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Module II - Maternal Health Training Module |
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Prepared for:
Health of the Urban Poor (HUP) Program
Population Foundation of India
B-28, Qutab Institutional Area, New Delhi-110016
Population Foundation of India is implementing Health of the Urban Poor (HUP) Program which is supported by
USAID/ India and working in 8 states and 5 demonstration cities – (Pune, Bhubaneswar, Jaipur, Delhi and Agra).
Plan India and Bhoruka Charitable Trust (BCT) are the implementing partners in Pune and Jaipur respectively.
Prepared in technical collaboration with:
“CINI Chetana, the training wing of Child In Need Institute”
Vill & P.O. : Amgachia, West Bengal
Special Inputs:
Dr. Swati Mahajan (Demonstration Officer)
Dr. Jatin Dhingra (Consultant, City Demonstration)
Dr. Mainak Chatterjee (Public Health Specialist)
Dr. Sainath Banerjee (Chief of Party)
Note : Replication of any content of the document should be done with consent from HUP
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Contents
Introduction
1
Training Objectives
2
SESSION: 1
3
1.1 Perspective building on health
3
1.2 Right age of marriage and pregnancy
3
SESSION: 2
5
Antenatal care (ANC)
5
2.1 Signs and symptoms of pregnancy
5
2.2 Diagnosis of pregnancy
6
2.3 Determining of LMP and EDD
8
2.4 Essential components of Antenatal care
8
• Early registration
• Routine checkup
• Immunization
• IFA and Diet
• Importance of rest during pregnancy
• Care during pregnancy
• Personal health and hygiene
2.5 High risk pregnancy
11
• Identification Skill
2.6. Danger Signs during pregnancy and referral (both emergency and non-emergency referral)
11
2.7 Anemia during pregnancy
13
• Skills of identifying Anemia
• Management of Anemia
• Counseling of pregnant women and her family members on anemia
2.8. Management of Malaria During pregnancy
16
• Counseling of pregnant women and her family members on malaria
2.9 Skills to identify symptoms of Vitamin A, B and iodine deficiency and symptoms of Edema
17
2.10 Skills of measuring Blood Pressure
18
2.11 Myths and misconceptions / do's and don'ts during the period
20
2.12 Role of Link Workers/Cluster coordinators
20
2.13 Role of family members
21
2.14 Available government Schemes
22
• Janani Suraksha Yojana - JSY
• Janani Sishu Suraksha Karyakram – JSSK
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SESSION: 3
24
Intra-Natal Care
24
3.1 Importance of Birth preparedness
24
3.2 Birth preparedness and complication readiness (BPCR) for safe delivery
24
3.3 Importance of institutional delivery
25
3.4 Development of birth preparedness plan (birth micro plan)
26
3.5 Role of link worker in BPCR in institutional delivery
28
3.6 Preparation for Safe Home Delivery (maintaining 5 cleans) through Skilled Birth Attendant
28
3.7 Complications during delivery: 3 Delays
29
3.8 Identification of nearest First Referral Unit (FRU)
30
3.9 Stages of delivery
30
3.10 Danger signs in labour and delivery
31
3.11 Role of Link Workers/Cluster coordinators
32
3.12 Role of family members
32
SESSION: 4
33
Post Partum Care
33
4.1 Essential care of newborn immediately after delivery (in home delivery)
33
• Hand washing before touching baby
• Cleaning and wrapping
• Early initiation of breast feeding
• Care of newborn - Eye, Cord and thermal Care (Temperature control and prevention of hypothermia)
• Birth weight recording with the help of Link worker
4.2 Postnatal care of mother
36
• Schedule of post natal visits / checkups (as per GOI norm)
• Special needs of a lactating woman and Counseling of family members during Post natal period
• Counseling on exclusive breastfeeding till six months
4.3 Danger Signs during post natal period and referral (both emergency and non-emergency referral) 37
• Excessive bleeding
• Puerperal sepsis
• Convulsion with or without swelling of face and hands, severe headache and blurred vision
• Anemia
• Breast engorgement and infection
• Perineal swelling and infection
• Post-partum mood changes
4.4 Role of Link Workers/Cluster coordinators
38
4.5 Role of family members
38
SESSION: 5
Mock Session
Annexures
40
Annexure-1- BEmOC and CEmOC
40
Annexure-2- PNC Checklist
41
Annexure -3- LMP-EDD-Pre Term Calendar
42
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Training Schedule for Link Workers of the Health of the Urban Poor Program
Total time: 6 and ½ hrs. (Excluding breaks)
Duration: 3 days
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Total time: 7 hrs. 15 min.
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Total time: 6 and ½ hrs. (excluding breaks)
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Introduction
Health of the women and children in a country is indicative of the commitment of the
Government of that country towards the overall development and welfare of its
people. Government of India has taken up number of steps to promote the health of
the women and children and is trying to extend the domain and improve the quality of
health services. Govt. of India has been in the process of refining the mother and child
health care approach by adopting inter-sectoral coordination and increasing avenues
of communications among service providers of different cadres and streams and local
govt. bodies to act on health.
To support this initiative a three days ToT Module (Training of the Trainers Module) has
been prepared for Link Worker, Cluster Coordinator and Project Coordinator on
Maternal Health. This training will include theory sessions, field visits and some
practical activities. This would be a ready reckoner for the staff. This module will guide
them for imparting training to the community representatives with standardized
information and messages.
The field workers play a critical role as they help to generate critical health awareness
in the community particularly among those who are poor and underserved, facilitate
linkages with health services and help women & children in accessing necessary health
care services. Moreover they have a role as health activists and they have a pivotal role
in mobilizing people particularly women in taking an active part in matters relating to
maternal health & well-being.
Link worker's capacity & skills in providing first level contact care, identification of
danger signs & arrangement of prompt referrals in maternal health emergencies
becomes even more meaningful & has major impact on improving health outcomes.
The module focuses on building competencies of HUP field staff (Link Workers, Cluster
Coordinators Project Coordinators) in Maternal Health at family/community level.
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Training Objective
To equip the participants with appropriate knowledge and skills about
Antenatal Care, Intranatal care and Postnatal Care so that, they can
perform their duties effectively.
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Session: 1
1.1 Perspective building on health
Objectives of the session
1. Knowledge about health following Life Cycle Approach (LCA)
2. Know about determinants of health
3. Understand linkages among the different determinants
Facilitator should ask the participants about their perception regarding health. Different connotations will evolve
from the group, and then the facilitator will summarize the concept.
Health is defined in the WHO constitution of 1948 as
“A state of complete physical, social and mental well-being and not merely the absence of disease or infirmity”
Facilitator can show a documentary film of 20 minutes duration, called Haule-Haule to the participants. In this movie
all the aspects of reproductive health (RH) with gender issues have been very well depicted. The facilitator should
ask the participants to analyze all the characters of the film and the RH issues covered in details either in group
activity or verbally after showing the film. Then the facilitator can summarize the session with the following
outcomes:
The factors which influence health are multiple
• Health behaviors and lifestyles
• Environment and surroundings
• Social condition
• Economic condition
• Socio-cultural background
• Gender
• Education
• Employment and working condition
• Access to appropriate health services
These, in combination, create different living conditions which have an impact on health. Positive change in these
lifestyles and living conditions will make possible to bring a change in the health status.
1.2 Right age of marriage and pregnancy
According to the Indian constitution the age of a marriage is 18 years for a girl and 21 years for a boy, for all
communities. The Child Marriage Restraint Act, 1929, defines a child as a person who, if a male, has not completed
21 years of age, and if a female, has not completed 18 years of age. Under Section 5 of this Act whoever performs,
conducts or directs any child marriage shall be punishable with simple imprisonment up to three months and shall
also be liable to fine.
