Post Natal Care

Providing High Quality Postpartum Care for the Women and the Newborn
TVET-PROGRAMME TITLE: MIDWIFERY Level- IV
TTLM
Unit of Competence: Providing High Quality
Postpartum Care for the Women and the Newborn
Module Title: Providing High Quality Postpartum Care
for the Women and the Newborn
MODULE CODE : HLT MWR4 M03 0112
MODULE DESCRIPTION: This module aims to provide the learners with
the knowledge, skills and right attitudes required by midwife high quality
culturally sensitive postnatal care including post partum assessment
diagnosis, and management for women and the newborn.
LEARNING OUTCOMES
At the end of the module the learner will be able to:.
LO1. Provide comprehensive culturally sensitive post partum care

LO2. Organize and evaluate maternal health programs
LO3. Demonstrates and understanding of the physiology of the puerperium
Lo4. Demonstrates the skills needed to support the woman and her family
during the postnatal period
Lo5. Demonstrates a basic knowledge of the physiology and needs of the
newborn
Lo6. Demonstrates the skills needed to safely care for the newborn
Lo7. Demonstrate and understanding of the particular psychosocial needs of
the woman and provide support as appropriate
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Prepared by yegetinesh k. . (BSC midwifery)
Lo8. Identify postpartum complications and manage accordingly
Introduction LO1;Postpartum Care
This guide will also assist you to attain the learning outcome stated in the cover page.
Specifically, upon completion of this Learning Guide, you will be able to:-
 Introduction
 Nutrition, exercise, rest, sleep and support with domestic during postnatal
 Establish and support breast feeding Strategies
Learning Activities
1. Read the specific objectives of this Learning Guide.
2. Read the information written in the “Information Sheet 1-3”.
3. Accomplish the “Summary Self-Check questions for Lo1” in the last page.
4. If you earned a satisfactory evaluation, read the “learning out 2”.
Then, accomplish “Summary self-check questions in LO2”. However, if you’re rating is
unsatisfactory, see your teacher for further instructions?
5. Submit your accomplished Summary Self-Check questions.
However, if your rating is unsatisfactory, see your teacher for further instructions.
*Your teacher will evaluate your output either satisfactory or unsatisfactory. If unsatisfactory,
your teacher shall advice you on additional work. But if satisfactory you can proceed to the next
topic.
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Information1 INTRODUCTION TO POSTNATAL
Postpartum care is the attention given to the general social, mental, and physical welfare
of the mother and infant during the postpartum period. The care should respond to the
special and immediate needs of the mother and her baby during their hospital stay and
follow up after discharge. The majority of the maternal deaths and morbidities occur
during the postpartum period.
Biologically, the postpartum period is the time after birth, a time in which the mother's
body, including hormonal levels and uterine size, return to pre-pregnancy conditions and
extends up to the sixth week postpartum. It is also known as postnatal period or
puerperium.
Aims
 Promote psychosocial well being of mother, baby and family.
 Recognize complications early and provide appropriate Management.
 Encourage early and exclusive breastfeeding.
 Provide individualized health promotion messages.
 Provide information, screening and management of STDs.
 Provide information and counselling related to family planning.
Components of postpartum care
 1. Early detection and management of complications

 2. Promoting health and preventing disease
 3. Providing woman-centered education and counseling
1. Early detection and management of complications

 The postpartum evaluation starts by reviewing the parturient clinical document
including antepartum and intrapartum records. Complications such as cardiac disease,
preeclampsia, obstructed labor, cesarean delivery that require close monitoring and
treatment are identified in the patient’s medical document. Besides reviewing the
clinical records, the parturient should be evaluated thoroughly during the immediate
postpartum period, 6th day and 6th week postpartum visits.
2. Promoting health and preventing disease

 Iron/ folate: 1 tablet to be taken by mouth once a day for at least 40 days postpartum
 Vitamin A: one dose of 200,000 IU within 30 days after childbirth in vitamin A deficient
regions
 Iodine supplementation: 400–600 mg by mouth or IM as soon as possible after childbirth
if never given, or if given before the third trimester (only in areas where deficiencies
exist)
 Six monthly presumptive treatments with broad-spectrum anti-helminthes in areas of
significant prevalence
 Sleeping under a bed net in malarias areas
 Tetanus toxoid
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 VDRL/ RPR
 HIV testing (opt-out)
3. Providing woman-centered education and counseling

The education and counseling should address postpartum needs such as nutrition,
Breast feeding, family planning, sexual activity, early symptoms of complications and
preparations for possible complications.
Postpartum counseling should take place at a private area to allow women to ask
questions and express their concerns freely. If this is not feasible, counseling could be
done by the women’s bed provided that privacy is ensured. It is advisable to involve husbands of
postpartum women (after the permission of the woman) in this counseling and in receiving
instructions before discharge.
During Puerperium the following will occur:-

 The reproductive organs return to their non-pregnant state
 Lactation is established
 The foundation of the relationship between the infant and parents are laid
 Mother recovers from the stress of pregnancy, delivery and assumes responsibility of the
care of the baby.
 The recovering (Reversing) period for some of the physiological changes which occurred
during pregnancy
Principles of care of baby and mother during puerperium
o Promoting the physical well-being of the baby and the mother
o Encourage the breast feeding and promote maternal-child relationship
Postnatal physical examination
- Head Hair
- General appearance of the face-is it puffy, anemic?
- Eyes – for signs of anemia or jaundice?
- Ears, ringing, deafness?
- Nose stiffness?
- Are lips dry? Crackled? Pale?
- Tongue – Dry, coated, pure?
- Teeth – clean decay (carriers)?
- Breast for engorgement mass, presence of milk nipple? Flat? Erect? Retracted? Inverted?
- Abdomen for any tenderness, distension full bladder
 If there is C/S ensure healing of the wound
 Measure height of the funds
 Lower extremities – for varicose veins, venous, thrombosis oedema
 Vulval inspection – edema varicose veins, hemorrhoids, and perineum, is there stitch?
Clean? Infected? Edematous it so give salt sitz bath?
 lochia – amount, colour, consistency, odour
Vital signs
BP, pulse, temperature1 - take BP and PR every:
• 15 minutes for first 2 hours
• 30 minutes for 1 hour
3 hours then after
All findings should be recorded accordingly
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Information Sheet 2 Nutrition, exercise, rest, sleep and support with domestic
during postnatal
Nutrition after childbirth

Eating and drinking in the first few hours
Most mothers are ready to eat soon after the birth, and it is good for them to eat any kind of
nutritious food they want. If a new mother is not hungry, she should at least have something to
drink. Fruit juice or atmit tea is good because it gives energy. Many women want something
warm to drink, like tea. Some juices, like orange juice, also have vitamin C, which can help
healing. (But she should avoid soda pop like Coke, which is full of sugar and chemicals but has
no nutrition.)
If the mother cannot (or will not) eat or drink within two to three hours after the birth:
- She may be ill. Check for bleeding, fever, a hypertensive disorder, or other signs
of illness that may be taking away her appetite.
- She may be depressed (sad, angry, or without any feelings). Encourage her to talk
about her feelings and needs.
- She may believe that certain foods are bad to eat after a birth. Gently explain to
her that she must eat to recover from the birth and to be able to care for her baby.
Counseling on postnatal nutrition
After delivery, women’s routine food intake should be increased to cover the energy cost of
breastfeeding and for her to recover her normal energy and health.. She should eat about 10%
more than before she was pregnant if she is not moving around much or doing her usual work and
about 20% more if she is physically active. In practical terms, she is advised to take at least one or
two additional meals every day. Nutritional counseling should include:
- Advising the mother to eat a variety of high protein, high energy foods (as much
as the family can afford), such as meat, milk, fish, oils, nuts, seeds, cereals, beans
and cheese, to keep her healthy and strong. Your nutritional advice should
depend on what is available at home and on what they eat as their staple diet. The
most important thing is to tell them that she needs to eat more than usual.
- Exploring whether there are important cultural taboos about eating foods which
are really nutritionally healthy. For example, in some cultures it is considered bad
to eat high-protein foods, spicy foods, or cold foods after a birth. Respectfully
advise against these taboos and tell the woman that there is no nutritious food
item that needs to be restricted.
- Talk to family members, particularly the partner and/or the mother-in-law, and
encourage them to help ensure the woman eats enough of a wide variety of foods
and avoids hard physical work.
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- Advise the mother to take micronutrient supplementation regularly to prevent deficiency

disorders and anemia,
Exercise and ambulation
Advantage: -
 Increases muscle tone and venous return from the legs and lower abdomen
 Increases drainage of the lochia and volume of the urine
 Provided , it is normal 6hrs after delivery, postnatal exercise should begin as
soon as possible especially for multipara and continue throughout puerperium
 Normal activities may be resumed as soon as the woman feels ready.
 When to start an exercise routine depends on the woman; its safety
depends on
whether complications or disorders are present. Usually, exercises to
strengthen
abdominal muscles can be started once the discomfort of delivery (vaginal or
cesarean) has subsided, typically within one day for women who deliver vaginally
and later for those who deliver by cesarean section.
 Sit-ups or curl-ups, (rising from supine to semi-setting position), done in
bed with the
 hips and knees flexed, tighten only abdominal muscles, usually without
causing backache.
 Negel’s exercise are also recommended to strengthen the pelvic floor
Personal hygiene and perineal care
 If delivery was uncomplicated, showering and bathing are allowed.
 Vaginal douching is avoided in early puerperium, till after bleeding stops
completely and all wounds are healed.
 The vulva should be cleaned from front to back.
 Women are encouraged to defecate before leaving the hospital, although
with early discharge, this recommendation is often impractical.
 Maintaining good bowel function can prevent or help relieve existing
hemorrhoids,which can be treated with warm sitz baths
Emotional support
 Transient depression (baby blues) is common during the first week after
delivery.
 Symptoms are typically mild and usually subside by 7 to 10 days.
 Treatment is supportive care and reassurance.
Persistent depression, lack of interest in the infant, suicidal or homicidal thoughts,
hallucinations, delusions, or psychotic behavior may require intensive counseling and
antidepressants or antipsychotic.
Women with a preexisting mental disorder are at high risk of recurrence or exacerbation
during the puerperium and should be monitored closely.
The mother and baby are not isolated from other family members for cultural reasons. You may
have solved this problem during earlier conversations with the family, but during every visit make
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sure that the mother has all the necessary social support and that family members are visiting her
regularly.
Together with the community leaders you should try to bring an end to the practice of seclusion,
keeping the new mother and baby away from social relations, if it is still practiced in your
community. Instead, advise and explain to the woman to always have someone near her for the
first 24 hours and family members should be in regular contact every day during the first week to
respond quickly to any danger signs in her condition.
Fathers and other family members can help
Encourage the partner to be around the mother at least for the first week of the postnatal period to
provide emotional support and to take care of her and the baby. In the Ethiopian context, caring
for the new mother is usually the responsibility of the grandmother and/or the mother-in-law. As
they have already gone through all of these experiences, they are good at providing physical and
emotional support to the mother and her baby. They can free her from the routine domestic
chores, and this should be encouraged.
When the mother isn’t interested in her baby
Some mothers do not feel good about their new babies. There can be many reasons for this. The
mother may be very tired, or she may be ill or bleeding. She may not have wanted a baby, or may
be worried that she cannot take care of one. She may be very depressed: signs of this are if the
woman seems sad, quiet, and has no interest in anything. Also watch for other signs of abnormal
behavior which are different from her usual way of behaving.
What to do if you are concerned about a mother’s lack of interest in her baby:
- Check her carefully for signs of blood loss or infection, or a hypertensive

disorder. She may be ill, rather than depressed or anxious.
- You might talk to the mother about her feelings, or you may feel it is better to
leave her alone, and to watch and wait.
- If you know that she was seriously depressed after a past birth, talk to the family
about giving her extra attention and support in the next few weeks. Usually this
depression passes in time, but sometimes it takes a few weeks or even months,
and you may need to refer her for additional assessment and treatment. If she
demonstrates any of the signs of postpartum refer her urgently.
- Make sure someone in the family takes care of the new baby if the mother cannot
- or will not.
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Information Sheet 3 Establish and support breast feeding Strategies
Breastfeeding
− Early skin to skin contact of mother and baby and immediate initiation of breast feeding
• Initiate breastfeeding within 2-3 hours of CS; when the mother is conscious
• Incase breast feeding can’t be started due to either maternal or newborn illness,
feeding the baby has to be initiated if possible by milk sucked from the mother herself.
− Rooming in throughout the hospital stay of mother and baby
− Women should be encouraged to maintain exclusive breast feeding for six months
and should be educated about effective breastfeeding practices, as well as common
breastfeeding problems, how to continue breast feeding for two years and to start
complementary feeding after six months.
Postpartum education and counseling includes:
• Correct positioning of the baby at the breast
• Exclusive breast feeding.: No other fluids e.g., glucose, or sugar water
should be given
• Encouraging breast feeding on demand
− If there is a medical contraindication to breastfeeding, firm support of the breasts can
suppress lactation. For many women, tight binding of the breasts, cold packs, and
analgesics followed by firm support effectively control temporary symptoms while
- lactation is being suppressed
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Self check questions
1.what is postnatal care?

2 What is the aim of postnatal care
3 .write the compressive element of postnatal care
4. Give health education for postnatal mother
Answer sheet
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2_____________________________
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3____________________________________
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4_____________________________________________________________________________
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INTRODUCTION LO2; Schedules of participation in

postnatal care
 Follow up visit during postnatal

 Measure activity during this visit
Learning Activities
2. Read the information written in the “Information Sheet 1”.
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topic.
Information sheet 1 LO2; Schedules of participation in

postnatal care
Hospital stay:
Hospital stay after delivery varies depending on the parturients’ condition. Women
with complications stay longer period. Most women have normal pregnancy, labor,
delivery and postpartum period; and usually they are discharged within a day of
delivery. The minimum in-hospital say is 6 hours after which the risk of life
endangering conditions such as PPH due to atonic uterus or genital trauma,
postpartum eclampsia etc. are less likely. The use of this hospital stay should be well
organized so that all parturients and their babies get the basic postpartum care. At the
time of discharge, the evaluation should be thorough; the parturient and her baby
should get all the basic postpartum care; and appointment be given. Providing women
with a summery of their condition, especially for those with complication, is
essential.
Follow-up visit:
Women should be informed that they should make a follow up visit to the hospital or
to a health unit on 6th day and at six weeks postpartum. The schedule should not be
rigid. It should incorporate maternal (family) convenience and medical condition.
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Frequency and Timing

 First visit - First week postpartum
 Second visit - Sixth week postpartum. However, all women should be assessed within 24
hours after delivery.
 However, there have been recommendations with somewhat different and more frequent
schedule. An example is:
 First visit six hours after birth;
 Second visit 6 days after birth;
 Third visit 6weeks after birth; and this visit is the old one
Provide four postnatal visits,

I. at 6-24 hours
II. 3 days
III. 7 days and
IV. 6 weeks.
6 to 24 hours visit/evaluation:
 • Check for danger signs in the newborn and in the mother
 • Counsel mother/family to keep the baby warm
 • Counsel mother/family on optimal breastfeeding
 • Check umbilicus for bleeding
 • Counsel mother to keep umbilicus clean and dry and infection prevention actions
 • Weigh newborn, if not weighed at birth
 • Immunize newborn with OPV & BCG
 • Give Vitamin K, 1mg IM if not given before
 • Give one capsule of 200,000 Vitamin A to the mother
 • Counsel the lactating mother to take at least 2 more varied meals than usual
3 days visit:
 • Check for danger signs in the newborn
 • Counsel and support optimal breastfeeding
 • Follow-up of kangaroo mother care
 • Follow-up of counseling given during previous visits
 • Counsel mother/family to protect baby from infection
 • Give one capsule of 200,000IU Vitamin A to the mother if not given before
 • Immunize baby with OPV & BCG if not given before
6 weeks visit:
 • Check for danger signs in the newborn
 • Counsel and support optimal breastfeeding
 • Immunization, DPT1- HEP 1-Hib, OPV 1
 • Counsel mother/father on the need of family planning
 • Counsel mother/family to protect baby from infection
 • Give one capsule of 200,000IU Vitamin A to the mother if not given before
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1.write all postnatal visit ?
3. write activity perform in each visit?
Answer sheet
1._________________________________
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2.1______________________________
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2.2__________________________
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2.3_______________________
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INTRODUCTION LO3;Physiology of post partum period
 Introduction to normal puerperium

 Normal & abnormal lochia
 process of lactation and bonding, supporting the mother-infant
Learning Activities
topic.
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INFORMATION Physiology of post partum period

SHEET 1
1 Normal physiology of puerperium

Definition:- It is the period from the expulsion of the placenta to the time when reproductive
organ returns to its non gravid state both anatomically and physiologically.
The retrogressive changes are mostly confined to the reproductive organs with the exception of
the mammary glands which show features of activity
Duration:-postnatal period is the time from the delivery of the placenta& membranes to the
return of the woman’s reproductive tract to its non-pregnant state and lasts for six week
The woman progressing through the puerperium is called puerperal
The postpartum period is arbitrarily divided into
A. Immediate – the first 6 - 24 hours

B. Early – 3 - 7 days and
C. Remote/late – 7 days up to six weeks
Characterized by
 Reproductive organ return to non gravid state
 Other physiological change occur during pregnancy are reversed
 Lactation established
 Increase bond b/n mother & infant
 The mother recovers from the stress of pregnancy& delivery.
Care of the puerperium is based on
 Promoting physical well being of the mother& the baby
 Encourage infant feeding& promoting maternal& child relationship.
 Full fill her mothering role
Mgt of Normal Puerperium
Objectives: - The improvement of physical well-being
- The establishment of emotional well-being
- The prevention of infection
- The promotion of breast feeding
- The provision of baby care teaching
Immediate care (after expulsion of the placenta)
- Rest, comfort, meal, sleeps
- Prevention of PPH
- Express clots and give ergometrine
Daily Care
- Antiseptic Sterility techniques when giving care
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Room, linen and skin should be clean

Wear masks
- Vital Sign PR and Temperature should be normal besides BP.
- Vulval toilet → If able by the pt herself otherwise by the nurse
- Fundal height Reduces every day by 1 or 2 cm (one finger)
At about 12days uterus is no more palpable above the symphysis
- Lochia Daily observation
-Amount excessive suggests retained products
Scanty amount suggest poor drainage
- Colour Persistent red lochia shows danger of hemorrhage
- Odour→ offensive lochia, with pyrexia and sub-involution suggests infection
- Consistency There may be pieces of membranes
- Bladder large amounts of urine secreted during the 1 st few days
- Diet nourishing food with Fe(Iron) and roughage
Rest and sleep – Women may be kept awake by some discomfort, which should be relived,
sedation.
Hygiene bath and vulval toilet daily
- Advice on discharge
- On family planning, postnatal visit, circumcision, care of cord and episiotomy
After pain: - is a pain in felt usually by multi para 2-3days after delivery.
Treatment Tell the pt that it goes –off
If sever anti pain
Anatomical and Physiological changes of puerperium
Involution is used to refer the retrogressive change taking place in all of the organs and
structures of the reproductive tract
A. Changes in the endocrine activity
- HPL, estrogen, progesterone and HCG ↓ following rapidly after the expulsion of the placenta
- The fall of estrogen allows prolactin acting on the alveoli to produce milk.
- Due to breast feeding the prolactin remains high and the resumption of the follicle stimulation
in the ovary is suppressed
- In women who do not breast feed the level of the circulating prolactin fall after 14-21 days of
birth
Involution of Ux
 Is the turning of the Ux to its normal size, tone& position of non pregnant state and becomes
firm& retracted with alternate hardening and softening.
 The Ux measures 15x 12 x 8-10 cm (length, breath& thickness respectively& weight about
1000 gram just after delivery of the fetus it becomes at or below umbilicus and decrease
one finger per day.
 At the end of the 6th week it weight about 60grm
Table I. The approximate weight of Ux on the respective postnatal weeks
Weight of Ux Postnatal week

