Immediate Postpartum Care of Mothers and Newborns

1. Immediate Postpartum Care of Mothers and Newborns

2. Learning objectives By the end of this module the participants will: Understand the importance of effective postpartum care for mothers and newborns Gain effective and safe skills in mother and newborn postpartum care Understand the advantages of breastfeeding for mothers and newborns and the principles of correct breast attachment 2

3. Post delivery Assessment • Greatest risk for postpartum complications is during the first 24 hours after delivery • Identification of potential problems; immediate intervention; reassessment

4. Most maternal deaths occur during labor, delivery and the immediate post-partum period Percent of maternal deaths in developing countries 0-1 day 2-7 days 8-14 days 15-21 days 22-30 days 31-42 days Day of maternal death after delivery Source: X. F. Li et al., International Joumal of Gynecology & Obstetrics 54 (1996): 1-10

5. Major Postpartum Complications and Diseases Postpartum hemorrhage Postpartum infections Eclampsia Urinary tract diseases Perineal and vaginal pain 5

6. Hypertension, post-partum hemorrhage and severe abortive outcomes are the leadingdirect causes of maternal deaths Source: Philippine Health Statistics, 2003

7. Majority of newborns die due to stressful events surroundingdelivery 50 percent of neonatal deaths occur in the first two days of life Number of deaths Day of Life

8. Four Basic Principles of Postpartum Care Ensure the physical well-being of mother and child Help to establish early and successful breastfeeding Support the mother's self-confidence Provide counselling on family planning and care for the baby after discharge from the maternity 8

9. Immediate postpartum period includes: • Assessment, • Monitoring, • Support of the baby's health and well-being; and of the mother's physiological and emotional adaptation following birth;

10. Assessment includes: • Condition of uterus • Amount of bleeding • Bladder & voiding • Vital Signs • Perineum

11. Uterus • Process of Involution • Height • First Day = below or at Umbilicus • Consistency • Firm, Round, Smooth; Not “Boggy” • Location • Midline

12. Lochia • Amount • Estimate of Drainage • Number of Pads • Color • Rubra • Serosa • Alba

13. Regular monitoring of vaginal discharge and involution of the uterus Timeframe Within the first two hours: every 15 min Withinthe third hour:every 30 min Within the next three hours: every hour

14. Vital Signs • Elevated Temperature • Normal finding for first 24 hours • Sign of Dehydration • Sign of Infection • Bradycardia • Normal Finding

15. Tachycardia • Infection • Hemorrhage • Pain • Anxiety • Lowered Blood Pressure • Orthostatic Hypotension • Shock • Elevated Blood Pressure • Pregnancy-induced Hypertension

16. Bladder • Encourage to void post delivery • Assess for Bladder Distention: • Uterine Atony • UTI • Catheterize in 6 hours if not voided (Dr.) • Measure Urine Output

17. Perineum • Assessment for: • Hematomas • Laceration • Ecchymosis • Edema • Intact Suture Line • Signs of Infection

18. Monitoring the general condition of mother and newborn • Encouraging the mother to be active early after delivery

19. Four Basic Needs of Newborns • Love • Warmth • Breastfeeding • Prevention of Infections

20. Support of Mother’s Self-Confidence • Treat the mother as an adult and responsible person • Provide her with accurate and comprehensive information • Give her an opportunity to make decisions on her own • Support her in making such decisions

21. Danger Signs in Women in the Postpartum Period • Vaginal bleeding (more then 2–3 sanitary pads in 30 minutes) • Elevated temperature • Breathing difficulty • Abdominal pain • Breast and nipple pain • Urinary incontinence • Perineal pain or pus discharge • Foul smell of vaginal discharge

22. Initial Rapid Assessment of the Newborn and Principles of Neonatal Care

23. Initiates spontaneous breathing Experiences changes in cardiovascular system Starts regulating own body temperature Initiates feeding Initiates interaction with surrounding environment including bonding with mother, father and family How the Newborn Adapts to Extra-Uterine Life

25. Prepare premises for birth Dry the newborn on mother’s abdomen or chest Assess newborn’s well-being Classify, manage, be ready to start neonatal resuscitation Clean airways (if necessary) Maintain skin-to-skin contact & cover both; place warm cap on baby’s head Cut/clamp the cord Principles of Newborn Care Basic Steps (1) Steps from 2 to 5 are simultaneous within 30 seconds after birth

26. Initiate breastfeeding Prophylactic treatments (e.g., eye care) Do not leave mother and baby alone Examine baby, measure weight and length and swaddle loosely Organize 24 hour rooming-in Principles of Newborn Care Basic Steps (2)

27. Universal Precautions Follow hand washing rules Follow the Universal Precautions: Wear gloves: sterile or highly disinfected; clean Protect yourself from any contact with biological fluids (blood or amniotic fluid). Wear long plastic/fluid resistant apron and shoes Wear eye protection Wear gloves if you touch any biological fluids (placenta/blood, instruments, laundry) Dispose of wastes (placenta, blood, sharps and pieces of glass) safely Use sterile instruments

28. Preparation for Birth Trained health professionals (e.g., midwife) are available Each birth should take place in a room, which meets the following criteria: Individual Clean Warm (temperature must not be below 25°C) Medically safe for mother and baby Equipped for free birth positions

