After the Delivery of the Baby, What Still Needs to Be Delivered?

• Always begin with Rapid cess and management (RAM) B3-B7.

• Next, use the chart on Examine the woman in labour or with ruptured membranes D2-D3 to appraise the clinical situation and obstetrical history, and decide the phase of labour.

• If an aberrant sign is identified, use the charts on Respond to obstetrical problems on access D4-D5.

• Care for the woman according to the stage of labour D8-D13 and reply to problems during labour and commitment as on D14-D18.

• Use Give supportive care throughout labour D6-D7 to provide back up and care throughout labour and delivery.

• Tape findings continually on labour tape and partograph N4-N6.

• Keep mother and baby in labour room for one hour after delivery and apply charts Care of the mother and newborn within first hour of commitment placenta on D19.

• Next use Care of the mother subsequently the get-go hour following delivery of placenta D20 to provide care until discharge. Use nautical chart on D25 to provide Preventive measures and Advise on postpartum care D26-D28 to advise on intendance, danger signs, when to seek routine or emergency care, and family planning.

• Examine the mother for belch using chart on D21.

• Exercise not discharge female parent from the facility earlier 12 hours.

• If the female parent is HIV-infected or adolescent, or has special needs, see G1-G11 H1-H4.

• If attending a delivery at the woman's home, meet D29.

D2. EXAMINE THE WOMAN IN LABOUR OR WITH RUPTURED MEMBRANES

Get-go practice Rapid cess and management B3-B7. Then use this nautical chart to assess the adult female's and fetal status and decide phase of labour.

View in own window

Inquire, CHECK RECORD

Look, LISTEN, FEEL

History of this labour: When did contractions begin? How frequent are contractions? How strong? Accept your waters broken? If aye, when? Were they articulate or green? Take you had any haemorrhage? If yes, when? How much? Is the infant moving? Do you have any concern? Check record, or if no tape: Inquire when the delivery is expected. Make up one's mind if preterm (less than 8 months meaning). Review the birth plan. If prior pregnancies: Number of prior pregnancies/deliveries. Whatever prior caesarean section, forceps, or vacuum, or other complication such every bit postpartum haemorhage? Any prior third caste tear? Current pregnancy: RPR status C5. Hb results C4. Tetanus immunization status F2. HIV status C6. Infant feeding plan G7-G8. Receiving any medicine.

Observe the woman's response to contractions: → Is she coping well or is she distressed? Is she pushing or grunting? Cheque abdomen for: → caesarean section scar. → horizontal ridge across lower abdomen (if nowadays, empty float B12 and observe again). Feel abdomen for: → contractions frequency, duration, whatsoever continuous contractions? → fetal lie—longitudinal or transverse? → fetal presentation—caput, breech, other? → more than one fetus? → fetal move. Listen to the fetal heart beat out: → Count number of beats in 1 infinitesimal. → If less than 100 beats per minute, or more than 180, plough woman on her left side and count again. Measure blood pressure. Measure temperature. Look for pallor. Await for sunken optics, dry out oral cavity. Pinch the skin of the forearm: does it go back quickly?

Next: Perform vaginal examination and make up one's mind stage of labour

D3. DECIDE STAGE OF LABOUR

View in ain window

ASK, Check RECORD	Await, LISTEN, FEEL	SIGNS	CLASSIFY	MANAGE
Explain to the woman that yous volition give her a vaginal examination and enquire for her consent.	Look at vulva for: → bulging perineum → any visible fetal parts → vaginal bleeding → leaking amniotic fluid; if yes, is it meconium stained, foul-smelling? → warts, keloid tissue or scars that may interfere with commitment. Perform vaginal examination DO Non shave the perineal area. Prepare: → clean gloves → swabs, pads. Wash easily with lather before and after each examination. Wash vulva and perineal areas. Put on gloves. Position the woman with legs flexed and apart. Practise NOT perform vaginal exam if bleeding at present or at whatsoever fourth dimension after 7 months of pregnancy. Perform gentle vaginal examination (do non outset during a contraction): → Determine cervical dilatation in centimetres. → Feel for presenting office. Is it difficult, round and smooth (the head)? If not, identify the presenting part. → Feel for membranes – are they intact? → Feel for cord – is it felt? Is it pulsating? If so, act immediately every bit on D15.	Bulging thin perineum, vagina gaping and head visible, total c ervical dilatation.	IMMINENT Delivery	See 2d stage of labour D10-D11. Record in partograph N5.
		Cervical dilatation: → multigravida ≥5 cm → primigravida ≥half-dozen cm	LATE Agile LABOUR	See first stage of labour – active labour D9. Start plotting partograph N5. Record in labour record N5.
		Cervical dilatation ≥4 cm.	Early ACTIVE LABOUR
		Cervical dilatation: 0-iii cm; contractions weak and <2 in ten minutes.	NOT All the same IN ACTIVE LABOUR	See first stage of labour — non active labour D8. Record in labour record N4.

Next: Answer to obstetrical bug on admission.

