Guidelines For Antenatal Care Final

Health Minister’s Message
Women are strong pillars of any vibrant society. Motherhood is an event

of joy and celebration for every family. However, high maternal mortality
during pregnancy and childbirth is a matter of great concern worldwide.
Maternal mortality is a strong indicator for measuring the attention paid
to the health care of the women.
The burden of maternal mortality is quite high in India at 254 deaths per 100,000 live births
as per the data of Sample Registration System (SRS) for the period 2004-06. However, India
is committed to meet the MDG 5 target of less than 100 deaths per 100,000 live births by
the year 2015.
GoI’s strategy for maternal mortality reduction focuses on building a well functioning
Primary Health Care System, which can provide essential obstetric care services with a
backbone of skilled birth attendant for every birth, whether it takes place in the facility or
at home, which is linked to a well developed referral system with an access to emergency
obstetric care for all women who experience complications.
The revised guidelines are meant for orientation and training of our ANMs/LHVs and SNs
who are there at the Primary level of health care and are the first contact of care, particularly
for women residing in rural areas. I hope these guidelines will help in knowledge and skill
acquisition of all the service providers involved in mid-wifery care services and will thus
help in reduction of maternal mortality.
I complement Maternal Health division for bringing out the guidelines along with the
training tools.
(Ghulam Nabi Azad)

New Delhi Union Minister for Health &
Date: April 2010 Family Welfare
Ministry of H&FW
Government of India
Preface
Government of India has a commitment under National Population

Policy, NRHM/RCH to ensure universal coverage of all births with
skilled attendance both in the institution and at community level and
to provide access to emergency obstetric and neonatal care services for
women and the new born.
In accordance with the GoI’s commitment for universal skilled birth attendance, a policy
decision was taken to permit ANMs/LHVs and SNs to give certain injections and undertake
interventions for Basic Management of Complications which might develop while providing
care during pregnancy and child birth. Accordingly, guidelines for Ante-Natal Care & Skilled
Attendance at Birth by ANMs/LHVs and SNs as well as training tools were published in the
year 2005.
However, based on the evidence of implementation and also due to certain technical
advancements, there was a need to revise these guidelines and also the training package. The
revised Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs and
SNs have been updated, which will help the trainees in skill and acquisition of knowledge in
various technical interventions.
The Maternal Health Division of the Ministry based on inputs from experts, NGOs and
development partners has revised the guidelines accordingly for use by State and District
program Officers, Trainers and also ANMs/LHVs and SNs who are involved in practicing
mid-wifery. It is hoped that the revised guidelines would improve the quality of SBA Training
in the states and help in providing quality essential obstetric services thereby accelerating
the reduction of maternal mortality.
(K. Sujatha Rao)

New Delhi Secretary (Health & FW)
Date: April 2010 Ministry of H&FW
Government of India
Foreword
NRHM has a commitment for reduction of maternal and infant mortality/

morbidity so as to meet the National and Millennium Development
goals. The quality of services rendered and also handling of Basic and
Comprehensive Obstetric Care services at the health facilities particularly
at primary and secondary level has a bearing on reduction of maternal
mortality ratio.
To achieve these objectives, steps have been taken under NRHM to appropriately
strengthen and operationalise the 24X7 PHCs and designated FRUs in handling Basic and
Comprehensive Obstetric Care including Care at Birth. For improvement of service delivery,
it is important that the service providers particularly the ANMs/LHVs and SNs are oriented
on care during pregnancy & childbirth so that the primary and secondary health facilities
can effectively handle complications related to pregnancy and care of new born.
GoI has already launched the guidelines and training package for training of paramedical
workers i.e., ANMs/LHVs and SNs for developing their skills in provision of care during
pregnancy and child birth. However, based on the feedback received and due to new
technical advancements, there was a need to revise the guidelines and also the training
package.
The training guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs
and SNs have now been updated and revised. This will assist the health personnel involved
in midwifery practice particularly at sub-centre and 24x7 PHCs to effectively provide the
requisite quality based services for women and newborns nearest to their place of residence.
It is expected that the trainers as well as the trainees will be benefitted in updating their
knowledge and skills by using these guidelines along-with the training tools and thus help
reducing the maternal mortality and morbidity by early identification and management of
basic complications during pregnancy, childbirth and in post partum period.
(P. K. Pradhan)
New Delhi AS & MD, NRHM
Date: April 2010 Ministry of H&FW
Government of India
Acknowledgement
National and international evidences indicate that reduction of maternal

and infant mortality and morbidity can be accelerated if women are
provided skilled care during pregnancy and child birth.
Based on these evidences, the Government of India has taken a policy

decision that every birth, both institutional and domiciliary, should be
attended by a skilled birth attendant. Accordingly, necessary policy decisions were taken
for empowering ANMs/LHVs and SNs for handling basic obstetric care and common
complications including Essential Newborn Care and Resuscitation Services. Pre-service
and in-service training for these paramedical workers has already been initiated and is
being implemented in the states to make them proficient in the provision of care during
pregnancy and child birth.
From time to time, there is a need to update the technical knowledge and training tools,
these being first published in the year 2005. Maternal Health Division of this Ministry with
inputs from development partners like WHO, UNFPA, UNICEF and Professional Bodies
like FOGSI, IAP, NNF has now revised the first edition of the guidelines. The revised version
has to be now disseminated to the states.
The second edition of the Guidelines would not have been possible without the active interest,
and encouragement provided by Ms K. Sujatha Rao, Secretary (H&FW) and Shri Naresh
Dayal, Ex Secretary, Ministry of Health & Family Welfare. I also take this opportunity
to appreciate the inputs given by development partners specially Dr. Rajesh Mehta,
Dr. Sunanda Gupta and Dr. Vinod Anand of WHO- India, Dr Sonia Trikha, UNICEF-India
and Dr. Dinesh Aggarwal, UNFPA. Contribution of TNAI, INC, JICA, USAID, DFID and
also from states particularly Dr. Ajeesh Desai from Gujarat and Dr. Archana Mishra from
Madhya Pradesh is also acknowledged.
I also take this opportunity to thank Dr. Bulbul Sood, Dr. Aparajita Gogoi, Ms. Medha
Gandhi, Dr. Annie Mathew of CEDPA India and Dr. Manju Chhugani, Faculty, College
of Nursing from Jamia Hamdard University for extending their support while the
guidelines and training tools were being drafted. The contributions from FOGSI and
other experts particularly Dr. Sudha Salhan & Dr. H.P. Anand from Safdarjung Hospital,
Dr. Kamla Ganesh, Ex HOD & Dr. Sagar Trivedi and her team from Lady Harding
Medical College Hospital, Dr. Reva Tripathi from Maulana Medical College hospital also
needs special mention.
For achieving the revision of the guidelines, hard-work and untiring efforts of Dr. Himanshu
Bhushan, AC(MH), Dr. Manisha Malhotra, AC(MH), Dr. Avani Pathak and Rajeev Agarwal
of Maternal Health Division is highly appreciated. The inputs from RCH, Family Planning
& Child Health Division helped in firming up various components of these guidelines
I hope the guidelines and the training tools will help the states in strengthening the technical
interventions and in better implementation of SBA Training.
(Amit Mohan Prasad)

New Delhi Joint Secretary (RCH)
Date: April 2010 Ministry of H& FW
Government of India
Programme Officer’s Message
GoI has a commitment under NRHM/RCH to ensure universal coverage of all births with skilled
attendance both in the institution and at community level and to provide access to emergency
obstetric and neonatal care services for women and the new born. With this objective in mind,
SBA Training for ANMs/LHVs and SNs is presently been undertaken in all the State/UTs to
equip Auxillary Mid-Wives (ANMs) and Staff Nurses (SNs) for managing normal deliveries,
identify complications, do basic management and then refer at the earliest to higher facilities
thereby empowering them to save the life of both the mother and new born.
The earlier Guidelines in the year 2005 for Antenatal Care and Skilled Attendance at Birth
by ANMs/LHVs and SNs has been revised and updated based on current scientific evidence
and certain technical updates in the field. The revised Guidelines along with the Handbook
provides up-to-date, comprehensive, evidence based information and defines and illustrates
the skills needed to keep pregnant women, mothers and their newborns healthy, including
routine and preventive care as well as early detection and management of life threatening
problems. It will require effective training, logistics and supportive supervision to make
skilled attendance at every birth in the country, a reality.
I hope that states will adopt the revised training package for effective implementation of
the SBA training to enhance the quality. It is suggested that the training centres must be
proficient and practicing the technical protocols defined and illustrated in the guideline
before they take up the training batches. The first step for this should be the orientation/
training of all the health professionals involved in care during pregnancy and child birth
at the training centre itself. Timely nomination, Provision of essential supplies such as
Partographs, mannequins, drugs and structured monitoring through Quality Assurance
Cell at the State, District and Facility level should be the next step. Up-scaling SBA Training
by creating more training centres either at the government health facility or through Public-
Private Partnership is another important step for achieving our commitment for attending
every births by skilled personnel.
I am optimistic that if all the above inputs are implemented in a coordinated manner, the
time is not far away for achieving universal coverage of births with skilled attendance both
in the institution and at community level. I take this opportunity to thank everyone who has
contributed in framing the training package.
(Dr. Himanshu Bhushan)

New Delhi Assistant Commissioner
Date: April 2010 Maternal Health Division
Ministry of H& FW
Government of India
Contents
Introduction 1
Module I: Management of Normal Pregnancy, Labour and
the Post-partum Period 5
Care During Pregnancy—Antenatal Care 7
Antenatal care 7
Early registration 9
Detection of pregnancy 10
Number and timing of visits 10
Seek help for early registration and antenatal check-up 10
Estimate the number of pregnancies in your area 11
Keep a track of all pregnant women by name 12
Record keeping 13
Antenatal check-up 13
Components of Antenatal Check-up 13
Care During Labour and Delivery—Intra-partum Care 39
Introduction 39
Monitoring and managing the stages of labour 43
Preparing for discharge (Annexure Vll) 58
Care after Delivery—Post-partum Care 59
Post-partum visits 59
Module II: Management of Complications during Pregnancy,

Labour and Delivery, and in the Post-partum Period 71
Complications during Pregnancy, Labour and Delivery and in
the Post-partum Period 73
Vaginal bleeding 73
Pregnancy-induced hypertension 78
Convulsions—Eclampsia 79
Anaemia 80
Urinary tract infection 81
Pre-term labour 81
Premature or pre-labour rupture of membranes 81
Foetal distress 82
Obstructed labour 82
Prolapsed cord 83
Retained placenta and placental fragments 83
Vaginal and perineal tears 83
Puerperal sepsis 84
Breast conditions 84
Module III: Ensuring the Quality of Care 87

Community Involvement 89
Review of maternal deaths 90
Counselling And Suportive Environment 91
Rights of women 91
Supportive care during a normal delivery 92
Supportive care during an emergency/complication 92
Prevention of Infection 94
Sources of infection 94
Why should infection be prevented? 94
Principles of prevention of infection 94
Standard precautions for prevention of infections 95
Procedure for washing hands 96
Dos and Don’ts of waste management 102
ANNEXURES 105
Abbreviations
AMTSL : Active Management of the Third Stage of Labour

ANC : Antenatal Check-Up
ANM : Auxiliary Nurse Midwife
APH : Antepartum Haemorrhage
ASHA : Accredited Social Health Activist
AWW : Anganwadi Worker
CBO : Community-Based Organisation
CCT : Controlled Cord Traction
CHC : Community Health Centre
COC : Combined Oral Contraceptive
CPD : Cephalopelvic Disproportion
DDK : Disposable Delivery Kit
DMPA : Depot Medroxyprogesterone Acetate
ECP : Emergency Contraception Pill
EDD : Expected Date of Delivery
FHR : Foetal Heart Rate
FHS : Foetal Heart Sound
FRU : First Referral Unit
FS : Female Sterilisation
GoI : Government of India
HBsAg : Hepatitis B Surface Antigen
HCG : Human Chorionic Gonadotrophin
HIV : Human Immunodeficiency Virus
HLD : High Level Disinfection
HMIS : Health Management Information System
HPS : High Performing States
ICTC : Integrated Counselling and Testing Centre
IFA : Iron Folic Acid
IMNCI : Integrated Management of Neonatal and Childhood Illness
IUCD : Intrauterine Contraceptive Device
IUD : Intrauterine Death
IUGR : Intrauterine Growth Retardation
JSY : Janani Suraksha Yojana
KMC : Kangaroo Mother Care
LAM : Lactational Amenorrhea Method
LHV : Lady Health Visitor
LLIN : Long-Lasting Insecticidal Net
LMP : Last Menstrual Period
LPS : Low Performing States
MMR : Maternal Mortality Ratio
MO : Medical Officer
MoHFW : Ministry of Health and Family Welfare
GUIDELINES
xi
Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs/SNs
MoWCD : Ministry of Women and Child Development
MPHW : Multipurpose Health Worker
MTP : Medical Termination of Pregnancy
MVA : Manual Vacuum Aspiration
NFHS : National Family Health Survey
NGO : Non-Governmental Organisation
NRHM : National Rural Health Mission
NSV : No-Scalpel Vasectomy
NVBDCP : National Vector-Borne Disease Control Programme
ORS : Oral Rehydration Solution
P/V : Per Vaginum
PHC : Primary Health Centre
PIH : Pregnancy-Induced Hypertension
PIP : Programme Implementation Plan
PNC : Postnatal Check-Up
PNDT : Pre-Natal Diagnostic Technique
POC : Products of Conception
PPH : Post-partum Haemorrhage
PPTCT : Prevention of Parent-to-Child Transmission
PRI : Panchayati Raj Institution
PROM : Premature Rupture of Membranes
RCH : Reproductive and Child Health
RDK : Rapid Diagnostic Kit
RPR : Rapid Plasma Reagin
RR : Respiratory Rate
RTI : Reproductive Tract Infection
SBA : Skilled Birth Attendant
SC : Sub-Centre
SDM : Standard Days’ Method
SHG : Self-Help Group
SN : Staff Nurse
STI : Sexually Transmitted Infection
TBA : Traditional Birth Attendant
TT : Tetanus Toxoid
UT : Union Territory
UTI : Urinary Tract Infection
VDRL : Venereal Disease Research Laboratory
VHND : Village Health and Nutrition Day
GUIDELINES
xii
Introduction
Pregnancy and childbirth are normal events in the life of a woman. Though most pregnancies
result in normal birth, it is estimated that about 15% may develop complications, which
cannot be predicted. Some of these may be life threatening for the mother and/or her baby.
The presence of skilled attendants is therefore, crucial for the early detection and also for
appropriate and timely management of such complications. The Government of India (GoI)
has a commitment under its National Rural Health Mission (NRHM)/Reproductive and
Child Health (RCH)-II programme to ensure universal coverage of all births with skilled
attendance, both at the institutional and at the community level and to provide access to
emergency obstetric and neonatal care services for women and newborns, and thereby
restrict the number of maternal and newborn deaths in the country.
Maternal death is defined as the death of a woman while pregnant or within 42 days of the
termination of pregnancy (delivery or abortion), irrespective of the duration and site of
pregnancy, from any cause related to or aggravated by pregnancy or its management, but
not due to accidents, trauma or incidental causes.
The Maternal Mortality Ratio (MMR), i.e. number of maternal deaths per 100,000 live
births in India is very high. According to the latest data given by the Registrar General of
India for the period 2004-2006, the MMR was estimated to be 254 per 100,000 live births.
Like elsewhere in the world, the five major direct obstetric causes of maternal mortality in
India are haemorrhage, puerperal sepsis, hypertensive disorders of pregnancy, obstructed
labour and unsafe abortions contributing to about 70% of maternal deaths in the country.
Maternal anaemia is a major contributor to the ‘indirect’ obstetric causes. While most of
these causes cannot be reliably predicted, early detection and timely management can save
most of these lives.
Women below the age of 18 years or above 40 years have greater chances of having pregnancy
related complications. Primigravidas and grand multiparas (those who have had four or
more pregnancies) are at a higher risk of developing complications during pregnancy and
labour. Research shows that women who have spaced their children less than 36 months
apart have greater chances of delivering premature and low birth weight babies, thereby
increasing risk of infant mortality. An interval of less than two years from the previous
pregnancy or less than three months from the previous abortion increases the chances of
the mother developing anaemia.
Since any pregnancy can develop complications at any stage, so timely provision of obstetric
care services is extremely important for management of such cases and as such, every
pregnancy needs to be cared for by a Skilled Birth Attendant (SBA) during pregnancy,
childbirth and the post-partum period. GoI considers an SBA to be a person who can handle
common obstetric and neonatal emergencies and is able to timely detect and recognise when
a situation reaches a point beyond his/her capability, and refers the woman/newborn to an
appropriate facility without delay.
GUIDELINES
1
Introduction
To be called an SBA, the health workers (Auxiliary Nurse Midwives (ANMs), Lady Health
Visitors (LHVs) and Staff Nurses (SNs)) must possess technical competence related to
routine care provision including identification and immediate management of complications
arising during pregnancy and childbirth.
In India, 52.3% of births take place at home and of these, just 5.7% of births are attended by
a skilled person (District Level Household and Facility Survey [DLHS]-3, 2007–08). These
figures highlight that a high proportion of births in the country are still being undertaken by
an unskilled person and as such, contribute to large number of maternal deaths. Therefore,
the presence of an SBA at every delivery, along with the availability of an effective referral
system, can help reduce maternal morbidity and mortality to a considerable extent. Past
experiences with Traditional Birth Attendants (TBAs) have indicated that TBAs were
not able to identify and manage complications during pregnancy and child birth despite
repeated trainings, therefore, GoI does not consider TBAs as SBAs.
What can be done to combat maternal deaths?
Most of the maternal deaths are linked with three types of delays which can result in an
increase in maternal morbidity and mortality. They are:
Delay 1: Delay in recognising the problem (lack of awareness of danger signs) and deciding
to seek care (due to inaccessible health facility, lack of resources to pay for services/supplies
and medicines)
Delay 2: Delay in reaching the health facility (due to unavailability of transport, lack of
awareness of appropriate referral facility)
Delay 3: Delay in receiving treatment once a woman has arrived at the health facility (due
to inadequately equipped health facility, lack of trained personnel, emergency medicines,
blood, etc.)
Sensitising the community and family for right decision at right time and timely referral
through pre-identified transport can address the first two delays and would help women
access the services available as and when required. Simultaneously, the health workers need
to be technically competent and facility adequately equipped to provide services/care to the
woman reaching the health facilities. This would help in ensuring the provision of skilled
attendance to all women during pregnancy and childbirth.
The ANM has an important role to play in reducing the MMR by fulfilling the role
of a SBA: providing comprehensive Antenatal Care (ANC) and Postnatal Care (PNC);
identifying complications in a timely manner, and referring women with complications
after basic management to a higher centre for further management.
GUIDELINES
2
Another major step in this direction is the GoI policy initiative to empower the ANM,
LHV, SN and Multipurpose Health Worker – Female (MPHW-F) for undertaking certain
life saving measures to make them competent (Annexure ix). These measures are as
follows:
To undertake Active Management of Third Stage of Labour (AMTSL).
To use uterotonic drugs for the prevention of Post-Partum Haemorrhage (PPH).
To use drugs in emergency situations to stabilise the patient prior to referral.
To perform basic procedures in emergency situations.
This guideline is a tool for empowering ANMs, LHVs, SNs or for any other paramedical
health worker engaged in providing maternal care during pregnancy, childbirth and
thereafter. It has been prepared keeping in mind that these workers would be providing care
at the level of the Sub-Centres (SCs) or in a domiciliary setting. However, ANMs/LHVs/
SNs can also use the guideline while working at the Primary Health Centre (PHC) or any
other health care facility. Medical Officers (MOs) and LHVs may follow this while providing
supportive supervision to SBAs at the SCs and PHCs.
The guideline incorporates evidence-based best practices for the provision of skilled care by
providers during pregnancy, at birth and in post-partum period. It is hoped that this will serve
as reading material during SBA training in the RCH-II programme under the NRHM.
Infrastructure and programmatic support must be in place to enable health personnel

adhere to the recommended guidelines for the delivery of services. Necessary efforts to
ensure availability of equipment, drugs and supplies for the corresponding interventions
must be made by concerned persons. Programme managers and supervisors should monitor
the implementation of these guidelines during their routine supervisory visits. Adequate
budgeting for these activities should be reflected in the Programme Implementation Plan
(PIP) of the state.
This training module can also be used by Non-Governmental Organisations (NGOs) and
private sector health facilities engaged in the delivery of services.
GUIDELINES
3
Introduction
Module I
Management of Normal
Pregnancy, Labour and
the Post-partum Period
Care During Pregnancy—Antenatal Care
KEY MESSAGES
• Register every pregnancy within 12 weeks.
• Track every pregnancy by name for provision of quality ANC, skilled
birth attendance and postnatal services.
• Ensure four antenatal visits to monitor the progress of pregnancy.
This includes the registration and 1st ANC in the first trimester.
• Give every pregnant woman Tetanus Toxoid (TT) injections and
Iron Folic Acid (IFA) supplementation.
• Test the blood for haemoglobin, urine for sugar and protein at
EVERY VISIT.
• Record blood pressure and weight at EVERY VISIT.
• Advise and encourage the woman to opt for institutional delivery.
• Maintain proper records for better case management and follow up.
• Do not give a pregnant woman any medication during the first
trimester unless advised by a physician.
Antenatal care
Antenatal care is the systemic supervision of women during pregnancy to monitor the
progress of foetal growth and to ascertain the well-being of the mother and the foetus. A
proper antenatal check-up provides necessary care to the mother and helps identify any
complications of pregnancy such as anaemia, pre-eclampsia and hypertension etc. in the
mother and slow/inadequate growth of the foetus. Antenatal care allows for the timely
management of complications through referral to an appropriate facility for further
treatment. It also provides opportunity to prepare a birth plan and identify the facility for
delivery and referral in case of complications. As provider of ante natal care, you are involved
in ensuring a healthy outcome both for the mother and her baby.
However, one must realise that even with the most effective screening tools, one cannot
predict which woman will develop pregnancy-related complications during and immediately
after child birth. You must therefore:
Recognise that ‘Every pregnancy is special and every pregnant woman must receive
special care’.
Complications being unpredictable may happen in any pregnancy/child birth and we
should be ready to deal with them if and whenever they happen.
Ensure that ANC is used as an opportunity to detect and treat existing problems, e.g.
essential hypertension.
Prepare the woman and her family for the eventuality of an emergency.
Make sure that services to manage obstetric emergencies are available on time.
MODULE
7
Management of Normal Pregnancy, Labour and the Post-partum Period
I
Quality ANC has several components, which are described below.
A. A few primary steps:

Ensure early registration and see to it that the first check-up is conducted within 12
weeks (first three months of pregnancy).
Track every pregnancy for conducting at least four antenatal check-ups (including the
first visit for registration), keeping in mind all the essential components listed under
section B.
Administer two doses of TT injection.
Provide at least 100 tablets of IFA.
B. Essential components of every antenatal check-up:

Take the patient’s history.
Conduct a physical examination–measure the weight, blood pressure and respiratory
rate and check for pallor and oedema.
Conduct abdominal palpation for foetal growth, foetal lie and auscultation of Foetal
Heart Sound (FHS) according to the stage of pregnancy.
Carry out laboratory investigations, such as haemoglobin estimation and urine tests (for
sugar and proteins).
C. Desirable components
Determine the blood group, including the Rh factor.
Conduct the Venereal Disease Research Laboratory (VDRL)/Rapid Plasma Reagin
(RPR) test to rule out syphilis.
Test the woman for Human Immuno deficiency Virus (HIV*).
Check the blood sugar.
Carry out the Hepatitis B Surface Antigen (HBsAg) test.
D. Counselling
Help the woman to plan and prepare for birth (birth preparedness/micro birth plan).
This should include deciding on the place of delivery and the presence of an attendant
at the time of the delivery.
Advantages of institutional deliveries and risks involved in home deliveries.
Advise the woman on where to go if an emergency arises, and how to arrange for
transportation, money and blood donors in case of an emergency.
Educate the woman and her family members on signs of labour and danger signs of
obstetric complications.
Emphasise the importance of seeking ANC and PNC.
Advise on diet (nutrition) and rest.
Inform the woman about breastfeeding, including exclusive breastfeeding.
Provide information on sex during pregnancy.
Warn against domestic violence (explain the consequences of violence on a pregnant
woman and her foetus).
Promote family planning.
Inform the woman about the Janani Suraksha Yojana (JSY)/any other incentives offered
by the state.
GUIDELINES
8
*Tie up with the nearest Integrated Counselling and Testing Centre (ICTC)/Prevention of
Parent-to-Child Transmission (PPTCT) facility for counselling and testing for HIV.
Early registration
Timing of the first visit/registration
The first visit or registration of a pregnant woman for ANC should take place as soon as the
pregnancy is suspected. Every woman in the reproductive age group should be encouraged
to visit her health provider if she believes she is pregnant. Ideally, the first visit should
take place within 12 weeks. However, even if a woman comes for registration later in her
pregnancy, she should be registered and care should be provided to her according to the
gestational age. Her husband and mother-in-law should be counselled to give her support
during pregnancy, delivery, after an abortion and during the post-partum period.
Early detection of pregnancy is important for the following reasons:

It facilitates proper planning and allows for adequate care to be provided during
pregnancy for both the mother and the foetus.
Record the date of the Last Menstrual Period (LMP), and calculate the Expected Date of
Delivery (EDD).
The health status of the mother can be assessed and any medical illness that she might be
suffering from can be detected and also to obtain/record baseline information (on blood
pressure, weight, haemoglobin, etc.)
Helps in timely detection of complications at an early stage and manage them
appropriately by referral as and where required.
This also helps in providing the woman the option of an early abortion. If so,then refer
the woman at the earliest to a 24-hour PHC or First Referral Unit (FRU) (whichever is
closer) that provides safe abortion services. It is important to find out as early as possible
whether the woman wants to go in for an abortion so that the procedure can be done
safely as per the legal provisions laid down under the Medical Termination of Pregnancy
(MTP) Act, 1972.
Remember
Before referring the woman for the abortion, make sure that the closest 24-hour PHC
provides safe abortion services.
Manual Vacuum Aspiration (MVA) is a safe and simple technique for termination of
early pregnancy and is available at 24 x 7 PHCs (upto 8 weeks) and other higher facilities
(upto 12 weeks) for safe abortion.
Be alert to the possibility of pregnant women undergoing pre natal sex determination.
Diagnosis of sex of foetus is illegal under the provisions of PC-PNDT Act.
However, as per the MTP Act, abortions are legal for up to 20 weeks of pregnancy, though
they can be conducted only under certain circumstances (which exclude sex selection).
If a pregnancy is detected early and the woman is provided care from the initial stage, it
facilitates a good interpersonal relationship between you and her. She will thus, be more
likely to express her particular needs and wants while planning for the delivery.
MODULE
9
I
All women in the reproductive age group should be advised to have folic acid for 2–3
months pre-conception and continue with it during the first 12 weeks of pregnancy.
This remarkably reduces the incidence of neural tube defects in the foetus. A daily
dose of 400 μg folic acid taken orally is the recommended daily dose.
Low iodine levels during pregnancy can cause cretinism, which can lead to mental/
physical retardation of the baby. So regular consumption of iodated salts is advised, as
a prophylactic measures.
Detection of pregnancy
The simplest way for you to confirm pregnancy in the first trimester is to conduct a urine
examination using a pregnancy test kit. The pregnancy test should be offered to any woman
in the reproductive age group who comes to you with a history of amenorrhoea or symptoms
of pregnancy.
The GoI has made the ‘Nischay’ pregnancy test kit available across the country. Other test kits
are also available in the market. These kits detect pregnancy on the basis of the presence of
Human Chorionic Gonadotrophin (hCG) hormone in the urine. This test can be performed
soon after a missed period and is simple to perform. It requires just five minutes and two
drops of the woman’s urine. Pregnancy test kits have also been provided to Accredited Social
Health Activists (ASHAs)/link workers in your area, and they might use the kits during
their community visits. Ensure that the kits are available to them and they report positive
results to you. The woman should be counselled appropriately on the results of the test.
(Practice the steps of Detection of Pregnancy using a Pregnancy Test Kit - Checklist No: 1.4 in the
SBA Handbook)
Number and timing of visits

