WHO Technical Consultation on Postpartum and Postnatal Care€¦ · postpartum and postnatal care delivered by skilled providers. The purposes of revision are to encourage and support

WHO Technical Consultation onPostpartum and Postnatal Care

Department of Making Pregnancy Safer

© World Health Organization 2010

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WHO/MPS/10.03

This document was prepared by Mathai Matthews, von Xylander Severin and Zupan Jelka based on the WHO Technical consultation on postpartum and postnatal care held in Geneva, October 29-31, 2008.

The contributions of the chairperson (Sally Marchant) and the international panel of experts, the assistance of Elizabeth Zisovska and Ruby Jose in the preparations for the meeting, the contributions of WHO staff from the departments of Child and Adolescent Health, Reproductive Health and Research, Nutrition for Health and Development, Immunization, Vaccines and Biologicals, Mental Health and Substance Abuse and HIV/AIDS, and the support from USAID are gratefully acknowledged.

Preface 1

1 Introduction 2

2 Providing postpartum and postnatal care: towards a new concept 3

3 Updating WHO guidelines on postpartum and postnatal care 5

4 Scope of the updated WHO guidelines 6

5 Preparations for the WHO Technical Consultation on Postpartum and Postnatal Care 7

5.1 Identifying existing guidelines and epidemiological evidence 7

5.1.1 Criteria for review 7

5.1.2 Identification of existing guidelines 7

5.2 Clinical and programmatic guidelines 9

5.2.1 Clinical and programmatic guidelines 9

5.2.2 Clinical and programmatic questions on postpartum and postnatal care 10

5.3 Formation of the international panel of experts 10

6 WHO Technical Consultation on Postpartum and Postnatal Care 11

6.1 Objectives 11

6.2 Participants and proceedings 11

6.3 Defining terms 12

6.4 Assessment of existing guidelines and information on the postnatal period 12

6.4.1 Epidemiological considerations in the postnatal period 12

6.4.2 Timing of postnatal care provision 13

6.4.3 Content of the postnatal care package 14

6.5 Conclusions 14

7 Next steps 16

References 17

Figure 1-3 19

Tables 1-4 23

1. List of participants 52

2. Glossary 56

Contents

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WHO Technical consultation on postpartum and postnatal care

Preface

The period soon after childbirth poses substantial health risks for both mother and newborn infant. Yet the postpartum and postnatal period receives less attention from health care providers than pregnancy and childbirth. Models of postpartum and postnatal care have changed little since first developed a century ago.

The World Health Organization (WHO) is in the process of revising and updating its guidance on postpartum and postnatal care delivered by skilled providers. The purposes of revision are to encourage and support broader provision of care and to foster a new, woman-centred concept of care that promotes health as well as maintains vigilance against dangerous complications. In October 2008 an expert consultation took place in Geneva to advise WHO on the coverage, form and content for revised and updated guidance. This meeting, which is documented here, prepared for an upcoming technical consultation to develop the guidance itself.

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Introduction

The first hours, days and weeks after childbirth are a dangerous time for both mother and newborn infant. Among the more than 500 000 women who die each year due to complications of pregnancy and childbirth (1), most deaths occur during or immediately after childbirth (2). Every year three million infants die in the first week of life, and another 900 000 die in the next three weeks (3).

Bleeding and infection following childbirth account for many maternal deaths (4), while preterm birth, asphyxia and severe infections contribute to two thirds of all neonatal deaths (5). Appropriate care in the first hours and days after childbirth could prevent the great majority of these deaths. Thus, it has been recommended that skilled health professionals attend all births, to assure the best possible outcome for both mother and newborn infant (6). A large proportion of women continue to lack such care, however. On average, skilled birth attendants cover 66% of births worldwide, and some parts of Africa and Asia have much lower coverage rates (7). The fact that two thirds of maternal and newborn deaths occur in the first two days after birth (5,8) testifies to the inadequacy of care.

Care in the period following birth is critical not only for survival but also to the future of mothers and newborn babies. Major changes occur during this period that determine their well-being and potential for a healthy future.


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2. Providing postpartum and postnatal care: towards a new concept

In developed countries virtually all women and their infants receive postpartum and postnatal care, albeit the nature and frequency of this care varies considerably. In developing countries the need for care and support after birth was, until recently, less well recognized. Despite its importance, this period is generally the most neglected. Rates of provision of skilled care are lower after childbirth than during pregnancy or childbirth, even though both the risks for illness and the potential to improve longer-term outcomes are as great (2).

There are few data on early postnatal care specifically, but clearly many women do not receive optimal care. Many women who give birth in facilities are discharged within hours after childbirth without any indication where they can obtain further care or support. Also, harmful health care practices are still prevalent and contribute to mortality. For example, care providers or institutions may not promote, protect and support early initiation of breastfeeding, and they may even delay or discourage breastfeeding, thus undermining successful exclusive breastfeeding. More than half of infants are not exclusively breastfed (9), contributing to malnutrition and infections.

Current models of postpartum care in developed countries originated in the beginning of the 20th century in response to the high maternal and neonatal mortality rates of the time (2). Postpartum care for the mother has conventionally focussed on routine observation and examination of vaginal blood loss, uterine involution, blood pressure and body temperature. Guidance for health-care professionals on other postpartum practices has been limited (10). Similarly, postnatal care for the baby has conventionally focussed on cord care, hygiene and weight monitoring and feeding and/or immunizations, without systematic, comprehensive assessment and care of newborns.

The timing and content of this care has remained more or less unchanged since the beginning. Only recently have there been any suggestions for change. Attention to the dramatic reduction in maternal and newborn mortality rates in developed countries that occurred around the middle of the 20th century, accompanied by the increased involvement and participation of women themselves in the nature of their care, has led to interest in revising the current remit for provision of care.

Research into the current coverage and content of postpartum and postnatal care has been limited. The average and the range in the number of visits or contacts that women and their infants have with their health-care providers are not well documented. Even in developed countries there has been little evaluation to assess whether current models of care meet individual women’s and babies’ physical and emotional health needs and whether they make the most appropriate use of the skills and time of the relevant health care professionals and of financial resources. The needs of fathers/partners have not been thoroughly evaluated. Neither have the concerns of women from diverse cultures been adequately explored. Nor has there been comprehensive study of the requirements of women with specific needs, such as women with physical disabilities or following complications of childbirth.

The major purposes of postpartum and postnatal care are to maintain and promote the health of the woman and her baby and to foster an environment that offers help and support to the extended family and community for a wide range of related health and social needs. These needs can involve physical and mental health as well as social and cultural issues that can affect health and well-being. Also, new parents need support for parenting and its responsibilities. Thus, the conceptual

4WHO Technical consultation on postpartum and postnatal care

framework for guidance on postpartum and postnatal care should place the woman and her baby at the centre of care provision. This concept promotes the appreciation that all postpartum and postnatal care should be delivered in partnership with the woman and her family and should be individualized to meet the needs of each mother-infant dyad.

While this concept of care does not directly relate to the management of a condition or an acute situation, recognizing danger signs and taking timely action if they appear are crucial. Delays can be fatal. Therefore, guidance also should reflect the epidemiological pattern of health conditions occurring in the postpartum and postnatal period and thus address important public health needs at the appropriate times.

It is important to identify the essential, or core, care that every woman and her newborn baby should receive during the first six weeks after birth, based upon the best evidence available. Besides clinical interventions, core care will include providing information to support the woman in caring for herself and her baby and also building the support of family and community. For most women and babies the postpartum and postnatal periods are uncomplicated. Still, core postpartum and postnatal care also should include recognizing, evaluating and intervening appropriately if any deviation occurs from the expected course of events after childbirth.

In broader context, most care in the postpartum and postnatal period takes place at home, where the woman is caring for herself and her baby, supported by her family. One objective of postpartum and postnatal care delivered through the health system is to encourage mothers and families to adopt evidenced-based practices at home and to build sustaining community support for these practices.

Increasingly, women (and mothers) are formally employed. These women need maternity protection, which should include maternity leave. Maternity Protection Conventions of the International Labour Organization (11) specify the maternity benefit package, which includes 14 weeks of paid maternity leave to ensure exclusive breastfeeding. For women who have given birth but do not have a live infant, the Conventions specify six weeks of paid maternity leave.

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3. Updating WHO guidelines on postpartum and postnatal care

In 1998 WHO published Postpartum care of the mother and newborn: a practical guide (12), based on the best available evidence and the consensus of experts at that time. This guidance was relatively weak in a number of areas, particularly where a more quantified, measurable standard or recommendation might have facilitated both understanding and implementation. For example, there were no recommendations on the optimal length of stay in the postnatal ward, on the optimal number and timing of subsequent contacts between the mother-infant dyad and the health worker or on just what needs to be done at each contact. Such guidance now seems important to managing and improving care. Also, these guidelines provided relatively little information on issues related to HIV infection, adolescent pregnancy and mental health. As a follow-up to the 1998 guidelines, in 2003 WHO published Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice (13) to provide more detailed guidance on delivering evidence-based interventions at the primary care level. WHO recommendations on guideline development (14) call for updating all guidelines periodically to include current best evidence-based practices. Thus, in 2008 WHO began the process of updating the guidance to assure that it reflects practices based on current evidence.

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4. Scope of the updated WHO guidelines

The updated guidelines will focus on births taking place with skilled attendance, since skilled attendance is so important to maternal and perinatal survival (8,15). Recommendations on postpartum and postnatal care should include clinical guidance for health care providers, guidance for care of the woman and newborn in the home, and programmatic guidance for delivering postpartum and postnatal services and developing community activities.

As previously noted, however, skilled care at birth is far from universal, and particularly limited when birth takes place at home, and more efforts to achieve universal coverage are necessary. Hence, needs for care following home births will be reviewed separately, and guidelines will be developed through the appropriate process.

The updated guidelines will advise policy-makers, programme managers and health-care providers on the content and timing of the core care that should be offered to all women and their infants during the postpartum and postnatal period. The guidelines will address:

appropriate objectives, purpose, content and timing of postpartum and postnatal contacts and care for the woman and her baby;

best health care practices and competencies for assessment of postpartum and postnatal health and management of postpartum and postnatal problems in the woman and/or her infant;

the information and support that women and their families require during the postpartum and postnatal period;

planning of postpartum and postnatal care;

good practices in communication between health-care providers and women, their partners and other family and community members.

These guidelines will focus on the overall needs of a healthy woman and her healthy baby. The guidelines will identify complications and advise appropriate referral, but they will not provide detailed advice on managing medical complications that occur before, during or after the birth; on existing pregnancy-related or other diseases or conditions; or on any aspect of antenatal or intrapartum care, including procedures immediately following the birth. Furthermore, these guidelines will not cover special care that a woman or her baby may require in rare circumstances or aim to provide guidance on neonatal screening programmes for metabolic or other diseases. Instead, the guidelines will refer to other documents that provide guidance on these matters.


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5. Preparations for the WHO Technical Consultation on Postpartum and Postnatal Care

In accord with the recommended process for development of WHO guidelines (14), a core group was formed to work on guidelines development. The core group comprises staff from different WHO programmes working in the area of maternal and newborn health and related fields. Approval for development of guidelines came from the Assistant Director General, Family and Community Health cluster, and the Guidelines Review Committee.

5.1 Identifying existing guidelines and epidemiological evidence

5.1.1 Criteria for review

As part of the approved plan for guidelines development, the core group reviewed both existing guidance and epidemiological evidence. The group reviewed WHO and other guidelines related to postpartum and postnatal care in search of best practices and supporting evidence. The criteria for inclusion in this review were these:

The guidance addressed clinical care and/or service delivery at any stage during pregnancy, childbirth, or the postpartum and postnatal period.

Supporting evidence for the guidance was accessible for review and grading.

For WHO guidelines, the guidelines were developed or updated in the preceding 10 years.

For other, non-WHO guidelines: The guidelines were developed by an international or national organization responsible for

providing guidance or by a professionals’ organization working in the area of maternal and newborn health.

The guideline development process was documented.

Recommendations are practical and applicable to a variety of settings worldwide, including those with restricted resources.

The review excluded guidelines and recommendations that cannot be generalized because they are based on a single study, one setting or very similar settings.

The WHO guidelines and other guidelines identified are listed below in section 5.1.2. A limitation of the search method was its restriction to guidelines in English. Also, there was no search in the grey literature. The core group did not contact professionals’ organizations to identify other relevant guidelines that they might have developed.

Epidemiological information on the timing of the occurrence of complications came from standard obstetric (16) and neonatology (17) textbooks, other publications (18,19) and WHO sources listed below.

5.1.2 Identification of existing guidelines

With the help of related programmes in WHO, the core group identified all WHO guidelines relevant to postpartum and postnatal care published in the last 10 years. These included:

Postpartum care of the mother and newborn: a practical guide. WHO, 1998.

Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. 2nd ed. WHO, 2006.


Managing newborn problems: a guide for doctors, nurses and midwives. WHO, 2003.

Integrated management of childhood illness. WHO and UNICEF, 2008 (http://whqlibdoc.who.int/publications/2008/9789241597289_eng.pdf)

Pocket book of hospital care for children. Guidelines for the management of common illnesses with limited resources. WHO, 2005.

WHO Technical Working Group on Essential Newborn Care. Essential newborn care. WHO, 1996.

WHO Recommendations for the Prevention of Postpartum Haemorrhage. WHO, 2007.

Family planning. a global handbook for providers. WHO and Johns Hopkins Bloomberg School of Public Health, 2007.

International code of marketing of breast-milk substitutes. WHO, 1981.

Evidence for the ten steps to successful breastfeeding. WHO, 1998.

Vaccine Position Papers (http://www.who.int/immunization/documents/positionpapers/en/index.html)

“Maternal mental health and child health and development” (http://www.who.int/mental_health/prevention/suicide/MaternalMH/en/index.html)

Selected practice recommendations for contraceptive use. WHO, 2004.

Iron deficiency anaemia. Assessment, prevention and control. WHO, 2001.

The initial Internet search for non-WHO guidelines used the following key words: postpartum, postnatal, puerperium, mother care, newborn care, guidelines. The search used the Boolean operators AND, OR, NOT. Guidelines were retrieved from individual web sites or through the web site of the Geneva Foundation for Medical Education and Research (see below).

Guidelines of UK National Institute for Health and Clinical Excellence (NICE) (10) (http://www.nice.org.uk/Guidance/CG/Published/CG37)

Guidelines of the American Academy of Pediatrics, Committee on Fetus and Newborn (1) (http://www.aap.org/visit/cmte17.htm)

Family-centred maternity and newborn care: national guidelines from the Public Health Agency of Canada. (http://www.phac-aspc.gc.ca/dca-dea/publications/fcmc00-eng.php) (21)

National Guidelines Clearinghouse web site (http://www.guideline.gov/browse/guideline_index.aspx)

American Academy of Family Physicians (http://www.aafp.org/online/en/home/clinical/clinicalrecs.html and http://www.aafp.org/afp/20060301/849.html)

Auckland, New Zealand, District Health Board Newborn Services (http://www.adhb.govt.nz/newborn/)

Canadian Paediatric Society (some of their guidelines are presented as joint statements with the American Academy of Pediatrics) (http://www.cps.ca/english/publications/FetusAndNewborn.htm)

Royal Prince Alfred Hospital (Sydney, Australia) (http://www.cs.nsw.gov.au/rpa/neonatal/)

Geneva Foundation for Medical Education and Research (http://www.gfmer.ch/Guidelines/Guidelines_topics.htm) (http://www.gfmer.ch/Guidelines/Neonatology/Newborn.htm)

Indian Academy of Pediatrics (http://www.iapindia.org)

Perinatal Education Programme (South Africa). Manual 4: Primary newborn care: a learning programme for professionals. 2001. (http://pepcourse.co.za/index.php?option=com_content&task=blogcategory&id=21&Itemid=32)

South African National Department of Health. Standard treatment guidelines and essential drugs list. Adult, hospital level. 1998. (http://www.hst.org.za/uploads/files/edladult.pdf)

Save the Children. Saving newborn lives: care of the newborn reference manual. 2004.

(http://www.savethechildren.org/publications/technical-resources/saving-newborn-lives/snl-publications Care-of-the-Newborn-Reference-Manual-Eng.pdf)

95. Preparations for the WHO Technical Consultation on postpartum and postnatal care

Additional queries searched the following databases for updated evidence on certain specific recommendations published after 2006:

Search by topic in Cochrane Library Pregnancy and childbirth Neonatal

Search in Centre for Reviews and Dissemination (RD) Database of Abstracts of Reviews of Effects (DARE) National Health Service, National Institute for Health Research

5.2 Review and critical appraisal

5.2.1 Clinical and programmatic guidelines

Only three of the identified guidelines met the selection criteria:

Guidelines of the UK National Institute for Health and Clinical Excellence (NICE) (10) (http://www.nice.org.uk/Guidance/CG/Published)

Guidelines of the American Academy of Pediatrics, Committee on Fetus and Newborn (20) (http://www.aap.org/visit/cmte17.htm)

Family-centred maternity and newborn care: national guidelines, Public Health Agency of Canada, 2000 (http://www.phac-aspc.gc.ca/dca-dea/publications/fcmc00-eng.php) (21).

Overall, among the guidelines reviewed (10,13,20,21,22), there are inconsistencies in the definitions used, discrepancies in recommendations and lack of specific discharge criteria for mother or baby. None of the guidelines covers mothers and babies with special needs such as mothers delivered by caesarean section, low-birth-weight babies, preterm babies, twins, mothers and babies with certain health problems and special vulnerable groups of mothers such as adolescents and mothers living with HIV. None of the guidelines addresses birth without a skilled attendant and none, except the WHO guideline (13), addresses postnatal care after home birth. The few guidelines that specify levels of evidence come from developed countries and are based on their well-developed health care services for the postnatal period. They are specific to that context, which limits their applicability in less developed settings.

Recommendations for follow-up assessments after discharge from the facility vary among the guidelines. Most guidelines recommend a visit within the first week after discharge, but the exact timing differs. Most also recommend a 6-week follow-up visit for the mother and newborn. For both these recommendations, evidence for the timing and the benefits of such visits is not stated.

Among the guidelines reviewed, only the NICE guideline (10) on routine postnatal care provides clear information on the guidelines development process as well as on levels of supporting evidence. The evidence basis for the NICE guideline comes from a comprehensive review of English-language literature, up to the year 2000, on routine postnatal care of women and their babies. The UK National Collaborating Centre for Primary Care, at the University of Leicester, conducted this review.

The care pathway in the NICE guideline provides a practical framework for the development of global guidelines. This care pathway was “designed to indicate the essential steps in the care of mother and baby after birth and the expected progress of both the woman and the newborn through the first six to eight weeks postpartum” (10). Three components of care provide the basic themes for the pathway: maintaining maternal health, infant feeding and maintaining infant health. These themes are very similar to the pathways for postpartum and postnatal care in the WHO guidelines (13), as are the three time bands in the NICE guidelines, which cover the postnatal period: within the 24 hours following birth (12 hours minimum), 2 to 7 days and 8 to 42 days. The interventions covered include assessment of well-being, preventive measures, responding to concerns, information for home/self care and infant feeding, and on care-seeking.


NICE developed the guidelines for a setting with universal access and coverage with skilled care for both birth and postnatal care. Current coverage in most of the world is still far from universal, however. Still, most countries have policies and are accelerating actions to provide skilled care for every birth, with emphasis on facility-based childbirth care wherever feasible.

While acknowledging that there are thus some limitations to the applicability of the NICE guideline, the WHO core group used it as the reference for comparison with other guidelines, both those of WHO and those of other organizations. Comparison tables appeared in the background document for the technical consultation, and they are included in this report as Tables 1–3. In these tables an asterisk indicates that an intervention appears in both NICE and WHO guidelines. Interventions in the WHO guideline but missing in the NICE care pathway appear at the end of each section. The consultation used this framework to identify key clinical interventions and gaps in the current guidelines.

5.2.2 Clinical and programmatic questions on postpartum and postnatal care

At the October 2008 meeting, participants reviewed the guidelines and other information with an eye to answering the following clinical questions on postpartum and postnatal care:

1. How long following birth and prior to discharge should a woman and her baby be under direct care of a skilled attendant in order to avoid mortality and morbidity and to maintain health? (immediate postnatal care)a. How long should immediate postnatal care be provided to a woman and her baby after uncompli-

cated birth of a healthy baby? b. How long should immediate postnatal care be provided for women and/or their babies with special

needs (e.g. caesarean section, preterm birth, multiple births)?

2. What care should be provided during the immediate postnatal period to maintain the health of the woman and her baby? a. What routine care is required for a woman after uncomplicated birth and for a healthy baby in the

immediate postnatal period? What are the criteria for discharge of the woman and her baby?b. What additional care is required in the immediate postnatal period for women and babies with

special needs? What are the criteria for discharge?

3. After the immediate postnatal period, how often and when should routine care be provide to a woman and her baby to avoid mortality and morbidity and to maintain health?a. For all women?b. For women with special needs?

