PREFACE

Maternal survival and wellbeing is challenged by complications of pregnancy, childbirth and unsafe
abortion. The major causes of maternal death include sepsis, haemorrhage, hypertensive disorders
of pregnancy, obstructed labour and abortion complications, with anaemia being an important
underlying cause of many maternal deaths. Infections, asphyxia and pre-maturity are the leading
causes of death in the newborn especially in the first week of life. Late neonatal deaths are due to
infections acquired after birth, many of which are associated with poor hygiene, lack of information
on adequate newborn care and/or poor neonatal feeding practices.

Maternal and newborn health remains a priority for the health sector and the Safe Motherhood
Programme aims to improve women's health in general, and specifically to reduce maternal and
newborn mortality and morbidity. The main strategies of the programme are to increase coverage,
to improve on the quality of health services and to heightened awareness about maternal and new
born health issues in the community.

The 2014 Demographic and Health Survey revealed that access to maternal and newborn health
services has increased, even though there continues to be disparities between rural and urban areas.
As a result of the increased access to maternal and newborn, health facilities are faced with the
challenge of providing services to an increased client load, a factor that could lead to quality being
compromised. The need for improving the skills of service providers through the provision of
updated clinical management protocols therefore has been become more urgent so that a minimum
standard of care is delivered to women during pregnancy and childbirth as well as to infants in the
first few weeks of life.

It is in the light of this that the National Safe Motherhood Service Protocol has been revised to
ensure that service providers have a current reference for care based on the best available evidence.
The document outlines step-by-step actions for identifying and treating complications of pregnancy,
labour/delivery and the postpartum/postnatal period and has been designed to provide guidance at
all levels of the health care delivery system. All personnel involved in the care of women, e.g.
doctors, midwives, physician assistants, nurses (public health, community and enrolled) should find
this manual useful.

In addition to serving as a reference for clinical decision-making, the protocol should provide the
basis for advocacy for the provision of inputs that can ensure improvement in the survival and
wellbeing of women in pregnancy and childbirth as well as newborns. This will contribute to the
attainment of the sustainable development goals, to which the country has subscribed.

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 ACKNOWLEDGEMENT

The Ghana Health Service wishes to express its appreciation to the task team that worked tirelessly
to develop the first edition of the National Safe Motherhood Service Protocol in 2008 as well as
contributors to the second edition.

Contributors To First Edition

Dr. (Mrs.) Henrietta Odoi-Agyarko
Professor Sydney Adadevoh
Dr. Joseph Taylor
Mrs. Gladys Kankam
Ms. Perfect Blebo
Dr. Sylvia Deganus
Dr. Ali Samba
Dr. Richard Adanu
Dr. Gyikua Plange-Rhule
Dr. Gloria Quansah Asare
Dr. Patrick Aboagye
Dr. Isabella Sagoe-Moses
Ms. Rejoice Nutakor
Mrs. Gladys Brew
Dr. Rhoda Manu

Contributors To Current Edition

Dr. Patrick K Aboagye
Professor Sydney K. Adadevoh
Dr. Sylvia Deganus
Dr. Peter Baffoe
Dr. Isaac Koranteng
Dr. Priscilla Wobil
Dr. Joseph Adu
Dr. Francis Damali
Dr. Isabella Sagoe-Moses
Ms. Doris Amarteifio
Mrs. Vivian Ofori-Dankwa
Dr. Roseline Doe
Dr. Charles Fleischer-Djoleto
Mrs. Gladys Brew
Mr. Emmanuel Ayire Adongo

Special thanks go to Professor Baafour Opoku for reviewing the final draft of the current edition.
The review was jointly sponsored by the UNFPA Country Office and the USAID Systems for
Health Project.

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 INTRODUCTION

Review of the National Safe Motherhood Service Protocol is based on current available evidence
and recommendations from the World Health Organization on guidelines for maternal and newborn
care. The review also took into account the paradigm shift towards task sharing/task shifting in the
bid to ensure access to care, including emergency obstetric and newborn care, especially at the
periphery so that preventable maternal and newborn deaths can be avoided.

In this current edition, the first part consist of general information, education and communication on
safe motherhood while the second part consists of routine care as well as management of
complications during pregnancy, labour/delivery and the postpartum period. The management of
complications has been considered at the various levels of service delivery. The community level
refers to care provided within the home or at a facility manned by a community health officer or a
community health nurse. The basic care level refers to a facility with a midwife while the
comprehensive level refers to a referral facility.

While the management of complications of pregnancy and childbirth has generally remained the
same, there has been an expansion of procedures for managing haemorrhage, the leading cause of
maternal deaths in the postpartum period. The service provider at community level has also been
given an expanded role of providing basic management before referring a woman with postpartum
haemorrhage. Management of complications of the newborn has been expanded to include various
conditions of the sick newborn as well as conditions of the mother that put the baby at risk.

The annex section of this current edition contains a learning guide for managing some obstetric
emergencies and provides more illustrations on various procedures, including flow charts on the
management of selected maternal and newborn complications.

Specific protocols for family planning and post-abortion care are presented respectively in the
National Family Planning Protocol and the Comprehensive Abortion Care Services Standards and
Protocol.

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Safe Motherhood

Safe Motherhood is concerned with maintaining the health of the woman/and her new-born throughout the
process of pre-conception, pregnancy, childbirth and the post-delivery period. It means creating the
circumstances within which a woman is enabled to choose whether she will become pregnant or not, and if
she does, ensure she receives optimum care for prevention and treatment of pregnancy complications. It
also mean having access to trained birth assistants, emergency obstetric care if she needs it, and care after
birth, so that death or disability from complications of pregnancy and childbirth can be avoided for both
mother and baby.

Goal
The goal of the safe motherhood programme is to improve the health of women and their new-borns in
general and specifically to contribute to the reduction in maternal and new-born morbidity and mortality.

Components:

 Pre-conception care
 Antenatal care
 Labour and delivery care
 Postnatal care
 Family planning
 Comprehensive Abortion Care
 Health education and counselling

Pre-conception care is the counselling and care given to women planning to become pregnant. It involves
detecting and managing health problems that might affect the woman and her baby later and ensuring that
women with medical illnesses such as diabetes and hypertension have these conditions controlled before
becoming pregnant. It also involves steps taken to reduce the risk of birth defects and other problems; for
example, folic acid supplements given to women to prevent neural tube defects.

Antenatal, labour/delivery and postnatal care are the services provided from the time pregnancy is
confirmed until six weeks following childbirth and these will be considered in the ensuing sections of the
document. Family planning and post-abortion care are dealt with in separate management protocols.

Health education and counselling are important aspects of all the other components and provide
opportunities for promoting safe motherhood in formal settings such as health facilities and schools and
informal settings such as organized community groups as well as faith-based gatherings. The mass
media also provide cost-effective communication channels for reaching policy makers, civil society and
the general public. Some health education and counselling topics are outlined in appendix 3.

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 I. ANTENATAL CARE

Antenatal care (ANC) is the health care and education/counselling given during pregnancy. Antenatal
services are an important part of preventive and promotive health care.

A. OBJECTIVES
The objectives of ANC include:

1. To promote and maintain the physical and mental health and social wellbeing of mother and baby by
providing information and education to the pregnant woman on nutrition, rest, sleep, personal hygiene,
family planning, immunization, sexually transmitted infections (STIs) including HIV, danger signs, birth
preparedness and complication readiness.
2. To detect and manage high-risk conditions arising during pregnancy, whether medical, surgical or
obstetric.
3. To ensure the safe delivery of a full term healthy baby with minimal stress or injury to mother and
baby.
4. To help prepare the mother physically, psychologically and socially to breastfeed successfully,
experience normal puerperium and to take good care of the baby.

In order to promote quality care, antenatal services must be organized in such a manner as to provide
comprehensive and individualized care. As much as possible, all care activities for the pregnant woman
e.g. history taking, physical examination and treatment, should be done by the same care provider
(Focused Antenatal Care).

B. ROUTINE MANAGEMENT

Number and Timing of Visits: After pregnancy is confirmed at booking visit, the number of times a
client needs to be seen during pregnancy may vary according to her needs. For the uncomplicated
pregnancy it is recommended that at least four ANC visits should be made according to the following
schedule:

First scheduled Visit From onset of pregnancy up to 16 weeks gestation

Second scheduled Visit Between the 20th to 24th weeks of pregnancy
Third scheduled Visit Between 28th and 32nd week of pregnancy
Fourth scheduled Visit Between 36th and 38th week of pregnancy

A woman who is being seen according to the above visit schedule should be counselled to report to the
clinic at any time she feels unwell or has any problem. The woman should be seen more frequently if
complications are identified at any time during the pregnancy.

Booking Visit: The purpose of care at this initial visit is to confirm the pregnancy and identify existing
or potential problems that could adversely affect the pregnancy and childbirth. This visit also offers the
opportunity to determine if she will require routine or specialized care and plan her continuing care.

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Assessing the Client

Take a Comprehensive History: History must include the following information:

i) Personal Information
Name, age, home address, telephone number, educational status, occupation, marital status,
husband/partner’s information (name, address, telephone number), next of kin (name, address,
telephone number)
ii) Obstetric History
Past obstetric history (including all pregnancies, deliveries, outcomes and complications)
History of the present pregnancy (record LMP and calculate EDD and estimate the gestational age)
Information on STIs should be recorded
iii) Contraceptive history
iv) Medical and surgical history, including any known allergies to medication
v) Family medical history

Ways to Determine the Estimated/Expected Date of Delivery

Using Calendar Method

To find the Due Date: Add 7 to the day of the LMP and 9 to the month or
subtract 3 from the month. For example, in her LMP was 6th May 2016, add
7 to the 6, giving 13, then take 3 from May (May is month 5), giving 2
(month 2 is February). The EDD is therefore 13th February 2016.

If the number of days obtained by adding 7 to the day of the LMP exceeds
the days in the months obtained by adding 9 or subtracting 3from the
month of the LMP the EDD is obtained as follow: Subtract the number of
days in the new month from the number of days obtained. The result
obtained is the new day; add one month to the new month obtained to get
the month of the EDD. For example, if the LMP is 26 th April 2016, adding
7 to 26 will be 33. Subtracting 3 from 4 (April is the 4 th month) will give 1
(Which is January). However, January has 31 days, so you need to subtract
31 from 33, giving you 2. You then add one month to January, giving you
2 which is February. The EDD is therefore 2nd February 2016.

Take the first day of the last monthly bleeding then add 7 days and count
backward 3 months. For example, if her last monthly bleeding started May
6, count back 3 months (April 6, March 6, February 6). Then add 7 days
(February 6 + 7 days). February 13 is her due date.
Using Gestational Wheel
To find the Gestation and Due Date: Rotate the wheel until the Start of
Last Menstrual Period arrow on the smaller wheel coincides with the date
of the last menstrual cycle on the bigger wheel. Read the Due Date on the
gestation/pregnancy wheel

Using Ultrasound
If LMP is unknown request for ultrasound and note that the date on the
earliest scan is the most accurate.

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Perform Physical Examination
General Examination
 Examine the woman from head to toe with emphasis on examination of the conjunctiva and nail
beds for pallor (anaemia). Note her gait for any sign of pelvic deformity and check her feet for
edema. Check and record the following:
- Temperature
- Pulse
- Blood Pressure
- Weight and height

 Examine the breast for:

- Discharge
- Lumps
- Nipple, whether everted or inverted

Abdominal and Obstetric Examination:

 Inspect abdomen for its shape and note presence of any scars,
 Palpate for tenderness, uterine size, and other organ enlargements
 Measure the symphysio-fundal height in centimetres after 20 weeks.
 Check for fetal lie, presentation, and descent if at term
 Auscultate fetal heart tones after 20 weeks

Vulvo-vaginal Examination
 Inspect the vulva and perineum for abnormal discharges, rashes, warty growths and ulcers.

SYMPHYSIO-FUNDAL HEIGHT IN CM

Fig. 1

Laboratory and Other Investigations

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Request/ perform the following:
 Urine for Protein and Sugar
 Midstream specimen of urine for bacteria, ova and pyuria (pus cells in urine)
 Stool for ova and parasites e.g. worms
 Blood for:
- Haemoglobin level (Hb)
- Sickling (Hb electrophoresis if positive)
- Group and Rhesus factor (Antibody titre if Rhesus negative)
- Syphilis Test
- HIV Testing and Counselling
- G6PD Deficiency
- Hepatitis B Test
 Pelvic Ultrasound (for dating, fetal viability and abnormality, location of fetus and placenta)

Any previous investigation results must be reviewed before next visit is scheduled.
Care Provision
Client Education
Education is an essential part of antenatal care and should continue throughout pregnancy. Through
education, women learn what they can do to protect their health during pregnancy, why medical care is
important, and what danger signs to watch out for. In order for education to be effective, health workers
should observe the following principles:
 Courtesy and kindness: Treat Clients with respect and empathy especially if they are unsure or
frightened,
 Listen and ask: Many women already know a great deal about pregnancy and childbirth. Before
telling them what they should do, ask questions to find out what they know and what they want
to learn.
 Individualize the Health Education: relate topics to the gestational age, the woman’s needs and
specific problems identified.
 Answer questions: In addition to providing the basic information outlined below, health workers
should respond kindly to any questions or concerns women may have.

Give personal attention: Every woman is different and has different problems, therefore every
woman should be given information, education and counselling as an individual.

Cover the following topics during client education:

 Explain the purpose of antenatal care, as well as:
- Timing of next visit
- Total number of visits
- What to expect at subsequent visits
 Briefly explain physiological changes and events in pregnancy (e.g. changes in the breasts, growth
of the fetus, onset of labour, etc.)
 Care of her health
- Diet and nutrition: Use food charts in the maternal health record book to educate woman

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 - Rest and exercise: Encourage woman to take between 6-10 hours of sleep each night, and
try to rest for one hour during the day, undertake moderate exercise regularly, if her daily
activities do not entail much physical exercise. (Refer to pages 11-14 on exercises).
- Personal hygiene:-advice woman to keep her body clean, especially the hands, genital
area and breasts, to minimize chances of infection.
- Malaria prevention: Educate woman to keep her environment clean, use insecticide
treated nets (ITN) and on the purpose of Intermittent Preventive Treatment of Malaria
(IPT)
- Educate the woman on importance of family planning and options of contraceptives
available

 Danger signs during pregnancy

- Swelling of feet, hands, or face

- Severe headache or blurred vision
- Dizziness
- Severe abdominal pain
- Persistent vomiting
- Jaundice
- Rupture of the membranes
- Pale conjunctiva, tongue, palms, nail-beds
- Offensive and/or discoloured discharge from vagina,
- Bleeding from the vagina
- Fever
- Absence of fetal movements

 Birth preparedness and complication readiness

- How to reach help when complications develop
- Where she will deliver
- Support person
- Plan for finances, transportation and other preparations for delivery and complications
- Blood donation
 Education on misuse of drugs, and substance abuse
Give woman information on: -
- Antenatal drugs:- why they are given, how they should be taken
- Abuse/misuse of drugs and herbs
- Why Alcohol should be avoided during pregnancy
- Harmful consequences of smoking
- Harmful effects of Skin bleaching
 Explain effects of sexually transmitted infections including HIV and Cervical cancer:
Educate mother on:

- Factors affecting Mother to Child Transmission of HIV

- Prevention of STIs including HIV
- Benefits of HIV testing

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 - Offer HIV counselling and testing
- Counsel woman on the use of condom to prevent some STIs and discuss other sex- related
issues

Prescribe and/or administer the following:

i. Oral Iron daily (Non–anaemic clients)
ii. Folic acid daily
iii. First dose anti-malarial drugs;-3 tablets of sulfadoxine 500 mg-pyrimethamine 25mg (SP)

Anti-malarial drugs:-
All pregnant women should receive monthly doses of sulfadoxine pyrimethamine from 14
weeks/quickening till they go into labour.

A single dose consists of SP consist of 3 tablets of sulfadoxine 500 mg-

pyrimethamine25mg.
Health care provider should dispense and directly observe client-taking dose. (DOT)

iv. Anti-helminthic: Mebendazole500mg stat after first trimester

v. Give insecticide treated net
vi. Give Tetanus-toxoid immunisation. See schedule below:

Tetanus Immunization Schedule for the nonimmunized woman

 Number  When to give  Duration of Protection

 1st Dose At first contact (booking) No protection

 2nd Dose Four weeks after1st dose 1-3 years

 3rd Dose Six Months after 2nd dose  At least 5 years
 4th Dose At least one Year after 3rd dose At least 10 years
 5th Dose At least one Year after 4th dose Life-long

If there is enough evidence that the patient had completed the schedule as above, there will be no
need for a repeat or booster

Record all information gathered during history, physical examination and counselling provided as
well as treatment prescribed in the maternal health record book

At the end of the first visit, all information gathered through history, physical examination,
laboratory and other investigations should be fully and carefully analysed to plan subsequent care of
the client. Record all decisions made in the maternal record book. Clients with normal healthy
pregnancies will follow the routine protocols and visit schedules. Those with identified complications
will be managed accordingly.

Subsequent Visits
At every subsequent visit, refer to previous antenatal notes, findings and decisions made.

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a. History:
i. Ask about general health status since last visit.
ii. Ask about any new complaints or concerns, as well as the presence of any of the danger signs.
iii. Ask about fetal movements if gestation is more than 20 weeks
iv. Follow up on any previous problems identified and/or treated at earlier visit.

b. Physical Examination:
i. Check blood pressure, and measure weight.
(NB: in general, weight gain should not exceed 0.5 kg weekly)
ii. Look for anaemia, goitre, fever, jaundice, swelling of face, feet and hands and signs of physical
abuse

c. Obstetric Examination: measure symphysio-fundal height and compare with gestational age. If in the
third trimester determine lie, presentation, position, and descent if at term and listen to the fetal heart
tone.

d. Laboratory Investigations:
i. Test urine for sugar and albumin
ii. Check Hb (at 28 weeks and 36 weeks, or more frequently if indicated)
e. Administration of Drugs:
i. Re-supply enough of iron and folic acid to last till the next visit
ii. Give anti-malarials as necessary :SP for IPT
iii. Give Tetanus and Diphtheria immunization if indicated
iv. Commence Anti-Retroviral Treatment where indicated

f. Client education and counselling:

Continue with client education and counselling as relevant to client’s needs and gestational age as
follows:
i. Discomforts of pregnancy
ii. Birth preparedness and complication readiness
iii. Danger signs
iv. Sexual activity and safe sex
v. Signs and symptoms of labour
vi. Breastfeeding and breast care
vii. Infant feeding options for HIV positive mothers
viii. Family planning methods
ix. Postnatal care (Importance and schedule )
x. Newborn care, immunization schedule and danger signs in the newborn

At each subsequent ANC visit, information gathered through history physical examination and
laboratory investigations for each client should be carefully analysed to determine if pregnancy is
progressing normally or if new complications have developed. Complications identified should be
managed as per protocols.

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EXERCISE TO STRENGTHEN MUSCLES

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Common discomfort of pregnancy

Pregnant women report to the clinic in between scheduled visits because of minor discomforts. Below is a
table of these discomforts and how they can be managed.

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 The table below shows the Common Discomforts of Pregnancy, their Physiological Basis and how to manage them

Complaint, Signs and Anatomic/Physiologic Prevention and Relief Measures Signs that May indicate a problem for
Symptoms Basis which client must report for Care

Abdominal and groin pain Enlarging uterus Advise her and partner as follows: - Loss of appetite may indicate
stretches the round Lie on the side with knees and hips bent appendicitis
Cramps ligaments and muscles Place a pillow between the knees and
Twinges another pillow under the abdomen Abdominal pain in the first trimester
Pulling sensations or may also indicate an ectopic pregnancy
sudden When pain becomes bothersome try any of
Pain on the sides of the the following: Upper abdominal pain that may be
lower abdomen. Gently massage or apply firm pressure relieved by food but re-occurs 2-3 hours
Occurs most commonly over the painful area. later with, loss of appetite, nausea or
during 2nd – 3rd trimester Apply warm cloth or take warm baths vomiting, intolerance of fatty foods
Flex the knees onto the abdomen may indicate gall bladder disease or
peptic ulcer
Breast Changes Hormonal changes of Wear a well-fitting bra while sleeping A lump
pregnancy cause Keep nipples dry and clean to protect Dimpling/puckering
Bilateral increase in size changes in breast in from infection Redness
Tenderness or tingling preparation for lactation Return for care if signs and symptoms Sores
Thin, Clear yellowish nipple and breast feeding worsen Rashes
discharge Area of scaling

Above may indicate carcinoma

Leg Cramps Unclear cause If pain becomes troublesome Localized pain over a vein
Gently massage or apply firm pressure Swelling of the affected limb which
Onset is sudden and Occasionally from over the painful area may indicate thrombosis
duration short. pressure of fetal head Straighten knee and flex foot upward Calf muscle tenderness and
on nerves as head Stand on toes of affected leg and swelling of the one affected limb
Most commonly occurs descends Press heel toward the floor may indicate deep vein thrombosis
during the 2nd and 3rd Take frequent breaks from sitting or (DO NOT MASSAGE LEG)
trimester standing for long periods Numbness/tingling of fingers and
Return for care if signs and symptoms toes
worsen

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 The table below shows the Common Discomforts of Pregnancy, their Physiological Basis and how to manage them

Complaint, Signs and Anatomic/Physiologic Prevention and Relief Measures Signs that May indicate a problem for
Symptoms Basis which client must report for Care

Complaint, Signs Anatomic/Physiologic Basis Prevention and Relief Measures Signs that May indicate a problem
and Symptoms for which client must report for
Care
Swelling (oedema) of Hormonal changes cause: - When lying down, lie on your left Headache
ankles and feet Increase in levels of side with legs slightly elevated Blurred vision
Appears at the end sodium When sitting, slightly elevate your Nausea or vomiting
of the day, after Congestion in veins in feet/legs Epigastric pains
sitting or standing lower legs  Avoid: - Above may indicate severe pre-
for a long time Fluid leakage from Crossing the legs when sitting eclampsia
Disappears after capillaries become easier Tight or restrictive bands around legs Fatigue or sleeplessness
rest or elevating Enlarged uterus puts and Dizziness or fainting
feet pressure on veins when Sitting or standing for long periods Pallor
Most commonly the woman is sitting and, Increase intake of fluids Breathlessness and rapid heart beat
occurs during the especially when lying Return for care if signs and symptoms Above may indicate severe anaemia
2nd – 3rd trimester down on her back leading worsen Localized pain over a vein, swelling
to: of the affected limb may indicate
Blood increase in leg superficial thrombosis
veins Calf muscle tenderness swelling of
Varicose veins becoming the affected limb may indicate deep
swollen and twisting vein thrombosis
Bowel changes – Constipation Ensure good diet which includes Rapidly progressing difficulty in
Constipation Hormonal effects relax Increased intake of fresh fruits and defecation
commonly occurs smooth muscles slowing vegetables A feeling of gas in abdomen
during the 2nd – 3rd digestion and elimination Increased intake of fluids Vomiting
trimester Slowed digestion Drink hot or cold fluids on empty stomach Rapid distension of abdomen
increases water absorbed preferably in the mornings Worsening general condition
from colon Empty bowels promptly when the urge is Above may indicate bowel obstruction
Enlarged uterus puts felt
pressure on the lower bowel Avoid laxative use, lubricate enemas
slowing movement through If signs and symptoms worsen, report
intestines

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Complaint, Signs and Anatomic/Physiologic Prevention and Relief Measures Signs that May indicate a problem
Symptoms Basis and when Client must report for Care
Frequent Urination Enlarged uterus puts Void when the urge to urinate is felt - If frequent urination is accompanied
Increase in frequency pressure on the Lean forward when voiding to help empty by pain and fever, it may indicate
especially at night bladder the bladder completely UTI
Leaking of urine when During the day the Do not restrict fluid intake but limit intake - Increased thirst
sneezing, coughing or lower legs and feet of fluid containing natural diuretics e.g. - Passing of large volumes of urine
laughing become swollen, coffee, tea - Excessive hunger
(Most commonly occurs but when the If signs and symptoms worsen return for Above may indicate, diabetes mellitus.
during the 1st and 3rd woman rests with care
trimester) her feet up, the fluid
is reabsorbed and
excreted by the
kidneys
Increased volume of
fluid in the body
Increased blood
flow to kidneys
Increased excretion
of sodium and water
Nausea or vomiting Hormonal effect on - Eat biscuits, crackers, dry bread or Nausea and vomiting associated
Smooth muscles of other grain food with
Most commonly occurs the upper GI tract - Eat smaller, but more frequent meals Epigastric pain, headache, blurred
during the 1st trimester Changes in - Avoid over eating and eating of fatty, vision, flashes of light may
carbohydrate fried and spicy foods indicate severe pre-eclampsia
metabolism - Drink fluids between meals rather than Loss of appetite, intolerance of fatty
with meals food may indicate gall bladder
- Sit upright for a least one hour after disease
meals Dehydration may indicate
Get plenty of fresh air, take short hyperemesis
walks, sleep with windows open Fever or chills may indicate malaria
Avoid lying down immediately after or urinary tract infection
eating
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 Avoid odours or other known factors
likely to induce vomiting
Avoid brushing the teeth or cleaning
the tongue soon after meals
If signs and symptoms worsen, return for
care.

Vaginal Discharge Increased vascularity of  Ensure good personal hygiene Profuse, watery, frothy, foul
genital tract leading to Keep the vulva area as clean and dry smelling, yellowish or greenish
increased vaginal as possible discharge.
secretion and cervical Change wet pants often Intense itching of vulva with cheesy
mucus production Wear cotton instead of nylon discharge indicate candida infection
underwear Sores, ulcers or warts on genitals or
Flare up of latent Avoid douching any of these symptoms in the
candida infection If signs and symptoms worsen, return for care woman’s partner(s) which may
indicate sexually transmitted
infection (STI)
Fatigue or sleeplessness Decreased  Ensure adequate diet Dizziness or fainting
metabolism in early  Take micronutrients supplement as Pallor
Most commonly occurs pregnancy directed Breathlessness,
during the 1st trimester Increase in blood  Get daily exercise Rapid heartbeat,
volume and flow,  Massage the lower back Swelling of limbs,
which causes heart  Avoid over exertion and Headache.
to work harder  Avoid smoking and alcohol These may indicate severe anaemia or
Emotional stress  The woman’s partner must be supportive cardiac failure
If signs and symptoms worsen report for care
Haemorrhoids  Hormonal changes Eat adequate diet  Constipation with anal pain
cause enlargement Take adequate fluids  Bleeding on defecation which may
Swollen veins in and around and congestion of Increase intake of high fibre foods like indicate an anal fissure
the rectum, associated with rectal veins fresh fruits and vegetables
pain, itching and bleeding  Enlarged uterus puts  Have warm sitz baths
pressure on rectal  If haemorrhoids is protruding apply ice
Most commonly occurs veins packs to the area and gently reinsert
during 2nd – 3rd trimester  Constipation haemorrhoid into the rectum
 Apply anaesthetic ointment if necessary.
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 Avoid:
Constipation or diarrhoea
Straining during bowel movements
Sitting for long periods especially on
hard surface
 If signs and symptoms worsen return for
care

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STEPS IN IDENTIFICATION/MANAGEMENT OF CONDITIONS / COMPLICATIONS

COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

a. Anaemia; Haemoglobin  Assess client for severity and possible cause of anaemia  Same as Basic Care Level
less than11g /dl  Do laboratory investigations to confirm severity and  Diagnose cause and type of anaemia
cause with laboratory investigations,
Moderate 7-10.9g/dl Hb including:
Sickling  Full Blood Count (FBC), Sickling,
Severe less than 7g/dl Blood Film (BF) for malarial parasites (mps). Blood Grouping and Cross Matching,
Stool RE BF for Malarial Parasites, Blood film
COMMUNITY LEVEL Urine RE comment
 Ask for following If gestation is greater than 28 weeks and/or client has  Hb Electrophoresis
symptoms: symptoms of severe anaemia and/or Hb is less than 7g/dl  G6PD
Feeling tired or REFER to next level  Stool RE
breathless on the  Depending on gestational age and
slightest exertion If Hb is 7-I0.9gm/dl: - severity of anaemia, treat with oral iron
Palpitation or dizziness  Advise on diet and folic acid, or blood transfusion
Examine the conjunctiva,  Treat Anaemia with Iron tablets (when severe or client is at term)
tongue, palms and nail beds for  Folate (Folic Acid)  Treat associated conditions (e.g.,
pallor; if present, counsel client  Multivitamins malaria intestinal parasites)
to eat food rich in iron/folate  Give broad spectrum anti-helminthics if indicated  Monitor Hb level closely for
and Vit. C (leafy green (Mebendazole 500mg stat.) improvement
vegetables, red meat, liver),  Advise on place of delivery if near term.
 If Hb improves, continue Iron/Folate, improved diet and
and REFER  Ensure availability of donor blood if
monitor fortnightly
near term
Start preparing Blood Donors REFER  No client should be allowed to into
If HB dropped further, or remains unchanged labour with an HB lower than 10g/dl.

