract
Effects of Prolonged Labor
Maternal
 Infection
 Uterine rupture
 Genital fistulas
 Maternal Death


Fetal
 Infection
 Asphyxia and traumatic injury to the
baby
 Stillbirth
 Neonatal death
Prolonged Latent Phase
o Diagnosis is made retrospectively
 If contractions cease, the woman is in FALSE LABOR
o If cervix dilated less than 4 cm for more than 8 hours, reassess
 If no sign of infection: may be observed further provided maternal
and fetal status are good.
 If with sign of infection: give antibiotics Ampicillin 2 grams p.o.
and refer
Prolonged Active Phase
o Cervix does not dilate 1 cm per hour
o Recognize slow progress of labor with a partograph: cervical dilatation
to the right of the alert line.
o May be due to
1. Poor uterine contractions
2. Malposition or malpresentation
3. Disproportion between fetal size and pelvic size
o Reassess uterine contractions
o If less than 3 contractions in 10 minutes, each lasting less than 40
seconds, suspect inadequate uterine activity and refer to higher level
care
o If contractions are efficient (3 contractions in 10 minutes, each
lasting more than 40 seconds), suspect cephalopelvic disproportion,
obstruction, malposition or malpresentation
o REFER to higher level care.

Before Transfer
o Start IV infusion to rehydrate
o Give antibiotics
o Give supportive care*
o Monitor maternal and fetal condition
o Ensure referral letter is completed and make transportation
arrangements. Contact the referral center to advise them of transfer.
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
Supportive Care
o Make the patient comfortable.
o Encourage companion to rub the woman’s back, wipe her face and
brow with a wet cloth, assist her to move about
o Explain all procedures to the woman, seek permission and discuss
findings with her
o Encourage her to empty her bladder regularly
o Encourage breathing techniques.
VI. SHOULDER DYSTOCIA
 Predisposing Factor
Maternal
 Abnormal Pelvic Anatomy
 Gestational Diabetes
 Post-term pregnancy
 Previous shoulder dystocia
 Maternal obesity
 Short stature





FETAL
o Suspected macrosomia
LABOR RELATED
o Assisted vaginal delivery
o Protracted active phase of
1st stage labor
o Protracted second stage
labor
Diagnosis: TURTLE SIGN
o Fetal head is delivered but remains tightly applied to the vulva
o Chin retracts and depresses the perineum
Avoid 4Ps
o Pull
o Push
o Panic
o Pivot
Management of Shoulder Dystocia
o A – Ask for help (from the woman’s husband or labor companion,
other healthcare providers. Prepare for resuscitation of the baby.)
o L– lift/hyperflex legs
o A – anterior shoulder disimpaction
o R – rotation of posterior shoulder
o M – manual removal of posterior arm
o E – episiotomy
o R – roll over onto “all fours”
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McRobert’s Maneuver – Flex woman’s
legs sharply on her abdomen
Suprapubic pressure is applied with the
heel of clasped hands from the posterior
aspect of the anterior shoulder to dislodge
it.
ROTATION OF THE POSTERIOR
SHOULDER
• Place the hand behind the posterior
shoulder of the fetus.
• Rotate the posterior shoulder 180
degrees in a corkscrew manner so
that the impacted anterior shoulder is
released.
MANUAL REMOVAL OF THE
POSTERIOR ARM
Arm is flexed at the elbow. Hand is
grasped and swept across the chest and
delivered.
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ROLL OVER ON ALL FOURS

After shoulder dystocia
1. Remember the SIGNIFICANT risk of maternal injury (tears) and
postpartum hemorrhage
2. Actively manage the third stage
3. Inspect for and repair 1st or 2nd degree tear or lacerations
4. Resuscitate the baby, examine for evidence of trauma
5. Explain to the woman and all those involved in the delivery exactly what
occurred and what were done
6. Record
 Duration of attempts to resolve dystocia
 Maneuvers performed
 Condition of baby at delivery, description of injuries, bruises
 Time from delivery of fetal head to delivery of the body
 Documentation of the discussion with woman/relatives
VII. UMBILICAL CORD PROLAPSE
 Umbilical cord lies in the birth canal below the
presenting part
 Cord is visible at the vagina following rupture of
membranes
 General management:
o Give oxygen at 4-6 liters per minute by mask
or nasal cannula

If Cord is pulsating – fetus is alive
o Diagnose stage of labor
o Wear high level disinfected gloves. Insert
hand into the vagina and push presenting
part up to decrease pressure on the cord
dislodge presenting part from the pelvis.
o Place other hand on the abdomen in the
suprapubic region to keep the presenting part
out of the pelvis
o REFER
 If cord is not pulsating – baby is dead
o Give supportive care to the woman
o Attempt vaginal delivery
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VIII. POSTPARTUM HEMORRHAGE
• Recognizing postpartum hemorrhage
o Bleeding >500 ml after childbirth
o Pad or cloth soaked in less than 5 minutes
o Constant trickling of blood
OR
o Delivered outside health center and still bleeding
•
What to do:
o Call for extra help
o Massage uterus until it is hard and give OXYTOCIN 10 units IM
o Give IV fluids with 20 units oxytocin at 60 drops per minute
o Empty the bladder: catheterize if necessary
o Check and record BP and pulse every 15 minutes
o Establish cause of bleeding
•
Causes of postpartum hemorrhage
o Uterine atony
o Tears of the cervix, vagina, or perineum
o Retained placenta
o Retained placental fragments
o Inverted uterus
o Ruptured uterus
•
Check if placenta is delivered.
Placenta is not delivered
o When uterus is hard, deliver
placenta by controlled cord
traction
o If unsuccessful and bleeding
continues – remove placenta
manually and check placenta
o Give appropriate IM/IV
antibiotics
o If unable to remove placenta –
REFER urgently to hospital
o During transfer, continue IV
fluids with 20 units oxytocin at
30 drops/minute
Placenta is delivered
o Check placenta
o If placenta complete
 Massage uterus to express
any clot
 If uterus remains soft, give
OXYTOCIN 10 units IM
 Continue IV fluids with 20
units Oxytocin at 30
drops/min
 Continue uterine massage
until it is hard
o If placenta is incomplete or not
available for inspection:
 Refer woman urgently to
hospital
o Placenta is complete and vaginal
bleeding continuous:
o
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HOW TO MAKE PROPER REFERRALS
 Referral must be TIMELY
STEPS TO FOLLOW:
1. Give emergency treatment.
2. Discuss decision with woman, partner/spouse and relatives. Explain why patient
is advised to transfer.