D4-D5. RESPOND TO OBSTETRICAL PROBLEMS ON Access

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

View in ain window

	SIGNS	Classify	Treat AND ADVISE
	Transverse lie. Continuous contractions. Abiding pain betwixt contractions. Sudden and severe abdominal pain. Horizontal ridge across lower belly. Labour >24 hours.	OBSTRUCTED LABOUR	If distressed, insert an Four line and give fluids B9. If in labour >24 hours, give appropriate IM/Iv antibiotics B15. Refer urgently to infirmary B17.
FOR ALL SITUATIONS IN RED Below, REFER URGENTLY TO Infirmary IF IN Early on LABOUR, MANAGE Only IF IN Late LABOUR
	Rupture of membranes and any of: → Fever >38˚C → Foul-smelling vaginal belch.	UTERINE AND FETAL INFECTION	Give appropriate IM/Four antibiotics B15. If late labour, evangelize and refer to hospital afterwards delivery B17. Program to treat newborn J5.
	Rupture of membranes at <eight months of pregnancy.	Chance OF UTERINE AND FETAL INFECTION AND RESPIRATORY DISTRESS SYNDROME	Give appropriate IM/IV antibiotics B15. If late labour, deliver D10-D28. Discontinue antibiotic for female parent after delivery if no signs of infection. Plan to treat newborn J5.
	Diastolic blood pressure >90 mmHg.	PRE-ECLAMPSIA	Assess further and manage equally on D23.
	Severe palmar and conjunctival pallor and/or haemoglobin <7 thou/dl.	Severe ANAEMIA	Manage equally on D24.
	Breech or other malpresentation D16. Multiple pregnancy D18. Fetal distress D14 Prolapsed string D15.	OBSTETRICAL Complexity	Follow specific instructions (see page numbers in left column).
	Warts, keloid tissue that may interfere with delivery. Prior third degree tear. Bleeding any time in third trimester. Prior delivery by: → caesarean secion → forceps or vacuum commitment. Age less than 14 years.	RISK OF OBSTETRICAL Complexity	Practice a generous episiotomy and carefully control delivery of the head D10-D11. If late labour, deliver D10-D28. Have help available during delivery.
	Labour before 8 completed months of pregnancy (more than than one calendar month before estimated date of delivery).	PRETERM LABOUR	Reassess fetal presentation (breech more than common). If woman is lying, encourage her to lie on her left side. Telephone call for help during delivery. Routine commitment by caesarean section for the purpose of improving preterm newborn outcomes is not recommended, regardless of cephalic or breech presentation. The use of magnesium sulfate is recommended for women at adventure of imminent preterm birth before 32 weeks of gestation for prevention of cerebral palsy in the babe and kid B13. Behave delivery very carefully as small baby may pop out suddenly. In detail, control delivery of the head. Prepare equipment for resuscitation of newborn K11.
	Fetal center charge per unit <120 or >160 beats per minute.	POSSIBLE FETAL DISTRESS	Manage as on D14.
	Rupture of membranes at term and before labour.	RUPTURE OF MEMBRANES	Give appropriate IM/Four antibiotics if rupture of membrane >xviii hours B15. Plan to treat the newborn J5.
	If two or more of the post-obit signs: → thirsty → sunken eyes → dry oral fissure → skin compression goes dorsum slowly.	Dehydration	Give oral fluids. If not able to potable, requite one litre Iv fluids over three hours B9.
	HIV test positive. Taking ARV handling or prophylaxis.	HIV-INFECTED	Ensure that the woman takes ARV drugs as prescribed G6, G9 Support her choice of infant feeding G7-G8.
	No fetal movement, and No fetal center trounce on repeated examination	POSSIBLE FETAL Expiry	Explain to the parents that the baby is non doing well.

Side by side: Give supportive care throughout labour

D6-D7. Give SUPPORTIVE Intendance THROUGHOUT LABOUR

Employ this nautical chart to provide a supportive, encouraging atmosphere for nascency, respectful of the adult female'due south wishes.

Communication

• Explain all procedures, seek permission, and hash out findings with the woman.

• Keep her informed about the progress of labour.

• Praise her, encourage and reassure her that things are going well.

• Ensure and respect privacy during examinations and discussions.

• If known HIV-infected, find out what she has told the companion. Respect her wishes.

Cleanliness

• Encourage the adult female to bathe or shower or wash herself and genitals at the onset of labour.

• Launder the vulva and perineal areas earlier each test.

• Wash your hands with soap before and subsequently each exam. Use clean gloves for vaginal examination.

• Ensure cleanliness of labour and birthing area(s).

• Clean upwardly spills immediately.

• Practice Non give enema.

Mobility

• Encourage the adult female to walk around freely during the showtime stage of labour.

• Support the adult female'southward choice of position (left lateral, squating, kneeling, standing supported by the companion) for each phase of labour and delivery.

Urination

• Encourage the woman to empty her bladder often. Remind her every ii hours.

Eating, drinking

• Encourage the woman to consume and drink as she wishes throughout labour.

• Nutritious liquid drinks are important, fifty-fifty in late labour.

• If the adult female has visible severe wasting or tires during labour, make sure she eats and drinks.

Breathing technique

• Teach her to notice her normal breathing.

• Encourage her to breathe out more slowly, making a sighing noise, and to relax with each breath.

• If she feels lightheaded, unwell, is feeling pins-and-needles (tingling) in her face, hands and feet, encourage her to breathe more than slowly.

• To preclude pushing at the finish of first stage of labour, teach her to pant, to exhale with an open up mouth, to take in 2 brusk breaths followed by a long breath out.

• During delivery of the head, ask her non to button but to breathe steadily or to pant.

Pain and discomfort relief

• Suggest change of position.

• Encourage mobility, as comfortable for her.

• Encourage companion to:

  →

  massage the adult female'due south back if she finds this helpful.

  →

  hold the adult female's manus and sponge her face between contractions.

• Encourage her to use the breathing technique.

• Encourage warm bath or shower, if available.

• If woman is distressed or anxious, investigate the cause D2-D3.

• If hurting is abiding (persisting between contractions) and very severe or sudden in onset D4.

Birth companion

• Encourage support from the chosen nascence companion throughout labour.

• Describe to the nativity companion what she or he should do:

  →

  Always be with the woman.

  →

  Encourage her.

  →

  Help her to breathe and relax.

  →

  Rub her back, wipe her forehead with a moisture cloth, do other supportive actions.

  →

  Give support using local practices which practice non disturb labour or delivery.

  →

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

  →

  Encourage her to drink fluids and eat as she wishes.

  →

  Assist her to the toilet when needed.

• Ask the birth companion to call for help if:

  →

  The woman is bearing downwards with contractions.

  →

  There is vaginal bleeding.

  →

  She is suddenly in much more pain.

  →

  She loses consciousness or has fits.

  →

  There is any other concern.

• Tell the birth companion what she or he should Non practice and explain why:

• Do Non encourage woman to push.

• DO NOT give advice other than that given past the health worker.

• Practise NOT keep woman in bed if she wants to motion around.

D8. FIRST Stage OF LABOUR: Not IN ACTIVE LABOUR

Use this chart for care of the adult female when NOT IN Active LABOUR, when neck dilated 0-three cm and contractions are weak, less than ii in ten minutes.

View in own window

MONITOR EVERY Hour:	MONITOR EVERY 4 HOURS:
For emergency signs, using rapid cess (RAM) B3-B7. Frequency, intensity and duration of contractions. Fetal centre rate D14. Mood and behaviour (distressed, anxious) D6.	Cervical dilatation D3 D15. Unless indicated, do not do vaginal exam more often than every four hours. Temperature. Pulse B3. Blood pressure D23.
Record findings regularly in Labour record and Partograph N4-N6. Record time of rupture of membranes and colour of amniotic fluid. Requite Supportive intendance D6-D7. Never exit the adult female solitary.

View in ain window

Assess PROGRESS OF LABOUR	TREAT AND ADVISE, IF REQUIRED
After 8 hours if: → Contractions stronger and more frequent but → No progress in cervical dilatation with or without membranes ruptured.	Refer the adult female urgently to infirmary B17.
Subsequently 8 hours if: → no increase in contractions, and → membranes are non ruptured, and → no progress in cervical dilatation.	Discharge the woman and advise her to return if: → hurting/discomfort increases → vaginal haemorrhage → membranes rupture.
Cervical dilatation four cm or greater.	Begin plotting the partograph N5 and manage the woman as in Active labour D9.