500gram End of 1st week
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300-350 gram End 2nd week

100 gram At 6th week
60 gram At 8th week& non-pregnant state
After delivery the top of fundus is approximately 2/3-3/4 up b/n symphasis pubis and
umbilicus then it rises to the level of umbilicus within few hours and remains at the level of
or one finger breadth below umbilicus for a day& then involutes 1-2cm/day (one finger
breadth/day).
After the 10th day, it descends into the pelvis being abdominally non-palpable above the
symphysis pubis
If at any postnatal time, the top of the fundus is above the umbilicus, the following should
be considered
- Filling of the Ux with blood or blood clots in the early postnatal hours
- Displacement of the Ux by a distended bladder
Mechanisms
 Ischemia (Localized anemia)-caused by retraction of Ux muscle& blood vessel contracts &
blood circulation decrease.
 Autolysis or self-digestion - muscle fibers digested by proteolytic enzyme, waste products
then passes to blood stream& eliminate by the kidney.
 Oxytocin action: - oxytocin action on the uterus end cause to contract the most marked
reduction in the size of the uterus takes place during the 1 st 10days of puerperium.
 Immediately after the delivery, the fundus of the contracted pelvis is found at or just below
the mother’s umbilicus.
 One week after delivery it is possible just above the symphysis pubis, by 10-12day no more
palpable. At the end of the puerperium the uterus weight 60-100gms
 Involution of Ux involves the reorganization and shedding of the deciduas/endometrium,
the placental site, decrease in size& weight and change in location of the Uterus and by the
color& amount of the lochia
 Involution is facilitated if the mother is breast feeding
 At 6wks of postpartum complete regeneration of the endometrium at the placental site takes
place
 The blood vessels degenerate and become obliterated followed by thrombosis and new
vessels grow inside the thrombi
Cervix
 Immediately after delivery, the Cervix is extremely soft, flabby and floppy. It may be
edematous, especially anteriorly if there was an anterior lip during labor
 It looks congested and readily admits two to three finger
 Contract slowly & the external os admits two fingers for a few days but at the end of the 1 st
week narrows down to admit a tip of finger only.
 The contour of the Cervix takes longer time to regain (6wks) and the external os never
reverts to the nulliparous state
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 The broad& round ligaments, which accompanied the Uterus during its increase in size are
now lax b/c of the extreme stretching of the ligaments.
 By the end of the puerperium the ligaments regain their non-pregnant length and tension
Vagina and perineum
 Immediate post delivery vagina remains quite stretched, may have some degree of edema
and gapes, open at the introits. In a day or so it regains enough tone that the gaping reduces
and the edema subsides. Its size decreases with the return of the vaginal rugae by about the
third postpartum week
 Perineal muscle tightening exercises will restore its tone
 It takes long time to involute (4-8 weeks)
 It can never be the same degree as in pre pregnant state.
INFORMATION Normal and abnormal Lochia

SHEET 2
Lochia
Definition:- is the name given to the Ux discharge that escapes vaginally from the body of the
uterus, cervix& vagina during puerperium
 it lasts from the 1st day up to - 15th days
 reaction - Alkaline
 Odor - heavy & unpleasant but not offensive
 The odor is strongest in the lochia serosa. It is still stronger if mixed with perspiration, and
must be carefully differentiated from a foul odor indicative of infection
 Lochia begins as a heavy discharge in the early postpartum hours and decreases to a
moderate amount as lochia rubra, a small amount as lochia serosa and a scanty amount as
lochia alba.
 The amount of the discharge varies according to the positional change of the woman.
 The normal duration of lochia discharge may extend up to three weeks.
 As it changes in color, it changes its descriptive name, i.e. rubra, serosa and alba
Lochia rubra - red in colure as it contains blood and decidual tissue
-Lasts 1-4 days
-Consists of - Blood
-Chorion
-Sheds of fetal membrane
-Decidua
-Amniotic fluid
-Lanugo
-Vernix caseosa &
-Meconium
Lochia serosa - yellowish or pink in colure
-Lasts 5-9 days
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-Contains less blood, more serum as well as leukocytes, wound exudates,

deicidal tissue and mucus from the Cervix.
Lochia Alba - pale white in color
- consists of leukocytes, deicidal cells& mucus.
-Lasts 10-15 days
The cardiovascular system and kidneys: -
- Within 24-48hrs following the birth of the baby the withdrawal of estrogen allows a
diuresis(an increased excretion of urine) to take place, reducing its plasma volume to
normal proportions and mother passes much amount of urine.
- Renal activity increase in early period of puerperium especially the 1 st seven days.
- Breasts
o The 1st 3-4days of the puerperium, the breast become heavy and engorged
o The rise of prolactin acts up on the alveoli of the breast and stimulates milk production
o Fall of prolactin occurs if baby is not sucking and engorgement gradually will reduce.
Breast – the first two days following delivery, no further anatomical changes occur in the breasts.
Secretion from the breasts called colostrums, which starts during Pregnancy, becomes more
abundant during this period.
-Colostrum is a deep yellow, serous fluid that is alkaline in reaction and has higher specific
gravity, protein, sodium chloride and vitamin A content than breast milk. It contains antibodies
(IgA, IgG& IgM) and humeral factors (lactiferrin) that provide immunological defense to the
newborn.
-Colostrum has a laxative action on the baby b/c of large fat molecules in it and facilitates passage
of meconeum
-Lactation is initiated in all puerperal women normally and naturally unless effectively prohibited
by a lactation suppressant. Some secretary activity is present (Colostrum) during Pregnancy and
accelerated following delivery
-Milk secretion actually starts on the third/fourth postpartum day around this time the breast
becomes engorged, tense and tender and feels warm
-The secretary activity (lactogenesis) is enhanced by growth hormone, thyroxin, glucocorticoids
and insulin
-The milk ejection reflex is inhibited by factors such as pain, breast engorgement or adverse
psychic condition
INFORMATION process of lactation and bonding, supporting the

mother-infant
SHEET 3
Stimulation of lactation
The methods that can be adopted during Pregnancy include
- Improving the maternal desire to breast feed the baby through education
- Care and preparation of the nipple
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- Following delivery the mother should be encouraged to

a. Put the baby to breast as soon as possible after delivery
b. Nurse the baby every 2-3 hours without missing any feeding
c. Take plenty of oral fluids
Suppression of lactation
Suppression becomes necessary if the baby is born dead or dies in the neonatal period or when the
woman does not want to breastfeed her baby or if breast feeding is contraindicated. Either
hormones or mechanical means may be used to achieve suppression.
Drugs
1. bromocriptine (parlode) 2.5mg orally twice daily for two weeks. This inhibits prolactin
secretion
2. Ethynyl estradiol 0.05mg twice daily for five days
3. Combination of estrogen and testosterone preparation (mixogen), IM soon after delivery
Use of parlodel may be associated with early return of ovulation and hormonal preparations carry
the risk of thromboembolic complication.
Mechanical methods can be used effectively when lactation is to be suppressed after the
establishment of milk secretion. For this the woman should:
- Stop breastfeeding
- Not express or pump out milk from breasts
- Apply a tight compression bandage or binder for 2-3days
Other changes occurs during puerperium :-The physiological change that occurred during
pregnancy on uterus, kidneys the GIT, Abdominal wall, the ligament of the Uterus, the Wall of
the vein the pelvic floor, perineum, vagina and vulva are reversed and they gain their normal
muscle tone gradually.
To be effective this process postnatal exercise, avoidance of constipation early ambulation are
necessary.
The increased vascularity which occurred during pregnancy causes some degree of bruising and
edema in the perineum and the reabsorption takes place on the 3 rd or 4th day.
Mgt of Normal Puerperium
Objectives: - The improvement of physical well-being
- The establishment of emotional well-being
- The prevention of infection
- The promotion of breast feeding
- The provision of baby care teaching
Immediate care (after expulsion of the placenta)
- Rest, comfort, meal, sleeps
- Prevention of PPH
- Express clots and give ergometrin
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1.List type of lochia and characterize them

2.how you stimulate breast milk
3. write mechanism that use for milk suppression
4.write different physiologic change in post natal and write there mechanism
Answer sheet
1__________________
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2_____________________________________________________________________________
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3_____________________________________________________________________________
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4_____________________________________________________________________________
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23
INTRODUCTION LO4:Demonstrates the skills needed to support the

woman and her family during the postnatal period
 Provision of health education

 Standard infection prevention practices
Learning Activities
topic
Information sheet 1 Provision of health education
Provision of health education & demonstration

Infant feeding—The advantages of breast feeding (it is clean, nutritious, prevents infection, helps
family planning); the dangers of bottle feeding (risk of diarrhea, reduction in mother's milk
supply); how to increase the supply of breast milk (maternal diet, fluids, feeding soon after birth)
Diarrhea—The dangers of diarrhea; what to do if the infant develops diarrhea (continue breast
feeding, give oral rehydration solution, go to a health centre or doctor if diarrhea persists)
Symptoms and response to acute respiratory infection—Visit a health worker if the infant
develops cough, chest indrawing, fast breathing, or poor feeding Immunization—The importance
of full immunization; where to go for the first or subsequent injections Family planning—The
importance of restarting contraception no later than 8 weeks after birth; the location of the nearest
24
family planning clinic; the choice of methods; the availability of sterilization services at the
hospital.
Uninterrupted (exclusive) breastfeeding

Providing care for neonate after delivery.
- identifying neonate - start breast feeding
- Thermoregulation (preventing hypothermia draught)
- Instructing mother to baby bonding
- General examination of new born.
- Vaccination.
Providing care for mother & neonate to assist breast feeding
 It is always advisable to provide counseling about newborn feeding during the antenatal
period and continue reinforcing it during the postnatal period.
 This teaching should focus on establishing and maintaining optimum breastfeeding.
 Assessment of breast productivity
 Ability of neonate to suck
 Ability of mother to breastfeed her neonate
 Breast feeding & its recommendation
 Technique of breast feeding
Optimum breastfeeding criteria
- Initiation of breastfeeding within one hour after birth (early breastfeeding).

- Nothing is given to the baby other than breast milk for the first six months
(exclusive breastfeeding).
- Colostrum is not thrown away. It is rich in protein and antibodies and is useful to
the newborn; you should tell the mother to feed it to her newborn, because it is
the first ‘immunization’ that her baby will get.
- The mother is sitting in a good position while breastfeeding.
- The baby has good attachment to the breast while breastfeeding.
- There is effective suckling.
When you arrive for a postnatal visit, ask the mother to put the baby to the breast to check for
good positioning and good attachment (we describe how you do this below). If the baby was fed
recently, wait for at least an hour before putting him or her back to the breast. This will allow you
to observe how the baby is breastfeeding and identify if there are any breastfeeding problems,
which you can help the mother to overcome. Before you leave the house, ensure the mother
understands how to breastfeed her baby optimally
Assessment of breast feeding

 Before the mother leave the health institution, you need to assess whether the baby suck the
breast or not
 If the infant do not suck the breast assess the cause & solve the problem.
 The cause may be from the mother or from the infant.
Maternal cause - Abnormal structure & shape of the breast like - Retracted nipple & cracked
nipple
-Infection of the breast like mastitis
-Soreness of the breast.
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-Lack of knowledge about the advantage of breast feeding.

-Unwanted pregnancy, unwanted infant
Child cause - Prematurity
-Congenital abnormality - cleft lip
-Cleft palate
-Blocked nose
Management of breast feeding
 Limit the number of breast feeding in order to prevent soreness on the nipple for the 1 st few
days.
 Both breasts must be used at each feed.
 The baby should feed both breasts after finishing the 1st one.
 If the baby satisfy with the 1st breast feed the next breast at the next feed.
 Each feed should last for only 20-30 min.
 The breast should hold away the baby’s nose during feeding.
 The baby should feed at regular interval i.e. at least of 8 feed /24hrs
 Giving the first feeding within one hour of birth, correct positioning of the baby to allow
good attachment to the breast, frequent feeds no prelactal feeds or other supplements.
Psychological support for breastfeeding mother.
- Successful infant feeding requires cooperation b/n the mother and her baby
- Promptly establishing comfortable, satisfying feeding practices contributes greatly to the
infant’s and mother’s emotional well-being
- Feeding should be initiated to maintain normal metabolism and growth during the transition
from fetal to extra uterine life
 To promote maternal – infant bonding
 To decrease risks of :-
Hypoglycemia
 Hyperbilirubinaemia and
 Hyperkalemia
 Azotemia:- excess of urea
- Neonates should start breastfeeding immediately after birth (with in 30 minutes)
- The neonate should feed the breast milk frequently and as much as he/she wants (Every 3-4
hour/day= day and night)
- Neonates should start breastfeeding immediately after birth (with in 30 minutes)
The neonate should feed the breast milk frequently and as much as he/she wants (Every 3-4
hour/day= day and night
EBF (EXCLUSIVE BREAST FEEDING) - is giving breast milk alone for the first
6 months of life except medication
 WHO recommended that every infant should exclusively breast-fed until 6 months of age
Advantages of EBF
- Breast-feeding is essential for the survival of the infant in most situations in developing
countries
- It has overwhelming advantages anywhere in the world
Colostrums - produced during the first few day of lactation
-is particularly beneficial in preventing infections
- Human-milk exactly has right nutritional quality for the young infant’s needs.
 Generally breast-feeding has the following advantages:-
- Breast-milk is the natural food for full-term infants during the 1 st months of life
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- Always readily available at proper temperature

- Needs no time for preparation
- Fresh and free of contaminating bacteria
- Allergy and intolerance to cow’s milk create significant disturbances and feeding
difficulties
- these are not seen in breast-fed infants
- Human-milk contains bacterial and viral antibodies
- Macrophages normally present in human colostrums and milk may be able to synthesize
complement, lysozyme and lactoferrone
- Supply the necessary nutrients to the infant
- It has psychological advantage for both the mother and infant
- Prematurely born baby usually thrive on breast milk
NB- The low vitamin K content of human-milk may contribute to hemorrhagic disease of the
newborn, so, 1 mg of vit k administration is recommend for all infants, especially for those who
will be breast-fed
Partially breast feeding
 Mean that the baby breast feeds part of the time but has some artificial feeds or supplements.
N.B The best & safest way to feed a baby is breast feeding exclusively.
 Partial breast feeding is better than no breast feeding at all.
Proper weaning feed
 Weaning is process of expanding the diet of the infant to include foods & drinks other than
breast milk
 The best age of starting weaning is 6months.
Signs that a baby is sucking in a good position is
-The baby’s whole body is facing his mother & is close to her.
-The baby’s face close up to the breast
-The baby’s mouth is wide open
-The baby’s lower lip is turned out ward.
-There is more areola showing above the baby’s upper lip & less areola showing below
the lower lip.
-You can see the baby sucking slow, deep sucks & sometimes pauses.
-The baby is relaxed & happy & satisfied at the end of the feed.
-The mother doesn’t feel nipple pain
-You may be able to hear the baby swallowing
Signs of good position
-Infant’s neck is straight or slightly bends back.
-Infant’s body is turned towards the mother
-Infant’s whole body is supported.
-Infant’s body is close to the mother
Sign of good attachment
-There should be more areola visible above the infant’s mouth than below
-Infant’s mouth should be wide open
-Infant’s lower lip turned out ward.
-Infant’s chin should touch the breast (or very close).
If an infant is not well attached, the result may be: pain and damage to the nipples or: The
infant may not take enough milk (breast-milk) effectively, may cause engorgement
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- If the infant is not well attached

 He/she may be unsatisfied after breast feeds; want to feed very often or for a very long
time
 The infant may get too little milk and not gain weight
 The breast-milk may dry up
 All the above problems may improve if attachment can be improved
 If attachment is not good, you may see
 Chin not touching breast
 Mouth not wide open, lips pushed for word
 Lower lip turned in or
 More areola (or equal amount) visible below infants mouth than above it
- If you see any of these signs of poor attachment, the infant is not well attached
Good attachment
Effective suckling
Good signs of effective suckling are if the newborn takes slow, regular and deep sucks,
sometimes pausing. The mother should tell you that she is comfortable and pain free.
If you observe that the attachment and suckling are inadequate, ask the mother to try again and
reassess how well the baby is feeding. If they still cannot establish optimum breastfeeding, then
you should assume that the newborn has a feeding.
problem and/or the mother has breast problems that make attachment difficult. If so refer the baby
and the mother to a health facility for further advice and care.
Advantage of breast feeding
-It is the best natural food for babies
 It contain protein, fat, lactose, vitamins & iron which are more easily absorbable & help in
its growth & development
-If provides water for infants even in hot warm climate.
 Breast milk, especially the colostrums, contains anti - infective factors that help to protect
the infant against infection, but not against HIV.
-It is free from contamination
-It is available for 24hrs & requires no special preparation
-It protects the baby from allergy & intolerance.
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-It is not costy

-It strengthen bonding b/n mother & baby
-Provide protection from neonatal hypokalcemia
-Helps to space children
-Helps the Uterus to return to its normal size.
What are the benefits of breastfeeding?
Breastfeeding provides many benefits to both the newborn and mother. You should encourage
mothers to breastfeed exclusively for at least the first six months by explaining the benefits to
them.
Benefits to the newborn of breastfeeding
Breast milk is the ideal feed for full term newborns as it provides all the nutrients in the correct
amount and proportion for normal growth and development until the age of six months. It is
easily digested and absorbed.
Also, breast milk is clean and warm, and avoids the dangers of feeding formula milk which comes
as a powder and has to be made up with water and fed in a bottle.
There is a risk of infection from making the milk with contaminated water, or if the bottles and
teats are not properly sterilized. If the mother makes several feeds at one time, and she cannot
keep them cold because she has no refrigeration facilities, bacteria may grow in the warm milk.
Also, if she puts too little or too much milk powder in each bottle, the baby will suffer from
malnourishment if the formula is too weak, or it will get an excessive load on its organs from too
concentrated formula.
Breast milk contains many anti-infective factors, such as antibodies, living cells and molecules
that help the baby's body to fight infection. It also encourages the growth of beneficial bacteria in
the newborn's bowel. These properties of breast milk help to prevent diarrheal diseases, the major
cause of death of newborns in poor communities.
Breast milk also decreases the risk of allergy in the newborn. Allergies are adverse reactions of
the body against components of the diet, pollen from plants, animals and other harmless things
that touch the body or get into it through the nose, mouth or eyes. Newborns are more at risk of
allergies if there is a strong family history of allergy.
Benefits to the mother of breastfeeding