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Moreover, the right age of getting pregnant is 20 years and above. The main reason behind it is that both girls and
boys before this age are not fully capable to reproduce, to decide if and when to bear a child.
The risks of early pregnancy and childbirth are: increased risk of dying, increased risk of premature labour,
complications during delivery, low birth-weight, and a higher chance that the newborn will not survive. Unsafe
abortion is the other major risk for teenage women.
Pregnancy-related deaths are the leading cause of mortality for 15-19 year-old girls (married and unmarried)
worldwide. Mothers in this age group face a 20 to 200 per cent greater chance of dying in pregnancy than women
aged 20 to 24.
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Session: 2
MATERNAL HEALTH
Objectives of this session
By the end of the session the Health worker will learn about:
• Diagnosing pregnancy by using Nischay Kit
• Determining Last Menstrual Period (LMP) and Expected Date of Delivery (EDD)
• The key components of antenatal check-up
• Identification of danger signs during the antenatal period and appropriate referral
• Diagnosis and management of Anemia
• Developing plans for birth preparedness
• Follow-up with pregnant women
• Safe delivery and understand pregnancy outcomes as abortion, live birth, stillbirth or newborn death
• The key components of postnatal care
• Identification of complications during post-partum period and appropriate referral.
Maternal health means ensuring essential maternal and newborn care during pregnancy and childbirth, and
strengthening the management of maternal complications and obstetric emergencies.
It is divided into 3 parts
• Antenatal care
• Intra-natal care
• Postpartum care
ANTENATAL CARE
2.1 Signs and Symptoms of pregnancy
Pregnancy can be suspected when an eligible woman shows the following features:
• Cessation of menstruation
• Nausea
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• Vomiting (in first three months)
• Enlargement of abdomen
• Increased urination
• Breast changes (after first three months)
• Perception of movement by the mother inside her own abdomen around 16 weeks
• Feeling heaviness in the body
2.2 Pregnancy diagnosis
Diagnosis of pregnancy should be done as early as possible after the first missed period.
There are two ways to diagnose pregnancy early:
• Missed periods
• Pregnancy testing : through use of the Nischay home pregnancy test card (A positive test means that the woman
is pregnant and a negative test means that the woman is not pregnant)
Nischay Kit
The Nischay Kit contains the following:
1. A test card
2. A disposable dropper
3. A moisture absorption packet (not required for testing)
Methodology
1. Collect the the first morning urine sample in a clean and dry glass or in a plastic bottle.
2. Take two drops of urine in the sample well (morning sample).
3. Wait for 5 minutes.
4. If two violet color lines come in the test region (T), the woman is pregnant.
5. If she wants to continue with the pregnancy, advice her to undergo antenatal care.
6. If she does not want to continue with the pregnancy this time, advice her for safe abortion.
7. If only one violet color line comes in the test region (T), the woman is not pregnant.
8. Tell her about family planning methods and help her in choosing the most appropriate one.
9. If no colored line appears in the test region (T), repeat the test next morning using a new pregnancy
Test Card.
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Two drops
of urine
• Collect the morning urine in a clean and dry glass
or a plastic bottle.
C
T
S
• Take two drops of urine in the sample well
• Wait for 5 minutes
You are
Pregnant
• If two violet colour lines come in the test region
(T), the women is pregnant.
• If she wants to continue with the pregnancy, advise
C
T
S
her to undergo antenatal care.
• If she does not want to continue with the
pregnancy this time, advise her for safe abortion.
You are
not Pregnant
• If the violet colour line in the test region (T) is one
only, the woman is not pregnant.
C
T
S
• Tell her about family planning methods and help
her in choosing the most appropriate one.
Repeat
the test
• It there is no colour line in the test region (T),
repeat the test next morning using a new
C
T
S
Pregnancy Test Card.
Confirmation of Pregnancy
After a pregnancy is suspected / expected (either by the mother or by the health worker), it can be confirmed by
conducting a Urine test. It will be positive 2 weeks after the missed period.
Early confirmation of pregnancy is needed because, earlier the care of pregnancy is initiated, and more are the risks
reduced from pregnancy and childbirth.
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2.3 Determining LMP and EDD
When pregnancy is diagnosed, Health worker should help the pregnant woman in calculating the probable date
when she is likely to deliver.
Steps to find the EDD
• Find out from the woman the date of the first day of her Last Menstrual Period (LMP)
• Then count nine months after that date.
• Add seven days to that date.
• The date which comes is the Expected date of Delivery.
For Example,
If the first day of the LMP is:
Nine months later is:
Adding seven days is:
Therefore, the expected date of delivery is
2.10.2011
2.07.2012
9.07.2012
9.07.2012
This method only gives an approximate date of delivery, and baby may be born anytime during 15 days before or
after the EDD.
If the baby delivers much before the EDD, that is in between 7 months to 8 ½ months of pregnancy then the baby
will be a premature baby. In this case baby needs special care and attention as per the doctor's advice.
2.4 Essential components of antenatal care
• Early registration of pregnancy - After the confirmation of pregnancy it should be registered within 12 weeks of
pregnancy at the health centre/hospital.
• Routine antenatal checkups: As per the Government of India norms, minimum four antenatal checkups are must
for any pregnant women.
– 1st visit to the antenatal clinic as soon as pregnancy is suspected and ensure early registration
(within 12 weeks)
– 2nd visit between 14 -26 weeks
– 3rd visit between 28 -34 weeks
– 4th visit at 9th month (after 36 weeks)
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1st Visit (within 12 weeks)
2nd Visit ( between 14-26 weeks)
3rd Visit ( between 28-34 weeks)
4th visit (After 36 weeks)
Each antenatal check up (ANC) session should include
• Measuring Blood Pressure (BP)
• Recording of weight
• Clinical Examination for Anemia and pedal edema
• Per abdomen examination to assess the fundal height, fetal lie & position
• Screening of high risk cases
• Laboratory investigations like Hemoglobin estimation & Urine for albumin & sugar
• Counseling on Diet & rest
• Advice on danger signs & complication readiness
• Advice on essential newborn care & family planning esp. spacing of children where required
• Regular monitoring and counselling for mental well being
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Immunization - Two Tetanus Toxoid injections at an
interval of four to six weeks. If a dose has been
administered to the woman within the last three
years, then only one dose is required.
Diet and IFA: At least 100 IFA tablets are to be
consumed during pregnancy. Anemic woman must
consume 200 IFA tablets. Besides this, regular intake of
three colors of food (green, white and yellow) in
gradually increasing quantities to be ensured during the
pregnancy. Drink plenty of water.
Monthly weight check up should be done. Weight of a
pregnant lady should increase by about 1 kg per month.
By the end of the pregnancy women might weigh about
10.5 – 11 kg more than she did before she became
pregnant. This is the average weight gain during
pregnancy.
• Care during Antenatal period
– Adequate rest- The mother should get at least 8 hours of sleep at night, and 2 hours of bed rest at noon
lying on her side.
– Avoiding physical exhaustion, heavy workload, travelling and mental disturbance are a must.
– Addiction or exposure to smoking, chewing tobacco or consumption of alcohol should be strictly avoided.
– Referral to district hospital or suitably equipped First Referral Unit (FRU) in case of emergency or on
observing any of the danger signs.
– Development of birth preparedness plan.
• Personal health and hygiene
– Taking bath daily and maintaining cleanliness of private parts of the body.
– The breast and specially the nipple should be kept clean so that it can be infection free otherwise it may
result in redness, itchiness and cracked nipple.