Ensure that every pregnant woman makes at least four visits for ANC, including the first
visit/registration. It should be emphasised that this is only a minimum requirement and
that more visits may be necessary, depending on the woman's condition and needs.
Suggested schedule for antenatal visits
1st visit: Within 12 weeks—preferably as soon as pregnancy is suspected—for
registration of pregnancy and first antenatal check-up
2nd visit: Between 14 and 26 weeks
3rd visit: Between 28 and 34 weeks
4th visit: Between 36 weeks and term
It is advisable for the pregnant woman to visit the MO at the PHC for an antenatal check-
up during the period of 28–34 weeks (third visit). Besides this, she may also be advised and
guided to avail investigation facilities, which are not available with you like Blood Grouping
etc. at the nearest PHC/CHC/FRU.
Seek help for early registration and antenatal check-up

Registering every pregnancy within 12 weeks is primarily the responsibility of the
ANM. Opportunities such as the Village Health and Nutrition Day (VHND) should be
optimally utilised for ensuring early registration and antenatal check-ups.
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You can take the help of various people who are likely to be aware of the pregnant women
in the village and will help in updating your list. These include ASHAs, Anganwadi Workers
(AWWs) as well as various community-based functionaries, such as members of Mahila
Mandals, Self-Help Groups (SHGs), NGOs, panchayat and village health committees.
School teachers and other important people in the village could also be in the know.
Estimate the number of pregnancies in your area

To ensure complete registration, it is essential that you know the estimated number of
pregnancies to be registered annually in your area.
Calculating the expected number of annual pregnancies in your area will help you judge
how good your pregnancy registration is. In case the number of pregnancies registered
is less than that of the estimated pregnancies, you need to track down the pregnancies
you have missed with the help of ASHAs and AWWs.
Estimating the number of pregnancies will also help you judge whether you have an
adequate stock of the supplies required to provide routine ANC (such as TT injections, IFA
tablets and ANC record forms) and tackle any complications that arise during this period.
The following steps may be followed to calculate the expected number of pregnancies annually:
You must know the birth rate and population size of the area under your jurisdiction.
The birth rate of your area can be obtained from the MO at the PHC or you can consult
the available district/state/national figures. It is advisable to use the available local figures
for the birth rate for correct estimation.
To know the exact population of the area under your jurisdiction, use the latest
demographic data/census reports.
The expected number of live births may be calculated as shown in Box 1.
Box 1: Total number of expected pregnancies/year
Expected number of live births (Y)/year:
Birth rate (per 1000 population) X population of the area

1000
As some pregnancies may not result in a live birth (i.e. abortions and stillbirths may
occur), the expected number of live births would be an under-estimation of the total
number of pregnancies. Hence, a correction factor of 10% is required, i.e. add 10% to the
figure obtained above.
So, the total number of expected pregnancies (Z)=

Y + 10% of Y
As a thumb rule, in any given month, approximately half the

number of pregnancies estimated above should be in your records.
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Box 2: Estimation of the number of pregnancies annually
Birth rate = 25/1000 population

Population under the SC = 5000
Therefore, expected number of live births = (25 X 5000)/1000
= 125 births
Correction factor
(pregnancy wastage) = 10% of 125 (i.e. [10/100] X 125)
= 13
Therefore, total no. of expected pregnancies in a year = 125 + 13 = 138
In any month, the ANM should have about 69 pregnancies registered with her.
If the number of women registered with you is less than expected, then you should
approach community leaders and key people mentioned earlier, in order to ensure that
more pregnant women are registered and come for ANC. The matter should also be
communicated to the ASHA/link worker so that she can visit every house in the area
and ensure that all pregnant women are registered.
Some women may be receiving ANC from the private sector. Ensure that their names
together with the names of the facilities where they are registered are mentioned in your
antenatal register.
Keep a track of all pregnant women by name

As the ANM, you must refer to your register to keep track of all pregnant women in
your area. In case a woman who is registered with you does not return for her antenatal
check-up, then she must be followed up at her home and counselled to go for regular
antenatal check-ups.
An antenatal check-up after a missed appointment should include all the components
of the missed visit(s) as well as those that correspond to the present visit. For example,
the woman should be given her TT injection and supply of IFA tablets, her weight and
blood pressure should be checked and recorded and she should be counselled besides
being screened for complications.
It is very likely that women might not come for ANC early in their pregnancy. You
should take the help of the AWWs, ASHAs, panchayat members and so on to track
pregnant women who have not come for their antenatal check-ups.
Once such women have been tracked down, arrangements should be made to give them
ANC as soon as possible. These women should also be counselled on the importance of
complete ANC for the better health of the baby and the mother.
A policy decision has been taken for a name-based tracking system whereby pregnant
women and children can be tracked for their ANCs and immunisation along with a
feedback system for the ANM, ASHA etc. This has been done to ensure that all pregnant
women receive their ANCs and PNCs and children receive full immunisation. This will
also help in tracking and ensuring ANC/PNC for missed/left out cases.
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Record keeping
For the purpose of record keeping, the following must be done:
A Mother and Child Protection Card should be duly completed for every woman
registered by you. The case record should be handed over to the woman. She should
be instructed to bring the record with her during all subsequent check-ups/visits and
also to carry it along with her at the time of delivery. (Annexure l –Mother and Child
Protection Card).
This card has been developed jointly by the Ministry of Health and Family Welfare
(MoHFW) and Ministry of Women and Child Development (MoWCD) to ensure
uniformity in record keeping. This will also help the service provider to know the details
of previous ANCs/PNCs both for routine and emergency care.
The information contained in the card should also be recorded in your antenatal register
as per the Health Management Information System (HMIS) format.
Antenatal check-up
Preparing for and conducting antenatal check-ups
Before beginning each antenatal check-up at your SC or during the VHND, ensure that
all the required instruments and equipment are available and are in working condition.
These include a stethoscope, blood pressure apparatus, weighing scale, inch tape,
foetoscope, thermometer, Mother and Child Protection Card and register, watch, gloves,
0.5% chlorine solution, syringes and needles, hub cutter, spirit swabs, IFA tablets, TT
injections, and equipment for testing haemoglobin and urine.
You must greet every pregnant woman in a friendly manner at each visit.
Listen to the woman's problems and concerns, and counsel her and her relatives.
Remember, all women need social/psychological support during pregnancy.
The antenatal examination should be carried out at an appropriate place where there is
enough privacy for conducting abdominal palpation.
All findings must be accurately recorded.
Components of Antenatal Check-up

I. History-taking
During the first visit, a detailed history of the woman needs to be taken to:
(i) Confirm the pregnancy (first visit only).
(ii) Identify whether there were complications during any previous pregnancy/confinement
that may have a bearing on the present one.
(iii) Identify any current medical/surgical or obstetric condition(s) that may complicate
the present pregnancy.
While taking the history, please find and record the following information from the pregnant
woman:
Menstrual history to calculate the EDD

It is important to record the date of the LMP during the first visit as this helps to calculate
the EDD and prepare a birth plan.
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Remember that the LMP refers to the FIRST day of the woman’s last menstrual period.
Make sure that the woman is not referring to the date of the first missed period, i.e. the
date when menstruation was expected to occur the following month and failed to occur.
This mistake will lead to a miscalculation of the gestational age and EDD by about four
weeks.
If the woman is unable to remember the exact date, encourage her to remember some
major event, festival or occurrence which she might link with her LMP. A calendar with
the Indian system of months and local festivals might come in handy while determining
the LMP.
If the exact date of the LMP is not known and it is late in the pregnancy, ask for the
date when the foetal movements were first felt. This is known as ‘quickening’ and is felt
at around 20 weeks of gestation. This information would give a rough idea about the
period of gestation, which needs to be correlated with the fundal height to estimate the
gestational age. Calculate the EDD on this basis. A special note should be made of such
cases in the records.
If the woman is not able to recollect any of the above things, encourage her to mention
what she believes is her current month of pregnancy. For example, if a woman has come
to the ANC clinic on 20 September and says that she completed eight months of her
pregnancy 10 days ago, it becomes clear that she will be completing her ninth month on
10 October and her EDD (9 months plus 7 days) is 17 October.
If the woman has undergone a test to confirm the pregnancy, ask her the approximate
date of the test and also, after how many days of amenorrhoea it was conducted. This
will also assist you in estimating her LMP.
The LMP is used to calculate the gestational age at the time of check-up and the EDD.
The following formula is used to calculate the EDD. It is based on the assumption that
the menstrual cycle of the woman was regular before conception and that it was a 28–30
days’ cycle.
EDD = Date of LMP + 9 months + 7 days
Symptoms during pregnancy

You must ask the woman about the symptoms that might be causing her some discomfort.
Symptoms can be normal for any pregnancy or it can indicate a complication which needs
immediate attention. Ask her about the following symptoms:
Box 3: Symptoms indicating discomfort
Nausea and vomiting

Heartburn
Constipation
Increased frequency of urination
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Box 4: Symptoms indicating complications
Fever
Persistent vomiting
Abnormal vaginal discharge/itching
Palpitations, easy fatigability
Breathlessness at rest/on mild exertion
Generalised swelling of the body, puffiness of the face
Severe headache and blurring of vision
Passing smaller amounts of urine and burning sensation during micturition
Vaginal bleeding
Decreased or absent foetal movement
Leaking of watery fluid per vaginum (P/V)
Note: In case the symptoms mentioned in Boxes 3 and 4 are present, refer to Table 2 at the end of
this chapter.
Obstetric history/history of previous pregnancies

It is essential to ask a woman about her previous pregnancies or obstetric history. This
is important especially if she had any complications in previous pregnancies, as some
complications may recur during the present pregnancy. Be particular about asking for
records to validate the history given of the previous pregnancy.
Obstetric history
The following information must be obtained while taking the obstetric history:
Ask about the number of previous pregnancies. Confirm whether they were all live
births, and if there was any stillbirth, abortion or any child who died.
Ascertain the date and outcome of each event, along with the birth weight, if known. It is
especially important to know about the last pregnancy. Find out if there was any adverse
perinatal (period between 7 days before birth and 28 days after birth) outcome.
Obtain information about any obstetric complications and events in the previous
pregnancies (specify which pregnancy). The complications and events to be inquired
about are as follows:
Recurrent early abortion
Post-abortion complications
Hypertension, pre-eclampsia or eclampsia
Ante-Partum Haemorrhage (APH)
Breech or transverse presentation
Obstructed labour, including dystocia
Perineal injuries/tears
Excessive bleeding after delivery
Puerperal sepsis.
Ascertain whether the woman has had any obstetrical operations (caesarean sections/
instrumental delivery/vaginal or breech delivery/manual removal of the placenta).
Ask for a history of blood transfusions.
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A bad obstetric history (as detailed in Box 5) is an indication for referral to a higher health
facility, where further antenatal check-ups and the delivery can be conducted.
Box 5: Indications for referral to the 24-hour PHC for ANC and delivery as per the
previous obstetric history
Stillbirth or neonatal loss

Three or more spontaneous consecutive abortions
Obstructed labour
Premature births, twins or multiple pregnancies
Weight of the previous baby <2500 g or >4500 g
Admission for hypertension or pre-eclampsia/eclampsia in the previous pregnancy
Surgery on the reproductive tract
Congenital anomaly
Treatment for infertility
Spinal deformities, such as scoliosis/kyphosis/polio
Rh negative in the previous pregnancy
History of any current systemic illness(es)/past history of illness

Find out whether the woman has or is suffering from any of the following:
High blood pressure (hypertension)
Diabetes
Breathlessness on exertion, palpitations (heart disease)
Chronic cough, blood in the sputum, prolonged fever (tuberculosis)
Renal disease
Convulsions (epilepsy)
Attacks of breathlessness or asthma
Jaundice
Malaria
Other illnesses, e.g. Reproductive Tract Infection (RTI), Sexually Transmitted Infection
(STI) and HIV/AIDS.
Family history of systemic illness

Once you have ruled out the presence of any systemic illness, ask the woman whether
there is a family history of hypertension, diabetes or tuberculosis. If present, such a history
predisposes the woman to developing these problems during pregnancy (e.g. hypertensive
disorders of pregnancy and gestational diabetes). As pregnancy is a physiologically stressful
period, it can unmask the underlying tendency to develop these disorders.
In addition, ask whether there is a family history of thalassaemia or whether anybody in the
family has received repeated blood transfusions. You must also ask if anybody in the family
has had twins and/or given birth to an infant with congenital malformation, as the presence
of such a history in the family increases the chances of the woman giving birth to a child
with the same condition.
History of drug intake or allergies

It is important to find out if the woman is allergic to any drug, or if she is taking any drug
GUIDELINES
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that might be harmful to the foetus. Find out whether she has taken any treatment or drugs
for infertility. If so, she has a higher chance of having twins or multiple pregnancies.
History of intake of habit-forming or harmful substances

Ask the woman if she chews or smokes tobacco and/or if she takes alcohol. If so,she needs to
be counselled to discontinue the use of these substances during pregnancy, as they harm the
developing foetus. The woman should be advised to continue to abstain from taking alcohol
and using tobacco even after the delivery because it may cause other problems/complications,
such as addiction and/or cancer. Further, passive smoking can harm the foetus.
(Practise history-taking during antenatal check-up - Checklist No1.1 in SBA Handbook)
II. Physical examination

This activity will be nearly the same during all the visits. The initial readings may be taken
as a baseline with which the later readings are to be compared.
A. General examination
Pallor
The presence of pallor indicates anaemia. The woman should be examined for pallor at each
visit. For this, one needs to examine the woman’s conjunctiva, nails, tongue, oral mucosa
and palms. Increasing pallor should be co-related with Hb estimation and would require
investigation or referral to the MO.
Estimate the woman’s haemoglobin using a haemoglobinometer.
Jaundice
Jaundice is a yellowish staining of the skin and sclera (the whites of the eyes), caused by
high levels of the chemical bilirubin in the blood. Jaundice is not a disease, but a sign
that can occur in many different diseases.
Look for yellowish discolouration of the skin and sclera. The colour of the skin and sclera
vary depending on the level of bilirubin. When the bilirubin level is mildly elevated,
they are yellowish. When the bilirubin level is high, they tend to be brown.
Approximately 3%–5% of pregnant women have abnormal liver function tests and
however, jaundice in pregnancy is relatively rare but has potentially serious consequences
for maternal and foetal health.
Pulse
The normal pulse rate is 60–90 beats per minute. If the pulse rate is persistently high or low,
with or without other symptoms, the woman requires medical attention at the PHC/FRU.
Respiratory rate
It is important to check the Respiratory Rate (RR), especially if the woman complains of
breathlessness. Normal respiratory rate is 18-20 breathes per minute. If the RR is above
30 breaths per minute and pallor is present, it indicates that the woman may have severe
anaemia, heart disease or associated medical problems. She must be immediately referred to
the MO for further investigation and management of any illness that may be present.
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Oedema
Oedema (swelling), which appears in the evening and disappears in the morning after a
full night’s sleep, could be a normal manifestation of pregnancy.
Any oedema of the face, hands, abdominal wall and vulva is abnormal. Oedema can be
suspected if a woman complains of abnormal tightening of any rings on her fingers. She
must be referred immediately for further investigations.
If there is oedema in association with high blood pressure, heart disease, anaemia or
proteinuria, the woman should be referred to the MO.
Non-pitting oedema indicates hypothyroidism or filariasis and requires immediate
referral for investigations.
Blood pressure
Measure the woman’s blood pressure at every visit. This is important to rule out
hypertensive disorders of pregnancy.
Hypertension is diagnosed when two consecutive readings taken four hours or more
apart show the systolic blood pressure to be 140 mmHg or more and/or the diastolic
blood pressure to be 90 mmHg or more.
High blood pressure during pregnancy may signify Pregnancy-Induced Hypertension
(PIH) and/or chronic hypertension.
If the woman has high blood pressure, check her urine for the presence of albumin. The
presence of albumin (+2) together with high blood pressure is sufficient to categorise
her as having pre-eclampsia. Refer her to the MO immediately.
If the diastolic blood pressure of the woman is above 110 mmHg, it is a danger sign
that points towards imminent eclampsia. The urine albumin should be estimated
at the earliest. If it is strongly positive, the woman should be referred to the FRU
IMMEDIATELY.
If the woman has high blood pressure but no urine albumin, she should be referred to
the MO at 24 hours PHC.
A woman with PIH, pre-eclampsia or imminent eclampsia requires hospitalisation and
supervised treatment at a 24-hour PHC/FRU.
Weight
A pregnant woman's weight should be taken at each visit. The weight taken during the
first visit/registration should be treated as the baseline weight. As you might find it
difficult to carry the weighing scale provided to you when you go to conduct ANC at the
village level, it is advisable that you borrow the AWW’s weighing machine, making sure
that it works properly.
Normally, a woman should gain 9–11 kg during her pregnancy. Ideally after the first
trimester, a pregnant woman gains around 2 kg every month.
If the diet is not adequate, i.e. if the woman is taking less than the required amount of
calories, she might gain only 5–6 kg during her pregnancy. An inadequate dietary intake
can be suspected if the woman gains less than 2 kg per month. She needs to be put on food
supplementation. You should take the help of the AWW in this matter, especially for those
categories of women who need it the most. Low weight gain usually leads to Intrauterine
Growth Retardation (IUGR) and results in the birth of a baby with a low birth weight.
Excessive weight gain (more than 3 kg in a month) should raise suspicion of pre-
eclampsia, twins (multiple pregnancy) or diabetes. Take the woman's blood pressure
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and test her urine for proteinuria or sugar. If her blood pressure is high, i.e. more than
140/90 mmHg, and her urine has proteins or sugar, refer her to the MO at the PHC.
Breast examination
Observe the size and shape of the nipples for the presence of inverted or flat nipples.
Try and pull out the nipples to see if they can be pulled out easily. Flat nipples that can
be pulled out do not interfere with breastfeeding. Truly inverted nipples might create a
problem in breastfeeding. If the nipples are inverted, the woman must be advised to pull
on them and roll them between the thumb and index finger.
A 10 cc or 20 cc disposable plastic syringe can also be used for correcting inverted
nipples. Cut the barrel of the syringe from the end where the needle is attached. Take out
the plunger and put it in from the opposite end, which is the cut end of the syringe. Push
the piston forward fully, and gently place the open end of the barrel in such a way that
it encircles the nipple and areola. Pull back the plunger, thus creating negative pressure.
The nipple will be sucked into the barrel and pulled out in the process.
Figure 1: Correcting an inverted nipple using a syringe
STEP ONE
Cut the end of a plastic syringe
STEP TWO
Insert piston from cut end
STEP THREE
Mother gently pulls

the piston
Look for crusting and soreness of the nipples. If these are present, the woman must be
advised on breast hygiene and the use of emollients such as milk cream.
The breasts must be palpated for any lumps or tenderness. If there are lumps or
tenderness, refer the woman to the MO.
(Practise conducting general examination: pallor, pulse; respiratory rate; oedema; BP; weight;
jaundice and breast examination – Checklist No 1.2 in SBA Handbook)
B. Abdominal examination
Examine the abdomen to monitor the progress of the pregnancy and foetal well-being and
growth. The abdominal examination includes the following:
1. Measurement of fundal height
2. Determination of foetal lie and presentation by fundal palpation, lateral palpation and
pelvic grips
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3. Auscultation of the FHS
4. Inspection of scars/any other relevant abdominal findings.
Preparation for abdominal examination

Ask the woman to empty her bladder (give her a clean bottle to collect a sample of urine
for testing) immediately before proceeding with the abdominal examination. This is
important as even a half-full bladder might result in an increase in the fundal height.
Ask the woman to lie on her back with the upper part of her body supported by cushions.
Never make a pregnant woman lie flat on her back, as the heavy uterus may compress
the main blood vessels returning to the heart and cause fainting (supine hypotension).
Ask her to partially flex her hips and knees.
Stand on the woman’s right side to examine her in a systematic manner.
You may divert the woman’s attention with conversation.
Your hand must be warm and should be placed on the abdomen till the uterus is relaxed
before you begin palpation. Poking the abdomen with the fingertips should be avoided
at all costs.
Maintain privacy throughout the examination.
Fundal height
This indicates the progress of the pregnancy and foetal growth. The uterus becomes an
abdominal organ after 12 weeks of gestation. The gestational age (in weeks) corresponds
to the fundal height (in cm) after 24 weeks of gestation. Remember that while measuring
the fundal height, the woman’s legs should be kept straight and not flexed.
The normal fundal height is different at different weeks of pregnancy. To estimate the
gestational age through the fundal height, the abdomen is divided into parts by imaginary
lines. The most important line is the one passing through the umbilicus. Then divide the
lower abdomen (below the umbilicus) into three parts, with two equidistant lines between
the symphysis pubis and the umbilicus. Similarly, divide the upper abdomen into three parts,
again with two imaginary equidistant lines, between the umbilicus and the xiphisternum.
See where the fundus of the uterus is and judge according to the indicators given below:
Figure 2: Measurement of Fundal Height
At 12th week Just palpable above the symphysis pubis
th
At 16 week At lower one-third of the distance between
the symphysis pubis and umbilicus
At 20th week At two-thirds of the distance between the
symphysis pubis and umbilicus
At 24th week At the level of the umbilicus
th
At 28 week At lower one-third of the distance between
the umbilicus and xiphisternum
At 32nd week At two-thirds of the distance between the
umbilicus and xiphisternum
At 36th week At the level of the xiphisternum
th
At 40 week Sinks back to the level of the 32nd week,
but the flanks are full, unlike that in the
32nd week
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If there is any disparity between the fundal height and the gestational age as calculated from
the LMP or if there is a difference of 3 cm or more or if there is no growth compared to
the previous check-up, then it should be considered significant. Such cases require further
investigation and should be referred to the MO.
If the height of the uterus is more or less than that indicated by the period of amenorrhea,
the possible reasons could be as follows:
Height of the uterus more than that indicated by the period of amenorrhea
Wrong date of LMP
Full bladder
Multiple pregnancy/large baby
Polyhydramnios
Hydrocephalus
Hydatidiform mole
Height of the uterus less than that indicated by the period of amenorrhea
Wrong date of LMP
IUGR
Missed abortion
Intrauterine Death (IUD)
Transverse lie
Foetal lie and presentation

Determining the foetal lie and presentation is relevant only in late pregnancy (32 weeks
onwards). Before that, it is important to only palpate the foetal parts while conducting an
abdominal examination.
The normal lie at term in the majority of pregnancies is longitudinal, with a cephalic
presentation. Any other lie is abnormal and the woman must be referred to an FRU for the
delivery.
Palpation to determine foetal lie and presentation

The pelvic grips (four in number) are performed to determine the lie and the presenting
part of the foetus.
Palpate for the foetal lie and assess whether it is longitudinal, transverse or oblique.
Remember that even if a malpresentation is diagnosed before 36 weeks, no active
management or intervention is recommended at that point of time. Advise the woman
to go in for an institutional delivery.
All health workers should be able to recognise a transverse lie. Missing it can be
disastrous because there is no mechanism by which a woman with a transverse lie can
deliver normally, i.e. vaginally. The woman needs an elective caesarean section, i.e. she
must not go into labour. She should, therefore, be referred to an FRU where emergency
obstetric services and facilities for a caesarean section are available. Failure to perform a
timely caesarean section can lead to obstructed labour, rupture of the uterus and death
of the woman and the foetus.
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Figure 3: Foetal lie and Presentation
A. Fundal palpation/fundal grip B. Lateral palpation/lateral grip
This manoeuver helps determine the lie and presentation of This manoeuver is used to locate the foetal back.
the foetus.
C. First pelvic grip/superficial pelvic grip D. Second pelvic grip/deep pelvic grip
The third manoeuver must be performed gently. It helps to This manoeuver, in experienced hands, will be able to tell us
determine whether the head or the breech is present at the about the degree of flexion of the head.
pelvic brim. If the head cannot be moved, it indicates that
the head is engaged. In the case of a transverse lie, the third
grip will be empty.
Foetal heart sound and foetal heart rate

If the Foetal Heart Rate (FHR) is between 120 and 160 beats per minute, it is normal.
If it is less than 120 beats per minute or more than 160 beats per minute, the woman
should be referred to the MO.
Remember that the FHS cannot be heard through the abdomen with the help of a
stethoscope or foetoscope before 24 weeks of pregnancy. Hence, checking for the FHS
should start only when the gestational age is more than 24 weeks.
Figure 4: Location of FHS using foetoscope
(Note: ROA right occipitoanterior

LOA left occipitoanterior)
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Foetal movements
Foetal movements are a reliable sign of foetal well-being. Foetal movements, also called
‘quickening’, begin at around 18–22 weeks of pregnancy. They are felt earlier in a multigravida
and later in a primigravida. At every antenatal visit, the ANM should ask the pregnant woman
about the foetal movements. Decreased movements may be an indication of foetal distress.
Women in whom the foetal movements are decreased need to be referred to the FRU.
Although the pattern of foetal movement may change prior to labour due to reduced space,
foetal activity should continue throughout pregnancy and labour.
How to count foetal movements: Ask the woman to lie down in the left lateral position for
an hour, three times a day after meals. Count the number of foetal movements in each hour.
If the total number of movements in all three periods is less than 10, the woman should be
referred to the FRU.
Multiple pregnancy
This must be suspected if the following are detected on abdominal examination:
An unexpectedly large uterus for the estimated gestational age
Multiple foetal parts discernable on abdominal palpation.
If a multiple pregnancy is suspected, refer the woman to the MO in the PHC for confirmation
of the diagnosis and counsel her to have her delivery in an institution.
(Practise abdominal examination: determining fundal height; foetal lie and presentation;
counting foetal heart rate; examination for multiple pregnancy – Checklist No 1.3 in SBA
Handbook)
III. Laboratory investigations

The following laboratory investigations can be carried out at the facilities indicated below:
At the SC:
Pregnancy detection test
Haemoglobin estimation
Urine test to assess the presence of sugar and proteins
Rapid malaria test
At the PHC/CHC/FRU:
Blood group, including Rh factor
VDRL/RPR
HIV testing
Rapid malaria test (if unavailable at SC)
Blood sugar testing
HBsAg
Haemoglobin estimation
The initial haemoglobin level will serve as a baseline with which the later results, obtained
at the three subsequent antenatal visits, can be compared. Haemoglobin estimation can be
done at SCs or the outreach level by the Sahli method.
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A woman who has a haemoglobin level below 11 g/dl at any time during the pregnancy is
considered to be suffering from anaemia.
Box 6: Levels of Anaemia in Pregnancy

Haemoglobin level Degree of anaemia
> 11 g/dl Absence of anaemia
7–11 g/dl Moderate anaemia
Less than 7 g/dl Severe anaemia
If the woman is found to be anaemic, start her on a therapeutic dose of IFA [see below, under
‘IFA supplementation’]. Estimate the haemoglobin level again after one month. If it has not
increased, refer the woman to a higher facility with a good laboratory infrastructure and
trained personnel so that the cause of the anaemia can be determined and the requisite
treatment started.
Blood grouping and Rh factor

During the third antenatal visit, i.e. between 28 and 34 weeks, encourage the woman to
go to the PHC/FRU and get her blood group, including the Rh factor, tested. In case the
woman suffers from haemorrhage, knowledge regarding her blood group would come in
handy if blood transfusions have to be arranged, helping to save precious time and the
life of the woman. It also detects Rh negative pregnancies and appropriate management
can be initiated.
Testing the urine for the presence of protein (albumin)

This is a very important test used for the detection of pre-eclampsia, which (along with
eclampsia) is one of the five major causes of maternal mortality. This test is to be carried out
at the field level at every antenatal visit.
Testing the urine for the presence of sugar