D9. Beginning STAGE OF LABOUR: IN ACTIVE LABOUR

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

View in own window

MONITOR EVERY 30 MINUTES:	MONITOR EVERY iv HOURS:
For emergency signs, using rapid assessment (RAM) B3-B7. Frequency, intensity and elapsing of contractions. Fetal center rate D14. Mood and behaviour (distressed, anxious) D6.	Cervical dilatation D3 D15. Unless indicated, do not do vaginal test more ofttimes than every 4 hours. Temperature. Pulse B3. Blood pressure D23.
Record findings regularly in Labour record and Partograph N4-N6. Record time of rupture of membranes and colour of amniotic fluid. Give Supportive intendance D6-D7. Never leave the woman solitary.

View in ain window

Assess PROGRESS OF LABOUR	Care for AND Advise, IF REQUIRED
Partograph passes to the right of Alert LINE.	Reassess woman and consider criteria for referral. Telephone call senior person if available. Alert emergency transport services. Encourage woman to empty bladder. Ensure adequate hydration but omit solid foods. Encourage upright position and walking if woman wishes. Monitor intensively. Reassess in 2 hours and refer if no progress. If referral takes a long time, refer immediately (DO NOT wait to cross activeness line).
Partograph passes to the right of ACTION LINE.	Refer urgently to hospital B17 unless nascence is imminent.
Cervix dilated ten cm or bulging perineum.	Manage every bit in Second stage of labour D10-D11.

D10-D11. SECOND Phase OF LABOUR: DELIVER THE Baby AND GIVE IMMEDIATE NEWBORN CARE

Apply this chart when cervix dilated 10 cm or bulging sparse perineum and head visible.

View in ain window

MONITOR EVERY v MINUTES:
For emergency signs, using rapid assessment (RAM) B3-B7. Frequency, intensity and elapsing of contractions. Fetal heart rate D14. Perineum thinning and bulging. Visible descent of fetal caput or during contraction. Mood and behaviour (distressed, anxious) D6. Tape findings regularly in Labour record and Partograph N4-N6. Give Supportive care D6-D7. Never exit the woman alone.

View in own window

Deliver THE BABY	Treat AND Propose IF REQUIRED
Ensure all delivery equipment and supplies, including newborn resuscitation equipment, are available, and identify of delivery is clean and warm (25°C) L3.
Ensure bladder is empty. Assist the woman into a comfy position of her choice, as upright as possible. Stay with her and offer her emotional and physical support D10-D11.	If unable to pass urine and bladder is full, empty bladder B12. Do Not allow her prevarication apartment (horizontally) on her back. If the woman is distressed, encourage pain discomfort relief D6.
Allow her to push equally she wishes with contractions.	Practice Not urge her to button. If, later 30 minutes of spontaneous expulsive efforts, the perineum does not begin to thin and stretch with contractions, do a vaginal examination to confirm full dilatation of cervix. If cervix is not fully dilated, await 2d stage. Identify adult female on her left side and discourage pushing. Encourage breathing technique D6.
Await until head visible and perineum distending. Launder easily with clean water and lather. Put on gloves only earlier delivery. See Universal precautions during labour and delivery A4.	If second stage lasts for ii hours or more without visible steady descent of the head, call for staff trained to use vacuum extractor or refer urgently to infirmary B17. If obvious obstruction to progress (warts/scarring/keloid tissue/previous third caste tear), do a generous episiotomy. Practise NOT perform episiotomy routinely. If breech or other malpresentation, manage as on D16.
Ensure controlled commitment of the head: → Keep one paw gently on the head every bit information technology advances with contractions. → Back up perineum with other hand and cover anus with pad held in position by side of paw during delivery → Leave the perineum visible (between thumb and first finger). → Ask the mother to breathe steadily and non to push during delivery of the head. → Encourage rapid animate with mouth open.	If potentially dissentious expulsive efforts, exert more than pressure on perineum. Discard soiled pad to prevent infection.
Experience gently around baby's neck for the cord. Check if the confront is clear of mucus and membranes.	If cord nowadays and loose, deliver the baby through the loop of cord or slip the cord over the baby's head; if string is tight, clamp and cut cord, then unwind. Gently wipe face clean with gauze or fabric, if necessary.
Expect spontaneous rotation of shoulders and commitment (within i-2 minutes). Utilize gentle downward pressure to deliver top shoulder. And so lift baby upwardly, towards the mother'due south abdomen to deliver lower shoulder. Place baby on abdomen or in female parent'due south arms. Note fourth dimension of delivery.	If filibuster in delivery of shoulders: → Exercise NOT panic simply call for aid and inquire companion to aid → Manage as in Stuck shoulders D17. If placing newborn on abdomen is non acceptable, or the female parent cannot hold the baby, identify the baby in a clean, warm, safe place close to the mother.
Thoroughly dry out the infant immediately. Wipe optics. Discard wet fabric. Assess baby's breathing while drying. If the baby is non crying, observe breathing: → breathing well (breast ascension)? → non breathing or gasping?	Do Non leave the infant wet - she/he will get cold. If the infant is not breathing or gasping (unless babe is expressionless, macerated, severely malformed): → Cutting cord quickly: transfer to a firm, warm surface; commencement Newborn resuscitation K11. CALL FOR HELP - one person should treat the mother.
Exclude second infant. Palpate mother'south abdomen. Give 10 IU oxytocin IM to the mother. Watch for vaginal haemorrhage.	If 2nd baby, Exercise Non give oxytocin at present. GET Assist. Deliver the 2d babe. Manage as in Multiple pregnancy D18. If heavy bleeding, repeat oxytocin 10-IU-IM.
Change gloves. If not possible, wash gloved hands. Clamp and cut the string (one-iii minutes later nascency): → put ties tightly around the cord at 2 cm and v cm from babe's abdomen. → cut between ties with sterile musical instrument. → observe for oozing blood.	If claret oozing, identify a 2d tie between the skin and the first tie. DO Non apply any substance to the stump. DO NOT bandage or bind the stump.
Go out baby on the mother's breast in skin-to-pare contact. Place identification label. Cover the baby, cover the caput with a lid.	If room cool (less than 25°C), use additional coating to cover the female parent and baby.
Encourage initiation of breastfeeding K2.	If HIV-infected mother has chosen replacement feeding, feed appropriately. Check ARV treatment needed G6, G9.