20
COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

b. Gestational Hypertension Measure blood pressure in sitting position (recommended) Same steps as for Basic Care Level
in Pregnancy
Definition: Mild Disorder
Mild Disorder
Admit and monitor fetal and maternal
Systolic BP greater than  If diastolic blood pressure is equal to 90mmHg or greater
condition with the support of laboratory
140mmHg or diastolic BP or Systolic is more than 140mmHg, ask the woman if she
investigation, start anti-hypertensive
greater of 90 mmHg after 20 has following symptoms:
medication and aim at delivery at 38 weeks
weeks of pregnancy. - Severe headache
- Nausea or vomiting Maternal and fetal monitoring
Classified as mild and severe. - Blurred vision
Monitor:-
- Flashes of light
- BP 4 hourly,
Mild Disorder - Epigastric pain and
- Urine protein daily,
If diastolic BP is between  Check protein in urine
90mmHg and < 110mmHg - Reflexes daily
and/or Systolic BP between  If no symptoms present repeat after one-hour rest - Maternal weight measurement weekly
140 and < 160  If diastolic blood pressure is still equal to 90mmHg or - Fetal heart rate auscultation twice daily
greater or Systolic is more than 140mmHg, counsel and -Fetal kick count daily
refer. - Symphysio-fundal height measurement
Severe Disorder Severe Disorder weekly
If diastolic BP is ≥ 110 mmHg If the patient has severe disorder Refer patient urgently
(Systolic ≥160 mmHg)
after initial treatment with: Perform Laboratory Investigations
If in addition to the  If BP is equal or greater than 160/110mmHg, give oral Hb, Platelet Count, BUN, Uric acid, LFT,
hypertension protein is also Nifedipine 20mg St. Bed Side Clotting Test
found in the urine (proteinuria)  MgSO4 loading dose if indicated as per protocol
then the condition is called Anti-hypertensive medication
preeclampsia. Preeclampsia - NB: avoid SL Nifedipine Give or continue Antihypertensive
can also be mild (proteinuria (Nifedipine, Hydralazine, Aldomet) as per
<3+) or severe (proteinuria  Give IM Dexamethasone 6mg if Fetal maturity is less protocol
>=3+) in addition to presence than 34 weeks and refer
of certain symptoms and signs Severe disorder
COMMUNITY LEVEL  Control BP with IV hydralazine
Ask for symptoms, such as
 Control/Prevent fit with MgSO4 as
severe headaches, blurred
21
COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

vision, flashes of light or per protocol if not already given

epigastric pain:  Deliver as soon as practicable
irrespective of gestational age
Look for oedema of feet,
 Pass urine catheter and monitor
hands, face, ankles (e.g. rings
too tight for fingers. or shoes urine output
too tight)  Give IM Dexamethasone 12mg bd
for 24 hours if Fetal maturity is less
REFER immediately than 34 weeks
Start preparing blood donors  Perform laboratory investigation as
above including BEDSIDE
CLOTTING TIME

Hydralazine Regime
 If diastolic blood pressure is greater
than 110mmHg or Systolic BP above
160mmHg : -
- Give hydralazine 5mg IV slowly
(over 5 minutes)
- Monitor BP every 30 min.
- If diastolic blood pressure remains
greater than 110mmHg and/ or
Systolic BP greater than 160mmHg,
repeat the dose at 30 minutes
intervals until diastolic BP is
100mmHg. Do not allow diastolic
to go below 100mmHg.
- Do not give more than 20mg in total

Mode of Delivery
- Expedite delivery within 24 hours
22
COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

- If maternal and fetal conditions are

stable and cervix is favourable attempt
vaginal delivery
Deliver by C/S
- If in labour but not near second stage
monitor progress of labour, maternal
and fetal condition closely. Deliver by
Vacuum when in second stage.
- Conduct active management of third
stage with oxytocin (DO NOT GIVE
ERGOMETRINE)

STEPS IN IDENTIFICATION, AND MANAGEMENTOF CONDITION/COMPLICATION

COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

c) Eclampsia MANAGE AS PER SEVERE PRINCIPLES OF MANAGMEENT

PRE-ECLAMPSIA AND REFER 1. Control fits with MgSO4 protocol
High blood pressure URGENTLY 2. Control BP
with or without 3. Deliver patient if not delivered already
Proteinuria and
Convulsion

COMMUNITY
LEVEL

Ask if woman had fits,

was woman found
unconscious, or was
23
fitting soon after
delivery.

If yes,
- Prevent her from
hurting herself;
- Remove sharp or
dangerous objects
from near patient
- Do not restrain her
- When fit is over,
place her on her
side to prevent her
from choking on
vomit; then
REFER

24
STEPS IN MANAGEMENT OF CONDITIONS/COMPLICATIONS

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
d) Chronic /Essential If client is a known hypertensive patient on Investigate for cause of Hypertension if necessary
Hypertension treatment, counsel her on need for additional rest Evaluate cardiovascular system
Signs/Symptoms of worsening Hypertension and Do laboratory investigations
Diastolic B/P more family planning Urea/Creatinine /Uric acid levels
than 90mmHg and or Manage as gestational hypertension and REFER
Systolic is more than to Comprehensive care level after counselling. If client was on anti-hypertensive medication before
140mmHg pregnancy and BP was well controlled continue same
Before 20 weeks medication if there is no contraindication for
gestation pregnancy.

COMMUNITY Start Antihypertensive medication if BP poorly

LEVEL controlled: i.e. If diastolic BP > 100mmHg systolic BP
>160 mmHg.
REFER (Recommended drugs are Aldomet and Nifedipine)

AVOID DIURETICS

Plan regular ANC visits schedules with client.

Monitor BP, urine Albumin,
Fetal growth and condition

If proteinuria develops consider Super- imposed pre-

eclampsia and manage as above

25
STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
e) Diabetes Mellitus Suspect Diabetes in a woman with the following If above risk factors are present, screen for diabetes
in pregnancy risk factors: using the following methods;

Symptoms:  Family history of diabetes  Fasting blood sugar (FBS) and 2hour post-
 Personal history of diabetes prandial
 Polyuria
 History of big babies (Birth Weight>(4.0kg)
 Polydipsia,  Random blood sugar (RBS)
 Symphysio Fundal height large for gestation
 Polyphagia
 Repeated miscarriages  Oral glucose tolerant test (OGTT)
COMMUNITY  Previous unexplained stillbirth(s)
LEVEL  Previous babies with congenital malformation
FBS<5.3 mmol/Normal
 Polyhydramnious FBS> 5.3 - 7.5 mmol/L- Do OGTT
If woman complains
 Maternal weight >90kg FBS>7.5 mmol/L, Manage as diabetes
of any of the above
symptoms  Recurrent Urinary Tract Infections(UTI) or
Candidiasis If diabetes is confirmed, refer to Obstetrician.
REFER  Presence of Symptoms
 Glycosuria (Glucose in urine)

In the presence of one or more of the above risk

factors REFER to the next level.

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
f) Fever in Make differential Diagnosis (Malaria, Urinary Same as Basic Care Level plus
Pregnancy tract infection, Respiratory tract infection,
26
Temperature 38oC Meningitis, Hepatitis, Typhoid mastitis) Investigate further if no improvement, and treat cause
and above of fever
 Check vital signs,
COMMUNITY Examine: Manage other complications
LEVEL  Chest (respiratory rate, air entry, added
 Ask about fever, sounds)
general malaise,  Abdomen (tenderness and enlargement, liver,
vomiting, cough, spleen, renal angle tenderness)
headache, loss of  Breast (tenderness, nipple discharge)
appetite, dysuria  Inspect Genitalia for discharge
and frequency  Conduct Laboratory Examination: Hb, WBC,
MPs, Urinalysis
 Reduce high  Check wellbeing of foetus
temperature by  Manage according to cause or refer to higher
tepid sponging level as appropriate
 Give Tabs
Paracetamol 1g tid
and encourage
fluid intake

REFER

27
STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/PROBLEM BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

h) Complicated Malaria: Do laboratory investigations:- SAME AS BASIC CARE LEVEL PLUS
Full blood count,
Signs and Symptoms are as in Bf for mps Laboratory Tests
Uncomplicated Malaria plus the Urine analysis
following: Renal function test, serum electrolyte
Tepid sponging
Persistent vomiting Liver function tests
Persistent temperature more than 38oC Give IV 5% Dextrose or Dextrose saline IM or IV
Severe anaemia Quinine 10mg/kg Blood group and X-match if anaemic,
Jaundice Or IM Artesunate 2.4mg /kg body weight
Dark Brown urine Check random blood sugar
Drowsiness Or Rectal Artesunate 10mg/kg body weight (4 X
Poor urine output 200mg) Give or continue full course of anti-malarial
Convulsion treatment
Give tabs Paracetamol1g stat if conscious: Give
COMMUNITY LEVEL rectal Paracetamol if unconscious
Carry out tepid sponging Monitor fetal well being
Refer immediately Identify donors if anaemic and
REFER

28
QUININE, ARTESUNATE REGIMEN
QUININE REGIMEN 10mg/kg ARTESUNATE REGIMEN
 Quinine 600 mg in IV infusion to run at 30 drops per minute  Give rectal Artesunate10mg/kg body weight tat as a pre-
 Give IV infusions , 3 litres in 24 hours referral treatment.
 Monitor fluid balance and urine output In the event that it is expelled within 30 minutes , it should be
 Give Anticonvulsants where necessary repeated
 Give IV diazepam 10 mg ( Refer diazepam protocol)

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARELEVEL C

PROBLEM
i) Urinary Tract Ask about symptoms: Same as Basic Care Level Plus
Infection (UTI) - pain or difficulty with urination, fever, pain in Take urine for culture and sensitivity
the flanks
Fever plus Nausea, and or vomiting: If culture result is not available and
Painful urination  Reduce high temperature by tepid Pyelonephritis is suspected and patient has persistent
Frequent urination sponging vomiting
and urgency  Give Paracetamol1gtid
Supra pubic pain  Encourage fluid intake Start IV antibiotics
Back / loin pain Do laboratory investigations  IV Cefuroxime 750mg 8 hourly until fever free
Abdominal pain Urine RE for 48hours, then tabs 500mg bid ×5
Nausea/ vomiting Full blood count  IV Ceftriazone1g bid until fever free for
If Urine RE show pus cells >10/HPF, Protein +, 48hours, then tabs Cefuroxime 500mg bid x 5
COMMUNITY RBC+ Bacteria present
LEVEL FBC shows raised WBC count >10,000 If culture results become available treat accordingly

Ask woman about Start Broad spectrum Antibiotics Repeat Urine RE /CS one week after completion of
symptoms: pain or  Amoxicillin 500mg plus Clavulanic acid treatment to confirm cure.
difficulty with 125mg bid for 7 days
urination, fever, loin  Or Tab Nalidixic acid 1g qid for 7 days Ensure vigilant maternal and fetal monitoring
pains: throughout the pregnancy
29
 Nausea, and or  Or Tab Cefuroxime 500mg bid for 5
vomiting: days
 Reduce high  If symptoms persist after 48 hours
temperature by REFER
 tepid sponging
 Give If patient improves Continue treatment
Paracetamol 1g Repeat Urine RE one week after treatment to
tid confirm cure
 Encourage fluid Ask about pain in the flanks (kidney area)
intake If pain in the flanks present, REFER
REFER

STEPS IN MANAGEMENTOF CONDITION/COMPLICATION

COMPLICATION/PROBLEM BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Vaginal Bleeding in If any bleeding from vagina: Ask about Assess severity of bleeding
Pregnancy amount  Evaluate quickly general condition of patient
 Assess severity of bleeding  Check - Pallor, Pulse, BP, Temp
 Evaluate quickly general condition of  Examine abdomen: gestational age, fetal heart sounds,
Before 28 weeks patient tenderness, distension
 Check - Pallor, Pulse, BP, Temp  Inspect Vulva/ Vagina: Severity of bleeding,
COMMUNITY LEVEL  Examine Abdomen: gestational age,  Do speculum examination to check state of cervical os and
fetal heart sounds, tenderness, presence of Product of Conception (POC)
If any bleeding from vagina, distension  If cervical os is closed, manage as threatened abortion and
 Inspect vulva/ vagina for severity of request for ultrasound scan.
(Do not perform vaginal bleeding,  If cervical os is opened or POC is seen in the os, manage as
examination)  Do speculum examination to check state inevitable or incomplete abortion.
of cervical os and presence of product
REFER (Accompany patient to of conception (POC)  If in shock or bleeding profusely:
the next level)  If cervical os is closed, manage as  Mobilize help (Take blood sample for Grouping/Cross-
threatened abortion and request for matching
ultrasound scan.
Start preparing blood donors  If cervical os is opened or POC is seen Urgently Resuscitate
in the os, manage as inevitable or Start IV Fluids: Normal Saline/ Ringers lactate
incomplete abortion. First 1000 ml in 15 – 30 min
30
 Second 1000mls in the next hour
If in shock or bleeding profusely: Transfuse if necessary
Mobilize help (Take blood sample for
Grouping and Cross-matching to be done at Request for Laboratory
next level
Urgently Resuscitate: Hb, WBC,
Start IV Fluids: Normal Saline/ Ringers Do ultrasound for fetal viability, placenta localisation and to rule
lactate out ectopic and molar pregnancies
First 1000 ml in 15 – 30 min
Second 1000 mls in the next hour and
REFER

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
j) Threatened If any bleeding from vagina: Ask about amount Same as for Basic Care Level
abortion
 Evaluate quickly general condition of Do laboratory/other investigations including
patient
SUSPECT WHEN:  Check - Pallor, Pulse, BP, Temp Hb, Blood grouping/cross-matching,
 Light to moderate  Examine Abdomen: gestational age, fetal Ultra sound for fetal viability, rule out ectopic and
bleeding heart sounds, tenderness, distension molar pregnancy
 Closed cervical os  Inspect Vulva/ Vagina: Assess severity of
 Uterine size bleeding, Give Iron supplements : Manage as in Basic level
corresponds to  Do speculum examination to check state of
dates cervical os and presence of product of
 Absent or slight conception (POC)
cramping or lower Perform Bimanual examination to assess
abdominal pain  Size and position of uterus

31
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
If bleeding is mild and cervical os is closed

Advise on adequate rest and to avoid strenuous

activity and sex
COMMUNITY
LEVEL
Educate the woman to report if bleeding
worsens, in pain and febrile
Ask about amount of
bleeding
Give Paracetamol 1g tid for 3 days
If bleeding stops:
If slight (less than two
pad changes in 24
Monitor for fetal growth
hours)
Refer for ultrasound scan for fetal viability if
Encourage fluid intake
available, Start ANC
and REFER

If bleeding is heavy
REFER (accompany
patient to the next
level)
Start organising blood
donors

(Do not perform

vaginal examination)

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

32
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
k) Inevitable abortion Assess severity of bleeding SAME AS BASIC CARE LEVEL PLUS
Evaluate quickly general condition of patient
SUSPECT WHEN:  Check - pallor, pulse, BP, Temp Do investigations
 Moderate to heavy Examine abdomen: gestational age Blood: Hb Grouping and Cross-matching; X-match if
bleeding fetal heart sounds, tenderness, distension intention to transfuse
 Dilated cervical os  Inspect Vulva/ Vagina:
Do speculum examination to check state of
 Cramping or lower Ensure post abortion follow up:
cervical os and presence of POC
abdominal pain  Provide Family planning counselling
 Fetal membrane Perform bimanual examination to assess  Treat Anaemia if indicated with Iron/ Folate
bulging  Size and position of uterus
 Feel for masses or tenderness in adnexa and
COMMUNITY Pouch of Douglas,
LEVEL  Perform pelvic ultrasound if available
Ask about amount of If uterus is less 10 weeks gestation
bleeding Plan for evacuation of uterine contents by
MVA.
If slight (less than two If evacuation is not immediately possible or
pad changes in 24 uterus is more than 10 weeks, arrange to
hours) transfer for EOU at next level as soon as
Encourage fluid intake possible.
and REFER Give antibiotics after MVA
 Amoxicillin 500mgtid for 7 days plus
If bleeding is heavy, Metronidazole 400 mg tid x 7 days
Organise blood donors
 Doxycycline 100mg bid for 7 days plus
and REFER
(accompany patient to Metronidazole 400 mg tid x 7days
the next level)
Give tabs Paracetamol 1000mg tid for 3 days or
(Do not perform Diclofenac Suppository 100mg bid for 3 days
vaginal examination)
Before REFERRAL
33
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
If evacuation is not possible by MVA
Give Misoprostol 400mcg orally; repeat once
after 4 hours, if necessary

Set an IV line (Normal Saline/Ringers lactate)

Accompany client to the next level.

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
m) Complete Abortion Confirm diagnosis through history and Same as Basic Care Level plus
examination and ultrasound.
SUSPECT WHEN: Conduct investigations
 Light bleeding If abortion is complete cover patient with Blood: Hb, Grouping and Cross ’matching
 Closed cervix antibiotics
 Uterus is smaller
 Amoxicillin 500mgtid for 7 days plus Ensure post abortion follow up:
than dates
Metronidazole 400 mg tid x 7days  Provide Family Planning counselling
 No or light  Treat anaemia if indicated with Iron/ Folate
 Doxycycline 100mg bid for 7 days plus
cramping
Metronidazole 400 mg tid x 7days
 History of
expulsion of Give tabs Paracetamol 1000mg tid for 3 days
products of or Diclofenac Suppository 100mg bid for 3
conception days

COMMUNITY Ensure post abortion follow up:

LEVEL  Provide Family Planning counselling
Ask about amount of
bleeding and expulsion  Treat Anaemia if indicated with Iron/
of products of Folate
conception
34
SEPTIC ABORTION BASIC CARE LEVEL COMPLREHENSIVE CARE LEVEL
SUSPECT WHEN Do quick evaluation of the patient SAME AS BASIC CARE PLUS
 Patient has  If condition is stable take history from
passed out POC patient Continue with resuscitations
 History of  Do a general examination as well as Labs: FBC, LFTs, RFTs, Blood cultures, Endocervical
having abdominal examination swabs for culture
tempered with  Assess abdomen for tenderness and Modify antibiotics according to sensitivity patterns
the pregnancy distension Evacuate the uterus using MVA, if not done
 Fever  Do a pelvic examination assessing the Post abortion contraception and counselling
 General malaise vagina and cervical os for POC
 Offensive  Assess the size of the uterus
vaginal  Assess the adnexa and the pouch of
discharge Douglas for fullness and tenderness
 Lower  Set up IV line and administer IV fluid
abdominal pain and parenteral antibiotics
COMMUNITY  Do a pelvic ultrasound if available
LEVEL  If there POCs in utero, evacuate the
 Ask of uterus using MVA at least two hours
symptoms after starting antibiotics
 Check BP  Change to oral antibiotics 48 hours after
and pulse fiver has subsided and continue for a
 Organise week
blood donor  If patient is not stable, start immediate
and REFER resuscitation
urgently  Organise blood donors and REFER
immediately.
 Accompany patient

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

35
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
n) Ruptured Ectopic Do quick evaluation of patient  Same steps as for Basic Care Level
pregnancy
 Check BP, Temperature, Pulse,
Continue resuscitation
 Assess abdominal tenderness, distended
 Woman of child abdomen Urgent Hb, Sickling, Grouping &Cross-matching of
bearing age blood sample
 History of  Set up IV line immediately, start Arrange for immediate Laparotomy
Amenorrhoea (there resuscitation and refer urgently
may be no history of (DO NOT WAIT FOR BLOOD before performing
amenorrhoea) surgery)
 Take blood sample for grouping and X’
 abdominal matching to be sent to next level
pain/Lower Transfuse if necessary (auto transfuse if possible)
Give anti D if indicated
Abdominal pains  REFER immediately (Accompany
 Fainting/Collapse patient)
 Light to moderate  Organise blood donors Before discharge from hospital:
bleeding Educate on
 Intra-operative findings
COMMUNITY
 Future fertility implications
LEVEL
Ask of symptoms  Probable risk for another ectopic
Check BP and pulse  Treat anaemia with Iron /folate
 Provide Family Planning counselling
REFER Urgently
(Accompany patient to
the next level)

Organise blood donors

o) Molar Pregnancy Confirm diagnosis through history, examination SAME AS BASIC LEVEL PLUS
and review of scan report (if available)
 Moderate to heavy Continue Resuscitation
Arrange referral
36
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
bleeding Before transfer, If bleeding is heavy Do investigations:
 Partial expulsion of Pregnancy test /Serum BHCG
POC which  Start resuscitation as above Blood: FBC, Sickling, Grouping& Cross Matching
 Take blood for Grouping &Cross matching Pelvic Ultrasound
resembles
to be done at next level Chest X-ray
grapes/vesicles
 Give Misoprostol 400mcg orally
 Excessive Transfuse blood if necessary
nausea/vomiting Start Antibiotics: Amoxicillin 1g Evacuate uterus by suction curettage (electronic or
 Cramping lower MVA)
abdominal pain Keep sample of tissue passed for examination at  Oxytocin 20 units in 500 ml N/S or R/L at 60
next level drops per minute once evacuation is under way
 Early onset pre-
eclampsia Note: Uterus can be easily perforated if D&C is done
Do not perform vaginal examination
Take specimen for histological examination
(before 20 weeks of
gestation)
Subsequent management:
No evidence of fetus
 Educate patient about need for long term follow up
 Explain importance of avoiding pregnancy for one
COMMUNITY
year.
LEVEL
 Provide hormonal contraceptive preferably POCs
If slight bleeding(less
 Treat anaemia with iron/Folate. .
than 2 pad changes in
24 hours)
Encourage fluid intake Refer for specialist care if possible.
and REFER
If specialist care not accessible: Follow up with serum
If bleeding is heavy, beta HCG or urine pregnancy test for one year as
REFER (accompany follows
patient to the next
level)  Weekly for first 4 weeks then
Organise blood donors  Two weekly for 2 months then
 Monthly for 3 months then
 Three monthly for 6 months

37
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
If pregnancy test remains positive after 8 weeks or
becomes positive at any time during the period
REFER for specialist care

STEPS IN MANAGEMENTOF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
p) Antepartum If any bleeding from vagina: Continue resuscitation
Haemorrhage(APH) Reassess woman’s condition
(Vaginal bleeding after Let the patient lie down Conduct physical examination
28 weeks of gestation Do laboratory investigation:
and before delivery ) Ask about amount of blood loss to assess  Blood for Hb, bed side clotting
severity of bleeding  Grouping & cross matching, clotting profile
COMMUNITY Conduct physical examination  Urine for protein
LEVEL  Check vital signs BP, Pulse, Respiration  Determine cause and severity of bleeding
Let the patient lie down
 DO NOT perform any vaginal Transfuse if in shock, OR Hb less than 7g/dl
DO NOT perform any Examination
vaginal examination  Secure IV access Do ultrasound scan to confirm
 Take sample to be sent to the next level  Cause of bleeding i.e., placenta praevia or
REFER immediately and start resuscitation abruption placentae and
(accompany patient to  Fetal viability and maturity
next level) If bleeding is heavy and/or patient is in shock:
(Pale, BP less than 90/60, Pulse is rapid more Deliver immediately if:
Organise blood donors than 120 beats /, min)  Pregnancy is more than 37 weeks
Treat for shock and REFER (accompany patient  Bleeding is severe
to next level)
 Unstable feto/maternal condition
Organise blood donors
Manage until 37 weeks if:
 The pregnancy is less than 37 weeks
 Bleeding stops or minimal
38
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
 Stable feto/maternal condition

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
q) Abruptio placenta If abruption is suspected: Same as Basic Care Level plus

(Vaginal bleeding in Ask about amount of blood loss to assess Do laboratory investigations:
late Pregnancy: After severity of bleeding  Hb, sickling,
28 weeks and before Conduct physical examination  Clotting profile
delivery Check vital signs: BP, pulse respiration  Urine protein
 Blood Grouping and cross matching and save 2
Bleeding may be DO NOT PERFORM VAGINAL units
concealed i.e. Retained EXAMINATION  Ultrasound for placental localization if available
inside the uterus
If bleeding is light and patient is stable Deliver quickly irrespective of gestation
Intermittent or constant  Check Hb, sickling and blood group
abdominal pain  Perform bedside clotting test (see appendix) 1. If in labour, cervix is favourable, and
–if clotting does not occur after 7 mins, or a or delivery is imminent; Augment
Shock: may be out of soft clot forms and breaks down indicates Labour with Oxytocin infusion
proportion with visible coagulopathy
blood loss 2. If not in labour or delivery not imminent
Organise donors and REFER
Tense/ Tender Uterus Deliver by Caesarean Section
If Bleeding is very heavy and /or Patient is in If coagulopathy DIC, transfuse with fresh blood, fresh
Decreased or absent shock: (Pale, BP less than 90/60, pulse is rapid frozen plasma if available,
39
 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
fetal movements more than 120 beats / minute) IV tranexamic acid 1g 8 hourly

Fetal distress or absent Treat for shock as above Ensure continuing follow up postpartum to correct
fetal heart sounds anaemia.
Take blood for grouping and cross-matching
(analysis will be at next Level)
COMMUNITY
LEVEL (Do not give Colloids e.g. Dextran or Dicks
Ask if any bleeding Plasma)
from vagina
Let the patient lie down Inspect perineum to see if presenting part is
Visible and delivery imminent.
DO NOT perform any
vaginal Examination Organise blood donors and accompany patient
to next level if delivery is not imminent
REFFER immediately
(accompany patient to If delivery is imminent (presenting part is
next level) visible, cervix fully dilated)
Organise blood donors  Deliver by Vacuum extraction
 Perform active management of third stage

After delivery of placenta set up infusion - 20

units oxytocin in 500ml Normal Saline at 20–40
drops /min for six hours.

Monitor patient closely for

 Vital signs
 Look for signs of bleeding
 Record urine output

Refer when patient is stable. Accompany

patient

40
COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
STEPS IN
r) Placenta /MANAGEMENT
Praevia OFpraevia
If Placenta CONDITION/COMPLICATION
is suspected: Same as for Basic Care Level

Vaginal bleeding in Ask about amount of blood loss to assess If bleeding is slight, maternal and fetal condition
late Pregnancy: After severity of bleeding remain stable and gestation is less than 37 weeks:
28 weeks and before
delivery Conduct physical examination Admit and monitor mother and baby closely on ward
Bleeding may be for rest of duration of pregnancy
provoked by sex Check vital signs: BP, pulse respiration
Do laboratory investigations:
Shock is in proportion DO NOT PERFORM VAGINAL  Hb, sickling,
with visible blood loss EXAMINATION  have 2 units cross matched Blood ready

Fetal condition is If bleeding is light and patient is stable Correct anaemia: Iron /Folate or Transfuse if
normal  Check Hb, sickling and blood group necessary
 Perform bedside clotting test –if clotting Do Ultrasound to determine type of praevia (if
Abnormal fetal lie and does not occur after 7 mins, or a soft clot available)
presentation forms and breaks down indicates
coagulopathy Plan for delivery at after 37+ completed weeks
Empty lower uterine
pole and uterus is Organise donors and REFER If bleeding is very heavy, and/or Maternal condition is
relaxed deteriorating
COMMUNITY If Bleeding is very heavy and /or Patient is in
LEVEL shock: (Pale, BP less than 90/60, pulse is rapid Consider use of steroids for fetal lung
If any bleeding from more than 120 beats / minute) then treat for Maturation if gestation is less than 34
vagina shock weeks (IM Dexamethasone 12mg bid
Let the patient lie down 24 hours)
(Do not give Colloids eg Dextran or Dicks
DO NOT perform any Plasma) Deliver by Caesarean section
vaginal examination Take blood sample (for grouping & Cross  Conduct follow up in postpartum.
matching at next level)  Correct anaemia.
REFFER immediately Inspect perineum to see if presenting part is
(accompany patient to visible and delivery imminent.
next level) Organise blood donors and accompany patient
Organise blood donors to next level if delivery is not imminent
41
to next level
If delivery is imminent (presenting part is
visible, cervix fully dilated)
 STEPS IN MANAGEMENT OF CONDITION/COMPLICATION
COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
s) Hyperemesis Ask of frequency of vomiting Same as Basic Care Level plus
Gravidarum Examine to assess state of hydration:
Assess severity of dehydration: Take history and examine to exclude other
Excessive vomiting  Look for sunken eyes causes of vomiting (e.g., appendicitis, hepatitis, malaria,
Generalised weakness  Monitor urine output obstructed bowel)
 Assess skin turgor
COMMUNITY Do lab investigations including:
LEVEL Do laboratory investigation to exclude other FBC,BF for mps, liver function tests, blood, urea,
Ask client if she has causes of vomiting: electrolytes and creatinine
excessive vomiting  Check blood for malaria parasites
during early pregnancy.  Urine RE Urine RE & CS
If she does,
If dehydration is mild: Do ultrasound to exclude
 Encourage small,  Molar pregnancy
frequent oral sips of  Provide reassurance,  Multiple gestation
fluids  Encourage intake of fluids,
 Encourage small,  Urge bed rest Monitor fluid intake and Urine output
frequent feeds
 Educate to avoid If severe: Nil by mouth until vomiting controlled
spicy and/or oily  Give IV fluids (N/saline, R/lactate, 5%
foods Dextrose) Resuscitate with IV fluids (dextrose5%,
 Monitor her BP, Pulse and urine output N/saline or Ringer's lactate)
Monitor progress; if no Give Anti emetics drugs
improvement after 24 If symptoms persist after 24 hours  Promethazine 25- 50 mg bid, or
hours: REFER  Metoclopramide 10 mg bid
REFER to next Level
Give inj. vitamin B supplement

If other cause of vomiting is identified treat appropriately.