– Wash hands thoroughly with soap and clean water before and after eating food and after using toilets.
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2.5 High risk pregnancy
Identification signs
If a pregnant women falls under any of the following category, her pregnancy would be called high risk pregnancy. In
that case she needs special care and attention.
• Young mothers below 19 years of age.
• Mothers who are over 40 years of age.
• Mothers who already have three children.
• Mothers with a bad obstetric history - those who had abortion, those who had complications in a previous
pregnancy like prolonged labour/obstructed labour, those who underwent assisted delivery or had C-section,
those who had still births/neonatal death.
• Mothers with short stature (height below 5ft).
• Pregnant Women with high blood pressure, jaundice, any cardiovascular disease, diabetes or any
systemic illness.
2.6 Recognition of Danger Signs during pregnancy
All pregnant women are at risk of complications. But there are some conditions, which lead to a higher risks of
complications, and are threat to the life of mother and baby. Mother should be cautious about the warning
signs /danger signals of pregnancy indicating the presence of major problems so that they can call for early
management.
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Following are the danger signs and symptoms and actions to be taken accordingly:
Danger signs in women
Bleeding from vagina
How to recognize
Action to be taken
Bleeding - any amount (bright
red bleeding or clots or tissue) at
any time of pregnancy
Immediate referral to the
nearest health facility which is
functional for 24 hours
Loss of fetal movement
Absence of movement/ kicking
or severe abdominal pain
Immediate referral to the
nearest health facility which is
functional for 24 hours
Headache/dizziness/blurred vision
Severe headache and blurred
vision or severe headache and
spots before the eyes
Immediate referral to the
nearest health facility which is
functional for 24 hours
Swollen face/hands
Pitting edema over back palm
and foot
Immediate referral to the
nearest health facility which is
functional for 24 hours
Convulsions/fits
Eyes roll, face and limbs twitch,
body gets stiff and shakes, fists
clinched
Immediate referral to the
nearest health facility which is
functional for 24 hours
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Non-Emergency referral during Pregnancy:
Problem
Severe anemia
Night Blindness
Fever
Pain/burning when
urinating
White Discharge
Multiple pregnancies
Weight loss
Itching/Scabies/boil on
skin with pus
How to recognize
Action to be taken
Tongue very pale, weakness, general Refer to nearest Health Centre(HC)
swelling in body
Pregnant women find it difficult to Refer to HC
see at dusk
Skin warm to touch Temp > 100-
degree F (37.8 degree Celsius)
Give Paracetamol tablet.
If no relief after 48 hours, refer to
nearest health facility
Frequent urination and urgency.
Pain/burning when passing urine
Let mother drink plenty of water.
If no relief after 24 hours, refer to
nearest health facility
Passage of white discharge per Refer to nearest health facility
vagina, itching in private parts
Suspicion/provisional diagnosis by
ANM or by doctor after abdominal
examination.
Refer to nearest health facility
No weight gain over a continuous Refer to nearest health facility
period
Skin rashes with itching could be
present in other family members as
well
Scabies
Presence of pus filled boils
For boils, advice women to apply hot
fomentations to the area thrice daily.
If no improvement after 2 days, refer
to nearest health facility
For scabies, refer to ANM/Health
Centre.
2.7 Anemia during pregnancy
In India, anemia among women is very common. The chances of a mother having a delivery before term, or even
dying are higher among mothers with severe anemia. In order to ensure that all women have normal Hb level, all
pregnant women should be given iron and folic acid tablets (IFA) tablets.
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Identification of Anemia
Anemia can be detected by a simple blood test, which measures the amount of a pigment called
Hemoglobin (Hb)
Hemoglobin level
More than 11g/dl
7 - 11 g/dl
Less than 7 g/dl
Degree of Anemia
Absence of Anemia / Normal
Moderate Anemia
Severe Anemia
Common symptoms of severe anemia include: Very pale tongue, weakness & generalized swelling in body
Management of Anemia
• For women who do not have anemia (Hb more than 11g/dl)
The pregnant woman should take one tablet of IFA every day for at least 100 days (prophylactic dose), starting after
the first trimester. This dosage regimen is to be repeated again for three months after the delivery.
• If a woman is found to be anemic
1. The woman should be given two IFA tablets per day for three months.
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2. The Hb level needs to be estimated again after one month. If the level increases, you should tell the woman to
continue with two tablets if IFA daily until the Hb comes to normal.
3. If the Hb does not rise in spite of taking IFA tablets, in the prescribed dose, you should refer the woman to the
nearest health facility that is equipped to manage complications in pregnancy.
4. One should refer women with severe anemia immediately to the nearest HC for further treatment. Such
women may need injections or blood transfusions.
5. The dosage regimen of two IFA tablets per day should be repeated for three months post-partum also.
6. One should also encourage the pregnant woman, where ever possible, to increase her dietary intake of iron-rich
food.
Counseling of pregnant women on anemia
• Encourage women to take iron-rich foods such as green leafy vegetables, whole pulses, ragi, jaggery, meat and
liver. This advice should be discussed with family and finalized based on the family situation.
• Encourage the woman, where possible, to take plenty of fruits and vegetables containing vitamin C (such as
mango, guava, orange and sweet time) as these enhance the absorption of iron.
• IFA tablets should not be consumed with tea, coffee, milk or calcium tablet as it reduces the absorption of iron.
• Counsel the women on the necessity of taking IFA and the dangers associated with anemia.IFA tablets must be
taken regularly, preferably in the morning If the woman has nausea and pain in abdomen, she may take the
tablets after meals or at night. This will avoid nausea.
• Many women do not take IFA tablets regularly due to some common side-effects such as nausea, constipation
and black stools. Tell women not to worry about passing black stools while consuming IFA as it is normal. Inform
the women that the side-effects after taking IFA tablets are common and not serious, and will reduce over time.
• In case of constipation, the woman should drink more water and add roughage (plenty of green leafy
vegetables) to her diet.
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2.8 Management of malaria during pregnancy
Malaria is an infection caused by parasite (microorganism) called Plasmodium. This is transmitted by the bite of
female anopheles mosquito. There are two types of malaria: Malaria caused by Plasmodium Vivax which is not
dangerous or fatal and Malaria caused by Plasmodium Falciparum which is also known as cerebral malaria and can
cause damage to the brain, liver and lungs.
Signs and symptoms
• The patient can have fever, high shivering and sweating, which can occur on alternate days (in case of
Plasmodium vivax) and every day at a certain time with Falciparum type infection.
• Sometimes the patient has continuous fever, malaise and headache.
• Malaria affects more frequently and more severely children below five years, pregnant women, or patients who
are already ill.
• Falciparum malaria can affect the brain: causing clouding of consciousness, fits, or paralysis leading to death.
How to suspect malaria: Any person living in a malaria affected area, who develops fever must be suspected as
having malaria. If fever is with chills and rigor and headache, it is even more likely.
How to confirm
The way of confirming malaria is through a blood examination of the pregnant women at nearest health centre.
Sometimes the blood smears can be negative, and a repeat smear is required. If the result comes positive, treatment
should start in the health centre or hospital.
Counseling of pregnant women and her family members on ways of controlling malaria
Encourage the pregnant women and family members to apply the following ways of avoiding malaria
There are two ways:
i) Do not allow mosquitoes to multiply:
• Spray insecticides at the sites where mosquitoes sit, dry up breeding pits.
• Not allowing water to stagnate - pour a spoon of oil over the water surface in small collections. This is
enough to kill the mosquito larvae.
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• Water in drains and canal should not be allowed to remain stagnant in one place and it should be flushed
and cleaned once in a week.
ii) Do not allow mosquitoes to bite:
• Wear clothes that cover the body, like full sleeved shirts.
