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Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. 3rd edition. Geneva: World Health Organization; 2015.

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Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. 3rd edition.

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DCHILDBIRTH: LABOUR, DELIVERY AND IMMEDIATE POSTPARTUM CARE

  • Always begin with Rapid assessment and management (RAM) B3-B7.
  • Next, use the chart on Examine the woman in labour or with ruptured membranes D2-D3 to assess the clinical situation and obstetrical history, and decide the stage of labour.
  • If an abnormal sign is identified, use the charts on Respond to obstetrical problems on admission D4-D5.
  • Care for the woman according to the stage of labour D8-D13 and respond to problems during labour and delivery as on D14-D18.
  • Use Give supportive care throughout labour D6-D7 to provide support and care throughout labour and delivery.
  • Record findings continually on labour record and partograph N4-N6.
  • Keep mother and baby in labour room for one hour after delivery and use charts Care of the mother and newborn within first hour of delivery placenta on D19.
  • Next use Care of the mother after the first hour following delivery of placenta D20 to provide care until discharge. Use chart on D25 to provide Preventive measures and Advise on postpartum care D26-D28 to advise on care, danger signs, when to seek routine or emergency care, and family planning.
  • Examine the mother for discharge using chart on D21.
  • Do not discharge mother from the facility before 12 hours.
  • If the mother is HIV-infected or adolescent, or has special needs, see G1-G11 H1-H4.
  • If attending a delivery at the woman's home, see D29.

D2. EXAMINE THE WOMAN IN LABOUR OR WITH RUPTURED MEMBRANES

First do Rapid assessment and management B3-B7. Then use this chart to assess the woman's and fetal status and decide stage of labour.

ASK, CHECK RECORDLOOK, LISTEN, FEEL
History of this labour:
  • When did contractions begin?
  • How frequent are contractions? How strong?
  • Have your waters broken? If yes, when? Were they clear or green?
  • Have you had any bleeding? If yes, when? How much?
  • Is the baby moving?
  • Do you have any concern?
Check record, or if no record:
  • Ask when the delivery is expected.
  • Determine if preterm (less than 8 months pregnant).
  • Review the birth plan.
If prior pregnancies:
  • Number of prior pregnancies/deliveries.
  • Any prior caesarean section, forceps, or vacuum, or other complication such as postpartum haemorhage?
  • Any prior third degree tear?
Current pregnancy:
  • RPR status C5.
  • Hb results C4.
  • Tetanus immunization status F2.
  • HIV status C6.
  • Infant feeding plan G7-G8.
  • Receiving any medicine.
  • Observe the woman's response to contractions:

    Is she coping well or is she distressed?

  • Is she pushing or grunting?
  • Check abdomen for:

    caesarean section scar.

    horizontal ridge across lower abdomen (if present, empty bladder B12 and observe again).

  • Feel abdomen for:

    contractions frequency, duration, any continuous contractions?

    fetal lie—longitudinal or transverse?

    fetal presentation—head, breech, other?

    more than one fetus?

    fetal movement.

  • Listen to the fetal heart beat:

    Count number of beats in 1 minute.

    If less than 100 beats per minute, or more than 180, turn woman on her left side and count again.

  • Measure blood pressure.
  • Measure temperature.
  • Look for pallor.
  • Look for sunken eyes, dry mouth.
  • Pinch the skin of the forearm: does it go back quickly?

Image childbirthfu1.jpgNext: Perform vaginal examination and decide stage of labour

D3. DECIDE STAGE OF LABOUR

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYMANAGE
  • Explain to the woman that you will give her a vaginal examination and ask for her consent.
  • Look at vulva for:

    bulging perineum

    any visible fetal parts

    vaginal bleeding

    leaking amniotic fluid; if yes, is it meconium stained, foul-smelling?

    warts, keloid tissue or scars that may interfere with delivery.

Perform vaginal examination
  • DO NOT shave the perineal area.
  • Prepare:

    clean gloves

    swabs, pads.

  • Wash hands with soap before and after each examination.
  • Wash vulva and perineal areas.
  • Put on gloves.
  • Position the woman with legs flexed and apart.
DO NOT perform vaginal examination if bleeding now or at any time after 7 months of pregnancy.
  • Perform gentle vaginal examination (do not start during a contraction):

    Determine cervical dilatation in centimetres.

    Feel for presenting part. Is it hard, round and smooth (the head)? If not, identify the presenting part.

    Feel for membranes – are they intact?

    Feel for cord – is it felt? Is it pulsating? If so, act immediately as on D15.

  • Bulging thin perineum, vagina gaping and head visible, full c ervical dilatation.
IMMINENT DELIVERY
  • See second stage of labour D10-D11.
  • Record in partograph N5.
  • Cervical dilatation:

    multigravida ≥5 cm

    primigravida ≥6 cm

LATE ACTIVE LABOUR
  • See first stage of labour – active labour D9.
  • Start plotting partograph N5.
  • Record in labour record N5.
  • Cervical dilatation ≥4 cm.
EARLY ACTIVE LABOUR
  • Cervical dilatation: 0-3 cm; contractions weak and <2 in 10 minutes.
NOT YET IN ACTIVE LABOUR
  • See first stage of labour — not active labour D8.
  • Record in labour record N4.

Image childbirthfu1.jpgNext: Respond to obstetrical problems on admission.

D4-D5. RESPOND TO OBSTETRICAL PROBLEMS ON ADMISSION

Use this chart if abnormal findings on assessing pregnancy and fetal status D2-D3.

SIGNSCLASSIFYTREAT AND ADVISE
  • Transverse lie.
  • Continuous contractions.
  • Constant pain between contractions.
  • Sudden and severe abdominal pain.
  • Horizontal ridge across lower abdomen.
  • Labour >24 hours.
OBSTRUCTED LABOUR
  • If distressed, insert an IV line and give fluids B9.
  • If in labour >24 hours, give appropriate IM/IV antibiotics B15.
  • Refer urgently to hospital B17.
FOR ALL SITUATIONS IN RED BELOW, REFER URGENTLY TO HOSPITAL IF IN EARLY LABOUR, MANAGE ONLY IF IN LATE LABOUR
  • Rupture of membranes and any of:

    Fever >38˚C

    Foul-smelling vaginal discharge.

UTERINE AND FETAL INFECTION
  • Give appropriate IM/IV antibiotics B15.
  • If late labour, deliver and refer to hospital after delivery B17.
  • Plan to treat newborn J5.
  • Rupture of membranes at <8 months of pregnancy.
RISK OF UTERINE AND FETAL INFECTION AND RESPIRATORY DISTRESS SYNDROME
  • Give appropriate IM/IV antibiotics B15.
  • If late labour, deliver D10-D28.
  • Discontinue antibiotic for mother after delivery if no signs of infection.
  • Plan to treat newborn J5.
  • Diastolic blood pressure >90 mmHg.
PRE-ECLAMPSIA
  • Assess further and manage as on D23.
  • Severe palmar and conjunctival pallor and/or haemoglobin <7 g/dl.
SEVERE ANAEMIA
  • Manage as on D24.
  • Breech or other malpresentation D16.
  • Multiple pregnancy D18.
  • Fetal distress D14
  • Prolapsed cord D15.
OBSTETRICAL COMPLICATION
  • Follow specific instructions (see page numbers in left column).
  • Warts, keloid tissue that may interfere with delivery.
  • Prior third degree tear.
  • Bleeding any time in third trimester.
  • Prior delivery by:

    caesarean secion

    forceps or vacuum delivery.

