ASHA Module 6

Skills
that Save Lives
Part A

Being an ASHA 1
 Contents

PART A: Being an ASHA 5

1. Role of ASHA 7
2. Activities of an ASHA’s 8
3. Measurable Outcomes of the ASHA Programme 9
4. Essential Skills for an ASHA 10
5. Qualities that Make an ASHA Effective 12
6. Conducting a Home Visit 13
7. Village Health and Nutrition Day (VHND) 15
8. What Records do the ASHA Maintain 17
9. ASHA Support and Supervision 18

PART B: Maternal Health 19

1. Pregnancy Diagnosis 21
2. Birth Preparedness for a Safe Delivery 26
3. Management of Anaemia 28
4. Identifying complications during Pregnancy and Delivery 30
5. Care during Delivery 34
6. Post-Partum Care 38

PART C: Newborn Health 41

1. Care of the Baby at the time of Delivery 43
2. Schedule of Home Visits for the care of the Newborn 44
3. Examining the Newborn at Birth 44
4. Breastfeeding 50
5. Keeping the Newborn Warm 57
6. Management of fever in newborn 60

Annexes 61

Contents 3
 About this book

The sixth and seventh modules cover areas whose content is already
familiar to the ASHA. In addition, this module includes the development
of specific competencies in healthcare for mothers and children. It is thus,
intended to serve as a refresher module, building on existing knowledge
and the development of new skills in the area of maternal and child health.
ASHAs that are newly recruited into the programme, could directly
start with Module 5, 6 and 7. This module is also designed to serve as a
reading material for ASHAs, and is therefore, to be given to each ASHA.
A companion communication kit for the ASHA to use when she conducts
home visits and village meetings has also been developed. There is also a
manual for trainers with training aids to use during the training of ASHA.
The training plan envisages a total of 20 to 24 days of residential training, to
impart the skills that these two modules are teaching.

Acknowledgements
The sections on maternal and newborn care are excerpted from the SEARCH
Manual on ‘How to Train ASHA in Home-Based Newborn Care’ and
SEARCH developed ASHA Reading Material on Home-Based Newborn Care.
Thanks are due to Members of the National ASHA Mentoring Group, United
Nations Children’s Fund (UNICEF), Breastfeeding Promotion Network of
India (BPNI), the Public Health Resource Network (PHRN), and the training,
maternal and child health and malaria divisions of the ministry for providing
extensive feedback, and also HLFPPT for providing information on Nischay
Kit. The Integrated Management of Neonatal Childhood Illnesses (IMNCI)
package is also incorporated into these modules.
ASHA Module 6

4 Simple Skills that Save Lives

PART A

Being an
ASHA
 PART A

Being an ASHA

Objectives of this Session

By the end of this session, the ASHA will learn about:

• The role of an ASHA and the activities expected of her.

• The health outcomes that her work should result in.

• The sets of skills that she needs to be effective in.

• The records that she has to maintain.

• The arrangements for her support and supervision.

1. Role of ASHA
ASHA is considered to be a healthcare facilitator and provider of a limited
range of healthcare services. Health rights would be integral to her work
and would be focused in the areas of community mobilisation to improve
health status, access to services, and promote people’s participation in health
programmes.

Didi, which day is the ANM

coming to our village?

This is the first day of diarrhoea. Do Didi, they are charging me at the govt
I have go to the far away town or is hospital and I don’t have the money to
there something you can suggest? pay – can you help me?
Part A

Being an ASHA 7
 2. Activities of an ASHA’s
ASHA’s work consists mainly of five activities:

1. Home Visits: For two to three hours every day, for at

least four or five days a week, the ASHA should visit the
families living in her alloed area. Home visits should
take place at least once in a month if not more. Home
visits are mainly for health promotion and preventive
care. Over time, families will come to her when there is
a problem and she would not have to go so oen to their
houses. Meeting them anywhere in the community/
village is enough. However, where there is a child
below two years of age or any malnourished child or a
pregnant woman, she should visit the families at home
for counselling them. Also, if there is a newborn in the
house, a series of five visits or more becomes essential.
2. Aending the Village Health and Nutrition Day
(VHND): On one day every month, when the Auxiliary
Nurse Midwife (ANM) comes to provide immunisation
and other services in the village, ASHA will promote
aendance by those who need the Anganwadi or ANM
services and helps with service delivery.

3. Visits to the health facility: This is usually

accompanying a pregnant woman or some other
neighbour who requests her services for escort. The visit
could also be to aend a training programme or review
meeting. In some months, there would be only one visit,
in others, there would be more.

4. Holding village level meeting of women’s groups, and

the Village Health and Sanitation Commiee (VHSC),
for increasing health awareness and to plan health
work.

5. Maintain records which would make her more

organised and make her work easier, and help her to
plan beer for the health of the people.

The first three relate to facilitation or provision of healthcare

and the last two are supportive and mobilisational
activities.
ASHA Module 6

8 Simple Skills that Save Lives

3. Measurable Outcomes of the ASHA Programme
In the course of conducting these five activities, the ASHA should ensure the
following:

Maternal Health
1. That every pregnant woman and her family receive health information for
promotion of appropriate healthcare practices – diet, rest and for increased use
of services which would focus on care in pregnancy, delivery, postnatal care and
family planning services.
2. That every pregnant woman avails of antenatal care and postnatal care at the
monthly health worker clinic/VHND.
3. That every family with a pregnant woman has made a plan and is prepared for
the event of childbirth.
4. That every couple that needs contraceptive services is counselled on where to
avail of the service.

Newborn and Child Health

1. That every newborn is visited as per the schedule, more oen if there are
problems and receives essential home-based care as well as appropriate referral
for the sick newborn.
2. That every family receives the information and support it needs to access
immunisation.
3. That all families with children below the age of two years are counselled and
supported for – prevention and management of malnutrition and anaemia and for
prevention of illness such as malaria, recurrent diarrhoea and respiratory infection.
4. That every child below five years with diarrhoea, fever, Acute Respiratory
Infection (ARI) and worms, brought to her aention is counselled on whether
referral is immediately required or whether, given the problems of access to a
doctor, first contact curative care with home remedies and drugs in her kit, the
child can be managed.

Disease Control
1. That those individuals noticed during home visits as having chronic cough or
blindness or a skin patch in a high leprosy block are referred to the appropriate
centre for further check-up.
2. That those prescribed a long course of drugs for tuberculosis or leprosy or surgery
for cataract are followed up and encouraged to take the drugs or go for surgery.
3. That those with fever which could be malaria (or kala – azar) have their blood
tested to detect the disease and provide appropriate care/referral.
4. That the village and health authorities are alerted to any outbreak of disease she
notes during her visits.
Note: Each outcome is not a separate activity. They are part of the protocol
followed during a single activity _ the home visit.
Part A

Being an ASHA 9
 4. Essential Skills for an ASHA
The essential skills that an ASHA requires can be classified into six sets.
These are simple skills requiring only a few hours to learn, but they can save
thousands of lives. These six sets of skills are given below:

1. Maternal Care 2. Newborn Care when visiting the

a. Counselling of pregnant newborn at home:
women a. Counselling and problem solving on
b. Ensuring complete antenatal breastfeeding
care through home visits and b. Keeping the baby warm
enabling care at VHND c. Identification and basic
c. Making the birth plan and management of LBW (Low Birth
support for safe delivery Weight) and pre-term baby
d. Undertaking post-partum d. Examinations needed for
visits, Counselling for family identification/first contract care for
planning. sepsis and asphyxia

3. Child Care
a. Providing home care for diarrhoea, Acute
Respiratory Infections (ARI), fever and appropriate
referral, when required
b. Counselling for feeding during illness
c. Temperature management
d. De-worming and treatment of iron deficiency
anaemia, with referral where required
e. Counselling to prevent recurrent illness especially
diarrhoea.
ASHA Module 6

10 Simple Skills that Save Lives

 4. Nutrition 5. Infections
a. Counselling and a. Identifying persons whose
support for exclusive symptoms are suggestive
breastfeeding of malaria, leprosy,
b. Counselling mothers tuberculosis, etc. during
on complementary home visits, community
feeding level care and referral
c. Counselling b. Encouraging those who
and referral of are put on treatment to
malnourished take their drugs regularly
children. c. Encouraging the village
community to take
collective action to prevent
spread of these infections
and individuals to protect
themselves from getting
infected.

6. Social Mobilisation
a. Conducting women’s group meetings
and VHSC meetings
b. Assisting in making village health plans
c. Enabling marginalised and vulnerable
communities to be able to access health
services.

In addition, there are important skills related to self-awareness, communication, and organising a
meeting which have been already taught in Module 5.
Part A

Being an ASHA 11
 5. Qualities that Make an ASHA Effective

For an ASHA to be effective in improving people’s access to health services

and their health status, an ASHA should:

• Have the knowledge and skills to explain the basic maternal and child
health services, educate on preventive and promotive aspects of maternal
and child health, and provide some measure of immediate relief and
advice if there is any illness.

• Have the knowledge and skills on other general health issues, especially
related to common infections, and be able to provide information on
access to services and preventive and promotive aspects of healthcare.

• Be friendly and polite with people and known among community, and
establish rapport with the family during household visits.

• Be a special friend to the needy, the marginalised, and the less powerful.

• Possess the art of listening.

• Have the skill of coordination with Panchayati Raj Institution (PRI), AWW
and ANM.

• Be competent in conducting meetings in the community.

• Be motivated and feel happy and rewarded to help community/serve

people.

• Have a positive aitude and be keen to learn new skills.

ASHA Module 6

12 Simple Skills that Save Lives

6. Conducting a Home Visit
The purpose of the home visit is to interact
with the family, especially the young
women of the house, so as to develop
a rapport with them, communicate key
health messages, support them for beer
healthcare practices, identify illness early
and provide appropriate advice.

In particular, homes with a pregnant woman, or a woman who had an

abortion or delivery within the last one month, or with any child below two
or any malnourished child needs regular home visits.

The first step is to gather information to understand the situation. You should
ask appropriate initial questions, listen to the woman’s response actively,
and do not interrupt the woman while she is speaking. Once the mother
has finished, ask further questions to clarify what she has said. Then seek
more information by asking more detailed and probing questions about the
duration of illness and the symptoms.

