Microsoft word - key elements of ppc at community level based on who guideline _final_ _2_.doc
of Postpartum Care
at the Community Level
Based on WHO Guidelines
May Post, M.D.
Reproductive Health Advisor
CATALYST Consortium was asked by USAID to prepare a short paper based on WHO Postpartum Care (PPC) guidelines. The objective of this paper is to provide participants at the community-based postpartum care network meeting with a short overview of WHO’s guidelines related to PPC. The paper’s focus is on key elements of PPC at the community level.
Much of the information in this paper is derived from two WHO publications:
• WHO, 2003. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for
• WHO, 1998. Postpartum Care of the Mother and Newborn: A Practical Guide
These reports can be downloaded from www.who.int/reproductive-health/publications/listing_maternal_newborn.en.html This paper focuses on basic postpartum care for the normal mother and newborn at the community level
. It is by no means comprehensive, and readers should refer to the full WHO documents and other references (listed at the end) for more detailed information including management of maternal/newborn complications and Prevention of Maternal to Child Transmission.
Key Elements of Postpartum Care at the Community Level Based on
1.1 Focus and Content of the Paper
The paper focuses selectively on basic postpartum care (PPC) for the normal mother and newborn at the community level, and therefore does not include management of complications. It is presented mainly in a bulleted list format for a quick overview.
The recommendations are generic and should be adapted to local needs, resources, skills and capabilities at the community level.
1.2 Definition of Postpartum Period
The postpartum period is defined as one hour following the delivery of the placenta through the first six weeks of an infant’s life.
1.3 Aims of Care in the Postpartum Period
• Support of the mother and her family in the transition to a new family constellation,
• Prevention, early diagnosis and treatment of complications of mother and infant,
including the prevention of vertical transmission of diseases from mother to infant
• Referral of mother and infant for specialist care when necessary
• Counseling on maternal nutrition, and supplementation if necessary
• Counseling and service provision for contraception, birth spacing and the resumption
1.4 Frequency of Postpartum Care
The general opinion of the WHO Technical Working Group was that, with limited resources, contact with the health care system at least during the first twenty-four hours and before the end of the first week would be the most effective strategy.
2. Care and Service Provision in the Postpartum Period
2.1 The First 24 Hours After Birth
• Check for completeness of placenta and membranes
• Assess general maternal well-being (blood pressure, body temperature)
• Identify and respond to/refer immediate postpartum problems such as excessive
bleeding (i.e., a pad soaked in less than five minutes), fever, elevated blood pressure
• Check for pallor (conjunctiva and palms)
• Check perineum for tears, inflammation, discharge
• Check for uterine contraction and fundal height. Feel if uterus is hard and round
• Initiate early (within one hour) and frequent, exclusive breastfeeding and assist the
mother to adopt correct breastfeeding practices
• Advise on maternal/newborn danger signs and where to go for help
• Advise on when to return for next postpartum check-up
• Wipe baby with wet cloth and dry (Do not bathe)
• Monitor baby for breathing: listen for grunting, count breaths, look for chest in-
drawing. Respond immediately if problems identified.
• Ensure thermal protection—provide a warm environment, keep newborn in skin-to-
• Assess general well-being (movements, muscle tone, swelling/bruises at the
• Identify complications (e.g., birth asphyxia) or danger signs and respond immediately
2.2 The First Week Postpartum
The current norm for duration of stay in a health facility for delivery is 24-48 hours in an
uncomplicated vaginal delivery. Therefore, whether the birth took place in a health
facility or at home, there is need for some form of follow-up postpartum care.
Consultations with mother and baby should be early in the first week (at least once at day
and followed-up as required.
2.2.1 The Mother
• Check for general well-being of the mother (temperature, pallor, blood pressure)
• Check uterus—is it hard and well contracted?
• Check for distended bladder—ask about problems with passing urine
o Breasts for mastitis, cracked nipples, engorged breasts, not enough milk
o Vulva and perineum for tear, swelling, pus
o Fever and foul discharge/foul lochia, hemorrhoids
o Legs: thrombophlebitis, signs of thrombosis
• Give iron folate supplementation for women who are anemic and counsel on
compliance. Dispense three months iron/folate supply if indicated.
• Provide information regarding maternal/newborn problems and where to seek help
o Rapid plasma reagin (RPR) status for syphilis. Refer for RPR test if test not
o Tetanus Toxoid (TT) immunization status and refer if due
o Check if vitamin A has been given. If not, give (one) 200,000 IU vitamin A
capsule once. Explain that Vitamin A will help her to recover better and that the baby will receive the vitamin through her breast milk
o In areas of high endemicity of parasitic infestations, check when the last dose
of mebendazole was given. Give once in 6 months
• Encourage baby and mother to sleep under insecticide-treated bed net (in malaria
• Counsel and advise on the following and refer as necessary:
o Maternal and newborn psychosocial needs
o Voluntary counseling and testing of HIV and prevention of mother-to-child
transmission (PMTCT) practices as appropriate
• Care in the first week postpartum includes a routine neonatal examination.