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

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

View in own window

MONITOR MOTHER EVERY 5 MINUTES:	MONITOR BABY EVERY 15 MINUTES:
For emergency signs, using rapid assessment (RAM) B3-B7. Feel if uterus is well contracted. Mood and behaviour (distressed, anxious) D6. Time since tertiary phase began (fourth dimension since birth).	Breathing: mind for grunting, look for breast in-cartoon and fast breathing J2. Warmth: check to come across if anxiety are cold to touch J2.
Record findings, treatments and procedures in Labour record and Partograph (pp.N4-N6). Give Supportive care D6-D7 Never exit the woman alone.

View in own window

Deliver THE PLACENTA	TREAT AND Propose IF REQUIRED
Ensure 10-IU oxytocin IM is given D11. Look strong uterine contraction (two-three minutes) and deliver placenta by controlled cord traction: → Place side of ane hand (usually left) above symphysis pubis with palm facing towards the female parent'due south umbilicus. This applies counter traction to the uterus during controlled cord traction. At the same time, use steady, sustained controlled cord traction. → If placenta does not descend during 30-40 seconds of controlled string traction, release both string traction and counter traction on the abdomen and expect until the uterus is well contracted again. Then echo controlled cord traction with counter traction. → Equally the placenta is coming out, grab in both hands to prevent vehement of the membranes. → If the membranes do not slip out spontaneously, gently twist them into a rope and movement them upwardly and downward to assist separation without vehement them.	If, after 30 minutes of giving oxytocin, the placenta is not delivered and the woman is NOT bleeding: → Empty bladder B12 → Encourage breastfeeding → Repeat controlled string traction. If woman is bleeding, manage as on B5 If placenta is not delivered in another xxx minutes (i hour after delivery): → Remove placenta manually B11 → Give appropriate IM/Iv antibiotic B15. If in one hr unable to remove placenta: → Refer the woman to infirmary B17 → Insert an IV line and give fluids with xx IU of oxytocin at 30 drops per infinitesimal during transfer B9. Practice Not exert excessive traction on the cord. Exercise Not clasp or push the uterus to evangelize the placenta.
Check that placenta and membranes are complete.	If placenta is incomplete: → Remove placental fragments manually B11. → Give appropriate IM/IV antibiotic B15.
Check that uterus is well contracted and there is no heavy bleeding. Repeat cheque every 5 minutes.	If heavy bleeding: → Massage uterus to miscarry clots if any, until it is hard B10. → Give oxytocin ten IU IM B10. → Call for help. → Start an IV line B9, add 20 IU of oxytocin to 4 fluids and give at 60 drops per infinitesimal N9. → Empty the bladder B12. If bleeding persists and uterus is soft: → Keep massaging uterus until it is hard. → Employ bimanual or aortic compression B10. → Go on Iv fluids with 20 IU of oxytocin at 30 drops per minute. → Refer adult female urgently to infirmary B17.
Examine perineum, lower vagina and vulva for tears.	If tertiary degree tear (involving rectum or anus), refer urgently to hospital B17. For other tears: apply pressure level over the tear with a sterile pad or gauze and put legs together. Cheque afterward 5 minutes. If bleeding persists, repair the tear B12.
Collect, guess and tape blood loss throughout third phase and immediately afterwards.	If blood loss ≈ 250 ml, but haemorrhage has stopped: → Program to continue the woman in the facility for 24 hours. → Monitor intensively (every xxx minutes) for 4 hours: → BP, pulse → vaginal bleeding → uterus, to brand sure information technology is well contracted. → Assist the adult female when she beginning walks later on resting and recovering. → If not possible to notice at the facility, refer to hospital B17.
Clean the woman and the area below her. Put germ-free pad or folded clean cloth nether her buttocks to collect blood. Help her to alter apparel if necessary.
Proceed the mother and baby in delivery room for a minimum of i hour subsequently delivery of placenta.
Dispose of placenta in the correct, safe and culturally advisable manner.	If disposing placenta: → Employ gloves when handling placenta. → Put placenta into a bag and place information technology into a leak-proof container. → Always carry placenta in a leak-proof container. → Incinerate the placenta or bury information technology at least 10 m away from a water source, in a 2 g deep pit.

Reply TO PROBLEMS DURING LABOUR AND Delivery

D14. IF FHR <120 OR >160bpm

View in own window

ASK, CHECK Record	LOOK, Mind, FEEL	SIGNS	Allocate	TREAT AND ADVISE
IF FETAL HEART Rate (FHR) <120 OR >160 BEATS PER Infinitesimal
	Position the woman on her left side. If membranes have ruptured, look at vulva for prolapsed cord. Come across if liquor was meconium stained. Echo FHR count after xv minutes	Cord seen at vulva.	PROLAPSED CORD	Manage urgently every bit on D15.
		FHR remains >160 or <120 after thirty minutes observation.	BABY NOT WELL	If early on labour: → Refer the woman urgently to hospital B17 → Go on her lying on her left side. If tardily labour: → Telephone call for help during delivery → Monitor after every contraction. If FHR does not return to normal in xv minutes explain to the adult female (and her companion) that the infant may not exist well. → Prepare for newborn resuscitation K11.
		FHR returns to normal.	Infant WELL	Monitor FHR every 15 minutes.

Next: If prolapsed cord

D15. IF PROLAPSED String

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

View in own window

Ask, Cheque Record	LOOK, LISTEN, Feel	SIGNS	CLASSIFY	TREAT
	Look at or feel the string gently for pulsations. Experience for transverse prevarication. Do vaginal test to determine status of labour.	Transverse prevarication	OBSTRUCTED LABOUR	Refer urgently to hospital B17.
		Cord is pulsating	FETUS ALIVE	If early labour: Push the caput or presenting part out of the pelvis and hold it higher up the skirt/pelvis with your hand on the abdomen until caesarean section is performed. Instruct assistant (family, staff) to position the woman's buttocks college than the shoulder. Refer urgently to hospital B17. If transfer not possible, allow labour to continue. If tardily labour: Call for additional assist if possible (for mother and baby). Prepare for Newborn resuscitation K11. Ask the adult female to presume an upright or squatting position to assistance progress. Expedite delivery by encouraging woman to push with contraction.
		String is not pulsating	FETUS PROBABLY Expressionless	Explain to the parents that baby may not be well.

