SBA - Presentation 5 (c)

Care after delivery:

Postpartum Care

Maternal Health Division

Ministry of Health & Family Welfare
Government of India
 Objectives
To learn
• Number and timing of postpartum visits for mother
and baby
• History-taking, examination, management and
counseling during postpartum visits
• Steps for referral and transfer of baby

Care after delivery: Postpartum Care 2

 Importance of Postpartum Care
• More than 60% of maternal deaths take
place during postpartum period
• First 48 hours are most crucial
• Most maternal and neonatal complications
occur during this period.

Care after delivery: Postpartum Care 3

 Postpartum visits by ANM/ASHA

Visits After delivery at home / sub centre After delivery at PHC/FRU

(woman discharged after 48 hrs)

First visit 1st day(within 24 hrs) Not applicable

Second visit 3rd day after delivery 3rd day after delivery

Third visit * 7th day after delivery 7th day after delivery

Fourth visit 6 weeks after delivery 6 weeks after delivery

* There should be three additional visits in case of babies with low birth weight, on days 14, 21 and 28
as per Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines.

Care after delivery: Postpartum Care 4

 First postpartum visit
Mother New born
• History • History
• Examination • Examination
• Management and Counseling • Newborn care
– Postpartum care and hygiene – Keeping baby warm
– Nutritional advice – Hygiene
– Rest – Cord care
– IFA supplementation – Breast feeding
– Contraception – Immunization
– Breast feeding
– Birth registration

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 First postpartum visit: Mother
History
• Place of delivery
• Initiation of breast feeding
• Any complaints :
Excessive bleeding
Abdominal pain
Convulsions
Loss of consciousness
Pain in legs , fever
Urinary retention
Difficulty in breathing
Foul smelling lochia
Care after delivery: Postpartum Care
Examination
• Pulse, BP, RR. Temp
• Pallor
• Abdomen : tender uterus, refer to FRU
• Vulva and perineum:
tear, swelling or pus,
refer to FRU after initial management
• Excessive bleeding P/V
refer to FRU after initial management
• Breast : lump, tender
refer to FRU
6
 First postpartum visit: Mother
Management / Counseling

1. Postpartum care and hygiene

Advise the mother to
• Wash perineum daily and after passing urine and stools
• Change perineal pads every 4 - 6 hours
• Wash hands frequently and take bath daily

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 First postpartum visit: Mother
Management / Counseling contd..

2. Nutritional Advice
• To increase intake of fluid and food especially iron and
protein rich foods like green leafy vegetables, jaggery, lentils,
eggs and meat
• Increase intake of milk and milk products like curd, cheese
etc

3. Advise adequate rest

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 First postpartum visit: Mother
Management / Counseling contd..

4. IFA Supplementation
• Women with normal Hb are advised to take 1 IFA tablet daily
for 3 months
• If Hb below 11 gm%, advise her to take 2 IFA tabs daily and
repeat Hb after 1 month

5. Contraception
• Counsel couple regarding contraception

Care after delivery: Postpartum Care 9

 First postpartum visit: Mother
Management / Counseling contd..

6. Breastfeeding
Advise the mother-
• For exclusive breast feeding on demand, at least 6 to 8 times
during day & 2-3 times during night

AVOID PRE- LACTEAL FEEDS

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 First postpartum visit: Mother
Breast feeding problems:

Cracked /sore nipples

Advise the mother:
• to apply hind milk for soothing effect
• ensure correct positioning and attachment of baby

Engorged breasts
Advise the mother:
• to continue breast feeding
• to put warm compresses
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 First postpartum visit: Mother
Registration of birth

Emphasize the importance of registration of birth

with local panchayat
• It is a legal document
• Required for many purposes

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 Postpartum period: danger signs
Woman should be counseled
to report to FRU if she has

• Fever
• Convulsions
• Excessive bleeding
• Severe abdominal pain
• Difficulty in breathing
• Foul smelling lochia

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 First postpartum visit for baby
History taking:
• Ask if breast feeding has been initiated
• Inquire whether the baby has passed urine and meconium
• Elicit h/o any problems in newborn

Refer to FRU if
• Not feeding well
• Cold to touch or fever
• Baby is lethargic or has had convulsions
• Difficulty in breathing

