COVER NEW 03/2/04 13:27 Page 1 Integrated Management of Pregnancy and Childbirth Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice World Health The World Bank Organization Group R Department of Reproductive Health and Research, Family and Community Health, World Health Organization, Geneva Integrated Management of Pregnancy and Childbirth Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice World Health Organization Geneva 2003 WHO Library Cataloguing-in-Publication Data Pregnancy, childbirth, postpartum and newborn care : a guide for essential practice. At head of title: Integrated Management of Pregnancy and Childbirth. 1.Labor, Obstetric 2.Delivery, Obstetric 3.Prenatal care 4.Perinatal care — methods 5.Postnatal care - methods 6.Pregnancy complications - diagnosis 7.Pregnancy complications - therapy 8.Manuals I.World Health Organization. ISBN 92 4 159084 X (NLM classification: WQ 175) © World Health Organization 2003 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination,World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications — whether for sale or for noncommercial distribution — should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed in Singapore FOREWORD In modern times, improvements in knowledge and technological advances have greatly improved the It is against this background that we are proud to present the document Pregnancy, Childbirth, health of mother and children. However, the past decade was marked by limited progress in reducing Postpartum and Newborn Care: A guide for essential practice, as new additions to the Integrated maternal mortality and a slow-down in the steady decline of childhood mortality observed since the mid Management of Pregnancy and Childbirth tool kit. The guide provides a full range of updated, evidence- 1950s in many countries, the latter being largely due to a failure to reduce neonatal mortality. based norms and standards that will enable health care providers to give high quality care during pregnancy, delivery and in the postpartum period, considering the needs of the mother and her newborn Every year, over four million babies less than one month of age die, most of them during the critical first baby. week of life; and for every newborn who dies, another is stillborn. Most of these deaths are a consequence of the poor health and nutritional status of the mother coupled with inadequate care We hope that the guide will be helpful for decision-makers, programme managers and health care before, during, and after delivery. Unfortunately, the problem remains unrecognized or- worse- accepted providers in charting out their roadmap towards meeting the health needs of all mothers and children. as inevitable in many societies, in large part because it is so common. We have the knowledge, our major challenge now is to translate this into action and to reach those women and children who are most in need. Recognizing the large burden of maternal and neonatal ill-health on the development capacity of individuals, communities and societies, world leaders reaffirmed their commitment to invest in mothers and children by adopting specific goals and targets to reduce maternal and childhood-infant mortality as part of the Millennium Declaration. There is a widely shared but mistaken idea that improvements in newborn health require sophisticated and expensive technologies and highly specialized staff.The reality is that many conditions that result in perinatal death can be prevented or treated without sophisticated and expensive technology.What is required is essential care during pregnancy, the assistance of a person with midwifery skills during Dr.Tomris Türmen childbirth and the immediate postpartum period, and a few critical interventions for the newborn during Executive director the first days of life. Family and Community Health (FCH) FOREWORD Foreword Acknowledgements ACKNOWLEDGEMENTS The Guide was prepared by a team of the World Health Organization, Department of Reproductive This guide represents a common understanding between WHO, UNFPA, UNICEF,and the World Bank of Health and Research (RHR), led by Jerker Liljestrand and Jelka Zupan. key elements of an approach to reducing maternal and perinatal mortality and morbidity.These agencies co-operate closely in efforts to reduce maternal and perinatal mortality and morbidity.The The concept and first drafts were developed by Sandra Gove and Patricia Whitesell/ACT International, principles and policies of each agency are governed by the relevant decisions of each agency’s Atlanta, Jerker Liljestrand, Denise Roth, Betty Sweet,Anne Thompson, and Jelka Zupan. governing body and each agency implements the interventions described in this document in CKNOWLEDGEMENTS accordance with these principles and policies and within the scope of its mandate. A Revisions were subsequently carried out by Annie Portela, Luc de Bernis, Ornella Lincetto, Rita Kabra, Maggie Usher,Agostino Borra, Rick Guidotti, Elisabeth Hoff, Mathews Matthai, Monir Islam, The guide has also been reviewed and endorsed by the International Confederation of Midwives, the Felicity Savage,Adepeyu Olukoya, and Aafje Rietveld. International Federation of Gynecology and Obstetrics and International Pediatric Association. Valuable inputs were provided by WHO Regional Offices and WHO departments: ■ Reproductive Health and Research ■ Child and Adolescent Health and Development ■ HIV/AIDS ■ Communicable Diseases ■ Nutrition for Health and Development International Confederation International Federation of International ■ Essential Drugs and Medicines Policy of Midwives Gynecology and Obstetrics Pediatric Association ■ Vaccines and Biologicals ■ Mental Health and Substance Dependence The financial support towards the preparation and production of this document provided by UNFPA and ■ Gender and Women’s Health the Governments of Australia, Japan and the United States of America is gratefully acknowledged, as is ■ Blindness and Deafness financial support received from The World Bank. In addition,WHO’s Making Pregnancy Safer initiative is grateful to the programme support received from the Governments of the Netherlands, Norway, Sweden Editing: Nina Mattock and the United Kingdom of Great Britain and Northern Ireland. Layout: rsdesigns.com sàrl Cover design: Maíre Ní Mhearáin WHO acknowledges with gratitude the generous contribution of over 100 individuals and organizations in the field of maternal and newborn health, who took time to review this document at different stages of its development.They came from over 35 countries and brought their expertise and wide experience to the final text. TABLE OF CONTENTS B EMERGENCY TREATMENTS FOR THE WOMAN B9 INTRODUCTION Airway, breathing and circulation A B9 Manage the airway and breathing B9 Insert IV line and give fluids Introduction B9 If intravenous access not possible How to read the Guide B10-B12 Bleeding Acronyms B10 Massage uterus and expel clots Content B10 Apply bimanual uterine compression Structure and presentation B10 Apply aortic compression Assumptions underlying the guide B10 Give oxytocin B10 Give ergometrine B11 Remove placenta and fragments manually PRINCIPLES OF GOOD CARE A B11 After manual removal of placenta B12 Repair the tear and empty bladder A2 Communication B12 Repair the tear or episiotomy A3 Workplace and administrative procedures B13-B14 Important considerations in caring for a woman with eclampsia or pre-eclampsia A4 Universal precautions and cleanliness B13 Give magnesium sulphate A5 Organising a visit B13 Important considerations in caring for a woman with eclampsia B14 Give diazepam B14 Give appropriate antihypertensive drug QUICK CHECK, RAPID ASSESSMENT AND MANAGEMENT OF WOMEN OF CHILDBEARING AGE B15 Infection B B15 Give appropriate IV/IM antibiotics B2 Quick check B16 Malaria B3-B7 Rapid assessment and management B16 Give arthemether or quinine IM B3 Airway and breathing B16 Give glucose IV B3 Circulation (shock) B17 Refer the woman urgently to the hospital B4-B5 Vaginal bleeding B17 Essential emergency drugs and supplies for transport and home delivery B6 Convulsions or unconscious B6 Severe abdominal pain B6 Dangerous fever BLEEDING IN EARLY PREGNANCY AND POST-ABORTION CARE B7 Labour B B7 Other danger signs or symptoms B19 Examination