• Use Mosquito nets treated with insecticides so that infected mosquitoes do not reach the sleeping person.
The mosquitoes coming in contact with the net may die later.
• Use of mosquito repellent, e.g. burning neem leaves to drive mosquitoes away.
If the pregnant women suffer from malaria the family members are advised to:
• Give Paracetamol for fever. Also advise sponging with warm water when needed.
• If test is positive for malaria - Ensure access to chloroquine or Artesunate and completion of course.
Combination treatment (ACT) drug is now recommended. The dose of the drug depends of the age group.
• Nowadays, the recommendation is to treat for malaria only if the test is positive.
• If the test is not available, or cannot be done, it is permissible to give a course of chloroquine. This would still be
needed in many areas.
• If despite treatment fever does not begin to come down within two or three days, or persists even after a week,
referral becomes mandatory.
2.9 Symptoms of Vitamin A, B, Iron and Iodine deficiency and symptoms of Edema
Nutrient
Vitamin A
Vitamin B
Deficiency symptoms
• Bitot's spots
• Foamy patches on conjunctiva
• Color blindness
• Acne
• Dry skin
• Ichthyosis
• Dry hair
• Blurred vision
• Dark spots in front of eyes
• Itching, burning, watery, sandy
eyes
• Eczema and skin ulcers
• Edema
• Fungus infection
• Lemon-yellow skin
• Burning and sore tongue
• Cracked lips
• Mouth ulcers
Management
Consumption of yellow-orange fruits
and vegetables rich in carotenoids
that will prevent Vitamin A deficiency
related night blindness. Besides,
these breast milk also contains
Vitamin A.
Group B vitamins are particularly
concentrated in meat, fish, in liver
and meat products. Good sources for
Vitamin B include whole grains,
potatoes, bananas, lentils, chili
peppers, beans, nutritional yeast, and
molasses.
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Nutrient
Iron
Iodine
Deficiency symptoms
• Fatigue
• Shortness of breath
• Headache
• Irritability
• Dizziness
• Craving for ice or clay
• Weight loss
Management
The best sources of iron include
fortified cereals, chicken and chicken
liver, lean red meat, dried beans and
legumes, oysters, leafy greens, nuts
and whole grains. Vitamin C enhances
the absorption of iron consumed in
the same meal. Foods containing
vitamin C include oranges, amla,
lemon juice, strawberries, broccoli,
tomatoes and bell peppers.
Disorders:
• Miscarriage
• Stillbirths
• Congenital anomalies
• Increased perinatal morbidity and
mortality
• Goiter
• Hypothyroidism
• Endemic mental retardation
The primary sources of dietary iodine
are saltwater fish, seaweed and trace
amounts are present in grains. Salt
was selected as the medium for
iodine supplementation because its
intake is uniform across all
socioeconomic strata and across all
seasons of the year. Therefore,
everybody is advised to take iodized
salt in their food.
Edema
Symptoms: Mild swelling of the feet, hands, abdomen, breasts and face may occur. This is worse at the end of the
day and may disappear after a night's rest. Rings may need to be taken off and looser clothes may need to be worn in
the evening. In all the cases advice should be taken from the doctor.
2.10 Measuring Blood Pressure (BP)
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• Blood pressure is the force of blood against the walls of the artery.
• Hypertension means high blood pressure.
• Hypotension means low blood pressure.
• Brachial artery is a blood vessel that goes from your shoulder to just below your elbow. You measure the
pressure in this artery.
• Systolic pressure is the highest pressure in an artery when your heart is pumping blood to your body.
• Diastolic pressure is the lowest pressure in an artery when your heart is at rest.
Advise the person before measuring her blood pressure:
• Should not use caffeine, alcohol, or tobacco products 30 minutes before measuring blood pressure.
• Go to the bathroom and empty bladder before measuring blood pressure.
• Rest for 3 to 5 minutes before measuring blood pressure. Do not talk.
• Sit in a comfortable position, with legs and ankles uncrossed and back supported.
• Place left arm, raised to the level of your heart, on a table or a desk, and sit still.
• Wrap the cuff smoothly and snugly around the upper part of her bare arm.
• Check to see that the bottom edge of the cuff is 1 inch above the crease of elbow.
How a manual or aneroid monitor can be used?
• Put the stethoscope ear pieces into your ears, with the ear pieces facing forward.
• Place the stethoscope disk on the inner side of the crease of elbow.
• Rapidly inflate the cuff by squeezing the rubber bulb to 30 to 40 points higher than last systolic reading. Inflate
the cuff rapidly, not just a little at a time.
• Slightly loosen the valve and slowly let some air out of the cuff. Deflate the cuff by 2 to 3 millimeters per second.
If you loosen the valve too much, you won't be able to determine blood pressure.
• As you let the air out of the cuff, you will begin to hear heartbeat. Listen carefully for the first sound. Check the
blood pressure reading by looking at the pointer on the dial. This number will be systolic pressure.
• Continue to deflate the cuff. Listen to heartbeat. You will hear heartbeat stop at some point. Check the reading
on the dial. This number is diastolic pressure.
• Write down blood pressure, with the systolic pressure before the diastolic pressure (for example, 120/80).
• If you want to repeat the measurement, wait 2 to 3 minutes before reinflating the cuff.
Normal
Prehypertension
High blood pressure: Stage 1
High blood pressure: Stage 2
Systolic (first/top number)
Less than 120
120-139
140-159
160 or higher
Diastolic (second/bottom number)
Less than 80
80-89
90-99
100 or over
Hypotension, or low blood pressure, happens when systolic pressure is consistently below 90--or 25 points below
normal reading. This can be determined by several blood pressure readings over several days. Hypotension can be a
sign of shock, which is a life threatening condition. Contact doctor for both Hypertension and Hypotension cases
immediately.
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2.11 Myths and Misconceptions during pregnancy
Facilitator should ask the participants about myths and misconceptions during pregnancy that are well known
in their working area. Some of them are:
• Since pregnancy is thought of as a natural process, families may think that antenatal check-ups are
unnecessary.
• In some places, women tend to hide their pregnancy for fear of the "evil eye" or other traditional beliefs.
• Some women have important taboos about foods which are nutritionally important for good health (for
example, some protein-rich foods).
• Excess consumption of food retards the growth of the child because the distended stomach does not give
space to the uterus to expand.
• Some believe that tetanus toxoid is an injection that will prevent future pregnancies.
• The more the mother undergoes exertion the smoother will be the delivery.
• In some places, families will first seek help from traditional healers.
• Beliefs in bad omen or spirits may prevent mothers from seeking care, especially if the emergency occurs
during certain times of the day (for example, after sundown).
• The expecting mother should sleep keeping an article of iron underneath her pillow to ward off
evil spirits.
• The more the mother faces difficulties the better because then she will deliver a baby boy.
• In many cultures, bathing the baby soon after birth to "purify" him/her is a common practice.
• Sometimes blades of grass, bark fibers, reeds, or fine roots are used for cutting the cord. This is harmful
because such materials often harbor germs and thus increase the risk of infections, such as tetanus.
• Colostrum may be thrown away because it is considered unclean.
• Because breastfed baby demand feeds more frequently, it is often thought that breast milk is not enough,
and other milks and liquids are given unnecessarily to the baby.
2.12 Role of Link workers/ Cluster Coordinators
• The Link workers/ Cluster Coordinators should maintain a register where information of all the pregnant women
should be recorded.