3. Help arrange transport of patient.
4. Inform the referral center by mobile phone, landline or radio.
5. Ensure support.
6. Always send a referral letter with the patient. The referral must state the
following:
 Date and time; Emergency or Non-emergency
 Problems identified
 Findings and action taken.
7. If the hospital is far away (> 1 hour trip),
 Give appropriate treatment on the way.
 Continue to monitor patient
 Record all findings & treatment given.
8. A relative or friend should accompany the patient → help look after the woman
during the journey.
9. Do not delay. Go straight to the hospital.
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References:
POGS CLINICAL PRACTICE GUIDELINES ON NORMAL LABOR AND DELIVERY,
2nd edition, November 2009
POGS CLINICAL PRACTICE GUIDELINES ON THIRD TRIMESTER BLEEDING AND
POSTPARTUM HEMORRHAGE
ALARM INTERNATIONAL (A Program to Reduce Maternal and Neonatal Mortality and
Morbidity), The Society of Obstetricians and Gynecologists of Canada, 4th edition.
Integrated Management of Pregnancy and Childbirth. Pregnancy, Childbirth,
Postpartum and Newborn Care: A guide for essential practice in Philippine Setting.
Adapted from the World Health Organization by the Department of Health.
Community-Managed Maternal and Newborn Care: A Guide for Primary health Care
Professionals. Department of Health, San Lazaro Manila, 2006
Barbara Kinzie and Patricia Gomez, Basic Maternal and Newborn Care: A Guide for
Skilled Providers, JHPIEGO, 2004
Midwives Manual on Maternal Care. Maternal and Child Health Service, Department of
Health, San Lazaro Manila. 2000
Newborn Care Until the First Week of Life: Clinical Practice Pocket Guide
WHO 2009
WHO Pregnancy Child Birth, Postpartum, Newborn care: A Guide for Essential
Practice in Philippine Setting, Manila 2003
Prepared by the POGS MDG COUNTDOWN TASK FORCE 2010
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CARE OF THE NEWBORN
MDG 4: Reduce child mortality
Target: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate
 More than 10 million children under five die every year.
 Almost 90% of all child deaths are attributable to just six conditions (WHO)
1. neonatal causes 2. Pneumonia
3. Diarrhea
4. Malaria
5.Measles
6. HIV/AIDS.
MDG to reduce child mortality requires:
•Universal coverage with key effective, affordable interventions:
1. care for newborns and their mothers
2. infant and young child feeding
3. Vaccines
4. prevention and case management of diarrhoea
5. pneumonia and sepsis
6. malaria control
7. Prevention and care of HIV/AIDS
 In countries with high mortality, these interventions could reduce the number of
deaths by more than half.
WHO promotes three main strategies:
1. integrated management of childhood illness
2. expanded programme on immunization
3. infant and young child feeding.
•Attention to newborn health is being increasingly incorporated into each of
these delivery strategies, complemented by interventions aimed at making
pregnancy safer.
Newborn Mortality
Health statistics show that worldwide:
»About 4 million babies die each year.
»Another 4 million babies each year are stillborn; most die in late pregnancy or labor.
»Most newborn deaths occur in developing countries.
The “Two Thirds” Rule
•Two thirds of infant deaths occur in the first month of life
•Of those, two thirds die in the first week of life
•Of those, two thirds die in the first 24 hours of life
Newborn Survival
“Most newborn deaths are entirely preventable, which are attributed to a number of
simple, low-cost actions that can be taken by health care workers, mothers, and
families.”
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Immediate Essential Newborn Care
Objectives
•To describe and carry out the evidence based routine care of a newborn baby at the
time of birth and prevent complications.
Basic needs of a baby at birth
•To breathe normally
•To be warm
•To be protected
•To be fed
Preparing to Meet the Baby’s Needs
“Good care of the newborn begins with good preparation”
Preparing to Meet the Baby’s Needs at birth
1. Warm delivery room 25-28C, draft free
2. Two clean and warm towels or cloth
3. Newborn size self inflating bag and masks in two sizes: normal and small newborn
4. Suction device 100 mmHg pressure
5. Rolled up piece of cloth
6. Clean dry warm surface
STANDARD PRECAUTIONS
 Always remember the importance of observing precautions to help protect the
mother and baby and ourselves from infections with bacteria, viruses including HIV
 Wear 2 sets of sterile gloves
Steps : Immediate Essential Newborn Care
• Call out time of birth.
• Deliver the baby prone on the mother’s abdomen.
• Dry the newborn thoroughly for a full 30 seconds.* Remove wet cloth.
• Check breathing while drying.
• Position newborn prone on the mother’s abdomen in skin-to-skin contact. Cover
the back with a dry blanket.
– If this is not possible, place newborn in a warm, safe place close to the
mother.
• Exclude second baby
• Wait for cord pulsation to stop (approx 1-3min)
• Remove first set of gloves
• Clamp cord at 2cm away from newborn skin using sterile plastic cord
clamp and apply sterile forceps 5cm away from the skin then cut the cord
• Maintain skin-to-skin contact; do not separate baby from the mother until a full
breastfeed; watch for feeding cues.
• Place identification band on ankle.
• Give eye prophylaxis within the first hour .Delay Vit K and immunization until after
90min of uninterrupted skin to skin contact
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•Drying the newborn
– Stimulates the newborn to breathe normally
– Minimizes heat loss
When drying the newborn,
 Dry the body and the head well
 Remove wet cloth
 Wrap the baby in clean dry cloth covering the head
 Do not remove the vernix!!!
WHO emphasizes thermal care of the newborn as an essential intervention
Thermal care is a priority behavior in the Mother-Infant Package of interventions
in developing countries.
Skin-to-Skin Contact (SSC)
 Provides warmth
 Improves bonding
 Provides protection from infection by exposure of the baby to good bacteria of
the mother
 Increases the blood sugar of the baby
Non-immediate clamping of the umbilical cord
 Allows the newborn to get a free blood transfusion from the placenta
 Reduces the risk of anemia in both term and preterm babies
 Reduces the risk of transfusions and intraventricular hemorrhage in preterms
Initial



Cord care
Do not apply any substance to the stump
Do not bind or bandage the stump
Leave the stump uncovered
Assessing the baby
 During the first hour after complete delivery of the placenta the baby (and the
mother) should be monitored every 15 minutes.
 After the cord is cut, assess the baby for any signs of illness, eg. chest indrawing
 If the baby is doing well, continue skin-to-skin contact and provision of warmth
Monitor the mother and baby
 Never leave the woman and newborn alone
 Keep the mother and baby in the delivery room
 Record findings, treatments and procedures in the labor record
 Monitor every 15 minutes:
o Breathing: listen for grunting, look for chest in-drawing and fast breathing.
o Warmth: check to see if feet are cold to touch.