Breastfeeding is (almost) free – the mother needs additional food while she is breastfeeding, but
the cost is much cheaper than buying formula feeds or bottles.
It is instantly available at all times, so the mother does not have the trouble of sterilizing bottles
and teats(nipple), and preparing formula feeds many times every day. It is emotionally satisfying
for the mother to successfully breastfeed her baby and the close contact helps to form a strong
bond between mother and newborn.
The hormone (oxytocin) that triggers the milk to spurt from the breast by contracting the tiny
muscles around the nipple also makes the muscles in the uterus contract. So breastfeeding helps
the uterus to return to its normal size.
■What other benefit can you suggest results from the contractions of the myometrium (the muscle
layer in the uterus) during breastfeeding?
29
□The contractions help to close the torn blood vessels where the placenta detached from the
uterine wall, and this reduces the amount of normal vaginal bleeding during the puerperium, and
decreases the risk of postpartum haemorrhage.
Breastfeeding helps the mother to lose excessive weight if she gained too much during the
pregnancy. Not breastfeeding alters the shape of a woman’s breasts.
Breastfeeding and birth control
Exclusive breastfeeding (feeding only breast milk to the baby and no other fluids or foods) greatly
reduces the chance of the mother becoming pregnant again if it is begun early (within an hour of
the birth), and maintained for the recommended first six months. Explain to the mother and her
partner that if a woman has sex and is not exclusively breastfeeding, she can become pregnant as
soon as four weeks after delivery. Therefore, information on when to start a contraceptive method
will vary depending on whether the woman is breastfeeding or not.
In Ethiopia it is recommended that you try to convince mothers to put their babies on exclusive
breastfeeding for six months for many reasons, including that it will suppress her menstrual cycle,
but only if she fulfills the following criteria:
I. The baby should be exclusively breastfed on demand (whenever the baby wants to be
fed) a minimum of 8-12 times a day, including at least one feed during the night.
II. The interval between daytime feeds should not be more than four hours apart and night
feeds should not be more than six hours apart.
III. If her menstrual periods return even while she is exclusively breastfeeding, she could
easily become pregnant!
Emphasize that after six months, she will not be protected from becoming pregnant by
breastfeeding alone. She should choose another family planning method.
Disadvantage of breast feeding
-Transmission of micro organism such as - Hepatitis
-Cytomegalo virus
-HIV
-Inconvenience to a working mother
-Deficient in vit K
-Deficient in vit D
Counseling the HIV-positive mother about feeding her baby
Mothers who are HIV-positive and their babies need special care before, during and after labour
and delivery. Therefore, if the mother is counseled and HIV-tested before or during pregnancy,
and she knows that she is HIV positive, you should try to convince her to deliver her baby in a
health facility. That way she and her baby will get special care from health professionals with
special training in delivering babies from HIV-positive mothers, and preventing maternal to child
transmission (PMTCT of HIV).
In the postnatal period, she may need to take antiretroviral (ARV) drugs prescribed for her by the
HIV clinic, and your support is vital in helping her to keep to her drug regimen. Maintain
confidentiality about her status and conduct frequent visits to this woman as she may require a lot
of psychosocial support immediately after the delivery. If it is available link her with the
community social support group. Always make sure her partner is counseled and HIV-tested and
also involved in the whole care process.
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Breast milk or formula

 Formula- milk is used if the mother could never breast feed for various reasons
- Animal milk and numerous “modified formulas” are widely available, but are very
expensive
- Whatever is fed to the non-breast-fed infant, is extremely dangerous because of :-
 Likelihood of over dilution
 Bacterial contamination
- The feeding-bottle is especially risky as it is very difficult to clean
 Advise the mother to use cups or spoons for feeding her infant
From this our focus is on the risk of HIV being transmitted from the mother to her newborn baby
in her breast milk, and how you can support and counsel her about feeding options. If 20 HIV-
positive mothers breastfeed their HIV-negative babies exclusively for the first six months, on
average 1-3 of the babies will become infected with HIV through its mother’s breast milk. So the
mother has a difficult choice to make. She has to balance the risk to her baby from HIV
transmission during breastfeeding, against the risk of not breastfeeding and losing all the benefits
described above. Formula feeding also exposes the baby to increased risk of infection from
unsterilized bottles and malnutrition from incorrectly made feeds.
Replacement feeding and the AFASS criteria
Exclusive breastfeeding is NOT recommended for the babies of HIV-positive women, since the
only way to protect the baby completely from HIV transmission from its mother is to feed it on
formula milk. This is known as replacement feeding. However, many families cannot afford to
buy milk formula to feed the baby, and bottle feeding may be socially unacceptable in some
communities. With all these issues in mind the World Health Organization (WHO) has set the
following criteria (known as the AFASScriteria), which need to be met before counseling an
HIV-positive mother to use formula milk:
1. Acceptable: Replacement feeding for breast milk is acceptable by the mother, the family
and others who are close to the family.
2. Feasible: The mother has access to clean and safe water for cleaning the feeding bottles,
teats, measuring cup and spoon, and diluting the formula milk if it comes as a powder.
3. Affordable: The family can afford to buy enough formula milk or animal milk to feed the
baby adequately.
4. Sustainable: The mother is able to prepare feeds for the child as frequently as
recommended and as the baby demands.
5. Safe: The formula milk should be safe and nutritious for the health of the baby.
When replacement feeding fulfils the AFASS criteria, avoidance of all breastfeeding by HIV-
positive mothers is recommended.
Reducing the HIV risk from breastfeeding
If replacement feeding is rejected by the HIV-positive mother, for whatever reasons, there are
some things that she can do to reduce the risk of HIV transmission during breastfeeding. Counsel
her to:
- Keep the intervals between breast feeds as short as possible (no longer than three
hours) to avoid accumulation of the virus in her breast milk.
- If she develops a bacterial infection (mastitis) of the breast, or she has a cracked
nipple, stop feeding from the infected breast and seek urgent treatment.
- Check the infant’s mouth for sores and seek treatment if necessary.
31
- Make a transition to replacement feeding if her circumstances change and she can
meet the AFASS criteria.
At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and
safe, counsel her to continue breastfeeding, but with additional complementary foods. All
breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be
provided.
Breast Hygiene: advice on the care of the breasts is particularly important in any primigravida
who might not come into the maternity unit for delivery
- The midwife and/or other health workers should advise the nursing mother to use simple
cleanliness procedures
 She should wash her hands with soap and water
Wash the nipples with plain water, avoid washing with soap b/c washing with soap
removes the natural oil form the skin of the nipple & areola and the skin become dry & is
more easily damage & creaked
 Her nipples should be kept dry; expose to air and sunlight if possible
-Keeping breast hygiene is very important using clean towel & warm water before
feeding .
Information sheet 2 Standard infection prevention practices
Standard infection prevention practices according to the infection prevention guideline
Standard precautions are meant to reduce the risk of transmission of blood borne and other
pathogens
from both recognized and unrecognized sources. They are the basic level of infection control
precautions
which are to be used, as a minimum, in the care of all patients. Hand hygiene is a major
component of standard precautions and one of the most effective methods to prevent
transmission of pathogens associated with health care. In addition to hand hygiene, the use of
personal protective equipment should be guided by risk assessment and the extent of contact
anticipated with blood and body fluids, or pathogens.
Important advice
 Promotion of a safety climate is a cornerstone of prevention of transmission of pathogens in

health care.
 Standard precautions should be the minimum level of precautions used when providing care
for all patients.
 Risk assessment is critical. Assess all health-care activities to determine the personal
protection that is indicated.
32
 Implement source control measures for all persons with respiratory symptoms through
promotion of
respiratory hygiene and cough etiquette
Health policy
 Promote a safety climate.
 Develop policies which facilitate the implementation of infection control measures.
Hand hygiene
 Perform hand hygiene by means of hand rubbing or hand washing
 Hands should always be washed with soap and water if hands are visibly soiled, or exposure to
spore-forming organisms is proven or strongly suspected, or after using the restroom. For other
indications, if resources permit, perform hand rubbing with an alcohol-based preparation.
 Ensure availability of hand-washing facilities with clean running water.
 Ensure availability of hand hygiene products (clean water, soap, single use clean towels,
alcohol-based hand rub). Alcohol-based hand rubs should ideally be available at the point of
care
Personal protective equipment (PPE)
 ASSESS THE RISK of exposure to body substances or contaminated surfaces BEFORE
any health-care activity. Make this a routine!
 Select PPE based on the assessment of risk:
 clean non-sterile gloves.
 clean, non-sterile fluid-resistant gown.
 mask and eye protection or a face shield.
Respiratory hygiene and cough etiquette
Education of health workers, patients and visitors.

Use of source control measures.
Hand hygiene after contact with respiratory secretions.
Spatial separation of persons with acute febrile respiratory symptoms.
33
1.What is the difference b/n good attachment and good position?

2.What is the advantage and disadvantage of breast feeding
3.list infection prevention slandered
4.why cow milk is not recommended in early age
Answer sheet
1._____________________________________________________________________
________________________________________________________________________
______________________________________________________________________________
2.__________________________________________________________________________
____________________________________________________________
.
3._____________________________________________________________________________
4_____________________________________________________________________________
__________________________________________________________________________
34
INTRODUCTION LO5:Demonstrates a basic knowledge of the

physiology and needs of the newborn
This guide will also assist you to attain the learning outcome stated in the cover page. Specifically,
upon completion of this Learning Guide, you will be able to:-
 Newborn adaptation to extra-uterine life.

 infant growth and development.
Learning Activities
*Your teacher will evaluate your output either satisfactory or unsatisfactory. If unsatisfactory, your
teacher shall advice you on additional work. But if satisfactory you can proceed to the next topic
Information sheet 1 Newborn adaptation to extra-uterine life
Newborn adaptation to extra-uterine life

Temperature regulation
Newborns come from a warm environment to the cold and fluctuating temperatures of this world. They
are naked, wet, and have a large surface area to mass ratio, with variable amounts of insulation, limited
metabolic reserves, and a decreased ability to shiver. Physiologic mechanisms for preserving core
temperature include vasoconstriction (decrease blood flow to the skin), maintaining the fetal position
(decrease the surface area exposed to the environment), jittery large muscle activity (generate muscular
heat), and "non-shivering thermogenesis". The latter occurs in "brown fat" which is specialized adipose
tissue with a high concentration of mitochondria designed to rapidly oxidize fatty acids in order to
generate metabolic heat. The newborn capacity to maintain these mechanisms is limited, especially in
premature infants. As such, it is not surprising that some newborns may have problems regulating their
temperature. As early as the 1880s, infant incubators were used to help newborns maintain warmth, with
humidified incubators being used as early as the 1930s.
Basic techniques for keeping newborns warm include keeping them dry, wrapping them in blankets,
giving them hats and clothing, or increasing the ambient temperature. More advanced techniques include
incubators (at 36.5 °C), humidity, heat shields, thermal blankets, double-walled incubators, and radiant
warmers while the use of skin-to-skin "kangaroo care" interventions for low birth-weight infants have
started to spread world-wide after its use as a solution in developing countries.
Information sheet 2 Infant growth and development
35
Infant growth and development

Growth is the progressive increase in the size of a child or parts of a child. Development is progressive
acquisition of various skills (abilities) such as head support, speaking, learning, expressing the feelings
and relating with other people. Growth and development go together but at different rates .
Continuous normal growth and development indicate a good state of health and nutrition of a child.
Abnormal growth or growth failure is a symptom of disease. Hence, measurement of growth is an
essential component of the physical examination.
Factors affecting growth and development
Each child’s path or pattern of growth and development is determined by genetic and environmental
factors. The genetic factors determine the potential and limitations of growth and development. If
favourable, the environmental factors, such as adequate nutrition, facilitate the achievement of the genetic
potential of growth and development. Unfavourable factors, acting singly or in combination, slow or stop
growth and development. Some of the unfavourable factors are malnutrition, infections, congenital
malformations, hormonal disturbances, disability, lack of emotional support, lack of play, and lack of
language training. To promote optimum growth, these environmental factors can be removed or
minimized. Once they are removed, there follows a period of catch up growth. During this period the
growth rate is greater than normal. This growth rate continues until the previous growth pattern is
reached. Then the growth rate is reduced to the normal rate determined by the individual’s genetic factors.
A child genetically determined to be tall grows slightly more rapidly than a child genetically determined
to be short. Similarly, a child genetically determined to be clever develops their intellect more rapidly
than a child genetically determined to be less intelligent .
There are various measurements that are used to measure growth. These are:
 weight,
 height,
 head circumference,
 mid upper arm circumference (MUAC)
 the eruption of teeth
Measuring weight
For measuring the weight, a beam balance or spring balance is used. Before weighing a child, check the
weighing scale to ensure it is working properly.
Adjust the pointer of the scale to zero (“0”) by turning the knob on the top of the scale to account for the
extra weight of the weighing pants;
Ask the parent to remove any heavy clothes and shoes including the nappies and to dress the child in the
weighing pants.
Measuring the Head Circumference
The head circumference measurements are used for estimating the growth of the brain. At birth, the head
circumference of a term baby averages 34 cm. The head circumference grows most rapidly in the first
year: 2 cm monthly in the first 3 months, 3 cm during the next 3 months, and 3 cm in the last 6 months.
This means that the average head circumference is 44 cm at 6 months and 47 cm at 12 months of age.
Thus, the head circumference grows by 12 Cm during the first year
36
The head circumference is measured by encircling the head with an unstretchable tape measure, or a
piece of string in the absence of a tape measure. This is passed over the most prominent part of the
occiput posteriorly and just above the supraorbital ridges anteriorly to obtain the greatest distance around
the head. The piece of string used in the absence of a tape measure is then measured with a ruler to obtain
the head circumference.
Measuring the mid upper arm circumference (MUAC)
The measurements of mid upper arm circumference (MUAC) are used for determining whether the child
is well nourished or malnourished.
The mid upper arm circumference increases fairly rapidly to about 16 cm by the age of one year. In the
period 1 to 5 years, the mid upper arm circumference increases by only 1 cm. So, irrespective of age, the
mid upper arm circumference of well nourished children ranges 16 -17 cm in the period 1-5 years.
Conversely, if the mid upper arm circumference of a child of 1 to 5 years of age is less than 16 cm, that
child has malnutrition and corrective intervention should be carried out.
The mid upper arm circumference is measured using a tape or string in the absence of a tape. The tape or
string is placed around the upper arm, midway between the olecranon and acromion processes. Care is
taken not to pull the tape or string too tightly. The measurement is read. The string used in the absence of
a tape measures is then measured with a ruler to obtain the mid upper arm circumference.
Measuring the length and height
An average term baby is 50 cm long. The length increases by 50% in the first year. In the second year, the
average height growth is about 12 cm. The birth length doubles by 4 years of age. After the second year
of age, the annual height growth averages 5-6 cm until the beginning of the adolescent growth spurt.
Height growth stops at about the age of 18 years in girls and at the age of about 20 years in boys.
The length of a child is measured in the first 3 years and the height is measured after 3 years of age. The
length is measured using a horizontal measuring board put on the ground or on a table. The child is laid
on his back with the head against the fixed head board. A helper holds the child’s head so that the eye
angle- external ear canal line is vertical and also keeps the body straight. With one hand of the health
worker, the child’s knees are pressed down to straighten the child’s legs fully while, with the other hand,
the sliding foot board is placed to touch the child’s heels firmly. With the foot board in place, the child’s
length is read on the metre scale
To measure the height, a bare foot child stands with the feet together. The heels, the buttocks and the
occiput lightly touch the measuring device. The head is aligned so that that the external eye angle-
external ear canal plane is horizontal. The child is told to stand tall and is gently stretched upward by
pressure on the mastoid processes with the shoulders relaxed. The sliding head piece is lowered to rest
firmly on the head.
. An average term newborn weighs 3.5 kg (range 2.5 kg- 4.6 kg). The birth weight must be plotted in the
first box of the growth chart and recorded in the appropriate space on the growth chart. The birth month
should be written in the first box of the growth chart. Within the first 3-4 days, a term newborn loses 5-
10 % of the birth weight. This weight loss is usually regained in 2 weeks by term babies and longer by
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premature babies. An average term baby doubles the birth weight in 4-6 months, triples it by one year and
quadruples it by two years of age.
Importance of Growth Monitoring:
 Health workers and parents should monitor the growth of children for the following reasons
 For early detection of abnormal growth and development
 To facilitate the early treatment or correction of any conditions that may be causing abnormal
growth and development.
 To provide an opportunity for giving health education and advice for the prevention of
malnutrition.
Normal Development Milestones
Age range Motor Development Language and social development
Birth When prone turns head to one Cries
side to avoid suffocation
3-6 Months Good head control Can follow an object with eyes,
plays with hands
6-9Months Can sit unsupported Grasps actively, makes loud noises
9-12Months Able to stand Understands a few words, tries to use them
9-18Months Able to walk Grasps small objects with thumb and index finger
15-30Months Able to run around as much as he want say several words or even some sentences
3 Years Plays actively, is able to jump and climb Starts talking a lot, is curious and
asks many questions
1. How neonate adapt external environment?

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2. what is the difference b/n growth and development?

3.how you meseaure growth
Answer sheet
1.________________________________________________________________________
___________________________________________________________________________
_________________________________________________________
2_________________________________________________________________________
__________________________________________________________________________
____________________________________________
3________________________________
_______________________________
______________________________
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INTRODUCTION LO6;Assessing and identifying abnormal conditions

of the newborn.
 abnormal conditions of the newborn

 Integrated Management of New born and Child Illness
 Immunizatiion
 Prevention of anaemia, malaria, intestinal parasites
Learning Activities
Information sheet 1 Abnormal conditions of the newborn
Congenital anomalies
Definition: a congenital abnormality is any defect in form, structure or function.
Causes:Chromosomal abnormalities
Single gene defects
Teratogenic causes
Multifactorial causes
Unknown causes
OESOPHAGEAL ATRESIA: occurs when there is incomplete canalization of the esophagus in early
intrauterine development. This abnormality should be suspected in the presence of maternal
Polyhydramnios and should be screened for after birth in all such affected pregnancies. At birth the
baby has copious amounts of mucus coming from the mouth. Passing orogastric tube should
attempt but it may travel less than 10- 12cm. Radiography will confirm the diagnosis. He should be
transferred immediately to a pediatrics surgical unit.
RECTAL ATRESIA AND IMPERFORATED ANUS:careful examination of the perineum is an
important aspect of any newborn examination. An imperforate anus should be obvious at birth on
examination of the baby, but a rectal atresia might not become apparent until it is noted that the
baby has not passed meconium. All babies should be referred for surgery.
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Talipes
Talipes equinovarus (TEV, CLUBFOOT): is the descriptive term for a deformity of the foot where
the ankle is bent downwards(plantar flexed) and the front part of the foot is turned inwards
(inverted).
Talipes calaneovalgus: describes the opposite position where the foot is dorsiflexed and everted.
It is thought that deformities are more likely to occur when intra uterine space has been at a
premium, for example in multiple pregnancy. TEV is also more likely to occur in conjunction with
spin bifida deformities, they may be unilateral or bilateral.
More severe forms will require one or more of manipulation, splinting, or surgical correction. The
advice of an orthopedics surgeon should be sought as soon as possible after birth as early treatment
with manipulation or splinting may enhance results.
Neonatal Jaundice
Def’n:-it is the yellow discoloration of the skin caused by accumulation of excess bilirubin in the
tissues and serum. It becomes apparent at serum bilirubin concentration of 5-7mg/dl. Jaundiced
shoulder& trunk indicates a level of 8-9mg/dl, lower body appears at 10-12mg/dl and entire body
at 12-15mg/dl
Formation of bilirubin
It is formed mainly from the non iron fraction of hem of broken down Hgb. RBCs are removed from
the circulation &broken down in the reticuloendothelial system. The Hgb in the RBCs break down
into it byproducts of globin, iron& hem. Globin is reused by the body to make proteins& iron is
stored/ reused for making new RBCs. Hem is rapidly bound to serum albumin complex (indirect
bilirubin). The complex so formed is carried to the liver cells for conjugation by the enzyme
glucuronyl transfers to form water soluble (direct bilirubin) which is nontoxic and excreted either
in urine or feces
Unconjugated bilirubin is fat soluble, cannot be excreted easily either in bile or urine andcan build
up in blood and be deposited in the extra-vascular fatty and nerve tissues, e.g. under the skin& in
the brain. Deposits under skin lead to jaundice while in the brain can cause bilirubin toxicity or
kernicterus
Excretion of bilirubin
The conjugated or water soluble bilirubin is excreted via the biliary system into the small intestine
where it is converted into urobilinogen by the intestinal bacteria. This urobilinogen is then oxidized
to form orange colored urobilin. Most of the conjugated bilirubin is excreted by the feces as
stercobilinogen and a small amount is excreted in the urine
Complication of hyperbilirubinemia
Kernicterus (bilirubin toxicity) it is fatal if not detected promptly and treated effectively. It is an
encephalopathy that is caused by deposition of unconjugated bilirubin in the basal nuclei of the
brain.
-Hyperbilirubinaemia causing kernicterus varies from 15-20mg/dl depending on maturation of the
baby. Hypoxia, acidosis, hypoglycemia, hypothermia and sepsis enhances the pathogenesis so that
the condition may develop even at a lower level of bilirubin
-Excess level of conjugated bilirubin cannot cause kernicterus.
Clinical manifestations
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- Lethargy and poor feeding