Side by side: If breech presentation

D16. IF BREECH PRESENTATION

View in ain window

Expect, Mind, FEEL	SIGNS	Treat
On external test fetal caput felt in fundus. Soft torso part (leg or buttocks) felt on vaginal examination. Legs or buttocks presenting at perineum	If early labour	Refer urgently to hospital B17.
	If tardily labour	Call for additional help. Ostend full dilatation of the cervix by vaginal test D3 Ensure bladder is empty. If unable to empty bladder run across Empty bladder B12. Prepare for newborn resuscitation K11. Deliver the baby: → Assist the woman into a position that volition allow the baby to hang down during commitment, for case, propped up with buttocks at border of bed or onto her hands and knees (all fours position). → When buttocks are distending, make an episiotomy. → Allow buttocks, trunk and shoulders to deliver spontaneously during contractions. → After delivery of the shoulders let the babe to hang until next contraction.
	If the head does not evangelize after several contractions	Place the baby astride your left forearm with limbs hanging on each side. Identify the centre and index fingers of the left manus over the malar cheek basic on either side to apply gentle downwardly pressure to assist flexion of head. Keeping the left paw as described, place the index and ring fingers of the right mitt over the baby'due south shoulders and the middle finger on the baby's head to gently aid flexion until the hairline is visible. When the hairline is visible, raise the baby in upward and forward direction towards the mother's belly until the olfactory organ and rima oris are free. The assistant gives supra pubic force per unit area during the period to maintain flexion.
	If trapped arms or shoulders	Feel the babe's chest for arms. If not felt: Hold the baby gently with hands around each thigh and thumbs on sacrum. Gently guiding the baby downwards, plow the baby, keeping the dorsum uppermost until the shoulder which was posterior (below) is at present anterior (at the top) and the arm is released. Then turn the baby dorsum, over again keeping the back uppermost to deliver the other arm. And then proceed with commitment of caput as described above.
	If trapped head (and baby is dead)	Tie a i kg weight to the babe'southward feet and look full dilatation. And then go along with commitment of head as described above. NEVER pull on the breech DO NOT let the adult female to push button until the cervix is fully dilated. Pushing too before long may cause the head to exist trapped.

Next: If stuck shoulders

D17. IF STUCK SHOULDERS (SHOULDER DYSTOCIA)

View in own window

	SIGNS	TREAT
	Fetal caput is delivered, only shoulders are stuck and cannot be delivered.	Call for additional assistance. Ready for newborn resuscitation. Explain the problem to the woman and her companion. Ask the woman to lie on her back while gripping her legs tightly flexed against her chest, with knees wide apart. Ask the companion or other helper to go on the legs in that position. Perform an adequate episiotomy. Inquire an banana to utilize continuous pressure downward, with the palm of the hand on the abdomen straight above the pubic area, while yous maintain continuous downwards traction on the fetal head.
	If the shoulders are still not delivered and surgical aid is not bachelor immediately.	Remain calm and explain to the adult female that y'all demand her cooperation to try another position. Assistance her to prefer a kneeling on "all fours" position and ask her companion to agree her steady - this elementary change of position is sometimes sufficient to dislodge the impacted shoulder and achieve delivery. Introduce the right hand into the vagina along the posterior curve of the sacrum. Attempt to deliver the posterior shoulder or arm using pressure from the finger of the right hand to hook the posterior shoulder and arm downwards and forwards through the vagina. Consummate the rest of delivery every bit normal. If not successful, refer urgently to hospital B17. DO NOT pull excessively on the head.

Next: If multiple births

D18. IF MULTIPLE BIRTHS

View in own window

SIGNS	TREAT
Prepare for delivery	Ready commitment room and equipment for nascency of ii or more babies. Include: → more warm cloths → two sets of cord ties and razor blades → resuscitation equipment for two babies. Suit for a helper to assist you with the births and care of the babies.
Second stage of labour	Deliver the starting time infant following the usual procedure. Resuscitate if necessary. Label her/him Twin 1. Inquire helper to attend to the first baby. Palpate uterus immediately to determine the lie of the second baby. If transverse or oblique lie, gently turn the infant by abdominal manipulation to caput or breech presentation. Bank check the presentation past vaginal examination. Check the fetal eye rate. Await the return of strong contractions and spontaneous rupture of the second bag of membranes, normally inside one 60 minutes of nascency of first baby, just may be longer. Stay with the adult female and proceed monitoring her and the fetal heart rate intensively. Remove wet cloths from underneath her. If feeling chilled, cover her. When the membranes rupture, perform vaginal examination D3 to check for prolapsed cord. If present, come across Prolapsed cord D15. When strong contractions restart, ask the mother to bear downwardly when she feels set up. Deliver the second babe. Resuscitate if necessary. Label her/him Twin ii. After cut the cord, ask the helper to attend to the 2nd baby. Palpate the uterus for a tertiary baby. If a 3rd baby is felt, proceed equally described above. If no third baby is felt, go to third stage of labour. DO Not attempt to deliver the placenta until all the babies are born. DO NOT give the mother oxytocin until later the birth of all babies.
Third stage of labour	Give oxytocin x IU IM after making sure there is non another baby. When the uterus is well contracted, evangelize the placenta and membranes by applying traction to all cords together D12-D23. Before and after delivery of the placenta and membranes, observe closely for vaginal bleeding because this adult female is at greater risk of postpartum haemorrhage. If bleeding, see B5. Examine the placenta and membranes for abyss. In that location may be one large placenta with 2 umbilical cords, or a separate placenta with an umbilical string for each babe.
Immediate postpartum care	Monitor intensively as risk of bleeding is increased. Provide immediate Postpartum care D19-D20. In addition: → Keep mother in health eye for longer observation → Programme to measure haemoglobin postpartum if possible → Give special support for care and feeding of babies J11 and K4.

Adjacent: Care of the mother and newborn within first hour of delivery of placenta

D19. Intendance OF THE Mother AND NEWBORN WITHIN FIRST Hour OF DELIVERY OF PLACENTA

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

View in own window

MONITOR MOTHER EVERY 15 MINUTES:	MONITOR Baby EVERY 15 MINUTES:
For emergency signs, using rapid assessment (RAM) B3-B7. Feel if uterus is difficult and round.	Animate: mind for grunting, expect for chest in-drawing and fast animate J2. Warmth: check to see if feet are cold to bear upon J2.
Tape findings, treatments and procedures in Labour record and Partograph N4-N6. Keep mother and infant in delivery room - do non split them. Never go out the woman and newborn lonely.