This is a test used to diagnose women with gestational diabetes. This test is to be carried
out at the field level at every antenatal visit. If a woman's urine is positive for sugar, refer
her to the MO to get her blood sugar examined and a glucose tolerance test carried out,
if required.
(Practise steps of estimation of Hb; urine for protein and sugar – Checklist No. 1.4 in SBA
Handbook)
IV. Interventions
IFA supplementation
While talking to the pregnant woman, stress the need for increased intake of iron during
pregnancy and also if she is anaemic. This helps preventing the complications due to
anaemia. Besides recommending IFA supplementation, counsel the woman to increase
her dietary intake of iron-rich foods, such as green leafy vegetables, whole pulses,
jaggery, meat, poultry and fish. Ensure that you have adequate supplies of IFA in your
stock to meet the requirements of all pregnant women registered with you.
Prophylactic dose: All pregnant women need to be given one tablet of IFA (100 mg
elemental iron and 0.5 mg folic acid) every day for at least 100 days, starting after the
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24
first trimester, at 14–16 weeks of gestation. This is the dose of IFA given to prevent
anaemia (prophylactic dose). This dosage regimen is to be repeated for three months
post-partum.
Therapeutic dose: If a woman is anaemic (haemoglobin less than 11 g/dl) or has pallor,
she needs two IFA tablets per day for three months. This means that a pregnant woman
with anaemia needs to take at least 200 tablets of IFA. This is the dose of IFA needed
to correct anaemia (therapeutic dose). This dosage regimen is to be repeated for three
months post-partum in women with moderate to severe anaemia.
The haemoglobin should be estimated again after a month. If the level has increased,
continue with two tablets of IFA daily till it comes up to normal. If it does not rise in
spite of the administration of two tablets of IFA daily and dietary measures, refer the
woman to the MO at the PHC.
Women with severe anaemia (haemoglobin of less than 7 g/dl), or those who have
breathlessness and tachycardia (pulse rate of more than 100 beats per minute) due to
anaemia, should be started on the therapeutic dose of IFA and referred immediately to
the MO in the FRU for further management.
Counselling
Many women do not take IFA tablets regularly due to some common side-effects such
as nausea, constipation and black stools. Inform the woman that these side-effects are
common and not serious. Explain the necessity of taking IFA and the dangers associated
with anaemia. The woman should be counselled on the issues mentioned below:
IFA tablets must be taken regularly, preferably early in the morning on an empty
stomach. In case the woman has nausea and pain in the abdomen, she may take the
tablets after meals or at night. This will help avoid nausea.
Dispel the myths and misconceptions related to IFA and convince the woman about
the importance of IFA supplementation. An example of a common myth is that the
consumption of IFA may affect the baby’s complexion.
It is normal to pass black stools while consuming IFA. Tell the woman not to worry
about it.
In case of constipation, the woman should drink more water and add roughage to
her diet.
IFA tablets should not be consumed with tea, coffee, milk or calcium tablets as these
reduce the absorption of iron.
IFA tablets may make the woman feel less tired than before. However, despite feeling
better, she should not stop taking the tablets and must complete the course, as advised
by the health care provider.
Ask the woman to return to you if she has problems taking IFA tablets. Refer her to the
MO for further management.
Emphasise the importance of a high protein diet, including items such as black gram,
groundnuts, ragi, whole grains, milk, eggs, meat and nuts, for anaemic women.
Encourage the woman to take plenty of fruits and vegetables containing vitamin C
(e.g. mango, guava, orange and sweet lime), as these enhance the absorption of iron.
Administration of TT injection
The administration of two doses of TT injection is an important step in the prevention
of maternal and neonatal tetanus (tetanus of the newborn).
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The first dose of TT should be administered as soon as possible, preferably when the
woman registers for ANC.
The second dose is to be given one month after the first, preferably at least one month
before the EDD. If the woman skips one antenatal visit, give the injection whenever she
comes back for the next visit.
If the woman receives the first dose after 38 weeks of pregnancy, then the second dose
may be given in the postnatal period, after a gap of four weeks.
If the woman has been previously immunised with two doses during a previous
pregnancy within the past three years, then give her only one dose as early as possible in
this pregnancy.
The dosage of TT injection to be given is 0.5 ml. Tetanus toxoid to be administered
by deep intramuscular injection. It should be given in the upper arm, and not in the
buttocks as this might injure the sciatic nerve.
Inform the woman that there may be a slight swelling, pain and/or redness at the site of
the injection for a day or two.
Malaria prophylaxis and treatment

No prophylaxis is recommended, but insecticide-treated bed nets or Long-Lasting
Insecticidal Nets (LLIN) should be given on a priority basis to pregnant women in
malaria-endemic areas. These women should be counselled on how to use the LLINs.
Check with the MO of your PHC whether your area is malaria-endemic or not.
In non-endemic areas, all clinically suspected cases as per the National Vector-Borne
Disease Control Programme (NVBDCP) guidelines should preferably be investigated
for malaria with the help of microscopy or a Rapid Diagnostic Kit (RDK), if these are
available with you.
In high malaria-endemic areas, pregnant women should be routinely tested for malaria
at the first antenatal visit. Screen the woman for malaria every month by conducting
the rapid diagnostic test even if she does not manifest any symptoms of malaria. If a
pregnant woman shows symptoms of malaria at any time, she should be tested. If the
result is positive, refer her to the PHC for treatment.
V. Micro-birth Planning & Counselling

Micro-birth planning
The JSY is a centrally sponsored demand promotion scheme for promoting institutional
delivery among poor pregnant women. The scheme integrates cash assistance with delivery
and post-delivery care. The objective of the scheme is to reduce maternal and neonatal
mortality through institutional care. The details of the JSY are given in Annexure II. Micro-
birth planning is an integral part of the JSY.
Under the scheme, ANMs have to draw up a micro-birth plan or birth preparedness plan
for each pregnant woman in their area. It is necessary to draw up the micro-birth plan in
advance to prepare the pregnant woman and her family for any unforeseen complications
and to prevent maternal morbidity and mortality due to delays.
As a community worker, you have to help the ASHAs to bring pregnant women to you as early
as possible to ensure that a birth plan is prepared for each pregnant woman. This will help you
GUIDELINES
26
to track down these women for the provision of regular ANC, referral in case of emergency
and counselling to convince them to opt for institutional delivery. The Maternal and Child
Protection Card should be correctly and completely filled by you. Counsel the woman to bring
this card along at every visit.
Micro-birth planning has the following components:

1. Registration of pregnant woman and filling up of the Maternal and Child Protection
Card and JSY card/below poverty line (BPL) certificates/necessary proofs or
certificates for the purpose of keeping a record.
2. Informing the woman about the dates of antenatal visits, schedule for TT injections
and the EDD.
3. Identifying the place of delivery and the person who would conduct the delivery.
4. Identifying a referral facility and the mode of referral.
5. Taking the necessary steps to arrange for transport for the beneficiary.
6. Making sure that funds are available to the ANM/ASHA.
Counselling
A. Planning and preparing for birth (birth preparedness)
Details of the activities to be carried out while planning and preparing for birth are listed
below:
1. Registration of the pregnant woman: During the woman’s first antenatal visit, fill up
the Maternal and Child Protection Card and the antenatal register.
Inform her of the dates of her subsequent antenatal visits and emphasise the importance
of making all these visits in time.
2. Identification of a skilled provider for birth: Help all pregnant women to reach a
decision regarding the health care provider they want for conducting their delivery. An
SBA should be preferred over an unskilled birth attendant. (Note that TBAs, trained or
untrained, do not fall into the category of SBAs.) Other factors such as the condition of
the pregnant woman, her financial situation, the distance to the health care facility and
transport facilities, all need to be kept in mind before finally reaching a decision on the
choice of the SBA.
Institutional delivery
All pregnant women must be encouraged to opt for an institutional delivery.
Explain to the woman why delivery at a health facility is recommended and emphasise the
following:
Complications can develop at any time during pregnancy, during delivery or in the
postnatal period. These complications are not always predictable. If they are not handled
by professionals at the health facility, they can cost the mother and/or the baby their
life.
Since a health facility has staff, equipment, supplies and drugs, it can provide the best
care. It also has a referral system should the need for referral arise.
Home delivery
If in spite of all your efforts the pregnant woman decides to go for a home delivery, tell her
that there are situations when complications arise and a home delivery may be risky and
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potentially life-threatening. Disposable Delivery Kits (DDKs) are to be supplied to those
pregnant women in your community who insist on having a home delivery.
Explain the ‘six cleans’ to such women. These are clean surface, clean hands, clean cord
cut, clean cord tie, clean umbilical stump and clean perineum. Counsel and help them to
maintain the ‘six cleans’ during delivery at home.
You should keep a record of such women and continue counselling them during all their
subsequent antenatal visits to opt for an institutional delivery. You should prepare yourself
to attend to such women at their home during delivery. The pregnant woman, her family
members or the ASHA should call you (the ANM) to conduct the delivery at home.
The items required during and immediately after delivery at home include:
Presence of an ANM for conducting the delivery
The Maternal and Child Protection Card (for complete information regarding the
antenatal period)
Clean towels/cloth for drying and wrapping the baby
Clean clothes that have been washed and sun-dried for the mother and the baby
Sanitary pads/clean cloth for the mother
Supplies like Inj. Oxytocin, Tab. Misoprostol, Cord Clamps, Sterile Surgical Knife with
Blade, Paediatric size Bag and Mask and other emergency drugs
A dry and comfortably warm environment\room
Food and water for the woman and the support person.
3. Recognising the signs of labour: Advice the woman to go to the health facility or
inform the ASHA to contact the SBA if the woman has any one of the following signs,
which indicate the start of labour:
A bloody, sticky discharge from the vagina (‘show’)
Painful uterine contractions increasing in duration, frequency and intensity with the
passage of time.
4. Identify and arrange for referral transport: Delay in reaching a health care facility is
one of the major ‘delays’ responsible for maternal mortality. It is, therefore, necessary to
ensure the following:
If the woman has decided to deliver at a health facility, ensure that a vehicle is available
to transport her to the health facility whenever required.
Even if the woman decides to deliver at home, a vehicle should be identified and kept
ready to transport her to the nearest health facility or referral centre in case she or the
newborn develops complications.
The contact number of the ambulance or vehicle provided by the state, private or any other
provider, should be available with the ANM/ASHA, and should be communicated to the
pregnant woman and her family members.
If a vehicle is not available in the village, help of the panchayat, village health committee,
Mahila Mandals, youth groups or any other such groups can be taken to decide on how to
obtain a vehicle in case of an emergency.
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5. Locate the nearest PHC/FRU: The woman and her family members should be aware of
the nearest health facilities: the PHC, where 24-hour emergency obstetric care services
are available and the FRU, where facilities for a blood transfusion and surgery are
available.
6. Identify support people: These people are needed to help the woman look after her
children and/or household, arrange for transportation, and/or accompany her to the
health facility. Seek help from either the close relatives of the woman or community-
based health functionaries, such as the AWW/ASHA.
7. Finances: The woman and her family should be assisted in calculating an estimate of
expenses of the delivery and related aspects (such as transport). They should also be
advised to keep an emergency fund, or have a source for emergency funding in case of
complications. Keep in mind the various schemes that are available for assisting women
with transportation facilities or providing funds for maternal health (such as the JSY)
and whatever other schemes may have been launched in your state. Help the woman and
her family access these schemes and collect the allocated funds to pay for the delivery.
Also, keep yourself up to date on any new schemes that may be launched by the GoI and the
state government from time to time.
B. Complication readiness—recognising danger signs during pregnancy, labour and

after delivery/abortion
The pregnant woman and her family/caretakers should be informed about the potential
danger signs during pregnancy, delivery and in the post-partum period. She must be told
that if she has any of the following signs during pregnancy or delivery or in the post-partum/
post-abortion period, she should immediately visit a PHC/FRU without waiting, be it day or
night. Also, counsel her to inform you and the ASHA.
In case you detect a complication during examination or the woman arrives at your centre
with complications, you must refer her to the FRU/24-hour PHC. Also, see to it that she
carries a filled in referral slip with her (see Annexure III for referral slip).
Box 7: Danger signs during pregnancy and labour and after delivery/abortion
Visit FRU Visit 24 hour PHC
Malpresentation High fever with or without abdominal
pain, too weak to get out of bed
Multiple pregnancy Fast or difficult breathing
Any bleeding P/V during pregnancy and Haemoglobin 7–11 g% even after
after delivery (a pad is soaked in less consuming IFA tablets for 30 days
than 5 minutes)
Severe headache with blurred vision Excessive vomiting, unable to take
anything orally
Haemoglobin <7 g% Breathlessness at rest
Convulsions or loss of consciousness Reduced urinary output with high BP
Decreased or absent foetal movements High BP (>140/90 mmHg) with or
without proteins in the urine
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Active labour lasting longer than 12
hours in a primipara and more than 8
hours in a multipara
Continuous severe abdominal pain
Premature rupture of membranes
(PROM) before 37 weeks
High BP (>140/90 mmHg) with proteins
in the urine, and severe headache with
blurred vision or epigastric pain
Temperature more than 38°C
Foul smelling discharge before or after
delivery/abortion
Ruptured membranes for more than 18
hours
FHR >160/minute or <120/minute
Perineal tear ( 2nd, 3rd and 4th degree)
Note: If the ANM is not able to decide on whether she should send a case to the FRU or 24 hour PHC, she
should refer the case to the FRU.
C. Diet and rest

The woman should be advised to eat more than her normal diet throughout her
pregnancy. Remember that a pregnant woman needs about 300 kcal extra per day, over
and above her usual diet, and 500 kcal extra in the post-partum period. She should be
told that she needs these extra calories in order to maintain her health as a mother and
meet the needs of the growing foetus, and for successful lactation.
Special categories of women who require additional nutrition during pregnancy have
been identified. These include the following:
Women who are underweight (less than 45 kg)
Women who have an increased level of physical activity, above the usual levels,
during pregnancy
Adolescent girls who are pregnant
Those who become pregnant within two years of the previous delivery
Those with multiple pregnancy
Women who are HIV positive.
The woman’s food intake should be especially rich in proteins, iron, vitamin A, vitamin
C, calcium and other essential micronutrients.
Other members of the family especially those who take decisions regarding the type
of food brought home and/or to be given to the pregnant woman such as the woman’s
husband and mother-in-law should also be taken into confidence and counselled on the
recommended diet for the pregnant woman. Encourage them to help ensure that the
woman eats enough and avoids hard physical work.
Some of the recommended dietary items are cereals, milk and milk products (such as curd
and paneer), green leafy vegetables and other vegetables, pulses, eggs, meat (including
fish and poultry), groundnuts, ragi, jaggery and fruits (like mango, guava, orange, sweet
lime and watermelon).
The woman should avoid taking tea, coffee or milk within an hour after a meal, as these
have been shown to interfere with the absorption of iron. Also, advise her to take foods
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30
rich in proteins and vitamin C (e.g. lemon, amla, guava and oranges), as both help in the
absorption of iron.
The diet should be rich in fibre to avoid constipation.
While giving dietary advice, keep in mind the woman’s socio-economic status, food
habits and taste, as well as the locally and seasonally available produce.
Taboos against certain foods must be looked into while counselling the woman on her
dietary intake. If there are taboos related to nutritionally important foods, the woman
should be advised against these taboos. Certain communities adhere to particular
taboos (especially omissions) for the purpose of sex selection of the foetus. These should
be strongly discouraged.
If a woman has PIH, she should be encouraged to take a normal diet with no restrictions
on fluid, calories and/or salt intake. Such restrictions do not prevent PIH from turning
into pre-eclampsia and may be harmful for the foetus.
The woman should be advised to sleep for eight hours at night and rest for another two
hours during the day. She should be told to refrain from doing heavy work, especially
lifting heavy weights as this can adversely affect the birth weight of the baby. The other
members of the household should be taken into confidence and advised to help the
woman carry out her routine household chores.
The woman should be advised to refrain from taking alcohol, tobacco in any form or
addictive drugs such as opium derivatives during pregnancy as these have adverse effects
on the foetus. For example, they can slow growth in utero and even after delivery.
The woman should be advised not to take any medication unless prescribed by a qualified
health practitioner.
All pregnant women should be told to lie on their left side while resting and avoid the
supine position (lying flat on the back), especially in late pregnancy, as it affects both the
maternal and foetal circulation. Due to the pressure exerted by the pregnant uterus on
the main pelvic veins, a reduced quantity of circulating blood reaches the right side of
the heart. This causes a reduced supply of oxygen to the brain and can lead to a fainting
attack, a condition referred to as the supine hypotension syndrome. It can also result in
abnormal FHR patterns and in addition, may cause a reduction in the placental blood
flow. If the supine position is preferred, recommend the use of a small pillow under the
lower back, at the level of the pelvis.
D. Breastfeeding
Pregnancy is the ideal time to counsel the mother on the benefits of breastfeeding her baby.
Though breastfeeding is almost universal in India, the following key messages need to be
given to the would-be mother:
Box 8: Key messages on breastfeeding

Initiate breastfeeding especially colostrum feeding within an hour of birth.
Do not give any pre-lacteal feeds.
Ensure good attachment of the baby to the breast.
Exclusively breastfeed the baby for six months.
Breastfeed the baby whenever he/she demands milk.
Follow the practice of rooming in.
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Initiation of breastfeeding: Counsel the mother that breastfeeding should ideally be
initiated immediately after birth, preferably within one hour, even if the birth has been by
caesarean section. The sucking and rooting reflexes of the newborn, which are essential for the
baby to successfully start breastfeeding, are the strongest immediately after delivery, making
the process of initiation much easier for the mother and the baby. These reflexes gradually
become weaker over the span of a few hours, thus making breastfeeding difficult later on.
It is a common practice in India to delay the initiation of breastfeeding. It is a myth

that colostrum (the first milk) is harmful for the baby and should be discarded, and
pre-lacteal feeds given instead. Pre-lacteal feeds may not be hygienic and can cause
intestinal infections in the baby leading to diarrhoea.
Advantages of initiation of early breastfeeding

These are as follows:
The sucking and rooting reflexes in the newborn are the strongest immediately
after delivery, making breastfeeding easier.
Sucking helps in the release of Oxytocin which helps in contraction of uterus and
thus helps in preventing PPH.
The newborn’s sucking helps to produce more breast milk.
The baby receives colostrum, which is very rich in vitamin A and protective
antibodies. This protects the baby from infections such as diarrhoea, tetanus and
respiratory tract infections.
Mothers have less bleeding after birth if they breastfeed immediately.
Early breastfeeding helps the mother and baby to develop a close bond.
Exclusive breastfeeding for six months: Impress upon the mother that only breast
milk and nothing but breast milk is to be given to the baby for the first six months. The
baby should not be given even water. The mother should be assured that breast milk
has enough water to quench the baby’s thirst (even in the peak of summer) and satisfy
his/her hunger for the first six months. The mother should be advised to take special
care in the case of a female child seeing to it that she is adequately breastfed and not
discriminated against because of her sex.
Demand feeding: This refers to the practice of breastfeeding the child whenever he/
she ‘demands’ milk by crying. The practice of feeding the child by the clock should be
actively discouraged. After a few days of birth, most children will develop their own
‘hunger cycle’ and will require to be fed every 2–4 hours. Remember that each child is
different as far as the feeding requirement and timings are concerned.
The practice of giving night feeds should be actively encouraged. Often, there is a
misconception that breastfeeding the baby at night disturbs the mother’s sleep, thus
depriving her of adequate rest. Inform the woman and her husband that this is not so.
Night feeds help the baby to sleep more soundly.
Rooming in (keeping the mother and baby together): This refers to the practice of
keeping the mother and baby in the same room, preferably on the same bed. This is
usually practiced in the Indian setting. This practice should be encouraged as it has
many advantages, such as the following:
It makes demand feeding easier to practice, as the mother can hear the child cry,
and also helps in the early detection of aspiration, if it occurs.
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It keeps the baby warm, thus preventing hypothermia in the newborn.
It helps to build a bond between the mother and the baby.
Advise the woman not to keep the baby too close to herself in the bed so as to prevent
smothering.
E. Sex during pregnancy

It is safe to have sex throughout pregnancy, as long as the pregnancy is uncomplicated.
Sex should be avoided during pregnancy if there is a risk of abortion (history of
previous recurrent spontaneous abortions, or threatened abortion in the current
pregnancy), a risk of pre-term delivery (history of previous pre-term labour), or a
history of APH or PROM.
Some women experience a decreased desire for sex during pregnancy. The husband
should be informed that this is normal and the woman's consent should be sought
before engaging in sex.
Some couples find engaging in sex uncomfortable during pregnancy. The husband must
see to the comfort of the woman while engaging in sexual activities.
Advice couples to have safe sex and use condoms especially if the woman has discharge
or itching in the vaginal area or the husband has urethral discharge or experiences
burning while urinating.
The couple should be advised to abstain from having sex during the first six weeks post-
partum or longer if the perineal wounds have not healed by then.
F. Domestic violence
Pregnancy should be a time of peace and safety, but for many women it can be a time when
they face violence. According to the National Family Health Survey III (2005-6), in India
39.7% of ever married women suffer from either physical and/or sexual violence. Domestic
abuse and violence against pregnant women has immediate and lasting effects both on the
pregnant woman and the foetus. Some of the complications might be visible directly, such
as blunt trauma to the abdomen, haemorrhage (including placental separation), uterine
rupture, miscarriage/still birth, pre-term labour and PROM, all of which need to be ruled
out. At times such trauma/violence can have indirect effects leading to psychological stress
which might have long lasting effects both for the mother and foetus.
The husband and immediate family members of the pregnant woman should be briefed
about the serious consequences that violence could have on the pregnancy, on the woman’s
health and on the physical and mental health of the child to be born. The woman herself
should be counselled in private, and enabled to access support systems from within or
outside the family, during and after the pregnancy. Health workers should be alert to signs
of continuing violence even in the post-partum period.
G. Family Planning
Pregnancy is the best period for family planning counselling as it gives the couple time to
think about and choose the method they would want to use after the birth of their baby. The
woman should be advised on birth spacing or limiting, as necessary. Explain to her and her
husband that if after the delivery she is not exclusively breastfeeding and has unprotected
sex, she can become pregnant as early as six weeks after delivery. Therefore, it is important
to start thinking in advance about which family planning method to use.
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The couple should be advised to abstain from having sex during the first six weeks post-partum,
or longer if the perineal wounds have not healed by then.
Ask about the couple’s plans for having more children. If they desire more children then
advice them that a gap of 3–4 years between pregnancies is healthy for the mother and the
child.
The couple should be given advice on the range of contraceptive methods available to them.
These include the ones described below:
Lactational Amenorrhoea Method (LAM)

A woman can use a natural method, such as lactational amenorrhoea, as a method of
contraception, provided she keeps three points in mind:
Amenorrhoea: The woman should be amenorrhoeic and her menstrual cycle should not
have resumed after delivery. Whenever it resumes, she cannot use this method.
Lactation: The woman should be exclusively breastfeeding her baby, i.e. the baby should
be given no complementary foods or fluids. She should be feeding the baby eight times
or more during the day, with a gap of not more than four hours between feeds, including
at least one night feed. Even a single missed feed increases the risk of pregnancy.
Table 1: Methods of post-partum contraception

Contraceptive COC DMPA ECP IUCD FS NSV
method (For husband)
Breastfeeding (fully or nearly fully or partial)

<6 weeks post- No No (unless Yes Post- placental Immediate Any time
partum other more insertion within 10 post-partum
suitable minutes of delivery, sterilisation after
options are not only by trained 24 hours to 7 days
available) provider of childbirth
>6 Weeks to <6 No Yes Yes
months post- Immediate post- or
partum partum <48 hours
of childbirth by > 6 weeks
>6 Months post- Yes (linked Yes Yes trained provider post-partum
partum with return
of menstrual Post-partum >6
cycles) weeks post-partum
Not breastfeeding
<21 days No Yes Yes <48 hours After 24 Any time

>21 days Yes Yes Yes after childbirth or hours to
>6 weeks 7 days of after
post-partum childbirth
or
>6
weeks
post-partum
COC: combined oral contraceptive, DMPA: depot medroxyprogesterone acetate, ECP: emergency contraception pill, IUCD: intrauterine
contraceptive device, FS: female sterilisation, NSV: no-scalpel vasectomy
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Six months: The woman cannot use this method for more than six months post-partum,
even if she has not started menstruating again.
Intrauterine Contraceptive Device (IUCD)

Copper-containing IUCDs can be inserted within 48 hours of childbirth (post-placental
insertion: within 10 minutes of the delivery of the placenta; immediate post-partum
insertion: within 48 hours of the delivery) by a service provider who is trained specifically
for post-placental IUCD insertion. Alternatively, they can be inserted more than six weeks
post-partum. The expulsion rate is high after post-partum insertion compared with interval
insertion. The IUCD has the advantage of offering protection for 10 years or even more,
depending on the type of IUCD inserted. Those IUCDs which contain copper are safe and
reliable, and women should be advised to visit the PHC or FRU for insertion.
Condoms
These can be safely used as soon as, and for as long as, the woman/couple so desires. It should
be impressed upon the couple that condoms should be used correctly and consistently,
during each act of sexual intercourse. The brand supplied free of cost by the government is
‘Nirodh’. Many other brands are available, which are either socially marketed or available in
the open commercial market. These may also be offered to the couple if they are interested.
Injectables
Injectable hormonal depot preparations for contraception are commercially available in the
market. They are safe for lactating mothers as they do not interfere with lactation and have
no known side-effects on the infant. Depot Medroxyprogesterone Acetate (DMPA) acts for
three months and is commonly available. The injection can be given immediately after an
abortion or delivery.
Natural methods
Natural methods of contraception, such as abstinence, periodic abstinence (e.g. the Standard
Days’ Method [SDM]), and cervical mucus method, may be discussed with the couple. This
is especially important in cases where religious bindings prohibit the couple from using any
other method of contraception.
Oral contraceptive pills

The use of combined oral contraceptive pills (such as the government supplied Mala-N and
Mala-D, and other commercially and socially marketed brands) is not advisable during the
post-partum period, as the woman is lactating during that time. Combined oral contraceptive
pills are known to decrease the milk output. However, the woman may be advised to use
them after six months of delivery, once her menstrual cycle resumes.
The woman may, however, use progestin-only pills six weeks after childbirth if she is
breastfeeding the baby, or immediately after birth if she is not breastfeeding the baby. At
present, these are not supplied by the government and have to be bought from the commercial
market. These pills have the advantage of having no effect on the output of breast milk and
can therefore, be safely used by lactating women.
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Emergency contraception pills
Emergency Contraception Pills (ECPs) can be used any time during the post-partum
period, within 72 hours following unprotected sexual intercourse. However, women should
be counselled that ECPs have to be used for emergency purposes only and not as a regular
form of contraception. They should be advised to shift to regular and more effective methods
of contraception.
Female sterilisation
If the couple has achieved its desired family size, the woman may be advised to undergo
a tubectomy, a permanent method of contraception. Immediate post-partum female
sterilisation, using the minilaparotomy technique, can be offered 24 hours after the delivery
of the baby up to seven days post-partum. Apart from immediate post-partum female
sterilisation, female sterilisation can also be offered any time after six weeks of the delivery.
No-scalpel vasectomy
If the couple has achieved its desired family size and wishes to adopt a permanent method
of contraception, the husband may be encouraged to opt for No-Scalpel Vasectomy (NSV).
This is a simple and safe surgical procedure, which provides lifelong and effective protection
against pregnancy. It can be performed any time during the post-partum period. However,
the couple must be warned that the procedure will take three months to become effective
and hence, they need to use other back-up methods of contraception, such as condoms and
oral contraceptive pills, for three months after the NSV.
(Practice antenatal counselling – Checklist No 1.5 in SBA Handbook)
(Annexure lV – A table of activities to be carried out at each ANC visit)