- High-pitched cry and loss of mororeflex
- Prostration and respiratory distress
- Opisthonus and nastagmus
- Hyper pyrexia and convulsions
- Enlarged liver and spleen
Prevention –regular and periodic estimation of blood bilirubin level in susceptable babies.
Types of jaundice
Physiological jaundice
More than 50%term& 80% preterm neonates will have some physiological jaundice. There is
regular rise of unconjugated bilirubin from 1.5-2mg/dl in the cord blood serum to 5-7mg/dl on the
3rd day of life. In a term well baby physiological jaundice never appears before 24hrs of age, never
exceeds 12-13mg/dl and usually fades by a week of age
Causes - increased RBCs break down
-
Decreased albumin binding capacity-the ability of neonates to actively transport
bilirubin to the liver for conjugation is reduced due to lower albumin concentration
or albumin binding capacity
- Enzyme deficiency newborn infants have low level of Uride Diphospho- Glucuronyl
Transferace (UDP-GT) enzyme activity during the 1st 24hrs of life. UDP-GT is the
major enzyme involved in bilirubin conjugation
- Increased enterohepatic re-absorption of bilirubin which is increased in neonates as
they lack the normal enteric bacteria that break down bilirubin to the urobilinogen
Management - no specific treatment is generally required
- Adequate feeding
- Careful observation of newborn will help to distinguish b/n health babies with
normal physiological response
- In premature babies, rising bilirubin level to critical level require use of
phototherapy or phenobarbiton administration
Pathological Jaundice
Usually appears within 24hrs of birth and characterized by a rapid rise in serum bilirubin and
prolonged jaundice
Features of pathological jaundice
- Clinical jaundice appears within 24hrs of life

- Increase in bilirubin >5mg/dl per day
- Total bilirubin >13mg/dl
- Persistence of clinical jaundice for 710 days in term and 2wks in preterm infants
Causes of pathological jaundice
The underlying etiology of pathological jaundice is some interference with bilirubin production,
conjugation, transportation and excretion
1. Increased production due to excessive RBC hemolysis. Conditions that can lead to
increased hemolysis includes
- Hemolytic disease of the newborn
-Fetomaternal blood group incompatibility
-Increased RBC fragility (congenital sphirocytosis)
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-Deficient RBC enzyme –Glucose-6phosphate dehydrognase (G6PD)
- Neonatal sepsis, which can lead to increased Hgb break down

- Polycytemia delayed cord clamping and infants of of DM mothers.
- Extravasated blood such as in cephalohematoma and bruising
2. Defective conjugation
- Diminished production of the enzyme glucuronyl transference
- Immature liver cells as in premature babies
- Dehydration, starvation, hypoxia& sepsis b/c O2 and glucose are required for
conjugation
- Metabolic disorders such as galactosemia
3. Transport and excretion failure

- Hepatic obstruction caused by congenital abnormalities such as biliary atresia, bile plugs or
absence of common bile ducts
- Excess conjugated bilirubin caused by infection, or idiopathic neonatal jaundice
- Umbilical cord sepsis leading to ascending thrembophlbitis, obstruction of biliary canaliculi and
liver cells
Assessment and diagnosis
In evaluating neonatal jaundice, it is important to determine whether the jaundice results from the
physiological break down of bilirubin or the presence of another underlying factors and weather
the infant is at high risk for kernicterus. Ass’t includes observation of risk factors
Risk factors – birth trauma or evident bruising and prematurity
- Family History of jaundiced siblings or hemolytic disease

- Ethnic predisposition to jaundice or inherited disease (pathological jaundice is more
common in Asia, Africa and Mediterranean male infants)
- Delayed feeding or meconeum passage
- Jaundice within 24hr suggests hemolysis
- Prolonged jaundice may indicate serious disease such as hypothyroidism or
obstructive jaundice
- Extent of changes in skin and sclera color
- Presence of lethargy, decreased eagerness to feed, vomiting, irritability, a high-
pitched cry, dark urine or light stools
- Presence of dehydration, starvation, hypothermia, acidosis and hypoxia
Laboratory evaluation
- Serum bilirubin to determine if the bilirubin is unconjugated or conjugated

- Direct coomb’s test to detect the presence of maternal antibodies on fetal RBCs
- Hgb/hematocrit estimation to assess any anemia
- Reticulocyte count (elevated with hemolysis when new RBC is being formed)
- ABO blood group and Rhesus type for possible incompatibility
- Peripheral blood smear-red cell structure for abnormal cells
- WBC count to detect any infection
- Serum samples for specific immunoglobulin for the TORCH infections
- Glucose 6-phosphate dehydrognase (G6PD) assay
- Urine for substances such as galactose
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Management/treatment
For the mgt of jaundice, it is important to differentiate b/n healthy babies whose jaundice is a
normal physiological response and those with an underlying serious illness or liver disease
A number of Rx strategies are available to reduce bilirubin levels. These include phototherapy,
exchange transfusion and possibly drug treatment
Phototherapy
Can be used to prevent the concentration of unconjugated bilirubin in the blood from reaching
levels where neurotoxicity may occur. During phototherapy the neonate’s skin surface is exposed to
high intensity light, which photochemically converts fat-soluble, unconjugated bilirubin into water
soluble bilirubin, which can be excreted in bile and urine
Indications for phototherapy
Phototherapy is started quickly, at lower bilirubin levels in infants:
- Who are smaller or preterm

- Who are sick particularly with hemolysis
- In whom jaundice appears within 12-24hrs
Bilirubin levels indicating phototherapy are:
- 17-22mg/dl(280-365mmol)for term infants who become jaundiced after 48hrs

- 8-10mg/dl(140-165mmol)for preterm infants >1500gm
- 5-8mg/dl(80-140mmol)for preterm infants <1500gm
The serum bilirubin level at which phototherapy is discontinued varies. Declining serum bilirubin
levels below 13mg/dl (215mmol ) are generally accepted as necessary for stopping
phototherapy.
Types of phototherapy
1. Conventional system- fluorescent lamps are used to deliver high intensity

light. The effectiveness depends on the wave lengths, the distance b/n the
light& infant, and amount of skin exposure. The infant is usually placed at
45-60cm distance from the light with skin exposed. The infants’
testes/ovaries and eyes should be protected from light. Turning the infant
frequently ensures maximum skin exposure. The Rx is generally continuous
with interruption only for essential care, like feeding or nappy changing
with 6hrs on and 6hrs off.
2. Fiberoptic light system- fiberoptic blankets/woven fiberoptic pads which
deliver high intensity light with no UV or infrared radation are wrapped
around the infant under the clothing. More skin is exposed to light & the
pads can be used day& night with minimal supervision. This also reduces
some of the side effects such as increased insensible fluid loss and eliminates
the need for eye protection.
Care of the baby undergoing phototherapy
- Observing any side effects

- Eye care and estimation of bilirubin levels
- Skin care and monitoring temperature& hydration
- Neurobehavioral status and sensory deprivation
- Hypocalcaemia and the need of parents
Exchange transfusion
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It is a life saving procedure in severely affected hemolytic disease of the newborn. This process
removes bilirubin from the body and is in cases of hemolytic disease, also replaces sensitized
erythrocytes with blood that is compatible with the mother’s and infant’s serum.
Except in Rh incompatibility, exchange transfusion may now be seen as a 2 nd choice of treatment
when phototherapy has failed. It is considered when there is a risk of bilirubin toxicity or
kernicterus.
Indications
Rh-positive with direct Coombs’ test positive babies having:
- Cord blood Hgb less than 15g percent

- Previous definite History of an affected infant due to hemolytic disease
- Birth weight less than 2,500g
- Rapidly developing jaundice with unconjugated bilirubin >5mg percent
Objectives of exchange transfusion are to:
- Correct the anemia by replacing the Rh-positive sensitized RBC (normal or

hemolysed) with compatible Rh-negative RBC
- Remove the circulating antibodies
- Eliminate the circulating bilirubin
While about 80-90% of the fetal blood is exchanged during the procedure, transfusion of Rh-
negative blood cannot alter the Rh-factor of the baby’s blood. The replacement temporarily helps to
tide over the crisis from anemia and hyperbilirubinemia for about two weeks. Thereafter the baby
produces his own Rh-positive blood.
Nature and amount of blood transfused
Blood for exchange should be Rh-negative, whole blood from unsensitized donors with the same
ABO grouping to that of the baby or group “O”. The blood should be cross-matched with the
mother’s serum. (It does not cause any harm if Rh-negative blood is transfused to Rh-positive
individual
The blood should be freshly collected and the amount is about 170ml/kg body weight of the baby
Complications
Immediate complications are:
- Cardiac failure due to raised venous pressure& over loading of the heart
- Air embolism and Hyperkalemia
- Clotting and massive embolism
- Tetani, acidosis and sepsis
- Hypocalcaemia and hypoglycemia
- Coagulopathies due to thrombocytopenia
Late complications
- Necrotizing enterocolitis
- Extra hepatic portal hypertension due to thrombosis of portal vein
Drug therapy
Drugs are used as an adjuvant therapy
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- Phenobarbitone 2mg/kg is administered twice daily IM for babies undergoing

phototherapy. It increases the glucuronyl transferase enzayme activity in the fetal&
neonatal liver to conjugate the bilirubin
- Antibiotics are administered for 3-5days
Hypothermia
Keeping the baby warm
Newborn babies cool down or heat up much quicker than older children or adults because they cannot
regulate their body temperature as easily as adults. They are particularly vulnerable to hypothermia,
which means excessive cooling of the baby, so the body temperature falls below 35.5oC measured in the
baby’s armpit (or use a rectal thermometer). If this low temperature continues even for a short time, it will
cause the baby’s body systems to stop functioning properly and this is life-threatening. Hypothermia is a
major cause of morbidity and mortality in a newborn baby, particularly pre-term babies (born before 36
weeks of gestation) and those with low birth weight (below 2,500 gm).
Hypothermia is usually caused more by the mother’s lack of knowledge rather than lack of covers and
clothes to keep the baby warm. So make sure you explain to the mother the importance of keeping the
baby warm all the time to ensure that a normal body temperature of above 36.5°C and below 37.5°C can
be maintained.
How to take the newborn’s temperature
Place the thermometer in the newborn's armpit (or rectum if you have a rectal thermometer) for two to
three minutes, then read the temperature according to the type of thermometer you have.
Thermometers should be stored dry when not in use. Before and after you take anyone’s temperature, the
thermometer should be cleaned with antiseptic to prevent carrying infection from one person to another. It
is important to notice when the temperature is even a little bit lower than normal, before it reaches as low
as 35.5oC.
When are newborns at greatest risk of hypothermia?
Newborns that have particular problems in producing enough heat in their bodies, or who lose too much
heat because of poor care by the mother, are at the greatest risk.
Newborns that may not produce enough heat include those who are:
- Preterm
- Underweight for gestational age
- Wasted (thin)
- Infected
- Hypoxic (starved of oxygen during labour and delivery).
Newborns that lose too much heat include those who are:
- Wet after washing, or left in wet clothes

- Have not been fed enough
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-
Exposed to a cold environment, not enough clothes or covers, especially when they are
sleeping
- Naked when they are breastfed
- Fed close to a cold window, in a draught of cold air.
How do newborns lose heat?
The mechanisms of how the newborn loses heat are:
 Convection this happen when the baby is exposed to cool surrounding air or to a draught from
open doors and windows or a fan.
 Conduction this is the loss of heat when the newborn lies on a cold surface. Newborns lose heat
by conduction when placed naked on a cold table, weighing scale or are wrapped in a cold
blanket or towel.
 Evaporation This is the loss of heat from a newborn's wet skin to theSurrounding air newborns
lose heat by evaporation after delivery or after a bath. Even a newborn in a wet nappy can lose
heat by evaporation.
 Radiation this is the loss of heat from a newborn's skin to distant cold objects, such as a cold
window or wall etc.
Finally, knowing that the newborn can lose heat by the four mechanisms described above, you should
counsel the mother to avoid exposing the baby to drafts. Counsel her that before she removes the baby's
clothes for a bath close all doors and windows; cover the wet baby and dry him or her quickly.
The warm chain principle in postnatal care
The mother should understand that keeping the baby warm is not a one-time job; it is rather a continuous
job which means adhering to the warm chain principle. A warm chain is a system of keeping a baby warm
immediately after delivery, wherever it occurs (at a health facility or the mother’s home), during
transportation and while feeding and caring for the baby. The components of the warm chain are listed as
follows.
Components of the warm chain
- Drying and wrapping the baby immediately at birth.

- Keeping the baby warm during any procedure, including resuscitation.
- Keeping the immediate newborn in skin-to-skin contact with the mother.
- Early initiation of breastfeeding within one hour of the birth; the warm milk and contact
with the mother's body helps to keep the newborn baby warm.
- Postponing bathing the newborn for the first 24 hours.
- Keeping the baby warm during transportation.
- Dressing the baby in appropriate clothing and bedding at all times.
The warm chain principle has to be maintained for all babies, but special care should be taken to keep
preterm and low birth weight babies warm.
Hypoglycemia
This is the commonest acquired metabolic disorder. The management of the neonate is important as any
prolonged or recurrent hypoglycemia can result in mental retardation and permanent neurological
damage.
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In term infants, hypoglycemia occurs when blood glucose is 40mg/dl, within the first 3days of life and
45mg/dl after 3days. The fetus stores glucose as glycogen in the liver and muscles and as subcutaneous
tissue& body fat in third trimester. After birth, the baby must make metabolic adjustment to maintain
normal blood glucose. To meet the baby’s energy needs during the initial hours after birth, hepatic
glycogen is released and the neonate is able to use fatty acids as an alternative energy source.
Etiology
 Decreased stores
- Prematurity
- Intrauterine growth retardation
- Starvation
 Hyperinsulinism
- Infant of DM mother
- Erythroblastosis (Rhesus hemolytic disease)
- Islet cell hyperplasia or hyperfunction
- Insulin producing tumors and inborn metabolic errors
- Maternal tocolytic therapy with beta sympathomimetic agents
 Other causes
- Sepsis, shock and asphyxia
- Hypothermia, glycogen storage disease and galactosemia
- Adrenal insufficiency and CNS hemorrhage
 Iatrogenic causes
- Cessation of hypertonic glucose infusions
- Exchange transfusions
Clinical signs of hypoglycemia
Many infants are asymptomatic, particularly the preterm. Common signs described are:
- Tremors and jittery movements

- Hypotonia and lethargy
- Poor feeding and refusal to suck
- Apnea and cyanosis
- Seizures and weak or high pitched cry
Management –effective mgt of the baby’s feeding and temperature control will help to prevent
hypoglycemia. Blood glucose screening, using whole blood obtained by capillary heel stab, must be done.
Early oral or gavage feeding with 10% glucose water every 2hours until blood glucose levels are stable
and then wean to breast or formula.
Minimize calorie expenditures by minimizing stress and keeping the baby warm. The prognosis is good
unless the hypoglycemia has been prolonged over days.
Neonatal sepsis
Neonatal sepsis is a blood infection that occurs in an infant younger than 90 days old. Early-onset sepsis
is seen in the first week of life occurs after 1 week and before 3 months of age.
Causes
Neonatal sepsis can be caused by bacteria such as Escherichia coli (E.coli), Listeria, and some strains of
streptococcus. Group B streptococcus (GBS) has been a major cause of neonatal sepsis. However, this
48
problem has become less common because women are screened during pregnancy. The herpes simplex
virus (HSV) can also cause a severe infection in a newborn baby. This happens most often when the
mother is newly infected.
Early-onset neonatal sepsis most often appears within 24 hours of birth. The baby gets the infection from
the mother before or during delivery. The following increase an infant's risk of early-onset bacterial
sepsis:
GBS colonization during pregnancy

Preterm delivery
Water breaking (rupture of membranes) longer than 18 hours before birth
Infection of the placenta tissues and amniotic fluid (chorioamnionitis)
Babies with late-onset neonatal sepsis are infected after delivery. The following increase an infant's risk
of sepsis after delivery:
Having a catheter in a blood vessel for a long time

Staying in the hospital for an extended period of time
Symptoms
Infants with neonatal sepsis may have the following symptoms:
Body temperature changes

Breathing problems
Diarrhea or decreased bowel movements
Low blood sugar
Reduced movements
Reduced sucking
Seizures
Slow or fast heart rate
Swollen belly area
Vomiting
Exams and Tests
Lab tests can help diagnose neonatal sepsis and identify the cause of the infection. Blood tests may
include:
Blood culture
C-reactive protein
Complete blood count (CBC)
If a baby has symptoms of sepsis, a lumbar puncture (spinal tap) will be done to look at the spinal fluid
for bacteria. Skin, stool, and urine cultures may be done for herpes virus, especially if the mother has a
history of infection.
A chest x-ray will be done if the baby has a cough or problems breathing.
Urine culture tests are done in babies older than a few days.
Treatment
49
Babies younger than 4 weeks old who have fever or other signs of infection are started on intravenous
(IV) antibiotics right away. (It may take 24 to 72 hours to get lab results.) Newborns whose mothers had
chorioamnionitis or who may be at high risk for other reasons will also get IV antibiotics at first, even if
they have no symptoms.
The baby will get antibiotics for up to 3 weeks if bacteria are found in the blood or spinal fluid. Treatment
will be shorter if no bacteria are found.
An antiviral medicine called acyclovir will be used for infections that may be caused by HSV. Older
babies who have normal lab results and have only a fever may not be given antibiotics. Instead, the child
may be able to leave the hospital and come back for checkups.
Babies who need treatment and have already gone home after birth will most often be admitted to the
hospital for monitoring.Yellow skin and whites of the eyes (jaundice)
Possible Complications
Complications may include:
 Disability
 Death
 When to Contact a Medical Professional
 Seek medical help right away for an infant that shows symptoms of neonatal sepsis.
Prevention
Pregnant women may need preventive antibiotics if they have:
Chorioamnionitis
Group B strep colonization
Given birth in the past to a baby with sepsis caused by bacteria
Other things that can help prevent sepsis include:
Preventing and treating infections in mothers, including HSV

Providing a clean place for birth
Delivering the baby within 12 to 24 hours of when the membranes break (Cesarean delivery should
be done in women within 4 to 6 hours or sooner of membranes breaking.)
Information sheet 2 Integrated Management of New born and Child Illness
What is IMC I( Integrated Management of Childhood Illness )?

