Maternal and Child Health (MCH) Services

Status of maternal and child health in Nepal

Maternal health is an important part of the health care system aimed at reducing morbidity and mortality related to pregnancy. The health care that a woman receives during pregnancy, at the time of delivery and soon after delivery is important for survival and well-being of both the mother and the child.

The term “Maternal and child health” refers to the promotive, preventive, curative and rehabilitative care for mothers and children. It includes the sub-areas of maternal health, child health, family planning, school- health, handicapped children and care of children in special setting such as day care centers. Maternal and child health care is a method of delivering health care to special group in the population which is especially vulnerable to disease, disability or death. These groups (e.g. children in under 5 years and women in the reproductive age group (15-49) years.

MCH care is now conceived of as all activities which promote health and prevent or solve health problems of mother and children, irrespective of whether they are curative, diagnostic, preventive or rehabilitative and whether they are carried out in health centers or in the home by primary health care workers, traditional dais or highly trained specialists.

According to the 2016 Nepal Demographic and Health Survey (NDHS), the maternal mortality rate has fallen from 539 maternal deaths per 100,000 live births to 239 maternal deaths per 100,000 live births between 1996 and 2016. Similarly, the neonatal mortality rate reduced during this period from 50 deaths per 1000 live births in 1996 to 21 deaths per 1000 live births in 2016.Receiving antenatal care (ANC) on specified months as per national protocol, delivering at health institutions or being assisted by skilled birth attendants (SBA) at health institutions and at home, and receiving postnatal care (PNC) are vital to preventing maternal and newborn deaths. Nepal is a signatory to the Sustainable Development Goals (SDGs), which have set ambitious targets for the country to reduce the MMR to 70 per 100,000 live births and neonatal mortality to 12 per 1,000 live births, and to achieve coverage of 90% for four ANC visits, institutional delivery, SBA delivery, and three PNC check-ups by 2030 (National Planning Commission 2017). However, further improvement is needed to meet the 2030 target. Along with the targets for reducing maternal and neonatal mortality, there are also targets for increasing the coverage of essential services related to pregnancy and childbirth that can help achieve the mortality targets.

The specific objectives of MCH are:

• Reduction of morbidity and mortality rates for mothers and children.
• Promotion of reproductive health.
• Promotion of the physical and psychological development of child with in the family.

Antenatal care    

Antenatal care is the care of women during pregnancy or systematic supervision (examination and advice) of women during pregnancy is called antenatal care.

In other words, antenatal care is the promotive and preventive care of pregnant women during the antenatal period that is the period from the day she gets pregnancy confirmed till the onset of true labour pain. It is called prenatal or antepartum care.

Objectives of antenatal care

• To promote, protect and maintain the health of the mother during pregnancy
• To detect high risk cases and give them special attention
• To prepare the mother for a normal labour lactation and care of children
• To foresee complications and prevent them
• To monitor the progress of pregnancy
• To remove anxiety and dread associated with delivery
• To educate the mother about the important of birth spacing, the availability and use of different Family Planning method.
• To reduce maternal and infant mortality and morbidity
• To prevent congenital deformity by educating mother not to expose harmful medicine or substances this may be teratogens
• To build up a trusting relationship between family and care participate in and make an inform choice.

Prenatal care and advice

• Pre-conceptional care
• Creating awareness in the community for maintenance of maternal health.
• Early diagnosis of pregnancy
• Initial prenatal/antenatal evaluation
• Focused four antenatal visit
• Assessment for referral
• Birth preparedness and complication readiness plan

Pre-conceptional care

It is an integral part of antenatal care because health during pregnancy depends on health before pregnancy. A comprehensive pre-conceptional care program has the potential to assist women by reducing risks, promoting healthy lifestyle and improving readiness for pregnancy. Factors that could potentially affect perinatal outcomes are identified and women are advised about the risks involved. Pre-conceptional counseling should be done by skill birth attendant.

Creating awareness in the community for maintenance of maternal health

Awareness programs should be carried out in the community by service providers and other government and non-government organization regarding the important of antenatal care to an individual pregnant woman, her husband family and community members. Awareness should be created with emphasis on birth preparedness and complication readiness and nutrition. Information should be provided danger signs in pregnancy and importance preventive interventions e.g. taking iron calcium, important of rest, treatment of disease in certain areas and tetanus immunization.

Early diagnosis of pregnancy

The first visit or registration of pregnant women for antenatal care should take place as soon as the pregnancy is suspected, ideally before or at the 12^th weeks of pregnancy.