  • Age less than 14 years.
RISK OF OBSTETRICAL COMPLICATION
  • Do a generous episiotomy and carefully control delivery of the head D10-D11.
  • If late labour, deliver D10-D28.
  • Have help available during delivery.
  • Labour before 8 completed months of pregnancy (more than one month before estimated date of delivery).
PRETERM LABOUR
  • Reassess fetal presentation (breech more common).
  • If woman is lying, encourage her to lie on her left side.
  • Call for help during delivery.
  • Routine delivery by caesarean section for the purpose of improving preterm newborn outcomes is not recommended, regardless of cephalic or breech presentation.
  • The use of magnesium sulfate is recommended for women at risk of imminent preterm birth before 32 weeks of gestation for prevention of cerebral palsy in the infant and child B13.
  • Conduct delivery very carefully as small baby may pop out suddenly. In particular, control delivery of the head.
  • Prepare equipment for resuscitation of newborn K11.
  • Fetal heart rate <120 or >160 beats per minute.
POSSIBLE FETAL DISTRESS
  • Manage as on D14.
  • Rupture of membranes at term and before labour.
RUPTURE OF MEMBRANES
  • Give appropriate IM/IV antibiotics if rupture of membrane >18 hours B15.
  • Plan to treat the newborn J5.
  • If two or more of the following signs:

    thirsty

    sunken eyes

    dry mouth

    skin pinch goes back slowly.

DEHYDRATION
  • Give oral fluids.
  • If not able to drink, give 1 litre IV fluids over 3 hours B9.
  • HIV test positive.
  • Taking ARV treatment or prophylaxis.
HIV-INFECTED
  • Ensure that the woman takes ARV drugs as prescribed G6, G9
  • Support her choice of infant feeding G7-G8.
  • No fetal movement, and
  • No fetal heart beat on repeated examination
POSSIBLE FETAL DEATH
  • Explain to the parents that the baby is not doing well.

Image childbirthfu1.jpgNext: Give supportive care throughout labour

D6-D7. GIVE SUPPORTIVE CARE THROUGHOUT LABOUR

Use this chart to provide a supportive, encouraging atmosphere for birth, respectful of the woman's wishes.

Communication

  • Explain all procedures, seek permission, and discuss findings with the woman.
  • Keep her informed about the progress of labour.
  • Praise her, encourage and reassure her that things are going well.
  • Ensure and respect privacy during examinations and discussions.
  • If known HIV-infected, find out what she has told the companion. Respect her wishes.

Cleanliness

  • Encourage the woman to bathe or shower or wash herself and genitals at the onset of labour.
  • Wash the vulva and perineal areas before each examination.
  • Wash your hands with soap before and after each examination. Use clean gloves for vaginal examination.
  • Ensure cleanliness of labour and birthing area(s).
  • Clean up spills immediately.
  • DO NOT give enema.

Mobility

  • Encourage the woman to walk around freely during the first stage of labour.
  • Support the woman's choice of position (left lateral, squating, kneeling, standing supported by the companion) for each stage of labour and delivery.

Urination

  • Encourage the woman to empty her bladder frequently. Remind her every 2 hours.

Eating, drinking

  • Encourage the woman to eat and drink as she wishes throughout labour.
  • Nutritious liquid drinks are important, even in late labour.
  • If the woman has visible severe wasting or tires during labour, make sure she eats and drinks.

Breathing technique

  • Teach her to notice her normal breathing.
  • Encourage her to breathe out more slowly, making a sighing noise, and to relax with each breath.
  • If she feels dizzy, unwell, is feeling pins-and-needles (tingling) in her face, hands and feet, encourage her to breathe more slowly.
  • To prevent pushing at the end of first stage of labour, teach her to pant, to breathe with an open mouth, to take in 2 short breaths followed by a long breath out.
  • During delivery of the head, ask her not to push but to breathe steadily or to pant.

Pain and discomfort relief

  • Suggest change of position.
  • Encourage mobility, as comfortable for her.
  • Encourage companion to:

    massage the woman's back if she finds this helpful.

    hold the woman's hand and sponge her face between contractions.

  • Encourage her to use the breathing technique.
  • Encourage warm bath or shower, if available.
  • If woman is distressed or anxious, investigate the cause D2-D3.
  • If pain is constant (persisting between contractions) and very severe or sudden in onset D4.

Birth companion

  • Encourage support from the chosen birth companion throughout labour.
  • Describe to the birth companion what she or he should do:

    Always be with the woman.

    Encourage her.

    Help her to breathe and relax.

    Rub her back, wipe her brow with a wet cloth, do other supportive actions.

    Give support using local practices which do not disturb labour or delivery.

    Encourage woman to move around freely as she wishes and to adopt the position of her choice.

    Encourage her to drink fluids and eat as she wishes.

    Assist her to the toilet when needed.

  • Ask the birth companion to call for help if:

    The woman is bearing down with contractions.

    There is vaginal bleeding.

    She is suddenly in much more pain.

    She loses consciousness or has fits.

    There is any other concern.

  • Tell the birth companion what she or he should NOT do and explain why:
  • DO NOT encourage woman to push.
  • DO NOT give advice other than that given by the health worker.
  • DO NOT keep woman in bed if she wants to move around.

D8. FIRST STAGE OF LABOUR: NOT IN ACTIVE LABOUR

Use this chart for care of the woman when NOT IN ACTIVE LABOUR, when cervix dilated 0-3 cm and contractions are weak, less than 2 in 10 minutes.

MONITOR EVERY HOUR:MONITOR EVERY 4 HOURS:
  • For emergency signs, using rapid assessment (RAM) B3-B7.
  • Frequency, intensity and duration of contractions.
  • Fetal heart rate D14.
  • Mood and behaviour (distressed, anxious) D6.
  • Cervical dilatation D3 D15.
  • Unless indicated, do not do vaginal examination more frequently than every 4 hours.
  • Temperature.
  • Pulse B3.
  • Blood pressure D23.
  • Record findings regularly in Labour record and Partograph N4-N6.
  • Record time of rupture of membranes and colour of amniotic fluid.
  • Give Supportive care D6-D7.
  • Never leave the woman alone.
ASSESS PROGRESS OF LABOURTREAT AND ADVISE, IF REQUIRED
  • After 8 hours if:

    Contractions stronger and more frequent but

    No progress in cervical dilatation with or without membranes ruptured.

