Download Immediate Postpartum Care of Mothers and Newborns

Effective Perinatal Care (EPC)
Immediate Postpartum Care of
Mothers and Newborns
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Learning objectives
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Effective Perinatal Care (EPC)
By the end of this module the participants will:
Understand the importance of effective postpartum care for
mothers and newborns
Gain effective and safe skills in mother and newborn
postpartum care
Understand the advantages of breastfeeding for mothers and
newborns and the principles of correct breast attachment
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8C-2
 Greatest risk for postpartum complications is during
the first 24 hours after delivery
 Identification of potential problems; immediate
intervention; reassessment
Effective Perinatal Care (EPC)
Post delivery Assessment
8C-3
Percent of maternal deaths in developing countries
0-1 day
2-7 days
8-14 days
15-21 days
22-30 days
Effective Perinatal Care (EPC)
Most maternal deaths occur during labor, delivery and
the immediate post-partum period
31-42 days
Day of maternal death after delivery
Source: X. F. Li et al., International Joumal of Gynecology & Obstetrics 54 (1996): 1-10
8C-4
Major Postpartum Complications
and Diseases
Effective Perinatal Care (EPC)
 Postpartum hemorrhage
 Postpartum infections
 Eclampsia
 Urinary tract diseases
 Perineal and vaginal pain
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8C-5
pregnancy with
abortive outcome,
10.50%
other complications
related to pregnancy,
45.10%
postpartum
hemorrhage, 17.70%
Effective Perinatal Care (EPC)
Hypertension, post-partum hemorrhage and severe abortive outcomes
are the leading direct causes of maternal deaths
hypertension
complicating
pregnancy, childbirth
and puerperium,
26.60%
Source: Philippine Health Statistics, 2003
8C-6
50 percent of neonatal deaths occur in
the first two days of life
Effective Perinatal Care (EPC)
Number of deaths
Majority of newborns die due to stressful events
surrounding delivery
Day of Life
8C-7
 Ensure the physical well-being of mother and child
 Help to establish early and successful breastfeeding
 Support the mother's self-confidence
 Provide counselling on family planning and care for
the baby after discharge from the maternity
Effective Perinatal Care (EPC)
Four Basic Principles of Postpartum
Care
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8C-8
 Assessment ,
 Monitoring ,
 Support
of the baby's health and well-being; and of the
mother's physiological and emotional adaptation
following birth ;
Effective Perinatal Care (EPC)
Immediate postpartum period includes:
8C-9
– Condition of uterus
– Amount of bleeding
– Bladder & voiding
– Vital Signs
– Perineum
Effective Perinatal Care (EPC)
Assessment includes:
8C-10
 Process of Involution
 Height
– First Day = below or at Umbilicus
 Consistency
– Firm, Round, Smooth; Not “Boggy”
 Location
Effective Perinatal Care (EPC)
Uterus
– Midline
8C-11
 Amount
– Estimate of Drainage
– Number of Pads
 Color
– Rubra
– Serosa
– Alba
Effective Perinatal Care (EPC)
Lochia
8C-12
Effective Perinatal Care (EPC)
1. Regular monitoring of vaginal discharge and
involution of the uterus
Timeframe
Within the first two hours: every 15 min
Within the third hour: every 30 min
Within the next three hours: every hour
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8C-13
 Elevated Temperature
– Normal finding for first 24 hours
– Sign of Dehydration
– Sign of Infection
 Bradycardia
Effective Perinatal Care (EPC)
Vital Signs
– Normal Finding
8C-14
–
–
–
–
Infection
Hemorrhage
Pain
Anxiety
 Lowered Blood Pressure
– Orthostatic Hypotension
– Shock
Effective Perinatal Care (EPC)
 Tachycardia
 Elevated Blood Pressure
– Pregnancy-induced Hypertension
8C-15
 Encourage to void post delivery
 Assess for Bladder Distention:
– Uterine Atony
– UTI
 Catheterize in 6 hours if not voided (Dr.)