Monitor client closely for progress of pregnancy

42
 STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
t) Premature Rupture Take history to determine duration of liquor  Same as for Basic Care Level plus
of Membranes leakage, gestational age, onset of labour. If membranes have been ruptured and gestation is less
(PROM) Examination: than 37 weeks,
 Inspect Vulva to confirm diagnosis Assess and monitor mother and fetus carefully for
Rupture of membranes  Assess fetal maturity and well-being, e.g. infection (fever, rapid pulse, offensive liquor, fetal
after 37 completed fundal height, fetal heartbeat, fetal movement distress)
weeks but before the  Signs of labour
onset of labour  Conduct sterile speculum examination to see Do investigations:
The term Preterm if there is leakage of fluid from the cervical os  Full blood count(FBC), urine RE,
PROM is used if on straining or coughing vaginal swab for C/S
membranes rupture after  Assess mother for signs of infection (Fever,  Ultrasound for fetal well-being & liquor
28 completed weeks but Rapid pulse, offensive liquor) volume
before 37 completed  Start antibiotics (Amoxicillin 500 mg tid or
weeks. Erythromycin 500 mg qid plus Metronidazole If no signs or symptoms of infection and fetal condition
400 mg tid) is satisfactory
COMMUNITY  Give stat dose of IM Dexamethasone 6 mg  Start course of broad spectrum antibiotics (if not
LEVEL stat if gestation is less than 34 weeks already done)
 REFER Amoxicillin 500 mg tid or Erythromycin 500 mg qid
Ask client if she is plus
losing fluid from the If delivery is imminent, conduct delivery Metronidazole 400 mg tid x5 days. Do NOT give
vagina amoxyclav or augmentin

REFER  Consider corticosteroids for

fetal lung maturation (IM Dexamethasone 12 mg bid
for 24 hours ) if gestation is less than 34 weeks and there
are no symptoms and signs of chorioamnionitis
 Deliver at 36 weeks or earlier if necessary

If signs of infection
 Start Antibiotics course: IV ampicillin, IV
metronidazole, IV gentamicin
 Deliver immediately
If gestation is more than 37 weeks
43
 Deliver immediately
Aim for vaginal delivery: (see Appendix for cervical
STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
u) Uterine size bigger Take history Same as Basic Care Level plus
or smaller than  To confirm date of LMP
gestational age  Determine onset of quickening or ask for Determine cause of discrepancy
presence of fetal movements
Size of the uterus does  Ask for history of fibroids
not correspond to the  Check maternal weight gain Ultrasound investigation for:
gestational age of  Dating,
pregnancy reported by Palpate abdomen to exclude  Viability,
the woman or  Molar pregnancy  Liquor volume,
calculated from her last  Multiple pregnancy  Multiple gestation,
menstrual period (more  Pelvic tumour e.g. fibroids
 Fetal death
than + /- 2 weeks)
 Fibroids
 Polyhydramnious Laboratory investigations:
COMMUNITY Hb, Sickling, BF for mps
 IUGR
LEVEL
If growth restriction is suspected recheck Manage as per cause
Woman is not sure of
symphysio-fundal height in two weeks if
duration of pregnancy
unchanged refer to next LEVEL
REFER
REFER for ultrasound at next level (where
possible) if LMP is undetermined OR If any of
the above diagnosis is suspected, REFER

44
 STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
v) Fetal Death Ask onset of problem and any associated symptoms Same as Basic Care Level plus
or illnesses
Fetal movements not felt after Ask of Confirm diagnosis with ultrasound.
20 weeks gestation  bleeding  Perform Laboratory Exam: Hb, Sickling, BF mps, blood
 Liquor loss group and Rhesus factor, VDRL, FBS and Random blood
Fundal height decreases or  Fever sugar, Clotting profile.
remains unchanged  Rashes and  Have 2 units of blood cross-matched blood and arrange for
 Previous stillbirth delivery fresh frozen plasma
Disappearance of symptoms
of pregnancy Examination: Compare present symphysio-fundal Plan delivery: -
height to previously documented measurement  Discuss with client expectant management (SVD) if
Breast engorged with nipple duration of IUD is less than 4 weeks and maternal
discharging breast milk Auscultate for fetal heart sounds if not heard, condition is stable.
perform an ultrasound scan to confirm fetal If duration of IUD is more than 4 weeks or if platelet count is
No fetal heart sounds located viability. (Ask for a second opinion to confirm) low or Clotting profile result is abnormal, or maternal
condition is poor start antibiotics
 Correct anaemia and or clotting abnormality (transfuse if
COMMUNITY LEVEL If fetal heart sounds are absent and or decrease or Hb is less than 7g/dl)
lack of growth in uterine size  Ripen cervix (if unfavourable)
Woman complains of not  Induce labour with Oxytocin
feeling fetal movements or of Explain problem to woman and provide support  Perform Caesarean section if Induction is not possible or
decrease in uterine size or fails
not feeling pregnant any If unsure of state of fetus Refer to next level  Monitor closely for PPH
longer
 Send foetus for autopsy if possible

After delivery ensure follow up:

REFER
 Provide emotional support
 Grief counselling
 Educate on breast care
 Suppress Lactation using firm tight brassiere/
bromocriptine /cabergoline
 Educate on cause of IUFD and future obstetric implication

45
 II. LABOUR AND DELIVERY CARE

A. OBJECTIVES

The goal of care during labour and delivery is to ensure a healthy mother and a healthy baby.
The specific objectives are to ensure:
 Proper management of the four stages of labour, and
 Early identification and management (treatment and/or referral) of complications.

DEFINITION OF LABOUR
Labour is said to occur when there are regular, painful uterine contractions resulting in progressive cervical
effacement and dilatation.

There are four stages of labour.

 First stage
 Second stage
 Third stage and
 Fourth stage

FIRST STAGE OF LABOUR

The first stage is from the onset of labour to full dilatation of the cervix. It consists of latent and active
phases.

The latent phase: In the latent phase, the cervix undergoes effacement and dilates up to 4cm. Contractions
occur less than 3 in 10 minutes and last less than 20 seconds. The onset and duration of the latent phase
may be difficult to determine but it may last as long as 12 hours.

The active phase: The active phase begins with the cervix at least 4cm dilated and it should normally not
last for more than six hours with contractions occurring 3-4 times in ten minutes, each lasting 40-60
seconds. The cervix dilates from 4 to 10 cm at an average rate of 1cm/hr.

A. ROUTINE MANAGEMENT OF THE FIRST STAGE OF LABOUR

Throughout labour the service provider must be empathetic and show kindness to the woman.

The following routine care should be given during the first stage:

ASSESSING THE CLIENT

a. Take history:
i) Onset and symptoms of labour – show or regular intermittent lower abdominal pains

46
 ii) Danger symptoms- bleeding from the vagina, reduced or excessive fetal movement, fever,
offensive liquor, severe headache and visual disturbance

iii) Review maternal health record book if available. If not, ask about past obstetric,
medical/surgical history to determine any contraindications to vaginal delivery or need for
special care. Take note of medical conditions such as Sickle Cell Disease, Diabetes Mellitus
and Hypertensive Disorders in Pregnancy.

b. Perform physical examination/assessment (observe stringent aseptic procedures):

i. Thorough general physical examination
ii. Abdominal examination
iii. Vaginal examination (Except when the client is bleeding or loosing liquor)

Check for:
Show
Ruptured membranes (Leakage of liquor)
Cervical dilatation

c. Look for any abnormalities such as abnormal fetal heartbeat, offensive/meconium-stained

liquor, large or small abdomen.

d. Record findings

e. Monitor Labour
i. In the Latent Phase, monitor and record all findings on labour observation chart as shown
below.

47
 LABOUR CHART
Name: Gravida: Para: Client Registration No.:

Date of Admission: Time of Admission: Raptured Membranes: Yes/No Hours:

Urine Fluid Intake Remarks

Amniotic Cervical Medica Volu Pro Acet Gluc
Time FHR Fluid Dilatation Descent Contractions tions Pulse BP me tein one ose Type Amount  
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               

48
Schedule for Monitoring Labour in the Latent Phase

 Contractions – ½ hourly
 Pulse – ½ hourly
 Fetal Heart Rate– ½ hourly
 Descent – 4 hourly
 Cervical Dilatation - 4 hourly
 Amniotic Fluid – 4 hourly
 Temperature and Blood Pressure – 4hourly
 Medications- when necessary
 Urine – 4 hourly
 Fluid intake – when necessary

Perform vaginal examinations every four hours unless otherwise indicated. Once dilatation reaches 4cm or
above (i.e. Client is in active labour) 2 to 3hourly vaginal examinations may be necessary. Avoid too
frequent vaginal examinations to prevent infection.

ii. Active phase

 Start a Partograph when cervical dilatation is at least 4cm
 Plot the progress of labour on the Partograph
 Take appropriate action if problems are identified with the progress of labour.

f. Explain to mother and/or accompanying person(s)

- Progress of labour
- Reasons for:
 Any intervention
 Referral

g. Give emotional support and re-assurance.

USING THE PARTOGRAPH

The WHO partograph has been modified to make it user friendly. The latent phase has been removed and
plotting on the partograph begins in the active phase when the cervix is 4cm dilated. A sample partograph
is included (Table 1 below).

49
50
OBSERVATIONS ON PARTOGRAPH
LABOUR FETUS MOTHER
Contractions (Frequency Fetal heart rate Temperature, Pulse & BP
and Duration)
Cervical Dilatation Moulding Fluid intake/output
Descent of fetal head in Caput formation Urine-Protein & Acetone
fifths
Membranes Colour of amniotic fluid Medications given

DOCUMENTATION ON THE PARTOGRAPH

PATIENT INFORMATION: Fill out the name, gravidity, parity, hospital number, date and time of
admission in labour, and time of rupture of membranes
FETAL HEART RATE: Record every half hour
AMNIOTIC FLUID: Record the colour of amniotic fluid at every vaginal examination:
 I: Membranes intact
 C: Membranes Ruptured, Liquor clear
 M: Meconium Stained Liquor
 B: Blood Stained Liquor
 A: Absence of Liquor

MOULDING
 Bones are separated and sutures can be felt easily: 0
 Bones just touching each other: +
 Bones are overlapped but reducible: ++
 Bones are overlapped and cannot be separated +++

CERVICAL DILATATION: Assessed at every vaginal examination and marked with a cross (X)
Begin plotting on the partograph at cervical dilatation of 4cm and above. The first plot should be on the
alert line.

ALERT LINE: A line starting at 4cm of cervical dilatation to the point of expected full dilatation (10 cm)
at the rate of 1cm per hour.

ACTION LINE: A line parallel and 4hours to the right of the alert line.

DESCENT IS ASSESSED BY ABDOMINAL PALPATION: Refers to the part of the head (divided into 5
parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5,
the sinciput is at the level of the symphysis pubis.

Abdominal palpation for descent of fetal head

51
Landmarks for Descent

When the entire head is felt, it is measured as five fifths above the brim. Five of your fingers can cover the head above the brim.

When the baby's head is four fifths above the brim, it is just entering the brim. When it is three-fifths above, 3 of your fingers can still go
partially round the head.

When it is two fifths above the brim, only 2 fingers measure the head because more than half of the head has entered the brim. You can no
longer feel the roundness of the head. The head is now ENGAGED. It is almost impossible to move the head.

52
HOURS: Refers to the time elapsed since onset of active phase of labour (observed or extrapolated).

TIME: Record actual time.

CONTRACTIONS: Chart every half hour; palpate the number of contractions in 10 minutes and the
duration of each contraction in seconds. Dots represent contractions of less than 20 seconds’ duration.
Diagonal lines indicate moderate contractions of 20-40 seconds duration. Solid shading represent
contractions of longer than 40 seconds’ duration.

OXYTOCIN: Record the amount of oxytocin per volume IV fluids per minute every 30 minutes
when used.
DRUGS GIVEN: Record any additional drugs given.
PULSE: Record every 30 minutes and mark (∙)
BLOOD PRESSURE: Record every 4 hours and mark with arrows.
TEMPERATURE: Record every 4 hours in the appropriate box
URINARY OUTPUT: Measure and record volume and test for protein and acetone every 2 hours

NOTE : Do not use partograph if initial assessment indicates need for emergency caesarean section.

53
 C. MANAGEMENT OF COMPLICATIONS IN FIRST STAGE OF LABOUR

STEPS IN MANAGEMENT OF CONDITIONS/COMPLICATIONS

PROBLEM BASIC CARE LEVEL

COMPREHENSIVE CARE LEVEL
A. Prolonged Latent  Take history  Take history
phase  Examine the woman  Examine the woman.
 If labour is not established Determine cause of slow progress
Contractions occur less If labour is not established, observe woman in antenatal ward for at least 24 hours
than 3 in 10 minutes and REFER
last less than 20 seconds.
Duration more than 12
hours
COMMUNITY LEVEL
Ask frequency of
contractions, and
duration of labour.
Refer
B. Prolonged  Take history and examine woman.
Active phase  Monitor and record observations on partograph/ examine partograph attached to
 Take history and examine referral letter
(more than 6 woman.  Assess uterine contractions
hours)
 Monitor and record  If contractions are occurring less than 3 in 10 minutes and lasting less than 40
Contractions occur 3-4 observations on seconds, suspect inefficient/hypotonic uterine action
times in ten minutes, partograph: if dilatation - If membranes have already ruptured, re-assess pelvic capacity and size of baby
with each lasting 40-60 crosses the to exclude Cephalo-Pelvic Disproportion (CPD). If no CPD or any
seconds. contraindication for augmentation of labour with oxytocin e.g. Grand-
" Alert" line
COMMUNITY LEVEL multiparity, and there has been progress in cervical dilatation, augment labour
Encourage her to drink fluids with oxytocin:
Ask frequency of or set up IV fluids (Normal * Regimen:
contractions, and Saline) - Infuse oxytocin 5 units in 500mls of D/S or N/S at 10 drops per minute and
duration of labour increase the infusion rate by 10 drops per minute every 30 minutes until

54
PROBLEM BASIC CARE LEVEL
COMPREHENSIVE CARE LEVEL
contractions occur 3-4 in 10 minutes lasting 40-60 seconds. The rate of
REFER
infusion must not go beyond 60 drops per minute
Refer - Monitor with partograph
- Perform C-Section as indicated by partograph plotting or if fetal distress
develops
- If membranes have not ruptured, rupture membranes if cervical dilatation is
between alert and action line and head descent is 3/5thor less.
 If contractions are occurring 3 in 10 minutes and lasting more than 40
seconds but descent is poor and dilatation slow, suspect CPD,
Obstruction, Malposition or Mal-presentation.
- Deliver by caesarean-section ( foetus alive or dead )

C. Obstructed
labour  Take history
Labour comes to a  Continue or start IV fluids  Follow steps as in basic maternal care
standstill due to  Take blood for grouping  Continue IV fluids and broad spectrum antibiotics
mechanical causes. This and cross-matching  Reassess woman to confirm obstruction
is usually preceded by  Perform C-section (baby alive or dead)
prolonged labour (15-  Give broad spectrum
18hrs). antibiotics
The woman looks:  IV Amoxicillin +
Exhausted Clavulanic Acid1.2g stat or
Restless IV Cefuroxime 1.5g stat,
Dehydrated (sunken Plus
eyes, dry lips, etc.), IV Metronidazole 500mg
anxious stat
Pulse is raised,
there may be fever,
concentrated urine,  Examine the woman for
oedematous cervix, signs of obstruction. If
greenish or foul smelling confirmed,
liquor. REFER immediately
55
PROBLEM BASIC CARE LEVEL
COMPREHENSIVE CARE LEVEL
The fetal head has large
caput and excessive
moulding
The fetus may be dead or
alive.

COMMUNITY LEVEL

Start IV fluids if possible

Refer immediately
Follow same steps as for basic care
D. Ruptured uterus
- Ensure adequate resuscitation
There is continuous Take blood for grouping and - Perform Laparotomy and hysterectomy or repair of the uterus
bleeding from vagina, cross matching
abdomen is hard or Start iv fluids
painful to touch:
If in shock, manage (as per
appendix)
 Insert Foley’s catheter
 Organise blood donors to
COMMUNITY LEVEL
accompany woman
Start IV fluids if possible - Start broad spectrum
Refer immediately antibiotics
- IV Amoxicillin +
Clavulanic Acid 1.2g
stat or
- IV Cefuroxime 1.5g stat.

 REFER immediately
PROBLEM BASIC CARE LEVEL
COMPREHENSIVE CARELEVEL
A. Prolonged Latent  Take history
phase  Examine the woman.
56
PROBLEM BASIC CARE LEVEL
COMPREHENSIVE CARE LEVEL
Contractions occur less If client has not delivered after Determine cause of slow progress
If labour is not established, observe woman in antenatal ward for at least 24hours
than 3 in 10 minutes and 10 hours labour, OR client
last less than 20 seconds. reported in second stage which
from history has lasted more
Duration more than 12
than 1 hour
hours
COMMUNITY LEVEL
Ask frequency of REFER
contractions, and
duration of labour.
Refer
E. Prolonged  Take history and examine woman.
Active phase  Monitor and record observations on partograph/ examine partograph attached to
 Take history and examine referral letter
(more than 6 woman.  Assess uterine contractions
hours)
 Monitor and record  If contractions are occurring less than 3 in 10 minutes and lasting less than 40
Contractions occur 3-4 observations on seconds, suspect inefficient/hypotonic uterine action
times in ten minutes, partograph: if dilatation - If membranes have already ruptured, re-assess pelvic capacity and size of baby
with each lasting 40-60 crosses the to exclude Cephalo-Pelvic Disproportion (CPD). If no CPD or any
seconds. contraindication for augmentation of labour with oxytocin e.g. Grand-
" Alert" line
COMMUNITY LEVEL multiparity, and there has been progress in cervical dilatation, augment labour
Encourage her to drink fluids with oxytocin:
Ask frequency of or set up IV fluids (Normal * Regimen:
contractions, and Saline) - Infuse oxytocin 2.5 units in 500mls of D/S or N/S at 10 drops per minute and
duration of labour increase the infusion rate by 10 drops per minute every 30 minutes until
contractions occur 3-4 in 10 minutes lasting 40-60 seconds. The rate of
REFER infusion must not go beyond 60 drops per minute
Refer - Monitor with partograph
- Perform C-Section as indicated by partograph plotting or if fetal distress
develops
- If membranes have not ruptured, rupture membranes if cervical dilatation is
between alert and action line and head descent is 3/5thor less.
57
PROBLEM BASIC CARE LEVEL
COMPREHENSIVE CARE LEVEL
 If contractions are occurring 3 in 10 minutes and lasting more than 40
seconds but descent is poor and dilatation slow, suspect CPD,
Obstruction, Malposition or Mal-presentation.
- Deliver by caesarean-section ( foetus alive or dead )

F. Obstructed
labour
Labour comes to a  Take history
standstill due to  Follow steps as in basic maternal care
 Continue or start IV fluids
mechanical causes. This  Continue IV fluids and broad spectrum antibiotics
 Take blood for grouping
is usually preceded by  Reassess woman to confirm obstruction
and cross-matching
prolonged labour (15-  Perform C-section (baby alive or dead)
18hrs).  Give broad spectrum
The woman looks: antibiotics
Exhausted
 IV Amoxicillin +
Restless
Clavulanic Acid1.2g stat or
Dehydrated (sunken
IV Cefuroxime 1.5g stat,
eyes, dry lips, etc.),
Plus
anxious
IV Metronidazole 500mg
Pulse is raised,
stat
there may be fever,
concentrated urine,
oedematous cervix,  Examine the woman for
greenish or foul smelling signs of obstruction. If
liquor. confirmed,
The fetal head has large
caput and excessive REFER immediately
moulding
The fetus may be dead or
alive.

COMMUNITY LEVEL
58
PROBLEM BASIC CARE LEVEL
COMPREHENSIVE CARE LEVEL

Start IV fluids if possible

Refer immediately
Follow same steps as for basic care
G. Ruptured uterus
 Manage appropriately depending on:
There is continuous Take blood for grouping and - Ensure adequate resuscitation
bleeding from vagina, cross matching - Perform Laparotomy and hysterectomy or repair of the uterus
abdomen is hard or Start iv fluids
painful to touch:
If in shock, manage (page …)
 Insert Foley’s catheter
 Organise blood donors to
accompany woman
COMMUNITY LEVEL
- Start broad spectrum
Start IV fluids if possible antibiotics
Refer immediately - IV Amoxicillin +
Clavulanic Acid 1.2g
stat or
- IV Cefuroxime 1.5g stat.

 REFER immediately

Notes on use of oxytocin:

 Oxytocin should not be used in women of parity five or more or women with scarred uterus. In women of parity 1 – 4, oxytocin
should be used with caution.
 Do not augment or induce labour if there are no facilities for emergency surgery (Caesarean Section).
 Stop augmentation of labour if fetal distress develops.

59
B. ROUTINE MANAGEMENT OF SECOND STAGE OF LABOUR

The second stage starts from full dilatation of the cervix to the birth of the baby. It usually lasts up to
30 minutes in multiparae, and 60 minutes in nulliparae. The clinical signs/symptoms indicating that the
second stage has started include the following:

 Contractions become stronger and are of longer durations, lasting 40-60 seconds and occur at
shorter intervals (3 contractions in 10 minutes)
 The woman feels pressure in the rectum accompanied by the urge to defecate
 The perineum bulges and the anus dilates
 Nausea and retching may occur as the cervix reaches full dilatation

All these signs/symptoms may not always be present. To confirm that the second stage has begun,
perform a vaginal examination to assess the condition of the cervix and the station of the presenting
part.

IMMEDIATE PREPARATION FOR DELIVERY

 Explain to patient what to expect during delivery
 Ensure clean and warm delivery room free from all infections
 Delivery trolley containing all necessary items for delivery should be ready
 Identify a helper or assistant
 Newborn resuscitation equipment must be ready for use (refer Annex)
 Resuscitation surface should be clean and warm

DELIVERY STEPS

MOTHER
 Position patient according to her preference
 Wash hands with soap and water and dry with a towel
 Wear protective clothing (plastic apron, boots, goggles and mask)
 Wash hands again with soap and water and dry with sterile towel
 Put on sterile gloves on both hands
 Clean vulva/perineum with antiseptic solution e.g. Chlorhexidine
 Drape the woman appropriately for delivery
 Check delivery trolley and instruments

 Encourage woman to bear down when in expulsive stage and to rest in between
contractions
 Maintain flexion of the head as it comes out of the vagina
 Prevent soiling of the perineum using a sanitary pad to cover the anus
 Await spontaneous delivery of the head with subsequent contractions

61
  Support the head and allow restitution (external rotation through 45°)
 You may wipe baby’s face gently with gauze
 Feel gently around the baby’s neck for the cord
- If the cord is present and loose, slip it gently over the head
- If the cord is tight around the neck, clamp at 2 points and cut in
between clamps, then unwind the cord
 Deliver anterior shoulder by applying gentle downward pressure on the head
during subsequent contractions
 Lift baby up towards mothers’ abdomen and deliver the posterior shoulder
 Place the baby on mothers’ lower abdomen and note time of delivery
 Palpate the mothers’ abdomen to exclude second baby
 Give 10 IU oxytocin IM to mother. If not available or if for any reason cannot
be given, give Misoprostol 600 mcg (3 tablets orally)
 Watch for vaginal bleeding

BABY
 Dry the baby thoroughly, and remove the wet cloth
 Assess baby’s breathing while drying(refer to box 2, if baby is not
crying or breathing)
 Put baby skin-to-skin on the mother’s chest
 Cover mother and baby with a clean dry cloth

 Whilst doing the above, assess baby’s condition at 1 minute using the
APGAR score
 Clamp and cut the cord after pulsations have ceased or between 1 to 3
minutes, whichever comes first
- Put 2 clamps or ties tightly around the cord at 2 cm and 5 cm from the
baby’s abdomen
- Cut in between the clamps
- Observe the cord for oozing of blood

 Assess baby’s condition at 5 minutes using the APGAR SCORE

 Keep baby on mother’s chest in skin to skin contact for at least 1 hour (for
warmth and bonding)
 Put identification label on the baby
 Cover the baby’s body and head to keep the baby warm
 Encourage mother to initiate breastfeeding
 Monitor baby’s breathing

Note: Collect cord blood for grouping and Rhesus factor where indicated

62
APGAR SCORE (the score ranges between 0 to 10 using five features)

Features 2 1 0

Appearance Pink lips, but blue Blue or pale all

Pink all over
(colour) hands and feet over

Pulse (heart rate) ≥ 100 beats/min < 100 beats/min Absent

Grimace (reflex to Cry or pull away when Grimace/feeble cry No response to

stimulation) stimulated when stimulated stimulation

Activity (muscle Flexed arms and legs

Some flexion None
tone) that resist extension

Respiration Strong cry, breathing Weak cry, irregular

Absent
(breathing) well breathing, gasping

NB: APGAR SCORE of 3 or below at 1 minute, and 6 or below at 5 minutes after delivery; Start
resuscitation and Inform a paediatrician if available or REFER

63
 C. MANAGEMENT OF COMPLICATIONS IN SECOND STAGE OF LABOUR AT SELECTED LEVELS OF THE
HEALTHSYSTEM

STEPS IN MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL CARE

a) Prolonged second stage (more  Take history and assess patient:
than one hour) - Size, presentation and level of descent of foetus,  Follow same steps as in basic care level
moulding, caput, fetal heart rate  Manage specific cause (see below)
If the woman reported in the second - Contractions
stage which from the history or - Vital signs of mother
records, has lasted more than one If no disproportion and fetal presentation is favourable:
hour:  Ensure hydration and empty bladder
 Rupture membranes (if still intact)
COMMUNITY LEVEL
 Urge patient to bear down with each contraction

Ask / determine duration of second

stage of labour from history or  Check descent; if 0/5 or 1/5 with very slight or no
records. moulding or caput:
o Perform vacuum extraction, if trained
If more than 1 hour, Refer promptly o Give broad spectrum antibiotics) e.g. IV
accompanied by attendant Amoxicillin + Clavulanic acid 1.2g stat OR IV
Cefuroxime 1.5g stat and
 If not trained in vacuum extraction,

REFER IMMEDIATELY
Note: See specific causes of prolonged second stage and
their management below,

b) Mal-presentation/ malposition  Follow same steps as in Basic Care Level

 Do vaginal examination; if presentation is breech:  Manage specific cause
If the baby’s arm, foot, buttocks, - Perform episiotomy (if necessary), when perineum is If shoulder, brow, face, persistent occipito-
umbilical cord, face, brow and distended and deliver the baby (see appendix) posterior position, is present, deliver by
shoulder can be seen or felt
65
 - If other mal-presentation / mal-position(shoulder, Caesarean section
COMMUNITY brow, face, occipito-posterior, etc.) is present
LEVEL
REFER

Refer promptly accompanied by

attendant
COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL CARE
a) Prolonged second stage (more  Take history and assess patient:
than one hour) - Size, presentation and level of descent of foetus,  Follow same steps as in sub-district
moulding, caput, fetal heart rate  Manage specific cause (see below)
If the woman reported in the second - Contractions
stage which from the history or - Vital signs of mother
records, has lasted more than one If no disproportion and presentation is favourable:
hour:  Ensure hydration and empty bladder
 Rupture membranes (if still intact)
COMMUNITY LEVEL
 Urge patient to bear down with each contraction