The second step aer listening is to first praise the mother for how she
is managing and reinforce the correct actions she is taking. Then make
suggestions to the mother/woman on what further she needs to do – in short
sentences and in clear blocks of information. Repeat the key information to
make sure that the mother has understood it. You should ask whether the

All Visits
(Basic communication skills to create friendly environment)
• Greeting.
• Explain why she is visiting today.
• Act in a way so family feels they can confide in her.
• Speak in a gentle tone.
• Use simple words in local language.
• Be respectful.
• Praise what the woman is doing correctly and build up her self-confidence.
• Point out why you are discouraging some health practices; do not merely
condemn it or brand it as bad, superstition etc.
• Ask, don’t tell.
• Check if the woman has any questions.
• Answer in simple language.
• Thank the woman after the visit and inform the family when you (ASHA) will
return.
Part A

Being an ASHA 13
 suggestion is applicable and acceptable, and whether she would be able to
implement it. If necessary, ask the woman to repeat what has been suggested.
Discuss further and come to an understanding of what can be done

Then the third step, you should discuss and try to correct any
misconceptions or rumours.

Finally, you should also arrange for follow-up visit or referral.

Do NOT “prescribe” health advice: You need to “counsel.” See the examples
below:

Gratuitous Ineffective Messages Useful Health Communication Message

To prevent diarrhoea, pay attention To prevent diarrhoea, please ensure that you
to cleanliness. wash your hands with soap and water before
preparing food or feeding the child and after
cleaning up after defecation.
Take good care of the child. Are you able to find enough time to feed the
child? To play with the child? Who looks after
the child when you are at work?
Your child is now one year old. You Would it be possible for you to give your child
must give it nutritious food. an egg daily (or milk, green vegetables etc)?
How would you manage it? Can you afford
it? Would other children in the family also
demand it, and would that create a problem?

Difficult Situations
If the woman is shy
• Speak of general things to ‘warm her up’.
• Encourage the woman to speak.
• Praise the woman more to make her confident.
• Repeat the questions.
If the woman is non-cooperative or argumentative
• Praise the women to make her feel secure.
• Sympathise with her and be friendly; do not get angry.
• Spend more time in listening to her.
• Do not push if the woman is still not immediately receptive but just say that
you would like to come again.
If the woman is curious and asks many questions
• Answer her questions in simple language.
• Explain that you will be coming every month so they can talk again.
ASHA Module 6

14 Simple Skills that Save Lives

7. Village Health and Nutrition Day (VHND)
VHND is a common platform for allowing the people to access the services of
the ANM and the male health worker and of the Anganwadi Centre (AWC).
It is held at the AWC once every month. The ANM gives immunisation to the
children, provides antenatal care to pregnant women and provides counselling
and contraceptive services to eligible couples. In addition, the ANM provides a
basic level of curative care for minor illness with referral where needed.

The VHND is an occasion for health communication on a number of key

health issues. It should be aended by the members of the PRI, particularly
the women members, pregnant women, women with children under two,
adolescent girls and general community members. The VHND is to be seen as
a major mobilisation event to reinforce health messages. You should provide
information on the topics given below during the VHND. These topics can be
taken up one by one and completed over a period of one year.

Topics for Health Communication during the VHND

• Care in pregnancy, including nutrition, importance of antenatal care and
danger sign recognition.

• Planning for safe deliveries and postnatal care.

• Exclusive breastfeeding and the importance of appropriate

complementary feeding.

• Immunisation: the schedule and the importance of adhering to it.

• Importance of safe drinking water, hygiene and sanitation, and discussion

on what actions can be taken locally to improve the situation.

• Delaying the age at marriage, postponing the first pregnancy and the need
for spacing.

• Adolescent health awareness, including nutrition, retention in school till

high/higher secondary level, anaemia correction, menstrual hygiene and
responsible sexual behaviour.

• Prevention of Malaria, TB and other

communicable diseases.

• Awareness on prevention and seeking care

for RTI/STI and HIV/AIDS.

• Prevention of tobacco use and alcoholism.

What should you do for a successful

VHND?
• Make a list of the following and ensure
their presence during the VHND meeting:

 Pregnant women for their antenatal or

postnatal care.
Part A

Being an ASHA 15
  Women who need to come for ANC for first time or for repeat visit.

 Infants who need their next dose of immunisation.

 Malnourished children.

 TB patients who are on anti-TB drugs.

 Those with fever who have not been able to see a doctor.

 Eligible couples who need contraceptive services or counselling.

 Any others who want to meet the ANM.

• Specially identifying families who are new migrants, living in hamlets

or are vulnerable because of poverty or otherwise marginalised and
ensuring their aendance.

• Coordinate with the AWW and the ANM to know in advance which day
the VHND is scheduled so as to inform those who need these services and
the community, especially the VHSC members.

• Undertake a part of the health communication work done at the VHND.

ASHA Module 6

16 Simple Skills that Save Lives

 8. What Records do the ASHA Maintain

a. Village Health
Register

b. ASHA Diary

c. Drug Kit
Stock Register

a. Village Health Register in which you will record details of pregnant

women, children, 0-5 years, eligible couples and others in need of services.

b. An ASHA diary which is a record of your work and also useful for
tracking performance based payments due to you.

c. Maintaining drug kit stocks: You are provided with a drug kit so as to be
able to treat minor ailments/problems. The drug kit contains: Paracetomol
tablets, Albendazole tablets, Iron Folic Acid (IFA) tablets, Chloroquine
tablets, Oral Rehydration Salts (ORS), and eye ointment. In addition,
the kit may contain condoms and oral contraceptive pills, pregnancy
testing kits, and malaria testing kits. The contents of the kit may change
depending on the needs of the state.

The drug kit is to be re-filled on a regular basis from the nearest PHC. To
keep a record of consumption of the drugs, and for effective re-filling and
ensuring adequate/timely availability, a drug kit stock card is maintained.
This can be completed by the person who refills the kit or by you.

(Annexe 1: Sample drug kit stock card)

Part A

Being an ASHA 17
 9. ASHA Support and Supervision
• For ASHA to be effective and for her skills to be
updated, she needs both on-the-job support and
refresher trainings.

• Each ASHA will be supported in the field by an

ASHA facilitator.

• The ASHA facilitator will interact with ASHA at

least twice if not thrice a month.

• At least one of these interactions will be in the

form of a “mentoring” visit to the hamlet where
she provides her services. This would focus on
mentoring or on-the-job training.

• Another one or two interactions would be in a local review meeting. This

could be held at Gram Panchayat (GP) level, or at the sector level or even
at the block level.

• Each of the facilitators will have a clear protocol of activities to follow

for the mentoring visit to the ASHAs and for the review meetings. The
purpose of these interactions are:

a Collecting health related information as observed by ASHA and

information on what work ASHA is doing.

b For providing support to the ASHA to manage the health problems

they encounter.

c For providing training and refresh or update their knowledge and

skills.

d For helping ASHAs plan their work.

e For building up mutual solidarity and motivation.

f For troubleshooting problems, especially as regards payments and

addressing grievances.

g For refills to their drug kit

• The Medical Officer In-charge of the block PHC/CHC should aend at

least one monthly meeting of all ASHAs in the Primary Health Centre
(PHC) area, to review work progress.
ASHA Module 6

18 Simple Skills that Save Lives

PART B

Maternal
Health
 PART B

Maternal Health

Objectives of this session

By the end of the session the ASHA will learn about:

• Diagnosing pregnancy using Nischay Kit.

• Determining Last Menstrual Period (LMP) and Expected Date of Delivery (EDD).

• Key components of antenatal check-up1.

• Identification of problems and danger signs during the antenatal period and appropriate referral.

• Provide appropriate care for anaemia.

• Developing plans for birth preparedness.

• Follow-up with pregnant women.

• Knowledge of safe delivery.

• Understand obstetric emergencies and enable appropriate referral for emergencies.

• Updating Maternal Health Cards with support from the ANM.

1. Pregnancy Diagnosis
Diagnosis of pregnancy should be done as early as possible aer the first missed
period.

There are two ways to diagnose pregnancy early:

• Missed Periods
• Pregnancy testing: through use of the Nischay home pregnancy test card
 The Nischay test card can be used easily by you to test if a woman is pregnant.
 The test can be done immediately aer the missed period.
 A positive test means that the woman is pregnant.
 The benefit of early diagnosis of pregnancy is that the woman can be
registered early by the ANM and start geing antenatal care soon.
 A negative test means that the woman is not pregnant. In case she is not
pregnant and does not want to get pregnant, you should counsel her to
adopt a family planning method.

Instructions for the use of the Nishcay Kit are in Annexe 2.

1
All knowledge areas in this chapter have been covered in ASHA Module 2.
Part B

Maternal Health 21
 Determining LMP and EDD
When pregnancy is diagnosed, you should help the pregnant woman in
calculating the probable date when she is likely to deliver.

Steps to find the EDD

• Find out from the woman the date of the first day of her LMP.

• Then count nine months aer that date.

• Add seven days to that date.

For example,

If the first day of the LMP is: 10th Dec. 2009

Nine months later is: 10th Sept. 2010
Adding seven days is: 17th Sept. 2010
Therefore, the expected date of delivery is 17th September 2010

Note: This method only gives an approximate date of delivery, and baby may be
born anytime during 15 days before or after the EDD.

31 1 2
30 3
The Circle Aid for 29 4

Determining Last Menstrual 28 5

Period (LMP) and Expected 27 6

Date of Delivery (EDD) 7
26
8
This picture drawn beside 25
9
helps you in estimating the
24
date of delivery. 10

23 11

22 12
21 13
20 14
19 15
18 17 16

The Measuring Strip to Determine Change in Year

1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
September

September
November

November
December

December
February

February
October

October
January

January
August

August
March

March
April

April
May

May
June

June
July

July

2010 2011
ASHA Module 6

22 Simple Skills that Save Lives

Facts about Antenatal Check-up
How many antenatal check-ups?

Four antenatal visits must be ensured, including registration within the first
three month period. The suggested schedule is as below:

1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—

for registration of pregnancy and first antenatal check-up

2nd visit: Between 14 and 26 weeks

3rd visit: Between 28 and 34

weeks

4th visit: After 36 weeks

It is advisable for the pregnant

woman to visit the Medical Officer
(MO) at the PHC for the third
antenatal visit, as well as availing
of the required investigations at
the PHC.