GUIDELINES
36
Table 2. Symptoms and signs that an ANM might encounter, probable diagnosis and
action to be taken at SC level
Symptoms Signs/ Most probable Action(s) to be
investigations diagnosis taken
A Heartburn and nausea - Reflux Advise the woman to avoid spicy and
oesophagitis oily foods.
Ask her to take cold milk during
attacks.
If severe, antacids may be prescribed.
B Vomiting during the - May be Advise the woman to eat small
first trimester physiological frequent meals; avoid greasy food;
(morning eat lots of green vegetables; and
sickness) drink plenty of fluids.
If vomiting is excessive in the
morning, ask her to eat dry foods,
such as roti/paratha, biscuits or toast,
after waking up in the morning.
C Excessive vomiting, The woman may be Hyper- emesis Start IV Ringer lactate, 500 ml,
especially after the dehydrated— dry gravidarum and refer the woman to the MO at
first trimester tongue, loss of skin 24 hour PHC/FRU.
turgor, decreased urine
output in severe cases.
Tachycardia may be
present.
D Palpitations, easy Conjunctival and/or Severe anaemia Refer her to the MO at FRU for
fatiguability, pallor of the palm further management.
breathlessness at rest present Advise her to have a hospital
Hb <7 g/dl delivery.
E1 Puffiness of the face, Check protein in Hypertensive Advise her to reduce workload and
generalised body urine. disorder to rest.
oedema Check BP. of pregnancy Advise on danger signs.
Re-assess at the next antenatal visit
If BP >140/90 mmHg or in one week if more than eight
on 2 readings and months pregnant.
proteinuria absent If hypertension persists after one
week or at next visit, refer to hospital
or MO.
If diastolic BP is ≥90 Pre-eclampsia Refer to hospital.
mmHg on two readings Revise birth plan.
and 2+ proteinuria
E2 Puffiness of the face, If diastolic BP is Severe pre- Give Inj Magsulf, 5 g (10 ml), deep
generalised body ≥110 mmHg and eclampsia IM, in each buttock.
oedema 3+ proteinuria Refer urgently to hospital.
Severe headache
Blurred vision
Epigastric pain
Reduced urine output
F Increased frequency May be Re-assure her that it will be relieved
of urination up to 10–12 physiological on its own.
weeks of pregnancy due to pressure
of the gravid
uterus on the
urinary bladder.
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G Increased frequency Tenderness may be UTI Refer the woman to the MO at the
of urination after 12 present at the sides PHC.
weeks, or persistent of the abdomen and
symptoms, or burning on back.
urination Body temperature
may be raised.
H Constipation Physiological Advise the woman to take more
fluids, leafy vegetables and a fibre
rich diet.
If not relieved, give her Isabgol (2
tablespoons to be taken at bedtime,
with water or milk).
Do NOT prescribe strong laxatives as
they may start uterine contractions.
I Pain in the abdomen Fainting Ectopic Refer the woman to the MO at the
Retropubic/ pregnancy FRU.
suprapubic pain UTI
J Bleeding P/V, before 20 Check the pulse Threatened If the woman is bleeding and the
weeks of gestation and BP to assess for abortion/ retained products of conception can
shock. spontaneous be seen coming out from the vagina,
Ask for history of abortion/ remove them with your finger.
violence. hydatidiform Start IV fluids.
mole/ectopic Refer her to the MO of a 24-hour
pregnancy PHC/FRU.
Spontaneous Put her in touch with local support
abortion due to groups.
violence Do NOT carry out a vaginal
examination under any
circumstances.
K Bleeding P/V, after 20 Check the pulse Antepartum
weeks of gestation and BP to assess for haemorrhage
shock.
L Fever Body temperature is Site of infection Refer her to the MO at 24 hour
raised somewhere, PHC/FRU.
Peripheral smear for including If malaria is diagnosed, refer her
malarial parasite +ve possible sepsis to the PHC for management of
Malaria malaria according to the NVBDCP
guidelines.
M Decreased or absent FHS heard, and is Baby is Normal. Re-assure the woman.
foetal movements within the normal Repeat FHS after 15 minutes.
range of 120–160/ If the FHS is still out of the normal
minute. range, refer her to the MO at 24 hour
PHC/FRU.
FHS heard, but the Foetal distress Inform the woman and her family
rate is <120/minute that the baby might not be well.
or >160/minute Refer her to the MO at 24 hour
FHS not heard Intrauterine PHC/FRU.
foetal death
N Abnormal vaginal Vaginal discharge RTI/STI Refer the woman to the MO.
discharge, with or with or without Advise her on vaginal hygiene, i.e.
without abdominal pain odour cleaning the external genitalia with
soap and water.
O Leaking of watery Wet pads/cloths PROM Refer the woman to the MO at FRU.
fluids P/V
FRU: first referral unit; NVBDCP: National Vector Borne Disease Control Programme; FHS: foetal heart sound; BP: blood pressure; UTI:
urinary tract infection; RTI: reproductive tract infection; STI: sexually transmitted infection; PROM: premature rupture of membranes;
P/V: per vaginam
GUIDELINES
38
Care During Labour and Delivery—Intra-partum Care
KEY MESSAGES
Mother
• Let the woman choose the position she desires and feels
comfortable during labour.
• Maintain a partograph which will help you recognise the need for
action at the appropriate time and thus ensure timely referral.
• Ensure active management of the third stage of labour, thereby
preventing post-partum haemorrhage (PPH).
Newborn
• Maintain airway and breathing.
• Maintain body temperature and prevent hypothermia.
• Initiate breastfeeding within the first hour of birth.
• Recognise danger signs and make timely and appropriate referrals.
Introduction
Normal labour is a spontaneous process of expulsion of the foetus and placenta. However
it is important to remember that during the intra partum period the woman and the baby
go through physical as well as mental trauma. You, as an SBA, have the responsibility of
providing the necessary care for the management of labour as well as emotional support,
and must ensure a successful outcome for the mother and the baby.
Assessment, Supportive Care and Vaginal Examination during Labour

Assessment
Assessment consists of the following components:
Inquire about the woman’s history of labour, asking the following questions:
When did the contractions begin?
How frequent are the contractions? How strong are they?
Has there been any watery discharge? If so, what colour was it?
Has there been any bleeding? If so, how much?
Is the baby moving?
Are there any other complaints?
Check the woman’s record for history of the present pregnancy, e.g. the haemoglobin
status, TT immunisation, Rh status, any complications and any other significant history.
If there is no record, then ask the following:
When was the LMP/what is the period of amenorrhea? On this basis, determine
the EDD.
Ask for the history of any past pregnancy.
Any other significant history.
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Conduct general physical examinations, record the temperature, pulse, blood pressure
and weight, and check for pallor, oedema, and so on.
(Refer Checklist 1.1 and 1.2 in SBA Handbook).
Conduct an abdominal examination to assess the foetal lie and presentation, FHR, and
frequency and duration of contractions.
(Refer Checklist 1.3 in Handbook).
Conduct a P/V examination to decide the stage of labour (as mentioned later in this
section).
Supportive care
Encourage and re-assure the woman that things are going well.
Maintain and respect the privacy of the woman during examination and discussion.
Explain all examinations and procedures to be carried out on the woman, seek her
permission before conducting them and discuss the findings with her.
Encourage the woman to bath or wash herself and her genitals at the onset of labour.
Make sure that the birthing area is clean, so as to prevent infection.
See to it that the room where the delivery is to take place is warm and draught-free, and
the temperature is between 25°C and 28°C.
Encourage the woman to empty her bladder frequently. Remind her to pass urine every
two hours or so.
The presence of a second person or a birth companion of the woman's choice, in addition
to an SBA, is beneficial. However, the number of birth companions should be limited to
one. Birth companions provide comfort, emotional support, re-assurance, encouragement
and praise. At a practical level too, the presence of a second person is valuable. Additional
assistance may be required at any time during the labour or in the event of an emergency.
The companion can be useful even if it is only to go and seek help.
The woman should be allowed to remain mobile during the first stage of labour as this
helps to make the labour shorter and less painful.
The woman should be free to choose any position she wishes to and feels comfortable during
labour and the delivery. She may choose the left lateral, squatting, kneeling, or even standing
(supported by the birth companion) position. Remember, given a choice, the woman will
often change positions as no position is comfortable for a long period of time.
Encourage the birth companion to help relieve the woman’s pain by:
Massaging her back
Holding her hand
Sponging her face between contractions.
There are certain other non-pharmacological methods of relieving pain during labour, like:
Speaking to woman in calm, soothing and gentle voice.
Praise the woman and offer her encouragement and re-assurance.
Practising relaxation techniques, such as deep breathing exercises, is beneficial.
Placing a cool cloth on the woman’s forehead is soothing.
Assisting the woman in voiding urine and changing her position will make her
more comfortable.
GUIDELINES
40
Women who are not likely to require general anaesthesia, can (if they wish) have
light, easily digestible, low-fat food during labour. This is because labour requires
large amounts of energy. In the case of women who have not eaten for some time
or who are undernourished, the effects of labour can quickly lead to physiological
exhaustion, dehydration and ketosis (maternal acidosis), which can result in
foetal distress. Therefore, encourage the woman to eat and drink as she wishes
throughout labour.
An enema should not be routinely given during labour. It should be given only if there is
an indication, e.g. if the woman complains of constipation on admission or at the onset
of labour. Please remember that a soap and water enema should never be given.
(Practise conducting assessment of woman in labour - Checklist No 2.1 in SBA Handbook)
Vaginal examination
During a vaginal examination, determine the following:
A. Pelvic adequacy
B. Progress of labour
C. Stage of labour
Remember
Vaginal examinations are rarely required during pregnancy.
During labour, vaginal examination should not be attempted more than once every
four hours (to avoid unnecessary infection).
Do not carry out a vaginal examination if the woman is bleeding at the time of
labour or at any time during pregnancy. Manage this as a case of ‘vaginal bleeding
in pregnancy’ [refer to Module 2].
Do not start a vaginal examination during a contraction.
Steps for doing a P/V examination:

Do not shave the perineal area.
Explain to the woman what is being done and always ask for her consent before doing a
vaginal examination.
Ask the woman to pass urine.
Wash your hands with soap and water before and after each examination. Carry out the
vaginal examination under strict aseptic conditions.
Place the woman in the supine position with her legs flexed and apart.
Perform the vaginal examination very gently, wearing clean/sterile gloves.
Clean the vulva and perineal area with a mild antiseptic solution. Wipe the vulva first,
then labia majora and lastly labia minora with cotton swabs from the anterior to the
posterior direction. Use a swab only once. Use separate swabs for each side.
Separate the labia with the thumb and forefinger of the left hand and clean the area
once again.
Use two fingers of the right hand (index and middle fingers) and insert them gently into
the vaginal orifice without hurting the woman.
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A. Pelvic adequacy
Pelvic assessment is important in the case of both primigravidas and multigravidas,
who have a past history of prolonged or difficult labour, which could be associated with
Cephalopelvic Disproportion (CPD).
In a normal pelvis:
The sacral promontory is not reached.
The sacrum is well curved.
The ischial spines are not prominent and both ischial spines cannot be felt by the finger
inserted, at the same time.
B. Determining progress of labour—cervical effacement and cervical dilatation in

centimeters
Assessing cervical effacement and dilatation during a vaginal examination is important to
monitor the progress of labour.
Cervical effacement: This is progressive shortening and thinning of the cervix during
labour.
Cervical dilatation: This is an increase in the diameter of the cervical opening in
centimeters (distance in centimeters between the outer aspects of both examining
fingers.) A fully dilated cervix has an opening of 10 cm—at this stage, the cervix is no
longer felt on vaginal examination.
Normal effacement and dilatation will facilitate expulsion of the foetus in the second
stage of labour.
(Practise vaginal examination to decide the stage of labour and pelvic assessment - Checklist No. 2.2 in
SBA Handbook)
Figure 5: Cervical effacement and dilation
Presenting part
30% effaced
80% effaced
Cervix
No dilatation / Fully dilated

effacement Fully effaced
3 cms dilated 8 cms dilated

GUIDELINES
42
True labour pain versus false labour pain: True labour pain has the following features
and can be clearly differentiated from false labour pain:
Box 9: True Vs False labour pain

True labour pain False labour pain
Begins irregularly but becomes regular and predictable Begins irregularly and remains irregular
Felt first in the lower back and sweeps around to the Felt first abdominally and remains confined to the
abdomen in a wave pattern. abdomen and groin
Continues no matter what the woman’s level of activity Often disappears with ambulation or sleep
Increases in duration, frequency and intensity with the Does not increase in duration, frequency or intensity
passage of time with the passage of time
Accompanied by ‘show’ (blood-stained mucus discharge) Show absent
Achieves cervical effacement and cervical dilatation Does not achieve cervical effacement and cervical dilatation
C. Deciding the stages of labour
Box 10: Stages of labour

First stage This is the period from the onset of labour pain to the full dilatation of the cervix, i.e. to 10 cm. This stage takes
about 12 hours in primigravidas and 6–8 hours for multigravidas. It is divided into the latent and active stages.
Latent stage (not in active labour):
Cervix is dilated <4 cm
Contractions weak (less than 2 contractions in 10 minutes)
Active stage: Cervix is dilated >4 cm
Second stage This is the period from full dilatation of the cervix to the delivery of the baby. This stage takes about two
hours for primigravidas and about half an hour for multigravidas.
Third stage This is the period from after delivery of the baby to delivery of the placenta. This stage takes about 15
minutes to half an hour, irrespective of whether the woman is a primagravida or multigravida.
Fourth stage This is the first two hours after the delivery of the placenta. This is a critical period as PPH, a potentially
fatal complication, is likely to occur during this stage.
Monitoring and managing the stages of labour

First stage of labour
Oxytocic drugs for inducing/accelerating labour should not be administered before delivery
as their use is associated with a high incidence of rupture of the uterus.
Box 11: Monitoring and managing first stages of labour

Monitoring Action/Management
Latent stage, i.e. not in active labour
Monitor the following every one hour: Record time of rupture of membranes and colour of
Contractions: amniotic fluid.
Frequency—how many contractions in 10 Never leave the woman alone.
minutes Allow her to remain mobile.
Duration—for how many seconds each Let her choose the position in which she is comfortable.
contraction lasts. If after eight hours, the contractions are stronger and more
FHR: Normal FHR is between 120 and 160 beats/ frequent but there is no progress in cervical dilatation, with
minute or without rupture of the membranes, it indicates non-
Presence of any sign of an emergency (difficulty in progress of labour. Refer the woman urgently to an FRU.
breathing, shock, vaginal bleeding, convulsions or If after eight hours, there is no increase in intensity/
unconsciousness) frequency/duration of contractions, the membranes are not
Monitor the following every four hours: ruptured and there is no progress in cervical dilatation, ask
Cervical dilatation (in cm) the woman to relax. Advise her to come/send for you again
Temperature when the pain/discomfort increases, and/or there is vaginal
Pulse bleeding, and/or the membranes rupture.
Blood pressure
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Active stage
Monitor the following every 30 minutes: Never leave the woman alone.
Maternal pulse Start maintaining a partograph when the woman
Contractions—frequency and duration reaches active labour.
FHR Re-assess the woman and consider criteria for referral.
Presence of signs such as meconium blood-stained Call a senior person, if available. Alert emergency
amniotic fluid, prolapsed cord. transport services.
Encourage the woman to empty her bladder.
Monitor the following every four hours: Ensure adequate hydration but omit solid foods.
Cervical dilatation (in cm) by P/V Encourage her to maintain an upright position and walk,
Temperature if she wishes.
Blood pressure Monitor intensively, using the partograph. Refer
immediately if there is no progress.
Partograph
The partograph is a graphic recording of the progress of labour and the condition of the
mother and foetus. It is a tool which helps assess the need for action and recognises the need
for referral at the appropriate time. This facilitates timely referral to save the life of the mother
and foetus.
Follow the instructions below carefully while filling the partograph:
Identification data–Note down the woman’s name and age, parity, date and time of
admission, registration number and time of rupture of the membranes.
Foetal condition
Count the FHR every half an hour.
Count the FHR for one full minute.
The rate should be preferably counted immediately after a uterine contraction.
If the FHR is below 120 beats per minute or above 160 beats per minute, it indicates
foetal distress. Manage as indicated later under ‘Foetal Distress’.
Remember that each of the small boxes in the vertical column of the partograph
represents a half-hour interval.
Note the condition of the membranes and observe the colour of the amniotic fluid as
visible at the vulva every half an hour.
Record in the partograph as follows:
Membranes intact (mark ‘I’)
Membranes ruptured:
- Clear liquor (mark ‘C’)
- Meconium-stained liquor (mark ‘M’)
Labour
Begin plotting on the partograph only when active labour starts. Active labour starts
when the cervical dilatation is 4 cm or more and the woman is having at least two good
contractions every 10 minutes.
Record the cervical dilatation in centimeters every four hours.
In this phase, cervical dilatation progresses by approximately 1 cm per hour and is often
quicker in multigravidae.
GUIDELINES
44
Plot the first recording of cervical dilatation on the Alert line. Write the time accordingly
in the corresponding row for time. After four hours, conduct a vaginal examination and
plot the cervical dilatation in centimeters on the graph.
If the Alert line is crossed (the plotting moves to the right of the Alert line), it
indicates prolonged/obstructed labour and you should be alert that something is
abnormal with the labour.
Note the time when the Alert line is crossed. The woman needs to be referred urgently
to the FRU. Please remember to send the partograph along.
Crossing of the Action line (the plotting moves to the right of the Action line)
indicates the need for intervention. There is a difference of four hours between the
Alert line and the Action line. By the time the Action line is crossed, the woman
should ideally have reached the FRU for the appropriate intervention. Refer as
soon as Alert line is crossed and do not wait for referral till the Action line
is crossed.
Chart the contractions every half an hour; count the number of contractions over
10 minutes and note their duration in seconds. Record the number of good uterine
contractions (lasting more than 20 seconds) in 10 minutes every half an hour and
accordingly, blacken the boxes on the partograph.
Maternal condition
Record the maternal pulse on the graph every half an hour and mark with a dot (.).
Record the woman’s blood pressure on the graph every four hours, using a vertical
arrow ( ) with the upper end of the arrow signifying the systolic blood pressure and
the lower end indicating the diastolic blood pressure.
Record the temperature every four hours and note it on the temperature graph.
Interventions
Mention any drug that has been administered during labour, including the dosage, route
and time of administration. Also include the food items and liquids consumed by the
woman during labour.
Box 12: Indications for referral to the FRU on the basis of the partograph
If the FHR is <120 beats/minute or >160 beats/minute

If there is meconium- and/or blood-stained amniotic fluid
When the cervical dilatation plotting crosses the Alert line (moves towards the right
side of the Alert line)
If the contractions do not increase in duration, intensity and frequency.
If the maternal vital signs, i.e. the pulse (more than 100/min), BP (>140/90 mmHg)
and temperature (>38º C), cross the normal limits.
(A simplified version of the partograph is provided below for your reference.)

(Practise Management of First Stage of Labour - Checklist No 2.3 and Case studies 1–3 in SBA
Handbook)
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THE SIMPLIFIED PARTOGRAPH
IDENTIFICATION DATA
Name: W/o: Age: Parity: Reg. No:
Date & Time of Admission: Date & Time of ROM:

A) Foetal Condition
200
190
180
Foetal 160
150
heart 140
rate 130
120
110
100
90
80
Amniotic fluid
B) Labour
10
9
8 n
Cervix (cm) 7 Alert Actio
[Plot X] 6
5
4
Hours 1 2 3 4 5 6 7 8 9 10 11 12
Time
5
Contraction 4
3
per 10 min 2
1
C) Interventions
Drugs and
IV fluids given
D) Maternal Condition
180
160
150
140
Pulse 130
and 120
110
BP 100
90
80
70
60
Temp (°C)
GUIDELINES
46
Second stage of labour
The second stage of labour begins when the cervix is fully dilated and ends with the expulsion
of the foetus. When the woman reaches this stage, she should be transferred to the labour
room if she is in another room. She should not be allowed to walk during this stage.
The following are the signs of imminent delivery:

Vulval gaping
Thinned-out and bulging perineum
Anal pouting
Visibility of the baby’s head at the vulva.
Usually, the above signs of imminent delivery appear within two hours of full dilatation
of the cervix in primigravidas and one hour in multigravidas.
Monitor the frequency and duration of the contractions every half an hour. Count the
number of contractions occurring every 10 minutes and their duration in seconds, and
also monitor the FHR every five minutes. Be vigilant regarding the presence of any
emergency signs, such as shock, difficulty in breathing, vaginal bleeding, convulsions
and unconsciousness.
During delivery, positions such as standing, squatting and being on all fours make
pushing easier. Therefore, if the woman finds it difficult to push, or there is slow descent
of the presenting part, you should help her to change her position.
When the cervix is fully dilated, during a contraction, encourage the woman to
√ take deep breaths and push down.
Bearing down efforts are not required until the head has descended into the
× perineum. Therefore, the woman should be advised not to push actively until
the foetal head is distending the perineum.
Occasionally, the woman may feel the urge to push before the cervix is fully
dilated. This must be discouraged as it can result in oedema of the cervix, which
may delay the progress of labour.
Do not apply fundal pressure on the abdomen to facilitate expulsion of the baby.
Delivery of the head

Take the following precautions to ensure that the delivery of the head is a controlled one:
Keep one hand gently on the head as it advances with the contractions.
Support the perineum with the other hand and cover the anus with a pad held in position
by the side of the hand
Ask the mother to take deep breaths and to bear down only during a contraction.
Once the head is out, use gauze to gently wipe the mucus off the baby’s face.
Feel gently around the baby’s neck for the presence of the umbilical cord, check:
If the cord is present and is loose around the neck, deliver the baby through the
loop of the cord, or slip the cord over the baby’s head.
If the cord is tight around the neck, place two clamps on the cord and cut between
the clamps, and then unwind it from around the neck.
Delivery of the shoulders and the rest of the baby

Wait for spontaneous rotation and delivery of the shoulders. This usually happens within
1–2 minutes.
Apply gentle pressure downwards to deliver the top (anterior) shoulder.
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Then lift the baby up, towards the mother’s abdomen, to deliver the lower (posterior)
shoulder.
The rest of the baby’s body follows smoothly.
Figure 6: Delivery of head and shoulders: Fetal head movements during labour (left occiput anterior position)
1. Head floating, before engagement 2. Engagement, flexion, descent 3. Further descent, internal rotation 4. Complete rotation, beginning
extension
5. Complete extension 6. External rotation of head and 7. Delivery of anterior shoulder 8. Delivery of posterior shoulder
internal rotation of shoulders
Note the time of birth and put identification tag on the baby.
Place the baby on the mother’s abdomen. (If the baby is not delivered onto the mother’s
abdomen, make sure there is a warm towel or cloth to receive the baby.)
Look for meconium. If there is none, proceed to dry the baby with a warm towel or piece
of clean cloth. (Do not wipe off the white greasy substance covering the baby’s body.
This substance, called vernix, helps to protect the baby’s skin.)
After drying, the wet towels or clothes should be replaced and the baby is loosely
wrapped in a clean, dry and warm towel. If the baby remains wet, it leads to heat loss.
Wipe both the eyes (separately) with sterile gauze.
If meconium is present and the baby is not crying, apply suction to the mouth and then
the nose.
To assess the baby’s breathing:
If the baby is breathing well and the chest is rising regularly, between 30–60 times a
minute, provide routine care.
If the baby is not breathing or is gasping, call for help. The steps of resuscitation (as
described at the end of this chapter) need to be carried out immediately. Anticipate
the need for resuscitation, especially if the woman has a history of eclampsia, bleeding,
prolonged/obstructed labour or pre-term birth.
Clamp the cord when cord pulsation stops. It normally takes about 1–3 minutes for the cord
to stop pulsating. Put clean thread ties tightly around the cord at approximately 2-3 cm from
GUIDELINES
48
the baby’s abdomen and cut between the ties with a sterile, clean blade. If there is oozing,
place a second tie between the baby’s skin and the first tie. Cutting the cord after an interval
of 1–3 minutes, helps to avoid neonatal anaemia, as it results in transfusion of an increased
amount of blood into the foetal circulation.
Leave the baby between the mother’s breasts to start skin-to-skin care. Cover the baby’s head
with a cloth. Cover the mother and the baby with a warm cloth.
(Practise Management of Second Stage of Labour - Checklist No. 2.4 in SBA Handbook)
Third stage of labour

Active Management of the Third Stage of Labour (AMTSL)
AMTSL is recommended for all deliveries and consists of the following three activities:
1. Uterotonic drug— Inj. Oxytocin is the drug of choice for all health facilities
(including SC), whereas Tab. Misoprostol is to be used when adequate refrigeration of
Injection Oxytocin is not possible during high temperature. Tab. Misoprostol can also
be used for home delivery or any OR delivery.
2. Controlled cord traction.
3. Uterine massage.
1) Uterotonic drug
An uterotonic drug enhances contraction of the uterine muscles, thereby facilitating
expulsion of the placenta and diminishing bleeding. This helps to prevent PPH. An
uterotonic drug should be given after the delivery. Rule out the presence of another baby
before giving the uterotonic drug.
Oxytocin is the drug of choice for AMTSL at the SC/PHC/FRU/health facility. It should
be kept at a temperature 4-8°C but should not be frozen. It should ideally be stored in a
refrigerator.
Administer 10 units of oxytocin injection (intramuscular) to the mother if the delivery
has taken place at the SC/PHC/FRU/health facility or give her a Tablet Misoprostol tablet
(600 mcg) orally if the mother has been delivered at home and Injection Oxytocin is
not available due to the problems of high ambient temperatures and unavailability of a
refrigerator.
You can also use it at the SC/PHC in case an Oxytocin injection is not available or
if there are problems related to refrigeration. Inform the woman that shivering and
gastrointestinal disturbances are common side-effects of Misoprostol, and should not
be a cause for worry.
2) Controlled Cord Traction (CCT)

CCT is a technique that assists in the expulsion of the placenta, and helps to reduce the
chances of a retained placenta and subsequent bleeding, i.e. PPH.
Clamp the maternal end of the umbilical cord close to the perineum with a pair of artery
forceps.
Hold the clamped end of the cord with one hand.
Place the other hand on the mother’s abdomen to feel the uterine contraction.
Maintain slight tension on the cord.
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When the uterus contracts, as will be evidenced by the uterus becoming hard and
globular, gently pull downwards on the cord to deliver the placenta. Simultaneously,
place one hand just above the pubic symphysis to apply counter-traction (pressure in
the opposite/upward direction towards the umbilicus) on the uterine fundus.
If the placenta does not descend within 30–40 seconds of CCT, do not continue to pull
on the cord.
Wait for the uterus to contract strongly again and repeat CCT with counter-traction.
Do not exert excessive traction on the cord while performing CCT. Do not repeat the
manoeuvre more than once.
As the placenta delivers, hold it with both hands to prevent tearing of the membranes.
Normally, the placenta delivers within five minutes of the birth of the baby if the third
stage of labour is managed actively.
If the membranes do not slip out spontaneously, gently turn the placenta so that the
membranes are twisted into a rope and move them up and down to assist separation. If
pulled at, the thin membranes can tear off and get retained in the uterus.
If the membranes tear, use your fingers or a pair of sponge forceps to remove any pieces
of membrane that might be present.
Figure 7: Controlled cord traction Remember, you should never apply cord traction (pull)
without a contraction and without applying counter traction
(push) above the pubic symphysis with the other hand.
Ensure that the placenta is delivered completely with all
uterus the membranes. Retained placental fragments or pieces of
membrane will cause PPH. This can be suspected if a portion
metal clamp of the maternal surface of the placenta is missing or the
membranes with their vessels are torn.
If the placenta is not delivered after 30 minutes of inj.
Oxytocin or Tablet Misoprostol, refer the woman to an FRU.
placenta
Information on the drugs given, the dosage and time of
administration on the referral slip, should also be sent along
with the woman.
Figure 8: Examination of the placenta Examination of the placenta, membranes and the
umbilical cord
Examine the placenta and the membranes for completeness as
follows:
Maternal surface of the placenta:
Hold the placenta in the palms of the hands, keeping the
palms flat and the maternal surface facing you. Look for
the following:
All the lobules (15–20) must be present.
The lobules should fit together.
There should be no irregularities in the margins.
If any of the lobes are missing or the lobules do not fit
together, suspect that some placental fragments may have
been left behind in the uterus.
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Foetal surface
Hold the umbilical cord in one hand and let the placenta and membranes hang
down like an inverted umbrella.
The umbilical vessels will be seen passing from the cord and gradually fading into
the edge of the placenta.
Look for free-ending vessels and holes which may indicate that a lobule has been
left behind in the uterus.
Look for the insertion of the cord, particularly the velamentous insertion (the point where
the cord is inserted into the membranes and from where it travels to the placenta).
Membranes
Both the layers (chorion and amnion) can be seen at the edge of the hole where the
membranes rupture and the foetus comes out.
If the membranes are ragged, place them together and make sure that they are
complete.
Umbilical cord
Normally, the umbilical cord has two arteries and one vein. If only one artery is
found, look for congenital malformations in the baby.
3) Uterine massage
This technique helps in contraction of the uterus and thus prevents PPH.
Immediately after delivery of the placenta, massage the fundus of the uterus through
the woman’s abdomen until it is well contracted. Repeat the uterine massage every 15
minutes for the first two hours.
Ensure that the uterus does not become relaxed (soft) after you stop the uterine massage.
If the uterus remains soft and flabby, the woman may be suffering from Atonic PPH.
Manage as per the steps given for management of Atonic PPH in Module 2.
(Practise Conducting AMTSL - Checklist No. 2.5 in SBA Handbook)
Fourth stage of labour

The first two hours after the delivery of the placenta are referred to as the fourth stage of
labour. This stage comprises both observation and care of the mother and newborn. The
mother and her newborn should not be separated, unless required.
Care of the mother

After the delivery of the placenta, check to see if the uterus is well contracted (i.e. it is
hard and round) and ascertain that there is no heavy bleeding. Repeat the check every
15 minutes.
If the uterus is not well contracted and there is bleeding, massage the uterus and expel
the clots. If the bleeding continues, manage as indicated under ‘Management of post-
partum haemorrhage’.
Examine the perineum, lower vagina and vulva for tears. If present, manage as indicated
under ‘Management of vaginal and perineal tears’, Module 2.
Clean the woman and the area beneath her. Put a sanitary pad or a folded cloth under
her buttocks to collect the blood. Counting the number of pads/cloths soaked will help
in estimating the amount of blood lost.
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Estimate the amount of blood loss throughout the third stage of labour and immediately
afterwards. If the bleeding has stopped, observe the woman for the next 24 hours. If
bleeding has not stopped, then manage as post-partum haemorrhage, as per steps given
in module II.
Check the following every 15 minutes for the first two hours:
General condition, blood pressure and pulse
Vaginal bleeding
Uterus, to make sure that it is well contracted.
Dispose of the placenta in the correct, safe and culturally appropriate manner. Use gloves
while handling the placenta. Put the placenta into a leak-proof bag containing bleach.
Incinerate the placenta or bury it at least 10 metres away from a source of water in a pit
that is 2 metres deep.
Counsel the mother to breastfeed, including colostrum feeding, within an hour of
the birth. Ask her to take warm fluids, eat well, take adequate rest, sleep and maintain
hygiene. The latter would include maintaining perineal hygiene, taking a bath every day
and washing her hands before handling the baby.
Encourage the woman to pass urine. If the woman has difficulty in passing urine, or
the bladder is full (as evidenced by a swelling over the lower abdomen just above the
symphysis pubis) and she is uncomfortable, help her pass urine by gently pouring warm
water over her vulva.
Ask the birth companion to stay with the mother and not leave her and the newborn
alone. Ask the companion to call for help if any of the following conditions occur:
Excessive bleeding per vaginum
Dizziness, severe headache, visual disturbance or epigastric pain
Convulsions
Increased pain in the perineum
Urinary incontinence or inability to pass urine.
Care of the newborn

Place an identity label with the mother’s name and any other identification information
as may be required on the baby’s wrist or ankle, if not done earlier.
Give the baby a vitamin K injection 1.0 mg, intra muscular to all newborns weighing
1500 gms and above and in a dose of 0.5 mg to newborns weighing less than 1500 gm.
As per the current provision SNs/LHVs are permitted to administer Injectable drugs
like Vitamin K to new born.
The site for the injection is the quadriceps muscle group of the upper, outer thigh
by Sterile 1-inch needle of the smallest size, available.
Vitamin K is needed for prevention of hemorrhagic disease of new born. Babies
have very little vitamin K in their bodies at birth. Vitamin K does not cross the
placenta into the developing baby, and the gut does not have any bacteria to make
vitamin K before birth. There is very little vitamin K in breast milk and it takes
several weeks before the normal gut bacteria start making it.
Examine the baby quickly for malformations or any birth injury. If there is major
malformation or severe birth injury, refer the baby to the newborn unit in the FRU.
Ensure that the baby is warm during the examination and when being transported.
GUIDELINES
52
Check the baby’s colour and breathing every five minutes.
If the baby becomes cyanotic (bluish) or is having difficulty in breathing (less than 30 or
more than 60 breaths per minute), make initial attempts at resuscitation. If this does not
help, a referral to the MO at the FRU is necessary.
Check if the baby is warm, by feeling his/her feet every 15 minutes.
If the baby’s feet feel cold, check the axillary temperature.
If the baby’s temperature is below 36.5°C, provide warmth to the baby by placing
him/her under a radiant warmer.
Teach the mother to provide skin-to-skin contact, a component of Kangaroo
Mother Care (KMC).
Two components of KMC are skin-to-skin contact and exclusive breastfeeding.
Figure 9: How to provide KMC

Provide privacy to the mother.
Request the mother to sit or recline comfortably.
Undress the baby gently. However, keep the cap,
nappy and socks on.
Place the baby prone on the mother’s chest in an
upright and extended posture, between her breasts,
in skin-to-skin contact. Turn the baby’s head to one
side to keep the airway clear.
Cover the baby with the mother’s blouse, ‘pallu’ or
gown. Wrap both baby and mother with a blanket or
shawl.
Ask the mother to breastfeed the baby frequently.
If possible, warm the room with a heating device.
If the mother is not available, skin-to-skin contact
may be provided by the father or any other adult.
When skin-to-skin contact is not possible:

Keep the room warm with a home heating device.
Clothe the baby in 1–2 layers (summer).
Clothe the baby in 3–4 layers (winter) and cover the
head, hands and feet with a cap, gloves and socks,
respectively.
Let the baby and mother lie together on soft, thick
bedding.
Cover the baby and the mother with an additional
quilt, blanket or shawl in cold weather.
Check the cord for bleeding every 15 minutes.