IMCI is an integrated approach to child health that focuses on the well-being of the whole child. IMCI
aims to reduce death, illness and disability, and to promote improved growth and development among
children under five years of age. IMCI includes both preventive and curative elements that are
implemented by families and communities as well as by health facilities.
The strategy includes three main components:
 Improving case management skills of health-care staff

 Improving overall health systems
50
 Improving family and community health practices.
The IMNCI case management process is presented on two different sets of charts: one for managing sick
young infants aged from birth up to two months and a separate one for managing sick children aged from
two months up to five years. First decide which chart to use depending on the age of the child. Up to five
years means the child has not yet had his or her fifth birthday. If the child is not yet two months of age,
the child is considered a young infant. A child who is two months old would be in the group two months
up to five years, not in the group birth up to two months. When you look the IMNCI chart booklet you
will see the different charts for the two age groups.
Since management of the young infant aged from birth up to two months is somewhat different from the
management of older infants and children, it is described on a different chart:
Assess, classify and treat the sick young infant.
The case management process for sick children aged two months up to five years is presented on three
charts:
 Assess and classify the sick child

 Treat the child
 Counsel the mother
For each visit, when you see the mother, or the child’s caregiver, with the sick child:
Greet the mother appropriately and ask about the child

Take the child’s weight and temperature and record the measurements
Ask the mother what the child’s problems are
Determine if this is an initial or follow-up visit for this problem.
General danger signs (GDS)
Since IMNCI takes a holistic approach to assessing, classifying and treating childhood illnesses it is
important to look for general danger signs as well as symptoms and signs of specific childhood
illnesses.
The general danger signs are signs of serious illness that are seen in children aged two months up
to five years and will need immediate action to save the life of the child.
Information sheet 3 Prevention of different parasite
Prevention of different parasite

Parasitic infection or infestation can occur in children of all ages. Infants, toddlers, and very young
children in day care settings are at risk for the parasitic disease called giardiasis that causes diarrhea and
is spread through contaminated feces. Pinworm infection (enterobiasis) also occurs among preschool and
young school-age children. Both preschool and school-age children can become infested with head lice
51
(pediculosis) or scabies, both of which are spread by close person-to-person contact as is common during
childhood play.
Children of all ages can develop parasitic diseases such as giardiasis and cryptosporidiosis from
swallowing contaminated water during swimming, playing, and other activities in contaminated
recreational water (e.g. pools, fountains, lakes, rivers and streams, etc.). Pets and other animals can be a
potential source of parasites that can affect children. Toxoplasmosis is spread by ingesting soil or litter-
box contents with infectious cat feces. Children can also be born with this infection if their mother was
infected during pregnancy.
Malaria
Children under 5 years of age are one of most vulnerable groups affected by malaria. There were an
estimated 438 000 malaria deaths around the world in 2015, of which approximately 69% were in
children under 5 years of age.
hildren in malaria-endemic countries are at high risk of the ill effects of malaria infection. The majority of
the world's malaria deaths are in African children under 5 years of age.
. Children should be sure to take antimalarial drugs before, during, and after the trip, use repellant, sleep
under an insecticide-treated bed net or in an air-conditioned room, and wear protective clothing.
WHO recommends the following package of interventions for the prevention and treatment of
malaria in children:
use of long-lasting insecticidal nets (LLINs);
in areas with highly seasonal transmission of the Sahel sub-region of Africa, seasonal malaria
chemoprevention (SMC) for children aged between 3 and 59 months;
in areas of moderate-to-high transmission in sub-Saharan Africa, intermittent preventive therapy for
infants (IPTi), except in areas where WHO recommends administration of SMC;
prompt diagnosis and effective treatment of malaria infections.
Prevention of anemia
Iron deficiency can cause anemia, a shortage of hemoglobin in the blood. This can lead to weakness,
fatigue, a pale face and earlobes, and brittle, spoon-shaped nails. There are other causes of anemia besides
nutritional deficiencies, including massive or chronic blood loss.
. Normal hemoglobin values are:
infants and children 11 to 13 grams
women 12 to 16 grams
men 14 to 18 grams
You can prevent iron-deficiency anemia by making wise food choices
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1,Breastfeed your baby as long as possible. Once upon a time it was believed that breastfed babies needed
iron supplements because human milk was low in iron. Yet, breastfed babies studied at four to six months
of age had a higher hemoglobin than infants who were fed iron-fortified formula. Breastfed babies have
been found to have sufficient iron stores for nine months or longer. Human milk remains an important
part of baby’s diet, even after the introduction of solids.
2.Use an iron-fortified formula. If bottle feeding, use an iron-fortified formula, preferably beginning at
birth, but at least starting by three months of age. Continue iron-fortified formula for at least one year or
as long as baby’s doctor recommends, which is usually until infant is eating adequate amounts of other
dietary sources of iron. Do not use “low-iron” formulas, which do not contain sufficient iron for a
growing baby’s needs.
3.Delay cow’s milk feeding for infants; limit it for toddlers. The Committee on Nutrition of the American
Academy of Pediatrics recommends that parents delay using cow’s milk as a beverage until a baby is at
least one year of age. There are two iron-related reasons for this: cow’s milk is low in iron, and cow’s
milk can irritate the intestinal lining, causing bleeding and the loss of iron. This is a tiny amount of blood
loss, but over a long period of time it can be significant. The combination of poor iron intake and
increased iron loss sets a baby up for iron deficiency anemia, and excessive milk consumption is a
common cause of iron deficiency anemia in toddlers. An eighteen-month-old who consumes forty ounces
of milk a day may be plump, but is probably very pale. Unless advised otherwise by your baby’s doctor,
limit your toddler’s cow milk intake to no more than 24 ounces a day.
Combine foods wisely. Eating a food rich in vitamin C along with a good iron source will help your body
use the iron. Here are some classic examples:
spaghetti with meat and tomato sauce
meat and potatoes
chicken fajitas with broccoli, sweet pepper, and tomatoes
hamburger and coleslaw
nitrate-free hot dogs and orange juice
fruit, iron-fortified cereal, and raisins
fresh fruit with raisins
4.Try prune juice as a regular beverage. Prune juice is one of the few juices that is high in iron (3
milligrams of iron per cup). The process involved in making prune juice retains more of the fruit’s
original nutrients than the juicing of other fruits.
NUTRITIP
Don’t Skin the Iron
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Leave the skin on the potatoes when making homemade fries. This way you’ll get more nutrition into a
french-fry-loving picky eater. The potato skin is rich in nutrients and contains five times the amount of
iron as the whole rest of the potato. Compliment those restaurants who have the nutritional wisdom to
leave the skins on the fries. And, don’t forget to eat the skin on your baked potato.
5.Cook in iron pots. The acid in foods seems to pull some of the iron out of the cast-iron pots. Simmering
acidic foods, such as tomato sauce, in an iron pot can increase the iron content of the brew more than ten-
fold. Cooking foods containing other acids, such as vinegar, red wine, lemon or lime juice, in an iron pot
can also increase the iron content of the final mixture.
6.Bake with iron-rich grains. The usual wheat used to make bread and pastries is relatively low in iron
(around one milligram of iron per half cup). Lesser known grains, such as amaranth (8 milligrams per half
cup) and quinoa (9 milligrams per half cup) are much richer in iron. Barley grains contain four milligrams
of iron per half cup. Mixing these grains into the wheat flour you use when you bake will increase the
iron content of the finished product.
1.How can you prevent different parasits?

2.Wha is the different b/n physiologic and pathologic jaundice?
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3. what is the cause for physiologic jaundice?

4. what is the complication and its mgt of jaundice?
5. What is neonatal hypoglycemia and its cause?
6.classify neonatal sepsis
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INTRODUCTION LO 7 Advice and counseling on post partum care &

hygiene
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 Immunizatiion
 Low birth weight
 Danger sign, during puerperium to Mother and newborn
Learning Activities
Information sheet 1 Preterm and Low Birth Weight Babies
Preterm and Low Birth Weight Babies

We will explain the many reasons why they need special care, and how to give it, and also how to counsel
mothers and other family members on looking after them. The focus is on managing the problems of
feeding preterm and low birth weight babies, and of keeping them warm. In particular, you will learn
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about a relatively recent and highly successful method of maintaining the body heat of early or tiny
babies, known as Kangaroo Mother Care (KMC).
Why do preterm or low birth weight babies need special care?
Preterm and low birth weight babies are at increased risk of dying from hypothermia, infection,
breathing problems and immaturity of their vital organs. As a result they may be unable to adapt to
life outside the uterus. The key reasons why they need special care are summarized as follow:
Characteristics of preterm and low birth weight babies
- Parts of their nervous system are not yet well developed.

- They have little fat under the skin; especially their brown fat is low. Brown fat is very
important to generate heat for the newborn baby; it is found mainly over the shoulders,
back, kidneys, neck and armpits.
- They lie very still so they can't generate heat by moving much.
- They have a high ratio of surface area to body weight compared to that of a child or adult,
so they lose heat quickly from their skin.
- They have immature lungs so they have breathing problems.
- They don't have much immunity so they will be extra vulnerable to infection.
- The veins in their brain are thin and immature and are prone to bleeding.
- They may be too weak to feed well.
An example of why preterm and low birth weight babies need special care is that they have a very poor
resistance to fight infectious disease, because their immune system is not yet well developed. Therefore,
on top of what is required for all babies, you and the mother need to be meticulous about hygiene and
other infection prevention measures. Everyone who handles the baby should wash their hands very
thoroughly first and handle the baby very carefully. You can easily damage the soft and thin immature
skin of the preterm or low birth weight baby, creating an entry point for infection.
Classification of preterm and low birth weight babies
The lower the birth weight and gestational age of the newborn, the higher the risk of complications and
death and the more special care the newborn needs.
The special care they will need should take into account the classification of early and tiny babies, as
described below.
Classification on birth weight
In relation to birth weight, most preterm babies are low birth weight or very low birth weight, as
classified below:
- Low birth weight: Babies born with birth weight between 1,500-2,499 gm. These babies
can usually be managed safely at home with some extra care and support.
- Very low birth weight: Babies born with birth weight less than 1,500 gm. A life-
threatening problem in such tiny babies is that suckling, swallowing and breathing are not
well coordinated, so they require special attention in order to feed them adequately and
safely. They also have great difficulty in maintaining their body temperature, so they are
at increased risk of hypothermia. These babies need advanced life support and should be
referred immediately to a hospital with special care facilities for very tiny babies.
However, at the present time, such facility-based care may not be accessible to rural
families in some parts of Ethiopia.
Classification on gestational age
A premature baby is a baby born before 37 completed weeks of pregnancy.
Based on the gestational age, preterm babies are further classified as follows:
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 Preterm baby: Babies born between the gestational ages of 32-36 weeks of gestation, as
calculated from the mother’s last normal menstrual period (LNMP date). These babies can
usually be managed safely at home with some extra care and support.
 Very preterm baby: Babies born between the gestational ages of 28-31 weeks as calculated from
the LNMP date. Like very low birth weight babies and for the same reasons, they have problems
in feeding and maintaining their body temperature. If possible, they should be referred urgently
for specialist care at a hospital.
Counseling on how to feed preterm and low birth weight babies
The breast milk produced by the mothers of preterm babies+
is even more nutritious than the milk produced by mothers whose babies were born at full term.
Therefore, a preterm mother’s milk is the best milk for the preterm or low birth weight baby and it should
not be discarded, as no other milk can replace its benefits.
Breastfeeding and cup feeding
During the first week of the baby’s life, the mother needs extra support from you and from the family to
encourage her to initiate exclusive breastfeeding and maintain it until her tiny baby is able to suckle
without any problem.
Babies born between 34-36 weeks of gestation can usually suckle breast milk adequately, but very
preterm babies may have difficulty breastfeeding.
Breastfeeding a very preterm baby is a challenge. The frequency of feeding should be every two hours,
including through the night.
If babies born before 34 weeks cannot suckle adequately, they can be fed expressed breast milk using a
small very clean cup. Tiny or early babies who are able to suckle breast milk may also need feeding with
additional expressed breast milk from a cup occasionally, to make sure they are getting enough
nourishment. All babies who are on cup feeding have to be given around 60 ml/kg/day (that is 60 ml of
breast milk for every kilogram of the baby’s weight every day) and increase this by 20 ml/kg/day as the
baby demands more feeding.
Extremely preterm babies born before 32 weeks of gestation may not be able to breastfeed at all and need
to be started on intravenous fluids. This is one of the reasons why all babies less than 32 weeks of
gestation should be referred to health facilities immediately.
Tips to help a mother breastfeed a preterm or low birth weight baby
Express a few drops of milk on the baby’s lip to help the baby start feeding.
Offer the whole breast, not just the nipple, so the baby can get a good mouthful. Give the baby short rests
during a breastfeed; suckling is hard work for a preterm or tiny baby.
If the baby coughs, gags, or spits up milk when starting to breastfeed, the milk may be spurting out too
fast for the little baby. Teach the mother to take the baby off the breast if this happens. Hold the baby
against her chest until the baby can breathe well again. Then put it back to the breast after the first gush of
milk has passed.
If the preterm baby does not have enough energy to suck for long, or its sucking reflex is not strong
enough, teach the mother how to express her breast milk by hand and then feed it to the baby from a cup.
Expressing breast milk
Expressing breast milk can take 20-30 minutes or longer to start with, but it gets quicker with practice.
First tell the mother to wash her hands and her breasts with soap and water, and dry them with a very
clean towel. Then prepare a cleaned and boiled cup or jar with a wide opening. If she is unable to boil the
whole container, pour some boiling water into it and leave it there until just before she is ready to put
milk into it; then pour the water away.
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This will keep the milk safe from bacteria.

The mother should sit comfortably and lean slightly towards the container.
Show her how to hold the breast in a ‘C-hold’ (her hand is shaped like a big letter C. Press the thumb and
fingers back toward the chest wall, then role the thumb forward as if taking a thumb print, so that milk is
expressed from all areas of the breast. Express the milk from one breast for at least three to four minutes
until the flow slows and then shift to the other breast. Thinking about feeding her baby while she
expresses her milk may help the milk to flow out more easily.
Breast milk can be saved at room temperature for up to six hours if the room is not very hot and the milk
is stored in a sterilized container. Or it can be stored for longer in a refrigerator, if the mother has one.
Wherever it is stored the milk must be warmed to body temperature before it is fed to the baby. To warm
up the stored breast milk, put the container to stand for a while in a bowl of warm water. Never boil breast
milk! Boiling destroys nutrients and antibodies.
Show mothers how to cup feed the baby
Show the mother and other family members how to hold the baby closely sitting a little upright. Hold a
small very clean cup half-filled with expressed breast milk to the baby’s lower lip. When the baby
becomes awake and opens its mouth, keep the cup at the baby’s lips letting the baby take the milk slowly.
Give the baby time to swallow and rest between sips.
When the baby takes enough and refuses any more, put the baby up to the shoulder and ‘burp’ her or him
by rubbing the baby’s back to expel air that may have been swallowed with the milk.
■What are the special tips and skills about breastfeeding that you may need to explain or teach the mother
of a preterm baby?
□You should tell her about the importance of always using her own breast milk to feed the baby; putting a
few drops of milk onto the baby’s lip to encourage it to start suckling; how to express her breast milk and
store it safely; and how to cup feed the baby.
Special care to keep preterm and low birth weight babies warm
Preterm and low birth weight babies have great difficulty in maintaining their body temperature. They
very easily lose heat, and hypothermia is life threatening in their delicate condition. You should always
follow the warmchain principle for any baby, whatever its weight or age, but in addition, early and tiny
babies should get the following special care:
- Immediately after the birth, put the baby in skin-to-skin contact with the mother,
followed by Kangaroo Mother Care, which is described below.
- Extra blankets or any extra local cloth made of cotton are needed to cover both the
mother and the baby. An important thing to remember (which is often forgotten) is that
the baby’s head needs to be well covered. This is because more than 90% of the heat loss
is through the head if it is left uncovered.
- There should be an extra heat source in the room where the preterm baby is looked after.
- Delay bathing for at least 48 hours after delivery, and always use warm water.
- Initiate breastfeeding or cup feeding as early as possible and feed the baby at least every
two hours.
Kangaroo Mother Care
Kangaroo Mother Care (KMC), called after the way that kangaroos look after their young, has been
shown to be an extremely effective method of caring for preterm and low birth weight babies. It involves
holding a newborn in skin-to-skin contact, day and night, prone and upright on the chest of the mother, or
another responsible person if the mother is unable to do it all the time.
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Evidence from using KMC to support preterm and low birth weight babies shows that it results in greater
stability of the baby’s heart rate and breathing, lower rates of infection and better weight gain. In the
mother it results in increased breast milk supply, and she is more likely to succeed in exclusive
breastfeeding.
KMC procedures
After you have explained about the KMC procedures to the mother (or another KMC provider) you
should follow the steps:
Preparations for Kangaroo Mother Care
- Make sure the room is clean and warm.

- Provide privacy to the mother so she can open her clothing at the front, exposing her
breasts.
- Request the mother to sit or recline comfortably.
- Undress the baby gently, except for cap, nappy (diaper) and socks.
- Place the baby lying flat, facing the mother’s chest in an upright and extended posture,
between the mother’s breasts, in skin-to-skin contact.
- Turn the baby’s head to one side to keep the airways clear. Keep the baby in this position
for 24 hours every day except for brief breaks.
- Cover the baby with the mother’s shawl, or gown; wrap the baby mother together with an
added blanket, and put a cap on the baby’s head.
- Breastfeed the baby frequently, at least 8-12 times a day.
Reassure the mother that babies can receive most of the necessary daily care, including breastfeeding,
while in KMC. The baby is removed from the skin to- skin contact only for changing the diaper, general
body hygiene and cord care, and to assess the baby during your postnatal visit. It is only for the first three
to five days after the birth that the mother may need to lie in bed. Once the baby’s condition is stable, the
mother can walk and do her routine work while the baby is in KMC, and they can sleep together in KMC
at night
Checking the baby is OK in KMC
At every postnatal visit you should:
- Count the baby’s respiratory rate and make sure there is no fast breathing.
- Observe that the baby is breastfeeding optimally.
- Measure the baby’s temperature in the armpit and make sure it is normal.
- If everything is OK, reassure the family but tell them to send for you immediately if there
is any problem.
Counseling the family on the benefits of KMC
KMC may seem an unusual way of caring for the baby, so it is very important that you allow time for
counseling the mother, the father and the family about what it entails, as well as about its benefits. She
(and they) will need to be convinced and willing to undertake KMC for several days continuously. And
the father and other members of the family will need to be ready to provide the necessary emotional and
physical support to the mother while she is giving KMC.
So, what are the benefits of KMC?
- Breastfeeding: KMC increases breastfeeding rates as well as increasing the duration of

breastfeeding.
- Thermal control: Prolonged skin-to-skin contact between the mother and her preterm/low
birth weight newborn provides effective temperature control with a reduced risk of
hypothermia.
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- Early weight gain: Tiny babies gain more weight on KMC than on conventional postnatal
care.
- Less morbidity: Babies receiving KMC have more regular breathing and are less likely to
stop breathing. It also protects her baby against infection.
Of course it may not be possible for all mothers to take on KMC. You will need to satisfy yourself that
the mother does not have any complications or medical illness which would mean that she is not strong
enough to manage it on her own. If that is the case you should explore whether the father or another close
member of the family might share the KMC with the mother, or give KMC exclusively if the mother is ill.
Finally, mothers who have successfully managed to give KMC have increased confidence and a deep
satisfaction that they are able to do something so special for their tiny baby.
How long should KMC continue?
When the mother and baby are comfortable with the process, KMC should continue for as long as
possible, or until the gestational age reaches term
(40 weeks) or the baby’s weight reaches 2,500 gm. But if the baby weighs more than 1,800 gm and its
temperature is stable, there are no respiratory problems and the baby is feeding well, it can be safely
weaned from KMC before 40 weeks. And when the baby has had enough of being in KMC, it starts to
communicate with the mother in its own ways, by wriggling, by moving a lot, pulling their limbs out of
the wrapping and by crying until they are removed from the wrapping.
Finally, if you follow all these guidelines and help your families with preterm or low birth weight babies
to care for them, you are sure to save some young lives. And what could be better than that!
Information sheet 2 IMMUNIZATION
IMMUNIZATION
- Immunity-is the resistance of the body against disease producing agent.
- Immunization-is the production of immunity by artificial means or
-is the process by which an individual’s immune system

becomes fortified gains an agent (known as the immunogenic).
-Immunogenicity-is the property that enables a substance to provoke an immune response.
 The most important elements of the immune system that are important by immunization are B-
cell and T-cells (and their antibodies they produce)
 Memory B-cells and memory T-cells are responsible for swift response to a second encounter
to foreign molecule
 Vaccine –is an antigen design to induce immunity against a particular pathogen. It is production
of antibodies
 Vaccination is the administration of any vaccine or toxoid for prevention of disease. It is an
active form of immunization,
1) Immunity divided into two
1.1) Congenital /innate /non-specific immunity
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-is the natural resistance of the body

E.g.-skin, mucus membrane, secretion, coughing, sneezing
Acquired /specific immunity
Acquired or specific immunity divided in to two

Active acquired immunity
 The child body makes its own antibody

 It is long lasting immunity
1.2.2 –Passive acquired immunity
 The child gets ready made antibodies

 Short live immunity
 Begins to work very quickly.
 1.2.1 Active acquired immunity divided in two
A) Naturally acquired active immunity
The child makes immunity after exposure to a disease.
B) Artificial acquired active immunity
 The child develop antibodies after administration of antigen/vaccine

1.2.2 Passive acquired immunity divided in to two.
A) Natural acquired passive immunity
 Trans-placental transferred material antibodies in the body of the child.

