Integrated Maternal and Newborn Care Basic Skills Course ...

HEALTH INTEGRATED PROGRAMMING MATERNAL FOR AND 

REBUILDING NEWBORN CARE STATES 

A BASIC BRIEFING SKILLS PAPERCOURSE 

2009 

REFERENCE MANUAL

INTEGRATED MATERNAL AND 

NEWBORN CARE 

BASIC SKILLS COURSE 

2009 

REFERENCE MANUAL 

September 2009 

This publication was produced for review by the United States Agency for International Development. It 

was prepared by USAID/BASICS and POPPHI. 

The authors’ views expressed in this publication do not necessarily reflect the views of the United States 

Agency for International Development or the United States Government.

Reference Manual 

U.S. Agency for International Development 

Bureau for Global Health 

Office of Health, Infectious 

Diseases and Nutrition 

Ronald Reagan Building 

1300 Pennsylvania Ave., NW 

Washington, D.C. 20523 

Tel: (202) 712-0000 

Email: globalhealth@phnip.com 

www.usaid.gov/our_work/global_health 

Deborah Armbruster, Project Director 

-or- 

Susheela M. Engelbrecht, Sr. Program Officer 

POPPHI 

PATH 

1800 K St., NW, Suite 800 

Washington, DC 20006 

Tel: (202) 822.0033 

www.pphprevention.org 

Indira Narayanan, Sr. Technical Advisor, 

Newborn Health 

-or- 

Gladys Mazia, Technical Officer, 

Newborn Health 

USAID/BASICS 

4245 N. Fairfax Dr., Suite 850 

Arlington, VA 22203 

Tel: (703) 312-6800 

Fax: (703) 312-6900 

Email: basics@basics.org 

www.basics.org 

Support for this publication was provided by the USAID Bureau for Global Health. 

USAID/BASICS (Basic Support for Institutionalizing Child Survival) is a global project to assist developing 

countries in reducing infant and child mortality through the implementation of proven health interventions. 

BASICS is funded by the U.S. Agency for International Development (contract no. GHA-I-00-04-00002- 

00) and implemented by the Partnership for Child Health Care, Inc., comprised of the Academy for 

Educational Development, John Snow, Inc., and Management Sciences for Health. Subcontractors 

include the Manoff Group, Inc., the Program for Appropriate Technology in Health, and Save the Children 

Federation, Inc. 

The Prevention of Postpartum Hemorrhage Initiative (POPPHI) is a USAID-funded, five-year project 

focusing on the reduction of postpartum hemorrhage, the single most important cause of maternal deaths 

worldwide. The POPPHI project is led by PATH and includes four partners: RTI International, 

EngenderHealth, the International Federation of Gynaecology and Obstetrics (FIGO), and the 

International Confederation of Midwives (ICM). 

Integrated maternal and newborn care 

Basic skills course 

iii

Recommended Citation 

Basic Support for Institutionalizing Child Survival (BASICS) and the Prevention of Postpartum 

Hemorrhage Initiative (POPPHI). 2009. Integrated Maternal and Newborn Care Basics Skills Course: 

Reference Manual. Arlington, Va., USA: for the United States Agency for International Development 

(USAID). 

This publication is one in a series that make up the USAID/BASICS Newborn Health tool kit. The tool kit 

comprises: 

Facility Level Tools: 

• Reference Manual 

• Technical Presentations 

• Facilitator’s Guide 

• Participant’s Notebook 

• Clinical Logbook with Learning and Evaluation Checklists 

Community Level Tools: 

• Guide for Training Community Health Workers/Volunteers to Provide Maternal and Newborn 

Health Messages 

• Set of Counseling Cards 

iv 


Basic skills course


ACKNOWLEDGEMENTS 

Main Authors 

Indira Narayanan 

Sr. Technical Advisor, Newborn Health 

USAID/BASICS, USA 

Susheela Engelbrecht 

Sr. Program Officer 

USAID/POPPHI, PATH, USA 

Additional Contributing Authors 

USAID/BASICS Project 

Goldy Mazia 

Technical Officer, Newborn Health 


Gloria Ekpo 

Technical Officer, Pediatric HIV/AIDS 


USAID/POPPHI Project 

Deborah Armbruster 

Director 

USAID/POPPHI, PATH, USA 

Madagascar 

Jean Pierre Rakotovao 

Team Leader 

USAID/BASICS, Madagascar 

Julia Rasoaharimalala 

Physician, Department of Pediatrics 

Central Hospital for Mothers and Children 

Antananarivo 

Osé Andrianarivony 

Physician, Dept of Obstetrics 

Maternity Hospital, Befelatanana 

Antananarivo 

Senegal 

Haby Signate Sy 

Professor of Pediatrics 

Albert Royer Central University Hospital 

Dakar 

Saliou Diouf 

Professeur of Pediatrics 

Institute of Social Pediatrics 

University C.A. Diop 

Dakar 

Aboubacry Thiam 

Regional Advisor, Africa Region 

USAID/BASICS, Senegal 

Democratic Republic of Congo (DRC) 

Celestin N. Nsibu 

Pediatrician 

University of Kinshasa 

Delphin I. Muyila 

Pediatrician 

General Hospital, Kinshasa 

Lucie M. Zikudieka 

Coordinator, Newborn Health 

USAID/BASICS, DRC 

Kanza NSIMBA 

Team Leader 

USAID/BASICS, DRC 

Marie Claude Mbuyi 

Coordinator, Reproductive Health 

USAID/AXxes, DRC 

Michel Mpunga 

Focal Person, Newborn Health 

USAID/AXxes, DRC 

Editing and Formatting 

Charlotte Storti 

Consultant 


Paul Crystal 

Communications Manager 


Christa Peccianti 

Program Coordinator 




v

NOTE: 

Content on definitions, newborn resuscitation, and minor and major infections was adapted 

from Le Manuel de Référence–Sante du Nouveau-né. Ministère de Sante et USAID/BASICS, 

2005. 

All unidentified black and white illustrations were taken from: Engelbrecht, SM. Guide de la 

Matrone: Tome 2–La consultation postnatale. Editions Nanondiral: Dakar, Sénégal, 1998. 

vi 




TABLE OF CONTENTS 

INTRODUCTION ....................................................................................................................... 1 

Four Million Neonatal Deaths: Where do they occur?................................................................. 1 

Four Million Neonatal Deaths: What do babies die of?............................................................... 2 

Four Million Neonatal Deaths: When do they occur?.................................................................. 2 

CHAPTER 1: PREVENTING INFECTION ................................................................................. 4 

Principles of Infection Prevention ............................................................................................... 4 

Equipment and Supplies Related to Resuscitation ....................................................................22 

CHAPTER 2: CLINICAL DECISION-MAKING ........................................................................ 23 

The Problem-Solving Method....................................................................................................23 

Documentation of Care .............................................................................................................26 

CHAPTER 3: MATERNAL CARE TO IMPROVE MATERNAL AND NEWBORN SURVIVAL..29 

Every Pregnancy is “At Risk”.....................................................................................................29 

Maternal Conditions Affecting Fetal and Newborn Survival .......................................................30 

Antenatal Care..........................................................................................................................33 

Delays Resulting in Maternal and Newborn Deaths ..................................................................40 

Birth-Preparedness Plan ...........................................................................................................40 

Complication-Readiness Plan ...................................................................................................42 

CHAPTER 4: PREVENTING POSTPARTUM HEMORRHAGE............................................... 44 

Causes of Postpartum Hemorrhage..........................................................................................44 

PPH Prevention and Early Detection.........................................................................................45 

CHAPTER 5: ROUTINE CARE DURING THE THIRD STAGE OF LABOR .......................... ..48 

Preparation for the Birth............................................................................................................48 

Essential Newborn Care ...........................................................................................................55 

Care During the Third Stage of Labor .......................................................................................62 

CHAPTER 6: MONITORING THE WOMAN AND NEWBORN DURING THE FIRST SIX 

HOURS POSTPARTUM ……………………………………………………………………………….77 

Monitoring the Woman..............................................................................................................77 

Monitoring the Newborn ............................................................................................................80 

CHAPTER 7: ROUTINE POSTPARTUM CARE FOR THE WOMAN ...................................... 83 

Male Involvement......................................................................................................................83 

Postpartum Care.......................................................................................................................84 

CHAPTER 8: RESUSCITATION FOR BIRTH ASPHYXIA ...................................................... 93 

Causes of Birth Asphyxia ..........................................................................................................94 

Preparation for Resuscitation....................................................................................................94 

Steps in Newborn Resuscitation ...............................................................................................99 

Post-Resuscitation Care .........................................................................................................104 



vii

CHAPTER 9: BASIC SYSTEMATIC EXAMINATION OF A NEWBORN AT PERIPHERAL 

CENTERS……………………………………………………………………………………………. . 109 

Preparing for the Examination.................................................................................................109 

Carrying out the Exam ............................................................................................................110 

CHAPTER 10: POSTNATAL CARE OF THE NEWBORN, AT THE FACILITY AND DURING 

POSTNATAL VISITS ……………………………………………………………………………….. 116 

Timing of Most Neonatal Deaths .............................................................................................116 

Components of Postnatal Care ...............................................................................................116 

CHAPTER 11: DIAGNOSING AND TREATING BREASTFEEDING PROBLEMS................ 126 

Common problems..................................................................................................................126 

Prevention and Treatment.......................................................................................................126 

Expressing and Feeding Breast Milk .......................................................................................132 

CHAPTER 12: CARE OF THE LOW BIRTH WEIGHT BABY, INCLUDING KANGAROO 

MOTHER CARE ...............................................................................................................…..137 

Factors Associated with Low Birth Weight...............................................................................137 

Preventing Low Birth Weight...................................................................................................137 

Care of Low Birth Weight Babies ............................................................................................141 

Discharge of the Low Birth Weight Baby .................................................................................147 

CHAPTER 13: TREATMENT OF INFECTIONS IN THE NEWBORN .................................... 149 

The Timing of Infections..........................................................................................................149 

Types of Neonatal Infection.....................................................................................................150 

Identifying and Treating Major Infections.................................................................................151 

Identifying and Treating Minor Infections.................................................................................154 

APPENDIX A: Selection and Storage of Uterotonic Drugs.................................................158 

APPENDIX B: Alternative Assessment/Physical Examination of the Newborn at More 

Established Peripheral Centers ...........................................................................................163 

APPENDIX C: Glossary.........................................................................................................168 

REFERENCES .......................................................................................................................171 

viii 




List of Figures 

Intro. 1 Where do newborns die? p. 1 

Intro. 2 What do newborns die of? p. 2 

Intro. 3 When do newborns die? p. 3 

1.1 Hand washing p. 6 

1.2 Hand rubbing p. 8 

1.3 Putting gloves on p. 10 

1.4 Taking gloves off p. 10 

1.5 One-hand technique for needle recapping p. 12 

1.6 Sharps containers p. 13 

1.7 0.5% chlorine solution p. 17 

2.1 Clinical decision making algorithm p. 28 

3.1 Signs of iron-deficiency anemia p. 30 

5.1 Positions that a woman may adopt during labor p. 51 

5.2 The modified WHO partograph p. 52 

5.3 Positions that a woman may adopt during childbirth p. 53 

5.4 Initial steps in the care of the baby at birth p. 55 

5.5 Two measures to prevent thermal loss at the time of birth p. 56 

5.6 Use of a pre-sterilized disposable cord clamp p. 57 

5.7 Signs of proper attachment at the breast p. 59 

5.8 Preparing oxytocin injection p. 66 

5.9 Put the baby on the mother’s abdomen p. 66 

5.10 Rule out the presence of a second baby p. 67 

5.11 Give a uterotonic drug p. 67 

5.12 Pulsating and nonpulsating umbilical cord p. 67 

5.13 Keep the baby in skin-to-skin contact p. 68 

5.14 Clamping the umbilical cord near the perineum p. 69 

5.15 Palpate the next contraction p. 69 

5.16 Applying CCT with countertraction to support the uterus p. 70 

5.17 Supporting the placenta with both hands p. 70 

5.18 Delivering the placenta with a turning and up-and-down motion p. 71 

5.19 Massaging the uterus immediately after the placenta delivers p. 71 

5.20 Teach the woman how to massage her own uterus p. 72 

5.21 Examining the maternal side of the placenta p. 72 

5.22 Checking the membranes p. 73 

5.23 Gently inspect the lower vagina and perineum for lacerations p. 73 

5.24 Encourage breastfeeding within the first hour after birth p. 74 

7.1 Routine postpartum physical, obstetrical, and gynecological exam p. 84 

8.1 A warming table p. 95 

8.2 De Lee mucous aspirator p. 96 

8.3 Self-inflating bag and mask for ventilation of babies p. 97 

8.4 Sample list of equipment for newborn resuscitation p. 98 

8.5 Correct positioning p. 100 

8.6 Methods for stimulating the baby p. 101 

8.7 Correct positioning of the mask and formation of a good seal p. 102 

8.8 Giving supplemental oxygen p. 103 

8.9 Algorithm for resuscitation for birth asphyxia p. 107 

8.10 Algorithm for integration of AMTSL, ENC and resuscitation for birth 

asphyxia 

p. 108 



ix

List of Figures (cont.) 

11.1 Two positions for breastfeeding p. 127 

11.2 Preparing and using a syringe for treatment of inverted nipples p. 132 

11.3 Anatomy of the breast p. 133 

11.4 How to express breast milk p. 134 

11.5 Three methods of feeding p. 135 

12.1 Basic evaluation of LBW babies to determine need for referral p. 140 

12.2 The kangaroo with the baby in the pouch p. 142 

12.3 Kangaroo mother care p. 143 

12.4 How to dress the baby for kangaroo care p. 144 

12.5 Photo example of kangaroo mother care p. 144 

12.6 The mother, father, or another family member may keep the baby on the p. 146 

chest 

12.7 Key components of care of the LBW infant p. 147 

12.8 Algorithm for care of the LBW baby p. 148 

Appendix C.1 Newborn periods p. 169 

List of Tables 

Table 1 Mixing a 0.5% chlorine decontamination solution p. 19 

Table 2 Steps in the problem-solving method p. 23 

Table 3 Timing of SP dose p. 34 

Table 4 Schedule for giving tetanus toxoid p. 36 

Table 5 Key steps for immediate care of the newborn p. 61 

Table 6 Comparison of physiologic and active management of the third stage of p. 64 

labor 

Table 7 Bristol and Hinchingbrooke study results comparing active and 

p. 65 

physiologic management of the third stage of labor 

Table 8 Monitoring of the baby in the first six hours after birth p. 81 

Table 9 Schedule for routine postpartum visits p. 84 

Table 10 Guidelines for identifying danger signs at peripheral centers p. 112 

Table 11 Key steps in examining the newborn at a peripheral center p. 115 

Table 12 Suggested timings of postnatal visits p. 123 

Table 13 Care of the newborn during the 4-6 weeks after birth p. 124 

Table 14 Summary of Postnatal Evaluation and Care of the Baby p. 125 

Table 15 Complications in low birth weight and preterm babies p. 139 

Table 16 Practical guidelines for identifying and treating major infections at 

p. 152 

peripheral centers 

Table 17 Summary of treatment of minor infections p. 157 

Table A1 Uterotonic drugs for AMTSL p. 159 

Table A2 Change in effectiveness of injectable uterotonic drugs after one year of p. 160 

controlled storage 

Table A3 Recommended guidelines for transport and storage of uterotonic drugs p. 161 

x 




About the Learning Materials 

This learning package for integrated maternal and newborn care consists of a reference 

manual, a series of technical presentations, a participant’s notebook, a facilitator’s guide, and a 

clinical logbook. This learning package was developed for use by nurses, midwives, and doctors 

providing childbirth and immediate postpartum care for the woman and newborn in peripheral 

health care facilities. 

These documents comprise a set and should be used together. 

Facility Level Tools 

• The Reference Manual contains the theoretical content for the training course. It is 

intended to serve as the “textbook” or reference for participants and facilitators. 

• The series of Technical Presentations contains PowerPoint slides of the different 

sessions. This will help in having more uniform training sessions and, along with the 

checklists, provide the key elements of each topic for easier learning. 

• The Facilitator’s Guide includes lesson plans, knowledge evaluation tests (pre-test, 

mid-course test, and post-test) and their suggested answers, answers for learning 

exercises, and guidelines for conducting a clinical training program. 

• The Participant’s Notebook assists participants throughout the training program. The 

notebook has the following components: overview of and agenda for the training 

program, learning objectives, learning exercises, and additional printed materials. 

• The Clinical Logbook contains learning/practice guides or checklists and checklists for 

evaluating competencies, a logbook for clinical experiences, and a guide for the clinical 

practicum. Note: The checklists for evaluating competencies are also available as a 

separate document to be used after training during follow-up supervision. 

Community Level Tools 

• Guide for Training Community Health Workers/Volunteers to Provide Maternal and 

Newborn Health Messages. 

• A set of counseling cards 



xi

The above resources are distinguished within the series by an identifying icon located on the top 

of the odd-numbered pages: 


Technical Presentations 

✚ 

Facilitator’s Guide 

Participant’s Notebook 

Clinical Logbook 

Guide for Training Community Health 

Workers/Volunteers to Provide Maternal and 

Newborn Health Messages 

xii 




List of Abbreviations 

AFASS 

AMTSL 

ANC 

ARV 

BP 

CCT 

CHW 

CMV 

CPT 

DIC 

EBM 

ENC 

FH 

FP 

FIGO 

Hb 

HLD 

HIV 

ICM 

IM 

IMCI 

IPTp 

IPTI 

ITN 

IU 

IUD 

IUGR 

IV 

LAM 

LBW 

MNH 

MTCT 

PMTCT 

POPPHI 

PPC 

acceptable, feasible, affordable, sustainable, and safe 

active management of the third stage of labor 

antenatal care 

antiretroviral 

blood pressure 

controlled cord traction 

community health worker 

cytomegalovirus 

cotrimoxazole prophylaxis therapy 

disseminated intravascular coagulopathy 

expressed breast milk 

essential newborn care 

fundal height 

family planning 

International Federation of Gynecology and Obstetrics 

hemoglobin 

high-level disinfection 

human immunodeficiency virus 

International Confederation of Midwives 

intramuscular 

integrated management of childhood illnesses 

intermittent preventive treatment in pregnancy 

intermittent preventive treatment in infants 

Insecticide-treated bednets 

international unit 

intrauterine device 

intrauterine growth retardation 

intravenous 

lactational amenorrhea method (for family planning) 

low birth weight 

maternal neonatal health 

mother-to-child transmission of HIV/AIDS 

prevention of mother-to-child transmission of HIV/AIDS 

postpartum hemorrhage prevention initiative 

postpartum care 



xiii

PPH 

PPPH 

PROM 

RAM 

RPR 

SP 

STI 

TSL 

TT 

USAID 

UTI 

VDRL 

VVM 

WHO 

postpartum hemorrhage 

prevention of postpartum hemorrhage 

premature rupture of membranes 

rapid assessment and management 

Reactive Plasma Reagin 

sulfadoxine-pyrimethamine 

sexually transmitted infections 

third stage of labor 

tetanus toxoid 

United States Agency for International Development 

urinary tract infection 

Venereal Disease Research Laboratory 

vaccine vial monitor 

World Health Organization 

xiv 




INTRODUCTION 

While there has been a significant decrease in the mortality of children over the years, it has 

occurred mostly among infants and in children from one to five years of age. The mortality in the 

short but critical neonatal period (the first four weeks) still remains high and has not followed the 

same declining trend. Globally, an estimated four million deaths occur in these four weeks, with 

a similar number of stillbirths. During the past decade, a considerable amount of interest has 

been focused on newborns, with increased advocacy in this area leading to a number of 

operational research projects and programs. 

FOUR MILLION NEONATAL DEATHS: WHERE DO THEY OCCUR? 

4 Million Deaths: 

Where do newborn babies die? 

1.1 million (28% of all 

newborn deaths) 

occur in Sub Saharan 

Africa 

1.5 million (38% of all 

newborn deaths) 

occur in 4 countries 

of South Asia 

Lancet series, 2005 

99% of newborn deaths are in low/middle income countries 4 

66% in Sub Saharan Africa and South Asia 

Figure Intro. 1. Where do newborns die? 

Reprinted with permission from Elsevier (The Lancet, 2005, Vol 365, pg. 13) 



1

FOUR MILLION NEONATAL DEATHS: WHAT DO BABIES DIE OF? 

The major causes of death in the neonatal period are shown in Figure Intro. 2 and include 

infections, birth asphyxia, and prematurity. 

Causes of Neonatal Mortality 

Others 9% 

Congenital malformations 

7% 

Diarrhea 3% 

Neonatal tetanus 

3% 

Prematurity 

31% 

Neonatal Infections 

25% 

Birth asphyxia/trauma 

23% 

Source: WHO. The Global Burden of Disease: 2004 update. WHO, Geneva, 2008 

Figure Intro. 2. What do newborns die of? 

Among premature newborns, many die of complications of prematurity rather than of 

prematurity itself. In low-resource developing countries, infections are the most common 

complication and cause of death. Preventing infections, therefore, is a key strategy to reducing 

neonatal mortality in these countries. 

FOUR MILLION NEONATAL DEATHS: WHEN DO THEY OCCUR? 

As short as the neonatal period is, covering only the first four weeks of life, it is the most critical; 

indeed, 75 percent of all neonatal deaths take place in the first week and 50 percent within 24 

hours after birth. The postpartum/postnatal period, especially the early phase, is also the most 

neglected part of the pregnancy, delivery, and postpartum continuum of care. In short, 

newborns are least likely to receive care during the period when they are at the greatest risk of 

dying. 

2 




4 Million Newborn Deaths: 

When do newborn babies die? 

Up to 50% 

of neonatal 

deaths are in 

the first 24 hours 

75% of neonatal 

deaths are in 

the first week – 

3 million deaths 

Time 

when most babies die is 

when coverage of 

quality care is lowest 

5 

Figure Intro. 3. When do newborns die? 

Adapted with permission from Elsevier (The Lancet, 2005, Vol 365, pg. 13) 

Strategies to improve newborn health need to address policy issues, the supply side of health 

system strengthening, and the demand side at home and in the community to improve family 

behaviors. Current pre-service training for doctors, nurses, and midwives in essential newborn 

care has often been inadequate and at times inappropriate, so that health workers upon 

completion of their undergraduate course often lack basic skills in this area, including prevention 

and treatment of infections and birth asphyxia. Continuing education programs in newborn care 

are therefore essential to improving health worker skills. Still other support is needed to improve 

supervision and to provide and maintain basic equipment and supplies. 

Since the health and survival of the newborn are closely tied to that of the mother, it is important 

to integrate maternal and newborn health care into training programs wherever possible. 

Although it is not feasible to integrate all aspects of maternal and newborn care, this set of 

materials links selected aspects, including active management of the third stage of labor with 

care of the baby at birth, resuscitation for birth asphyxia, postnatal care of the mother and the 

baby, basic examination of the baby, care of the low birth weight infant, and prevention and 

treatment of major and minor infections. 



3

CHAPTER 1: Preventing Infection 1 

PRINCIPLES OF INFECTION PREVENTION 

Infection prevention practices are based on the following five principles/actions: 

• Every person (client or staff) is considered potentially infectious. 

• Hand washing is the single most important practice for preventing crosscontamination. 

• Wear gloves before touching: 

o anything wet: broken skin, mucous membranes, blood, or other body fluids. 

o when there is a special risk of transmitting infection to or from the client. 

• Use protective gear (aprons, face masks, eye goggles, and caps) when splashes 

or spills of body fluids are expected. 

• Use safe work practices (e.g., do not recap or bend needles), following 

guidelines for handling and cleaning instruments and disposal of sharps and 

medical waste. 

Hand Washing 

Hand washing significantly reduces the number of potentially infection-causing organisms on 

health workers’ hands and decreases the incidence of client sickness and death due to clinicacquired 

infections. It also protects the health worker from contact with blood and other body 

fluids. 

Wash hands on the following occasions: 

• Immediately when you arrive at work. 

• Before examining each client (mother or baby). 

• After examining each client (mother or baby). 

• Before putting on gloves for clinical procedures (such as a pelvic exam or an IUD 

insertion). 

• After touching any instrument or object that might be contaminated with blood or other 

body fluids, or after touching mucous membranes. 

• After removing any kind of gloves (hands can become contaminated if gloves contain 

tiny holes or tears). 

• After using the toilet or latrine. 

• Before leaving work. 

1 This section provides guidelines on infection prevention practices to use when providing maternal and 

newborn services and is mainly adapted from materials developed by JHPIEGO, EngenderHealth, and 

WHO. 

4 




Materials required for hand washing include: 

• clean running water 

• liquid soap (preferably in a receptacle fixed to the wall) or small pieces of soap, ideally 

used only once. Where feasible, liquid antiseptic soap would be better for places such as 

the delivery room and operation theater. 

• sink or bowls 

• veronica bucket (bucket with a tap) 

• individual towels 

The steps in hand washing are: 

1. Remove watches, bracelets, and rings. 

2. Nails should be short and without nail polish; artificial nails should not be worn. 

3. Wet hands with running water. 

4. Rub hands together with soap and lather well up to the elbows, covering all surfaces for 

15-30 seconds. When attending deliveries, carrying out procedures, and where the 

hands are visibly soiled, wash longer, for about two minutes. 

5. Weave fingers and thumbs together and slide them back and forth, taking care to rub 

well between the fingers and the back of the hand. 

6. Rinse hands under a stream of clean, running water until all soap is gone. 

7. If there is no running water, hands should not be dipped inside the bowl of water; 

instead, the water should be poured over the hands from another container. 

8. Blot hands dry with a clean, dry towel or air-dry them; air-drying is the best, especially 

when sterile gloves have to be worn. 

These steps are illustrated in Figure 1.1. 



5

Figure 1.1. Hand washing. 

(WHO Guidelines on Hand Hygiene, 2006). 

6 




The Hand Rub 

When hand washing is not possible, use of the hand rub is recommended. But so long as 

running water is available, the hand rub should not be used as a substitute for attending 

deliveries or when the hands are visibly soiled. The materials required are alcohol and a 

glycerine solution. The steps in hand rubbing are: 

1. Add 2 mL of glycerine, propylene glycol, or sorbitol to 100 mL of 60-90% alcohol. 

2. Pour about 1 teaspoon of the rub in the palm of the hand. 

3. Rub hands together, including in between the fingers and under the nails, until dry. 

4. Wash hands with soap and water after using the hand rub 5 times. 

The technique using the alcohol-based formulation is shown in Figure 1.2. 



7

Figure 1.2. Use of alcohol-based rub for hand hygiene. 

(WHO Guidelines on Hand Hygiene, 2006.) 

8 




Use of Gloves 

Gloves protect the client from contact with micro-organisms on the health worker’s hands and 

the health worker from contact with blood and other body fluids. 

Three types of gloves are commonly used: 

• Examination gloves (for contact with skin and intact mucous membranes and 

wherever there is risk of exposure for the health worker) 

• Sterile/disposable surgical gloves (for contact with tissues under the skin or with the 

bloodstream, and preferably for conducting deliveries) 

• Utility or heavy-duty household gloves, reusable after cleaning (for handling dirty linen, 

instruments, and waste, for housekeeping and cleaning contaminated surfaces) 

Wear gloves when: 

• performing a procedure. 

• there will be contact with intact mucous membranes. 

• there will be contact with the tissues under the skin or with the bloodstream. 

• handling soiled items (e.g., instruments and gloves). 

• disposing of contaminated waste. 

When gloves are required, a separate pair of gloves must be used with each woman or baby to 

avoid cross-contamination. Disposable gloves are preferred, but when resources are limited, 

surgical gloves can be reused if they are: 

• decontaminated by soaking in 0.5% chlorine for 10 minutes. 

• washed and rinsed. 

• sterilized by autoclaving or high-level disinfected by boiling or steaming. 

Single-use or disposable surgical gloves should not be reused more than three times, even after 

the above steps, because invisible tears may occur. 

Note: Do not use gloves that are cracked, peeling, visibly torn, or 

that contain holes. 



9

Putting gloves on 

Follow the steps below in putting gloves on. 

Step 1. Preparation for putting on surgical gloves. “Gloves are cuffed to make it easier to put 

them on without contaminating them. When putting on sterile gloves, remember that the first 

glove should be picked up by the cuff only (see drawing below). The second glove should then 

be touched only by the other sterile glove.” Follow steps 2-6 as illustrated below. 

Figure 1.3. Putting gloves on. (EngenderHealth, online course: 

http://www.engenderhealth.org/ip/surgical/sum4.html) 

Step 7. “Adjust the glove fingers until the glove fits comfortably.” 

Taking gloves off 

Figure 1.4. Taking gloves off. (EngenderHealth, online course: 

http://www.engenderhealth.org/ip/surgical/sum4.htm) 

Additional Protective Clothing 

Other kinds of protective clothing are listed and discussed below: 

• coats/gowns 

• waterproof aprons 

• masks 

• caps 

• eye covers/face shields 

• boots/slippers 

10 




Gowns and waterproof aprons protect clients against micro-organisms and protect the 

provider’s skin and clothes from contact with blood and other fluids. 

• Always wear a clean, preferably sterile gown during delivery. 

• If the gown has long sleeves, place gloves over the gown sleeve to avoid contaminating 

the gloves. 

• Ensure that gloved hands are held high above the level of the waist and do not come 

into contact with the gown. 

Masks protect clients against micro-organisms expelled during talking, coughing, and 

breathing, provided they are worn and used correctly, covering the mouth and nose. 

They also protect the provider’s nose and mouth from splashes of blood and other fluids. 

Caps protect clients against micro-organisms in hair and skin shed from the provider's 

head. No protection has been documented for providers. 

Eye covers/face shields protect the provider’s eyes from splashes of blood and other 

fluids. No protection has been documented for clients. 

Changing slippers at entry into the delivery room prevents bringing in the dirt from 

outside. 

Treatment of Soiled Linen 

Correct handling of linen prevents the spread of infections to hospital personnel who transport, 

sort, and clean the linen. It also prevents accidental injuries to hospital personnel who transport, 

sort, and clean the linen. Linen for delivery rooms, surgery, and neonatal units should be 

sterilized. 

The materials required to treat soiled linen include: 

• utility gloves 

• heavy duty plastic bags or buckets with covers 

• detergent 

• water 

• a washing machine (ideal and far better than washing by hand) 

No additional precautions (e.g., pre-rinsing, labelling, separating, or double bagging) are 

necessary, regardless of the patient diagnosis, if standard precautions are used in all situations. 

The guidelines for treating soiled linen are as follows: 

• Housekeeping and laundry personnel should wear gloves and other personal protective 

equipment as indicated when collecting, handling, transporting, sorting, and washing 

soiled linen. 

• When collecting and transporting soiled linen, handle it as little as possible and with 

minimum contact to avoid accidental injury and spreading of micro-organisms. 

• Consider all cloth items (e.g., surgical drapes, gowns, wrappers) used during a 

procedure as infectious; even if there is no visible contamination, the item must be 

laundered. 



11

• Carry soiled linen in covered containers or plastic bags to prevent spills and splashes, 

and confine the soiled linen to designated areas (an interim storage area) until 

transported to the laundry. 

• Carefully sort all linen in the laundry area before washing. Do not presort or wash linen 

at the point of use. 

• Pre-soak heavily soiled linen in soap, water, and bleach; wash separately from nonsoiled 

linen. 

• Hand- or machine-wash (the latter is preferred). 

• Air- or machine-dry completely (latter preferred). If air-drying, keep linen off the ground 

and away from animals and dirt. 

• Sterilize linen for delivery rooms, operation theaters, and neonatal units by autoclaving 

that avoids burning. The linens should be in packs of not more than 5 kg; they may be in 

suitable drums. 

• After autoclaving, store in a clean, dry, preferably closed storage area. 

Handling Sharp Instruments 

Careful handling of “sharps” protects the client, health worker, and housekeeping staff from 

accidental injuries and exposure to blood and body fluids. Guidelines: 

• Do not leave sharp instruments or needles (“sharps”) in places other than “safe” zones. 

• Use a tray or basin to carry and pass sharp items. 

• Pass instruments with the handle (not the sharp end) pointing toward the receiver. 

• Warn others before passing sharps. 

Needles and syringes 

Follow these guidelines to ensure safe handling of needles and 

syringes: 

• Use each needle and syringe only once. 

• Do not take the needle and syringe apart after use. 

• Do not recap, bend, or break needles before disposal. 

• Dispose of needles and syringes in a puncture-proof 

container. 

It is not recommended to recap needles. Where it is 

unavoidable, as in a situation where the needle cannot be 

placed in an appropriate, safe receptacle for “sharps,” then 

recap the needle, using the “one-hand technique” for recapping 

(Figure 1.5). 

Step 1: Place the cap on a hard, flat surface. 

Step 2: Hold the syringe with one hand and use the needle to 

“scoop up” the cap. 

Step 3: When the cap covers the needle completely, hold the 

base of the needle and use the other hand to make sure the cap 

is firmly in place. 

Figure 1.5. One-hand technique for 

needle recapping. (WHO and 

CDC, 2007) 

12 




Dispose of hypodermic needles and other sharps properly in a puncture-proof (heavy 

cardboard, glass, metal, or thick plastic) container (sharps container shown below). 

Figure 1.6. Sharps containers 

Make hypodermic needles unusable by burning them or, when the above container is ¾ full, 

seal the opening and burn the container or fill the container with decontaminating solution, seal 

the opening, and bury the container. 

Preventing Splashes 

Wear appropriate protective goggles, gloves, and gown during delivery. Preventing splashes 

protects the client, health worker, and housekeeping staff from accidental injuries and exposure 

to blood and body fluids. 

Prevent splashes from blood or amniotic fluid by following these guidelines: 

• Avoid snapping the gloves when removing them, as this may cause contaminants to 

splash into the eyes, mouth, or onto the skin or on others. 

• Hold instruments and other items under the surface of the water while scrubbing and 

cleaning to avoid splashing. 

• Place items gently into the decontamination bucket to avoid splashes. 

• Avoid rupturing membranes during a uterine contraction. 

• Stand to the side when rupturing membranes to avoid splashes from amniotic fluid. 

• Cut the cord, using sterile scissors or a scalpel blade, under cover of a gauze swab to 

prevent blood spurting. 

• Always wear gloves when handling the placenta and handle it carefully. Keep it in a leakproof 

plastic bag or other container until it can be disposed of by burning or burying. The 

placenta should not be disposed of in a river or open garbage pit. 

Note: If blood or body fluids get in the mouth or on the skin, wash 

liberally with soap and water as soon as it is safe for the woman 

and baby. If blood or body fluids splash in your eyes, wash out 

well with water. 

The Steps of Processing Instruments 

Proper processing involves several steps that reduce the risk of transmitting infections from 

used instruments and other items to health care workers and clients. These steps are: 

1) decontamination, 2) cleaning, 3) either sterilization or high-level disinfection (HLD), and 

4) storage. For proper processing, it is essential to perform the steps in the correct order. 

1. Decontamination kills viruses (hepatitis B and C, HCV, HIV) and many other germs. It 

makes items safer to handle during cleaning and easier to clean (hence, decontamination 

should always be done before cleaning). 



13

The materials needed for decontamination are: 

• clean water 

• chlorine solution/chlorine tablets/chlorine powder 

• buckets with covers 

• measuring cups 

• a clock or timer 

The four steps of decontamination are: 

1) Fully immerse instruments and reusable gloves in 0.5% chlorine solution after use. 

(Details of preparation of this solution are noted below.) 

2) Soak for 10 minutes and rinse immediately. 

3) Change the solution every day or earlier if it is dirty or cloudy. 

4) Wipe surfaces (exam tables) and spills with chlorine solution. 

2. Cleaning removes blood, other body fluids, tissue, and dirt. It also reduces the number of 

germs and makes sterilization or HLD more effective. If a blood clot remains on an instrument, 

germs in the clot may not be completely killed by sterilization or HLD. 

The materials needed for cleaning are: 

• detergent 

• buckets or basins 

• water 

• toothbrush/brush 

• utility gloves 

The steps of cleaning are: 

1) Wear utility gloves, a mask, and protective eyewear when cleaning instruments and other 

items. 

2) Using a soft brush, detergent, and water, scrub instruments and other items vigorously 

to completely remove all blood, other body fluids, tissue, and other foreign matter. Hold 

instruments and other items under the surface of the water while scrubbing and cleaning 

to avoid splashing. Disassemble instruments and other items with multiple parts, and be 

sure to brush in the grooves, “teeth,” and joints of items where organic material can 

collect and stick. 

3) Rinse items thoroughly with clean water to remove all detergent. Any detergent left on 

the items can reduce the effectiveness of further chemical processing. 

4) Allow items to air-dry (or dry them with a clean towel). 

Note: Instruments that will be further processed with chemical solutions 

must dry completely to avoid diluting the chemicals; items that will be 

boiled or steamed do not need to be dried first. 

3A. High-level disinfection (HLD) kills viruses (hepatitis B and C, HCV, HIV) and many other 

germs, but does not reliably kill all bacterial endospores. It is the only acceptable alternative 

when sterilization is not available. 

14 




The materials needed for HLD include: 

• a pot with a lid 


• a steamer used for HLD 

• disinfectant 

• boiled water 

Three methods of high-level disinfection are described below: 

Boiling: 

• Immerse items fully in water, cover with a lid, and boil for 20 minutes (sufficient up to a 

height of 5500 meters/18,000 feet). 

• Start timing when the water begins to boil. Do not add anything to the pot after timing 

begins. 

• Drain off the water and keep covered before use or storage. Store for one week 

maximum. 

Steaming: 

• Steam instruments, gloves, and other items on the steaming tray for 20 minutes. 

• Be sure there is enough water in the bottom pan for the entire steam cycle. 

• Bring water to a rolling boil. Start timing when the steam begins to come out from under 

the lid. Do not add anything to the pan after timing starts. 

• Drain off the water and store in covered steamer pans. Store for one week maximum. 

Chemical HLD: 

• Sterilants used include 2.65% glutaraldehyde and hypochlorite/chlorine preparations 

noted below in this chapter. 

• Cover all items completely with disinfectant. 

• Soak for 20 minutes. 

• Rinse with boiled water. 

• Air-dry before use and storage. 

3B. Sterilization kills all germs, including endospores, but is not possible in all settings. 

The materials required are: 

• an autoclave 

• an oven 

• chemical or mechanical indicators 

• chemical products (e.g., glutaraldehyde) 

• wraps/drums for autoclaving 

• an autoclave tape 

• sterile pickups 


Sterilization can be done by dry (oven) or wet heat (autoclave), depending on the materials and 

supplies to be sterilized. For example, glass items can be kept in the hot air oven, but some 

items, such as those made of rubber and cloth, need to be autoclaved. 



15

Steam sterilization (autoclave): 

• 121 °C (250 °F); 106 kPa (15 lbs/in 2 ) pressure: 20 minutes for unwrapped items, 30 

minutes for wrapped items. 

• Decontaminate, clean, and dry items before sterilization. 

• Allow the pressure to drop to “zero” before opening the autoclave. 

• Allow items to dry before removing. 

Dry-heat (oven): 170 °C (340 °F) for 1 hour or 160 °C (320 °F) for 2 hours. 

Chemical sterilization: 

• Soak items in glutaraldehyde for 8 to10 hours or formaldehyde for 24 hours. 

• Rinse with sterile water. 

4. Storage/Usage. If items are stored properly they will not become contaminated after 

processing. Proper storage is as important as proper processing. Items processed through the 

first three steps can be stored up to one week in an HLD/sterilized container. 