Essential components2 of antenatal care

• Early registration
• Regular weight check
• Blood test for anaemia
• Urine test for protein and sugar
• Measure blood pressure
• One tablet of IFA every day
for three months to prevent
anaemia
• Treatment for anaemia
• Two doses of Tetanus Toxoid
(TT) vaccine
• Nutrition counselling
• Preparing for birth.

2
The components of ANC have already been covered in Module 2.
Part B

Maternal Health 23
 Where are ANC services provided?
The nearest place for ANC services for a woman is at the AWC during the
monthly VHND. The pregnant woman could also go to the Sub-Centre,
where the ANM will provide ANC services. ANC services are also provided
at the PHC or Community Health Centre (CHC) or district hospital.

Identification of problems and danger signs

Given below are complications that can occur during the antenatal period for
which pregnant women must seek treatment in an institution:

• Jaundice, high blood pressure, fever with chills, or bleeding

• Severe anaemia

• Women with protein and sugar in their urine

• Swelling of feet, face and hands.

Given below are danger signs for which pregnant women must seek delivery
in a centre where they can manage complications including those requiring
surgery and blood transfusion.

• Mothers who had a complication in a previous pregnancy

(C section, prolonged labour, stillborn, neonatal death)

• Pregnant women with severe anaemia.

• Pregnant women having any of the danger signs of the antenatal period
which are still persisting at the time of delivery.

Some women are to be considered more at risk of developing complications

during delivery and therefore, must opt for an institutional delivery. These
include:

• Young mothers (below 19 years of age)

• Mothers who are over 40 years of age

• Mothers who already have three children

• Mothers who have excessive weight gain or do not gain enough weight.

Key tasks to be undertaken during ANC

• List all pregnant women: Ensure that you cover the women in the poorest
families, and in any sections which tend to get le out, e.g. women from
SC/ST communities, women living in hamlets far from the main village,
or in hamlets that fall between villages and newly migrant women.

• Educate pregnant women about care in pregnancy, especially on the

importance of increased nutrition, rest, and complete ANC services.
ASHA Module 6

24 Simple Skills that Save Lives

• Emphasise the importance of a balanced and nutritious diet during
pregnancy. The diet of the pregnant woman should contain a mix of
cereals, pulses (including beans and nuts), vegetables including greens,
milk, eggs, meat and fish. If possible, the family should be encouraged to
add oils, jaggery and fruits to the diet. Meat and nuts are especially good
for anaemic women. You should explain to the mother and family that no
foods should be forbidden during pregnancy.

• See when ANC is due for each check-up and remind them appropriately.

• Escort pregnant woman to VHND where they are hesitant or need such
support.

• Ensure that all components of ANC are delivered.

• Ensure that the Maternal Card is updated.

Planning for Save Delivery

You should
• Know how to calculate the EDD and communicate this to the pregnant woman.

• Know which institutions in the area provide different levels of care and establish linkages with
providers there.

• At least once before delivery, take the pregnant woman to this centre and introduce her to the
providers.

• Know what transport is available _ whether funded by the state or other private means _ that is easily
accessible and affordable and how to call on it when the need arises.

• Assist all pregnant women and families to prepare plans for birth: including identifying funding
sources should money be required at short notice. Sometimes Self-Help Groups (SHGs) may advance
money in emergency even if the woman is not a member. This is most important for women in remote
hamlets, or in communities which are currently not availing of institutional delivery or those at high
risk for complications.

• Know what records (BPL card) need to be carried to the institution.

• Share birth plans with ANM and PHC MO at the VHND or monthly meeting.

• Identify mothers with complications, or a high likelihood of developing complications with support
from the ANM. Inform them of the institutions that it is most advisable for them to go to and motivate
the mother and the family to go there and escort them if required.
Part B

Maternal Health 25
 2. Birth Preparedness for a Safe Delivery
What is Birth Preparedness?
This is a method of planning in advance by the pregnant
mother and her family for a safe and comfortable delivery
and for care aer delivery. You should help every family
make this plan in consultation with the ANM.

What are the choices available to the mother?

1. If there are any danger signs or complications:
Identify the nearest institution (CHC/District Hospital)
which has the staff and equipment to provide
Comprehensive Emergency Obstetric and Newborn
Care (CEmONC), and counsel the mother and the
family to go there.

2. If there are no complications: Counsel the mother to go to the PHC which is

open 24 X 7, where there is a team of doctors and nurses or ANMs to conduct
the delivery and provide care for the mother and newborn. These institutions
can manage some complications and transfer immediately to a higher facility
if complications requiring surgery or blood transfusion develop. The list of
such institutions can be obtained from the ANM. The place should be clean
and safe and friendly and have a skilled nurse or doctor at all times. The
woman would have to stay there for 48 hours aer delivery.

3. If there are no complications and mother and her family are reluctant or
unable to go to the 24x7 PHC or if it is too far away: Advise the mother
could go the Sub-Centre, provided it is accredited as a delivery centre,
which means the ANM has been trained as a Skilled Birth Aendant (SBA),
and is available, and there are minimum facilities for delivery.

4. If there are no complications or not a high risk case for developing

complications and the mother and family insist on delivering at home,
despite counselling: You could work with the ANM to enable a delivery
by SBA. This should be agreed to only if you are sure that the family can
organise transport and funds at very short notice. The SBA should be able
to arrive within 30 minutes of the onset of labour at the home/Sub-Centre
and should able to stay through the process of labour and for a few hours
aerwards. A team of two or three women with experience in aending at
labour would be helpful.

What does a birth preparedness plan contain?

(See Annexe-3 for format for individual plan)

When should a birth preparedness plan be readied?

It should be ready as early as possible aer confirming the pregnancy, and

in consultation with the family (husband, mother-in-law, or other decision
makers). You should review the plan in the third trimester (aer seventh
month) with the family and the ANM. At this time, the choice of institution
ASHA Module 6

and the transport should be finalised.

26 Simple Skills that Save Lives

Decisions People Make

Woman’s choice
If I go to the PHC which is open 24 hours, I will be
Where should I go cared for and can rest for two days. Also, if there
for a safe delivery? is any surgery needed, they can rush me to the big
hospital quickly.

If danger signs or complications develop before

the delivery, I will need to go to the big hospital
straight away, but I hope that does not happen.

I will also need to ensure that I have an escort,

maybe the ASHA, to accompany me, and that
someone is taking care of the children and
things at home.

Birth Micro Plan of ASHA/ANM/AWW

If she has any danger signs or complications, I will ask

her to go to the CHC or DH when her delivery is due.
I must also make arrangements to ensure that
the transport is ready and available at that time.

If she has no complications, I will counsel her to go

I help every family with a pregnant to the 24X7 PHC, and for this too, I must ensure that
woman to make a birth plan. transport arrangements are made in time.

But if she and her family do not want to go that far

and the 24X7 PHC is crowded, I will advise her to go to
the nearby sub-centre where two ANMs are trained to
conduct deliveries and one of them is always there.

For some women, family circumstances and beliefs

make even going to the sub-centre difficult. I will then
get the ANM to come to her house, and will assist in the
preparations needed, after counselling that a safe delivery
in this situation may not always be possible.
Part B

Maternal Health 27
 3. Management of Anaemia
In India, anaemia among women is very common. The chances of a mother
having a delivery before term, or even dying are higher among mothers
with severe anaemia. In order to make sure that all women have good iron
stores, all pregnant women should be given iron tablets, even if they are not
anaemic. Anaemia can be detected by a simple blood test, which measures
the amount of a pigment called Haemoglobin (Hb). Low levels of Hb mean
that the woman has anaemia (see box below). The test should be performed
during the antenatal check-up. This can be done at the VHND by the ANM.

Haemoglobin level Degree of anaemia

More than 11 g/dl Absence of anaemia/Normal
7-11 g/dl Moderate anaemia
Less than 7 g/dl Severe anaemia

If a woman during the time of pregnancy has Hb level below 11g/dl, she is
considered to be suffering from anaemia.

Common symptoms of severe anaemia include:

• Very pale tongue

• Weakness

• General swelling in body.

For women who do not have anaemia (Hb more than 11 g/dl)
The pregnant woman should take one tablet of IFA every day for at least 100
days (prophylactic dose), starting aer the first trimester, at least 14-16 weeks
of gestation to prevent anaemia. This dosage regimen is to be repeated again
for three months aer the delivery.

If a woman is found to be anaemic:

• The woman should be given two IFA tablets per day for three months.
This means that a pregnant woman with anaemia needs to take at least
200 tablets of IFA. Besides taking IFA tablets, you should encourage the
pregnant woman, where possible, to increase her dietary intake of iron-
rich food.

• The Hb level should be estimated again aer one month. If the level
increases, you should tell the woman to continue with two tablets of IFA
daily until the Hb comes to normal. If the Hb does not rise in spite of
taking IFA tablets, in the prescribed dose, you should refer the woman
to the nearest facility that is equipped to manage complications in
pregnancy.

• You should refer women with severe anaemia immediately to the nearest
PHC/CHC/DH for further treatment. Such women may need injections or
blood transfusions.
ASHA Module 6

28 Simple Skills that Save Lives

• The dosage regimen of two IFA tablets per
day should be repeated for three months
post-partum also.

Counselling pregnant women on anaemia:

• Encourage women to take iron-rich foods

such as green leafy vegetables, whole
pulses, ragi, jaggery, meat and liver. This
advice should be discussed with family and
finalised based on the family situation.

• Encourage the woman, where possible,

to take plenty of fruits and vegetables
containing vitamin C (such as mango, guava, orange and sweet lime) as
these enhance the absorption of iron.

• Counsel the women on the necessity of taking IFA, the dangers associated
with anaemia, and inform the women that these
side-effects are common and not serious, and will reduce over time.

• IFA tablets must be taken regularly, preferably early in the morning on an

empty stomach. If the woman has nausea and pain in abdomen, she may
take the tablets aer meals or at night. This will avoid nausea.

• Dispel the myths and misconceptions related to IFA and convince the
woman about the importance of taking it. An example of a common myth
is that the consumption of IFA may affect baby’s complexion.

