Care after delivery: Postpartum Care

1. SBA - Presentation 5 (c) Care after delivery:Postpartum Care Maternal Health Division Ministry of Health & Family Welfare Government of India

2. 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

3. 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 complicationsoccur during this period. Care after delivery: Postpartum Care

4. Postpartum visits by ANM/ASHA * 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. 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 Care after delivery: Postpartum Care

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

6. 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 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 Care after delivery: Postpartum Care

7. 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 Care after delivery: Postpartum Care

8. 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 Care after delivery: Postpartum Care

9. 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

10. 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 Care after delivery: Postpartum Care

11. 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 Care after delivery: Postpartum Care

12. 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 Care after delivery: Postpartum Care

13. 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 Care after delivery: Postpartum Care

14. 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 Care after delivery: Postpartum Care

15. 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 Care after delivery: Postpartum Care

16. 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 and Birth injury If present Care after delivery: Postpartum Care

17. 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 Care after delivery: Postpartum Care

18. 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. Care after delivery: Postpartum Care

19. First postpartum visit for baby Immunization of Newborn Counsel mother on where and when to take baby for immunization Care after delivery: Postpartum Care

20. 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 Care after delivery: Postpartum Care

21. 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. Care after delivery: Postpartum Care

22. 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 Care after delivery: Postpartum Care

23. 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 Care after delivery: Postpartum Care

24. 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 Care after delivery: Postpartum Care

25. 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 Care after delivery: Postpartum Care

26. 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 Care after delivery: Postpartum Care

27. 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 Care after delivery: Postpartum Care

28. 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 Care after delivery: Postpartum Care

29. 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 Care after delivery: Postpartum Care

30. 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 Care after delivery: Postpartum Care

31. Thank you Care after delivery: Postpartum Care