Making a Chlorine Decontamination Solution 

The ability to decontaminate instruments is a critical step in preventing infection. The most 

common decontamination process is to soak instruments in a 0.5% chlorine solution for 10 

minutes. Chlorine solutions made from sodium hypochlorite are usually the most inexpensive, 

fast-acting, and effective for decontamination. A chlorine solution can be made from: 

• liquid household bleach (sodium hypochlorite) 

• bleach powder or chlorine compounds available in powder form (calcium hypochlorite or 

chlorinated lime) 

• chlorine-releasing tablets (sodium dichloroisocyanurate) 

Chlorine-containing compounds contain a certain percentage of "active" (or available) chlorine. 

Active chlorine in these products kills microorganisms. The amount of active chlorine is usually 

stated as a percentage and differs among products, an important fact to ensure preparation of a 

chlorine solution with 0.5% "active" chlorine that can be used to decontaminate gloves and 

instruments. 

With regard to chlorine products, note the following: 

Different products may contain different concentrations of available chlorine, and the 

concentration should be checked before use. 

• In countries where French products are available, the amount of active chlorine is 

usually expressed in "degrees chlorum." One degree chlorum is equivalent to 0.3% 

active chlorine. 

• Household bleach preparations can lose some of their chlorine over time. Use newly 

manufactured bleach if possible. If the bleach does not smell strongly of chlorine, it may 

not be satisfactory for the purpose and should not be used. 

• Thick bleach solutions should never be used for disinfection purposes (other than in 

toilet bowls), as they contain potentially poisonous additives. 

16 




When preparing chlorine solutions for use note that: 

• Because of their low cost and wide availability, chlorine solutions prepared from liquid or 

powdered bleach are recommended. 

• Organic matter destroys chlorine, and freshly diluted solutions must therefore be 

prepared whenever the solution looks as though it needs to be changed (such as when it 

becomes cloudy or heavily contaminated with blood or other body fluids). 

• Chlorine solutions gradually lose strength, and freshly diluted solutions must therefore 

be prepared daily. 

• Calculate the ratio of water to liquid bleach, bleach powder, or chlorine-releasing tablets 

(see the calculations below). 

• Clean, clear water should be used to make the solution because organic matter destroys 

chlorine. 

• Use plastic containers for mixing and storing bleach solutions, as metal containers are 

corroded rapidly and also affect the bleach. 

• Prepare bleach solutions in a well-ventilated area because they give off chlorine. 

• Label the container with the percentage of the diluted decontamination solution prepared 

and note the day and time prepared. 

• A 0.5% bleach solution is caustic. Avoid direct contact with skin and eyes. 

Calculating the water-to-liquid-household-bleach ratio to make a 0.5% chlorine solution 

Chlorine content in liquid bleach is available in different concentrations. You can use any 

concentration to make a 0.5% chlorine solution by using the following formula: 

[% chlorine in liquid bleach divided by 0.5%] minus 1 = parts of water for each 

part bleach 

Note: "Parts" can be used for any unit of measure (e.g., ounce, 

liter, or gallon) and do not have to represent a defined unit of 

measure (e.g., a pitcher or container). 

For example: To make a 0.5% chlorine solution from a 3.5% chlorine concentrate, use one part 

chlorine and six parts water: 

[3.5% divided by 0.5%] minus 1 = [7] minus 1 = 6 parts water for each part 

chlorine 

Figure 1.7. 0.5% chlorine solution 

+ 



17

Calculating the water-to-bleach-powder ratio to make a 0.5% chlorine solution 

When using bleach powder to make a decontamination solution, calculate the ratio of bleach to 

water using the following formula: 

[% chlorine desired divided by % chlorine in bleach powder] times 1,000 = grams 

of powder for each liter of water. 

Note: When bleach powder is used, the chlorine solution will likely 

appear cloudy or milky. 

For example: To make a 0.5% chlorine solution from calcium hypochlorite powder containing 

35% available chlorine, use the following formula: 

[0.5% divided by 35%] times 1,000 = [0.0143] times 1,000 = 14.3 

Therefore, dissolve 14.3 grams of calcium hypochlorite powder in one liter of water in order to 

get a 0.5% chlorine solution. 

Calculating the water-to-chlorine-releasing-tablet ratio to make a 0.5% chlorine solution 

Follow the manufacturer's instructions when using chlorine-releasing tablets because the 

percentage of active chlorine in these products varies. If instructions are not available with the 

tablets, ask for the product instruction sheet or contact the manufacturer. Table 1 provides 

details on how to mix a decontamination solution with chlorine. 

18 




Table 1. Mixing A 0.5% Chlorine Decontamination Solution 

Liquid bleach (sodium hypochlorite solution) 

Type or brand (by country) 

% or grams 

active chlorine 

8 º Chlorum * 2.4% 

JIK (Kenya, Zambia), Robin Bleach 

(Nepal) 

Water-to-chlorine = 

0.5% solution 

10 mL bleach in 40 mL water 

1 part bleach to 4 parts water 

3.5% 10 mL bleach in 60 mL water 

12 º Chlorum 3.6% 1 part bleach to 6 parts water 

Household Bleach (Indonesia, USA), 

ACE (Turkey), Eau de Javel (France) 

15 º Chlorum, Lejia (Peru), 

Blanquedor, Cloro (Mexico) 

5% 

6% 

Lavandina (Bolivia) 8% 

Chloros (United Kingdom) 10% 

Chloros (United Kingdom), Extrait de 

Javel (France), 48 º Chlorum 

Dry powders 


15% 

% or grams 













0.5% solution 

Calcium hypochlorite 70% 7.1 grams per liter 

Calcium hypochlorite 35% 14.2 grams per liter 

Sodium dichloroisocyanurate (NaDCC) 60% 8.3 grams per liter 

Tablets 


Chloramine tablets * 

Sodium dichloroisocyanurate 

(NaDCC-based tablets) 

% or grams 


1 gram chlorine 

per tablet 

1.5 grams 

chlorine per tablet 


0.5% solution 

20 grams per liter 

(20 tablets per liter) 

4 tablets per liter 

*Chloramine releases chlorine slower than hypochlorite. Before using the solution, be sure the tablet is 

completely dissolved. 



19

Waste Disposal 

Proper waste disposal: 

• minimizes the spread of infections and reduces the risk of accidental injury to staff who 

handle the waste. 

• prevents the spread of infection to clients, visitors, and the local community. 

• helps provide an aesthetically pleasing atmosphere. 

• reduces odors. 

• attracts fewer insects and does not attract animals. 

• reduces the likelihood of contamination of the soil or ground water with chemicals or 

micro-organisms. 

There is no risk from uncontaminated waste such as office paper, boxes, packages, plastic 

containers, and food-related trash which can be disposed of according to local guidelines. 

Materials needed to dispose of waste include: 

• Separate waste containers for medical and nonmedical waste 

• “Sharps” containers 

• An interim storage area 

• An incinerator, an on-site burial pit 

• Protective gear, including utility gloves 

Proper handling of contaminated waste, such as items with blood or body fluid, is required to 

minimize the spread of infection to other staff and the community. Proper handling includes: 

• Wearing heavy-duty gloves. 

• Transporting solid contaminated waste to the disposal site in covered containers 

• Disposing of all sharp items in puncture-resistant containers 

• Carefully pouring liquid waste down a drain or flushable toilet 

• Burning or burying contaminated solid waste 

• Washing hands, gloves, and containers after disposal of infectious waste 

Housekeeping 

Good housekeeping reduces micro-organisms, reduces the risk of accidents, and provides an 

appealing work and service-delivery space. 

Materials required for good housekeeping include: 

• Detergent and water (for cleaning of walls, windows, ceilings, doors, floors, and 

equipment such as stethoscopes and weighing scales) 

• Disinfectant solution (0.5% chlorine solution for decontamination of soiled area before 

cleaning with detergent and water) 

• Disinfectant cleaning solution (0.5% chlorine solution with detergent): 

o Add detergent until the solution is slightly foamy. 

o Use for cleaning contaminated areas (examination and delivery rooms, operation 

theaters, floors, sinks, toilets/latrines, waste containers, beds, mattresses, etc.). 

Do not mix chlorine solution with cleaning solutions such as ammonia or phosphoric 

acid. 

20 




Recommended cleaning procedures are as follows: 

• Cleaning procedures will depend upon the potential risk of contamination. Low-risk areas 

include waiting rooms and administrative areas. High-risk areas are toilets, latrines, and 

sluice rooms, and client-care areas such as operating theaters, procedure rooms, 

laboratories, areas where instruments are cleaned and processed. 

• Develop and post cleaning schedules where all housekeeping staff can see them. Make 

sure that cleaning schedules are closely maintained. 

• Clean immediately: after spills, procedures, and deliveries. 

• Clean daily (at each shift if work load is excessive): delivery, operation, and 

examination/procedure rooms; floors, furniture, toilets/latrines, waste containers; and 

wipe incubators and radiant warmers with disinfectant solutions. 

• Always wear gloves (preferably thick utility gloves) when cleaning. 

• Use a damp or wet mop or cloth for walls, floors, and surfaces, instead of dry-dusting or 

sweeping, to reduce the spread of dust and micro-organisms. 

• Scrubbing is the most effective way to remove dirt and micro-organisms. Scrubbing 

should be a part of every cleaning procedure. 

• Wash surfaces from top to bottom so that debris falls to the floor and is cleaned up last. 

Clean the highest fixtures first and work downward; for example, clean ceiling lamps, 

then shelves, then tables, and then the floor. 

• Change cleaning solutions whenever they appear to be dirty. A solution is less likely to 

kill infectious micro-organisms if it is heavily soiled. 

• Clean up spills of potentially infectious fluids immediately. When cleaning up spills: 

o Always wear gloves. 

o If the spill is small, wipe it with a cloth that has been saturated with a disinfectant 

(0.5% chlorine) solution. 

o If the spill is large, cover (flood) the area with a disinfectant (0.5% chlorine) solution, 

mop up the solution, and then clean the area with a disinfectant cleaning solution. 

CLEAN DELIVERY CARE 

Related to clean delivery practices, some promote the concept of the three "cleans"—clean 

hands, clean surface, and clean cord care—or the five "cleans": clean hands, clean surface, 

clean instrument for cutting the cord, clean ligatures for tying the cord, and then keeping the 

cord clean and dry. There is also the seven cleans: the five cleans plus clean perineum and 

keeping the vagina clean without introducing anything unclean inside it. 

The main supplies needed for the “cleans” include: 

• A waterproof plastic cover (to provide a clean surface) 

• Soap 

• An unused razor blade kept in its cover for cutting the cord 

• Clean cord ties (both the razor blade and the cord ties should preferably be boiled for at 

least 10 minutes before use) 

• Clean, washed, and sun-dried towels kept in a clean container for drying and wrapping 

the baby 

• A clean perineum 

• A clean vagina without introducing anything unclean inside 



21

While the above may be acceptable at the community level, it is essential to take even greater 

care at the facility level where with some advocacy and planning it will eventually be possible to 

have as many sterile or disposable items as possible, especially those that come in direct 

contact with the perineum or the baby. These precautions will help prevent hospital-acquired 

infections which are particularly resistant to antibiotics and, hence, all the more dangerous. 

While it may be initially difficult to achieve these goals, it is necessary to keep aiming high, to be 

persistent on this important matter, and not be satisfied in just achieving “cleanliness.” 

EQUIPMENT AND SUPPLIES RELATED TO RESUSCITATION 

Equipment must be cleaned and disinfected after each use, and consumable supplies must be 

replaced. Manufacturers provide specific information on how to clean and disinfect/sterilize 

various pieces of equipment. Their guidelines should be carefully observed; failure to respect 

the guidelines may result in severe and/or lethal neonatal infection. 

Resuscitator Bag and Mask 2 

“The mask and the patient valve should both be disinfected after each use since they are 

exposed to the newborn and to expiratory gases. The bag and the inlet valve should be 

disinfected after use with an infected newborn, and otherwise occasionally. 

The valve and the mask must first be disassembled, inspected for cracks and tears, washed 

with water and detergent, and rinsed. Selection of the decontamination method will depend on 

the material. Silicone and rubber bags and patient valves can be boiled for 10 minutes, 

autoclaved at 136 °C, or disinfected by soaking in a disinfectant. Dilution of disinfectant and 

exposure time should be in accordance with the instructions of the manufacturer. All parts must 

be rinsed with clean water after chemical disinfection and air-dried before assembling. 

After re-assembling, the bag must be tested to check that it works correctly. Most manufacturers 

give step-by-step instructions for this procedure. If instructions are not available, use the 

following test: Block the valve outlet by making an airtight seal with the palm of the hand; 

squeeze the bag and feel the pressure against the hand; observe if the bag re-inflates when the 

seal is released; if the bag is not functioning correctly, it should be repaired before use. Repeat 

the test with the mask attached to the bag.” 

The steps noted above relate to ideal conditions. Frequently, there is only one bag with no 

possibility of fixing or replacing it in case of damage. Many health workers have difficulty in 

reassembling the parts. If this is the case, it might be more feasible to clean the different parts 

with a damp cloth. The mask can be easily separated and cleaned with at least soap and water, 

dried, and fixed back on the front outlet of the bag. 

Aspiration Catheters and Suction Devices 

Disposable catheters and suction devices must be discarded; they are not recommended for reuse 

even after thorough cleaning. If these devices are not available on site, mothers should be 

asked to bring a suction bulb when they come for the delivery since a new bulb can be washed, 

sterilized, and used for the baby if required, and then discarded. 

2 The text under this heading is reproduced from the WHO/Safe Motherhood “Basic Neonatal 

Resuscitation – A Practical Guide.” 

22 




CHAPTER 2: Clinical Decision-Making 

THE PROBLEM-SOLVING METHOD 

Clinical decision-making is the systematic process by which skilled providers make judgments 

regarding a patient's condition, diagnosis, and treatment. Skilled providers possess the skills 

and knowledge to perform procedures correctly. It is not enough to just perform procedures 

correctly, however. You must also choose the correct procedure to meet the woman or infant’s 

needs. In addition, you must be able to choose the right time to use a particular clinical skill. The 

problem-solving method guides you in giving care that is safe and effective, provides an 

organized way to approach and manage care, and uses skills and processes that are common 

in everyday life. 

Why Is It Important to Use the Problem-Solving Method? 

Using a methodical approach to solve problems has three advantages: 

• It helps you gather information in an organized manner. 

• It helps you gather complete information so that a problem can be correctly identified. 

• It helps you avoid using interventions that are not needed. 

Steps in Resolving a Problem 

The key steps in problem-solving are noted in Table 2. 

Step 1: History 

Table 2. Steps in the Problem-Solving Method 

Take a targeted history. 

Step 2: Physical examination 

Step 3: Identification of 

problems/needs 

Step 4: Care plan 

Step 5: Follow-up 

Perform a targeted physical examination. 

Identify needs and problems. 

Make a plan of care based on identified needs and 

problems. 

Follow up with the client to evaluate the care that has 

been provided. 

This step repeats all the steps of the problem-solving 

method, starting with step 1. 

Step 1: Take a targeted history 

In this step providers will ask specific questions (what, how, where, when, who, why) about a 

problem to help make a diagnosis or determine the cause of the problem. Ask the client why 

she has come. The reason for seeking care is called the “chief complaint.” The provider asks 

the client about the problem (signs, symptoms, etc.) or stated need (vaccination, antenatal care 



23

visit, etc.). Listen carefully to all the answers; the client’s answers are important and will help 

you identify the problems. Write down the important points in the answers. 

There are two types of histories: 

• A routine history: This type of history is taken for every woman coming in for routine 

antenatal, postnatal, family planning, services, etc. Everyone who comes in for care will 

be asked the same questions, and the information will be documented on a standard 

form. 

• A targeted history: This type of history is taken when a client comes in with a complaint. 

You will tailor the questions you ask around the complaint that the client has and will get 

information from the client that will help you identify problems or make a diagnosis. 

The following skills are important for taking a complete history: 

• Make sure the woman feels welcome. 

• Help the woman feel comfortable with your actions. 

• Provide a private area to talk and assure the woman of confidentiality. 

• Encourage the woman to talk and ask questions. 

• Ask questions in a kind and interested way. 

• Listen carefully to all the answers. 

Ask specific questions about signs and symptoms to help identify the problem(s). The client’s 

answers about her problems are the findings of this first step. The results from this first step will 

guide the provider through step 2. 

Note: If the woman comes with an emergency, you will ask very few 

questions, as immediate action may be required. You may have to ask 

questions of the family who accompanies the woman. 

Step 2: Perform a targeted physical examination 

After explaining to the woman what you are planning to do, examine the areas of the client’s 

body that relate to the information you gathered in step 1. A physical examination includes 

observation, palpation, percussion, auscultation, and smell. 

There are two types of physical examinations: 

• A routine physical examination: Sometimes you will need to do a general or full 

examination of the body. In the case of a woman registering (booking) for antenatal care, 

you will need to know about the condition of her entire body. A general examination of 

the body may also help you to find problems that the woman herself has not recognized. 

This also applies to a baby who may be just brought in for a routine service such as 

immunization. 

• A targeted physical examination: This type of physical examination is performed when a 

client comes in or a baby is brought in with a problem. You will tailor the physical 

examination around the complaint that the client has and will get information that will 

help you identify problems or make a diagnosis. 

Results from the physical examination are the findings of this step. Order laboratory or other 

diagnostic tests as needed. 

Examination of the baby has some other components that are described in chapter 9 and in 

Appendix B. 

24 




Step 3: Identify needs and problems 

This is the third step of the problem-solving method. Using the information from steps 1 and 2, 

the provider will identify problems the client is experiencing. Identification of needs or problems 

is done by thinking about findings, what the client has said (history), and what was found in the 

physical examination. The provider will compare the findings with what is known about normal 

findings to determine if the condition is normal or if there is a problem. 

If the findings are all normal, the provider will proceed to identify the client’s needs. These are 

the things the client needs to remain healthy, such as immunizations, birth preparedness in the 

antenatal period, or counseling on nutrition and basic care of the woman and her baby. 

If the findings indicate there is a problem, the provider will compare the abnormal findings with 

what she/he remembers or finds in references about complications. If the findings match those 

for a complication, the provider will determine the diagnosis. Sometimes, it is difficult to 

determine an exact diagnosis. In this case, either eliminate some diagnoses and use a 

differential diagnosis or describe the problem and refer the woman/baby for further evaluation 

and care. 

It is important that all the client’s problems and needs are treated, not just the problem that 

caused her to come to you. A pregnant woman may need information on family planning 

methods, good nutrition during pregnancy, how to relieve hemorrhoid pain, and where to go for 

immunizations for her small children—all in one visit. She may have come with only one 

complaint, problem, or question. Make certain that you write all the problems or needs on her 

record/antenatal form. 

Step 4: Make a plan of care 

This is the fourth step of the problem-solving method. The provider will decide what should be 

done to solve each problem or meet each need. Ideally, the provider will develop the care plan 

with the client, the client’s mother, or the client’s family members. 

The following actions should be considered for each problem or need, and the provider must 

decide which to do first, second, and so on. Sometimes medical treatment will be needed first. 

For example, when a woman has a retained placenta and is bleeding heavily, you must stop the 

bleeding by manually removing the placenta before laboratory tests can be done. You may then 

give her more treatment, education or counseling, or refer her. Or, when a woman who is six 

months pregnant comes to you and is feeling very tired, you will test her hemoglobin (Hb) before 

giving her treatment, education and counseling, or referring her. 

A baby brought with a danger sign needs referral to an appropriate center after giving the first 

dose of antibiotics, whereas a newborn infant with a minor infection may be managed locally 

along with routine basic care, such as giving immunizations. 

Here are some appropriate actions a provider might write in the plan of care developed for the 

client: 

• Medical treatment. Choose the correct medication, procedure, or treatment by following 

the clinical protocols. 

• Education. Help the woman learn to care for herself well. Always teach women the 

danger signs they should be aware of in themselves and their babies and where to go if 

any of these signs or symptoms appear. 

• Counseling. Help the client understand the problem or needs. Work with her to develop 

a way to treat the problem or meet the needs. 



25

• Laboratory tests or other investigations. These include laboratory tests, ultrasound or 

x-ray examination as required and as feasible. Follow the clinical protocol guidelines for 

the appropriate use of these methods to obtain more information about the problem. 

• Referrals. Use other resources in the area, such as doctors, hospitals, education 

programs, women’s groups, or charity groups to help the woman meet her needs. 

• Plan for follow-up. After you take appropriate action, you will see the woman/baby again 

and repeat the process. 

This is how the problem-solving method is used, over and over again until the problem is 

resolved. Thank her for coming to see you and schedule an appointment for her return. Explain 

why you want her to return. Make sure she knows the danger signs and emphasize that she 

needs to come back immediately if she sees a danger sign in herself or her baby. When you are 

scheduling a return visit, the time she should return will depend upon how severe her problem is 

and how long it should take to improve. You may need to see her in 24 hours, 2-3 days, 2 

weeks, or later. If she could develop a serious complication from her problem, she should be 

seen frequently until she is out of danger. Newborn babies with minor problems are often asked 

to be brought back after 48 hours. Low birth weight babies may be followed up on weekly until 

they are gaining weight and doing well. 

Step 5: Follow-up to evaluate the care provided 

Repeat the problem-solving method when you see the client at her next visit, which could be 

when she returns for a routine care appointment or for a check-up after treatment for a problem. 

By repeating the problem-solving method, the provider will find out if the problem is solved, is 

staying the same, or is getting worse. In some cases, the provider may need to develop a new 

plan for treating the patient. The mother may need to have information repeated to be sure she 

understands. She may need a different medication or treatment. She may need to be referred to 

a doctor or hospital. The provider will also find out if there are other new problems or different 

needs. Care needs to be taken to record all findings and actions taken. A clear report in the 

client’s record helps others to give continued quality care. 

Somewhat similar plans apply to the newborn. However, since staff competence and facility 

resources and supplies may be more limited related to the care of the sick newborn at 

peripheral centers, babies with danger signs will frequently need to be referred to a suitable 

higher center or hospital for appropriate care. 

Documentation of Care 

The problem-solving method provides a clear and organized way to record the information 

about a woman’s problem and how it was managed. Along with the date and time record: 

• all symptoms, based on what the woman tells you 

• findings from the physical examination and laboratory information 

• problems and needs identified 

26 




When writing the plan of care, make sure it is tailored to respond to the problems and needs 

identified in the mother and her baby. For each problem/need, write the following information: 

• treatments prescribed 

• prophylaxis prescribed 

• laboratory or other examinations ordered 

• counseling and education given 

• referrals made 

• date to return for care and evaluation. 

All items should be clearly and carefully written in the records or cards of the mother/baby and 

in the delivery room and clinic registers. When the recording is good and complete, the care is 

usually good and complete. 



27

Clinical Decision-Making 

Receive the client and 

respond immediately. 

Perform a quick check on 

each patient to evaluate for 

danger signs. 

Danger signs? 

No 

Gather information: Take a 

history and perform a 

physical examination. 

Yes 

Begin emergency 

assessment and 

management, 

including plans for 

referral where 

required. 

B1 

Identify problems/ 

make a diagnosis. 

Evaluate the plan of 

care (begin the steps 

all over again). 

Make a plan of care. 

Implement the plan of 

care. 

Figure 2.1. Clinical decision making algorithm 

28 




CHAPTER 3: Maternal Care to Improve 

Maternal and Newborn Survival 

The fetus’ growth and development depend on the health of the mother. The mother’s body 

provides nutrition, rest, oxygen, and protection to the fetus. A healthy woman, who receives 

good antenatal care, has a much greater chance of giving birth to a healthy, term baby and of 

surviving pregnancy and childbirth. 

The goals of antenatal care are as follows: 

• To promote and maintain the physical, mental, and social health of the mother and baby 

by providing education on nutrition, personal hygiene, and the birthing process. 

• To detect and manage complications during pregnancy, whether medical, surgical, or 

obstetrical. 

• To develop a birth-preparedness and complication-readiness plan. 

• To help prepare the mother to breastfeed successfully, experience normal puerperium 

(the period from 4-6 weeks after delivery), and take good care of the child physically, 

psychologically, and socially. 

EVERY PREGNANCY IS “AT RISK” 

In the past, health services used a risk system to identify “high risk” pregnancies so that these 

women could be referred to specialized care centers. A “risk factor” is anything that increases a 

person's chances of developing a disease or a complication. Risk factors may be associated 

with but do not necessarily cause a particular disease or complication. In addition, persons 

without the risk factor can also develop the disease or complication. 

More than 10 years of experience with the risk factor approach have shown us that it has many 

limitations, including: 

• So-called “risk factors” cannot predict complications because they are usually not the 

direct cause of the complication; for example, although young age can be associated 

with eclampsia, it does not always cause eclampsia. Women in older age groups can 

also develop eclampsia. 

• Because maternal mortality is a relatively rare event in the population at risk, i.e., all 

women of reproductive age, and because the so-called “risk factors” are relatively 

common in the same population, these “risk factors” are not good indicators to identify 

women who actually do experience complications. 

• The majority of women who actually did experience a complication were considered “low 

risk,” while the majority of the women (90 percent) considered to be “high risk” gave birth 

without experiencing a complication. 

What can be done, then? The literature strongly suggests that: 

• All health care providers and families understand that “normal pregnancy” and “normal 

birth” are retrospective diagnoses and can only be made at the end of pregnancy and 

childbirth. 

• All pregnancies be regarded as potentially at risk and managed with the utmost care. 



29

• All pregnant women receive at least four focused (quality) antenatal visits. 

• Detection of risk factors should be modified to put the emphasis on educating the 

women, men, and family members about danger signs and the actions necessary to get 

timely access to maternal health services if the woman experiences a complication. 

• The so-called risk factors, instead of being considered as markers or indicators of 

complications, should be regarded as factors associated with complications, and their 

importance for each pregnancy and childbirth should be considered on a case-by-case 

basis. 

• The presence of risk factors implies a need for more careful monitoring, not because 

they are necessarily predictive of complications. For many of them (e.g., age), nothing 

can be done to alter the risk factor. However, additional care and watchfulness may 

prevent a complication from arising or enable its early detection and management. 

MATERNAL CONDITIONS AFFECTING FETAL AND NEWBORN SURVIVAL 

This section will discuss maternal conditions, pregnancy-related complications, and maternal 

infections that have an impact on fetal and newborn health and survival. 

Iron-deficiency Anemia 

Figure 3.1. Signs of iron-deficiency anemia 

An anemic pregnant woman has a high risk of getting 

ill (because of lowered resistance to infection), of 

having a low birth weight (LBW) infant with a birth 

weight of less than 2500 grams, of giving birth 

prematurely before 37 completed weeks of gestation, 

of suffering from postpartum hemorrhage and heart 

failure, and of dying. Many women are already anemic 

when they become pregnant; closely spaced 

pregnancies, malaria, hookworm, sickle cell anemia, 

and frequent and chronic infections are some of the 

causes of anemia. 

Iodine Deficiency 

Iodine needs increase greatly during pregnancy because iodine is essential for the development 

and maturation of the fetal nervous system. Iodine deficiency in the pregnant woman has been 

associated with: 1) in the fetus: abortion, stillbirth, retardation of cerebral development, and 

congenital anomalies; 2) in the newborn: low birth weight, goiter, and neonatal hypothyroidism; 

and 3) in the adult: goiter and complications from goiters. 

Malnutrition 

Maternal undernutrition during pregnancy is associated with low birth weight. Low birth weight, 

in turn, has been shown to correlate with an increased incidence of the following: neonatal, 

infant, and child morbidity and mortality, small head circumference, mental retardation, cerebral 

palsy, learning problems/disabilities, visual and hearing defects, neurologic defects, and poor 

infant growth and development. 

30 




Malaria 

Susceptibility to malaria parasitemia is increased during 

pregnancy, particularly in the primigravida or women in their 

first malaria-exposed pregnancy. Malaria in pregnancy can 

cause severe anemia, provoke an abortion, premature birth, 

or the birth of a stillborn. Because placental sequestration of 

malarial parasites can occur, newborns of women who have 

suffered from malaria during pregnancy tend to be smaller, 

weaker, and more vulnerable to infections. 

Urinary Tract Infections 

Urinary tract infections (UTI) during pregnancy increase the risk of low birth weight infants and 

prematurity . Neonatal problems that are associated with UTI include sepsis and pneumonia. 

The risk of urinary tract infection on adverse perinatal outcomes is greatest among those with 

the most severe infection of the kidney, known as pyelonephritis. 

Syphilis 

Untreated maternal syphilis increases the risk of spontaneous abortion, stillbirth, congenital 

infection in the newborn, and neonatal mortality. Early detection and treatment is necessary to 

halt the devastating effects of progressive syphilis in the woman and to prevent transmission to 

her baby and her partner. The test for syphilis should be repeated in the third trimester if the 

woman or her partner engages in risky sexual behavior. 

HIV 

Infection with HIV affects many aspects of antenatal care. A woman infected with HIV requires 

additional care to keep her as healthy as possible, to prevent transmission to her baby and her 

partner, to treat her HIV infection, and to link her to appropriate support and help her make 

decisions about the future, including avoiding unintended pregnancies. The risk of mother-tochild 

transmission (MTCT) of HIV is 15-45 percent; more than 90 percent of pediatric AIDS 

cases are due to MTCT. Untreated maternal HIV can also result in increased incidence of 

stillbirths and newborn deaths, low birth weight, intrauterine growth retardation, and possibly 

spontaneous abortion and preterm birth. 

Diabetes 

Uncontrolled diabetes during pregnancy can result in maternal morbidity and mortality and is 

associated with an increase in perinatal/neonatal mortality. In addition, certain fetal anomalies 

are more common in babies of diabetic mothers, and the larger size of babies born to diabetic 

mothers may contribute to cephalopelvic disproportion, obstructed labor, and increased 

occurrence of birth asphyxia and birth trauma. Finally, the baby of a diabetic mother is also at 

increased risk for hypoglycemia, which may occur in the immediate postpartum period, and for 

jaundice, which may develop during the early neonatal period. 



31

Preeclampsia and Eclampsia 

Women who develop preeclampsia during pregnancy are all at increased risk of complications 

in the antenatal period, during labor and childbirth, and in the postpartum period. The 

increased risk applies to the mother as well to the fetus. In cases of severe preeclampsia, 

delivery should occur within 24 hours of the onset of symptoms. In cases of eclampsia, 

delivery should occur within 12 hours of the onset of convulsions. Delivery should take place 

as soon as the woman’s condition has stabilized, regardless of gestational age. Delaying 

delivery to increase fetal maturity will risk the lives of both the woman and the fetus and may 

result in the birth of a pre-term baby. 

Perinatal outcome is strongly influenced by gestational age and the severity of hypertension. 

Severe preeclampsia is associated with different degrees of fetal complications. The main 

impact on the fetus is undernutrition as a result of utero-placental vascular insufficiency, 

which leads to growth retardation. There are short and long-term effects; the immediate 

impact observed is fetal growth retardation, resulting in greater fetal liability. Fetal health as 

well as the fetus’ weight are highly compromised, leading to various degrees of fetal 

morbidity, and fetal damage may be such as to cause fetal death. 

Pre-Labor Rupture of Membranes 

Pre-labor rupture of membranes (PROM) may pose immediate risks such as 

cord prolapse, cord compression, and placental abruption. PROM is believed to 

have an association with maternal and fetal infection, with the risk considered 

to increase proportionally to the time between membrane rupture and birth, the 

risk being greater when the duration exceeds 18 hours. PROM also increases 

the risk of Caesarean operation and extends the duration of the hospital stay. 

If PROM occurs before 37 weeks, there is an additional risk of giving birth to a 

premature infant. 

Vaginal Bleeding in Later Pregnancy and Labor 

Any amount of bleeding during pregnancy and labor can put the life of the 

woman and fetus in danger. Preterm delivery and low birth weight are associated 

with second trimester hemorrhage. Abruptio placentae, placenta praevia, and 

uterine rupture are all associated with fetal distress and death. 

If the woman is Rh-negative, there is a risk of maternal iso-immunization if 

maternal and fetal blood mix when hemorrhage occurs. This may have an impact 

on the baby and will certainly have consequences for future pregnancies. 

32 




ANTENATAL CARE 

Antenatal care (ANC) should begin as early as possible in the pregnancy. Appropriate 

scheduling depends on the gestational age of the pregnancy and also the woman’s individual 

needs. For women whose pregnancies are progressing normally, the following schedule for a 

minimum of four ANC visits may be sufficient: 

1 st Visit: 16 weeks (by the end of 4 months) or as soon as 

the woman thinks she is pregnant 

2 nd Visit: 24-28 weeks (6-7 months) 

3 rd Visit: 32 weeks (8 months) 

4 th Visit: 36 weeks (9 months) for a total of 2 visits 

during the 3 rd trimester 

Elements of a Routine Antenatal Visit 

During a routine antenatal visit, a skilled provider should: 

• Perform a systematic examination including a rapid assessment to recognize danger 

signs and features of advanced labor and respond immediately and appropriately. 

• Detect pregnancy-related complications, fetal complications, medical conditions, and 

infections. 

• Take a detailed history to identify abnormalities and problems/potential problems that 

may affect the pregnancy: social problems, medical problems, history of obstetrical 

complications with previous pregnancies or births, and reported symptoms/problems. 

• Perform a physical, obstetrical, and gynecological exam. 

• Perform the following laboratory tests to evaluate the woman’s health and her pregnancy 

and screen for selected medical conditions and infections. Where essential tests are not 

feasible at the peripheral center, the woman must be referred to an appropriate facility. 

o Hemoglobin levels (first visit/as needed). 

o RPR (Reactive Plasma Reagin) or VDRL (Venereal Disease Research Laboratory) at 

first visit or as needed: The test should be repeated in the 3 rd trimester if the woman 

or her partner engages in risky sexual behavior. 

o HIV (first visit/repeat in 3 rd trimester/as needed): If the woman volunteers for testing 

or if the testing is initiated by the health care provider, a test should be conducted as 

early as possible during the pregnancy. A positive HIV status affects many aspects of 

ANC. Therefore, steps should be taken to prevent transmission of the virus to the 

baby and for appropriate treatment of the mother. 

o Urine for glucose: This test is used to screen for diabetes, which is a condition 

beyond the scope of basic care. Although many women with normal glucosetolerance 

tests spill sugar in their urine without any associated problems for mother 

or child, this test can help identify women who actually do have high blood glucose 

levels. 

o Urine for protein: This test is used to screen for preeclampsia, which is a condition 

beyond the scope of basic care. Although proteinuria is most commonly associated 

with preeclampsia or eclampsia, a woman's urine can test positive for protein if she is 

severely anemic, has kidney disease, or has a urinary tract infection, or if the urine 



33

has been contaminated by blood (or if she has schistosomiasis), vaginal discharge, 

or amniotic fluid. 

o Grouping and Rhesus factor: All pregnant women should have their blood grouped 

for ABO and Rhesus (Rh) types. Knowing the woman’s blood type can facilitate 

transfusion in the case of an emergency. Knowing her Rhesus type will allow timely 

administration of Rhesus antibodies (anti-D immunoglobulin) to prevent maternal 

iso-immunization. Women with Rh-negative blood group are screened for Rhesus 

antibodies with an indirect Coombs’ test. If there are no antibodies, the blood will be 

retested at 28 and 34 weeks of pregnancy. If antibodies are found at any stage, 

referral to a specialist will be required to decide on management of the pregnancy 

and the newborn. 

o Urine test for bacteriuria (as needed): This test is used to diagnose urinary tract 

infections, which are conditions beyond the scope of basic care. 

o Other tests as needed based on findings in history and physical examination. 

• Provide prophylaxis for health promotion and disease prevention: TT, intermittent 

preventive treatment (IPTp) of malaria, insecticide-treated bednets, iron/folate tablets, 

broad-spectrum anti-helminthics, and other nutritional supplements as needed. 

• Provide treatment for any medical conditions, illnesses, and infections detected. 

• Manage any pregnancy-related complications. 

• Provide client-centered and gestational-age-specific counseling for women and partners/ 

supporters. 

• Help the woman and her partner/support person develop a birth-preparedness and 

complication-readiness plan. Begin discussing the plan at the first visit and bring it up to 

date at each subsequent visit. 

• Ideally, during the antenatal visits, the mother should be counseled on basic preventive 

care of herself and her baby after delivery, identification of danger signs, and the 

required care-seeking. A number of women may end up delivering at home even after 

having visited the antenatal clinic. 

• Refer all women who need specialized care for any reason to an appropriate hospital. 

Health Promotion and Disease Prevention 

Certain medications or simple health care measures can prevent or reduce the risk of suffering 

from specific health problems. The following measures should be explained and offered to all 

pregnant women. 

Preventing malaria 

• Intermittent preventive treatment (IPTp) 

of malaria with sulfadoxine-pyrimethamine 

(SP) 500 mg + 25 mg. Do not give SP 

during the first trimester of pregnancy or 

during the 9th month of pregnancy. 

SP Dose 

1 st dose 

Provide SP to all pregnant women: give 2 

doses to women who are not infected with 2 nd dose 

HIV; check national protocols for dose 

recommendations for women infected with 

HIV (if the woman is on cotrimoxazole 

prophylaxis, use another anti-malarial drug for IPTp). 

Table 3. Timing of SP dose 

Timing 

From 18 weeks (after 

quickening). Not before 16 

weeks gestation. 

At 28 weeks or 1 month 

After the 1 st dose. 

34 




Have the woman take the dose in front of the provider. Do not give the dose on an 

empty stomach; ask the woman to eat something before taking the tablets. There should 

be at least one month between doses. 

Note: Studies are looking for evidence of an interaction between folic 

acid and SP when these drugs have been used together in the 

management of acute malaria. Refer to national protocols for the latest 

recommendations. 

• An insecticide-treated bednet is another way to 

protect the pregnant woman against malaria, reducing 

cases of malaria and subsequent risks of maternal 

anemia and death. Advise the mother to use an 

insecticide-treated bednet (see also the chapter on 

postpartum care of the mother). 

Prevent iodine deficiency 

In areas where iodine deficiency is high, consult country protocols for pregnant women. 

Advise women to use iodized salt. 

Prevent iron-deficiency anemia 

Iron is essential to compensate for the increased blood volume that occurs during pregnancy 

and to ensure adequate fetal growth and development. Iron needs increase during the 

pregnancy as the fetus grows. The pregnant woman can help meet these increased needs for 

iron by taking iron and folic acid tablets and by ensuring that she has an adequate and balanced 

diet. Iron-rich foods include meat, especially liver and giblets, apricots, prunes, eggs, dry 

legumes, peanuts, other nuts, and green leafy vegetables. 

Iron/folate supplementation to prevent anemia is administered as follows: 

• If the woman’s hemoglobin is between 8-11 g/dL, give 

ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic 

acid 400 mcg by mouth once daily. 

• If the woman’s hemoglobin is ≤7 g/dL, treat for anemia: give 

ferrous sulfate or ferrous fumarate 120 mg by mouth plus 

folic acid 400 mcg by mouth once daily for 3 months/follow 

national protocols. 

• Continue to give ferrous sulfate or ferrous fumarate 60 mg 

by mouth plus folic acid 400 mcg by mouth once daily for at 

least 3 months after childbirth. 

