Best practices for post natal care

In the continuum of care, coverage quality and equity of care is unsatisfactory during the post-natal period. This is a crucial phase in life that influences the outcome for the mother and the newborn baby. WHO recommends the adoption of a unifying term for post-natal phase to fully accommodate the needs of the mothers and the newborn babies. Based on evidence, WHO recommends best practices for use during the post-natal care.  

Except in specialized hospitals post-natal care is generally provided by one person (usually trained in midwifery). She is mostly focused on child birth but is not very skilled in helping the mothers and newborn babies to be skilled during their hospital stay. These midwives should be more skilled in monitoring mothers and newborn babies for danger signs and in providing care counselling and advice to meet the numerous needs of the mother and the newborn baby. This is quite challenging in India as well as low and middle developing countries where there are numerous challenges to the provision of post-natal care in the hospitals and during home visits.

WHO has made recommendations for postnatal care based on evidence and systematic reviews. The following recommendations are based on weak moderate or strong evidence. Until more evidence emerges, these should continue to be followed to reduce morbidity and mortality and also to promote health and development. These recommendations are summarized below:

Postnatal Care for all mothers and newborns      

  1. Number of post-natal visits and their timing- In low risk women with normal vaginal delivery, stay in the hospital is recommended for a period of at least 24 hours after child birth for the mothers and newborns to be stabilized and for discharge preparedness to ensure smooth transitioning from the hospital to home.

At least, four post-natal care visits in low risk mothers and newborn babies are recommended between child birth and 42 days of life.

In the hospital, the essential post-natal contacts include (a) first within one hour after child birth (b) one before the child is discharged i.e. within 24 hours after child birth. In case of home birth, at least one post-natal visit is recommended before the end of 24 hours, (c) one between 3-7 days after child birth (this would be done through home visitation in low risk child birth) in contrast, in case of C section this is a part of care in the hospital and these mothers and babies should receive care according to the protocol and SOPs being used in the hospital, and (d) one at 42 days after child birth.

The above mentioned recommendations are essential but additional visits may be required depending on specific requirements in each case. Extra contacts, advice and care may be needed to address the problems of baby with low birth weight, baby with birth defect, baby born to an HIV positive mother or a sick baby or a sick mother. During each post-natal contact, it is important to examine the mother and the baby for detection of one or more danger signs (for treatment or referral) and also advice and counsel about care for the mother and the baby. This contact provides opportunity to refer the mother and or the baby if they are sick and cannot be treated at home.

  1. Provide postnatal care in the first 24 hours to all mothers and babies ─regardless of where the birth occurs. This is the period of maximum risk for the mother and the baby since maximal deaths occur in the mothers and newborn babies during this period.

A full clinical examination should be done around 1 hour after birth, when the baby has had his/her first breastfeed. In case of facility births, make sure that the mother and the baby are well and stable and they have been prepared for home care through discharge preparedness. The mother and the baby should be checked again before discharge.

In the case of home births, there should be an effort made to ensure a visit within the first 24 hours after child birth to ensure breast feeding as soon as possible, check the baby’s weight, check the mother and the baby for any danger signs and most importantly to congratulate the family for the new arrival and reassure the mother that all is well with her.

  1. Check for danger signs in the mother and newborn At each of the four postnatal care checkups, mothers and newborns should be assessed for key clinical signs of severe illness and referred as needed. Clinical signs have been identified in the mother and the newborn as danger signs that can be identified at home by a CHW or by a skilled provider in a health facility. The common danger signs in the mother and the newborn baby are summarized in the table. These danger signs should be looked for in each mother and in each newborn baby during each contact. Simple algorithms recommended by WHO should be used for the mother and the newborn. These algorithms help in recognition of problems, timely decision making and action.
  2. Promote exclusive breast feeding Promotion of breast feeding should be initiated as a part of birth preparedness. Exclusive breast feeding is useful for the mother and the baby. Continue to promote early and exclusive breastfeeding (EBF) within all delivery settings including antenatal care, at delivery, and in all postnatal care visits. Consistent with the previous WHO guidelines, evidence shows EBF reduces the risks of mortality and morbidity in the first month of life (compared to partial and predominant breastfeeding) and improves post-neonatal outcomes. It also encourages improved birth spacing by delaying the return to fecundity. With the trend of increase in institutional delivery rates in many developing countries, policies and programs should actively promote facility-based and home based counselling and support for EBF including counselling on common breastfeeding problems and ways to manage them if they occur. It is important that early initiation of breast feeding and exclusive breast feeding should be an important target in settings where home delivery rates are high. It is important to emphasize the numerous benefits of exclusive breast feeding for the mother and the newborn baby.

Newborn babies

  1. Cord care Clean dry cord care remains the standard recommendation for all babies born in health facilities. This is also the recommendation for home deliveries in areas where the neonatal mortality rate is less than 30/1000 live births. In locations with high neonatal mortality rates, cord care needs emphasis. Harmful traditional practices should be discouraged. These include applications like cow dung, talcum powder, oil, etc. In home deliveries. The application of chlorhexidine is recommended to replace the harmful traditional practices.
  2. Delay bathing of newborn babies and prevent hypothermia Bathing should be delayed until at least 24 hours after birth in all newborn babies. In case of low birth weight babies, bathing should be delayed for longer periods of time to prevent hypothermia. In home deliveries, promote early drying of the newborn to prevent hypothermia and promote skin to skin contact as soon after childbirth as possible. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps. The mother and baby should not be separated and should stay together in the same room 24 hours a day.
  3. Multi sensorial stimulation and frequent communication Post-natal home visits are a good opportunity to promote multi sensorial stimulation. The senses that should be targeted in newborn period include touch, vision, hearing, balance, taste and smell. Multi sensorial stimulation assumes greater importance in low birth weight infants and those who were admitted to the hospital for a long duration of time. Preterm and low-birth-weight babies should be identified immediately after birth and should be provided special care as per national guidelines. Multi sensorial stimulation should be a focus of counselling in low birth weight, premature and small for gestational age babies.
  4. Immunizations and other preventive measures- Immunization should be given before the baby is discharged from the facility. Vitamin K should be given as a routine. These interventions should be provided as soon after child birth as is possible in case of home deliveries.
  5. Reinforce key newborn care messages Key health messages should be shared among families and providers. WHO re-emphasizes key elements of newborn care including delayed bathing, skin-to-skin contact and timely immunization according to national schedule. Given the vulnerability of preterm and low-birth-weight babies, interventions are needed to identify these newborns in home and facility settings and ensure that they receive special care as per their specific needs.