 Measure Urine Output
Effective Perinatal Care (EPC)
Bladder
8C-16
 Assessment for:
–
–
–
–
–
–
Hematomas
Laceration
Ecchymosis
Edema
Intact Suture Line
Signs of Infection
Effective Perinatal Care (EPC)
Perineum
8C-17
Effective Perinatal Care (EPC)
 Monitoring the general condition of mother and
newborn
 Encouraging the mother to be active early after
delivery
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8C-18
Four Basic Needs of Newborns
Effective Perinatal Care (EPC)
 Love
 Warmth
 Breastfeeding
 Prevention of Infections
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8C-19
Support of Mother’s Self-Confidence
 Provide her with accurate and comprehensive
information
 Give her an opportunity to make decisions on her own
Effective Perinatal Care (EPC)
 Treat the mother as an adult and responsible person
 Support her in making such decisions
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8C-20
Danger Signs in Women in the
Postpartum Period
Effective Perinatal Care (EPC)
 Vaginal bleeding (more then 2–3 sanitary pads in 30
minutes)
 Elevated temperature
 Breathing difficulty
 Abdominal pain
 Breast and nipple pain
 Urinary incontinence
 Perineal pain or pus discharge
 Foul smell of vaginal discharge
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8C-21
Effective Perinatal Care (EPC)
Initial Rapid Assessment of
the Newborn and Principles
of Neonatal Care
8C-22
 Initiates spontaneous breathing
 Experiences changes in cardiovascular system
 Starts regulating own body temperature
 Initiates feeding
Effective Perinatal Care (EPC)
How the Newborn Adapts to
Extra-Uterine Life
 Initiates interaction with surrounding environment
including bonding with mother, father and family
8C-23
8C-24
Effective Perinatal Care (EPC)
1. Prepare premises for birth
2. Dry the newborn on mother’s
abdomen or chest
3. Assess newborn’s well-being
4. Classify, manage, be ready to start
neonatal resuscitation
5. Clean airways (if necessary)
6. Maintain skin-to-skin contact & cover
both; place warm cap on baby’s head
7. Cut/clamp the cord
Steps from 2
to 5 are
simultaneous
within
30 seconds
after birth
Effective Perinatal Care (EPC)
Principles of Newborn Care
Basic Steps (1)
8C-25
8. Initiate breastfeeding
9. Prophylactic treatments (e.g., eye care)
10. Do not leave mother and baby alone
11. Examine baby, measure weight and length and
swaddle loosely
12. Organize 24 hour rooming-in
Effective Perinatal Care (EPC)
Principles of Newborn Care
Basic Steps (2)
8C-26
 Follow hand washing rules
 Follow the Universal Precautions:
– Wear gloves: sterile or highly disinfected; clean
– Protect yourself from any contact with biological
fluids (blood or amniotic fluid).
 Wear long plastic/fluid resistant apron and shoes
 Wear eye protection
 Wear gloves if you touch any biological fluids
(placenta/blood, instruments, laundry)
Effective Perinatal Care (EPC)
Universal Precautions
– Dispose of wastes (placenta, blood, sharps and
pieces of glass) safely
 Use sterile instruments
8C-27
 Trained health professionals (e.g., midwife) are
available
 Each birth should take place in a room, which meets
the following criteria:
-
Individual
Clean
Warm (temperature must not be below 25°C)
Medically safe for mother and baby
Equipped for free birth positions
Effective Perinatal Care (EPC)
Preparation for Birth
8C-28
 Clean table with radiant heater
 Warm towels to dry the baby
 Appropriate clothes: warm cap, socks and blanket
for baby
 Wall clock with a second hand
 Suction equipment
 Set for cord clumping/cutting
 Resuscitation equipment (bag and masks sized for
newborn)
 Digital thermometer or low-reading thermometer
(can read <35°С)
 Essential drugs (drugs for resuscitation, vitamin K,
eye ointment)
Effective Perinatal Care (EPC)
Equipment Required for Every Birth
8C-29
Drying the Baby
 The baby should be put immediately on the
mother’s chest, where drying is completed with a
dry, warm towel
 Remove wet towels
 Dress the baby in a cap and socks
Effective Perinatal Care (EPC)
 The baby must be dried immediately after birth
 Cover the baby with a dry warm blanket
8C-30
Newborn Heat Loss
Effective Perinatal Care (EPC)
Evaporation
Convection
Conduction
8C-31
8C-32
Effective Perinatal Care (EPC)
 Body temperature between – 36,5-37,5ºC = Normal
 Body temperature below 36.5ºС = Hypothermia
 36,4-36,0ºС = Cold stress/mild hypothermia
– Start to re-warm the baby
 35,9-32ºС = Moderate hypothermia
– Danger!!!
Effective Perinatal Care (EPC)
What Is Hypothermia?