Intermittent preventive treatment of hookworm to prevent anemia 

Hookworm is a major cause of iron deficiency anemia and should be treated with a dose of 

mebendazole or albendazole every 6 months. A pregnant woman can safely take mebendazole 

or albendazole during the second and third trimesters of her pregnancy. Hookworm can also be 

prevented by always wearing shoes when walking outside. 



35

In areas endemic for hookworm (prevalence of 20 percent or more), give one of the 

following treatments starting after 16 weeks gestation and repeating every 6 months: 

• albendazole 400 mg by mouth once; or 

• mebendazole 500 mg by mouth once or 100 mg twice a day for 3 days 

In highly endemic areas (prevalence of 50 percent or more), repeat the antihelminthic 

treatment 12 weeks after the first dose. 

Prevent newborn tetanus with tetanus toxoid 

Tetanus continues to kill many newborns and women in countries all 

over the world, in spite of the fact that neonatal tetanus can be 

prevented by immunizing women of childbearing age with tetanus toxoid 

(TT), either during pregnancy or outside of pregnancy. All women need 

to be informed about the series of five tetanus shots and should have a 

permanent card. A woman also needs to know that the risk of tetanus 

infection is much decreased if she is assisted by a skilled attendant at 

birth. 

Guidelines for giving tetanus toxoid: 

TT 1 

Table 4. Schedule for giving tetanus toxoid 

Dose 

Schedule 

0.5 mL 

At first contact with woman of childbearing age or 

at first antenatal care visit, as early as possible. 

TT 2 0.5 mL At least 4 weeks after TT1. 

TT 3 0.5 mL At least 6 months after TT2. 

TT 4 0.5 mL At least 1 year after TT3. 

TT 5 0.5 mL At least 1 year after TT4. 

Note: A woman has lifetime protection against tetanus after she has 

received five doses of TT. 

Health Education During Pregnancy 

Birth spacing 

Healthy timing and spacing of pregnancy through family planning is one of the most critical and 

essential preventive ways of improving the health of women and children, with additional 

benefits to the family and community. It is a key intervention associated with reduced risk of low 

birth weight, prematurity, and deaths in newborns and infants, as well as decreased health risks 

to mothers after abortions and births. Parents should use their family planning method of choice 

and wait before conceiving again for a period of two years following a birth and for at least six 

months after an abortion. 

36 




Informing the pregnant woman about options for family planning gives her the time to reflect, 

talk with friends, talk with her husband/partner, and become educated about what choices she 

has. Contrary to popular practice, talking about family planning is very important during the 

pregnancy, although it may be taboo in some cultures. If the woman is not ready to talk about 

all the methods, you can plant the seed and provide future opportunities for discussion. 

Nutrition during pregnancy 

All pregnant women need particularly nutritious meals throughout their pregnancy. A pregnant 

woman needs the nutritious foods available to the family: milk, fruit, vegetables, meat, fish, 

eggs, grains, peas, and beans. All these foods are safe to eat during pregnancy. 

Women will feel stronger and be healthier during pregnancy if 

they eat foods that are rich in iron, vitamin A, and folic acid. 

These foods include meat, fish, eggs, green leafy vegetables, 

and orange or yellow fruits and vegetables. Growing 

adolescent girls may have higher nutritional requirements in 

order to support their own growth. 

Health care providers can provide pregnant women with iron 

tablets to prevent or treat anemia and, in vitamin-A-deficient 

areas, an adequate dosage of vitamin A to help prevent 

infection. Pregnant women should not take more than 10,000 international units (IU) of vitamin 

A per day or 25,000 IU per week. Advise mothers to take iodized salt. Women who do not have 

enough iodine in their diet are more likely to have miscarriages and risk having an infant who is 

mentally or physically disabled. Goiter is a clear sign that a woman is not getting enough iodine. 

Rest 

A pregnant woman needs additional rest during pregnancy. In early pregnancy, the woman will 

feel tired as her body becomes accustomed to being pregnant. As the pregnancy advances, the 

larger fetus makes greater demands and causes greater strains on her body, and she will need 

more and more rest. During pregnancy, in addition to whatever amount of sleep she normally 

needs, she should have additional periodic rest periods during the day, preferably lying down 

with her feet elevated. In addition, she should avoid sitting or standing for long periods during 

the day. 

In most cultures women do not get permission to rest during pregnancy. Many families feel that 

if the woman works hard through pregnancy the delivery will be easier. It may be the provider’s 

role to play advocate for the woman and help her find creative ways to reduce her workload and 

find more time for rest. 

Safer sex 

To assure good relations between the woman and her partner, it is important to address the 

issue of sexual intercourse. Sometimes the pregnant woman may not feel the desire to have 

sex, and she needs to feel empowered enough to refuse. If she does desire having intercourse, 

she needs to know that the only time that intercourse is discouraged is if there is suspected 

premature rupture of membranes, bleeding, bleeding and cramps in the first trimester, or 

infection of the partner; and that having sex will not harm the fetus. In addition, it may be 

necessary to make changes in position to accommodate the enlarged abdomen or find 

alternative methods of satisfying both male and female sexual needs. 



37

It is important to discuss issues of safer sex because infidelity by the male partner can be 

highest during the third trimester of pregnancy. The risk of getting HIV through sex can be 

reduced if: 1) people don't have sex, 2) if they reduce the number of sex partners, 3) if 

uninfected partners have sex only with each other, or 4) if people have safer sex, i.e., sex 

without penetration or while using a condom. Correct and consistent use of condoms can save 

lives by preventing the spread of HIV. 

Hygiene 

Due to hormonal changes brought about by the pregnancy, pregnant women sweat more and 

have more vaginal discharge than women who are not pregnant. The pregnant woman needs, 

therefore, to be vigilant about her personal hygiene to prevent infections and disease. Gentle 

reminders about needs for bathing and wearing clean clothes are never misplaced. 

When the woman comes in for antenatal care, the provider can remind her about other simple 

hygiene rules that can help her prevent diseases: hand washing, treatment and care of drinking 

water, avoiding raw meats, reheating leftovers well, and being careful about coming into contact 

with people who are ill. 

Dental care is also important during pregnancy because estrogen can make gum tissues 

edematous. Using a dental stick or using a toothbrush and toothpaste are equally appropriate. 

Breastfeeding 

Provide advice on breastfeeding, especially on early initiation without pre-lacteal feeds and on 

continuing exclusive breastfeeding on demand. Further details on normal breastfeeding are 

noted in chapter 5 under care of the baby at birth. 

Prevention of mother-to-child transmission (PMTCT) of HIV 

Offer HIV testing and counseling to all pregnant women and their sexual partners. The following 

are the standard HIV pre-test session messages in all PMTCT settings: 

• Help the client understand basic information on HIV transmission and prevention. 

• Explain in simple terms how HIV infection can be transmitted from mother to child. 

• Explain how transmission of the infection from mother to child can be prevented. 

• Explain the importance of HIV testing. 

• Explain HIV testing processes and procedures, including issues of confidentiality. 

• Discuss implications of positive and negative test results. 

• Explain the importance of partner testing: 

o discordance 

o disclosure and partner referral 

• Explain risk-reduction and available services: 

o prevention of sexual transmission of HIV 

o PMTCT interventions, including ARV prophylaxis and safer infant feeding 

o referral for prevention, care, treatment, and support 

• Discuss with HIV-positive clients the mode of delivery and feeding options. Assist them in 

identifying HIV support services. 

• Provide information on health timing and spacing of pregnancy and family planning. 

• Encourage continuous healthcare attendance and delivery care. 

38 




Provide post-test counseling to HIV-positive and negative women based on national guidelines. 

Counseling for those whose HIV test results are negative should include the following minimum 

information: 

• Provide the HIV test result. 

• Explain the test result, the window period, and a recommendation to retest in case of a 

recent exposure. 

• Assess understanding of the result. 

• Identify and address client questions. 

• Discuss: 

o partner HIV testing and disclosure 

o safer sex and risk reduction (negative prevention) 

o exclusive breastfeeding 

o antenatal care, post-delivery care 

o importance of delivering in a healthcare facility 

o infant care 

• Provide referrals and take-home information. 

In the case of individuals whose HIV test results are positive, the health care provider should: 

• Provide the HIV test result and support. 

• Assess understanding of the result. 

• Identify and address client questions. 

• Discuss: 

o ARV therapy or prophylaxis 

o other relevant preventive health measures, such as good nutrition, use of cotrimoxazole 

and, in malaria areas, use of insecticide-treated bednets 

o infant feeding options 

o treatment and support services for the client and family 

o partner HIV testing and disclosure 

o safer sex and risk reduction (positive prevention) 

o antenatal care, post-delivery care 

o importance of delivering in a healthcare facility 

o infant care and diagnosis 

• Discuss infant feeding options and support the woman to carry out her choice. 

• Encourage and offer referral for testing and counseling of partners and children, HIV 

testing for the infant, and the follow-up that will be necessary. 

• Provide take-home information. 



39

DELAYS RESULTING IN MATERNAL AND NEWBORN DEATHS 

The factors that often prevent women and newborns from getting the life-saving health care they 

need include: 

• distance from health services 

• cost (direct fees as well as the cost of transportation, drugs, and supplies) 

• multiple demands on women’s time 

• women’s lack of decision-making power within the family 

• poor quality services, including poor treatment by health providers and discourteous 

behavior which makes women reluctant to use services 

These have been described as the following delays: 

• Delay in recognizing the problem: When a woman or newborn experiences a danger 

sign, someone must recognize that there is a problem. If pregnant women, their 

families, and women caring for them don’t know the danger signs that indicate the 

woman or newborn is experiencing a complication, they will not know when they need to 

seek care. 

• Delay in deciding to seek care: When a problem arises, the woman and her family 

have to decide to seek care. If the primary decision-maker is not present, it may mean 

that the woman is not allowed to seek care, or take her newborn for care, or that seeking 

care is delayed. 

• Delay in arriving at the appropriate facility: Once a decision is made to seek care, the 

woman and her family must find a means of transport and the necessary funds to go to 

the appropriate facility. If there are no means of transport and/or the woman and her 

family do not have the necessary funds, the woman or newborn will not get to the 

appropriate health care facility in a timely fashion. 

• Delay in receiving quality care: Once the woman or newborn has reached the 

appropriate facility, care providers must provide quality services for whatever emergency 

has transpired. If the care provided is not good quality or appropriate, then the woman 

or newborn will have reached the appropriate facility in vain. 

When delays occur in recognizing problems and referring women or newborns to appropriate 

health care facilities, the result can lead to maternal and newborn deaths. One solution to 

combat these problems is to work with the pregnant woman and her family to develop two 

plans: a birth-preparedness plan and a complication-readiness plan. 

BIRTH-PREPAREDNESS PLAN 

Having a birth plan can reduce delayed decision-making and increase the probability of timely 

care. A birth-preparedness plan is an action plan made by the woman, her family members, and 

the health care provider. Often this plan is not a written document but an ongoing discussion 

between all concerned parties to ensure that the woman receives the best care in a timely 

manner. Each family should have the opportunity to make a plan for the birth. Health care 

providers can help the woman and her family develop birth-preparedness plans and discuss 

birth-related issues. Work with the woman to: 

1. Make plans for the birth: 

• Discuss the idea of a birth plan and what to include during the first visit. 

• Inquire about the birth-preparedness plan during subsequent visits. 

40 




• Ask if arrangements are made for a skilled birth attendant and the birth setting during the 

antenatal visit in the eighth month. 

• If the woman is planning a home delivery with a 

skilled birth attendant, discuss access to a safe 

delivery kit consisting of: 1) a piece of soap for 

cleaning the birth attendant’s hands and the 

woman’s perineum, 2) a plastic sheet about one 

square meter for use as a clean delivery 

surface, 3) a clean string for tying the umbilical 

cord (usually two pieces), and 4) a clean razor 

blade for cutting the cord. Advise the 

woman/family to boil the threads to be used as 

cord ties and the blade in water for 10 minutes 

before use. 

2. Make birth-related decisions: 

• where to give birth 

• who will be the skilled birth attendant 

• how to contact the provider 

• how to get to the place of birth 

• who will be the birth companion 

• who will take care of the family while the woman is absent 

• how much money is needed for care and transport and how to access these funds 

• what transport will be used and how to ensure its availability 

3. Prepare for the birth: 

• Discuss items needed for the birth (perineal pads/cloths, soap, clean bed sheets) on the 

third antenatal visit. 

• Confirm necessary items are gathered near the due date. 

4. Save money: 

Note: In some cultures, superstition surrounds buying items for an 

unborn baby. If this is not the case, families can prepare for the birth 

by buying baby supplies such as blankets, diapers, and clothes. 

• Discuss why and how to save money in preparation for the birth during the first visit. 

• Discuss how to plan to make sure that any funds needed are available at birth. 

• Check that the woman and her family have begun saving money or that they have ways to 

access necessary funds. 

Note: Encourage the family to save money so necessary funds are 

available for routine care during pregnancy and birth. Assess financial 

needs with the women as well as sources for accessing these funds 

so they are available before labor. If traditional beliefs do not permit 

getting clothes ready, advise the family to keep aside at least pieces 

of cloth/linen/blanket to dry and wrap the baby. 



41

COMPLICATION-READINESS PLAN 

The complication-readiness plan is an action plan that outlines steps that can be discussed and 

determined prior to an emergency. Developing this plan helps the family to be prepared for and 

respond quickly when the woman or newborn has a complication and needs medical care. It is 

important that a complication-readiness plan is prepared with the woman and her chosen family 

members. Unless others are involved, the woman may have difficulties putting the plan into 

action should complications occur for her or her baby. 

Recognizing maternal danger signs 

Women, family members, and community caregivers must know the signs of life-threatening 

complications. Many hours can be lost from the time a complication is recognized until the time 

arrangements are made for the woman to reach help. For postpartum hemorrhage, the time 

from the start of bleeding to death can be as little as two hours. In too many cases, families of 

women who died in pregnancy, birth, or postpartum, did not recognize the problem in time. It is 

critical to reduce the time needed to recognize problems and make arrangements to receive 

care at the most appropriate level of care. Women, family members, and community caregivers 

must know the signs of life-threatening complications. 

Maternal danger signs include: 

• vaginal bleeding (any vaginal bleeding during pregnancy, heavy vaginal bleeding or a 

sudden increase in vaginal bleeding during the postpartum period) 

• pre-labor rupture of membranes (PROM) 

• breathing difficulties 

• fever 

• severe abdominal pain 

• severe headache/blurred vision 

• convulsions or loss of consciousness 

• pain during urination, bloody or scanty urine 

• foul-smelling discharge from vagina, tears, and incisions 

• calf pain, with or without swelling 

• night blindness 

• verbalization or behavior indicating the mother may hurt the baby or herself 

• hallucinations 

Note: A pregnant woman should seek care immediately even if she is 

experiencing only one of the danger signs listed. 

Save money 

Similar to the birth-preparedness plan, the family should be encouraged to save money so 

necessary funds are available for emergencies. In many situations, women either do not seek or 

receive care because they lack funds to pay for services. 

Choose a decision-maker in case of emergency 

In many families, one person is the primary decision-maker. Too often other members of the 

family do not feel they can make decisions if that person is absent. This can result in death 

when an emergency occurs and the primary decision-maker is absent. It is important to discuss 

how the family can make emergency decisions without disrupting or offending cultural and 

42 




family values. If possible, find out which family member can make a decision in the absence of 

the chief decision-maker. 

Have an emergency transportation plan 

Too many women and newborns die because they suffer serious complications and do not have 

access to transportation to the type of health care facility that can provide needed care. Each 

family should develop a transportation plan during the woman’s early pregnancy in case the 

woman experiences complications and urgently needs a higher level of care. This plan should 

be prepared during pregnancy and after giving birth, either before discharge from the health 

facility or immediately after returning home. The plan should address the following: 

• where to go if complications arise 

• how to get to the next level of care in case of an emergency 

• who in the family will accompany the woman 

Have an emergency blood donation plan 

Many health care facilities lack an adequate, safe blood supply for transfusions. After birth, 

women are more likely to need blood transfusions because the complications they experience 

from birth lead to blood loss. For these reasons, it is extremely important that the woman and 

her family determine blood donors that can be available if needed. 



43

CHAPTER 4: Preventing Postpartum Hemorrhage 3 

The loss of some blood during childbirth and postpartum is normal and cannot be avoided. 

However, losing any amount of blood beyond normal limits can cause serious problems even for 

women with normal hemoglobin levels. For many anemic women, even the normal amount of 

blood loss might be catastrophic. Fortunately, providers can take action to prevent unnecessary 

blood loss. 

Note: The importance of a given volume of blood loss varies with 

the woman’s health status. A woman with a normal hemoglobin 

level may tolerate blood loss that would be fatal for an anemic 

woman. (WHO, 2007) 

Postpartum hemorrhage (PPH) is defined as vaginal bleeding in excess of 500 mL occurring 

less than 24 hours after delivery; severe PPH is blood loss exceeding 1000 mL. Delayed PPH 

is excessive vaginal bleeding (vaginal bleeding increases rather than decreases after delivery), 

occurring more than 24 hours after childbirth. 

Because it is difficult to measure blood loss accurately, research shows that blood loss is 

frequently underestimated. For instance, nearly half of women who deliver vaginally often lose 

at least 500 mL of blood, and those who give birth by Caesarean delivery normally lose 1000 

mL or more. For many women, this amount of blood loss does not lead to problems; however, 

outcomes are different for each woman. 

For severely anemic women, blood loss of as little as 200 to 250 mL can be fatal. This fact is 

especially important to keep in mind for women living in developing countries where significant 

numbers of women have severe anemia. For these reasons, a more accurate definition of PPH 

might be any amount of bleeding that causes a change for the worse in the woman’s condition 

(e.g., low systolic blood pressure, rapid pulse, signs of shock). 

Predicting who will have PPH based on risk factors is difficult because two-thirds of women 

who have PPH have no risk factors. Therefore, all women are considered at risk, and 

preventing hemorrhage must be incorporated into the care provided at every birth. 

Note: Every woman is at risk for postpartum hemorrhage. 

CAUSES OF POSTPARTUM HEMORRHAGE 

There are several possible reasons for severe bleeding during and after the third stage of labor. 

Uterine atony, or inadequate uterine contraction, is the most common cause of severe PPH in 

the first 24 hours after childbirth. Contractions of the uterine muscle fibers help to compress 

maternal blood vessels. Bleeding may continue from the placental site if contractions are not 

adequate. Many factors can contribute to the loss of uterine muscle tone, including: 

• retained placenta or placental fragments 

• partial placental separation 

• overdistention of the uterus due to multiple gestation, excess amniotic fluid, large baby, 

or multiparity 

3 Adapted from PATH. OUTLOOK Volume 19, Number 3, May 2002. 

44 




• prolonged labor 

• induction or augmentation of labor 

• precipitous labor (labor lasting less than 3 hours) 

• a full bladder 

Undetected or untreated lower genital tract lacerations, such as cervical, vaginal, or perineal 

lacerations and episiotomy, are the second most common cause of PPH. Episiotomy causes 

loss of blood and can lead to lacerations. Lacerations can also be caused by deliveries that are 

poorly controlled, difficult, or managed with instruments (e.g., large baby, twins, or non-cephalic 

presentation). When the woman has genital lacerations, it is still important to check for and treat 

uterine atony because these conditions may occur together. 

Other causes include: 

• retained placenta or placental fragments. If the uterus is not empty, it cannot contract 

adequately. This can occur if even a small part of the placenta or membranes is 

retained. A partially separated placenta may also cause bleeding. 

• uterine rupture and uterine inversion. Although rare, these conditions also cause PPH. 

• disseminated intravascular coagulation (DIC). Although uncommon, this clotting 

disorder—associated with preeclampsia, eclampsia, prolonged labor, abruptio 

placentae, and infections—is a significant and serious cause of PPH. (Coagulation 

means a defect in the body's mechanism for blood clotting. While there are several 

possible causes for coagulopathies, they generally result in excessive bleeding and a 

lack of clotting.) 

• harmful traditional practices. Women with genital lacerations caused by traditional birth 

attendants and traditional healers for prolonged labor at home may be brought to the 

facility with PPH. 

Preventing PPH and careful monitoring during the first hours after birth are critical for every 

woman at every birth. Despite the best strategies to prevent blood loss, approximately three 

percent of women will still lose blood in excess of 1000 mL. Preparing for early treatment of 

PPH (e.g., additional uterotonic drugs and arranging for blood where feasible) is critical to 

women’s health. 

PPH PREVENTION AND EARLY DETECTION 

It is impossible to predict which women are more likely to have a PPH. Many factors may 

contribute to uterine atony or lacerations. Addressing these factors may help prevent PPH and 

reduce the amount of bleeding a woman may have. Taking a preventive approach can save 

women’s lives. 

Despite the best efforts of health providers, women may still suffer from PPH. If PPH does 

occur, positive outcomes depend on how healthy the woman is when she has PPH (particularly 

her hemoglobin level), how soon a diagnosis is made, and how quickly effective treatment is 

provided after PPH begins. 

To prevent PPH and reduce the risk of death, routine preventive actions should be offered to all 

women from pregnancy through the immediate postpartum period. 



45

During Antenatal Care 

Health care providers should take the following steps during antenatal care: 

• Develop a birth-preparedness plan. Women should plan to give birth with a skilled 

attendant who can provide interventions to prevent PPH (including AMTSL), and can 

identify and manage PPH, and refer the woman for additional treatment if needed. 

• Develop a complication-readiness plan that includes recognition of danger signs and 

what to do if they occur, where to get help and how to get there, and how to save money 

for transport and emergency care. For more information, see chapter 3. 

• Routinely screen to prevent and treat anemia during preconceptual, antenatal, and 

postpartum visits. Counsel women on nutrition, focusing on available iron and folic acidrich 

foods, and provide iron/folate supplementation during pregnancy. 

• Help prevent anemia by addressing major causes, such as malaria and hookworm. 

• For malaria, encourage use of insecticide-treated bednets, provide intermittent 

preventive treatment during pregnancy to prevent asymptomatic infections 

among pregnant women living in areas of moderate or high transmission of 

Plasmodium falciparum, and ensure effective case management for malaria 

illness and anemia. 

• For hookworm, provide treatment at least once after the first trimester. 

• Determine the woman’s blood group where feasible. 

• In cases where the woman cannot give birth with a skilled attendant, prevent 

prolonged/obstructed labor by providing information about the signs of labor, when labor 

is too long, and when to come to the facility or contact the birth attendant. 

• Avoid procedures such as external cephalic version to correct abnormal lie of the baby. 

• Prevent harmful practices by helping women and their families recognize harmful 

customs practiced during labor (e.g., providing herbal remedies to increase contractions, 

health workers giving oxytocin by intramuscular injection during labor). 

• Take culturally sensitive actions to involve men and encourage understanding about the 

urgency of labor and need for immediate assistance. 

During the First and Second Stages of Labor 

Health care providers should take the following steps during the first and second stages of 

labor: 

• Use a partograph to monitor and guide management of labor and quickly detect 

unsatisfactory progress. 

• Ensure early referral when progress of labor is unsatisfactory. 

• Encourage the woman to keep her bladder empty. 

• Limit induction or augmentation use for medical and obstetric reasons. (Induction means 

stimulating uterine contractions to produce delivery before the onset of spontaneous 

labor; augmentation means stimulating the uterus during labor to increase the frequency, 

duration, and strength of contractions.) 

• Limit induction or augmentation of labor to facilities equipped to perform a Caesarean 

delivery. 

• Do not encourage pushing before the cervix is fully dilated. 

• Do not use fundal pressure to assist the birth of the baby. 

• Do not perform routine episiotomy. Consider episiotomy only with complicated vaginal 

delivery (e.g., breech, shoulder dystocia, forceps, vacuum, scarring from female genital 

cutting or poorly healed third- or fourth-degree tears, and fetal distress). 

46 




• Assist the woman in the controlled delivery of the baby’s head and shoulders to help 

prevent tears. Place the fingers of one hand against the baby’s head to keep it flexed 

(bent), support the perineum, and instruct the woman to use breathing techniques to 

push or stop pushing. 

During the Third Stage of Labor 

Health care providers should take the following steps during the third stage: 

• Provide active management of the third stage of labor (AMTSL)—the single most 

effective way to prevent PPH. 

• Do not use fundal pressure to assist the delivery of the placenta; instead, apply pressure 

on a woman's abdomen to help expel the placenta. 

• Do not perform controlled cord traction (CCT) without administering a uterotonic drug. 

• Do not perform CCT without providing countertraction to support the uterus. 

After Delivery of the Placenta 

Health care providers should provide the following care during the immediate postpartum period 

(the first six hours after childbirth): 

• Routinely inspect the vulva, vagina, perineum, and anus to identify genital lacerations. 

Cervical examination is only recommended when the cause of PPH has not been 

diagnosed and uterine atony, lower genital lacerations, and retained placenta are ruled 

out. 

• Inspect the placenta and membranes for completeness. 

• Evaluate if the uterus is well contracted and massage the uterus at regular intervals after 

placental delivery to keep the uterus well-contracted and firm (at least every 15 minutes 

for the first 2 hours after birth). 

• Teach the woman to massage her own uterus to keep it firm. Instruct her on how to 

check her uterus and to call for assistance if her uterus is soft or if she experiences 

increased vaginal bleeding. 



47

CHAPTER 5: Routine Care during the 

Third Stage of Labor 

PREPARATION FOR THE BIRTH 

Developing a birth-preparedness plan during pregnancy will help ensure that the woman in labor 

arrives at the health care facility in a timely manner and can be assisted by a skilled birth 

attendant. Ideally there should be at least two qualified providers at each birth to ensure that 

both the woman and her newborn receive the quality care they need. Having two qualified 

providers is especially important if either the woman or her newborn require additional care. 

Preparing the Delivery Room 

The following guidelines will be helpful in preparing the delivery room. 

• Ensure that the client care area is adequately prepared by: 

o placing waste products and contaminated objects (from the previous birth) into the 

appropriate containers. 

o wiping down surfaces with 0.5% chlorine solution. 

o tidying the area. 

o checking that the injection safety box is accessible and does not require changing. 

o making sure that buckets with 0.5% chlorine are available for decontamination and 

that the solution does not need to be changed. 

• Make sure that the woman’s bodily privacy is protected (curtains, doors that close, etc.); 

if permitted, ask the woman if she would like a companion with her during childbirth and 

facilitate that person’s presence in the delivery room. 

• Check that all needed equipment and instruments for delivery care, essential maternal 

and newborn care, newborn resuscitation, and adult resuscitation are available, clean, 

sterile/HLD, and in good working order and readily accessible. 

• Make sure that the room is warm (at least 25-28 °C/77.0-82.4 °F) and free from drafts 

from open windows and doors or from fans. This is especially true for the area in the 

room where newborns receive special care, such as resuscitation. Make sure that all of 

the windows are closed. 

• If the temperature of the room is less than optimal, a heater should be available to warm 

the room. In some circumstances, it might be easier to warm a small area of a room 

rather than the whole room. In hot weather, air conditioning or fans should be turned off 

or adjusted in the delivery room. 

• Make sure that supplies needed to keep the newborn baby warm are prepared. The 

supplies should include as a minimum: two absorbent pieces of cloth/towels large 

enough to cover a newborn baby's whole body and head, a cap, a sheet or blanket for 

covering mother and baby, and suitable baby clothes if feasible/acceptable. In cool 

weather, a source of heat should be available to pre-warm the clothes and towels. 

• Even though the care of a normal baby can be carried out while he/she is in skin-to-skin 

contact with the mother’s chest, it is important to have a “corner or area for the newborn” 

in the delivery room where all the equipment and supplies can be collected and kept 

together. Ideally there should be a heater/source of warmth under or near which the 

48 




linen and blanket for the baby can be kept for pre-warming before the delivery, and 

where resuscitation can be carried out. 

• Make sure that all surfaces the woman and baby will come in contact with are clean, 

warm, and dry. 

• Make sure the room is well-lit. 

• Review and complete the woman’s medical records (if available): 

o the antenatal care card (take special care to check the woman’s HIV status, and if 

she is infected with HIV, ask about her antiretroviral (ARV) regimen and if she has 

brought ARV drugs for her baby) 

o partograph 

o any other records she may have with her 

• Maintain cleanliness of the woman and her environment: 

o Encourage the woman to wash herself or bathe or shower at the onset of labor. 

o Put a clean, waterproof sheet under the woman’s bottom. 

o Clean the vulval and perineal areas before each examination. 

o Wash hands with soap before and after each examination. 

o Ensure cleanliness of laboring and birthing area(s). 

o Clean up all spills immediately. 

• Follow infection prevention practices to reduce exposure to blood and other body fluids 

during labor and delivery, and thereby help protect the woman and providers from 

infection: 

o Wash hands with soap and water and dry with a clean, dry cloth before examining 

each client; after examining each client; before putting on gloves for clinical 

procedures (such as a vaginal exam or examination of the placenta); after touching 

any instrument or object that might be contaminated with blood or other body fluids, 

or after touching mucous membranes; after handling blood, urine, or other 

specimens; after removing any kind of gloves; after using the toilet or latrine. 

o Wear protective clothing: sterile/HLD gloves, masks, gowns, and waterproof aprons, 

caps, eye covers/face shields. 

• During the first stage of labor, preferably in between contractions and before 

contractions are very intense: 

o Explain and offer AMTSL to the woman and obtain her permission to apply it. 

o Explain skin-to-skin contact and that the newborn will be placed first on her abdomen 

and then on her chest, and obtain her permission to do this. 

o Explain that essential newborn care will be provided while the baby is in skin-to-skin 

contact with her and obtain her permission; care includes placing an identification 

bracelet on the baby, eye and cord care, vitamin K1 injection, and early initiation of 

breastfeeding . 

Routine Care for the Woman in Labor 

Regardless of how the third stage of labor is managed, basic care for the woman and baby 

during labor and postpartum remains the same. The following actions represent the elements of 

essential care for the woman during labor. 



49

Supportive care during labor 

• Encourage the woman to have personal support from a person of her choice throughout 

labor and birth: 

o Encourage support from the chosen birth companion. 

o Arrange seating for the companion next to the woman. 

o Encourage the companion to give adequate support to the woman during labor and 

childbirth (rub her back, wipe her brow with wet cloth, assist her to move about). 

• Ensure good communication and support by staff: 

o Explain all procedures, seek permission, and discuss findings with the woman. 

o Provide a supportive, encouraging atmosphere for birth, respectful of the woman’s 

wishes. 

o Ensure privacy and confidentiality. 

• Ensure mobility: 

o Encourage the woman to move about freely. 

o Support the woman’s choice of position for birth. 

• Encourage the woman to empty her bladder regularly. 

Note: Do not routinely give an enema to women in labor. 

• Encourage the woman to eat and drink as she wishes. If the woman has visible severe 

wasting or tires during labor, make sure she is fed. Nutritious liquid drinks are important, 

even in late labor. 

• Teach breathing techniques for labor and delivery. Encourage the woman to breathe out 

more slowly than usual and relax with each expiration. 

• Help the woman in labor who is anxious, fearful, or in pain: 

o Give her praise, encouragement, and reassurance. 

o Give her information on the process and progress of her labor. 

o Listen to the woman and be sensitive to her feelings. 

If the woman is distressed by pain: 

• Suggest changes of position (Figure 5.1). 

• Encourage mobility. 

• Encourage her companion to massage her back or hold her hand and sponge her face 

between contractions. 

• Encourage breathing techniques. 

• Encourage a warm bath or shower. 

• If necessary, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV 

slowly or give morphine 0.1 mg/kg body weight IM. Do not give Pethidine (to avoid 

respiratory depression and birth asphyxia in the baby) if you envisage that the baby is 

likely to be delivered within 2 hours of administering the drug, especially not in peripheral 

centers since Naloxone (0.1mg/kg) that can be used to reverse the respiratory 

depressant effect of Pethidine may not be available. 

If the woman is infected with HIV, follow national protocols to prevent mother-to-child 

transmission of HIV/AIDS. 

50 




Figure 5.1. Positions that a woman may adopt during labor. (WHO, 2003) 

Monitor progress of the first stage of labor using the partograph 

Findings which suggest satisfactory progress in the first stage of labor are: 

• regular contractions of progressively increasing frequency and duration. 

• rate of cervical dilatation at least 1 cm per hour during the active phase of labor (cervical 

dilatation on or to the left of alert line). 

• cervix well applied to the presenting part. 

Findings which suggest unsatisfactory progress in first stage of labor are: 

• irregular and infrequent contractions after the latent phase, or 

• rate of cervical dilatation slower than 1 cm per hour during the active phase of labor 

(cervical dilatation to the right of alert line), or 

• cervix poorly applied to the presenting part. 

Use the partograph card (see Figure 5.2 below) to monitor progress of the first stage of labor. 

Unsatisfactory progress in labor can lead to prolonged labor (the woman has been 

experiencing labor pains for 12 hours or more without delivery). Be sure to transfer women 

immediately to a facility with operative facilities as soon as unsatisfactory progress has been 

identified. 

Other signs that indicate the woman is experiencing a complication include: 

• There is vaginal bleeding in labor and delivery. 

• The diastolic blood pressure is 90 mm Hg or more. 

• The woman complains of severe headache or blurred vision. 

• The woman is found unconscious or having convulsions. 

• The fetal heart rate is less than 100 or more than 180 beats per 

minute after a contraction. 

• Membranes have been ruptured for more than 12 hours before 

childbirth. 

• The woman has a fever. 

Follow national 

protocols for 

management 

and referral of 

complications. 



51

Figure 5.2. The modified WHO partograph. (WHO, 2003) 

52 




Supportive care during childbirth 

• Encourage the woman to have a companion with her who can provide support for her 

during childbirth. 

• Encourage the woman to assume the position she prefers. 

Figure 5.3. Positions that a woman may adopt during 

childbirth. (WHO, 2003) 

• Help the woman empty her bladder when the second stage is near. 

• Inform the woman of her baby’s sex and health status and provide information about the 

care you are providing her baby. 

• Make sure the woman is comfortable. 

Preparation for Care of the Baby at Birth 

The mother and her baby must, as far as possible, remain together. It is only when special care 

is required for one of them, where it is not safe to have the two together, that the baby should be 

looked after in a separate place. 

As noted earlier, it is ideal to have two qualified persons attending the delivery so that both the 

mother and baby can receive adequate care. This is particularly useful if either or both develop 

problems needing care. However, this is usually not feasible, especially at peripheral centers. 

However, with some advance planning one can explore training another staff member, even a 

less qualified person, to assist the skilled birth attendant to facilitate the latter in dealing with the 

key problems. 

Preparation of the newborn corner in the delivery room 

Ideally all items necessary for the baby should be kept in a designated area, the “newborn baby 

corner.” This corner can also be used to resuscitate an asphyxiated baby or provide any special 

care as required. This area should have a table and ideally an overhead heater/warmer. For 

normal babies not requiring special care, most routine care can be carried out on the baby 

placed on the mother’s chest. 

It is absolutely essential that the delivery room, including items for resuscitation (see chapter 8 

on resuscitation for birth asphyxia), is ready at all times. In addition it is mandatory that the staff 

on duty verify that this is so at the beginning of each day, every shift, and when called to attend 

a delivery. 

Make sure that all equipment, including those for resuscitation, is available, in functioning order, 

and clean or sterile as needed. 



53

Checklist to prepare for the care of the baby at birth 

Display the checklist of all required items on the wall near the table at eye level, framed with a 

glass cover or within a display or notice board to protect the paper. More details related to the 

equipment for resuscitation are noted in chapter 8 on resuscitation for birth asphyxia. The 

checklist should contain the following items: 

• A warm room with no drafts or open windows. 

• A table with a firm mattress covered with a washable surface such as a plastic or rubber 

sheet. Over this a clean, preferably sterile cloth/linen should be placed just before 

delivery. The clean/sterile equipment and supplies can be placed on it, leaving enough 

room for special care for the baby, such as resuscitation. 

• A source of heat. Ideally this should be an overhead heater (the heat source being a 

heating rod or a set of bulbs). A hot water bottle is not recommended as it may result in 

burns. If its use is unavoidable, make sure that the water is warm, not hot, and the bottle 

is wrapped in several layers of cloth. In addition, for extra safety check the skin of the 

baby in contact with the bottle frequently for excessive heat or redness. 

• Three to five pieces of clean, preferably sterile cloths to dry and wrap the baby (cap 

where available) and blanket where required. 

• A wall thermometer to monitor the room temperature. 

• A clinical thermometer to measure the axillary temperature. 

• Suction equipment (for details see chapter 8 on resuscitation): 

o De Lee mucous extractor or 

o Suction machine (electrical/foot operated) with simple suction catheters 8F and 10F. 

In the absence of a suction machine, a 10 mL syringe attached to the catheter can 

be used to remove the secretions. 

o If a rubber bulb is used for suction, it should be sterilized. It is not recommended to 

use the same bulb for multiple infants due to the risk of the transmitting major 

infections. 

• Newborn resuscitator bag (240-500 mL) with two baby face masks (#1 for normal size 

babies, # 0 for LBW babies). In general, where resources are limited, the 500 mL bag is 

preferable as it can be used for the normal weight and the larger proportion of low birth 

weight infants. 

• A supplemental oxygen source, if available. If cylinders are used, check that they have 

adequate oxygen. Note, however, that supplemental oxygen is not required for 

resuscitation in most cases. 

• A wall clock with second hand for noting the time of birth and where necessary to count 

the respiratory and heart rate if there is no timer or watch. In case of an emergency 

situation such as asphyxia, it is easy to lose track of time. It is important to note the time 

of birth and the time spent in the procedure, since there is a time limit to active 

resuscitation. If no respiration is noted after twenty minutes, it is necessary to stop all 

action. 

• A stethoscope where available. 

• Miscellaneous: sterile gauze/pieces of sterile cloth and gloves, either sterile or high-level 

disinfected. 

All equipment has to be disinfected and cleaned after use. The manufacturer gives specific 

instructions for cleaning, disinfection, and sterilization of equipment. Follow these instructions 

carefully. 

54 




Advance preparation for skin-to-skin contact between baby and mother and early 

breastfeeding 

Close contact between the mother and baby after birth will promote temperature maintenance 

and breastfeeding. Hence, where the mother and baby are normal, it is good for the baby to be 

kept with the mother in skin-toskin contact. In fact, most of the care that a normal baby 

requires can be carried out while he/she is with the mother, initially on her abdomen and later, 

after the cord is cut, on her chest. Because some centers may not have been following this 

practice, mothers may not be aware of these steps or be prepared for them. To get the mother’s 

acceptance and cooperation, it is essential that these plans are discussed with the mother 

before delivery so that she is prepared for them; otherwise, there may be some challenges in 

implementing these steps. 

ESSENTIAL NEWBORN CARE 

The initial steps in the care of the baby at birth, such as drying, wrapping, and evaluation of 

breathing, are similar for all babies. Subsequent care, however, may be different if there are 

problems such as birth asphyxia. 

Dry the Infant 

• Place the infant on the abdomen of the mother. 

• Wipe the face and dry the baby thoroughly immediately after birth and discard the wet 

cloth. Do not let the baby remain wet, as this will cool the body and make him/her 

hypothermic. 

• Let the baby stay prone in skin-to-skin contact on the abdomen and cover the baby 

quickly, including the head, with a fresh dry cloth. 

Figure 5.4. Initial steps in the care of the baby at birth. 



55

Evaluate Breathing 

• Check if the baby is crying while drying him/her. 

• If the baby does not cry, see if the baby is breathing properly. 