Initial prenatal evaluation

As soon as pregnancy is confirmed, through evaluation of her general health and pregnancy should be done. In this process the service provider should take a thorough examination and do the necessary investigations e.g. urine pregnancy test.

Focused antenatal visit

• 1^st visit 4 month of pregnancy
• 2^nd visit 6 months of pregnancy
• 3^rd visit 8 months of pregnancy
• 4^th visit during last month (9 month) or 1 week before Expected Date of Delivery
• Monitor Blood Pressure, weight and fetal heart rate
• Detection and management of co-existing conditions and complications
• HIV-voluntarily counseling and testing
• Counseling for breast feeding, family planning, danger signs, HIV/STIs and nutrition
• Treatment of diagnosed infection syphilis, gonorrhea or tuberculosis
• Tetanus diphtheria 2 dose.
• Iron and folate 60 mg iron and 400 microgram of folate after 12 weeks of pregnancy to 6 weeks after delivery
• Tab Albendazole one dose after 12 weeks of pregnancy.

Assessment for referral

• Recognize the complications manage if needed and refer.
• Detection and management of associated diseases e.g. Pregnancy Induced Hypertension, management of pregnancy associated with medical disorders e.g. anemia, heart disease, diabetes etc.

Birth preparedness and complication readiness

• Four out of ten pregnant or postpartum women will experience some complications related to their pregnancy, for about 15% of these women, the complication will be potentially life threatening and require immediate emergency obstetrical care. Since most of these complications cannot be predicted every pregnancy necessitates preparation for a possible emergency.

Notes: Types of delay: Delay 1- Delay in deciding to seek care. Delay 2-Delay in reaching the healthcare facility. Delay 3- Delay in receiving care.

Every pregnant women and her family should have a birth preparedness and complications readiness plan that includes.

Birth preparedness

• A plan of where to have the delivery- Home or health facility
• A skill birth attendant during delivery
• Supplies needed for a clean delivery (in home delivery is preferred SDK or basic items such as clean sheet or plastic to use as a clean delivery surface, a new blade, clean thread for cord tie, soap, water)
• Supplies needed for a clean postpartum period for mother and new born-clean cloth for mother and newborn, a towel or cloth to wipe the baby, a clean wrap for the baby and sanitary pads/cloth for the mother.

Complication readiness

• A person or person designated to make decision on her behalf, in case she is unable to make them
• A way to communicate with a source of help (Skill attendant facility transportation)
• Emergency funds
• Emergency transportation
• Blood donors
• The name and the location of the nearest hospital that has 24 hours functioning emergency obstetric care services.

No longer recommended during ANC

• Numerous visit- 4 visits are sufficient for pregnancies without complications additional visits do not affects maternal or perinatal outcomes.
• Measurement of maternal height- is a poor too for determining cephalo pelvic disproportion as maternal height varies among societies.
• Examination of ankle edema-50-80% of women with normal pregnancies experience ankle edema. Hypertension with edema is less associated with fetal death than hypertension without edema.
• Examination of fetal position before 36 weeks- fetal position is not stable before 36 weeks.

Antenatal visit

Antenatal visit should be started as soon as after pregnany has confirmed. Antenatal visit must be at least four focused or goal oriented visit and can be have anytime if problems aroused. According to WHO at least four ANC visit should be recommended to the pregnant mother.

• First visit- it should be carried out before 4 month
• Second visit- on sixth months
• Third visit- on eight months
• Fourth visit- on nine month

The 2016 WHO ANC guidelines recommend that pregnant women have eight ANC contacts with the health system during each pregnancy. The Government of Nepal has adopted the eight ANC contact protocol as follows.

• First visit – up to 12 weeks  
• Second visit- up to 16 weeks
• Third visit- from 20–24 weeks
• Fourth visit – within 28 weeks
• Fifth visit- in 32 weeks
• Sixth visit- in 34 weeks
• Seventh visit-  in 36 weeks
• Eighth visit-  from 38–40 weeks (Ministry of Health and Population 2019).

The NDHS 2022 reports shows that 80% of women had at least four ANC visits for their most recent live birth and/or stillbirth in the 2 years preceding the survey. However, only 6% had eight or more visits.