• Many women do not take IFA tablets regularly due to some common
side-effects such as nausea, constipation and black stools. Tell women not
to worry about passing black stool while consuming IFA. It is normal.

• In case of constipation, the woman should drink more water and add
roughage (plenty of green leafy vegetables) to her diet.

• IFA tablets should not be consumed with tea, coffee, milk or calcium tablet
as it reduces the absorption of iron.

• IFA tablets may make the woman feel less tired than before. However,
despite feeling beer, she should not stop taking the tablets and must
complete the course as advised by the healthcare provider.

• Ask the woman to return to you if she has problem taking IFA tablets.

How do you get the IFA?

The IFA tablets are part of your drug kit. Try to ensure that you always have
enough stock. Either your facilitator or a person appointed by the MO of the
PHC is given the responsibility of refills for the drug kit. IFA tablets are also
made available at VHND or in any health facility.
Part B

Maternal Health 29
 4. Identifying complications during Pregnancy and Delivery
Danger signs can occur at any time during pregnancy or delivery. You should
be alert to these signs. A woman who experiences any one of these signs may
be in serious danger and you should immediately facilitate referral to a health
facility. You should also educate family members on how to recognise these
complications and be prepared for immediate referral.

Health problems during pregnancy that need immediate referral

Danger signs in women How to recognise

Bleeding from vagina Bleeding - any amount
(bright red bleeding or clots or
tissue)

Loss of foetal movement Absence of movement/

kicking or severe abdominal
pain

Headache/dizziness/blurred vision Severe headache and blurred

vision or severe headache and
spots before the eyes
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30 Simple Skills that Save Lives

Swollen face/hands Pitting oedema over back palm

Convulsions/fits Eyes roll, face and limbs

twitch, body gets stiff and
shakes, fists clinched

Non-Emergency referral during pregnancy

Problem How to recognise Action to be
taken
Severe anaemia Tongue very Refer to PHC/
pale, weakness, Dist./Tertiary
general swelling Hospital
in body

Night Blindness Pregnant women Refer to ANM

find it difficult to or PHC
see at dusk
Part B

Maternal Health 31
 Fever Skin warm to Give
touch paracetamol
tablet. If no
Temp > 100
relief after 48
degree F (37.8
hours, refer to
degree Celsius)
PHC.

Pain/burning when urinating Frequent Let mother

urination and drink plenty of
urgency. Or pain/ water. If no relief
burning when after 24 hours,
passing urine refer to PHC.

White Discharge Passage of white Teach mother

discharge per to use gentian
vagina, itching in violet; place
private parts high in her
vagina daily. If
no relief after
5 days, refer to
PHC/Hospital.

Non-Emergency referral during pregnancy

Problem How to recognise Action to be take
Itching/Scabies/boil on skin with pus Skin rashes with itching For boils, advice women
could be present in other to apply hot fomentations
family members as well to the area thrice daily.
If no improvement after
Scabies
2 days, refer to PHC. For
Presence of pus filled scabies, refer to ANM/
boils PHC.
Bad obstetric history Always ask the pregnant Refer to CHC/DH
woman about past
history of abortion,
still birth, or neonatal
death, or whether she
developed complications
in last pregnancy
especially one which
required surgery.
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32 Simple Skills that Save Lives

Multiple pregnancies Suspicion/Knowledge: Refer to CHC/DH.
usually suspected by Ultrasound examination
ANM or by doctor after would confirm this.
abdominal examination.

Malpresentation Suspicion/Knowledge: Refer to CHC/DH.

Diagnosed by ANM or Ultrasound examination
doctor after abdominal would confirm this.
examination.

Danger signs in labour and delivery

These danger signs can occur at any time:

• Bleeding (fresh blood)

• Swollen face and hands

• Baby lying sideways

• Water breaks but labour does not start within 24 hours or less

• Colour of water - green or brown

• Prolonged labour - woman pushing for more than 12 hours (eight hours in the
case of women who have already had children) with the baby not coming out

• Fever

• Fits

• Retained placenta
Part B

Maternal Health 33
 5. Care during Delivery

Objectives of the Session

By the end of this session, the ASHA will learn about:

• Aend and observe delivery and record various events.

• Record the time of birth in Hours, Minutes and Seconds, using a digital
wrist watch.

• Record pregnancy outcomes as abortion, live birth, still birth or

newborn death.

Key tasks to be undertaken:

• Know what are the important tasks in taking care of the newborn.

• Be able to carry out these tasks if required.

• Ensure that SBA does not apply fundal pressure or gives injections to
speed up labour.

• Put baby to breast as soon as possible aer birth (provided mother is

comfortable).

• If the delivery is taking place at home, in case of complications, mother

and baby should be referred to the nearest health facility.

Observation of the delivery process was

Pregnancy and the Birth Processes
not part of previous ASHA training
Pregnant Woman Full-Term
modules. In this module, you will be
oriented to normal delivery processes
and newborn care, and also develop the
skills for recording the various events and
Notice that the mouth of the pregnancy outcome. Even though you are
uterus is tightly closed. Head not required to manage delivery, you may
of the baby is towards mouth have to help if the delivery starts during
of uterus and baby’s umbilical transport. This knowledge also gives you
cord is attached to placenta confidence to know more about this.
which is attached to uterus.
You should try and stay with the pregnant
woman through delivery in the institution
or at home, and post-partum period.
You could therefore also be a ‘Birth
Companion’ to the mother during the stay
at the institution. This is not a compulsion,
but a desirable service. Alternatively,
a close relative could also be the birth
(a) (b)
companion.
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34 Simple Skills that Save Lives

Before Delivery
The delivery room should be
cleaned before the delivery.
If the delivery is happening at
home, you should facilitate a
clean delivery space.

Immediately after birth, if the

baby remains naked, it may
become cold. Hence, baby
clothes should be kept ready
before delivery.

Safe Delivery
Three Stages of Labour

1st Stage of labour

Starts from the beginning of pain until the mouth of the womb is fully open. This
happens inside and cannot be seen. The bag of water also breaks at the end of
this stage. The fluid is usually clear but may be yellow or green or red.

This first stage of labour usually lasts about 8 to 12 hours in the first pregnancy.
May take much less time in subsequent pregnancies.

(a) (b) (c) (d)

Illustration (a) - drawing of side view of a pregnant woman.

In illustration (b) - the mouth of the womb is almost closed, and thick.

In illustration (c) - the mouth is thinner and is opening little.

In (d) - the mouth of the womb is fully open. When the womb is completely
open, it is the end of the first stage of labour. At this time, the water bag usually
breaks. This first stage of labour usually lasts about 8 to 12 hours. It takes longer
if the woman is having her first baby.
Part B

Maternal Health 35
 2nd Stage of labour
Contractions push the baby out of the womb: the delivery of the baby.

This second stage of labour usually lasts about one hour.

(a) (b) (c) d

During the second stage of labour, the baby moves down the birth canal until the
baby’s head is showing at the opening of the vagina. After the head is delivered,
the shoulders come out and then the rest of the body.

3rd Stage of labour

The contractions cause the placenta to separate out from
the uterus and be pushed out. delivery of the placenta.

The third stage of labour usually takes only a few minutes. if

it takes above 20 to 30 minutes there is cause for concern.

The Process of Delivery

In this process, ASHA can see on the outside when the baby starts to move
through the vagina in the process of being born. During each contraction, a
lile more of the head is seen (a, b, c).

(b) (c)
(a)

(d) (e) (f)

ASHA Module 6

36 Simple Skills that Save Lives

The very top of the head comes first, then the eyes, nose and mouth (d). While
in most babies, the eyes are facing the floor; sometimes they are born looking
towards the ceiling. When the baby’s head is out, it turns to one side (e) and the
shoulders and rest of the body are delivered (f). Once out, the baby will cry.

Delivery of Placenta
The cord will be connected to the placenta which is still inside the womb.

The placenta usually comes out aer 15-20 minutes.

Points for you to pay attention to if you are also present at the time of delivery in
the institution:

• It is not necessary to shave the area, or give an enema to the mother at the
time of delivery.

• All deliveries do not require an episiotomy (cut at the perineal site).

• Fundal pressure (pushing on the abdomen) should not be applied.

• You should be alert if injections are being given to hasten the delivery
process. Such injections can cause a baby who is still born, birth of a
baby who is unable to breathe, or even cause the death of the newborn.
However, the same injections are advisable after the baby has been born
in order to control bleeding after delivery. Only the ANM or doctor should
give the injection.

• When the mother and baby stay in the hospital and if you are staying with
them as a birth companion, she should ensure that the mother and baby
are seen by the MO and nurse at least twice a day and whenever required
if there are problems.
Part B

Maternal Health 37
 6. Post-Partum Care
Post-partum care is the period aer delivery of the placenta up to six weeks
aer birth.3

Objectives of the session

By the end of this session, the ASHA will learn about:

• Schedule of visits and tasks to be performed at each visit.

• Understand the possible complications of the post-partum period.

• Be able to identify the complications and refer appropriately.

Tasks for you to undertake during this period

• Conducting home visits to mother and child: Mothers and newborns
need care from the time of birth to six weeks aer the delivery.
The recommendation for postnatal care is to visit on the 3rd day
aer delivery, on the 7th day and at the end of six weeks, i.e on the
42nd day. For the newborn, the recommendation is to visit on the
3rd day, 7th day, 14th day, 21st day and 28th day. Aer this period,
visits are still needed once in two weeks till the child is two years
old for nutrition advice, immunisation advice, and support for
breastfeeding and complementary feeding, for illness prevention
and just to remain in touch.

• In effect therefore, you would need to visit on the 3rd, 7th, 14th day,
21st, and 28th day, and aer that, once every two weeks starting from
the 42nd day, till the child is two years old. If the child is born at
home, then of course you should be there at birth or at least visit her
within the first hour.

• Advice to the mother during these visits:

 Assess the mother for signs of complications (see below for the
list of complications) and ensure appropriate referral.

 Encourage her to rest for at least six weeks aer childbirth.

Families should be counselled to allow this.

 Encourage her to eat more food than usual. She can eat any kind
of food but high protein foods – pulses and legumes (nuts are
especially useful), foods of animal source. She should also drink
plenty of fluids.