• If the baby is not breathing and/or is gasping: 

o Call for help. The assistant can provide basic care for the mother while you provide 

the more specialized care for the baby who is not breathing. 

o Cut the cord rapidly and start resuscitation as described in chapter 8 on 

resuscitation. 

o If the baby breathes well, continue routine essential newborn care. 

• Do not do suction of the mouth and nose as a routine. Do it only if there is meconium, 

thick mucous, or blood. 

• Announce the time of birth and the sex of the infant after you have made certain that the 

baby is breathing well. 

Prevent Hypothermia 

Keep the baby warm by placing him/her in skin-to-skin contact on the mother’s abdomen. 

Cover the baby’s body and head with a cloth. If the room is cool (


• Cutting the cord: Squeeze the cord at the site where it is to be cut to flatten it, but do not 

milk the cord, especially towards the baby. Cut the cord with sterile scissors or a scalpel 

blade, under a piece of gauze in order to avoid splashing of blood. At every delivery, a 

pair of scissors or a scalpel with blade should be designated for this purpose. If an 

episiotomy is performed, use a different pair of scissors for cutting the cord. 

• Tying the cord: Tie the cord firmly with sterile ligatures after the mother and baby are 

stable and after implementation of AMTSL. In finally tying the cord, make sure that it is 

tied tightly with 2-3 knots, about two fingers (about 2-3 cm) from the baby’s abdomen 

and cut the cord 2 cm from the ligature. Check for bleeding/oozing and retie if 

necessary. The cord may be tied by using sterile cotton ties, elastic bands, or presterilized 

disposable cord clamps (see Figure 5.6). 

• Advise the mother not to cover the cord with the diaper. 

• Counsel the family not to apply harmful substances such as clay, herb mixtures, or 

butter on the cord. 

• If recommended by the Ministry of Health, apply an antiseptic on the umbilical stump 

after washing hands with soap and water. In such cases, demonstrate to the mother 

before she leaves the facility how to apply the antiseptic on the cord, including the base. 

Eye Care 

Figure 5.6. Use of a pre-sterilized disposable cord clamp. 

• Apply prophylactic eye drops as recommended by the Ministry of Health (tetracycline 

ophthalmic drops or ointment). 

• Apply prophylactic drops or ointment as follows: 

o Wash your hands with soap and water if not washed earlier. 

o Place the infant on the back. 

o Clean the baby’s eyes by swabbing each eye separately with a sterilized cotton swab 

or cloth (boiled for 10 minutes and then cooled). 

o Hold one eye open or depress the lower eyelid, allow one drop of medication to fall 

into the eye. If using ointment, put a ribbon of ointment along the inside of the lower 

eyelid. Repeat the procedure on the other eye. 

o Make sure the tip of the dropper or the tube does not touch the baby’s eyes or other 

objects. 



57

Assess for Major Defects 

The following defects may need special inputs at birth: 

• cleft lip and palate. The mother will need additional support for feeding; she may need to 

give expressed breast milk with a small cup. 

• esophageal atresia (usually associated with excessive secretion in the mouth) 

• “open” spinal defects 

• imperforate anus 

The last three conditions need urgent referral to appropriate hospitals for surgery. 

Give Vitamin K1 

Give vitamin K1 intramuscular (1 mg for term infant and 0.5 mg for the very low birth weight 

infant


Place an Identification Label on the Baby 

Place the identification tag /label on the wrist and ankle (as recommended by the Ministry of 

Health). If a ready-made disposable identification is not available, prepare one locally using 

sticking plaster and gauze strips. Note, at a minimum, the names of the mother and, if available, 

the father, and the date and time of birth. 

Early, Exclusive Breastfeeding 

• Inform the mother about the importance of colostrum and encourage her to initiate 

breastfeeding early within one hour of birth, without giving the baby any other milks, fluids, 

or foods. 

• Tell the mother to breastfeed the baby frequently and on demand, day and night (about 8-10 

times in 24 hours). 

• Advise the mother not to use pacifiers. 

• Assist the mother to breastfeed the baby within the first hour after the birth/before 

transferring out of the delivery room. Help the mother to find as comfortable a position as 

feasible. Some of the steps noted below may need to be modified depending on the type of 

table available in the delivery room. Make sure that: 

o The baby’s whole body is fully supported and held close at the level of the breast and 

turned toward the mother. 

o The mother, if possible, holds the breast with thumb on top and other fingers at the 

bottom without touching the nipple. 

o When the baby opens his/her mouth widely, the nipple and most of the surrounding 

areola are introduced into the mouth. 

o The baby’s nose is not blocked by the breast tissue. 

o The mother does not feel pain in the nipple when the baby sucks. If she does, show her 

how to release the nipple from the baby’s mouth (by gently depressing the baby’s chin) 

and reintroduce the nipple after the pain subsides. 

o That attachment at the nipple is appropriate (see Figure 5.7 below). 

o Unrestricted time is allowed for the feeding. 

Signs of a proper attachment: 

• The baby’s chin is touching or nearly 

touching the breast. 

• The mouth is wide open. 

• The lower lip is everted (turned outward). 

• Most of the areola is inside the mouth, 

especially the part below so that the areola 

is visible more above the mouth than 

below. 

• The sucking is slow and deep and 

swallowing is audible. 

Figure 5.7. Signs of proper attachment at the breast. (WHO, 2003) 



59

Weigh the Baby and Record the Weight 

• Take the weight when the baby is stable and warm. 

• Place a clean cloth or paper on the pan of the weighing scale. 

• Adjust the weight so it reads “zero” with the paper/cloth on it. 

• Place the baby over the pan. If a cloth was used, fold it to cover the body of the baby. 

• Note the weight when the baby and pan are not moving. 

• Never leave the baby unattended on the scale. 

• Write down the weight of the baby in the partograph/maternal/baby charts and in the 

delivery room registers as recommended by the Ministry of Health. 

• Return the baby to skin-to-skin contact with the mother. 

Keep the Mother and Baby Together 

If no emergency care is required, keep the baby warm by putting her/him in skin-to-skin contact 

with the mother and covering both with a clean cloth/blanket as required. If the baby cannot be 

in skin-to-skin contact with the mother due to issues such as a Cesarean operation, an ill 

mother, or an ill baby, then wrap her/him with a clean dry cloth and/or blanket, taking care to 

cover the head, and keep the baby away from drafts. 

Note: Never leave the woman and newborn alone soon after delivery. 

Avoid separating the mother and the baby. 

Counsel the Mother and Family 

Counsel the mother before she leaves the delivery room. However, if she is very tired after 

delivery, only talk to her about the key points noted below. 

• Keep the baby warm. 

• Continue breastfeeding frequently on demand day and night. 

• Do not give any other fluids/food to the baby. 

• Do not apply any harmful substances on the cord, such as ash or herbal preparations. 

More detailed counseling can be done in the postnatal period in the facility before the mother is 

discharged and at subsequent postnatal visits. The major issues are noted in chapter 10 on 

postnatal care. 

60 




If the mother’s HIV status is positive: 

• Take particular care not to suction the mouth and the nose unless it is absolutely 

necessary. 

• Consider swabbing the whole body of the baby with chlorhexidine (0.25%) swabs/wipes as 

recommended by the Ministry of Health. 

• Administer ARV prophylaxis (niverapine and AZT or others as recommended by the 

Ministry of Health). 

• Infant feeding options for mothers whose HIV status is positive include the following: 

o exclusive breastfeeding, taking care to avoid problems such as engorged breasts 

and sore nipples, until six months, followed by rapid switch to formula feeds and 

complementary feeding with semi-solids. 

o use of expressed breast milk (EBM) rendered safe by flash heating of the milk (see 

below), continued with complementary feeds with semisolids from the age of six 

months (see chapter 11 on breastfeeding). 

o use of formula feeds with complementary feeds from birth with semi-solids from the 

age of six months. Formula feeds are applicable when replacement feeding is 

acceptable, feasible, affordable, sustainable, and safe (AFASS); avoidance of all 

breastfeeding by HIV-infected women is recommended. (WHO, 2009) 

• The actual type of feeding will depend on the mother’s choice. You as the health care 

provider should ensure that she is given the counseling and support she needs. 

• It is important to stress the dangers of “mixed” feeding (breast milk and formula). 

Table 5. Key Steps for Immediate Care of the Newborn 

(The order may be changed according to the local needs, except for steps 1-3.) 

Step 1 Dry the baby and keep him/her warm by placing the baby on the mother’s 

abdomen. 

Step 2 Assess breathing. Make sure the baby is breathing well. 

Step 3 If the baby does not breathe, clamp/tie and cut the cord immediately and start 


If the baby does cry/breathes well, clamp/tie and cut the cord after pulsations 

stop or after 2-3 minutes. 

Step 4 Place the infant in skin-to-skin contact on the mother’s chest and cover both with 

clean linen and blanket as required. Carry out all the steps noted below up to #9, 

preferably with the baby on the mother’s chest. 

Step 5 Administer eye drops/eye ointment. 

Step 6 Administer vitamin K1. 

Step 7 

Step 8 

Step 9 

Step 10 

Note 

Place the baby identification bands on the wrist and ankle. 

Initiate breastfeeding within the first hour. 

Select the appropriate method of feeding for the HIV-infected mother, based on 

informed choice. 

Weigh the infant when he/she is stable. 

Record observations and treatment provided in the registers/appropriate 

chart/cards. 

Defer the bath for at least six hours. 

Clean the newborn of an HIV-infected mother as recommended by the Ministry of 

Health. 



61

CARE DURING THE THIRD STAGE OF LABOR 

The third stage of labor is usually uneventful, with delivery of the placenta taking place without 

complications. During this stage of labor, however, the woman may encounter complications 

that could lead to maternal morbidity and mortality. The most common complication is 

postpartum hemorrhage or vaginal bleeding in excess of 500 mL that occurs less than 24 hours 

after childbirth. (See chapter 4 for more information on PPH.) 

PPH may cause or worsen anemia or deplete iron stores in women, causing weakness and 

fatigue. If severe, PPH may result in shock or maternal death. A blood transfusion may help 

improve anemia in women and shorten hospital stays, but transfusion carries risks of reaction 

and infection and is not universally available. Because many health facilities lack an adequate 

supply of safe blood, PPH can often strain the resources of the best blood banks. 

PPH may increase the likelihood of other issues: 

• The need for emergency anesthetic services. 

• Manual exploration or use of instruments inside the uterus (increasing the risk of sepsis). 

• Prolonged hospitalization. New studies show that extended hospitalizations can cause 

significant and long-term financial hardships for the woman and her family. 

• Delayed breastfeeding. 

Additionally, women who have severe PPH and survive (“near misses”) are significantly more 

likely to die in the year following the PPH. 

Length of the Third Stage 

Considerable research has examined how active management affects the third stage of labor. 

Investigations found that 50 percent of placental deliveries occur within five minutes, and 90 

percent are delivered within 15 minutes. Other large studies confirm the rapid delivery of the 

placenta; a WHO study found a mean delivery time of 8.3 minutes. A third stage of labor lasting 

longer than 18 minutes is associated with a significant risk of PPH. When the third stage of labor 

lasts longer than 30 minutes, PPH occurs 6 times more often than it does among women whose 

third stage lasted less than 30 minutes. 

Description of Active Management of the Third Stage of Labor (AMTSL) 

The majority of PPH occurs during the third stage of labor. During this stage, the muscles of the 

uterus contract, helping the placenta to separate from the uterine wall. The amount of blood lost 

depends on how quickly this happens, since the uterus can contract more effectively after the 

placenta is expelled. The third stage of labor lasts between 5 and 15 minutes. If the third stage 

lasts longer than 30 minutes, it is considered to be prolonged and is associated with 

complications. If the uterus does not contract normally (such as in uterine atony) after the 

placenta is delivered, the blood vessels at the placental site stay open and hemorrhage results. 

Because the estimated blood flow to the uterus is 500 to 800 mL/minute at term, most of which 

passes through the placenta, severe postpartum hemorrhage can happen within just a few 

minutes. 

Active management of the third stage of labor (AMTSL) is a combination of actions performed 

during the third stage to speed delivery of the placenta and prevent uterine atony by increasing 

uterine contractions. The components of AMTSL are: 

• Administration of a uterotonic drug within one minute after the baby is born (oxytocin is 

the uterotonic of choice) and a second baby has been ruled out. 

62 




• Controlled cord traction (CCT) with simultaneous countertraction to the uterus. 

• Uterine massage immediately after delivery of the placenta. 

Current evidence indicates active management of the third stage of labor (administration of 

uterotonic drugs, controlled cord traction, and fundal massage after delivery of the placenta) can 

reduce the incidence of postpartum hemorrhage by up to 60 percent in situations where: 

• National guidelines support the use of AMTSL (active management of the third 

stage of labor). 

• Health workers receive training in using AMTSL and administering uterotonic 

drugs. 

• Injection safety is ensured. 

• Necessary resources (uterotonic drugs and cold chain for storage of 

uterotonic drugs; equipment, supplies, and consumables for infection 

prevention and injection safety) are available. 

Skilled birth attendants all over the world can play an important role in preventing unnecessary 

maternal deaths by applying this simple, low cost, evidence-based intervention. 

Approaches for Managing the Third Stage 

There are two main approaches for managing the third stage of labor: the physiologic (or 

expectant) approach and the active approach. Table compares how the third stage is 

managed using each of these approaches. 



63

Uterotonic 

Signs of placental 

separation 

Delivery of the 

placenta 

Uterine massage 

Advantages 

Disadvantages 

Table 6. Comparison of Physiologic and Active Management 

of the Third Stage of Labor (AMTSL)4 

Physiologic (expectant) 

management 

Uterotonic is not given before 

the placenta is delivered. 

Wait for signs of separation: 

• gush of blood 

• lengthening of cord 

• uterus becomes rounder and 

smaller as the placenta 

descends 

Placenta delivered by gravity 

assisted by maternal effort. 

Massage the uterus before the 

placenta is delivered. 

• Does not interfere with normal 

labor process. 

• Does not require special 

drugs/supplies. 

• May be appropriate when 

immediate care is needed for 

the baby (such as 

resuscitation) and no trained 

assistant is available. 

• May not require a birth 

attendant with injection skills. 

• The length of the third stage is 

longer compared to AMTSL. 

o Blood loss is greater 

compared to AMTSL. 

o Increased risk of PPH. 

Active management 

Uterotonic is given within one 

minute of the baby’s birth (after 

ruling out the presence of a 

second baby). 

Do not wait for signs of 

placental separation. Instead: 

• Palpate the uterus for a 

contraction. 

• Wait for the uterus to contract. 

• Apply CCT with 

countertraction. 

Placenta delivered by controlled 

cord traction (CCT) while 

supporting and stabilizing the 

uterus by applying countertraction. 

Massage the uterus after the 

placenta is delivered. 

• Decreases the length of the 

third stage. 

• Decreases the likelihood of 

prolonged third stage. 

• Decreases average blood loss. 

• Decreases the number of PPH 

cases. 

• Decreases the need for blood 

transfusion. 

• Requires uterotonic drugs and 

items needed for 

injection/injection safety. 

• Requires a birth attendant with 

experience and skills giving 

injections and using CCT. 

(The definition of active management as described in this table differs from the original research protocol 

in the Bristol and Hinchingbrooke trials because the original protocols included immediate cord clamping 

and did not include massage of the uterus. In the Hinchingbrooke trial, midwives used either CCT or 

maternal effort to deliver the placenta.) 

4 Rogers J, et al. 1998. Active versus expectant management of the third stage of labour: the 

Hinchingbrooke randomized controlled trial. Lancet 351:693–699. 

64 




Scientific evidence supporting AMTSL 

Giving a uterotonic drug to prevent PPH promotes strong uterine contractions and leads to 

faster retraction and placental separation and delivery. Several large, randomized controlled 

trials have investigated whether physiologic management or active management is more 

effective in preventing PPH. These trials have consistently shown that active management 

provides several benefits for the mother compared to physiologic management. Table 7 

provides detailed results from two important studies comparing active and physiologic 

management of the third stage of labor. 

These results show that only 12 women need to receive AMTSL to prevent one case of PPH. 

This means that AMTSL is a very effective and cost-efficient public health intervention. These 

studies also confirm that AMTSL decreases: 

PPH 

• the incidence of PPH 

• the length of the third stage of labor 

• the percentage of third stages of labor lasting longer than 30 minutes 

• the need for blood transfusion 

• the need for uterotonic drugs to manage PPH 

Table 7. Bristol and Hinchingbrooke Study Results Comparing Active and 

Physiologic Management of the Third Stage of Labor 

Factors 

Study 

Active 

Management 

Physiologic 

Bristol 5 5.9% 17.9% 

Hinchingbrooke 6.8% 16.5% 

Average length of the third stage Bristol 5 minutes 15 minutes 

of labor Hinchingbrooke 8 minutes 15 minutes 

Third stage of labor longer than Bristol 2.9% 26% 

30 minutes Hinchingbrooke 3.3% 16.4% 

Blood transfusion needed 

Bristol 2.1% 5.6% 

Hinchingbrooke 0.5% 2.6% 

Additional uterotonic drugs Bristol 6.4% 29.7% 

needed to manage PPH Hinchingbrooke 3.2% 21.1% 

5 Prendiville et al. 1988. The Bristol third stage trial: active versus physiological management of the third 

stage of labour. BMJ, 297: 1295–1300. 



65

Preparing for Active Management 

Before or during the second stage of labor: 

• Prepare the injectable uterotonic (10 IU of oxytocin is the 

preferred injectable uterotonic) in a sterile syringe before 

second stage (Figure 5.8) or have oxytocin in Uniject or 

600 mcg of misoprostol available. 

• Prepare other essential equipment and supplies for birth, the 

third stage of labor, and the care of the baby, including 

resuscitation, before onset of the second stage of labor. 

• Ask the woman to empty her bladder when the second stage 

is near. 

• Assist the woman into her preferred position for giving birth 

(e.g., squatting, semi-sitting). 

Figure 5.8. Preparing oxytocin injection. 

(Gomez et al., 2005) 

Steps for AMTSL 

There are three main components or steps of AMTS—administering a uterotonic drug, CCT, 

and massaging the uterus—which should be implemented along with the provision of immediate 

newborn care. Before reading this part of the Reference Manual, watch the DVD “AMTSL: A 

demonstration.” If you can’t watch it at this time, continue with your reading but try to watch it at 

some other time before you begin practicing AMTSL. 

1. Thoroughly dry the baby, assess the baby’s breathing and perform resuscitation if 

needed, and place the baby in skin-to-skin contact with the mother. 

Figure 5.9. Put the baby on the mother’s 

abdomen. (POPPHI, 2007) 

After delivery, immediately dry the infant and assess the 

baby’s breathing. Then place the reactive infant, prone, on 

the mother’s abdomen.* Remove the cloth used to dry the 

baby and keep the infant covered with a dry cloth or towel to 

prevent heat loss. 

*If the infant is pale, limp, or not breathing, it is best to keep 

the infant at the level of the perineum to allow optimal blood 

flow and oxygenation while resuscitative measures are 

performed. Early cord clamping may be necessary if 

immediate attention cannot be provided without clamping 

and cutting the cord. 

66 




2. Administer a uterotonic drug within one minute of the baby’s birth. 

Administering a uterotonic drug within one minute of the baby’s birth stimulates uterine 

contractions that will facilitate separation of the placenta from the uterine wall. Before giving the 

uterotonic drug, it is important to rule out the presence of another baby. If the uterotonic drug is 

administered when there is a second baby, there is a small risk that the second baby could be 

trapped in the uterus. 

The steps for administering a uterotonic drug include: 

1. Before performing AMTSL, gently palpate the 

woman’s abdomen (Figure 5.10) to rule out the 

presence of another baby. At this point, do not 

massage the uterus. 

Figure 5.10. Rule out the presence of a 

second baby. (POPPHI, 2007) 

2. If there is not another baby, begin the procedure by 

giving the woman 10 IU of oxytocin IM in the upper 

thigh (Figure 5.11). This should be done within one 

minute of childbirth. If available, a qualified assistant 

should give the injection. 

Figure 5.11. Give a uterotonic drug. 

(POPPHI, 2007) 

3. Cut the umbilical cord. 

Clamp and cut the cord (Figure 5.12) following strict hygienic techniques after cord pulsations 

have ceased or approximately 2-3 minutes after the birth of the baby, whichever comes first. 

Figure 5.12. Pulsating and nonpulsating umbilical cord. (POPPHI, 2007) 



67

4. Keep the baby warm. 

Place the infant directly on the mother’s chest, prone, 

with the newborn’s skin touching the mother’s skin 

(Figure 5.13). While the mother’s skin will help 

regulate the infant’s temperature, cover both the 

mother and infant with a dry, warm cloth or towel to 

prevent heat loss. Cover the baby’s head with a cap 

or cloth. 

Figure 5.13. Keep the baby in skin-to-skin 

contact. (POPPHI, 2007) 

5. Perform controlled cord traction. 

CCT helps the placenta descend into the vagina after it has separated from the uterine wall 

and facilitates its delivery. It is important that the placenta be removed quickly once it has 

separated from the uterine wall because the uterus cannot contract efficiently if the placenta is 

still inside. CCT includes supporting the uterus by applying pressure on the lower segment of 

the uterus in an upward direction towards the woman’s head, while at the same time pulling with 

a firm, steady tension on the cord in a downward direction during contractions. Supporting or 

guarding the uterus (sometimes called “counter-pressure” or “countertraction”) helps prevent 

uterine inversion during CCT. CCT should only be done during a contraction. 

Note: CCT is not designed to separate the placenta from the uterine wall 

but to facilitate its expulsion only. If the birth attendant keeps pulling on an 

unseparated placenta, inversion of the uterus may occur. 

The steps for CCT include: 

1. Wait for cord pulsations to cease or approximately 2-3 minutes after birth of the 

baby, whichever comes first, and then place one clamp 4 cm from the baby’s 

abdomen. 

Note: Delaying cord clamping allows for transfer of red blood cells from 

the placenta to the baby that can decrease the incidence of anemia 

during infancy. 

2. Gently milk the cord towards the woman’s perineum and place a second clamp 

on the cord approximately 2 cm from the first clamp. 

3. Cut the cord using sterile scissors under cover of a gauze swab to prevent blood 

spatter. After the mother and baby are safely cared for, tie the cord. 

68 




4. Place the clamp near the woman’s perineum to make CCT easier (Figure 5.14). 

Figure 5.14. Clamping the umbilical cord near the perineum. (Gomez, et al, 2005) 

5. Hold the cord close to the perineum 

using a clamp. (Figure 5.15) 

6. Place the palm of the other hand on the 

lower abdomen just above the woman’s 

pubic bone to assess for uterine 

contractions (Figure 5.15). If a clamp is 

not available, controlled cord traction 

can be applied by encircling the cord 

around the hand. 

Figure 5.15. Palpate the next contraction. 


7. Wait for a uterine contraction. Only do CCT when there is a contraction. 



69

8. With the hand just above the pubic bone, apply external pressure on the uterus in 

an upward direction (toward the woman’s head) (Figure 5.16). 

9. At the same time with your other hand, 

pull with firm and steady tension on the 

cord in a downward direction (follow 

the direction of the birth canal). Avoid 

jerky or forceful pulling. 

Figure 5.16. Applying CCT with 

countertraction to support the uterus. (POPPHI, 2007; Gomez, et al, 2005) 

If the placenta does not descend during 30-40 seconds of controlled cord traction (i.e. 

there are no signs of placental separation), do not continue to pull on the cord: 

• Gently hold the cord and wait until the uterus is well contracted again. If 

necessary, use a sponge forceps to clamp the cord closer to the perineum as it 

lengthens; 

• With the next contraction, repeat controlled cord traction with countertraction. 

10. Do not release support on the uterus 

until the placenta is visible at the 

vulva. Deliver the placenta slowly 

and support it with both hands 

(Figure 5.17). 

Figure 5.17. Supporting the placenta with both hands. 


70 




11. As the placenta is delivered, hold and gently turn it with both hands until the 

membranes are twisted (Figure 5.18). 

12. Slowly pull to complete the delivery. Gently move membranes up and down until 

delivered (Figure 5.18). 

Figure 5.18. Delivering the placenta with a turning and up-and-down motion. 

(POPPHI, 2007; ANCM, 2008) 

Note: If the membranes tear, gently examine the upper vagina 

and cervix wearing high-level disinfected or sterile gloves and use 

a sponge forceps to remove any pieces of remaining membrane. 

6. Massage the uterus. 

Massage the uterus immediately after delivery 

of the placenta and membranes until it is firm 

(Figure 5.19). Massaging the uterus stimulates 

uterine contractions and helps to prevent PPH. 

Sometimes blood and clots will be expelled 

during this process. After stopping massage, it 

is important that the uterus does not relax 

again. 

Figure 5.19. Massaging the uterus immediately after the placenta delivers. (POPPHI, 2007) 



71

Instruct the woman how to massage her own uterus, and ask her to call if her uterus becomes 

soft (Figure 5.20). 

Figure 5.20. Teach the woman how to 

massage her own uterus. (POPPHI, 2007) 

Care after delivery of the placenta 

7. Examine the placenta. 

Examine the fetal and maternal sides of the placenta and membranes to ensure they are 

complete. A small amount of placental tissue or membranes remaining in the woman can 

prevent uterine contractions and cause PPH. 

Note: Follow infection prevention guidelines when handling 

contaminated equipment, supplies, and sharps. 

1. To examine the placenta for completeness hold the placenta in the palms of the 

hands with the maternal side facing upward and make sure that all lobules are 

present and fit together (Figure 5.21). 

Figure 5.21. Examining the maternal side of the placenta. 

(Gomez, et al, 2005) 

72 




2. Hold the cord with one hand, allowing the placenta and 

membranes to hang down. Place the other hand inside 

the membranes, spreading your fingers to ensure that 

membranes are complete (Figure 5.22). 

3. Dispose of the placenta as appropriate. 

8. Examine the lower vagina and perineum. 

Figure 5.22. Checking the membranes. 

(Gomez et al, 2005) 

1. Gently separate the labia and inspect the lower 

vagina and perineum for lacerations that may 

need to be repaired to prevent further blood loss 

(Figure 5.23). 

2. Repair lacerations or episiotomy. 

Figure 5.23. Gently inspect the lower vagina and 

perineum for lacerations. (POPPHI, 2007) 

3. Gently cleanse the vulva, perineum, buttocks, and back with warm water and a clean 

compress. 

4. Apply a clean pad or cloth to the vulva. 

5. Evaluate blood loss. 

6. Explain all examination findings to the woman and, if she desires, her family. 



73

9. Provide immediate care. 

After examining the placenta and external genitals, continue caring for the mother and newborn. 

If the woman has chosen to breastfeed, the 

mother and baby may need assistance to 

breastfeed within the first hour after the birth 

and before transferring them out of the 

delivery room (Figure 5.24). Assess the 

readiness of the woman and newborn to 

breastfeed before initiating breastfeeding; 

do not force the mother and baby to 

breastfeed if they are not ready. 

Figure 5.24. Encourage breastfeeding within the first 

hour after birth. (POPPHI, 2007) 

Also ensure that: 

• Infection prevention practices are strictly followed. 

• The baby is kept warm. 

• The mother and baby are kept together. 

• The mother and baby are not left alone. 

• The woman and baby stay in the delivery room for at least one hour after delivery of the 

placenta. 

• PMTCT interventions are provided per national guidelines. 

• AMTSL practices are recorded as required by local protocols (on the partograph, 

woman’s chart, or delivery log). 

• The woman receives information about how she will be cared for during the next few 

hours. 

• The woman is given a chance to ask questions and receive information about her 

queries and concerns. 

10. Monitor the woman and newborn immediately after delivery 

of the placenta. 

During the first two hours after the delivery of the placenta, monitor the woman at least every 15 

minutes (more often if needed). Perform a comprehensive examination of the woman and 

newborn one and six hours after childbirth. Continue with routine care for the woman and 

newborn, provide interventions to prevent/reduce the risk of MTCT of HIV according to national 

guidelines, and follow applicable requirements for recording information about the birth, 

monitoring of the woman and newborn, and any care provided. 

74 




Managing the Third Stage When the Birth Attendant Is Alone and the Baby Needs 

Resuscitation 

There is a potential “conflict of interest” in caring for the mother and baby when the baby needs 

resuscitation. How the provider cares for each one will depend upon several factors: if the birth 

attendant is alone or has an assistant and what type of resuscitative efforts are required for the 

baby. 

If the birth attendant is alone and the baby is not breathing or is gasping at birth, the birth 

attendant will manage the third stage of labor as follows: If the baby begins breathing after 

stimulation, active management of the third stage of labor will most likely be possible. Place the 

baby in such a position that you can observe him/her during implementation of AMTSL: 

1. Administer a uterotonic drug within one minute after the baby is born (oxytocin is the 

uterotonic of choice) and a second twin has been ruled out. 

2. Apply controlled cord traction with simultaneous countertraction to the uterus. 

3. Perform uterine massage immediately after delivery of the placenta. 

If the baby requires resuscitation with bag and mask, there are two possible scenarios: 

Scenario 1: The provider is alone but is able to administer a uterotonic drug within one 

minute after birth of the baby: 

1. Administer a uterotonic drug within one minute after the baby is born (oxytocin 10 IU 

IM or misoprostol 600 mcg by mouth) and a second twin has been ruled out. 

2. Deliver the placenta either by maternal effort or with assistance of the provider. 

3. Perform uterine massage immediately after delivery of the placenta. 

Scenario 2: The provider is alone and is not able to administer a uterotonic drug within 

one minute after birth of the baby: 

1. Perform physiologic management of the third stage of labor. 

2. Perform uterine massage immediate after delivery of the placenta. 

Managing the Third Stage When the Woman Is Infected with HIV 

The practice of AMTSL is the same for all women regardless of their HIV status. However, 

women who are HIV-infected may choose not to breastfeed, so providers need to respect and 

support the woman’s choice for infant feeding. In addition, providers need to ensure that 

national guidelines for PMTCT are implemented for the woman and newborn in addition to 

routine care during labor, childbirth, and in the immediate postpartum. 

Recommendations for Selecting a Uterotonic Drug to Prevent PPH 

In the context of active management of the third stage of labor, if all injectable uterotonic drugs 

are available: 

• Skilled attendants should offer oxytocin to all women for prevention of PPH in preference 

to ergometrine/methylergometrine. This recommendation places a high value on 

avoiding adverse effects of ergometrine and assumes similar benefit for oxytocin and 

ergometrine for preventing PPH. 

• Skilled attendants should offer oxytocin for prevention of PPH in preference to oral 

misoprostol (600 mcg). This recommendation places a high value on the relative benefits 

of oxytocin in preventing blood loss compared to misoprostol, as well as the increased 

adverse effects of misoprostol compared to oxytocin. 



75

In the context of active management of the third stage of labor, if oxytocin is not available but 

other injectable uterotonics are available: 

• Skilled attendants should offer ergometrine/methylergometrine or the fixed drug 

combination of oxytocin and ergometrine to women without hypertension or heart 

disease for prevention of PPH. 

• Skilled attendants should offer 600 mcg misoprostol orally for prevention of PPH to 

women with hypertension or heart disease for prevention of PPH. 

In the context of prevention of PPH, if oxytocin is not available or the birth attendants’ skills are 

limited, misoprostol should be administered soon after the birth of the baby. The usual 

components of giving misoprostol include: 

• Administration of 600 mcg misoprostol orally after the birth of the baby. 

• Controlled cord traction only when a skilled attendant is present at the birth. 

• Uterine massage after the delivery of the placenta as appropriate. 

76 




CHAPTER 6: Monitoring the Woman and Newborn 

during the First Six Hours Postpartum 

The first six hours after childbirth is a critical period for maternal and newborn health and 

survival, and providers need to carefully monitor the woman and her newborn to detect and 

appropriately manage complications in a timely manner. Early recognition of danger signs by 

providers, women, and families and timely, appropriate management of complications could 

significantly reduce the incidence of maternal and newborn death and disability. 

The woman and her newborn should remain in the delivery room for at least one hour after 

delivery of the placenta, and for longer periods as necessary. After this, they should be 

transferred to an area where they can continue to be closely monitored for at least an additional 

five hours. If at all possible, women and newborns should not be discharged from the facility 

before 12 hours after delivery of the placenta. 

MONITORING THE WOMAN 

PPH is the most important single cause of maternal death in the world, and the majority of these 

deaths (88 percent) occur within four hours of delivery, indicating that they are a consequence 

of events in the third stage of labor. It is therefore imperative that the provider carefully monitor 

the woman to assess if the uterus is well contracted and how much the woman is bleeding 

during the hours following childbirth. 

During the first hour after delivery of the placenta, while the woman is still in the delivery room, 

the provider should monitor the following parameters at least every 15 minutes (more often if 

needed): 

• Uterine contraction: 

o Palpate the uterus to check for firmness. 

o Massage the uterus until firm. (Ask the woman to 

call for help if bleeding increases or her uterus gets 

soft.) 

o Ensure the uterus does not become soft after 

massage is stopped. 

o Instruct the woman how the uterus should feel and 

how she can massage it herself. 

• Before beginning, explain 

what you will be doing to the 

woman. 

• If all vital and other signs 

are normal, reassure the 

woman. If they are not 

normal, act immediately. 

• Vaginal bleeding 

• Blood pressure and pulse 

Note: Action should be taken immediately to evaluate and treat 

PPH if excessive bleeding is detected. 

During this time the provider will also: 

• ensure the woman has sanitary napkins or clean material to collect vaginal 

blood. 

• encourage the woman to eat, drink, and rest. 



77

• facilitate breastfeeding. 

• encourage the woman to empty her bladder and ensure that she has passed 

urine. 

• ensure the room is warm (25 °C). 

• ask the woman’s companion to watch her and call for help if bleeding or pain 

increases, if the woman feels dizzy or has severe headaches, visual 

disturbance, or epigastric distress. 

• keep the mother and baby together. 

• never leave the woman and newborn alone. 

• document all findings and care provided. 

Just prior to transfer out of the delivery room or at least one hour after childbirth, ideally the 

provider should perform a comprehensive exam of the woman. 

Monitoring the Woman 1-6 Hours after Delivery of the Placenta 

During the next five hours the woman and newborn should be placed in an area where 

providers can easily continue to monitor their condition. During hours 1 to 5 after delivery of the 

placenta, the provider will monitor the woman as follows: 

• Uterine contraction, vaginal bleeding, 

blood pressure, and pulse: 

o every 15 minutes for 1 hour 

o then every 30 minutes for the third 

hour 

o then every hour for three hours 

Danger Signs: BP, pulse, vaginal bleeding, 

and uterus 

• Diastolic BP ≥90 mmHg 

• Systolic BP 110 beats/minute 

• Pad soaked in less than 5 minutes 

• Constant trickle of blood 

• Estimated blood loss of 250 mL or more or a woman 

who gave birth at home and presents with persistent 

vaginal bleeding 

• Uterus is neither hard nor round 

• Genital laceration extending to the anus or rectum 

Danger Signs: Temperature and Respiration 

• Temperature >38 °C 

• Rapid breathing 

• Palmar or conjunctival pallor associated with 30 respirations 

per minute or more (the woman is quickly fatigued or has 

rapid breathing at rest) 

• Temperature and respiration 

every 4 hours 

• Urinary bladder (assist the woman to 

empty her bladder, if distended/full, every 

hour) 

Danger Signs: Bladder 

• The woman cannot void on her own and her 

bladder is distended and the woman is 

uncomfortable. 

• Urinary incontinence 

78 




Danger Signs: Breastfeeding 

• The baby is not taking the breast well. 

• Breastfeeding has not yet been initiated. 

• Breastfeeding 2 to 3 

times in the 6 hours 

• Psychological reactions every hour 

Danger Sign 

• Negative feelings about herself or the baby 

Counsel and care for the woman 1-6 hours after delivery of the placenta 

During this time, the provider should: 

• Encourage the woman to eat, drink, and rest. 

• Ensure the room is warm (25 °C). 

• Ask the woman’s companion to watch her and call for help if bleeding or pain increases, 

if the woman feels dizzy or has severe headaches, visual disturbance or epigastric 

distress. 

• Keep the mother and baby together. 

• Monitor the mother and baby frequently as noted. 

• Document all findings and care provided. 

• Perform a comprehensive exam of the woman six hours after childbirth. 

Taking care to respect the family’s culture and customs, congratulate the family and discuss 

how they can help the woman care for herself. 

• Her body, clothing, bedding, and environment should be kept clean to prevent 

infection. 

• She needs to eat well. Ask the family what foods they have available. 

Encourage them to offer her plenty of the foods she wants. Keep cultural 

beliefs and practices in mind. 

• She needs to drink frequently because fluids help her body produce milk and 

replace lost fluids. A simple way to remember is to try and have something to 

drink at the baby’s feed times. 

• She needs to get enough rest. She has just worked very hard so she needs 

to rest after this job. Getting enough rest is one of the most important things 

she can do to help herself and her baby. It will help her uterus stay hard and 

get smaller sooner, so she bleeds less. 

• She can move around as much as she feels able. She shouldn’t do any hard 

work or lift any heavy objects. Someone should help her with any heavy 

house work. 

• If she experiences pain after delivery, she can take some 

paracetamol/acetaminophen to help relieve the discomfort. 



79

MONITORING THE NEWBORN 

The mother and the baby should be kept together as far as possible and separation must be 

avoided. Evaluate the baby when the mother is examined. In these early hours the key 

elements to be monitored include breathing, color, temperature, the cord, and evaluation for 

danger signs. 

Before the evaluation, explain to the mother what will be done. Check the baby whenever the 

mother is evaluated: 

• every 15 minutes during the first 2 hours after birth 

• every 30 minutes during the third hour after delivery 

• every hour during the next 3 hours 

Monitoring of the baby in the first six hours is summarized in the chart below. 

80 




Table 8. Monitoring of the baby in the first six hours after birth 

Note: Wash hands with soap and water before touching the baby. 

Ensure when using items such as the thermometer that it is washed 

with soap and water and swabbed with alcohol before every use. 

Parameter Frequency of assessment Danger signs 

• Respiration 

• Color 

• Temperature (Record 

axillary temperature at 

least once in the first 6 

hours. At other times, 

touch the baby’s hands 

and feet and check 

axillary temperature if 

they are cold.) 

• Umbilical cord for 

bleeding 

• Presence of other 

danger signs 

• Ensure breastfeeding 

within one hour of birth 

and subsequent 

exclusive breastfeeding 

on demand 

• First voiding of urine 

(within 48 hours) 

• First stool (within 24 

hours) 

Assess the baby in general 

when the mother is 

assessed in the AMTSL 

strategy: 

• immediately after birth 

then 

• every 15 minutes for 2 

hours, then 

• every 30 minutes for 1 

hour, then 

• every hour for the next 3 

hours 

Check anal opening after 

birth. 

Ask about urine and stools 

every day and before 

discharge from the health 

care facility. 

• Rapid respirations (more than 60 

respirations per minute) 

• Slow respirations (less than 30 

respirations per minute) 

• Flaring of the nostrils 

• Grunting 

• Severe subcostal retractions 

• Poor sucking/not sucking 

• Cyanosis, especially of the lips and 

tongue. (Cyanosis of the hands and 

feet may also be due to hypothermia 

for which the baby needs to be 

warmed.) 

• Hypothermia: body feeling cold 

(temperature 38 °C, some feel 

that in the newborn it’s better to act 

when the temperature is even 37.5 °C. 

• Convulsions. 

• Umbilical cord bleeding usually in the 

first day or two; needs retying of the 

cord; referral not required if that is the 

only sign. 