  • Refer the woman urgently to hospital B17.
  • After 8 hours if:

    no increase in contractions, and

    membranes are not ruptured, and

    no progress in cervical dilatation.

  • Discharge the woman and advise her to return if:

    pain/discomfort increases

    vaginal bleeding

    membranes rupture.

  • Cervical dilatation 4 cm or greater.
  • Begin plotting the partograph N5 and manage the woman as in Active labour D9.

D9. FIRST STAGE OF LABOUR: IN ACTIVE LABOUR

Use this chart when the woman is IN ACTIVE LABOUR, when cervix dilated 4 cm or more.

MONITOR EVERY 30 MINUTES:MONITOR EVERY 4 HOURS:
  • For emergency signs, using rapid assessment (RAM) B3-B7.
  • Frequency, intensity and duration of contractions.
  • Fetal heart rate D14.
  • Mood and behaviour (distressed, anxious) D6.
  • Cervical dilatation D3 D15.
  • Unless indicated, do not do vaginal examination more frequently than every 4 hours.
  • Temperature.
  • Pulse B3.
  • Blood pressure D23.
  • Record findings regularly in Labour record and Partograph N4-N6.
  • Record time of rupture of membranes and colour of amniotic fluid.
  • Give Supportive care D6-D7.
  • Never leave the woman alone.
ASSESS PROGRESS OF LABOURTREAT AND ADVISE, IF REQUIRED
  • Partograph passes to the right of ALERT LINE.
  • Reassess woman and consider criteria for referral.
  • Call senior person if available. Alert emergency transport services.
  • Encourage woman to empty bladder.
  • Ensure adequate hydration but omit solid foods.
  • Encourage upright position and walking if woman wishes.
  • Monitor intensively. Reassess in 2 hours and refer if no progress. If referral takes a long time, refer immediately (DO NOT wait to cross action line).
  • Partograph passes to the right of ACTION LINE.
  • Refer urgently to hospital B17 unless birth is imminent.
  • Cervix dilated 10 cm or bulging perineum.
  • Manage as in Second stage of labour D10-D11.

D10-D11. SECOND STAGE OF LABOUR: DELIVER THE BABY AND GIVE IMMEDIATE NEWBORN CARE

Use this chart when cervix dilated 10 cm or bulging thin perineum and head visible.

MONITOR EVERY 5 MINUTES:
  • For emergency signs, using rapid assessment (RAM) B3-B7.
  • Frequency, intensity and duration of contractions.
  • Fetal heart rate D14.
  • Perineum thinning and bulging.
  • Visible descent of fetal head or during contraction.
  • Mood and behaviour (distressed, anxious) D6.
  • Record findings regularly in Labour record and Partograph N4-N6.
  • Give Supportive care D6-D7.
  • Never leave the woman alone.
DELIVER THE BABYTREAT AND ADVISE IF REQUIRED
  • Ensure all delivery equipment and supplies, including newborn resuscitation equipment, are available, and place of delivery is clean and warm (25°C) L3.
  • Ensure bladder is empty.
  • Assist the woman into a comfortable position of her choice, as upright as possible.
  • Stay with her and offer her emotional and physical support D10-D11.
  • If unable to pass urine and bladder is full, empty bladder B12.
  • DO NOT let her lie flat (horizontally) on her back.
  • If the woman is distressed, encourage pain discomfort relief D6.
  • Allow her to push as she wishes with contractions.
DO NOT urge her to push.
  • If, after 30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin and stretch with contractions, do a vaginal examination to confirm full dilatation of cervix.
  • If cervix is not fully dilated, await second stage. Place woman on her left side and discourage pushing. Encourage breathing technique D6.
  • Wait until head visible and perineum distending.
  • Wash hands with clean water and soap. Put on gloves just before delivery.
  • See Universal precautions during labour and delivery A4.
  • If second stage lasts for 2 hours or more without visible steady descent of the head, call for staff trained to use vacuum extractor or refer urgently to hospital B17.
  • If obvious obstruction to progress (warts/scarring/keloid tissue/previous third degree tear), do a generous episiotomy. DO NOT perform episiotomy routinely.
  • If breech or other malpresentation, manage as on D16.
  • Ensure controlled delivery of the head:

    Keep one hand gently on the head as it advances with contractions.

    Support perineum with other hand and cover anus with pad held in position by side of hand during delivery

    Leave the perineum visible (between thumb and first finger).

    Ask the mother to breathe steadily and not to push during delivery of the head.

    Encourage rapid breathing with mouth open.

  • If potentially damaging expulsive efforts, exert more pressure on perineum.
  • Discard soiled pad to prevent infection.
  • Feel gently around baby's neck for the cord.
  • Check if the face is clear of mucus and membranes.
  • If cord present and loose, deliver the baby through the loop of cord or slip the cord over the baby's head; if cord is tight, clamp and cut cord, then unwind.
  • Gently wipe face clean with gauze or cloth, if necessary.
  • Await spontaneous rotation of shoulders and delivery (within 1-2 minutes).
  • Apply gentle downward pressure to deliver top shoulder.
  • Then lift baby up, towards the mother's abdomen to deliver lower shoulder.
  • Place baby on abdomen or in mother's arms.
  • Note time of delivery.
  • If delay in delivery of shoulders:

    DO NOT panic but call for help and ask companion to assist

    Manage as in Stuck shoulders D17.

  • If placing newborn on abdomen is not acceptable, or the mother cannot hold the baby, place the baby in a clean, warm, safe place close to the mother.
  • Thoroughly dry the baby immediately. Wipe eyes. Discard wet cloth.
  • Assess baby's breathing while drying.
  • If the baby is not crying, observe breathing:

    breathing well (chest rising)?

    not breathing or gasping?

DO NOT leave the baby wet - she/he will become cold.
  • If the baby is not breathing or gasping (unless baby is dead, macerated, severely malformed):

    Cut cord quickly: transfer to a firm, warm surface; start Newborn resuscitation K11.

  • CALL FOR HELP - one person should care for the mother.
  • Exclude second baby.
  • Palpate mother's abdomen.
  • Give 10 IU oxytocin IM to the mother.
  • Watch for vaginal bleeding.
  • If second baby, DO NOT give oxytocin now. GET HELP.
  • Deliver the second baby. Manage as in Multiple pregnancy D18.
  • If heavy bleeding, repeat oxytocin 10-IU-IM.
  • Change gloves. If not possible, wash gloved hands.
  • Clamp and cut the cord (1-3 minutes after birth):

    put ties tightly around the cord at 2 cm and 5 cm from baby's abdomen.

    cut between ties with sterile instrument.

    observe for oozing blood.