If the cord is bleeding, re-tie it more tightly.
Do not apply any substance to the stump.
Leave the stump uncovered and dry.
Wipe off any meconium or blood from the baby’s skin.

Encourage breastfeeding within an hour of birth.
Emphasise the importance of colostrum, which helps to protect the baby against
infections.
Check if the baby’s position and his/her attachment to the breast are correct at
the first feed.
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The baby can feed whether the mother is lying down or sitting. What is
important is that both mother and baby should be comfortable.
Do not give artificial teats or pre-lacteal feeds, such as sugar water or local
foods, or even water to the newborn.
Weigh all babies before they leave the delivery room.
Delay the baby’s first bath to beyond 24 hours of birth.
Ensure that the baby is dressed warmly and is with the mother.
Watch for complications such as convulsions, coma and feeding problems. Refer the
baby if these are present.
(Practise Care of the Mother and Newborn - Checklist No. 2.6 in SBA Handbook)
Newborn Resuscitation
Approximately 10% of newborns require some assistance to begin breathing at birth;
about 1% need extensive resuscitative measures to survive.
It is not possible to predict which babies will require resuscitation. It is, therefore,
important to be prepared to resuscitate every newborn.
Resuscitation must be anticipated at each birth. Up to half of newborns who require
resuscitation have no identifiable risk factors before birth. An increased risk of breathing
problems may occur in babies who are:
Pre-term
Born after a long traumatic labour
Born to mothers who received sedation during the late stages of labour
Babies who are not breathing or are gasping need resuscitation.
If the baby needs resuscitation, initiate all the initial steps in the flowchart below within
a few seconds.
Box 13: Equipment used for resuscitation
Bag and mask equipment Self-inflating bag (volume 250–500 ml); face masks, size
0 and 1(cushioned-rim masks preferred)
Suction equipment Mucus extractor/mechanical suction and tubing
Miscellaneous Radiant warmer

Firm, padded resuscitation surface
Warm linen
Clock with a seconds hand
Oxygen source with flowmeter (if available)
Gloves
Shoulder roll
Cord tie/clamp
Sterile blade/scissors
GUIDELINES
54
Newborn Resuscitation
BIRTH
No meconium—dry the baby
Meconium present—suction mouth, nose
(if baby is not crying) and dry the baby
ASSESS BREATHING
Not breathing well Breathing well/crying
Initial steps Routine care

Cut cord Place the baby on mother’s abdomen
Place on firm, flat surface Wipe mouth and nose
Provide warmth Clamp & cut the cord (after 1–3 mins of birth)
Position baby with neck slightly extended Keep baby with mother
Suction mouth and then nose Initiate breastfeeding
Stimulate, reposition Watch colour and breath
Observation/care
Assess breathing Provide warmth
Observe colour, breathing and temperature
Breathing Initiate breastfeeding
well Watch for complications (convulsions, coma,
feeding problems)
Not breathing well Refer when complications develop
Provide bag and mask ventilation for

30 seconds; ensure chest rise. Make
arrangements for referral
Assess breathing
Breathing well
Not breathing well
Call for help and make

arrangements for referral
Continue Bag and Mask
ventilation
Add Oxygen, if available
Assess Heart Rate

(Umblical pulsation: check for 6 sec and
multiply by 10)
Heart Rate > 100
Heart Rate < 100
Continue Ventilation with Oxygen Continue Bag and Mask ventilation

Provide advanced care (chest compression, If breathing well, slowly discontinue
medication and intubation, if a MO, if ventilation and provide observational
adequate, is available) care
Organised Referral
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Figure 10: Correct position of the head for ventilation Steps of resuscitation
1. Provide warmth. Dry and shift the baby to a newborn
corner, and place him/her under a radiant warmer. The baby
should not be covered with a blanket or towels.
2. Position the baby. Place the baby on its back. Position the
head by slightly extending the neck in the sniffing position.
Care should be taken to prevent hyperextension or flexion of
the neck. To help maintain the correct position, you may place
a towel or a rolled blanket under the baby’s shoulders.
3. Clear airway
Suction the mouth first and then the nose, using the mucus extractor/mechanical
suction and tubing.
If mechanical suction is used, gently introduce the suction tube 5 cm into the baby’s
mouth, until the 5-cm mark is at the baby’s lips.
Use suction while withdrawing the tube.
Next, introduce the suction tube 1–2 cm into each nostril.
Use suction while withdrawing the tube and until there is no mucus.
4. Dry, stimulate to breathe and reposition

Often, positioning the baby and suctioning will provide enough stimulation to initiate
breathing. Drying will also provide stimulation. Wet towels should be discarded and
fresh pre-warmed towels should be used for continued drying and stimulation.
Forms of stimulation that are safe and appropriate and provide additional tactile
stimulation include:
Flicking the soles of the feet
Gently rubbing the newborn’s back, trunk or extremities.
If there is still no breathing and you have the resuscitation equipment, start ventilation.
5. Ventilation
Check the following before beginning ventilation:
Select a mask of the appropriate size. It should cover the mouth, nose and tip of the
chin, but not the eyes.
Be sure there is a clear airway.
Position the baby’s head.
Position yourself at the bedside, beside the baby’s head, to use a resuscitation device
effectively. This position leaves the chest and abdomen unobstructed for visual
monitoring of the baby.
Figure 11: Self-inflating bag Use a self-inflating resuscitation bag (Ambu bag). Check
the bag before use.
Use oxygen with an oxygen reservoir (if available) to
increase oxygen delivery to the baby.
GUIDELINES
56
Positioning the bag and mask on the face Figure 12: Correctly positioning the mask on the face
The mask is held on the face with the thumb,
index and/or middle finger, which should
encircle much of the rim of the mask, while the
ring and fifth fingers bring the chin forward to
maintain a patent airway.
An airtight seal between the rim of the

mask and the face is essential to achieve the
ventilation (positive pressure) required to
inflate the lungs. Look for the presence of chest
Figure 13: Ventilation with bag and mask
rise with each ventilation.
Frequency of squeezing the bag

During the initial stages of resuscitation, breaths should be delivered at a rate of
40–60 breaths per minute. To help maintain this rate, try saying to yourself:
Squeeze------- Two-------Three------- Squeeze
If you squeeze the bag and release while you say, ‘Two, three,’ you will probably find
you are ventilating at a proper rate.
If the chest does not expand adequately, it may be due to one or more of the following
reasons:
The seal is inadequate—re-apply the mask to the face and try to form a better seal.
The airway is blocked—correct the baby’s position and clear any secretions present from
the mouth and nose.
Not enough pressure is being given—you may be squeezing the bag with inadequate
pressure. Increase the pressure by squeezing adequately.
6. Assess breathing
Assess breathing again after 30 seconds. If the baby is breathing well, provide observational
care, such as providing warmth. Record the baby’s breathing and temperature and watch for
complications (convulsions, coma, breathing problems).
If the baby is not breathing well, call for help, continue to use the bag and mask, and start
using oxygen if it has not been started earlier and is available.
Assess heart rate:

Feel the pulse in the umbilical cord or listen to the heart beat with a stethoscope while
you stop ventilation for 6 seconds.
Feel the pulse in the umbilical cord where it is attached to the baby’s abdomen.
If no pulse can be felt in the cord, you or your helper must listen over the left side of the
chest with the stethoscope and count the heart beat.
To count the heart rate, count the number of beats in 6 seconds and multiply this by 10. This
can provide a quick estimate of the beats per minute (e.g. if you count 8 beats in 6 seconds,
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the baby’s heart rate is 80 beats per minute). A heart rate of above 100 beats is normal, while
one less than 100 beats per minute is slow.
If the heart rate is 100 or more per minute, continue ventilation and assess breathing. If the
baby is breathing well, slowly discontinue ventilation and provide observational care. If the
heart rate is less than 100 per minute, or if the baby is not breathing well after continued
ventilation, a referral is necessary. A newborn will benefit from transfer only if it is properly
ventilated and kept warm during transport.
×
Resuscitation practices that are not effective or are harmful
These include:
Routine aspiration (suction) of the baby’s stomach at birth
Postural drainage
Squeezing the chest to remove secretions from the airway
Routinely giving sodium bicarbonate to newborns
(Practise Conducting Resuscitation of Newborn - Checklist No. 2.7 in SBA Handbook)
Preparing for discharge (Annexure Vll)

The following should be kept in mind before the baby is discharged. The box below also lists
certain danger signs which require the baby or mother to return for care immediately.
Box 14: Discharge of the mother and the baby

Baby Mother
Ensure that the baby is warm, Ensure that the uterus is hard and is not
breathing normally, and accepting and bleeding.
retaining breast milk, and that the cord
is clean. Counsel the mother about:
Diet and rest
The baby should receive: Exclusive breastfeeding
BCG Need to take iron tablets
OPV – 0 Family planning
Hepatitis B – 0 Hygiene to prevent infection of mother and
her baby
vaccinations preferably before discharge Avoiding sexual intercourse till perineal
from the health facility. A record of these wound heals
vaccinations should be entered in the When to return for follow-up
baby’s card. Complete immunisation of baby
Danger signs—return immediately: Danger signs—return immediately

If baby is breastfeeding poorly Increase in vaginal bleeding
If baby develops fever or feels cold to Convulsions
the touch Fast or difficult breathing
Breathes fast If mother has fever and is too weak to get
Has difficulty in breathing out of bed
Has blood in the stool Severe abdominal pain
If the palms and soles are yellow Swollen, red or tender breasts
Has convulsions Dribbling of urine or inability to pass urine
Pain in the perineum or draining pus
Foul smelling lochia
GUIDELINES
58
Care after Delivery—Post-partum Care
KEY MESSAGES
Mother
• Make at least four post-partum visits to ensure that complications
during the post-partum period are recognised in time.
• Look out for symptoms and signs of PPH and puerperal sepsis during
post-partum visits as they are the major causes of maternal mortality.
• Advise the mother on colostrum feeding and exclusive breastfeeding.
• Advise the couple on family planning.
Newborn
• Keep the baby warm.
• Ensure care of the umbilicus, skin and eyes.
• Ensure good suckling while breastfeeding.
• Screen the newborn for danger signs.
• Advise the mother and family members on immunisation.
Conventionally, the first 42 days (six weeks) after delivery are considered the post-partum
period. The first 48 hours of the post-partum period, followed by the first one week, are
the most crucial period for the health and survival both of the mother and her newborn.
Most of the fatal and near-fatal maternal and neonatal complications occur during this
period. Evidence has shown that more than 60% of maternal deaths take place during the
post-partum period.
Post-partum visits
Number and timing of post-partum visits by ANM/ASHA
Box 15: Post-partum visits

Visits After home delivery/ After delivery at PHC/FRU
delivery at SC (woman discharged after 48 hours)
First visit 1st day (within 24 hours) Not applicable
Second visit 3rd day after delivery 3rd day after delivery
Third visit* 7th day after delivery 7th day after delivery
Fourth visit 6 weeks after delivery 6 weeks after delivery
There should be three additional visits in the case of babies with low birth weight, on
days 14, 21 and 28 (as per the Integrated Management of Neonatal and Childhood
Illness [IMNCI] guidelines).
The first 48 hours after delivery are the most critical in the entire post-partum period.
Most of the major complications of the post-partum period, such as PPH and eclampsia,
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which can lead to maternal death, occur during this period. Hence, a woman who has
just delivered needs to be closely monitored during the first 48 hours. It is your duty
to inform the woman about the importance of staying at the health facility where she
has delivered for at least 48 hours, so that proper care is provided to her. You must
emphasise that monitoring is essential for her and the baby.
If you have not been involved in conducting the delivery, you should go and pay a visit
to the mother during the first 24 hours after delivery or as soon as the woman reaches
her home from the health facility. Ask her for the Mother and Child Protection Card
and or discharge/delivery card (if delivered at an institution). The card will have all the
antenatal and delivery details if she has visited a health facility for antenatal check-ups
and her delivery. Take her history and conduct a quick examination, as described below.
If the woman has delivered at home, find out who attended the delivery and ask the birth
attendant about the delivery. If the birth attendant is not an SBA (for example, she might be
a relative of the woman or a TBA), and is staying with the woman during the initial post-
partum period, explain to her the possible complications that could arise, the symptoms
and signs to look for, and the necessary action to be taken, including referral.
The next most critical period is the first week following the delivery. A considerable
number of complications can occur during this period, both for the mother as well as
the baby. Hence, visits have to be made to the mother and the baby on the 3rd and 7th
days after delivery.
First visit for mother

A. History-taking
This is especially important if you were not present for the delivery. Review the events at
labour and birth to identify any risk factor or events during the birth that may be important
in the management of the mother and the baby. Ask the following:
1. Where did the delivery take place?
2. Who conducted the delivery?
3. Is there a history of :
a. any complications during the delivery?
b. bleeding P/V (how many pads or pieces of cloth are getting soaked with blood)
c. convulsions or loss of consciousness
a. pain in the legs
d. abdominal pain
e. fever
f. dribbling or retention of urine
g. any breast tenderness, etc.
4. Has the mother started breastfeeding the baby?

5. Has she started her regular diet?
6. Are there any other complaints?
B. Examination
1. Check the woman’s pulse, blood pressure, temperature and respiratory rate.
2. Check for the presence of pallor.
GUIDELINES
60
3. Conduct an abdominal examination. Normally, the uterus will be well contracted, i.e.
hard and round. If it is soft and uterine tenderness is present, then refer the woman to
the FRU.
4. Examine the vulva and perineum for the presence of any tear, swelling or discharge of
pus. If any of these is present, refer the woman to the FRU.
5. Examine the pad for bleeding to assess if the bleeding is heavy, and also see if the lochia
is healthy and does not smell foul (for puerperal sepsis). If these signs are present, refer
the woman to the FRU.
6. Examine the breasts for any lumps or tenderness, check the condition of the
nipples and observe breastfeeding. If the woman has any complaints regarding the
condition of her breasts, refer her to the MOs at PHC/FRU. (Refer to Module 2 - Breast
conditions).
C. Management/counselling
Give the woman and her family the following advice:
1. Post-partum care and hygiene

She should have someone near her for the first 24 hours to take care of her and
the baby.
She should wash the perineum daily and after passing stools.
The perineal pads must be changed every 4–6 hours or more frequently if there
is heavy lochia. This is essential to ensure that the woman does not contract any
infection.
Cloth pads should be washed with soap and water and dried in the sun. It is,
however, preferable to use sanitary pads, which can be thrown away.
She should bathe daily.
She should take enough rest and sleep.
She should wash her hands before and after handling the baby, especially after
cleaning and before feeding the baby.
Rooming in of the mother with the baby is advisable.
Advise the mother on how to look after her newborn, e.g. how to bathe the newborn,
maintain warmth and exclusive breastfeeding.
2. Nutrition
She should increase her intake of food and fluids.
Advise her to refrain from observing taboos that exist in the community
against nutritionally healthy foods (e.g. the taboo against eating solid food for
six days).
Talk to the woman’s family members, such as her husband and mother-in-law, to
encourage them to ensure that she eats enough and avoids heavy physical work.
3. Contraception
Advise the couple regarding the return of fertility.
Advise the couple on birth spacing or limiting the size of the family.
Advise the couple to abstain from sexual intercourse for about 6 weeks post-partum,
or till the perineal wounds heal.
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4. Breastfeeding
Ask the mother whether breastfeeding was initiated within one hour of the birth.
If breastfeeding is still not initiated, then assist her in breastfeeding the baby
immediately.
Observe breastfeeding and check if there is good attachment and effective
suckling.
Advise her to feed the baby colostrum.
Ask her to breastfeed in a relaxed environment, free from any mental stress.
Explain that breast milk is sufficient and the best for the baby. Stress exclusive
breastfeeding and demand feeding.
She should breastfeed frequently, i.e. at least 6–8 times during the day and 2–3
times during the night. She should not give water or any other liquid to the baby.
Emphasise that breast milk is enough in quantity to satisfy the baby’s hunger and
that the baby does not even require water while on breastfeeds.
She should breastfeed from both breasts during a feed. The baby should finish
emptying one breast to get the rich hind milk before starting on the second breast.
Breastfeeding problems:
If the mother is having difficulty breastfeeding, teach her the correct position
to ensure good attachment.
If the nipples are cracked or sore, she should apply hind breast milk, which has
a soothing effect, and ensure correct positioning and attachment of the baby.
If she continues to experience discomfort, she should feed expressed breast
milk with a clean spoon from a clean bowl.
Figure 14: Expressing breast milk If the breasts are engorged, encourage the mother to let
the baby continue to suck without causing too much
discomfort to the mother. Putting a warm compress on
the breast may help to relieve breast engorgement.
If an abscess is suspected in one breast, advise the mother
to continue feeding from the other breast and refer her to
the FRU.
Massaging the breast

Pre-lacteal feeds should not be given.
5. Registration of birth
Explain the importance of getting the birth of the baby
registered with the local panchayat. This is a legal document.
The child will require the birth certificate for many purposes
in the future, e.g. school admission.
6. IFA supplementation
She should take one IFA tablet daily for three months.
If she was anaemic prior to the delivery, recheck her Hb
level.
Express breast milk by pressing thumb and If Hb < 11g/dl, then advise her to take two IFA tablets daily
other fingers in towards the body for three months and if after one month her Hb level hasn’t
improved, refer her to PHC
If Hb is < 7 g/dl refer to FRU.
GUIDELINES
62
7. Danger signs
Counsel the mother to go directly to the FRU without waiting if she notices the
following danger signs:
Excessive bleeding, i.e. soaking more than 2–3 pads in 20–30 minutes after
delivery.
Convulsions
Fever
Severe abdominal pain
Difficulty in breathing
Foul-smelling lochia
First visit for baby

A. History-taking
This is especially important if you were not present at the delivery. Keep the following in
mind and ask the mother/relative taking care of the mother and baby:
1. When did the child pass urine and meconium?

2. Has the mother started breastfeeding the baby and are there any difficulties in
breastfeeding?
3. Is there a history of problems such as the following:
The baby has fever.
The baby is not suckling well (could have ulcers or white patches in the mouth—
thrush).
The baby has difficulty in breathing.
The umbilical cord is red or swollen, or is discharging pus.
The movements of the newborn are less than normal (normally, newborns move
their arms or legs or turn their head several times in a minute).
There is skin infection (pustules)—red spots which contain pus or a big boil.
There are convulsions.
4. Are there any other complaints?

5. If any of the above problems is present, refer the newborn to the FRU. However,
there is no need for referral in case of umbilical discharge or if the number of skin
pustules is less than 10. Provide home treatment, as detailed in IMNCI guidelines
for these problems and refer the baby to the FRU only if there is no improvement
after two days.
B. Examination
1. Count the respiratory rate for one minute. The normal respiratory rate is 30-60 breaths
per minute. If it is less than 30 breaths per minute or more than 60 breaths per minute,
refer the baby to the FRU as per the steps for referral set forth in Box 17.
(Practise ‘How to Count Respiratory Rate’ – Checklist No. 3.1 in SBA Handbook)
2. Look for severe chest indrawing:

Mild chest indrawing is normal in an infant because the chest wall is very soft.
Severe chest indrawing (lower chest wall goes in when the infant breathes in) is a
sign of pneumonia and is serious in an infant.
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Refer the baby to an FRU as per the steps for referral set forth in Box 17.
(Practise ‘How to Look for Chest Indrawing’ – Checklist No. 3.1 in SBA Handbook)
3. Check the baby’s colour:

Check for pallor.
Check for jaundice. It is not normal if appears less than 24 hours after birth and the
palms and soles are yellow. Refer the baby to an FRU as per the steps for referral
detailed in Box 17.
(Practise ‘How to Look for Jaundice’ – Checklist No. 3.1 in SBA Handbook )
Check for central cyanosis (blue tongue and lips). This is an abnormality and such
cases need to be urgently referred. Follow the steps for referral detailed in Box 17.
4. Check the baby’s body temperature. The temperature can be assessed by recording the
axillary temperature or feeling the infant’s abdomen or axilla.
If the temperature is less than 36.5º C or above 37.4º C, the newborn needs to
be urgently referred to an FRU, as per the steps for referral listed in Box 12.
(Practise ‘How to Check Temperature – Checklist No. 3.1 in SBA Handbook)
5. Examine the umbilicus for any bleeding, redness or pus. If there is any, provide treatment
and refer the baby to an FRU if there is no improvement after two days.
6. Examine for skin infection:

Red rashes on the skin may be seen 2–3 days after birth. These are normal.
If there are 10 or more pustules (red spots or blisters which contain pus) or a big
boil/abscess, refer the newborn to the FRU immediately.
7. Examine the newborn for cry and activity:

If the newborn is not alert and/or has a poor cry; is lethargic/unconscious; or if the
movements are less than normal, he/she needs to be referred to the FRU.
8. Examine the eyes for discharge. Check if they are red or if the eyelids are swollen. Provide
treatment and refer the baby to the FRU if there is no improvement after two days.
9. Examine for congenital malformations and any birth injury. If there are any, refer the
newborn to the FRU.
Give the mother the following advice:
1. She should maintain hygiene while handling the baby.
2. She should delay the baby’s first bath to beyond 24 hours after birth.
3. In cool weather, the baby’s head and feet should be covered and he/she should be dressed
in extra clothing. The baby must be kept warm at all times.
4. She should not apply anything on the cord, and must keep the umbilicus and cord dry.
5. She should observe the baby while breastfeeding and try to ensure proper/good attachment.
Good attachment of the baby to the mother’s breast: Ensure that the baby’s mouth is
attached correctly to the breast.
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Box 16: Signs of good attachment of the baby to the mother’s breast
The four signs of good attachment are:

1. Chin touching breast (or very close)
2. Mouth wide open
3. Lower lip turned outward
4. More areola visible above than below the mouth
Figure 15: A baby well attached to the Figure 16: A baby poorly attached to the
mother’s breast mother’s breast
Poor attachment results in the following:

It causes pain and/or damage to the nipples, leading to sore nipples.
The breast does not get completely emptied of milk, resulting in breast
engorgement.
The milk supply becomes poor, so that the baby is not satisfied and is irritable after
feeding.
The baby does not put on enough weight.
If the baby is having the following problems, take him/her immediately to the MO at the
FRU:
The baby is not breastfeeding.
The baby looks sick (lethargic or irritable).
The baby has fever or feels cold to the touch.
Breathing is fast or difficult.
There is blood in the stools.
The baby looks yellow, pale or bluish.
The baby’s body is arched forward.
The movements of the body, limbs or face are irregular.
The umbilicus is red, swollen or draining pus.
The baby has not passed meconium within 24 hours of birth.
There is diarrhoea.
Counsel the mother on where and when to take the baby for immunisation.
(Annexure l – Mother and Child protection card and Immunisation schedule)
(Practise conducting Care of the Mother and Newborn during 1st Post-partum Visit –
Checklist No. 3.1 in SBA Handbook)
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Second and third visits for mother
A. History-taking
A similar history needs to be taken as during the first visit. Apart from the questions asked
during the first visit, also ask the mother the following:
Is there continued bleeding P/V? This, i.e. post-partum bleeding occurring 24 hours or
more after delivery, is known as ‘delayed’ PPH. (Manage as indicated in ‘PPH’, Module 2.)
Is there foul-smelling vaginal discharge? This could be indicative of puerperal sepsis.
(Manage as indicated in ‘Puerperal sepsis’, Module 2.)
Has there been any fever?
Is there a history of swelling (engorgement) and/or tenderness of the breast? (Refer to
‘Breast conditions’ Module 2.)
Is there any pain or problem while passing urine (dribbling or leaking)?
Is there fatigue and is she ‘not feeling well’?
Does she feel unhappy or cry easily? This indicates post-partum depression, and usually
occurs 4–7 days after delivery. Assure her that everything will be fine and refer her to the
MO only if the problem persists.
B. Examination
This is similar to the examination conducted during the first visit. It includes the following:
Check the pulse, blood pressure and temperature.
Check for pallor.
Conduct an abdominal examination to see if the uterus is well contracted (hard and
round), and to rule out the presence of any uterine tenderness. If there is a problem,
refer the woman to the FRU.
Examine the vulva and perineum for the presence of any swelling or pus. If either of
these is present, refer her to the FRU.
Examine the pad for bleeding and lochia. Assess if it is profuse and whether it is foul-
smelling. If so, refer her to the FRU.
Examine the breasts for the presence of lumps or tenderness. If either is present, then
refer her to the FRU.
Check the condition of the nipples. If they are cracked or sore, manage as described
earlier.
Diet and rest
Inform the mother that during lactation, she needs to eat more than her normal
pre-pregnancy diet. This is because she needs to regain her strength during the
period of exclusive breastfeeding and also for her baby to derive its full nutritional
requirements from breast milk.
She should be advised to take foods rich in calories, proteins, iron, vitamins and
other micro-nutrients (milk and milk products, such as curd and cottage cheese;
green leafy vegetables and other seasonal vegetables; pulses; eggs; meat, including
fish and poultry; groundnuts; ragi; jaggery; fruits, such as mango, guava, orange,
sweet lime and watermelon).
GUIDELINES
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The taboos on food imposed by the family and community are usually stronger
and greater in number in the post-partum period and during lactation than during
pregnancy. These should be enquired into and the mother advised against following
them if they are harmful to her and/or her baby.
The mother needs sufficient rest during the post-partum period; to be able to
regain her strength. Advise her to refrain from doing any heavy work during the
post-partum period, and to focus solely on looking after herself and her baby. Her
family members should also be advised to ensure this.
Contraception
Inform the mother that whenever her periods begin again and/or she stops exclusive
breastfeeding, she can conceive even after a single act of unprotected sex.
Inform the couple about the various choices of contraceptive methods available
and help them choose the method most suitable to them. (Refer to Annexure V—
Post-partum family planning.)
Second and third visits for baby

