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.
8WHO Technical consultation on postpartum and postnatal care
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)
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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.
10WHO Technical consultation on postpartum and postnatal care
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.
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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
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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.
14WHO Technical consultation on postpartum and postnatal care
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
WHO Technical consultation on postpartum and postnatal care
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
WHO Technical consultation on postpartum and postnatal care
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.
18WHO Technical consultation on postpartum and postnatal care
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)
19WHO Technical consultation on postpartum and postnatal care
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
20WHO Technical consultation on postpartum and postnatal care
Condition Days Weeks
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
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 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)
22WHO Technical consultation on postpartum and postnatal care
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)
23WHO Technical consultation on postpartum and postnatal care
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
24WHO Technical consultation on postpartum and postnatal care
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.
25WHO Technical consultation on postpartum and postnatal care
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
.
26WHO Technical consultation on postpartum and postnatal care
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
.
27WHO Technical consultation on postpartum and postnatal care
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.
28WHO Technical consultation on postpartum and postnatal care
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
.
29WHO Technical consultation on postpartum and postnatal care
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
.
30WHO Technical consultation on postpartum and postnatal care
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.
31WHO Technical consultation on postpartum and postnatal care
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
32WHO Technical consultation on postpartum and postnatal care
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
33WHO Technical consultation on postpartum and postnatal care
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.
34WHO Technical consultation on postpartum and postnatal care
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.
35WHO Technical consultation on postpartum and postnatal care
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)
36WHO Technical consultation on postpartum and postnatal care
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
)
37WHO Technical consultation on postpartum and postnatal care
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.
38WHO Technical consultation on postpartum and postnatal care
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
39WHO Technical consultation on postpartum and postnatal care
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.
40WHO Technical consultation on postpartum and postnatal care
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
?
41WHO Technical consultation on postpartum and postnatal care
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]
43WHO Technical consultation on postpartum and postnatal care
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.
45WHO Technical consultation on postpartum and postnatal care
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
47WHO Technical consultation on postpartum and postnatal care
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]
49WHO Technical consultation on postpartum and postnatal care
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.
50WHO Technical consultation on postpartum and postnatal care
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]
51WHO Technical consultation on postpartum and postnatal care
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]
52WHO Technical consultation on postpartum and postnatal care
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
53WHO Technical consultation on postpartum and postnatal care
Name Designation Address
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
54WHO Technical consultation on postpartum and postnatal care
Name Designation Address
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]
55WHO Technical consultation on postpartum and postnatal care
Name Designation Address
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]
56WHO Technical consultation on postpartum and postnatal care
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.
57WHO Technical consultation on postpartum and postnatal care
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