• Ask the mother how she feels about the baby, how the baby is feeding and about any
• Assess the baby’s general condition: is the baby active and feeding well? (be alert for
the “too good baby”, who never cries)
• Observe how mother breastfeeds, and help the mother to improve the technique
• Check baby’s skin: is it clean (no pustules), not jaundiced?
• Check baby’s eyes: are eyes clean (not draining pus)?
• Check baby’s mouth: is mouth clear of thrush?
• Identify the following danger signs and respond/refer promptly:
o Umbilical infection (redness, swelling, pus discharge)
• Immunization—in countries and populations at high risk of tuberculosis infection,
infants receive BCG as soon as possible after birth. A first injection of hepatitis B
vaccine is also given in the first week as called for, as well as the first dose of oral poliomyelitis vaccine (OPV).
2.3 Six Weeks Postpartum
If the mother and baby are healthy, frequent support by a caregiver is no longer necessary after the first week. Traditionally, the mother is asked to come back for a check-up 6 weeks after birth, with the baby. 2.3.1 The Mother
• Ask the mother about her well-being and possible complaints or problems. There is
more maternal morbidity in the postpartum period than most caregivers are aware of.
• Perform a pelvic examination IF
the woman complains about pain or other
discomfort. Check for healing of large tears, pain, swelling, pus.
• Check hemoglobin, especially if anemia has occurred during pregnancy or in the
postpartum period, and if necessary a prescription of iron may again be given.
• Check if vitamin A has been given after delivery. If not, give (one) 200,000 IU
• Make sure the mother and family know problems to watch for, are aware of danger
signs if they arise and when/where to seek care.
o Attendance at well-baby/under-5 clinic
• It is important, if possible, to involve the husband or partner in the consultation.
Questions should be answered, and information given, with special emphasis on birth spacing and family planning (FP) counseling.
• Immunization—the baby receives a second dose of OPV and the first dose of the
diphtheria/pertussis/tetanus (DPT) vaccine.
• Weigh and assess baby’s weight gain
2.4 Advice and Counseling
• Emphasize the importance of hygiene and hand washing to prevent infection:
Include the following information in breastfeeding counseling:
• Keep newborn in skin-to-skin contact with mother soon after delivery.
• Initiate breastfeeding within ½ to 1 hour after birth.
• Give baby the first milk (colostrum), which is nutritious.
• Counsel on exclusive breastfeeding. WHO recommends that infants should be
breastfed exclusively from birth to at least 4 and if possible 6 months of age.
• Emphasize that breastfeeding should be given as often as the child desires, day and
• Teach correct positioning and attachment for breastfeeding.
• Give special support to preterm, and low birth weight babies with breastfeeding.
• Advise the mother to drink plenty of fluids, eat more, eat healthy foods and rest while
o Postpartum bleeding can be reduced due to uterine contractions caused by
o Breastfeeding can help delay a new pregnancy.
o Breast milk contains the water and the nutrients that a baby’s body needs
o Breast milk has unique antibodies that help protect the baby against
• Women’s food intake should be increased by 10% to 20% during lactation. Advise
the woman to eat a greater amount and variety of healthy foods. Give examples of types of food and the amount to eat.
• Determine if there are taboos about foods which are nutritionally healthy. Advise the
188.8.131.52 Prevention of micronutrient deficiencies
Iodination of salt has been shown to be a highly effective means of preventing iodine deficiency. Iodized oil by mouth or injection can be used as an interim measure in endemic regions where provision of iodized salt may not be feasible. Women of childbearing age including pregnant women, infants and preschool children are among the target populations for iodized oil.
• Advise and counsel on the effects of iodine deficiency to the fetus (e.g., brain
damage) and in childhood (e.g., mental retardation, neurological disorders, cretinism).
• Check if the administration of iodized oil was done in the last trimester of pregnancy.
Otherwise, a dose of iodized oil should be given to the mother early after delivery.
• Advise and counsel on prevention of vitamin A deficiency—effects of deficiency
(e.g., childhood blindness) and types of food to take to prevent deficiency.
• Check if vitamin A has been given. The recommended dose for lactating mothers is
one 200,000IU vitamin A capsule once, after delivery or within six weeks of delivery.
A high dose of vitamin A to women of childbearing age in general, or to lactating women more than two months after delivery may be teratogenic in early pregnancy.