3
Post-partum care has been covered in ASHA Module 2.
ASHA Module 6

38 Simple Skills that Save Lives

  Encourage and support for exclusive breastfeeding (Please see section
on Breastfeeding-Part C, Section 3)

 Discuss with the mother the need for contraceptive services.

Caution her on the risk of unprotected sex and the high
chances of conceiving again. You should counsel her on the
importance of spacing the next child birth for her own
health and that of the baby. You should help her in making
the choice of the method of family planning, whether spacing or
limiting.

Complications during the post-partum period

Some women can develop complications aer
the childbirth. The symptoms of these major
complications are:

1. Excessive bleeding: Ask the mother if the

bleeding is heavy. Oen this is quite obvious,
but sometimes it may be difficult to judge.
If the woman is using more than five pads
a day or more than one thick cloth in a day,
she is having heavy bleeding. You should
immediately refer her to an institution which
manages complications. You should also ask
the mother to begin breastfeeding immediately, that should help reduce
the bleeding. Referral is most urgent. Even the delay of a few minutes can
make a difference.

2. Puerperal Sepsis (Infections): Ask if the discharge is foul smelling. If the

answer is yes, then suspect infection. Fever, chills and pain in abdomen
along with the foul smell make infections even more likely. You should
measure temperature to confirm fever. Referral is required since the
mother needs antibiotics. Referral on the same day is advisable.

3. Convulsions with or without swelling of face and hands, severe

headache, and blurred vision: Such patients need immediate referral. If
ANM is available within 15 minutes, she can stabilise the patient before
referral.

4. Anaemia: You should check if the mother is pale and enable the mother to
get her blood Hb status checked (for management of anaemia in the post-
partum period, please see Section 3).

5. Breast engorgement and Infection: (Part C: Newborn Health)

Part B

Maternal Health 39
 6. Perineal Swelling and Infection: If the mother has
a small tear at the opening of her vagina (or has had
stitches during the delivery), she should keep the area
clean. She can apply cloth dipped in hot water, twice a
day and hold it to her genitals. This will give her relief
and help the healing. If there is fever, she should be
referred to the PHC or CHC. A tablet of paracetomol
would help both the pain and the fever.

7. Post-Partum Mood Changes: Some women may

suffer from mood changes aer delivery. They need
counselling and family support. The changes usually
disappear aer a week or so. If the changes become
severe then referral is required.
ASHA Module 6

40 Simple Skills that Save Lives

PART C

Newborn
Health
Part C

Newborn Health 41
 PART C

Newborn Health

Objectives of the session

By the end of this session, the ASHA will learn about:

• Observe and assist during the immediate newborn period in case she is
present at the time of delivery.

• Observe the baby during the first hour, during the first two days and
during the first month to take care of the newborn, support and help
the mother to breastfeed, and to keep the baby warm.

• Know what her specific role is during the home visits, and learn how to
care for the newborn.

1. Care of the Baby at the time of Delivery

Many babies die immediately after birth due to
asphyxia. In case of home delivery, when mild labour
pains start, you can manage asphyxiated babies by
removing mucus and can initiate respiration with the
help of the instruments you have.

You should encourage the mother to

start breastfeeding immediately after
the delivery, as this will help in quick
delivery of placenta and minimises
bleeding. Starting to breastfeed
immediately after the birth makes
the baby stronger.

Chances of the baby’s death and

getting sick are higher among the
babies born before time (pre-term)
and in LBW babies, (Weight less
than 2500 gm increases the risk
and below 1800 gm, the risk is
considered very high.)
Part C

Newborn Health 43
 2. Schedule of Home Visits for the care of the Newborn
The purpose of these visits is to ensure that the newborn is being kept warm
and breastfed exclusively. Encourage the mother to breastfeed, discourage
harmful practices such as bole feeds, early baths, giving other substances by
mouth, and to identify early signs of sepsis or other illnesses in the newborn.

• The newborn requires a visit immediately aer birth (or within the first
24 hours), and on Day 2, if the baby is born at home.

• If the baby is born at a facility, persuade and support the mother to stay
for at least 48 hours, and therefore, the first two visits are taken care of
in the institution. However, if you are there with the mother, as a birth
companion, then you could be of assistance to the nurse/ANM there.

• If the baby is born in a health facility, or at home, you should visit the
baby on Days 3, 7, 14, 21 and 28.
Additional visits are needed for newborn babies which are LBW, born
before term and are sick.

3. Examining the Newborn at Birth

Steps for you to take “just after” the baby is born
if the baby is born at home, or if you are present at the delivery,

1. Ask the mother about/observe the fluid aer the waters break.

2. If the fluid is yellow/green, as soon as the head is seen (even before

delivery of complete baby), clean the mouth of the baby with gauze piece.

3. As soon as the baby is born, note the time of birth and start counting time.

4. Observation of baby at birth or within the first 30 seconds and at 5

minutes aer birth for movement of limbs, breathing and crying. The
figure below will enable the assessment of whether the newborn should
be recorded as a live or still birth. All six have to be “No” to declare a still
birth. Even if one is “yes” the baby should be declared as live birth.

5. If there is no cry or a weak cry, if there is no breathing or weak breathing

or gasping, this condition is called Asphyxia. If the baby is asphyxiated
(does not breathe at birth), and there is no doctor or nurse, you should
try to help and this skill is taught to you, in Module 7. However, in many
such newborns, your efforts may not make enough difference and you
should not feel bad or blame yourself for this. (Management of asphyxia
will be taught in Module 7).
ASHA Module 6

44 Simple Skills that Save Lives

 Stillbirth Decision Tree Examination at 30 seconds
Cry Limb Movement Breathing

no no no
Examination at 5 minutes
Cry Limb Movement Breathing

no no no

Still Birth

Examination at 30 seconds
Cry Limb Movement Breathing

yes yes yes

Examination at 5 minutes
Cry Limb Movement Breathing

no no no

Live Birth

Part C

Newborn Health 45
 6. Provide normal care at birth.

 Dry the baby: Immediately aer delivery, the newborn should be

cleaned with a so moist cloth and then the body and the head wiped
dry with a so dry cloth. The so white substance with which the
newborn is covered is actually protective and should not be rubbed off.

 The baby should be kept close to mother’s chest and abdomen.

 The baby should be wrapped in several layers of clothing/woollen

clothing depending upon the season.

 The room should be warm enough for an adult to feel just

uncomfortable. The room should be free from strong wind.

8. You should weigh the newborn and decide whether the baby is normal or
LBW.

9. Determine whether the baby is term or pre-term.

10. Measure newborn temperature.

First examination of newborn

a. You should conduct the first examination within first 24 hours of delivery
look for the following:
• Whether the baby has any abnormality such as curved limbs, jaundice,
bump on head, cle lip.
ASHA Module 6

46 Simple Skills that Save Lives

• How the baby is suckling at the breast.

• Whether the baby has loose limbs.

• Listen to the cry of the baby.

• Provide care of eyes. If there is pus/purulent discharge from

eyes and no doctor or nurse available, apply tetracycline
ointment. Even for normal eyes, tetracycline is used as a
preventive, so even in doubt as to whether it is pus, it could
be given.

• Keep umbilical cord dry and clean.

b. General precautions the family must take

The newborn is delicate and can easily fall sick if the family
and mother are not careful. You should explain some general
precautions that the family should take.

• Bathing the baby: Although it is recommended that the baby should not
be bathed until the first seven days, many families would like to bathe
the baby on the first or second day. You should explain that bathing the
baby and leaving it wet or exposed may cause it to get cold and fall sick.
Thus, it is beer to wipe the baby with a warm wet cloth and dry the baby
immediately, at least for the first five to seven days.

• Keep the baby away from people who are sick.

• People who are sick with cold, cough, fever, skin infection, diarrhoea, etc.
should not hold the baby or come in close contact with the baby.

• The newborn baby should not be taken to places where there are other
sick children.

• The newborn baby should also not be taken to places where there are
large gatherings of people.

c. What are you expected to do during the newborn visits?

• Enquire and fill the mother’s information on home visit form. (Annexe 6)

• Enquire and fill newborn information on home visit form. These forms
help you to think about all the steps you need to take. (Annexe 7)

• Take out the necessary equipment from the bag and keep on a clean cloth.

• Wash your hands well as taught.

• Then examine the baby – a. measure temperature, b. weigh the baby, and
c. perform other activities in the sequence provided in the newborn home
visit form. (Annexe 8 & 9)

• Provide the care of eyes, skin and cord.

• Check that the home visit form is filled in completely.

Part C

Newborn Health 47
 d. Learning proper hand washing
You must make sure that your hands are washed properly with soap before
touching the baby. You should also teach the mother and family members to
wash their hands before touching the baby.

(Please see Annexe 7 for skills checklist for hand washing)

e. Learning how to measuring temperature

You should measure the temperature of the newborn using a special
thermometer to see if the body temperature is normal or if baby has
hypothermia (colder than normal).

(Please see Annexe 8 for skills checklist for measuring temperature)

f. Learn how to weigh the new born

• Baby should be weighed within two days of birth.

• It is important to weigh the baby aer birth because babies may require
special care on the basis of the birth weight.

• It is beer to use a special colour-coded weighing machine meant just for

weighing newborn which records the weight as green, yellow or red.

(Please see Annexe 7,8 & 9 for skills checklist)

 If the baby’s weight is “in the green zone: baby’s weight is normal and can
be managed with normal care as described above.

 If in the yellow zone, the baby is mildly under weight, but can be managed
at home with extra care as given below. (below 2.5 kg but above 1.8 kg).

 If in the red coloured zone, this means that the baby is very small and
must be referred to the health centre. These babies also need extra care
as given below.
(less than 1.8 kg)

g. Learn how to take care of babies less than 2.5 kg

Babies whose weight is in the yellow or red zone are small and require extra
care as follows:
• Provide extra warmth.

• Family should ensure.

 Baby is wrapped well with thin sheets and blankets.

 The head is covered to prevent heat loss.

 The baby is kept very close to the mother’s abdomen and chest.

 Warm water filled boles wrapped in cloth may be kept on either side
of the baby’s blankets, when not being kept close to the mother’s body.

 The baby must be fed more frequently.

ASHA Module 6

48 Simple Skills that Save Lives

 Remember:

The usual bathroom scales cannot reliably record small

differences in weights. That is why bathroom scales cannot
accurately record newborn weight and it is not advisable to
use these for weighing newborns.