View in own window

CARE OF MOTHER AND NEWBORN	INTERVENTIONS, IF REQUIRED
WOMAN Assess the amount of vaginal bleeding. Encourage the woman to eat and drinkable. Ask the companion to stay with the mother. Encourage the adult female to pass urine.	If pad soaked in less than v minutes, or constant trickle of claret, manage as on D22. If uterus soft, manage as on B10. If bleeding from a perineal tear, repair if required B12 or refer to hospital B17.
NEWBORN Wipe the eyes. Utilise an antimicrobial within 1 hr of birth. → either one% silver nitrate drops or ii.five% povidone iodine drops or 1% tetracycline ointment. DO NOT launder away the eye antimicrobial. If blood or meconium, wipe off with moisture material and dry. Do NOT remove vernix or bathe the babe. Continue keeping the baby warm and in skin-to-peel contact with the mother. Encourage the female parent to initiate breastfeeding when infant shows signs of readiness. Offer her help. Do Non requite artificial teats or pre-lacteal feeds to the newborn: no water, sugar water, or local feeds.	If breathing with difficulty — grunting, chest in-drawing or fast breathing, examine the baby as on J2-J8. If feet are cold to touch or female parent and babe are separated: Ensure the room is warm. Encompass mother and baby with a blanket → Reassess in ane hr. If still cold, measure out temperature. If less than 36.5°C, manage as on K9. If unable to initiate breastfeeding (mother has complications): → Program for culling feeding method K5-K6. → If mother HIV-infected: requite treatment to the newborn G9. → Support the female parent'south option of newborn feeding G8. If baby is stillborn or dead, give supportive care to female parent and her family unit D24.
Examine the mother and newborn one hour afterwards commitment of placenta. Apply Appraise the female parent after commitment D21 and Examine the newborn J2-J8	Refer to hospital now if woman had serious complications at admission or during commitment but was in belatedly labour.

D20. Intendance OF THE MOTHER ONE Hour Afterward Commitment OF PLACENTA

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

View in own window

MONITOR MOTHER AT 2, iii AND four HOURS, THEN EVERY iv HOURS:
For emergency signs, using rapid cess (RAM) B4-B7. Feel uterus if hard and round.
Tape findings, treatments and procedures in Labour tape and Partograph N4-N6. Keep the female parent and baby together. Never exit the woman and newborn lone. DO Non discharge before 24 hours.

View in own window

Intendance OF Female parent	INTERVENTIONS, IF REQUIRED
Accompany the female parent and baby to ward. Propose on Postpartum intendance and hygiene D26. Ensure the female parent has sanitary napkins or make clean material to collect vaginal blood. Encourage the mother to eat, drink and balance. Ensure the room is warm (25°C).	Make sure the adult female has someone with her and they know when to call for help. If HIV-infected: give her appropriate treatment G6, G9.
Ask the mother's companion to watch her and call for help if haemorrhage or pain increases, if mother feels dizzy or has severe headaches, visual disturbance or epigastric distress.	If heavy vaginal bleeding, palpate the uterus. → If uterus non firm, massage the fundus to make it contract and miscarry any clots B6. → If pad is soaked in less than v minutes, manage as on B5. → If bleeding is from perineal tear, repair or refer to hospital B17.
Encourage the mother to empty her bladder and ensure that she has passed urine.	If the mother cannot pass urine or the bladder is full (swelling over lower abdomen) and she is uncomfortable, help her by gently pouring water on vulva. Exercise Not catheterize unless you lot have to.
Check record and give whatsoever treatment or prophylaxis which is due. Suggest the mother on postpartum care and nutrition D26. Propose when to seek care D28. Counsel on birth spacing and other family unit planning methods D27. Repeat examination of the female parent earlier discharge using Assess the mother after delivery D21. For baby, run into J2-J8	If tubal ligation or IUD desired, make plans before belch. If mother is on antibiotics because of rupture of membranes >18 hours simply shows no signs of infection now, discontinue antibiotics.

D21. ASSESS THE Mother Subsequently Delivery

After an uncomplicated vaginal birth in a health facility, salubrious mothers and newborns should receive care in the facility for at least 24 hours after nascency. Employ this nautical chart to examine the mother the first time after delivery (at ane hour after commitment or subsequently) and for discharge. For examining the newborn use the nautical chart on J2-J8.

View in own window

ASK, Bank check Record	LOOK, Heed, FEEL	SIGNS	CLASSIFY	Care for AND ADVISE
Cheque record: → bleeding more than than 250 ml? → abyss of placenta and membranes? → complications during delivery or postpartum? → special treatment needs? → needs tubal ligation or IUD? How are you feeling? Do you have any pains? Practice you lot accept any concerns? How is your babe? How do your breasts experience?	Measure temperature. Feel the uterus. Is it hard and round? Look for vaginal bleeding Await at perineum. → Is at that place a tear or cutting? → Is it red, swollen or draining pus? Look for conjunctival pallor. Look for palmar pallor.	Uterus hard. Piddling haemorrhage. No perineal trouble. No pallor. No fever. Blood pressure normal. Pulse normal.	MOTHER WELL	Keep the mother at the facility for 24 hours after delivery. Ensure preventive measures D25 Advise on postpartum care and hygiene D26. Counsel on diet D26. Counsel on nativity spacing and family planning D27 Advise on when to seek care and side by side routine postpartum visit D28. Reassess for discharge D21 Continue any treatments initiated earlier. If tubal ligation desired, refer to hospital within 7 days of delivery. If IUD desired, refer to appropriate services within 48 hours.

Next: Respond to problems immediately postpartum

If no problems, go to page D25.

D22-D24. RESPOND TO Issues IMMEDIATELY POSTPARTUM

View in own window

ASK, CHECK Tape	Wait, Heed, FEEL	SIGNS	Classify	TREAT AND ADVISE
IF VAGINAL BLEEDING
	A pad is soaked in less than five minutes	More than than ane pad soaked in 5 minutes Uterus not hard and not round	HEAVY BLEEDING	See B5 for handling. Refer urgently to hospital B17.
IF FEVER (TEMPERATURE > 38°C)
Fourth dimension since rupture of membranes Abdominal hurting Chills	Repeat temperature measurement after two hours If temperature is still >38ºC → Look for aberrant vaginal discharge. → Mind to fetal heart rate → feel lower belly for tenderness	Temperature all the same >38°C and whatsoever of: → Chills → Foul-smelling vaginal belch → Low abdomen tenderness → FHR remains >160 afterward → 30 minutes of observation → rupture of membranes >eighteen hours	UTERINE AND FETAL INFECTION	Insert an IV line and give fluids quickly B9. Give appropriate IM/IV antibiotics B15. If babe and placenta delivered: → Requite oxytocin ten IU IM B10. Refer woman urgently to hospital B17. Appraise the newborn J2-J8. Treat if any sign of infection.
		Temperature nevertheless >38°C	RISK OF UTERINE AND FETAL INFECTION	Encourage adult female to drink plenty of fluids. Measure temperature every 4 hours. If temperature persists for >12 hours, is very high or rises rapidly, give appropriate antibiotic and refer to hospital B15.
IF PERINEAL TEAR OR EPISIOTOMY (Washed FOR LIFESAVING CIRCUMSTANCES)
	Is at that place bleeding from the tear or episiotomy Does it extend to anus or rectum?	Tear extending to anus or rectum.	THIRD Degree TEAR	Refer woman urgently to hospital B15.
		Perineal tear Episiotomy	SMALL PERINEAL TEAR	If bleeding persists, repair the tear or episiotomy B12.