• Absence of stool or urine after the 24 

hours and 48 hours, respectively 

As part of newborn monitoring, the following guidelines are standard: 

• Look first for the general status of the baby to see that he/she is active and has a good 

pink color in the lips, palms, and soles. 

• Count the respiratory rate which is normally between 30-60/minute without flaring of the 

nostrils and severe subcostal retraction. 



81

• Temperature: Take the axillary temperature of the baby with a clinical thermometer cleaned 

with an alcohol swab (normal = 36.5-37.5 °C) at least once in the six hours. At other times, 

at least verify the body temperature by touching the abdomen, palms, and soles and ensure 

that they are all warm. If they are cold, recheck axillary temperature. If the palms and soles 

are cold or blue, it suggests that the baby is 

not warm enough. If the abdomen is cold, it 

suggests an even more severe 

hypothermia. Rewarm the baby, preferably 

by placing in skin-to-skin contact with the 

mother’s chest and covering the baby with 

layers of clean cloth and a blanket. If, 

however, this does not warm the baby, it 

represents a serious danger sign that 

necessitates urgent referral. 

• Monitoring for danger signs: These signs, 

adapted from research studies, are noted in 

the adjacent box and described in greater 

detail in the session on major neonatal 

infections or “sepsis.” 

• Assess for major defects that need special 

inputs. Asses for these defects if they have 

not been monitored soon after birth: 

o cleft lip and palate (needs additional 

support for feeding and may need 

feeding of expressed breast milk with a 

cup/spoon) 

o esophageal atresia (usually associated 

with excessive secretion in the mouth) 

o ‘open’ spinal defects 

o imperforate anus 

Danger Signs 

• Sucking poor or weak or not 

sucking at all 

• Inactivity/lethargy/moving only on 

stimulation 

• Fever/body too hot or 

hypothermia/body too cold 

• Rapid breathing/difficulty in 

breathing 

• Convulsions 

• Persistent vomiting/abdominal 

distension 

• Severe umbilical infections 

(redness/swelling surrounding the 

umbilicus and/or foul smell with or 

without pus) 

The first five signs are the most important. 

Although all the danger signs have been 

listed for completeness, the last three 

more often appear later in the postnatal 

period. Related to the cord, on the first day 

or two look particularly for oozing of blood/ 

bleeding for which the cord must be retied 

properly. 

If the baby is normal and no danger signs are noted, provide any routine care due and reassure 

the mother. If there are any problems/danger signs take the necessary steps promptly. 

In this period the baby continues to need basic care such as temperature maintenance, cord 

care, cleanliness, steps for prevention of infection, and exclusive, frequent breastfeeding on 

demand. Administer the first vaccines such as a dose of oral polio vaccine, BCG, and hepatitis 

B based on the recommendations of the Ministry of Health. 

82 




CHAPTER 7: Routine Postpartum Care for the Woman 

It is usually a joyful event when a woman gives birth to a baby she wants. Despite the pain and 

discomfort, birth is the long-awaited culmination of pregnancy and the start of a new life. 

However, birth is also a critical time for the health of the mother and her baby. Problems may 

arise that, if not treated promptly and effectively, can lead to ill health and even death for one or 

both of them. Nonetheless, the postpartum period is often neglected by maternity care. The lack 

of postpartum care ignores the fact that the majority of maternal deaths and disabilities occur 

during the postpartum period and that early neonatal mortality remains high. 

Postpartum care needs to be a collaborative effort between the woman, her family, community 

health workers, facility health care providers, health care managers, community groups, and 

policy makers. All members need to be informed of the components of quality postpartum care. 

In spite of the fact that so many deaths occur in the postpartum, very few women seek care and 

very few providers offer early postpartum services. Providers must offer quality services to 

ensure that women use these essential services that can substantially improve their chance of 

survival. 

This section covers various components of postpartum care. Individual Ministries of Health and 

implementing organizations can determine by consensus the priorities to be covered, especially 

in the early phases of implementation, depending on funds and time available for training, 

follow-up supervision, and monitoring and evaluation. 

MALE INVOLVEMENT 

In most communities, it is not traditional for men to be included in postpartum and newborn 

care, but where men have been encouraged to participate, they have shown that they are willing 

to do so. It may take several years before this becomes routine, but vaccination and homebased 

child health records also took several years to establish. Even small or busy clinics can 

be encouraged to identify a space (even the porch) where men can feel comfortable to wait and 

receive information from a trained male staff member about sex in the postpartum and the risk 

that unprotected sex outside the marriage holds for their baby, their wife, and themselves. 

Both men and women should be aware of the following facts: 

• Sexual relations may be resumed as soon as it is comfortable for the woman and she is 

ready for it. The couple should use condoms when having sex, particularly if the woman 

still has lochia. 

• The early weeks of breastfeeding are times when women are at particular risk of 

becoming infected with HIV for the following reasons: 

o Men may have sex with partners other than their spouse(s) during the period of 

pregnancy and childbirth-related abstinence at home. 

o Women are more susceptible to HIV for a range of biological reasons at this time. 

• The risk of MTCT is much higher when the woman is newly infected with a very high 

viral load. 

• Mixed feeding carries particular risks for MTCT of HIV and other newborn infections. 



83

POSTPARTUM CARE 

Ideally a comprehensive examination of the woman should be performed at one hour and six 

hours after delivery and before discharge from the health care facility. For women who are not 

having any problems, the following schedule for routine postpartum visits may be sufficient: 

Table 9. Schedule for routine postpartum visits 

Visits 

Timing 

1 st Visit 

Within the first week postpartum, 

preferably within 2 or 3 days 

2 nd Visit 4-6 weeks 

During a routine postpartum visit, a skilled provider will: 

• perform a rapid assessment to recognize danger signs and signs/symptoms of 

complications or problems and respond immediately and appropriately. 

• detect pregnancy-related complications, hemorrhage, medical conditions, and infections 

by: 

o taking a detailed history to identify any problems/potential problems; social problems, 

medical problems, problems during the most recent pregnancy and birth; and 

reported symptoms/problems. 

o performing a physical, obstetrical, and gynecological exam. 

o if the woman’s HIV status is positive, carrying out clinical staging and assessing for 

opportunistic infections. 

Figure 7.1. Routine postpartum physical, obstetrical, and gynecological exam 

84 




• perform the following laboratory tests to evaluate the woman’s health and screen for 

selected medical conditions and infections: 

o hemoglobin levels (as needed). 

o RPR (or VDRL): The test should be done if the woman’s status is not known. 

o HIV (first visit/if last test >3 months ago/as needed): If the woman does not know 

her status and volunteers for testing, a test should be conducted. A positive HIV 

status affects many aspects of care for the woman and her newborn. 

o check CD4 count according to national protocols if the woman’s HIV status is 

positive. 

• provide prophylaxis for health promotion and disease prevention: TT, intermittent 

insecticide-treated bednets (ITN), iron/folate tablets, vitamin A, broad-spectrum antihelminthics, 

and other nutritional supplements as needed. 

• promote safer sexual practices. 

• if the woman’s HIV status is positive, provide prophylaxis for opportunistic infections 

according to national guidelines. 

• provide treatment for any medical conditions, illnesses, and infections detected. 

• manage any pregnancy-related complications. 

• provide PMTCT interventions according to national guidelines. If the woman is not 

already on ARV treatment, consider referring her for care with an HIV specialist. 

• provide client-centered counseling for women and partners/supporters. 

• help the woman and her partner/support person develop a complication-readiness plan. 

• refer all women who need specialized care for any reason. 

Importance of Routine Couple Visits 

A routine couple visit prior to discharge from the facility enables discussion with the 

partner/father about warning signs of complications in the woman and newborn and the need to 

make a plan for urgent transport and referral. He can also learn what he can do to protect his 

wife's and newborn’s health and understand the importance of exclusive breastfeeding. In these 

ways a couple discharge visit can contribute to maternal and perinatal health. 

The couple visit also provides an opportunity for both partners to be educated about treatment 

and prevention of sexually transmitted infections, the importance of family planning, and the 

availability of different family planning methods, including vasectomy. 

If the male partner has not yet been tested for HIV, the couple can be counseled and 

encouraged to be tested without the danger of blame being put on the woman because she has 

been tested first. Where appropriate, condoms can be demonstrated, promoted, and provided. 

A couple visit acknowledges the usual gender role of men in protecting their family and in 

making decisions. 

Health Promotion and Disease Prevention 

Certain medications or simple health care measures can prevent or reduce the risk of suffering 

from specific health problems. The following measures should be explained and offered to all 

women. 



85

Prevent malaria 

• Ask whether the woman and newborn will be sleeping 

under a bednet. If yes: 

o Ask if it has it been dipped in insecticide. 

o Advise her to dip it every six months. 

If not, advise her to use an insecticide-treated bednet, and 

provide information to help her do this. 

Note that WHO/GMP (Global Malaria Program) now recommends use of long lasting 

insecticidal nets (LLINs) that maintain efficacy for at least 3 years. 6 

Prevent vitamin A deficiency 

• Give 200,000 IU vitamin A capsules after delivery 

or within six weeks of delivery. 

• Explain to the woman that the capsule with vitamin 

A will help her to recover better and that the baby 

will receive the vitamin through her breast milk. 

• Ask her to swallow the capsule in your presence. 

• Explain to her that if she feels nauseated or has a 

headache, it should pass in a couple of days. 

• Do not give capsules with high dose of vitamin A 

during pregnancy. 

Prevent iron-deficiency anemia 

• For intermittent preventive treatment of hookworm to 

prevent anemia, provide doses of a broad antihelminthic 

(to be taken every six months) to women living in 

hookworm endemic areas. 

• Iron/folate supplementation to prevent anemia. 

• If hemoglobin is between 8–11 g/dL, give ferrous sulfate or 

ferrous fumerate 60 mg by mouth plus folic acid 400 mcg by 

mouth once daily for at least three months after childbirth. 

• If hemoglobin is ≤7 g/dL, treat for anemia according to 

national protocols. 

(Note: The ferrous sulfate or fumerate dose will depend upon 

the woman’s hemoglobin. Follow national guidelines on the 

specific treatment, as this may vary from country to country.) 

6 Source: http://www.who.int/mediacentre/news/releases/2007/pr43/en/index.html; accessed on March 

26, 2009 

86 




Prevent tetanus 

• Tetanus toxoid (TT). Provide TT if a dose is due and remind 

women to keep the TT cards and vaccinations up to date. 

. 

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, and 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 counseling 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 the partner and mother-in-law, to encourage them to 

help ensure the woman eats enough and avoids hard physical work. 

• Remind the woman and her family that a 

breastfeeding woman needs to eat extra. In 

order to eat enough for herself and to 

produce enough milk, she should ideally eat 

five to seven times a day. If possible, she 

should try to eat smaller quantities of food at 

more frequent intervals during the day. In 

low-resource settings in developing countries 

where women eat less frequently, she should 

take at least one extra meal a day. 

• A breastfeeding woman needs to drink a lot. She should try 

to drink something after every time her baby breastfeeds. 



87

Advise on postpartum care and hygiene 

Advise 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 avoid sexual intercourse until the perineal wound heals and it is comfortable for her. 

• To have enough rest and sleep. 

• About the importance of washing to prevent infection of the mother and her baby: 

o Wash the perineum daily and 

after fecal excretion. 

o Change perineal pads every 4 

to 6 hours, or more frequently if 

there is heavy lochia. 

o Wash used pads or dispose of 

them safely. 

o Wash the body once daily 

during bathing with soap and 

water. 

o Wash hands before handling 

the baby, at least after 

changing the diaper/napkin, 

after using the toilet herself, 

and after cleaning the house. 

Wash hands every time before handling a low birth weight baby. 

Advise on the need for rest and sleep during the postpartum 

Explain to the woman: 

• That a breastfeeding woman needs 

additional time to rest. This is because 

she is recovering from pregnancy and 

childbirth, breastfeeding, and taking 

care of a little baby, which takes up a 

lot of her time. 

• That she can try to negotiate with 

family members to help with 

household chores so that she can take 

more time to rest. 

• That she can ask a health care 

provider to help her explain her needs in the postpartum to her partner and family 

members. 

88 




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 counseling session. 

• Explain that after birth, if she has sex and is 

not exclusively breastfeeding, she can 

become pregnant as soon as four weeks after 

delivery. Therefore it is important to start 

thinking early about what family planning 

method she and her partner will use. 

• Her fertility can return even before she 

commences menstruation after childbirth. 

• Ask about plans for having more children. If 

she (and her partner) want more children, 

advise that waiting at least 3-5 years between 

pregnancies is healthier for the mother and child. 

• After a live birth, couples should use an effective family planning (FP) method of their choice 

consistently for at least two years before trying to become pregnant again, and not more 

than five years after the last birth. After a miscarriage or abortion, couples should use an 

effective FP method of their choice consistently for at least six months before trying to 

become pregnant again. 

• Counsel on safe sex, including use of condoms for dual protection from sexually transmitted 

infections (STI) or HIV and pregnancy. Promote their use, especially if there is a risk of 

sexually transmitted infections or HIV. 

• For HIV-positive women, follow guidelines for family planning considerations. 

• Her partner can decide to have a vasectomy (male sterilization) at any time. 

Family planning methods 

Information on when to start family planning methods after delivery and the actual method to be 

used will vary depending on whether a woman is breastfeeding or not. Make arrangements for 

the woman to see a family planning counselor or counsel her directly. 

Family planning options for the non-breastfeeding woman that can be used immediately 

postpartum include: condoms, 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). Options for the nonbreastfeeding 

woman that should be delayed for 3 weeks include: combined oral 

contraceptives, combined injectables, and fertility awareness methods. 

A breastfeeding woman may choose the lactational amenorrhea method (LAM), but she will be 

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. 



89

• Method options for the breastfeeding woman that can be used immediately postpartum 

include: lactational amenorrhea method, condoms, spermicide, female sterilization 

(within 7 days or delay 6 weeks), copper IUD (within 48 hours or delay 4 weeks). 

• Method options for the breastfeeding woman that should be delayed for 6 weeks include: 

Progestogen-only oral contraceptives, Progestogen-only injectables, implants, 

diaphragm. 

• Method options for the breastfeeding woman that should be delayed for 6 months 

include: combined oral contraceptives, combined injectables, fertility awareness 

methods. 

Advise on sexual intercourse during the postpartum period 

Explain to the woman: 

• that she can have sex as soon as she is ready and it is comfortable, but she should use 

a condom if she still has lochia discharge. 

• that unless partners have sex only with each other and are sure that they are both 

uninfected, they should practice safer sex. Safer sex means non-penetrative sex (where 

the penis does not enter the mouth, vagina, or rectum) or the use of a new latex condom 

for every act of intercourse. (Latex condoms are less likely to break or leak than animalskin 

condoms or the thinner more “sensitive” condoms.) Condoms should never be 

reused. 

Advise on danger signs 

Advise the woman to go to a hospital or health center immediately, day or night without 

waiting, if she experiences any of the following signs: 

• Vaginal bleeding: more than two or three 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 

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• Severe abdominal pain • Feels ill 

• Swollen, red or tender breasts, or sore nipple 

(seek advise as soon as feasible) 

• Urine dribbling or pain on micturition 

• Pain in the perineum or draining pus 

• Foul-smelling lochia 



91

Discuss how to prepare for an emergency in postpartum 

• Advise the woman to always have someone near for at least 24 hours after delivery to 

respond to any change in her condition. 

• Discuss with the woman and her partner and family about emergency issues: 

o where to go if there are danger signs 

o how to reach the hospital 

o how to meet the costs involved 

o options for family and community support 

• Advise the woman to ask for help from the community, if needed. I1- 

• Advise the woman to bring her home-based maternal record to the health center, even 

for an emergency visit. 

Advise on when to return 

• Encourage the woman to bring her partner or family 

member to at least one visit. 

• Explain the timing of routine postpartum visits. When the 

mother and baby are normal: 

o the first visit should be within the first week, preferably 

within 2-3 days. 

o the second visit should be 4-6 weeks postpartum. 

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CHAPTER 8: Resuscitation for Birth Asphyxia 

Birth asphyxia is a major cause of death in the newborn period, accounting for about 23 percent 

of deaths in the first four weeks of life. From 3-5 percent of newborns do not start spontaneous 

breathing at birth. A great number of newborns do not receive appropriate care because many 

birth attendants do not have the knowledge, ability, or the appropriate equipment and supplies 

to perform the necessary steps of resuscitation in an optimal manner. It is extremely important 

to train healthcare personnel in this area to prevent neonatal deaths and disability. 

The term birth asphyxia indicates the baby’s inability to commence and maintain 

breathing. A normal baby at birth has a good cry; continues to breathe well; has a pink tongue, 

lips, palms and soles; and has adequate reactions and good muscle tone, with the limbs well 

flexed and moving well. The slight bluish tinge of the palms and soles commonly seen in babies 

at birth is due to vasoconstriction of the local blood vessels as a result of the chilling that takes 

place at birth. This chilling is due to the baby coming from a warm intrauterine environment to 

the colder exterior and to the evaporation of the amniotic fluid. The blue color changes rapidly 

to pink as the baby is dried, wrapped, and warmed. 

Basic resuscitation of the newborn is not the exclusive field of a specialist. Midwives, nurses, 

and doctors who attend deliveries at all levels should have the skills and resources to 

resuscitate babies with birth asphyxia in order to decrease neonatal mortality and morbidity. 

This training program of staff at the peripheral health centers will focus on: 

• drying and stimulation and maintenance of temperature 

• clearing of the airways 

• ventilation with bag and mask 

It will not deal with cardiac massage, intubation, or the use of drugs because: 

• more than 80 percent of asphyxiated babies require only stimulation, clearing of airways, 

and ventilation for revival. 

• health workers at peripheral centers (such as health centers and health posts) targeted 

in this training program are likely to deal with far fewer cases of birth asphyxia and are 

thus more likely to lose some of their skills unless there is constant supervision and 

opportunities to practice, at least on mannequins which, in practice, does not often 

happen. It is thus better to limit this discussion to the minimum actions required to deal 

with most cases. 

Each of the following is a prerequisite to successful neonatal resuscitation: 

• anticipation 

• appropriate preparation 

• timely recognition of the signs of asphyxia 

• rapid implementation of treatment 

It is best to have two persons to provide appropriate care at resuscitation, even if the two are 

not equally skilled. Hence, centers should plan in advance and train additional persons at the 

site who can assist the more skilled person carrying out the specialized tasks for resuscitation. 



93

CAUSES OF BIRTH ASPHYXIA 

Some causes of birth asphyxia are noted below. It should be noted, however, that up to 50 

percent of newborns who require resuscitation may have no identifiable risk factors before birth. 

Hence, persons attending any delivery should be prepared and ready to initiate resuscitation, if 

required. 

Maternal causes for birth asphyxia include: 

• eclampsia 

• bleeding (e.g., placenta previa/abruption) 

• fever 

• maternal sedation/anesthesia 

• abnormal presentations 

• prolonged/difficult labor 

• infections such as malaria, syphilis, tuberculosis, and HIV/AIDS 

Causes in the newborn include: 

• cord prolapse/knot 

• thick meconium in the amniotic fluid (may be due to fetal distress, but if aspirated into 

the lungs may perpetuate asphyxia after birth) 

• prematurity/IUGR 

• post-maturity 

• multiple births 

• selected congenital malformations 

PREPARATION FOR RESUSCITATION 

The cry of the baby at birth is generally considered to be the first sign of extrauterine life and 

good health. Most newborns cry and start breathing immediately after birth and adapt well to the 

extrauterine environment. All that is needed is to be surrounded by a clean and warm 

environment and to be carefully monitored. Breathing must be established before the baby is 

given to the mother to be kept warm. 

A suitable room and the necessary equipment should be ready, and health workers should be 

well prepared for resuscitation at every birth without delay. The life and brain of the infant are 

at stake. While routine essential care of the baby can be carried out while the baby is placed on 

the mother’s abdomen or chest, it is convenient to designate a “newborn baby corner or area” 

where resuscitation and other special care for the baby can be carried out. It should have a 

table with a firm mattress covered with a clean rubber or plastic sheet and a clean, preferably 

sterile cloth, under a warmer where all necessary equipment and supplies can be placed and 

readily accessed. 

Equipment for Preventing Hypothermia 

The following equipment is recommended for preventing hypothermia: 

• A warm room. Make sure the room is warm, with no drafts or open windows. 

• A source of heat. 

• A clean treatment surface/table should be available, preferably with an overhead 

warmer. Where overhead heaters are very expensive, a “warming table” can be 

manufactured locally by fixing either a heating rod or 2-3 bulbs on a wooden frame (as 

shown in Figure 8.1), taking care that the wiring is well done in order to avoid inadvertent 

94 




“shocks.” Where a heating rod is fixed, an additional lamp will be required to provide 

adequate lighting. Babies under the warmer should always be monitored to ensure that 

that they are maintaining their body temperature appropriately and are not too cold or 

hot. In general, water bottles are not recommended due to the risk of burns. If there is no 

alternative to a bottle, the water must be warm and the bag containing the bottle must be 

wrapped in a thick cloth or several layers of cloth. The baby must be frequently checked 

to ensure that the skin is not excessively hot or red. 

Figure 8.1. A warming table. (USAID/BASICS Senegal Newborn Health Program) 

• Three to five pieces of clean, preferably sterile, cloth to dry and wrap the baby, a cap 

where available, and a washable blanket or several layers of cloth where required. 

• A wall thermometer to monitor the room temperature. 

• A thermometer to measure the axillary temperature of the baby. 

Equipment for Aspiration of Secretions 

The following suction equipment is recommended: 

• De Lee mucous aspirator. This is perhaps the simplest item to use (see Figure 8.2). It 

consists of two tubes attached to a transparent trap. One tube end is introduced into the 

baby’s mouth and throat, and the health worker applies suction with his mouth at the tip 

of the other tube; the trap is to prevent aspirated material from entering the health 

worker’s mouth. The item comes in individual pre-sterilized packs. Since cleaning and 

decontamination of the narrow tubes present challenges and due to the risk of infection, 

especially of HIV/AIDS, only a “single use” with careful application of suction is 

recommended to avoid any risk of the secretions entering the tube in the care provider’s 

mouth. In fact, for safety, it might be better to use a fresh aspirator. After use, the item 

should be discarded in a safe manner and not reused, even after cleaning and 

disinfection. Some practitioners do not recommend the use of this aspirator because of 

the potential risk of secretions entering the care provider’s mouth, despite the presence 

of the trap. 



95

Figure 8.2. De Lee mucous aspirator. (WHO: Safe Motherhood: 

Basic Newborn Resuscitation-A Practical Guide) 

• Suction machine (electrical/foot operated) used with single-use simple catheters 8F and 

10F may be better than an aspirator, as there is no risk of secretions contaminating the 

oral mucosa of the care provider. Notes on use: 

o In newborn infants, the negative pressure used for the suction should not be more 

than 100 mm/Hg or 130 cm of water. Most suction machines may attain pressures 

often ranging from 400-600 mm/Hg and at times going up to 700 mm/Hg (when 

being used for adults). Suction at a high negative pressure may result in bradycardia 

and/or apnea in the baby due to vagal stimulation. 

o Since the same aspirator may be used for the mother and the newborn, care should 

be taken to change the level of the negative pressure of the suction. A clearly visible 

sticker should be attached permanently to the equipment with the following message: 

“Adjust the pressure to 100 mm/Hg or 130 cm of water for the newborn infant.” 

o The suction tubes/catheters used with the machine should also be the pre-sterilized 

single use variety and should not be reused. 

o In the absence of a suction machine, a 10 mL syringe attached to the suction 

catheter can also be used to remove the secretions but may not be so effective. 

o In many centers in advanced countries, a rubber bulb is used for suction, but it 

should be used only for one baby. The bulb is also readily available in many 

countries in Africa, but it is commonly used repeatedly on several babies. It is not 

possible to clean this properly or to even verify that it is clean, as the bulb is opaque. 

Hence, the rubber bulb is not recommended in developing countries. If no other 

item is available for suctioning, a new bulb may be washed, boiled, and used for only 

one baby and then discarded. 

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Equipment for Ventilation 

• Bag and mask: a newborn resuscitator bag (240-500 mL) with appropriate size face 

masks (#1 for normal size newborn babies, #0 for LBW babies). (See Figure 8.3.) In 

general, where resources are limited, the 500 mL bag is preferable as it can be used for 

the normal weight baby and for the larger low birth weight infants which constitute the 

biggest proportion of the high-risk group. Notes: 

Figure 8.3. Self-inflating bag and mask for ventilation of babies. 

o The resuscitator bag should be the self-inflating kind that inflates automatically after 

it is squeezed and released. Bags that require a flow of air/oxygen mixes to inflate 

are, in general, not appropriate for resuscitation. 

o In certain models the mask consists of one piece of silicone/siliconized rubber; in 

others, it consists of two parts, a plastic component to which a different transparent 

soft plastic/rubber/silicone piece is attached. Make sure that the pieces are 

appropriately attached so that the soft part is the one that comes in contact with the 

baby’s face and not the hard plastic part that can hurt the baby. 

o Check that the mask fits properly with the bag. 

o To check the functioning of the self-inflating bag, block the mask by making a seal 

with the palm of the hand. 

o Then squeeze the bag. Make sure that you feel pressure against your hand that 

indicates that the seal is working well without leaks. When the pressure is raised, it 

can also force the pressure-release valve open. When the pressure is released, the 

balloon should reinflate. 

o Squeeze the bag only to the extent necessary to expand the chest. Excessive 

pressure carries a risk of injury to the lungs. 

• A supplemental oxygen source, if available. If cylinders are used, check that they have 

adequate oxygen. Note that while it is good to have supplemental oxygen available, it is 

not required in most cases. 

• A wall clock with a second hand. In dealing with emergency situations such as asphyxia, 

it is easy to lose track of time. It is important to note the time of birth and the time spent 

in resuscitation, since there is a time limit to active resuscitation. The clock can also be 

used to check the heart and respiratory rate in the delivery room. 



97

• A stethoscope where available. 

• Miscellaneous: sterile gauze/pieces of sterile cloth and sterile/HLD gloves. 

Attempts should be made to procure as many sterile items as possible in order to avoid 

nosocomial infection which will increase morbidity and mortality. All equipment has to be 

cleaned and disinfected after use. The manufacturer gives specific instructions for cleaning, 

disinfecting, and sterilizing equipment. Follow these instructions carefully. 

To ensure that all the necessary items are kept ready for every delivery, attach a list on the wall 

near the table for resuscitation in the “baby corner.” To protect the list it can be laminated or 

framed with a glass cover or attached inside a locked notice board. Here is a sample: 

Equipment and Supplies for Newborn Resuscitation in the 

“Baby Corner or Area” of the Delivery Room 

It is mandatory to ascertain (a) every morning, (b) at the beginning of every shift, and 

(c) before each delivery that the equipment/supplies listed below are available, in 

working order, sterile/clean, and ready to be used. 

1. A heat and light source 

2. A table for resuscitation with a mattress with a clean washable surface covered 

with a clean, preferably sterile cloth. This could be part of the warming table. 

3. Three to five pieces of clean, preferably sterile, cloth to dry and wrap the baby, 

including the head, a cap or bonnet, where available, and a washable blanket or 

several layers of cloth where required. 

4. Sterile gauzes/pieces of cloth 

5. Disposable sterile (preferable)/high-level disinfected gloves 

6. Suction equipment with suction tubes/catheters 

7. A self-inflating bag (500 mL) and masks (sizes 1 and 0) 

8. A wall clock with a second hand 

9. A wall thermometer 

10. A clinical thermometer to record the axillary temperature of the baby 

11. Disposable syringes (1 mL, 2 mL, 10 mL) 

12. Vitamin K1 

13. A weighing scale 

Figure 8.4. Sample list of equipment for newborn resuscitation 

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Identifying a Baby with Birth Asphyxia 

The baby may have the following features: 

• does not cry at birth 

• is either not breathing or has very slow breathing (less than 20/minute) or is gasping 

• is blue or pale 

• is limp and not moving or not responding properly to stimulation 

The Apgar score is used at hospitals to assess the status of the baby in relation to breathing, 

heart rate, color, muscle tone, and reflex response to stimulation at 1, 5, and 10 minutes after 

birth. Low scores at 5 and 10 minutes have also had some correlation with a poorer long-term 

outcome, but this correlation is not always consistent. However, in most peripheral centers the 

scoring is frequently carried out in a wrong/inappropriate manner. The score, in any case, is not 

required and must not be used to make decisions to carry out resuscitation. Hence, the Apgar 

score will not be covered in this training session. 

STEPS IN NEWBORN RESUSCITATION 

The initial actions for resuscitation are similar for all babies, irrespective of the status of the baby 

and presence or absence of asphyxia. After each step, an evaluation of the condition must be 

made to judge progress so that the appropriate next step can be implemented. Evaluation and 

action constitute a cycle that has to be repeated in a timely manner until the baby recovers or a 

decision is made to discontinue an unsuccessful resuscitation. Universal precautions for the 

safety of the baby and the staff and steps for prevention of infection are also mandatory. 

Preparation 

Switch on the heating source before the delivery to warm the table top/mattress for the baby. 

Place the linen for the baby on the table under the warmer so that it gets warmed up before the 

delivery. Wash your hands and wear sterile gloves. 

Immediate Care in the Case of Meconium in the Amniotic Fluid 

If the amniotic fluid is stained by meconium, and especially in case of thick meconium: 

• Suction the mouth and nose as soon as the head is delivered on the perineum and before 

the delivery of the shoulders. Tell the mother not to push for a little while, giving time to 

suction the mouth and nose of the baby. Based on research results, this preliminary 

suction before full delivery is not carried out in centers in advanced countries; instead, 

early suction, including endotracheal suction, is carried out immediately after delivery if the 

baby is not crying. However, in low-resource settings, such as peripheral centers in 

developing countries where intubation is not feasible, suctioning of the mouth and nose 

before delivery of the shoulders is likely to decrease the risk of meconium inhalation into 

the lungs that could cause additional problems. 

• After full delivery of the baby, if no breathing is observed, suction the mouth and nostrils 

before drying and stimulation. Do not suction a baby who is already crying. 



99

Drying the Baby and Keeping the Baby Warm (Initial Steps for All Babies) 

• In general, the first step immediately after birth is to dry the baby well. Drying the baby well 

also serves to provide safe stimulation to a baby who is not breathing. While drying, verify 

if the baby is breathing/crying. 

• If the baby is breathing well, follow the steps noted above in the section of care of the baby 

immediately after birth. 

• If the baby is not breathing, discard the wet cloth. Wrap the baby’s body and head with a 

fresh dry cloth, keeping the baby on the mother’s abdomen, and verify again if he/she is 

breathing. Where it is clean and feasible, placing the baby who is not breathing on the 

table between the mother’s legs will allow a better flow of blood to the baby. 

• If the baby is still not breathing, clamp and cut the cord. If you have an assistant who can 

deal with/observe the mother and a separate place for special care, take the baby there 

and place it under a warmer (if available) for commencing additional steps for 


Position of the Baby 

Initially during the steps noted above, the baby can be turned on one side with the head slightly 

extended. However, if the baby is still not breathing, it is convenient to have the baby on its back 

on a warm, firm surface with the head towards you. The head should be slightly extended, 

which you can do either by extending the head slightly with your hand or by placing a roll of 

linen under the shoulders to raise them by 2-3 cm (see Figure 8.5). 

Positioning during Resuscitation 

Correct position 

(Neck slightly extended) 

Newborn with elevated shoulders 2 to 3 cm. with a small linen roll, 

placed below, to slightly extend the neck. 

The neck may be extended by positioning with the hand 

without the linen roll 

Incorrect positions 

Neck hyperextended 

Neck flexed 

Figure 8.5. Correct positioning. 

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Clearing of the Airways 

• If the baby is still not breathing, clear the airways by suction. Make sure that: 

o The suction tube is introduced enough to suction effectively, but no more than 5 cm into 

the mouth or 3 cm into the nostrils. Suction the mouth before the nostrils because if the 

nose is suctioned first, it may stimulate the baby to breathe and if there is thick mucus 

in the mouth/throat, it may get inhaled or aspirated. 

o Suction should be carried out gently and only when pulling out the tube, not when 

introducing it. 

o Suction should not be applied for more than 20 seconds. 

• Re-examine the baby. If the baby starts to cry or breathe well, proceed with routine 

essential care of the newborn. 

• If the baby is still not breathing or is just gasping, carry out the steps noted below. 

Tactile Stimulation 

Usually stimulation through proper drying and suctioning of the mouth and nose are adequate. 

At the most, if the baby is still not breathing, very brief additional stimulation by flicking or 

slapping the soles of the feet may be tried before commencing ventilation with the bag and 

mask. Perform these steps quickly. All the above steps should take approximately 30 seconds. 

Do not slap repeatedly; it is not only harmful but will also waste precious time which could be 

better used in ventilating the baby as noted below. 

Figure 8.6. Methods for stimulating the baby. 

Ventilating the Newborn with the Bag and Mask 

• All the above steps should be carried out quickly to ensure that ventilation where required 

is started within one minute after birth. 

• Verify that the baby’s neck is in slight extension, either held in position with a hand or by 

placing a small cloth roll (2.5 cm-3.0 cm) under the shoulders (whichever is more 

convenient for the care provider). 

• Use the proper size mask: 

o Use #1 for normal size babies and #0 for LBW babies. 

o Make sure the mask covers the baby’s chin, mouth, and nose, but not the eyes (see 

Figure 8.7). 



101

• Form a proper seal between the mask’s edge and the baby’s face so that air does not leak 

out during ventilation. 

FORM A PROPER SEAL 

BETWEEN THE MASK 

AND FACE 

CORRECT 

INCORRECT 

Figure 8.7: Correct positioning of the mask and formation of a good seal. 

• Commence ventilation at about 40 times a minute (the range for ventilation is 

40-60 breaths/minute). A simple way is to count “one – two – breathe” and squeeze the 

bag at each “breathe.” 

• Make sure the baby’s chest rises and the valve of the self-inflating bag moves with each 

inflation; this is an indication that ventilation is efficient. If this does not happen, adjust the 

position of the head of the infant and the bag, suction the mouth and nose again to remove 

secretions, and proceed with ventilation with a slightly higher pressure. You must see the 

chest rise. 

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• Reassess the baby’s breathing after one minute. 

o If the newborn cries and spontaneous breathing is established, stop ventilation and 

observe for at least 5 minutes. If the baby is breathing normally (30-60 respiratory 

movements/minute), proceed with routine essential newborn care. 

o If the baby is still not breathing or is gasping, assess the heart rate with a stethoscope if 

available, or by feeling the umbilical cord pulsations. Count the heart rate or the umbilical 

pulsations for 6 seconds and multiply by 10 to obtain the heart rate per minute. 

If the heart rate is more than 100/minute, continue ventilation. 

If the heart rate is less than 100/minute, clear the infant’s airways again, reposition 

the bag, and continue bagging until spontaneous breathing is established. 

o If the heart rate cannot be evaluated, continue ventilation as long as the chest is 

expanding well. If not, clear the infant’s airways again, reposition the bag, and continue 

bagging until spontaneous breathing is established. 

• If the baby is blue, especially in the mouth and tongue, give supplemental oxygen, if 

available. (Figure 8.8.) Remember, most babies do not require supplemental oxygen for 

resuscitation. If oxygen is administered, it can be carried out with the bag and mask. 

Attach the oxygen tube to the resuscitator bag at the oxygen inlet end. Remember: if the 

resuscitator bag is used, oxygen will reach the baby only if the bag is squeezed 

repeatedly as in ventilation. Oxygen can be given to a baby that is already breathing but is 

blue by holding the mask of the resuscitator bag above the face and squeezing the bag 

periodically. 

• Other methods of giving oxygen to a baby who is breathing are indicated in the diagrams 

below. They include holding the oxygen tube with the flow of oxygen with or without a 

cupped hand or through a facemask. In general a flow of 1-2 L/minute of oxygen should be 

adequate. 

Figure 8.8. Giving supplemental oxygen. 



103

When to Discontinue Resuscitation 

While it is essential to carry out the steps for resuscitation in a correct and timely manner, it is 

equally important to know when the process should be terminated. Conventionally, if a newborn 

does not breathe and does not cry for 20 minutes, resuscitation should be discontinued. A 

newborn who is not breathing 20 minutes after appropriately managed resuscitation has already 

suffered from significant hypoxia and merely continuing ventilation without ancillary support 

carries the risk of further brain damage and long-term disability. Intensive care is appropriate at 

this time. At a peripheral center, where it is not feasible to provide such care, a baby who is not 

breathing should be managed as best as feasible locally, unless facilities exist to transport the 

baby with effective ventilation to an appropriate higher referral center where intensive care is 

available. Otherwise, the baby is likely to die on the way or reach the center in a state from 

which it cannot be revived or that may be associated with severe disability. 

Dangerous/Inefficient Resuscitation Practices 

Avoid harmful practices such as: 

• Vigorous aspiration of the mouth and nose of the baby. It may result in bradycardia or 

cardiac arrest due to vagal stimulation. 

• Postural drainage with head down. 

• Slapping of the baby’s back. 

• Compression of the chest to eliminate secretions. This is dangerous since it may lead to 

rib fractures, pulmonary lesions, and even death. 

• Strong stimulation of the newborn, such as slapping the buttock. 

• Immersing the baby in cold water and then in hot water. 

• Introducing a glass thermometer in the anus, as this may result in injury. 

• Use of medication such as sodium bicarbonate administered without indication before 

breathing is established or rapidly in high concentrations. 

POST-RESUSCITATION CARE 

After resuscitating the asphyxiated baby, the health care worker has to provide routine essential 

care, monitor the infant for problems/complications, counsel the family, and document all events 

and actions. All equipment needs to be decontaminated/cleaned/sterilized before it can be used 

again (see chapter 1) and all disposable or consumable/single-use supplies need to be 

replenished. 

Care Following A Successful Resuscitation 

• Prevent hypothermia; keep the baby warm and dry and if feasible in skin-to-skin contact 

with the mother, covering his/her body and head over the mother’s chest, keeping the 

face exposed. 

• Examine the baby and evaluate the respiratory rate: 

o If the infant has cyanosis, breathing problems such as rapid breathing with a rate of 

more than 60/minute, intercostal retractions, and/or expiratory grunting, administer 

supplemental oxygen as illustrated above. If these do not subside, refer the baby. 

104 




• Measure the axillary temperature: 

o If the temperature remains above or equal to 36.5 ºC, keep the baby on the mother’s 

chest. 

o If the temperature is less than 36.5 ºC, warm the baby by skin-to-skin contact or by 

placing under a warmer as is most appropriate, based on available equipment and 

the status of the baby and mother. If the infant remains hypothermic, this represents 

a danger sign; refer the baby to the appropriate referral center. 

• After resuscitation, reassess the baby periodically every 15 minutes for 2 hours and 

every 30 minutes for 6 hours for breathing, color, and activity. Continue assessment, 

including evaluation of feeding, every 3 hours for the next 48-72 hours. 

• If the baby develops respiratory difficulty or any one of the danger signs noted in 

chapter 13 on major infections, refer him/her to the appropriate referral center following 

the guidelines for appropriate referral in the same chapter. 