What care should the skilled attendant provide after the immediate postnatal period to avoid mortality and morbidity and to maintain the health of the woman and the baby?

5.3 Formation of the international panel of experts

An international panel of experts was formed to assist the guidelines development process. This panel includes individual experts with appropriate background and experience—as clinicians, researchers, programme managers, or policy-makers. A sub-group of this international panel, balanced for technical expertise and regional representation, was invited to participate in the WHO Technical Consultation on Postpartum and Postnatal Care in Geneva from 29 to 31 October 2008. All participants at this consultation received in advance a background document that described the rationale and the development process for the WHO Recommendations on Postpartum and Postnatal Care, methods for reviews of guidelines and epidemiological issues related to postpartum and postnatal care, a summary of the findings of these reviews, the care pathway tables and a glossary.

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6.1 Objectives

The objectives of the technical consultation were:

To identify key topics for development and/or update of the recommendations for care for mother and baby in the postpartum and postnatal periods;

To prioritize topics for which available evidence should be reviewed.

More specifically, the technical consultation was planned to address the following questions:

What postnatal services currently are being offered?

What are the best practices that can be recommended for postnatal care, based on existing knowledge, to promote the optimal health of the mother and newborn infant dyad and their families?

In addition to strictly biomedical criteria, what characteristics of the individual woman or baby should be considered to select an appropriate approach to care?

What approaches seem most promising (in terms of effectiveness and cost, for example)?

What care is needed after discharge to meet the woman’s and the baby’s physical and psychosocial needs?

What are the unmet needs of women and newborn babies after home birth without a skilled attendant?

How should adherence to standards/guidelines be monitored?

What modifications could and should be made in existing data systems to permit continuous monitoring of postnatal care in both public and private systems, including, for example, electronic medical records, programme information, vital registration, health surveys?

6.2 Participants and proceedings

Participants in the consultation are listed in Annex 1. They included members of the panel of invited technical experts, representatives of UN agencies, observers and WHO secretariat. Participants in the Technical Consultation represented a wide range of clinical, programmatic and research expertise from the different WHO regions.

All presentations and most discussions were in plenary sessions (see Annex 2 for agenda). In addition to prior submission of the formal, signed declarations of interests, all participants were asked to declare any conflict of interest related to the issues to be discussed. None of the participants had any conflict of interest to declare. In addition to the background document provided in advance, participants received during the meeting copies of the two key WHO publications on postpartum and postnatal care (12,13).

The meeting participants discussed the information from the reviews. The task of this panel was not to provide final recommendations but rather to guide WHO secretariat’s processes for completing the review. The panel made all decisions by consensus.

6. WHO Technical Consultation on Postpartum Care


The four questions and their sub-questions on care pathways (see Section 5.2.2) helped the panel to focus on identifying areas in current WHO guidelines that need revision. The panel agreed that the four questions have practical value to implementation: Answers to questions 1 and 3 are of key importance for policy decisions, particularly in relation to the timing of the provision of care. Answers to questions 2 and 4 will give programme managers sufficient technical details on the content of the care package. Section 6.4, below, summarize the discussions and recommendations and supporting evidence addressing the four questions The panel also agreed on the definitions to be used in the guidelines (see next section).

6.3 Defining termsThe terms “postpartum period” and “postnatal period” are often used interchangeably but sometimes separately, when “postpartum” refers to issues pertaining to the mother and “postnatal” refers to those concerning the baby. The terms “antenatal”, “antepartum”, “intranatal” and “intrapartum” refer to issues pertaining to events before or during childbirth.

For care after childbirth, the panel agreed that adopting just a single term would aid clarity. Therefore, the panel agreed that the term “postnatal” should be used for all issues pertaining to the mother and the baby after birth. The postnatal period begins immediately after the birth of the baby and extends up to six weeks (42 days) after birth. For the purposes of describing care provision, the postnatal period consists of immediate, early and late periods (see following paragraphs). Management of the third stage of labour was considered part of care during labour and hence excluded from the discussions. Also, while physiological changes that occur during pregnancy and childbirth may take longer than six weeks to return to the non-pregnant state, the guidance documents will cover only the first six weeks (42 days) after birth. Usually, the end of this period is associated with the implementation of interventions such as promotion of contraception and infant immunization, although some contraceptive methods, such as the lactational amenorrhoea method, the IUD, vasectomy and female sterilization, should be discussed even before childbirth, and some immunizations, such as those against hepatitis B and tuberculosis (BCG), may be given at birth.

The immediate postnatal period refers to the time just after childbirth, during which the infant’s physiology adapts and the risks to the mother of postpartum haemorrhage and other significant morbidity are highest. The immediate postnatal period covers the first 24 hours from birth. Close direct or indirect supervision by a skilled attendant is required in this period so that any problems can be identified promptly and appropriate intervention or referral can take place.

Some problems—for example, with infant feeding or infection—may first manifest themselves during the first week after birth (that is, after Day 1, the immediate postnatal period). In order to better organize care, the time frame for the period after the first 24 hours is described in terms of days. While there can be a 23-hour discrepancy in the description of “a day”, this framework appears to be generally used and understood. Therefore, the panel agreed to refer to the period from Days 2 through 7 as the early postnatal period and the period from Days 8 through 42 as the late postnatal period.

Definitions of other terms appear in the Glossary (see Annex 3).

6.4 Assessment of existing guidelines and information on the postnatal period

6.4.1 Epidemiological considerations in the postnatal period

Large numbers of women and newborn babies have no access to health care immediately following birth. Hence, their risks of ill health and death are high. Demographic and Health Surveys (DHS) conducted in 30 developing countries in five regions between 1999 and 2004 reported that a country average of nearly 40% of all women with a live birth in the five years before the survey did not receive any postpartum care

136. WHO Technical Consultation on postpartum care

check-ups (23). Among the women who gave birth outside facilities, on average just over 70% received no postpartum care. Among all women who did receive postnatal care, health professionals reportedly provided 57% of postnatal care. The remainder received postnatal care from traditional birth attendants (TBA) (36%) and others (7%).

Some 50% of maternal deaths and 40% of neonatal deaths occur within 24 hours after childbirth (4). The risks decrease after the first few hours but do not vanish entirely. Some problems may arise during the early postnatal period and, less often, in the late postnatal period. Recognizing the clustering of adverse events and risks (see Figures 1–3) helps in selecting the optimal times to provide postnatal care.

Figure 1 presents information on the frequency and severity of conditions for the mother and infant by day for the first week and then by week. Although data on the incidence and severity of these medical conditions in developing countries are scarce, the panel noted that the information provided in this figure was useful to the discussions on optimal timing of contacts and the contents of care. The panel recommended identifying mortality data from different settings to strengthen the information base relevant to the length of stay and timing of contacts. Figure 1 also shows the optimum period for delivering preventive measures.

Some 3% to 4% of women have lost their babies in the first days after delivery (4). It is important to increase awareness that these women need postnatal care as much as women with infants.

6.4.2 Timing of postnatal care provision

In light of the recommendation for skilled care for every birth and universal access to maternity services, the panel’s discussions of the timing of postnatal care provision remained focused on settings where skilled attendants provide care. At the same time, the panel fully recognized that home deliveries without skilled attendants remain common in some settings and that guidance for those settings is very much needed.

There is only sparse and low-quality evidence on optimal length of stay under the direct or indirect care of skilled attendants, for the mother, the baby or the dyad. Where a healthy, term baby has been born in an uncomplicated delivery, most guidelines call for the dyad to stay under observation by a skilled attendant for 24 to 48 hours. If mother and baby are discharged from the facility sooner than 48 hours, a qualified professional or skilled attendant should assess them within 24 to 48 hours after discharge. The panel agreed, based on epidemiological data, that the first 24 to 48 hours are the most critical time for the woman and the baby, and thus it is a life-saving policy to provide individualized care during the immediate postnatal period under the direct or indirect supervision of a skilled attendant.

The panel acknowledged the difficulty of defining “healthy mother” and “healthy baby”. The panel agreed that, for the purpose of the guidelines, these terms should refer to women and babies without any problems. Practice guidelines should provide specific criteria, related to clinical observations, for deciding when a woman and infant are “healthy” and fit for discharge to home care.

Given the lack of evidence on the precise optimal timing of postnatal care, the panel advised broadening the criteria for the evidence and practice review. The panel also recommended that, before discharge, women (and their families) should receive clear and specific key information and instructions on home care for themselves and their babies, with special attention to breastfeeding and early identification of danger. The panel recognized the importance of community support for such key practices as breastfeeding, general hygiene and use of health services.

The panel also discussed who should provide early postnatal care. There are different types of providers and potential providers of early postnatal care in the community. Which model is best will depend on the structure of the health care system, the quality of care and information provided in the immediate postnatal period and the experiences and expectations of women.

The panel recommended review of evidence on the effectiveness of professional care and support in improving postnatal outcomes. Such evidence would inform more precise guidance and information on the timing of the care provider’s contacts with the mother and infant in the first week after childbirth.


The panel agreed that women should have ready access to services any time that they have concerns about themselves or their babies. There is not enough evidence, however (and additional search probably will not yield more), to specify when exactly a scheduled contact would be most appropriate to improve outcomes. The consensus was that, towards the end of the late postnatal period, there is probably no need for a “postnatal contact” as such. Instead, this contact should be considered a time for closure of the perinatal period and smooth transition to other programmes such as women’s health and family planning, child health and immunization. This late postnatal contact—the closure contact—should be organized to link with ongoing care as currently provided for all women and infants.

6.4.3 Content of the postnatal care package

The panel agreed on the importance of defining the content of the package of care that should be provided in the postnatal period. Once this package is defined, the timing of delivery of the package could be better defined and guidance could be provided on the length of time that mothers and their newborn babies should be under the supervision of health care professionals.

Most postnatal care packages include:

Identification and management of potentially serious outcomes for the woman and her infant (a focus on “killers”);

Routine measures that have minimal effect on outcomes and, while not costly in themselves, add up to become costly when applied to the whole population;

Recommendations for special conditions and circumstances.

Most guidelines reviewed include similar interventions. In the NICE guidelines these are categorized as those for maintaining women’s health, those for maintaining infants’ health, and those for infant feeding (10). Under each of the headings the NICE guidelines describe three types of interventions—core care, concerns and core information. Tables 1–3 list the NICE interventions. The panel agreed to use a framework similar to that of the NICE guidelines for its discussions. The panel decided, however, to list the new WHO recommendations under two headings—“mother” and “newborn infant”—thus merging the “infant feeding” and “maintaining infant health” columns.

The panel identified the recommendations for which supporting evidence must be reviewed, those for which no further evidence review is required, and those for which the evidence on wider applicability should be considered. The panel also agreed that, for settings with a high prevalence of malaria, HIV or adolescent pregnancies, routine care should include basic interventions related to prevention and management of those conditions. Approaches appropriate for adolescents will be necessary, as will additional contacts for specific problems, such as prevention of mother-to-child transmission of HIV. Table 4 summarizes the panel’s suggestions.

6.5 Conclusions

The panel concluded that the guidelines should consider the needs of the mother-infant dyad. Any recommendation should place the woman and her newborn at the center of health provision and allow women to make informed choices about their own care and their babies’. The panel agreed that the woman and her partner/family require more information than they usually receive on care of the baby and mother within the first week after childbirth.

As for the timing of contacts after discharge, support for exclusive breast feeding (EBF) at the end of the first week, when feeding difficulties most often occur, can prolong EBF. Hence, a visit at this time would be appropriate. Still, the experiences and expectations of women and their families should be considered when deciding the timing of postnatal visits. Barriers to the uptake of services and/or access to services also should be considered when deciding on schedules for postnatal care.

156. WHO Technical Consultation on postpartum care

The availability of effective community support after discharge from a facility also is important. The competencies required in the community for postnatal support that improves outcomes should be studied. The formal health sector is responsible for continuing care in the postnatal period after discharge from facilities, but communities can help. Evidence should be evaluated on the effectiveness of current models of collaboration between health services and communities that appear to be transferable to low-resource settings.

The panel noted that additional information is required to make recommendations on the timing and frequency of postnatal visits. To obtain more information, the panel recommended identification and review of non-English language guidelines as well as review of information and evidence on the following: :

women’s expectations and experiences with care in the postnatal period;

current practice and best evidence on the timing and number of postnatal visits;

existing models of collaboration for postnatal care among heath care providers and among levels of care, including the family and the community;

the closure of the postnatal period for the mother and baby;

the effect of the competencies of the giver of postnatal care on maternal and infant health outcomes;

the roles of different types of care providers in reducing maternal and neonatal morbidity and mortality;

the cost-effectiveness of different types of community support in reducing maternal and neonatal morbidity and mortality;

The panel expressed concerns about the limited amount of evidence and the impossibility of generalizing from it to the variety of settings in the world and in particular to settings with little or no access to skilled and/or facility-based care for childbirth. The panel agreed that a review of qualitative evidence should be considered.

Many interventions in postnatal care are applicable to most countries and settings. Some principles apply in all settings and for all time bands—e.g. standard precautions, maintenance of records, maintaining competencies, monitoring and evaluation. The panel asked the WHO secretariat to identify those common areas and include them in a preamble to the guidelines as “Principles of Good Care”. Health system requirements, however, may differ for different time bands and so will need more specific consideration. A tool for countries on how to select appropriate care pathways for specific settings, including health system requirements, would be useful.

The panel noted that some important situations were not addressed. While these situations are not the primary focus of the proposed guidelines, it is important to highlight special considerations in such situations. These include malnourished women (obese and undernourished mothers); domestic and gender-based violence; use of alcohol, tobacco, and illicit drugs; mothers who have lost their babies or have babies with disabilities; mothers with very limited education or with language difficulties; mothers with medical or mental health problems; the small baby; multiple births; sick or disabled infants or infants with congenital anomalies; infants of mothers with tuberculosis, malaria, HIV, or syphilis; and those born to sex workers. Such factors can lead to physical and mental ill health for both the mother and the baby, during the pregnancy and after, or may be linked to a negative nurturing environment with adverse long-term effects on infant health and development.

16


7. Next steps

The technical consultation identified key issues for which recommendations should be developed or updated. These include technical, programmatic and implementation issues.

The next steps for WHO include developing and prioritizing questions to be addressed and assessing potential beneficial and harmful effects of postnatal care interventions. These steps will involve electronic consultation with the international panel of experts. Based on the results of these exercises, systematic reviews of evidence to address these questions will be commissioned.

The panel recommended holding a second technical consultation of a sub-group of the international panel of experts in Geneva to review the evidence on priority questions and make recommendations on guidelines for postnatal care for births with skilled attendants. Issues of implementation and cost implications also will be considered. These new and updated WHO guidelines for postnatal care are scheduled for publication in 2010.

17


Reference

1. World Health Organization (WHO), UNICEF, UNFPA, The World Bank. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and The World Bank. Geneva, WHO, 2008.

2. The world health report 2005: make every mother and child count. Geneva, World Health Organization, 2005.

3. Ahman E, Zupan J. Neonatal and perinatal mortality: country, regional and global estimates 2004. Geneva, World Health Organization, 2007.

4. Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet, 2006, 368:1189–1200.

5. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? where? why? Lancet, 2005, 365:891–900.

6. Making pregnancy safer: the critical role of the skilled attendant: a joint statement by WHO. ICM and FIGO. Geneva, World Health Organization, 2004.

7. Proportion of births attended by a skilled health worker, 2008 updates—fact sheet. Geneva, World Health Organization, 2008.

8. Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet, 2006, 368:1284–1299.

9. World health statistics 2009. Table 5. Risk factors. Geneva, World Health Organization, 2009 (http://www.who.int/whosis/whostat/EN_WHS09_Table5.pdf)

10. Demott K et al. Clinical guidelines and evidence review for post natal care: routine post natal care of recently delivered women and their babies. London, National Collaborating Centre for Primary Care and Royal College of General Practitioners, 2006 (http://www.nice.org.uk/Guidance/CG37)

11. C183 Maternity protection convention. Geneva, International Labour Organization, 2000 (http://www.ilo.org/ilolex/cgi-lex/convde.pl?C183)

12. Postpartum care of the mother and newborn: a practical guide. Geneva, World Health Organization, 1998.

13. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, World Health Organization, 2006.

14. WHO handbook for guideline development. Geneva, World Health Organization, 2008.

15. The world health report 2005: make every mother and child count. Policy brief one: integrating maternal, newborn and child health programmes. Geneva, World Health Organization, 2005 (http://www.who.int/whr/2005/media_centre/pb_1_en.pdf)

16. Cunningham FG et al. Williams obstetrics. New York, McGraw-Hill, 2005.

17. MacDonald MG, Mullett MD, Seshia MMK, eds. Avery’s neonatology: pathophysiology and management of the newborn. Philadelphia, J.B. Lippincott, 1994.


18. Marchant S et al. A survey of women’s experiences of vaginal loss from 24 hours to three months after childbirth (the BLiPP study). Midwifery, 1999, 15:72–81.

19. Bang RA et al. Maternal morbidity during labour and the puerperium in rural homes and the need for medical attention: a prospective observational study in Gadchiroli, India. British Journal of Obstetrics and Gynaecology, 2004, 111:231–238.

20. Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics, 2004, 113:1434–1436.

21. The Public Health Agency of Canada. Family-centred maternity and newborn care: national guidelines. Ottawa, 2000 (http://www.phac-aspc.gc.ca/dca-dea/prenatal/fcmc1-eng.php)

22. Cargill Y, Martel MJ, Society of Obstetricians and Gynaecologists of Canada. Postpartum maternal and newborn discharge. Journal of Obstetrics and Gynaecology Canada, 2007, 29:357–363.

23. Fort, AL, Kothari, MT, Abderrahim N. Postpartum care: levels and determinants in developing countries. Calverton, Maryland, USA, Macro International, 2006 (http://www.measuredhs.com/pubs/pub_details.cfm?ID=676)


Figures

Condition Days Weeks

1 2 3 4 5 6 7 2 3 4 5 6

% of maternal deaths* 60% 17% 13% 4%

% of neonatal deaths** 32% 8% 10% 7% 4% 5% 5% 15% 14%

Maintaining maternal health

Metritis

Eclampsia

Anaesthesia and thromboembolism

Perineal wound infection

Abdominal wound infection

Septic thrombophlebitis

Secondary postpartum haemorrhage

Urine retention

Urinary tract infection

Severe anaemia

Obstetric fistula

Depression and anxiety

Psychosis

Women with female genital mutilation

Support for HIV+ woman

PMTCT of HIV / Antiretroviral treatment (ART)

Syphilis testing/treatment

Tetanus toxoid if unimmunized

Vitamin A supplementation

Postnatal and emergency plan

Nutrition counselling

Counselling on safer sex, including condom use

Birth spacing and family planning counselling

Selection/initiation of family planning method†

Figure 1 Obstetric and neonatal epidemiology: timing of onset of condition or provision of care



1 2 3 4 5 6 7 2 3 4 5 6

Infant feeding

Breast engorgement

Feeding difficulty

Mastitis

Breastfeeding counselling and support

Teaching mother replacement feeding

HIV+ mother breastfeeding

Support for Lactational Amenorrhoea Method

Care givenLow/mediumfatality rate

High fatality rate

Figure 1 (continued)

21Figures: WHO Technical consultation on postpartum and postnatal care


1 2 3 4 5 6 7 2 3 4 5 6

% of maternal deaths* 60% 17% 13% 4%

% of neonatal deaths** 32% 8% 10% 7% 4% 5% 5% 15% 14%

Maintaining infant health

Asphyxia

Trauma

Respiratory Distress Syndrome

Other preterm breathing problems

Sepsis—early onset

Sepsis—late onset

Nosocomial infections (special care)

Community-acquired severe infection

Omphalitis

Local infection

Serious jaundice

Malformation (visible/treatable)

Tetanus

Congenital syphilis

ART initiation for HIV-exposed infant

HIV testing of HIV-exposed infant

Gonococcal ophthalmia

Chlamydia infections

Immunization

Growth monitoring

Information and advice on home care

Postnatal and emergency care plan

Care givenLow/mediumfatality rate

High fatality rate

Figure 1 (continued)


0%

5%

10%

15%

20%

25%

30%

35%

1 2 3 4 5 6 7 2 3-4

Days of life Weeks of life

0%

10%

20%

30%

40%

50%

60%

70%

Day 1 Day 2 Day3-7 2-6w

Figure 3: Proportion of neonatal deaths by day

Figure 2: Proportion of maternal death by days postpartum

Source (Figure 3): Baqui AH et al. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bulletin of the World Health Organization, September 2006, 84(9): 706–713.

Source (Figure 2): Baqui AH et al. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bulletin of the World Health Organization, September 2006, 84(9): 706–713.

* Hurt LS, Ronsmans C. Time since pregnancy and mortality in women of reproductive age in Matlab, Bangladesh. Presented at the British Society for Population Studies; December 2002; London, UK (See also Ronsmans and Graham, 2006 (4).)