First visit

In first antenatal visit following activities are done:

1. History taking

• Demographic information
• Menstrual history
• Obstetric history
• Past history
• Medical and surgical history
• Family history
• Drug history
• History of immunization
• Socio economic history
• Contraceptive history
• History of allergy

2. General physical examination

3. Abdominal examination

4. Laboratory investigation

• Blood test (HIV, HBsAg, HCV, HB, Blood grouping, Random glucose, CBC)
• Urine test (*UPT, protein and albumin) *UPT- urine pregnancy test

5. Ultrasonography

6. Client education and counseling

. Advice to the pregnant woman

• Support from husband and family
• Nutrition: greater amount, variety of nutritious healthy foods (vegetables, meat, cereals, milk, starchy food). Eat at least one extra meal a day, smaller but more frequent meals and drink plenty of fluids.

8. Counseling on safe sex, healthy habits

9. Counsel and explain them about danger signs 

10. Iron and calcium supplementation

11. Emphasis on the next ANC visit

Second visit

Activities

1. Listen to the woman’s problems and concern

2. Ask about present pregnancy for swelling of hand and feet, shortness of breath, feeling of fetal movement

3. Perform physical exam as vital signs, general head to toes exam

Abdomen- fundal height in cm and compare with weeks of gestation, palpate fetal part, listen fetal heart sound

4. Laboratory investigations: urine routine for proteinuria, hemoglobin if the first visit was < 7 gm% and if sign of anemia present

5. Assess for referral as presence of danger signs

• Vaginal bleeding
• High blood pressure
• Proteinuria
• Blurring of vision with severe headache
• Look for sign of cardiac failure

6. Care and counseling

• Continue iron/folate and calcium
• Give one dose of tab Albendazole 400mg
• Give injection Tetanus Diphtheria first dose 0.5 ml deep IM in the upper arm. Counsel for next dose after 1 month
• Educate and counsel about birth preparedness, complications readiness, nutrition, emergency fund, transportation, emphasis on next visit.

Third visit

1. Listen to the woman’s problem and concerns
2. Ask for abdominal or back pain, leaking, swelling of face and hand, signs of anemia, shortness of breath, feeling of fetal movements
3. Examine woman for vital sign, signs of complication, measure symphysio- fundal height, palpate fetal part, listen fetal heart sound
4. Education and counseling on:
5. Continuation of iron and calcium supplementation
6. Birth preparedness and complications readiness
7. Confirm the place of delivery, service provider and transport
8. Schedule next appointment
9. Contraception and importance of postpartum visit
10. Importance of exclusive breast feeding.

Fourth visit

1. Listen to the woman’s problem and concerns
2. Ask for abdominal or back pain, bleeding, leaking, swelling of face and hand, feeling of fetal movements
3. Examine for vital signs, swelling of face, hand and feet, sign of anemia, cyanosis and jaundice
4. Examine abdomen for fundal height, palpate fetal part, listen fetal heart sound and confirm the lie and presentation
5. Assess for referral for any complications

• Presence of bleeding per vagina
• Detection of high Blood Pressure or proteinuria
• Suspicion of multiple pregnancies, mal-presentation, fetal growth retardation
• Less fetal movement or woman doesn’t feel fetal movements.

6. Care and counseling

• Continuation of iron and calcium
• Sign of initiation of labor as presence of show/discharge, leaking
• Review birth preparedness and readiness plan
• Advice and counsel on exclusive breastfeeding
• Counsel on importance of postnatal visit within 72 hours of delivery
• Schedule next appointment is not delivered by 41 weeks.

Risk approach

The risk assessment approach, introduce in the late 1970s continue to be widely practiced. Health provider classified pregnant women as” high risk” those who have greater chances of developing complications in the current pregnancy based on physical characteristics and medical history (too young, too old, too short, number of previous pregnancy). Those identify at risk are referred to a hospital for medical care and for their delivery.

The “risk approach” is a managerial tool aimed at providing maximum benefit to reproductive women. Its purpose is to provide better services for all but with special attention to those who need them most.

The central purpose of antenatal care is to identify “high risk” cases (as early as possible) from a large group of antenatal mothers and manage for them skilled care. While continuing to provide appropriate care for all mothers.