  • If blood oozing, place a second tie between the skin and the first tie.
DO NOT apply any substance to the stump.
DO NOT bandage or bind the stump.
  • Leave baby on the mother's chest in skin-to-skin contact. Place identification label.
  • Cover the baby, cover the head with a hat.
  • If room cool (less than 25°C), use additional blanket to cover the mother and baby.
  • Encourage initiation of breastfeeding K2.
  • If HIV-infected mother has chosen replacement feeding, feed accordingly.
  • Check ARV treatment needed G6, G9.

D12-D13. THIRD STAGE OF LABOUR: DELIVER THE PLACENTA

Use this chart for care of the woman between birth of the baby and delivery of placenta.

MONITOR MOTHER EVERY 5 MINUTES:MONITOR BABY EVERY 15 MINUTES:
  • For emergency signs, using rapid assessment (RAM) B3-B7.
  • Feel if uterus is well contracted.
  • Mood and behaviour (distressed, anxious) D6.
  • Time since third stage began (time since birth).
  • Breathing: listen for grunting, look for chest in-drawing and fast breathing J2.
  • Warmth: check to see if feet are cold to touch J2.
  • Record findings, treatments and procedures in Labour record and Partograph (pp.N4-N6).
  • Give Supportive care D6-D7
  • Never leave the woman alone.
DELIVER THE PLACENTATREAT AND ADVISE IF REQUIRED
  • Ensure 10-IU oxytocin IM is given D11.
  • Await strong uterine contraction (2-3 minutes) and deliver placenta by controlled cord traction:

    Place side of one hand (usually left) above symphysis pubis with palm facing towards the mother's umbilicus. This applies counter traction to the uterus during controlled cord traction. At the same time, apply steady, sustained controlled cord traction.

    If placenta does not descend during 30-40 seconds of controlled cord traction, release both cord traction and counter traction on the abdomen and wait until the uterus is well contracted again. Then repeat controlled cord traction with counter traction.

    As the placenta is coming out, catch in both hands to prevent tearing of the membranes.

    If the membranes do not slip out spontaneously, gently twist them into a rope and move them up and down to assist separation without tearing them.

  • If, after 30 minutes of giving oxytocin, the placenta is not delivered and the woman is NOT bleeding:

    Empty bladder B12

    Encourage breastfeeding

    Repeat controlled cord traction.

  • If woman is bleeding, manage as on B5
  • If placenta is not delivered in another 30 minutes (1 hour after delivery):

    Remove placenta manually B11

    Give appropriate IM/IV antibiotic B15.

  • If in 1 hour unable to remove placenta:

    Refer the woman to hospital B17

    Insert an IV line and give fluids with 20 IU of oxytocin at 30 drops per minute during transfer B9.

DO NOT exert excessive traction on the cord.
DO NOT squeeze or push the uterus to deliver the placenta.
  • Check that placenta and membranes are complete.
  • If placenta is incomplete:

    Remove placental fragments manually B11.

    Give appropriate IM/IV antibiotic B15.

  • Check that uterus is well contracted and there is no heavy bleeding.
  • Repeat check every 5 minutes.
  • If heavy bleeding:

    Massage uterus to expel clots if any, until it is hard B10.

    Give oxytocin 10 IU IM B10.

    Call for help.

    Start an IV line B9, add 20 IU of oxytocin to IV fluids and give at 60 drops per minute N9.

    Empty the bladder B12.

  • If bleeding persists and uterus is soft:

    Continue massaging uterus until it is hard.

    Apply bimanual or aortic compression B10.

    Continue IV fluids with 20 IU of oxytocin at 30 drops per minute.

    Refer woman urgently to hospital B17.

  • Examine perineum, lower vagina and vulva for tears.
  • If third degree tear (involving rectum or anus), refer urgently to hospital B17.
  • For other tears: apply pressure over the tear with a sterile pad or gauze and put legs together.
  • Check after 5 minutes. If bleeding persists, repair the tear B12.
  • Collect, estimate and record blood loss throughout third stage and immediately afterwards.
  • If blood loss ≈ 250 ml, but bleeding has stopped:

    Plan to keep the woman in the facility for 24 hours.

    Monitor intensively (every 30 minutes) for 4 hours:

    BP, pulse

    vaginal bleeding

    uterus, to make sure it is well contracted.

    Assist the woman when she first walks after resting and recovering.

    If not possible to observe at the facility, refer to hospital B17.

  • Clean the woman and the area beneath her. Put sanitary pad or folded clean cloth under her buttocks to collect blood. Help her to change clothes if necessary.
  • Keep the mother and baby in delivery room for a minimum of one hour after delivery of placenta.
  • Dispose of placenta in the correct, safe and culturally appropriate manner.
  • If disposing placenta:

    Use gloves when handling placenta.

    Put placenta into a bag and place it into a leak-proof container.

    Always carry placenta in a leak-proof container.

    Incinerate the placenta or bury it at least 10 m away from a water source, in a 2 m deep pit.

RESPOND TO PROBLEMS DURING LABOUR AND DELIVERY

D14. IF FHR <120 OR >160bpm

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
IF FETAL HEART RATE (FHR) <120 OR >160 BEATS PER MINUTE
  • Position the woman on her left side.
  • If membranes have ruptured, look at vulva for prolapsed cord.
  • See if liquor was meconium stained.
  • Repeat FHR count after 15 minutes
  • Cord seen at vulva.
PROLAPSED CORD
  • Manage urgently as on D15.
  • FHR remains >160 or <120 after
  • 30 minutes observation.
BABY NOT WELL
  • If early labour:

    Refer the woman urgently to hospital B17

    Keep her lying on her left side.

  • If late labour:

    Call for help during delivery

    Monitor after every contraction. If FHR does not return to normal in 15 minutes explain to the woman (and her companion) that the baby may not be well.

    Prepare for newborn resuscitation K11.

  • FHR returns to normal.
BABY WELL
  • Monitor FHR every 15 minutes.

Image childbirthfu1.jpgNext: If prolapsed cord

D15. IF PROLAPSED CORD

The cord is visible outside the vagina or can be felt in the vagina below the presenting part.

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT
  • Look at or feel the cord gently for pulsations.
  • Feel for transverse lie.
  • Do vaginal examination to determine status of labour.
  • Transverse lie
OBSTRUCTED LABOUR
  • Refer urgently to hospital B17.
  • Cord is pulsating
FETUS ALIVEIf early labour:
  • Push the head or presenting part out of the pelvis and hold it above the brim/pelvis with your hand on the abdomen until caesarean section is performed.
  • Instruct assistant (family, staff) to position the woman's buttocks higher than the shoulder.
  • Refer urgently to hospital B17.
  • If transfer not possible, allow labour to continue.
If late labour:
  • Call for additional help if possible (for mother and baby).
  • Prepare for Newborn resuscitation K11.
  • Ask the woman to assume an upright or squatting position to help progress.
  • Expedite delivery by encouraging woman to push with contraction.
  • Cord is not pulsating
FETUS PROBABLY DEAD
  • Explain to the parents that baby may not be well.