All babies below 1.8 kg must be taken to a 24x7 facility or other facility known
to provide referral care for sick newborn and examined by a doctor or nurse.

h. Umbilical cord care

• Cord should be kept clamped for at least 24 hrs aer the birth. The clamp
can be removed when the cord is dried and occluded

• No application of any medicine is required if there is no bleeding or

discharge.

• The umbilical cord should be kept clean and dry at all times.
i. Eye care
Skill checklist for applying eye ointment

If a newborn has pus discharging from its eyes you can put antibiotic
ointment in the baby’s eyes or a capsule which is available in the market.

How to put antibiotic ointment:

• Gently pull the baby’s lower eyelid down.

• Squeeze a thin line of ointment moving from the inside corner to the
outside of the eye.

• Do not touch the baby’s eye with the tip of the tube. If the tube touches the
babies eyes, it shouldn’t be used again.

• If the eyes are swollen with pus, then put the ointment two times a day for
5 days. Part C

Newborn Health 49
 4. Breastfeeding

Objectives of the session

By the end of this session, the ASHA will learn about:

• Counsel mother for breastfeeding.

• Provide breastfeeding support.

• Emphasise importance of early and exclusive breastfeeding.

• Help mother to express milk and feed babies who cannot suckle at
birth.

• Manage breastfeeding problems (engorgement, cracked nipple,

mother feels she does not have enough milk).

a. Benefits for the baby

• Early skin-to-skin contact keeps the baby warm.

• It helps in early secretion of breast milk.

• Feeding first milk (colostrum) protects the baby from diseases.

• Helps mother and baby to develop a close and loving relationship.

b. Benefits for the mother

• Helps womb to contract and the placenta is expelled easily.

• Reduce the risk of excessive bleeding aer delivery.

c. Important facts about breastfeeding

• Start breastfeeding immediately or at least within one hour aer birth.
Give nothing else, not even water.

• Baby should be put to the mother’s breast even before placenta is

delivered. It is useful for both the baby as well as the mother.

• Breastfeed as oen as the baby wants and for as long as the baby wants.
Baby should be breastfed day and night at least 8-10 times in 24 hours.

• Feeding more oen helps in production of more milk. The more the baby
sucks, more milk is produced.

• Baby should not be given any other liquid or foods such as sugar water,
honey, ghui, goat’s/cow’s milk and not even water.
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50 Simple Skills that Save Lives

d. Breastfeeding observation tips
Signs of breastfeeding going well Signs of possible difficulty
Mother’s body relaxed, comfortable, confident, eye Mother tense, leans over baby. Not much eye contact
contact with baby, touching or touching

Baby’s mouth well attached, covering most of the Mouth not opened wide, not covering areola
areola, opened wide, lower lip turned outwards
Lips around nipple
Suckling well, deep sucks, bursts with pauses Rapid sucks, cheeks tense or sucked in Smacking or
clicking sounds
Cheeks round, swallowing heard or seen
Baby calm and alert at breast, stays attached, Mother Baby restless or crying, slips off breast; Mother not
may feel uterus cramping, some milk may be leaking feeling cramping, no milk is leaking (showing that
(showing that milk is flowing) milk is not flowing)
After feed, breast soft, nipples protruding After feed, breast full or enlarged, nipples may be red,
cracked, flat or inverted

e. Correct position for breastfeeding

To obtain maximum benefit of breastfeeding, the baby should be held in the
correct position and be put correctly to the breast. The baby is in the correct
position when:

• While holding the baby, the mother also supports the baby’s boom, and
not just the head or shoulders.

• Mother holds the baby close to her body.

• The baby’s face is facing the breast, with nose opposite the nipple

Breastfeeding Positions

Cradle Position Side-lying Position

Underarm Position Alternate Underarm Position

Part C

Newborn Health 51
 f. Counselling tips
• You are there to help the mother, not to take over.

• Use verbal and non-verbal skills to make her feel at

ease.

• Encourage and praise her; every mother has the

ability to breastfeed. Oen mothers are worried that
they are inexperienced and lack the confidence. Many
women do not breastfeed successfully because they
do not get good advice, support and encouragement.
• If she says something that you do not agree with, do not say ‘that is
wrong’. Do not make her feel bad or stupid. You can repeat what she says
(For example, ‘I hear you saying that you think you don’t have enough
milk....’ Ask her why she thinks so. Listen to what she is saying and why).

• Aer you assess the breastfeeding, you should check the baby’s weight
gain.

• Give advice in simple and clear language.

• Make sure the mother understands what you are saying.

• Have her repeat what she will try to do.

g. Why only breastfeeding?

Giving other food or fluid may harm the baby in following ways

• It reduces the amount of breast milk taken by the baby.

• It may contain germs from water or on feeding boles or utensils. These

germs can cause diarrhoea.

• It may be too dilute, so the baby becomes malnourished.

• Baby does not get enough iron from cow’s and goat’s milk and may thus
develop anaemia.

• Baby may develop allergies.

• Baby may have difficulty digesting animal milk; the milk can cause
diarrhoea, rashes or other symptoms. Diarrhoea may become persistent.

• Breast milk provides all the water a baby needs. Babies do not need extra
water even during the summer months.
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52 Simple Skills that Save Lives

Managing Common Breastfeeding Problems

Sore nipples
Causes: poor latch-on or positioning at breast

Management
• Improve attachment and/or position.
• Continue breastfeeding (reduce engorgement if present).
• Build mother’s confidence.
• Advise her to wash breast once a day; not to use soap for this.
• Put a little breast milk on nipples after feeding is finished (to lubricate the nipple) and air-dry.
• Wear loose clothing.
• If nipples are very red, shiny, flaky, itchy, and their condition does not get better with above treatment, it
may be fungus infection. Apply gentian violet paint to nipples after each breastfeed for five days. If the
condition does not improve, refer to a doctor.

Inverted nipples
Sometimes the nipple will retract in to the breast, and can be checked even during pregnancy.
The best treatment is to encourage the mother to gently pull out the nipple and roll it, several times in a day.

Not enough milk

Causes: Delayed initiation of breastfeeding; infrequent
feeding; giving fluids other than breast milk; mother’s
anxiety, exhaustion, insecurity; inadequate family support.

Management
• Decide whether there is enough milk or not:
 Does the baby pass urine six times or more each day?
 Has the baby gained sufficient weight? (During the 1st week there is
usually a small weight loss, after that a newborn should gain 150-
200 gm per week.)
 Is the baby satisfied after feeds?
• Re-assure mother.
• If there is not enough milk, have the baby feed more often.
• Check breastfeed to observe mother attachment and positioning of the
mother and baby.
• Encourage rest. Emphasise the mother to drink and eat more.
• Praise her and return for follow-up.
Part C

Newborn Health 53
 Engorged and painful breasts (very full breasts)
Causes: Delayed initiation of breastfeeding, poor attachment, incomplete
emptying of breasts, restricting the length of the feeds.

Management
• Prevent by:
 Starting breastfeeding soon after delivery and
feeding often..
 Ensuring correct attachment.
 Encouraging on-demand feeding.
• If baby is able to suckle, feed more frequently, help with positioning.
• If the baby is not able to attach, apply warm compresses to breast,
gently massage from outside toward the nipple and express some milk
until the areola is soft, then put baby to the breast, making sure that the
attachment is correct.
• Have baby feed often to empty out the breasts. If it is not possible, ask
the mother to express some milk herself.
• If breasts are red and hard, continue to feed often. Use warm
compresses and gently massage breasts towards nipple. Take
mother’s temperature. If she has fever, mother should visit the doctor.
She should continue to breastfeed (from both sides) even if she is
taking antibiotics.

Expressing milk by hand

1. Wash hands with soap and water.

2. Place a warm compress on the breast for a few minutes if desired.

3. Gently massage the breast starting from the chest moving toward the
nipple; do this in a circle (near the underarm, and then to the boom of
the breast etc.), so that all parts of the breast are massaged.

4. Lean forward and support the boom of the breast with one hand.

5. Hold the areola between thumb and two fingers of other hand. Put her
hand on the areola above the nipple and the two fingers on the areola
below the nipple.

6. Press toward the chest (about 1-2 cm) and then squeeze the milk
reservoirs beneath the areola (do not squeeze the nipple).

7. Press and release the thumb and first finger several times until the milk
drips out. Use a clean bole or a cup to collect the milk. Milk may drip at
the beginning and then spray out aer it starts flowing.

8. Rotate the thumbs and finger around the areola so that the milk is
removed from all the reservoirs.
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54 Simple Skills that Save Lives

 Expressing milk

Feeding baby with

traditional spoon like
utensil used for milk
feeding

9. Repeat with the other breast.

Signs that the baby is not getting enough milk

• Poor weight gain

 Weight gain of less than 500 gm in a month
 Less than birth weight after two weeks

• Passing small amounts of concentrated urine

 Less than six times a day
 Yellow and strong smelling

• Other signs are:

 Baby not satisfied after breastfeed and often cries
 Very frequent breastfeeds
 Very long breastfeeds
 Baby refuses to breastfeed
 Baby has hard, dry or green stools
 No milk comes when mother tries to express
 Breast did not enlarge
 Milk did not come in.
Part C

Newborn Health 55
 Mothers and families think that in the following situations, their milk is not
enough, but in fact, these do not affect the breast milk supply:

• Age of mother
• Sexual intercourse
• Return of menstruation
• Disapproval of relatives and neighbours
• Age of baby
• Caesarean Section
• Many children
• Simple, ordinary diet
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56 Simple Skills that Save Lives

5. Keeping the Newborn Warm

Objectives of the session

By the end of this session, the ASHA will learn about:

• Identify the newborn whose body temperature is less than

normal and whose body temperature is more than normal.

• Teach mothers how to keep the newborns warm.

• Teach mothers how to re-warm cold babies.

• Teach mothers how to control newborn temperature in hot

weather.

• Learn to take the temperature.

Keeping newborn warm and the problem of hypothermia

Why is it important to keep baby warm after delivery?
Babies have difficulty maintaining their temperature at
birth and in the first day of life.They come out wet, and
lose heat quickly. If they get cold, they use up energy,
and can become sick. LBW and pre-term babies are at
greater risk of geing cold.