Ask / determine duration of second

stage of labour from history or  Check descent; if 0/5 or 1/5 with very slight or no
records. moulding or caput:
- Perform vacuum extraction, if trained
If more than 1 hour, Refer promptly - Give broad spectrum antibiotics) e.g. IV Amoxicillin
accompanied by attendant + Clavulanicacid1.2g stat OR IV Cefuroxime 1.5g
stat and
- If not trained in vacuum extraction,

 REFER IMMEDIATELY
Note: See specific causes of prolonged second stage and
their management below,

b) Mal-presentation/ malposition  Follow same steps as in Basic Care Level

 Manage specific cause
66
If the baby’s arm, foot, buttocks, If shoulder, brow, face, persistent occipito-
umbilical cord, face, brow and  Do vaginal examination; if presentation is breech: posterior position, is present, deliver by
shoulder can be seen or felt - Perform episiotomy (if necessary), when perineum is Caesarean section
distended and deliver the baby (see appendix)
COMMUNITY - If other mal-presentation / mal-position(shoulder,
LEVEL brow, face, occipito-posterior, etc.) is present

REFER
Refer promptly accompanied by
attendant

COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL

CARE

c) Cephalo-pelvic disproportion  Take blood for grouping and cross-matching  Follow same steps as in Basic Maternal
(analysis to be done at district hospital) Care Level
 Take blood for Hb, FBC, Sickling,
-If woman’s abdomen or baby appears Start I.V fluids 500 mls N/S grouping and cross-matching
too big  Insert Foley’s catheter  Perform C-section (baby alive or dead)
- If on assessment, the pelvis appears  Give broad spectrum antibiotics e.g. IV Amoxicillin +
inadequate Clavulanicacid1.2g stat OR IV Cefuroxime 1.5g stat  If urine is bloody or bladder
and oedematous, retain Foley’s catheter for 1
COMMUNITY LEVEL week.
Refer promptly accompanied by
 REFER
attendant

d) Twins or multiple pregnancy  Examine and identify presentation of the leading  Follow same steps as in Basic Maternal
If the abdomen or uterus is unusually twin Care Level
large or more than two fetal poles are  Monitor woman and fetuses
felt  If breech, see appendix for breech delivery - Take blood for Hb, FBC, sickling,
67
 COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL
CARE

 If cord is felt, (see management of cord prolapse) grouping and cross-matching

COMMUNITY LEVEL  If cervix is fully dilated and presentation is cephalic,
Refer promptly accompanied by deliver normally;
attendant
NB do not give IM Oxytocin after delivery of first twin
 If presentation of second twin is favourable:
- Rupture membranes if indicated
- Monitor woman and foetus
- If no delivery within 30 minutes
REFER

e) Fetal Distress  Do vaginal examination to determine progress of  Follow same steps as in Basic Maternal
Signs include: labour Care Level
- Fetal heart rate <120 or  If baby is alive:
>160bpm  If cervix is fully dilated, descent is 0/5 or 1/5 and no - Deliver by vacuum extraction
- Fetal heart rate irregular cephalo-pelvic disproportion: OR
- Deliver by vacuum extraction if trained - C-section
[NB: these signs can indicate fetal  If delivery does not occur within 30 mins: 
distress with or without meconium- - Turn mother on left side and give intranasal oxygen  If baby is dead; (and there is no
stained liquor]. - Start IV infusion (normal saline ) CPD/Obstruction)
 If there is maternal fever with fetal tachycardia - Allow spontaneous vaginal delivery.
COMMUNITY LEVEL - Start broad spectrum antibiotics e.g. IV Amoxicillin + - Perform C – Section if there are other
Make Patient to lie in the left side (left Clavulanic acid1.2g stat OR IV Cefuroxime 1.5g stat indications for it.
lateral position) AND
- Start anti-malaria treatment Record medications on
Refer promptly accompanied by
referral form and
attendant
- REFER

COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL

CARE

68
 COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL
CARE

c) Cephalo-pelvic disproportion  Take blood for grouping and cross-matching  Follow same steps as in Basic Maternal
(analysis to be done at district hospital) Care Level
 Take blood for Hb, FBC, Sickling,
-If woman’s abdomen or baby appears Start I.V fluids 500 mls N/S grouping and cross-matching
too big  Insert Foley’s catheter  Perform C-section (baby alive or dead)
- If on assessment, the pelvis appears  Give broad spectrum antibiotics e.g. IV Amoxicillin +
inadequate Clavulanicacid1.2g stat OR IV Cefuroxime 1.5g stat  If urine is bloody or bladder
and oedematous, retain Foley’s catheter for 1
COMMUNITY LEVEL week.
Refer promptly accompanied by
 REFER
attendant

d) Twins or multiple pregnancy  Examine and identify presentation of the leading  Follow same steps as in Basic Maternal
If the abdomen or uterus is unusually twin Care Level
large or more than two fetal poles are  Monitor woman and fetuses
felt  If breech, see appendix for breech delivery  If woman has been in labour at a lower
 If cord is felt, (see management of cord prolapse) health facility and delivery did not occur
COMMUNITY LEVEL  If cervix is fully dilated and presentation is cephalic, within one hour
Refer promptly accompanied by deliver normally; - Perform C-section
attendant  If woman has been referred from lower
NB do not give IM Oxytocin after delivery of first twin level
 If presentation of second twin is favourable: - Follow same steps as for basic care
- Rupture membranes if indicated level
- Monitor woman and foetus - Take blood for Hb, FBC, sickling,
- If no delivery within 30 minutes grouping and cross-matching
REFER - Perform C-section

e) Fetal Distress  Do vaginal examination to determine progress of labour  Follow same steps as in Basic Maternal
Signs include: Care Level

69
 COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL
CARE

o Fetal heart rate <120 or  If cervix is fully dilated, descent is 0/5 or 1/5 and no  If baby is alive:
>160bpm cephalo-pelvic disproportion: - Deliver by vacuum extraction
o Fetal heart rate irregular  Deliver by vacuum extraction if trained OR
 If delivery does not occur within 30 mins: o C-section
[NB: these signs can indicate fetal - Turn mother on left side and give intranasal oxygen 
distress with or without meconium- - Start IV infusion (normal saline )  If baby is dead; (and there is no
stained liquor].  If there is maternal fever with fetal tachycardia CPD/Obstruction)
- Start broad spectrum antibiotics e.g. IV Amoxicillin + o Allow spontaneous vaginal delivery.
COMMUNITY LEVEL Clavulanic acid1.2g stat OR IV Cefuroxime 1.5g stat o Perform C – Section if there are other
Make Patient to lie in the left side (left AND indications for it.
lateral position) - Start anti-malaria treatment Record medications on
referral form and
Refer promptly accompanied by - REFER
attendant

COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL

CARE

f) Cord Prolapse o Ask woman to stop pushing  Follow same steps as in basic maternal
care
 If umbilical cord can be seen or  Check to see cord is pulsating. If yes  Take blood for Hb, FBC, Sickling,
felt in vagina o Prevent cord from coming out of vagina by placing Grouping and Cross-matching
 a pad on the vulva  If baby is alive
 COMMUNITY LEVEL o Prevent compression of cord by presenting part by o Deliver by vacuum extraction
 Ask woman to stop pushing instilling 300mls or more of N/S into the bladder o Perform C-section if indicated.
70
 COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL
CARE

 Place a clean cloth or pad on through indwelling catheter  If no sign of obstruction and
the vulva to prevent cord from o Place mother in left lateral position and elevate hips presentation is favourable
coming out o Administer high concentration of oxygen, available o Allow normal delivery if baby is
(6 – 7 litres/min. by mask) dead.
 Place mother on the left
o If cervix is fully dilated, presentation is cephalic
 Put pillows under her hip to
and descent O/5 and baby is alive,
elevate it
 Assist delivery immediately by vacuum extraction, if
 Refer patient immediately trained
 If cervix is not fully dilated and fetal heart is present or
there is mal-presentation/malposition
 REFER

 If cord not pulsating, check for signs of obstruction

(refer obstructed labour)
 If there is obstruction
Give broad spectrum antibiotics.
o IV Amoxicillin + Clavulanic Acid 1.2g stat or IV
Cefuroxime 1.5g stat. and REFER

 If no sign of obstruction and presentation is favourable

o Allow normal delivery if baby is dead.

COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL

CARE

f) Cord Prolapse o Ask woman to stop pushing  Follow same steps as in basic maternal
care
 If umbilical cord can be seen or  Check to see cord is pulsating. If yes  Take blood for Hb, FBC, Sickling,
felt in vagina o Prevent cord from coming out of vagina by placing Grouping and Cross-matching
 a pad on the vulva  If baby is alive
71
 COMPLICATIONS BASIC MATERNAL CARE COMPREHENSIVE MATERNAL
CARE

 COMMUNITY LEVEL o Prevent compression of cord by presenting part by o Deliver by vacuum extraction
 Ask woman to stop pushing instilling 300mls or more of N/S into the bladder o Perform C-section if indicated.
 Place a clean cloth or pad on through indwelling catheter
the vulva to prevent cord from o Place mother in left lateral position and elevate hips
coming out o Administer high concentration of oxygen, available
(6 – 7 litres/min. by mask)
 Place mother on the left
o If cervix is fully dilated, presentation is cephalic
 Put pillows under her hip to and descent O/5 and baby is alive,
elevate it  Assist delivery immediately by vacuum extraction, if
 Refer patient immediately trained
 If cervix is not fully dilated and fetal heart is present or
there is mal-presentation/malposition
 REFER

 If cord not pulsating, check for signs of obstruction

(refer obstructed labour)
 If there is obstruction
Give broad spectrum antibiotics.
o IV Amoxicillin + Clavulanic Acid1.2g stat or IV
Cefuroxime 1.5g stat. and REFER

 If no sign of obstruction and presentation is favourable

o Allow normal delivery if baby is dead.

72
D. ROUTINE MANAGEMENT OF THIRD STAGE OF LABOUR – DELIVERY OF PLACENTA

The third stage starts after delivery of the baby and ends with delivery of the placenta.

After delivery of the baby:

Conduct Active Management of Third Stage of Labour (AMTSL)

(Palpate the mother’s abdomen to exclude second baby)
 Give Oxytocin IM 10IU within one minute of delivery of the baby
- Feel for contraction

 Deliver placenta by controlled cord traction

- Place one hand just above the pubic bone on top of the drape covering the woman’s abdomen with
the palm facing the mother’s umbilicus, gently apply counter traction in an upward direction
- Wrap umbilical cord on right hand and apply gentle outward traction after uterine contraction
- Maintain counter pressure with the left hand in the suprapubic area whilst applying traction to
cord
- Release left hand to receive placenta at introitus and place it in a receiver (bowl or dish)
-
 Massage uterus. Repeat every 15 minutes for 2 hours

Examinations following delivery of the placenta

Examine the placenta and membranes for:
- Completeness of lobes and membranes (Look for signs of any extra lobes)
- Presence of cord vessel abnormality
- Retro-placental clots
- Any other abnormality
- Weigh placenta
- Examine perineum and vagina for bleeding, laceration/tear

 Repair episiotomy or any 1st or 2nd degree tear

 Estimate volume of blood loss

Note; 3rd or 4th degree perineal tear and cervical tear should be done in theatre by a competent doctor.

73
74
75
D. ROUTINE MANAGEMENT OF FOURTH STAGE OF LABOUR (IMMEDIATE POSTPARTUM
CARE)

The fourth stage is the first six hours following the delivery of the placenta.

MOTHER

First Two Hours

- Monitor mother’s BP and pulse every 15 minutes
- Palpate and massage the uterus every 15 minutes for two hours to ensure it remains firmly
contracted
- Inspect the introitus every 15 minutes for any active bleeding
- Encourage mother to empty bladder frequently
- Put the baby to mother’s breast within half hour of delivery

Next Four Hours

- Monitor blood pressure and pulse every 2 hours
- Check temperature at least once during this period
- Palpate the uterus (ensure it is well contracted) and inspect perineum for vaginal bleeding every
1 hour
- Teach mother to continue massaging the uterus abdominally
- Support mother to breastfeed (refer to PMTCT guidelines for HIV positive mother)

Subsequent Care (6-24 Hours)

- Continue to support mother to breastfeed baby
- Educate mother to empty bladder and change sanitary pads frequently
- Observe for vaginal bleeding
- Continue monitoring Temperature, Pulse, Respiration and Blood Pressure ( at least 4 hourly)

BABY

Immediate Routine Care of the New-Born

First hour of birth

 Keep baby in skin to skin contact on the mother’s chest for at least 1 hour
 Monitor baby every 15 minutes
o Breathing: Look for fast breathing (≥ 60 bpm), grunting, chest in-drawing
o Colour: look at the colour of the baby’s lips, hands and feet
o Temperature: check the temperature (axillary) and feel the hands and feet (Normal
temperature: 36.50C to 37.40C, Low temperature: <36.50C, High temperature:
≥ 37.50C)
o Activity: Look for decreased or abnormal movements, excessive crying, sucking
 Help the mother to initiate breastfeeding within 30 minutes of birth

76
One to two hours
 Apply Chloramphenicol eye drops or 0.5% Tetracycline eye ointment on both eyes
 Provide cord care using methylated spirit (70% alcohol)/Chlorhexidine 7.1%
 Weigh the baby on a clean scale
o Normal weight: 2.5-4.0 kg
o Low birth weight: <2.5 kg
o Big baby: > 4.0 kg
 Give Vitamin K1:
o 0.5mg for baby’s weighing <2.0kg
o 1.0mg for baby’s weighing ≥ 2.0kg
 Examine the baby and document your findings (use newborn examination form)

Based on the baby’s weight, temperature and examination findings, determine whether the baby
o Has a danger sign(s) and needs advanced care. It is important to look for danger
signs first, so that emergency care can be provided immediately to prevent death.
o Has a problem, or
o Is normal and well
Make sure you communicate to the mother as you provide care and examine baby for problems
and danger signs.

Two to Six hours

 Continue to check temperature, pulse, breathing and colour every 30 minutes for the 2nd hour
and hourly from the 3rd to the sixth hour
 Observe the cord for bleeding every hour
 Breastfeed on demand

Subsequent Care of the Newborn (6 – 24 hours of life)

 Continue monitoring the baby every 3 – 4 hours for the next 18 hours
 Advise mother about breastfeeding problems
 Reassess baby (cord for bleeding, look for jaundice and danger signs)
 Begin immunizations
 Babies with normal birth weight can be given a bath after 6 hours. Withhold bath till
after 24 hours for low birth weight babies
 Give mother and family guidance and advise on newborn danger signs, breastfeeding
and how to care for the baby at home
 Inform them of the 2nd and 3rd postnatal schedule and link them up with a community
health nurse or midwife in her community for continuity of care

77
Before Discharge
When considering discharge, re-assess the baby and breastfeeding. When possible, discharge from the birth
facility should not occur until 24 hours after birth. A longer period of hospitalisation should be considered
for infants who have had problems such as low birth weight, low temperature or breathing problems. Prior
to discharge, preparedness for home care is established by assessment for potential problems in both the
mother and the baby.
Signs of successful breastfeeding should be present prior to discharge. If successful breastfeeding has not
been established, a feeding should be observed for signs of poor attachment.
A second complete examination of the baby should be performed prior to discharge from the birth facility.
The provider should look for signs of severe jaundice. The umbilicus should be examined for redness and
swelling at the base and drainage of pus. These are signs of infection of the cord. When present, cord
cleaning should be done with methylated spirit and oral antibiotics started.

When discharge is appropriate, Give parents guidance for home care:

Prepare parents on the care of their babies by helping them understand the key messages about home care.

Key messages for Parents before going home:

 Exclusive breastfeeding for at least 6 months provides the best nutrition for babies, and helps
protect against infection. Healthy babies feed every 2-4 hours or 8-12 times per day and sleep well
between feedings. From around day six after birth, well-fed babies urinate 6-8 times per day.
 Recognition and management of common breastfeeding problems, including engorgement,
cracked nipples and mastitis. This can help improve rates of exclusive breastfeeding. Advise
mothers that nipple pain should not be felt and is usually a sign of poor attachment. If a
breastfeeding mother develops a fever, or in general feel unwell, they should seek health care.
 Completion of all scheduled immunizations
 Recognition of danger signs such as severe jaundice and seeking appropriate care helps babies
receive advanced care, which can be life-saving.
 Inform/ educate parents about other healthy practices e.g. use of insecticide treated nets, family
planning
 Inform/ educate parents about the time and place of the next postnatal visit.
 Nutritional requirements for mother's health and breast-feeding: Advice should be given on the
various food groups in a balanced diet (see guide in Maternal health record) In addition encourage
mother to drink at least 8 glasses of water each day if breast-feeding. She should also avoid alcohol
and tobacco, which decrease breast milk production.
 Personal Hygiene:
1. Washing hands before touching the baby and proper cord care help prevent infections
2. Advice mother to Keep genital area clean and dry
3. Change perineal pads at least 4-6 hourly during first week and thereafter twice daily
4. Avoid douching, insertion of herbal products and use of tampons.

78
5. Use clean cotton underwear, and use loose fitting clothing
6. Wipe genitals from front to back (Vulva to anus)

 Rest and Activity: To facilitate full recovery and general wellbeing following childbirth as well as
cope with the demands of breastfeeding and child care, the new mother will require adequate rest.
Advise mother to have periodic rest during the day when baby is sleeping. During the first 4-6
weeks after delivery the woman should be encouraged to obtain domestic help and to delay
returning to employment.
 Postpartum Exercise: Educate woman on the importance and types of postnatal exercises (Refer
antenatal part for exercises)
 Sexual Relations and Safer Sex: woman should avoid sexual intercourse until after lochia has
stopped and perineal wounds have healed. After this time a woman can resume sexual intercourse
whenever she feels ready and comfortable.
Inform her that she is more susceptible to sexually transmitted infections during the post-partum
period. Using a condom consistently can help protect her against these infections.
 Family Planning (FP): Discuss future fertility plans with the woman and counsel her on family
planning. Inform her of return to fertility especially if not breastfeeding. If breast-feeding inform
her about benefits and limitations of lactational Amenorrhea. Provide clients preferred choice of
FP (refer if not readily available)
 Continue iron and folate supplementation for six weeks after delivery
 Continue tetanus toxoid immunization according to the standard schedule as indicated
 Anti D Immunoglobulin: administer Anti D immunoglobulin 1500 IU or 300 mcg to Rhesus
Negative mothers who give birth to Rhesus Positive babies within 72 hours of delivery.

NB: Clients should demonstrate their knowledge of the key messages. This can be done by asking
them to repeat key messages and addressing gaps identified in their knowledge.

79
MANAGEMENT OF COMPLICATIONS OF THIRD AND FOURTH STAGES OF LABOUR AT SELECTED LEVELS OF THE
HEALTH SYSTEM

STEPS IN TREATMENT/MANAGEMENT OF CONDITION/COMPLICATION

COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

a) Post-partum Haemorrhage (PPH) [is  Give/continue IV fluids 500 mls normal saline (N/S)  Follow the steps as for basic level
bleeding of 500mIs or more from the or ringers lactate (R/L). Give as much as may be care
vagina before, during or after delivery required to maintain circulation]  Give blood transfusion, if necessary
of placenta, or any blood loss that  Monitor for signs of SHOCK or fluid overload  Identify the cause of haemorrhage
causes maternal condition to  Resuscitate if necessary (see flow chart for SHOCK o Atonic uterus
deteriorate]. management in appendix) o Retained placenta, retained
 Take blood for Hb, grouping and cross-matching fragments or pieces of placenta
COMMUNITY  Give I.V/IM 10 IU oxytocin stat and 20 IU o Occult rupture of uterus or
LEVEL Oxytocin in 500mls normal saline to run at 40 – incomplete rupture of uterus,
 Call for help 60drops per minute OR insert Misoprostol 800 µg (4 ruptured uterus
 Massage/rub the uterus tablets) rectally o Inversion of uterus
continuously to expel blood and  Insert Foleys catheter for continuous bladder o Lacerations or tears of vulva,
blood clots drainage vagina and cervix
 Start IV fluids  If bleeding continues, examine for lacerations of o Coagulopathy
perineum, vagina or cervix; if laceration present:  Manage appropriately as described
 Insert misoprostol 800µg Suture
rectally under the respective sections
 If placenta is delivered:
Call ahead to alert referral - Massage uterine fundus and stimulate nipples
hospital - Do bimanual compression of the uterus if
 Arrange transport necessary
 Transport patient in Anti-shock - Examine placenta for completeness and extra
Garment if available lobe
If bleeding continues organise blood donors to
 Refer immediately accompany mother
 - Arrange transport
 REFER
80
 COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

 If bleeding ceases or stops:

 Give broad spectrum antibiotics for 5 days
 Observe for 24 hours
 Check Hb
 Give haematinics

 If bleeding with placenta still in utero, see section on

retained placenta
b). Atonic Uterus  Massage/rub uterus continuously to expel blood and  Follow same steps as for basic level
(The uterus that fails to contract after blood clots care
delivery of the placenta)  Empty bladder if full – Insert Foley’s catheter for  Give blood transfusion if necessary
- There is excessive bleeding and continuous bladder drainage  Examine to identify other causes of
- Uterus remains soft and distended,  Resuscitate (if necessary) and monitor for signs of bleeding and manage appropriately
and shock (see flow chart for shock) (see sections below)
- Lacks tone)  Give 20 IU oxytocin in 500mls of N/Saline or  If bleeding continues in spite of the
Ringers Lactate to run at 40 drops per minute above measures
COMMUNITY LEVEL NOTE: Do not give more than 3.0 litres of oxytocin  Perform bimanual compression of the
infusion uterus
 Massage/rub the uterus  Give broad spectrum antibiotics  Insert hydrostatic condom tamponade
continuously to expel blood and  Take blood for grouping and cross-matching (refer to procedure in appendix)
blood clots  If bleeding continues,  Assess clotting status (e.g. use
 Start IV fluids - Give/insert misoprostol 800µg rectally, if not bedside clotting test)
 Make sure the woman empties already given - If blood does not clot after 7 minutes
- Do bimanual uterine compression or a soft clot forms that breaks down
her bladder
- Organise blood donors to accompany mother easily, suspect coagulopathy and
 Insert misoprostol 800µg - Insert hydrostatic condom tamponade manage appropriately
rectally - Arrange transport
 Arrange transport
 Refer immediately  REFER
If bleeding ceases or stops
Check Hb.
Observe for 24 hours
c). Retained Placenta: Placenta is not  Empty bladder  Follow same steps as for basic level
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 COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

delivered within 30 minutes of delivery maternal care

of baby:  If trained to do manual removal:  Manage appropriately.
 Ensure that the bladder is empty
COMMUNITY LEVEL - Give broad spectrum antibiotics e.g. IV Catheterize if necessary
 Start IV fluids if possible Amoxicillin + Clavulanic Acid1.2g stat or IV  If placenta is visible, ask woman to
Cefuroxime 1.5g stat. bear down to aid expulsion
 Refer immediately  If placenta can be felt in the vagina,
o Remove placenta manually under analgesia. - remove it
Give pethidine100mg and diazepam 10mg  If placenta is not delivered, give
slowly iv –Do not mix in the same syringe oxytocin 10 IU IV slowly if not
o Examine the placenta and membranes for already done.
completeness and extra lobe  If placenta is not delivered after 30
minutes of oxytocin administration
o Give 20 units oxytocin in 500mls N/Saline to run and uterus is contracted, do gentle
at a rate of 40-60 drops per minute to keep the controlled cord traction (avoid
uterus contracted forceful traction of the cord).
o Massage the uterus  If controlled cord traction fails, do
manual removal of placenta
OR insert Misoprostol 800 µg rectally NB: watch for very adherent tissues,
o Continue with Tabs Amoxicillin + Clavulanic which may be placenta accreta. Do not
Acid 625 mg bd x 7 days and metronidazole use any instrument for removal.
400mg tid x 7 days Instruments may cause uterine
perforation.
If bleeding still continues  Continue IV oxytocin infusion as
 If not trained to do manual removal: for Basic Maternal level Care
 REFER  If bleeding continues assess clotting
status and correct appropriately
NOTE: If placenta is retained, refer even if there is no  Give broad-spectrum antibiotics as
bleeding above.

d). Retained fragments of placenta  If placenta is delivered but uterus remains soft and  Follow steps as in basic level
bleeding continues maternal care
COMMUNITY LEVEL  Start IV fluids 500ml N/S or R/L  Do manual exploration of the uterus

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 COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

 Give misoprostol 800 µg rectally - Remove placental fragments

 Start IV fluids if possible  If trained to do manual removal  If bleeding continues, do bed side
 Insert misoprostol 800µg o Do manual exploration of the uterus and Feel clotting test
rectally for and remove retained placental fragments  If coagulopathy:
 Arrange transport
(Technique is similar to that described for  Transfuse grouped and cross-
manual removal of placenta) matched fresh blood, or fresh
 Refer immediately  Give 20 IU oxytocin in 500mls N/Saline at a rate of frozen plasma.
40 – 60 drops per minute to keep uterus contracted
 If no oxytocin available or haemorrhage
continues
 Give Misoprostol 800µg rectally, if not already given
at community level
 If not trained to do manual exploration of uterine
cavity, give broad spectrum antibiotics
(Intravenously) and REFER

e) Inversion of uterus  Empty bladder  Follow steps as in basic level care

The uterus is said to be inverted if it  Start IV fluids 500mls N/Saline or R/L  Give broad spectrum antibiotics:
turns inside out during the delivery of  Resuscitate if necessary - IV Amoxicillin + Clavulanic Acid
the placenta. This may be complete or  Monitor for signs of shock 1.2g stat or IV Cefuroxime 1.5g stat.
partial  Take blood for grouping and cross-matching - Metronidazole 500mg IV stat then
 Complete inversion: The inside  Examine the woman to confirm inversion Perform manual
of the uterus can be seen outside  DO NOT GIVE OXYTOCIN replacement/repositioning of the uterus
the vagina. (refer to the learning guide in the
 If woman is in severe pain, give Pethidine100mg IV
 Partial inversion: The fundus slowly over 5 minutes appendix)
caves in and does not seem well  If successful, give IV oxytocin
 Give broad spectrum antibiotics
defined on abdominal palpation 10 units stat and continue iv
o IV Amoxicillin + Clavulanic Acid 1.2g stat or IV oxytocin infusion (20 units in
COMMUNITY LEVEL 500mls N/Saline or Ringer’s
Cefuroxime 1.5g stat. IV Metronidazole 500mg
stat lactate)
 Start IV fluids if possible  If replacement is not successful
o and REFER
 REFER TO A TERTIARY
 Refer immediately CENTRE
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 COMPLICATION BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

h) Hypertensive Disorders in the Manage as specified in section on Antenatal care,

postpartum period

84
 III POSTPARTUM CARE

OBJECTIVES

The objectives of postpartum care are:

1. To maintain the physical and psychological well-being of mother and baby

2. To perform comprehensive screening for detection, treatment and /or referral of complications of both
mother and baby
3. To detect and treat and/refer complications in the mother and the baby
4. To provide health education on nutrition, danger signs, family planning, infant feeding/breastfeeding
and immunization of the baby

Schedule of Postnatal visits for the mother and baby: There should be at least three review visits:

1. The first visit should be within the first 48 hours after delivery
2. The second visit is on the 6th or 7th day after delivery
3. The last postnatal visit is at 6 weeks
Client should however be encouraged to visit the health facility at any time if she has any problems or
concerns relating to herself or her baby.

Essential Activities at Postpartum Clinic

ii) Examination of mother and baby
iii) Promotion of breastfeeding, including early initiation
iv) Identification and management of conditions e.g. Malaria, Anaemia
v) Micronutrient supplementation
vi) Immunization of the mother (where necessary)
vii) Immunization of the baby
viii) Health education and counselling
ix) Family planning motivation, and linkage with FP clinic for counselling and services
x) HIV testing and counselling (if not already done)
xi) Antiretroviral treatment (for HIV infected mothers and exposed babies)
xii) Birth registration

B. ROUTINE MANAGEMENT OF POSTPARTUM

Ensure that the following conditions are met:

 Consulting area provides privacy

85
  Clients and accompanying support persons are treated with respect and
kindness
 Clinic area, toilet facilities and area for nappy changes are clean
 Mother and baby care services are within same area
 Client receives continuing care from same providers as much as possible

FIRST AND SECOND VISITS

Maternal Assessment

a. History

Welcome client and establish rapport:

If client has maternal health record: quickly review for personal details, antenatal and delivery notes

If client has no maternal health records provide one and in addition take comprehensive history including
history of recent pregnancy, labour and delivery outcomes, past obstetric history, medical and surgical
history, family and social history.