E.g. TT vaccine for the mothe
B) Artificial acquired passive immunity.
 Formed antibodies are administered to the child

e.g T.A.T
Determinants of the immune response

The nature and magnitude of the response to vaccine or toxoid depends on the following factors:
Age –presence of high concentration of maternal antibody and immature response to some
vaccines in the first four months of life impair immunization. The measles vaccine is given at
9months of age to reduce this effect.
- Rout of administration –vaccines given orally induce mucosal secretion of IgA e.g. OPV
vaccine
- Using an improper route to administer the vaccine may reduce the immune response e.g. BCG
is administer ID rather than IM
- Nature of vaccine –live attenuated vaccines induce immunity with a single dose which lasts
longer than inactivated ones
- Genetic –individuals genetically vary in their ability to respond to the same vaccine
- Potency –ensuring the potency of a vaccine, especially live attenuated, requires keeping the
cold chain. This helps to determine the quality of EPI program
- vaccine-preventable diseases and the vaccines in use to prevent them:
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- • Diphtheria
- • Hib Disease
- • Hepatitis B
- • Measles
- • Pertussis (whooping cough)
- • Polio
- • Tetanus
- • Tuberculosis
- • Yellow fever
- Vitamin A deficiency (VAD), which is being addressed as part of national
- immunization programs in many developing countries
Types of vaccine
1. Live attenuated infectious agent
o Virus: E.g. Oral Polio Vaccine (OPV), Measles, Yellow fever

o Bacteria: E.g. BCG
2. Inactivated toxic vaccine
Whole cell:
Virus : Inactivated polio vaccine (IPV)
Bacteria: whole cell pertussis
Fractional:
Protein based
Sub unit: accelular pertussis
Toxoid : Tetanus, dephtheria
Polysaccharide based: Pure-meningococcal
Conjugated Haemophilus influenza type b (Hib), Pneumoccocal conjugate vaccine (PCV)
3.Recombinant: Hepatitis b.
 Organisms in live attenuated vaccines multiply in the recipient until the desired immune
responses occur, similar to that which occurs in natural infection. Thus, live –attenuated viral
vaccines (measles, mumps) are likely to confer lifelong protection with a single immunization
dose, In contrast many in activated or killed vaccines which have lesser antigenic mass, requires
booster vaccinations to provide protection.
 Responses of individuals to the same vaccine vary/differ because the immune response to specific
antigen is genetically determined.
 The nature and magnitude of the response to vaccine are determined by many factor, including:
 Chemical and physical state of the antigen
 Mode of administration
 Catabolic rate of antigen
 Host factor (age, nutrition, gender, and preexisting antibodies)
 Antigen processing and genetic determinant of the host.
Contra indication
1. Don’t give BCG to an infant that has S/S of ADIS

2. Anaphylaxis /hypersensitivity reaction in previous dose.
Target group for EPI
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 All<1 years old child

 All women of child bearing age (15-49) years
Diphtheria
 Diphtheria is a bacterial infection causedby Corynebacterium diphtheriae. The infection can
involve almost any mucous membrane, but the most common sites of infection are the tonsils and
pharynx. This type of diphtheria can lead to obstructed breathing and death. In tropical countries,
the disease usually affects the skin (cutaneous diphtheria) and may result in high levels of natural
immunity against respiratory diphtheria. In its tonsillar and pharyngeal form, diphtheria infection
results in the formation of a bluish-white membrane that can cover the back of the throat.
The membrane causes gagging and difficulty in swallowing and breathing.
Treatment – Diphtheria antitoxin and antibiotics (erythromycin or penicillin) are prescribed for
suspected diphtheria. Cases are isolated and contacts are vaccinated with diphtheria toxoid to prevent
additional cases. People in close contact with diphtheria patients should also be given antibiotics.
Diphtheria Toxoid
The most effective way to control diphtheria is to prevent it through immunization of children in their
first year of life with three doses of diphtheria toxoid, in the trivalent presentation of diphtheria, tetanus,
and pertussis (DTP). Diphtheria toxoid can also be used to immunize adults during outbreaks.
What is DPT vaccine?
 Made from diphtheria toxoid, tetanus toxoid and Pertusis killed vaccine
 Is liquid vaccine
 DPT vaccine should never frozen
 The “shake test’’ will determine if the vaccine has been damaged by freezing.
What is its potential side effect?
 Usually reaction to DPT vaccine are mild .S/E include:
Fever -Up to half of the children complain fever in the evening
The fever should disappear within a day.
Soreness-up to half of the children may have pain, redness or swelling at the injection site.
Convulsion (related to fever) =>1:12500
 Anaphylactic reactions are extremely rare

Administration summary of DPT vaccine
Contraindications – There are no contraindications to DTP except that it

should not be given to children who have suffered a severe reaction to a previous dose.
DPT-HepB-Hib combination (Pentavalent Vaccine)
DPT-HepB+Hib vaccine is called a pentavalent vaccine that protects against five diseases: diphtheria,
tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b. it is a liquid vaccine that does not need
reconstitution. It is given three times at the age of 6, 10 and 14 weeks of age of infants.
Characteristics, Schedule and Administration of DPT-HepB-Hib combination vaccine

Type of vaccine Pentavalent vaccine
Number of doses Three
Schedule 6, 10, 14 weeks of age
Contraindications Do not use as a birth dose
Mild local and systemic reactions like soreness, redness or swelling are common
Adverse reactions
but usually subside within one to three days. Mild fever
Special precautions* Do not use as a birth dose, usually not given over 6 years of age
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Dosage 0.5ml
Injection site Left outer mid-thigh
Injection type Intramuscular
Storage Store between 2°C–8°C. Never freeze
*DPT-HepB-Hib is combination vaccine therefore it cannot be given as birth dose because of its
DPT component
Measles
It is an acute viral infection characterized by a varietyof symptoms, including fever, rash, cough,
conjunctivitis, diarrhea, ear infections, pneumonia, and brain inflammation.
Measles vaccine
Measle vaccine is provided as a powder with diluents in a separate vial. Before it can be used it must be
reconstituted
The reconstituted vaccine must be discarded after 6 hr end of immunization session
Complaint and side effect
Soreness – few experiences pain and tenderness at the injection site within 24 hrs but it can resolve
within 2 to 3 days
Fever – 5% develops moderate fever 5-12 days after receiving
Rash- 1:20 develops mild rash 5-12 days after receiving severe reaction
 Anaphylaxis -1:1,000,00
 Severe allegic1:100,000
 Thrombocytopenia 1:30,000
 Encephalitis 1:1,000,000
Characteristics, schedule and administration of measles vaccine
Type of vaccine Live attenuated viral

Number of doses One dose. Second opportunity not less than one month after first dose
Schedule 9–11 months of age
Booster A second opportunity for measles immunization is recommended (routine or
campaign)
Contraindications Severe reaction to previous dose; immune disorders (not HIV infection)
Adverse reactions Malaise, fever, rash 5–12 days later; rarely, encephalitis, anaphylaxis
Special precautions None
Dosage 0.5ml
Injection site Left upper arm
Injection type Subcutaneous
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Storage Store between 2°C–8°C (vaccine maybe frozen for long-term storage but not the
diluent)
- Infants at high risk (HIV-infected, in closed communities such as refugee camps, or in the presence of
an outbreak) may receive a dose at 6 months of age followed by an extra dose at 9 months.
- Measles vaccine is reconstituted as powder with a diluent in a separate vial. It must be reconstituted
only with the diluent from the manufacturer before it can be used. Any remaining reconstituted vaccine
must be discarded after 6hrs/end of the session whichever comes first.
1.4 Tuberculosis (TB)

Tuberculosis (TB) is caused by the bacterium Mycobacterium tuberculosis which usually attacks the
lungs, but can also affect other parts of the body, including the bones, joints, and brain. Not everyone who
is infected with tuberculosis bacteria develops the disease. People who are infected may not feel ill and
may have no symptoms. The infection can last for a lifetime, but the infected person may never develop
the disease itself. People who are infected but who do not develop the disease do not spread the infection
to others.
Prevention: Immunization of infants with Bacille Calmette-Guérin vaccine (BCG) can protect against
TB meningitis and other severe forms of TB in children less than five years old. BCG vaccine is not
recommended after 12 months of age because the protection provided is variable and less certain
Characteristics, Schedule and Administration of BCG vaccine
Type of vaccine Live attenuated bacterial

Number of doses One
Schedule At or as soon as possible after birth
Contraindications Symptomatic HIV infection
Adverse reactions* Local abscess, regional lymphadenitis; rarely, distant spread to osteomyelitis,
disseminated disease
Special precautions Correct intradermal administration is essential. A special AD syringe is used for the
administration of BCG vaccine
Dosage 0.05ml
Injection site Outer upper right arm or shoulder
Injection type Intradermal
Storage Store between 2°C–8°C (vaccine maybe frozen for long-term storage but not the
diluent)
*Swelling, abscess, lymphadenitis occurs due to unsterile technique, injection under the skin or too much
vaccine was injected
** BCG vaccine should be discarded six hours after reconstitution or at the end of a session, which ever
comes first.
1.5 Pneumococcal disease

Pneumococcus is a bacterium that causes a group of diseases called Pneumococcal disease. This includes
severe ones such as pneumonia, meningitis, bacteraemia, and milder diseases such as middle ear infection
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(otitis media), sinusitis and bronchitis.
Prevention: Immunization of children with Pneumococcal Conjugated Vaccine (PCV) can prevent
pneumococcal diseases, Pneumococcal pneumonia, pneumococcal meningitis, other Invasive
Pneumococcal diseases (Pneumococcal bacteremia and septicemia) and mild pneumococcal infection
such as otitis media.
Ethiopia has introduced PCV 10 a liquid vaccine that is given in three doses with similar schedule with
pentavalent vaccine at 6 , 10, and 14 weeks of age. The vaccine is given on the right upper outer thigh
(0.5ml intramuscularly).
. Characteristics, Schedule and Administration of PCV vaccine

Type of vaccine Conjugated vaccine (ten serotypes)
Number of doses Three
Schedule 6, 10, 14 weeks of age
Infants who have had severe allergic reactions to a prior dose or any component of the
Contraindications vaccine.
Mild local and systemic reactions like soreness, redness or swelling are common
Adverse reactions
but usually subside within one to three days. Mild fever
Dosage 0.5ml
Injection site Right upper outer thigh
Injection type Intramuscular
Storage Store between 2°C–8°C. Never freeze
All opened vials (vials without the cap and its VVM) must be discarded 6 hours from first opening or at
the end of each session, whichever comes first.
Rotavirus disease
Rotavirus disease is a diarrheal disease caused by a virus called rotavirus. Rotavirus is the most common
cause of severe diarrheal disease in infants and young children worldwide. Diarrheal disease is one of the
leading causes of under five mortality accounting for an estimated annual death of 1.8 million <5 years
age children globally. In Ethiopia, diarrheal diseases are among the top leading cause of under five
mortality, and it is estimated approximately 28,000 children die each year of Rotavirus infections.
Clinical manifestation
 Rotavirus disease is characterized by diarrhea, vomiting and fever, and may lead to severe
dehydration and death.
 Death is usually caused by dehydration due to rotavirus gastroenteritis.
 Diarrhea is defined as watery or loose stools three times per day or more than the usual frequency
for the individual.
Prevention: The preventive package highlights five main elements:-
 Promotion of early and exclusive breastfeeding and vitamin A supplementation
 Promotion of hand washing with soap
 Improved water supply quantity and quality including treatment and safe storage of household
water
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 Community-wide sanitation promotion.

 Rotavirus vaccination.
Rotarix vaccine:
The best way to protect babies from rotavirus disease is vaccination with rotavirus vaccine.
There are two brands of rotavirus vaccine: RotaTeq TM and RotarixTM. Both vaccines are effective
and safe. Government of Ethiopia has planned to introduce the Rotarix TM vaccine by late 2013.

 Rotavirus vaccine is a liquid vaccine for oral use. It comes in a tube specially designed for direct
oral administration. 1vial = 1 dose. 1 tube has 1.5mL liquid. The rotavirus vaccine must be
given to babies orally, which means swallowed and not injected.

 Table 1.8. Characteristics, Schedule and Administration of Rotarix vaccine
Type of vaccine Live, attenuated
Number of doses Two
Schedule 6, 10 weeks of age
Hypersensitivity after previous administration of rotavirus vaccines
Contraindications
Previous history of intussusceptions
Children may be more irritable and have loss of appetite. Some children may also
Adverse reactions experience fever, fatigue, diarrhea, and vomiting
Dosage 1 tube (1.5ml), Only for oral use

Storage Store between 2°C–8°C. Do NOT freeze
Polio
Polio is a disease of the central nervous system caused by three closely related polioviruses:
types 1, 2, and 3. Approximately 5% of people exposed to any of these viruses have influenza-like
symptoms such as fever, loose stool, sore throat, headache, or upset stomach. Some may have pain or
stiffness in the neck, back, and legs, and 1% become paralyzed .
paralytic polio, severe muscle pains follow the milder symptoms, and then paralysis develops, usually in
the first week of illness. The use of one or both legs or arms may be lost, and breathing without a
respirator may become impossible. People with these severe symptoms can, but do not always,
recover. Prior to the eradication initiative, polio was the leading cause of lameness worldwide .
Oral polio vaccine (OPV) protects against the virus that causes polio. It is a liquid vaccine that is provided
in two types of containers:
 Small plastic dropper bottles

 Glass vials with droppers in a separate plastic bag.
WHO does not — as of July 2003 — recommend the adoption of IPV, either alone or in a sequential
schedule, in developing countries for the following reasons: unresolved issues related to the
immunogenicity of IPV when administered at birth, six, ten and 14 weeks of age in the EPI vaccination
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schedule, the continued focal circulation of wild poliovirus on two continents, the relatively high cost of
IPV and the operational complexities of introducing a vaccine which requires syringes and needles, while
OPV is given orally.
Oral polio vaccine (OPV) protects against the virus that causes polio. It is a liquid vaccine that is provided
in two types of containers:
There is a very small risk of vaccine-associated paralytic polio (VAPP), with approximately two to four
cases having been reported for every one million children immunized.
Administration summary: OPV
Type of vaccine Live oral polio vaccine (OPV)
Number of doses Four in endemic countries (including birth dose)

Schedule At birth*, 6, 10, 14 weeks
Booster Supplementary doses given during polio eradication activities
Contraindications None
Adverse reactions VAPP very rarely (approximately 2 to 4 cases per million children
vaccinated)
Special precautions Children known to have rare congenital immune deficiency

syndromes should receive IPV rather than OPV.
Dosage 2 drops
Injection site –
Injection type –
Storage Store between 2°C–8°C ( maybe frozen for long-term storage)
* for polio endemic countries
1. Meningococcal Vaccine
What is meningococcal vaccine?
There are two vaccines widely available that protect against different types of meningococcal
meningitis. One protects against types A, C, Y, and W-135 of the disease, while the second protects
against types A and C. A third trivalent A, C, W conjugate vaccine is currently being used in a small
number of countries but should become more widely available soon. The conjugate vaccine links the
polysaccharide to a protein carrier. This enables the vaccine to be more immunogenic in infants and
induces an immunological memory which gives longer-lasting protection.
The vaccines are packaged as a powder with diluent in single and multi-dose vials. The vaccine forms a
clear liquid when reconstituted.
How safe is meningococcal vaccine and what are its potential side-effects?
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Mild reactions include:
Soreness. Some people experience redness or pain at the injection site. These symptoms usually last
one to two days.
Fever. A small percentage of people who receive the vaccine develop a fever.
Severe adverse reactions, including allergic reactions (anaphylaxis, urticaria, wheeze, angioedema),
somnolence and neurological reactions (e.g., seizures, paraesthesia and anaesthesia), have been
reported very rarely.
Administration summary: Meningococcal vaccine
Type of vaccine Purified bacterial capsular polysaccharide (AC, AC/W135, Y)
Number of doses One
Schedule Not less than three months; older than three years recommended
Booster Every three to five years
Contraindication Severe adverse reaction to previous dose
Adverse reactions Occasional mild local reaction, mild fever
Special precautions Children aged under two years of age are not protected by the
vaccine
Dosage 0.5 ml
Injection site Upper arm
Storage Store between 2°C–8° C
2. Yellow fever (YF) vaccine

What is YF vaccine?
Yellow fever vaccine is recommended as part of the routine national immunization programme in
countries where the disease is endemic. The vaccine is a powder that must be reconstituted with diluent
provided before use (see Module 7). It is essential that only the diluent supplied with the vaccine be
used.
Reconstituted vaccine must be kept at 2ºC–8°C and discarded after six hours or at the end of the
immunization session, whichever comes first.
70
How safe is YF vaccine and what are its potential side-effects?
Mild reactions to the vaccine include:
Headache, muscle pain, or mild fever. Fewer than 5% of people who receive YF vaccine develop these
symptoms.
Serious side-effects resulting from immunization are rare. About 5–20 cases of anaphylaxis have been
reported for every one million doses of YF vaccine; the rate of true anaphylaxis is likely to be much
lower. Up to four cases of encephalitis per 100 000 doses have been reported in infants less than six
months old for whom the vaccine is not routinely recommended. If a serious reaction does occur, health
workers should report the problem to supervisors immediately. Those who have a severe reaction
should not receive additional doses.
Administration summary: YF vaccine
Type of vaccine Live viral

Number of doses One dose
Schedule 9 months of age with measles vaccine
Booster International health regulations require a booster every 10 years
Contraindications Egg allergy; immune deficiency from medication or disease;
symptomatic HIV infection; hypersensitivity to previous dose;
pregnancy a
Adverse reactions Hypersensitivity to egg; rarely, encephalitis in the very young; hepatic
failure. Rare reports of death from massive organ failure
Special precautions Do not give before six months of age; avoid during pregnancy
Dosage 0.5ml
Injection site Upper right arm
Storage Store between 2°C–8°C
All children in developing countries diagnosed with measles should receive two doses of vitamin A
supplements given 24 hours apart. Giving Vitamin A can help prevent eye damage and blindness.
Vitamin A supplementation reduces the number of deaths from measles by 50 %.
Vitamin A treatment dosage
Age Immediately on Next day Follow-up

diagnosis
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Infants less than 6 months old 50 000 IU 50 000 IU Third dose 2–4
weeks later if there
are signs of
Infants aged 6–11 months 100 000 IU 100 000 IU xerophthalmia
Children aged 12 months and 200 000 IU 200 000 IU

over
Tetanus toxoid vaccine
 It protects against tetanus & neonatal tetanus

 Provides as liquid form
 It is available in different formulation :TT, DPT, DT, Td
 Its antibody pass through placenta
 TT/Td/DT/DPT vaccines should never be frozen
TT immunization schedule for pregnant women
Dose of TT or Td When to give Expected duration of protection
TT-1 At first contact or as early as possible None

during pregnancy
TT-2 At least 4 wks after TT1 1-3 years
TT-3 At least 6 months after TT -2 5 years
TT4 At least 1 year after TT3 10 years
TT-5 At least 1 years after TT4 For all child bearing years or
longer
Vaccine, vaccine preventable diseases and vaccine preparation
Name of Prevention of Diseases Form Preparation