** Baqui AH et al. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bulletin of the World Health Organization, September 2006, 84(9):706–713.

† Lactational amenorrhea method (LAM): starts with initiation of fully or nearly fully breastfeeding. Condoms and spermicides: can start at any time. Vasectomy: woman’s partner can have vasectomy at any time, ideally during her pregnancy. Female sterilization: within seven days; otherwise wait six weeks. Copper-bearing IUD: within 48 hours; otherwise wait four weeks. Hormonal methods: Fully breastfeeding women can start progestogen-only methods at six weeks or combined hormonal methods at six months; women who are partially breastfeeding can start any hormonal method at six weeks; women not breastfeeding can start progestogen-only methods immediately and combined methods at 21 days. (Source: Family planning: a global handbook for providers. WHO & JHSPH, 2007)


Tabl

esRe

com

men

dati

ons

for

rout

ine

post

nata

l car

e of

wom

en a

nd t

heir

bab

ies,

Nat

iona

l Col

labo

rati

ng C

entr

e fo

r Pr

imar

y Ca

re, 2

006

Code

s us

ed in

Tab

les

1–3:

For

NCC

PC g

uide

lines

in th

ese

tabl

es, t

he s

tren

gth

of e

vide

nce

is la

belle

d A,

B, C

, or D

, with

A b

eing

the

stro

nges

t. Al

l oth

er, u

nla-

belle

d re

com

men

datio

ns a

re o

f str

engt

h D

(goo

d pr

actic

e po

int—

GPP

).

A re

com

men

datio

n la

belle

d w

ith a

n as

teris

k (*

) app

ears

in b

oth

NIC

E/N

CCPC

(10)

and

WHO

gui

delin

es.

Reco

mm

enda

tions

that

app

ear i

n th

e cu

rren

t WHO

gui

delin

es, P

regn

ancy

, chi

ldbi

rth, p

ostp

artu

m a

nd n

ewbo

rn c

are

(PCP

NC

2006

), b

ut n

ot in

the

NIC

E/N

CCPC

gu

idel

ines

are

incl

uded

in a

sep

arat

e ro

w u

nder

eac

h he

adin

g. N

ote

that

WHO

reco

mm

enda

tions

ass

ume

a hi

gh p

reva

lenc

e of

ana

emia

(iro

n de

ficie

nt, p

aras

itic)

an

d of

sex

ually

tran

smitt

ed in

fect

ions

.

Tabl

e 1

Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Core

Car

eCo

re C

are

Core

Car

e

* M

easu

re a

nd d

ocum

ent b

lood

pre

ssur

e (B

P)

1.

once

with

in 6

hou

rs a

fter t

he la

st m

easu

rem

ent

take

n so

on a

fter b

irth

as a

com

pone

nt o

f lab

our

care

.

* To

ilet f

acili

ties

that

are

hyg

ieni

c an

d en

sure

2.

pr

ivac

y sh

ould

be

prov

ided

in th

e cl

inic

al s

ettin

g.

* Do

cum

ent u

rine

void

with

in 6

hou

rs.

3.

* Al

l wom

en s

houl

d be

enc

oura

ged

to m

obili

ze a

s 4.

so

on a

s ap

prop

riate

follo

win

g th

e bi

rth.

1.

Asse

ssm

ent f

or e

mot

iona

l att

achm

ent s

houl

d be

ca

rrie

d ou

t at e

ach

post

nata

l con

tact

.

2. (

A) V

itam

in K

sho

uld

be o

ffere

d fo

r all

infa

nts

and

(A) a

dmin

iste

red

with

a s

ingl

e do

se o

f 1 m

g IM

. If

pare

nts

decl

ine

IM v

itam

in K

for t

heir

baby

, ora

l vi

tam

in K

sho

uld

be o

ffere

d as

sec

ond

line.

1. D

urin

g th

e fir

st h

our o

f life

:

a. (C

) * M

othe

r and

bab

y sh

ould

not

be

sepa

rate

d.b.

(A) *

Ski

n-to

-ski

n co

ntac

t sho

uld

be e

ncou

rage

d.

c. *

Bre

astfe

edin

g sh

ould

be

initi

ated

.

2. W

here

pos

tnat

al c

are

is p

rovi

ded

in a

clin

ical

set

ting,

the

envi

ronm

ent s

houl

d in

clud

e:

(A) *

Rou

nd-t

he-c

lock

room

ing-

in a

nd c

ontin

uing

mat

er-

nal s

kin

to b

aby’

s sk

in c

onta

ct w

hen

poss

ible

.

Priv

acy.

*

Adeq

uate

rest

for t

he w

oman

with

out i

nter

rupt

ion

due

to c

linic

al ro

utin

e.

Ac

cess

for t

he w

oman

to fo

od a

nd d

rink

on d

eman

d.

(B

) * F

orm

ula

milk

sho

uld

not b

e gi

ven

to b

reas

tfed

babi

es in

hos

pita

l unl

ess

med

ical

ly in

dica

ted.

(A) T

he d

istr

ibut

ion

of c

omm

erci

al p

acks

, for

exa

mpl

e th

ose

give

n to

wom

en w

hen

they

are

dis

char

ged

from

ho

spita

l, w

hich

con

tain

form

ula

milk

or a

dver

tisem

ents

fo

r for

mul

a sh

ould

not

be

used

.

Tim

e Ba

nd 1

: Wit

hin

the

first

24

hour

s af

ter

deliv

ery


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Br

east

pum

ps s

houl

d be

ava

ilabl

e in

the

clin

ical

set

ting,

pa

rtic

ular

ly fo

r wom

en w

ho h

ave

been

sep

arat

ed fr

om

thei

r bab

ies,

to e

stab

lish

lact

atio

n. A

ll w

omen

who

use

a

brea

st p

ump

shou

ld b

e of

fere

d in

stru

ctio

ns o

n th

e co

rrec

t us

e.

3. (

A) *

Bre

astfe

edin

g su

ppor

t to

a w

oman

sho

uld

be m

ade

avai

labl

e re

gard

less

of t

he lo

catio

n of

car

e.

4. W

omen

sho

uld

be o

ffere

d sk

illed

sup

port

incl

udin

g m

othe

r-to

-mot

her o

r pee

r sup

port

from

the

com

men

cem

ent o

f br

east

feed

ing.

5. A

wom

an s

houl

d no

t be

aske

d ab

out f

eedi

ng m

etho

d un

til

afte

r firs

t ski

n-to

-ski

n co

ntac

t.

6. A

dditi

onal

sup

port

with

pos

ition

ing

and

atta

chm

ent t

o co

mm

ence

bre

astfe

edin

g sh

ould

be

offe

red

to a

ll w

omen

who

ha

ve h

ad:

(C

) nar

cotic

ana

lges

ia o

r gen

eral

ana

esth

etic

, as

the

baby

m

ay n

ot in

itial

ly b

e re

spon

sive

to fe

edin

g;

a ca

esar

ean

sect

ion,

par

ticul

arly

to a

ssis

t with

han

dlin

g an

d po

sitio

ning

the

baby

to p

rote

ct th

e w

oman

’s ab

dom

i-na

l wou

nd;

in

itial

con

tact

with

thei

r bab

y de

laye

d.

7. (

A) *

Unr

estr

icte

d fre

quen

cy a

nd d

urat

ion

of b

reas

tfeed

ing

shou

ld b

e en

cour

aged

.

8. *

A h

ealth

-car

e pr

ofes

siona

l sho

uld

disc

uss

a w

oman

’s ex

perie

nce

with

bre

astfe

edin

g da

ily a

fter b

irth,

to a

sses

s w

ith

her i

f she

is o

n co

urse

to b

reas

tfeed

effe

ctiv

ely

and

iden

tify

need

fo

r add

ition

al s

uppo

rt. B

reas

tfeed

ing

prog

ress

sho

uld

then

be

asse

ssed

and

doc

umen

ted

in th

e ca

re p

lan

at e

ach

post

nata

l co

ntac

t.

9. (

A) W

ritte

n br

east

feed

ing

educ

atio

n m

ater

ials

as a

sta

nd-a

lone

in

terv

entio

n ar

e no

t rec

omm

ende

d.

10. (

A) A

ll m

ater

nity

car

e pr

ovid

ers

(whe

ther

wor

king

in h

ospi

tal

or in

prim

ary

care

) sho

uld

impl

emen

t an

exte

rnal

ly ev

alua

ted

stru

ctur

ed p

rogr

amm

e th

at e

ncou

rage

s br

east

feed

ing

usin

g th

e Ba

by F

riend

ly In

itiat

ive

as a

min

imum

sta

ndar

d.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

WH

O P

CPN

C 20

06:

1. G

ive

a Ho

me-

base

d M

ater

nal H

ealth

Rec

ord

befo

re

disc

harg

e an

d di

scus

s its

use

.

2. A

ll po

stpa

rtum

wom

en s

houl

d ha

ve re

gula

r as

sess

men

t of v

agin

al b

leed

ing,

ute

rine

cont

ract

ion,

fu

ndal

hei

ght a

nd te

mpe

ratu

re m

easu

red

rout

inel

y.

3. A

ll w

omen

sho

uld

be e

xam

ined

one

hou

r afte

r de

liver

y of

pla

cent

a, in

clud

ing

asse

ssm

ent o

f an

aem

ia.

4. E

nsur

e m

othe

r and

bab

y ar

e sl

eepi

ng u

nder

im

preg

nate

d be

d ne

t.

WH

O P

CPN

C 20

06:

1. S

uppo

rt fo

r bre

astfe

edin

g at

faci

lity

shou

ld b

e pr

ovid

ed b

y he

alth

pro

fess

iona

ls.

2. H

elp

mot

her i

nitia

ting

brea

stfe

edin

g w

ithin

1 h

our.

3. A

sses

s br

east

feed

ing

regu

larly

and

hel

p m

othe

r if n

eede

d.

4. O

nly

disc

harg

e th

e ba

by if

mot

her f

eels

com

pete

nt

brea

stfe

edin

g.

5. T

each

all

mot

hers

how

to re

lieve

eng

orge

men

t and

exp

ress

br

east

milk

and

feed

the

baby

by

cup.

WH

O P

CPN

C 20

06:

1. F

irst c

linic

al e

xam

inat

ion

shou

ld b

e do

ne a

roun

d an

ho

ur a

fter t

he b

irth

to a

sses

s if

baby

can

sta

y w

ith

the

mot

her o

r nee

ds a

dditi

onal

car

e or

refe

rral

to

spec

ial c

are.

2. A

sses

s fo

r mal

form

atio

ns a

nd b

irth

inju

ries.

3. E

nsur

e th

erm

al p

rote

ctio

n im

med

iate

ly a

fter b

irth

and

subs

eque

ntly.

4. T

each

mot

her c

arin

g fo

r the

bab

y, en

surin

g hy

gien

e, w

arm

th, c

ord

care

, sle

epin

g un

der a

bed

ne

t, sl

eepi

ng p

ositi

on o

n ba

by’s

back

or s

ide,

in a

sm

oke-

free

envi

ronm

ent.

Teac

h m

othe

r how

to c

are

for a

sm

all b

aby

(pre

term

and

/or l

ow b

irth

wei

ght).

5. G

ive

spec

ial s

uppo

rt to

bre

astfe

edin

g th

e sm

all

baby

or t

win

s.

6. T

each

mot

her t

o ob

serv

e fo

r dan

ger s

igns

in th

e ba

by a

nd to

cal

l hea

lth w

orke

r if s

he h

as c

once

rns.

7. E

xam

ine

befo

re d

isch

arge

. Dis

cuss

with

mot

her

post

nata

l car

e an

d em

erge

ncy

plan

.

8. O

nly

disc

harg

e sm

all b

abie

s if

disc

harg

e cr

iteria

m

et: e

xclu

sive

bre

astfe

edin

g, s

tabl

e te

mpe

ratu

re,

wei

ght g

ain,

mot

her f

eelin

g co

mpe

tent

car

ing

for

the

baby

.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Conc

ern

Conc

ern

Conc

ern

1. W

omen

with

flat

or i

nver

ted

nipp

les

shou

ld b

e ad

vise

d th

at

thes

e ar

e no

t con

trai

ndic

atio

ns to

bre

astfe

edin

g an

d su

ppor

t of

fere

d as

nee

ded.

2. I

f a w

oman

is e

xper

ienc

ing

brea

st o

r nip

ple

pain

, the

wom

an

or h

ealth

-car

e pr

ofes

sion

al s

houl

d re

view

pos

ition

ing

and

atta

chm

ent.

3. A

bab

y w

ho is

not

att

achi

ng e

ffect

ivel

y m

ay b

e en

cour

aged

to

open

his

/her

mou

th u

sing

diff

eren

t stim

uli.

4. S

kin-

to-s

kin

cont

act o

r mas

sagi

ng a

bab

y’s

feet

sho

uld

be u

sed

to w

ake

the

baby

.

1. *

Infa

nts

who

dev

elop

jaun

dice

with

in th

e fir

st 2

4 ho

urs

shou

ld b

e ur

gent

ly in

vest

igat

ed. (

Actio

n le

vel

2)

1. (

D) If

infe

ctio

n is

sus

pect

ed a

wom

an’s

tem

pera

ture

sh

ould

be

take

n an

d do

cum

ente

d. If

a w

oman

’s te

mpe

ratu

re is

abo

ve 3

8°C,

it s

houl

d be

mea

sure

d ag

ain

in 4

–6 h

ours

.

2. (

B) A

sses

smen

t of v

agin

al lo

ss a

nd u

terin

e in

volu

tion

and

posi

tion

shou

ld b

e un

dert

aken

if

a w

oman

has

exc

essi

ve o

r offe

nsiv

e va

gina

l los

s, ab

dom

inal

tend

erne

ss o

r fev

er. A

ny a

bnor

mal

ities

in

the

size

, ton

e an

d po

sitio

n of

the

uter

us s

houl

d be

eva

luat

ed. I

f no

uter

ine

abno

rmal

ity is

foun

d,

cons

ider

oth

er c

ause

s of

sym

ptom

s (u

rgen

t act

ion)

.

3. *

If d

iast

olic

blo

od p

ress

ure

is g

reat

er th

an 9

0 m

m

Hg, a

nd th

ere

are

no o

ther

sig

ns a

nd s

ympt

oms

of

pre-

ecla

mps

ia, t

he m

easu

rem

ent o

f blo

od p

ress

ure

shou

ld b

e re

peat

ed w

ithin

4 h

ours

.

4. *

If a

wom

an h

as n

ot v

oide

d by

6 h

ours

pos

tpar

tum

an

d m

easu

res

to e

ncou

rage

mic

turit

ion,

suc

h as

ta

king

a w

arm

bat

h or

sho

wer

, are

not

imm

edia

tely

su

cces

sful

, bla

dder

vol

ume

shou

ld b

e as

sess

ed a

nd

cath

eter

isat

ion

cons

ider

ed. (

urge

nt a

ctio

n)

5. *

If a

wom

an is

obe

se, s

he w

ill re

quire

in

divi

dual

ised

car

e.

6. *

Imm

edia

te re

ferr

al (e

mer

genc

y ac

tion)

is re

quire

d if

ther

e is

: a.

Sud

den

or p

rofu

se b

lood

loss

or l

oss

acco

mpa

-ni

ed b

y an

y of

the

sign

s an

d sy

mpt

oms

of s

hock

, in

clud

ing

tach

ycar

dia,

hyp

oten

sion

, hyp

oper

-fu

sion

and

cha

nge

in c

onsc

ious

ness

, sho

uld

rece

ive

emer

genc

y m

edic

al a

ctio

n.

b. (

A) D

iast

olic

BP

is g

reat

er th

an 9

0 m

m H

g an

d ac

com

pani

ed b

y an

othe

r sig

n or

sym

ptom

of

pre-

ecla

mps

ia, o

r if d

iast

olic

BP

is g

reat

er th

an

90 m

m H

g an

d is

not

redu

ced

belo

w 9

0 m

m H

g w

ithin

4 h

ours

.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

WH

O P

CPN

C 20

06:

Giv

e pr

even

tive

mea

sure

s:

1. A

sses

s th

e st

atus

of t

etan

us im

mun

izat

ion

and

syph

ilis

and

HIV

test

.

2. G

ive

3-m

onth

sup

ply

of ir

on/fo

lic a

cid.

3. G

ive

vita

min

A.

4. G

ive

mot

her i

nsec

ticid

e-tr

eate

d be

dnet

.

5. G

ive

supp

ortiv

e ca

re to

the

wom

en w

ho lo

st h

er

baby

.

WH

O P

CPN

C 20

06:

1. R

esus

cita

te a

bab

y th

at is

not

bre

athi

ng

spon

tane

ousl

y af

ter b

irth.

2. A

sses

s ge

stat

iona

l age

and

wei

gh th

e ba

by.

3. T

each

mot

her p

rovi

ding

add

ition

al c

are

for a

sm

all

baby

(pre

term

, low

birt

h w

eigh

t).

Core

Info

rmat

ion

Core

Info

rmat

ion

Core

Info

rmat

ion

c. T

he te

mpe

ratu

re re

mai

ns a

bove

38

°C o

n th

e se

cond

read

ing

or th

ere

are

othe

r obs

erva

ble

sym

ptom

s an

d m

easu

rabl

e si

gns

of s

epsi

s. d.

A w

oman

com

plai

ns o

f uni

late

ral c

alf p

ain,

re

dnes

s, sw

ellin

g, s

hort

ness

of b

reat

h or

che

st

pain

.

1. (

C) *

All

wom

en s

houl

d be

giv

en in

form

atio

n ab

out

the

phys

iolo

gica

l pro

cess

of r

ecov

ery

afte

r birt

h,

and

that

som

e he

alth

pro

blem

s ar

e co

mm

on, w

ith

advi

ce to

repo

rt a

ny h

ealth

con

cern

s to

hea

lth-c

are

prof

essi

onal

, in

part

icul

ar:

a. S

igns

and

sym

ptom

s of

PPH

: su

dden

and

pr

ofus

e bl

ood

loss

or p

ersi

sten

t inc

reas

ed

bloo

d lo

ss; f

aint

ness

; diz

zine

ss; p

alpi

tatio

ns/

tach

ycar

dia.

1. W

omen

sho

uld

be o

ffere

d in

form

atio

n an

d re

assu

ranc

e on

:

Colo

stru

m, w

hich

will

mee

t the

nee

ds o

f the

bab

y in

the

first

few

day

s af

ter b

irth.

(C) *

Tim

ing

of th

e in

itial

bre

astfe

ed, i

nclu

ding

the

prot

ec-

tive

effe

ct o

f col

ostr

um, w

hich

is c

ultu

rally

app

ropr

iate

.

* Th

e nu

rtur

ing

bene

fits

of p

uttin

g th

e ba

by to

the

brea

st

in a

dditi

on to

the

nutr

ition

al b

enefi

ts o

f bre

astfe

edin

g.

1. *

At e

ach

post

nata

l con

tact

par

ents

sho

uld

be

offe

red

info

rmat

ion

and

guid

ance

to e

nabl

e th

em

to: As

sess

thei

r bab

y’s

gene

ral c

ondi

tion.

Iden

tify

war

ning

sig

ns to

look

for i

f the

ir ba

by is

un

wel

l.

Cont

act a

hea

lth-c

are

prof

essi

onal

or e

mer

genc

y se

rvic

e if

requ

ired.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Core

Info

rmat

ion

Core

Info

rmat

ion

Core

Info

rmat

ion

WH

O P

CPN

C 20

06:

1. A

dvis

e on

saf

er s

ex in

clud

ing

use

of c

ondo

ms.

2. A

dvis

e on

pos

tpar

tum

car

e an

d hy

gien

e, e

spec

ially

ha

nd w

ashi

ng.

3. C

ouns

el o

n nu

triti

on.

4. C

ouns

el o

n bi

rth

spac

ing

and

fam

ily p

lann

ing

with

spe

cial

att

entio

n to

lact

atio

nal a

men

orrh

oea

met

hod

(LAM

).

5. A

dvis

e on

rout

ine

post

part

um c

are,

on

dang

er s

igns

an

d po

stpa

rtum

em

erge

ncy

plan

.

WH

O P

CPN

C 20

06:

1. C

ouns

ellin

g m

othe

rs o

f low

-birt

h-w

eigh

t (LB

W)

infa

nts

on d

isch

arge

:

Excl

usiv

e br

east

feed

ing

Ke

epin

g th

e ba

by w

arm

Da

nger

sig

ns fo

r see

king

car

e.

L

BW b

abie

s sh

ould

be

follo

wed

up

for w

eekl

y w

eigh

ing,

ass

essm

ent o

f fee

ding

and

gen

eral

he

alth

unt

il th

ey h

ave

reac

hed

2.5

kg.