• Emphasize the importance of a balanced and nutritious diet during pregnancy. The diet of the pregnant woman
should contain a mix of cereals, pulses (including beans and nuts) and vegetables including greens, milk, eggs,
meat and fish. If possible, the family should be encouraged to add oils, jaggery and fruits to the diet. Meat and
nuts are especially good for anemic women. Explain to the mother and family that no foods should be forbidden
during pregnancy.
• Inform all pregnant woman about the existing maternal health related schemes like JSY, JSSK, Nischay Yan,
Ayushmati, Jagriti.
• See when ANC is due for each check-up and remind them appropriately.
• Escort pregnant woman to health centre as required.
• Ensure that full antenatal coverage is being given to pregnant women and all components of ANC are delivered.
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• Ensure that the services related to antenatal care are updated in respective cards (investigation results and
medicine etc.).
• Counsel pregnant women and her family members about danger signs during pregnancy, importance of
institutional delivery, post natal care, newborn care, registration under Janani Suraksha Yojana, birth spacing ,
personal hygiene etc.
• Help the mother and her family members in preparing a micro plan for institutional delivery.
2.13 Role of family members
The pregnant women and family members should follow the instructions and advice of the health workers, HUP field
staff and doctors of health centres/ hospital. Beside that:
• Always keep the pregnant women happy.
• Ensure pregnant women are not left alone especially around the EDD.
• Escort her to the health centre on the due date of ANC.
• Ensure all the recommended examinations are done timely.
• Take care of her diet.
• Don't tell her to do heavy work.
• Take care of her rest.
• Arrange money for delivery.
• Arrange vehicle for taking her to the hospital at the time of delivery.
• If there is any sign of danger, immediately take her to the hospital.
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2.14 Available Government Schemes
Janani Suraksha Yojana- JSY
Janani Suraksha Yojana (JSY) is a program to provide safe motherhood and to reduce the mortality rates of the
mother and child. This scheme encourages institutional delivery, care during gestation period, delivery period and
post delivery. This scheme is especially for the people living below the poverty line.
Under this scheme states have been divided into two groups:
• Low Performance State (LPS): Those states having low institutional delivery rate, like- Uttar Pradesh,
Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Orissa, Rajasthan and Jammu
and Kashmir.
• High Performance State (HPS) - Remaining states where institutional delivery rate is high.
On the basis of these two groups of states, the principles of Janani Suraksha Yojana are as below:
• In all the low performance states all the pregnant women during their delivery, will get benefits from this
program.
• In all the high performance states only those pregnant women who are below the poverty line will be taken care
of (BPL) and they should be above 19 years of age and benefit is only up to 2 live births.
• In accordance with the program there is a necessity for all the benefitted pregnant women to have an
institutional delivery.
• For this registration is must at government health centre/Hospitals or at an accredited or Govt recognized
hospital.
Monetary benefit for institutional delivery:
LPS
HPS
In villages
Rs 1400/-
Rs 700/-
In cities
Rs 1000/-
Rs 600/-
Monetary help includes nutrition during pregnancy period and also the cost of transportation to the
institution.
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• Janani Shishu Suraksha Karyakram - JSSK
Janani Shishu Suraksha Karyakram (JSSK) to ensure better facilities for women and child health. The program was
launched in Haryana on June 01, 2011.
The new initiative of JSSK would provide completely free and cashless services to pregnant women including normal
deliveries and caesarean operations and sick new born (up to 30 days after birth) besides to and fro transport in
Government health institutions in both rural and urban areas.
The Free Entitlements for pregnant women under JSSK would include:
• Free and Cashless Delivery,
• Free C-Section,
• Free treatment of sick-new-born up to 30 days,
• Exemption from User Charges,
• Free Drugs and Consumables,
• Free Diagnostics (Blood, Urine test, Ultrasonography etc.),
• Free Diet during stay in the health facility - 3 days in case of normal delivery and 7 days in case of caesarean
section,
• Free Provision of Blood,
• Free Transport from Home to Health facility.
• Free Transport between facilities in case of referral and also drop back from Institutions to home after 48
hours stay.
Free Entitlements for Sick newborns till 30 days after birth are:
• Include free treatment,
• Free drugs and consumables,
• Free diagnostics,
• Free provision of blood,
• Exemption from user charges,
• Free Transport from Home to Health Institutions
• Free Transport between facilities in case of referral and free drop back from Institutions to home.
The launch of JSSK will encourage all pregnant women to deliver at public health facilities and fulfill the commitment
of achieving cent percent institutional delivery. It will also empower service providers working at the health facilities
in providing quality ante-natal, intra-natal and post natal services at the institution. Providing free treatment to sick
neonates will help in decreasing the neonatal mortality rate. This initiative will help in reducing both maternal and
infant mortality and morbidity.
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Session: 3
Intra- Natal Care
As far as possible encourage all women to have an institutional delivery.
3.1 Importance of Birth preparedness
Preparing for the delivery allows planning for:
• Preparing ahead of time allows to select and arrange for the best available care
• A safe and comfortable delivery
• For care after delivery
• Helps in case of emergency to protect the health of the woman and baby.
• Getting benefits of Govt. schemes like JSY and JSSK
3.2 Birth preparedness and complication readiness (BPCR) for
safe delivery
This is a method of planning in advance by the pregnant mother and her family for a safe and comfortable delivery
and for care after delivery. Health worker should review the plan in the third trimester (after seventh month) with
the family and HUP Link worker/ Cluster Coordinator. At this time, the choice of institution for delivery and the mode
of transport should be finalized.
What are the choices available to the mother?
• If there are any danger signs or complications: Identify the nearest institution, which has the staff and
equipment to provide Comprehensive Emergency Obstetric and Newborn Care and counsel the mother and the
family to go there.
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• If there are no complications: Counsel the mother to go to the health facility which is open 24 X 7, where there
is a team of doctors and nurses to conduct the delivery and provide essential care for the mother and newborn.
These institutions can provide obstetric first aid and arrange transfer immediately to a higher facility if
complications requiring surgical interventions or blood transfusion develop.
• If there are no complications and mother and her family are reluctant or unable to go to the health facility or if it
is too far away: Advise the mother for home delivery with skilled birth attendant, and there should be minimum
facilities for delivery.
Skilled Birth Attendant (SBA)
A Skilled Birth Attendant (SBA) is defined as "an accredited health professional - such as midwife, doctor or
nurse - who has been educated and trained to achieve proficiency in the skills needed to manage normal
(uncomplicated) pregnancies, childbirth and immediate postnatal period and in the identification,
management and referral of complications in women and newborns."
Government of India considers the "Skilled Birth Attendant" as a person who can handle common obstetric
and neonatal emergencies, recognize when the situation reaches a point beyond his/her capability and refers
the woman or the newborn to a FRU/appropriate facility without delay (Ref: Government of India Guidelines
For ANC and Skilled Attendance at Birth by ANMs and LHVs).
Government of India has taken policy initiatives to empower the ANMs (Auxiliary Nurse Midwives/LHVs (Lady
Health visitors) /SNs (Staff Nurses) to make them competent for undertaking certain life saving measures.
These measures are as follows:
• Permission to use Uterotonic drugs for prevention of PPH (Post Partum Hemorrhage)
• Permission to use drugs in emergency situations prior to referral for stabilizing the patient
• Permission to perform basic procedures at community level in emergency situations
3.3 Importance of institutional delivery
• Complications can develop at any time during delivery without warning.
• An institution has qualified and trained staff, equipment, supplies, and drugs available to provide the best care.
Hospital
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3.4 Development of birth preparedness plan (birth micro plan)
The pregnant women with their family members should do micro-
planning of birth preparedness before delivery so that the delivery can be
safe and comfortable.