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Washing should be delayed until after 6 hours
• Washing exposes to hypothermia
• The vernix is a protective barrier to bacteria such as E. coli and Group B Strep
• Washing removes the crawling reflex
Initiation of breastfeeding
 To begin with the baby will want to rest. Every baby is different and the rest
period may take from a few minutes to 30 or 40 minutes before the baby shows
signs of wanting to breastfeed.
 Help the mother and baby into a comfortable position
 Only once the newborn shows feeding cues (e.g. opening of mouth, tonguing,
licking, rooting), make verbal suggestions to the mother to encourage her
newborn to move toward the breast e.g. nudging.
 Health workers should not touch the newborn unless there is a medical
indication.
 Do not give sugar water, formula or other prelacteals.
 Do not give bottles or pacifiers.
 Do not throw away colostrum.
 If the mother is HIV-positive, counsel the mother on breastfeeding
SKIN TO SKIN CONTACT & BREASTFEEDING
Initiate breastfeeding within the first hour after birth
 To help a baby successfully breastfeed after birth, we should:
–Give the baby to the mother for skin-to-skin contact
–Let the baby feed when he is ready:
 Signs of readiness to breastfeed:
–Baby looking around
–Mouth open
–searching
Counsel on positioning and attachment
When the baby is ready, tell the mother to:
 Make sure the newborn’s neck is not flexed nor twisted.
 Make sure the newborn is facing the breast, with the newborn's nose opposite
her nipple and chin touching the breast.
 Hold the newborn's body close to her body.
 Support the newborn’s whole body, not just the neck and shoulders.
 Wait until her newborn’s mouth is opened wide.
 Move her newborn quickly onto her breast, aiming the infant's lower lip well
below the nipple
Signs of good attachment and suckling:
 Mouth wide open
 Lower lip turned outwards
 Baby's chin touching breast
 More areola is visible above the baby’s mouth
 Sucking is slow, deep with some pauses
*If the attachment or suckling is not good, try again and reassess.
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The first breast feed
–Check attachment and positioning when the baby is feeding
–Let the baby feed for as long as he wants on both breasts
–Keep the mother and baby together for as long as possible after delivery
–Delay tasks such as weighing, washing, eye care, injections, etc. until after the first
feed





If the baby does not feed in 1 hour, examine the baby.
If healthy, leave the baby with the mother to try later. Assess in 3 hours, or earlier if
the baby is small
If the mother is ill and unable to breastfeed, help her to express breast milk and feed
the baby by cup
If unable to initiate breastfeeding, plan for alternative feeding method
If mother HIV+ and chooses replacement feeding, feed accordingly
Eye Care
 Wipe the eyes
 Apply an eye antimicrobial within 1 hour of birth:
o 1% silver nitrate drops or 2.5% povidone iodine drops or 1% tetracycline
ointment or erythromycin eye drops
 Do not wash away the eye antimicrobial
Administer:
 Vitamin K - IM upper outer quadrant (vastus lateralis) of the thigh.
- 0.5 mg preterm baby
- 1.0 mg term baby
 Hepatitis B Vaccine. 0.5 ml IM on the upper outer quadrant (vastus lateralis) of
the thigh
 BCG 0.05 ml Intradermal on the deltoid area
Summary: WHO emphasizes thermal care of the newborn as an essential intervention
“Warm Chain”
 a draft-free, warm room (at least 25 o C);
 immediate drying of the newborn;
 skin-to-skin contact on the mother’s abdomen/chest for all care, covered, for at
least 2 hours after birth;
 helping the mother to breastfeed within one hour of birth;
 postponement of bathing for at least 6, but preferably 24 hours;
 dressing in warm clothing.
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HIV and Newborn care at birth
If the mother has HIV/AIDS:
 Universal precautions must be followed as with any other delivery and after care.
 Her baby can have immediate skin-to-skin contact
 Breastfeeding can begin when the baby is ready after delivery
 Do not give the baby any other food or drink
 Good attachment and positioning are vital
 If replacement feeding, prepare formula for the mother for the first few feeds
In the first two hours after birth, do the following after skin-to-skin and initiation of
breastfeeding:
1. Weigh or measure the baby
2. Bath the baby
3. Dress the baby
4. Eye care, Vit. K and Immunization
Summary
 Make sure that the delivery area is ready for the mother and baby
 Observe universal precautions at all times (Protection)
 Keep the delivery room warm (warmth, protection)
 Have resuscitation equipment near the delivery bed (breathing)
 Have clean warm towels/cloths ready for the baby (protection, warmth)
 Have a sterile kit to tie/clamp and cut the cord. Apply antimicrobial to the eyes.
Give Vit. K, Hepatitis B and BCG(protection)
 Keeping the mother and baby in skin-to-skin contact encourages early
breastfeeding (warmth, feeding)
NEWBORN RESUSCITATION
INTERVENTION: See Algorithm on Resuscitation (p 21).
ACTION:
Start resuscitation if the newborn is not breathing or is gasping after 30 seconds of
drying or before 30 seconds of drying if the baby is completely floppy and not breathing.
Clamp and cut the cord immediately. If necessary, transfer the newborn to a dry, clean
and warm surface. Keep the newborn wrapped or under a heat source if available.
Inform the mother that the newborn needs help to breathe.
INTERVENTION
ACTION: Open airway
Position the head so it is slightly extended.
Introduce the suction tube:
– First, into the newborn’s mouth 5 cm from the lips and suck while withdrawing.
– Second, 3 cm into each nostril and suck while withdrawing.
– Repeat once, if necessary taking no more than a total of 20 secs.
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Notes:
- Do not suction mouth and nose prior to delivery of the shoulders of babies with
meconium stained amniotic fluid.
K11
INTERVENTION ACTION: Ventilate, if still not breathing
1. Place mask to cover chin, mouth and nose to achieve a seal.
Squeeze bag attached to the mask with 2 fingers or whole hand, according to bag size,
2 or 3 times.
 Observe rise of chest.
 If chest is not rising, reposition baby’s head
 If baby’s chest is still not rising, check for adequate mask seal
 If chest is still not rising, squeeze bag harder.
 If chest is rising, ventilate at 40 breaths per minute until newborn starts crying or
breathing.
2. Reassess at 30-second intervals. If baby still fails to improve, check the following:
Failure To Improve Checklist
 Face-mask seal tight?
 Airway clear of secretions?
 Head positioned properly?
 Is contact with the soft tissue of the
 infant’s anterior neck being avoided?
 Resuscitator working properly?
 Adequate pressure being used?
 Air distending the stomach?