 Below 32ºС = Severe hypothermia
– Severe condition, risk of death
– Skilled care urgently needed
8C-33
 Decrease O2
 Decrease glucose
 Surfactant destroy
 Decrease suckling ability
Respiratory
distress
Acidosis
Hypoglycemia
 Bleeding
 Convulsions
 Infections
 Brain damage
Effective Perinatal Care (EPC)
Hypothermia
8C-34
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Warm delivery room >25°C
Immediate drying (remove wet towels)
Early skin-to-skin contact (at least two hours)
Early breastfeeding (within one hour after birth)
Bathing, weighing and complete examination of the
baby postponed
Dress the baby adequately
Organize rooming-in
Organize thermal protection during resuscitation and
transportation
Health professionals trained in implementing every
step of the warm chain
Effective Perinatal Care (EPC)
“Warm Chain” Means:
8C-35
How to Dress the Baby Appropriately
 Encourage the mother to use baby clothes from
home
 Encourage dressing the baby in warm, loose, soft
clothes
 Cover baby’s head (25% of baby’s heat is lost from
the head)
 Cover baby with a blanket
Effective Perinatal Care (EPC)
Baby needs to be kept warm and dry
8C-36
The Harm of Tight Swaddling
 Decreases blood circulation
 Restricts free limb movement thus impairing
breastfeeding because the baby cannot move
his/her head or mouth properly
Effective Perinatal Care (EPC)
 Blocks diaphragm movement
 Prevents the baby from keeping warm due to lack
of air between the body and swaddling sheets
 Results in babies who sleep more and feed less
8C-37
 Conduct an assessment of the newborn’s status just
after birth to identify:
– Infants who require resuscitation and/or have special
needs
– Infants who are healthy and can stay with their
mothers
Effective Perinatal Care (EPC)
Assess the Newborn’s Well-Being
 Perform the assessment while drying the baby
8C-38
Components of the Assessment
After birth:
1. Spontaneous breathing or crying? Good tone?
 Dry the baby on the mother’s abdomen
 Provide warmth, keep skin-to-skin with mother
 Clear airway if needed
2. Assess breathing, heart rate, colour and tone
The assessment needs to be done
within 30 seconds after birth
Effective Perinatal Care (EPC)
Before birth:
1. Gestational age/estimated birth weight
2. If the amniotic fluid is stained with meconium
8C-39
Apgar Score
 Pulse
 Grimace
 Appearance
Effective Perinatal Care (EPC)
 Activity
 Respiration
8C-40
Apgar Scoring
0
2
Heart rate
Absent
Slow (<100
beats/min)
≥100 beats/min
Breathing
Absent
Slow, irregular
Cood, crying
Muscle tone
Limp
Some flexion
Active motion
Reflex irritability No response
Grimace
Cough, sneeze
Colour
Pink body with
blue extremities
Completely pink
Blue or pale
Effective Perinatal Care (EPC)
Sign
Score
1
8C-41
Classification and Management
healthy newborn care
2. Inadequate/no spontaneous breathing – start
neonatal resuscitation
3. Adequate breathing, gestational age <37 weeks,
weight <2,500 g, no malformations/traumas – give
Effective Perinatal Care (EPC)
1. Adequate breathing, gestational age >37 weeks,
weight >2,500 g, no malformations/traumas – give
special care for low birth-weight baby
4. Adequate breathing, malformations/birth traumas –
give special care according to malformation/birth
trauma
8C-42
 Not mandatory for every infant
 Clean the airways only in the case:
– Bloody or meconium-stained amniotic fluid
– Neonatal resuscitation
 Use a bulb/catheter
 No longer than 5 seconds if no meconium
 No deeper than 5 cm from the lip edge or 3 cm
from the nostril (in a full term baby)
Effective Perinatal Care (EPC)
Cleaning the Airway
8C-43
Early Skin-to-Skin Contact
 Fulfils bonding needs of mother and infant
 Sensitive bonding period not to be missed
Effective Perinatal Care (EPC)
 Supports newborn’s thermal adaptation
 Facilitates early initiation of breastfeeding
 Colonizes baby with mother’s flora
8C-44
Effective Perinatal Care (EPC)
Skin-to-Skin Contact
8C-45
Cord Clamping and Cutting
– Delayed cord clamping is beneficial for baby
– Early clamping: only in emergency (resuscitation)
 How?