A. History-taking
The same questions should be asked during history-taking as during the first post-
partum visit. If any of the problems inquired about is present, refer the baby to the
FRU.
B. Examination
Observe the baby and record the following:
Whether he/she is sucking well
If there is difficulty in breathing (fast or slow breathing and chest indrawing).
If there is fever or the baby is cold to the touch.
If there is jaundice (yellow palms and soles)
Whether the cord is swollen or there is discharge from it
If the baby has diarrhoea with blood in the stool
If there are convulsions or arching of the baby’s body
Refer the baby to the PHC/FRU if any of the above is present.
In addition to the lines along which counselling was provided during the first visit, counsel
the mother on the following:
She should exclusively breastfeed the baby for six months.
She should feed the baby on demand.
She should be encouraged to “room in”.
Supplementary foods should be introduced at 6 months of age. She can continue
breastfeeding simultaneously.
Also talk to the mother about the following:

Baby’s weight loss: The baby loses a little weight in the first three days after birth. This is a
normal process and the mother should not worry about it. After the third day, the baby
starts gaining weight and regains its birth weight by the first week.
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Hygiene of the baby: While bathing the baby, special attention should be paid to the
head, face, skin flexures, cord and napkin area. These should be dried properly with soft
cloth.
When and where to seek help in case of signs of illness: Inform the mother when to seek
help and where to go in case the baby shows any signs of illness.
Immunisation: The baby should be immunised as per the Universal Immunisation
Programme (see Annexure I.a —Vaccination chart for infants and children).
(Practise conducting Care of the Mother and Newborn during 2nd & 3rd Post-partum Visit
– Checklist No 3.2 in SBA Handbook)
Fourth visit for mother

A. History-taking
Ask the mother the following:
Has the vaginal bleeding stopped?
Has her menstrual cycle resumed?
Is there any foul-smelling vaginal discharge?
Does she have any pain or problem while passing urine (dribbling or leaking)?
Does she get easily fatigued and/or ‘does not feel well’?
Is she having any problems with breastfeeding?
B. Examination
This examination includes the following:
Check the woman’s blood pressure.
Check for pallor.
Examine the vulva and perineum for the presence of any swelling or pus.
Examine the breasts for the presence of lumps or tenderness. If either is present, refer
her to the MO.
Diet and rest:
As in the second and third visits, emphasise the importance of nutrition.
Contraception:
Emphasise the importance of using contraceptive methods for spacing or limiting
the size of the family.
Fourth visit for baby

A. History-taking
Ask the mother the following:
Has the baby received all the vaccines recommended so far?
Is the baby taking breastfeeds well?
How much weight has the baby gained?
Does the baby have any kind of problem?
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B. Examination
Check the weight of the baby.
Check if the baby is active/lethargic.
Emphasise the importance of exclusive breastfeeding.
Tell the mother that if the baby is having any of the following problems, he/she should
be taken immediately to the MO at the FRU.
The baby is not accepting breastfeeds.
He/she looks sick (lethargic or irritable).
The baby has fever or feels cold to the touch.
The baby has convulsions.
Breathing is fast or difficult.
There is blood in the stools.
The baby has diarrhoea.
Counsel the mother on where and when to take the baby for further immunisation.
(Practise Post-partum Care - Checklist 3.1 and 3.2 in SBA Handbook)
Box 17: Steps for transfer and referral of the baby
If the baby needs to be transferred to a 24 hour PHC/FRU, ensure that the transfer is safe
and timely. It is important to prepare the baby for the transfer, communicate with the
receiving facility and provide care during the transfer.
Preparation
Explain to the family the reason for transferring the baby to a higher facility.
If possible, transfer the mother with the baby so that she can continue to breastfeed or
provide expressed breast milk.
You or another health care worker should accompany the baby.
Ensure that the baby is not exposed to heat or cold.
Ask a relative to accompany the baby and mother, if possible.
Communication
Fill up a referral form with the baby’s essential information and send it with the baby.
If possible, contact the health care facility in advance so that it can be prepared to
receive the baby.
Care during transfer

Keep the baby in skin-to-skin contact with the mother. If this is not possible, keep the
baby dressed and covered and have the mother/relative accompany you.
In hot weather, ensure that the baby does not become overheated.
Ensure that the baby receives breastfeeds. If the baby cannot be breastfed, give
expressed breast milk with a clean spoon or from a cup.
Maintain and clear the airway, if required.
If the baby is receiving oxygen, check the oxygen flow and tubing every 15 minutes.
Assess the baby’s respiratory rate every 15 minutes. If the baby is not breathing at all,
is gasping or has a respiratory rate of less than 30 breaths per minute, resuscitate him/
her using a bag and mask.
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Module II
Management of
Complications during
Pregnancy, Labour and
Delivery, and in the
Post-partum Period
Management of Complications during Pregnancy,
Labour and Delivery, and in the Post-partum Period
KEY MESSAGES
• Educate the woman, her family and the community regarding the danger
signs during pregnancy, labour and delivery and the post-partum period.
• Make local arrangements for transporting the woman to a higher health
facility should the need arise.
• Always refer the woman to the appropriate health facility with a referral slip.
• Encourage and prepare the family members to donate blood should the
need arise
• Do not carry out a vaginal examination on women who have bleeding during
pregnancy beyond 12 weeks.
• Manage PPH by giving intravenous Oxytocin (20 IU) in 500 ml of Ringer
Lactate at the rate of 40–60 drops per minute and refer the woman to a
higher health facility immediately.
• Unless proven otherwise, assume that all cases of convulsions during
pregnancy, labour and the post-partum period are due to eclampsia.
Magnesium sulphate injection is the drug of choice for controlling
eclamptic fits.
Vaginal bleeding
Vaginal bleeding can occur during pregnancy, delivery or in the post-partum period.
Types of vaginal bleeding:

a. Early pregnancy (before 20 weeks of pregnancy).
b. Late pregnancy (after 20 weeks of pregnancy) or APH
c. PPH—blood loss of 500 ml or more following and up to six weeks after delivery
Types of PPH:
Immediate PPH/primary PPH—during and within 24 hours of delivery
Delayed PPH/secondary PPH—after 24 hours of delivery until six weeks post-
partum
A. Vaginal bleeding in early pregnancy

This refers to vaginal bleeding before 20 weeks of pregnancy.
The probable causes could be a threatened or spontaneous abortion, an ectopic pregnancy or a
hydatidiform mole. In some cases, it may be a very early pregnancy, and the woman might not
even be aware that she is pregnant. On the other hand, the woman might not be pregnant, and
the vaginal bleeding might instead be menorrhagia (excessive bleeding during periods).
Incomplete spontaneous abortion

The following are the signs of incomplete spontaneous abortion:
• There is heavy bleeding and lower abdominal pain.
• There is a history of expulsion of the products of conception (POC).
• Abdominal examination shows the presence of uterine tenderness and the fundal height
is less than the period of gestation.
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Management of Complications during Pregnancy, Labour and Delivery, and in the Post-partum Period
II
• Management:
If retained POC are seen in the vagina, remove them gently with a finger. The
procedure must be carried out under aseptic conditions.
If the bleeding does not stop and/or the woman is in shock, establish an intravenous
line immediately and give intravenous fluids rapidly.
Send the woman to the MO with a referral slip.
Complete abortion
The following are the signs of complete abortion:
• There is light bleeding or there has been heavy bleeding which has now stopped.
• There is lower abdominal pain.
• There is a history of expulsion of POC.
• Abdominal examination shows a uterus that is softer than normal, and the fundal height
is less than the period of gestation.
• Management:
Observe the woman for 4–6 hours. Advise her to take rest.
If the bleeding decreases or stops, explain the facts to her, reassure her and advise
her to go home after you have checked her vital signs.
Advise her to return to you or the MO if the bleeding recurs.
Threatened abortion
The following are the signs of threatened abortion:
• There is light bleeding.
• The woman complains of lower abdominal pain.
• There is no history of expulsion of POC.
• Abdominal examination shows the uterus to be softer than normal, and the fundal
height corresponds to the period of gestation.
• On P/V examination, the cervical os is found to be closed.
• Management:
If the bleeding decreases or stops, explain the facts to the woman, reassure her and
advise her to go home after you have checked her vital signs.
Advise her to avoid strenuous exercise/work and to avoid sexual intercourse.
Advise her to take bed rest.
Send her to the MO with a referral slip for further advice.
Care and advice after an abortion

The care of a woman who has been through an abortion consists of the following and she
should be advised as described below.
Follow up: Advise the woman to return for follow up and to go directly to the MO for
treatment if:
There is increased bleeding.
The bleeding does not decrease even after a week.
There is foul-smelling vaginal discharge.
There is abdominal pain.
She has a fever and feels unwell.
There is weakness, dizziness or fainting.
GUIDELINES
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Self-care: The woman must be given advice on self-care
Ask her to rest for a few days, especially if she is feeling tired.
Advise her to use disposable sanitary napkins, if available. If not, then she should change
the cloth/pad every 4–6 hours. The cloth should be washed with soap and water and
dried in the sun.
She should wash the perineum daily with soap and water.
Advise her to avoid sexual intercourse until the bleeding stops.
Family planning: Give the woman advice on family planning methods

Explain to her that she can conceive soon after the abortion if she resumes sexual
intercourse, unless she uses a contraceptive.
Any family planning method can be used after a first-trimester (up to 12 weeks’ gestation)
abortion.
If the woman has an infection, the insertion of an IUCD or female sterilisation should
be delayed till the infection is treated completely.
Give advice on the correct and consistent use of condoms if she or her partner is at risk
for STI or HIV infection.
Address her concerns regarding future pregnancy through counselling.
Tell the woman that if, after the abortion, there is a delay of six weeks or more in the resumption
of her menstrual cycle, she should go to the MO for an examination and advice
B. Vaginal bleeding in late pregnancy (APH)

Vaginal bleeding any time after 20 weeks of pregnancy is called APH. The most serious
causes are placenta praevia (placenta lying at or near the cervix), abruptio placentae
(detachment of the placenta before the birth of the foetus) or a ruptured uterus. Any
bleeding (light or heavy) at this time of pregnancy is dangerous.
Remember
P/V should not be performed in women who have bleeding during pregnancy beyond 20 weeks.
Immediate management of bleeding in late pregnancy:
Establish an intravenous line and start intravenous fluids (Ringer lactate/normal saline).
Refer the woman to an FRU which has facilities for blood transfusion.
(Practise Management of Vaginal Bleeding in Early pregnancy - Case study No. 4 and 5 Checklist No. 4.1 in
SBA Handbook)
C.1. Bleeding during and within 24 hours of delivery (immediate PPH)

PPH is defined as the loss of 500 ml or more of blood during or within 24 hours of the birth
and up to six weeks after delivery.
PPH may be immediate or delayed.

Immediate PPH may be due to a number of causes, such as:
Atonic uterus
Tears in the lower vagina, cervix or perineum
Retained placenta or placental fragments
Inverted or ruptured uterus
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The following flowchart gives the method by which the cause of immediate PPH can be diagnosed
and managed. You have to ascertain from the records whether oxytocin injection has been given as
part of the AMTSL.
Management of PPH
Shout for Help: Mobilise all available health personnel.

Evaluate Vital Signs: Pulse, BP, respiration and temperature
Establish IV. Line (draw blood for blood grouping & cross matching and catheterise
the bladder, if at health facility).
Start rapid infusion of Normal Saline/Ringer Lactate & 1L in15-20min, if possible
Massage the uterus to expel the clots.
Give Oxygen @ 6-8 L per minute by mask (if at health facility)
Monitor Vital Signs and blood loss (every 15 minutes)
Monitor fluid intake and urinary output.
Check to see if placenta has been expelled
Placenta not delivered Placenta delivered
Retained Placenta Examine placenta & membranes

for completeness
Inj Oxytocin 20 IU in
500 ml RL @ 40-60
drops per minute and Complete Not Complete
refer to FRU* (A portion of the maternal surface missing or
there are torn membrances & vessels, suspect
Feel the consistency of retained placental frgaments)
Uterus Per Abdomen
Remove retained pieces of placenta

Uterus well contracted. Soft and flabby Uterus & membranes digitally or with
(Traumatic PPH) (Atonic PPH) sponge holding forceps, under
supervision of M.O.
Look for tears/lacerations Administer Uterotonics

in vagina/cervix. continue Uterine massage Observe and assess
Inj Oxytocin 20 U in 500ml bleeding
of RL/DNS-I/V
Pack the vagina and refer to FRU*
Bimanual Compression of Uterus
Hardening of the uterus felt Patient still bleeding & uterus remains flabby
Continue uterine massage & Oxytocin drip and refer to FRU*
Refer to FRU*
*Steps for Referral:

Referral should be made with Referral Slip (Annexure III) with I.V. line intact and
all interventions recorded.
Preferably a Health worker should accompany the patient to referral institution
Telephone message should be conveyed to the Referral Institution/Doctor with
information on Patient’s Blood Group and status.
GUIDELINES
76
The general steps to be taken for the management of PPH, before referring the woman to
an FRU, are as follows.
Evaluate her general condition and look for signs of shock (cold, clammy skin), check
the level of consciousness, pulse (should not be weak or fast, at 110 per minute or more),
blood pressure (systolic should not be less than 90 mmHg), respiration (the RR should
not be more than 30 breaths per minute) and temperature
Monitor the vital signs every 15 minutes and estimate the amount of blood loss.
Try and ascertain the cause of PPH using the flowchart given above.
Give the woman an Oxytocin injection (10 IU, intramuscular stat). (If she has already
received a prophylactic Oxytocin injection or a Misoprostol tablet during AMTSL, this
is not required).
Massage the uterus to expel blood and blood clots. Blood clots trapped in the uterus will
inhibit effective contractions.
Establish an intravenous line and start an intravenous infusion of Ringer Lactate or
normal saline. Do not use dextrose solutions unless others are unavailable.
Add 20 IU of oxytocin to 500 ml of Ringer Lactate/normal saline that is running
intravenously at the rate of 40–60 drops per minute. (If an intravenous line cannot be
established, give her an intramuscular Oxytocin injection(10 IU) stat).
If the bleeding persists and the uterus continues to be in the relaxed state (i.e. it is soft),
make arrangements for transporting the woman to the FRU, where facilities for blood
transfusion and appropriate surgical care are available.
Do not give the woman anything to eat or drink since she may require an obstetric
intervention under anaesthesia.
If the woman is bleeding heavily, i.e. soaking one pad or cloth in less than five
minutes, or if she is in shock, give her fluids rapidly (60 drops per minute) through
another drip.
Raise the foot end of the bed so that her head is lower than her body. This will help
increase the flow of blood to the heart.
Keep the woman warm and covered with a blanket. If she is in shock, she might feel cold
even in warm weather.
Utilise the intervening time to perform bimanual
compression. Figure 17: Bimanual Compression
Uterus is pressed between hands
Steps of Bimanual compression are: Left hand placed on abdomen
Use a Foley catheter (preferable)/Plain catheter to
Bladder empty
catheterise and empty the urinary bladder. Right hand placed in vagina
Use a pair of sterile gloves.
Insert a gloved hand in the vagina and remove any
clots from the lower part of the uterus or the cervix.
Form a fist and place it in the anterior vaginal fornix and
apply pressure against the anterior wall of the uterus.
Ensure that family members/attendants accompany the
woman to the FRU. You should also accompany her, if
possible.
Arrange for two or three donors to donate blood in case
a blood transfusion is required. The donors should also
accompany the woman during referral.
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On the way to the FRU, try and estimate the amount of blood lost (by counting the
number of pads soiled).
Remember that the interval from the onset of PPH to death can be as little as two
hours, unless appropriate life-saving steps are taken immediately.
C.2. Bleeding 24 hours after delivery (delayed/secondary PPH)

Delayed PPH refers to bleeding which occurs 24 hours after delivery up to six weeks post-
partum. It could be due to retained clots or placental fragments, or due to an infection in
the uterus.
Management
Give an Oxytocin injection (10 IU, intramuscular) stat.
Start an intravenous infusion: inject 20 IU of Oxytocin into 500 ml of Ringer Lactate/
normal saline and administer at the rate of 40–60 drops per minute.
An infection is suspected if there is fever and/or foul-smelling vaginal discharge. Give
the woman the first dose of antibiotics (Ampicillin capsule, 1g orally; Metronidazole
tablet, 400mg orally; and a Gentamicin injection, 80mg intramuscular stat).
Refer the woman to the FRU.
(Practise Management of Shock and Vaginal bleeding after delivery – Case study 6 and How to establish
an IV line – Checklist 4.7 in SBA handbook)
Pregnancy-induced hypertension
PIH includes:
Hypertension—systolic blood pressure of 140 mmHg or more and/or diastolic blood
pressure of 90 mmHg or more, on two consecutive readings taken four hours or more
apart
Pre-eclampsia—hypertension with proteinuria
Eclampsia—hypertension with proteinuria and convulsions
Measure the woman’s blood pressure during every antenatal and postnatal visit. If it
is high (more than 140/90 mmHg), check it again after four hours. If the situation is
urgent, the blood pressure should be measured after one hour.
If the woman has hypertension, check her urine for the presence of proteins. The
combination of a raised blood pressure and proteinuria is sufficient to categorise the
woman as having pre-eclampsia.
Refer the woman to the 24 hour PHC/FRU so that she can receive anti-hypertensive
medication. She should be managed at home as per the advice of the MO.
Keep in touch with the woman or her family, and undertake appropriate follow up of
these cases.
GUIDELINES
78
Box 18: Follow-up care of women with pre-eclampsia
Advise the woman to come to you for a check-up twice a week regularly.
Monitor her blood pressure, her urine for the presence of proteins, and the foetal
condition.
Encourage her to take rest.
Encourage her to take a normal diet. She should not be advised to restrict her intake of
salt and fluids.
Advise her to go for an institutional delivery.
Inform her family members to take her urgently to the PHC/FRU if there are danger
signs such as:
Headache (increasing in frequency and duration)
Visual disturbances (blurring, double vision, blindness)
Oliguria (passing less than 400 ml urine in 24 hours)
Upper abdominal pain
Oedema, especially of the face, sacrum/lower back
Women who have a history of hypertension in previous pregnancies have a greater
chance of having a raised blood pressure in the present pregnancy also.
(Practise Management of PIH - Case study No. 7 and Checklist No. 4.3 and 4.8 in SBA
Handbook)
Convulsions—Eclampsia
Convulsions that occur during pregnancy, delivery or in the post-partum period should be
assumed to be due to eclampsia, unless proved otherwise.
Eclampsia is characterised by:
Convulsions
High blood pressure (a systolic blood pressure of 140 mmHg or more and/or a
diastolic blood pressure of 90 mmHg or more)
Proteinuria +2 or more.
Keep in touch with the woman or her family and undertake appropriate follow up of
the cases.
If the woman has convulsions, offer supportive care. The initial management of convulsions
includes the following:
Ensure that the airway is clear and she is breathing well
If the woman is unconscious, position her on her left lateral side to reduce the risk
of aspiration (vomitus and blood).
Clean the mouth and nostrils by applying gentle suction and remove the
secretions.
Remove any visible obstruction or foreign body from her mouth.
Keep a padded mouth gag between the upper and lower jaw to prevent tongue bite (do
not attempt this during a convulsion).
Administer the first dose of Magnesium Sulphate injection (as described below).
Keep her in the left lateral position.
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The first dose of Magnesium Sulphate injection:
Magnesium Sulphate injection has been provided in your kit (Magnesium Sulphate
50% w/v, 1 g in each 2 ml vial).
A 22-gauge needle and a 10 cc syringe has been provided in your kit.
Inform the woman, if she is conscious, that she may feel warm during the injection.
Inject 10 ml (5 g) of Magnesium Sulphate in each buttock (a total of 20 ml (10 g).
Ensure that this is given deep intramuscularly because otherwise, an abscess can form
at the site of injection.
After receiving the injection, the woman may have flushing, may feel thirsty, get a
headache, feel nauseous or even vomit.
Do not repeat the dose of Magnesium Sulphate.
Do not leave the woman alone. The presence of an attendant is mandatory.

Protect the woman from fall or injury.
Maintain a record of the vital signs.
Immediately arrange to refer the woman to an FRU and ensure that she reaches the FRU
as early as possible, preferably within two hours of receiving the first dose of Magnesium
Sulphate injection.
Accompany the woman to the FRU, if possible. Manage any convulsions that may occur
on the way.
If delivery is imminent, you may not have the time to transport the woman to an FRU. In
this case, deliver the baby after giving the first dose of Magnesium Sulphate injection. After
the delivery, you must refer her, together with the baby, to the FRU for further management.
(Practise Management of Convulsions in Eclampsia - Case study No. 8 and Checklist No. 4.4 and 4.6 in SBA
Handbook)
Anaemia
A haemoglobin level of less than 11 g/dl at any time during pregnancy or the post-partum
period is termed anaemia. A haemoglobin level of less than 7 g/dl is severe anaemia.
Prophylactic treatment against anaemia, in the form of IFA tablets, should be given to
every pregnant woman from the second trimester onwards. Each tablet should contain
100 mg elemental iron and 0.5 mg folic acid, and the dosage should be one tablet daily
for three months. The prophylactic treatment against anemia should be continued for
three months even in the post-partum period
All women with anaemia (haemoglobin less than 11g/dl) must be given the therapeutic
dose of IFA, i.e. one tablet twice a day, a period of at least 100 days (three months).
The treatment should be continued till the level of haemoglobin rises. The therapeutic
dosage of IFA should be continued for three months even in the post-partum period.
The woman should be given dietary advice regarding foods rich in iron, e.g. green leafy
vegetables, eggs, meat, lentils, beans and nuts. Foods rich in Vitamin C, such as citrus
fruits, increase the absorption of iron. Anaemic women should be advised to increase
their overall dietary intake.
A woman with severe anaemia and/or severe palmar/conjunctival/nail pallor, along
with any of the following, should be referred to the FRU for detailed tests and a blood
transfusion, if necessary:
30 breaths or more per minute
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Easy fatigability
Breathlessness even at rest
A woman with severe anaemia must deliver in an institutional setting.
Urinary tract infection

When a woman complains of fever and/or burning on urination and/or pain in either of the
flanks, UTI should be suspected.
Ask her to drink plenty of water and fluids.
Refer her to the MO for further management.
Pre-term labour
Pre-term labour is defined as the onset of labour prior to the completion of 37 weeks
of gestation.
If the delivery is not imminent, i.e. there is enough time to transport the woman, refer
her to the FRU. This is because the newborn may need specialised care, which might not
be possible at the domiciliary level/SC.
If the delivery is imminent, perform the delivery and refer the woman and baby to
the FRU, where facilities for neonatal care are available. The risk to the baby’s life
under such circumstances should be explained to the mother and the family. Do take
appropriate measures for thermal protection and early initiation of breastfeeding
during transport.
Premature or pre-labour rupture of membranes (PROM)

PROM is the rupture of membranes (bag of waters) before labour has begun. It can
occur either when the foetus is immature (before 37 weeks) or when it is it is mature
(term).
The woman may complain of watery fluid-like discharge P/V (leaking), which may be a
slight trickle or a gush of water before the onset of labour.
Ask her when the LMP was and calculate the gestational age.
Examine the discharge/fluid on her underwear/pad (if there is no evidence of fluid/
discharge, give her a pad to wear and assess again after an hour) for evidence of the
following:
Amniotic fluid: Amniotic fluid has a typical odour, by which one can confirm
whether it is a case of PROM. If amniotic fluid is present, assess its colour, i.e.
whether it is greenish or colourless. A greenish colour indicates foetal distress.
Foul-smelling vaginal discharge.
If the membranes rupture after 37 weeks and there is no fever or foul-smelling discharge,
it could signify the beginning of labour. If the woman plans to deliver in a health facility,
refer her to the FRU. If she plans to deliver at home or an SC, wait for the uterine
contractions to begin. If the contractions start within 8–12 hours of the rupture of the
membranes, manage the case like a normal delivery.
Refer the woman to the FRU in the following cases:
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If the membranes rupture after 37 weeks of pregnancy and labour pains do not start
even after 12 hours.
If the membranes rupture before 37 weeks (there is a risk of ascending infection,
resulting in uterine and foetal infection)
If the woman has fever (temperature of above 38°C), or has foul-smelling vaginal
discharge (indicates infection)
In the above conditions, before referral, give the woman the first dose of antibiotics (ampicillin
capsule, 1 g orally; Metronidazole tablet, 400 mg orally; and Gentamicin injection, 80 mg
intramuscular stat).
Foetal distress
Foetal distress indicates foetal hypoxia (lack of oxygen in the blood).
It can be diagnosed by:
Abnormal FHR (<120 or >160 beats/minute)
Meconium-stained amniotic fluid
Check the FHR every 15 minutes.