 Air leak (pneumothorax)?
3. If baby starts crying or breathing >30 per minute and has no chest-in-drawing, stop
ventilating:
4. Put the newborn in skin-to-skin contact on mother’s chest and continue care while
monitoring breathing and warmth.
5. Explain the baby’s condition to the mother.
If after 30 sec of effective bag/mask ventilation, the newborn is gasping/breathing
< 30/min or >30/min but has severe chest in-drawing:
 Continue bag/mask ventilation
 Continue assessing at 30 sec intervals while transporting or
 Proceed to intubation per advanced resuscitation guidelines, if skilled personnel
and equipment are available
If after 20 minutes of effective ventilation, the newborn does not start to breathe or gasp
at all, stop ventilating.
 Explain to the mother that the baby is dead, give supportive care and record the
event.
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Notes:
 While ventilating, refer and explain to the mother what happened, what you are
doing and why.
 Ventilate, if needed, during transport
 Record the event on the referral form and labor record.
K111DITIONAL CARE
Resuscitation With Bag & Mask
Self-inflating Bag: Basic Parts
Bag and Mask: Equipment
Masks
–Rims: Cushioned or non-cushioned
–Shape: Round or anatomic shape
–Anatomic shape
–Size: small or large
Position Bag and Mask on Face. Mask should cover tip of chin, mouth and nose.






Do not jam the mask down on the face
Do not allow your fingers or parts of the hands to rest on the newborn’s eyes
Do not put pressure on the throat (trachea)
Airtight seal is essential to achieve positive pressure.
Tight seal required for flow-inflating bag to inflate
Tight seal required to inflate lungs when bag is squeezed
How Hard to Squeeze the Bag
 Noticeable rise and fall of chest
 Bilateral breath sounds
 Improvement of color and heart rate
Frequency of Ventilation: 40 to 60 breaths per minute
If the Chest is Not Expanding Adequately: Possible causes
 Seal inadequate
 Airway blocked
 Not enough pressure given
Signs of Improvement after Positive pressure ventilation
 Improving color
 Spontaneous breathing
 Increasing heart rate
Post-resuscitation Care
Baby requires
 Close monitoring
 Anticipatory care
 Laboratory studies
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EXAMINATION OF THE NEWBORN BABY
When should a newborn baby be examined?
After birth:
• At around an hour
• before discharge from hospital (no discharge before 12 hours of age)
• If there is maternal concern about the baby’s condition
• If a danger sign observed during monitoring
After leaving the hospital:
• during the first week of life at a routine visit
• follow-up
• sick newborn visit.
Why do we examine the baby at birth and again at discharge?
At the time of birth:
• Overall assessment of the baby’s condition
• An initial set of observations
• To provide appropriate care and treatment
Before discharge and thereafter:
• To re-assess and monitor the baby’s condition
• To provide appropriate treatment if the baby’s condition changed from a
previous examination
• To give the mother guidance on continuing care
Universal precautions: remember to wash your hands before and after examining
the baby
DANGER SIGNS?
• History of convulsion
• Difficulty feeding
• Temperature of 37.5ºC and above
• Temperature <35.5ºC
• Movement only when stimulated
• Respiratory rate of 60 breaths per minute or more
• Severe chest in-drawing
TREAT AND ADVISE:
• Refer baby urgently to hospital
• After emergency treatment, explain the need for referral to the mother/father.
• Organize safe transportation.
• Always send the mother with the baby, if possible.
• Send referral note with the baby
• Inform the referral center if possible by phone or radio.
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Normal findings
A baby:
• passes urine six or more times a day after day 2.
• May pass six to eight watery stools a day.
• May have some vaginal bleeding for a few days during the first week after birth. It
is not a sign of a problem.
Assess Breathing
• Count number of breaths taken for one full minute.
• If not sure of breaths per minute, repeat count.
• Look for chest in-drawing
• Listen for grunting
• Normal respiratory rate of a newborn baby - 30 to 60 breaths per minute.
• No chest indrawing
• No grunting on breathing out
• Babies may breathe irregularly (up to 80 breaths per minute) for short periods of
time.
• Small babies (less than 2.5 kg at birth or born before 37 weeks gestation) may:
–have some mild chest in-drawing
–periodically stop breathing for a few seconds.
Color :
• Face, chest, tongue and lips are pink
• Hands and feet may be bluish during the first 48 hours
• Jaundice occurring on the second day lasting for about 14 days
Posture and tone:
•Arms and legs are well bent (flexed)
•Loosely clenched fists
•Flexed arms, hips and knees
•Preterm babies have less flexion
•Babies who were in breech position may have fully flexed hips and knees; the feet may
be near the mouth; or the legs and feet are at the side of the baby
Activity :
•Moves both arms and legs equally
•+ rooting, moro, grasp, sucking reflex
Warmth: Baby’s abdomen or back or feet feels warm
Heart Rate: Count the baby’s heartbeat for 1 full minute
• 100 – 160 beats/min
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Skin :
•Milia
•Mongolian spots
•Peeling/desquamation
•Erythema toxicum (red spots with tiny white centers) seen on the face, trunk and back
on day 2 and later
Head :
• Molding ( usually disappears in 2-3 days after birth)
• Caput succedaneum(soft swelling over the presenting part of the head
(disappears after 48 hours)
• Anterior fontanelle is flat and may swell when the baby cries
• Anterior fontanelle is flat and may swell when the baby cries
Eyes: no discharge
Mouth: Lips, gums and palate are intact
• Baby sucks vigorously on your finger
Chest :
• Moves equally with breathing
• Abdomen pushes out with each breath
• Breast nodules maybe enlarged (boys and girls)
Abdomen :
• Rounded, soft
• Umbilical cord is dry, no bleeding
• Small umbilical hernia is normal during the 1st year
Back and spine:
• Skin over the back has no openings
• No defects
Anus :
• Patent
• Baby passes stool by 24 hours
Female Genitalia :
• white vaginal discharge
• A bloody vaginal discharge that starts on day 2-3 and continues up to day 7
Male Genitalia:
• Foreskin retracted easily
• Urethra opens at the end of the penis
• Testes are felt in the scrotum
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Temperature :
• 36 - 37ºC axillary
• If no thermometer, feel the chest or back with the back of your hand
Weight :
• 2.5 up to 3.99 kg
• Weight loss of 5-10% of their birth weight in the first few days of life. Regains
birthweight by 10 – 14 days of life.
Weigh the Baby
Why do we weigh the baby?