Hospital
• Identify institution that provides different levels of care so that if any
complication occurs it can be handled properly and establish linkages
accordingly.
• Identify the blood storage centre to get blood, in case of any
emergency.
• Try to ensure institutional/skilled birth attendant conducted delivery.
• Know what transport is available -that is easily accessible and
affordable and how to call on it when the need arises.
• Identifying funding sources or arranges money that might be required
at a short notice.
• The pregnant mother must keep all relevant cards, reports etc. with her.
• Ensure that the expecting mother is not left alone especially around the Expected Date of Delivery (E.D.D.).
• The pregnant women should share the birth plan with the health worker or with the HUP Link worker/ Cluster
coordinator.
Format for Individual Birth Micro Plan
Name of Pregnant Woman:
Age:
Husband's name:
LMP:
EDD:
Cut-off date for pre-term delivery:
Past pregnancy history (Include abortion, if any):
Order of
pregnancy
Date of
delivery
dd/mm/yyyy
Place of delivery Type of
Hospital/Health delivery
Facility
Birth
outcome
Still/live
birth
Age &
status of
child
currently
Any other
complications
First
Second
Third
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Present Status:
Are there any danger signs? (If yes, please tick)
• Bleeding from vagina
• Loss of fetal movement
• Headache/dizziness/blurred vision
• Swollen face/hands/legs
• Convulsions/fits
• Severe anaemia
• Night Blindness
• Fever
• Pain/burning when urinating
• White Discharge from vagina
• Itching/Scabies/boil on skin with pus
• Bad obstetric history
• Multiple pregnancies
• Malpresentation of baby
Identify and mention is it emergency or non-emergency danger sings:
Nearest Health facility:
Distance:
Time:
Cost:
Distance to referral hospital
Time:
Cost:
• Is the vehicle fixed?
• Mother is informed about JSY and JSSK?
• Is mother eligible for JSY? Yes/No
• Is blood organized for the pregnant woman?
• Who will accompany her to the facility?
• Have they organized clothes for the baby?
Signature of Link Worker
Date
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3.5 Role of Link worker/ Cluster Coordinator in BPCR in institutional
delivery
If the delivery is institutional then the role of health workers becomes less as the doctors and nurses take care of
the women.
• Health worker should motivate and counsel the woman and her family members for a safe delivery at the
institution and if required escort pregnant women to the identified institution for delivery.
• The woman may not be empowered to make appropriate decisions. Hence, advocacy must be carried out with
the family, especially with the father and mother-in-law/ partner for making suitable arrangements.
• Ensure that cloths are arranged for the baby according to the season. For example in winter the child needs
warm woolen cloths.
• If needed ensure that one family member will stay in the institute.
3.6 Preparation for a Safe Home Delivery (maintaining 5 cleans)
through skilled birth attendant
Delivery must be at the institution, but if due to any serious difficulty the pregnant women are not able to go to the
institution then ensure that the home delivery is conducted by a skilled birth attendant (SBA) following some
precautions.
Prevention of infection during delivery is an essential part of ensuring safe motherhood. The birth attendant should
strictly maintain the Five Cleans to avoid any chance of infection:
• Clean hands - Wash hands thoroughly with soap and water
• Clean surface - Avoid using dirty rags or grass
• Clean blade - Do not cut the cord with a sickle or rusted knife
• Clean thread - Use the sterilized thread available in the delivery kit
• Clean stump - Avoid putting anything on it and keep it dry
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This session can be facilitated through a case analysis:
CASE STUDY
A 28 year old female name Ayesha Begum is a housemaid. She has to work daily throughout the day in other
people's home. Her husband Md. Riyaz is a daily laborer who works day and night to make both ends meet.
She has two small children, a boy of 3 years Akhtar and a girl of 1 year named Iram. The boy goes to a nearby
ICDS centre and his sister stays with his mother.
The woman got pregnant again and was visited by a HUP link worker/cluster coordinator. She counseled the
mother about registration of pregnancy, ANC, institutional delivery. Since her husband did not have time the
link worker/cluster coordinator escorted her to the hospital for registration along with her children so that
they are not left alone. The link worker/cluster coordinator met the woman's husband during his holiday and
told him that she has already registered his wife for ANC check ups and now it was his duty to take her for
regular medical checkups as and when told by the doctor. She even cited the necessity of doing so. Even after
a lot of explanation the husband refused. He said that his daily wage will not be given even if he takes a leave..
Thus, after listening this the link worker/cluster coordinator took the woman for her ANC checkups.
The link worker/cluster coordinator undertakes a birth preparedness micro planning of the woman with her
husband during her third trimester and encourages them for institutional delivery. But they were very
reluctant because their two children will not be taken care of, if they stay in the hospital during delivery period
and it was also not feasible for the husband to take such a long leave. Therefore, they force the link
worker/cluster coordinator for home delivery. She understands their situation and prepares for the home
delivery along with them.
What is the role of link worker/cluster coordinator in home delivery? What is the role of pregnant woman and
her husband?
What will be the micro planning for birth at home?
What norms should be followed by the skilled birth attendants?
3.7 Complications during delivery:
3 Delays
In case of a home delivery, there are possibilities of three most
common complications known as the three delays. :
• Water breaks but labour does not start within 24 hours or less
• Prolonged labour - woman pushing for more than 12 hours
(eight hours in the case of women who have already had
children) with the baby not coming out
• Retained placenta (placenta does not come out within 30
minutes of delivery)
In any of the above situation the patient should be immediately
transferred to the nearest health facility to save the lives of both the
mother and the baby.
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Three delays:
Three most common delays which can cause death of the mother or child or both are:
•First delay: In making the decision in the home to seek care
2
1
3
•Second delay: In getting to the health facility (Transport, road condition, distance, money etc.)
•Third delay: Not receiving immediate care after reaching the facility
3.8 What is a FRU (First Referral Unit)?
An existing facility (district hospital, sub-divisional hospital, community health centre etc.) can be declared a fully
operational First Referral Unit (FRU) only if it provides round-the-clock services for Emergency Obstetric and New-
born Care, in addition to all emergencies that any hospital is required to provide.
• 24-hour delivery services including normal and assisted deliveries
• Emergency Obstetric Care including surgical interventions like Caesarean Sections and other medical
interventions (*)
• New-born Care (*)
• Emergency Care of sick children
• Full range of family planning services including Laparoscopic Services
• Safe Abortion Services
• Treatment of STI / RTI
• Blood Storage Facility (*)
• Essential Laboratory Services
• Referral (transport) Services
(*): Critical determinants of functionality - there are three critical determinants of a facility being' declared' as a FRU:
availability of Surgical Interventions, New-born Care and Blood transfusion facility on a 24-hour basis.
Identification of the nearest First Referral Unit (FRU)
• Identification of the nearest place/ institution for delivery which provides appropriate care and establish
linkages accordingly and that will be the First Referral Unit (FRU).
• Discuss with the nurse/midwife when you should go for antenatal visits, when to reach the centre for the
delivery, and what to take with you.
• The institution should have qualified staff and equipments to provide comprehensive emergency obstetric and
newborn care and advice the mother and family members to go there.
3.9 Stages of Delivery
There are three stages of delivery
First Stage - Starts from beginning of pain until the mouth of the uterus/womb is fully dilated and open. At this time
the bag of water also breaks. It lasts about 8-12 hours in first pregnancy and takes around 5-6 hours in subsequent
pregnancies.
How can one recognize the onset of labour?
• Pains are felt at regular intervals by the woman in her abdomen, which increase in frequency, and last longer.
• Small quantity of blood stained mucus is expelled from the vagina.
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• The woman may feel a false labour pain a few hours to a few days before the true pain.