Vaccine
BCG Tuberculosis freeze dried 20 dose
OPV Polio liquid 10 dose

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Measles Measles freeze dried 10 dose
Penta valent Diphtheria, Pertussis (Whooping Cough), liquid

Tetanus, Hepatitis – B and H.Influenzae-b 1 dose
TT Tetanus liquid 10 dose
PCV10 Pneumococcal diseases liquid 2 dose
Rotarix Rotavirus infections liquid 1 dose
Vaccine Summary
National Immunization Schedule for Infants and women of child bearing age
Vaccine When to give Dose Route Site
BCG At birth or as early as possible till one 0.05ml Intra-dermal Right Upper Arm
year of age
Measles 9 completed months 0.5 ml Subcutaneous Left Upper Arm
Pentavalent1,2, At 6 weeks, 10 weeks & 14 weeks 0.5 ml Intra- Antero-lateral side of

3 muscular left mid-thigh
OPV0 At birth or as early as possible within 2 drops Mouth

the first 15 days
OPV1,2,3 At 6 weeks, 10 weeks & 14 weeks 2 drops Mouth
PCV 1,2,3 At 6 weeks, 10 weeks & 14 weeks 0.5 ml Intra- Antero-lateral side of
muscular right mid-thigh
Rotarix 1, 2 At 6 weeks and 10 weeks 1.5 ml Mouth
TT 1,2,3,4,5 At first contact, 4 weeks after TT1, 6 0.5 ml Intra- Left Upper Arm
months after TT2, one year after TT3 muscular
and one year after TT4
The cold chain

Vaccines are sensitive to heat and freezing and must be kept at the correct temperature from the time
they are manufacture until they are used. The system used for keeping and distributing vaccines in good
condition is called cold chain
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NB. Manufacturer national air port central vaccine storage Regional store zonal store
health center health post mother / child
Heat sensitive vaccine – OPV, measle & BCG
Cold sensitive vaccine –DPT, TT, DT.
Cold chain equipment
1. Refrigerators :
 It can be powered by electricity ,gas, kerosene or solar energy
 Should be able to hold a one month supply of vaccine and diluents
 Half of the total space in the refrigerator should be left empty to allow air to circulate
around the vaccines to keep them cool
 It can be 1. Front loading refrigerator
2. Ice lined refrigerator
2. Cold boxes
It is an insulated container that can be lined with cool water packs to keep the vaccine & diluent
cool (2-7days)
Cold boxes are used to:
1/ Transport monthly vaccine from district store to health facility
2/ Store vaccines when the refrigerator is out of order

3. Vaccine carriers
 Is like a cold box insulated container lined with frozen ice pack
 It keeps vaccines and diluents cold during transportation and /or temporary storage
 It has 48 hrs a maximum cold life if they did closed
4. Foam pads
 Foam pad is a piece of soft foam that fits on the top of cool water packs in a vaccine
carrier .There are some incision on it to allow vaccines to be inserted in the foam
 During immunization session the foam pad serves as a temporary lid to keep opened
inside the carrier, while providing a surface to hold protect and keep cool opened
vaccine vials
5. Ice- packs / cool water packs
- Are flat square plastic filled with water & frozen
- Used to keep vaccines cool inside the vaccine carrier & cold box
- Every health facilities should have minimum two set of ice packs
for each of their cold box and vaccine carrier one in the process
being frozen and the other one is in a cold box or vaccine carrier
Information sheet 3 Danger signals Of mother and newborn
danger signals, during puerperium for the mother (ACHES)

 A=Abdominal pain
 C=Chest pain
 H=Head ache
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 E=Eye problem
 S=Sever leg pain
Teach about danger signs for the newborn
Remember always to be vigilant, observant and gentle while assessing and managing a newborn baby,
especially during the first few days of life. And always be alert to the potential presence of the key danger
signs during the whole of the time you are with the mother and newborn.
General danger signs in newborns
-History of difficulty feeding or unable to feed now, ask the mother about the baby’s
feeding pattern.
- Histories of convulsion or convulsing now; ask the mother, has the baby had any fits?
- Newborn seems lethargic or unconscious.
- Movement only when stimulated.
- Fast breathing<=30 or >=60 breaths/minute, grunting, blue tongue& lips or gasping
- Severe lower chest in-drawing and fever.
- Hypothermia (baby is cold to the touch or axillary temperature<35 0C).
- Baby developed yellowish discoloration before 24 hours or >2wks of age; jaundice
observed on the palms of the hands and soles of the feet.
- There is red swelling of the eyes or eye discharge.
- Umbilicus is draining pus.
- More than 10 pustules (spots) are found on the skin.
- Feels hot to touch or axillary temperature >37.5oC and pale and bleeding
 Vomiting, no stool and swollen abdomen
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1.list all vaccine preventable illness

2.list daniger sign of newborn and mother
3 .what are the target group for immunization?
4.classify birth weight
5.what is KMC and its function?
6. write those group who are contraindication for BCG
7. what is the difference b/n passive and active immunity/
Answer sheet
1________________________
_________________________
_________________________
_________________________
2________________________
________________________
________________________
_______________________
3______________________
_______________________
________________________
________________________
4_______________________
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________________________
_______________________
5______________________
______________________
______________________
6_____________________
______________________
7____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
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INTRODUCTION LO 8; ABNORMAL PUERPRIUM
 Abnormal Puerprium
Learning Activities
Then, accomplish “Summary self-check questions in L08”. However, if you’re rating is
Information sheet 1 ABNORMAL PUERPRIUM
1. PROVIDING CARE FOR A MOTHER WITH PURERPERAL SEPSIS

Puerperal sepsis is any bacterial infection of the genital tract which occurs after the birth of a baby. It is
usually more than 24 hours after delivery before the symptoms and signs appear. If, however, the woman
has had prolonged rupture of membranes or a prolonged labour without prophylactic antibiotics, then the
disease may become evident earlier. It is a temperature elevation of 38 degree centigrade or more
78
occurring at least twice after the first 24 hours and before the 10 post partum day until 6 wks of
delivery or abortion.
- Site of infection include: the endometrium, breast tissue, perineal or abdominal wounds and the
venous system.
Causative organisms
- Arises as a result of the invasion, incubation and multiplication of an organism.
- The infection in the uterus is usually due to retained products of conception where the laws of
sterility have not been observed.Induced abortion is the main cause
- Interference during delivery
- low sterility technique
- Prolonged labour
- Early rupture of the membrane
- Microrganisms
- Puerperal sepsis is more likely to occur in the following women in whom bacteria could have
been introduced in to the genital tract during delivery.
 Women who had premature rupture of membrane & delivery was delayed
 Women who had instrumental or operative delivery.
 Women whose resistance to infection has broken down e.g DM, anaemia,
 Women who got dehydrated during labour
 Women who had severe haemorrhage or shock
- Some of the most common bacteria are:
- streptococci
- staphylococci
- Escherichia coli (E.coli)
- Clostridium tetani
- clostridium welchii
- Chlamydia
- Gonococci (bacteria which cause sexually transmitted diseases).
- More than one type of bacteria may be involved when a woman develops puerperal sepsis.
- Bacteria may be either endogenous or exogenous.
- Endogenous bacteria These are bacteria which normally live in the vagina and rectum without
causing harm (e.g. some types of streptococci and staphylococci, E.coli, clostridium welchii).
- Even when a clean technique is used for delivery, infection can still occur from endogenous
bacteria.
- Endogenous bacteria can become harmful and cause infection if:
- they are carried into the uterus, usually from the vagina, by the examining finger or by
instruments during pelvic examinations
- there is tissue damage, i.e. bruised, lacerated or dead tissue (e.g. after a traumatic delivery or
following obstructed labour)
- There is prolonged rupture of membranes because microorganisms can then enter the uterus.
- Exogenous bacteria These are bacteria which are introduced into the vagina from the outside
(streptococci, staphylococci, clostridium tetani, etc.).
- Exogenous bacteria can be introduced into the vagina:
- By unclean hands and unsterile instruments
- By droplet infection (e.g. a health provider sneezing, coughing onto own hands immediately prior
to examination)
- by foreign substances that are inserted into the vagina (e.g. herbs, oil, cloth)
- By sexual activity.
79
- Students should be aware of the problem of postpartum tetanus and sexually transmitted
diseases which are both caused by exogenous bacteria.
Risk factors for puerperal sepsis

Most common complications of puerperium occurring in 1-3% of vaginal deliveries& 25-50% of
c/s deliveries.
Route of deliveries
Prolonged rupture of membranes >12 hrs.
Prolonged labour
Multiple pelvic examinations
Chorioamnionitis
Intrauterine manipulations like manual removal
Remnants of placenta and genital lacerations
Systemic factor immune suppressive.
Some women are more vulnerable to puerperal sepsis, includingfor example those who are
anaemic and/or malnourished. For example, protracted labour, prolonged rupture of the
membranes, frequent vaginal examinations, a traumatic delivery, caesarean section and retained
placental fragments all predispose to puerperal infection.
Symptoms and signs of puerperal sepsis
The following symptoms and signs occur in puerperal sepsis:
- fever (temperature of 38°C or more)

- chills and general malaise
- lower abdominal pain and tender uterus
- Sub-involution of the uterus
- Purulent, foul-smelling lochia.
- Light vaginal bleeding and shock.
Types of puerperal sepsis
A. Localized: - involving the vulva and vagina (swabs or tampons left inside), episiotomy
or endometritis.
B. Generalized: - Spreading to the tubes (salpingitis) cellulites.

- Spreading to the peritoneum → peritonitis
- Spreading to the blood stream → septicemia
S/S: - Cardinal signs

A. Early raised temperature persisting for 24hours > 37 oC – Raised pulse rate 120/minute
B. late – Sub-involution
- Offensive lochia foul smelling
- increased WBC count
Investigations: - Physical examination to exclude all other infections like throat, Breast,
lungs, legs.
- High vaginal swab
- Blood (RBC), Hgb, WBC count and culture
1- Endomyometritis
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.It is infection of the endometrium and myometrium

.It is the commonest form of puerperal sepsis
.If untreated it progresses to pelvic peritonitis and generalized peritonitis, pelvic abscess,
septicemia and thrombophlebitis.
Symptoms like fever, profuse or malodors lochia, lower abdominal pain.
.Temperature of >38oC, tachycardia, lower abdominal tenderness and uterine tenderness with
sub involution.
. Laboratory investigations reveal leukocytosis.
Management
- All cases should be admitted
- Start broad spectrum antibiotics and continued until the patient is fever free for 24-48 hours.
- If there is RPC the uterus should be evacuated.
- Resuscitation with IV fluids, anti-pyretic and bed rest.
- Isolate the patient as this infection spreads quickly
- Antibiotics usually ampcillin until culture is back. Cloxacillin usually the most effective
antibiotics.
- Analgesics and antipyretics
Nursing Care
- Isolation of the pt
A clean and an infected patient should not be nursed at the same time
All the utensils should be separated
The room should be disinfected after discharge
- Antibiotics and analgesics according to the Dr’s order
- Iv fluid administration
- NGT and aspiration
- Input and output charge
- Care for pressure area
- Mouth care
- Bed bath
- Bladder catheterization
- Bowels: - Supposition or enema if there is constipation
- Room should be clean
Observation
- Vital signs or To, RR, PR every 4hrs
- Report any rise in temperature
- Mental status
- Sleep and appetite
- Fluid balance sheet
Complications
- Pelvic and generalized peritonitis, pelvic abscess, thrombophlebitis, septic shock and late
complication infertility and ectopic pregnancy.
Preventions
- Aseptic technique during procedure
- Avoid traumatic delivery
81
- Avoiding repeated pelvic examinations

- Preventing prolonged labour
- Proper third stage management
- Treating systemic illness and nutritional deficiency.
2- Wound infection
It includes episiotomy site infections, infections of lower genital tract tears and abdominal wound
infections after c/s or laparotomy.
Episiotomy site infection present with persistent pain and offensive discharge from the site.
Abdominal wound infection includes persistent pain, over the wound and tender indurated, swollen
and reddened wound edges with fever.
Management
- Removal of sutures and drain abscess if any.
- Provision of local wound care with antiseptic solutions
- Antibiotics indicated only if there are systemic signs of infections
- Secondary closure may be needed after signs of infection have cleared.
Signs & symptoms
- Sub-involution offensive lochia(1st sign)
- uterus became bulky ,painful & tender
Later:-
 pyrexia over37oC (high sweating fever and occasionally rigrs & chills)
 pulse rate of 120 and over
 foul smelling lochia
 severe abdominal tenderness
 raised WBC count
Investigation:-
- History of labour
- Physical examination
- High vaginal swab
- Blood WBC count.
Management
1-isolate pt this infection spreads quickly
2-antibiotics, usually Ampicilline, cloxacillne is also the most effective antibiotic.
3-Analgeric & antipyretic
The infection may be
1- localized involving the vulva, vagina, endometrium & episiotomy site
2- generalized by spreading to the uterus, peritoneum and old stream
If spread of infection occurs like Salpingitis, peritonitis, septicaemia,

- The is a very sick pt who needs good care and much kindness
- It is often seen in mothers who has been admitted to hospital with rusted(reddish) uterus C/s
after being many days in labour or after criminal abortion.
Nursing care:-
1-isolate the Patient
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2- Antibiotic &analgesics
3-Intraventous fluid
4- Intake& output balance
5- Frequent change of position (prevent decubitus)
6- General patient hygiene
HOW PUERPERAL SEPSIS OCCURS
The uterine infection may start before the onset of labour i.e. in cases of pre-labour rupture of the
membranes, during labour, or in the early postnatal period before healing of lacerations in the genital tract
and the placental site have taken place.
In cases of pre-labour rupture of membranes, antibiotics should be given either to treat amnionitis, if the
woman has fever and foulsmelling vaginal discharge, or as a prophylactic measure to reduce the risk of
infection.
Following delivery, puerperal sepsis may be localized in the perineum, vagina, cervix or uterus. Infection
of the uterus can spread rapidly if due to virulent organisms, or if the mother’s resistance is impaired. It
can extend beyond the uterus to involve the fallopian tubes and ovaries, to the pelvic cellular tissue
causing Thrombophlebitis of the uterine veins can transport infected clots to other organs. Severe
infection can be further complicated by septic shock and coagulation failure which gives rise to bleeding
problems. Puerperal sepsis can be rapidly fatal.
Women are particularly vulnerable to infection in the postpartum period because of the following factors:
1. The placental site is large, warm, dark and moist. This allows bacteria to grow very
quickly. It is an ideal medium to culture bacteria. In the laboratory, warm, dark and moist
conditions are produced artificially in order to help bacteria grow and multiply.
2. The placental site has a rich blood supply, with large blood vessels leading directly into
the main venous circulation. This allows bacteria in the placental site to move very
quickly into the bloodstream. This is called septicemia. Septicemia can lead to death very
quickly.
3. The placental site is accessible via the genital tract to both endogenous and exogenous
microorganisms. Only the vagina (7–10 cm long) separates the entrance to the uterus
from the vulva and perineum. Therefore, high standards of vulval and perineal cleanliness
during labour and after delivery are essential to prevent harmful bacteria (e.g. E.coli from
the rectum) from entering the uterus and causing metritis.
4. During the actual birth, women may have sustained tears in the cervix, vagina or perineal
area or have had an episiotomy. These areas of traumatized tissue are susceptible to
infection, especially if the aseptic technique during vaginal examinations and at delivery
was poor, and the situation is exacerbated by poor standards of perineal and vulval
cleanliness in the early postnatal period. Infection is usually localized initially, but can
spread to underlying and surrounding tissues and into the bloodstream, causing
septicemia.
OTHER CAUSES OF FEVER IN THE POSTPARTUM PERIOD

Fever in the puerperium can also be caused by:
- urinary tract infection (acute pyelonephritis)

- wound infection (e.g. scar of caesarean section)
- mastitis or breast abscess
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- thrombo-embolic disorders, e.g. thrombophlebitis or deep vein thrombosis

- respiratory tract infections (pneumonia)
- other medical conditions, such as malaria and typhoid
- human immune deficiency virus (HIV)-related infections.
Puerperal pyrexia: - is a temperature of 38oC occurring within 14days of delivery or
abortion.
Causes: - Puerperal sepsis or genital tract infection
- Breast and urinary tract infection

- Thromboembolic disorders and wound infection (C/S)
- None infectious disorders e.g. breast engorgement
- Pyelitis: - Acute inflammation of the pelvis of the kidney, caused by bacterial infection.
- cystitis:- inflammation of the urinary bladder
- Mastitis or breast abscess
Puerperal eclampsia: - is the onset of convulsion during puerperium: Occurs 48-72hrs after delivery
S/S – Elevated blood pressure
- edema of the legs, and feet, puffiness of the face
- Albumin urea
- Severe headache
- Epigastric pain and nausea
- Convulsion and coma
- Rapid pulse and bounding
- Raised temperature
Treatment: - Prevent patient from injury
- Clear air way
- Mouth spatula to prevent the tongue from biting (before convulsion)
- Relieve vasoconstriction
- Promote diuresis
- Sedatives as ordered by physician
- If severe- tracheal intubation may be required
Nursing/midwife Care: - Similar with eclampsia under abnormal pregnancy
Postpartum tetanus: -is infection of the mother or baby caused by clostridium tetani. Tetanus bacilli,
which grow in the intestines of animals and humans, are particularly prevalent in rural areas. They are
found in soil and dust and are spread by animal and human faeces. The organisms enter the body through
a laceration or break in the skin. In the case of puerperal sepsis, they may enter via lacerations of the
genital tract or through the unhealed placental site. In some countries, it is the practice to place herbs or
other substances that may be infected into the vagina during or after labour, in the mistaken belief that it
will be helpful. In babies, the point of entry is often the umbilical cord, especially if it is cut with a dirty
instrument, or in some cultures, herbs or cow dung are used to dress the cord.
Tetanus is an acute and often fatal disease, but it can be prevented by immunization. All women in
pregnancy should have their immunization status checked and be given a course of tetanus toxoid, if not
fully immunized. The schedule for immunization is as follows:
- First contact with women of childbearing age: Tetanus toxoid 1 (TT1)

- At least 4 weeks after TT1: Tetanus toxoid 2 (TT2)
- At least 6 months after TT2: Tetanus toxoid 3 (TT3)
- At least 1 year after TT3: Tetanus toxoid 4 (TT4)
- At least 1 year after TT4: Tetanus toxoid 5 (TT5)
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In areas where sexually transmitted infections(STIs) (e.g. gonorrhea and chlamydial infection) are
common, they cause many uterine infections. If a woman develops a STI during pregnancy and it remains
untreated, the microorganisms causing the disease will stay in the genital tract and may cause a uterine
infection after delivery. Uterine infections caused by STIs can be prevented by diagnosis of the condition
and implementing the appropriate treatment during pregnancy.
Psychiatric disorders in the postnatal period
Psychiatric disorders are relatively common after childbirth and may include postpartum ‘blues’,
postpartum depression (PPD), and postpartum psychosis.
-This is when the pt is mentally disturbed during the puerperium especially the first 2wks.
Puerperal and labour may place a great strain on the women and the result of this can have either
depression or mentally illness.
Postpartum ‘blues’ and postpartum depression
Hormone changes are thought to be the cause of postpartum blues, a mild, transient, self-limiting disorder
(it resolves on its own), which commonly arises during the first few days after delivery, and lasts up to
two weeks. It is characterized by signs of sadness, crying, anxiety, irritation, restlessness, mood
swings, headache, confusion, forgetfulness, and insomnia. It rarely has much effect on the woman’s
ability to function, or care for her baby.
Providing loving support, care and education has been shown to have a positive effect on recovery.
Loving support can help women to recover from postpartum ‘blues’.
But if women develops a serious postpartum depression (persistent sadness, low mood, difficulty in
finding motivation to do anything), it will greatly affect her ability to complete the normal activities
associated with daily living. Cases of depression need attention from trained mental health professionals
for supportive care and reassurance, so refer the woman as soon as you can. The role of the patient’s
family is also very important in the course of treatment. Women with high levels of depression are less
likely to initiate breastfeeding soon after the birth, and their babies are more likely to have episodes of
illness such as diarrhea.
■Can you suggest why the baby might be affected in this way?
□If breastfeeding is not commenced successfully the woman may bottle feed the baby with formula milk,
which carries a greater risk of infection to the baby from unclean bottles. A depressed mother may also
not take notice of health education messages about preventing infection in her newborn.
If two or more of the following symptoms occur during the first two weeks of the puerperium, refer the
mother:
- Inappropriate guilt or negative feelings towards herself