1. Assess weight gain
2. Provides a baseline and is part of growth monitoring
3. Indicates whether the baby is receiving adequate nutrition
4. Identifies a low birth weight baby who are at risk and needs monitoring and
special care
5. For drug calculation
6. Identifies babies who have an underlying condition and needs examination and
treatment
How to weigh a baby :
1. Take the scales to the baby
2. Prepare the scales. Cover pan with a clean cloth
3. Preparing and weighing the baby
 Remove all clothing including the diaper
 Weigh baby naked
 WAIT till baby stops moving
 Read and record the weight
 Wrap the baby
 Return baby to the mother
Scale maintenance
 Clean the scale pan between each weighing
 Calibrate daily
In postnatal clinics: Weigh a baby on THE SAME SCALES at each visit
Assess Breastfeeding
• If the baby is breastfeeding at the time of examination, observe and
assess the feed.
• If the mother is not breastfeeding, ask the mother to call the health worker
when the baby next wants to feed so that feeding can be observed.
• Observe breastfeeding for at least five (5) minutes.
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Normal findings:
• Baby should breastfeed at least 8X in 24 hours (at least every 3 hours)
• A low birthweight baby needs to breastfeed more often, at least every 2 to 21/2
hours.
• Suckling should be vigorous and suckling well
Make a plan and care for the needs and problems of the newborn
• Education and counseling
• Medical treatment
• Referral and follow up.
Abnormal findings and plan of action
CHECK
Color
Breathing
Posture and
tone
Skin
Head
ABNORMAL FINDINGS
< 24 hours old with yellow skin on
face
>24 hours old with yellow p[alms and
soles
(possible infection, blood group
incompatibility)
Pallor
(bleeding, poor circulation, cold, low
blood sugar)
Noisy breathing (grunting)
Flaring nostrils
Indrawing of the chest between ribs
(Obstruction of airway, infection)
RR < 30 or >60/min
Apnea or gasping
Limp, floppy
(prematurity, birth injury, asphyxia
Rigid, stiffness or arching of the back
Rhythmic movements of one or both
limbs
(tetanus, birth injury meningitis)
Pustules, blisters, red or purple spots
(localized infection but may lead to
sepsis if untreated
Cephalhematoma (swelling on one
side of the head)
ACTION
Refer
Make sure cord tie is tight
Warm the baby
Check respiration
Ensure breastfeeding
Refer
Refer
Newborn resuscitation
Refer
Keep baby warm
Give initial dose of antibiotics prior to
referral
Treat skin pustules:
Wash hands
Wash off pus and crusts with boiled
and cooled water and soap
Dry with a clean cloth
Paint with gential violet
None. the blood is slowly absorbed
and disappears by 1-2 months
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Eyes
Discharging pus
Sticky eyes
Swollen eyelids
( eye infection – gonorrhea or
chlamydia)
Mouth
Cleft lip / palate
(congenital abnormality
Abdomen
Distended and hard ( possible
intestinal obstruction)
Open tissue on the abdomen
( omphalocele, gastroschisis)
Abdomen
Bleeding from the umbilical cord
Red umbilicus or skin around it
(local umbilical infection)
Back and spine
Open tissue on the back (
neural tube defects)
External genital
organs
Unable to define gender
Boys external
genitalia
No urine or wet diaper by 24 hours
Urethra does not open at the end of
penis but under the penis; foreskin
not retractable
Scrotum is empty ( no testes felt)
Temp.
Weight
Axillary temp <36ºC or >37ºC, or
Baby’s back or chest feels cooler or
hotter than the skin of a normal
person
Weight less than 2500 grams
(preterm or SGA)
Refer
Wash hands
Wet clean cloth with cooled boiled
water
Use wet cloth to gently was off pus
from the baby’s eyes
Apply antimicrobial to eyes 4x a day
Re-assess in 2 days
Re-assure the mother
Encourage mother to breastfeed/
feed the baby expressed breast milk
by cup
Refer to specialist
Refer
Refer
Cover with sterile tissue soaked with
sterile saline solution
Retie the cord tightly
Treat umbilical infection
-wash hands
-wash off pus and crusts with cooled
boiled water
-dry with clean cloth
-paint with gentian violet
Refer
Cover with sterile tissues soaked with
saline solution
Refer
Refer
Explain to parents that the testes may
descend
Examine the baby again at 6 months
Refer if the testes has not come down
Refer
Give first dose of antibiotics
Keep the temperature normal
Special care
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Weight > 4000 grams
(infant of diabetic mother, risk of low
blood sugar
Feed as soon as possible after birth
Care of the newborn until Discharge
Teach and counsel a mother and her family about newborn care ;
 What care to give
 Why to give the care
Warmth
 Keep the room warm ( 25 - 28ºC)
 Skin-to-skin contact
 Dress the baby or cover with dry, clean cloth
 Cover the head with a cap especially if the baby is small
 Assess warmth - touch feet, abdomen or back
Sleep
 At night let the baby sleep with the mother or within easy reach to facilitate
breastfeeding
 Let the mother and baby sleep under a bed net to protect them from malaria
 A baby who is hard to wake up or sleeps too much may be sick
 Support breastfeeding
 Counsel on the importance of exclusive breastfeeding
 Encourage breastfeeding on demand day and night
 Do not give any other feeds or water
 Do not use artificial teats and pacifiers
Breastfeeding
 Ask the mother if there is a breastfeeding problem/difficulty.
 If mother has breastfeeding difficulty, assess breastfeeding
 Teach correct positioning and attachment
Key points to good attachment
 The baby’s mouth is widely open
 The tongue is far forward in the mouth, and may be seen over the bottom gum
 The lower lip is turned outwards
 The chin is touching the breast
 More areola is visible above the baby’s mouth than below it
Problems that may arise if the baby is not well attached to the breast
The baby:
 May cry a lot and be unhappy
 May be slow to gain weight, or may even lose weight
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The mother:
 May get sore/cracked nipples
 May get very full breasts which feel hard, sometimes they may feel hot and may
look red
Key points to good positioning
•The baby’s head and body are in a straight line
•The baby’s face is opposite the nipple and breast
•The baby’s upper lip or nose is opposite the mother’s nipple
•The baby is held as close to the mother’s body as possible
•The baby’s whole body is supported if the mother is in a sitting position.
Breastfeeding Care
 Before a baby is discharged assess if the baby is breastfeeding well.