Ask all clients about the following:

If she has any problems or concerns since delivery (Mother and Baby)
How she and her family are coping with the baby
Workload, rest and support
Baby’s name, sex, feeding and sleep patterns, stools
Postpartum discomforts (. e.g. after pains, bladder and bowel function)
Presence of postpartum danger signs or symptoms in mother or baby (See Box below)

Common discomforts of Postpartum period in Mother

After pains Fatigue and sleepiness

Perineal pain Headache
Bowel and urinary changes Sleeplessness Haemorrhoids
Stretch Marks Back pain Mood changes

MATERNAL DANGER SIGNS

Vaginal Bleeding (heavy or sudden increase)
Breathing difficulty
Fever
Severe abdominal pain
Severe headache and/or blurred vision
Convulsions / loss of consciousness
Foul smelling discharge from vagina

86
 Painful and tender wound (C-section, Episiotomy)
Pain in calf with or without swelling
Pain on urination / dribbling urine
Persistent vomiting
Breasts that are red hot and / feel painful
Abnormal behaviour

b. Examination: Examine mother from head to toe paying attention to the following:

General Examination: Observe her gait, mood, general cleanliness and behaviour towards baby, Check:
Temperature
Pulse
Blood pressure
Weight
Conjunctiva for pallor

Examination of Specific Areas:

Breast:
Examine for Lactation (i.e., flow of milk), sore/cracked nipples and engorgement, warm and sore breast

Abdomen;
Inspect: operation wound (if she has had a Caesarean section)
Palpate for tenderness and involution of uterus

Lower extremities:
Check for oedema, varicosities, and tenderness in calves

Perineum and external genitalia:

Inspect: overall appearance, lochia: flow, colour, odour, episiotomy/tears, swellings, Protrusions from
vagina, Anal area for haemorrhoids.
Perform: speculum and Bimanual pelvic examination if indicated (e.g. protruding vaginal lump, bleeding
per vagina, inspection of sutured vaginal tears, involuntary urine loss per vagina,)

c. Conduct the following Laboratory Tests

Blood for haemoglobin
Urine analysis

Newborn Assessment

The following guidelines can be used

a. Ask (mother)
b. Check
c. Look, Listen, Feel
d. Classify

87
 e. Decide on care

a. Ask Mother
- If baby has any problem or concern?
- How baby is feeding? (Observe)
b. Check
- Records of pregnancy, delivery, condition at birth
- Check weight, temperature, immunization status
c. Look, Listen, Feel the baby
- Carry out general examination from head to toe and front and back
- General appearance – colour, skeletal symmetry
- Reflexes
d. Classify and decide on care
 Well baby
- Focus of the care is prevention of neonatal infection
- Follow the routine EPI schedule for Ghana.
BCG is given intra-dermally in the shoulder.
Polio vaccine is given orally and is given at the same time as the BCG
Remind mothers that they will need to come later for subsequent immunisations.
- Educate mother on cord care, immunization, exclusive breast feeding, regular Post Natal Clinic and
Under 5 clinic
 Sick baby or baby with problem
- Manage the problem or refer

If a postpartum concern or complication is noted during any visit see chart below for management.

88
 MANAGEMENT OF COMMON DISCOMFORTS/CONCERNS IN THE POSTPARTUM PERIOD

DISCOMFORT/CONCERN Prevention, Relief measures and Alert signs that may

(Signs/Symptoms) Reassurance indicate a problem
After pains; Explain : Uterine tenderness
Due to uterine contraction Abdominal distension
Cramps/ contraction as in Breastfeeding increases chemical that Burning sensation during
labour, causes uterus to contract urination
Common in multiparous Provoked by full Bladder
women on Postpartum Days 2- Relief measures
4 and during Breastfeeding Walk around or change position
Lie face down with pillow under abdomen
Gently massage lower abdomen
Apply warm cloth or hot water bottle
Empty bladder frequently
Take paracetamol 500-1000mg 30 minute
before breast feeding
Perineal Pain Explain: Sloughing or reddened tear
Due to tissue trauma during delivery or episiotomy site,
Occurs during 1st and 2nd post- Pus discharge from wound
partum weeks period Relief measures all indicating infection
Advise to maintain good perineal hygiene
Apply ice packs (wrapped in cloth) Purplish swelling
Breast feed lying down or sit on cushion indicating haematoma
with hole middle (e.g. inner tube of tyre)
May Take paracetamol 500-1000mg or
Ibuprofen 400mg

Fatigue and sleepiness Explain: Associated:

Is normal reaction to hard work of labour Dizziness/fainting/palpitati
Interrupted sleep to feed and care for the ons/breathlessness/pallor
Common in first week baby that may indicate anaemia.
postpartum Emotional and physical stress of additional
Responsibilities Insomnia /excessive
sadness that may indicate
Relief measures depression
Take a nap when baby sleeps and whenever
possible Hallucinations/suicidal
Advise partner/family to share some of thoughts that may indicate
responsibilities for new born care and puerperal psychosis
household chore

Mood changes Reassure: Crying /feelings of sadness/

Tell her she is capable of taking care of her or being overwhelmed
Common during 1st and 2nd baby and can do a good job between days 3-4 which
post-partum weeks period Praise her for things she is doing right may indicate postpartum
In adolescents AND however small blues
primiparous women Allow her to ask questions and discuss her
anxieties. Insomnia /excessive

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DISCOMFORT/CONCERN Prevention, Relief measures and Alert signs that may
(Signs/Symptoms) Reassurance indicate a problem
Do not overwhelm her with too much sadness that may indicate
information at one time depression

Avoid unrealistic expectations for herself Hallucinations/suicidal

thoughts that may indicate
Advised partner/family to encourage and puerperal psychosis
support in caring for new born

Back pain Explain: Associated lower

Effect of pregnancy hormones on muscles abdominal tenderness, and
Common in first week and ligaments distension may indicate
postpartum but may persist due May be due to poor breastfeeding infection
to poor posture during breast posture, poor body mechanics and
feeding Increased breast size Flank/loin pain with
burning sensation on
Relief measures urination may indicate
Advise to use good body mechanics during urine tract infection
lifting e.g. during lifting (When lifting
squat rather than bend, keep spine erect so Numbness, muscular
that thighs/legs bear the weight and strain). weakness or wasting,
difficulty in walking,
Do not lift anything heavier than your baby uncontrolled urinating or
for the first few weeks postpartum defecating which may
indicate nerve disease
Practice “Angry cat exercise” See antenatal
exercise page)
Wear well-fitting / supportive brassiere
Sleep on firm mattress or surface
Apply ice pack / hot pad to area
Apply gentle massage over area
Take paracetamol 500-1000mg or
Ibuprofen 400mg

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 STEPS IN MANAGEMENT OF COMPLICATIONS IN THE POSTPARTUM PERIOD

COMPLICATION/ PROBLEM BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

a) Secondary Postpartum Do Quick assessment of woman to determine general condition of Same steps as for Basic Care Level
haemorrhage woman, to confirm diagnosis, and determine cause of bleeding.  Evaluate patient further to determine
(Secondary - 24 hours or more cause of bleeding. Manage shock and
after delivery) Review any referral notes for treatments already given severe anaemia if present.
 If in shock continue with IV fluid
Continuous slow bleeding  Assess: Total amount of blood loss through interview and resuscitation (See shock management
observation of bed clothes and pads page) Give blood transfusion if
Sudden bleeding or increase in  Check BP, pulse, temperature, and assess for shock; check for pallor indicated.
bleeding (If in shock begin IV fluid resuscitation immediately. If not in shock,  Re –evaluate to determine underlying
keep shock in mind as you evaluate further) cause of bleeding:
It is usually due to infection,  Examine abdomen to check for uterine size, firmness, and tenderness.  Obtain history of recent pregnancy,
particularly in association with: If uterus is not contracted, massage to stimulate contractions and also
 Retained pieces of placenta. labour /delivery, baby and
expel any blood clots postpartum.
 Obstructed labour, causing
necrosis of the cervix and vaginal Perform vulva/vaginal examination Ask about: Fever, abdominal pain,
wall Remove any clots/product in vagina and offensive lochia.
 Caesarean section and breakdown Inspect perineum /vagina/Cervix for any
of the uterine wound bleeding sites
Examine abdomen for uterine sub
Check if cervix is open and if products can be felt within. involution and signs of infection
COMMUNITY LEVEL  Do urgent pelvic Ultrasound scan if patient is stable

Set up IV access line; take blood for grouping and cross-matching. Do vaginal examination to determine:
Administer Misoprostol 800 mcg (4
tablets) rectally. Start IV fluid infusion (Normal saline or Ringers Solution) if in shock or  If Cervix is dilated indicating
bleeding is continuing. (See flow chart for Shock Management. possible retained placental tissues.
Record treatment given and amount Give inj. Oxytocin IV 10 units IM and add 20 units to 500 mls IV fluid.  If there are birth tract injuries.
of blood loss observed. Start IV antibiotics (Ampicillin 2g + Gentamycin 80mg + Metronidazole (Further examination under anaesthesia
500mg may be needed.)
Explain to patient /family the need for
urgent referral to facility with surgical If bleeding is profuse and/or persists do the following: Perform investigations, including
and blood transfusion services Repeat Oxytocin infusion  FBC
Encourage drinks, No Solid Food Administer Misoprostol rectally 800mcg stat if not already given  grouping and cross matching, of 2 or
Organise blood donors to Pass urine catheter to monitor urine output more units of blood
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 COMPLICATION/ PROBLEM BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

accompany patient -  high vaginal swab for C/S

Assist client/ family arrange Arrange prompt transfer to hospital  blood for C/S,
emergency transport  Ultrasound scan. (If indicated)
 REFER/ and accompany patient to If patient is stable and/or bleeding stops: If profuse and continuing bleeding
hospital if possible observe patient for at least 24 hours
Give iron and folic acid therapy. Suspect: retained products, ruptured
uterus/ Cervical or vaginal tears
Continue Oral Amoxicillin and metronidazole regimes for at least one
week  Continue resuscitation, IV antibiotics
and prepare patient for theatre
 Perform operative treatment
(e.g., evacuate uterus, repair any tears,
laparotomy)

Post surgery:
Monitor closely for:
- severe anaemia,
- wound infection,
- Uterine sub-involution and
sequelae of severe shock e.g.
renal failure, lactation failure.

b) Raised blood pressure BP> Manage as specified in the section on antenatal care,
140/90mmHg

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STEPS IN MANAGEMENT OF POSTPARTUM CONDITION/COMPLICATION

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
c) Puerperal Pyrexia/Sepsis  Do rapid evaluation to confirm diagnosis and Same steps as for Basic Care level
Upper genital tract infection determine condition of woman: Evaluate patient further to determine
underlying cause of infection
Diagnosis  Check level of consciousness, pallor, Temperature, Review any referral notes for treatments
complaints of: BP and Pulse (If in shock start immediate already given
* Profuse offensive vaginal resuscitation)
discharge with/without  Examine abdomen for distension, uterine size and Take comprehensive history: including
bleeding (lochia) tenderness. labour/delivery history, pregnancy outcome
* Fever  Inspect external genitalia for lochia and postnatal health. Ask if patient has
* Abdominal pains  Assess severity of infection: existing risk preconditions such as HIV
* Sub-involution of uterus infection or Diabetes Mellitus.
Start IV Cefuroxime 1500mg stat
Start analgesics: Paracetamol
Examine patient thoroughly
COMMUNITY LEVEL Give Tetanus Toxoid (if no record of immunization)
 Assess the severity of infection: (Signs of
Encourage adequate intake of oral fluids
septic shock, haemolysis, severe
If fever is present: anaemia) and the specific area involved
 Give plenty of drinks REFER and accompany patient if possible
 Examine abdomen for distension, hepato-
-Give paracetamol 1000mg (2
splenomegally, presence of abnormal
tablets)
masses e.g. abscess
REFER patient immediately  Conduct bimanual/pelvic examination:
check for opened cervical os, uterine
tenderness and sub-involution, abnormal
pelvic masses,/swellings,

 Conduct investigations (Hb, WBC, HVS

for c/s, blood C/S, urine c/s, Pelvic
ultrasound, HIV);
From above determine if there are other
underlying causes for severe sepsis e.g.:
Retained products, pelvic abscess, peritonitis,

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 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
septicaemia, HIV or Malaria
Start and maintain IV fluid resuscitation
Give IV Broad spectrum antibiotics
Clindamycin 300mg tds + Gentamycin 80mg
bd
(Change to recommended drugs when C/s
results are available.
Correct anaemia and nutritional deficiencies
Treat /manage promptly underlying causes
(e.g.: laparotomy, evacuation of uterus, ART
if indicated)

d) Lower genital tract infection Evaluate the patient as follows: Same as Basic Care level:
Check Temp, BP, Pulse and for pallor Review referral notes if available
*Infected vaginal lacerations Examine abdomen for uterine tenderness and size
*Perineal abscess Inspect the perineum and vagina to determine extent and Take comprehensive history: including
*Infected /gaped episiotomy/tear nature of problem: labour/delivery history, pregnancy outcome
*Perineal haematoma and postnatal health. Ask if patient has
Check Hb for anaemia existing risk pre-conditions such as history of
COMMUNITY LEVEL previous breast disease, HIV infection or
 Advise sitz baths (salt water or chlorhexidine ) Diabetes Mellitus.
If fever is present:  Give broad-spectrum antibiotic (Give antibiotics :
 Give plenty of drinks Amoxicillin-clavulanic acid 625mg bd for 7 days Examine patient thoroughly:
-Give paracetamol 1000mg (2  Give analgesics ( Paracetamol/Ibuprofen)  Assess the severity of infection: (Signs of
tablets) Give Tetanus immunization (as required) septic shock,)
 Teach perineal hygiene  Examine abdomen for signs of abdomino
REFER patient immediately Teach to breast feed lying down/or sit on ring cushion pelvic involvement) e.g. distension,
Provide nutritional advise hepato-splenomegally, presence of
 Monitor progress; if abnormal masses e.g. pelvic abscess
* No improvement after 72 hours  Conduct speculum / bimanual pelvic
* An abscess forms, worsens or persists examination: vagina to determine extent

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 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
* If there is a 3rd degree tear and nature of problem:
REFER  Conduct investigation (Hb, WBC,
If patient improves and infection of a gaped tear or HVS /Wound swab for c/s, Urine RE
episiotomy resolves: Pelvic ultrasound, HIV, FBS if
Re-suture and monitor healing on OPD basis indicated);
Institute appropriate antibiotic therapy (I.V
Clindamycin 300mg tds plus I.V
Gentamycin)
Manage any underlying risk conditions e.g.
Diabetes, HIV
Check for abscess or haematoma if present
incise and drain
If infection of gaped perineal wound
resolves, re-suture

Refer for specialist care if patient develops

vaginal fistula, (e.g. Rectal, Vesical) vaginal
stenosis
e) Thrombo-embolism Conduct Rapid assessment of woman if: - Conduct Rapid assessment of woman to
- There is breathing difficulty confirm diagnosis as in Basic Care level
Deep Vein Thrombosis - Cough with frothy sputum or bloody/pinkish
(Clotting of blood in leg veins) sputum Start Resuscitation:
- Cyanosis (Blue discolouration of eg. the tongue) Clear Airway and Give intra-nasal Oxygen
Pulmonary embolism - Signs of Shock IV Normal saline
- Altered level of consciousness Start anti-coagulant therapy;
Diagnosis e.g.; Enoxaparin 40mg subcutaneously.
 pain in calf muscles (back of Keep airway clear/ Position woman on left lateral
leg) with/or without swelling, position If client is stable
 Fever. Start IV Normal saline (20-40 drops /min Take History: Ask about medical history of
Start Intra-nasal Oxygen and thromboembolism, Pregnancy
 Sudden attack of difficulty in labour/delivery and postpartum history
Transfer to Hospital Immediately
breathing, coughing with Examine: Check Temperature, pulse, BP

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 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
pinkish sputum. Chest and respiratory system
Abdomen and groins for tenderness
Lower extremities
COMMUNITY LEVEL  Do Investigations: (Hb, WBC, Platelets,
clotting time, urine R/E Pelvic
If fever is present: ultrasound, chest X-ray)
 Give plenty of drinks If diagnosis is confirmed:
-Give paracetamol1000mg (2 Monitor Vitals closely
tablets) Continue Anticoagulant therapy and monitor
clotting status regularly
REFER patient immediately Treat underlying causes e.g. Pelvic infection

f) Puerperal Psychosis Prevent self-harm and harm to baby and neighbours and **Puerperal psychosis should be managed
REFER for urgent help in the same way as psychotic disorders at
Diagnosis: any other time, but with the additional
Elated mood (mania), Mothers with symptoms of postpartum psychosis should considerations regarding the use of drug
depression, confusion, be promptly referred for hospital care treatments when breast feeding.
hallucinations and delusions,
suicidal tendencies, Seek support of a psychiatrist/clinical
threats of physical harm to baby psychologist

COMMUNITY LEVEL

Ask relatives if depressed

confused, and/or has suicidal
tendencies

If present, REFER client

immediately

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 IDENTIFICATION AND MANAGEMENT OF POST -PARTUM CONDITIONS/COMPLICATIONS

COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PROBLEM
g) Breasts conditions Take history: ask of breast feeding difficulties and about  Same steps as for Basic Care Level
maturity and health condition of baby  Manage appropriately or REFER for specialist
Cracked/sore nipple Examine the woman; attention
Check her vital signs (Temp, Pulse and BP) and for pallor
Examine breasts:
Patient complains of Inspect for Swelling/redness/nipple sores/ Plus discharge
sore nipples and/or Palpate for tenderness/ lumps / fluctuant area
painful breastfeeding Examine Baby for general wellbeing;
Check for adequacy of urine
Examine mouth and palate for abnormality
COMMUNITY
LEVEL  Advise on:
Correct breast feeding techniques (i.e., make sure the
Ask about soreness of surrounding area as well as the nipple are in the infant’s
nipples and/or painful mouth, and that the infant's position is changed during
breastfeeding breastfeeding)

 To start feeding on the side that is less sore

If present, REFER
 When removing the baby from the breast, break suction
client
gently by; Pulling on the baby’s chin or by placing one
finger in the corner of the baby’s mouth
 To apply breast milk to affected nipple after feeding and
expose the breast (air dry)
 Not to use soaps or alcohol on the nipples
 Avoid tight brassieres that may irritate nipple and

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 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
aggravate pain
 If above measure do not provide relief she can take two
tablets of paracetamol 30 minutes before breast-feeding.
 Monitor progress; if condition persists for more than one
week and/or is interfering with breast feeding:
 REFER

If Mastitis or abscess is present: (Fever, swollen hot and tender

breast, with or without pus discharge) See sections below.

Refer baby if in poor general condition and/or mouth/palate

abnormality is detected

Same steps as for Basic Care Level

Breast Engorgement If trained in lactation management  Support mother express breast milk and
 Help mother to express breast milk feed baby by cup and spoon
 Help mother to attach baby to breast
Breast looks tight,  If baby cannot suckle at all give him or her expressed breast  Manage baby’s condition appropriately
shiny and Painful milk before REFERRAL
 Educate mother to continue to express as often as necessary
to make breast comfortable until engorgement stops
COMMUNITY
 Wear well-fitting supportive brassiere.
LEVEL
 Give Paracetamol 1000mg
If not trained in lactation management refer to next level
Ask about presence of
pain in breast  Do a thorough newborn assessment
- Examine for mouth abnormalities
If present, REFER  Determine cause of poor feeding
client If there is a newborn danger sign
- See Newborn care section
If there is no danger sign

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 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
- support mother to breastfeed
Mastitis Take history: ask about breast-feeding difficulties and Same steps as for Basic Care Level
about health condition of baby. Onset and duration of
Patient complains of symptoms. Take comprehensive history: including,
soreness of breast pregnancy, labour/delivery history and postnatal
and/or fever, and Confirm diagnosis health. Ask if patient has existing risk pre-
painful breastfeeding; Examine the woman; conditions such as HIV infection, Diabetes
Check her vital sign (Temp, Pulse and BP) and for pallor Mellitus or history of previous breast disease.
Breast is tender, hot Examine breasts:
and swollen. Inspect for Swelling/redness, nipple sores/ Pus discharge Examine patient thoroughly:
Palpate for tenderness/ lumps / fluctuant area  Assess the severity of infection: (look for
COMMUNITY signs of septic shock,)
LEVEL Examine Baby for general wellbeing;  Examine abdomen, pelvis and lower
Check for weight gain/loss extremities
Ask about fever, and  Conduct investigation (Hb, WBC, blood C/S;
If Mastitis (Fever, swollen, hot and tender breast, with or
painful breastfeeding Breast milk C/S, urine RE, HIV, FBS if
without pus discharge)
indicated);
Give analgesics: Paracetamol 1000mg tid
If present, REFER Give antibiotics :
client Institute appropriate antibiotic therapy
Amoxicillin-Clavulanic acid 625mg bd for 7 days or
Manage any underlying risk conditions e.g.
Clindamycin 300mg tid for 7 days
Diabetes, HIV.
Encourage increased fluid intake and rest
Breasts should be frequently emptied of milk through continued
breastfeeding or pumping Perform incision and drainage if abscess is
present
Monitor and review after 72 hours

REFER if
*No Improvement after 72 hour
*(Abscess develops, or
*Baby is in poor general condition)

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 COMPLICATION/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PROBLEM
Breast Abscess Take history: Ask about breast feeding difficulties andas for Basic Care Level
Same steps
about health condition of baby
Confirm diagnosis Take comprehensive history: including, pregnancy,
Examine the woman; labour/delivery history and postnatal health. Ask if
Patient complains of
Check her vital sign (Temp, Pulse and BP) andpatient
for pallor
has existing risk pre-conditions such as HIV
Painful breast swelling infection, Diabetes Mellitus or history of previous
Examine breasts:
with or without pus
Inspect for Swelling/redness, nipple sores/ Pus breast disease.
discharge, and fever
discharge
Palpate for tenderness/ lumps / fluctuant area Examine patient thoroughly:
Breast is tender,  Assess the severity of infection: (look for signs of
swollen, hot and/or septic shock,)
Examine Baby for general wellbeing;
discharging pus.  Examine abdomen, pelvis and lower extremities
Check for weight gain/loss
 Conduct investigation (Hb, WBC, blood C/S;
If Abscess is confirmed (Fever, swollen hot and Breast
tendermilk C/S, urine RE, HIV, FBS if
COMMUNITY indicated);
breast, with fluctuant mass with or without pus discharge)
LEVEL Give analgesics: Paracetamol1000mgtid
Give antibiotics : Institute appropriate antibiotic therapy
Ask about fever, Amoxicillin-Clavulanic acid 625 mg bd for 7Manage
days or any underlying risk conditions e.g.
Diabetes, HIV.
swelling of breasts and Clindamycin 300 mg tid for 7 days
discharge from breasts Encourage increased fluid intake and rest
Perform Incision and drainage if an abscess is present
Monitor and review after 72 hours
If present, REFER
client REFER if
No Improvement after 72 hours, or
Baby is in poor general condition

100
IDENTIFICATION AND TREATMENT /MANAGEMENT OF POSTNATAL CONDITION/COMPLICATION
KEY: STEPS IN IDENTIFICATION OF CONDITION/COMPLICATION

DANGER SIGN/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

COMPLICATION
Breathing difficulty in Baby If apneic or slow breathing, ventilate with  Same as for Basic Care level plus
 Not breathing (apnoea) bag and mask until baby breathes  Provide basic and advanced resuscitation when
 Gasping spontaneously. necessary
Difficulty breathing (slow breathing If difficulty in breathing, give oxygen by  Check oxygen saturation – maintain an oxygen
< 30bpmin, fast breathing ≥ nasal catheter or nasal prongs saturation of 90 – 98%
60bpmin, severe chest in-drawing or Give first dose of pre-referral antibiotics:  Take blood for Culture and Sensitivity and Full
grunting) intramuscularly (IM) Blood Count
Ampicillin 50mg/kg body weight 12 hourly  Start IV antibiotics - Ampicillin 50 mg/kg body
COMMUNITY LEVEL PLUS Gentamycin 5mg/kg body weight weight 12 hourly and Gentamicin 5mg/kg body
REFER weight daily for 7 days)
Ask if baby has difficulty in o Document care given  If respiratory problems persist or worsen over
breathing, fast breathing, or gasping o Counsel mother/family on referral 48 hours, take a Chest X-Ray
o Monitor the baby’s breathing, colour,  Rule out congenital heart disease
If present, REFER temperature and activity  Do an Echocardiography if available
o Document care given o Keep baby warm in skin to skin contact  Continue to monitor the baby’s breathing,
o Counsel mother/family on during referral colour, oxygen saturation, temperature and
referral activity
o Keep baby warm in skin to  Communicate the baby’s condition with the
skin contact during referral mother and father throughout the admission
period
 Observe the baby for 24 hours after
discontinuing oxygen and antibiotics.
 If baby is breathing normally, or preterm and
has not had an episode of apnoea for 7 days, is
feeding well, and there are no other problems
requiring hospitalization, discharge the baby
 Follow up in 1 week, or earlier if the mother

101
 notices any serious problems or danger signs

DANGER SIGN/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

COMPLICATION
Convulsions/seizures/twitching  Ensure airway is clear and baby is  Maintain airway, breathing and circulation
 Repetitive jerky movements breathing normally  Check blood sugar
of limbs or face  Give IM Phenobarbitone 20 mg/kg body  If < 2.5 mmol/l (hypoglycaemia) give
 Continuous extension or weight o 2 ml/kg body weight of intravenous
flexion of arms and legs,  Give pre-referral IM antibiotics (IV) 10% Dextrose OR
either synchronous or o Ampicillin 50mg/kg body weight 12 o 5 ml/kg body weight of 5% Dextrose as
asynchronous hourly PLUS Gentamycin 5mg/kg body a bolus
 Repetitive blinking, eye weight  Recheck blood sugar in 10 minutes
deviation, or staring  REFER  Maintain blood sugar between 3.0 – 7.0 mmol/l
 Repetitive movements of o Document care given  Give IV fluids as maintenance according to
mouth or tongue o Counsel mother/family on referral the weight
 Purposeless movement of the o Monitor the baby’s breathing, colour,
limbs, as if bicycling or temperature and activity Refer to guidelines on Newborn Care in the
swimming o Keep baby warm in skin to skin contact appendix
 Apnoea during referral  10% Dextrose OR 10% Dextrose in ⅕ Normal
 Baby may be conscious or saline
unconscious  Give IV/IM Phenobarbitone 20 mg/kg body
weight start
COMMUNITY LEVEL  If the convulsion recurs, give 10 mg/kg body
Ask if baby has any of above weight of Phenobarbitone and then 2.5 mg/kg
symptoms 12 hourly
 Do a lumbar puncture and send cerebrospinal
 If present, REFER client fluid for culture and sensitivity, when
o Document care given convulsions stop and patient is stable
o Counsel mother/family on  Give IV Ampicillin 50mg/kg body weight 12
referral hourly and Gentamicin 5mg/kg body weight
o Keep baby warm in skin to daily for 7 days
skin contact during referral  Continue to monitor the baby’s breathing,
colour, oxygen saturation, temperature and

102
 activity
 Communicate the baby’s condition with the
mother and father throughout the admission
period
 If the baby has not had a convulsion for three
days after discontinuing phenobarbitone, the
mother is able to feed the baby, has completed
antibiotics and there are no other problems
requiring hospitalization, discharge the baby
 Follow up in one week, or earlier if the mother
notices serious problems or danger signs (e.g.
feeding difficulty, convulsions)
DANGER SIGN/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
COMPLICATION
Low temperature (< 35.50C)  Warm the baby in skin to skin contact with  Same as in Basic Care level plus
mother, or place under a radiant heater, or  Check blood sugar
wrap baby with additional clothing and  Correct hypoglycaemia if present
COMMUNITY LEVEL sheets, cover head and put socks on baby  If baby cannot tolerate expressed breast milk
Ask if body of baby feels cold  Ensure that the room is warm, close the (by cup and spoon or tube), give IV
Take temperature windows maintenance fluids
 Warm the baby in skin to skin  Recheck temperature in 30 minutes  Take blood for Culture and Sensitivity and Full
contact with mother, or wrap  Breastfeed baby Blood Count
baby with additional clothing and  If baby cannot suck, give expressed  Give IV antibiotics:
sheets, cover head and put socks breastmilk o Ampicillin 50mg/kg body weight 12 hourly
on baby  Give pre-referral IM antibiotics and Gentamicin 5mg/kg body weight daily
 REFER o Ampicillin 50mg/kg body weight 12 for 7 days
o Document care given hourly PLUS Gentamycin 5mg/kg body  Continue to monitor the baby’s breathing,
o Counsel mother/family on weight colour, oxygen saturation, temperature and
referral  REFER activity
o Encourage breastfeeding o Document care given  Communicate the baby’s condition with the
o Keep baby warm in skin to o Counsel mother/family on referral mother and father throughout the admission
skin contact during referral o Monitor the baby’s breathing, colour, period
temperature and activity  Observe the baby for 24 hours after