When and why do most newborns get cold?

Most newborns lose heat in first minute aer delivery.
They are born wet. If they are le wet and naked, they lose a lot of heat to the
air. A newborn baby’s skin is very thin and its head is big in size compared
to its body. It loses heat very quickly from its head. Babies do not have the
capacity to keep themselves warm. If the newborn baby is not properly dried,
wrapped, and its head is not kept covered, it can lose 2 to 4 degree Celsius
within 10-20 minutes.

Example: If the baby’s temperature was 97.7 degree Fahrenheit (36.5 degree
Celsius) (normal temperature) at the time of birth and if there was a loss of
2.7 degree Fahrenheit because the baby was not properly dried and covered,
the body temperature will become 95 degree Fahrenheit (35.0 degree Celsius),
which is below normal.

What is the term for a situation when a baby’s temperature falls below
normal?
When a baby has a temperature below normal, it suffers from hypothermia.

What happens to a baby with hypothermia?

A baby who is cold, and has a low temperature (hypothermia) suffers from:

• Decreased ability to suckle at the breast, leading to poor feeding and

weakness.
Part C

Newborn Health 57
 • Increased susceptibility to infections.

• Increased risk of death, especially in LBW and pre-term babies.

How can you tell if a baby is hypothermic?

• The early sign is cold feet.

• Then, the body becomes cold.

• The best method is to measure the baby’s body temperature.

(This skill has already been taught to you)

How to keep newborns warm

Warming
• Before delivery, warm up the room (warm enough for adults).

• Immediately aer delivery, dry the baby.

• Put a cap on the baby since a lot of heat could be lost though its head.

• Place in skin-to-skin contact with mother.

• Cover or put clothes on the baby, wrap it up with clean cloth, and place it
close to its mother.

• Initiate early breastfeeding.

• Bathing for newborns:

 It is best to wait until the second day to bathe the baby. One should
wait seven days in case of LBW baby.

 If the family insists on bathing the first day, please ask them to delay
for at least six hours to give the baby time to adjust with its new
environment.

 For small and pre-term babies, do not give a bath until the baby
gains weight (this could be few weeks) and weight of baby become
2,000 gm.

• To keep a small baby clean, you can give a light oil massage but making
sure that the room is warm and the baby is not le uncovered for more
than 10 minutes. DO NOT pour oil into any orifice, like the nose or ears at
any time.

• Keep baby loosely clothed and wrapped.

• If it is very warm outside, make sure the baby is not too heavily clothed
and wrapped; the baby can also get too hot.
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58 Simple Skills that Save Lives

How to re-warm a baby getting cold?

<97 degree Fahrenheit (36.1 degree Celsius) or too cold <95 degree Fahrenheit
(35.0 degree Celsius)

• Increase the room temperature.

• Remove any wet or cold blankets and clothes.
• Hold the baby with its skin next to its mother’s skin (skin-to-skin contact) and place a warmed cloth
(not too hot to avoid burns) on its back or chest. As this cloth cools down, replace it with another
warmed one, and repeat until the baby is warmer. Continue until the baby’s temperature reaches the
normal range.
• Put on its clothes and its cap, put it in warm bag, and make it lie close to its mother.
• Continue to breastfeed the baby to provide calories and fluids to prevent a drop in the blood glucose level.
 A common problem in hypothermic babies.

If a baby is too cold <95 degree Fahrenheit (35.0 degree Celsius), follow the above advice, and

• Place skin-to-skin, and once the baby is a little warmer, then clothe baby and place in a bed pre-
warmed with warm clothes, or a hot stone or hot water bottle. (Remove these articles before putting
baby on the bed.)
• In an institutional delivery, there should be a newborn corner available with a radiant
warmer, or some other suitable heating arrangement where the newborn baby
can be kept.

Part C

Newborn Health 59
 6. Management of fever in newborn
A baby has fever if the temperature is above 99 degree Fahrenheit (37.2
degree Celsius). In the case of high body temperature of the baby during
summer, verify in the following manner whether this is due to the body being
overdressed or does it really have fever:

• Unwrap the baby and take off its cap.

• Ventilate the room too to cool the baby.

• Ask the mother to start breastfeeding.

• If there is a source of extra heat (like a fire) in the room, put it out.

• Wait for 30 minutes and take the temperature once again.

If the baby’s temperature returns to normal, explain to the mother that in very
warm weather, the baby does not have to kept covered with additional cloth
or kept wrapped.
If the temperature is still above normal aer the above measures have been
taken, refer the baby for treatment.
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60 Simple Skills that Save Lives

Annexes
Annexe 1: ASHA Drug Kit Stock Card
Month & Date of Refill (1) (2) (3) (N)
S.No. Name of Symbol* Balance Refill Balance Refill Balance Refill Balance Refill
Drug given given given given
1
2
3
4
5
‘n’

Balance: This is what was le in kit at the time of refill – aer recovering
explained drugs/supplies.

Refill: This is what was put into the kit.

*Symbol is a pictorial symbol that could be used to denote a drug, since oen,
the drugs comes labelled only in English.

Card is to be updated by person providing the refill.

Annexes 63
 Annexe 2: Instructions for Pregnancy
Test using Nischay Kit
The Nischay Kit contains the following:

1. A test card

2. A disposable dropper

3. A moisture absorption packet (not required for testing)

• Collect the morning urine in a clean and

dry glass or in a plastic bottle.
• Take two drops of urine in the sample
well.
• Wait for 5 minutes.

• If two violet colour lines come in the test

region (T), the woman is pregnant.
• If she wants to continue with the
pregnancy, advice her to undergo
antenatal care.
• If she does not want to continue with the
pregnancy this time, advice her for safe
abortion.

• If the violet colour line in the test

region (T) is one only, the woman is not
pregnant.
• Tell her about family planning methods
and help her in choosing the most
appropriate one.

If there is no colour line in the test region

(T), repeat the test next morning using a
new Pregnancy Test Card.
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64 Simple Skills that Save Lives

Annexe 3: Format for Individual Plans
(Birth Preparedness)
Name: Age:

Husband’s name:

HH income

LMP

EDD

Past pregnancy history (Include abortion, if any):

Order of Date of Place of Type of Birth Age and Any other

pregnancy delivery delivery: delivery: Outcome: Status of complications:
(Month and Home, SC, Natural, Live Birth, child currently Fever, Bleeding
Year) PHC, CHC, Forceps, Stillborn,
DH, C-Section
Private
Nursing
Home
First
Second
Third

• Any risk factors:

• Nearest SBA: Phone:
• Nearest 24X7 PHC: Distance: Time: Cost
• Nearest Sub-Centre with a Skilled Birth Aendant
• Nearest CHC with facilities to manage complications: Distance:
Time: Cost
• Distance to District Hospital:
• How much is transport going to cost?
• Is the vehicle fixed: Owner:
• Will we need extra money for the treatment ? How to organise it?
• Who will take care of the children when mother goes to the facility?
• Who will accompany her to the facility?
• Where will they stay?
• How will they finance their stay?
• Have they organised clothes and blankets for the baby?

Annexes 65
Annexe 4: Delivery Form (Fill in the form
completely even in the case of a stillbirth)
1) When did ASHA arrive at the hospital/woman’s home: Date:
For Supervisor#
Time: Hrs_________Min________Early morning/ morning/afternoon/evening/night Correct/Incorrect
2) When did woman’s mild labour pain starts? Date
Correct/Incorrect
Time: Hrs________Min_________Early morning/ morning/afternoon/evening/night
Look for the following danger signs and if present, shift mother immediately to Action taken
hospital
Yes/No/NA
Danger sign
Yes/No/NA
1) Delivery does not occur within 24 hrs of onset of mild Yes/No
Yes/No/NA
labour
Yes/No/NA
2) Any part of the baby other than head comes out first Yes/No Yes/No/NA
3) Mother is having excessive bleeding Yes/No
4) Placenta is not delivered within 30 mins after delivery Yes/No Correct/Incorrect
5) Mother is unconscious or is getting fits Yes/No
Correct/Incorrect
TBA/Neighbour or family member/Skilled Birth Attendant/Nurse/Doctor
Name: __________________________________________________________
4) Where was the delivery conducted? Correct/Incorrect
Correct/Incorrect
Name of the village/town: _________________________________________
Correct/Incorrect
Home/Sub-Centre/PHC/CHC/ District Hospital/Private Hospital Yes/No/NA
4 a) Nature of delivery: Normal/Caeserian Correct/Incorrect
5) Which part of the baby’s body came out first? Head/Cord/Other
6) Was the amniotic fluid thick and green/yellow? Yes/No #: Mar ‘Yes’ if necessary
and possible action has
If yes, was the mouth cavity of baby cleaned with a gauze piece immediately after
head came out? Yes/No been taken without any
mistake.
7) When did the baby come out fully? Date: ______________________
Record the time of birth: Early morning/morning/afternoon/evening/night

Time: Hours:_____________Minutes______________Seconds__________________

Name of the ASHA: ___________________________________Date:______________

Name of Trainer/Facilitator: ___________________________________Total Score

___________Block Name:______________

8) Immediate actions: Was action taken:

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66 Simple Skills that Save Lives

Dry the baby : Yes/No For Supervisors#

Cover the baby : Yes/No

Yes/No/NA
9a) Observe the baby at birth: Yes/No/NA

At 30 seconds At 5 minutes
a) Cry No/Weak/Forceful No/Weak/Forceful
Was ASHA present when
b) Breathing No/Gasping/Forceful No/Gasping/Forceful the baby came out?
c) Movement of limbs No/Weak/Forceful No/Weak/Forceful Yes/No/NA
Correct/Incorrect
9b) Diagnosis - Normal/Stillbirth
Correct/Incorrect
9c) If still birth - Fresh/Macerated
Correct/Incorrect
10) Sex of the child: Male/Female

11) Number of baby/babies born: 1/2/3

Yes/No/NA
12) Actions: Correct/Incorrect

Give the mother something to drink immediately after the delivery: Yes/No
Yes/No/NA
13) Time at which placenta came out fully? Hrs_________________Min___________ Yes/No/NA
Yes/No/NA
Immediate breastfeeding reduces mother’s bleeding and helps to quicken delivery
Other Information
of placenta
#: Mark ‘Yes’ if
14) Actions: necessary and possible
action has been taken
Cover the baby: Yes/No
Keep close to mother: Yes/No without any mistake
Early and exclusive breastfeeding: Yes/No
15) Special features/Comments/Observations, if any

________________________________________________________________________

________________________________________________________________________

Annexes 67
Annexe 5: First Examination of the Newborn
(Form)
(Examine one hour aer the birth but in any case within six hours from the birth. If ASHA is not present
on the day of delivery then fill the form on the day of her visit and write the date of her visit).