29. Equipment Required for Every Birth Clean table with radiant heater Warm towels to dry the baby Appropriate clothes: warm cap, socks and blanket for baby Wall clock with a second hand Suction equipment Set for cord clumping/cutting Resuscitation equipment (bag and masks sized for newborn) Digital thermometer or low-reading thermometer (can read <35°С) Essential drugs (drugs for resuscitation, vitamin K, eye ointment)

30. Drying the Baby The baby must be dried immediately after birth The baby should be put immediately on the mother’s chest, where drying is completed with a dry, warm towel Removewet towels Dress the baby in a cap and socks Cover the baby with a dry warm blanket

31. Newborn Heat Loss Evaporation Convection Radiation Conduction

33. What Is Hypothermia? Body temperaturebetween – 36,5-37,5ºC =Normal Body temperature below 36.5ºС =Hypothermia 36,4-36,0ºС=Cold stress/mild hypothermia Start to re-warm the baby 35,9-32ºС=Moderate hypothermia Danger!!! Below 32ºС=Severe hypothermia Severe condition, risk of death Skilled care urgently needed

34. Respiratory distress Hypothermia Acidosis Hypoglycemia

35. “Warm Chain” Means: Warm deliveryroom >25°C Immediate drying (remove wet towels) Early skin-to-skin contact (at least two hours) Early breastfeeding (within one hour after birth) Bathing, weighing and complete examination of the baby postponed Dress the baby adequately Organizerooming-in Organizethermal protection during resuscitation and transportation Health professionals trained in implementing every step of the warm chain

36. Baby needs to be kept warm and dry Encourage the mother to use baby clothes from home Encourage dressing the baby in warm, loose, soft clothes Cover baby’s head (25% of baby’s heat is lost from the head) Cover baby with a blanket How to Dress the Baby Appropriately

37. The Harm of Tight Swaddling Blocks diaphragm movement Decreases blood circulation Restricts free limb movement thus impairing breastfeeding because the baby cannot move his/her head or mouth properly Prevents the baby from keeping warm due to lack of air between the body and swaddling sheets Results in babies who sleep more and feed less

38. Assess the Newborn’s Well-Being Conduct an assessment of the newborn’s status just after birth to identify: Infants who require resuscitation and/or have special needs Infants who are healthy and can stay with their mothers Perform the assessment while drying the baby

39. Components of the Assessment After birth: Spontaneous breathing or crying? Good tone? Dry the baby on the mother’s abdomen Provide warmth, keep skin-to-skin with mother Clear airway if needed Assess breathing, heart rate, colour and tone The assessment needs to be done within 30 seconds after birth • Before birth: • Gestational age/estimated birth weight • If the amniotic fluid is stained with meconium

40. Apgar Score Activity Pulse Grimace Appearance Respiration

41. Apgar Scoring

42. Classification and Management Adequate breathing, gestational age >37 weeks, weight >2,500 g, no malformations/traumas– give healthy newborn care Inadequate/no spontaneous breathing – start neonatal resuscitation Adequate breathing, gestational age <37 weeks, weight <2,500 g, no malformations/traumas – give special care for low birth-weight baby Adequate breathing, malformations/birth traumas – give special care according to malformation/birth trauma

43. Cleaning the Airway Not mandatory for every infant Clean the airways only in the case: Bloody or meconium-stained amniotic fluid Neonatal resuscitation Use a bulb/catheter No longer than 5 seconds if no meconium No deeper than 5 cm from the lip edge or 3 cm from the nostril (in a full term baby)

44. Supports newborn’s thermal adaptation Fulfils bonding needs of mother and infant Sensitive bonding period not to be missed Facilitates early initiation of breastfeeding Colonizes baby with mother’s flora Early Skin-to-Skin Contact

45. Skin-to-Skin Contact

46. When? Delayed cord clamping is beneficial for baby Early clamping: only in emergency (resuscitation) How? Use sterile blade or scissors Cover the cord with a piece of cloth/gauze to prevent splashing of blood Cut the cord between the two clamps Be careful not to cut the baby – place your hand between the baby and the cutting instrument Use elastic tying material (e.g., rubber band) or plastic cord clamp rather than strings or bands to tie cord off Cord Clamping and Cutting

47. Observe if the newborn shows signs of readiness Help the mother to find a comfortable position Help the mother to attach baby to the breast Check if the newborn is correctly positioned Do not limit duration of breastfeeding Praise the mother Counsel the mother Early Breastfeeding

48. Early Breastfeeding

49. Preventive Procedures Prevention of bleeding Vitamin K: two options Oral administration of two doses of 2 mg each: one on the first day of life and the other on the seventh day of life Intramuscular injection at birth – single dose of 1 mg Prevention of conjunctivitis 1% tetracycline ointment (a drop the size of a rice seed) 0.5% erythromycin ointment is affordable, safe, and effective Give no later than one hour after birth

50. Monitoring the Baby during the First Two Hours Breathing: Reassess the baby’s breathing and colour every 15 minutes after birth for one hour, then every 30 minutes Count breathing rate (30–60 breaths per min) Listen for grunting Observe for severe chest in-drawing Check warmth Feel baby’s feet every 15 minutes. If cold, check axillary temperature Take auxiliary temperature at 30 minutes and at 2 hours