103
 o Encourage breastfeeding discontinuing antibiotics.
o Keep baby warm in skin to skin contact  If the temperature is normal for at least 48
during referral hours, baby is feeding well, and there are no
other problems requiring hospitalization,
discharge the baby.
 Follow up in one week, or earlier if the mother
notices serious problems or danger signs
DANGER SIGN/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
COMPLICATION
High temperature (≥37.50C)  Re-check temperature in 30 minutes  Same as in Basic Care level
 If temperature is still high, give pre-referral  Take blood for culture and sensitivity
IM antibiotics  Ensure baby is well hydrated and feeding very
o Ampicillin 50mg/kg body weight 12 well
COMMUNITY LEVEL hourly PLUS Gentamycin 5mg/kg  If high temperature persists
body weight  Take blood for Culture and Sensitivity and Full
Ask if baby’s body feels cold Blood Count
 REFER
o Document care given  Give IV antibiotics
Take temperature o Counsel mother/family on referral o Ampicillin 50mg/kg body weight 12 hourly
o Monitor the baby’s breathing, colour, and Gentamicin 5mg/kg body weight daily
 Remove extra clothing and for 7 days
temperature and activity
source of warmth o Encourage breastfeeding or expressed  Continue to monitor the baby’s breathing,
 Do not tepid sponge and Do not colour, oxygen saturation, temperature and
breast milk by cup
give paracetamol activity
o Keep baby warm in skin to skin contact
 Breastfeed baby  Communicate the baby’s condition with the
during referral
 REFER mother and father throughout the admission
o Document care given period
o Counsel mother/family on  Observe the baby for 24 hours after
discontinuing antibiotics. If temperature is
referral
normal for at least 48 hours, baby is feeding
o Encourage breastfeeding
well, and there are no other problems requiring
o Keep baby warm in skin to
hospitalization, discharge the baby.
skin contact during referral
 Follow up in one week, or earlier if the mother
notices serious problems or danger signs

104
DANGER SIGN/ BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
COMPLICATION

105
Lethargy (movement only when  Give pre-referral IM antibiotics  Same as in Basic Care level
stimulated or no movement at all) o Ampicillin 50mg/kg body weight 12  Check blood sugar
hourly PLUS Gentamycin 5mg/kg body  Correct hypoglycaemia if present
COMMUNITY LEVEL weight  If baby can tolerate nasogastric (NG) tube
 REFER feeding, give EBM by tube
Ask if baby not moving or moving o Document care given  If breast milk is not well tolerated, give IV
only when stimulated fluids
o Counsel mother/family on referral
o Monitor the baby’s breathing, colour,  Take blood culture
If symptoms present,  Do a lumbar puncture and send cerebrospinal
temperature and activity
o Encourage breastfeeding fluid for culture and sensitivity
 Give express breastmilk (EBM)  Give IV antibiotics
and feed baby by giving small o Keep baby warm in skin to skin contact
o Ampicillin 50mg/kg body weight 12 hourly
amounts or sips using a cup or during referral
and Gentamicin 5mg/kg body weight daily for
syringe 7 days
 Continue to monitor the baby’s breathing,
 REFER colour, oxygen saturation, temperature and
o Document care given activity
o Counsel mother/family on  Communicate the baby’s condition with the
referral mother and father throughout the admission
o Encourage breastfeeding period
o Keep baby warm in skin to  Observe the baby for 24 hours after
skin contact during referral discontinuing antibiotics. If the infection has
cleared, the baby is feeding well, and there are
no other problems requiring hospitalization,
discharge the baby.
 Follow up in one week, or earlier if the mother
notices serious problems or danger signs
 Observe the baby for 24 hours after
discontinuing antibiotics. If the infection has
cleared, the baby is feeding well, and there are
no other problems requiring hospitalization,
discharge the baby.
 Follow up in one week, or earlier if the mother

106
 notices serious problems or danger signs

SERIOUS BASIC CARE LEVEL SERIOUS CONDITIONS/PROBLEMS

CONDITIONS/PROBLEMS
Severe jaundice  Give pre-referral IM antibiotics  Same as in Basic Care level
o Ampicillin 50mg/kg body weight 12  Check blood sugar
 Estimate the severity of jaundice by hourly PLUS Gentamycin 5mg/kg body  Correct hypoglycaemia if any
observing in good daylight. weight  If baby can tolerate nasogastric (NG) tube
 Lightly press the skin of the feeding, give EBM by tube
 REFER
forehead, nose or gum with a finger  If breast milk is not well tolerated, give IV
o Document care given
to reveal the underlying colour of fluids based on weight of baby
the skin and subcutaneous tissue o Counsel mother/family on referral
o Monitor the baby’s breathing, colour,  Take blood for serum bilirubin, packed cell
 Estimate the severity of jaundice by volume, full blood count, G6PD screening,
day of life (age in hours) and the temperature and activity
culture and sensitivity, blood group and
area of the body where jaundice is o Encourage breastfeeding
Rhesus factor of mother and baby (group
seen o Keep baby warm in skin to skin
and cross-match blood)
contact during referral
 Give antibiotics if there are danger signs
Jaundice is severe when there is: Ampicillin 50mg/kg body weight 12 hourly and
 Yellowish discoloration of Gentamicin 5mg/kg body weight daily for 7
the skin (jaundice) in the days
first 24 – 48 hrs  Start Phototherapy (Newborn Annex table
 Yellowish discoloration of in the appendix)
the skin at any time with a  Exchange transfusion can also be done (see
danger sign eg. Not sucking Newborn Annex table in the appendix)
 Yellow palms and soles  Follow up in one week, or earlier if the
 Jaundice lasting > 2 weeks in mother notices any serious problems or
term and > 3 weeks in danger signs
preterm
 Pale stools

 These are RISK FACTORS for

107
 severe jaundice and these newborns
should be monitored closely for
jaundice and referred to a
comprehensive care facility:
 Ask about the following:
 Previous history of neonatal
jaundice in other siblings
 Previous history of
phototherapy or exchange
transfusion in other siblings
 Previous history of still birth or
early neonatal death
 Mother blood group O
 Mother rhesus negative
 Prematurity/low birth weight
 Cephalhaematoma, Sub-galeal
bleed
 Sepsis

COMMUNITY LEVEL

 If any yellowing of eyes, REFER

o Document care given
o Counsel mother/family on
referral
o Encourage breastfeeding
o Keep baby warm in skin to skin
contact during referral
SERIOUS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
CONDITIONS/PROBLEMS

Birth weight < 1.8 kg  Same as steps for COMMUNITY level  Same as Basic Care level plus
plus  Rule out maternal risk factors of infection

108
COMMUNITY LEVEL  REFER eg. PROM, prolonged labour
o Document care given  If maternal risk factors of infection are
 Place baby in continuous skin to o Counsel mother/family on referral present and/or danger sign(s):
skin contact between mother and o Monitor the baby’s breathing, colour, o Take blood for culture and sensitivity
baby immediately after birth temperature and activity o Ampicillin 50mg/kg body weight 12 hourly
 Encourage breastfeeding o Encourage breastfeeding and Gentamicin 5mg/kg body weight daily
 REFER o Keep baby warm in skin to skin for 7 days
o Document care given contact during referral  If preterm and < 1.5 kg
o Counsel mother/family on o Monitor the baby’s breathing, colour, o Give oral caffeine citrate (20mg/ml)
referral temperature and activity during 1 ml/kg body weight stat, then 0.5
o Encourage breastfeeding referral ml/kg body weight daily until
o Keep baby warm in skin to skin discharge
contact during referral  Provide Kangaroo Mother Care (see
newborn annex in the appendix),
 Monitor blood sugar and correct
hypoglycaemia if any
 If baby cannot suckle, express breast milk
and feed by cup and spoon or nasogastric
tube
 Continue to monitor the baby’s breathing,
colour, oxygen saturation, temperature and
activity
 Communicate the baby’s condition with the
mother and father throughout the admission
period
 Can discharge when:-
o There are no danger signs
o They are gaining weight on breastmilk
alone (20 – 30 gm/kg/day)
o They can maintain a normal temperature
(36.50C – 37.40C) in an open cot
o Mother is confident and able to care
for baby

109
  Give Iron supplements: 2 – 4 mg/kg per day
of elemental iron from 2 weeks to 6 months
 Low birth weight babies should be given all
immunizations according to the schedule
 Follow up baby weekly until baby weighs
at least 3.0 kg. Thereafter, time interval
between each follow up visit can be
increased
 Continue to provide long-term
neurodevelopmental assessment and
follow-up for preterm/LBW newborns
 Those who are preterm ≤ 32 weeks
gestation may need ophthalmological
evaluation and specialist attention
SERIOUS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
CONDITIONS/PROBLEMS
Bleeding from the cord or anywhere  Stop bleeding by putting pressure gauze  Same as Basic Care level
on the body on bleeding site  Look for signs of shock
 If cord bleeding, re-tie cord between the o Cold extremities, capillary refill time < 3
COMMUNITY LEVEL base of the cord and the first clamp seconds, fast and thready brachial pulse,
 Give IV Vitamin K1, if possible fast breathing, tachycardia (heart rate >
 Stop bleeding by putting pressure  REFER immediately 160 bpm), decreased urine output
gauze on bleeding site o Document care given  Look for signs of anaemia
 If cord bleeding, re-tie cord o Counsel mother/family on referral o Pallor – palms, soles, conjunctiva
between the base of the cord and the o Monitor the baby’s breathing, colour,  Correct shock
first clamp temperature and activity o Give 10 ml/kg body weight of Normal
 REFER o Encourage breastfeeding saline as a bolus, repeat after 10 minutes
o Document care given o Keep baby warm in skin to skin  Give IV Vitamin K1 1 mg.
o Counsel mother/family on contact during referral o Repeat Vitamin K1 if bleeding persists
referral or prothrombin time is prolonged,
o Encourage breastfeeding repeat after 8 hours
o Keep baby warm in skin to skin o If bleeding persists, consider other
contact during referral causes such as sepsis

110
  Take blood for urgent Hb, grouping and
cross-matching, FBC, clotting profile
When to haemotransfuse:
 If newborn is ≤ 24 hours old, haemo-
transfuse 20 ml/kg body weight of whole
blood if PCV is ≤ 40% or Hb is ≤ 13 g/dl
 If newborn is less than 1 week of age,
haemo-transfuse whole blood if PCV is ≤
35% or Hb is ≤ 11 g/dl
 If newborn is in shock, give 5 ml/kg body
weight of blood as a bolus, and the rest to
run over 4 hours
o Continue to monitor the baby’s
breathing, colour, oxygen saturation,
pulse, urine output, temperature and
activity
o Communicate the baby’s condition with
the mother/family throughout the
admission period
SERIOUS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
CONDITIONS/PROBLEMS
Asphyxia Same as Basic care level management for Same as Comprehensive care level
(Difficulty initiating or sustaining “breathing difficulty” management for “breathing difficulty”
breathing after birth)

COMMUNITY LEVEL
 REFER
o Document care given
o Counsel mother/family on
referral
o Encourage breastfeeding
o Keep baby warm in skin to skin
contact during referral

111
SERIOUS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
CONDITIONS/PROBLEMS
Big baby (weight > 4.0 kg) Same as for COMMUNITY  Start breastfeeding early
 Monitor blood glucose and correct
hypoglycaemia if present
COMMUNITY LEVEL  Find out whether mother is diabetic
 Start breastfeeding early  Examine baby for birth injuries and
 REFER manage accordingly (see Table on Birth
o Document care given injuries)
o Counsel mother/family on
referral
o Encourage breastfeeding
o Keep baby warm in skin to skin
contact during referral

OTHER PROBLEMS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Birth weight 1.8 kg to 2.0 kg (low birth  Prevent hypothermia/Maintain warmth  Same as for Basic Care Level PLUS
weight) o If baby is stable, provide  If there are danger signs or signs of
Kangaroo Mother Care (see infection:
REFER appendix ) o Provide emergency care
o Document care given o Prolong early skin to skin contact o Take blood for culture and
o Counsel mother/family on referral between mother and baby sensitivity
o Encourage breastfeeding  Encourage early and exclusive o Ampicillin 50mg/kg body weight
o Keep baby warm in skin to skin breastfeeding. If baby cannot suckle, 12 hourly and Gentamicin 5mg/kg
contact during referral express breast milk and feed by cup body weight daily for 7 days
 Monitor weight gain (should gain 20 – o Monitor the baby’s breathing,
30 g/kg body weight per day). colour, temperature and activity
 Follow up baby weekly until baby is at  Communicate the baby’s condition
least 3.0 kg with the mother and father throughout
the admission period

112
  Provide long-term neurodevelopmental
assessment and follow-up

OTHER PROBLEMS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Breastfeeding difficulty  If not yet breastfeeding and few hours  Same as Basic Care level
old  Preterm babies have difficulty in
 Feeding difficulty is common in babies o Help mother initiate breastfeeding breastfeeding and would need a lot of
during the first days of life.  If not well attached or not suckling support
 The difficulty is associated with effectively:  Alternative feeding methods such as
incorrect breastfeeding technique, o Teach mother correct positioning and cup feeding and tube feeding of
small size, or illness. attachment expressed breastmilk should be done
 If breastfeeding less than 10 times in for those who cannot suckle
COMMUNITY LEVEL 24 hours or inadequate weight gain
 If newborn is breastfed, Ask: o Counsel mother to increase the
o How many times in 24 hours? number of feeds.
o Does the newborn usually receive o Advise her to feed as often as
any other foods or drinks? possible and as long as the baby
o If yes, what and how often? wants, day and night
o Advise her to empty one breast before
 Assess breastfeeding: giving the other breast. She can also
o Check attachment, look for express the breast after breastfeeding
o More areola visible above than and give expressed breastmilk by cup
below the nipple o Advise mother to burp baby
o Mouth wide open after breastfeeding
o Lower lip turned outward  If giving other foods and drinks
o Chin touching the breast o Counsel mother to increase
 Is the newborn suckling effectively breastmilk and reduce/stop other
(that is, slow deep sucks, sometimes foods/drinks
pausing)  Follow up in 2 days

113
BIRTH INJURIES BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
1. Cephalhaematoma  Counsel the mother not to massage or  Same as Basic Care level
put warm compresses on swelling  Manage for jaundice and anaemia
 Do not aspirate a cephalhaematoma,  If increasing head size, give IV
even though it feels fluctuant. Vitamin K1 1 mg daily for at least 72
 Teach mother to look for signs of hours
jaundice and anaemia
 If there are signs of jaundice or
 Firm swelling/bump on one side or anaemia, or increasing head size,
both sides of the head REFER
 Does not cross suture lines
 Usually apparent within 4 hours of
birth
 Look for signs of jaundice and
anaemia

COMMUNITY LEVEL
 Counsel mother and
o REFER
BIRTH INJURIES BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

114
Fractures  Handle the limb gently  Same as for basic level
 Risk factors: difficult delivery,  Try not to move the limb as much as  Take an X-Ray of the affected limb
breech delivery, big baby, shoulder possible and teach the mother to how to (antero-posterior- AP and lateral)
dystocia do so  Give analgesics
 Look for limb swelling over the  Give analgesics: Syrup paracetamol  Immobilise the affected limb to reduce
bone of the baby’s arm or leg 1.25 mls 6 hourly (if < 2.5 kg), 2.5 mls pain
 Arms and legs are not moving 6 hourly (if ≥ 2.5 kg)
symmetrically  Explain to the mother that fractures Fracture of the humerus
 Baby cries when affected arm or will heal spontaneously, usually  First place a thin layer of cotton wool
leg is moved or touched without residual deformity, and that a under the armpit extending to the chest
hard swelling (callus) may be felt over  Place the affected limb in a flexed
the fracture site at two to three weeks position on the chest with the hand on
Note: Fracture of the clavicle of age. This is part of the normal the nipple
o Mothers usually present child with healing process.  Strap the affected limb to the chest
a hard swelling on the clavicular  REFER with a cotton crepe bandage
bone around 2 weeks of age when  Make sure it is not too tight
callus has formed.
 Ensure that the hands are exposed
o No treatment is needed
 Examine the hands for swelling,
o Reassure mother that the bone will
blueness of fingers and decreased
heal and the swelling will not cause movement of fingers
any problems for the baby.
 Immediately remove the strap if any of
the above occur, and re-wrap more
COMMUNITY LEVEL
loosely
 REFER  Observe for 24 hours in hospital
 If normal, teach mother to look for
signs of problems
 The baby should be brought to the
facility daily for the first three days
 Ask mother to report back if the strap
gets loose
 Have the mother return in 14 days to
remove the bandage and also a check
X-Ray for callus formation

115
Fracture of the femur
 Place the baby on her/his back and
place a padded splint (cardboard) under
the baby from the waist to below the
knee of the affected leg
 Strap the splint to the baby by
wrapping a cotton crepe bandage
around the waist and from the thigh to
below the knee of the affected leg.
 Ensure that the umbilicus is not
covered by the bandage.
 Observe for 24 hours in hospital
 Check the toes twice daily and teach
mother how to look for signs of
problems
 If the toes become blue or swollen,
remove the bandage and re-wrap it
more loosely;
 If the bandage is rewrapped, observe
the toes for blueness or swelling for an
additional three days.
 The baby should be brought to the
facility daily for the first three days
 Ask mother to report back if the strap
gets loose
 Have the mother return with the baby
in 14 days to remove the splint and also
a check X-Ray for callus formation

116
BIRTH INJURIES BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
Erb’s palsy  If there is no associated tenderness  Same as for Basic Care level
 Inability to move a limb or swelling, ask mother to report  Refer for physiotherapy
 The baby’s arm and hand are in an when the newborn is 7 days old
abnormal position  If still unable to move limb:
 Asymmetrical posture and  REFER
movement

COMMUNITY LEVEL
 REFER

BIRTH INJURIES BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

2. Sub-galeal bleed  Give Vitamin K1 and Same as Basic Care level
 A severe birth injury REFER  Correct shock and anaemia
 Scalp swelling apparent at birth or o Document care given  Give IV Vitamin K1 1 mg daily for at
within 2 hours, and becoming more o Keep in skin to skin contact least 72 hours
evident during the next 24 hours o Encourage mother to breastfeed  Check packed cell volume (PCV)
 Risk factors: o Counsel mother/family on  Take blood for urgent Hb, FBC,
o Vacuum extraction, referral grouping and cross-matching
underlying bleeding o Monitor the baby’s breathing,  Give analgesics: Syrup Paracetamol
disorder associated with a colour, temperature and activity 1.25 mls 6 hourly (if < 2.5 kg), 2.5 mls
difficult delivery 6 hourly (if ≥ 2.5 kg)

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  Look for a soft scalp swelling  Measure head circumference every 6
extending from the occipital region hours for the first 24 hours, then daily
and covering the whole scalp  Look out for signs of jaundice, anaemia
 Check for pain – baby cries when and shock
scalp is touched  Continue to monitor the baby’s
 Check if the swelling is fluctuant breathing, colour, temperature and
(feeling of free fluid) for pitting activity
oedema (sponginess) of the scalp  Communicate the baby’s condition
 Look for signs of anaemia and with the mother and father throughout
shock the admission period
 Look for other danger signs  Counsel the mother not to massage or
put warm compresses on scalp after
COMMUNITY LEVEL discharge
 If the baby’s heart and respiratory rates
 REFER are stable, Hb level is normal, no
jaundice, baby is feeding well, and
there are no other problems requiring
hospitalization, discharge the baby

CONGENITAL ABNORMALITIES BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Cleft lip/palate  Provide emotional support and  Same as Basic Care Level
reassurance to the mother  Assess baby for danger signs
COMMUNITY LEVEL  Explain to the mother that the most  If baby has a cleft lip or cleft palate and
 Provide emotional support and important thing to do at this time is to is unable to breastfeed, and also not
reassurance to the mother feed the baby to ensure adequate tolerating cup feeds:
 REFER growth until surgery can be performed. o Pass a nasogastric tube and feed
 Encourage mother to keep putting baby expressed breast milk
to breast o Encourage mother to keep putting to
 If the baby breastfeeds successfully breast
and there are no other problems o Monitor weight gain
requiring hospitalization, o Refer the baby to Paediatrician/

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  REFER Maxillo-facial surgeon or a
specialized clinic such as the KATH
Cleft Clinic for surgery and follow
up care
CONGENITAL ABNORMALITIES BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
Spina bifida  Provide emotional support and  Same as for Basic Care Level plus
reassurance to the mother.  Manage danger signs or signs of
COMMUNITY LEVEL  If the defect is not covered by skin: infection if present
o Cover with sterile gauze soaked in  Prevent infection as much as possible
 Provide emotional support and normal saline  Daily dressing with normal saline and
reassurance to the mother. o Keep gauze moist at all times, and cover with sterile gauze
 Cover with sterile gauze soaked in ensure that the baby is kept warm  Maintain warmth
normal saline o Organize transfer and refer the  Encourage breastfeeding
 REFER baby to a tertiary hospital or  Discuss further management with
specialized centre for further Neurosurgeon/ REFER to a Tertiary
evaluation or surgical care. hospital

CONGENITAL ABNORMALITIES BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Imperforate anus  Same as COMMUNITY plus  Same as Basic Care level plus
 REFER  Manage danger signs or signs of
COMMUNITY infection if present
 Provide emotional support and  Ensure patient is well hydrated
reassurance to the mother  REFER to a Tertiary hospital/Consult
 Ensure that the baby does not receive Surgeon/Paediatric surgeon
anything by mouth.
 REFER

LOCAL INFECTIONS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Ophthalmia neonatorum  Take history of onset and duration  Same as Basic Care level plus
 Ask about danger signs o If eye discharge is mild/not purulent,  If discharge is purulent, take an eye

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  Look for swab eyes with sterile cotton soaked swab for gram stain, culture and
o Eye discharge with saline and instil antibiotic drops sensitivity
o Discharging pus/purulent discharge or ointment  Irrigate with normal saline several times
o Eyes may also be swollen o 0.5% Tetracycline eye in a day
ointment daily for 5 days OR o Give IM Ceftriaxone 50 mg/kg (max 125
COMMUNITY LEVEL o Chloramphenicol eye drops mg) and
 Clean eyes with normal saline and several times per day or anytime o Oral Erythromycin 50mg/kg daily (4
 REFER mother breastfeeds and doses/day) for 10-14 days
chloramphenicol eye ointment at  Clean the eye with sterile cotton wool as
night for 5 days necessary
o If discharge is  Treat mother and partner and counsel on
purulent, irrigate with normal STI prevention
saline several times and refer  Communicate the baby’s condition with
the mother and father throughout the
 REFER admission period
o Document care given  Observe the baby for 24 hours after
o Encourage breastfeeding discontinuing antibiotics. If the infection
o Counsel mother/family on has cleared, no eye discharge or
referral swelling, baby is feeding well, and there
are no other problems requiring
hospitalization, discharge the baby.
 Long-term follow-up and
ophthalmologist review if needed

LOCAL INFECTIONS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Cord infection  Ensure cord hygiene: clean with  Same steps as for Basic Care level
 Ask about danger signs methylated spirit (or 7.1%  Take a cord swab for microscopy,
 Examine cord and the skin around the cord chlorhexidine) culture and sensitivity of discharge
 Look for an offensive cord, reddened base  If no danger signs, give oral  If there are danger signs, start IV
of cord, discharging pus antibiotics (Flucloxacillin 62.5mg 6 antibiotics: Flucloxacillin 25 mg/kg 6
 If the skin around the cord is red and hourly) for 7 days hourly PLUS Gentamicin for 7 days
hardened, or there is abdominal distension,  Monitor progress; if no improvement  Encourage breastfeeding
the infection is severe after 72 hours or if condition worsens  Monitor the baby’s breathing, colour,

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 or presence of danger signs temperature and activity
COMMUNITY LEVEL  REFER  Communicate the baby’s condition with
 Clean cord with spirit or chlorhexidine o Document care given the mother and father throughout the
 REFER o Encourage breastfeeding admission period
o Counsel mother/family on referral  Observe the baby for 24 hours after
o Monitor the baby’s breathing, discontinuing antibiotics. If the infection
colour, temperature and activity has cleared, cord no longer
discharging/offensive, base not
reddened, baby is feeding well, and there
are no other problems requiring
hospitalization, discharge the baby.
LOCAL INFECTIONS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
Impetigo (skin pustules)  If there are no danger signs, advise on  Same steps as for Basic Care level
 Ask and look for danger signs hand washing when handling baby  Take blood for culture and sensitivity,
 Look for redness around the lesion  Give oral antibiotics (Flucloxacillin full blood count
 Look for pus/yellowish fluid within the 62.5mg 6 hourly) for 7 days  If there are danger signs, start IV
lesion  Do not apply any herbal creams antibiotics: Flucoxacillin 25 mg/kg 6
 Assess number and size of lesions  Monitor progress; if no improvement hourly PLUS Gentamicin for 7 days
 More than 10 skin pustules or pustules after 72 hours or if condition worsens  Encourage breastfeeding
covering more than half of the body is  REFER  Monitor the baby’s breathing, colour,
severe o Document care given temperature and activity
o Encourage breastfeeding  Communicate the baby’s condition with
COMMUNITY LEVEL o Counsel mother/family on referral the mother and father throughout the
 REFER o Monitor the baby’s breathing, admission period
colour, temperature and activity  Observe the baby for 24 hours after
discontinuing antibiotics. If the infection
has cleared, pustules also cleared, baby
is feeding well, and there are no other
problems requiring hospitalization,
discharge the baby.

LOCAL INFECTIONS BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

Oral thrush  Apply topical antifungals:  Same as for Basic Care level

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  Look for white patches on the tongue,  Oral miconazole gel or Nystatin oral
inner aspect of the lips and cheeks. drops tid for 5 days
 Usually does not go away when cleaned  Continue for 2 more days after lesions
 Ask about HIV infection in the mother. have disappeared
Also look in the maternal health records  If mother has sore nipples, teach her to
(ANC card) apply antifungal ointment to the
 Examine the mother’s breast and nipple nipple area after every feed
area for sore nipples  Mother should wash the nipple and
areola very well before every
breastfeed
COMMUNITY LEVEL  Encourage mother to also express
 REFER breastmilk and feed by cup
 If the mother has HIV infection,
follow the PMTCT guidelines
 If baby is HIV exposed, ensure baby is
receiving anti-retrovirals (Syr
Zidovudine 4 mg/kg bd for 6 weeks)

MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PUT THE NEWBORN AT RISK
Premature rupture of membranes  Observe for danger signs or signs of sepsis  Take blood for culture and
(e.g. poor feeding, vomiting, breathing sensitivity if possible
COMMUNITY LEVEL difficulty) every four hours for 24 hours.  If a danger sign(s) is present, start
 REFER  Encourage breastfeeding antibiotics immediately –
 Maintain warmth o Give Crystalline Penicillin 50,000
 However, if baby has any danger sign, give IU/kg 6 hourly or Ampicillin
pre referral antibiotics and REFER 50mg/kg 12 hrly and Gentamicin
immediately 5mg/kg daily for 7 days
o Document care given  If there are no danger signs, do not
o Encourage breastfeeding start antibiotics immediately
o Keep in skin to skin contact o Observe for danger signs or signs

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o Counsel mother/family on referral of sepsis (e.g. poor feeding,
o Monitor the baby’s breathing, colour, vomiting, breathing difficulty)
temperature and activity every four hours for 72 hours.
o Encourage breastfeeding
o Maintain warmth
 If there are no signs of sepsis/danger
signs after 72 hours, baby is feeding
well and there are no other problems,
discharge the baby
 If the blood culture is negative, and
the baby still has no signs of sepsis
after 72 hours and is feeding well, with
no other problems requiring
hospitalization:
o Discharge the baby
o Explain to the mother the danger
signs/signs of sepsis, and ask her to
return with the baby if the baby
develops any signs of sepsis.
 If blood culture is positive, give IV
antibiotics
o Give Crystalline Penicillin 50,000
IU/kg 6 hourly or Ampicillin
50mg/kg 12 hrly and Gentamicin
5mg/kg daily for 7 days
 If the blood culture is not possible,
o Observe the baby for an additional
three days.
o If the baby remains well during
this time, discharge the baby
o Explain to the mother the signs of
sepsis and ask her to return with
the baby if the baby develops any
signs of sepsis.

