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WHO Recommendations on Postnatal Care of the Mother and Newborn. Geneva: World Health Organization; 2013 Oct.

Cover of WHO Recommendations on Postnatal Care of the Mother and Newborn

WHO Recommendations on Postnatal Care of the Mother and Newborn.

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Executive summary

The days and weeks following childbirth – the postnatal period – is a critical phase in the lives of mothers and newborn babies. Most maternal and infant deaths occur during this time. Yet, this is the most neglected period for the provision of quality care. WHO's Postpartum care of the mother and newborn: a practical guide (WHO/RHT/MSM/98.3) was published in 1998. Guidance from this document was included in the WHO guideline Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, published in 2004 (http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf). In keeping with the WHO Handbook on development of guidelines, these documents needed to be updated to include current best evidence-based practices.

To initiate the guidelines update process, WHO convened a technical consultation in October 2008. At this consultation, existing WHO and other agency guidelines related to postnatal care were reviewed for best practices and supporting evidence. Areas were identified where guidance was non-existent or conflicting, and these were prioritized for further work. The process of evidence review synthesis and establishment of a Steering Group and Guidelines Development Group (GDG) was taken up during 2011–2. Systematic reviews were commissioned to address the timing and content of postnatal care and contacts for the mother and newborn following normal childbirth. The GDG consultation to formulate recommendations was held in Geneva from 3–5 September 2012.

The primary audience for these guidelines is health professionals who are responsible for providing postnatal care to women and newborns, primarily in areas where resources are limited. These health professionals include physicians, midwives, nurses and auxiliary nurse-midwives providing primary health care in facilities and at home. The guidelines are also expected to be used by policy-makers and managers of maternal and child health programmes, health facilities, and teaching institutions to set up and maintain maternity and newborn care services. The information in these guidelines will be included in job aids and tools for both pre- and in-service training of health professionals to improve their knowledge, skills and performance in postnatal care.

The guidelines focus on postnatal care of mothers and newborns in resource-limited settings in low- and middle-income countries. The critical maternal health outcome considered was maternal morbidity (including haemorrhage, infections, anaemia and depression). The two critical neonatal outcomes were neonatal mortality and morbidity. Other important outcomes included growth, cognitive development and breastfeeding status.

The guidelines address timing, number and place of postnatal contacts, and content of postnatal care for all mothers and babies during the six weeks after birth. The guidelines include assessment of mothers and newborns to detect problems or complications, but the management of these conditions is addressed in other WHO documents (e.g. management of a mother with postpartum haemorrhage – PPH – or infection, care of a preterm or low-birth-weight newborn or a newborn with infection).

Through 2011–12, the Department of Maternal, Newborn, Child and Adolescent Health coordinated efforts to review and synthesize the evidence on the priority questions. The process included targeted systematic reviews of relevant literature, preparation of GRADE1 profiles, and analysis of the benefits and risks, values and preferences, and costs of implementation. The systematic reviews, meta-analyses and GRADE profiles were conducted by different expert groups using the methodology recommended by the Guidelines Review Committee.

In drafting the recommendations, the WHO Steering Group used the summaries of evidence for the critical outcomes, quality of evidence, risks and benefits of implementing the recommendations, values and preferences and costs. The draft recommendations, evidence summaries, GRADE tables and information on benefits and risks, values and preferences, and costs were presented to the GDG at its meeting held at WHO headquarters in Geneva, Switzerland, in September 2012. The GDG reviewed and discussed this information to finalize the recommendations. Individual members of the GDG filled in a worksheet to comment on the quality of evidence and the draft and strength of the recommendation before discussing these as a group. Where the GDG determined that there was insufficient evidence, consensus within the group was used as the basis of the recommendation. The decisions on the final recommendations and their strengths were made by consensus or, where necessary, by vote.

The recommendations for postnatal care of mothers and newborns are summarized in the table below. These recommendations will be regularly updated as more evidence is collated and analysed on a continuous basis, with major reviews and updates at least every five years. The next major update will be considered in 2018 under the oversight of the WHO Guidelines Review Committee.