• Explain that Vitamin A will help her to recover better and that the baby will receive
Anemia aggravates the effects of maternal blood loss and is thereby a major contributor to maternal mortality in the postpartum period.
• Encourage the consumption of foods rich in iron (dark green leafy vegetables) and
foods which enhance iron absorption (fruits and vegetables rich in vitamin C).
• Provide iron/folate supplementation and counsel on compliance.
It is often stated that in the postpartum period one of the major concerns of the woman (and her partner) is contraception
. Contraceptive counseling is one of the most important aspects of postpartum care. In the case of the parturient woman and her partner, a number of different factors affect the decision about the contraceptive method. These include: the physiological processes of the puerperium, when fertility returns and ovulation is re-established, whether or not the women is exclusively breastfeeding, and what the couple’s wishes are with regard to the resumption of sexual activity. Couples are frequently unaware of the implications of these different factors and this is a major argument for providing the opportunity to discuss family planning options at the earliest opportunity after birth.
Couples may be unaware of the range of family planning methods (short-term, long-acting, hormonal, barrier, temporary or permanent) available to suit their varying goals, choices and needs. Counseling, advice on the range of FP methods, and the provision of family planning services which accompanies it, must form an integral part of any postpartum service.
• Counsel or refer to appropriate FP services for counseling on the importance of
family planning. Include the partner or another member of the family as appropriate. Advice and counseling on birth spacing and family planning should include the following:
o Explain that after birth, if a woman has sex and is not exclusively
breastfeeding, she can become pregnant as soon as four weeks after delivery.
o Information on when
to start a contraceptive method will vary depending
on whether a woman is breastfeeding or not.
o Advise the correct and consistent use of condoms for dual protection from
sexually transmitted infections (STIs) or HIV and pregnancy. Promote condom use, especially if at risk for STIs and HIV.
o Give advice on range of family planning methods available including
o Explain different options available for the non-breastfeeding woman and
o LAM: For the breastfeeding woman, who is no more than 6 months
postpartum and who is breastfeeding exclusively (8 or more times a day, including at least once at night; no complementary foods or fluids), LAM can be used as a temporary FP method. Emphasize that after six months practicing LAM, she should choose another FP method to use alone or together with LAM.
o What is HIV and how it is transmitted?
o Advantage of knowing HIV status in pregnancy to get appropriate care
o Counsel on correct and consistent use of condoms
o Implications of test results (positive/negative)
o Benefits of involving and testing the male partner(s).
3. Selective Recommendations by the WHO Technical Working Group
The following are selective recommendations by the WHO Technical Working Group to strengthen the quality of postpartum care.
• Review the legislative/regulatory framework related to the scope and practice of
• Ensure availability and access to a comprehensive, continuous and integrated services
• Strengthen vital registration systems.
• Stimulate communities to examine how their attitudes and practices support or
obstruct the opportunity for women and newborns to receive the best available care.
• Develop positive strategies for increased male involvement in the postpartum period.
3.2 Care and service provision
• Identify the community’s perceptions of events in the postpartum period and of the
health system before designing services.
• Explore the community’s resources and involve the community itself in planning and
• Establish the incidence and prevalence of postpartum conditions in the community.
• Ensure culturally acceptable services for women and newborns.
• Develop/provide home-based maternal record for all women and newborns.
• Ensure care at all levels: in the community, health centre (including domiciliary
• Develop, together with the community, a complete functional chain of referral from
community to the district hospital and back.
• Strengthen district hospitals and health centers to such a level as to be able to cope
with emergencies, including blood transfusion services.
3.3 Tools for implementing quality postpartum care
• Guidelines/standards/norms on all aspects of postpartum care.
• Managerial guidelines on organization/integration of services, human resources,
• Health education/information and counseling materials
CATALYST Consortium. Optimal Birth Spacing Interval Pocket Guide.
Catalyst Consortium, Washington DC 2005 Indira Narayanan, Mandy Rose, Dilberth Cordero, Silvana Faillance, and Tina Sanghvi. The Components of Essential Newborn Care
. Published by the Basics Support for Institutionalizing Child Survival Project (BASICS II) for the United States Agency for International Development. Arlington, Virginia, June 2004. WHO (World Health Organization), 2002. Antenatal Care Randomized Trial.
www.who.int/reproductive health/publications/RHR_01_30/RHR_01_30_contents.en.html WHO (World Health Organization). 2002. Improving Neonatal Health in South-East Asia
Region: Report of a Regional Consultation, New Dehli, India, 1-5 April 2002 SEA-MCH-219
WHO (World Health Organization), 2003. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice
. www.who.int/reproductive-health/publications/pcpnc/ WHO (World Health Organization). Postpartum Care of the Mother and Newborn: A Practical Guide
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