• If the baby improves, commence routine essential newborn care: 

o Keep him/her warm and dry, if feasible in skin-to-skin contact with the mother. 

o Administer vitamin K (1mg intramuscular for a normal weight baby) to the baby. 

o As soon as the baby is stable, help the mother to start breastfeeding. A newborn 

that required resuscitation is at risk for hypoglycemia. 

o If the baby does not suck well, transfer him/her to a hospital that cares for sick 

newborns. If the baby has a good suck, it is sign that he is improving. 

o Defer the first bath preferably for at least 24 hours, until the baby is much more 

stable, warm, and continues to breathe and feed normally. 

o Provide all the routine care and counseling noted in the chapter on care of the 

normal baby at birth. 

o Record all the findings and treatment provided for birth asphyxia in the mother/baby 

records and in the delivery register. 

o Make sure that all equipment is decontaminated, cleaned, and sterilized as 

appropriate and all disposable supplies are replenished and kept ready for the next 

delivery. 

• Counsel the mother and the family regarding: 

o What was done for the baby and why, in simple terms. 

o Continuing breastfeeding on demand, and ask them to inform you if the baby does 

not demand to be fed or does not suck well. 

o Keeping the baby warm, in skin-to-skin contact where required, and to verify that the 

baby remains warm. 

o Identification of danger signs noted in chapter 9 on systematic examination of the 

baby. Even the presence of a single danger sign is important and requires referral to 

a higher center/hospital. 

• Where the baby has to be referred, follow all the steps for referral outlined in chapter 13 

on major infections. 

Care Following an Unsuccessful Resuscitation 

When resuscitation attempts are not successful, it is extremely important to inform the parents 

and provide an explanation. 



105

• Indicate that everything possible was done to save the baby. Respond to the questions 

the family may wish to ask and let them express their feelings. 

• Show the baby to the parents and family members and, if culturally appropriate, provide 

them with an opportunity to hold the baby. Ensure that the family has privacy for holding 

the baby in these sad circumstances. 

• Explain that the mother will need rest, good nutrition, and emotional support at home. 

• With the baby’s death, the mother will face mammary engorgement 2-3 days after 

delivery. Advise the mother to: 

o support the breasts with a large cloth band or a bra. 

o apply cold compresses on the breasts to decrease congestion and pain. 

o avoid breast massage or exposure to heat. 

o avoid stimulating the nipples. 

o prescribe oral paracetamol when necessary for pain. 

• Make arrangements to follow the mother for at least three days to make sure she is 

improving. 

• Discuss the options of family planning and explain that in this case there is a greater 

chance of the woman conceiving earlier and that for the health of the mother and future 

babies it is better to have an interval of three years before the birth of the next baby. 

• Prepare the death certificate and follow the protocol to register the death. 

Completing Medical Records 

All healthcare facilities must keep charts/documents that record each birth and information 

about the events surrounding the birth. The basic protocols must provide the necessary 

information, such as the condition of the infant at birth and if resuscitation or any other treatment 

was administered. This information must be copied into the health records of the baby where 

separate records exist for the baby. 

All problems detected at birth as well as procedures and treatment applied must be written 

legibly in the chart for future reference in case it is needed for healthcare or administrative 

reasons. The systematic collection of information is important to establish health statistics and 

to serve as educational material to improve the quality of care. Good documentation is also 

extremely important in case of medico-legal issues that may surface later. The following details 

should be present: 

• date and time of birth 

• condition of the baby at birth 

• procedures used to initiate breathing where applicable 

• time delay between birth and the first breath 

• observations during and after resuscitation, if any 

• result of resuscitation procedures 

• in case of unsuccessful resuscitation, list the likely reason(s) for failure 

• name of the healthcare worker(s) present at resuscitation 

The key steps in resuscitation and for integrating with AMTSL are summarized in the algorithms 

given below (Figures 8.9 and 8.10). 

106 




Figure 8.9 Algorithm for resuscitation for birth asphyxia 



107

Integration of AMTSL and ENC 

Keep required items for the mother and baby close by, load oxytocin in syringe. 

Inform the woman what is being planned in a way she can understand. 

Receive and dry the baby, discard wet linen. 

Baby cries well 

Cry not heard 

Place the baby on the mother’s 

abdomen; cover with a dry cloth. 

Inform the mother about her baby 

and AMTSL; administer uterotonic 

after checking for a second baby. 

Clamp cord when pulsations 

stop/2-3 minutes after birth. Place 

the baby on the mother’s chest 

and keep the baby warm. 

Place the baby on the mother’s abdomen; cover the 

baby with a dry cloth. 

Breathing well 

Inform the mother about 

her baby and AMTSL; 

administer uterotonic 

after checking for a 

second baby. 

Not breathing/ 

gasping 

Cut the cord; resuscitate 

the baby. If possible, 

administer uterotonic 

after checking for a 

second baby. 

Apply controlled cord traction + 

countertraction; perform uterine 

massage. 

Clamp cord when 

pulsations stop/2-3 mins. 

after birth. Place the baby 

on the mother’s chest and 

keep warm. 

Apply controlled cord 

traction + countertraction; 

perform uterine 

massage. 

Depending on the level of 

resuscitation efforts 

needed and whether an 

assistant is present, 

deliver placenta by 

maternal effort or 

controlled cord traction. 

Monitor the woman and baby closely. 

Implement ENC at birth: eye prophylaxis; cord care; warmth (skin-to-skin); breastfeeding. 

Continue routine care for the woman and her baby. 

Figure 8.10 Algorithm for integration of AMTSL, ENC and resuscitation for birth asphyxia 

108 




CHAPTER 9: Basic Systematic Examination of a 

Newborn at Peripheral Centers 

In major hospitals the pediatrician/neonatologist performs a systematic and complete 

examination of the newborn. This kind of evaluation is presently not feasible in the peripheral 

centers where such specialists are not available. The purpose of this manual is for peripheral 

healthcare workers to acquire competence in basic evaluation and care of the newborn infant, 

and the manual will therefore focus on basic components of care and evaluation. A somewhat 

more detailed systematic examination, noted in Appendix B, may be relevant at some of the 

larger, more established centers. 

While in general there is a systematic method of examination, it is important in some cases to 

adapt the steps to take into consideration certain situations that apply to very young babies such 

as newborns. The newborn infant is frequently asleep, for example, so it is advisable to take 

advantage of this to carry out those steps that require a quiet infant, such as counting the 

respiratory rate. On the other hand, if the baby is crying, it becomes easier to look into the 

mouth to identify the presence of problems such as a cleft lip or an infection such as thrush. If 

necessary, newborns can usually be calmed with breastfeeding, which provides an opportunity 

to evaluate sucking and attachment at the breast. 

PREPARING FOR THE EXAMINATION 

Timing of the Examination 

Examinations should be done at the following times: 

• As soon as feasible after birth when the baby is stable and warm. 

• At least once a day as long as the baby is in the facility. 

• Before discharge. This is extremely important in order to detect any high risk factors or a 

danger sign in the early stages. The latter may necessitate a longer stay at the facility, 

beginning treatment/referral to the hospital, or recommending an earlier follow-up visit. 

The early postpartum period is very important as 75 percent of deaths in newborns take 

place in the first week following birth. 

• At the first and subsequent follow-up visits in the postpartum period. 

Equipment and Supplies Needed for the Examination 

• a source of clean water, soap, alcohol/glycerine hand rub and clean towels 

• a clean examination table/mother’s bed (should be free of drafts and well-lit) 

• a baby weighing scale 

• a clean stethoscope 

• a clinical thermometer for recording axillary temperature 

• cotton swabs and alcohol 

• a tape measure 

• a watch or clock with a second hand or a timer to aid in measuring the respiratory rate 

• a mother/baby card 



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Preparation 

• Promote cleanliness of the site where the baby is examined. 

• Arrange to have adequate light. 

• Welcome the mother and her family/companion, install them comfortably in a draft-free 

area, and explain what you are going to do. 

• Wash hands with soap and water; if these are unavailable, use alcohol/glycerine 

hand rub. 

• Prevent heat loss/hypothermia. Select a draft-free area, keep the baby warm during 

examination with a heat source, or, if not available, keep the baby covered, close to the 

mother, and expose only the part(s) to be examined. 

CARRYING OUT THE EXAM 

Main Steps of the Exam 

1. Prepare a suitable place. 

2. Plan to maintain the baby’s temperature during the examination. 

3. Greet the mother and make her feel comfortable. 

4. Review available records of the mother and baby. 

5. Ask about danger signs and other problems. 

6. Check for danger signs (and refer the baby if even one sign is present). 

7. Check for jaundice. 

8. Check for minor infections. 

9. Evaluate breastfeeding. 

10. Weigh the baby. 

11. Document observations and care of the baby in appropriate charts/cards/registers. 

12. Counsel the mother on basic newborn care. 

Detailed advice for some of these 12 steps is provided in the following sections. 

Review the mother’s and baby’s records and ask about danger signs 

Look for information related to: 

• Pregnancy: Note any care received by the mother and risk factors for infection. 

• Regarding the delivery, note: 

o condition at birth, when the baby cried after birth and if it was spontaneous; if not, 

note what actions were taken to initiate the cry 

o birth weight 

o care given at birth (eye and cord care, vitamin K1 injection) 

o immunizations 

• Inquire about danger signs (see below). 

• Ask about any other problems the newborn may have. 

• Ask about the passage of stools and urine, specifically the approximate number 

per day (urine being passed more than six times a day is reasonable evidence of 

adequate breastfeeding). 

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The following three adaptations may be necessary during an examination of a newborn: 

• Count the respiratory rate whenever the baby is quiet. 

• If the baby cries, take advantage to examine the mouth to look for cleft palate or thrush. 

• If feeding is necessary to calm the baby, take advantage to observe attachment at the 

breast and quality and adequacy of the sucking. 

Check for danger signs 

Check for the following newborn danger signs: 

• Difficulty in sucking. The danger signs related to sucking/feeding can be assessed by 

asking the mother and verified by direct observation. 

• Lethargy, diminished activity, moving only when stimulated. Except in deep sleep, 

babies move frequently, both spontaneously and on stimulation. The arms and legs are 

flexed. If a limb is consistently kept straight, evaluate for paralysis. Note also if the limbs 

seem very limp or flaccid. 

• Fever or hypothermia. Assess the body temperature by at least touching the baby’s 

abdomen, hands, and feet and ensuring that all are warm. Where possible, note the 

axillary temperature with a thermometer leaving it in place for four minutes or as 

recommended by the manufacturer for axillary temperature recording. The normal 

temperature is 36.5-37.5 °C. The thermometer should be clean, preferably washed with 

soap and clean water, and wiped with an alcohol swab to prevent cross infection. Storing 

in liquid antiseptics should be done only if they are changed frequently. Otherwise there 

is risk of infections with Pseudomonas sps which may be highly resistant organisms. It is 

not recommended to take a rectal temperature as it is associated with a higher risk of 

infection and trauma. In the newborn infant, both fever and low body temperature 

outside the normal range of 36.5-37.5 °C are danger signs, especially if they are not 

reversed rapidly with simple steps, such as warming through skin-to-skin contact, or 

through removal of excess clothes, or covering in the hot weather. 

• Rapid breathing/difficulty in breathing. Assess respiration: the normal respiratory rate 

is 30-60 breaths/minute. There should be no flaring of the nostrils, grunting, or subcostal 

retractions. Although breathing can be somewhat irregular with short pauses, there 

should be no apnea, which is defined as cessation of breathing lasting for more than 20 

seconds or of a shorter duration associated with cyanosis, pallor, or bradycardia with a 

heart rate less than 110/minute. The normal heart rate ranges between 110-160 

beats/minute, with the lower rates when the baby is asleep and the higher rates when 

the baby is active or crying. 

• Convulsions. Features of convulsions are often atypical in the newborn, such as a 

“staring” look, blinking of eyelids, “chapping” movements of the lips, and clonic/tonic 

movements of the limbs. 

• Persistent vomiting and/or abdominal fullness . Vomiting is determined from the 

history taken from the mother. Occasional vomiting is normal, but persistent vomiting or 

green-colored vomitus are abnormal. 

• Severe umbilical infection. Lift the cord to see the base; check for pus discharge, 

redness, swelling, and foul smell. In the first day or two also check the cord for bleeding 

or oozing of blood. 

The danger signs are summarized in Table 10 below. 



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DANGER 

SIGNS 

Table 10. Guidelines for Identifying Danger Signs at Peripheral Centers 

IDENTIFICATION 

(Ask and look for) 

Sucking less 

or not 

sucking at all 

Lethargy/ 

inactivity 

Fever/ 

low body 

temperature 

Fast 

breathing/ 

respiratory 

difficulty 

Convulsions 

Persistent 

vomiting 

and/or 

abdominal 

distension 

Severe 

umbilical 

infection 

Not sucking at all; sucking less than usual; not opening the mouth when offered 

feeds; not demanding feeds. 

Not as active as usual, sleeping excessively, difficult to arouse, not waking up 

for feeds, lying limp, “loose-limbed,” excessively quiet or “too good.” 

Fever: Body hot to touch, history of the mouth feeling excessively hot during 

breastfeeding; temperature 38 °C or more. (While the temperature is usually 

>38 °C, some feel that in the newborn it is better to be on more watchful when 

the temperature is even 37.5 °C.) 

Low body temperature/hypothermia: body feels colder than normal; 

temperature less than 36.5 °C. 

Respirations more than 60/minute (count a second to verify), flaring of the 

nostrils, groaning or grunting, subcostal retraction. 

Features of convulsions are often atypical in the newborn such as a “staring” 

look, blinking of eyelids, “chapping” movements of the lips, clonic/tonic 

movements of the limbs. 

Occasional vomiting is common, but persistent vomiting or green-colored 

vomitus are abnormal. Abdominal distension or fullness may be present. 

Lift the cord to see the base. Look for spreading redness or swelling around the 

umbilicus and/foul smell with or without pus discharge. 

Earlier detection of problems such as major infections 

Babies with danger signs have to be taken long distances to the appropriate centers. Hence, 

ideally, infections need to be detected even earlier. Very early signs of infection are vague and 

difficult to recognize. They include the baby “not looking well” or having a “sick look” or “facial 

grimace.” They require careful daily observation. 

Mothers, family members, and health care providers (depending on whether the baby is at 

home or at a facility) should be encouraged to see the baby in adequate light at least once a 

day, especially in the first week. 

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Check for jaundice 

Unlike in older infants, it is not easy to see jaundice in the early phase in the eyes of the 

newborn. It is best assessed in the skin. Jaundice starts in the face and spreads down to the 

hands and feet. Gently press the tip of the nose, release the pressure, and observe the 

blanched area for any yellow tinge/color. It can also be seen in the grooves of the skin when the 

baby frowns or cries. 

This is the only time in life that some jaundice is normal, and this used to be termed physiologic 

jaundice of the newborn. It starts after the first 24 hours on the face and does not spread to the 

palms and soles and disappears by two weeks. When the color reaches the palms or soles, it 

correlates with a serum bilirubin of about 15 mg/100mL (or 256.5µmols/L). Such babies require 

referral for assessment and treatment, such as phototherapy. 

These guidelines apply only to full-term normal weight babies. Preterm and low birth weight 

babies require treatment at far lower levels of bilirubin. Hence, such babies with any jaundice 

need to be referred to a competent person/center for assessment and treatment. They should 

not be considered to have “physiological jaundice.” 

Here is a summary of referral criteria for jaundice: 

• starting early, within 24 hours of birth 

• present on the palms and soles 

• associated with a danger sign 

• occurring in a low preterm/birth weight baby 

• persisting beyond the second week of life 

Check for minor infections 

Conjunctivitis: Subconjunctival hemorrhage can be a normal finding following the delivery. 

Check for conjunctivitis, seen as redness and/or discharge. 

Thrush: Examine the tongue and the inner side of the mouth for oral thrush, seen as irregular, 

dirty, white patches on the tongue and inner sides of the cheeks. Thrush is different from the 

normal smooth white coating which may be seen over the middle of the tongue in some babies. 

It is best to look into the mouth when the baby cries or yawns. Avoid introducing a spatula or 

spoon into the mouth to open it. If doing this is unavoidable, then it must be done very gently, as 

vagal stimulation may result in bradycardia or even cardiac arrest. 

Skin infection including pustules on the skin: The lesions may be seen as yellowish 

pustules or as areas of peeling with underlying redness. Examine the skin from head to toe. 

Look particularly in the neck folds and elbow, behind the ears, in the axilla and groin. Turn the 

baby over and examine the back. 

Minor infections of the umbilicus: Look for pus discharge from the umbilicus or base of the 

cord (lift the cord to see the base) without redness or swelling over the surrounding skin and/or 

a foul smell. 



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Evaluate feeding 

This can be done at any convenient time as noted above, especially after excluding danger 

signs, such as the inability to suck, that need immediate attention. If the baby can suck well, 

evaluate the latching or attachment of the baby’s mouth at the breast. Note that: 

• The baby’s chin is touching or nearly touching the breast. 


• The lower lip is everted. 

• Most of the areola is inside the mouth, especially the part below, so that the areola is 

visible more above the mouth than below. 

• The sucking is slow and deep and swallowing is audible. 

Weigh the baby 

• Place a clean cloth or paper on the baby scale pan. 

• Adjust the scale so it reads “zero” with the paper/cloth on it. 

• Place the baby over the cloth or paper. If it is a cloth and of adequate size, fold it to 

cover the body of the baby. 



• Write down the weight of the baby in the mother/baby and delivery room records, based 

on recommendations of the Ministry of Health. 

• The normal weight range is 2.5-4 kg. Low birth weight is below 2500 grams. 

Document key findings 

Record all key observations in writing in the baby’s health cards and chart/delivery register. 

Counsel the mother/family 

Advise the mother on the following: 

• frequent breastfeeding on demand day and night 

• keeping the baby appropriately warm 

• cord care 

• general cleanliness, including washing hands before handling the baby at least after 

using the toilet, after changing the napkin/diaper, and after cleaning the house 

• having additional fluids and eating an extra meal 

• the danger signs to look for in herself and in the baby 

The key elements of the basic systematic examination of the newborn at peripheral centers are 

summarized in Table 11. 

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Table 11. Key Steps in Examining the Newborn at a Peripheral Center 

• Ask the mother for danger signs. 

• Ask about other problems. 

• Check/assess for danger signs that are features of major infections. (Even if 

there is only one danger sign, institute steps for transfer of the baby to an 

appropriate referral center). 

• Check for jaundice. 

• Check for minor infections. 

• Evaluate feeding. 

• Weigh the baby. 

• Prescribe treatment of minor infections. 

• Document the findings and care provided on cards/chart/record books. 

• Take advantage of this contact to provide care such as the necessary 

vaccines. 

• Counsel the mother/family members on basic care at home. 



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CHAPTER 10: Postnatal Care of the Newborn, at the 

Facility and During Postnatal Visits 

Some use the words postpartum and postnatal synonymously. Others use the word postpartum 

(after delivery) for the mother and the word postnatal (after birth) for the baby. In this session 

the word postpartum will be used for the mother and the word postnatal for the baby, for easy 

differentiation. 

The postnatal/postpartum period starts after the delivery of the placenta and extends to 6 weeks 

after birth. Guidelines for assessment and care may be followed during specific time intervals, 

as with the WHO classification: at birth, the first hour, around 6 hours, after 6 days, and after 6 

weeks. However, the length of the stay in the delivery room and the postnatal ward and the day 

of discharge vary considerably in different countries and at different levels of facilities. Thus, 

these intervals, especially the hourly ones, may at times be difficult to identify and adhere to. 

An alternative classification—with specific, easily identifiable times for specific activities rather 

than just the period of time that has elapsed—may be easier to use. This classification is as 

follows: 

• at birth (in the delivery room) 

• before the mother and baby leave the delivery room 

• every day during the stay at the facility 

• at discharge from the facility 

• at the postnatal visits 

TIMING OF MOST NEONATAL DEATHS 

As noted in the introduction, 50 percent of deaths in the newborn period take place within 24 

hours of birth and 75 percent by the end of the first week of life. 

There are currently no specific recommendations based on evidence for the timing and numbers 

of contacts in the postnatal period at the facility and in the community. There is some evidence 

to suggest that home visits by community health workers on day two have been correlated with 

a decrease in neonatal mortality. However, in view of the high mortality during the first week, it 

is clear that these recommendations for the postnatal period need to focus on this period, 

especially the first 48-72 hours. 

COMPONENTS OF POSTNATAL CARE 

The postnatal period has been the most neglected period in the pregnancy/delivery/postnatal 

continuum of care. Both health workers and mothers/families are not, in general, aware of the 

potential dangers and high mortality in the early postnatal period. Mothers and babies tend to 

stay home after a delivery, and there is also a lack of motivation among families to bring 

mothers and babies for early and regular check-ups, especially if the babies or mothers seem 

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normal. Skilled health workers do not generally carry out home visits in most countries; in some 

areas, it may be difficult to have community health workers make home visits at suitable times. 

Promotion of early postnatal visits is essential, but it is likely that strategies to deal with the 

different scenarios that exist and for “covering” the first week of life, including the first 2-3 days, 

are even more important. The possible scenarios for this critical period include the following. 

• Deliveries may take place at home, and both the mother and the baby may remain there 

throughout the neonatal/postpartum period, bound frequently by strong cultural practices 

that, in general, prevent them from going outside their homes. 

• Where deliveries take place at the facility level, the stay for a normal delivery may vary 

considerably, from a few hours to 2-3 days. Too early a discharge is frequently 

associated with inadequate time for evaluation, care, and counseling. Longer stays are 

associated with overcrowding, potential risk of nosocomial infections, increased costs, 

and poor compliance by families. 

• Chances of an early first visit to the health center after a home delivery and return after 

discharge from a facility birth depend on the degree of motivation, constraints due to 

challenges in family finances and transport, resulting in poor access, quality, and the 

cost of the care provided. 

Thus strategies for postnatal assessment and basic care need to include both facility and 

community components, involving trained skilled health workers and community health workers 

(CHWs), with links between the two. These may include home visits by CHWs and visits by 

mothers and babies at the facility, depending on the above scenarios. 

Through community mobilization and communication strategies, including interpersonal 

communication and traditional methods and use of mass media, families at home can learn 

about basic preventive care, identifying danger signs, and seeking appropriate care. Trained 

CHWs making home visits can also contribute to the latter components. It is far more difficult in 

most countries for skilled birth attendants to make home visits. Good links between community 

and facility level workers can help promote referrals to health centers as required. 

In facility deliveries, after birth, it is critical to ensure careful examinations of the mother and 

baby by the skilled birth attendant, with appropriate actions at three points: 

• just before transferring them out of the delivery room to the rooming-in ward 

• at least once a day during their stay at the facility 

• just before discharge 

These evaluations will help to identify special risk factors or problems in the early stages that 

may necessitate some treatment, a longer stay at the facility, special advice, and/or an earlier 

follow-up appointment. Proper counseling, especially at discharge, on preventive care at home, 

identifying danger signs, and appropriate care seeking are also extremely important. 

Content of the Postnatal Visit 

In addition to having an early visit/contact at the appropriate time, the content and quality of the 

visit need to be considered. Key components are noted below: 

• courteous, supportive behavior towards the mother/family 



117

• basic, systematic examination and care at appropriate times 

• provision of essential newborn care (ENC) through health workers, mothers and families, 

including: 

o cleanliness for prevention of infection 

o maintaining body temperature 

o continued cord care 

o exclusive breastfeeding on demand 

o additional care such as vaccines 

o identification and treatment of problems and referral 

• recording key information 

• treatment of any problems detected, locally or through referral 

• counseling the mother/family on ENC and follow-up 

Management Issues 

Proper management is required to ensure that postnatal care at the facility is implemented 

effectively. Key tasks include the following. 

• Develop supportive strategies to implement basic postnatal care during a facility stay 

and at postnatal visits. 

• Prepare the site (space, basic furniture, equipment, supplies and drugs). 

• Develop a user-friendly follow-up clinic. 

• Provide a client flow that aids the mother and baby to receive evaluation and care 

(routine MNH care, HIV/AIDS, PMTCT, family planning, and counseling) in a reasonable 

amount of time. 

• Ensure recording of information, maintenance, local review, and central transmission of 

data. 

Equipment and Supplies for Postnatal Visits 

• a clean, draft-free, and well-lit environment 

• water, soap, or alcohol-based hand scrub and clean towel/paper towel 

• a clean examining table with a mattress with a surface that can be cleaned (during the 

hospital stay the baby may be examined on the mother’s bed) 

• a thermometer for recording axillary temperature 

• a stethoscope 

• a baby weighing scale 

• a measuring tape 

• sterile syringes, cotton swabs, and alcohol 

• vitamin K1 

• antiseptic solutions 

• vaccines (BCG, oral polio vaccine and hepatitis B, as recommended by the Ministry of 

Health) 

• medication for the baby as recommended by the Ministry of Health, such as oral 

amoxicillin, cloxacillin, injectable ampicillin and gentamycin, tetracycline eye drops / 

ointment, mycostatin, gentian violet solution, Betadine solution 

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Steps of Postnatal Care at the Facility Level 

The following are the key steps of quality postnatal care at the facility level: 

Step 1: Carry out all tasks at the appropriate time. 

Step 2: Carry out a basic systematic examination of the baby. 

Step 3: Provide relevant care. 

Step 4: Document findings and care in a baby card/register. 

Step 5: Promote continued follow-up and schedule the next appointment. 

Step 6: Counsel the mother and family. 

These steps are explained in more detail below. 

Step 1: Carry out all tasks at the appropriate time 

Arrange for proper assessment and care at the following times: 

• at birth and during the first six hours 

• at least once a day during any stay at the facility 

• just before discharge 

• during postnatal follow-up visits 

Step 2: Carry out a basic systematic examination of the baby 

The examination should include the following steps: 

• Prepare to maintain the baby’s temperature during the examination. 

• Greet the mother and make her feel comfortable. 

• Review available records of the mother and baby. 

• Ask and asess for danger signs and other problems. 

• Check for jaundice. 

• Check for minor infections. 

• Evaluate infant feeding. 

• Weigh the baby. 

• Document all findings and care. 

Step 3: Provide relevant care 

• If a danger sign exists (even just one), administer the first dose of antibiotics and refer 

the baby. 

• Administer treatment for minor infections. 

• Administer immunizations, OPV, BCG, hepatitis B, if not already done. 

Step 4: Document findings and care in a baby card/register 

Step 5: Promote continued follow-up and schedule the next appointment 

• For newborns with minor infection, schedule a visit after two days. 

• For low birth weight babies follow up once a week until the baby is at least 2000 grams. 



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• Where feasible and available, place the mother/family in contact with a trained 

community health worker or volunteer. 

Step 6: Counsel the mother and family. 

Counsel the mother and family in the following topics: 

• Continue exclusive breastfeeding on demand, day and night, for six months. After that, 

start semisolid food but continue breastfeeding into the second year of life. Tell the 

mother that if breastfeeding is exclusive, frequent, and on demand, and if the woman 

has not resumed menstruation, it can also prevent pregnancy during the first six months. 

• Keep the baby warm: 

o The room where the baby stays should be warm and free of drafts. In cold weather 

the baby should be wearing warm clothes with a hat/cloth covering the head. Wet 

diapers should be changed quickly. The baby should sleep with the mother in bed. 

o Check the baby’s temperature, touching feet, hands, and abdomen (if the abdomen 

is cold, moderate to severe hypothermia is present). 

o Skin-to-skin contact is the best way of keeping the baby warm at home if the 

newborn is hypothermic, especially for a LBW baby. (See kangaroo mother care in 

chapter 12.) 

o Teach the mother/family how to avoid chilling during a bath (the section below also 

includes a few additional points for promoting cleanliness during bathing): 

Wash hands with soap and water before handling the newborn. 

Delay the first bath for at least 6 hours, preferably 24 hours after delivery. 

Have everything ready before the bath. 

Bathe the baby in a warm room with no drafts. 

Make sure the water is warm (verify this by touching the water with a clean hand 

or elbow). 

Take care to expose and clean all skin folds. 

Wash the baby’s hair last; dry the baby fast with a cloth or towel. 

Place the baby in skin-to-skin contact with the mother after the bath (if 

necessary). 

• Keep the cord and umbilicus clean: 

o Keep the cord dry and clean. 

o Fold the diaper below the cord so that it does not touch the cord. 

o Don’t apply harmful substances on the cord (e.g., ash, mud, clay, or herbs). 

o If recommended by the Ministry of Health/health center, apply the appropriate 

antiseptic on the cord, taking care to apply it to the base. 

• Additional basic hygiene/cleanliness of the baby: 

o Wash hands with soap and water before handling the baby, especially after changing 

the diaper/napkin, after cleaning the house, and after using the toilet. Hands should 

be washed every time before handling a low birth weight baby. 

o The baby should be cleaned/bathed daily, taking care to ensure that the folds of skin 

are exposed and cleaned. 

• Birth spacing and family planning: see chapter 7 on maternal postpartum care. 

• Prevention of malaria: see chapter 7 on maternal postpartum care. 

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• Identification of danger signs: 

o poor sucking or not sucking at all 

o inactivity or lethargy 

o fever (body too hot) or hypothermia (body too cold) 

o difficulty in breathing/rapid breathing 

o convulsions 

o repeated or persistent vomiting and/or abdominal distention 

o redness and/or swelling surrounding the base of the umbilicus, with our without pus 

discharge, and/or foul smell 

The first five danger signs are the most important. Although these are standard danger 

signs, it is essential to inform mothers that they should look at their babies carefully at least 

once a day in adequate light. Even if they do not detect a specific danger sign, mothers 

should still seek care from an appropriate health worker if they feel their baby is “not looking 

or doing well”. In this way, sick newborns can be identified and treated early which is 

particularly important in the newborn period when the condition can deteriorate rapidly. 

• Preparation for emergency issues in the mother or baby. Discuss with the woman and 

her partner and family about emergency issues: 

o where to go if there are danger signs 

o how to reach the hospital 

o how to meet the costs involved 

o options for family and community support 

• Advise the woman to ask for help from the community, if needed. 

• Advise the woman to bring her home-based maternal record to the health center, even 

for an emergency visit. 

Care for HIV-Positive Mothers and Their Exposed Infants 

For the baby, ask the following questions: 

• Was ARV medication for prophylaxis administered to the baby (according to the 

recommendation of the Ministry of Health)? If possible verify from any available records. 

• Is the baby currently on any ARV prophylaxis? 

• Is the baby receiving cotrimoxazole prophylaxis? (If not, counsel for commencing 

cotrimoxazole prophylaxis according to national guidelines.) 

• Has the baby been tested for HIV? 

o If yes, note and record the test result. 

o If not, refer the baby for HIV testing as early as six weeks after birth. 

• Check infant feeding options: 

o Provide support for the infant feeding choice. 

o If breastfeeding: 

Reinforce messages on care of the breast and prevention of problems. 

Address any questions, concerns, and problems related to breastfeeding. 

Warn about the risks of “mixed” feeding, giving both breast milk and formula. 



121

• Check the infant for the following: 

o inadequate weight gain 

o skin rashes 

o oral thrush 

For the mother, do the following: 

• Refer the mother for clinical assessment and evaluation of the need for ARV treatment if 

eligible. 

• Provide cotrimoxazole prophylaxis therapy (CPT) for the mother, according to national 

guidelines. 

• Counsel the mother on: 

o The benefits of birth spacing if she is not already using a family planning method: 

Stress the special importance and benefits of birth spacing/family planning. 

Provide information on available methods. 

Support her in her choice of the method, including LAM. 

Arrange for follow-up counseling and support on her chosen method. 

o Continued safer sex practices. 

o Frequent occurrence in the baby of diarrhea, acute respiratory infections, acute otitis 

media, opportunistic infections such as thrush and failure to thrive. 

o Symptoms of opportunistic infections in herself, such as fever, cough, night sweats, 

weight loss, diarrhea. 

o When to bring the child for immunization, weight check-up/growth monitoring, and for 

supplements such as vitamin A. 

• If no clinical HIV services are immediately available for referral of the mother and infant, 

counsel the mother about HIV in infants and the need to get testing and treatment as 

soon as possible. 

• Provide psychosocial support and link the mother to community support for HIV care and 

services. 

• Make an appointment for the next visit for HIV care according to national guidelines. 

• Place the family in contact with an available community health worker/volunteer where 

available and feasible. 

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Table 12. Suggested Timings of Postnatal Visits 

Ideally should be provided by a skilled attendant who is usually at the facility level, linked with a 

community health worker/volunteer (CHW). If access to the facility is extremely difficult, have the 

postnatal visit through the CHW. 

Scenario 1st postnatal visit 2d postnatal visit 3d postnatal 

visit 

Facility delivery, normal 

baby, discharge within 24 

hours 

In the first 2-3 days, 

ideally 2 days after 

birth 

5-7 days (may coincide 

with special events) 

4-6 weeks 

Facility delivery, normal 

baby discharge day 2 or 3 

Delivery by Cesarean 

section, normal baby and 

discharged after a week, in 

some cases earlier 

4-7 days Second week 4-6 weeks 

2 weeks 4-6 weeks 

Home delivery 

Ideally on day of birth 

and within day 48-72 

hours; If not feasible, 

at least one visit within 

48 hours. 

5-7 days (may be adjusted 

to accommodate special 

family events) 

4-6 weeks 

LBW should ideally stay at 

least 3-7 days at facility. 

Refer very small babies and 

those with problems to 

higher center. 

Visit every week until weight gain is adequate, e.g., 2000-2500 grams 

and the baby is doing well. 

The number and timing of home visits by the CHW can vary based on feasibility and the 

recommendations of the program implementing agency/MOH and on existing problems, but advocacy 

should be carried out for coverage during the first week, especially during the first 2 – 3 days. 



123

Table 13. Care of the Newborn during the 4-6 Weeks after Birth 

(Use with the learning checklist on the postnatal visit) 

Action At birth Before 

mother and 

baby leave 

the delivery 

room 

Provide care/ 

counseling 

Observe/look for 

Provide 

counseling 

Give specific 

care 

Brief examination, look for 

danger signs 

Targeted counseling, 

i.e., breastfeeding, protection 

against hypothermia, danger 

signs. 

Eye care 

Cord care 

Vitamin K 

Identification band 

Breastfeeding 

At least once a 

day during stay 

in postnatal 

ward 

From birth to six weeks 

At discharge 

Essential Newborn Care 

Full basic systematic examination 

Full counseling 

First 

postnatal 

visit 

Second 

postnatal 

visit 

BCG, OPV, and hepatitis B any time in the postpartum period 

according to the recommendations of the Ministry of Health. 

Care of the baby of the HIV positive mother including ARV. 

Third 

postnatal visit 

at 4-6 weeks 

DPT, 

oral polio, and 

BCG if not 

administered 

earlier and 

cotrimoxazole 

for babies of 

HIV positive 

mothers 

Weigh weight weight Weight weight weight weight weight 

Document 

information in 

mother/baby 

card registers 

X X X X X 

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Table 14. Summary of Postnatal Evaluation and Care of the Baby 

1. Implement tasks at the appropriate time. After birth, evaluate and provide care: 

• before transfer out of the delivery room. 

• at least once a day during the stay of the baby at the facility (more frequently for 

low birth weight babies and if a problem needing observation was noted). 

• at discharge. 

• during postnatal visits. 

2. Carry out a basic systematic examination of the baby (see session 9 for details). 

3. Provide appropriate care: 

• If a danger sign exists (even if only one), give the first dose of antibiotics and 

refer the baby. 

• Administer/prescribe treatment for minor infections. 

• Give immunizations: OPV, BCG, hepatitis B (based on recommendations of the 

Ministry of Health) if this was not already done. 

4. Document findings/care in mother/baby card/register. 

5. Promote continued follow-up and schedule the next appointment. 

6. Counsel the mother/family on basic preventive care at home, identifying danger signs 

and appropriate care seeking. 

7. Where the mother is HIV-positive, ensure appropriate care for the mother and baby. 

8. Where feasible and appropriate, put the family in contact with an available trained 

community health worker. 



125

CHAPTER 11: Diagnosing and Treating Breastfeeding 

Problems 

COMMON PROBLEMS 

Breastfeeding difficulties may be due to problems in breastfeeding techniques, problems with 

the baby, or breast conditions in the mother. Problems with the baby include but are not limited 

to: 

• congenital anomalies such as cleft lip or palate 

• prematurity 

• small baby or twin 

• inability to suck as with sepsis 

Breast conditions which sometimes cause difficulties with breastfeeding include but are not 

limited to: 

• sore nipples and nipple fissure 

• engorgement 

• mastitis 

• breast abscess 

• flat or inverted nipples 

Diagnosis and management of these breast conditions are important both to relieve the mother 

and to enable breastfeeding to continue. Care for breast conditions will need to include both 

management of the condition and assistance with breastfeeding technique. 

PREVENTION AND TREATMENT 

Cracked or Sore Nipples 

Sore nipples and superficial breaks in the skin, sometimes called “cracks,” are usually caused 

by poor attachment or feeding techniques. 

Prevention 

• Make sure the baby is properly attached to the breast. 

• Counsel the mother to keep her breasts clean and dry and to only use soap once per 

day when taking her bath. If she uses soap more often than once daily, she may get 

cracked nipples. 

• Help mothers find positions that are comfortable and help them feel relaxed; two 

common positions are the underarm position (holding the baby with the arm opposite the 

breast) and lying on the side. 

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Underarm position 

Side lying position 

Figure 11.1. Two positions for breastfeeding. (WHO, 1993) 

Management 

• Build the mother's confidence. 

• Improve attachment and continue breastfeeding. 

• Reduce engorgement; suggest frequent feeding and express breast milk if needed. 

• Treat for Candida if the skin is red, shiny, flaky; if there is itchiness or deep pain; or if 

soreness persists. 

• Advise the mother: 

o Not to wash her breasts more than once a day and not to use soap or rub hard with a 

towel. Breasts do not need to be washed before or after feeds; normal washing as for 

the rest of the body is all that is necessary. Washing removes natural oils from the 

skin and makes soreness more likely. 

o Not to use medicated lotions and ointments because these can irritate the skin, and 

there is no evidence that they are helpful. 

o To rub a little expressed breast milk over the nipple and areola with her finger after 

breastfeeding; this promotes healing. 

o To expose her breasts to the air for brief periods. 

o To start the feed on the unaffected breast. This may help if the pain seems to be 

preventing the oxytocin reflex. Change to the affected breast after the reflex starts 

working. 

o To breastfeed the baby in different positions at different feeds. 

• If breastfeeding is difficult, help the mother to express the milk. 

Breast Engorgement 

Breast engorgement is an exaggeration of the lymphatic and venous engorgement that occurs 

prior to lactation; it is not the result of over-distension of the breast with milk. Engorgement may 

occur between days 2 and 4, causing the breast to become hard and tense and the nipples to 

become taut, shiny, and hard; this usually resolves spontaneously in 24 to 48 hours. 

Symptoms of engorgement 

• breast pain and tenderness 

• symptoms occurring 3-5 days after delivery 

• hard enlarged breasts 

• both breasts affected 



127

Prevention 

It is normal for breasts to become larger, heavier, and a little tender when the milk becomes 

more plentiful on the second to sixth day following birth. This normal fullness usually decreases 

within the first few weeks after birth if the baby is feeding regularly and well. Breast fullness may 

develop into engorgement if the baby has not been feeding often or long enough. The key to 

preventing engorgement is to nurse frequently and unrestrictedly. 

Management 

• If the baby is not able to suckle, encourage the woman to express milk by hand or with a 

clean pump. 

• If the baby is able to suckle: 

o Encourage the woman to breastfeed more frequently, using both breasts at each 

feeding. 

o Show the woman how to hold the baby and help him/her attach. 

o Relief measures before feeding may include: 

̌ applying warm compresses to the breasts just before breastfeeding, or 

encourage the woman to take a warm shower. 