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MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PUT THE NEWBORN AT RISK
Offensive liquor/Chorio-amnionitis o Give pre-referral antibiotics:  Start antibiotics, irrespective of
o Give Crystalline Penicillin 50,000 IU/kg whether there are signs of
COMMUNITY LEVEL or Ampicillin 50mg/kg and Gentamicin sepsis/danger signs
 REFER 5mg/kg o Give Crystalline Penicillin 50,000
 REFER IU/kg 6 hourly or Ampicillin
o Document care given 50mg/kg 12 hrly and Gentamicin
o Encourage breastfeeding 5mg/kg daily for 7 days
o Keep in skin to skin contact  Communicate the baby’s condition
o Counsel mother/family on referral with the mother and father throughout
o Monitor the baby’s breathing, colour, the admission period
temperature and activity  If the blood culture is positive or if the
baby develops signs of sepsis,
o Continue antibiotics to complete 7 -
10 days of treatment
 If the blood culture is negative and
the baby still has no signs of sepsis
after five days of treatment with
antibiotics
o Discontinue antibiotics
 If the blood culture is not possible
but the baby still has no signs of
sepsis after five days of treatment
with antibiotics
o Discontinue antibiotics.
o Observe the baby for 24 hours after
discontinuing antibiotics:
o If the baby remains well, is feeding
well, and there are no other
problems requiring hospitalization,
discharge the baby
o Explain to the mother the signs of

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 sepsis and ask her to return with the
baby if the baby develops any signs
of sepsis.
MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PUT THE NEWBORN AT RISK
Meconium stained liquor  If there are no signs of breathing difficulty  Same as Basic Care level plus
 Meconium can be aspirated into APGAR score was ≥ 7, with no other risk  If there is breathing difficulty, manage
the lungs and cause severe factors for infection accordingly (refer to management of
respiratory problems and sepsis o No antibiotic treatment is needed breathing difficulty)
 Ask: Was the APGAR score < 7 o Encourage early and exclusive
at 5 minutes? breastfeeding
 Look for signs of breathing o Explain to the mother the signs of sepsis
difficulty and ask her to return with the baby if the
 Look for meconium staining on baby develops any signs of sepsis/danger
the skin, nails and cord signs
 If there are signs of breathing difficulty and
APGAR score was < 7,
COMMUNITY LEVEL o Give pre-referral antibiotics: Give
 If there is breathing difficulty Crystalline Penicillin 50,000 IU/kg or
REFER Ampicillin 50 mg/kg and Gentamicin
5mg/kg
 REFER
o Document care given
o Encourage breastfeeding
o Keep in skin to skin contact
o Counsel mother/family on referral
o Monitor the baby’s breathing, colour,
temperature and activity
MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PUT THE NEWBORN AT RISK
Diabetes in the mother Same as COMMUNITY LEVEL  Encourage and support early and
 Babies of diabetic mothers are at frequent breastfeeding, at least 8 to 10
high risk for developing low blood times daily (day and night)

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 glucose during the first three days of  Measure blood glucose (heel prick) at
life, even if they are feeding well. the following times:
o On admission
COMMUNITY LEVEL o Three hours after the first
 Encourage early breastfeeding measurement and then every six
and REFER immediately hours for 24 hours or until the blood
glucose has been normal for two
consecutive readings.
 If the blood glucose is < 2.5 mmol/l,
treat for low blood glucose
(hypoglycaemia)
 If the blood glucose has been normal
for 24 hours, the baby is feeding well,
and there are no other problems
requiring hospitalization, discharge the
baby
MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PUT THE NEWBORN AT RISK
HIV positive mother  Determine if the mother is receiving or has  Same as Basic Care level
 There are no specific signs or received antiretroviral treatment for HIV to
features diagnostic of HIV at birth prevent mother-to-child transmission
 Clinical signs of HIV may begin  Give baby antiretroviral drugs: Syr
appearing around six weeks of life, Zidovudine (AZT) 4 mg/kg bd for 6 weeks
but the baby’s HIV status can be  Reassure the mother and encourage exclusive
verified by PCR testing at 6 weeks breastfeeding
and antibody testing between 9  Follow the PMTCT guidelines
months to 18 months of age.
 Pregnant women with HIV should
receive antiretrovirals during
pregnancy and throughout the
breastfeeding period. This
intervention reduces the risk of
mother to child transmission
remarkably.

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COMMUNITY LEVEL
 Encourage breastfeeding and
REFER immediately

MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PUT THE NEWBORN AT RISK
Hepatitis B positive mother  Give the Hepatitis B vaccine (HBV) 0.5 ml  Same as BASIC CARE LEVEL
 Mothers who had acute hepatitis IM in the upper thigh as soon after birth as
during pregnancy or who are carriers possible (preferably within 12 to 72 hours of
of the hepatitis B virus, as birth).
demonstrated by a positive serologic  Give Hepatitis Immune Globulin 200 units
test for the hepatitis B surface IM in the other thigh (or IV depending on the
antigen (Hbs Ag), may transmit the manufacturer’s instructions) preferably
hepatitis B virus to their babies within 12 to 72 hours of birth
during pregnancy, labour and  If mother cannot afford the immunoglobulin,
delivery. give the vaccine
 Continue with routine immunization
COMMUNITY LEVEL schedule
 Encourage all hepatitis B positive  All Hepatitis B positive mothers should
mothers to breastfeed immediately breastfeed their babies immediately after
after birth delivery.
 REFER immediately  Do not delay breastfeeding if vaccine or
immunoglobulin has not been given
 REFER if you are unable to provide these
services
MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL
PUT THE NEWBORN AT RISK
Mother receiving anti TB treatment or  Reassure mother that it is safe for her to  Same as Basic Care level plus
suspected of having TB breastfeed her baby  Give prophylactic isoniazid 10 mg/kg
 Mother has active lung  Do not give the tuberculosis vaccine (BCG) body weight by mouth once daily for 6
tuberculosis and was treated for at birth months
less than two months before birth

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 or was diagnosed with  REFER  At the age of six weeks, re-evaluate the
tuberculosis after birth baby, noting weight gain and take a
chest X-ray, if possible
COMMUNITY LEVEL  If there are any findings suggestive of
 Encourage breastfeeding and active disease, start full anti-
REFER tuberculosis treatment
 If the baby is doing well and tests are
negative, continue prophylactic
isoniazid to complete six months of
treatment.
 Delay BCG vaccine until two weeks
after treatment is completed.
 If BCG was already given, repeat
BCG two weeks after the end of the
isoniazid treatment.
 Follow up in two weeks to assess
weight gain.

MATERNAL CONDITIONS THAT BASIC CARE LEVEL COMPREHENSIVE CARE LEVEL

PUT THE NEWBORN AT RISK
Mother tested positive for syphilis  If the mother tested positive for syphilis  Same as BASIC CARE LEVEL
and was treated adequately (2.4 MU of
penicillin) and the treatment started at
COMMUNITY LEVEL least 30 days before birth,
 Encourage breastfeeding and o No treatment is necessary.
REFER  If the mother was not treated for syphilis,
she was treated inadequately, or her
treatment status is unknown or uncertain
and the baby has no signs of syphilis
o Give the baby benzyl penicillin (IM/IV)
50,000 IU 12 hourly for 10 days
o Give the mother and her partner(s)
benzathine penicillin 1.8 gm IM as two

128
 injections at separate sites
o Refer the mother and her partner(s) for
follow-up to a clinic that offers services
for sexually transmitted infections.
o Follow up in four weeks to examine the
baby for growth and signs of congenital
syphilis (e.g. Palms and soles: Red rash,
grey patches, peeling of skin; nasal
congestion, jaundice, anaemia and
abdominal distension)

DISCOMFORT/CONCERN IN Prevention, Relief measures and Reassurance Alert signs that may indicate a problem
THE NEWBORN
(Signs/Symptoms)
Caput succedaneum Explain physiological basis: Swelling is:-
 Prolonged pressure from the uterus or  Increasing in size
vaginal wall during vertex (head-first)  Becoming soft
delivery as a result of difficult delivery.  Tender
This leads to swelling and bruising of the
scalp.
Relief measures:
 No treatment is needed
Reassurance:
 It will resolve completely within a few
days

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Swollen breast with milk Explain physiological basis:  Reddened, warm and tender breasts
discharge  Due to the maternal hormones in the  Discharging pus
baby’s blood  Fever or any danger sign in the newborn
Relief measures:
 None
Reassurance:
 Will resolve without any treatment within
two weeks. Mother should avoid
squeezing, massaging or expressing the
breast else it will become infected
Sub-conjunctival Haemorrhage Explain physiological basis:  Bleeding becoming extensive or not
 Red spot on the white of the  Due to rupture of small vessels in the eye resolving after 2 weeks
eye as a result of a difficult delivery  Bleeding from other areas of the body
Relief measures:  Discharge from the eyes
 No treatment needed
Reassurance:
 It does not affect vision resolves
spontaneously over a several days.
Tongue Tie Explain physiological basis:  Sore and cracked nipples
 Tongue tie is a little string This occurs when the frenulum fails to  Tongue tie still present at 6 months
of tissue (frenulum) beneath move back during development of the
the tip of the tongue that tongue or is too short, or when the tongue
restricts movement of the is heart shaped. It sometimes affects
tongue.
breastfeeding and speech.

Relief measures:
 Help mother position and attach well
 If the mother develops sore or cracked
nipples, the baby has to be referred to a
dentist or surgeon. If by 6 months the
tongue tie is still present, baby should be
referred to a dentist or surgeon. Midwives

130
 should refrain from cutting it.
Reassurance:
 Most tongue ties resolve as the babies
grow
 Encourage breastfeeding
Milia Prevention:  Redness, swelling, yellowish fluid (pus)
 These are tiny white bumps  Reduce heat by removing excess clothing, within the lesions
(cysts) that most commonly and keep baby’s face clean
appear across a baby's nose, Explain physiological basis:
chin or cheeks. They do not  Due to collection of secretions in skin
itch glands.
Relief measures:
 Avoid excess heat in the room, dress baby
with cotton clothing.
Reassurance:
 It will resolve in a few weeks without any
treatment
Diaper rash Prevention:  If the rash persists even after using zinc
 Frequent changing of diapers when baby oxide ointment, report to a doctor
stools or passes urine. Keep diaper area
clean and dry. Apply petroleum jelly or
shea butter after each diaper change. Do
not over tighten diapers
Explain physiological basis:
 Could be due to skin irritation from stool
and urine or a new product (diapers,
detergents
Relief measures:
 Applying zinc oxide ointment on
perineum before wearing the diaper
Reassurance:
 Usually resolves after some days
Mongolian blue spots (birth Explain physiological basis:  Any changes in shape, colour or thickness
mark)  Due to variations in skin pigments with

131
  They are birth marks, dark the areas affected having more
blue to gray in colour, these pigmentation/darkening of the skin
marks resemble bruises. Relief measures:
They usually occur on the  No treatment needed
baby’s back, buttocks or Reassurance:
legs.  Usually disappears by 2 years of age
Port wine stains (birth marks) Explain physiological basis:  Any changes in shape, colour or thickness
 They are birth marks made  It is believed they are due to a problem  Port-wine stains near the eye – refer to
up of tiny blood vessels. with the nerves that control how much the ophthalmologist
 They can be found capillaries widen in the area where the
anywhere on the body. port wine stain mark is. When the
 They vary in size from capillaries keep expanding, they allow a
small to whole body larger amount of blood to go into blood
regions. vessels and this causes a stain to form
 They are flat and red to under the skin.
blue in colour. The colour Relief measures:
often becomes a darker,  No treatment needed
purple colour with age. Reassurance:
 They may become thick  They do not grow in size, but grow in
and lumpy after many proportion as your child grows, they also
years. do not fade over time.
 Laser therapy can be done for cosmetic
reasons

Mucoid or bloody vaginal Explain physiological basis:  Bleeding from other sites like the nose,
discharge  Due to the maternal hormones in the mouth etc
baby’s blood
Relief measures:  Or prolonged bleeding after needle pricks
 None for blood sampling
Reassurance:
 Will resolve without any treatment.
Swollen labia/Swollen scrotal sac Explain physiological basis:  Increasing size of scrotal swelling when
 May be due to oedema following breech crying, irreducible

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 presentation during delivery. It could also  Change in scrotal skin colour (becoming
be due to collection of fluid in the scrotal dark), or scrotal tenderness
sac (hydrocoele).  Scrotal swelling present by 1 year
Relief measures:
 None
Reassurance:
 Usually resolves without any treatment.
 A hydrocoele usually resolves by the age
of 1 year.
Umbilical Hernia Relief measures:  Associated with abdominal distension
 None  Irreducible hernia in the absence of crying
Explain physiological basis: Reassurance:
Due to a defect in the abdominal  Mostly resolves by 1 year without any
wall allowing some contents of the treatment.
abdomen like the intestine to
protrude through the defect
Excessive stretching and crying Relief measures:  Abdominal distension
(colic) Good positioning and attachment of baby  Vomiting after every feed
to the breast, Frequent burping of baby
Explain physiological basis:
after feeding.
Babies swallow a lot of air
(aerophagia) during feeding and Reassurance:
crying and the gas/air in the  Frequency of colic reduces as the baby
abdomen causes pain. grows, usually resolves by 3 to 4 months
 Continue exclusive breastfeeding

Irregular breathing Relief measures:  Prolonged episodes of not breathing lasting

 This is when newborns stop  None more than 20 seconds especially in preterm
breathing for about 5 to 10 Reassurance: babies
seconds and then  It may be a normal breathing pattern of  Signs of respiratory distress, chest in-
immediately begin some newborns drawing and grunting
breathing again on their  It will change to a regular pattern as baby  Associated with signs of illness in the
own. grows newborn such as poor feeding, cyanosis and

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  The baby seems to be low body temperature etc
panting for a few seconds,
and then takes a few sighs,
pauses briefly, and goes
back to normal breathing.
 The variability is what
identifies these irregular
breathing patterns as
normal
Explain physiological basis:
 Not well understood

Vomiting (after feeds) Prevention:  Vomiting after every feed in large quantities
 Burping the baby (patting the baby’s back  Greenish vomitus
Explain physiological basis: gently) after every feed  Projectile or forceful vomiting
At the junction of the oesophagus  If baby is receiving expressed breastmilk,  Not passed meconium or stool
and the stomach is a ring of reduce the amount slightly  Abdominal distension
muscles that opens to let the milk  Keeping the baby in an upright position  Poor weight gain
drop into the stomach and then for a some minutes after breastfeeding
tightens to prevent the milk (and Relief measures:
the stomach contents) from moving  Same as prevention
back up into the oesophagus. Reassurance:
 Usually resolves as they grow
The irritation from reflux can
sometimes trigger vomiting
(possetting), and may cause other
symptoms.

Constipation/Irregular bowel Prevention:  Vomiting

movements  Breastfeed more often and on demand  Abdominal distension
 Constipation is not defined  Do not give formula feeds or bottle feed  Restlessnes
by how frequently a baby Relief measures:  Excessive crying
passes stool.  Same as prevention  Difficulty in breathing
 Rather, constipation is Reassurance:

134
 when the baby’s bowel  Breast fed babies rarely develop
movements are hard and constipation
cause pain or bleeding.
 The baby will groan or
strain when trying to pass
stool.
 Breast fed babies usually
pass stools after every feed
particularly during the first
week of life

Explain physiological basis:

Change in type of feed, decreased
breastmilk intake
Anterior fontanelle Relief measures:  Widened or bulging fontanelle
 A “soft spot” on the top  No relief measures needed  Very sunken
part a baby’s head.  No need to apply hot water or herbal  Delayed closure
 Usually measures about two medication
finger breaths Reassurance:
Explain physiological basis:  Closes by 18 months of life
The baby’s skull is made up of
several small flat bones with some
spaces (“soft spots”) in between
some of the bones. This allows for
brain growth

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136
CLIENT COUNSELLING AND EDUCATION:

INFORM MOTHERS ABOUT THE FOLLOWING ISSUES DURING POST-NATAL PERIOD.

Care of the baby

1. Infant feeding
o Encourage mother to breast feed exclusively (i.e. no other food or drinks) for 6 months.
o Give her the necessary support and advice to help her do so.
o Teach her how to deal with problems that may arise, such as sore nipples, difficulties with
suckling, and inadequate breast milk production.
2. Educate her on:
o Danger signs (not feeding well, convulsions, drowsy, lethargic, grunting, severe chest in
drawing, raised temperature, hypothermia and jaundice)
o Maintaining warmth
o Preventing infection
 Hand washing
 Personal hygiene
 Cord care: apply methylated spirit to the cord (or 7.1% Chlorhexidine as soon as it
becomes part of the national guidelines). Mother should not put anything else on the
cord such as toothpaste, shea butter, chalk, salt petre, crushed glass, herbs, cow dung
 Early and exclusive breastfeeding
o Ear piercing and circumcision
o Registration of birth
o Immunisation schedule for the baby
 BCG and OPV0. Give at first visit if baby did not receive this at birth
 OPV1 and Penta 1, Rotarix, Pneumovax: to be given at 6 weeks
o Malaria prevention using ITN
o Sickle cell screening
o Registration with NHIS
o Postnatal visits (within 0 – 3 days and 6 – 7 days, and 6 weeks)
Ask her about other child care challenges and help her to address them (e.g. Bonding, family
support)

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 APPENDICES

APPENDIX 2

Table 3: Newborn Examination

Preparations for newborn examination:
 Inform mother what you are going to do and encourage her to participate and ask
questions
 Wash hand thoroughly with soap and water and dry with clean cloth
 Wear gloves
 Examine in mother’s lap or place baby on a clean warm surface
 Have clean clothes and coverings ready to dress baby immediately after examination

Examine baby from head to toe:

Wash hands with soap and water
Observe the following:
 Colour
o Look for cyanosis, pallor (palms and soles), jaundice (forehead, nose, sclera, skin,
palms and soles)
 Posture and tone
o Normally the arms and legs are flexed. Look for decreased tone (floppy) or
increased tone (spastic)
 Activity and Movement
o Movement in all the limbs should be spontaneous and symmetrical. Look for
abnormal movements, convulsions, decreased movements, lethargy
 Skin
o Look for rashes, pustules, birth marks
 Head
o Look for swellings, feel the sutures, fontanelles – they should be flat not bulging
 Face
o Eyes
 Look for red spots on the conjunctiva – subconjunctival haemorrhage,
discharge, cataract, squint or other abnormality
o Mouth
 Look for cleft lip and palate, tongue tie
 Chest
o Look for engorgement of the breast tissue, count the respiratory rate (normal: 40 –
<60 breaths/min), grunting, chest indrawing
 Abdomen
o Look for reddened cord base, bleeding cord, discharging pus, offensive cord,
umbilical hernia, abdominal wall defects, and distended abdomen
 Genitalia
o Look for deformities or indeterminate sex, undescended testis, labia adhesion,
vaginal discharge or bleeding, imperforate anus

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  Extremities
o Look for deformities (e.g. extra digits, webbed fingers or toes, joint movements,
swellings or inability to move a limb
 Back
o Look for swellings on the spine, spina bifida, spinal deformities
 Anus
o Imperforate anus

Table 1: Newborn Resuscitation Equipment

Basic neonatal resuscitation equipment
Flat firm resuscitation surface
Heat source
Dry warm cot sheets
Bulb syringe/suction machine and nasogastric tubes (sizes 6,7,8)
Bag and Mask (250ml-500ml) and mask (size 0 for preterm babies, size 1 for term babies)
Clock with a second hand

Advanced neonatal resuscitation equipment

Source of oxygen
Oropharyngeal airways
Laryngoscopes with straight blades, 0 and 1
Nasogastric tubes
Tracheal tubes sizes 2.5 to 4.0mm
Umbilical catheterisation equipment
Adhesive tape

FIGURE 3: Basic resuscitation steps

1. Drying the baby

2. Positioning of the head to clear the airway

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3. Clearing the airway

4. Stimulating the baby to breathe – rubbing the back or trunk

5. Stimulating the baby to breathe – flicking the soles of the feet

140
 Table 7: HOW TO PERFORM BAG AND MASK VENTILATION

• Check equipment and select the correct mask – the mask should cover the bridge of
the nose to the chin (size # 1 for term, size # 0 for preterm)
• Stand at the head of the baby
• Position the head in a slightly extended “sniffing” position
• Apply mask to make a firm seal
• Ventilate at 40 breaths per minute – breathe/squeeze -two-three-breathe/squeeze- two-
three....
• Look for chest movement – a rise and fall of the chest wall

Figure 4: Performing bag and mask ventilation (Adapted from WHO pocket book, 2013)

141
FIGURE 5: How to ventilate

142
Figure 6: Introducing laryngoscope blade

Figure 7: Tube palcement and visualisation of the glottis

143
Table 2: Basic Newborn resuscitation (Helping Babies Breathe: HBB)

If the baby is not crying or breathing at birth:

 With the baby still on the mother’s abdomen
o Clear the airway only if there is meconium or a lot of secretions, by suctioning
the mouth first, then the nose
o If there is no meconium, dry the baby thoroughly
o And stimulate the baby to breathe by rubbing the back once or twice or
flicking the soles of the feet
 Check the breathing
o If baby is breathing well, keep warm in skin to skin contact on the mother’s
chest
 Assess the baby’s condition at 1 minute using the APGAR score
 Clamp and cut the cord after pulsations have ceased or between 1 to 3 minutes, whichever
comes first

But if the baby is still not breathing after stimulation:

 Quickly clamp and cut the cord
 Ask your assistant to inform mother that the baby is not breathing so you are going to
help the baby to breathe
 Move baby to the resuscitation surface
 Begin ventilation by 1 minute using a bag and mask (golden minute)

If the baby does not breathe after ventilating the baby for about 1 minute:
 Continue ventilation and call for help
 Take steps to improve on ventilation if the chest is not rising by doing the following
o Head:
 Reposition the head with the neck slightly extended
 Reapply the mask to the face to form a better seal

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 o Mouth:
 Check for secretions and clear the airway as necessary
 Open the baby’s mouth slightly before reapplying the mask
o Bag:
 Squeeze the bag a little harder

If the baby does not begin to breathe after 1 minute of improving ventilation:
 Continue ventilation and
 Ask another skilled helper to check the heart rate
o Feel the base of the umbilical cord for pulsations with your index and middle
finger or
o Listen to the heart beat over the left chest with a stethoscope
 Decide if the heart rate is normal or slow
o Count the pulsations or heart beat for 6 seconds and multiply what you get by
10
o Or compare with your pulse
o A heart rate of 100 beats/min or more is normal (sounds faster than your
pulse)
o A heart rate of less than 100 beats/min is slow (sounds slower than your pulse)
 Continue ventilation until the baby is breathing well

 If the heart rate is slow or normal and the baby does not breathe
o Continue ventilation and seek advanced care/refer to a higher level
facility/inform the Paediatrician
o Counsel the mother on the need for referral
o Transport mother and baby together, if possible
During transportation of the baby
 Make sure the baby is warm
o By placing in skin to skin contact with the mother
o If mother is not accompanying baby, then wrap baby very well with two cot
sheets, a cap and socks
 If baby can suckle, breastfeed the baby
 Monitor the baby every 15 minutes:
o Breathing: if there is difficulty in breathing, give oxygen
o Temperature: if temperature is < 36.50C, add extra blanket or cloth
o Colour: if pale or cyanosed, give oxygen and keep warm

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Figure 1: Helping Babies Breathe Action Flow Chart

146
Figure 8: Advanced Neonatal Resuscitation flow chart

DRUGS (when and what to give during neonatal resuscitation)

 If the newborn does not respond to ventilation and chest compressions, and the heart rate is still less
than 60 beats/min, then administration of drugs like adrenaline, is indicated.

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  Drugs that are indicated in newborn resuscitation
o Adrenaline
 Enhances oxygen delivery to the heart
 Dose: 10 mcg/kg (0.1 ml/kg of 1:10,000)
 Route: Intravenous or through the Endotracheal tube
 Further doses of 10 – 30 mcg/kg (0.1 – 0.3 ml/kg of 1:10,000) may be given at 3 – 5
minute intervals if there is no response
o Sodium bicarbonate
 Prolonged apnoea will lead to metabolic acidosis which depresses cardiac function.
 Indication: Correct metabolic acidosis and enhance the effects of oxygen and
adrenaline. Bicarbonate use remains controversial.
 Dose: 1 – 2 mmol/kg (2 ml/kg of 4.2% solution)
o Naloxone
 Indication: If the mother received pethidine or morphine, naloxone is the drug to
counteract respiratory depression in the newborn caused by these drugs.
 Give Naloxone only if there are signs of respiratory depression, following
resuscitation.
 Dose: After vital signs have been established, give IV Naloxone 0.1 mg/kg. Dose
can be repeated.
 Do not give Naloxone to babies whose mothers have recently abused narcotic drugs
o Intravenous fluids – 10% Dextrose, Normal Saline, Whole blood
 Hypoglycaemia
 Do a heel prick to obtain a blood sample and check random blood sugar
using a glucose test kit.
 A random blood sugar of < 2.5 mmol/l indicates hypoglycaemia
 Give intravenous 10% Dextrose 2 ml/kg as a bolus, and continue with a
maintenance infusion of 60 ml/kg on day 1 of life, if baby is unable to feed.
 Shock
 If you suspect blood loss or the newborn is in shock (cold extremities,
capillary refill time of > 3 seconds, weak thread fast pulse, lethargic, low
blood pressure)
 Give 10 ml/kg of Normal saline as a bolus, repeat after 15 minutes
 Anaemia
 If the newborn is anaemic from acute blood loss
 Give 20 ml/kg of O-negative blood
 The following drugs are not indicated in newborn resuscitation
o Hydrocortisone
o Atropine
o Aminophylline

Table 4: Maintenance Fluid for the Newborn

 Give IV fluids as maintenance
Fluids to give:
 10% Dextrose OR 10% Dextrose in ⅕ Normal saline

Age Volume

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 of fluids
Day 1 (24 hrs)
60 ml/kg
Day 2 (25-48 90 ml/kg
hrs)
Day 3 (49-72 120
hrs) ml/kg
Day 4 (> 72 150
hrs) ml/kg
Day 5 and 180
beyond ml/kg

Table 5: Treatment of jaundice based on bilirubin level

Phototherapy Exchange
transfusion
Healthy Preter Health Preter
Age newborn m y m
≥ 35 newbor newbor newbor
weeks n n n
< 35 ≥ 35 < 35
weeks weeks weeks
or any or any
risk risk
factors factors
Day 1 Any visible 260 220
jaundice µmol/l µmol/l
(15 (10
mg/dl) mg/dl)
Day 2 260 170 425 260
µmol/l µmol/l µmol/l µmol/l
(15 (10 (25 (15
mg/dl) mg/dl) mg/dl) mg/dl)
Day 3 310 250 425 340
µmol/l µmol/l µmol/l µmol/l
(18 (15 (25 (20
mg/dl) mg/dl) mg/dl) mg/dl)

Figure 2: Kangaroo Mother Care

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Table 6: HARMFUL WAYS OF STIMULATING BABIES TO BREATHE, and should NOT be done
1. Turning the baby upside down
2. Shaking the baby
3. Slapping the back
4. Rubbing with alcohol
5. Squeezing the rib cage or abdomen
6. Flexing the legs into the abdomen
7. Placing the baby in cold or hot water

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APPENDIX 1

Learning Guide for Selected Complications

Occipito-Posterior Position
1. Greet patient and allay anxiety
2. Review case notes and labour records
3. Explain procedure to patient
4. Determine Fetal Position By:

Abdominal examination
 Look for saucer-shaped depression below the umbilicus
 Determine descent of the fetal head
 Confirm occiput and sinciput to be at same level (laterally)
 Fetal limbs are palpable anteriorly on both sides of the midline
 Fetal heart tone may be heard far out in the flank

Vaginal Examination
 Wash hands with soap and water and dry with sterile towel
 Put on sterile gloves on both hands
 Clean and drape the patient
 Determine cervical dilatation
 Feel for the sagittal suture
 Locate the anterior fontanelle which is diamond shaped
 Confirm anterior fontanelle to the left or right of the pubic bone
 Determine adequacy of bony pelvis for vaginal delivery

Management
1. Give adequate analgesia
2. Set up IV infusion, if necessary
3. Consider oxytocic augmentation if there is no contraindication
4. Assess progress of labour by descent of head and cervical dilatation using the partograph and flexion of
head
5. Confirm full dilatation of cervix
6. Check if spontaneous rotation of head to occipito-anterior (OA) position has occurred
7. Allow normal vaginal delivery if spontaneous rotation to occipito-anterior position occurs within two
hours
8. Complete delivery as in normal vaginal delivery
9. Diagnose persistence of occipito-posterior position when spontaneous rotation does not occur within
two hours
10. Refer case to supervisor for delivery of baby by most appropriate method
 Spontaneous delivery as face-to pubis (with episiotomy)
 Perform vacuum extraction if head is low (station is +1 or +2)
 Perform forceps rotation and delivery if head is low (station is +1 or +2)
11. If Cephalo-pelvic disproportion is confirmed, perform caesarean section
12. Post-delivery tasks
 Compliment mother for her efforts

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  Dispose of soaked/soiled materials according to IP guidelines
De-contaminate used instruments by soaking in 0.5% chlorine solution
 Wash hands with soap and running water and dry with clean, dry cloth

Face Presentation
1. Greet patient and allay anxiety
2. Review case notes and labour records
3. Evaluate gestational age
4. Explain procedure to the patient
5. Perform abdominal exam
 Inspect contour of abdomen
 Palpate the abdomen
- Feel for round and prominent occiput
- Feel deep groove between fetal occiput and back
 Listen to fetal heart
6. Wash hands with soap and running water, dry with clean, dry towel
7. Put on sterile gloves on both hands
8. Perform vaginal exam
 Clean the perineum with antiseptic solution
 Perform digital vaginal examination
 Assess cervical dilatation
 Feel for orbital ridges, and alveolar margin
 Determine position of the chin
9. If pelvis is small or mento-posterior position occurs, perform Caesarean Section
10. If mento-anterior position and pelvic is adequate, allow labour to continue
11. Observe for abnormal labour pattern and proceed to Caesarean Section if this occurs
12. Perform normal post-delivery tasks

Do not perform Vacuum Extraction for face presentation

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Brow Presentation
 Review labour records, including partograph if available
 Wash hands with soap and running water and dry with a sterile towel
 Put on sterile gloves
 Perform vaginal examination to confirm brow presentation

Fetus
 Identify frontal suture
 Identify orbital ridges and bridge of nose
Maternal
 Ensure membranes are ruptured
 Determine dilatation of the cervix
 Determine station of the fetal head

If brow is confirmed:
 Explain findings to patient
 Perform venepuncture and take blood for grouping and cross-matching
 Set up IV infusion
 Inform anaesthetist, theatre staff and supervisor
 Prepare for Caesarean Section
 Perform caesarean section as in the appropriate learning guide

Do not deliver brow presentation by Vacuum Extraction, outlet Forceps or Symphysiotomy

Transverse Lie
Antenatal
1. Recognize transverse lie
 Determine fundal height
 Identify fetal poles to confirm transverse lie
 Determine position of head

2. Manage appropriately:
 Request ultrasound examination
 Perform ECV if not contraindicated

Labour
1. Palpate abdomen to confirm transverse lie
2. Wash hands with soap and running water and dry with sterile towel
3. Put on sterile gloves on both hands
4. Perform vaginal examination to ascertain:
 Cervical dilatation
 Ruptured membranes; status of liquor
 Cord prolapse
 Prolapse of arm or leg
 Palpate ribs, shoulder (scapula, acromion process)

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 5. Prepare patient for caesarean section
 Group and cross-match blood
 Inform Anaesthetist and supervisor

6. Perform caesarean section

 Lower segment transverse uterine incision, or
 Lower segment vertical incision or
 Upper segment vertical incision + BTL

In current obstetric practice, persistent transverse lie at term is delivered by elective caesarean
section whether the foetus is alive or dead

Twin Pregnancy and Delivery

Suspect Twin Pregnancy if uterus is larger than dates.