Image childbirthfu1.jpgNext: If breech presentation

D16. IF BREECH PRESENTATION

LOOK, LISTEN, FEELSIGNSTREAT
  • On external examination fetal head felt in fundus.
  • Soft body part (leg or buttocks) felt on vaginal examination.
  • Legs or buttocks presenting at perineum
  • If early labour
  • Refer urgently to hospital B17.
  • If late labour
  • Call for additional help.
  • Confirm full dilatation of the cervix by vaginal examination D3
  • Ensure bladder is empty. If unable to empty bladder see Empty bladder B12.
  • Prepare for newborn resuscitation K11.
  • Deliver the baby:

    Assist the woman into a position that will allow the baby to hang down during delivery, for example, propped up with buttocks at edge of bed or onto her hands and knees (all fours position).

    When buttocks are distending, make an episiotomy.

    Allow buttocks, trunk and shoulders to deliver spontaneously during contractions.

    After delivery of the shoulders allow the baby to hang until next contraction.

  • If the head does not deliver after several contractions
  • Place the baby astride your left forearm with limbs hanging on each side.
  • Place the middle and index fingers of the left hand over the malar cheek bones on either side to apply gentle downwards pressure to aid flexion of head.
  • Keeping the left hand as described, place the index and ring fingers of the right hand over the baby's shoulders and the middle finger on the baby's head to gently aid flexion until the hairline is visible.
  • When the hairline is visible, raise the baby in upward and forward direction towards the mother's abdomen until the nose and mouth are free. The assistant gives supra pubic pressure during the period to maintain flexion.
  • If trapped arms or shoulders
  • Feel the baby's chest for arms. If not felt:
  • Hold the baby gently with hands around each thigh and thumbs on sacrum.
  • Gently guiding the baby down, turn the baby, keeping the back uppermost until the shoulder which was posterior (below) is now anterior (at the top) and the arm is released.
  • Then turn the baby back, again keeping the back uppermost to deliver the other arm.
  • Then proceed with delivery of head as described above.
  • If trapped head (and baby is dead)
  • Tie a 1 kg weight to the baby's feet and await full dilatation.
  • Then proceed with delivery of head as described above.
NEVER pull on the breech
DO NOT allow the woman to push until the cervix is fully dilated. Pushing too soon may cause the head to be trapped.

Image childbirthfu1.jpgNext: If stuck shoulders

D17. IF STUCK SHOULDERS (SHOULDER DYSTOCIA)

SIGNSTREAT
  • Fetal head is delivered, but shoulders are stuck and cannot be delivered.
  • Call for additional help.
  • Prepare for newborn resuscitation.
  • Explain the problem to the woman and her companion.
  • Ask the woman to lie on her back while gripping her legs tightly flexed against her chest, with knees wide apart.
    Ask the companion or other helper to keep the legs in that position.
  • Perform an adequate episiotomy.
  • Ask an assistant to apply continuous pressure downwards, with the palm of the hand on the abdomen directly above the pubic area, while you maintain continuous downward traction on the fetal head.
  • If the shoulders are still not delivered and surgical help is not available immediately.
  • Remain calm and explain to the woman that you need her cooperation to try another position.
  • Assist her to adopt a kneeling on “all fours” position and ask her companion to hold her steady - this simple change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery.
  • Introduce the right hand into the vagina along the posterior curve of the sacrum.
  • Attempt to deliver the posterior shoulder or arm using pressure from the finger of the right hand to hook the posterior shoulder and arm downwards and forwards through the vagina.
  • Complete the rest of delivery as normal.
  • If not successful, refer urgently to hospital B17.
DO NOT pull excessively on the head.

Image childbirthfu1.jpgNext: If multiple births

D18. IF MULTIPLE BIRTHS

SIGNSTREAT
  • Prepare for delivery
  • Prepare delivery room and equipment for birth of 2 or more babies. Include:

    more warm cloths

    two sets of cord ties and razor blades

    resuscitation equipment for 2 babies.

  • Arrange for a helper to assist you with the births and care of the babies.
  • Second stage of labour
  • Deliver the first baby following the usual procedure. Resuscitate if necessary. Label her/him Twin 1.
  • Ask helper to attend to the first baby.
  • Palpate uterus immediately to determine the lie of the second baby. If transverse or oblique lie, gently turn the baby by abdominal manipulation to head or breech presentation.
  • Check the presentation by vaginal examination. Check the fetal heart rate.
  • Await the return of strong contractions and spontaneous rupture of the second bag of membranes, usually within 1 hour of birth of first baby, but may be longer.
  • Stay with the woman and continue monitoring her and the fetal heart rate intensively.
  • Remove wet cloths from underneath her. If feeling chilled, cover her.
  • When the membranes rupture, perform vaginal examination D3 to check for prolapsed cord. If present, see Prolapsed cord D15.
  • When strong contractions restart, ask the mother to bear down when she feels ready.
  • Deliver the second baby. Resuscitate if necessary. Label her/him Twin 2.
  • After cutting the cord, ask the helper to attend to the second baby.
  • Palpate the uterus for a third baby. If a third baby is felt, proceed as described above. If no third baby is felt, go to third stage of labour.
DO NOT attempt to deliver the placenta until all the babies are born.
DO NOT give the mother oxytocin until after the birth of all babies.
  • Third stage of labour
  • Give oxytocin 10 IU IM after making sure there is not another baby.
  • When the uterus is well contracted, deliver the placenta and membranes by applying traction to all cords together D12-D23.
  • Before and after delivery of the placenta and membranes, observe closely for vaginal bleeding because this woman is at greater risk of postpartum haemorrhage. If bleeding, see B5.
  • Examine the placenta and membranes for completeness. There may be one large placenta with 2 umbilical cords, or a separate placenta with an umbilical cord for each baby.
  • Immediate postpartum care
  • Monitor intensively as risk of bleeding is increased.
  • Provide immediate Postpartum care D19-D20.
  • In addition:

    Keep mother in health centre for longer observation

    Plan to measure haemoglobin postpartum if possible

    Give special support for care and feeding of babies J11 and K4.

Image childbirthfu1.jpgNext: Care of the mother and newborn within first hour of delivery of placenta

D19. CARE OF THE MOTHER AND NEWBORN WITHIN FIRST HOUR OF DELIVERY OF PLACENTA

Use this chart for woman and newborn during the first hour after complete delivery of placenta.