2. A

wom

an s

houl

d be

reas

sure

d th

at b

rief d

isco

mfo

rt a

t the

st

art o

f bre

ast f

eeds

in th

e fir

st fe

w d

ays

is n

ot u

ncom

mon

, bu

t thi

s sh

ould

not

per

sist

.

3. (

A) W

omen

who

leav

e ho

spita

l soo

n af

ter b

irth

shou

ld b

e re

assu

red

that

this

sho

uld

not i

mpa

ct o

n br

east

feed

ing

dura

tion.

4.

All w

omen

and

car

ers

who

are

giv

ing

thei

r bab

ies

form

ula

feed

sho

uld

be o

ffere

d ap

prop

riate

and

tailo

red

advi

ce to

en

sure

this

is u

nder

take

n as

saf

ely

as p

ossi

ble,

and

opt

imiz

es

infa

nt d

evel

opm

ent,

heal

th a

nd n

utrit

iona

l nee

ds.

5. A

wom

an w

ho w

ishe

s to

feed

her

bab

y fo

rmul

a m

ilk s

houl

d be

taug

ht h

ow to

mak

e fe

eds

usin

g co

rrec

t, m

easu

red

quan

titie

s of

form

ula,

as

base

d on

the

man

ufac

ture

r’s

inst

ruct

ions

, and

how

to c

lean

/ste

rilis

e fe

edin

g bo

ttle

s an

d te

ats

and

stor

e fo

rmul

a m

ilk.

2. D

urin

g an

y ph

ysic

al e

xam

inat

ion

of a

bab

y bo

th

pare

nts

shou

ld b

e pr

esen

t whe

re p

ossi

ble

to

enco

urag

e th

e pa

rtic

ipat

ion

of b

oth

in th

eir b

aby’

s ca

re a

nd to

pro

vide

an

oppo

rtun

ity fo

r bot

h to

le

arn

mor

e ab

out t

heir

baby

and

his

/her

nee

ds.

3. P

aren

ts s

houl

d be

offe

red

info

rmat

ion

on v

itam

in

K in

ord

er to

mak

e an

info

rmed

dec

isio

n ab

out i

ts

use.

4. (

C) P

aren

ts s

houl

d be

offe

red

info

rmat

ion

abou

t ph

ysio

logi

cal j

aund

ice

incl

udin

g:

Th

at it

nor

mal

ly o

ccur

s ar

ound

3–4

day

s af

ter

birt

h

* Re

ason

s fo

r mon

itorin

g an

d ho

w to

mon

itor.

b. S

igns

and

sym

ptom

s of

infe

ctio

n: fe

ver;

shak

ing;

abd

omin

al p

ain

and/

or o

ffens

ive

vagi

nal l

oss.

c.

Sig

ns a

nd s

ympt

oms

of th

rom

boem

bolis

m:

unila

tera

l cal

f pai

n; re

dnes

s or

sw

ellin

g of

ca

lves

; sho

rtnes

s of

bre

ath

or c

hest

pai

n.

d. S

igns

and

sym

ptom

s of

pre

-ecl

amps

ia:

head

ache

s ac

com

pani

ed b

y on

e or

mor

e of

th

e sy

mpt

oms

of v

isua

l dis

turb

ance

s, na

usea

, vo

miti

ng, f

eelin

g fa

int.

2. W

omen

who

hav

e ha

d an

epi

dura

l or s

pina

l an

aest

hesi

a sh

ould

be

advi

sed

to re

port

any

se

vere

hea

dach

e, p

artic

ular

ly w

hen

sitt

ing

or

stan

ding

.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Core

Car

eCo

re C

are

Core

Car

e

1. C

ompl

ete

new

born

phy

sica

l exa

min

atio

n sh

ould

be

per

form

ed w

ithin

72

hour

s of

birt

h.

2. *

The

par

ent-

held

chi

ld re

cord

sho

uld

be p

rovi

ded

to a

ll pa

rent

s w

ithin

the

first

thre

e da

ys o

f birt

h.

3. T

he a

ims

of a

ny p

hysi

cal e

xam

inat

ion

shou

ld b

e fu

lly e

xpla

ined

by

the

heal

th-c

are

prof

essi

onal

and

th

e fin

ding

s an

d re

sults

sha

red

with

the

pare

nts

and

reco

rded

in th

e po

stna

tal p

lan

and

the

pare

nt-

held

chi

ld re

cord

.

4. T

he N

ewbo

rn B

lood

Spo

t Tes

t sho

uld

be o

ffere

d to

al

l par

ents

whe

n th

eir i

nfan

ts a

re 5

–8 d

ays

of a

ge.

Info

rmed

con

sent

sho

uld

be o

btai

ned.

5. A

hea

ring

scre

en s

houl

d be

com

plet

ed p

rior t

o di

scha

rge

or b

y w

eek

4 in

the

hosp

ital p

rogr

amm

e or

by

wee

k 5

in th

e co

mm

unity

pro

gram

me.

6. (

B) H

ome

visi

ts s

houl

d be

use

d as

opp

ortu

nitie

s to

pro

mot

e pa

rent

- or m

othe

r-to-

child

em

otio

nal

atta

chm

ent.

7. (

B) A

ll w

omen

sho

uld

be e

ncou

rage

d to

dev

elop

so

cial

net

wor

ks a

s th

ese

prom

ote

posi

tive

mat

erna

l-inf

ant i

nter

actio

n.

8. (

A) G

roup

-bas

ed p

aren

t edu

catio

n pr

ogra

mm

es

desi

gned

to p

rom

ote

emot

iona

l att

achm

ent a

nd

impr

ove

pare

ntin

g sk

ills

shou

ld b

e av

aila

ble

to

pare

nts

who

wis

h to

acc

ess

them

.

9. (

A) A

ll ho

me

visi

ts s

houl

d be

use

d as

an

oppo

rtun

ity to

ass

ess

rele

vant

saf

ety

issu

es fo

r all

fam

ily m

embe

rs in

the

hom

e an

d en

viro

nmen

t and

pr

omot

e sa

fety

edu

catio

n an

d us

e of

bas

ic s

afet

y eq

uipm

ent.

Tabl

e 2

Tim

e Ba

nd 2

: Bet

wee

n tw

o an

d se

ven

days

(24-

168

hour

s)

1. A

nti-D

sho

uld

be o

ffere

d as

requ

ired

acco

rdin

g to

De

part

men

t of H

ealth

gui

delin

e w

ithin

72

hour

s of

bi

rth.

2. M

MR

shou

ld b

e of

fere

d as

requ

ired

acco

rdin

g to

De

part

men

t of H

ealth

gui

delin

e

3. *

Enq

uire

s sh

ould

be

mad

e ab

out g

ener

al w

ell-

bein

g an

d a

ll co

mm

on h

ealth

pro

blem

s in

clud

ing:

mic

turit

ion

and

urin

ary

inco

ntin

ence

bo

wel

func

tion

he

alin

g of

any

per

inea

l wou

nd

head

ache

fatig

ue

ba

ck p

ain.

4. *

Enc

oura

ge a

ll w

omen

to

use

self-

care

tech

niqu

es,

such

as

taki

ng g

entle

exe

rcise

, tak

ing

time

to re

st,

havi

ng h

elp

to c

are

for h

er b

aby,

talk

ing

to s

omeo

ne

abou

t her

feel

ings

and

that

she

is e

nabl

ed to

acc

ess

socia

l sup

port

netw

orks

.

5. *

Ask

all

wom

en a

bout

thei

r em

otio

nal w

ell-b

eing

, w

hat f

amily

and

soc

ial s

uppo

rt th

ey h

ave

and

thei

r us

ual c

opin

g st

rate

gies

for d

ealin

g w

ith d

ay-to

-day

m

atte

rs. A

ll w

omen

and

thei

r fam

ilies

/par

tner

s sh

ould

be

enc

oura

ged

to te

ll th

eir h

ealth

-car

e pr

ofes

siona

l ab

out a

ny c

hang

es in

moo

d, e

mot

iona

l sta

te a

nd

beha

viou

r tha

t are

out

side

of th

e w

oman

’s no

rmal

pa

ttern

.

6. O

bser

ve fo

r any

risk

s, sig

ns a

nd s

ympt

oms

of

dom

estic

abu

se a

nd k

now

who

to c

onta

ct fo

r adv

ice

and

man

agem

ent.

1. H

ealth

-car

e pr

ofes

siona

l sho

uld

disc

uss

a w

oman

’s pr

ogre

ss

with

bre

astfe

edin

g w

ithin

the

first

2 d

ays

post

partu

m to

ass

ess

if sh

e is

on c

ours

e to

bre

astfe

ed e

ffect

ivel

y.

2. A

sses

s fo

r effe

ctiv

e fe

edin

g as

the

wom

an’s

brea

st m

ilk c

omes

in

.

3. A

ll br

east

feed

ing

wom

en s

houl

d be

offe

red

info

rmat

ion

abou

t ho

w to

han

d-ex

pres

s th

eir b

reas

t milk

and

adv

ised

on h

ow to

st

ore

and

freez

e th

eir e

xpre

ssed

milk

.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Core

Car

eCo

re C

are

Core

Car

e

Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

WH

O P

CPN

C 20

06:

1. A

sk m

othe

r how

the

baby

is fe

edin

g.

2. I

f nec

essa

ry, o

bser

ve b

reas

tfeed

ing,

cor

rect

pos

ition

ing

and

atta

chm

ent.

Conc

ern

Conc

ern

Conc

ern

The

heal

th-c

are

prof

essi

onal

sho

uld

cont

inue

to

iden

tify,

eval

uate

and

man

age

com

mon

hea

lth

prob

lem

s as

app

ropr

iate

:

1. *

Car

ry o

ut a

sses

smen

t of p

erin

eum

if p

erin

eal

pain

is p

rese

nt. F

or p

ain

relie

f adv

ise:

(A) t

opic

al c

old

ther

apy

pa

race

tam

ol

(A

)Non

ster

oida

l ant

i-infl

amm

ator

y dr

ugs

(NSA

IDs)

if n

ot c

ontr

aind

icat

ed.

2. *

Sig

ns a

nd s

ympt

oms

of in

fect

ion,

inad

equa

te

repa

ir, w

ound

bre

akdo

wn

or n

on-h

ealin

g sh

ould

be

furt

her e

valu

ated

. (Ac

tion

leve

l 2)

3. *

Man

agem

ent o

f mild

pos

tnat

al h

eada

che

shou

ld

be b

ased

on

diffe

rent

ial d

iagn

osis

of h

eada

che

type

and

loca

l tre

atm

ent p

roto

cols.

4. I

f a w

oman

has

tens

ion

or m

igra

ine

head

ache

s, th

e he

alth

-car

e pr

ofes

sion

al s

houl

d of

fer a

dvic

e on

rela

xatio

n an

d av

oida

nce

of fa

ctor

s as

soci

ated

w

ith th

e on

set o

f hea

dach

es.

5. *

Bac

k pa

in s

houl

d be

man

aged

as

in th

e ge

nera

l po

pula

tion.

1. *

If b

reas

tfeed

ing

is n

ot p

rogr

essi

ng, s

uppo

rt a

nd a

ssis

tanc

e w

ith p

ositi

onin

g an

d at

tach

men

t on

the

brea

st s

houl

d be

pr

ovid

ed.

2. *

If n

ippl

e pa

in p

ersi

sts

afte

r rep

ositi

onin

g, c

onsi

der

eval

uatio

n fo

r thr

ush.

3. *

If s

igns

and

sym

ptom

s of

eng

orge

men

t are

pre

sent

, a

wom

an s

houl

d be

enc

oura

ged

to:

w

ear a

wel

l-fitt

ing

bra;

fe

ed fr

eque

ntly,

incl

udin

g pr

olon

ged

brea

stfe

edin

g fro

m

the

affe

cted

bre

ast;

m

assa

ge b

reas

ts a

nd, i

f nec

essa

ry, h

and

expr

ess

milk

;

(A) t

ake

anal

gesi

a if

nece

ssar

y.

4. *

If s

igns

and

sym

ptom

s of

mas

titis

are

pre

sent

, a w

oman

sh

ould

be

advi

sed

to:

(A

) con

tinue

bre

astfe

edin

g an

d/or

han

d ex

pres

sion

to

ensu

re e

ffect

ive

milk

rem

oval

and

, if n

eces

sary

, gen

tly

mas

sage

the

brea

st to

relie

ve a

ny b

lock

age;

(A

) see

k as

sist

ance

with

pos

ition

ing

and

atta

chm

ent;

ta

ke a

nalg

esia

com

patib

le w

ith b

reas

tfeed

ing,

for e

xam

-pl

e, p

arac

etam

ol;

In

crea

se h

er fl

uid

inta

ke.

1. I

f no

mec

oniu

m p

asse

d in

24

hour

s, re

fer f

or

eval

uatio

n. (A

ctio

n le

vel 2

) Che

ck w

ith d

igita

l ex

amin

atio

n.

2. (

C) *

If a

bab

y is

sus

pect

ed o

f bei

ng u

nwel

l, a

tem

pera

ture

sho

uld

be ta

ken

usin

g an

ele

ctro

nic

devi

ce w

hich

has

bee

n pr

oper

ly c

alib

rate

d an

d is

us

ed a

ppro

pria

tely.

3. *

A te

mpe

ratu

re o

f ≥38

°C is

abn

orm

al a

nd th

e ca

use

shou

ld b

e ev

alua

ted.

(Act

ion

leve

l 1)

4. C

are

for j

aund

ice:

*

Afte

r the

firs

t 24

hour

s, if

a ca

rer n

otic

es th

at

a ba

by is

jaun

dice

d, o

r tha

t jau

ndic

e is

wor

sen-

ing,

or t

he b

aby

is p

assi

ng p

ale

stoo

ls, th

e ca

rer

shou

ld b

e ad

vise

d to

repo

rt th

is to

a h

ealth

-ca

re p

rofe

ssio

nal

*

If a

baby

dev

elop

s ja

undi

ce, t

he in

ten-

sity

sho

uld

be m

onito

red

24 h

ours

late

r and

sy

stem

atic

ally

reco

rded

alo

ng w

ith th

e ba

by’s

over

all w

ell-b

eing

with

rega

rd to

hyd

ratio

n an

d al

ertn

ess.

A br

east

fed

baby

who

has

sig

ns o

f jau

ndic

e

10. H

ealth

-car

e pr

ofes

sion

als

shou

ld b

e al

ert t

o ris

k fa

ctor

s an

d si

gns

and

sym

ptom

s of

chi

ld a

buse

an

d if

ther

e is

rais

ed c

once

rn s

houl

d fo

llow

loca

l ch

ild p

rote

ctio

n po

licie

s.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

6. A

wom

an w

ith s

ome

invo

lunt

ary

leak

age

of a

sm

all v

olum

e of

urin

e sh

ould

be

taug

ht h

ow to

do

pelv

ic fl

oor e

xerc

ises

.

7. I

f con

stip

atio

n pr

esen

t, ad

vise

incr

ease

d in

take

of

fibre

and

flui

ds. I

f pro

blem

per

sist

s ad

vise

use

of

gent

le s

timul

ant l

axat

ive.

8. A

ll w

omen

with

hae

mor

rhoi

ds s

houl

d ta

ke

mea

sure

s to

avo

id c

onst

ipat

ion

and

shou

ld b

e of

fere

d m

anag

emen

t bas

ed o

n lo

cal t

reat

men

t pr

otoc

ols

9. I

f a w

oman

has

a h

aem

orrh

oid

whi

ch is

sev

ere

and

swol

len

or p

rola

psed

, or a

ny re

ctal

ble

edin

g, th

is

shou

ld b

e ev

alua

ted.

(Act

ion

leve

l 2)

10. *

Onc

e as

sess

ed, w

omen

with

the

follo

win

g co

nditi

ons

shou

ld b

e re

ferr

ed fo

r tre

atm

ent:

a. P

ersi

sten

t urin

ary

inco

ntin

ence

. (Ac

tion

leve

l 2)

b. F

aeca

l inc

ontin

ence

. (Ac

tion

leve

l 2)

c. S

ever

e or

per

sist

ent h

eada

che

and/

or o

ther

sy

mpt

om o

f pre

-ecl

amps

ia. (

Actio

n le

vel 1

) d.

If a

wom

an h

as s

usta

ined

a p

ostp

artu

m b

leed

-in

g, o

r com

plai

ns o

f per

sist

ent f

atig

ue, h

er

haem

oglo

bin

leve

l sho

uld

be e

valu

ated

and

, if

low

, tre

ated

acc

ordi

ng to

loca

l pol

icy.

5. (

C) W

omen

sho

uld

be a

dvis

ed to

repo

rt a

ny s

igns

and

sy

mpt

oms

of m

astit

is in

clud

ing

flu-li

ke s

ympt

oms,

red,

tend

er

and

pain

ful b

reas

ts to

thei

r hea

lth-c

are

prof

essi

onal

urg

ently

.

6. (

B) *

If s

igns

and

sym

ptom

s of

mas

titis

per

sist

mor

e th

an

seve

ral h

ours

, a w

oman

sho

uld

cont

act h

er h

ealth

-car

e pr

ovid

er a

nd m

ay re

quire

ant

ibio

tic tr

eatm

ent.

(Act

ion

leve

l 2)

7. I

f an

insu

ffici

ency

of m

ilk is

per

ceiv

ed b

y th

e w

oman

, her

br

east

feed

ing

tech

niqu

e an

d he

r bab

y’s

heal

th s

houl

d be

eva

luat

ed b

y an

app

ropr

iate

ly tr

aine

d he

alth

-car

e pr

ofes

sion

al. (

C) R

eass

uran

ce s

houl

d be

offe

red

to a

ssis

t th

e w

oman

in g

aini

ng c

onfid

ence

in h

er a

bilit

y to

pro

duce

en

ough

milk

for h

er b

aby.

8. (

B) *

If th

e ba

by is

not

taki

ng s

uffic

ient

milk

dire

ctly

fro

m th

e br

east

and

sup

plem

enta

ry fe

eds

are

nece

ssar

y, ex

pres

sed

brea

st m

ilk s

houl

d be

giv

en b

y a

cup

or b

ottle

. (C)

Su

pple

men

tatio

n w

ith fl

uids

oth

er th

an b

reas

t milk

is n

ot

reco

mm

ende

d.

9. E

valu

atio

n fo

r ank

ylog

loss

ia (t

ongu

e tie

) sho

uld

be m

ade

if br

east

feed

ing

prob

lem

s pe

rsis

t afte

r a re

view

of p

ositi

onin

g an

d at

tach

men

t by

a sk

illed

hea

lth-c

are

prof

essi

onal

or p

eer

coun

sello

r. If

anky

logl

ossi

a is

sus

pect

ed, f

urth

er e

valu

atio

n is

re

quire

d.

shou

ld b

e br

east

feed

freq

uent

ly, a

nd th

e ba

by

awak

ened

to fe

ed if

nec

essa

ry.

Br

east

fed

babi

es s

houl

d no

t be

rout

inel

y su

p-pl

emen

ted

with

form

ula,

wat

er o

r dex

tros

e w

ater

for t

he tr

eatm

ent o

f jau

ndic

e.

If

a ba

by is

sig

nific

antly

jaun

dice

d or

app

ears

un

wel

l, ev

alua

tion

of s

erum

bili

rubi

n le

vel

shou

ld b

e ca

rrie

d ou

t. (A

ctio

n le

vel 2

)

5. I

f thr

ush

is id

entifi

ed in

her

bab

y, th

e br

east

feed

ing

wom

an s

houl

d be

offe

red

info

rmat

ion

and

guid

ance

abo

ut re

leva

nt h

ygie

ne

prac

tices

. Sym

ptom

atic

thru

sh re

quire

s an

tifun

gal

trea

tmen

t.

6. (

C) If

pai

nful

nap

py ra

sh p

ersi

sts,

it is

usu

ally

ca

used

by

thru

sh (C

andi

da a

lbic

ans)

and

ant

i fu

ngal

trea

tmen

t sho

uld

be c

onsi

dere

d an

d fu

rthe

r eva

luat

ion

[mad

e] if

no

resp

onse

.

7. I

f a b

aby

is c

onst

ipat

ed a

nd fo

rmul

a-fe

d, th

e fo

llow

ing

shou

ld b

e ev

alua

ted:

feed

pre

para

tion

tech

niqu

e

quan

tity

of fl

uid

take

n

frequ

ency

of f

eedi

ng

co

mpo

sitio

n of

feed

.

8. A

bab

y w

ho is

exp

erie

ncin

g in

crea

sed

frequ

ency

an

d/or

loos

er s

tool

s th

an u

sual

sho

uld

be

eval

uate

d. (A

ctio

n le

vel 3

)

9. C

are

for e

xces

sive

cry

ing/

colic

:

A

baby

eith

er d

raw

ing

its k

nees

up

to it

s ab

dom

en o

r arc

hing

its

back

, in

the

abse

nce

of a

noth

er d

iagn

osis,

sho

uld

be a

sses

sed

for

unde

rlyin

g ca

use,

incl

udin

g in

fant

col

ic. (

Actio

n le

vel 2

)

As

sess

men

t of e

xces

sive

and

inco

nsol

able

cry

ing

shou

ld in

clud

e:

ge

nera

l hea

lth o

f the

bab

y


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Conc

ern

Conc

ern

Conc

ern

WH

O P

CPN

C 20

06:

1. C

heck

for a

naem

ia. G

ive

her a

3-m

onth

sup

ply

of

iron/

folic

aci

d ta

blet

s.