1. Confirm twin pregnancy

 In early pregnancy by ultrasound scan
 In late pregnancy by
- Abdominal palpation
- Ultrasound scan
2. Explain findings to patient
3. Outline management plan
4. Inform patient to come early in labour, or admit if necessary

Labour
1. Confirm that the lie of the leading twin is longitudinal
2. Set up IV line and take blood for grouping and X-matching and ensure compatible blood is
available
3. Ensure adequate pain relief
4. Inform supervisor, Anaesthetist, paediatrician about twin labour
5. Monitor both foetuses
6. Make sure delivery trolley and resuscitation equipment is set up for 2 babies
Delivery
1. Deliver first twin as in normal spontaneous vaginal delivery or assisted breech delivery; clamp and
cut cord.
2. Palpate the maternal abdomen to determine lie of second twin and auscultate for heart sounds.
3. If the lie is longitudinal
 Perform V/E and rupture the membranes, if no cord is felt
 Add oxytocin to drip, if contractions are inadequate
 Perform delivery of second twin
 Use vacuum, forceps or assisted breech delivery, if indicated

4. If lie is oblique or transverse, Perform external cephalic version (ECV)

 Ensure membranes are intact before performing ECV
 Reassure woman and allay anxiety
 Ask woman to bend knees slightly

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  Determine exact position of foetus
 Determine fetal poles
 Turn foetus by using steady pressure with one hand on either pole (turn in direction which
will increase flexion – foetus follows its nose)
 Stabilize when lie is longitudinal and presentation is cephalic
 Do V/E and rupture membranes
 Conduct normal vaginal delivery as in appropriate delivery learning guide

5. If membranes are ruptured and second Twin is in transverse lie and therefore require Internal
Podalic Version and Breech Extraction,
 Refer to supervisor

After delivery of the first twin, leave a clamp on the maternal end of the umbilical cord and do not
attempt to deliver the placenta until the second twin (or the last baby in multiple pregnancy) is
delivered.

Bedside Clotting Test

This is a procedure for rapidly assessing the clotting status.
1. Take 2 ml of venous blood into a small dry, clean, plain glass test tube (approximately 10mm x
75mm)
2. Hold the test tube in a close fist to keep it warm (+/- 37oC)
3. After 4 minutes, tip the tube slowly to see if a clot is forming. Then tip it again every minute until
the blood clots and the tube can be turned upside down. Failure of a clot to form after 7 minutes or a
soft clot that breaks down easily suggests coagulopathy.

Induction of Labour
1. Confirm that the indication for the induction still exist and can be justified
2. Rule out contra-indications
3. Do your abdominal examination to ensure that the lie is longitudinal with cephalic presentation and
fetal heart tone is normal unless there is intra-uterine fetal death.
4. Explain procedure to patient
5. Clean the vulva with antiseptic solution
6. If cervix is not favourable, ripen the cervix with 50mcg Misoprostol 6 hourly for maximum of 4
doses
7. Perform amniotomy, if cervix is favourable and set up oxytocin infusion
8. Remove gloves and wash hands
9. Add 5 units of oxytocin to 500ml of normal saline or Ringers Lactate or 5% Dextrose
10. Start with 15 drops per minute
11. Monitor uterine activity and fetal heart tones every 15 minutes
12. Increase by 15 drops per minute every 30 minutes up to 60 drops per minute or a lower rate
producing 3 contractions in 10 minutes each lasting 40 - 60 seconds

Perineal Tears
Classification of Perineal Tears:
First degree tear: involve the vagina mucosa or perineal skin only
Second degree tear: involves vaginal mucosa or perineal skin and muscles but the anal sphincter remains
intact
Third degree tear: includes partial or complete tear of the anal sphincter muscles as well as the perineal
skin and muscles

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Fourth degree tear: involves perineal skin and muscles, anal sphincter and rectal mucosa.

After repair of episiotomy or 3rd or 4th degree perineal tears:

- Perform vaginal examination to check adequacy of introitus, and
- Remove all gauze/swabs

Perform a rectal examination to identify:

- Occult 3rd and 4th degree perineal tears,
- Integrity of sphincter ani
- Presence of suture in the rectum
Clean perineum and apply sterile gauze to vulva
Wash hands with soap and water and dry with clean towel
Prescribe/give analgesics (paracetamol or diclofenac sodium) as needed.
Explain to mother:
- The extent of laceration if any
- Length of time before suture dissolves,
- Care of perineum, and
- Any other special care
Compliment mother for her efforts
NOTE: 3rd and 4th Degree perineal tears should be repaired in an operating theatre with appropriate
anaesthesia.

Repair of Episiotomy
 Wear sterile gloves on both hands
 Infiltrate the perineal tissues with local anaesthetic (0.5% lignocaine or xylocaine without
adrenaline), if not already done
 Close the vagina mucosa using continuing 2-0 vicryl suture
 Start the repair about 1.0 cm above the apex/top of the episiotomy incision
 Continue the suture to the level of the vagina opening
 At the opening of the vagina bring together the cut edges of the vagina
 Bring the needle under the vaginal opening and out through the incision and tie
 Suture the perineal muscles using 2-0 vicryl sutures in continuous fashion
 Close the skin using subcuticular 2-0 vicryl sutures

Uterine Inversion Correction

Pre-procedure
 Review for indicators
 Start an IV infusion
 Give Pethidine 50mg and diazepam 10mg IV slowly (do not mix in the same syringe) general
anaesthesia may be used
 Thoroughly cleanse the inverted uterus using antiseptic solution
 Apply compression to the inverted uterus with a moist, warm sterile towel

Procedure: - Manual Correction

 Wear sterile gloves
 Grasp the inverted uterus
 Push it through the cervix in the direction of the umbilicus to its normal anatomic position
 Stabilize the uterus using the other hand

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 Manually remove the placenta after correction, if still attached

Post-Procedure Care
 Give oxytocin 20 units in 500ml IV fluid (normal saline/Ringers lactate)
 Increase drops to 60 drops per minute if haemorrhage is occurs
 Give prophylactic antibiotic cover
- IV Amoxicillin +
- Watch for signs of infection and give broad spectrum antibiotics for Clavulanicacid1.2g stat OR IV
Cefuroxime 1.5g stat plus Metronidazole500mg IV
 Take and record vital signs
 5 – 7 days
 Repeat Pethidine IM 100mg 8hourly for 24hours

Condom Tamponade
Preparing and using the Condom Tamponade
Preparing the Device
1. Check to ensure that all components required for assembling the device are available in set (2
condoms, Foleys catheter (22+), suture, syringe, source of clean water/IV Infusion set).
2. Have an assistant ready to assist if available (To open condom, etc.)
3. Wash hands and wear sterile gloves or HDL gloves
4. Using aseptic techniques open a condom pack and place condom over balloon end of the Foleys
catheter tubing Rolls out condom completely over the tubing of catheter to a level below that of its
indwelling balloon About 2+ cm). Make sure that air is not trapped into the condom.
5. Using a suture/string, secure the condom over the Foleys catheter by tying its lower end snugly
below (2+ cm) the level of its indwelling balloon. The tie should be tight enough to prevent leakage
of water but should not strangulate catheter lumen and prevent inflow of water into condom.
6. Check for leakage at level of the tie by inflating balloon with about 20cc Water.
7. If there is no leakage of water from the condom tie site, further secure the condom by inflating
the in-dwelling catheter of the Foleys tubing with 5cc of water
8) Position woman in the dorsal or lithotomy position.
9) Using aseptic technique manually pass the condom end of the device via the cervix into the uterine
cavity. Position the entire condom unit of the device into the uterine cavity and as high as possible
in the uterus cavity.
Alternatively, place the condom end high into uterine cavity with aid of sponge holding / ovum forceps and
vaginal speculum
10. Connect the drainage end of the Foleys catheter to your inflation
Source device e.g. large syringe or infusion set tubing and bag.
(If infusion set tubing you may need to cut the giving set at level of yellow rubber to enable a good fit
to catheter)
11. Inflate condom gradually with water or saline whilst observing for continuing bleeding.
12. Stop inflation when no further bleeding is observed; this is often achieved at volume levels of 300-
400 mls.

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 13. Clamp or close off catheter when desired volume is achieved (bleeding is controlled) to maintain
the inflated volume within the catheter.
14. Record time of insertion and the total inflated volume.
15. If bleeding is not controlled within 15 mins of initial insertion of CT, abandon procedure and seek
surgical intervention immediately.

Post Insertion Care

16. Tamponade may be left In-situ for 6-24 hours if bleeding controlled and patient is stable.
17. Give Broad spectrum antibiotic cover (e.g. Inj. Ampicillin 1g IM/IV stat)
18. Continue to monitor patient closely, resuscitate and/or treat shock necessary
19. If at lower level health facility arrange and transfer patient to a center with theatre and blood
transfusion services
Deflation and Removal of the Balloon Tamponade
This should be done preferably at the referral center and after the patient has been stable with bleeding
controlled for at least 6 hours. Balloon deflation should be gradual.
20. Deflate condom balloon by letting out 50 mls of water/saline every hour.
21. Observe closely for resumption of bleeding. Re-inflate to previous level if bleeding re-occurs whilst
deflating.
22. If no bleeding occurs after letting out fluid clamp or close catheter to maintain tamponade at the
new lower volume.
23. Record time and amount of fluid volume let out at each deflation.
24. Remove catheter when all fluid has been successfully drained, uterus is well contracted and
bleeding has stopped.
 Note: the Condom and catheter are/is often spontaneously expelled by uterus into vagina
when volume levels reach about 50 mls).
25. Record time of complete balloon tamponade removal

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THE CONDOM TAMPONADE

UTERUS Water/NS

Inflate Condom with

water till no further
bleeding is
occurring
(Usually about
300-
500 mls)

Condom Giving set OR

String Foleys Catheter

Apply clamp to keep Clean

water within water
Condom after inflation

159
 ANNEXES
ANNEX 1: SHOCK
Shock is characterised by failure of the circulatory system to maintain adequate perfusion of the vital
organs. Shock is a life-threatening condition that requires immediate and intensive treatment.

Suspect or anticipate shock if at least one of the following is present:

 Bleeding in early pregnancy (e.g. abortion, ectopic or molar pregnancy)
 Bleeding in late pregnancy (e.g. placenta praevia, abruptio plancentae, ruptured uterus);
 Bleeding after childbirth (e.g. ruptured uterus, uterine atony, tears of genital tract, retained placenta
or placental fragments);
 Infection (e.g. unsafe or septic abortion, amnionitis, metritis, acute pyelonephritis);
 Trauma (e.g. injury to uterus or bowel during abortion, ruptured uterus, tears of genital tract)

Signs and symptoms

Diagnose shock if the following symptoms and signs are present:

 Fast, weak pulse (110 per minute or more)
 Low blood pressure (systolic less than 90mmHg)

Other symptoms and signs of shock include:

 Pallor (especially of inner eyelid, palms around mouth);
 Sweatiness or cold clammy skin;
 Rapid breathing (rate of 30 breaths per minute or more)
 Anxiousness, confusion or unconsciousness;
 Scanty urine output (less than 30ml per hour)

Management

IMMEDIATE MANAGEMENT
 CALL FOR HELP: Urgently mobilise all available personnel
 Monitor vital signs (pulse, blood pressure, respiration, temperature).
 If the woman is unconscious, turn her on her side to minimise the risk of aspiration if she vomits,
and to ensure that an airway is open.
 Keep the woman warm but do not over heat her, as this will increase peripheral circulation and
reduce blood supply to the vital centres.
 Elevate the legs to increase return of blood to the heart (if possible, raise the foot end of the bed).

SPECIFIC MANAGEMENT

 Start an IV infusion (two if possible) using a large-bore (16-gauge or largest available) cannula or
needle. Collect blood for estimation of haemoglobin, immediate cross-match and bedside clotting
test (see below), just before infusion of fluids.

 Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the rate of 1 L in 15-20
minutes.

Note: Avoid using plasma substitutes (e.g. dextran). There is no evidence that plasma substitutes are
superior to normal saline in the resuscitation of a shocked woman, and dextran can be harmful in large
doses.

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 -Give at least 2 L of these fluids in the first hour. This is over and above fluid replacement for ongoing
losses.

Note: a more rapid rate of infusion is required in the management of shock resulting from bleeding.
Aim to replace two to three times the estimated fluid loss.
Do not give fluids by mouth to a woman in shock

 If a peripheral vein cannot be cannulated, perform a venous cut down.

 Continue to monitor vital signs (every 15 minutes) and blood loss.
 Catheterise the bladder and monitor fluid intake and urine output.
 Give oxygen at 6-8 L per minute by mask or nasal cannulae

BEDSIDE CLOTTING TIME TEST

 Assess clotting status using this bedside clotting time test
- Take 2 ml of venous blood into a small, dry, clean, plain glass test tube (approximately 10
mm x 75 mm)
- Hold the tube in a close fist to keep it warm (±37 °C);
- After 4 minutes, tip the tube slowly to see if a clot is forming. Then tip it again every
minutes till the blood clots and the tube can be turned upside down;
- Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests
coagulopathy.

EPISIOTOMY
An episiotomy is a surgical incision made through the perineum to enlarge the vagina and assist childbirth.

The Indication (Purpose) of an Episiotomy

1. To aid the delivery of the presenting part when the perineum is tight and causing poor progress in
the second stage of labour.
2. To prevent the perineum from tearing when delivering big baby.
3. To allow more space for operative or manipulative deliveries, e.g. forceps, vacuum or breech
deliveries.
4. To shorten the second stage of labour, e.g. with fetal distress.
5. To reduce pressure on the fetal head when delivering a preterm infant.
Types of Episiotomy

There are 3 methods of performing an episiotomy:

1. Medio-lateral or oblique.
2. J-shaped. ( Rarely done and will not be discussed)
3. Midline (Median)

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Advantages and Disadvantages of Midline Episiotomy
The midline episiotomy involves cutting through less muscle tissue and following the natural line of the
perineum that a tear would take if it occurred. This can mean they are easier to repair, involve less blood
loss, heal better, and have less scarring and possibly less pain in the early weeks after the birth.

The disadvantages can be that performing a midline episiotomy increases the chances of the cut extending
through to the anus and causing a 3rd or 4th degree tear. In one study the incidence was shown to be as
high as 24% extending in this way.
Advantages and Disadvantages of Medio-lateral Episiotomy
A mediolateral episiotomy involves cutting into more muscle tissue and does not follow the natural way a
woman would tear. This can mean they are harder to repair, have increased bleeding, the cut may not heal
well, and it may produce more scarring, and possibly more pain in the weeks following the birth.

The advantage of a mediolateral episiotomy is that it is less likely to extend to a 3rd or 4th degree tear.
Performing a Mediolateral Episiotomy
The incision should only be started during a contraction when the presenting part is stretching the
perineum. Local anaesthesia should be administered if there is time. (1% lignocaine may be safely
infiltrated). Doing the episiotomy too early may cause severe bleeding and will not immediately assist the
delivery. The incision is started in the midline with the scissors pointed 450 away from the anus. It is
usually directed to the patient's right but can also be to the left. Two fingers of the left hand are slipped
between the perineum and the presenting part when performing a mediolateral episiotomy.

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Repairing an Episiotomy
Preparations for Repairing an Episiotomy.
1. This is an uncomfortable procedure for the patient. Therefore, it is essential to explain to her what is
going to be done.
2. The patient should be put into the lithotomy position if possible.
3. It is essential to have a good light that must be able to shine into the vagina. A normal ceiling light
usually is not adequate.
4. Good analgesia is essential and is usually provided by local anaesthesia which is given before the
episiotomy is performed. As 20 ml of 1% lignocaine may be safely infiltrated, 5-10 ml usually remains to
be given in sensitive areas. An episiotomy should not be sutured until there is good analgesia of the site.
5. In order to prevent blood which drains out of the uterus from obscuring the episiotomy site, a rolled pad
or tampon should be carefully inserted into the vagina above the episiotomy wound. As this is
uncomfortable for the patient, she should be reassured while this is being done.
6. Absorbable suture material should be used for the repair. Two packets of Vicryl 0 or 2-0 are required.
One on a round (taper) needle for the vaginal epithelium and muscles, and 1 on a cutting needle for the
skin. Non absorbable suture material such as nylon should not be used.
The Following Important Principles Apply to the Suturing Of an Episiotomy
1. The apex of the episiotomy must be visualised and the first suture put approximately 1 cm proximally.
2. Dead space must be closed.
3. Tissues must be brought together but not strangulated by excessive tension on the sutures.
4. Haemostasis must be obtained.
5. The needles must be handled with a pair of forceps and not by hand, and should be removed from the
operating field as soon as possible.
The Method of Suturing an Episiotomy
Three layers have to be repaired:
1. The vaginal mucosa.
2. The muscles.
3. The perineal skin
Suturing the vaginal mucosa
Place a suture (stitch) approximately 1 cm proximally to the apex (the highest point) of the incision in the
vaginal mucosa. Vaginal mucosa are re-approximated in a continuous fashion.

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Suturing the muscles
Insert interrupted sutures in the muscles. Start at the apex of the wound. The aim is to bring the muscles
together firmly and to eliminate any "dead space", i.e. any spaces between the muscles where blood can
collect. Remember that the sutures must be inserted at 90 degrees to the line of the wound.

The repair of the skin

Closure of the skin is performed with a subcuticular stitch. Sutures should be placed perpendicular to the
angle of the incision to prevent anatomic distortion of the perineum and vaginal opening.

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A. Interrupted stitch B. Continuous stitch C. Subcuticular stitch
How to Care for Episiotomy Wound
An episiotomy usually heals without complications, although it may take several weeks. Steps that can
reduce discomfort or promote healing include:
1. keeping the area clean by bathing and after going to the bathroom,
2. soaking in a sitz bath (Lukewarm water)
3. performing Kegel exercises,
4. taking pain medications and antibiotics
5. proper handwashing before and after perineal care
6. increase fruit juices that are rich in vitamin C to increase resistant against infection
7. Refrain from sexual intercourse, douching, and the use of tampons for 4–6 weeks, or until the
wound is completely healed.
How Can A Woman Lessen Her Chances of Having Episiotomy
Episiotomies are not always necessary, and there is much you can do to lessen your chances of having this
surgical incision. Some preventative measures are:
1. Good nutrition (Healthy skin stretches more easily)
2. Kegels (exercise for your pelvic floor muscles)
3. Prenatal Perineal massage
4. A slowed second stage (controlled pushing)
5. Warm compresses, perineal massage and support during delivery
Complications of Episiotomy
As with any surgical procedure, complications may occur. Some possible complications of an episiotomy
may include, but are not limited to, the following:
 bleeding
 tearing past the incision into the rectal tissues and anal sphincter
 perineal pain
 infection
 perineal hematoma
 pain during sexual intercourse
 problems urinating

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ANNEXE 2: FLOW CHARTS FOR MANAGEMENT OF MAJOR CAUSES OF MATERNAL
DEATHS
SHOCK
Monitor vital signs (BP, pulse, respiration)
Elevate feet
Give oxygen
Take blood for grouping and X-matching
Give IV fluids (Ringer’s lactate) 1 litre/20
Measure urine output

Are there signs of stabilization after 20-30 minutes?

Continue IV infusion and oxygen

Complete clinical assessment
Begin treatment of underlying cause of shock

Are there signs of stabilization after 2hours?

Adjust IV infusion and oxygen
Identify and treat underlying cause of shock
After the signs of stabilization Yes
Observe
REFER as necessary (Depends on cause of shock)

AT REFERRAL LEVEL (Hospital) No

Blood transfusion
Treat underlying cause of shock REFER
(Sepsis, haemorrhage, uterine rupture)

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 POST PARTUM HAEMORRHAGE
Resuscitation, if necessary
Take blood for grouping and X-matching
Give IV fluids (N/Saline) with 10 units
Oxytocin
Give inj. Ergometrine IV 0.2mg or IM 0.5mg if BP is
normal
Empty bladder
If bleeding continues……….

Are there tears/lacerations in perineum, vagina or cervix?

No Yes
Suture
Is placenta out? If bleeding not controlled,
organize blood donors
and REFER

Trained to do manual removal of

Examine placenta for completeness placenta
Massage fundus stimulate nipples
Do manual compression if necessary
If bleeding is controlled, give broad No Yes
spectrum antibiotics for 5 days
Observe for 24-48 hours, check HB
Give oxytocin 20-40 litre N/Saline
before discharge
Remove placenta if trained
If bleeding not controlled, organize blood
Examine for completeness and
donors and REFER
extra lobe
Give oxytocin 5 units IM, or ergometrine
Inj 0.25-0.5mg IM
Give antibiotics for 5 days if
Haemorrhage continues, REFER

Give antibiotics
REFER

A REFERRAL LEVEL (Hospital)

Give blood transfusion
Identify cause of haemorrhage, then manage appropriately (surgical if indicated)

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 PUERPERAL SEPSIS
Monitor vital signs for shock
Assess degree of infection

Is infection severe?
(Fever, 38.5 C, tender abdomen)

Yes No

Give antibiotics and Give amoxicillin or Cyrst, penicillin analgesics and metronidazole
Give IV fluids Give ergometrine or oxytocin IM if bleeding
REFER Monitor progress; if no improvement after 48 hours or if signs of
shock, give IV fluids and REFER

AT REFERRAL LEVEL, (Hospital)

Conduct bimanual examination
Conduct lab investigation (HVS, Blood c/s,
urine c/s
depending on result
Give specific antibiotics
Consider exploration of urine cavity
under anaesthesia

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 MANAGEMENT OF HYPERTENSIVE COMPLICATIONS IN PREGNANCY

Symptoms: if severe headache, blurred vision, swelling of

the face, hands and feet, upper abdominal pain,
palpitations, seizures
Signs: Blood pressure higher than 140/90mmhg
Laboratory: proteinuria

Mild preeclampsia Severe preeclampsia Eclampsia

Blood pressure less than Blood pressure of Grand mal seizures
160/110mmhg 160/110mmHg or higher Blood pressure of
Proteinuria 2+ or less Proteinuria of 2+ or more 140/90mmHg or higher
proteinuria

REFER if at health centre level

In addition, counsel on danger

signs of worsening preeclampsia
Encourage additional bed rest Transfer and Accompany patient to Hospital
Review with client her
complication readiness plan Start antihypertensive
Sublingual Nifedipine Protocol: 10mg sublingual
nifedipine every half hour until BP diastole is controlled at
between 90-100mmHg.

Start Anticonvulants
Start Magnesium sulphate
Loading dose:
4g IV (slowly as 20% solution)
5g IM into each buttock (as 50% solution)
Maintenance Dose: 5g IM every 4 hours into alternate
buttocks. If Breakthrough fits occur before next dose, give 2-
4g IV (as 20% solution)

OR Diazepam Protocol (See)

If in Labour and near delivery (cervical dilatation more than

7cm): Deliver patient before Transfer to hospital. Perform
active management of third stage.

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 At district hospital level

Mid Preeclampsia
Follow up twice weekly on out-patient basis if possible
Monitor BP and Urine albumin and fetal condition
Do not give anticonvulsants, antihypertensives, diuretics,
sedatives or tranquilizers

Admit if
Outpatient follow up is not possible
Or if worsening preeclampsia

Deliver if
Severe preeclampsia
Fetal compromise
Or if not spontaneous delivered at 40 weeks gestation.
(Do not allow pregnancy to go beyond the Expected Date
of Delivery

Severe Pre-eclampsia/Eclampsia
Start/continue Antihypertensive
Sublingual Nifedipine Protocol: 10mg sublingual nifedipine every half hour until BP
diastole is controlled at between 90-100mmHg.

Start/continue Anticonvulsants: Start Magnesium sulphate

Loading dose: 4g IV (slowly as 20% solution)
5g IM into each buttock (as 50% solution)
Maintenance Dose: 5g IM every 4 hours into alternate buttocks. If Breakthrough fits
occur before next dose give 2-4g IV (as 20% solution)

OR Diazepam Protocol (see)

Monitor and document: BP every 30minutes until stable, then 2-4 hourly
Urine output hourly
Respiratory rate and fetal heart rate 4 hourly
Conduct the following laboratory test: blood: full blood count, platelets, BUN,
Creatinine, liver function test: albumin.

If in Labour: Monitor progress of Labour and fetal wellbeing closely with partograph.
Expedite delivery if progress is unsatisfactory.

If not in labour: plan and deliver in 48 hours if severe pre-eclampsia

Plan and deliver with 12 if eclampsia.

Assess for ideal route of delivery (see decision making tree)

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APPENDIX 3
Health Education and Counselling Topics

1. Pre-conception Care
 General Health Screening and Genetic Counselling
 Female and Male Anatomy
 How conception occurs
 Importance of ANC

2. ANC Education
 Importance of Good Nutrition
 Medication during pregnancy
 Healthy lifestyle during pregnancy
 Basic information about some of the minor discomforts of pregnancy (Refer Clients to the
Pregnancy Information Booklet)
 Prevention of STIs including HIV
 Birth preparedness & complication readiness
 Importance of facility based delivery by a skilled provider
 Breastfeeding
 Family Planning
 Importance of post-natal care

3. Post-natal period
 Infant feeding
 Immunization for baby
 Resumption of sexual intercourse
 Family planning
 Continuing ARV regimen (where applicable)
 Care of the newborn, recognition of danger signs in the newborn and early care seeking
 Common concerns of the newborn period
 Appropriate nutrition, exercise, rest and relaxation for mother
 Birth registration

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