• Characteristics of false labour pain:
1) There is no expulsion of blood stained mucus,
2) The pain is irregular and does not increase with time,
3) Subsides within a few hours without any progress of labour.
Second stage - Contractions push the baby out of the womb, head is delivered first followed by shoulders and rest of
the body. It usually lasts one hour.
Third stage - Placenta is expelled out of the uterus. It usually takes only a few minutes.
3.10 Danger signs in labour and delivery
Danger signs can occur at any time during delivery. Some of the major problems that can arise during delivery
are as follows:
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• Bleeding (fresh blood)
• Swollen face and hands
• Baby in abnormal position
• Fluid breaks but labour does not start within 24 hours or less
• Color of fluid - green or brown
• Prolonged labour - woman pushing for more than 12 hours (eight hours in the case of women who have already
had children) with the baby not coming out
• Fever
• Retained placenta (placenta does not come out within 30 minutes of delivery)
• Rising Blood Pressure
• Fits/Convulsions
3.11 Role of Link workers/ Cluster Coordinators
But in any case the delivery happens at home then the role of link workers/ cluster coordinators increases.
• LW/CC should visit the pregnant women's house frequently as the EDD approaches and review the delivery plan
with the family members if required.
• In case of home delivery keep the women informed about the progress of labour.
• Praise the woman, encourage her and reassure her that things are going well.
• Ensure cleanliness of the delivery area.
• Ensure clean readymade pad/cloths and clean bedroll for home delivery. There should be clean towel also to
wrap the child.
• After home delivery see a doctor as early as possible.
3.12 Role of Family members
• After the 7th month, institution for delivery and transport must be finalized.
• At the onset of labour (1st stage starts,) escort the pregnant women to the hospital immediately.
• Till the delivery occurs one /two family members should be there so that in case of any emergency (blood
required or anything else) they can take prompt action.
• Arrange proper cloths for the newborn as per the season.
• In case of home delivery arrange skilled birth attendant (SBA) and required materials for delivery.
• Maintain the five cleans.
• After delivery take the mother to a doctor/hospital.
Hospital
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Session: 4
Post Partum Care
Post-partum care is the care required during the period after delivery of the placenta up to 42 days (six weeks).
4.1 Essential care for newborn
1. Hand washing before touching the baby
One of the most effective ways of preventing infection, a leading cause of death in mothers and babies, is frequent
washing of hands in a correct manner with soap and clean water.
When should Hands be Washed?
• Hands should be washed by the mother and members of the family before handling the baby, at least after
using the toilet, after changing the baby's diaper/napkin and after cleaning the house.
• Hands should be washed even more frequently before handling the low birth weight/preterm baby who is much
more susceptible to infections.
• The Link worker/ cluster coordinator must wash his/her hands before entering the house/room where there is a
newborn baby, particularly because it is good for the worker to review the baby for the status and presence of
danger signs with the mother. After washing, hands are best air-dried. If a cloth or towel is used, it must be
clean.
• Since Link workers/ cluster coordinators need to see and touch newborn babies, it is best that their nails are
short and clean to decrease germs under the nails.
Demonstration of hand washing
1. Removes bracelets, bangles and watches.
2. Demonstrate the correct method of hand washing taking care that while you carry out the procedure, each step
of the checklist noted below is read aloud by one of the participants or a co-facilitator. Show how to rub in the
soap well, taking care to clean the palms, back of the hands, in between the fingers, under the nails and the
arms up to the elbow for at least 20 seconds.
3. Demonstrate how to rinse the hands with or without help:
a. With help (ideal): the assistant pours the water from a container while the facilitator washes the hands over a
basin.
b. Without help: Pour water on your hands with a container by holding the handle. Do not plunge the hands inside
a basin of water as it may not be so clean and even if the water is clean it will get contaminated. After washing
hands pour some water to wash off any soap stains on the outside of the container.
4. Keeps hands raised and allows the hands and arms to "air dry".
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Checklist
1) Remove bangles and wrist watch
2) Wet hands and forearms up to elbow with clean water
3) Apply soap and scrub forearms, hands and fingers (especially nails)
thoroughly
4) Rinse with clean water
5) Air-dry with hands up and elbow facing the ground
6) Do not touch with your hands the ground, floor or dirty objects after
washing your hand
Number of Practices
12
3 45
Note: Use the checklist while observing the skills being implemented.
When a step is performed correctly, place a tick (ü ) in the box.
When a step is not performed correctly, place a cross (X) in the box.
Make sure to review the steps where crosses appear, so that performance can be improved.
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2. Cleaning and wrapping
Immediately after delivery, the newborn should be
cleaned with a soft moist cloth and then the body and
the head wiped dry with a soft dry cloth. The soft white
substance with which the newborn is covered is actually
protective and should not be rubbed off.
The baby should be wrapped in several layers of
clothing/woolen clothing depending upon the season.
3. Start breastfeeding immediately or at least within
half an hour after birth without giving any other fluids.
The newborn should be exclusively breastfed on demand
during the day and night, at least 8-10 times a day.
4. Care of newborn - Eye, Cord and Thermal
Care (Temperature control and prevention
of hypothermia)
• The eyes should be cleaned at birth and once every
day using sterile cotton swabs soaked in sterile water
or normal saline from medial to lateral side.
• Each eye should be cleaned using a separate swab.
• Keep umbilical cord dry and clean. Do not apply
anything on the cord, if there is no bleeding or
discharge.
• The room should be warm enough for an adult to feel just uncomfortable. The room should be free from strong
wind.
• Hypothermia: Babies have difficulty maintaining their temperature at birth and in the first day of life. They come
out wet, and lose heat quickly. When a baby has a temperature below normal, it suffers from hypothermia. A
baby who is cold, and has a low temperature (hypothermia) suffers from:
• Decreased ability to suckle at the breast, leading to poor feeding and weakness.
• Increased susceptibility to infections.
• Increased risk of death, especially in LBW and pre-term babies.
Therefore to keep the children warm increase the room temperature, cover or put clothes on the baby, wrap it up
with clean cloth, and place it close to its mother (skin-to-skin contact) or kangaroo care.
5. Birth weight recording of the newborn with the help of Link worker/Cluster
Coordinator:
Weighing the newborn- Baby should be weighed within 48 hours of birth with the help of Link worker/ Cluster
Coordinator. The weight of newborn child should be at least 2500 grams and a birth weight of less than that is
considered as dangerous.
It is important to weigh the baby after birth because babies may require special care on the basis of the birth weight.
Chances of the baby's death and getting sick are higher among the babies born before time (pre-term) and in LBW
babies.
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Low Birth weight (LBW) - Newborn with a birth weight of less than 2500 gms is known as a LBW infant.
Very Low Birth Weight - Newborn with a birth weight of below 1800 grams is classified as Very LBW.
The newborn may be weighed using a special color coded newborn weighing machine which records the weight as
green, yellow or red.
If the baby's weight is in the green zone, then it is normal
and can be managed with normal care - Weight is more than
2500 grams.
If the baby's weight is in the yellow zone, then the baby is
mildly underweight but can be managed at home with extra
care - Weight is between 1800-2500 grams.
If the baby's weight is in the red zone, then the baby is very
low birth weight and must be referred to a healthy facility -
Weight is less than 1800 grams.
Care of a LBW infant
The link worker/ cluster coordinator should advise the mother to take greater care of the low birth weight infant,
such as:
• Keeping the baby warm by skin-to-skin contact (kangaroo mother care).
• Breastfeeding more frequently.
• Delaying the first bath for a week or more but taking care to keep the baby clean by sponging the parts that get
dirty.