2. I

f fee

ling

unha

ppy

and

cryi

ng e

asily

, ass

ess

her f

or

depr

essi

on.

WH

O P

CPN

C 20

06:

1. A

sses

s br

east

s if

brea

stfe

edin

g di

fficu

lty o

r com

plai

nts.

WH

O P

CPN

C 20

06:

1. L

ook

for s

igns

of l

ocal

infe

ctio

ns (s

kin,

cor

d, e

yes)

. Te

ach

mot

her t

o tre

at lo

cal i

nfec

tion.

2. L

ook

for j

aund

ice.

Core

Info

rmat

ion

Core

Info

rmat

ion

Core

Info

rmat

ion

an

tena

tal a

nd p

erin

atal

his

tory

on

set a

nd le

ngth

of c

ryin

g

natu

re o

f the

sto

ols

fe

edin

g as

sess

men

t

wom

an’s

diet

if b

reas

tfeed

ing

fa

mily

his

tory

of a

llerg

y

pare

nt’s

resp

onse

to th

e ba

by’s

cryi

ng

an

y fa

ctor

s w

hich

less

en o

r wor

sen

the

cryi

ng.

Pa

rent

s of

a h

ealth

y ba

by w

ho h

as c

olic

sho

uld

be

reas

sure

d th

at th

e ba

by is

not

reje

ctin

g th

em a

nd

that

col

ic is

usu

ally

a p

hase

that

will

pas

s. Ho

ldin

g th

e ba

by th

roug

h th

e cr

ying

epi

sode

, acc

essi

ng

peer

sup

port

and

(A) h

ypoa

llerg

enic

form

ula

may

be

hel

pful

. (A)

Dic

yclo

verin

e sh

ould

not

be

used

.

1. A

wom

an s

houl

d be

offe

red

info

rmat

ion

and

reas

sura

nce:

Feed

ing

patt

erns

:

that

her

bab

y m

ay h

ave

a va

riabl

e fe

edin

g pa

tter

n, a

t lea

st

over

the

first

few

day

s, as

the

baby

take

s sm

all a

mou

nts

of

colo

stru

m a

nd th

en ta

kes

incr

easi

ngly

larg

er fe

eds

as th

e m

ilk s

uppl

y co

mes

in;

th

at w

hen

the

milk

sup

ply

is e

stab

lishe

d, a

bab

y w

ill g

ener

-al

ly fe

ed e

very

2–3

hou

rs, b

ut th

is w

ill v

ary

betw

een

babi

es

and,

if h

er b

aby

is h

ealth

y, th

e ba

by’s

indi

vidu

al p

atte

rn

shou

ld b

e re

spec

ted;

that

if a

bab

y do

es n

ot a

ppea

r sat

isfie

d af

ter a

goo

d fe

ed

from

the

first

bre

ast,

the

seco

nd b

reas

t sho

uld

be o

ffere

d.

Att

achm

ent

and

posi

tion

:

That

bei

ng p

ain

free

durin

g th

e fe

ed is

an

indi

cato

r of g

ood

posi

tion

and

atta

chm

ent.

1. P

aren

ts s

houl

d be

offe

red

info

rmat

ion

and

reas

sura

nce

on:

th

eir i

nfan

t’s s

ocia

l cap

abili

ties,

as th

is ca

n pr

o-m

ote

pare

nt–i

nfan

t atta

chm

ent;

na

ppy

rash

—Fr

eque

nt n

appy

cha

nges

and

cl

eans

ing

and

expo

sure

of t

he p

erin

eal a

rea

redu

ce b

aby’

s’ c

onta

ct w

ith fa

eces

and

urin

e.

Clea

nsin

g ag

ents

sho

uld

not b

e ad

ded

to b

ath

wat

er n

or s

houl

d lo

tions

or m

edic

ated

wip

es b

e us

ed. W

here

requ

ired,

the

only

cle

ansi

ng a

gent

w

hich

sho

uld

be u

sed

is m

ild n

on-p

erfu

med

so

ap.

(A

) * c

ord

care

—ho

w to

kee

p th

e um

bilic

al

cord

cle

an a

nd d

ry a

nd th

at a

ntis

eptic

s sh

ould

no

t rou

tinel

y be

use

d.

sa

fety

—ho

w to

redu

ce a

ccid

ents

, par

ticul

arly

1. (

C) T

he D

epar

tmen

t of H

ealth

Birt

h to

Fiv

e ha

ndbo

ok, w

hich

offe

rs g

ener

al in

form

atio

n ab

out

heal

th a

nd w

ell-b

eing

afte

r del

iver

y, sh

ould

be

prov

ided

to a

ll po

stpa

rtum

wom

en w

ithin

the

first

th

ree

days

afte

r birt

h an

d its

use

dis

cuss

ed.

2. *

Wom

en s

houl

d be

offe

red

info

rmat

ion

and

reas

sura

nce

abou

t:

perin

eal p

ain

and

perin

eal h

ygie

ne

ur

inar

y in

cont

inen

ce a

nd m

ictu

ritio

n

bo

wel

func

tion

fa

tigue

head

ache

back

pai

n


Core

Info

rmat

ion

Core

Info

rmat

ion

Core

Info

rmat

ion

O

ther

indi

cato

rs o

f goo

d at

tach

men

t inc

lude

:

less

are

ola

visi

ble

unde

rnea

th th

e ch

in th

an a

bove

the

nip-

ple

ch

in to

uchi

ng th

e br

east

, with

the

low

er li

p ro

lled

dow

n,

with

the

nose

free

mou

th is

wid

e op

en

th

e ba

by is

sw

allo

win

g.

Sign

s of

suc

cess

ful m

ilk t

rans

fer:

The

baby

has

:

audi

ble

swal

low

ing

su

stai

ned

rhyt

hmic

suc

k an

d sw

allo

win

g w

ith o

ccas

iona

l pa

uses

rela

xed

arm

s an

d ha

nds

m

oist

mou

th

sa

tisfa

ctio

n af

ter f

eedi

ng

re

gula

r soa

ked/

heav

y na

ppie

s.

The

wom

an:

fe

els

no b

reas

t or n

ippl

e pa

in

ex

perie

nces

her

bre

ast s

ofte

ning

may

exp

erie

nce

uter

ine

disc

omfo

rt

ex

perie

nces

no

com

pres

sion

of t

he n

ippl

e at

the

end

of th

e fe

ed

fe

els

rela

xed

and

slee

py.

En

gorg

emen

t—*

That

thei

r bre

asts

may

feel

tend

er, fi

rm

and

pain

ful w

hen

milk

‘com

es in

’ at o

r aro

und

3 da

ys a

fter

birt

h.

Sa

fety

—M

ilk, e

ither

form

ula

or e

xpre

ssed

bre

ast m

ilk, s

houl

d no

t be

heat

ed in

a m

icro

wav

e as

ther

e is

a d

ange

r of s

cald

ing

(adv

ise

fam

ily/p

artn

er a

s ap

prop

riate

).

Be

nefit

s of

bre

astf

eedi

ng—

That

bab

ies

who

are

ex

clus

ivel

y br

east

fed

for 6

mon

ths

will

acc

rue

the

grea

test

he

alth

ben

efits

and

dis

ease

pre

vent

ion.

scal

ds a

nd fa

lls.

2. P

aren

ts s

houl

d be

adv

ised

to re

port

to th

eir h

ealth

-ca

re p

rofe

ssio

nal c

hang

es in

the

baby

’s es

tabl

ishe

d bo

wel

pat

tern

(whi

ch w

ill ta

ke u

p to

7 d

ays

to

esta

blis

h), i

nclu

ding

har

d st

ools

that

are

diffi

cult

to

pass

or i

ncre

ased

freq

uenc

y of

loos

e st

ools.

3. (B

) * P

aren

ts s

houl

d be

giv

en in

form

atio

n in

line

w

ith th

e De

part

men

t of H

ealth

gui

danc

e ab

out

sudd

en in

fant

dea

th s

yndr

ome

(SID

S) a

nd c

o-sl

eepi

ng.

4. (

B) If

par

ents

cho

ose

to s

hare

a b

ed w

ith th

eir

infa

nt, t

hey

shou

ld b

e ad

vise

d ne

ver t

o sl

eep

on a

so

fa o

r arm

chai

r. Th

ey s

houl

d al

so b

e ad

vise

d th

at

ther

e is

incr

ease

d ris

k, e

spec

ially

whe

n th

e ba

by is

le

ss th

an 1

1 w

eeks

old

, [a

ssoc

iate

d w

ith] s

harin

g a

bed

all n

ight

and

cot

dea

th if

eith

er p

aren

t:

is a

sm

oker

has

rece

ntly

dru

nk a

ny a

lcoh

ol

ha

s ta

ken

med

icat

ion

or d

rugs

that

mak

e th

em

slee

p m

ore

heav

ily

is

ver

y tir

ed.

5. (

B) P

aren

ts s

houl

d be

adv

ised

that

if a

bab

y ha

s be

com

e ac

cust

omed

to u

sing

a p

acifi

er (d

umm

y)

whi

le s

leep

ing,

it s

houl

d no

t be

stop

ped

sudd

enly

du

ring

the

first

26

wee

ks.

6. A

ll w

omen

and

thei

r fam

ilies

sho

uld

be g

iven

in

form

atio

n ab

out a

vaila

bilit

y, ac

cess

and

aim

s of

all

post

nata

l pee

r, st

atut

ory

and

volu

ntar

y gr

oups

and

or

gani

satio

ns in

thei

r loc

al c

omm

unity

.

(B

) nor

mal

pat

tern

s of

em

otio

nal c

hang

es in

the

post

nata

l per

iod

and

that

thes

e us

ually

reso

lve

with

in 1

0–14

day

s of

giv

ing

birt

h. (T

his

info

rma-

tion

shou

ld b

e of

fere

d by

the

third

day

.)

co

ntra

cept

ion

co

ntac

t det

ails

for e

xper

t con

trac

eptiv

e ad

vice

.

3. *

All

wom

en s

houl

d be

offe

red

advi

ce o

n di

et,

exer

cise

and

pla

nnin

g ac

tiviti

es, i

nclu

ding

spe

ndin

g tim

e w

ith h

er b

aby.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

WH

O P

CPN

C 20

06:

1. A

dvis

e to

brin

g ho

me-

base

d re

cord

to h

ealth

cen

tre,

ev

en fo

r an

emer

genc

y vi

sit.

2. W

HO a

dvic

e on

nut

ritio

n:

Advi

se to

eat

a g

reat

er a

mou

nt a

nd v

arie

ty.

Reas

sure

that

she

can

eat

all

norm

al fo

od. S

pend

m

ore

time

with

thin

wom

en a

nd a

dole

scen

ts.

Ad

vise

the

wom

an a

gain

st ta

boos

.

3. F

amily

pla

nnin

g fo

r bre

astfe

edin

g w

omen

:

LAM

: For

no

mor

e th

an 6

mon

ths

post

part

um,

still

am

enor

rhoe

ic;

co

ndom

s, sp

erm

icid

e, fe

mal

e st

erili

zatio

n w

ithin

7

days

or d

elay

6 w

eeks

, IU

D w

ithin

48

hour

s or

de

lay

4 w

eeks

;

For n

on-b

reas

tfeed

ing

wom

en:

Im

med

iate

pos

tpar

tum

: con

dom

s, pr

oges

toge

n-on

ly p

ills

(PO

Ps),

prog

esto

gen-

only

inje

ctio

ns,

impl

ants

, sp

erm

icid

es.

Fe

mal

e st

erili

zatio

n w

ithin

7 d

ays

or d

elay

6

wee

ks, I

UD

with

in 4

8 ho

urs

or d

elay

4 w

eeks

;

Afte

r 3 w

eeks

: Com

bine

d or

al c

ontr

acep

tives

, co

mbi

ned

inje

ctab

les,

diap

hrag

m, f

ertil

ity a

war

e-ne

ss m

etho

ds.

Lo

cal b

reas

tfee

ding

sup

port

gro

ups—

How

to a

cces

s an

d w

hat s

ervi

ces

and

supp

ort t

hey

prov

ide.

2. A

bre

astfe

edin

g w

oman

who

requ

ests

info

rmat

ion

on p

repa

ring

a fo

rmul

a fe

ed s

houl

d be

adv

ised

on h

ow to

do

this.


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Core

Car

eCo

re C

are

Core

Car

e

1. *

At a

ny p

ostn

atal

con

tact

enq

uire

s sh

ould

con

tinue

to

be

mad

e ab

out g

ener

al w

ell-b

eing

and

all

com

mon

hea

lth p

robl

ems

(see

abo

ve).

2. A

ll w

omen

sho

uld

be a

sked

abo

ut re

sum

ptio

n of

se

xual

inte

rcou

rse

and

poss

ible

dys

pare

unia

as

part

of

an

asse

ssm

ent o

f ove

rall

wel

l-bei

ng 2

–6 w

eeks

af

ter b

irth.

3. *

At 1

0–14

day

s af

ter b

irth,

all

wom

en s

houl

d be

as

ked

abou

t res

olut

ion

of s

ympt

oms

of m

ater

nal

blue

s. If

sym

ptom

s ha

ve n

ot re

solv

ed, t

he w

oman

’s ps

ycho

logi

cal w

ell-b

eing

sho

uld

cont

inue

to b

e as

sess

ed fo

r pos

tnat

al d

epre

ssio

n, a

nd if

sym

ptom

s pe

rsis

t, ev

alua

ted.

(Act

ion

leve

l 2)

4. *

Con

tinue

to o

bser

ve fo

r any

indi

catio

n of

do

mes

tic a

buse

.

5. A

s pa

rt o

f the

wom

an’s

indi

vidu

al p

ostn

atal

car

e pl

an, t

he c

oord

inat

ing

heal

th p

rofe

ssio

nal s

houl

d en

sure

that

ther

e is

a re

view

of t

he w

oman

’s ph

ysic

al, e

mot

iona

l and

soc

ial w

ell-b

eing

at 6

–8

wee

ks p

ostp

artu

m w

hich

take

s in

to a

ccou

nt

scre

enin

g an

d m

edic

al h

isto

ry.

1. *

Bre

astfe

edin

g pr

ogre

ss s

houl

d be

ass

esse

d at

eac

h po

stna

tal

cont

act

1. *

Phy

sical

exa

min

atio

n sh

ould

be

repe

ated

at 6

–8

wee

ks o

f age

.

2. *

Offe

r to

com

men

ce in

fant

imm

uniza

tion

prog

ram

me.

Tabl

e 3

Tim

e Ba

nd 3

: Wee

ks 2

- 8 (f

rom

day

8 o

nwar

ds)


Mai

ntai

ning

Mat

erna

l Hea

lth

Infa

nt F

eedi

ngM

aint

aini

ng In

fant

Hea

lth

Conc

ern

Conc

ern

Conc

ern

Any

posi

tive

resp

onse

s to

que

ries

abou

t com

mon

he

alth

pro

blem

s sh

ould

be

eval

uate

d, tr

eate

d or

re

ferr

ed a

ppro

pria

tely

:

1. D

yspa

reun

ia

If

a w

oman

exp

ress

es a

nxie

ty a

bout

resu

min

g in

terc

ours

e, re

ason

s fo

r thi

s sh

ould

be

expl

ored

w

ith h

er.

If

a w

oman

is e

xper

ienc

ing

dysp

areu

nia

and

has

sust

aine

d pe

rinea

l tra

uma,

the

heal

th-c

are

prof

essi

onal

sho

uld

offe

r to

asse

ss th

e w

oman

’s pe

rineu

m.

A

wat

er-b

ased

lubr

ican

t gel

to h

elp

to e

ase

disc

omfo

rt d

urin

g in

terc

ours

e m

ay b

e ad

vise

d.

If

a w

oman

con

tinue

s to

exp

ress

anx

iety

abo

ut

sexu

al h

ealth

pro

blem

s, th

is s

houl

d be

eva

luat

ed

furt

her.

(Act

ion

leve

l 3)

2. *

A w

oman

who

se p

ostp

artu

m b

leed

ing

does

not

ce

ase

by th

e si

xth

wee

k po

stpa

rtum

sho

uld

be

refe

rred

. (Ac

tion

leve

l 3)

3. I

f per

sist

ent p

ostn

atal

fatig

ue is

impa

ctin

g on

th

e w

oman

’s ca

re o

f her

self

or b

aby,

unde

rlyin

g ph

ysic

al, p

sych

olog

ical

or s

ocia

l cau

ses

shou

ld b

e ev

alua

ted.

(Act

ion

leve

l 2)

1. I

f jau

ndic

e fir

st d

evel

ops

afte

r 7 d

ays

or re

mai

ns

jaun

dice

d af

ter 1

4 da

ys in

an

othe

rwis

e he

alth

y ba

by a

nd a

cau

se h

as n

ot a

lread

y be

en id

entifi

ed,

it sh

ould

be

eval

uate

d. (A

ctio

n le

vel 2

)


Core

Info

rmat

ion

Core

Info

rmat

ion

Core

Info

rmat

ion

WH

O P

CPN

C 20

06:

Che

ck p

reve

ntiv

e m

easu

res:

1. A

s in

Tim

e Ba

nd 2

.

In a

dditi

on:

2. C

heck

wom

an’s

supp

ly o

f pre

scrib

ed d

ose

of ir

on

and

fola

te. G

ive

3-m

onth

sup

ply.

3. A

dvis

e w

oman

to s

eek

help

from

com

mun

ity if

ne

eded

.

WH

O P

CPN

C 20

06:

As in

Tim

e Ba

nd 2

.

WH

O P

CPN

C 20

06:

Che

ck p

reve

ntiv

e m

easu

res.

FOR

ALL

TIM

E BA

ND

S

WH

O P

CPN

C 20

06:

1. W

ork

with

the

com

mun

ity in

pro

vidi

ng s

uppo

rt fo

r w

omen

.

2. E

stab

lish

links

with

trad

ition

al p

rovi

ders

.

3. I

nvol

ve c

omm

unity

in e

nsur

ing

qual

ity o

f car

e.

4. A

ddre

ss s

pecia

l con

sider

atio

ns fo

r car

ing

for p

regn

ant

adol

esce

nts,

wom

en li

ving

with

vio

lenc

e.

1. *

Adv

ise w

omen

to re

port

any

com

mon

hea

lth

prob

lem

s (s

ee a

bove

).

2. D

iscus

s in

itiat

ion

of s

exua

l act

ivity

and

pos

sible

dy

spar

euni

a.


Sugg

esti

ons

for

post

nata

l car

e gu

idel

ines

by

the

expe

rt p

anel

of t

he T

echn

ical

Con

sult

atio

n on

Pos

tpar

tum

and

Pos

tnat

al C

are,

29–

31 O

ctob

er 2

008

Thes

e su

gges

ted

guid

elin

es a

re b

ased

larg

ely

on th

e gu

idel

ines

of t

he N

atio

nal C

olla

bora

ting

Cent

re o

f Prim

ary

Care

(NCC

PC) (

10).

In N

CCPC

gui

delin

es in

this

tabl

e th

e st

reng

th o

f evi

denc

e is

labe

lled

A, B

, or C

, with

A b

eing

the

stro

nges

t. Al

l oth

er, u

nlab

elle

d re

com

men

datio

ns a

re o

f str

engt

h D

(goo

d pr

actic

e po

int—

GPP

). A

reco

mm

enda

tion

labe

lled

with

an

aste

risk

(*) a

ppea

rs in

bot

h N

CCPC

and

WHO

gui

delin

es.

Defi

niti

ons

of t

he p

anel

’s c

oncl

usio

ns (u

sed

in “

Stat

us”

colu

mn)

:

“Acc

epte

d”: T

he e

xper

t pan

el a

gree

d w

ith th

e N

CCPC

reco

mm

enda

tion

as p

rovi

ding

glo

bal p

ostn

atal

car

e gu

idan

ce, b

ased

on

avai

labl

e ev

iden

ce.

“Del

eted

”: T

he e

xper

t pan

el c

onsi

dere

d th

e N

CCPC

reco

mm

enda

tion

not a

ppro

pria

te a

s gl

obal

pos

tnat

al c

are

guid

ance

.

“Add

ed a

nd/o

r re

quir

ing

addi

tion

al e

vide

nce”

: The

exp

ert p

anel

con

side

red

thes

e ad

ditio

nal r

ecom

men

datio

ns im

port

ant f

or p

rovi

ding

glo

bal p

ostn

atal

car

e gu

idan

ce a

nd re

ques

ted

supp

ortin

g ev

iden

ce.