MONITOR MOTHER EVERY 15 MINUTES:MONITOR BABY EVERY 15 MINUTES:
  • For emergency signs, using rapid assessment (RAM) B3-B7.
  • Feel if uterus is hard and round.
  • Breathing: listen for grunting, look for chest in-drawing and fast breathing J2.
  • Warmth: check to see if feet are cold to touch J2.
  • Record findings, treatments and procedures in Labour record and Partograph N4-N6.
  • Keep mother and baby in delivery room - do not separate them.
  • Never leave the woman and newborn alone.
CARE OF MOTHER AND NEWBORNINTERVENTIONS, IF REQUIRED
WOMAN
  • Assess the amount of vaginal bleeding.
  • Encourage the woman to eat and drink.
  • Ask the companion to stay with the mother.
  • Encourage the woman to pass urine.
  • If pad soaked in less than 5 minutes, or constant trickle of blood, manage as on D22.
  • If uterus soft, manage as on B10.
  • If bleeding from a perineal tear, repair if required B12 or refer to hospital B17.
NEWBORN
  • Wipe the eyes.
  • Apply an antimicrobial within 1 hour of birth.

    either 1% silver nitrate drops or 2.5% povidone iodine drops or 1% tetracycline ointment.

  • DO NOT wash away the eye antimicrobial.
  • If blood or meconium, wipe off with wet cloth and dry.
  • DO NOT remove vernix or bathe the baby.
  • Continue keeping the baby warm and in skin-to-skin contact with the mother.
  • Encourage the mother to initiate breastfeeding when baby shows signs of readiness. Offer her help.
  • DO NOT give artificial teats or pre-lacteal feeds to the newborn: no water, sugar water, or local feeds.
  • If breathing with difficulty — grunting, chest in-drawing or fast breathing, examine the baby as on J2-J8.
  • If feet are cold to touch or mother and baby are separated:
  • Ensure the room is warm. Cover mother and baby with a blanket

    Reassess in 1 hour. If still cold, measure temperature. If less than 36.5°C, manage as on K9.

  • If unable to initiate breastfeeding (mother has complications):

    Plan for alternative feeding method K5-K6.

    If mother HIV-infected: give treatment to the newborn G9.

    Support the mother's choice of newborn feeding G8.

  • If baby is stillborn or dead, give supportive care to mother and her family D24.
  • Examine the mother and newborn one hour after delivery of placenta.
  • Use Assess the mother after delivery D21 and Examine the newborn J2-J8
  • Refer to hospital now if woman had serious complications at admission or during delivery but was in late labour.

D20. CARE OF THE MOTHER ONE HOUR AFTER DELIVERY OF PLACENTA

Use this chart for continuous care of the mother until discharge. See J10 for care of the baby.

MONITOR MOTHER AT 2, 3 AND 4 HOURS, THEN EVERY 4 HOURS:
  • For emergency signs, using rapid assessment (RAM) B4-B7.
  • Feel uterus if hard and round.
  • Record findings, treatments and procedures in Labour record and Partograph N4-N6.
  • Keep the mother and baby together.
  • Never leave the woman and newborn alone.
  • DO NOT discharge before 24 hours.
CARE OF MOTHERINTERVENTIONS, IF REQUIRED
  • Accompany the mother and baby to ward.
  • Advise on Postpartum care and hygiene D26.
  • Ensure the mother has sanitary napkins or clean material to collect vaginal blood.
  • Encourage the mother to eat, drink and rest.
  • Ensure the room is warm (25°C).
  • Make sure the woman has someone with her and they know when to call for help.
  • If HIV-infected: give her appropriate treatment G6, G9.
  • Ask the mother's companion to watch her and call for help if bleeding or pain increases, if mother feels dizzy or has severe headaches, visual disturbance or epigastric distress.
  • If heavy vaginal bleeding, palpate the uterus.

    If uterus not firm, massage the fundus to make it contract and expel any clots B6.

    If pad is soaked in less than 5 minutes, manage as on B5.

    If bleeding is from perineal tear, repair or refer to hospital B17.

  • Encourage the mother to empty her bladder and ensure that she has passed urine.
  • If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is uncomfortable, help her by gently pouring water on vulva.
DO NOT catheterize unless you have to.
  • Check record and give any treatment or prophylaxis which is due.
  • Advise the mother on postpartum care and nutrition D26.
  • Advise when to seek care D28.
  • Counsel on birth spacing and other family planning methods D27.
  • Repeat examination of the mother before discharge using Assess the mother after delivery D21. For baby, see J2-J8
  • If tubal ligation or IUD desired, make plans before discharge.
  • If mother is on antibiotics because of rupture of membranes >18 hours but shows no signs of infection now, discontinue antibiotics.

D21. ASSESS THE MOTHER AFTER DELIVERY

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. Use this chart to examine the mother the first time after delivery (at 1 hour after delivery or later) and for discharge. For examining the newborn use the chart on J2-J8.

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
  • Check record:

    bleeding more than 250 ml?

    completeness of placenta and membranes?

    complications during delivery or postpartum?

    special treatment needs?

    needs tubal ligation or IUD?

  • How are you feeling?
  • Do you have any pains?
  • Do you have any concerns?
  • How is your baby?
  • How do your breasts feel?
  • Measure temperature.
  • Feel the uterus. Is it hard and round?
  • Look for vaginal bleeding
  • Look at perineum.

    Is there a tear or cut?

    Is it red, swollen or draining pus?

  • Look for conjunctival pallor.
  • Look for palmar pallor.
  • Uterus hard.
  • Little bleeding.
  • No perineal problem.
  • No pallor.
  • No fever.
  • Blood pressure normal.
  • Pulse normal.
MOTHER WELL
  • Keep the mother at the facility for 24 hours after delivery.
  • Ensure preventive measures D25
  • Advise on postpartum care and hygiene D26.
  • Counsel on nutrition D26.
  • Counsel on birth spacing and family planning D27
  • Advise on when to seek care and next routine postpartum visit D28.
  • Reassess for discharge D21
  • Continue any treatments initiated earlier.
  • If tubal ligation desired, refer to hospital within 7 days of delivery. If IUD desired, refer to appropriate services within 48 hours.

Image childbirthfu1.jpgNext: Respond to problems immediately postpartum

If no problems, go to page D25.

D22-D24. RESPOND TO PROBLEMS IMMEDIATELY POSTPARTUM

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
IF VAGINAL BLEEDING
  • A pad is soaked in less than
  • 5 minutes
  • More than 1 pad soaked in 5 minutes
  • Uterus not hard and not round
HEAVY BLEEDING
  • See B5 for treatment.
  • Refer urgently to hospital B17.
IF FEVER (TEMPERATURE > 38°C)
  • Time since rupture of membranes
  • Abdominal pain
  • Chills
  • Repeat temperature measurement after 2 hours
  • If temperature is still >38ºC

    Look for abnormal vaginal discharge.

    Listen to fetal heart rate

    feel lower abdomen for tenderness

  • Temperature still >38°C and any of:

    Chills

    Foul-smelling vaginal discharge

    Low abdomen tenderness

    FHR remains >160 after

    30 minutes of observation

    rupture of membranes >18 hours

UTERINE AND FETAL INFECTION
  • Insert an IV line and give fluids rapidly B9.
  • Give appropriate IM/IV antibiotics B15.
  • If baby and placenta delivered:

    Give oxytocin 10 IU IM B10.