If the FHR remains below 120 or above 160 beats per minute even after 30 minutes and
the woman is in early labour, then do the following:
Explain the situation to the family.
Start an intravenous line with Ringer Lactate.
Administer intranasal oxygen, if available.
Keep the woman lying on her left side throughout the time she is being
transported.
Refer her to an FRU, which has facilities for the resuscitation of newborns.
If the FHR remains below 120 or above 160 beats per minute even after 30 minutes; the
woman is in late labour and delivery is imminent; and there is no time for transportation,
then do the following:
Call for assistance (MO, if available or any other person trained in care during
pregnancy and child birth).
While conducting the delivery, monitor the FHR after every contraction. If it does
not return to normal, explain to the woman and her family that the baby may not
be well.
Be prepared to resuscitate the newborn.
Let the assistant manage the woman after the delivery while you focus on the
process of neonatal resuscitation.
Obstructed labour
When the foetus cannot be delivered via the natural passage due to mechanical
obstruction, labour is said to be ‘obstructed’. Obstructed labour is a major obstetric
emergency and causes a high proportion of maternal and neonatal deaths.
With proper antenatal care and close monitoring of labour with a partograph, the problem
of obstructed labour can be avoided altogether.
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Ideentifying Obstructed Labour
Strong uterine contractions not leading to descent of the presenting part. The partograph
showing – graph crossing the alert line. Strong uterine contractions, both in number
and duration; foetal distress and rapid maternal pulse.
Horizontal ridge across the abdomen, below the level of the umbilicus.
Transverse lie and abnormal presentations are commonly associated with obstructed
labour. All cases of obstructed labour require management at a referral centre. Refer the
woman immediately to an FRU.
The following steps should be taken during transportation.
Establish an intravenous line and give fluids at a moderate rate (30 drops per minute).
If you cannot establish an intravenous line, give the woman sips of sweet fluids or
Oral Rehydration Solution (ORS) to prevent hypoglycaemia and dehydration. Do
not give solid food as she may need surgery.
Give the woman the first dose of antibiotics (ampicillin capsule, 1 g orally; Metronidazole
tablet, 400 mg orally; and Gentamicin injection, 80 mg intramuscular stat).
Ensure that you or any other health worker, who has sufficient knowledge and skills
related to labour and delivery, accompany the woman to the FRU.
Prolapsed cord
Prolapsed cord is the condition in which the umbilical cord lies in the birth canal below
the foetal presenting part, or is visible at the vagina following rupture of the membranes.
This is associated with foetal distress and can lead to death of the foetus because of an
obstruction of the blood flow to the foetus from the placenta.
The foetal outcome is poor in cases of prolapsed cord. The family should be counselled
and the woman referred to the FRU as early as possible.
When delivery is imminent, be prepared to resuscitate the newborn and also, to refer
the woman and infant to the FRU.
Retained placenta and placental fragments

The placenta is said to be retained if it is not delivered within half an hour of the birth of
the baby.
Bleeding may or may not occur in cases of retained placenta.
A partially separated placenta or retained placental fragments cause continuous vaginal

bleeding, leading to PPH. Manage such cases as in the case of PPH.
If the placenta is already separated and is lying in the birth canal, then remove it gently.
If it is not separated, refer the woman immediately to the FRU for manual removal of the
placenta. Do not attempt to undertake this procedure.
Vaginal and perineal tears

There are four degrees of tears:
A first-degree tear involves the vaginal mucosa and connective tissues.
A second-degree tear involves the vaginal mucosa, connective tissues and underlying
muscles.
A third-degree tear involves complete transection of the anal sphincter.
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Distinguish between superficial (first-degree) and deep perineal tears. You are only
permitted to manage first-degree tears.
A superficial tear that is not bleeding need not be sutured. All that needs to be done is
to clean the area and cover it with a clean pad.
If the superficial tear is bleeding, apply pressure on it for some time, approximately
10–15 minutes. This will help control the bleeding.
For deeper perineal tears (i.e. second-, third- and fourth-degree tears), refer the woman
to a 24 hour PHC/FRU.
Before transporting the woman, cover the tear with a sterile pad or gauze. Put the
legs of the woman together, but do not cross the ankles.
If the woman is bleeding heavily because of tears and you are unable to decide the
degree of the tear, put a vaginal pad into the vaginal cavity and refer the woman to
the FRU.
Before referral, establish an intravenous line and infuse fluids rapidly. Raise the foot
end of the stretcher and keep the woman warm during transportation.
Puerperal sepsis
Puerperal sepsis is infection of the genital tract at any time between the onset of rupture
of membranes or labour and till 42 days after delivery or abortion. Any two or more of the
following signs and symptoms are present.
Fever (temperature >38°C or > 100.5°F)
Lower abdominal pain and tenderness
Abnormal and foul-smelling lochia, may be blood-stained
Burning micturition
Uterus not well contracted
Feeling of weakness
Vaginal bleeding
Fever in the post-partum period could be due to causes other than puerperal sepsis such
as urinary tract infection (UTI), mastitis or other non-obstetric causes.
If the general condition of the woman is fair, give her the first dose of antibiotics (i.e.
ampicillin capsule, 1 g orally; Metronidazole tablet, 400 mg orally; and Gentamicin
injection, 80 mg intramuscular stat) and refer her to a PHC/FRU.
If the general condition of the woman is poor and she has the above signs and symptoms,
start her on intravenous fluids and give her the first dose of antibiotics. Refer her to a
MO at 24 hour PHC/FRU immediately.
(Practise Management of Puerperal Sepsis - Case study No. 9 in SBA Handbook)
Breast conditions
Breast conditions include mastitis, cracked/fissured nipples and breast engorgement
(being too full) and breast abscess. Breast examination should be an essential part of
routine post-partum examination.
Give the following advice.

Encourage the mother to continue breastfeeding. Tell her that if she does not
breastfeed, there will be further engorgement of the breasts.
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If the breasts are engorged, and the baby is unable to take the areola and nipple in
and suckle, tell the mother to apply hot, wet cloths on the breasts for 5–10 minutes
to make them soft. Ask her to hand-express a small amount of milk before putting
the baby to the breast.
Ask the mother to feed the baby from both the breasts during each feed.
If engorgement persists despite regular feeding, the mother may be advised to
express breast milk. She should empty her breasts at regular intervals and feed the
expressed milk to the baby.
Applying hind milk (the milk which comes out during the latter part of breastfeeding)
to sore and cracked nipples has a healing effect.
Ask the mother to avoid wearing tight-fitting bras.
If there is accompanying fever, redness or pain that does not subside despite the
above measures, refer the woman to the PHC.
Steps to be followed during referral of a woman
Keep the following points in mind while referring the woman to a higher centre.
After appropriate management of the emergency, discuss the decision to refer with the
woman and her relatives, especially those who are decision-makers in the family.
Quickly organise transport and possible financial aid.
Inform the referral centre by phone, if possible.
Accompany the woman, if possible; otherwise send another health worker/ASHA.
Send relatives who can donate blood, should the need arise.
Carry drugs and supplies such as an intravenous drip and set, antibiotics, Oxytocin
injection and Magsulph injection (provided in your delivery kit) (see Annexure VII)
in the vehicle in which the woman is being transported.
If the referral is being made after the delivery, send the baby with the mother, if
possible.
Write a referral note (see Annexure III) to the health personnel at the referral centre.
The note should contain the salient points about the following:
History
Main clinical findings
Medication given (dose, route and time of administration)
Other interventions done, if any
During the journey:
Watch the intravenous infusion.
Give appropriate treatment on the way, if the journey is long.
Keep a record of all the intravenous fluids and medications given, including the
time of administration, and of the condition of the woman from time to time.
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Module III
Ensuring the Quality of Care

Community Involvement
KEY MESSAGES
• Raise awareness among the community regarding danger signs
during pregnancy, labour and delivery, and the post-partum period.
• Seek the cooperation of other partners in the community, such as

SHGs, Community-Based Organisations (CBOs), Non-Governmental
Organisations (NGOs) and other community-level health
functionaries.
Informing and involving the community in the process of improving the health of women
will go a long way in bringing down maternal mortality. The community should be
empowered to tackle the health problems affecting the women. The VHNDs should be
utilised to generate awareness among communities and educate them on maternal
health issues.
The following is a list of things that you can do as a part of your responsibility to empower
the community to improve the health status of mothers and infants and share critical
information regarding maternal and child health issues with them.
Find out what the people know about maternal morbidity and mortality in their area.
Ask them to share this information with you and discuss how deaths and morbidity can
be prevented.
Discuss the role of families and communities in preventing these illnesses and deaths.
Share key messages on maternal and child health with community members and dispel
their misconceptions.
Discuss practical ways in which families and others in the community can support
the woman during pregnancy, delivery, after abortion and in the post-partum period.
Mention the need for the following:
Recognising and rapidly responding to emergency/danger signs during pregnancy,
delivery and the post-partum period
Accompanying the woman when she goes for delivery
Providing financial support for payment of medical fees and supplies
Providing care for children and other family members when the woman needs to
be away from home during delivery or when she needs rest
Motivating partners to help with the workload, accompany the woman to the
hospital, allow her to rest and ensure that she eats properly
Communication between husband and wife, including discussion regarding post-
partum family planning needs.
Discuss the following issues to support the community in preparing an action plan to
respond to emergencies. Engage other groups, such as SHGs, CBOs, NGOs and various
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How to identify emergency/danger signs: when to seek care
The importance of a rapid response to emergencies in reducing maternal death,
disability and illness
The transport options available, giving examples of how transport can be organised
Reasons for delay in seeking care and possible difficulties
What services (emergency obstetric care) are available and where
Costs and options for payment
A response plan during emergencies, including roles and responsibilities
The importance of blood transfusion for the mother in an emergency, and the need
for blood donation
Violence against women during pregnancy and its adverse effect on maternal and
newborn health outcomes.
It is important to establish links with ASHAs, AWWs, SHGs and other community
health workers who provide health care to the community. People have faith in them
and are likely to seek their help. Give them the correct information on safe motherhood
and seek their cooperation in reducing maternal mortality.
Discuss how you can support each other.
Respect their knowledge, experience and influence in the community.
Share with them the information you have on maternal morbidity and mortality,
and listen to their opinions on these issues. Provide them with copies of the health
education material that you distribute to community members and discuss the
content with them. Have them explain to you the knowledge that they share with the
community. Together, you can create information that is more locally appropriate.
Review together with families and groups how you can provide support for maternal
health to women
Involve them in counselling sessions for families and other community members.
Discuss the recommendation that all deliveries should be conducted by an SBA.
Also discuss the requirements for a safe delivery at home (when it is not possible
to follow this recommendation), post-partum care and when to seek emergency
care.
Review of maternal deaths

Maternal deaths are rare events at the village or SC level and therefore the community
may not register their importance. You, as the ANM and the health worker visiting the
area should build a rapport with SHGs and Panchayati Raj Institution (PRI) members to
undertake a social review of the maternal deaths reported from the villages under your
care. This ‘review’ focuses on finding the social factors responsible for maternal deaths.
Thus you should find out about the utilisation of ANC services, the place of delivery,
who attended the birth, and so on. Find out who made the decision to seek care in the
event of the obstetric complication and how soon this was done after the complication
arose. Find out about the availability of transport, the attitude of the health provider,
access to money, whether blood and donors were available when required, and so on.
A member of the bereaved family should also be included in this exercise. The findings
of the social review should be shared in PRI/SHG meetings with a view to prevent the
recurrence of such an event in the future. All maternal deaths in your area must be
reported to M.O. at block PHC for further review by him.
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90
Counselling and Suportive Environment
KEY MESSAGES
• Respect the right of women to receive maternity care services.
• Respectful communication and genuine empathy are the most
important elements of quality maternal care.
Pregnancy is a physiological event and is typically a time of joy and anticipation. Any
complication or risk of a complication that could lead to a problem shatters the dreams
of the pregnant woman and her family members. Often one comes across instances when
family members blame the health providers for adverse pregnancy outcomes, which leads to
unpleasant situations. An increasing trend of initiating legal cases against service providers
is also being noticed. Much of this can be avoided if women and their families are better
informed about care during pregnancy and signs of complications and appreciate the need
to seek care from a skilled health provider. You have an important role to play in ensuring
that correct information is disseminated on how to make pregnancies safer among women
and their families.
To prevent all the unpleasantness, you, as the health-care provider at the community level,
should keep the following points in mind while dealing with the woman and her family.
Respect the woman’s dignity and her right to privacy.
Be sensitive and responsive to the woman’s needs.
Be non-judgemental about the decisions that the woman and her family have made
regarding her care. You should provide corrective counselling, if required, but only
after the complication has been dealt with and not before or during the management
of problems.
Respect the right of women to receive maternity care services.
Rights of women
As the health-care provider, you should be aware of the rights women; when they receive
maternity care services. These are as follows.
Every woman receiving care has a right to information about her health.
Every woman has the right to discuss her concerns in an environment in which she feels
confident.
Every woman should know, in advance, all the relevant information regarding the type/s
of procedure/s that will be performed on her.
Every woman has a right to privacy. While working in a facility, procedures should be
conducted in an environment (e.g. labour wards) in which the woman’s right to privacy
is respected.
Every woman has a right to express her views about the care and services she receives.
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When you talk to a woman about her pregnancy or a related complication, you should use
simple language and basic communication techniques. This will help you establish an honest,
caring and trusting relationship with the woman. If a woman trusts you and feels that you have
her best interests at heart she will be more likely to either go to the PHC or call you at home to
conduct her delivery. She will also be more likely to approach you early in case she feels there
is a complication and share her experience with other women in the community who might
also be encouraged to use the services provided by you and at the PHC.
Supportive care during a normal delivery

Ensure that the woman has a companion of her choice and wherever possible the same
caregiver throughout labour and delivery. Supportive companionship can enable a
woman to face fear and pain and reduce loneliness and distress.
When possible, encourage the companion to take an active part in the care of the
woman. Position the companion at the head end of the woman to allow her/him to
focus on talking to the woman and caring for her emotional needs.
Both during and after the delivery/event, provide as much privacy as possible to the
woman and her family.
Supportive care during an emergency/complication

Emotional and psychological reactions of the woman and her family
The reaction of various members of the family to an emergency situation depends on the
social, cultural and religious circumstances, the personalities of the people involved and the
gravity of the problem. Common reactions of people to obstetric emergencies or maternal
death include:
Denial (feelings of ‘it can’t be true’)
Guilt regarding possible responsibility
Anger (frequently directed towards the health care staff, but often masking anger
directed at oneself for ‘failure’)
Depression and loss of self-esteem, which may be long-lasting
Disorientation
General principles of communication and support

While each emergency situation is unique, the following general principles offer guidance
on how to handle emergencies. Communication and genuine empathy are probably the
most important components of effective care in such situations.
At the time of the event

Listen to those who are distressed. The family/woman will need to discuss their hurt and
sorrow.
Do not change the subject or move on to easier or less painful topics of conversation.
Show empathy.
Tell the family/woman as much as you can and as much as they can understand about
what is happening. Understanding the situation and its management can reduce their
anxiety and prepare them for what happens next.
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Be honest. Do not hesitate to admit what you do not know. Maintaining trust matters
more than appearing knowledgeable.
If language/dialect is a barrier to communication identify someone to translate
for you.
After the event

Give practical assistance, information and emotional support.
Respect traditional beliefs and customs, and accommodate the family’s needs as far as
possible.
Explain the problem to help reduce anxiety and guilt. Repeat information several times
and give written information, if possible. People going through an emergency will not
remember much of what is said to them.
Many families and women blame themselves for what has happened. Counsel the family
and woman and allow them to reflect on the event.
Listen and express understanding and acceptance of the woman’s feelings. Non-verbal
communication may speak louder than words: a touch of the hand or a look of concern
can say an enormous amount.
You yourself may feel anger, guilt, sorrow, pain and frustration in the face of obstetric
emergencies that may lead you to avoid talking to the family/woman. Remember,
expressing your emotions is not a weakness.
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Prevention of Infection
KEY MESSAGES
• Hand washing is one of the most important measures for reducing
transmission of microorganisms and preventing infection.
• Always wear gloves when conducting procedures where there is
a risk of touching blood, body fluids, secretions, excretions or
contaminated items.
• Proper handling of contaminated waste minimises the spread of
infection to health care personnel and to the local community.
• 0.5% bleach solution is the least expensive and the most rapid-
acting and effective agent to use for decontamination.
The major objectives of prevention of infection are to prevent the occurrence and
minimise the risk of transmitting infections such as Hepatitis B, Hepatitis C and
HIV/AIDS to clients and the health-care staff when providing services.
Sources of infection
The sources of infection may be the health care delivery personnel or patients/people in
the community carrying microorganisms, the environment, blood, body fluids, secretions,
excretions, placenta, or contaminated sharps and other equipment.
Why should infection be prevented?

With appropriate practices for the prevention of infection, you can:
Prevent post-procedure infection including surgical-site infections, i.e. stitch abscess.
Prevent infections in service providers and other housekeeping staff
Protect the community from infections that originate in health care facilities
Lower the costs of health care since prevention is cheaper than the treatment of infections
and complications related to them.
Principles of prevention of infection

The following principles are recommended for prevention of infection.
All objects that come in contact with the patient should be considered potentially
contaminated.
Every person (members of the community/patients/health-care personnel) must be
considered potentially infectious.
If an object is disposable it should be discarded appropriately as waste. If it is reusable
then transmission of infective agents must be prevented by decontamination, cleaning,
disinfection or sterilisation.
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Standard precautions for prevention of infections
Standard precautions should be followed with every client/patient, regardless of whether
or not you think the client/patient might have an infection. This is important because it is
not possible to tell who is infected with HIV and the hepatitis viruses, and often infected
persons themselves do not know that they are infected.
Box 19: Standard precautions for prevention of infections

Hand washing
Use of protective attire
Processing of used items/equipment
Proper handling and disposal of sharps
Maintaining a clean environment
Biomedical waste disposal
1. Hand-washing
Proper washing of hands is the most important way to reduce the spread of infection in any
health care setting.
Appropriate times for health care staff to wash hands:

Immediately after arriving at work
Before and after examining each patient
After contact with blood, secretions, excretions or contaminated items/equipment
After handling specimens
Before putting on gloves
After removing gloves
Before leaving work
The main forms of hand hygiene
Box 20: Forms of Hand Hygiene
Technique Main purpose Agents Residual effect

Non-medicated
Routine hand washing Cleansing Short
soap
Cleansing after contact Non-medicated
Careful hand washing Short
with patient soap
Disinfection after
Hygienic hand rub Alcohol Disinfection
contamination
Surgical hand Pre-operative Antibacterial soap, Long
disinfection disinfection alcoholic solutions,
antiseptic solutions
Tips for hand washing:

Keep the soap bar in a soap dish and allow drainage.
Always use running water to wash hands—avoid dipping or washing your hands in a
basin of standing water.
Always use a separate towel or air dry your hands. Do not use shared towels to dry your
hands.
Make sure that your nails are clipped short.
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Procedure for washing hands
Roll up your sleeves to above the elbow. Remove your wrist watch, bangles, rings, or anything
that you may be wearing on the hands.
Wash your hands for two minutes in the following sequence:
1. Palms and fingers and web (inter-digital spaces)

2. Back of hands
3. Fingers and knuckles
4. Thumbs
5. Finger tips
6. Wrists and forearm up to elbow
Figure 18: Hand washing
Using plain water and soap, apply soap and lather thoroughly up to the elbow.
Always keep the elbows dependent, i.e. lower than your hands.
Rub for a minimum of 10–15 seconds.
Clean under the fingernails with a soft brush.
If running water is not available, use a bucket and pitcher. Do not dip your hands
into a bowl to rinse, as this re-contaminates your hands.
Close the tap with your elbow.
Dry your hands with a single-use sterile napkin or autoclaved newspaper pieces, or air
dry them.
Discard the napkin in the bin kept for the purpose. If you have used newspaper pieces,
throw them in the black bucket.
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Once you have washed your hands, do not touch anything, e.g. hair, pen or any fomite, till you
carry out the required job.
Remember:
Rinsing the hands with alcohol is NOT A SUBSTITUTE for proper hand-washing.
2. Use of protective attire

Gloves
Wear gloves when there is a risk of touching blood, body fluids, secretions, excretions
or contaminated items during the procedure. Put on clean/sterile gloves just before
touching the mucous membranes and non-intact (broken) skin.
A separate pair of gloves should be used for each client to avoid cross-contamination.
Although disposable gloves are preferred, when resources are limited, surgical gloves
can be reused provided they have been:
Decontaminated by soaking in 0.5% chlorine solution for 10 minutes
Washed and rinsed
Sterilised by autoclaving or High Level Disinfection (HLD), i.e. by steaming or
boiling
Do not use gloves that are cracked or peeling, or have detectable holes or tears.
Sterile, clean gloves should be worn during all delivery procedures.
Masks
Masks prevent microorganisms expelled during talking, coughing or breathing from
entering the client and protect the provider’s mouth from splashes of blood or other
fluids.
Masks should be worn while performing any procedure/intervention, such as while
conducting a delivery.
Eye covers
Eye covers are used to protect the eyes from accidental splashes of blood or other
body fluids. They should be used, for example, while conducting a delivery or cleaning
instruments.
Gowns/aprons
Gowns and waterproof aprons prevent microorganisms from the provider’s arms, body
and clothing from entering the client’s body and protect the provider’s skin and clothes
from splashes of blood and other fluids.
Caps
Caps prevent microorganisms from the hair and skin on the provider’s head from
entering the client.
Footwear
Footwear that is clean and sturdy helps minimise the number of microorganisms
brought into the surgical/procedure area and protects the service provider’s feet from
injury or splashes of blood and other fluids.
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3. Processing of items to be used
Processing instruments and other items used during clinical and surgical procedures
consists of four steps:
A) Decontamination
B) Cleaning
C) Sterilisation and HLD
D) Storage
DECONTAMINATION
Soak in 0.5% chlorine solution
10 minutes
THOROUGHLY WASH AND RINSE

Wear gloves and other protective barriers
(glasses, visors or goggles)
Preferred Acceptable
Methods Methods
STERILISATION HIGH-LEVEL
DISINFECTION (HLD)
Autoclave Dry Heat

Chemical Boil or Steam
106k Pa pressure
(15 lbs./in 2) Chemical
Lid on
121 0C (250 0F) 0
170 C
Soak 10-24 hours 20 minutes Soak
20 min. unwrapped 60 minutes
30 min. wrapped 20 minutes
COOL
(use immediately or store)
A) Decontamination: This kills viruses such as Hepatitis B, other Hepatitis viruses and HIV
and many other microorganisms making items safer for handling by staff that performs
cleaning and further processing. To decontaminate items use 0.5% bleach solution.
B) Cleaning: Cleaning refers to scrubbing with a brush, detergent and water and is a crucial
step in processing. Detergent is important for effective cleaning because water alone will not
remove protein, oils and grease.
Do not use hand soap for cleaning instruments and other items as fatty acids in soap will
react with the minerals of hard water, leaving behind a residue that is difficult to remove.
C) Sterilisation and HLD: Sterilisation ensures that items are free of all microorganisms
(bacteria, viruses, fungi and parasites) including endospores. Sterilisation kills all
microorganisms and is therefore recommended for items such as needles and surgical
GUIDELINES
98
instruments that come in contact with the bloodstream or tissues under the skin. When
sterilisation is not available HLD is the only acceptable alternative.
Sterilisation
There are three methods of sterilisation:
Steam sterilisation/autoclaving/pressure cooker autoclave
Dry heat sterilisation (electric oven)
Chemical (cold) sterilisation
Steam sterilisation/autoclaving/pressure cooker autoclave

A pressure cooker type autoclave is commonly used in rural areas. To use it properly fill
water in the autoclave (up to the ridge on the inner wall). Place the items loosely in it, place
the autoclave over the heat source (stove) and turn to high heat. Once steam starts coming
out of the pressure valve begin timing the sterilisation cycle. For this type of autoclave a
cycle of 20 minutes is suggested regardless of whether the items are wrapped or unwrapped.
After 20 minutes remove the autoclave from the heat source, open the pressure valve to
release the steam and allow it to cool for 15–30 minutes before opening it.
Dry heat sterilisation (electric oven)

When available, dry heat is a practical way to sterilise needles and other instruments. A
convection oven with an insulated stainless steel chamber and perforated shelving to allow
Figure 19: Steriliser/Pressure cooker

Excess pressure
Geared stream
relief valve
gauge
Control
Top handle Valve
Air exhaust
tube
the circulation of hot air is recommended, but dry heat (170º C for 60 minutes) sterilisation
can be achieved with a simple oven as long as a thermometer is used to verify the temperature
inside the oven.
Chemical (cold) sterilisation

An alternative to high-pressure steam or dry-heat sterilisation is chemical sterilisation often called
cold sterilisation. If objects need to be sterilised but high-pressure steam or dry heat sterilisation
would damage them then they can be chemically sterilised. Some high level disinfectants kill
endospores after prolonged exposure (10–24 hours). A commonly used chemical disinfectant is
2%–4% glutaraldehyde (the items must be soaked for at least 10 hours).
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High-level disinfection
HLD eliminates bacteria, viruses, fungi and parasites but does not kill all endospores which
cause diseases for example those causing tetanus and gas gangrene.
There are three methods of HLD.

Boiling: Boiling in water is an effective, practical way of HLD of instruments and other
items. Although boiling instruments in water for 20 minutes will kill all vegetative
forms of bacteria, viruses, yeast and fungi, it will not kill all endospores. Boiling is not
sterilisation.
Chemical HLD: Although a number of disinfectants are commercially available four
routinely used disinfectants are chlorine, glutaraldehyde, formaldehyde and hydrogen
peroxide.
Steaming: A steamer pan with holes in its bottom is used for steaming gloves, cannulae,
etc. for a duration of 20 minutes.
D) Storage: Sterilised items should be used or properly stored immediately after processing
so that they do not become contaminated. If they are not stored properly all the effort and
supplies used to properly process them will be wasted and the items may get contaminated.
Note: No matter what method is used do not store instruments or other items such as scalpel
blades and suture needles in solution; always store them dry. Microorganisms can live and
multiply in both antiseptic and disinfectant solutions and items left soaking in contaminated
solutions can lead to infections in clients.
4. Proper handling and disposal of sharps

The following measures should be strictly followed while handling needles and syringes.
Use each disposable needle and syringe only once.
Always wear utility gloves while handling sharps.
Dispose of the needle with a hub cutter which cuts the plastic hub of the syringe and not
the metal part of the needle.
Dispose of needles and syringes in a puncture-proof container.
Do not disassemble the needle and syringe after use. Make needles unusable after single
use by burning them in a needle destroyer.
Do not recap, bend or break needles before disposal.
Never burn syringes.
Dispose of the waste as follows: (i) dispose of needles and broken vials in a pit/tank, and
(ii) send the syringes and unbroken vials for recycling or to a landfill.
5. Maintaining a clean environment

The general cleanliness and hygiene of a facility are vital for the health and safety of
the staff, clients, visitors and the community at large. Maintaining a clean environment
with the help of good housekeeping and waste disposal practices is the foundation of
infection prevention.
The three following types of cleaning solutions are used during housekeeping at a health
facility.
GUIDELINES
100
Plain detergent and water: scrubbing with plain detergent and water easily removes
dirt and organic material such as grease, oil and other matter.
Disinfectant (0.5% chlorine solution): this is used to clean up spills of blood or
other body fluids.
Disinfectant cleaning solution (containing a disinfectant, detergent and water):
such solutions e.g. phenol and lysol, are used for cleaning areas such as operating
theatres, procedure rooms and latrines.
6. Biomedical waste disposal

Biomedical waste is waste that is generated during the diagnosis, treatment or immunisation
of human beings. There is evidence that viruses causing infections such as Hepatitis B and
HIV are transmitted via health care waste. These viruses can be transmitted through injuries
from needles that are contaminated with human blood.
The purpose of waste disposal is to:

Minimise/prevent the spread of infection to hospital personnel who handle waste
Prevent the spread of infection to the local community
Protect those who handle waste from accidental injury
The four steps of waste disposal are as shown below:
Figure 20: Steps of Wests Disposal
1. Segregation 2. Collection and storage
INCORRECT CORRECT
3. Transportation 4. Treatment and disposal
INCORRECT CORRECT
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ANMs who conduct deliveries at home or at the SC should collect all waste material
such as needles, syringes, gloves, placenta and cotton/gauze, in a leak-proof container/
puncture-proof cardboard box.
All the waste should then be disposed of in a pit that is two metres deep and situated at a
distance of 10 metres away from the water source. Ensure that all the waste is sprinkled
with bleach powder and covered with soil.
Dos and Don’ts of waste management

I. Segregation
Dos
1. Always segregate waste into infectious and non-infectious waste at the source of
generation.
2. Segregate infectious waste into:
Sharps: needles, blades, broken ampoules, vials and slides. These should be disposed
of in a puncture-proof container.
Non-sharps: soiled waste, such as syringes, dressings, gloves and masks. These are
to be disposed of in the red plastic bin/bag.
Anatomical waste, such as placenta. This is to be disposed of in the yellow plastic
bin/bag.
3. Non-infectious (general) waste such as waste similar to household waste including
packaging material, cartons, fruit and vegetable peels, syringe and needle wrappers and
medicine covers, should be disposed of in the black plastic bin/bag
Don’ts
Never mix infectious and non-infectious waste at the source of generation or during the
collection, storage, transportation or final disposal of waste.
II. Collection and storage

Dos
1. Always collect the waste in covered bins.
2. Fill the bin up to the three-quarter level.
3. Clean the bin regularly with soap and water.
Don’ts
1. Never overfill bins.
2. Never mix infectious and non-infectious waste in the same bin.
3. Never store waste beyond 48 hours.
III. Transportation
Dos
1. When carrying/transporting waste from the source of generation to the site of final
disposal, always carry it in closed containers.
2. Use dedicated waste collection bins for transporting waste.
GUIDELINES
102
Don’ts
1. Never transport waste in open containers or bags. It may spill and cause spread of
infections.
2. Never transport waste with sterile equipment.
IV. Treatment and disposal

Dos
1. Always remember to disinfect and shred the waste before its final disposal.
2. Remember the following while treating waste
Anatomical waste is to be buried deep at the SC.
Syringes are to be cut (with hub cutters) and chemically disinfected at the source of
generation before they are finally disposed of in the sharps pit located at the PHC.
Don’ts
1. Never throw infectious waste into general waste without any pre-treatment and
shredding
(Practise using checklist No. 5.1 & No. 5.2. in SBA Handbook)
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Annexures
ANNEXURE I: Mother and Child Protection Card
GUIDELINES
107
Annexures
ANNEXURE I ‘A’: Immunisation Schedule
National Immunisation Schedule for Pregnant Women, Infants and Children

Vaccine When to give Route and site
For Pregnant Women
TT-1 Early in pregnancy at first contact 0.5 ml Intramuscular in upper arm
TT-2 4 weeks after TT-1* 0.5 ml
TT-Booster If pregnancy occurs within three 0.5 ml
years of last TT vaccinations*
For Infants
BCG At birth (for institutional deliveries) or along 0.1 ml Intradermal in left upper arm
with DPT-1 (0.05 ml for
infant up to
1 month)
Hepatitis B 0^ At birth for institutional delivery, preferably 0.5 ml Intramuscular in outer mid-thigh
within 24 hours of delivery (antero-lateral side of mid-thigh)
OPV - 0 At birth, if delivery is in institution 2 drops Oral
OPV 1, 2 and 3 At 6 weeks, 10 weeks and 14 weeks 2 drops Oral
DPT 1, 2 and 3 At 6 weeks, 10 weeks and 14 weeks 0.5 ml Intramuscular in outer mid-thigh
(antero-lateral side of mid-thigh)
Hepatitis B1, 2 At 6 weeks, 10 weeks and 14 weeks 0.5 ml
and 3
Measles 9–12 months 0.5 ml Subcutaneous in right upper arm
Vitamin A At 9 months, with measles 1 ml Oral
(1st dose) (1 lakh IU)
For Children
DPT booster 1st booster at 16–24 months 0.5 ml Intramuscular in outer mid-thigh
2nd booster at 5 years of age 0.5 ml Intramuscular in upper arm
OPV booster 16–24 months 2 drops Oral
JE^ 16–24 months 0.5 ml Intramuscular in outer mid-thigh
MR 16–24 months 0.5 ml
Vitamin A 2nd dose at 16 months, with DPT/OPV 2 ml Oral

(2nd to 9th dose) booster. (2 lakh IU)
3rd to 9th doses are given at an interval of 6
months till 5 years of age.
TT 10 years and 16 years 0.5 ml Intramuscular in upper arm.
* TT-2 or booster dose is to be given before 36 weeks of pregnancy.