̌ massaging the woman’s neck and back. 

̌ having the woman express some milk manually prior to breastfeeding and wet 

the nipple area to help the baby latch on properly and easily. 

o Relief measures after feeding may include: 

̌ supporting breasts with a binder or brassiere. 

̌ applying cold compress to the breasts between feedings to reduce swelling and 

pain. 

̌ giving paracetamol 2 tablets or 1000 mg by mouth as needed, not to exceed 4 

times or 8 tablets a day. 

• Carefully examine the breast for signs of infection such as redness, inflammation, or 

pus. Check the woman’s temperature and ask if she has chills. 

• Follow up three days after initiating management to ensure response. 

Mastitis 

Mastitis is an infection of the breast associated with pain, redness, swelling, fever, and chills. 

Mastitis usually develops when bacteria enter the breast tissue through an injury to the breast. 

Injury to the breast may be caused by bruising from rough manipulation, breast over-distention, 

milk staying in the breast (stasis), or cracking or fissures of the nipple. 

Symptoms of mastitis 

• breast pain and tenderness 

• reddened, wedge-shaped area on breast 

• symptoms occurring 3-4 weeks after delivery 

• inflammation preceded by engorgement 

• usually only one breast affected 

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Management 

• Treat with antibiotics: 

o Cloxacillin 500 mg by mouth 4 times per day for 10 days, or 

o Erythromycin 250 mg by mouth 3 times per day for 10 days 

• Encourage the woman to: 

o Continue breastfeeding. 

o Support breasts with a binder or brassiere. 

o Apply cold compresses to the breasts between feedings to reduce swelling and pain. 

• Give paracetamol 500 mg by mouth as needed. 


The most important part of treatment is to improve the drainage of milk from the affected part of 

the breast. Look for a cause of poor drainage and correct it: 

• Look for poor attachment. 

• Look for pressure from clothes, usually a tight bra, especially if worn at night, or pressure 

from lying on the breast. 

• Notice what the mother does with her fingers as she breastfeeds. Does she hold the 

areola and possibly block milk flow? 

• Notice if she has large, pendulous breasts, and if the blocked duct is in the lower part of 

her breast. If so, suggest that she lifts the breast more while she feeds the baby, to help 

the lower part of the breast to drain better. 

Whether or not you find a cause, advise the mother to do these things: 

• Breastfeed frequently. The best way is to rest with her baby, so that she can respond to 

him/her and feed him/her whenever the infant is willing. 

• Gently massage the breast while her baby is suckling. Show her how to massage over 

the blocked area and over the duct which leads from the blocked area down to the 

nipple. This helps to remove the block from the duct. 

o She may notice that a plug of thickened milk comes out with her milk. (It is safe for 

the baby to swallow the plug.) 

• Apply warm compresses to her breast between feeds. 

Sometimes it is helpful to do these things: 

• Start the feed on the unaffected breast. This may help if pain seems to be preventing the 

oxytocin reflex. Change to the affected breast after the reflex starts working. 

• Breastfeed the baby in different positions at different feeds. This helps to remove milk 

from different parts of the breast more equally. Show the mother how to hold her baby in 

the underarm position or how to lie down to feed him/her, instead of holding him/her 

across the front at every feed. However, do not make her breastfeed in a position that is 

uncomfortable for her. 

• If breastfeeding is difficult, help her to express the milk: 

o Sometimes a mother is unwilling to feed her baby from the affected breast, especially 

if it is very painful. 

o Sometimes a baby refuses to feed from an infected breast, possibly because the 

taste of the milk changes. 

o In these situations, it is necessary to express the milk (see below). If the milk stays 

in her breast, an abscess is more likely. 



129

Breast Abscess 

Breast abscesses occur when mastitis is not appropriately or adequately treated, or if it is not 

treated in a timely manner. Intervention at the first signs of mastitis may prevent the condition 

from worsening and developing into a breast abscess. 

Symptoms 

• firmness 

• very tender breast 

• overlying erythema 

• fluctuant swelling in the breast 

• draining pus 

Management 

• Treat with antibiotics: 

o Cloxacillin 500 mg by mouth 4 times per day for 10 days, or 

o Erythromycin 500 mg by mouth 3 times (in severe cases up to 4 times) per day for 10 

days. 

• Drain the abscess: 

o General anesthesia is usually required. Hence, the mother may need to be referred 

to an appropriate center. 

o Make the incision radially, extending from near the alveolar margin towards the 

periphery of the breast to avoid injury to the milk ducts. 

o Wearing high-level disinfected gloves, use a finger or tissue forceps to break up the 

pockets of pus. 

o Loosely pack the cavity with gauze. 

o Remove the gauze pack after 24 hours and replace with a smaller gauze pack. 

• If there is still pus in the cavity, place a small gauze pack in the cavity and bring the edge 

out through the wound as a wick to facilitate drainage of any remaining pus. 

• Encourage the woman to: 

o Continue breastfeeding on the normal side and express out milk from the affected 

side. 

o Support her breasts with a binder or brassiere. 

o Apply cold compresses to the breasts between feedings to reduce swelling and pain. 

• Give paracetamol 500 mg by mouth as needed. 


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Inverted Nipples 

Some women have flat or inverted nipples which may reduce their confidence in their ability to 

breastfeed and cause some babies frustration when they are starting to breastfeed. There is no 

reason why women with inverted nipples cannot breastfeed. Antenatal treatment may not 

always be helpful. Assisting women with inverted nipples is most important soon after birth, 

when the baby starts breastfeeding. 

Management of flat and inverted nipples 

• Build the mother's confidence. 

o Explain that it may be difficult at the beginning, but with patience and persistence she 

can succeed. Explain that her breasts will improve and become softer in the week or 

two after delivery. Her baby's suckling will help to pull her nipples out. 

o Explain that a baby suckles from the breast not from the nipple. 

o Her baby needs to take a large mouthful of breast. Explain also that as her baby 

breastfeeds, he/she will pull the breast and nipple out. 

• Encourage her to give plenty of skin-to-skin contact and to let her baby explore her 

breasts. Let him/her try to attach to the breast on his/her own, whenever he/she is 

interested. Some babies learn best by themselves. 

• Help her to position her baby. 

o If a baby does not attach well by himself/herself, help the mother to position the baby 

so that he/she can attach better. Give her this help early, in the first day, before her 

breast milk “comes in” and her breasts are full. 

o Help her to try different positions to hold her baby. Sometimes putting a baby to the 

breast in a different position makes it easier for him/her to attach. For example, some 

mothers find that the underarm position is helpful (see Figure 11.1). 

• Help her to make her nipple stand out more before a feed. Sometimes making the nipple 

stand out before a feed helps a baby to attach. Stimulating her nipple may be all that a 

mother needs to do. Or she can use a hand breast pump or a syringe to pull her nipple 

out (see Figure 11.2). 

• Express her milk and feed it to her baby with a cup. Expressing milk helps to keep 

breasts soft so that it is easier for the baby to attach to the breast, and it helps to keep 

up the supply of breast milk. 

• She should not use a bottle because that makes it more difficult for her baby to take her 

breast. 

• Express a little milk directly into her baby's mouth; some mothers find that this is helpful. 

The baby gets some milk straight away so he/she is less frustrated, and he/she may be 

more willing to try to suckle. 



131

Figure 11.2. Preparing and using a syringe for treatment of inverted nipples. 

(WHO, 1993) 

EXPRESSING AND FEEDING BREAST MILK 

There are many situations in which expressing breast milk is useful and important to enable a 

mother to initiate or continue breastfeeding. The most useful way for a mother to express milk is 

by hand. It needs no appliance, so she can do it anywhere and at any time. With a good 

technique, it can be very efficient. It is easy to hand express when the breasts are soft; it is 

more difficult when the breasts are engorged or tender. Many mothers are able to express 

plenty of breast milk using unusual techniques, but if a mother's technique works for her, let her 

do it that way. If a mother is having difficulty expressing enough milk, however, then teach her a 

more effective technique. 

How to Prepare a Container for Expressed Breast Milk 

• Choose a cup, glass, jug, or jar with a wide mouth. 

• Wash the cup in soap and water. (She can do this the day before.) 

• Ideally, boil the cup for 10 minutes before use. 

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How to Express Breast Milk by Hand 

Teach a mother to do this herself; do not express her milk for her. Touch her only to show her 

what to do. Be gentle. Teach her to: 

• Wash her hands thoroughly. 

• Sit or stand comfortably and hold the container near her breast. 

• Put her thumb on her breast above the nipple and areola and her first finger on the 

breast below the nipple and areola, opposite the thumb. She supports the breast with her 

other fingers. 

• Press her thumb and first finger slightly inwards towards the chest wall. She should 

avoid pressing too far because that can block the milk ducts. 

• Press her breast behind the nipple and areola between her finger and thumb. She must 

press on the lactiferous sinuses beneath the areola. 

Figure 11.3. Anatomy of the breast. (WHO, 1993) 

• Sometimes in a lactating breast it is possible to feel the sinuses; they are like pods or 

peanuts. If she can feel them, she can press on them. 

• Press and release, press and release. 

o This should not hurt; if it hurts, the technique is wrong. 

o At first no milk may come, but after pressing a few times, milk starts to drip out. It 

may flow in streams if the oxytocin reflex is active. 

o Press the areola in the same way from the sides to make sure that milk is expressed 

from all segments of the breast. 

o Avoid rubbing or sliding her fingers along the skin; the movement of the fingers 

should be more like rolling. 

o Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the 

milk; this is the same as the baby sucking only the nipple. 



133

1) Place a finger and thumb on each side of the areola and press inwards 

towards the chest wall. 

2) Press behind the nipple and areola between your finger and thumb. 

3) Press from the sides to empty all segments. 

Figure 11.4. How to express breast milk. (WHO, 1993) 

• Express one breast for at least 3-5 minutes until the flow slows; then express the other 

side; and then repeat both sides. She can use either hand for either breast, and change 

when they tire. 

• Explain that to express breast milk adequately takes 20-30 minutes, especially in the first 

few days when only a little milk may be produced. It is important not to try to express in a 

shorter time. 

• The mother should express as much as she can as often as her baby would breastfeed. 

How to Feed a Baby by Cup 

Teach the mother to: 

• Hold the baby sitting upright or semi-upright on her lap. 

• Hold the small cup of milk to the baby's lips. 

• Rest the cup (or paladai or spoon) lightly on the baby’s lower lip and touch the outer part 

of the baby’s upper lip with the edge of the cup (see Figure 11.5). 

• Tip the cup (or paladai or spoon) so the milk just reaches the baby’s lips. 

• The baby becomes alert and opens his/her mouth and eyes. 

134 




• An LBW baby starts to take the milk into his/her mouth with the tongue. 

• A full term or older baby sucks the milk, spilling some of it. 

• Do not pour the milk into the baby's mouth. Just hold the cup to his/her lips and let the 

baby take it him/herself. 

• When the baby has had enough, he/she closes the mouth and will not take any more. If 

he/she has not taken the calculated amount, he/she may take more next time, or you 

may need to feed the baby more often. 

• Measure the baby’s intake over 24 hours, not just at each feed. 

• Advise the mother to burp the baby after the feed by placing him/her on the shoulder and 

gently rubbing or patting the back. 

• Encourage the mother to begin breastfeeding as soon as she is ready. 

Figure 11.5. Three methods of feeding: A. by cup, B. paladai, or C. by a cup and spoon. 

(WHO/IMPAC, 2003) 

Storing Expressed Milk 

Unheated expressed breast milk should be stored in as cool a place as possible. In general, 

unheated expressed breast milk may be stored: 

• for 1-2 hours if the ambient temperature is higher than 26 °C. 

• for up to 6 hours if the ambient temperature is 26 °C. 

• for up to 10 hours if the ambient temperature is between 19 °C and 22 °C. 

• for up to 24 hours in a refrigerator. 

• for up to 2 weeks in the freezer section of a refrigerator. 

• for up to 3 months in a stand-alone freezer. 

Note: If the electricity is not stable, expressed breast milk should only be stored for short periods 

in the refrigerator. 

If the mother has stored the milk either at ambient temperature or in a refrigerator or freezer, 

she needs to warm the milk by placing the closed container in a bowl of really warm or hot water 

before giving it to the baby and make sure the baby drinks it immediately. 



135

Special Guidelines for Mothers Who Are HIV-Positive 

Feeding options for HIV-positive mothers include the following: 

• Exclusive breastfeeding, taking care to avoid problems such as engorged breasts and 

sore nipples, until six months, followed by rapid switch to formula feeds and 

complementary feeding with semi-solids. 

• Use of expressed breast milk rendered safe by flash heating of the milk (see below), 

along with complementary feeds with semi-solids from the age of six months. 

• Use of formula feeds from birth, if AFASS conditions are met (when replacement feeding 

is acceptable, feasible, affordable, sustainable, and safe – WHO 2009) with semi-solids 

from the age of six months. 

Flash heating of expressed milk 

Flash heating of expressed breast milk is a method to destroy the HIV while still retaining the 

nutrients and much of the anti-infective factors unique to breast milk. This permits the HIVpositive 

mother to give breast milk to the baby and avoid formulas. 

Guidelines for the mother and family 

• Items required: 

o cups and spoons for feeding 

o jars with lids to collect and sterilize EBM 

o a container to boil the milk 

• Wash all utensils with soap and water. Sterilize these by boiling in a container of water 

for 10 minutes. 

• Express breast milk into the glass jar as noted above in this chapter. Remember to 

express the breasts as completely as possible so as to get the nutritious milk obtained at 

the end. The amount of milk to be collected in one jar is between 50-150 mL. If there is 

more milk, divide it into two jars. 

• Place the jar in a pan/container of water, making sure that the level of water is two 

fingers above the level of milk. 

• Heat the water on a very hot fire or, if on a stove top, turn the knob/dial to the highest 

setting until the water reaches a rolling boil (when it is boiling well with large bubbles). 

Stay close by because the process after this takes only a few minutes. Do not let the 

water boil too long as it will destroy the special nutrients in breast milk. 

• Remove the jar from the container as soon as the water comes to a good boil. Place the 

jar in a container of cool water, cover it with its clean lid, and let it stand until it reaches 

room temperature. This milk can then be kept at room temperature for six hours and fed 

to the baby. 

• Use a small cup, preferably directly to feed the baby. It is better than using a bottle which 

is more difficult to clean and carries the risk of causing diarrhea in the baby. 

136 




CHAPTER 12: Care of the Low Birth Weight Baby, 

Including Kangaroo Mother Care 

Low birth weight (LBW) babies weigh less than 2500 grams at birth. Babies may be low birth 

weight because they: 

• are born too early, before 37 completed weeks of gestation (preterm or premature). 

• have suffered intrauterine malnutrition or intrauterine growth retardation (IUGR), making 

them “small for date” or small for gestational age. Such babies may be term, preterm, or 

post-term (>42 completed weeks). 

Although the basic aspects of essential newborn care for LBW newborns are similar to those for 

normal infants, LBW babies, being vulnerable, need additional support, especially for 

temperature maintenance, feeding, prevention of infection, and detection and management of 

problems and complications. They are also associated with a greater risk for complications and 

a higher neonatal mortality. In fact, 60-80 percent of deaths in the neonatal period are among 

low birth weight babies, and they continue to have a high mortality during infancy. 

Even though LBW babies need extra care, most of them are the “larger” ones, above 

1500 grams. They can be managed with some extra care and with methods such as kangaroo 

mother care that are simple and low cost. The very small LBW babies needing more costly 

intensive care represent a much smaller proportion. 

FACTORS ASSOCIATED WITH LOW BIRTH WEIGHT 

Mothers may have a history of: 

• previously having had a LBW baby 

• being young (less than 16 years) or older (more than 35 years) 

• performing excessive physical work without appropriate rest 

• belonging to a low socio-economic group 

• having short intervals (less than two years) between pregnancies 

• having multiple pregnancies 

Mothers may have problems during pregnancy such as: 

• malnutrition 

• severe anemia 

• preeclampsia/eclampsia 

• infections during pregnancy such as urinary tract infection, malaria, syphilis, 

toxoplasmosis, herpes, CMV, Rubella, HIV/AIDS 

The fetus may be abnormal with: 

• certain congenital malformations 

• intrauterine acquired infection 

In 30-50 percent of cases of low birth weight, no obvious cause is found. 

PREVENTING LOW BIRTH WEIGHT 

Prevention of LBW presents challenges. Some interventions are noted below: 



137

• Ideally take preventive steps early with appropriate care and nourishment of the girl 

child. 

• Counsel families/mothers to ensure that women in general: 

o delay child bearing until they are at least 20 years old. 

o have adequate nutrition. 

o have sufficient rest and are not subjected to hard work during pregnancy. 

o have basic care to detect and treat problems before pregnancy. 

• Ensure through care and counseling that pregnant women: 

o receive quality prenatal care, including taking iron and folic acid to manage anemia 

and preventing malaria through the intermittent preventive treatment of malaria and 

use of insecticide-treated bednets. 

o recognize danger signs and seek appropriate care. 

o follow birth spacing (2-3 years) through being encouraged to use contraception. 

Complications of Low Birth Weight 

Low birth weight babies have several handicaps that make them more susceptible to a number 

of problems, many of which can be life threatening, especially in smaller, more preterm infants. 

Some of the key issues are noted in Table 15, along with some strategies for treatment and 

management. 

138 




Table 15. Complications in Low Birth Weight and Preterm Babies 

Handicap Problems Management 

Need referral to higher center 

Apnea less with KMC 

1. Lung immaturity Respiratory distress 

syndrome 

Apnea (pauses in 

respiration) 

2. Difficulty in 

maintaining body 

temperature 

Hypothermia very 

common 

Hyperthermia in hot 

weather 

KMC very useful in maintaining body 

temperature 

Use of appropriate clothing 

3. Immature sucking 

reflex and gastrointestinal 

system 

4. Immature immune 

systems and 

increased exposure, 

being dependent for 

care on others with 

frequent 

handling/procedures 

Difficulty in sucking, 

retaining, and 

assimilating feeds 

Increased infections 

associated with high 

mortality 

Frequent breast feeds 

Expressed breast milk fed with 

cup/spoon 

Prevention of infection (hygienic 

practices such as frequent hand 

washing, breastfeeding, use of EBM) 

Early identification and treatment of 

infections 

Avoidance of needless handling and 

procedures 

5. Bleeding due to 

immaturity of the liver 

and poor production 

of clotting factors 

6. Increased risk of 

jaundice 

High risk for bleeding at 

various sites, including 

intracranial bleeding 

LBW babies can have 

more prolonged jaundice 

and can have brain 

damage at lower levels 

of bilirubin 

Administration of vitamin K 

Prevention and treatment of 

problems such as asphyxia, 

infections and hypothermia 

LBW babies with any jaundice should 

be referred early to an appropriate 

center for evaluation and treatment 

Evaluation of Infants with Low Birth Weight 

Since this manual primarily relates to basic care at peripheral health facilities, it will not deal with 

how to differentiate between premature and growth-retarded babies. Rather, it will focus on 

how to identify babies that need to be transferred to a higher level of care and those that may be 

managed locally at the place of birth. It will also focus on a simple low-cost method of 

management of these vulnerable babies, namely, “kangaroo mother care”. 

In general, babies weighing more than 1800 grams at birth, without problems and danger signs, 

can fare well if managed appropriately. They may, thus, be cared for by trained personnel in a 



139

peripheral health center and later at home. Mothers and family members must be provided with 

appropriate counseling and support. 

Knowing the exact gestational age is not important in peripheral centers. In practical terms, what 

is more important is to determine the status of an individual baby to decide what actions need to 

be taken. Thus, the health worker should verify if the baby: 

• Can maintain temperature with simple aids such as extra clothing or skin-to-skin contact 

(kangaroo mother care, see further details below). 

• Can accept frequent breast feeds or expressed breast milk fed with alternate methods of 

feeding, such as the use of a cup, spoon, or an appropriate traditional feeding device 

(see chapter 11 on breastfeeding). 

• Is free of problems or danger signs (see chapter 9 on physical examination). 

Babies who fulfill the above criteria can be managed in peripheral centers and at home; ideally, 

however, if access to a suitable center is easy, they should be taken there for an assessment 

and counseling. Newborns not meeting the above criteria need to be referred to appropriate 

facilities that have the competence, equipment, and supplies to manage them. 

Fig. 12.1. Basic evaluation of LBW babies to determine need for referral. 

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CARE OF LOW BIRTH WEIGHT BABIES 

Provide extra care for these vulnerable babies. While in general the same basic care should be 

followed as with normal newborn babies, the LBW baby will require extra attention in three 

areas: 

• Temperature maintenance: They require extra clothing, covering, or prolonged skin-toskin 

contact (kangaroo mother care). 

• Early initiation of and more frequent feeding: They need additional support for feeding, 

including the use of expressed breast milk fed with a cup, spoon, or a suitable traditional 

feeding device. 

• Prevention of infection: As such babies are particularly prone to infection, great care 

should be taken to prevent infection, including: 

o washing of hands before handling the baby 

o breastfeeding/use of breast milk and avoidance of other milks and fluids 

o avoiding unnecessary visitors and needless handling 

Other care is the same as that for all newborns: 

• Weigh the baby at birth. 

• Check breathing and temperature frequently: every 15 minutes for the first 2 hours, 

every 30 minutes in the third hour, then every hour until 6 hours, and then every 3 hours 

or at feed times. Very small babies tend to stop breathing periodically (apnea). Such 

babies need to be stimulated by rubbing the back or a limb and will need to be taken to 

the referral hospital in the kangaroo mother care position with stimulation as required. 

The mother’s respiratory movements serve to stimulate the baby to breathe better with 

fewer apneic pauses. 

• If the baby has no breathing problems and sucks well: 

o Keep the baby in continuous skin-to-skin contact with the mother (see the section on 

kangaroo mother care below). 

o Cover the baby’s head with a hat or scarf. 

o If the LBW baby requires additional care, such as resuscitation, keep him/her under 

a warmer/heater. 

o Delay the baby’s first bath for one week after birth. Clean the dirty areas such as the 

face, groin, and skin folds with a damp cloth, using soap as required. If necessary 

give a sponge bath, exposing small portions at a time. Dry quickly and maintain 

temperature as noted above. 

• At birth give a dose of 1 mg of vitamin K IM (0.5 mg if the baby weighs

there is premature rupture of membranes or leaking of the amniotic fluid for 

more than 18 hours 

o Follow the other guidelines for referral noted in chapter 13 on major infections. 

Kangaroo Mother Care 

Kangaroo mother care (KMC) is a simple method that promotes the health and the well-being of 

the LBW/preterm baby by skin-to-skin contact with his/her 

mother or another person through maintaining the baby’s body 

temperature and encouraging exclusive breastfeeding. 

In some countries, mothers do not like being compared to an 

animal. If this is the case, describe this method of care as “skinto-skin 

contact” to protect the vulnerable low birth weight infant. 

Advantages of KMC 

For the baby: 

Figure 12.2. The kangaroo with the 

baby in the pouch. 

• It is a low cost method that is a good alternative to conventional care of preterm/LBW 

babies in low resource countries. 

• The outcome has been similar to use of an incubator, which is more expensive and more 

difficult to maintain. 

• The baby is comfortable in this position and is quieter, crying less frequently than in 

incubators. 

• The vertical position decreases the risk of aspiration, improves cardio-respiratory 

functions, and decreases apnea. 

• Closeness to the breast favors frequent sucking that prolongs the duration of 

breastfeeding. 

• The hospital stay is shorter. 

For the mother: 

• It helps to empower the mother as she plays the main role by providing warmth to her 

baby, protection against infections, and nutrition through breastfeeding. 

• It promotes mother-infant bonding and decreased rejection of preterm babies. 

• The method includes participation of the mother and family in the care of the baby. 

• It allows the mother to return to activities at home while caring for the baby. 

Preparation for Kangaroo Mother Care 

• Start KMC as soon as possible after birth, when breathing has been well established and 

the baby does not require any medical treatment. 

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• Explain the reasons for and advantages of KMC to the mother and the family: 

o KMC replaces the warmth within the uterus. 

o The baby is very close to the breast, facilitating frequent feedings. 

o KMC favors the milk ejection reflex and successful feeding. 

o The newborn is protected from exposure to the external environment and infections. 

• Requirements include: 

o a warm room without drafts 

o appropriate clothing for the mother, as needed and influenced by the weather 

o a square piece of clothing folded diagonally or a Lycra band to fix the baby to the 

mother’s chest 

o a cap, socks, and diapers for the newborn 

o a chair with an inclined back or a bed that can be adjusted with pillows, for example, 

at a 15-30 degree angle for the mother 

Selecting Babies for KMC: 

The common criteria for deciding whether to use KMC for an LBW baby include: 

• weight less than 2500 grams, although KMC can be used for any weight group 

• stable cardio-respiratory condition 

• ability to suck and swallow 

• maternal acceptance and family support 

The KMC Technique 

• Advise the mother to maintain good hygiene, including daily baths, change of clothes, 

frequent hand washing, and short and clean fingernails. 

Figure 12.3. Kangaroo mother care. 

(WHO, 2003) 

• Place the baby in skin-to-skin contact between the mother’s breasts with the baby’s feet 

below her breasts and the baby’s hands above; the baby’s hips should be in a “frog” 

position and the arms flexed (Figure 12.3). 

• Extend the head slightly and turn it to one side. Avoid excessive flexion or 

hyperextension of the neck. Turn the head to alternate sides periodically. This position 

keeps the airway open and allows eye contact between the mother and her baby. 

• Support the baby‘s head by pulling the wrap under the baby’s ear. 



143

• Place an additional cloth or a towel under the buttock of the baby to prevent dirtying the 

mother’s chest and dress if cloth diapers are used. Change the diapers frequently. 

• Some use a small baby vest to cover the back for extra thermal protection. Make sure in 

such cases that the front of the vest is open to allow the chest of the baby to be in direct 

contact with the chest of the mother (Figure 12.4). 

• Fix the baby to the mother’s chest by wrapping the clean cloth around the mother and 

the baby, leaving room to permit the baby’s abdominal breathing but being tight enough 

so that the baby does not slip out when the mother stands. Secure the cloth with a safe, 

secure knot and tuck the loose ends under the tied band. Alternatively, a circular Lycra 

band can be used to fix the baby. 

• Practice with the mother and supervise her until she is totally comfortable with the 

method. 

• Through advocacy and counseling encourage the other members of the family, including 

the father, to assist the mother in KMC. 

Figure 12.4. How to dress the baby for “Kangaroo Care.” 

(WHO, 2003) 

Figure 12.5. Photo of kangaroo mother care. (Source: Delphin Muyila, DRC) 

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Breastfeeding the LBW Baby in KMC 

• Explain to the mother the benefits of breast milk, especially for a LBW baby. 

• The baby is ready to start breastfeeding when he/she starts moving the tongue and 

mouth and shows interest in sucking his/her fingers or the mother’s skin. 

• Start breastfeeding when the baby is awake. 

• Promote frequent breastfeeding (about every 2-3 hours). 

• Help the mother get in a comfortable position on an armless chair in a quiet place, if 

possible. 

• Before starting to breastfeed, loosen the cloth wrap around the baby. 

• With the baby in skin-to-skin contact, follow the same steps for attachment and 

positioning as for the normal baby. 

• Being small, the baby will need more frequent breastfeeding, with several pauses during 

feeding. The baby needs to be allowed to feed while he/she still shows interest in 

sucking. 

• If the baby gags, coughs, or spits up, teach the mother to take the baby off the breast 

and the cloth wrap, hold the baby covered against her chest until she/he quiets down 

and breathes normally before retrying again. If the ejection reflex is strong, express a 

little milk before restarting feeding. 

• When the mother’s breasts are engorged, express enough breast milk to make the 

areola soft enough to introduce into the baby’s mouth to facilitate his/her sucking. 

• Some babies may need additional support: 

o Wait until the baby is awake. 

o Loosen the wrap around the baby. 

o Hold the baby with the mouth close to the nipple. 

o Express a few drops of breast milk. 

o Let the baby smell and lick the nipple and open the mouth. 

o Express milk into the baby’s open mouth. 

o Wait for the baby to swallow the milk. 

o Repeat the procedure until the baby closes his/her mouth and will not take any more 

milk even after stimulation. 

o Alternatively, milk can be expressed from the breast into a clean container that has 

been sterilized by boiling for 10 minutes, and feed the baby by cup, spoon, or a 

suitable traditional feeding device. 

Note: If the infant cannot suck/accept feeds, he/she needs referral for care 

at a higher level facility. Do not introduce milk into the mouth of the baby 

who cannot swallow. 

Counsel the Mother and Family about KMC 

Counsel the mother and the family: 

• On the benefits of KMC. 

• To use an extra cloth or towel beneath the baby’s bottom to avoid soiling of the mother’s 

clothes, and change the cloth/diaper frequently. If a cloth is used, advise to always use a 

clean, dry cloth for the newborn’s diaper. 



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• To feed the baby by breastfeeding/use of expressed breast milk frequently. If the LBW 

baby does not suck well or tires easily while sucking, advise use of expressed breast 

milk with a cup, spoon, or a suitable traditional feeding device (clean with soap and 

water and, ideally, boiled for 10 minutes.). 

• To remove the baby out of the skin-to-skin contact only for changing diapers, hygiene, 

and cord care. The low birth weight baby need not be bathed daily. The dirty parts, 

especially skin folds, can be sponged clean. When the baby is bathed, it is important to 

do so in a warm room with no draft, using warm water, finish as soon as possible, dry 

the body well, and recommence the skin-to-skin contact quickly. 

• To have continuous 24-hour kangaroo care until the baby’s weight increases. Another 

family member may replace the mother for periods of time to relieve the mother. 

Practicing KMC after Discharge 

Advise the mother and family to: 

Figure 12.6. The mother, the father, or another family 

member may keep the baby on the chest. 

• Continue kangaroo mother care at home. 

• Seek care with an appropriate health worker/center as designated if the baby develops 

any of the following danger signs (the first five are most important): 

o difficulty in sucking or not sucking at all 

o lethargy/inactivity 

o fever/body too hot or hypothermia/body feeling too cold 

o fast breathing/difficulty in breathing 

o convulsions 

o persistent vomiting, abdominal distension 

o redness, swelling around the umbilicus and/or foul smell, with or without pus 

discharge and/or pus discharge 

• Come for regular follow-up care: 

o Make the first follow-up appointment one week after discharge. 

o While the exact intervals may vary in individual cases, in general, counsel for 

continued weekly follow-up of the LBW infant until the baby is doing well and 

preferably until the weight reaches 2000 grams. 

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Follow-up checks by skilled health workers are ideal, but where the latter is not feasible at 

times, additional support through visits by trained community health workers should be 

instituted. Even in facility births try to link the family with a trained community health worker for 

additional follow-up. 

DISCHARGE OF THE LOW BIRTH WEIGHT BABY 

Babies are fit for discharge if: 

• Their general health is good. 

• There are no features of infection or danger signs. 

• The baby is sucking well, and breastfeeding is well established. 

• The baby is gaining weight or at least the weight is stabilized for three consecutive days 

(but some wait until the baby’s weight reaches 1800 grams). 

• The baby is maintaining temperature well, with extra clothing or with kangaroo mother 

care, for at least three consecutive days. 

• The baby has no obvious problems. 

• The health personnel judges that the mother is able to take care of her baby, and the 

mother/family feels confident with caring for the baby. 

Care for the LBW baby is summarized in the diagram and the algorithm below. 

Figure 12.7: Key components of care of the LBW infant: KMC/well wrapped close to the mother, 

cleanliness including frequent hand washing, early exclusive breastfeeding without pre-lacteal feeds, 

monitoring of weight gain/growth (Source: Counseling cards from Senegal). 



147

Care of the LBW baby 

(Birth weight less than 2500 gm; preterm - < 37 wks., 

intrauterine growth retardation, or both) 

Wash hands before touching the baby 

Dry and wrap the baby including head/start skin-to-skin contact 

Practice early and frequent exclusive breastfeeding 

Keep the baby warm, ideally through practicing kangaroo mother care 

Delay bathing for one week or until baby is well stabilized 

When bathing, use warm water, dry, wrap well or place in skin-to skin contact 

Evaluate baby 

YES 

Sucking well 

Maintaining temperature 

Has no danger signs 

NO 

Manage at centre/home 

Counsel mother/family 

Advise mother to check 

baby at home at feed 

times until s/he is doing 

well. Weekly follow-up 

by health worker 

At follow-up, if poor 

weight gain or baby has 

danger sign 

Send to referral 

center 

Figure 12.8. Algorithm for care of the LBW baby. 

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CHAPTER 13: Treatment of Infections 

in the Newborn 

Infections are the major cause of death during the neonatal period accounting for 35 percent of 

deaths in the first four weeks of life. Newborn infants, especially low birth weight infants, are at a 

particularly high risk for infection because of their underdeveloped immune processes and their 

increased exposure to germs since, being totally dependent on the mother, family members and 

other care providers, they come in frequent physical contact with a number of persons. 

Newborn babies are also susceptible to germs that do not readily cause major infections in 

normal older infants. Common organisms include E. coli, Klebsiella sps, Staphylococcus sps, 

and group B streptococci. Organisms vary by region, over time, and due to long-term use of 

antibiotics. 

In the newborn, minor/localized infections may spread easily. Rapid progression of disease is 

very common and it may become life threatening. This necessitates early identification and 

prompt treatment with antibiotics. In the later stages babies not only stop sucking but are also 

unable to accept and retain feeds, thereby necessitating intravenous fluids and antibiotics that 

are feasible only at higher level health centers. Hence, early identification and prompt treatment 

are essential. 

Socio-cultural factors also influence the impact of infections. Mothers and babies are confined to 

their homes, and even those who have facility births go home early and then continue to remain 

there. Danger signs, even if identified, are often attributed to nonmedical reasons, and 

appropriate care is not sought early so that when babies reach facilities, the disease has 

advanced considerably. Many families, moreover, do not have adequate faith in the care 

provided at facilities. Women are frequently not empowered, and major decisions in the family 

are made by the men. While paternal grandmothers may have some influence, mothers often 

have very little influence when medical decisions are being made. Some families are also 

handicapped by little or no access to services, either because of distance or due to lack of 

finances. 

Pre-service education of doctors, nurses, and midwives related to newborn care is often 

inadequate and inappropriate, so that basic health workers do not have the competence to 

manage newborn infants, especially sick babies. They also do not have the support of the 

necessary equipment, supplies, and drugs of appropriate sizes and strengths. Their interaction 

with families also presents challenges in some cases due to lack of courtesy. They often do not 

have the time nor the skills to establish rapport and to counsel mothers and families effectively. 

THE TIMING OF INFECTIONS 

Some infections are early onset and some are late onset. Early onset infections (from delivery 

through day 3) are usually acquired from maternal risk factors and during delivery. These 

factors include: 



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• maternal infections, including urinary tract infection during the last months of pregnancy 

• premature rupture of the membranes (>18 hours) 

• unhygienic delivery practices, including poor cord care 

These risk factors are significant and have important practical implications: 

• Babies with these maternal risk factors may appear normal at birth. 

• The signs may appear after the baby has returned home. 

• Identification of the maternal risk factors can lead to prophylactic antibiotic treatment that 

may be life saving. 

• These babies need careful follow-up and should benefit from a longer stay at the health 

center. 

• Even in the absence of laboratory tests in peripheral health centers, just taking a good 

maternal history may help identify these risk factors and enable suitable actions. 

Late-onset infections (day 4-28) are usually acquired from the environment in the home or 

facility. They are caused by several factors including: 

• Unhygienic use of formulas, other milk, and fluids instead of exclusive breastfeeding. 

• Poor newborn care practices, such as lack of proper hand washing, contact with unclean 

clothes and other items, infected persons, use of improperly cleaned/sterilized 

supplies/equipment (the last mentioned is particularly common at the facility level). 

• Excessive, invasive hospital procedures with poor infection control practices. 

TYPES OF NEONATAL INFECTION 

Major Infections 

Specific entities such as pneumonia, diarrhea, septicemia, and meningitis are difficult to 

diagnose in the newborn, as the signs may be nonspecific and the disease spreads rapidly to 

involve several organs. Hence, the catch-all term “neonatal sepsis” is used in the public health 

area. 

Relevant to diarrheas in the newborn period, babies receiving breast milk pass loose stools 

with separate watery and “curdy” portions several times a day, being particularly frequent in 

days 3-5. These are termed “transitional stools” and may be wrongly diagnosed as diarrhea, 

and oral rehydration solution/therapy may be given. The latter is not only needless, but it may 

also carry a risk of causing real infection if given in an unhygienic manner. 

The risk of diarrheas and other major infections is particularly high if initiation of breastfeeding is 

delayed and the newborn and the infant under six months receive other milks and fluids. Thus, 

even when the mother is HIV-positive and opts to give formula feeds, the health workers should 

counsel and support the family adequately to ensure that the feeds are given in a clean manner. 

Otherwise there is a real risk of the baby developing diarrhea with spread of infection that can 

result in complications and even death. Where appropriate care is not taken, especially in 

illiterate, low socio-economic groups, there will actually be a greater chance of babies dying of 

such infections than from HIV/AIDS. 

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Major infections in the newborn period are identified by the presence of one or more danger 

signs, as noted below in Table 16 (on practical guidelines for identifying and treating major 

infections at peripheral centers). 

Minor Infections 

The most common minor infections are: 

• thrush 

• conjunctivitis 

• skin infections 

• umbilical infection (localized) 

While the focus in this manual will be on the most common major and minor infections listed 

above, other newborn infections include syphilis, HIV/AIDS, Hepatitis B, and tetanus. 

IDENTIFYING AND TREATING MAJOR INFECTIONS 

Very early signs of major infection/neonatal sepsis are vague and sometimes difficult to 

recognize, but early detection is needed as it takes time to effect referral to suitable centers. 

These early features include vague signs such as the baby just “not looking well” or appearing 

as if “he/she is just not well,” at times described as a “facial grimace.” However, these early 

features are more difficult to detect and require careful daily observation. Mothers, family 

members, and health care providers should be encouraged to view the baby in adequate light at 

least once a day, especially in the first week or two. 

More conventional clinical features labeled as “danger signs” used to identify newborn sepsis 

include the following (the first five are the most important): 

• sucking less or poor/no sucking 

• lethargy or diminished activity/inactivity 

• fever (body too hot) or hypothermia (body feeling too cold) 

• rapid breathing/difficulty in breathing 

• convulsions 

• repeated or persistent vomiting and/or abdominal fullness 

• features of severe umbilical infection (peri-umbilical redness, swelling and/or foul 

smelling, with or without pus discharge and/or foul smell) 

The first five danger signs are the most important. Although these are standard danger signs, it 

is essential that health workers should look at babies carefully at least once a day in adequate 

light while they remain in the facility. Even if they do not detect a specific danger sign, health 

workers should take care if they feel the baby is “not looking or doing well”. In this way, sick 

newborns can be identified and treated early which is particularly important in the newborn 

period when the condition can deteriorate rapidly. Mothers should also be counseled on these 

points to promote early careseeking. 

Training personnel in good follow-up supervision is necessary to identify these danger signs. 

Since they are difficult to remember, especially when health workers do not see very many 



151

cases, it is very useful to have easily accessible job aids available (which could be adapted from 

Table 16 below). 