Next: If elevated diastolic claret pressure level

IF ELEVATED DIASTOLIC BLOOD Pressure level

View in own window

Enquire, Cheque Record	LOOK, LISTEN, FEEL	SIGNS	CLASSIFY	TREAT AND Propose
	If diastolic blood pressure level is ≥xc mmHg, echo subsequently 1 60 minutes rest. If diastolic blood pressure is yet ≥ninety mmHg, ask the woman if she has: → severe headache → blurred vision → epigastric pain and → check poly peptide in urine.	Diastolic blood pressure ≥110 mmHg OR Diastolic claret pressure ≥90 mmHg and ii+ proteinuria and any of: → astringent headache → blurred vision → epigastric pain.	SEVERE PRE-ECLAMPSIA	Give magnesium sulphate B13. If in early labour or postpartum, refer urgently to hospital B17. If late labour: → continue magnesium sulphate handling B13 → monitor blood pressure every 60 minutes. → Do NOT give ergometrine afterward delivery. Refer urgently to hospital later on commitment B17.
		Diastolic blood pressure 90-110 mmHg on two readings. 2+ proteinuria (on access).	PRE-ECLAMPSIA	If early on labour, refer urgently to hospital E17. If tardily labour: → monitor blood force per unit area every hr → Do Not requite ergometrine later commitment. If BP remains elevated after delivery, refer to infirmary E17.
		Diastolic blood pressure level ≥xc mmHg on two readings.	HYPERTENSION	Monitor blood force per unit area every 60 minutes. Do not give ergometrine after commitment. If blood force per unit area remains elevated after delivery, refer woman to hospital E17.

Next: If pallor on screening, check for anaemia

View in ain window

Enquire, Check RECORD	LOOK, LISTEN, FEEL	SIGNS	CLASSIFY	TREAT AND Advise
IF PALLOR ON SCREENING, CHECK FOR ANAEMIA
Bleeding during labour, delivery or postpartum.	Measure haemoglobin, if possible. Look for conjunctival pallor. Expect for palmar pallor. If pallor: → Is information technology severe pallor? → Some pallor? → Count number of breaths in → i minute	Haemoglobin <seven g/dl. AND/OR Astringent palmar and conjunctival pallor or Any pallor with >30 breaths per minute.	SEVERE ANAEMIA	If early labour or postpartum, refer urgently to infirmary B17 If late labour: → monitor intensively → minimize blood loss → refer urgently to hospital subsequently delivery B17.
		Any bleeding. Haemoglobin 7-11 chiliad/dl. Palmar or conjunctival pallor.	MODERATE ANAEMIA	Check haemoglobin subsequently 3 days. Give double dose of iron for 3 months F3. Follow up in 4 weeks.
		Haemoglobin >eleven g/dl No pallor.	NO ANAEMIA	Requite fe/folate for three months F3.
IF Mother SEVERELY Ill OR SEPARATED FROM THE Infant
				Teach female parent to limited breast milk every 3 hours K5. Assist her to limited breast milk if necessary. Ensure baby receives female parent's milk K8. Help her to institute or re-establish breastfeeding equally soon as possible. See K2-K3.
IF BABY STILLBORN OR DEAD
				Give supportive intendance: → Inform the parents equally soon as possible subsequently the baby's death. → Show the infant to the female parent, give the baby to the mother to hold, where culturally appropriate. → Offer the parents and family to exist with the dead baby in privacy as long as they demand. → Discuss with them the events earlier the death and the possible causes of death. Propose the mother on breast care K8. Counsel on advisable family planning method D27.

Adjacent: Give preventive measures

D25. GIVE PREVENTIVE MEASURES

Ensure that all are given before belch.

View in own window

Appraise, Cheque RECORDS	Treat AND Advise
Bank check RPR status in records. If no RPR during this pregnancy, do the RPR test L5.	If RPR positive: → Treat adult female and the partner with benzathine penicillin F6. → Treat the newborn K12
Bank check tetanus toxoid (TT) immunization status. Check when last dose of mebendazole was given.	Give tetanus toxoid if due F2. Requite mebendazole one time in 6 months F3.
Bank check woman's supply of prescribed dose of iron/folate.	Requite iii month'south supply of fe and counsel on adherence F2. Vitamin A in postpartum women is non recommended for the prevention of maternal and infant morbidity and mortality.
Ask whether woman and infant are sleeping under insecticide treated bednet. Counsel and propose all women.	Encourage sleeping nether insecticide treated bednet F4. Propose on postpartum intendance D26. Counsel on diet D26. Counsel on birth spacing and family planning D27. Counsel on breastfeeding K2. Counsel on safer sexual practice including apply of condoms G2. Advise on routine and follow-up postpartum visits D28. Propose on danger signs D28. Discuss how to set for an emergency in postpartum D28. Counsel of continued abstinence from tobacco, alcohol and drugs D26.
Record all treatments given N6. Record findings on domicile-based record.
Check HIV condition in records.	If HIV-infected: → Back up adherence to ARV G6. → Care for the newborn G9 If HIV test non done, the result of the latest test not known or if tested HIV-negative in early pregnancy, offering her the rapid HIV test C6, E5, L6.

D26. Advise ON POSTPARTUM Care

Advise on postpartum care and hygiene

• Advise and explain to the adult female:

• To always have someone near her for the commencement 24 hours to answer to any change in her condition.

• Not to insert anything into the vagina.

• To have enough rest and sleep.

• The importance of washing to preclude infection of the mother and her baby:

  →

  wash easily before handling baby

  →

  wash perineum daily and after faecal excretion

  →

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

  →

  launder used pads or dispose of them safely

  →

  wash the trunk daily.

• To avoid sexual intercourse until the perineal wound heals.

• To sleep with the baby under an insecticide-treated bednet.

Counsel on diet

• Advise the woman to eat a greater corporeality and variety of healthy foods, such equally meat, fish, oils, basics, seeds, cereals, beans, vegetables, cheese, milk, to assist her feel well and strong (requite examples of types of food and how much to eat).

• Reassure the female parent that she can eat any normal foods – these volition not impairment the breastfeeding babe.

• Spend more fourth dimension on nutrition counselling with very thin women and adolescents.