A fully immunised infant is one who has received BCG, three doses of DPT, three doses of OPV, three doses of Hepatitis
(wherever implemented), and measles before one year of age.
^ JE and Hepatitis B in select states/UTs/districts/cities
Note: The Universal Immunisation Programme is dynamic and hence, the immunisation schedule needs to be updated from time to time.
GUIDELINES
108
ANNEXURE II: Janani Suraksha Yojana
(A GoI Scheme)
1. Janani Suraksha Yojana (JSY) is an intervention for safe motherhood under the National
Rural Health Mission (NRHM). It is being implemented with the objective of reducing
maternal and neonatal mortality by promoting institutional delivery among poor
pregnant women. The scheme, launched on 12 April 2005 by the Hon’ble Prime Minister,
is under implementation in all states and Union Territories (UTs), with a special focus
on low-performing states (LPS).
2. JSY is an entirely centrally sponsored scheme, which integrates cash assistance with
delivery and post-delivery care.
3. The scheme has identified the Accredited Social Health Activist (ASHA) as an effective
link between the government and poor pregnant women. In states and UTs, wherever
Aanganwadi Workers (AWWs) and TBAs or ASHA-like activists have been engaged,
they can be associated with this scheme providing the service.
The role of ANMs (or other link health workers, including ASHAs) associated with JSY
would be:
To identify pregnant women who would be benefited by the scheme and facilitate their
registration for Ante-natal check-up (ANC).
To assist the pregnant woman in obtaining necessary certifications, wherever
necessary.
To provide the woman with and/or help her receive at least four ANC check-ups,
including registration and 1st ANC in which she is given Tetanus Toxoid (TT) injections
and Iron Folic Acid (IFA) tablets.
To identify a functional government health centre or an accredited private health
institution for referral and delivery.
To counsel the woman to opt for an institutional delivery.
To arrange referral transport for taking the pregnant women to the health facility.
To escort the woman to the predetermined health centre and stay with her till she is
discharged.
To arrange to immunise the newborn till the age of 14 weeks.
To inform the Auxiliary Nurse Midwives (ANM)/Medical Officer (MO) about the birth
or death of the child or mother.
To arrange for a postnatal visit within seven days of the delivery to track the mother’s
and new born’s health and make it easier for her to obtain care, wherever necessary.
To counsel the mother to initiate breastfeeding within half an hour to one hour of
delivery and continue to breastfeed till 6 months, and promote family planning.
Important Features of JSY

1. The scheme focuses on poor pregnant woman with a special dispensation for states that
have low institutional delivery rates, namely, the states of Uttar Pradesh, Uttarakhand,
Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu
GUIDELINES
109
Annexures
and Kashmir. While these states have been named Low Performing States (LPS), the
remaining states have been named High Performing States (HPS).
2. Tracking each pregnancy: Each beneficiary registered under this scheme should have a
JSY card, along with an MCH card. An identified link worker, such as an ASHA/AWW,
should mandatorily prepare a micro-birth plan for each beneficiary under the overall
supervision of the ANM and the MO at the Primary Health Centre (PHC). This will
effectively help in monitoring antenatal check-ups and post-delivery care.
3. The eligibility for cash assistance under the JSY is as shown below.
Eligibility for Cash Assistance
LPS All pregnant women delivering in government health centres, such as

Sub Centres (SCs)/Primary Health Centres (PHCs)/Community Health
Centres (CHCs)/First Referral Units (FRUs)/general wards of district or
state hospitals or accredited private institutions
HPS Pregnant women below the poverty line (BPL), of the
age of 19 years and above
LPS and HPS All scheduled caste/scheduled tribe (SC/ST)
women delivering in a government health centre,
such as SC/PHC/CHC/FRU/general wards of district or
state hospital or accredited private institutions.
Note: BPL certification is required in all HPS states. However, where BPL cards have not yet been issued or
updated, states/UTs would formulate a simple criterion for the certification of poor and needy expectant
mothers and empower the gram pradhan or ward member to issue such certificates.
The cash entitlement for different categories of mothers is as follows.
Cash Assistance for Institutional Delivery (in Rs)
Category Rural area Total Urban area Total

Mother’s ASHA’s Mother’s ASHA’s
package package package package
LPS 1400 600 2000 1000 200 1200
HPS 700 200* 900 600 200* 800
* w.e.f. 1 April 2009
Note 1: In both LPS and HPS, women who choose to deliver in an accredited private health
institution must produce a BPL or SC/ST certificate in order to access JSY benefits. In
addition, they must carry a referral slip from the ASHA, ANM or MO, and the Mother and
Child Protection Card – JSY card.
Note 2: The ANM/ASHA/MO should make it clear to the beneficiary that the government
is not responsible for the cost of the delivery if she chooses to go to an accredited private
institution for the delivery. She will only get her entitled cash.
Note 3: The scheme does not provide for the ASHA’s package for women who choose to
deliver in an accredited private institution.
GUIDELINES
110
4. Disbursement of cash assistance: As the cash assistance to the mother is meant mainly for
meeting the cost of the delivery, it should be disbursed at the institution itself.
a) The mother and the ASHA (wherever applicable) should get their entitled money at
the heath centre immediately on registration for delivery.
b) Generally the ANM/ASHA should carry out the entire disbursement process.
However, till the ASHA joins, an AWW or any identified link worker may also carry
out the disbursement under the guidance of the ANM.
4.1 In the case of pregnant women who choose to go to a public health institution for
the delivery, the entire cash entitlement should be disbursed at the health institution
at one go.
4.2 In LPS and HPS, BPL pregnant women, who are 19 years of age and above and
prefer to deliver at home, are entitled to a cash assistance of Rs 500 per delivery
up to two live births. The disbursement of such assistance should be carried out at
the time of delivery or around seven days before the delivery by an ANM/ASHA/
any other link worker. The rationale is that the beneficiary would be able to use
the cash assistance for her care during delivery or to meet the incidental expenses
of delivery. It should be the responsibility of the ANM/ASHA/MO at the PHC to
ensure timely disbursement of such assistance. Women choosing to deliver at home
must have a BPL certificate to access JSY benefits.
5. Compensation money: If the mother or her husband, of their own will, undergoes
sterilisation, immediately after the delivery, the compensation money available under
the existing Family Welfare Scheme should also be disbursed to the mother at the
hospital itself.
6. Accrediting private health institutions: In order to increase the choice of delivery care
institutions, at least two willing private institutions per block should be accredited to
provide delivery services. The state and district authorities should draw up a list of
criteria/protocols for such accreditation.
7. Equipping SCs for normal delivery: Women living in tribal and hilly districts find it
difficult to access a PHC/CHC for maternal care or delivery. A well-equipped SC is
a better option in such areas. Deliveries conducted in SCs which are accredited by
the state/district authorities will be considered as institutional deliveries, and women
delivering in such centres would be eligible for cash assistance under JSY.
Important: All states and UTs must undertake a process of accreditation of all such SCs, located
in Government buildings and have adequate facilities, including electric and water supply, and
the medical requirements of basic obstetric services, such as drugs, equipment and the services
of a trained midwife.
8. Monitoring:
8.1 Monthly meeting: To assess the effectiveness of implementation of the JSY, ANMs
should hold monthly meetings of all ASHAs/related link health workers under
them, possibly on a fixed day (such as the third Friday) of every month, at the SC
or at any anganwadi centre falling under their jurisdiction. If the scheduled day
happens to be a holiday, the meeting could be held on the following working day.
8.2 Monthly work schedule: At each monthly meeting, the ANM, besides reviewing the
current month’s work vis-à-vis the envisaged activities, should prepare a work schedule
for the month ahead for each ASHA/village-level health worker on the following:
GUIDELINES
111
Annexures
Feedback on previous month’s schedule
(a) The number of pregnant women who missed antenatal check-ups

(b) The number of cases in which the ASHA/link worker did not accompany the pregnant
women for delivery
(c) The number of identified beneficiaries who had home deliveries
(d) The number of postnatal visits missed by the ASHA
(e) The cases referred to the FRU and review of their current health status
(f) The number of children who missed immunisation
Fixing next month’s work schedule
(a) Note the names of the pregnant women identified for registration and taken to the health
centre/anganwadi centre for ANC.
(b) Note the names of the pregnant women to be taken to the health centre for delivery
(wherever applicable).
(c) Note the names of the pregnant women with possible complications to be taken to the
health centre for check-up and/or delivery.
(d) Note the names of women to be visited (within 7 days) after delivery.
(e) Prepare a list of infants/newborns for routine immunisation.
(f) Ensure the availability of imprest cash.
(g) Check whether referral transport has been organised.
Note 1: While no target needs to be fixed, some monthly goal for institutional deliveries for
the village may be kept in mind for the purpose of monitoring.
Note 2: A format of the monthly work schedule, to be filled by the ANM/ASHA, may be
printed. The format should incorporate the physical and financial aspects of the schedule.
GUIDELINES
112
ANNEXURE III: Referral Slip
Name of the Referring Facility:
Address:
Telephone:
Name of Mother:________________________________________________Age:____Yrs:
Husband’s Name: __________________________________________________________
Address:_________________________________________________________________
Referred on ___/___/____( d/m/yr) at ____________ (time) to ____________________
_________________________________ (Name of the facility) for management.
Provisional Diagnosis:
Admitted in the referring facility on ___/___/____( d/m/yr) at _________ (time) with chief
complaints of :
________________________________
________________________________
________________________________
Summary of Management (Procedures, Critical Interventions, Drugs given for

Management):
Investigations:
Blood Group:
Hb:
Urine R/E:
Condition at time of Referral:
Consciousness: Temp: Pulse: BP:

GUIDELINES
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Annexures
Others (Specify):__________________________________________________________
________________________________________________________________________
Information on Referral provided to the Institution Referred to: Yes / No
If yes, then name of the person spoken to:_____________________________________
Mode of Transport for Referral : Govt/Outsourced/EMRI/Personal/Others/None
Signature of Referring Physician/MO

(Name/Designation/Stamp)
GUIDELINES
114
ANNEXURE IV: Activities to be carried out at each
ANC visit
Activities to be carried out at each ANC visit

ACTIVITIES VISITS
1st visit 2nd visit 3rd visit 4th visit
Before 12 14–26 weeks 28–34 weeks (36 weeks
weeks to term)
History-taking Date of LMP
Order of pregnancy, birth interval
Symptoms during present
pregnancy
History of previous pregnancies
History of systemic illnesses
Family history of systemic illnesses
History of drug intake or allergies/
habit-forming substances
Physical Pallor
examination
General
Pulse
Respiratory rate
Blood pressure
Oedema
Weight
Jaundice
Breast examination
Any other
Abdominal Fundal height (in weeks)
examination
Foetal lie and presentation
Foetal heart rate
Foetal movements
Multiple pregnancy/breech
presentation/transverse lie-Refer in
these conditions
Laboratory Haemoglobin estimation
investigations
Urine test for sugar
Urine test for proteins
GUIDELINES
115
Annexures
ACTIVITIES VISITS
1st visit 2nd visit 3rd visit 4th visit
Before 12 14–26 weeks 28–34 weeks (36 weeks
weeks to term)
Blood group, including Rh factor
Rapid test for syphilis
Interventions IFA supplementation given
TT injection (2 injections)
Malaria (conduct rapid diagnostic
test only in endemic areas)
Counselling Planning and preparing for birth
(birth preparedness)
Recognising and preparing for
danger signs (complication
readiness)
Diet and rest
Infant-feeding
Sex during pregnancy
Domestic violence
Contraception
Denotes activities that need not be repeated
Note: The first visit refers to a woman’s first contact with the ANM/clinic. If the first visit
is later than recommended then carry out all the activities recommended up to time of the
first visit regardless of the gestational age.
Remember that it is not advisable to give a pregnant woman any medication during the first
trimester unless advised by a physician. Even then it must be ensured that the drugs given are
proven to be safe during pregnancy and do not have teratogenic effects (causing disability/
defects) on the foetus.
GUIDELINES
116
ANNEXURE V: Counselling Guide Post-partum
Family Planning
Counselling Guide: Post-partum Family Planning
Methods Benefits Limitations Client Considerations

Lactational • Good for mother and newborn • Does not protect • Effective if ALL three criteria are met:
Amenorrhea • Can be used right after delivery against STIs, including 1. Exclusive breastfeeding, day & night
Method (LAM) – no delay HIV/AIDS 2. Monthly bleeding has not returned
• No additional supplies/materials/ • Short-term method 3. Baby is less than six months old
expense – reliable for six Transition to another contraceptive method if
• 98% effective if all three criteria months any of the three criteria are not met
met
Post-partum • Can be used right after delivery • First few cycles may be Not appropriate for women who have:
Intra Uterine (first 48 hours) – no delay heavier, more painful • Cervical cancer or trophoblastic disease
Contraceptive • >99% effective • Does not protect • Uterine distortion (fibroids, septum)
Device (IUCD) • Immediate return of fertility after against STIs, including • Very high risk of having Gonorrhea/
removal HIV/AIDS Chlamydia
• Short-term or long-term • AIDS and not clinically well/on
protection ARV therapy
Delay insertion until after six weeks post-

partum, if not inserted during first 48 hours
post-partum
Combined Oral • Safe for nearly all women • Must remember to take Not appropriate for women who:
Contraceptive • About 99% effective, if used a pill every day • Has liver cirrhosis, infection or tumor
Pills (COCs) correctly • May have irregular • Has blood pressure 140/90 or higher
• No delay in return of fertility bleeding with first few • Is more than 35 years old and smokes
after stopping cycles • Has ever had stroke, blood clot, heart
• Protects against cancer of ovaries attack
and lining of uterus
Delay start until 6 months for breastfeeding
woman and 3 weeks for non-breastfeeding
woman
Emergency • Safe for nearly all women • Pill must be taken • May be used anytime during the
Contraception • Prevents pregnancy from within 72 hours of postnatal period within 72 hours
Pills (ECPs) unprotected sexual intercourse unprotected sexual following unprotected sexual
72 hours prior to the use of ECPs intercourse intercourse
only • Does not protect • To stay protected, the women should
• No delay in return of fertility against STIs, including start using another regular, appropriate
after stopping as they are used as HIV/AIDS contraceptive method immediately
Emergency Contraception only • Can provide supply before discharge
and not as regular contraceptive
pills
Progestin- • Safe for nearly all women • Does not protect • May be used immediately after delivery
only Injection • > 99% effective if all injections against STIs, including in the non-breastfeeding woman, and
(DMPA) are taken on time HIV/AIDS at 6 weeks for the breastfeeding woman
• Does not require daily action • Requires injection • Injection may be up to two weeks early
• May cause monthly bleeding to every three months or late
stop in some women • Return of fertility is
often delayed Can be started immediately after childbirth
for non-breastfeeding women
Delay start until six weeks for breastfeeding
woman
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117
Annexures
Methods Benefits Limitations Client Considerations
Progestin- • Safe for nearly all women • Does not protect • May be used immediately after
only Injection • > 99% effective if all against STIs, delivery in the non-breastfeeding
(DMPA) injections are taken on including woman, and at 6 weeks for the
time HIV/AIDS breastfeeding woman
• Does not require daily • Requires injection • Injection may be up to 2 weeks
action every three months early or late
• May cause monthly • Return of fertility is
bleeding to stop in some often delayed Can be started immediately after
women childbirth for non-breastfeeding
women
Delay start until 6 weeks for
breastfeeding woman
Condom • Can protect against • Must have reliable • Must be used with EVERY act of
pregnancy and some access to resupply sexual intercourse
sexually transmitted • About 85% effective • Must be used correctly every time
infections, including HIV • Can provide supply at the time of
• Can use as soon as couple discharge
resumes intercourse
Female • Permanent method of FP • Does not protect • For women who are certain that
Sterilisation • >99% effective against STIs, they want any more children.
• Simple procedure, serious including • Hospitals must be equipped to
complications rare` HIV/AIDS offer surgical procedures
• Requires surgical
procedure Can be done after 24 hours post-
deliver up to seven days
and after six weeks post-partum
No-Scalpel • Safe and simple surgical • Does not protect • For couples who are certain
Vasectomy procedure against STIs, that they do not want any more
(NSV) (For • Permanent method of FP including children
husbands) • 97-98 % effective HIV/AIDS • Hospitals must be equipped to
• Requires surgical offer surgical procedures
procedure • The couples should use other
methods of contraception like
condoms, OCPs and others
for three months post-NSV
procedure as the procedure takes
three months to become effective
Can be adopted anytime during

pregnancy and after delivery.
GUIDELINES
118
ANNEXURE VI: Discharge Slip
Name of the SC/PHC/CHC/FRU/DH :
Name of the Mother: Reg. No. :
Age : Address:
Date and Time of Admission :
Date and Time of Delivery :
Date and Time of Discharge :
Mode of Delivery : Vaginal/Instrumental/LSCS :
Indication for Instrumental/LSCS :
Delivery Outcome: (Live/Multiple/Preterm/SB/Abortion/Any other)
Details of the baby :
Sex : Weight : BF initiation: (mention duration in min. after delivery):
Investigation done : (if any, both for the mother and baby):
Any h/o complications : (if any, both for the mother and baby):
Mother Baby
(also mention immunisation given):
Condition at Time of discharge :
Advice given at time of discharge :
Date and place of next f/up :
Signature and Name of Health Care Provider :
Designation :
GUIDELINES
119
Annexures
ANNEXURE VII: Operational Guidelines of
Maternal and Newborn Health
Home Delivery with Skilled Birth Attendant
A. Home Delivery Kit Ringer lactate solution, 500 ml Sanitary napkins

Adhesive tape Bath towels
The delivery kit should contain Blood pressure apparatus with Clean sheets
disposable items, as well as supplies stethoscope Plastic sheeting to protect mattress
and essential drugs required for Foetoscope (to be placed under sheets during
conducting a home delivery. Measuring tape delivery – can cut up large plastic
Partographs bags if necessary)
POCKET 1: Disposable delivery kit Dipsticks for testing sugar and Disinfectant soap
(soap; new blade; clean thread; proteins in urine Cord clamp/Thread which can be
clean sheet; gloves; plastic apron; Puncture-proof box boiled.
gauze piece) Thermometer Disposable sterile new blade (to cut
Spirit, cotton and gauze the cord)
POCKET 2: Drugs Torch Disposable single-use gloves
Gentamicin injection Foley’s catheter One trash can (preferably lined with
Magnesium sulphate injection 50% Mucus sucker plastic bags) for trash and/or waste
Oxytocin injection Ambu bag and mask products
Ampicillin capsules Mouth gag Clean cotton blankets to receive
Metronidazole tablet Trash bag newborn
Misoprostol tablets Diapers
Paracetamol tablets B. Home Birth Checklist Clean clothes for newborn
ORS If it is cold, a source of heat should
Clean home be provided so that the newborn is
POCKET 3: Supplies Clean surfaces in room where not born into a cold environment.
Syringes with needle woman A 200 watt bulb is appropriate. A
(2 ml, 5 ml, 10 ml) will give birth traditional heating option, which
Needles 22 G Light for birth attendant (flashlight) generates minimal smoke, in case
Intravenous set Clean gowns for mother there is no electricity, may be used.
GUIDELINES
120
ANNEXURE VIII: Suggested List of Equipment,
Supplies and Drugs
SUB-CENTRE
Labour room: 4050 mm x 3000 mm
Clinic room: 3300 mm x 3300 mm
Examination room: 1950 mm x 3000 mm
Skilled Birth Attendance at Sub-Centre: Equipment, Supplies and Drugs

Suggested list of required furniture, other fittings and sundry articles at the Sub-Centre as per Indian Public Health
Standards (can be modified as per the local situation).
A. Furniture and Sundry Articles Linen Foetoscope

Bedsheets Intravenous stand
Furniture Towels for mother Vaccine carrier
Examination table Towels for baby Ice pack box
Labour table with mattress, Blankets for mother and baby
pillow and Kelly pad Clock Supplies
Writing table, armless chairs Hypochlorite solution
Medicine chest B. Equipment and Supplies Disposable syringes and needles
Wooden/Steel screen, curtains (10 cc, 5 cc and 2 cc)
Foot stool For Obstetric Care Foley urethral catheter
Bedside table Minor equipment Intravenous set
Revolving stools Blood pressure apparatus with Sponge holding forceps
Almirah stethoscope
Wooden side rack Weighing machine (adult) For Newborn Corner
Basin stand Weighing machine (baby) Radiant warmer/200-watt bulb
Inch tape Neonatal Ambu bag with face mask
Sundry articles Thermometer (oral and rectal) Oxygen cylinder
Plastic buckets, basins, mugs Partograph Charts Nasal catheter
Lamp/torch/candle and matchbox Instrument tray with cover Mucus extractor
Kerosene stove (310 x 195 x 63 mm) Cord ties
Saucepan with lid Kidney trays (1 big and 1 small)
Mackintosh Dressing drum For Laboratory Equipment
Drum with tap for storing water Cheatle forceps Haemoglobinometer (Sahle kit) with
(where piped water supply is Cord cutting scissor reagents and lancet
unavailable) (Umbilicus – Blunt ) Dipsticks (for testing urine albumin
Dustbin Artery forceps and sugar)
Surgical scissors, cord-cutting Reagents such as sulphuric acid,
Supplies scissors acetic acid, Benedict solution
Cleaning material (detergent) Sponge holder Specimen collection bottle (in case
Note: This list of annexures containing equipment, supplies and drugs is not comprehensive. For
details, refer to the appropriate GoI guidelines and protocols.
GUIDELINES
121
Annexures
uristix and diastix not available) IFA syrup (as per standards provided) Metronidazole tablet
Microscope glass slides Water-miscible vitamin concentrate Misoprostol tablets
(100 in a packet) IP (Vitamin A syrup) Paracetamol tablets
Cover slips (25 in a packet) ORS
Kit B (Individual drugs to be refilled in kits
Supplies Methylergometrine tablets IP as required)
Test-tubes, holder, test-tube stand Misoprostol tablets
match box, spirit lamp Oxytocin injection D. Infection Prevention and
Paracetamol tablets Waste Disposal
Methylergometrine injection
C. Drugs & Supplies
Albendazole tablets Sterile gloves
Dicyclomine tablets Plastic apron, caps, masks, shoe
Kit A
Chloramphenicol eye ointment cover, eye wear
ORS IP
Povidone iodine ointment Surgical brush for scrubbing
IFA tablets—large
Cotton bandage Boiler/Steriliser
Folic acid tablets IP
Absorbent cotton Autoclave (pressure cooker)
IFA tablets—small
Intravenous fluids (Ringer lactate)
Trimethoprim and
E. Basic amenities for the labour
sulphamethoxazole tablets IP
Others Drugs room
(paediatric)
Gentamicin injection
Methylrosanilinium chloride BP
Magnesium sulphate injection 50% 1. Attached toilet
(gentian violet crystals)
Oxytocin injection 2. Tank for water storage
Zinc sulphate dispersible tablets USP
Ampicillin capsules 3. Electricity back-up
GUIDELINES
122
ANNEXURE IX: Procedures and Drugs Permitted for
Use by Skilled Birth Attendants
Procedures and Drugs Permitted for Use by Skilled Birth Attendants
S. No. Condition Procedure / Drugs

1. Active Management of SBA should be proficient in AMTSL:
third stage of labor • Administration of Uterotonics
(Injection Oxytocin/Tablet Misoprostol)
• Controlled Cord Traction.
• Uterine massage.
2. Diagnosis of prolonged Plotting a partograph for every woman in labour
labour
3. Prevention of PPH Active management of the third stage of labour
• Administering Oxytocin injection (10 IU,
intramuscular) for deliveries at SC/PHC/
FRU/health facility
OR
Giving misoprostol tablet (3 tablets of 200 mcg
each, orally; total of 600 mcg) for home deliveries
• Providing controlled cord traction
• Conducting uterine massage
4. Management of PPH • Administering Oxytocin injection (10 IU,
intramuscular). (if not given during AMTSL)
• Administering 20 IU oxytocin in 500 ml of
Ringer lactate, intravenous, at the rate of 60
drops per minute
• Referring to FRU (if intravenous cannot be
given, referring after administering Oxytocin
injection (10 IU, intramuscular)
5. Management of eclampsia Giving one dose of magnesium sulphate
(10 ml) of 5 g, deep intramuscular, in each
buttock
• Referring to an FRU
6. Vaginal or perineal tears • Identifying different degrees of tears
• Managing first-degree tears by applying pad
and pressure
• Referring for second- and third-degree tears
7. Management of puerperal Giving first dose of the following antibiotics and
infections/PROM/Delayed referring
(Secondary) PPH • Gentamycin injection (80 mg, intramuscular)
• Ampicilin capsule (1000 mg, orally)
• Metranidazole tablet (400 mg, orally)
8. Incomplete abortion with Digital removal of retained products of
bleeding P/V conception
GUIDELINES
123
Annexures

Guidelines For Antenatal Care Final

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Health Minister’s Message

Women are strong pillars of any vibrant society. Motherhood is an event

(Ghulam Nabi Azad)

Government of India has a commitment under National Population

(K. Sujatha Rao)

NRHM has a commitment for reduction of maternal and infant mortality/

National and international evidences indicate that reduction of maternal

Based on these evidences, the Government of India has taken a policy

(Amit Mohan Prasad)

(Dr. Himanshu Bhushan)

Module II: Management of Complications during Pregnancy,

Module III: Ensuring the Quality of Care 87

AMTSL : Active Management of the Third Stage of Labour

What can be done to combat maternal deaths?

Infrastructure and programmatic support must be in place to enable health personnel

A. A few primary steps:

B. Essential components of every antenatal check-up:

Early detection of pregnancy is important for the following reasons:

Number and timing of visits

Seek help for early registration and antenatal check-up

Estimate the number of pregnancies in your area

The expected number of live births may be calculated as shown in Box 1.

Box 1: Total number of expected pregnancies/year

Expected number of live births (Y)/year:

Birth rate (per 1000 population) X population of the area

So, the total number of expected pregnancies (Z)=

As a thumb rule, in any given month, approximately half the

Birth rate = 25/1000 population

Keep a track of all pregnant women by name

Components of Antenatal Check-up

Menstrual history to calculate the EDD

EDD = Date of LMP + 9 months + 7 days

Symptoms during pregnancy

Box 3: Symptoms indicating discomfort

Nausea and vomiting

Obstetric history/history of previous pregnancies

Stillbirth or neonatal loss

History of any current systemic illness(es)/past history of illness

Family history of systemic illness

History of drug intake or allergies

History of intake of habit-forming or harmful substances

(Practise history-taking during antenatal check-up - Checklist No1.1 in SBA Handbook)

II. Physical examination

Estimate the woman’s haemoglobin using a haemoglobinometer.

Figure 1: Correcting an inverted nipple using a syringe

Cut the end of a plastic syringe

Insert piston from cut end

Mother gently pulls

Preparation for abdominal examination

Foetal lie and presentation

Palpation to determine foetal lie and presentation

Foetal heart sound and foetal heart rate

Figure 4: Location of FHS using foetoscope

(Note: ROA right occipitoanterior

III. Laboratory investigations

Box 6: Levels of Anaemia in Pregnancy

Blood grouping and Rh factor

Testing the urine for the presence of protein (albumin)

Testing the urine for the presence of sugar