Use of Antibiotics 

Administer antibiotics using these guidelines: 

• Ampicillin 50 mg/kg IM/IV every 12 hours in first 7 days and every 8 hours after day 8. 

• Gentamycin IM/IV once daily – 3 mg/kg for babies < 2500 grams. and 5 mg/kg in babies 

> 2500 grams. 

• Duration of treatment: 10 days. 

• At the peripheral health center, give the first doses IM prior to transfer to a higher level of 

care. 

• Continue to provide additional support such as feeding where feasible, temperature 

maintenance and cleanliness/avoidance of superadded or secondary infection. 

Danger Signs 

Table 16: Practical Guidelines for Identifying and Treating 

Major Infections at Peripheral Centers 

Note: The first five danger signs are the most important. 

Management of the newborn at risk for early infection: 

For a newborn with maternal infections and premature rupture of membranes of 18 hours or 

more, even in the absence of symptoms, give intramuscular antibiotic treatment (ampicillin and 

gentamycin), for at least 3 days and preferably for 5 days, as blood cultures are not feasible at 

peripheral centers. Observe the baby at the facility. If there are no danger signs, discharge the 

infant. If there are danger signs, transfer to a higher level of care. 

DANGER 

SIGNS 

IDENTIFICATION 

(Ask and look for/verify) 

MANAGEMENT 

Sucking less, 

or poorly, or 

not sucking at 

all 

Lethargy/ 

inactivity 

Fever/low 

body 

temperature 

Rapid 

breathing/ 

Not sucking at all; sucking less than 

usual; not opening the mouth when 

offered feeds; not demanding feeds. 

Not as active as usual, sleeping 

excessively, difficult to arouse, 

moving only when stimulated, not 

waking up for feeds, lying limp, 

“loose-limbed,” excessively quiet or 

“too good.” 

Fever: Body hot to touch, history of 

the mouth feeling excessively hot 

during breastfeeding; temperature 

more than 37.5 °C 

Hypothermia: Body colder than 

normal; temperature less than 36.5 

°C. 

Respiration more than 60/minute 

(verify by counting a second time), 

• Administer (a) First doses of the two 

antibiotics: ampicillin and 

gentamycin; (b) vitamin K 1 mg if it 

was not given at birth; (c) Diazepam 

if convulsions: 0.5 mL rectally, or IM 

(thigh) or slow IV . 

• Send the baby to the referral 

hospital. 

• Explain to the mother why the baby 

needs referral and advise her to go 

along with another attendant. 

• Advise how to care for the baby 

during transport: 

o Keep the baby warm by skin-toskin 

contact (see chapter 12 on 

LBW and KMC). 

o To prevent hypoglycemia, if the 

baby can accept feeds give 

direct breastfeeding or 

expressed breast milk with cup. 

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difficulty in 

breathing 

Convulsions 

Persistent 

vomiting 

Abdominal 

distension 

Severe 

umbilical 

infection 

flaring of the nostrils, groaning or 

grunting, severe sub-costal 

retraction. 

Features of convulsions are often 

atypical in the newborn, such as a 

“staring” look, blinking of eyelids, 

“chapping” movements of the lips, 

clonic/tonic movements of the limbs. 

Occasional vomiting is common but 

persistent vomiting is abnormal, as 

is green-colored vomitus. 

Distension or fullness of the 

abdomen. 

Spreading redness or swelling 

around the umbilicus and/or foul 

smell, with or without pus discharge. 

Do not attempt to feed a baby 

that cannot swallow fluids. 

o Check the baby frequently to 

ensure that there is no additional 

problem. 

o If possible, contact the referral 

center to inform them. 

• Send a referral note with the mother 

indicating: 

o name and address of the mother 

o date and time of birth 

o problems if any at birth 

o reasons for referral 

o treatment given 

o advice given 

The first five danger signs are the most important. Although these are standard danger 

signs, it is essential that health workers should look at babies carefully at least once a day in 

adequate light while they remain in the facility. Even if they do not detect a specific danger 

sign, health workers should take care if they feel the baby is “not looking or doing well”. In this 

way, sick newborns can be identified and treated early which is particularly important in the 

newborn period when the condition can deteriorate rapidly. Mothers should also be counseled 

on these points to promote early careseeking. 

Referral and Transport of Sick Newborns 

The condition of the sick newborn with sepsis may deteriorate rapidly. It is important to stabilize 

the baby prior to transfer. Some of the key tasks are noted below: 

• Provide information and counseling to the mother and family. 

• Explain to the mother and family members the problem and reason for the transfer. 

• Answer their questions. 

• Explain that even if the transport has its own risk, the required treatment cannot be 

provided at the peripheral health center or at home. 

• Describe what to expect at the referral center. 

• Explain care of the newborn during transport: 

o Keep the baby warm during the transport by placing him/her in skin-to-skin with the 

mother, covered with a cloth, with or without blanket, depending on the weather. This 

will also protect the baby from drafts and insects. 

o To prevent hypoglycemia, offer breastfeeds. If the suck is weak or absent, try to feed 

the baby expressed breast milk with a clean cup. Do not feed an infant who cannot 

swallow. 

o Check the baby’s condition frequently to detect other complications. 

• Prepare the baby for transport: 

o Arrange for the fastest means of transportation. 



153

o Transfer the mother and baby along with a family member. If possible, have a health 

care worker accompany them. 

o If possible, inform the referral center by telephone of the condition of the baby, 

including the maternal history. 

o Prepare for the transfer by stabilizing the baby’s condition to the extent possible and 

giving the first dose of antibiotics. 

• Document the referral and its time in the record book of the peripheral center. 

• The referral document of the baby to be sent with the family should contain the following: 

o name and address of the mother 

o date and time of birth 

o reason for referral 

o treatment initiated 

o all available information on pregnancy, labor, delivery, postnatal period, and 

supplemental information on the baby 

o advice given 

• If the transfer is delayed or not possible for any reason: 

o Continue the antibiotic treatment, breast feeding/feeding of expressed breast milk, 

and skin-to-skin contact. 

o Continue family support. 

IDENTIFYING AND TREATING MINOR INFECTIONS 

Conjunctivitis/Eye Infections 

At peripheral health centers it is not possible to carry out cultures. Unfortunately, gonococcal 

infection is a serious problem and can lead to blindness. Assume and treat as gonococcal 

infection if there is frank pus discharge in endemic areas in babies within the first week, with or 

without swelling: 

• Give ceftriaxone IM 50 mg/kg in a single dose. 

• While wearing gloves, clean the eyelids using cotton swabs that have been sterilized by 

boiling in clean water for at least 10 minutes and then cooled down before putting in the 

eye drops/ointment, such as tetracycline, as recommended by the Ministry of Health. 

Teach the mother and ask her to repeat the treatment 4 times/day. 

• If the mother and baby are near a health facility, there is no need to admit the mother 

and baby; otherwise they need to be admitted. 

• Treat the mother and partner, if not already treated. Give ceftriaxone 250 mg IM as a 

single dose to the mother and give a ciprofloxacin, 500 mg orally as a single dose to the 

partner. 

• Where the above drugs are not available, refer to an appropriate hospital. 

• If you are in a non-endemic area and the eyes are red and sticky, without excess pus 

discharge: 

o Continue cleaning the eyes and apply 1% tetracycline ointment to the affected eye(s) 

3-4 times a day until symptoms disappear. 

o If the problem persists after 2 days of general management and/or pus appears, start 

erythromycin by mouth 12.5 mg/kg every 8 hours for 14 days. 

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o As Chlamydia may be the cause, treat mother and partner, if not already treated, 

with erythromycin 500 mg orally 4 times a day for 7 days for the mother; tetracycline 

500 mg orally 4 times a day for 7 days or doxycycline 100 mg orally twice a day for 7 

days for her partner. 

Thrush 

Thrush is a fungal infection due to Candida species which is usually localized in the mouth or in 

the diaper area. 

Treating thrush in the mouth: 

• Oral thrush is seen as irregular, dirty white patches on the tongue and inner sides of the 

cheeks. 

• It is different from the normal smooth white patch that may be seen coating the middle of 

the tongue in some babies. If in doubt treat as thrush. 

• Apply mycostatin/nystatin oral solution or 0.5% gentian violet 4 times daily after feeds, 

continuing for 2 days after lesions have healed. 

• Have the mother apply mycostatin/nystatin cream or 0.5% gentian violet on her breasts 

after breastfeeding for as long as the baby is being treated. 

• Mothers should be advised to clean their breasts once a day with soap and water when 

bathing. Repeated washing with soap should not be done, as it will lead to drying and 

sore nipples. 

Treating thrush in the diaper area 

• Apply nystatin cream or 0.5% gentian violet at every diaper change, continuing for 2-3 

days after the lesions have healed. 

• Ensure the diaper is changed as soon as possible when soiled or wet, taking care to 

clean and dry the skin well. 

Local Infection of the Umbilicus 

Local umbilical infection may be associated with stickiness or pus discharge from the base of 

the cord or from the umbilicus after the cord falls off. Redness and swelling of the skin around 

the umbilicus and a foul smell are features of a serious umbilical infection. Treat the infection as 

follows: 

• While wearing gloves, clean the area with 60-90% alcohol or an antiseptic solution (2.5% 

polyvidone iodide, 4% chlorhexidine gluconate, triple dye, or gentian violet) 3-4 times a 

day. 

• Take care to lift the cord and apply the antiseptic to the base of the cord or, if the cord 

has fallen off, to the depth of the umbilicus. 

• Demonstrate the application to the mother. 

• Ask the mother to return for follow-up after 2 days. 

• Any worsening or signs of more serious infection noted above should be treated as 

“sepsis” and the baby should be referred to a higher center after giving the first doses of 

the antibiotics. 



155

Skin Infection 

The severity of skin infection is classified by the number and size of the lesions, and signs of 

sepsis as follows : 

• Fewer than ten pustules/blisters, with no signs of sepsis: 

o Wash the affected areas with an antiseptic. 

o Swab the pustules/blisters with gentian violet 4 times a day until they are healed. 

o Ask the mother to bring the baby for follow-up after 2 days. 

o If the lesions don’t clear but there are no danger signs, give erythromycin or 

cloxacillin by mouth for 5 days (50 mg/kg every 12 hours the first week of life; every 8 

hours the 2 nd week of life; and subsequently every 6 hours). If not available, try oral 

amoxicillin (every 12 hours the first week of life, older than 1 week, every 8 hours). 

• Ten or more pustules/blisters with no danger signs of sepsis: 

o Continue local treatment as noted above. 

o Give cloxacillin orally. 

o Ask the mother to come back for follow-up, ideally the next day or at least after 2 

days. 

o Assess the baby for signs of improvement (not spreading and drying): 

̌ If there is improvement, continue treatment to complete 5-7 days. 

̌ If there is no improvement, add gentamicin (Day 1-7): 4 mg/kg IM once daily for 

babies < 2 kg, 5 mg/kg once daily for babies ≥ 2 kg; day 8 and over: 7.5 mg/kg 

once daily for all weights and treat for 7-10 days. 

• For cellulitis/abscess: 

o If there is fluctuant swelling, incise and drain the abscess. If this is not feasible in the 

peripheral center, refer to the referral center after giving the first dose of the 

antibiotic. If cloxacillin cannot be given IV, give oral cloxacillin with IM injection of 

gentamycin 

o If admitted locally, assess the baby daily: 

If the baby improves, continue to complete 10 days of treatment. 

If there is no improvement, refer to the appropriate center. 

156 




Table 17: Summary of Treatment of Minor Infections 

PROBLEM IDENTIFICATION TREATMENT 

Conjunctivitis Pus discharge from 

the eyes with or 

without redness 

Treat as gonococcal infection in endemic 

areas: (ceftrioxone 50 mg/kgIM) plus 

eye toilet and tetracycline drops or 

Minor umbilical 

infection 

Thrush 

Pus discharge from 

umbilicus or base of 

cord 

Dirty white patches 

on the tongue, inner 

cheeks, and palate 

Pustules or peeling 

of skin 

ointment. Treat parents. 

Clean the cord base/depth of the umbilicus 

well with alcohol and apply antiseptic (such 

as chlorhexidine, Betadine, triple dye, or 

gentian violet). 

Local application of nystatin or gentian 

violet: a drop or two in the mouth 4 times a 

day. 

Pustules, boils, 

Clean the skin with an antiseptic solution. If 

impetigo 

not available, use soap and water. If less 

than 10 pustules, apply gentian violet paint 

twice a day. If more than 10, give oral 

antibiotics amoxicillin or erythromycin. If no 

improvement in 2 days change to oral 

cloxacillin for 7-10 days. 

Source: WHO. 2003. Managing Newborn Problems: A Guide for Doctors, Nurses and Midwives. 

PREVENTING INFECTIONS 

During the prenatal period: 

• Give tetanus immunization. 

• Follow guidelines for preventing and treating sexually transmitted diseases, HIV/AIDS, 

and malaria. 

During delivery: 

• Follow clean delivery practices; at the facility, as many of the items as possible coming 

in contact with the baby and for the delivery should be sterile. 

• Provide basic care of the newborn, including temperature maintenance, early and 

exclusive breastfeeding, eye care, cord and skin care, general hygiene, including hand 

washing. 

During the postnatal period give preventive care for the mother and the newborn, including 

general hygiene, hand washing, and the other components noted above. 

Follow-up care: 

• Ask the mother to bring back the baby after two days for follow-up. 

• Counsel the mother on identification of danger signs and to return immediately should 

even one danger sign be present. 

• Counsel the mother on basic preventive essential newborn care, including 

breastfeeding, cord care, and temperature maintenance. 

• Make an appointment for when the next immunizations are due. 



157

APPENDIX A: Selection and Storage 

of Uterotonic Drugs 

The information in this appendix comes from POPPHI. Prevention of Postpartum Hemorrhage: 

Implementing Active Management of the Third Stage of Labor (AMTSL): A Reference Manual 

for Health Care Providers. Seattle: PATH; 2007. Available at: 

http://www.pphprevention.org/AMTSLlearningmaterials.php. Accessed October 16, 2008. 

Uterotonics act directly on the smooth muscle of the uterus and increase the tone, rate, and 

strength of rhythmic contractions. The body produces a natural uterotonic—the hormone 

oxytocin—that acts to stimulate uterine contractions at the start of labor and throughout the birth 

process. 

Drugs such as oxytocin, ergometrine, and misoprostol have strong uterotonic properties and are 

used to treat uterine atony and reduce the amount of blood lost after childbirth. Oxytocin is 

widely used for induction and augmentation of labor. The use of a uterotonic drug immediately 

after the delivery of the newborn is one of the most important actions used to prevent 

postpartum hemorrhage. 

UTEROTONIC DRUGS USED FOR AMTSL 

Oxytocin is fast-acting, inexpensive, and in most cases has no side effects or contraindications 

for use during the third stage of labor. Oxytocin is also more stable than ergometrine in hot 

climates and light (when cold/dark storage is not possible). WHO recommends oxytocin as the 

drug of choice for AMTSL and advises that ergometrine, Syntometrine, or misoprostol be used 

only when oxytocin is not available. 

WHO recommends oxytocin as the drug of choice for AMTSL. 

Table A.1 compares dosage, route of administration, drug action and effectiveness, side effects, 

and cautions for the most common uterotonic drugs used for AMTSL. 

158 




Table A.1. Uterotonic Drugs for AMTSL 

Name of 

drug/preparation 

Dosage 

and route 

Drug action and 

effectiveness 

Side effects and cautions 

Oxytocin 

Posterior pituitary 

extract. Commonly 

used brand names 

include Pitocin or 

Syntocinon. 

Misoprostol 

Synthetic prostaglandin 

E 1 (PGE 1 ) analogue. 

Commonly used brand 

names include Cytotec, 

Gymiso, Prostokos, 

Vagiprost, U-Miso 

Ergometrine 

(methylergometrine), 

also known as 

ergonovine 

(methylergonovine) 

Preparation of ergot 

(usually comes in dark 

brown ampoule). 

Commonly used brand 

names include 

Methergine, Ergotrate, 

Ergotrate Maleate 

Syntometrine 

Combination of 5 IU 

oxytocin plus 0.5 mg 

ergometrine. 

Give 10 

units IM 

injection.* 

Give 600 

mcg (three 

200 mcg 

tablets) 

orally. 

Give 0.2 mg 

IM injection. 

Give 1 mL 

IM injection. 

• Acts within 2-3 

minutes. 

• Effect lasts 

about 15-30 

minutes. 

Orally: 

• Acts within 6 

minutes. 

• Peak serum 

concentration 

between 18 

and 34 

minutes. 

• Effect lasts 75 

minutes. 

• Acts within 6-7 

minutes IM. 

• Effect lasts 2- 

4 hours. 

Combined rapid 

action of oxytocin 

and sustained 

action of 

ergometrine. 

• First choice. 

• No known contraindications for 

postpartum use.** 

• Minimal or no side effects. 

• No known contraindications for 

postpartum use.** 

• Common side effects: shivering 

and elevated temperature. 

• Contraindicated in women with 

a history of hypertension, heart 

disease, retained placenta, 

preeclampsia, or eclampsia.*** 

• Causes tonic contractions (may 

increase risk of retained 

placenta). 

• Side effects: nausea, vomiting, 

headaches, and hypertension. 

Note: Do not use if the drug is 

cloudy; this means it has been 

exposed to excess heat or light and 

is no longer effective. 

• Same cautions and 

contraindications as 

ergometrine. 

• Side effects: nausea, vomiting, 

headaches, and hypertension. 

* 

If a woman has an IV, an option may be to give her 5 IU of oxytocin by slow IV push. 

** This is intended as a guide for using these uterotonic drugs during the third stage of labor. Different 

guidelines apply when using these uterotonic drugs at other times or for other reasons. 

*** Lists of contraindications are not meant to be complete; evaluate each client for sensitivities and 

appropriateness before using any uterotonic drug. Only some of the major postpartum contraindications 

are listed for the above drugs. 

IM = intramuscular; IV = intravenous 



159

DRUG EFFECTIVENESS 

Effects of Heat and Light on Uterotonic Drugs 

Two factors can influence the effectiveness of uterotonic drugs: temperature and light. This is 

especially important in hot temperatures and in conditions where refrigeration is not always 

available or reliable. A WHO research program examined the effectiveness of different 

injectable uterotonic drugs at various temperatures and light conditions. Table A.2 shows one 

comparison from this study. 

Table A.2. Change in Effectiveness of Injectable Uterotonic Drugs 

after One Year of Controlled Storage 

Uterotonic 

drug 

Dark 

4-8 º C 

Dark 

30 º C 

Light 

21-25 º C 

Oxytocin 0% loss 14% loss 7% loss 

Ergometrine 5% loss 31% loss 90% loss 

Effects of heat and light/key 

findings 

Minimal effect from light, more 

stable for longer time at higher 

temperatures than ergometrine. 

Significantly more affected by heat 

and light, not stable at higher 

temperatures. 

Keeping Uterotonic Drugs Effective 

The stability of a drug is defined by how well it maintains active ingredient potency (and other 

measures such as pH) when stored over time. Pharmaceutical companies conduct stability 

studies to determine the appropriate shelf-life, storage conditions, and expiration dating for safe 

storage of the oxytocin they produce. Manufacturers will recommend storage conditions based 

on the conditions under which they have performed stability studies, and will set the expiry date 

to be consistent with this. It is therefore important to read storage recommendations made by 

the manufacturer. 

Since ergometrine and Syntometrine are sensitive to heat and light, and oxytocin is sensitive to 

heat, following the storage guidelines is critical to ensure the optimal effectiveness of injectable 

uterotonic drugs. When drugs are inadequately stored, drug effectiveness can diminish, posing 

serious consequences for the postpartum woman. 

Storage practices in health care facilities vary widely and may not follow guidelines for correct 

storage. For example, vials of uterotonic drugs might be kept on open trays or containers in the 

labor ward, leaving them exposed to heat and light. Pharmacists, pharmacy managers, and birth 

attendants using oxytocin need to carefully read and follow recommended guidelines for 

transporting and storing uterotonic drugs. Recommended guidelines for transporting and storing 

specific uterotonic drugs are noted in Table A.3. 

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Oxytocin 

Table A.3. Recommended Guidelines for Transport and 

Storage of Uterotonic Drugs 

Drug Transport Storage 

Misoprostol 

Ergometrine / 

Syntometrine 

Unrefrigerated transport is 

possible if no more than one 

month at 30 °C. 

Protect from humidity. 

Unrefrigerated transport in 

the dark is possible if no 

more than one month at 30 

°C. Protect from freezing. 

Tips To Increase Uterotonic Drug Effectiveness 

In the pharmacy: 

• Check manufacturer’s 

recommendations; some 

manufacturers are producing oxytocin 

that is more heat stable than 

previously available. 

• Temporary storage outside the 

refrigerator at a maximum of 30 °C is 

acceptable for no more than 3 

months. 

• If possible, keep refrigerated at 2-8 

°C. 

• Store at room temperature in closed 

container and protected from 

humidity. 

• Store in the dark. 

• Keep refrigerated at 2-8 °C. 

• Store in closed container. 

• Protect from freezing. 

• Make sure that there are adequate stocks of uterotonic drugs, syringes, and injection 

safety materials. 

• Check the manufacturer’s label for storage recommendations. 

• Make sure that there is a system in place to monitor the temperature of the 

refrigerator/cold box; record the temperature in the refrigerator on a regular basis, 

preferably at the hottest times of the day (put thermometers in different parts of the 

refrigerator). 

• Make sure that there is a back-up system in place in case of frequent electricity cuts; for 

example, gas or solar refrigerators, placing ice packs in the refrigerator to keep it cool, 

etc. 

• Follow the rule of first expired-first out (or first in-first out) and maintain a log to keep 

track of expiration dates to reduce wastage of uterotonic drugs. 

• Store misoprostol at room temperature and away from excess heat and moisture. 

• To ensure the longest life possible of injectable uterotonics, keep them refrigerated at 2- 

8 °C. 

• Protect ergometrine and Syntometrine from freezing and light. 

In the delivery room: 

• Check the manufacturer’s label for recommendations on how to store injectable 

uterotonic drugs outside the refrigerator. In general: 



161

o Oxytocin may be kept outside the refrigerator at a maximum of 30 °C (warm, ambient 

climate) for up to three months and then discarded. 

o Ergometrine and Syntometrine vials may be kept outside the refrigerator in closed 

boxes and protected from the light for up to one month at 30 °C and then discarded. 

o Misoprostol should be stored at room temperature away from excess heat and 

moisture. 

• Record the temperature in the delivery room on a regular basis, preferably at the hottest 

times of the day. 

• Periodically remove ampoules from the refrigerator for use in the delivery room; carefully 

calculate the number removed from the refrigerator based on anticipated need. 

• Only remove ampoules or vials from their box just before using them. 

• Make sure that there are adequate stocks of syringes and injection safety materials. 

• Avoid keeping injectable uterotonics in open kidney dishes, trays, or coat pockets. 

Ergometrine loses 21-27 percent potency in one month of exposure to indirect 

sunlight. 

Oxytocin has no loss of potency after one month of exposure to indirect sunlight. 

162 




APPENDIX B: Alternative Assessment/Physical 

Examination of the Newborn at More 

Established Peripheral Centers 

TIMING OF ASSESSMENTS 

• As soon as feasible after birth. 

• At least once a day as long as the baby is in the facility. 

• Before discharge. This is extremely important to detect any high risk factor or a danger 

sign in the early stages. These may necessitate a longer stay at the facility, 

commencement of treatment/referral to the hospital, or the recommendation of an earlier 

follow-up visit. The early postpartum period is very important; 75 percent of deaths in 

babies take place in the first week following the birth. 

• At first and follow-up visits in the postnatal period. 

CONDUCTING THE ASSESSMENT 

Preparation 

• Wash your hands with soap and water. 

• Greet the mother/attendant, make her and the baby comfortable in a warm place free of 

drafts, and explain what is going to be done. 

Ask the Mother/Family 

• about any problems noted by them in the baby 

• how the baby is feeding 

• about stools, and urination (number, quality, etc) 

• about the presence of specific danger signs including: 

o difficulty in/poor feeding 

o lethargy or diminished activity 

o fever or body feeling too cold 

o fast breathing/difficulty in breathing 

o repeated vomiting and/or abdominal fullness 

o convulsions 

o signs related to severe umbilical infection (surrounding redness, swelling, foul smell 

with or without pus discharge) 

Assess for Danger Signs 

• Check for general alertness and activity. Except in deep sleep, babies move frequently, 

spontaneously, and on stimulation. The arms and legs are flexed. If a limb is consistently 

kept straight, evaluate for paralysis. Note also if the limbs seem very limp or flaccid. 

• Assess temperature: 

o Assess the body temperature by at least touching the baby’s abdomen, hands, and 

feet and ensuring all are warm. 



163

o Where possible note the axillary temperature with a thermometer leaving it in place 

for 4 minutes. The normal temperature is 36.5-37.5 °C. (The thermometer should be 

clean and wiped with at least an alcohol swab to prevent cross infection. Storing in 

liquid antiseptics should be done only if they are changed frequently. Otherwise there 

is a risk of infections with Pseudomonas. It is not recommended to take rectal 

temperature as a routine as it is associated with a higher risk of infection and 

trauma.) 

o In the newborn infant, both fever and low body temperature outside the normal range 

of 36.5-37.5 °C are danger signs. 

• Assess respiration: Normal respiratory rate is 30-60 breaths/minute. Although breathing 

can be somewhat irregular with short pauses, there should be no apnea which is defined 

as cessation of breathing lasting for more than 20 seconds or of a shorter duration 

associated with cyanosis, pallor, or bradycardia, with heart rate less than 110/minute. 

The normal heart rate ranges between 110-160 beats/minute, with the lower rates when 

the baby is asleep and the higher rates when the baby is active or crying. There should 

be no: 

o flaring of the nostrils 

o grunting 

o increased respiratory rate above 60/minutes 

o severe subcostal retractions 

• Look for abdominal fullness. 

• Examine the umbilical cord, taking care to lift it to see the base/umbilicus. Check for pus 

discharge, redness, swelling, foul smell. 

Take the Baby’s Weight 

• Place a clean cloth or paper on the baby scale pan. 

• Adjust the weight so it reads “zero” with the paper/cloth on it. 

• Place the baby over a paper or a cloth. If cloth, fold it to cover the body of the baby. 



• Write down the weight of the baby in the mother/baby and ward records based on 

recommendations of the Ministry of Health. 

• The normal weight range is 2.5-4 kg. Low birth weight is below 2.5 kg. 

Examine the Newborn 

In general newborn babies are examined from head to toe and front to back. 

Head 

• Note the general shape of the head and inspect the scalp for cuts or bruises from 

forceps or vacuum. Elongated or asymmetrical shape may be due to molding during 

birth. 

• Palpate the anterior fontanel and check for any bulging. 

• Caput succedaneum is a soft swelling over the part of the head that presented first. It 

disappears by 48 hours. 

164 




Eyes 

• Cephalhematoma is a subperiostial hemorrhage that is usually seen as a fluctuant 

swelling 48-72 hours after delivery. It never extends across the suture line. Most resolve 

within a few weeks and need no treatment. 

• Subconjunctival hemorrhage can be a normal finding following the delivery. 

• Check for conjunctivitis, seen as redness and/or discharge. 

Skin and mucous membranes 

• The lips, mouth, tongue, palms, and soles should be pink. If the palms and soles are 

bluish, it suggests that the baby may be not warm enough and may actually be 

maintaining temperature in a stressful manner through vaso-constriction of the 

peripheral vessels. If blueness persists after warming, it may be due to problems such 

as shock or a congenital heart defect. 

• The skin may also show other features that are normal for this age that disappear over 

varying periods of days or weeks, such as: 

o tiny raised white/pale yellow dots on the face (milia) 

o collections of tiny capillary vessels on the face over the forehead and upper lips 

(telangiectasia) 

o bluish areas over the back and limbs (“Mongolian spots/patches) 

o reddish spots/patches on the skin (toxic erythema) 

Check for jaundice 

Unlike in older infants, it is not easy to see jaundice in the early phase in the eyes of the 

newborn; it is best assessed in the skin. Jaundice starts in the face and spreads down to the 

hands and feet. 

• Gently press the tip of the nose, release, and observe the blanched area for any yellow 

tinge/color. It can also be seen in the grooves of the skin when the baby frowns or cries. 

• This is the only time in life that some jaundice in a full term baby does not require any 

treatment if it starts after the first 24 hours on the face and does not spread to the palms 

and soles, and disappears by two weeks. 

• When the color reaches the palms or soles, it correlates with a serum bilirubin of about 

15 mg/100 mL (or 256.5 µmols/L). Such babies require referral for assessment and 

treatment. 

• These guidelines apply only to full term normal weight babies. Preterm and low birth 

weight babies require treatment at far lower levels. Hence, such babies with any 

jaundice need to be referred to a competent person/center for assessment and 

treatment and should not be considered to have “physiological jaundice.” 

Mouth 

• Check for cleft lip and look inside the mouth for cleft palate. 

• Examine the tongue and the inner side of the mouth for oral thrush, seen as irregular, 

dirty white patches on the tongue and inner sides of the cheeks. Thrush is different from 

the normal smooth white patch that may be seen over the middle of the tongue in some 

babies. 



165

Chest 

• Look for symmetry and movement during breathing. 

• The breasts in both boys and girls may be engorged and secrete a small amount of milk. 

Do not express the baby’s breasts, as it may lead to trauma and infection. 

• Listen to the heart sounds with a stethoscope. The rate is faster in the newborn period, 

the range being 110-160/minute. Soft murmurs may be normal in the early newborn 

period. 

Abdomen 

Anus 

• The abdomen should be rounded and soft. 

• Check the umbilical cord for: 

o The presence of two arteries and one vein which is normal. The vein is seen as an 

elongated open slit and the arteries as thin cord-like structures. 

o Oozing of blood. If present, tie the cord again. 

o Signs of infection. In case of a pus discharge from umbilicus or the base of the cord, 

lift the cord to see the base. Redness or swelling over the surrounding skin and/or a 

foul smell are features of a major infection. 

• Later, after the umbilicus heals well, a small umbilical hernia may develop in some 

babies. It usually resolves spontaneously. Do not apply a coin or a pressure bandage 

over it. 

• Gently palpate the abdomen for masses. The liver and spleen are normally palpable. 

• Note when the baby passes stools (usually at birth or within 24-48 hours of the delivery). 

• At birth or when seen for the first time during the first few days after birth, check the 

position of the anus and ensure the patency of the anal opening. Where there is doubt, 

verify patency carefully and gently with a clean blunt rectal thermometer. 

Male genitalia 

• The urethra opens at the end of the penis. 

• Do not try to retract the prepuce, as it is often adherent at this stage. 

• One or both the testes are felt in the scrotum in a full term baby, but they may be 

undescended in a preterm infant. 

• If the baby has been circumcised, check for any signs of bleeding or infection. 

• Examine the groin and scrotal sac for hernias and hydroceles: 

o Hernias are reducible and are not trans-illuminated with a torch/flashlight. Although, 

usually it is not an emergency unless impacted or strangulated, such babies need to 

be referred to an appropriate hospital for assessment and planned management. 

o Hydroceles which can be trans-illuminated with a torch/flashlight may also be noted. 

They usually disappear in a few months or by the first birthday. 

Female genitalia 

• Examine the labia and clitoris; make sure there is no fusion of the labia. 

• The hymen is often prominent and may project out as the “hymenal tag,” which is 

normal. 

166 




• A white discharge from the vagina, with or without blood, is normal in the first week of 

life. Referral is required only if bleeding is excessive and should be done after 

administration of vitamin K1 (1 mg). 

Check the back 

• Turn the baby over gently, ensuring that the head is turned to one side, and examine the 

back for obvious defects such as a swelling or an open spina bifida along the vertebral 

column. Sometimes spina bifida occulta may be present without any obvious swelling or 

an opening but may manifest with a tuft of hair or a dimple. Although not urgent, such 

babies need referral to a higher center for x-rays of the spine. 

Assess Feeding 

This can be done at any convenient time after excluding danger signs, such as the inability to 

suck, that need immediate attention. If the baby can suck well, assess attachment of the baby’s 

mouth. Note that: 

• The baby’s chin is touching or nearly touching the breast. 


• The lower lip is everted. 

• Most of the areola is inside the mouth, especially the part below, so that it is visible more 

above the mouth than below. 

• The sucking is slow and deep and swallowing is often audible. 

Counsel the Mother/Family 

Advise the mother on: 

• frequent breastfeeding on demand day and night 

• keeping the baby appropriately warm 

• washing hands before handling the baby, at least after using the toilet and after 

changing the napkin/diaper 

• having an extra meal and additional fluids 

• the danger signs to look for in herself and in the baby 

• when she has to come with the baby for follow-up and for immunization (make an 

appointment) 



167

APPENDIX C: Glossary 

Active management of the third stage of labor (AMTSL): A combination of actions 

performed during the third stage of labor to prevent PPH. AMTSL speeds delivery of the 

placenta by increasing uterine contractions and prevents PPH by minimizing uterine 

atony. The components of AMTSL are: 

• Administration of a uterotonic drug within one minute after the baby is born (oxytocin is 

the uterotonic of choice) after verifying that there is no second baby. 

• Controlled cord traction (CCT). 

• Uterine massage immediately after delivery of the placenta. 

Controlled cord traction (CCT): Traction on the cord during a contraction combined 

with countertraction upward on the uterus with the provider’s hand placed immediately 

above the symphysis pubis. CCT facilitates expulsion of the placenta once it has 

separated from the uterine wall. 

Delayed cord clamping: Clamping the umbilical cord after cord pulsations have 

ceased. Studies show that delaying clamping and cutting of the umbilical cord is helpful 

to both full-term and preterm babies. In situations where cord clamping and cutting was 

delayed for preterm babies, these infants had higher hematocrit and hemoglobin levels 

and a lesser need for transfusions in the first 4 to 6 weeks of life than preterm babies 

whose cords were clamped and cut immediately after birth. 

Delayed PPH: Excessive vaginal bleeding (vaginal bleeding increases rather than 

decreases after delivery), occurring more than 24 hours after childbirth. 

Immediate PPH: Vaginal bleeding in excess of 500 mL, occurring less than 24 hours 

after childbirth. 

Immediate postpartum period: See fourth stage of labor. 

Infant mortality rate: Number of deaths during the first year of life, expressed per 1000 

live births. 

Live birth: A baby who is born alive as indicated by the baby moving, crying, breathing, having 

heart beats, or showing cord pulsations. 

Low birth weight infant: A newborn weighing less than 2500 grams at birth. A low birth weight 

infant (LBW) may be preterm, with or without intrauterine growth retardation (IUGR), or full term, 

or post term with IUGR. 

Neonatal mortality rate: Number of newborn deaths during the first 28 days of life, expressed 

per 1000 live births. 

Neonatal period: This period commences at birth and ends at 28 completed days of life. The 

neonatal period is divided into two parts: the early neonatal period extends from day 1 to 7 

completed days; the late neonatal period extends from day 8 to 28 completed days. 

Perinatal mortality rate: The number of stillbirths and deaths in the first week of life, expressed 

per 1000 live plus stillbirths. 

Perinatal period: This period extends from the 22d week of gestation to the end of the first 

week of life (7 completed days). In some developing countries, authorities feel that since 

168 




survival of babies born before 28 weeks is in practice not feasible, the definition of the 

commencement of the perinatal period should only be from 28 weeks. However, it is better to 

have definitions uniform across countries so that data can be compared. As conditions 

ameliorate in countries, outcomes will improve. 

Newborn - Definitions 

Perinatal Period 

Early 

neonatal 

period 

Late 

neonatal 

period 

22 wk 

Pregnancy 

Birth 

1 wk 4 wk 

Newborn period 

9 

Figure C.1. Newborn periods. 

Physiologic (expectant) management of the third stage of labor (PMTSL): 

Management of the third stage of labor that involves waiting for signs of placental 

separation and allowing for spontaneous delivery of the placenta aided by gravity and/or 

nipple stimulation. The components of PMTSL are: 

• Waiting for signs of separation of the placenta (cord lengthening, small blood loss, 

uterus firm and globular on palpation at the umbilicus). 

• Encouraging maternal effort to bear down with contractions and, if necessary, to 

encourage an upright position. 

• Uterine massage after the delivery of the placenta as appropriate. 

Placenta accreta: A severe obstetric complication occurring when the placenta attaches itself 

too deeply and too firmly into the wall of the uterus, preventing separation of the placenta from 

the uterus. 

Post term infant: A baby who is born after 42 completed weeks of gestation. 

Preterm infant: A baby who is born before 37 completed weeks of gestation. 

Retraction: The act of the uterine muscle pulling back. Retraction is the ability of the 

uterine muscle to keep its shortened length after each contraction. Together with 

contractions, retraction helps the uterus become smaller after the delivery of the baby. 



169

Severe PPH: Vaginal bleeding in excess of 1000 mL, occurring less than 24 hours after 

childbirth. 

Stages of labor 

• First stage of labor. The first stage of labor begins with the onset of contractions and 

ends when the cervix is fully dilated (10 cm). This stage is divided into two phases, 

known as the latent and active phases of labor. During the latent phase, the uterine 

cervix gradually effaces (thins out) and dilates (opens). This is followed by active labor, 

when the uterine cervix begins to dilate more rapidly and contractions are longer, 

stronger, and closer together. 

• Second stage of labor. The second stage of labor begins when the uterine cervix is 

fully dilated and ends with the birth of the baby. This is sometimes referred to as the 

pushing stage. 

• Third stage of labor. The third stage of labor begins with the birth of the newborn and 

ends with the delivery of the placenta and its attached membranes. 

• Fourth stage of labor (also known as the “immediate postpartum” period). The fourth 

stage of labor begins with the delivery of the placenta and goes from one to six hours 

after delivery of the placenta, or until the uterus remains firm on its own. In this 

stabilization phase, the uterus makes its initial readjustment to the nonpregnant state. 

The primary goal is to prevent hemorrhage from uterine atony and cervical or vaginal 

lacerations. 

Stillbirth: A baby who is born with no signs of life noted under “live birth.” Stillbirths are of two 

types: macerated stillbirth (when the body may be distorted, soft, often smaller than normal, 

and the skin is unhealthy with discoloration and peeling) and fresh stillbirth (when the body 

appears normal unless associated with a major congenital malformations and the skin appears 

normal in texture and consistency, although it may appear pale). Here the death has occurred 

fairly close to the time of birth. It may have been due to problems during labor. On some 

occasions a live birth with minimal signs of life, such as just a few cord pulsations or an 

occasional faint gasp, may mistakenly be passed off as a “stillbirth.” Improved care during labor 

and better recognition and reporting will result in a decrease in the number of fresh stillbirths. 

Hence, in maintaining records, it is worthwhile to try and differentiate between macerated and 

fresh stillbirths. 

Term infant: A baby who is born within 37-42 completed weeks of gestation. 

Uterine atony: Loss of tone in the uterine muscle. Normally, contraction of the uterine 

muscles compresses the uterine blood vessels and reduces blood flow, increasing the 

chance of coagulation and helping to prevent bleeding. The lack of uterine muscle 

contraction or tone can cause an acute hemorrhage. Clinically, 75 to 80 percent of PPH 

cases are due to uterine atony. 

Uterine massage: An action used after the delivery of the placenta in which the provider 

places one hand on top of the uterus to rub or knead the uterus until it is firm. 

Sometimes blood and clots are expelled during uterine massage. 

Uterotonic drugs: Substances that stimulate uterine contractions or increase uterine 

tone. 

170 




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