“Mod

ified

and

/or

requ

irin

g ad

diti

onal

evi

denc

e”: F

or p

rovi

ding

glo

bal p

ostn

atal

car

e gu

idan

ce, t

he e

xper

t pan

el s

ugge

sted

mod

ifica

tion

of th

e N

CCPC

reco

mm

enda

tions

and

re

ques

ted

supp

ortin

g ev

iden

ce.

Oth

er q

uest

ions

: Ope

n qu

estio

ns to

be

addr

esse

d du

ring

evid

ence

revi

ew.

Core

car

e

Stat

usM

othe

rN

ewbo

rn

Acc

epte

d1.

All

post

nata

l wom

en s

houl

d be

exa

min

ed w

ithin

one

hou

r afte

r de

liver

y of

pla

cent

a.1.

The

rmal

pro

tect

ion

shou

ld b

e en

sure

d im

med

iate

ly a

fter b

irth

and

subs

eque

ntly.

(Fro

m W

HO g

uide

lines

)

2. A

sses

smen

t for

em

otio

nal a

ttac

hmen

t sho

uld

be c

arrie

d ou

t at e

ach

post

nata

l con

tact

.

3. D

urin

g th

e fir

st h

our o

f life

:

(C) *

Mot

her a

nd b

aby

shou

ld n

ot b

e se

para

ted.

(A

) * S

kin-

to-s

kin

cont

act s

houl

d ta

ke p

lace

.

* Br

east

feed

ing

shou

ld b

e in

itiat

ed.

4. W

here

pos

tnat

al c

are

is p

rovi

ded

in a

clin

ical

set

ting,

the

envi

ronm

ent s

houl

d in

clud

e:

(A) *

Roo

min

g-in

and

con

tinui

ng m

ater

nal s

kin

to b

aby’

s sk

in c

onta

ct,

day

and

nigh

t, w

hen

poss

ible

.

* Ad

equa

te re

st fo

r the

wom

an w

ithou

t int

erru

ptio

n du

e to

clin

ical

rou-

tine.

Tabl

e 4

Tim

e Ba

nd 1

: Im

med

iate

pos

tnat

al c

are


Conc

ern

Stat

usM

othe

rN

ewbo

rn

(A

) * C

omm

erci

al p

acks

—fo

r exa

mpl

e, th

ose

inte

nded

for d

istr

ibu-

tion

to w

omen

whe

n th

ey a

re d

isch

arge

d fro

m h

ospi

tal—

that

con

tain

fo

rmul

a m

ilk o

r adv

ertis

emen

ts fo

r for

mul

a sh

ould

not

be

give

n.

Wom

en s

houl

d be

taug

ht to

han

d-ex

pres

s br

east

milk

, and

bre

ast

pum

ps s

houl

d be

ava

ilabl

e in

the

clin

ical

set

ting,

par

ticul

arly

for w

omen

w

ho h

ave

been

sep

arat

ed fr

om th

eir b

abie

s, to

est

ablis

h la

ctat

ion.

All

wom

en w

ho u

se a

bre

ast p

ump

shou

ld b

e of

fere

d in

stru

ctio

ns o

n its

co

rrec

t use

.

5. W

omen

sho

uld

be o

ffere

d sk

illed

sup

port

, inc

ludi

ng m

othe

r-to-

mot

her (

i.e.

peer

) sup

port

, fro

m th

e st

art o

f bre

astfe

edin

g.

6. A

dditi

onal

sup

port

with

pos

ition

ing

and

atta

chm

ent t

o co

mm

ence

br

east

feed

ing

shou

ld b

e of

fere

d to

all

wom

en w

ho h

ave

had:

(C

) nar

cotic

ana

lges

ia o

r gen

eral

ana

esth

etic

, as

the

baby

may

not

in

itial

ly b

e re

spon

sive

to fe

edin

g;

a ca

esar

ean

sect

ion,

par

ticul

arly

to a

ssis

t her

with

han

dlin

g an

d po

si-

tioni

ng th

e ba

by s

o as

to p

rote

ct h

er a

bdom

inal

wou

nd;

*

initi

al c

onta

ct w

ith h

er b

aby

dela

yed.

7. (

A) *

Bre

astfe

edin

g of

unr

estr

icte

d fre

quen

cy a

nd d

urat

ion

shou

ld b

e en

cour

aged

.

8. *

A h

ealth

-car

e pr

ofes

sion

al [t

o be

cha

nged

to “

heal

th c

are

prov

ider

”] s

houl

d di

scus

s w

ith th

e w

oman

dai

ly h

er e

xper

ienc

e w

ith b

reas

tfeed

ing,

to a

sses

s w

ith h

er w

heth

er s

he is

on

cour

se to

br

east

feed

effe

ctiv

ely

and

to id

entif

y an

y ne

ed fo

r add

ition

al s

uppo

rt.

Brea

stfe

edin

g pr

ogre

ss s

houl

d th

en b

e as

sess

ed a

nd d

ocum

ente

d in

the

care

pla

n at

eac

h po

stna

tal c

onta

ct.

9. (

A) W

ritte

n br

east

feed

ing

educ

atio

n m

ater

ials

can

sup

plem

ent d

irect

in

stru

ctio

n an

d co

unse

lling

, but

they

sho

uld

not s

ubst

itute

for d

irect

in

stru

ctio

n.

10. A

sin

gle

dose

of m

onov

alen

t hep

atiti

s B

vacc

ine

shou

ld b

e ad

min

iste

red

with

in 2

4 ho

urs

of b

irth

depe

ndin

g on

the

natio

nal

imm

uniz

atio

n sc

hedu

le.


Core

car

e

Stat

usM

othe

rN

ewbo

rn

Add

ed a

nd/o

r re

quir

ing

addi

tion

al

evid

ence

Priv

acy

for t

he w

oman

, hyg

ieni

c to

ilet f

acili

ties,

and

infe

ctio

n co

ntro

l m

easu

res

refle

ct b

asic

hum

an ri

ghts

and

nee

d to

be

men

tione

d up

fro

nt a

s a

prea

mbl

e to

the

guid

ance

on

post

part

um c

are.

1. E

ffort

s sh

ould

be

mad

e to

resu

scita

te a

bab

y th

at is

not

bre

athi

ng

spon

tane

ousl

y af

ter b

irth.

2. T

he b

aby

shou

ld b

e w

eigh

ed, a

nd g

esta

tiona

l age

, ass

esse

d.

3. A

mot

her s

houl

d be

taug

ht h

ow to

pro

vide

add

ition

al c

are

for a

sm

all b

aby

(pre

term

, low

birt

h w

eigh

t).

4. E

ven

if th

e w

oman

is n

ot g

oing

to b

reas

tfeed

, ski

n-to

-ski

n co

ntac

t sho

uld

still

be

enc

oura

ged.

5. B

reas

tfeed

ing

is d

efine

d to

mea

n th

at th

e ba

by is

rece

ivin

g on

ly b

reas

t milk

.

6. M

othe

r and

bab

y m

ay b

e di

scha

rged

if th

e m

othe

r is

com

fort

able

, br

east

feed

ing

is in

itiat

ed, a

nd th

e ba

by is

wel

l.

7. I

f the

wom

an is

not

com

fort

able

with

bre

astfe

edin

g, s

he s

houl

d no

t be

disc

harg

ed w

ithou

t add

ition

al s

uppo

rt.

8. (

A) A

ll m

ater

nity

car

e pr

ovid

ers

(whe

ther

wor

king

in h

ospi

tal o

r in

prim

ary

care

) sho

uld

impl

emen

t an

exte

rnal

ly e

valu

ated

, str

uctu

red

prog

ram

me

that

en

cour

ages

bre

astfe

edin

g, u

sing

the

Baby

Frie

ndly

Initi

ativ

e as

a m

inim

um

stan

dard

.

Mod

ified

and

/or

requ

irin

g ad

diti

onal

ev

iden

ce

1. B

lood

pre

ssur

e sh

ould

be

mea

sure

d w

ithin

6 h

ours

and

aga

in b

efor

e di

scha

rge.

Car

e pr

ovid

ers

shou

ld lo

ok fo

r and

reco

rd b

oth

hypo

tens

ion

and

hype

rten

sion

. Dis

char

ge s

houl

d be

del

ayed

unt

il co

nditi

on s

tabl

e.

2. U

rine

void

with

in th

e fir

st 6

hou

rs s

houl

d be

doc

umen

ted.

If p

lan

is to

di

scha

rge

with

in 6

hou

rs, d

ocum

ent u

rine

void

bef

ore

disc

harg

e. C

heck

fo

r urin

e re

tent

ion

if no

t voi

ded

befo

re 6

hou

rs a

nd e

nsur

e th

at fl

uid

inta

ke is

ade

quat

e.

3. A

ll w

omen

sho

uld

“be

enco

urag

ed to

be

ambu

lant

as

soon

as

poss

ible

” in

stea

d of

“m

obili

ze”.

4. A

ll po

stna

tal w

omen

sho

uld

be a

sses

sed

for s

igns

of s

hock

rela

ted

to

exce

ss b

lood

loss

.

5. A

hom

e-ba

sed

mat

erna

l and

chi

ld h

ealth

reco

rd s

houl

d be

mai

ntai

ned.

6. I

n m

alar

ial s

ettin

gs m

othe

r and

bab

y sh

ould

be

slee

ping

und

er a

n im

preg

nate

d be

dnet

.

1. (

B) *

For

mul

a m

ilk s

houl

d no

t be

give

n to

bre

astfe

d ba

bies

in h

ospi

tal u

nles

s m

edic

ally

indi

cate

d. [I

nste

ad o

f “fo

rmul

a m

ilk”,

add

“an

y ot

her l

iqui

ds”]

.

2. (

A) *

Bre

astfe

edin

g su

ppor

t sho

uld

be m

ade

avai

labl

e to

a w

oman

rega

rdle

ss

of th

e lo

catio

n of

car

e. [A

dd “

and

in a

ll sp

ecia

l circ

umst

ance

s”.]

3. (

A) V

itam

in K

sho

uld

be o

ffere

d fo

r all

infa

nts

and

(A) a

dmin

iste

red

as a

si

ngle

dos

e of

1 m

g IM

. If p

aren

ts d

eclin

e IM

vita

min

K fo

r the

ir ba

by, o

ral

vita

min

K s

houl

d be

offe

red

as s

econ

d lin

e.

Oth

er q

uest

ions

1. S

houl

d a

wom

an h

ave

acce

ss to

food

and

drin

k on

dem

and,

with

out

rest

rictio

n?1.

W

hat s

houl

d be

incl

uded

in ro

utin

e ca

re fo

r new

born

s w

ithou

t mot

hers

?


Conc

erns

Stat

usM

othe

rN

ewbo

rn

Acc

epte

d1.

If a

wom

an h

as e

xces

sive

or m

alod

orou

s va

gina

l los

s, ab

dom

inal

te

nder

ness

or f

ever

, the

n va

gina

l los

s an

d ut

erin

e in

volu

tion

and

posi

tion

shou

ld b

e as

sess

ed. A

ny a

bnor

mal

ities

in th

e si

ze, t

one

and

posi

tion

of th

e ut

erus

sho

uld

be e

valu

ated

. If n

o ut

erin

e ab

norm

ality

is

foun

d, c

onsi

der o

ther

cau

ses

of s

ympt

oms.

(Urg

ent a

ctio

n)

2. I

f dia

stol

ic b

lood

pre

ssur

e is

gre

ater

than

90

mm

Hg, a

nd th

ere

are

no o

ther

sig

ns o

f sev

ere

pre-

ecla

mps

ia, b

lood

pre

ssur

e sh

ould

be

mea

sure

d ag

ain

with

in 4

hou

rs.

1. A

bab

y w

ho is

not

att

achi

ng e

ffect

ivel

y m

ay b

e en

cour

aged

to o

pen

his/

her

mou

th u

sing

var

ious

stim

uli.

2. S

kin-

to-s

kin

cont

act o

r mas

sagi

ng a

bab

y’s

feet

sho

uld

be u

sed

to w

ake

the

baby

.

3. *

Infa

nts

who

dev

elop

jaun

dice

with

in th

e fir

st 2

4 ho

urs

shou

ld b

e ev

alua

ted

urge

ntly.

(Act

ion

leve

l 2)

Del

eted

1. I

f a w

oman

is o

bese

, she

will

requ

ire in

divi

dual

ized

car

e.[N

one]

Add

ed a

nd/o

r re

quir

ing

addi

tion

al

evid

ence

[Non

e]1.

Par

ents

sho

uld

be e

duca

ted

to re

cogn

ize

dang

er s

igns

in th

e ba

by.

2. P

aren

ts s

houl

d be

adv

ised

to s

eek

care

any

tim

e th

at th

ey a

re c

once

rned

for

thei

r new

born

’s he

alth

.

3. H

ealth

car

e pr

ovid

ers

shou

ld tr

eat s

ore

nipp

les,

and

wom

en s

houl

d be

ed

ucat

ed o

n se

lf-ca

re (e

vide

nce

is a

vaila

ble)

.

4. A

dvis

e m

othe

rs o

n ap

prop

riate

dur

atio

n of

bre

astfe

edin

g.

Mod

ified

and

/or

requ

irin

g ad

diti

onal

ev

iden

ce

1. I

f inf

ectio

n is

sus

pect

ed, b

ody

tem

pera

ture

sho

uld

be ta

ken

and

docu

men

ted.

If in

fect

ion

is n

ot s

uspe

cted

but

, on

rout

ine

chec

king

, bo

dy te

mpe

ratu

re is

abo

ve 3

8°C,

tem

pera

ture

sho

uld

be m

easu

red

agai

n in

4–6

hou

rs.

2. I

f a w

oman

has

not

voi

ded

by 6

hou

rs p

ostp

artu

m a

nd m

easu

res

to

enco

urag

e m

ictu

ritio

n ha

ve fa

iled,

inta

ke o

f flui

ds s

houl

d be

che

cked

. Bl

adde

r vol

ume

shou

ld b

e as

sess

ed a

nd c

athe

teriz

atio

n co

nsid

ered

. (U

rgen

t act

ion)

3. I

mm

edia

te re

ferr

al is

requ

ired

for m

ajor

com

plic

atio

ns, a

nd in

terim

life

-sa

ving

mea

sure

s sh

ould

be

take

n.

1. T

he s

tatu

s of

teta

nus

imm

uniz

atio

n an

d re

sults

of s

yphi

lis a

nd H

IV te

sts

shou

ld b

e as

sess

ed a

nd tr

eatm

ent i

nitia

ted

as a

ppro

pria

te. I

f tes

ting

was

not

und

erta

ken

befo

re d

eliv

ery,

it sh

ould

be

done

at t

his

time.

2. W

here

iron

defi

cien

cy a

naem

ia is

pre

vale

nt, g

ive

a 3-

mon

th s

uppl

y of

iro

n.

3. T

he w

oman

sho

uld

rece

ive

an in

sect

icid

e-tr

eate

d be

dnet

in a

ccor

danc

e w

ith n

atio

nal p

olic

y

4. G

ive

the

wom

an w

ho h

as lo

st h

er b

aby

supp

ortiv

e ca

re, i

nclu

ding

ac

com

mod

atio

n in

ano

ther

war

d. P

rovi

de c

ultu

rally

app

ropr

iate

grie

f su

ppor

t.

42Tables: WHO Technical consultation on postpartum and postnatal care

Core

info

rmat

ion

Stat

usM

othe

rN

ewbo

rn

Acc

epte

d1.

All

wom

en s

houl

d be

giv

en in

form

atio

n ab

out t

he p

hysi

olog

ical

pro

cess

of

reco

very

afte

r birt

h an

d he

alth

pro

blem

s th

at a

re c

omm

on, w

ith

advi

ce to

repo

rt a

ny h

ealth

con

cern

s to

hea

lth-c

are

prov

ider

s—in

pa

rtic

ular

:

sym

ptom

s an

d si

gns

of p

ostp

artu

m h

aem

orrh

age

sy

mpt

oms

and

sign

s of

infe

ctio

n

sym

ptom

s an

d si

gns

of th

rom

bo-e

mbo

lism

sy

mpt

oms

and

sign

s of

pre

-ecl

amps

ia.

2. W

omen

who

hav

e ha

d ep

idur

al o

r spi

nal a

naes

thes

ia s

houl

d be

ad

vise

d to

repo

rt a

ny s

ever

e he

adac

he, p

artic

ular

ly if

it o

ccur

s w

hen

sitt

ing

or s

tand

ing.

From

WHO

gui

delin

es:

3. W

omen

sho

uld

be g

iven

adv

ice

on p

ostn

atal

car

e an

d hy

gien

e,

espe

cial

ly h

and

was

hing

.

4. W

omen

sho

uld

be c

ouns

elle

d on

nut

ritio

n.

5.

Wom

en s

houl

d be

cou

nsel

led

on b

irth

spac

ing

and

fam

ily p

lann

ing,

w

ith s

peci

al a

tten

tion

to th

e la

ctat

iona

l am

enor

rhoe

a m

etho

d (L

AM).

Wom

en s

houl

d be

offe

red

info

rmat

ion

and

reas

sura

nce

on:

co

lost

rum

, whi

ch w

ill m

eet t

he n

utrit

iona

l nee

ds o

f the

bab

y in

the

first

fe

w d

ays

afte

r birt

h.;

(C

) * ti

min

g of

the

initi

al b

reas

tfeed

, inc

ludi

ng th

e pr

otec

tive

effe

ct o

f co

lost

rum

(adv

ised

in a

cul

tura

lly a

ppro

pria

te m

anne

r);

* th

e nu

rtur

ing

bene

fits

of p

uttin

g th

e ba

by to

the

brea

st in

add

ition

to

the

nutr

ition

al b

enefi

ts o

f bre

astfe

edin

g.

2. A

wom

an s

houl

d be

reas

sure

d th

at b

rief d

isco

mfo

rt a

t the

sta

rt o

f bre

ast

feed

s in

the

first

few

day

s is

not

unc

omm

on, b

ut th

is s

houl

d no

t per

sist

.

3. A

ll m

othe

rs a

nd o

ther

car

e-gi

vers

who

are

giv

ing

thei

r bab

ies

form

ula

feed

sho

uld

be o

ffere

d ap

prop

riate

and

tailo

red

advi

ce to

ens

ure

this

is

und

erta

ken

as s

afel

y as

pos

sibl

e an

d in

a w

ay th

at o

ptim

izes

infa

nt

deve

lopm

ent,

heal

th a

nd n

utrit

ion.

4. *

At e

ach

post

nata

l con

tact

par

ents

sho

uld

be o

ffere

d in

form

atio

n an

d gu

idan

ce to

ena

ble

them

to:

as

sess

thei

r bab

y’s

gene

ral c

ondi

tion

id

entif

y w

arni

ng s

igns

that

the

baby

is u

nwel

l

cont

act a

hea

lth-c

are

prof

essi

onal

or e

mer

genc

y se

rvic

e if

requ

ired.

5. D

urin

g an

y ph

ysic

al e

xam

inat

ion

of a

bab

y, bo

th p

aren

ts s

houl

d be

pre

sent

w

hene

ver p

ossi

ble;

this

will

enc

oura

ge th

e pa

rtic

ipat

ion

of b

oth

pare

nts

in

thei

r bab

y’s

care

and

pro

vide

an

oppo

rtun

ity fo

r bot

h to

lear

n m

ore

abou

t th

eir b

aby

and

his/

her n

eeds

.

6. P

aren

ts s

houl

d be

offe

red

info

rmat

ion

on v

itam

in K

so

that

they

can

mak

e an

in

form

ed d

ecis

ion

abou

t its

use

.

7. (

C) P

aren

ts s

houl

d be

offe

red

info

rmat

ion

abou

t phy

siol

ogic

al ja

undi

ce

incl

udin

g:

that

it o

ccur

s no

rmal

ly a

t aro

und

3–4

days

afte

r birt

h

* re

ason

s fo

r mon

itorin

g an

d ho

w to

mon

itor.

Conc

erns

Stat

usM

othe

rN

ewbo

rn

Oth

er q

uest

ions

1. W

hat i

s th

e ev

iden

ce fo

r pos

tnat

al a

dmin

istr

atio

n of

vita

min

A?

[Non

e]


Core

info

rmat

ion

Stat

usM

othe

rN

ewbo

rn

Acc

epte

d8.

Cou

nsel

ling

mot

hers

of l

ow-b

irth-

wei

ght (

LBW

) inf

ants

on

disc

harg

e sh

ould

cov

er:

ex

clus

ive

brea

stfe

edin

g

keep

ing

the

baby

war

m

dang

er s

igns

for s

eeki

ng c

are.

L

BW b

abie

s sh

ould

be

follo

wed

up

for w

eekl

y w

eigh

ing,

ass

essm

ent o

f fe

edin

g an

d ge

nera

l hea

lth u

ntil

they

hav

e re

ache

d 2.

