Newborn survival is inextricably linked to the health of the mother. Nowhere is this more evident than the high risk of death for newborns and infants whose mothers die in childbirth. For both newborns and mothers, the highest risk of death occurs at delivery, followed by the first hours and days after childbirth.
The postnatal period (the time just after delivery and through the first six weeks of life) is especially critical for newborns and mothers. Given the exceptional extent to which the deaths of mothers and babies occur in the first days after birth, the early postnatal period is the ideal time to deliver interventions to improve the health and survival of both the newborn and the mother.
When do most mothers and newborns die in the postnatal period?
Mothers and their new born babies are at highest risk of dying during the early neonatal period, especially in the ﬁrst 24 hours following birth and over the ﬁrst seven days after delivery. For some life-threatening maternal and new born conditions, effective postnatal care is either given in the ﬁrst few hours and days,or it will happen too late. The earlier these clinical conditions are detected, the more effectively they can be managed; the quicker they are referred for specialised treatment, the better the outcomes will be. Unfortunately, most of these interventions are highly time-dependant in order to be effective. You should keep this in mind while providing care to mothers and their babies in the ﬁrst few days of postnatal life.
What do mothers and newborns in the postnatal period die from?
The main purpose of providing optimal postnatal care is to avert both maternal and neonatal death, as well as long-term complications. To be effective you therefore need to know the major causes of death in the postnatal period, so that you can provide quality and timely postnatal care at the domestic and Health Post level. Knowing what mothers and newborns are dying from is important in order to identify the high impact interventions that address all the major causes of death during the postnatal period
Causes of maternal death in Africa.
- Postpartum haemorrhage
- Localised infection or disseminated infection(sepsis)
- Hypertensive disorders of pregnancy(pre-eclampsia, eclampsia)
- Obstructed labour
Why are women and newborns at high risk in the postnatal period?
The most critical period for complications in the postnatal mother arising from bleeding (post-partum haemorrhage) is in the ﬁrst 4 -6 hours after delivery, due to excessive blood loss from the site where the placenta was attached to the mother’s uterus, or from rupture of the uterus during labour and delivery. Haemorrhage can also threaten the baby’s life if it occurs before delivery and the baby is starved of oxygen and nutrients.
Both the mother and the baby are also at high risk of developing other complications if the physiological adjustments that take place in their bodies after the birth do not occur properly. This can result in loss of function or interruption of essential supplies of oxygen and nutrients needed to sustain life.
Physiological changes in the postnatal mother
During labour and delivery, there is inevitably some loss of blood and other body ﬂuids (for example, from vomiting and sweating), which is tolerable by the majority of women. Some degree of this is normal. Additionally, most women in labour remain for long hours without taking food or sufﬁcient ﬂuids, which can leave them dehydrated. Unless they are rehydrated quickly afterthe birth, physiological complications become more likely.
During pregnancy, activity in almost all the mother’s body systems changes, including the heart, lungs, blood volume and blood contents, reproductive system, breasts, immune system and hormones. In the postnatal period, all these dynamic body systems have to adjust from the pregnant state back to the pre-pregnant state, and there is apotential risk of complications as these adjustments occur. Common examples are breast infections and deep vein thrombosis (blood clots in the veins of the legs). The period in which these physiological adjustments take place in the postnatal mother is called the puerperium.
Additionally, labour is apainful experience for most women, particularly for those giving birth for the ﬁrst time. There is also tension and anxiety about the outcome of labour and delivery. Having ababy is a joy, but it can also be asource of worry. Women in the postnatal period are often coping with stressful conditions and thus they need sustained psychological support.
Complications in the newborn
Risk of infection
While in the uterus, the baby was well protected by the fetal membranes and the antibacterial action of the amniotic ﬂuid in which it was bathed, and by maternal antibodies that cross the placenta and defend it against infections that the mother has already encountered. After birth, antibodies in the colostrum (ﬁrst milk) and true breast milk, and natural barriers like the baby’s skin, give the new born most of the protection from infection that it has when newly born. Its own immune system will take several months to develop adequately.
Risk of asphyxia
The newborn baby’s blood circulation system undergoes major adjustments when it takes it’s ﬁrst breath outside the uterus. While the baby is in the uterus, very little blood goes to the lungs because the baby isn’t breathing air. Thefetal lungs cannot perform the gas exchange (absorbing oxygen and releasing waste carbon dioxide), which occurs from the moment of birth on wards.
Immediately at birth, the blood vessels that bypass the lungs are opened and all the blood in the baby’s circulation is then able to pass through the lungs, where it undergoes gas exchange. It is acritical moment for the newborn when the lungs start to function. Failure to breathe is a common reason for birth asphyxia. Also, preterm newborns of ten have difﬁculty in getting enough oxygen after birth because their lungs are not fully matured, so gas exchange does not occur effectively.
2013 WHO Recommendations on postnatal care
RECOMMENDATION 1: Timing of discharge from a health facility after birth After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth.
RECOMMENDATION 2: Number and timing of postnatal contacts If birth is in a health facility, mothers and newborns should receive postnatal care in the facility for at least 24 hours after birth. a If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth. At least three additional postnatal contacts are recommended for all mothers and newborns, on day 3 (48–72 hours), between days 7–14 after birth, and six weeks after birth.