 Do not discharge if breastfeeding is not yet established or if the baby is not
feeding well
Protection from infection
 Importance of washing her hands before and after handling the baby
 Cord care
 Keeping her baby clean
 Immunizations
Hygiene ( Washing, Bathing)
 Wash the face, neck and underarms daily
 Look for signs of infection while washing the baby
–Skin infection: spread the skin folds to look for pustules
–Cord infection: redness of skin, discharge, foul odor
–Eye infection: redness, swelling of eyelids, discharge
 Wash the buttocks when soiled. Dry thoroughly
Hygiene ( Washing, Bathing)
• Bath when necessary:
– Ensure the room is warm
–Use warm water for bathing
–Thoroughly dry the baby, dress and cover after bath
• Never use soap on a newborn’s face, only clean water
• Do not clean inside the NB’s ear canal or nose, only the outside
• Do not use baby powder
Cord care
• Wash hands before and after cord care
- Put nothing on the stump
- Fold diaper below the stump
- Keep stump loosely covered with clean clothes
- If the stump is wet, wash with clean water and soap, dry with clean cloth.
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•DO NOT bandage the stump or abdomen
•DO NOT apply substances or medicines to stump
•Avoid touching the stump unnecessarily
•If umbilicus is red or draining pus or blood, see the health worker
Eye care
•Do not apply anything on the baby’s eyes except an antimicrobial at birth!
Immunizations
•BCG and Hepatitis B
MONITORING THE BABY
•
Watch the baby for any danger signs:
–Breathing difficulty
–Noisy breathing (grunting)
–Fast of slow breathing
–Chest in-drawing
–Feels cold
–Fever
–Red swollen eyelids and with pus
–Redness of skin around the umbilicus with pus discharge
–Convulsions
–Jaundice/yellow skin
•Bleeding from the cord:
–Check if the tie is loose and retie the cord
–Press to stop bleeding
–Examine and assess the baby immediately
Check for special treatment needs
•Give prescribed treatments according to the schedule
o treatment for infections
o TB
o Congenital Syphilis
o Maternal illness: risk of bacterial infection
o Eye/cord infection
Advise the mother to seek care for the baby
• Return or go to the hospital immediately if the baby has:
- Difficulty breathing
- convulsions
- Fever or feels cold
- Bleeding
- Has diarrhea
- not feeding at all
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•
Go to the health center as quickly as possible if the baby has:
- Difficulty feeding
- Pus from eyes
- Skin pustules
- Yellow skin
- A cord stump which is red and draining pus
- Feed less than 5 times in 24 hours
- Other concern
NEWBORN RESUSCITATION
INTERVENTION: See Algorithm on Resuscitation (p 21).
ACTION:
Start resuscitation if the newborn is not breathing or is gasping after 30 seconds of
drying or before 30 seconds of drying if the baby is completely floppy and not breathing.
Clamp and cut the cord immediately, if necessary. Transfer the newborn to a dry, clean
and warm surface.Keep the newborn wrapped or under a heat source if available.Inform
the mother that the newborn needs help to breathe.
INTERVENTION
ACTION: Open airway
Position the head so it is slightly extended.
Introduce the suction tube:
– First, into the newborn’s mouth 5 cm from the lips and suck while withdrawing.
– Second, 3 cm into each nostril and suck while withdrawing.
– Repeat once, if necessary taking no more than a total of 20 seconds.
Notes:
- Do not suction mouth and nose prior to delivery of the shoulders of babies with
meconium stained amniotic fluid.
K11
INTERVENTION ACTION: Ventilate, if still not breathing
1. Place mask to cover chin, mouth and nose to achieve a seal.
2. Squeeze bag attached to the mask with 2 fingers or whole hand, according to bag
size, 2 or 3 times.
 Observe rise of chest.
 If chest is not rising:, reposition baby’s head
 If baby’s chest is still not rising check for adequate mask sealIf chest is still not
rising, squeeze bag harder.
 If chest is rising, ventilate at 40 breaths per minute until newborn starts crying or
breathing.
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3. Reassess at 30-second intervals.
 If baby still fails to improve, check the following:
Failure To Improve Checklist
– Face-mask seal tight?
– Airway clear of secretions?
– Head positioned properly?
– Is contact with the soft tissue of the
infant’s anterior neck being avoided?
– Resuscitator working properly?
– Adequate pressure being used?
– Air distending the stomach?
– Air leak (pneumothorax)?
– If baby starts crying or breathing >30 per minute and has no chest-in-drawing, stop
ventilating:
– Put the newborn in skin-to-skin contact on mother’s chest and continue care while
monitoring breathing and warmth.
Explain the baby’s condition to the mother.
If after 30 sec of effective bag/mask ventilation,the newborn is gasping/ breathing <30
per min or
> 30 per min but has severe chest in-drawing:
– Continue bag/mask ventilation
– Continue assessing at 30 sec intervals while transporting or
– Proceed to intubation per advanced resuscitation guidelines, if skilled personnel and
equipment are available
– If after 20 minutes of effective ventilation, the newborn does not start to breathe or
gasp at all,
stop ventilating.
– Explain to the mother that the baby is dead, give supportive care and record the event.
Notes:
– While ventilating, refer and explain to the mother what happened, what you are doing
and why.
– Ventilate, if needed, during transport
– Record the event on the referral form and labor record.
K11
K11D19K11
ADDITIONAL CARE
Resuscitation With Bag & Mask
Self-inflating Bag: Basic Parts
Bag and Mask: Equipment
Masks
Rims
–Cushioned
–Non-cushioned
Shape
–Round
–Anatomic shape
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Size
–Small
–Large
Position Bag and Mask on Face
Mask should cover
Tip of chin
Mouth
Nose
•Do not jam the mask down on the face
•Do not allow your fingers or parts of the hands to rest on the newborn’s eyes
•Do not put pressure on the throat (trachea)
•Airtight seal is essential to achieve positive pressure.
 Tight seal required for flow-inflating bag to inflate
 Tight seal required to inflate lungs when bag is squeezed
How Hard to Squeeze the Bag
Noticeable rise and fall of chest
Bilateral breath sounds
Improvement of color and heart rate
Frequency of Ventilation:
40 to 60 breaths per minute
If the Chest is Not Expanding Adequately
Possible causes
Seal inadequate
Airway blocked
Not enough pressure given
Signs of Improvement after Positive pressure ventilation
Improving color
Spontaneous breathing
Increasing heart rate
Post-resuscitation Care
Baby requires
Close monitoring
Anticipatory care
Laboratory studies
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Examination of the newborn baby
OBJECTIVES:
•To describe and carry out an examination of a baby soon after birth; before discharge
from hospital; during the first week of life at routine, follow-up or sick newborn visit and
identify any conditions which need specific care treatment or follow up.
•To assess, classify and treat a newborn baby using the ‘Examine the Newborn’ chart
J2-J8
When should a newborn baby be examined?
After birth:
•At around an hour
•before discharge from hospital (no discharge before 12 hours of age)
•If there is maternal concern about the baby’s condition
•If a danger sign observed during monitoring
After leaving the hospital:
•during the first week of life at a routine visit
•follow-up
•sick newborn visit.