2013 WHO Recommendations on postnatal care

RECOMMENDATIONSTRENGTH OF RECOMMENDATION & EVIDENCE QUALITY
PROVISION OF POSTNATAL CARE TO MOTHERS AND NEWBORNS
RECOMMENDATION 1: Timing of discharge from a health facility after birth
After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth.aWeak recommendation based on low quality evidence
RECOMMENDATION 2: Number and timing of postnatal contacts
If birth is in a health facility, mothers and newborns should receive postnatal care in the facility for at least 24 hours after birth. aStrong recommendation based on moderate quality evidence for newborns and low quality evidence for mothers
If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth.
At least three additional postnatal contacts are recommended for all mothers and newborns, on day 3 (48–72 hours), between days 7–14 after birth, and six weeks after birth.
RECOMMENDATION 3: Home visits for postnatal care
Home visits in the first week after birth are recommended for care of the mother and newborn.Strong recommendation based on high quality evidence for newborns and low quality evidence for mothers
CONTENT OF POSTNATAL CARE FOR THE NEWBORN
RECOMMENDATION 4: Assessment of the baby
The following signs should be assessed during each postnatal care contact and the newborn should be referred for further evaluation if any of the signs is present: stopped feeding well, history of convulsions, fast breathing (breathing rate ≥60 per minute), severe chest in-drawing, no spontaneous movement, fever (temperature ≥37.5 °C), low body temperature (temperature <35.5 °C), any jaundice in first 24 hours of life, or yellow palms and soles at any age.Strong recommendation based on low quality evidence
The family should be encouraged to seek health care early if they identify any of the above danger signs in-between postnatal care visits.
RECOMMENDATION 5: Exclusive breastfeeding
All babies should be exclusively breastfed from birth until 6 months of age. Mothers should be counselled and provided support for exclusive breastfeeding at each postnatal contact.Strong recommendation based on moderate quality evidence
RECOMMENDATION 6: Cord care
Daily chlorhexidine (7.1% chlorhexidine digluconate aqueous solution or gel, delivering 4% chlorhexidine) application to the umbilical cord stump during the first week of life is recommended for newborns who are born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1000 live births).Strong recommendation based on moderate quality evidence
Clean, dry cord care is recommended for newborns born in health facilities and at home in low neonatal mortality settings. Use of chlorhexidine in these situations may be considered only to replace application of a harmful traditional substance, such as cow dung, to the cord stump.
RECOMMENDATION 7: Other postnatal care for the newborn
Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours.GDG consensus based on existing WHO guidelines
Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps.
The mother and baby should not be separated and should stay in the same room 24 hours a day.
Communication and play with the newborn should be encouraged.
Immunization should be promoted as per existing WHO guidelines.
Preterm and low-birth-weight babies should be identified immediately after birth and should be provided special care as per existing WHO guidelines.
CONTENT OF POSTNATAL CARE FOR THE MOTHER
RECOMMENDATION 8: Assessment of the mother
First 24 hours after birth
All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth.GDG consensus based on existing WHO guidelines
Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours.
Urine void should be documented within six hours.
Beyond 24 hours after birth
At each subsequent postnatal contact, enquiries should continue to be made about general well-being and assessments made regarding the following: micturition and urinary incontinence, bowel function, healing of any perineal wound, headache, fatigue, back pain, perineal pain and perineal hygiene, breast pain, uterine tenderness and lochia.
Breastfeeding progress should be assessed at each postnatal contact.
At each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. All women and their families/partners should be encouraged to tell their health care professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern.
At 10–14 days after birth, all women should be asked about resolution of mild, transitory postpartum depression (“maternal blues”). If symptoms have not resolved, the woman's psychological well-being should continue to be assessed for postnatal depression, and if symptoms persist, evaluated.
Women should be observed for any risks, signs and symptoms of domestic abuse.
Women should be told whom to contact for advice and management.
All women should be asked about resumption of sexual intercourse and possible dyspareunia as part of an assessment of overall well-being two to six weeks after birth.
If there are any issues of concern at any postnatal contact, the woman should be managed and/or referred according to other specific WHO guidelines.
RECOMMENDATION 9: Counselling
All women should be given information about the physiological process of recovery after birth, and that some health problems are common, with advice to report any health concerns to a health care professional, in particular:
  • Signs and symptoms of PPH: sudden and profuse blood loss or persistent increased blood loss, faintness, dizziness, palpitations/tachycardia.
  • Signs and symptoms of pre-eclampsia/eclampsia: headaches accompanied by one or more of the symptoms of visual disturbances, nausea, vomiting, epigastric or hypochondrial pain, feeling faint, convulsions (in the first few days after birth).
  • Signs and symptoms of infection: fever, shivering, abdominal pain and/or offensive vaginal loss.
  • Signs and symptoms of thromboembolism: unilateral calf pain, redness or swelling of calves, shortness of breath or chest pain.
GDG consensus based on existing WHO guidelines
Women should be counselled on nutrition.
Women should be counselled on hygiene, especially handwashing.
Women should be counselled on birth spacing and family planning. Contraceptive options should be discussed, and contraceptive methods should be provided if requested.
Women should be counselled on safer sex including use of condoms.
In malaria endemic areas, mothers and babies should sleep under insecticide-impregnated bed nets.
All women should be encouraged to mobilize as soon as appropriate following the birth. They should be encouraged to take gentle exercise and make time to rest during the postnatal period.
RECOMMENDATION 10: Iron and folic acid supplementation
Iron and folic acid supplementation should be provided for at least three months.*

* The GDG noted that there is currently no evidence to change this recommendation and that WHO is working on developing specific guidelines for maternal nutrition interventions after birth.
GDG consensus based on existing WHO guidelines
RECOMMENDATION 11: Prophylactic antibiotics
The use of antibiotics among women with a vaginal delivery and a third or fourth degree perineal tear is recommended for prevention of wound complications.Strong recommendation based on very low quality evidence
The GDG considers that there is insufficient evidence to recommend the routine use of antibiotics in all low-risk women with a vaginal delivery for prevention of endometritis.
RECOMMENDATION 12: Psychosocial support
Psychosocial support by a trained person is recommended for the prevention of postpartum depression among women at high risk of developing this condition.Weak recommendation based on very low quality evidence
The GDG considers that there is insufficient evidence to recommend routine formal debriefing to all women to reduce the occurrence/risk of postpartum depression.Weak recommendation based on low quality evidence
The GDG also considers that there is insufficient evidence to recommend the routine distribution of, and discussion about, printed educational material for prevention of postpartum depression.Weak recommendation based on very low quality evidence
Health professionals should provide an opportunity for women to discuss their birth experience during their hospital stay.GDG consensus based on existing WHO guidelines
A woman who has lost her baby should receive additional supportive care.GDG consensus based on existing WHO guidelines
a

For the newborn this includes an immediate assessment at birth, a full clinical examination around one hour after birth and before discharge.

Footnotes

1

GRADE refers to the system for grading the quality of evidence and the strength of recommendations.

Copyright © World Health Organization 2014.

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Bookshelf ID: NBK190090

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