RECOMMENDATION 3: Home visits for postnatal care Home visits in the first week after birth are recommended for care of the mother and newborn.
RECOMMENDATION 4: Assessment of the baby The following signs should be assessed during each postnatal care contact and the newborn should be referred for further evaluation if any of the signs is present: stopped feeding well, history of convulsions, fast breathing (breathing rate of 60 per minute and above), severe chest in-drawing, no spontaneous movement, fever (temperature of 37.5 °C or above), low body temperature (temperature below 35.5 °C), any jaundice in first 24 hours of life, or yellow palms and soles at any age. The family should be encouraged to seek health care early if they identify any of the above danger signs in-between postnatal care visits.
RECOMMENDATION 5: Exclusive breastfeeding All babies should be exclusively breastfed from birth until 6 months of age. Mothers should be counselled and provided support for exclusive breastfeeding at each postnatal contact.
RECOMMENDATION 6: Cord care Daily chlorhexidine (7.1% chlorhexidine digluconate aqueous solution or gel, delivering 4% chlorhexidine) application to the umbilical cord stump during the first week of life is recommended for newborns who are born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1000 live births). Clean, dry cord care is recommended for newborns born in health facilities and at home in low neonatal mortality settings. Use of chlorhexidine in these situations may be considered only to replace application of a harmful traditional substance, such as cow dung, to the cord stump.
RECOMMENDATION 7: Other postnatal care for the newborn Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps.
The mother and baby should not be separated and should stay in the same room 24 hours a day. Communication and play with the newborn should be encouraged. Immunization should be promoted as per existing WHO guidelines. Preterm and low-birth-weight babies should be identified immediately after birth and should be provided special care as per existing WHO guidelines.
RECOMMENDATION 8: Assessment of the mother First 24 hours after birth All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours. Urine void should be documented within six hours.
Beyond 24 hours after birth At each subsequent postnatal contact, enquiries should continue to be made about general well-being and assessments made regarding the following: micturition and urinary incontinence, bowel function, healing of any perineal wound, headache, fatigue, back pain, perineal pain and perineal hygiene, breast pain, uterine tenderness and lochia. Breastfeeding progress should be assessed at each postnatal contact.
At each postnatal contact, women should be asked about their emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. All women and their families/partners should be encouraged to tell their health care professional about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern.
At 10–14 days after birth, all women should be asked about resolution of mild, transitory postpartum depression (“maternal blues”). If symptoms have not resolved, the woman’s psychological well-being should continue to be assessed for postnatal depression, and if symptoms persist, evaluated. Women should be observed for any risks, signs and symptoms of domestic abuse. Women should be told whom to contact for advice and management.
All women should be asked about resumption of sexual intercourse and possible dyspareunia as part of an assessment of overall well-being two to six weeks after birth. If there are any issues of concern at any postnatal contact, the woman should be managed and/or referred according to other specific WHO guidelines.
RECOMMENDATION 9: Counselling All women should be given information about the physiological process of recovery after birth, and that some health problems are common, with advice to report any health concerns to a health care professional, in particular:
Signs and symptoms of PPH: sudden and profuse blood loss or persistent increased blood loss, faintness, dizziness, palpitations/tachycardia.
Signs and symptoms of pre-eclampsia/eclampsia: headaches accompanied by one or more of the symptoms of visual disturbances, nausea, vomiting, epigastric or hypochondrial pain, feeling faint, convulsions (in the first few days after birth).
Signs and symptoms of infection: fever, shivering, abdominal pain and/or offensive vaginal loss.
Signs and symptoms of thromboembolism: unilateral calf pain, redness or swelling of calves, shortness of breath or chest pain.
Women should be counselled on nutrition. Women should be counselled on hygiene, especially handwashing. Women should be counselled on birth spacing and family planning. Contraceptive options should be discussed, and contraceptive methods should be provided if requested.
Women should be counselled on safer sex including use of condoms. In malaria endemic areas, mothers and babies should sleep under insecticideimpregnated bed nets. All women should be encouraged to mobilize as soon as appropriate following the birth. They should be encouraged to take gentle exercise and make time to rest during the postnatal period.
RECOMMENDATION 10: Iron and folic acid supplementation Iron and folic acid supplementation should be provided for at least three months.* * The GDG noted that there is currently no evidence to change this recommendation and that WHO is working on developing specific guidelines for maternal nutrition interventions after birth
RECOMMENDATION 11: Prophylactic antibiotics The use of antibiotics among women with a vaginal delivery and a third or fourth degree perineal tear is recommended for prevention of wound complications. The GDG considers that there is insufficient evidence to recommend the routine use of antibiotics in all low-risk women with a vaginal delivery for prevention of endometritis.
RECOMMENDATION 12: Psychosocial support Psychosocial support by a trained person is recommended for the prevention of postpartum depression among women at high risk of developing this condition. The GDG considers that there is insufficient evidence to recommend routine formal debriefing to all women to reduce the occurrence/risk of postpartum depression.
The GDG also considers that there is insufficient evidence to recommend the routine distribution of, and discussion about, printed educational material for prevention of postpartum depression. Health professionals should provide an opportunity for women to discuss their birth experience during their hospital stay. A woman who has lost her baby should receive additional supportive care.