ACCORDING TO NATIONAL GUIDELINES
Why do we examine the baby at birth and again at discharge?
At the time of birth:
•Overall assessment of the baby’s condition
•An initial set of observations
•To provide appropriate care and treatment
Before discharge and thereafter:
•To re-assess and monitor the baby’s condition
•To provide appropriate treatment if the baby’s condition changed from a previous
examination
•To give the mother guidance on continuing care
Universal precautions: remember to was your hands before and after examining
the baby
Examination Format
•Assess
–Ask, Check, Record
–Look, Listen, Feel
•Classify
•Treat or advise
•Record
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DANGER SIGNS?
•History of convulsion
•Difficulty feeding
•Temperature of 37.5ºC and above
•Temperature <35.5ºC
•Movement only when stimulated
•Respiratory rate of 60 breaths per minute or more
•Severe chest in-drawing
If Danger Signs present,CLASSIFY : POSSIBLE SERIOUS ILLNESS
TREAT AND ADVISE:
•Give first dose of 2 IM antibiotics Ampicillin
•Refer baby urgently to hospital
•After emergency treatment, explain the need for referral to the mother/father.
•Organize safe trasportation.
•Always send the mother with the baby, if possible.
•Send referral note with the baby
•Inform the referral center if possible by phone or radio.
Normal findings 1
A baby:
• passes urine six or more times a day after day 2.
•May pass six to eight watery stools a day.
•May have some vaginal bleeding for a few days during the first week after birth. It
is not a sign of a problem.
Assess Breathing
When assessing breathing:
•count number of breaths taken for one full minute.
•If not sure of breaths per minute, repeat count.
•Look for chest in-drawing
•Listen for grunting
•Normal respiratory rate of a newborn baby - 30 to 60 breaths per minute.
•No chest idrawing
•No grunting on breathing out
•Babies may breathe irregularly (up to 80 breaths per minute) for short periods of
time.
•Small babies (less than 2.5 kg at birth or born before 37 weeks gestation) may:
–have some mild chest in-drawing
–periodically stop breathing for a few seconds.
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Color :
• Face, chest, tongue and lips are pink
• Hands and feet may be bluish during the first 48 hours
• Jaundice occurring on the second day lasting for about 14 days
Posture and tone:
•Arms and legs are well bent (flexed)
•Loosely clenched fists
•Flexed arms, hips and knees
•Preterm babies have less flexion
•Babies who were in breech position may have fully flexed hips and knees; the
feet may be near the mouth; or the legs and feet are at the side of the baby
Activity :
•Moves both arms and legs equally
•+ rooting, moro, grasp, sucking reflex
Warmth: Baby’s abdomen or back or feet feels warm
Heart Rate: Count the baby’s heartbeat for 1 full minute
• 100 – 160 beats/min
Skin :
•Milia
•Mongolian spots
•Peeling/desquamation
•Erythema toxicum (red spots with tiny white centers) seen on the face, trunk and
back on day 2 and later
Head :
• Molding ( usually disappears in 2-3 days after birth)
• Caput succedaneum(soft swelling over the presenting part of the head
(disappears after 48 hours)
• Anterior fontanelle is flat and may swell when the baby cries
• Anterior fontanelle is flat and may swell when the baby cries
Eyes: no discharge
Mouth: Lips, gums and palate are intact
• Baby sucks vigorously on your finger
Chest :
• Moves equally with breathing
• Abdomen pushes out with each breath
• Breast nodules maybe enlarged (boys and girls)
Abdomen :
• Rounded, soft
• Umbilical cord is dry, no bleeding
• Small umbilical hernia is normal during the 1st year
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Back and spine:
• Skin over the back has no openings
• No defects
Anus :
• Patent
• Baby passes stool by 24 hours
Female Genitalia :
• white vaginal discharge
• A bloody vaginal discharge that starts on day 2-3 and continues up to day 7
Male Genitalia:
• Foreskin retracted easily
• Urethra opens at the end of the penis
• Testes are felt in the scrotum
Temperature :
• 36 - 37ºC axillary
• If no thermometer, feel the chest or back with the back of your hand
Weight :
• 2.5 up to 3.99 kg
• Weight loss of 5-10% of their birth weight in the first few days of life.
Regains birthweight by 10 – 14 days of life.
Weigh the Baby
Why do we weigh the baby?
•Assess weight gain( K7)
•Provides a baseline and is part of growth monitoring
•Indicates whether the baby is receiving adequate nutrition
•Identifies a low birth weight baby who are at risk and needs monitoring and special
care
•For drug calculation
•Identifies babies who have an underlying condition and needs examination and
treatment
How to weigh a baby :
Take the scales to the baby
Prepare the scales
»Cover pan with a clean cloth
Preparing and weighing the baby
»Remove all clothing including the diaper
»Weigh baby naked
»WAIT till baby stops moving
»Read and record the weight
»Wrap the baby
»Return baby to the mother
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Scale maintenance
»Clean the scale pan between each weighing
»Calibrate daily
In postnatal clinics:
Weigh a baby on THE SAME SCALES at each visit
Assess Breastfeeding
•If the baby is breastfeeding at the time of examination, observe and assess the feed.
•If the mother is not breastfeeding, ask the mother to call the health worker when the
baby next wants to feed so that feeding can be observed.
•Observe breastfeeding for at least five (5) minutes.
Normal findings:
• Baby should breastfeed at least 8X in 24 hours (at least every 3 hours)
• A low birthweight baby needs to breastfeed more often, at least every 2 to 21/2
hours.
• Suckling should be vigorous and suckling well
Make a plan and care for the needs and problems of the newborn
• Education and counseling
• Medical treatment
• Referral and follow up.