– Use sterile blade or scissors
– Cover the cord with a piece of cloth/gauze to prevent
splashing of blood
– Cut the cord between the two clamps
– Be careful not to cut the baby – place your hand
between the baby and the cutting instrument
– Use elastic tying material (e.g., rubber band) or plastic
cord clamp rather than strings or bands to tie cord off
Effective Perinatal Care (EPC)
 When?
8C-46
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Observe if the newborn shows signs of readiness
Help the mother to find a comfortable position
Help the mother to attach baby to the breast
Check if the newborn is correctly positioned
Do not limit duration of breastfeeding
Praise the mother
Counsel the mother
Effective Perinatal Care (EPC)
Early Breastfeeding
8C-47
Effective Perinatal Care (EPC)
Early Breastfeeding
8C-48
Preventive Procedures
 Prevention of bleeding
 Oral administration of two doses of 2 mg each: one on
the first day of life and the other on the seventh day
of life
 Intramuscular injection at birth – single dose of 1 mg
 Prevention of conjunctivitis
– 1% tetracycline ointment (a drop the size of a rice
seed)
– 0.5% erythromycin ointment is affordable, safe, and
effective
– Give no later than one hour after birth
Effective Perinatal Care (EPC)
– Vitamin K: two options
8C-49
 Breathing: Reassess the baby’s breathing and
colour every 15 minutes after birth for one hour,
then every 30 minutes
– Count breathing rate (30–60 breaths per min)
– Listen for grunting
– Observe for severe chest in-drawing
 Check warmth
Effective Perinatal Care (EPC)
Monitoring the Baby during the
First Two Hours
– Feel baby’s feet every 15 minutes. If cold, check
axillary temperature
– Take auxiliary temperature at 30 minutes and at 2
hours
8C-50
 Before re-warming, remove the baby’s cold clothing
 Place skin-to-skin on mother and dress in prewarmed shirt open at front, diaper, hat and socks
 Cover mother and baby with a warm blanket
 Check baby’s axillary temperature every hour
 Keep with mother skin-to-skin until temperature is
in normal range OR
 If temperature still <36.5°С after 2 hours, reassess
the baby
 Keep the room temperature higher than 25°С (may
require additional heaters)
Effective Perinatal Care (EPC)
How to Re-Warm the Baby?
8C-51
 Postpone complete examination of the newborn for
2 hours
 Measure the baby’s weight and length, and provide
cord care during the complete examination of the
baby
Effective Perinatal Care (EPC)
Complete Assessment of the
Newborn
 Record in the baby’s file the time of the first
attachment to the breast, first defecation and first
urination
 Postpone bathing/cleaning of the baby for at least
six hours (the later the better)
8C-52
Rooming-in
 Mother should perform routine care of the baby
 Maternity staff should help the mother
Effective Perinatal Care (EPC)
 Mother and baby should stay together from birth
 In the case of caesarean section, mother and baby
should be together as soon as the mother is awake
 Family members can help the mother
8C-53
Effective Perinatal Care (EPC)
Rooming-in
8C-54
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History of difficulty feeding
Floppy or lethargy
Fast or slow breathing, or severe chest in-drawing
Grunting
 Convulsions
 Fever (temperature >38ºC)
 Temperature <35,5ºC or not rising after re-warming
 Umbilicus draining pus or bleeding from stump or
cut
 Yellow palms and soles in any age
Effective Perinatal Care (EPC)
Danger Signs in Baby
8C-55
Discharge of the Mother from the
Maternity
Effective Perinatal Care (EPC)
 Objective consideration of the mother’s condition
(no complaints, stable haemodynamics, no bleeding
and no signs of infection)
 Mother has been counselled on newborn feeding,
postpartum contraception, and dangerous signs in
the postpartum period
 Mother has been trained in the care and monitoring
of her newborn
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8C-56
Discharge of the Newborn from the
Maternity
Effective Perinatal Care (EPC)
 Breastfeeding or alternative feeding method is
established
 Newborn maintains body temperature
 No signs of umbilical cord inflammation
 No danger signs
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8C-57
Conclusions
 Appropriate skills for neonatal resuscitation
 Correct initial assessment and effective newborn
care
Effective Perinatal Care (EPC)
 Staff and equipment needed to be prepared for
every delivery
 Delay all non-essential procedures for at least 2
hours
 Complete assessment includes measure of baby’s
weigh and length, and cord care
8C-58