• Decide if there are important taboos about foods which are nutritionally healthy.

  Advise the woman against these taboos.

• Talk to family members such every bit partner and mother-in-law, to encourage them to help ensure the woman eats plenty and avoids difficult physical piece of work.

Counsel on Substance Corruption

• Advise the woman to keep abstinence from tobacco

• Practice not take any drugs or medications for tobacco cessation

• Talk to family unit members such as partner and mother-in-law, to encourage them to help ensure the woman avoids second-hand smoke exposure

• Alcohol

• Drugs

• Dependence

D27. COUNSEL ON Nascence SPACING AND FAMILY PLANNING

Counsel on the importance of family planning

• If appropriate, inquire the woman if she would similar her partner or another family member to be included in the counselling session.

• Explicate that later on nascency, if she has sexual practice and is not exclusively breastfeeding, she tin can get meaning as soon every bit 4 weeks later on delivery. Therefore it is important to start thinking early on about what family planning method they will employ.

  →

  Ask about plans for having more than children. If she (and her partner) want more children, advise that waiting at least two years earlier trying to get pregnant again is good for the mother and for the infant's health.

  →

  Information on when to first a method after delivery will vary depending on whether a woman is breastfeeding or non.

  →

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

• Councel on safer sex including utilise of condoms for dual protection from sexually transmitted infection (STI) or HIV and pregnancy. Promote their apply, specially if at risk for sexually transmitted infection (STI) or HIV G2.

• For HIV-infected women, run into G4 for family planning considerations

• Her partner tin determine to have a vasectomy (male sterilization) at any time.

Method options for the not-breastfeeding adult female

View in ain window

Can be used immediately postpartum	Condoms Progestogen-only oral contraceptives Progestogen-only injectables Implant Spermicide Female person sterilization (within 7 days or delay 6 weeks) Copper IUD (immediately post-obit expulsion of placenta or inside 48 hours)
Delay 3 weeks	Combined oral contraceptives Combined injectables Fertility sensation methods

Lactational amenorrhoea method (LAM)

• A breastfeeding adult female is protected from pregnancy only if:

  →

  she is no more than six months postpartum, and

  →

  she is breastfeeding exclusively (eight or more times a day, including at to the lowest degree once at dark: no daytime feedings more than iv hours apart and no nighttime feedings more than half-dozen hours apart; no complementary foods or fluids), and

  →

  her menstrual cycle has not returned.

• A breastfeeding adult female can besides choose any other family unit planning method, either to utilize alone or together with LAM.

Method options for the breastfeeding adult female

View in ain window

Tin exist used immediately postpartum	Lactational amenorrhoea method (LAM) Condoms Spermicide Female sterilisation (within 7 days or filibuster six weeks) Copper IUD (within 48 hours or delay 4 weeks)
Delay vi weeks	Progestogen-only oral contraceptives Progestogen-simply injectables Implants Diaphragm
Delay six months	Combined oral contraceptives Combined injectables Fertility awareness methods

D28. ADVISE ON WHEN TO Return

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

Routine postnatal contacts

View in own window

Kickoff CONTACT: inside 24 hours after childbirth.

SECOND CONTACT: on mean solar day three (48-72 hours)

Third CONTACT: between mean solar day 7 and 14 later on birth.

Concluding POSTNATAL CONTACT (CLINIC VISIT): at 6 weeks later on birth

Follow-upwards visits for problems

View in own window

If the trouble was:	Return in:
Fever	ii days
Lower urinary tract infection	2 days
Perineal infection or hurting	2 days
Hypertension	1 calendar week
Urinary incontinence	1 week
Severe anaemia	2 weeks
Postpartum blues	2 weeks
HIV-infected	ii weeks
Moderate anaemia	4 weeks
If treated in hospital for any complication	According to hospital instructions or according to national guidelines, just no after than in 2 weeks.

Advise on danger signs

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

• vaginal haemorrhage:

  →

  more than two or iii 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 go out of bed.

• severe abdominal pain.

• calf hurting, redness or swelling, shortness of breath or chest pain.

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

• fever

• abdominal hurting

• feels ill

• breasts swollen, reddish or tender breasts, or sore nipple

• urine dribbling or pain on micturition

• hurting in the perineum or draining pus

• foul-smelling lochia

• severe low or suicidal behaviour (ideas or attempts)

Discuss how to set for an emergency in postpartum

• Advise to always have someone near for at to the lowest degree 24 hours after commitment to reply to any change in condition.

• Discuss with adult female and her partner and family about emergency issues:

  →

  where to become if danger signs

  →

  how to reach the infirmary

  →

  costs involved

  →

  family and community support.

• Discuss habitation visits: in addition to the scheduled routine postnatal contacts, which can occur in clinics or at dwelling, the mother and newborn may receive postnatal home visits by customs wellness workers.

• Propose the woman to ask for assistance from the community, if needed I1-I3.

• Advise the woman to bring her home-based maternal record to the health centre, even for an emergency visit.

D29. Home Delivery BY SKILLED Attendant

Utilize these instructions if you are attending delivery at domicile.

Preparation for habitation commitment

• Cheque emergency arrangements.

• Go along emergency transport arrangements up-to-date.

• Carry with you all essential drugs B17, records, and the delivery kit.

• Ensure that the family prepares, as on C18.

Delivery care

• Follow the labour and delivery procedures D2-D28 K11.

• Observe universal precautions A4.

• Requite Supportive care. Involve the companion in care and support D6-D7.

• Maintain the partograph and labour record N4-N6.

• Provide newborn care J2-J8.

• In settings with high neonatal mortality use chlorhexidine to the umbilical stump daily for the first week of life.

• Refer to facility as soon every bit possible if whatever abnormal finding in female parent or infant B17 K14.

Immediate postpartum care of female parent

• Stay with the adult female for showtime 2 hours afterwards delivery of placenta C2 C13-C14.

• Examine the mother before leaving her D21.

• Advise on postpartum care, nutrition and family planning D26-D27.

• Ensure that someone will stay with the female parent for the offset 24 hours.

Postnatal care of newborn

• Stay until infant has had the get-go breastfeed and help the mother good positioning and attachment K3.

• Advise on breastfeeding and breast care K2-K4.

• Examine the babe earlier leaving J2-J8.

• Immunize the babe if possible K13.

• Advise the family about danger signs and when and where to seek care K14.

• If possible, return within a day to check the mother and infant.

• Propose on the commencement postnatal contact for the mother and the babe which should be as early on as possible within 24 hours of nascence K14.

For both

• Return subsequently 24 hours and on day three after commitment.

• Complete home-based tape.

blakewhosent.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/books/NBK326674/