Objectives

1. Monitoring the woman and newborn during the first six hours postpartumName of presenter: Prevention of Postpartum Hemorrhage Initiative (POPPHI) ProjectBASICS

2. Objectives By the end of this session, participants will be able to: Identify principles of care to follow when providing care to the woman and newborn during the first 6 hours after childbirth. Describe how to integrate maternal and newborn care. Monitor the woman and newborn during the first 6 hours after childbirth.

3. Importance of monitoring the woman and newborn during the first 6 hours A large number of maternal and newborn deaths occur during the first few hours after the birth. AMTSL will only prevent up to 60% of PPH cases.

4. Principles of care when monitoring the woman and newborn during the first 6 hours postpartum (1) Ensure the room is warm and that there are no drafts. Monitor the woman and her newborn at the same time; always remember to check the baby when you check the mother, and vice versa. Document all findings, treatments, and care provided. Keep the woman and the newborn in the delivery room for at least one hour and longer if their condition is not stable. DO NOT discharge the woman or her newborn from the facility before at least 12 hours after birth.

5. Keep the woman and newborn together. As far as possible, avoid leaving the woman and newborn alone. Facilitate early initiation of infant feeding: Wherever possible, promote breastfeeding. If the woman’s HIV status is positive and she chooses not to breastfeed, counsel about giving formula feeds safely. Keep the baby in skin-to-skin contact with the mother to keep him/her warm. Principles of care when monitoring the woman and newborn during the first 6 hours postpartum (2)

6. Provide PMTCT interventions Inform the woman and companion of danger signs in the woman and newborn and ask them to call for help immediately should they notice them. Perform a basic, systematic examination of the woman and the newborn: At least once in the first 6 hours, but preferably at 1 hour and 6 hours after birth. Once a day during their stay at the facility. Before discharge from the facility. Principles of care when monitoring the woman and newborn during the first 6 hours postpartum (3)

7. Care for the woman after delivery of the placenta (1) • Ensure the woman’s body, clothing, bedding, and environment are kept clean to prevent infection. • Ensure the woman has sanitary napkins or clean material to collect vaginal blood. • Encourage the woman to eat, drink, and rest. • Facilitate the infant feeding choice of the mother. • Encourage the woman to empty her bladder and ensure that she has passed urine. 7

8. Care for the woman after delivery of the placenta (2) • Encourage the woman move around as much as she feels able. • If she experiences pain after delivery, provide paracetamol/acetaminophen to help relieve the discomfort. • Ask the woman’s companion to watch her and call for help if bleeding or pain increases, if mother feels dizzy or has severe headaches, visual disturbance or epigastric distress. • Provide additional care if the woman is infected with HIV. 8

9. Monitoring the woman during the first 6 hours postpartum Every 15 minutes for 2 hours, then Every30 minutes for 1 hour, then Everyhour for3 hours • Blood pressure, pulse • Vaginal bleeding • Uterine contraction • Check the bladder (help the woman void if the bladder is full) • Breastfeeding • Psychological responses Everyhour for6 hours • Temperature • Respiration Every4 hours

10. Maternal danger signs (1) Danger Signs: BP, pulse, vaginal bleeding, and uterus • Diastolic BP ≥90 mmHg • Systolic BP <60 mmHg • Pulse >110 beats/min • Pad soaked in less than 5 minutes • More than one sanitary napkin soaked in five minutes • Slow, continuous bleeding or a sudden increase in vaginal bleeding • Uterus is neither hard nor round • Genital laceration extending to the anus or rectum. 10

11. Maternal danger signs (2) Danger Signs: Temperature and Respiration • Temperature > 38 °C • Rapid breathing • Palmar or conjunctival pallor associated with 30 respirations per minute or more (the woman is quickly fatigued or has rapid breathing at rest) Danger Signs: Bladder • The woman cannot void on her own and her bladder is distended and the woman is uncomfortable • Urinary incontinence 11

12. Maternal danger signs (3) Danger Signs: Breastfeeding • The baby is not taking the breast well • Breastfeeding has not yet been initiated Danger Sign: Bonding • Negative feelings about herself or the baby 12

13. Case study: Ms. Kabongo Ms. Kabongo gave birth at 1:20 pm. It is now 3:50 pm. You assess Ms. Kabongo and find the following: BP: 120/70, Pulse: 88 beats/minute. Uterus well-contracted; vaginal bleeding: < 1 sanitary pad since the last time you checked her 30 minutes ago. Bladder is distended and Ms. Kabongo cannot pass urine. The newborn is breastfeeding well. Ms. Kabongo looks very happy. Q. Are there any danger signs? 13

14. Case study: Ms. Kabongo Answer: Danger sign: Ms. Kabongo’s bladder is distended and she cannot pass urine.

15. Case study: Ms. Mpo • Ms. Mpo gave birth at 3:00 pm. It is now 7:00 pm. You assess Ms. Mpo and find the following: • BP: 90/-, Pulse: 120 beats/minute. • Uterus well-contracted; Vaginal bleeding: > 7 sanitary pads since the last time you checked her 1 hour ago. • Ms. Mpo just passed urine. • The newborn is breastfeeding well. • Ms. Mpo has cold, clammy skin. • Q.Are there any danger signs?