Check
Color
Abnormal findings and plan of action
Abnormal findings
Action
< 24 hours old with yellow skin Refer
on face
>24 hours old with yellow
p[alms and soles
(possible infection, blood group
incompatibility)
Pallor
(bleeding, poor circulation,
cold, low blood sugar)
Make sure cord tie is tight
Warm the baby
Check respiration
Ensure breastfeeding
Refer
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Breathing
Posture and tone
Noisy breathing
Refer
(grunting)
Flaring nostrils
Indrawing of the chest between
ribs
(Obstruction of airway,
infection)
RR < 30 or >60/min
Apnea or gasping
Limp, floppy
(prematurity, birth injury,
asphyxia
Rigid, stiffness or arching of the
back
Rhythmic movements of one or
both limbs
(tetanus, birth injury meningitis)
Newborn resuscitation
Refer
Keep baby warm
Give initial dose of antibiotics prior to
referral
Skin
Pustules, blisters, red or purple Treat skin pustules:
spots
Wash hands
(localized infection but may lead Wash off pus and crusts with boiled and
to sepsis if untreated
cooled water and soap
Dry with a clean cloth
Paint with gential violet
Head
Cephalhematoma (swelling on None. the blood is slowly absorbed and
one side of the head)
disappears by 1-2 months
Eyes
Discharging pus
Sticky eyes
Swollen eyelids
( eye infection – gonorrhea or
chlamydia)
Mouth
Cleft lip / palate
(congenital abnormality
abdomen
Distended and hard ( possible
intestinal obstruction)
Abdomen
Refer
Wash hands
Wet clean cloth with cooled boiled water
Use wet cloth to gently was off pus from
the baby’s eyes
Apply antimicrobial to eyes 4x a day
Re-assess in 2 days
Re-assure the mother
Encourage mother to breastfeed/ feed
the baby expressed breast milk by cup
Refer to specialist
Refer
Open tissue on the abdomen ( Refer
omphalocele, gastroschisis)
Cover with sterile tissue soaked with
sterile saline solution
Bleeding from the umbilical cord Retie the cord tightly
Red umbilicus or skin around it Treat umbilical infection
(local umbilical infection)
-wash hands
-wash off pus and crusts with cooled
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boiled water
-dry with clean cloth
-paint with gentian violet
Back and spine
Open tissue on the back (
neural tube defects)
External genital organs Unable to define gender
Refer
Cover witjh sterile tissues soaked with
saline solution
Refer
No urine or wet diaper by 24
hours
Boys external genitalia Urethra does not open at the
end of penis but under the
penis; foreskin not retractable
Temp.
Weight
Refer
Scrotum is empty ( no testes
felt)
Explain to parents that the testes may
descend
Examine the baby again at 6 months
Refer if the testes has not come down
Axillary temp <36ºC or >37ºC,
or
Baby’s back or chest feels
cooler or hotter than the skin of
a normal person
Weight less than 2500 grams
(preterm or SGA)
Refer
Give first dose of antibiotics
Keep the temperature normal
Special care
Weight > 4000 grams
Feed as soon as possible after birth
(infant of diabetic mother, risk of
low blood sugar
Care of the newborn until Discharge
Teach and counsel a mother and her family about newborn care ;
•What care to give
•Why to give the care
Warmth
Keep the room warm ( 25 - 28ºC)
Skin-to-skin contact
Dress the baby or cover with dry, clean cloth
Cover the head with a cap especially if the baby is small
Assess warmth - touch feet, abdomen or back
Sleep
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•At night let the baby sleep with the mother or within easy reach to facilitate
breastfeeding
•Let the mother and baby sleep under a bed net to protect them from malaria
•A baby who is hard to wake up or sleeps too much may be sick
Support breastfeeding
•Counsel on the importance of exclusive breastfeeding
•Encourage breastfeeding on demand day and night
–Do not give any other feeds or water
–Do not use artificial teats and pacifiers
Breastfeeding
•Ask the mother if there is a breastfeeding problem/difficulty.
•If mother has breastfeeding difficulty, assess breastfeeding
•Teach correct positioning and attachment
Key points to good attachment
The baby’s mouth is widely open
•The tongue is far forward in the mouth, and may be seen over the bottom gum
•The lower lip is turned outwards
•The chin is touching the breast
•More areola is visible above the baby’s mouth than below it
Problems that may arise if the baby is not well attached to the breast
The baby:
•May cry a lot and be unhappy
•May be slow to gain weight, or may even lose weight
The mother:
•May get sore/cracked nipples
•May get very full breasts which feel hard, sometimes they may feel hot and may
look red
Key points to good positioning
•The baby’s head and body are in a straight line
•The baby’s face is opposite the nipple and breast
•The baby’s upper lip or nose is opposite the mother’s nipple
•The baby is held as close to the mother’s body as possible
•The baby’s whole body is supported if the mother is in a sitting position.
Breastfeeding Care
•Before a baby is discharged assess if the baby is breastfeeding well.
•Do not discharge if breastfeeding is not yet established or if the baby is not feeding
well
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Protection from infection
•Importance of washing her hands before and after handling the baby
•Cord care
•Keeping her baby clean
•Immunizations
Hygiene ( Washing, Bathing)
•Wash the face, neck and underarms daily
•Look for signs of infection while washing the baby
–Skin infection: spread the skin folds to look for pustules
–Cord infection: redness of skin, discharge, foul odor
–Eye infection: redness, swelling of eyelids, discharge
•Wash the buttocks when soiled. Dry thoroughly
Hygiene ( Washing, Bathing)
•Bath when necessary:
– Ensure the room is warm
–
Use warm water for bathing
–
Thoroughly dry the baby, dress
and cover after bath
•Never use soap on a newborn’s face, only clean water
•Do not clean inside the NB’s ear canal or nose, only the outside
•Do not use baby powder
Cord care
•Wash hands before and after cord care
- Put nothing on the stump
- Fold diaper below the stump
- Keep stump loosely covered with clean clothes
- If the stump is wet, wash with clean water and soap, dry with clean cloth.
•DO NOT bandage the stump or abdomen
•DO NOT apply substances or medicines to stump
•Avoid touching the stump unnecessarily
•If umbilicus is red or draining pus or blood, see the health worker
Eye care
•Do not apply anything on the baby’s eyes except an antimicrobial at birth!
Immunizations
•BCG
•Hepatitis B
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MONITORING THE BABY
•Watch
the baby for any danger signs:
–Breathing difficulty
–Noisy breathing (grunting)
–Fast of slow breathing
–Chest in-drawing
–Feels cold
–Fever
–Red swollen eyelids and with pus
–Redness of skin around the umbilicus with pus discharge
–Convulsions
–Jaundice/yellow skin
•Bleeding from the cord:
 Check if the tie is loose and retie the cord
 Press to stop bleeding
 Examine and assess the baby immediately
Check for special treatment needs
•Give prescribed treatments according to the schedule
treatment for infections
TB
Congenital Syphilis
Maternal illness: risk of bacterial infection
Eye/cord infection
Follow up Visits
•Routine visits:
•Follow-up Visits
•
Advise the mother to seek care for the baby
•Return or go to the hospital immediately if the baby has:
- Difficulty breathing
- convulsions
- Fever or feels cold
- Bleeding
- Has diarrhea
- not feeding at all
•Go to the health center as quickly as possible if the baby has:
- Difficulty feeding
- Pus from eyes
- Skin pustules
- Yellow skin
- A cord stump which is red and draining pus
- Feed less than 5 times in 24 hours
- Other concern
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