  • Refer woman urgently to hospital B17.
  • Assess the newborn J2-J8.
    Treat if any sign of infection.
  • Temperature still >38°C
RISK OF UTERINE AND FETAL INFECTION
  • Encourage woman to drink plenty of fluids.
  • Measure temperature every 4 hours.
  • If temperature persists for >12 hours, is very high or rises rapidly, give appropriate antibiotic and refer to hospital B15.
IF PERINEAL TEAR OR EPISIOTOMY (DONE FOR LIFESAVING CIRCUMSTANCES)
  • Is there bleeding from the tear or episiotomy
  • Does it extend to anus or rectum?
  • Tear extending to anus or rectum.
THIRD DEGREE TEAR
  • Refer woman urgently to hospital B15.
  • Perineal tear
  • Episiotomy
SMALL PERINEAL TEAR
  • If bleeding persists, repair the tear or episiotomy B12.

Image childbirthfu1.jpgNext: If elevated diastolic blood pressure

IF ELEVATED DIASTOLIC BLOOD PRESSURE

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
  • If diastolic blood pressure is ≥90 mmHg, repeat after 1 hour rest.
  • If diastolic blood pressure is still ≥90 mmHg, ask the woman if she has:

    severe headache

    blurred vision

    epigastric pain and

    check protein in urine.

  • Diastolic blood pressure ≥110 mmHg OR
  • Diastolic blood pressure ≥90 mmHg and 2+ proteinuria and any of:

    severe headache

    blurred vision

    epigastric pain.

SEVERE PRE-ECLAMPSIA
  • Give magnesium sulphate B13.
  • If in early labour or postpartum, refer urgently to hospital B17.
  • If late labour:

    continue magnesium sulphate treatment B13

    monitor blood pressure every hour.

    DO NOT give ergometrine after delivery.

  • Refer urgently to hospital after delivery B17.
  • Diastolic blood pressure 90-110 mmHg on two readings.
  • 2+ proteinuria (on admission).
PRE-ECLAMPSIA
  • If early labour, refer urgently to hospital E17.
  • If late labour:

    monitor blood pressure every hour

    DO NOT give ergometrine after delivery.

  • If BP remains elevated after delivery, refer to hospital E17.
  • Diastolic blood pressure ≥90 mmHg on 2 readings.
HYPERTENSION
  • Monitor blood pressure every hour.
  • Do not give ergometrine after delivery.
  • If blood pressure remains elevated after delivery, refer woman to hospital E17.

Image childbirthfu1.jpgNext: If pallor on screening, check for anaemia

ASK, CHECK RECORDLOOK, LISTEN, FEELSIGNSCLASSIFYTREAT AND ADVISE
IF PALLOR ON SCREENING, CHECK FOR ANAEMIA
  • Bleeding during labour, delivery or postpartum.
  • Measure haemoglobin, if possible.
  • Look for conjunctival pallor.
  • Look for palmar pallor. If pallor:

    Is it severe pallor?

    Some pallor?

    Count number of breaths in

    1 minute

  • Haemoglobin <7 g/dl. AND/OR
  • Severe palmar and conjunctival pallor or
  • Any pallor with >30 breaths per minute.
SEVERE ANAEMIA
  • If early labour or postpartum, refer urgently to hospital B17
  • If late labour:

    monitor intensively

    minimize blood loss

    refer urgently to hospital after delivery B17.

  • Any bleeding.
  • Haemoglobin 7-11 g/dl.
  • Palmar or conjunctival pallor.
MODERATE ANAEMIA
  • Check haemoglobin after 3 days.
  • Give double dose of iron for 3 months F3.
  • Follow up in 4 weeks.
  • Haemoglobin >11 g/dl
  • No pallor.
NO ANAEMIA
  • Give iron/folate for 3 months F3.
IF MOTHER SEVERELY ILL OR SEPARATED FROM THE BABY
  • Teach mother to express breast milk every 3 hours K5.
  • Help her to express breast milk if necessary. Ensure baby receives mother's milk K8.
  • Help her to establish or re-establish breastfeeding as soon as possible. See K2-K3.
IF BABY STILLBORN OR DEAD
  • Give supportive care:

    Inform the parents as soon as possible after the baby's death.

    Show the baby to the mother, give the baby to the mother to hold, where culturally appropriate.

    Offer the parents and family to be with the dead baby in privacy as long as they need.

    Discuss with them the events before the death and the possible causes of death.

  • Advise the mother on breast care K8.
  • Counsel on appropriate family planning method D27.

Image childbirthfu1.jpgNext: Give preventive measures

D25. GIVE PREVENTIVE MEASURES

Ensure that all are given before discharge.

ASSESS, CHECK RECORDSTREAT AND ADVISE
  • Check RPR status in records.
  • If no RPR during this pregnancy, do the RPR test L5.
  • If RPR positive:

    Treat woman and the partner with benzathine penicillin F6.

    Treat the newborn K12

  • Check tetanus toxoid (TT) immunization status.
  • Check when last dose of mebendazole was given.
  • Give tetanus toxoid if due F2.
  • Give mebendazole once in 6 months F3.
  • Check woman's supply of prescribed dose of iron/folate.
  • Give 3 month's supply of iron and counsel on adherence F2.
  • Vitamin A in postpartum women is not recommended for the prevention of maternal and infant morbidity and mortality.
  • Ask whether woman and baby are sleeping under insecticide treated bednet.
  • Counsel and advise all women.
  • Encourage sleeping under insecticide treated bednet F4.
  • Advise on postpartum care D26.
  • Counsel on nutrition D26.
  • Counsel on birth spacing and family planning D27.
  • Counsel on breastfeeding K2.
  • Counsel on safer sex including use of condoms G2.
  • Advise on routine and follow-up postpartum visits D28.
  • Advise on danger signs D28.
  • Discuss how to prepare for an emergency in postpartum D28.
  • Counsel of continued abstinence from tobacco, alcohol and drugs D26.
  • Record all treatments given N6.
  • Record findings on home-based record.
  • Check HIV status in records.
  • If HIV-infected:

    Support adherence to ARV G6.

    Treat the newborn G9

  • If HIV test not done, the result of the latest test not known or if tested HIV-negative in early pregnancy, offer her the rapid HIV test C6, E5, L6.

D26. ADVISE ON POSTPARTUM CARE

Advise on postpartum care and hygiene

  • Advise and explain to the woman:
  • To always have someone near her for the first 24 hours to respond to any change in her condition.
  • Not to insert anything into the vagina.
  • To have enough rest and sleep.
  • The importance of washing to prevent infection of the mother and her baby:

    wash hands before handling baby

    wash perineum daily and after faecal excretion

    change perineal pads every 4 to 6 hours, or more frequently if heavy lochia

    wash used pads or dispose of them safely

    wash the body daily.

  • To avoid sexual intercourse until the perineal wound heals.
  • To sleep with the baby under an insecticide-treated bednet.