Part I: For Supervisor#

1) Date of Birth_________________________________
Correct/Incorrect
2) Pre-term cut-off date: ______________________ Is baby pre-term? Yes/No
3) Date of first examination_____________________ First examination done
Time: Early morning Morning Afternoon Evening Night _________ Hrs____
Days:___ Hrs:____
_____________
4) Does mother have any of the following problems? After birth
a. Excessive bleeding Yes/No
Yes/No/NA
b. Unconscious/fits Yes/No
Action: If yes, refer immediately to hospital Action taken Yes/No

Correct/Incorrect
(In case of stillbirth, do not perform further examination but complete the
examination of the mother as per home visit form on day 2, 3, 7, 15, 28) Correct/Incorrect
5) What was given as the first feed to baby after birth? __________
6) At what time was the baby first breastfed? Hrs_______Min_______
How did baby take feed? Mark  Correct/Incorrect
1) Forcefully
Correct/Incorrect
2) Weakly
3) Could not breastfeed but had to be fed with spoon Yes/No/NA
4) Could neither breastfeed nor take milk given by spoon
Yes/No/NA
7) Does the mother have breastfeeding problem? Yes/No
Write the problem________________________________________
If there is problem in breastfeeding, help the mother to overcome it
Correct/Incorrect
Part II:
First examination of the baby Correct/Incorrect
1) Temperature of the baby (Measure in axial and record):___________
Correct/Incorrect
2) Eyes: Normal
Swelling or oozing pus Yes/No/NA
3) Is umbilical cord bleeding: Yes/No
Action: If yes, either ASHA, ANM or TBA can tie again with clean thread. Action
taken: Yes/No

Name of ASHA__________________________________Date_____________________ #Mark yes if necessary

Name of trainer: ___________________________Total Score______________________ and possible action has
Block:____________________________________________________________________ been taken without any
mistake
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68 Simple Skills that Save Lives

4) Weight: Kg_____ Gm_____ Colour on scale: Red/Yellow/Green For Supervisor

Weighing matches
5) Record  X
with the colour?
Yes/No
1. All limbs limp
2. Feeding less/stop Correct/Incorrect
3. Cry weak/stopped

Action taken?

Routine Newborn Care Yes/No/NA

Whether the task was performed Yes/No/NA

1) Dry the baby Yes/No Yes/No/NA

2) Keep warm, don’t bathe,

wrap in the cloth, keep Yes/No Yes/No

closer to mother Yes/No

3) Initiate exclusive breastfeeding Yes/No

Yes/No

6) Anything unusual in baby? Curved limbs/Cleft lip/Other________________________

___________________________________________________________________________

For Supervisor

Form checked by: Name___________________________________________Date____________________

Corrections:_____________________________________________________________________________
________________________________________________________________________________________

Unusual or different observation: __________________________________________________________

Whether the form has been completed? Yes/No

Signature _________________

Annexes 69
 ASHA Module 6

Annexe 6: Home Visit Form

(Examination of Mother and Newborn)
Ask/Examine Day 2 Day 3 Day 7 Day 15 Day 28 Day 42 Action by the ASHA Supervisory
Check
Date of ASHA’s visit --------- ----------- ----------- ---------- ---------- -----------

70 Simple Skills that Save Lives

A. Ask Mother Action Take
No. of times mother takes full meal If less than 4 times or Y/N Y/N
in 24 hrs if meals not full, advise
mother to do so
Bleeding: How many pads are If more than 5 pads,
changed in a day refer mother to
hospital
During the cold season, is the baby Yes/ Yes/ No/ Yes/ Yes/ No/ Yes/ No/ Yes/ Advise the mother
being kept warm (near mother, No/ No/NA NA NA No/NA to do so, if not being
clothed and wrapped properly) NA done
NA
Is the baby being fed properly Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Advise the mother to
(whenever hungry or at least 7-8 do so, if not being done
times in 24 hrs)
Is baby crying incessantly or passing Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Advise mother to feed
urine less than 6 times a day the baby after every 2
hours
B. Examination of mother
Temperature: Measure and record Temperature up to
102 degree F (38.9
degree C)- treat with
Paracetamol, and if the
temperature is above
it, refer to hospital)
Foul smelling discharge and fever Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No If yes, refer the mother
more than 100 degree F (37.8 to hospital
degree C)
Is mother speaking abnormally or Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No If yes, refer the mother
having fits? to hospital
Mother has no milk since delivery or Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
if perceives breast milk to be less
Cracked nipples/painful and/or Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
engorged breast
 Ask/Examine Day 2 Day 3 Day 7 Day 15 Day 28 Day 42 Action by the ASHA Supervisory
Check
Date of ASHA’s visit --------- ----------- ----------- ---------- ---------- -----------
C. Examination of Baby Action Take
Are the eyes swollen or with pus Y/N Y/N
Weight (on day 7, 15, 28 and 42)
Temperature: Measure and Record
Skin:
Pus filled pustules
Cracks or redness on the skin fold
(thigh/Axilla/Buttock)
Yellowness in eyes or skin:
Jaundice

D. Check now for the following signs of sepsis: If sign is present mention - Yes, if it is absent, mention - No
Record the observations on Day 1 from the first examination of newborn form
Ask/Examine Day 1 Day 2 Day 3 Day 7 Day 15 Day 28 Day 42 Action by the Action Taken
ASHA
--------- ----------- ----------- ---------- ---------- -----------
Y/N Y/N
All limbs limp
Feeding less/Stopped

Cry weak/Stopped

Distended abdomen or mother says ‘baby

vomits often’
Mother says ‘baby is cold to touch’ or baby’s
temperature >99 degree F (37.2 degree C)

Chest indrawing
Pus on umbilicus

Supervisor’s note: Incomplete work/incorrect work/incorrect record/incorrect record

Name of ASHA:__________________________________________________________Date:___________________
Name of Trainer/Facilitator:________________________________________________________________________

Annexes 71
 Annexe 7: Skills Checklist: Handwashing
Number of Practices
Checklist 1 2 3 4 5

1) Remove bangles and wrist watch

2) Wet hands and forearms up to elbow with clean water (Fig. 1)
3) Apply soap and scrub forearms, hands and fingers (especially nails)
thoroughly (Fig 2 to 7)
4) Rinse with clean water
5) Air-dry with hands up and elbow facing the ground (Fig 8)
6) Do not touch with your hands the ground, floor or dirty objects after
washing your hand

Note: Use the checklist while observing the skills being implemented.

When a step is performed correctly, place a tick () in the box.

When a step is not performed correctly, place a cross (X) in the box.

Make sure to review the steps where crosses appear, so that performance can be improved.
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72 Simple Skills that Save Lives

Annexe 8: Skills Checklist:
Measuring Temperature
Picture/Illustration Skills Checklist For Peer Record
1 2 3 4 5
1) Take thermometer out of its storage case, hold at
broad end, and clean the shinning tip with cotton ball
soaked in spirit.

2) Press the pink button once to turn the

thermometer on. You will see “188.8” flash in the
centre of the display window, then a dash (-), then
the last temperature taken and then three dashes
(- - - ) and a flashing “F” in the upper right corner.

3) Hold the thermometer upward and place the

shinning tip in the centre of the armpit. Place arm
against it. Do not change the position.

4) You will hear a beep sound every 4 seconds while

the thermometer is recording the temperature. When
you hear 3 short beeps, look at the display. When
“F” stops flashing and the number stop changing,
remove the thermometer.
5) Read the number in the display window.

6) Record the temperature reading on the form.

7) Turn the thermometer off by pushing the pink

button one time.

8) Clean the shinning tip of the thermometer with a

cotton ball soaked in spirit.
9) Place thermometer back in its storage.

Annexes 73
Annexe 9: Skills Checklist: Weighing the Baby
Scale Type 1:
Picture/Illustration Skills Checklist For Practice
1 2 3 4 5

1. Place the sling on scale

2. Hold scale by top bar off the floor,
keeping the adjustment knob at eye level.
3. Turn the screw until its top fully covers
the red and ‘O’ is visible.

4. Remove sling on hook and place it on a

clean cloth on the ground.
5. Place body with minimum clothes on, in
sling and replace the sling on hook.
6. Holding top bar carefully, as you stand
up, lift the scale and sling with baby off the
ground, until the knob is at eye level.

7. Read the weight.

8. Gently put the sling with baby in it, on
the ground and unhook the sling.
9. Remove the baby from the sling and
hand it over to its mother.
10. Record the weight.

Scale Type 2:
ASHA Module 6

Salter Scale Weighing machine (for up to 10 kg)

74 Simple Skills that Save Lives

 Acronyms

ANM Auxiliary Nurse Midwife

ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWW Anganwadi Worker
ARI Acute Respiratory Infection
ANC Antenatal Care
AIDS Acquired Immuno-deficiency Syndrome
ART Anti-Retroviral Therapy
BEmoC Basic Emergency Obstetric Care
BCG Bacillus Calmee-Guerin
BPNI Breastfeeding Promotion Network of India
CEmoC Comprehensive Emergency Obstetric Care
CHC Community Health Centre
DPT Diphtheria, Tetanus and Pertussis
EDD Expected Date of Delivery
FRU First Referral Unit
GP Gram Panchayat
GV paint Gentian Violet paint
HBNC Home-Based Newborn Care
IFA Iron Folic Acid
IMNCI Integrated Management of Neonatal Childhood Illnesses
LBW Low Birth Weight
LMP Last Menstrual Period
MO Medical Officer
ORS Oral Rehydration Solution
PHC Primary Health Centre
PRI Panchayati Raj Institution
SBA Skilled Birth Aendant
TB Tuberculosis
TT Tetanus Toxoid
UNICEF United Nations Children’s Fund
VHND Village Health and Nutrition Day
VHSC Village Health and Sanitation Commiee

Acronyms 75