5 kg

.

Del

eted

1. A

dvis

e on

rout

ine

post

nata

l car

e, o

n da

nger

sig

ns a

nd p

ostn

atal

em

erge

ncy

plan

.

2. D

evel

op w

ith th

e w

oman

and

the

fam

ily a

pos

tnat

al c

are

and

emer

genc

y pl

an.

1. (

A) W

omen

who

leav

e ho

spita

l soo

n af

ter g

ivin

g bi

rth

shou

ld b

e re

assu

red

that

ear

ly d

isch

arge

sho

uld

not a

ffect

bre

astfe

edin

g du

ratio

n.

Add

ed a

nd/o

r re

quir

ing

addi

tion

al

evid

ence

[Non

e]1.

Th

e fa

ther

sho

uld

be e

ncou

rage

d to

par

ticip

ate

in th

e ca

re o

f the

bab

y.

Mod

ified

and

/or

requ

irin

g ad

diti

onal

ev

iden

ce

[Non

e]1.

A

wom

an w

ho m

akes

an

info

rmed

dec

isio

n to

feed

her

bab

y fo

rmul

a m

ilk [t

o be

add

ed: “

in s

peci

al c

ircum

stan

ces”

] sho

uld

be ta

ught

how

to

mak

e fe

eds

usin

g co

rrec

t, m

easu

red

quan

titie

s of

form

ula,

as

base

d on

the

man

ufac

ture

r’s in

stru

ctio

ns, a

nd h

ow to

cle

an/s

teril

ize

feed

ing

bott

les

and

teat

s (to

be

repl

aced

with

“fe

edin

g ut

ensi

ls”)

and

sto

re fo

rmul

a m

ilk.

Oth

er q

uest

ions

[Non

e][N

one]

44Tables: WHO Technical consultation on postpartum and postnatal careTi

me

Band

2: e

arly

pos

tnat

al c

are

1. D

ocum

enta

tion

of m

ater

nal h

ealth

sho

uld

cont

inue

.

2. T

he h

ealth

-car

e pr

ovid

er s

houl

d ch

eck

whe

ther

sup

port

for t

he m

othe

r is

ava

ilabl

e at

hom

e.

3. T

he h

ealth

-car

e pr

ovid

er s

houl

d ch

eck

for g

ende

r iss

ues

(rela

ted

to

havi

ng a

girl

chi

ld) t

hat m

ay re

sult

in h

arm

or e

mot

iona

l tra

uma

for

the

mot

her.

4. U

sefu

l pra

ctic

es fo

r mal

aria

pre

vent

ion

shou

ld b

e re

info

rced

..

5. G

ood

prac

tices

in th

e ho

me

for m

ater

nal w

ell-b

eing

sho

uld

be

rein

forc

ed.

6. W

omen

sho

uld

be c

ouns

elle

d an

d ad

vise

d ag

ains

t pot

entia

lly h

arm

ful

trad

ition

al p

ract

ices

.

7. W

omen

sho

uld

be a

dvis

ed w

hen

supp

lem

enta

tion

of n

utrit

ion

wou

ld

be n

eces

sary

.

Core

car

e

Stat

usM

othe

rN

ewbo

rn

Acc

epte

d1.

Enq

uirie

s sh

ould

be

mad

e ab

out g

ener

al w

ell-b

eing

and

all

com

mon

he

alth

pro

blem

s in

clud

ing

mic

turit

ion

and

urin

ary

inco

ntin

ence

, bow

el

func

tion,

hea

ling

of a

ny p

erin

eal w

ound

, hea

dach

e, fa

tigue

and

bac

k pa

in.

2. E

ncou

rage

all

wom

en to

use

sel

f-car

e te

chni

ques

, suc

h as

gen

tle

exer

cise

and

rest

.

3. A

ll w

omen

sho

uld

be a

sked

abo

ut th

eir e

mot

iona

l wel

l-bei

ng, w

hat

supp

ort f

or b

aby

care

they

hav

e fro

m fa

mily

, par

tner

, and

soc

ial

netw

ork;

wha

t em

otio

nal a

nd p

sych

olog

ical

sup

port

they

hav

e.

4. T

he h

ealth

-car

e pr

ovid

er s

houl

d w

atch

for a

ny ri

sks,

sign

s, an

d sy

mpt

oms

of d

omes

tic a

buse

and

kno

w w

hom

to c

onta

ct fo

r adv

ice

and

man

agem

ent.

1. T

he h

ealth

-car

e pr

ofes

sion

al s

houl

d fu

lly e

xpla

in th

e ai

ms

of a

ny p

hysi

cal

exam

inat

ion,

sho

uld

shar

e th

e fin

ding

s w

ith p

aren

ts a

nd s

houl

d re

cord

the

resu

lts in

the

post

nata

l pla

n an

d in

the

pare

nt-h

eld

mat

erna

l and

chi

ld h

ealth

re

cord

.

2. A

ppro

pria

te im

mun

izat

ions

sho

uld

be p

rovi

ded

acco

rdin

g to

nat

iona

l pol

icie

s.

3. (

B) H

ome

visi

ts s

houl

d be

use

d as

opp

ortu

nitie

s to

pro

mot

e em

otio

nal

atta

chm

ent b

etw

een

mot

her a

nd c

hild

.

4. (

B) A

ll w

omen

sho

uld

be e

ncou

rage

d to

dev

elop

soc

ial n

etw

orks

sin

ce s

uch

netw

orks

pro

mot

e po

sitiv

e m

ater

nal-i

nfan

t int

erac

tion.

5. (

A) G

roup

-bas

ed p

aren

t edu

catio

n pr

ogra

mm

es d

esig

ned

to p

rom

ote

emot

iona

l att

achm

ent a

nd im

prov

e pa

rent

ing

skill

s sh

ould

be

avai

labl

e to

pa

rent

s w

ho w

ant t

hem

.

6. (

A) A

ll ho

me

visi

ts s

houl

d be

use

d as

opp

ortu

nitie

s to

ass

ess

rele

vant

saf

ety

issu

es fo

r all

fam

ily m

embe

rs in

the

hom

e an

d en

viro

ns a

nd to

pro

mot

e sa

fety

edu

catio

n an

d us

e of

bas

ic s

afet

y eq

uipm

ent.

Del

eted

[Non

e]1.

Hea

lth-c

are

prof

essi

onal

s sh

ould

be

aler

t to

risk

fact

ors

and

sign

s an

d sy

mpt

oms

of c

hild

abu

se a

nd, i

f the

re is

rais

ed c

once

rn, s

houl

d fo

llow

loca

l ch

ild p

rote

ctio

n po

licie

s.

Add

ed a

nd/o

r re

quir

ing

addi

tion

al

evid

ence

1. I

f nec

essa

ry, t

he h

ealth

-car

e pr

ovid

er s

houl

d ob

serv

e br

east

feed

ing

and

corr

ect p

ositi

onin

g an

d at

tach

men

t.


Core

car

e

Stat

usM

othe

rN

ewbo

rn

Mod

ified

and

/or

requ

irin

g ad

diti

onal

ev

iden

ce

1.

The

prac

tice

of L

AM s

houl

d be

rein

forc

ed, a

nd o

ptio

ns fo

r fam

ily

plan

ning

and

birt

h sp

acin

g w

hen

LAM

is n

o lo

nger

app

ropr

iate

sho

uld

be d

iscu

ssed

.

1. B

reas

tfeed

ing

supp

ort s

houl

d be

pro

vide

d. U

se s

trat

egie

s to

sup

port

br

east

feed

ing.

2. *

The

par

ent-

held

chi

ld [t

o be

mod

ified

to “

mat

erna

l and

chi

ld”]

reco

rds

shou

ld b

e pr

ovid

ed to

all

pare

nts

with

in th

e fir

st th

ree

days

follo

win

g bi

rth.

3. T

he N

ewbo

rn B

lood

Spo

t Tes

t sho

uld

be o

ffere

d to

all

pare

nts

whe

n th

eir

infa

nts

are

5–8

days

of a

ge, o

r per

loca

l gui

delin

es. I

nfor

med

con

sent

sh

ould

be

obta

ined

from

par

ents

.

4.

A he

arin

g sc

reen

sho

uld

be c

ompl

eted

bef

ore

disc

harg

e or

els

e by

wee

k 4

in th

e ho

spita

l pro

gram

me

or b

y w

eek

5 in

the

com

mun

ity p

rogr

amm

e.

[Rec

omm

enda

tions

2 a

nd 3

are

to b

e co

mbi

ned

and

chan

ged

to “

met

abol

ic a

nd

othe

r scr

eeni

ngs

shou

ld b

e do

ne a

ccor

ding

to n

atio

nal p

olic

y.”]

Oth

er q

uest

ions

1.

Wha

t add

ition

al s

uppo

rt a

nd c

are

shou

ld b

e of

fere

d to

wom

en w

ith

spec

ial n

eeds

?1.

Wha

t is

the

evid

ence

for t

he b

enefi

t of t

he p

hysi

cal e

xam

inat

ion

perfo

rmed

at

abo

ut 7

2 ho

urs

afte

r the

birt

h?

8. T

he e

mer

genc

y pl

an m

ade

durin

g th

e an

tena

tal p

erio

d sh

ould

be

rein

forc

ed a

nd e

xpan

ded.

9. P

aren

ts’ c

ompe

tenc

e w

ith in

fant

car

e sh

ould

be

asse

ssed

and

rein

forc

ed.

10. A

sses

smen

t sho

uld

be m

ade

of th

e m

othe

r’s e

mot

iona

l att

achm

ent t

o th

e ba

by (e

ye c

onta

ct a

nd s

timul

atio

n), e

spec

ially

if p

regn

ancy

resu

lted

from

rape

.

46Tables: WHO Technical consultation on postpartum and postnatal careCo

rnce

rn

Stat

usM

othe

rN

ewbo

rn

Acc

epte

d1.

The

per

ineu

m s

houl

d be

ass

esse

d if

ther

e ar

e co

ncer

ns s

uch

as p

ain

or

swel

ling.

2. S

igns

and

sym

ptom

s of

infe

ctio

n sh

ould

be

asse

ssed

.

3. S

igns

and

sym

ptom

s of

pre

-ecl

amps

ia s

houl

d be

ass

esse

d.

4. A

wom

an w

ith in

volu

ntar

y le

akag

e of

a s

mal

l vol

ume

of u

rine

shou

ld

be ta

ught

pel

vic

floor

exe

rcis

es.

5. I

f con

stip

atio

n is

pre

sent

, inc

reas

ed in

take

of fi

bre

and

fluid

s sh

ould

be

adv

ised

. If t

he p

robl

em p

ersi

sts,

use

of a

gen

tle la

xativ

e sh

ould

be

advi

sed.

6. I

f a w

oman

has

hae

mor

rhoi

ds th

at a

re s

ever

ely

swol

len

and

prol

apse

d or

any

rect

al b

leed

ing,

this

sho

uld

be e

valu

ated

.

7. W

omen

with

the

follo

win

g co

nditi

ons

shou

ld b

e re

ferr

ed fo

r tre

atm

ent:

pers

iste

nt u

rinar

y in

cont

inen

ce, f

aeca

l inc

ontin

ence

, sev

ere

pers

iste

nt

head

ache

or s

usta

ined

pos

tpar

tum

ble

edin

g.

1. *

If b

reas

tfeed

ing

is n

ot p

rogr

essi

ng, s

uppo

rt a

nd a

ssis

tanc

e w

ith

posi

tioni

ng a

nd a

ttac

hmen

t on

the

brea

st s

houl

d be

pro

vide

d.

2. (

C) S

uppl

emen

tatio

n w

ith fl

uids

oth

er th

an b

reas

t milk

is n

ot re

com

men

ded.

3. I

f no

mec

oniu

m is

pas

sed

in 2

4 ho

urs,

the

baby

sho

uld

be re

ferr

ed fo

r ev

alua

tion.

4. I

f a b

aby

is s

uspe

cted

of b

eing

unw

ell,

body

tem

pera

ture

sho

uld

be ta

ken

prop

erly

usi

ng a

n el

ectr

onic

dev

ice

that

has

bee

n co

rrec

tly c

alib

rate

d.

5. A

tem

pera

ture

of >

38°C

is a

bnor

mal

, and

the

caus

e sh

ould

be

eval

uate

d.

6.

Care

for j

aund

ice:

Th

e ca

re-g

iver

sho

uld

be a

dvis

ed to

not

ify a

hea

lth-c

are

prof

essi

onal

if,

afte

r the

firs

t 24

hour

s, a

baby

is ja

undi

ced,

jaun

dice

is w

orse

ning

, or t

he

baby

is p

assi

ng p

ale

stoo

ls.

If a

baby

dev

elop

s ja

undi

ce, t

he in

tens

ity s

houl

d be

mon

itore

d 24

hou

rs

late

r and

sys

tem

atic

ally

reco

rded

alo

ng w

ith th

e ba

by’s

over

all w

ell-

bein

g w

ith re

gard

to h

ydra

tion

and

aler

tnes

s.

A br

east

fed

baby

who

has

sig

ns o

f jau

ndic

e sh

ould

be

brea

stfe

d fre

-qu

ently

, and

the

baby

sho

uld

be a

wak

ened

to fe

ed if

nec

essa

ry.

Br

east

fed

babi

es s

houl

d no

t be

rout

inel

y su

pple

men

ted

with

form

ula,

w

ater

or d

extr

ose

wat

er fo

r the

trea

tmen

t of j

aund

ice.

If

a ba

by is

sig

nific

antly

jaun

dice

d or

app

ears

unw

ell,

eval

uatio

n of

ser

um

bilir

ubin

leve

l sho

uld

be c

arrie

d ou

t. (A

ctio

n le

vel 2

)

7. I

f thr

ush

is id

entifi

ed in

her

bab

y, th

e br

east

feed

ing

wom

an s

houl

d be

of

fere

d in

form

atio

n an

d gu

idan

ce a

bout

rele

vant

hyg

iene

pra

ctic

es.

Sym

ptom

atic

thru

sh re

quire

s an

tifun

gal t

reat

men

t.

8. (

C) If

pai

nful

nap

py ra

sh p

ersi

sts,

it is

usu

ally

cau

sed

by th

rush

(Can

dida

al

bica

ns),

and

anti-

fung

al tr

eatm

ent s

houl

d be

con

side

red.

The

con

ditio

n m

erits

furt

her e

valu

atio

n if

ther

e is

no

resp

onse

to tr

eatm

ent.

9. I

f a b

aby

is c

onst

ipat

ed a

nd fo

rmul

a–fe

d, th

e fo

llow

ing

shou

ld b

e ev

alua

ted:

fe

ed p

repa

ratio

n te

chni

que

qu

antit

y of

flui

d ta

ken


Corn

cern

Del

eted

[Non

e]1.

Hea

lth-c

are

prof

essi

onal

s sh

ould

be

aler

t to

risk

fact

ors

and

sign

s an

d sy

mpt

oms

of c

hild

abu

se a

nd, i

f the

re is

rais

ed c

once

rn, s

houl

d fo

llow

loca

l ch

ild p

rote

ctio

n po

licie

s.

Add

ed a

nd/o

r re

quir

ing

addi

tion

al

evid

ence

1. T

he w

oman

sho

uld

rece

ive

educ

atio

n ab

out t

he d

ange

r sig

ns o

f dee

p-ve

in

thro

mbo

sis, s

econ

dary

pos

tpar

tum

hae

mor

rhag

e, e

clam

psia

, sep

sis, a

nd

brea

st p

robl

ems.

2. T

he w

oman

sho

uld

rece

ive

educ

atio

n ab

out f

amily

pla

nnin

g.

3.Th

e w

oman

sho

uld

rece

ive

educ

atio

n ab

out m

ater

nal n

utrit

ion.

From

WHO

gui

delin

es:

1. T

he b

aby

shou

ld b

e ch

ecke

d fo

r sig

ns o

f loc

al in

fect

ions

(ski

n, c

ord,

eye

s).

2. M

othe

rs s

houl

d be

taug

ht to

trea

t loc

al in

fect

ion.

3. T

he b

aby

shou

ld b

e ch

ecke

d fo

r sig

ns o

f jau

ndic

e.

1. I

f nec

essa

ry, t

he h

ealth

-car

e pr

ovid

er s

houl

d ob

serv

e br

east

feed

ing

and

corr

ect p

ositi

onin

g an

d at

tach

men

t.

fre

quen

cy o

f fee

ding

co

mpo

sitio

n of

feed

.

10. A

bab

y w

ho is

exp

erie

ncin

g in

crea

sed

frequ

ency

of s

tool

s an

d/or

loos

er

stoo

ls th

an u

sual

sho

uld

be e

valu

ated

. (Ac

tion

leve

l 3)

11. C

are

for e

xces

sive

cry

ing/

colic

:

A

bab

y ei

ther

dra

win

g its

kne

es u

p to

its

abdo

men

or a

rchi

ng it

s ba

ck, i

n th

e ab

senc

e of

ano

ther

dia

gnos

is, s

houl

d be

ass

esse

d fo

r und

erly

ing

caus

e,

incl

udin

g in

fant

col

ic. (

Actio

n le

vel 2

)

A

sses

smen

t of e

xces

sive

and

inco

nsol

able

cry

ing

shou

ld in

clud

e:

gene

ral h

ealth

of t

he b

aby

an

tena

tal a

nd p

erin

atal

his

tory

on

set a

nd le

ngth

of c

ryin

g

natu

re o

f the

sto

ols

fe

edin

g as

sess

men

t

wom

an’s

diet

, if b

reas

tfeed

ing

fa

mily

his

tory

of a

llerg

y

pare

nts’

resp

onse

to th

e ba

by’s

cryi

ng

any

fact

ors

that

less

en o

r wor

sen

the

cryi

ng.

P

aren

ts o

f a h

ealth

y ba

by w

ho h

as c

olic

sho

uld

be re

assu

red

that

the

baby

is n

ot re

ject

ing

them

and

that

col

ic is

usu

ally

a p

hase

that

will

pas

s. Ho

ldin

g th

e ba

by th

roug

h th

e cr

ying

epi

sode

, obt

aini

ng p

eer s

uppo

rt a

nd

(A) h

ypoa

llerg

enic

form

ula

may

be

help

ful.

(A) D

icyc

love

rine

shou

ld n

ot

be u

sed.

48Tables: WHO Technical consultation on postpartum and postnatal care

Core

info

rmat

ion

Stat

usM

othe

rN

ewbo

rn

Acc

epte

d1.

W

omen

sho

uld

be o

ffere

d in

form

atio

n an

d re

assu

ranc

e ab

out p

erin

eal

pain

and

hyg

iene

, urin

ary

inco

ntin

ence

and

mic

turit

ion,

bow

el fu

nctio

n,

fatig

ue, h

eada

che,

bac

k pa

in, a

nd n

orm

al p

atte

rns

of e

mot

iona

l ch

ange

s.

2. A

ll w

omen

sho

uld

be o

ffere

d ad

vice

on

diet

, exe

rcis

e, a

nd fa

mily

pl

anni

ng.

1. P

aren

ts s

houl

d be

offe

red

info

rmat

ion

and

reas

sura

nce

on:

th

eir i

nfan

t’s s

ocia

l cap

abili

ties,

as th

is c

an p

rom

ote

pare

nt-in

fant

att

ach-

men

t;

napp

y ra

sh: F

requ

ent n

appy

cha

nges

and

cle

ansi

ng a

nd e

xpos

ure

of th

e pe

ri-an

al a

rea

redu

ce b

abie

s’ c

onta

ct w

ith fa

eces

and

urin

e. C

lean

sing

ag

ents

sho

uld

not b

e ad

ded

to b

ath

wat

er n

or s

houl

d lo

tions

or m

edic

ated

w

ipes

be

used

. Whe

re re

quire

d, th

e on

ly c

lean

sing

age

nt th

at s

houl

d be

us

ed is

mild

, unp

erfu

med

soa

p.

(A) *

cor

d ca

re: h

ow to

kee

p th

e um

bilic

al c

ord

clea

n an

d dr

y an

d th

at

antis

eptic

s sh

ould

not

rout

inel

y be

use

d.

safe

ty: h

ow to

redu

ce a

ccid

ents

, par

ticul

arly

sca

lds

and

falls

.

2. P

aren

ts s

houl

d be

adv

ised

to re

port

to th

eir h

ealth

-car

e pr

ofes

sion

al c

hang

es

in th

e ba

by’s

esta

blis

hed

bow

el p

atte

rn (w

hich

will

take

up

to 7

day

s to

es

tabl

ish)

, inc

ludi

ng h

ard

stoo

ls th

at a

re d

ifficu

lt to

pas

s an

d in

crea

sed

frequ

ency

of l

oose

sto

ols.

3. (

B) *

Par

ents

sho

uld

be g

iven

info

rmat

ion

abou

t sud

den

infa

nt d

eath

sy

ndro

me

(SID

S) a

nd c

o-sl

eepi

ng.