Counsel on nutrition

  • Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong (give examples of types of food and how much to eat).
  • Reassure the mother that she can eat any normal foods – these will not harm the breastfeeding baby.
  • Spend more time on nutrition counselling with very thin women and adolescents.
  • Determine if there are important taboos about foods which are nutritionally healthy.
    Advise the woman against these taboos.
  • Talk to family members such as partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work.

Counsel on Substance Abuse

  • Advise the woman to continue abstinence from tobacco
  • Do not take any drugs or medications for tobacco cessation
  • Talk to family members such as partner and mother-in-law, to encourage them to help ensure the woman avoids second-hand smoke exposure
  • Alcohol
  • Drugs
  • Dependence

D27. COUNSEL ON BIRTH SPACING AND FAMILY PLANNING

Counsel on the importance of family planning

  • If appropriate, ask the woman if she would like her partner or another family member to be included in the counselling session.
  • Explain that after birth, if she has sex and is not exclusively breastfeeding, she can become pregnant as soon as 4 weeks after delivery. Therefore it is important to start thinking early about what family planning method they will use.

    Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 2 years before trying to become pregnant again is good for the mother and for the baby's health.

    Information on when to start a method after delivery will vary depending on whether a woman is breastfeeding or not.

    Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process).

  • Councel on safer sex including use of condoms for dual protection from sexually transmitted infection (STI) or HIV and pregnancy. Promote their use, especially if at risk for sexually transmitted infection (STI) or HIV G2.
  • For HIV-infected women, see G4 for family planning considerations
  • Her partner can decide to have a vasectomy (male sterilization) at any time.

Method options for the non-breastfeeding woman

Can be used immediately postpartumCondoms
Progestogen-only oral contraceptives
Progestogen-only injectables
Implant
Spermicide
Female sterilization (within 7 days or delay 6 weeks)
Copper IUD (immediately following expulsion of placenta or within 48 hours)
Delay 3 weeksCombined oral contraceptives
Combined injectables
Fertility awareness methods

Lactational amenorrhoea method (LAM)

  • A breastfeeding woman is protected from pregnancy only if:

    she is no more than 6 months postpartum, and

    she is breastfeeding exclusively (8 or more times a day, including at least once at night: no daytime feedings more than 4 hours apart and no night feedings more than 6 hours apart; no complementary foods or fluids), and

    her menstrual cycle has not returned.

  • A breastfeeding woman can also choose any other family planning method, either to use alone or together with LAM.

Method options for the breastfeeding woman

Can be used immediately postpartumLactational amenorrhoea method (LAM)
Condoms
Spermicide
Female sterilisation (within 7 days or delay 6 weeks)
Copper IUD (within 48 hours or delay 4 weeks)
Delay 6 weeksProgestogen-only oral contraceptives
Progestogen-only injectables
Implants
Diaphragm
Delay 6 monthsCombined oral contraceptives
Combined injectables
Fertility awareness methods

D28. ADVISE ON WHEN TO RETURN

Use this chart for advising on postnatal care after delivery in health facility on D21 or E2. For newborn babies see the schedule on K14. Encourage woman to bring her partner or family member to at least one visit.

Routine postnatal contacts

FIRST CONTACT: within 24 hours after childbirth.
SECOND CONTACT: on day 3 (48-72 hours)
THIRD CONTACT: between day 7 and 14 after birth.
FINAL POSTNATAL CONTACT (CLINIC VISIT): at 6 weeks after birth

Follow-up visits for problems

If the problem was:Return in:
Fever2 days
Lower urinary tract infection2 days
Perineal infection or pain2 days
Hypertension1 week
Urinary incontinence1 week
Severe anaemia2 weeks
Postpartum blues2 weeks
HIV-infected2 weeks
Moderate anaemia4 weeks
If treated in hospital for any complicationAccording to hospital instructions or according to national guidelines, but no later than in 2 weeks.

Advise on danger signs

Advise to go to a hospital or health centre immediately, day or night, WITHOUT WAITING, if any of the following signs:

  • vaginal bleeding:

    more than 2 or 3 pads soaked in 20-30 minutes after delivery OR

    bleeding increases rather than decreases after delivery.

  • convulsions.
  • fast or difficult breathing.
  • fever and too weak to get out of bed.
  • severe abdominal pain.
  • calf pain, redness or swelling, shortness of breath or chest pain.

Go to health centre as soon as possible if any of the following signs:

  • fever
  • abdominal pain
  • feels ill
  • breasts swollen, red or tender breasts, or sore nipple
  • urine dribbling or pain on micturition
  • pain in the perineum or draining pus
  • foul-smelling lochia
  • severe depression or suicidal behaviour (ideas or attempts)

Discuss how to prepare for an emergency in postpartum

  • Advise to always have someone near for at least 24 hours after delivery to respond to any change in condition.
  • Discuss with woman and her partner and family about emergency issues:

    where to go if danger signs

    how to reach the hospital

    costs involved

    family and community support.

  • Discuss home visits: in addition to the scheduled routine postnatal contacts, which can occur in clinics or at home, the mother and newborn may receive postnatal home visits by community health workers.
  • Advise the woman to ask for help from the community, if needed I1-I3.
  • Advise the woman to bring her home-based maternal record to the health centre, even for an emergency visit.

D29. HOME DELIVERY BY SKILLED ATTENDANT

Use these instructions if you are attending delivery at home.

Preparation for home delivery

  • Check emergency arrangements.
  • Keep emergency transport arrangements up-to-date.
  • Carry with you all essential drugs B17, records, and the delivery kit.
  • Ensure that the family prepares, as on C18.

Delivery care

  • Follow the labour and delivery procedures D2-D28 K11.
  • Observe universal precautions A4.
  • Give Supportive care. Involve the companion in care and support D6-D7.
  • Maintain the partograph and labour record N4-N6.
  • Provide newborn care J2-J8.
  • In settings with high neonatal mortality apply chlorhexidine to the umbilical stump daily for the first week of life.
  • Refer to facility as soon as possible if any abnormal finding in mother or baby B17 K14.

Immediate postpartum care of mother

  • Stay with the woman for first two hours after delivery of placenta C2 C13-C14.
  • Examine the mother before leaving her D21.
  • Advise on postpartum care, nutrition and family planning D26-D27.
  • Ensure that someone will stay with the mother for the first 24 hours.

Postnatal care of newborn

  • Stay until baby has had the first breastfeed and help the mother good positioning and attachment K3.
  • Advise on breastfeeding and breast care K2-K4.
  • Examine the baby before leaving J2-J8.
  • Immunize the baby if possible K13.
  • Advise on newborn care K9-K10 M6-M7.
  • Advise the family about danger signs and when and where to seek care K14.
  • If possible, return within a day to check the mother and baby.
  • Advise on the first postnatal contact for the mother and the baby which should be as early as possible within 24 hours of birth K14.

For both

  • Return after 24 hours and on day 3 after delivery.
  • Complete home-based record.
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