• Taking the baby to the nearest health facility if he/she cannot maintain temperature or suck the breast.
4.2 Postnatal care of mother
Postnatal care of the women starts after completion of delivery and it includes care till six weeks (42 days) after
delivery.
Schedule / checkups of post natal visits
According to Government norm, the women should visit the hospital at least 4 times during Postnatal period:
• 1st Visit: Within 24 hours of delivery
• 2nd Visit: Within 3 days after delivery
• 3rd Visit: Within 7 days after delivery
• 4th Visit: Within 42 days after delivery
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Advise to be given in the Post natal period
• Encourage the mother to rest for at least six weeks after childbirth so that healing occurs properly. Families must
be counseled on this.
• Encourage her to eat more food than usual. She can eat any kind of food but high protein foods - pulses and
legumes (nuts are especially useful), foods of animal source are preferred. She should also drink plenty of fluids.
• Counsel her to take the required supplements (iron and folate, vitamin A) and medications (e.g., anti-malarials,
deworming) as advised by the doctor/ physician.
• Discuss with her regarding the maintenance of personal hygiene Taking bath daily and specially cleaning the
breasts and nipple to avoid infection in newborn.
• Discuss with her regarding the need for contraception. Counsel her on the importance of spacing the next birth
and the choice of spacing methods available.
Counseling on exclusive breastfeeding till six
months
• Encourage and support for exclusive breastfeeding. Mother
should feed colostrum (the first yellowish milk).
• No other thing like honey, water etc should be given to the
newborn.
• The mother should start feeding her child within half an hour
of birth.
4.3 Complications during post natal period and referral (both
emergency and non-emergency referral)
Emergency referral
• Excessive bleeding: Ask the mother if the bleeding is heavy. Often this is quite obvious, but sometimes it may be
difficult to judge. If the woman is using more than five pads a day or more than one thick cloth in a day, she is
having heavy bleeding. You should immediately refer her to an institution, which manages complications.
Referral is most urgent. Even the delay of a few minutes can make a difference. Ask the mother to begin
breastfeeding immediately, which should help reduce the bleeding.
• Puerperal Sepsis (Infections): Ask if the discharge is foul-smelling. If the answer is yes, then suspect infection.
Fever, chills and pain in abdomen along with the foul smell make infections even more likely. You should
measure temperature to confirm fever. Referral is required since the mother needs antibiotics. Referral on the
same day is advisable.
• Convulsions with or without swelling of face and hands, severe headache, and blurred vision: Such patients
need immediate referral.
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Non-emergency referral
• Breast engorgement and Infection: Causes delayed initiation of breastfeeding, poor attachment, incomplete
emptying of breasts, restricting the length of the feeds. The problem is managed by starting breastfeeding soon
after delivery and feeding more often and ensuring correct attachment and encouraging on-demand feeding.
In this condition the breasts becomes red and hard, advice the mother to continue to feed the child often.
Warm compresses and gentle massage of breasts towards nipple should be done. If mother has fever, she
should visit the doctor. She should continue to breastfeed (from both sides) even if she is taking antibiotics.
• Perineal Swelling and Infection: If the mother has a small tear at the opening of her vagina (or has had stitches
during the delivery), she should keep the area clean. She can apply cloth dipped in hot water, twice a day and
hold it to her genitals. This will give her relief and help in healing. If there is fever, she should be referred to the
nearest health facility. A tablet of paracetamol would help to relieve both pain and fever.
• Anemia: Sometimes excessive bleeding might cause anemia. Counsel her on consuming iron and folic acid
supplements as per doctor's advice.
• Post-Partum Mood Changes: Some women may suffer from mood changes after delivery. They need counseling
and family support. The changes usually disappear after a week or so. If the changes become severe then
referral is required.
4.4 Role of Link workers/ Cluster Coordinators
• Ensure the four prescribed postnatal checkups of the mother.
• Counseling on diet and rest.
• Counseling on early initiation of breast feeding and exclusive breast feeding for the first six
months.
• Counseling and support during breast feeding and handling any problems related to breast
feeding.
• Counseling on birth spacing. LW/ CC should help her in making the choice of the
appropriate spacing method.
• Ensure that baby should be weighed within 48 hours in case of a home delivery.
• Counsel the mother regarding essential newborn care, keeping the baby warm and about
any danger signs so that the baby could be referred immediately.
4.5 Role of family members
The members of the family and the mother are required to listen to the advice and follow the instructions of the
health workers and the doctors. Other than that:
• According to the instructions the woman should be taken to the nearest health centre or a hospital for a post
delivery checkup.
• Take care of the mother's food habits and encourage her to eat more because she is breast feeding her baby.
• The mother should be on complete rest for six weeks and should not be allowed to do any heavy work.
• In case of any fatality take the mother to the hospital as soon as possible.
• The newborn as well as the mother should be kept in a warm room and care should be taken about proper
clothing of the newborn in accordance with the season so that his/her body stays warm.
• Washing hands properly before touching the child and holding the child with clean hands.
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• The child should be kept exclusively on breast feeding for first six months and top feed like water, honey, cow
milk should be avoided.
• Avoid applying, kajal in the child's eyes and oil massage especially on the umbilicus. Keep the cord stump dry.
• In case of expression of danger signs or fever by the child take him/her to the nearest health facility.
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Annexures
Annexure -1 : BEmOC and CEmOC (Basic Emergency Obstetric Care
and Comprehensive Emergency Obstetric Care)
Emergency obstetric care (EmOC) refers to the care of women and newborns during pregnancy, delivery and the
time after delivery. Women in emergency situations must have access to EmOC
Basic EmOC can be provided in health centres, while comprehensive EmOC must be provided in facilities at the
hospital level. For EmOC services to be effective, basic EmOC must be linked to community services, and an efficient
referral system must be in place.
Components of Basic EmOC include:
• Treatment for sepsis
• Treatment for eclampsia
• Treatment for prolonged or Obstructed labour
• Post-abortion care (PAC)
• Treatment for incomplete miscarriage
• Removal of the placenta
• Assisted delivery using forceps or suction
Comprehensive EmOC services include the services listed above, and also:
• Surgery (specifically, Caesarean section)
• Anesthesia
• Safe blood transfusion observing universal HIV precautions
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Annexure - 2: Post Natal Checklist
Name of the HUP Link Worker/Cluster Coordinator:
Date:
1. Number of times mother takes full meals in 24 hours: ……………………………............................………………………
(4 full meals is must for lactating mother)
2. Bleeding: how many pads are changed in a day: ………………………………………………………...………………………………
(More than 5 pads in a day need referral)
3. Temperature: Measure and record: ……………………………………………………………………………………………………………
(More than 102 F needs referral)
4. Foul smelling discharge ………………………………………………………………………………………………………………………………
(If yes, send the mother to hospital)
5. If mother perceives breast milk to be less for baby ………………………………………………………………………………………
(If yes, counsel mother)
6. Is the mother speaking normally or having fits ………………………………………………………………………………………………
7. Family members are supportive or not …………………………………………………………………………………………………………
(If not, counsel them)
8. Is mother using any Family Planning method …………………………………………………………………………………………………
(If no, counsel her)
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Notes
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For more information contact:
Health of the Urban Poor (HUP) Program
Population Foundation of India
B- 28, Qutab Institutional Area, New Delhi - 110 016, Ph. No. +91-11-43894166, Fax. +91-11- 43894199
E-mail: info_hup@populationfoundation.in Website: www.populationfoundation.in
Disclaimer: This document is made possible by the support of the American people through the United States Agency for International Development (USAID).
The contents are the responsibility of Population Foundation of India and do not necessarily reflect the views of USAID or the United States Government.