4. (

B) If

par

ents

cho

ose

to s

hare

a b

ed w

ith th

eir i

nfan

t, th

ey s

houl

d be

adv

ised

ne

ver t

o sl

eep

on a

sof

a or

arm

chai

r. Th

ey s

houl

d al

so b

e ad

vise

d th

at th

e ris

k of

SID

S is

incr

ease

d, e

spec

ially

whe

n th

e ba

by is

less

than

11

wee

ks o

ld, i

f ei

ther

par

ent:

is

a s

mok

er

has

rece

ntly

dru

nk a

ny a

lcoh

ol

Corn

cern

Mod

ified

and

/or

requ

irin

g ad

diti

onal

ev

iden

ce

1. W

here

iron

defi

cien

cy a

naem

ia is

pre

vale

nt, s

uppl

emen

t and

che

ck fo

r an

aem

ia.

. If

the

baby

is n

ot ta

king

suf

ficie

nt m

ilk d

irect

ly fr

om th

e br

east

and

su

pple

men

tary

feed

s ar

e ne

cess

ary,

expr

esse

d br

east

milk

sho

uld

be g

iven

by

cup

or b

ottle

. [De

lete

“or

bot

tle”.

]

2. I

f bre

astfe

edin

g pr

oble

ms

pers

ist a

fter a

ski

lled

heal

th-c

are

prof

essi

onal

or

peer

cou

nsel

lor h

ad re

view

ed p

ositi

onin

g an

d at

tach

men

t, ev

alua

tion

for

anky

logl

ossi

a (to

ngue

tie)

sho

uld

be m

ade.

If a

nkyl

oglo

ssia

is s

uspe

cted

, fu

rthe

r eva

luat

ion

is re

quire

d. [S

earc

h qu

estio

n w

ill b

e fo

rmul

ated

to lo

ok fo

r ev

iden

ce.]

Oth

er q

uest

ions

Wha

t is

the

best

way

to in

form

wom

en a

bout

mai

ntai

ning

thei

r hea

lth

and

wel

l-bei

ng a

nd a

bout

reco

gnizi

ng a

nd re

spon

ding

to d

ange

r sig

ns

conc

erni

ng th

eir h

ealth

?

[Non

e]


Core

info

rmat

ion

Stat

usM

othe

rN

ewbo

rn

Del

eted

[Non

e][N

one]

Add

ed a

nd/o

r re

quir

ing

addi

tion

al

evid

ence

1. A

ll w

omen

sho

uld

be to

ld to

brin

g th

eir h

ome-

base

d he

alth

reco

rds

on e

very

vis

it, e

ven

in a

n em

erge

ncy.

1. T

he w

oman

sho

uld

be in

form

ed h

ow to

mai

ntai

n go

od b

reas

tfeed

ing

prac

tice

and

offe

red

or re

ferr

ed fo

r sup

port

(app

ly s

trat

egie

s fo

r br

east

feed

ing

supp

ort).

Mod

ified

and

/or

requ

irin

g ad

diti

onal

ev

iden

ce

1. T

he m

ater

nal a

nd in

fant

hea

lth re

cord

sho

uld

be m

aint

aine

d.[N

one]

Oth

er q

uest

ions

[Non

e]1.

How

effe

ctiv

e is

scr

eeni

ng fo

r ill

heal

th in

new

born

s by

hea

lth w

orke

rs/

pare

nts?

2. W

hat i

s th

e be

st w

ay to

teac

h pa

rent

s ab

out m

aint

aini

ng in

fant

hea

lth

and

wel

l-bei

ng a

nd re

cogn

izin

g an

d re

spon

ding

to d

ange

r sig

ns re

late

d to

infa

nt il

l hea

lth?

3. W

hat i

s th

e be

nefit

of c

ouns

ellin

g an

d ad

visi

ng th

e pa

rent

s ag

ains

t po

tent

ially

har

mfu

l pra

ctic

es?

4. W

hat i

s th

e im

pact

on

infa

nt h

ealth

of c

erta

in s

afet

y is

sues

: pos

t-co

nflic

t situ

atio

ns, s

leep

ing

posi

tion,

vio

lenc

e, n

egle

ct?

5. W

hat i

s th

e be

nefit

of c

ontin

uity

of d

ocum

enta

tion

and

care

?

6. W

hat a

re th

e be

nefit

of c

ouns

ellin

g th

e pa

rent

s ag

ains

t har

mfu

l tr

aditi

onal

pra

ctic

es?

7. W

hat i

s th

e be

nefit

of a

sses

sing

and

rein

forc

ing

the

pare

nts’

co

mpe

tenc

e w

ith in

fant

car

e.

8. W

hat i

s th

e be

nefit

of a

sses

sing

em

otio

nal a

ttac

hmen

t (ey

e co

ntac

t an

d st

imul

atio

n)?

9. W

hat i

s th

e im

pact

of K

anga

roo

Mot

her C

are?

ha

s ta

ken

med

icat

ion

or d

rugs

that

mak

e he

r/him

sle

ep m

ore

heav

ily

is v

ery

tired

.

5. (

B) P

aren

ts s

houl

d be

adv

ised

that

, if a

bab

y ha

s be

com

e ac

cust

omed

to

usin

g a

paci

fier (

dum

my)

whi

le s

leep

ing,

this

pra

ctic

e sh

ould

not

be

stop

ped

sudd

enly

dur

ing

the

first

26

wee

ks.

6. A

ll w

omen

and

thei

r fam

ilies

sho

uld

be g

iven

info

rmat

ion

abou

t the

av

aila

bilit

y of

, acc

ess

to a

nd a

ims

of a

ll po

stna

tal p

eer,

stat

utor

y an

d vo

lunt

eer s

uppo

rt g

roup

s an

d or

gani

zatio

ns in

thei

r com

mun

ity.


Tim

e Ba

nd 3

: Lat

e po

stna

tal c

are

Core

info

rmat

ion

Stat

usM

othe

rIn

fant

Acc

epte

d1.

Enq

uirie

s sh

ould

be

mad

e ab

out g

ener

al w

ell-b

eing

.

2. R

esum

ptio

n of

sex

ual i

nter

cour

se s

houl

d be

dis

cuss

ed a

nd

enqu

iries

, mad

e.

3. W

omen

sho

uld

be a

sked

abo

ut re

solu

tion

of m

ater

nal b

lues

.

4. O

bser

vatio

n fo

r sig

ns o

f dom

estic

abu

se s

houl

d co

ntin

ue.

5. A

wom

an’s

phys

ical

, em

otio

nal,

and

soci

al w

ell-b

eing

sho

uld

be

revi

ewed

at 6

–8 w

eeks

pos

tpar

tum

.

1. B

reas

tfeed

ing

prog

ress

sho

uld

be a

sses

sed

at e

ach

post

nata

l con

tact

.

2. *

Phy

sica

l exa

min

atio

n sh

ould

be

repe

ated

at 6

–8 w

eeks

of a

ge.

Del

eted

[Non

e][N

one]

Add

ed a

nd/

or r

equi

ring

ad

diti

onal

ev

iden

ce

1. D

ocum

enta

tion

in th

e ho

me-

base

d m

ater

nal a

nd c

hild

hea

lth re

cord

shou

ld c

ontin

ue.

1. B

reas

tfeed

ing

supp

ort s

houl

d co

ntin

ue.

Mod

ified

and

/or

req

uiri

ng

addi

tion

al

evid

ence

1. M

ater

nal n

utrit

ion

and

supp

lem

enta

tion

shou

ld b

e pr

ovid

ed a

s re

quire

d.

2. T

he w

oman

sho

uld

be re

min

ded

of th

e da

nger

sig

ns, e

spec

ially

of

seco

ndar

y po

stpa

rtum

hae

mor

rhag

e.

3. W

here

mal

aria

is p

reva

lent

, use

ful p

ract

ices

for m

alar

ia p

reve

ntio

n sh

ould

be

rein

forc

ed.

4. G

ood

prac

tices

in th

e ho

me

for m

ater

nal w

ell-b

eing

sho

uld

be

rein

forc

ed.

1. *

Offe

r to

begi

n th

e in

fant

imm

uniz

atio

n pr

ogra

mm

e [to

be

adde

d:

“acc

ordi

ng to

nat

iona

l im

mun

izat

ion

polic

y”]

Oth

er q

uest

ions

[Non

e][N

one]


Corn

cern

s

Stat

usM

othe

rIn

fant

Acc

epte

d1.

Any

pos

itive

resp

onse

s to

que

ries

abou

t com

mon

hea

lth p

robl

ems

shou

ld b

e ev

alua

ted

and

the

prob

lem

, eith

er tr

eate

d or

refe

rred

ap

prop

riate

ly—

for e

xam

ple,

dys

pare

unia

, per

sist

ent v

agin

al

blee

ding

, and

per

sist

ent p

ostn

atal

fatig

ue.

1. I

f jau

ndic

e fir

st d

evel

ops

afte

r 7 d

ays

or if

an

othe

rwis

e he

alth

y ba

by

rem

ains

jaun

dice

d af

ter 1

4 da

ys, a

nd a

cau

se h

as n

ot a

lread

y be

en

iden

tified

, the

cau

se s

houl

d be

eva

luat

ed. (

Actio

n le

vel 2

)

Del

eted

[Non

e][N

one]

Add

ed a

nd/

or r

equi

ring

ad

diti

onal

ev

iden

ce

[Non

e][N

one]

Mod

ified

and

/or

req

uiri

ng

addi

tion

al

evid

ence

[Non

e][N

one]

Oth

er q

uest

ions

[Non

e][N

one]

Core

info

rmat

ion

Stat

usM

othe

rIn

fant

Acc

epte

d1.

Wom

en s

houl

d be

adv

ised

to re

port

any

hea

lth p

robl

ems.

[Non

e]

Del

eted

[Non

e][N

one]

Add

ed a

nd/

or r

equi

ring

ad

diti

onal

ev

iden

ce

1. W

omen

sho

uld

be a

dvis

ed to

see

k he

lp fr

om th

e co

mm

unity

if

need

ed.

1. C

heck

pre

vent

ive

mea

sure

s as

spe

cifie

d in

WHO

gui

delin

es.

Mod

ified

and

/or

req

uiri

ng

addi

tion

al

evid

ence

1. W

here

iron

defi

cien

cy a

naem

ia is

pre

vale

nt, s

uppl

emen

t and

che

ck

for a

naem

ia.

2. U

sefu

l pra

ctic

es fo

r mal

aria

pre

vent

ion

shou

ld b

e re

info

rced

.

3. T

he p

ract

ice

of L

AM s

houl

d be

rein

forc

ed, a

nd o

ptio

ns fo

r fam

ily

plan

ning

and

birt

h sp

acin

g w

hen

LAM

is n

o lo

nger

app

ropr

iate

sh

ould

be

disc

usse

d.

[Non

e]

Oth

er q

uest

ions

[Non

e][N

one]


List of participants

Name Designation Address

Maharaj Kishan BHAN Secretary to the Government of India Ministry of Science and TechnologyDepartment of BiotechnologyBlock-2, 7th Floor C.G.O. ComplexLodi Road, New Delhi–110 003, India

Patricia GOMEZ Clinical Specialist, ACCESS Program Jhpiego—an affiliate of Johns Hopkins University 1615 Thames Street Baltimore, Maryland 21231, USA

Hassan Said BA’AQEEL National and Gulf Center for Evidence Based Medicine King Abdulaziz Medical City, National Guard Health Affairs Address: KAMC, P. O. Box 9515 (internal 6110), Jeddah 21423, Saudi Arabia

Gianfranco GORI U.O. di Ostetricia e Ginecologia Ospedale “Morgagni-Pierantoni” Viale Forlanini 34 I-47100 Forli (FC), Italy

Margareta LARSSON Uppsala University HospitalDepartment of Women’s and Children Health751 85 Uppsala, Sweden

Packirisamy PADMANABAN Advisor (Public Health Administration)

National Health Systems Resource Centre National Rural Health Mission Ministry of Health and Family Welfare NIHFW campus, Baba Gangnath Marg, Munirka, New Delhi-110067, India

Ravindran JEGASOTHY Senior Consultant & Head Department of Obstetrics & Gynaecology Hospital Kuala Lumpur Jalan Pahang 50586 Kuala Lumpur, Malaysia

Tina LAVENDER Professor of Midwifery University of ManchesterSchool of Nursing, Midwifery and Social WorkOxford RoadManchester, UK

Sally MARCHANT Midwife/Editor MIDIRS 9 Elmdale Road Clifton Bristol BS8 1SL, UK

Vineetha KARUNARATNE Community Medicine Specialist No. 4, 1st Kottawa Lane Embuldeniya Nugegoda, Sri Lanka

Maria Asuncion A. SILVESTRE Associate Professor University of the Philippines College of Medicine Consultant Neonatologist, Section of Newborn Medicine Philippine General HospitalTaft Avenue, Manila, Philippines

Roland Edgar MHLANGA Consultant Department of Obstetrics and Gynecology Nelson Mandela School of MedicineUniversity of KwaZulu-Natal 719 Umbilo Road Durban 4000, South Africa

Khaled YUNIS Professor of Paediatrics Director Newborn Services Director National Collaborative Perinatal Neonatal Network American University of Beirut PO Box 11-0236/E29, Lebanon



Ellen MBWEZA Senior Lecturer in Maternal and Child Health

DepartmentUniversity of Malawi Kamuzu College of Nursing P.O. Box 415 Blantyre, Malawi

Vincent FAUVEAU United Nations Population Fund (UNFPA)UNFPA Office GenevaInternational Environment House11, Chemin des AnémonesCH-1219 ChâtelaineGeneva, Switzerland

Yaron WOLMAN United Nations Population Fund (UNFPA)UNFPA Office GenevaInternational Environment House11, Chemin des AnémonesCH-1219 ChâtelaineGeneva, Switzerland

Pia AXEMO Senior Advisor Reproductive Health The World Bank,HNP 7-7011818 H Street, NWWashington, DC 20433, USA

Elizabeth ZISOVSKA Chief of the Neonatal Department University Clinic for Gynaecology and ObstetricsSkopje, Macedonia

Ruby JOSE Professor and Head of Obstetrics and Gynaecology Unit 1

Christian Medical College & HospitalVellore 632004, India

ObserversLily KAK United States Agency for International

Development (USAID)GH/HIDN 3.7.82, RRB1300 Pennsylvania Avenue, NWWashington, DC 20523, USA

Neal BRANDES United States Agency for International Development (USAID)GH/HIDN 3.7.70, RRB1300 Pennsylvania Avenue, NWWashington, DC 20523, USA

Johanne SUNDBY University of OsloSection for International HealthPO Box 1130 Blindern0317 Oslo, Norway

Ellen MBWEZA Senior Lecturer in Maternal and Child Health Department

University of Malawi Kamuzu College of Nursing P.O. Box 415 Blantyre, Malawi

Oona CAMPBELL Professor in Epidemiology and Reproductive Health

London School of Hygiene & Tropical Medicine Room 258e, Keppel St, London WC1E 7HT, UK

Nita BHANDARI Joint Director Society for Applied Studies 45, Kalu Sarai New Delhi-110016, India

Anne-Marie BERGH University of Pretoria MRC Unit for Maternal and Infant Health Care Strategies PO Box 667 Pretoria 0001, South Africa



Suzanne JACOB SERRUYA Ministerio de Saude Esplanada dos MinisteriosSecretaria de Ciencia, Tecnologia e InsumosEstrategicosDepartmento de Ciencia e TecnologiaCEP: 70.058-900Bloco G - Brasilia/DF, Brazil

José M. BERTOLOTE Professor - Dept. of Neurology, Psychology and PsychiatryGraduate Programme on Public HealthBotucatu Medical School – UNESP, Brazil

Shams El ARIFEEN Epidemiologist, Head, CHU Child Health UnitThe International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)68 Shahid Tajuddin Ahmed Sharani Mohakhali (GPO Box 128, Dhaka 1000)Dhaka 1212, Bangladesh

WHOSEARO

Ardi KAPTININGSIH Medical officer [email protected]

SECRETARIAT

Child and Adolescent Health (CAH)Rajiv BAHL Medical officer Email: [email protected]

Virginia CAMACHO Medical officer Email: [email protected]

Nutrition for Health and Development (NHD)Maria Del Carmen CASANOVAS

Technical Officer Email: [email protected]

Reproductive Health and Research (RHR)Ahmet Metin GULMEZOGLU Medical Officer Email: [email protected]

Mariana WIDMER Technical Officer Email: [email protected]

HIV/AIDSYing-Ru Jacqueline LO Coordinator Email: [email protected]

Mental Health and Substance Abuse (MSD)Mohammad Taghi YASAMY Medical Officer Email: [email protected]

Immunization, Vaccines and Biologicals (IVB)Steven WIERSMA Medical Officer Email: [email protected]

Making Pregnancy Safer (MPS)Monir ISLAM Director Email: [email protected]

Maurice BUCAGU Medical Officer Email: [email protected]

Viviana MANGIATERRA Coordinator Email: [email protected]



Matthews MATHAI Medical Officer Email: [email protected]

Razia PENDSE Technical Officer Email: [email protected]

Annie PORTELA Technical Officer Email: [email protected]

Anuraj SHANKAR Coordinator Email: [email protected]

Severin VON XYLANDER Medical Officer Email: [email protected]

Juliana YARTEY Technical Officer Email: [email protected]

Jelka ZUPAN Coordinator Email: [email protected]


Glossary

Assessment A core health care professional making a judgement about the well-being of a woman or infant.

Breastfeeding counsellor A woman who has received specific training in counselling skills to provide support to breastfeeding women.

Breastfeeding peer support Support offered by women who have themselves breastfed, are usually from similar socio-economic backgrounds and locality to the women they are supporting and who have received minimal training to support breastfeeding women.

Coordinating healthcare professional

A named health care professional who is responsible for organizing the care of a woman and her baby during any stage of the postnatal period.

Dyad Mother and baby as a couple or pair.

Evaluation Action based upon assessment of a woman or infant which may require referral or additional competencies to provide treatment.

Exclusive/full breastfeeding Breast milk feeding without supplementation in the form of other solid or liquids.

First postnatal contact First contact after the end of intrapartum care.

Formula milk/artificial milk Modified cow’s milk or modified soy liquid used for infant feeding in lieu of breast milk.

Healthcare professional Clinically educated and certified individual who provides postnatal care for a woman and/or her baby; most commonly midwives, general practitioners, health visitors.

Healthy baby A healthy baby should have normal colour for his/her ethnicity, maintain a stable body temperature, pass urine and open his/her bowels at regular intervals. A healthy baby initiates feeds, sucks well on the breast (or bottle) and settles between feeds.

A healthy baby is not excessively irritable or tense and is not excessively sleepy or floppy. The vital signs of a healthy baby should fall within the following ranges:

Respiratory rate normally 30–60 breaths per minute

Pulse rate, normally between 100–160 in a newborn

Body temperature in a normal room environment of around 37 degrees Centigrade (if measured)

Induration The hardening of a normally soft tissue or organ.

Maternity support worker An individual who has received appropriate training and work under midwife or health visitor supervision in hospital or community postnatal care teams, providing basic care and support for women and their babies.

Parents Presumed to be the biological parents and primary carers of an infant, although it is recognized that this term may include other carers, such as grandparents, foster or adoptive parents, etc.

Partners Individuals in a relationship, who may be of either sexual orientation.

Peer counsellor A woman who has herself breastfed, is from similar socio-economic background and locality to the women she is counselling and who has received specific training in counselling skills to provide support to breastfeeding women.

Postnatal care Care during the first 6–8 weeks after birth.


Follow-up Planned visit to/by a skilled health professional for a specific problem outside a routine visit.

Readmission Hospitalization after a discharge from a facility for the same or related condition.

Routine care Scheduled contacts with women and their babies at periods for estimated maximum impact on maintaining health and providing a package of effective interventions to all women and babies.

Situational care Care that is required because of incidence or prevalence of public health problems such as malaria, HIV, STIs, FGM, adolescent pregnancy. Care can be clinical or social support.

Skilled health attendant

An individual who has received education and training to provide skilled postnatal care for a woman and/or her baby. These include midwives, general practitioners, and health visitors but may also apply to other health care workers who have acquired appropriate skills in postnatal care.

Uncomplicated vaginal delivery

Unassisted vaginal birth of baby and placenta, with no maternal complications.

Visit Routine care.

Additional glossary

www.who.int/making_pregnancy_safer

For more information, please contact:

Department of Making Pregnancy SaferWorld Health OrganizationAvenue Appia 20, CH-1211 Geneva 27, SwitzerlandFax: +41 22 791 5853Email: [email protected]

For updates to this publication, please visit:www.who.int/making_pregnancy_safer

Documents

WHO Technical Consultation on Postpartum and Postnatal Care€¦ · postpartum and postnatal care delivered by skilled providers. The purposes of revision are to encourage and support