 

Post-partum mothers

  1. Examination of post- partum mothers and advice All the post-partum mothers should be examined according to the same schedule as the newborn babies. The health care providers should be skilled in assessing the newborn as well as the post-partum mother. All postpartum women should be assessed for excess vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) starting one hour after child birth. Blood pressure should be measured shortly after birth, after 6 hours and again at 24 hours (This may not be possible in home deliveries). Passage of urine void should be assessed within six hours. After 24 hours assess for urinary incontinence, passage of stool, healing of perineal wound, headache, fatigue, back pain, and examine perineal region, breast pain, uterine tenderness and lochia. Breastfeeding progress should be assessed at each postnatal contact. At each postnatal contact, women should be asked about their emotional wellbeing.
  2. Advising women about danger signs All women should be given information about the physiological process of recovery after birth. They should be told what is not normal. This includes recognition of excess vaginal bleeding- sudden profuse blood loss or persistent blood loss. Faintness, dizziness, palpitation, headaches, visual disturbances, nausea vomiting, epigastric pain or burning, fever with shivering, severe abdominal pain, foul discharge, thick discharge from vagina. Unilateral calf pain, redness or swelling of calves, shortness of breath or chest pain should be reported immediately. Women should be told that they should not ignore any of the above symptoms.
  3. Counseling on nutrition and self-care All women should be counselled on nutrition after child birth. They should be advised to eat well and drink plenty of fluids. They should eat whatever they like and neither food nor fluids should be restricted. In some cultures, the food and fluids restrictions are imposed. The health workers should counsel the families that happiness of woman her positive attitude are very useful for the health of the newborn and the mother. Women should be counselled on hygiene, especially handwashing. Women should be counselled on birth spacing and family planning. Contraceptive options should be discussed, and contraceptive methods should be provided if requested. Women should be counselled on safer sex including use of condoms. In malaria endemic areas, mothers and babies should sleep under insecticide impregnated bed nets. All women should be encouraged to become mobile as soon as possible Even after C-section, early mobility should be encouraged. They should be encouraged to take gentle exercise and make time to rest during the postnatal period. Iron and folic acid supplementation should be provided for at least three months. Calcium should be advised as appropriate. Rest is very important and the mother should be counseled to sleep during the day if her baby has kept her awake during the night.
  4. Advice on routine antibiotic administration Antibiotics are widely used after child birth in many settings. Routine antibiotics should be discouraged in normal or low risk deliveries. However, the use of antibiotics among women with a normal vaginal delivery and a third or fourth degree perineal tear is recommended for prevention of wound complications.
  5. Psychosocial support Family support and coping strategies should be assessed and guidance provided as per needs. Assess any changes in mood, emotional state and behavior that are not the usual pattern for the woman. At 7–14 days after birth, all women should be asked about resolution of mild, transitory postpartum depression (“maternal blues”). If symptoms have not resolved, or have worsened, then appropriate guidance, support and treatment should be provided. Other important issues are resumption of normal family routines. Families should be provided opportunities to discuss any behavior of the woman that is different from her earlier behavior before child birth. A woman who has lost her baby (neonatal death, still birth, abortion or miscarriage) should receive additional supportive care.

 Danger signs to look for in the mother and the newborn baby

S No. Danger signs in the mother Danger signs in the newborn
1. Excess bleeding (> 500 ml. estimate) Poor sucking or poor feeding or not feeding at all
2. Severe anemia (Hemoglobin < 7 g/dl) Lethargic, inactivity
2. Fits (convulsions) Fast breathing or severe chest indrawing
3. High fever (not controlled by paracetamol) Fever or body feels cold
4. Foul smelling discharge PV Fits (convulsions)
5. Severe breathing difficulty short of breath Red swollen cord stump or foul discharge
6. Feels very weak, sweaty More than 10 pustules or a big abscess
7. Painful micturition  or incontinence Visible congenital defect
8. Severe abdominal pain Very low birth weight (<2000 grams)
9. Breast is swollen, red or tender or sore nipple Jaundice on the first day or yellow palms and soles or deep yellow abdomen at any time during the first two weeks
10. Inappropriate behevaiour or feels very low Oral thrush
11. Red painful calf  

 

Key references

  1. Post natal care for mothers and newborns- World Health Organization who.int/…/WHO-MCA-PNC-2014 Briefer.
  2. WHO technical consultation on post partum and post natal care. WHO/MPS/10.3. World Health Organization 2013 Guidelines April 2015 mcsprogram.org
  3. Postnatal care:A critical opportunity to save mothers and newborns. prb.org/pdf07/snl_pncbrieffinal. Accessed 17 December 2016
  4. Caring for the newborn at home. Caring for the newborns and children in the community WHO Postnatal care: published 2015.
  5. Postnatal care home visits.pdf-MCHIP mchip.net/…/postnatal accessed 12.17.16

Contribution:

Dr Vijay Kumar SWACH

Dr Suresh Dalpath NHM Haryana

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