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 First postpartum visit for baby

Examination of newborn Refer to FRU

Cry and activity Poor cry
Lethargic / unconscious

Chest in drawing Severe chest in drawing is a sign of pneumonia

Respiration If <30 or ≥ 60 breaths /min

Central Cyanosis Bluish discoloration of tongue and lips

Body temperature If temperature is <35.5oC or > 37.4o C

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 First postpartum visit for baby

Examination of newborn Refer to FRU

Umbilical stump Any bleeding, redness or pus

Skin infection If ≥ 10 pustules or a big boil

Jaundice If appears in < 24 hrs of birth

Eyes Redness, discharge or swelling

Congenital malformation If present

and Birth injury

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 First postpartum visit for baby
Breast Feeding : Signs of good attachment
• Chin touching breast
• Mouth wide open
• Lower lip turned outward
• More areola visible above than below the mouth

A baby well attached to the breast A baby poorly attached to the breast

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 First postpartum visit for baby
Breast Feeding: Effects of poor attachment
• Pain and damage to nipples, leading to sore nipples
• Breast is not emptied completely, resulting in
breast engorgement
• Poor milk supply: baby not satisfied
• Poor weight gain of baby.

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 First postpartum visit for baby
Immunization of Newborn
Counsel mother on where and when
to take baby for immunization

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 2nd and 3rd visit for mother
On 3rd and 7th day following delivery

History taking:
As on first visit
In addition ask for history of
• Continued bleeding P/V, foul discharge P/V
• Swelling or tenderness of breast.
• Feeling unhappy or crying easily

Examination: Same as on 1st visit

Management and Counseling: Same as on 1st visit

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 2nd and 3rd visit for baby
History taking and Examination:
Same as in first visit

Management and Counseling:

In addition to counseling in first visit, advise the mother :
To exclusively breast feed for six months.
To wean at six months.

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 Fourth visit for mother
At 6 weeks following delivery

History taking:
Ask the mother for following:
• Has vaginal bleeding stopped?
• Has menstrual cycle returned?
• Is there any foul smelling vaginal discharge?
• Any problems regarding breast feeding?
• Any other complaints?
• Give relevant advice & refer to M.O. if needed

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 Fourth visit for mother
Examination:
Similar to examination during previous visit

Management and Counseling:

Diet and Rest:
Emphasize importance of nutrition as in second and third visit.

Contraception:
Emphasize importance of using contraceptive methods for
spacing and limiting family size

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 Fourth visit for baby
History taking:
Ask the mother about
• Vaccines received by baby so far
• Is baby taking breast feed well?
• Weight gain of baby
• Any other problem

Examination:
• Check weight of baby.
• General examination of baby

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 Fourth visit for baby
Management and Counseling:
Emphasize on exclusive breast feeding

Refer baby to F.R.U. if

• Not sucking well at breast
• Is lethargic / unconscious
• Has fever or is cold to touch
• Cord - swollen or discharge present
• Diarrhea, blood in stool
• Convulsions
• Difficulty in breathing
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 Key messages
Post partum care: Mother
• Make at least 4 postpartum visits for timely recognition
of complications like PPH, puerperal sepsis
• Advise mother on nutrition
• Advise mother on rest, hygiene, breast feeding and
contraception

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 Key messages
Post partum care: New born
Screen for danger signs in newborn

Advise the mother to

• Keep baby warm
• Take care of umbilicus, skin & eyes
• Give exclusive breast feeds
• Ensure correct positioning & attachment to breast
• Immunize the baby

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 Steps for transfer and referral of baby

Preparation:
• Explain reason for transferring baby to higher facility
• If possible transfer the mother with baby so that she can feed
the baby
• A health care worker should accompany baby
• Ask relative to accompany baby and mother

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 Steps for referral of baby
Communication:
• Fill up a referral form with baby’s essential information and
send it with baby
• If possible contact health care facility in advance

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 Steps for transfer of baby
Care during transfer:
• Keep baby in skin to skin contact with mother, if not possible
keep baby dressed and covered
• Ensure that baby receives feeds
• If baby gasping or respiratory rate <30 breaths /minute,
resuscitate baby using bag and mask

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Thank you

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