- Cries easily
- Decreased interest or pleasure
- Feels tired and agitated all the time
- Disturbed sleep, sleeping too much or sleeping too little
- Diminished ability to think or concentrate, Marked loss of appetite.
- There may also be episodes of postpartum psychosis, marked by delusions or

hallucinations – seeing or believing things that are not real.
Early signs: - Persistent insomnia for no apparent reason
- The night duty should check if the mother sleeps at night, otherwise report to the doctor.
Later sign: - Patient does not like nurse or Doctor or husband or all of them
85
- Becomes restless, refused, food, becomes emaciates

 Post partum blues or depression should not be mixed up with mental illness
Rx: - Reassurance, don’t leave her alone
- Remove her baby, she may harm him/her
- Remove everything that can harm her self
- Sedation according to Dr’s order
Depression or mental illness
Early sign:-
- persistent insomnia for no apparent reason
- it is the duty of the night nurse to check if the mother sleep at night and if not to report it and give
sedative ordered by doctor
Later signs
- pt does not like nurse or doctor or husband or all of them.
- She may become restless and have incorrect speech
- She refuses food and often become emaciated
Treatment:- Reassure her don’t leave her alone.
- Remove her baby (she may harm him)

- Remove anything that can harm herself
- Report to doctor who orders sedative
NB- “post partum depression” or” post partum blues” or “3 rd day blue” must not be mixed up with mental
illness.
Infections of genital tract
Vulval haematoma: it is a swelling containing a collection of blood on the vulva or labia, caused by
ruptured varicose vein or trauma.
Management:
o The clot may have to be evacuated and the area sutured or packed and sutured later
o If haematoma is small, not infected, not painful and not increasing in size, it can be left alone and it
will be absorbed by itself.
Vulval infection:-
N.B:- Vulval irritation is often caused by clothes being washed by strong soap, irritation is sometimes
caused by vaginal discharge; this irritation is not an infection.
Chlamydia
o A newly found bacterial infection which is sexually transmitted
o One species causes trachoma in tropical climates and is responsible for many causes of non specific
urethritis and ophtalmia neonatorem
Symptoms: - burning discharge
Treatment: - tetracycline (TTC)
Syphilitic condyloma
 This condyloma is highly infectious and patient should be put on treatment at once, usually penicillin
 Condyloma:- growth usually found on the vulva
Vulval viral warts:-
Wart: - a small hard benign growth on the skin
These are caused by virus, are not contagious, and can spread extensively during pregnancy
Treatment: - hygiene; it may disappear with this, if not they can be removed by electric cautery or surgery
under general anaesthesia.
86
Purities vulvae:-
 It is a distressing condition; it makes the pt. want to scratch the vulva.
Causes: - there are many causes:
 Conditions associated with vaginal discharge
 Scabies
 Pediculosis
 Tread worms
 Systemic conditions: - e.g. Glycosuria in DM.
 Local allergy from closing, soap and cosmetics
 Urinary and faecal incontinence
 Obstructive jaundice
Diagnosis: - History, P/E, Lab investigación
Lab investigation includes:-
 Urine examination for sugar and bile salts
 Serum bilirubin if jaundice is present
 Microscopic examination of any genital discharge
Treatment: - Find and treat the cause, but if you can’t find the cause refer to hospital.
Bartholin’s abscess and Bartholin’s cyst
Bartholin’s abscess:-
 The two Bartholin’s glands lie posterior and laterally on either side of vaginal orifice.
 Their secretion which pass through the Bartholin’s ducts opening on the inner side of the labium
minora, lubricate the vagina during sexual intercourse.
 The glands and their ducts are often infected in acute conditions such as gonorrhoea.
 The ducts get blocked and abscess of the gland forms.
S/S:
Pain full swelling at the vaginal entry
Marked oedema of the labium minus on the affected side
A tender shiny mass in the posterior part of the labium majus.
There might be fluctuation in the abscess
The pt. may have a vaginal discharge and fever, generalized malaise
The abscess may rupture spontaneously, pt. gets relief but the abscess may from soon.
Management
 Refer the pt. to the hospital
 The RX is an operation called Marsupialization (an oval pieces of the skin over lying the swelling and
near the exit of the duct is cut out)
 The contents of the abscess are emptied and the edges of over sewn with fine cat gut
 The pus (specimen) is send to lab for gram staining and culture, sensitivity.
 Treat gonorrhoea and other infection found with antibiotics
Bartholin’s cyst: it is a condition caused by blockage of the duct of the gland, usually after the gland has
been infected or after a Bartholin’s abscess.
 The duct might also be damaged during an episiotomy. It lies in the labium majus.
S/S:-
 A swelling at the vaginal entry which is not painful
 A non tender oval swelling in the posterior one third of the labium majus
 The swelling is more movable beneath the skin on its anterior aspect than posteriorly
Management: - Refer the patient to hospital.
The management is Marsupialization: just as a Bartholin’s abscess.
Nursing/midwife care:
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 Providing pre, intera and post operative care

 Administering medication as ordered.
 Providing emotional support as other gynaecological problems.
Providing care for a mother with breast problem.
There are five common breast problems in the puerperium:
1-Breast engorgement
2 -Cracked & retracted nipple
3-Breast abscess
4-Failing lactation.
5- Mastitis
Breast engorgement
Definition:- Abnormal accumulation of milk in the breast due to excessive production of milk or
obstruction to out flow of milk or poor removal of milk by the baby.
This is where the ducts become blocked usually occur b/n 3 rd& 5th day and the milk cannot pass the
lymphatic’s become engorged and the breast become edematous.
-It usually manifests after the milk secretion states (3 rd or 4th postpartum day)
Symptoms - The breasts are full, hard and heavy due to venous and lymphatic engorgement and edema
-Breast feels tender, tense & firm
-Nipple becomes edematous & flushed
-The veins over the breast becomes engorged & prominent
-Pain full breast feeding.
-Increased body Temperature.
Prevention: -
- Clean and dry nipples properly after each feed
- Don’t let the baby suck for a long period during the 1st two days after delivery.
- Make sure that the baby’s mouth is on the nipple properly
- Express the breast during pregnancy so that the colostrum comes out
- This is done from the 36th wks and it clears the ducts.
Treatment:-If the nipples are cracked and sore take the baby off the breast for 48hrs, until the cracks are
healed.
- Express the milk and feed the baby with a cup of spoon
- Apply heat to the nipples TID(three times a day) for 20 → will help healing
- Zinc benzoic ointment
- Keeps baby at breast feeds
- Decrease fluid intake
- A binder will help to support the breast
- Doctor may order diuretics (like lasix 20 -40 mg) usually a singer dose.
Nursing/midwife care
-Support the breast with a binder or brassieres.
-Manual expression of any milk after each feeding & keeping the interval short b/n feeds.
-The cause of poor sucking by the baby should be corrected.
-Analgesics for pain.
Puerperal mastitis: - is an inflammation of the breast which is not treated may proceed to abscess
formation
- Common organism: - staphylococcus aurous.
- It is usually caused by either cracked nipples or engorged breasts.
88
Source of infection -The baby

-Out breaks of skin
Predisposing factors: -
- Multiplication of organisms in engorgement
- Bruising of the breast tissue
- Cracked nipple which permits the inflammation:-introduction of organism sometimes from the
baby’s nose.
S/S: - A sharp rise in temperature 38.3oC – 40oC with chills
- Rapid pulse
- Throbbing pain and tenderness in the breast
- A diffuse or wedge shaped indurated reddened area
- Generalized malaise with head ache and shivering
- The over laying skin is hot & flushed feels tense & tender.
- Sever pain & swelling on the guardant of the breast with its apex at the nipple.
Mgt: – Avoid acute arrangement and cracked nipples cleanliness of breasts, hands Prompt, recognition of
the early sign and immediate administration of antibiotics
Prophylaxis
-Support the breast with binder
-ANC to nipple
-Prevention of engorgement
-Isolation of the infected baby
Curative-Isolation of mother & baby
- Cloxacillin is the drug of choice

- Crystalline penicillin 5,000,000IU stat then 500,000 ID IU 4-6hrs.
- Suspension of breast feeding until the infection is controlled on the affected side.
- Manual expression of milk to prevent engorgement.
- Suppression of lactation by - bromocriptine 2.5mg Po for 14days.
- Antibiotics - cloxacilline 500mg Po qid for 7-10days.
- Crystalline penicillin 5,000,000IU stat then 500,000 ID IU 4-6hrs.
- A procaine penicillin 900,000 IU or 3me is then given daily
- Analgesics to reduce pain & to induce sleep
E.g. Codeine, panadol
Prevention:-
 Treat cracked nipple & engorged breast
 Keeps the breast with good hygiene
Breast Abscess – is the pus formation in the breast
-The breast is usually recognized by a triangular red area& fluctuated when you press it
-caused by neglected mastitis.
S/S -Pain, tenderness & indurations increases, the skin is red shiny and the breast much enlarged
- Fluctuation and alteration in vital sign
- Raise in temperature and sweating
- Rapid pulse and brawny edema
- Rigors are common
- Axially gland becomes tender & enlarged and edema
Mgt: - Isolation
- Incision and drainage
- Bacteriological examination of the pus
89
- Appropriate antibiotics
- Large dressing after incision in firmly
- Antipain as needed
Prevention
-Treat acute mastitis properly
Retracted nipple
 -Is common in primigravida

-If left uncorrected it may lead to difficulty in breast feeding & predispose to cracked nipple.
 Manually pulling out the retracted nipple during the last two month of pregnancy is
useful to rectify the defect.
 After delivery, the nipple is pulled out by the suction of disposable syringe.
 The procedure may have to be repeated for few days.
Cracked nipple
 The nipple may become painful due to loss of surface epithelium, with the formation of a
raw area on the nipple - called cracked nipple.
 This is when the nipple gets a cut in them caused by the baby while sucking and
predisposed to by lack of proper breast hygiene in prenatal time &which baby is feeding
Cause -In adequate hygiene resulting in the formation of a crust over the nipple
-Retracted nipple.
-Vigorous sucking & inadequate milk flow.
S/S -Soreness & pain at the site of fissure.
-If infected leads to mastitis.
 Prevention:-
- Rolling the nipple during pregnancy
- During puerperium not allowing baby to suck too long or to suck on empty breast
- warming breast before and after feeding to avoid crust which may cause cracking
- Local cleanliness during pregnancy & puerperium.
Rx Take baby off breast baby must be spoon fed

-Keep the nipple dry & exposed to air.
-Breast milk should removed by manual expression or pump.
-If infected apply antiseptic cream locally.
-Apply analgesic tincture of benzoin after the night feeding.
-If it fails to heal, breast feeding from an affected breast is stopped for 24 hrs.
-Apply either Nupercaine cream which has an antibiotic
-Analgesic for pain.
Failing lactation
Causes - Debilitating state of mother
-Elderly primigravida
-Depression (anxiety) state of mother
-Premature baby who is too weak to suck.
-Painful breast lesion.
-Failure to feed (suck) the baby regularly.
Rx
90
Antenatal -Health education about the advantage of breast feeding.

-Correction of abnormalities like retracted nipple.
-Proper breast hygiene especially in the last two months of pregnancy.
-Improving the general health status of the mother.
Postnatal -Encourage adequate fluid intake
-Nurse the baby regularly.
-treat painful lesion
-Give drug like prolactin (thyroid extract)
Sub-involution
Definition-is incomplete return of an organ (Uterus) to its non pregnant size & shape during puerperium.
It is a term applied when the uterus doesn’t contract properly to its normal size, the first day after
delivery. The fundus rises to the umbilicus then gradually shrinks about 1cm each day.
Causes: - Retained placenta
- Puerperal sepsis
- Prolonged labour
- Weak uterine muscle
- Grand- multiparty
- Endometritis
- Myoma - Interfering with the complete contraction of the ux.
Sign and symptoms: -
- Bulky and soft uterus
- Lochia is profuse and reddish brown
- The fundal height remains stationary for a few days
Prevention: - Make sure that the placenta is expelled & complete
- Put the baby to the breast as soon as possible, if both mother and the baby are normal.
- Keep the uterus well rub bed up and contracted after delivery
- Get the mother out of the bed the first day after delivery, provided that she is normal
Rx: - If there is retained product, massage the uterus and evacuate and curettage will be performed
Ergometrine 0.5mg tablets 1-2 times PO TID for a week or every 12 hrs to improve complete involution
of Uterus
-Antibiotics if the Uterus is tender on palpation.
-Ampicilline 500mg Po qid for 10-14 days.
Deep vein thrombosis (DVT)
Deep vein thrombosis (DVT)a blood clot, almost always is one of the deep veins in the legsis a rare
complication during the puerperium.
However, when it occurs it can be rapidly fatal if the clot breaks away from the vein in the leg and travels
to the heart, lungs or brain, blocking vital blood vessels.
The chance of developing a DVT is more common during pregnancy than in the non-pregnant state, and
the risk increases during the puerperium. Why deep veins in the legs develop clots (thrombosis) is not
exactly known.
However, the risk is much higher when the postnatal woman spends most of the time in bed and doesn’t
walk about much for several days after the birth.
In most parts of Ethiopia, the local custom is for postnatal women to remain in bed, with no activity
except a short walk to use the latrine. So it is important for you to identify the clinical features of DVT,
make a diagnosis and refer her to a hospital as early as possible. Pregnant women are at increased risk of
91
DVT b/c - hyper coagulable state of the blood. It is a condition when a clot formation in the venous
usually of the lower limbs
Clinical features of deep vein thrombosis (DVT)
- Pain in one leg only: usually sudden onset, persistent and aching type of pain.
- Tenderness: the area is painful when you touch it.
- Swelling: the affected leg is swollen with greater than 2 cm difference in circumference
compared to the other (healthy) leg. The swelling may be in the calf or the thigh.
- Palpable cord: you may feel a cord-like structure deep in the swollen leg.
- Change in limb colour: the affected leg appears a little bit red.
- Calf pain: she will feel pain when you try to do extreme extension at the ankle joint.
- Rarely bilateral and Fever
- Positive “Homan’s sign” - pain on dorsiflexion of the foot.
Rx -Immobilization of the leg & immediate referral.
-Anticoagulant – warfarin or Heparin
Throbophlebitis: - is an inflammation 2nd to a clot that has formed in superficial veins or varicose veins
as a result of stasis & hyper-coagulability state of blood during pregnancy & puerperium.
S/S- Reddened area over the vein is not due to infection but as a result of clot reaction
- Pain in the leg
- The area is firm on palpation from clotting lying in it
Mgt: - Bed rest

- Supportive bandage or elastic is warm
- Elevate the leg when sitting & exercise
- Analgesics e.g. Butazolidine
- Heparin or anticoagulant
Phelebothrombosis: - is a condition when a clot is formed in the deep vein of the calf of
femoral and some times in the iliac vein.
Causes: - After pelvic or abdominal operation
- Vein stasis (woman aged > 35years)
- High parity and - Obese
S/S pain and swelling

Danger: - Fragments can be detached and cause pulmonary embolus
- If the clots is large the artery is completely blocked and sudden death can occur
Mgt: - Anticoagulant e.g. Heparin
- Early ambulation or exercise
- Prevention of anemia
- Bed rest and anti pain until pain disappears
- Bed should be elevated
Pulmonary embolism: - is caused by clots that blocks the artery being traveled from the
veins in the pelvis or legs
S/S: - Pt may collapses and dies without warning
- Acute chest pain due to ischemia of the lung
- Blood stained sputum
- Cyanosis and collapse
- Dyspnea and hypotension
- Marked distress and respiratory failer& cardiac arrest
92
Mgt: - Call the physician urgently

- Pt will be propped up with pillows and O2 is given
- Anticoagulant therapy
- Administration of IV morphine
- Resuscitation if necessary
- Investigation → Chest cardiography
→E C G
93
1. What is throbophlebitis ?
2. what is the different b/n deep DVT and superficial DVT ?
3.What is the cause for peurperial sepsis?
4.What is pph and is cause?
5 What Puerperal mastitis and its mgt?
Note: satisfactory rating >= 50%; Unsatisfactory < 50%.
Answer sheet
1____________________________________________________________________________________
____________________________________________________________________________________
_______________
2____________________________________________________________________________________
_____________________________________
3____________________________________________________________________________________
_______________________________________
4____________________________________________________________________________________
_______________________________________________________
5____________________________________________________________________________________
____________________________________________________________________
-
94

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Post Natal Care

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Providing High Quality Postpartum Care for the Women and the Newborn

TVET-PROGRAMME TITLE: MIDWIFERY Level- IV

At the end of the module the learner will be able to:.

LO1. Provide comprehensive culturally sensitive post partum care

Lo8. Identify postpartum complications and manage accordingly

Introduction LO1;Postpartum Care

 Establish and support breast feeding Strategies

Information1 INTRODUCTION TO POSTNATAL

 1. Early detection and management of complications

1. Early detection and management of complications

2. Promoting health and preventing disease

3. Providing woman-centered education and counseling

During Puerperium the following will occur:-

Nutrition after childbirth

- Advise the mother to take micronutrient supplementation regularly to prevent deficiency

- Check her carefully for signs of blood loss or infection, or a hypertensive

Information Sheet 3 Establish and support breast feeding Strategies

Self check questions

1.what is postnatal care?

INTRODUCTION LO2; Schedules of participation in

 Follow up visit during postnatal

Information sheet 1 LO2; Schedules of participation in

Frequency and Timing

Provide four postnatal visits,

Self check questions

1.write all postnatal visit ?

3. write activity perform in each visit?

INTRODUCTION LO3;Physiology of post partum period

 Introduction to normal puerperium

INFORMATION Physiology of post partum period

1 Normal physiology of puerperium

A. Immediate – the first 6 - 24 hours

Room, linen and skin should be clean

Weight of Ux Postnatal week

300-350 gram End 2nd week

INFORMATION Normal and abnormal Lochia

-Contains less blood, more serum as well as leukocytes, wound exudates,

INFORMATION process of lactation and bonding, supporting the

- Following delivery the mother should be encouraged to

Self check questions

1.List type of lochia and characterize them

INTRODUCTION LO4:Demonstrates the skills needed to support the

 Provision of health education

Information sheet 1 Provision of health education

Provision of health education & demonstration

Uninterrupted (exclusive) breastfeeding

- Initiation of breastfeeding within one hour after birth (early breastfeeding).

Assessment of breast feeding

-Lack of knowledge about the advantage of breast feeding.

- Always readily available at proper temperature

- If the infant is not well attached

-It is not costy

Benefits to the mother of breastfeeding

Breast milk or formula

Information sheet 2 Standard infection prevention practices

Standard infection prevention practices according to the infection prevention guideline

 Promotion of a safety climate is a cornerstone of prevention of transmission of pathogens in

respiratory hygiene and cough etiquette

 Promote a safety climate.

 Develop policies which facilitate the implementation of infection control measures.

 Perform hand hygiene by means of hand rubbing or hand washing

indications, if resources permit, perform hand rubbing with an alcohol-based preparation.

 Ensure availability of hand-washing facilities with clean running water.