16. Case study: Ms. Mpo Answer: Danger signs: BP: 90/-, Pulse: 120 beats/minute. Vaginal bleeding: > 7 sanitary pads since the last time you checked her 30 minutes ago. Ms. Mpo has cold, clammy skin. Ms. Mpo’s bleeding is most likely due to a genital tear.

17. Case study: Ms. Kabamba Ms. Kabamba gave birth at home 4 hours ago. She came to the health center because she has been bleeding excessively. You find: Pulse: 96 beats/minute; BP: 110/70; Respirations: 21/ minute; Temperature: 37 °C.  Her uterus is soft. The sanitary cloths are soaked in blood; she put this cloth there about one hour ago. There are no vaginal or perineal tears. Her conjunctivae are pale. Her extremities are hot; she is fully conscious and oriented. She just passed “a good amount” of urine. Q.Are there any danger signs?

18. Case study: Ms. Kabamba Answer: Danger signs: Her uterus is soft. The sanitary cloths are soaked in blood; she put this cloth there about one hour ago. Her conjunctivae are pale. Ms. Kabamba’s bleeding is most likely due to uterine atony.

19. Case study: Ms. Tona • You assisted Ms. Tona during labor. You actively managed the third stage of labor. Thirty minutes after delivery of the placenta you notice that Ms. Tona has soaked 4 sanitary pads since you checked her 15 minutes ago. When you check her you find: • Pulse: 112 beats/minute; BP: 80/40; Respirations: 36/minute. • Her uterus is soft. • Temperature: 36 °C; pale conjunctivae; cold extremities. • Ms. Tona is very anxious. • You can’t remember the last time she passed urine. • The newborn is breastfeeding well. Q.Are there any danger signs?

20. Case study: Ms. Tona Answer: Danger signs: Soaked 4 sanitary pads in 15 minutes. Pulse: 112 beats/minute; BP: 80/40; Respirations: 36/minute.  Her uterus is soft. Temperature: 36 °C; pale conjunctivae; cold extremities.  Ms. Tona is very anxious. You can’t remember the last time she passed urine. Ms. Tona’s bleeding is most likely due to uterine atony.

21. Monitoring of the newborn in the first six hours • Respiration • Color • Axillary temperature at least once and then by touching the extremities and the abdomen • (if extremities are not warm, check axillary temperature) • Make sure the cord is not bleeding • Ensure exclusive breastfeeding starting within 1 hour every 15 minutes for 2 hours, then every 30 minutes in the next 1 hour, then every hour during the next 3 hours Check anus at birth; first stool within 24 hours • The first stool (meconium) • The first urine First urine in 48 hours

22. Danger signs in the newborn (1) Danger signs are primarily related to sepsis which is the leading cause of death. The first 5 signs are the most important. Poor sucking/not sucking Lethargy/inactivity/moving only on stimulus Fever/hypothermia Respiratory difficulty (tachypnea/fast breathing > 60/minute, grunting, nasal flaring, subcostal retractions) Convulsions

23. Danger signs in the newborn (2) 6. Persistent vomiting or green vomit / abdominal distention 7. Umbilical Cord - Note: danger signs related to severe infection will not be present in the first six hours of life. At this time look for bleeding; if it is present, retie the cord.

24. Case study: Baby Kabongo Baby Kabongo was born at 9:20 am It is now 11:50 am. During routine monitoring, you find: The color of the palms, soles, lips, and tongue is pink. Respiratory rate is 45/minute with no grunting or subcostal retraction. Mother informs you that the baby breastfed for 10 minutes. Blood is oozing from the umbilicus. Q. What steps should be taken?

25. Case study: Baby Kabongo Answer: Interpretation of the findings and actions needed: The only abnormality is blood oozing from the umbilical cord. There are no real serious danger signs at this stage. Action: Retie the cord. Counsel the mother. Continue monitoring.

26. Case study: Baby Mpo Baby Mpo was born at 3:00 pm. Routine monitoring findings at 6:00 pm are: • Respiratory rate 65/minute; repeat count is 70/minute. • Grunting. • Mother says that the baby sucked weakly when offered the breast. Q. What do the findings indicate? What should be done?

27. Case study: Baby Mpo Answer: The baby has two danger signs: breathing too fast and a weak suck. The baby needs to be referred to the appropriate referral center after administration of the first doses of antibiotics; details related to this will be discussed during the session on major infections.

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29. Summary • How often should the woman and baby be monitored during the first six hours after birth? • What will you monitor in the woman? • What will you monitor in the baby? • How will you know if a woman is bleeding too much in the postpartum period? • How will you know if the baby’s temperature is normal in the postnatal period? • When should you examine the woman and newborn in the postnatal period? 29

30. Review session objectives By the end of this session, participants will be able to: Identify principles of care to follow when providing care to the woman and newborn during the first 6 hours after childbirth. Describe how to integrate maternal and newborn care. Monitor the woman and newborn during the first 6 hours after childbirth.

31. Learning activities • Please complete learning activities found in the Participant’s Notebook for Session 6. • You may work individually or in groups on the learning activities during breaks, in the evening, or in the clinical area when there are no clients. • You may correct your answers individually or with another participant or the facilitator. • See a facilitator if you have questions.