The following are the example of high risk pregnancies:

• Short statured primi (140 cm and below)
• Multiparous pregnant women
• Too early pregnancy-below 20 years
• Too elderly pregnancy-after 35 years of age
• Teenage pregnancy
• Abnormal or mal-presentation e.g. breech and transverse lie.
• Women who have twins’ pregnancy
• Pre-eclampsia- eclampsia
• Women with risk of HIV/Aids
• Preterm or post term pregnancy
• Women history of previous, C/S, still birth, abortion, Antepartum hemorrhage, postpartum hemorrhage, instrumental delivery.
• Pregnant women who abuse tobacco, alcohol or drugs of addiction
• Pregnant women suffering from anemia, PIH, TB, epilepsy, heart disease, malnutrition, kidney disease, liver disease etc.
• A women conceived after treatment of infertility

Intranatal care/domiciliary care

Intranatal care means care given during labour or delivery period

Domiciliary midwifery

This refers to care given to a mother and the baby at home rather than the hospital by a registered midwife during antenatal, intra-natal and postnatal periods.

It is defined as a home delivery service undertaken by a community midwife or the flying squad (made up of the doctor, experienced midwife, anesthetist and pediatrician) with a delivery kit thereby allowing patients to deliver in their homes.

Advantages of domiciliary care:

1. The mother delivers in familiar surroundings.
2. Minimal family disruption.
3. Cost-effective.
4. Enhanced emotional and physical support for the mother.
5. Family participation is encouraged.
6. Lower risk of cross-infection compared to hospitals.
7. Emphasis on the normality of childbirth.

Disadvantages of domiciliary care

1. The mother may receive less medical and nursing supervision compared to a hospital setting.
2. Limited opportunity for adequate rest for the mother.
3. Potential for the mother to resume domestic duties too soon.
4. Difficulty in promptly referring to a hospital in the presence of complications.
5. Risk of complications if there are no trained individuals, including the possibility of infection, premature pushing, perineal tear, and postpartum hemorrhage.

Those involved in domiciliary care include:

1. Traditional Birth Attendants (TBAs)
2. Female Community Health Volunteers (FCHVs)
3. Mother groups from the community

Health personnel from health institutions such as: Auxiliary Nurse Midwives (ANM), Staff Nurses, Health Assistants (HA) and Doctors. These professionals may be associated with Health Posts (HP), Primary Health Centers (PHC), and hospitals, playing crucial roles in providing care and support in a home setting.

1. Preparation for delivery to mother and significant family members

• A pregnant mother and her family should begin preparing for the baby around the 7-8 months of pregnancy.
• Preparation of the mother for labour:

The mother and her family should be taught;

When and how to bear down in the 2nd stage of labour.

Dietary considerations during labour, emphasizing mainly liquid intake.

Explanation of the labour process, including what to do and what not to do.

• Delivery position: Information and guidance on appropriate delivery positions should be provided.

2. After delivery

• Breast care and breastfeeding: Guidance on proper breast care and breastfeeding techniques.
• The way of handling the baby: Instruction on appropriate methods of handling and caring for the newborn.
• Baby bath, eye, and cord care: Information on the correct procedures for bathing the baby, caring for the eyes, and managing the umbilical cord.
• Immunization of the baby: Guidance on the essential immunizations for the newborn.
• Family planning: Discussion about family planning options and considerations.
• The needs of the baby: Ensuring the baby’s well-being, including maintaining a warm room temperature (21-23°C), providing proper nourishment, ensuring fresh air, offering motherly care, promoting exercise, managing elimination, appropriate clothing, protection, and preventing infection.

3. Items needed for child birth

• Baby wrapper (made from clean old cloth, should be soft)
• Bathing soap
• Mustard oil for massaging the baby
• Towel
• Baby clothes, bhoto, cholo, suruwal
• Napkin (made from soft cloths)
• Pillow filled with mustard seeds
• Blanket for baby

4. Items for mother

• Petticoat and sari
• Blouse
• Items for morning care
• Sanitary pads
• Food (e.g., meat, rice, ghee, chaku, milk, and some fruits and vegetables)
• If the mother is alone at that time, arrangements for a relative or any other person for the care of the mother and baby should be made.

5. Items needed for conducting delivery in home

• Clean clothes
• Bowls or dekchi
• Soap/water
• Sterile scissors or blade for cord cutting
• Two clamps or forceps if available
• Thread to tie the cord
• Mud pot to receive the placenta
• Cotton, gauze, sanitary pads
• Syringe needle and ergometrine

SAFE Clean Delivery Kit (SCDK)

The box should be ready at all times, and the checklist should include:

1. Soap
2. Towel
3. Plastic apron
4. Bed Sheet
5. Newspaper
6. Plastic bag for waste
7. Enema
8. Shaving set
9. Episiotomy equipment
10. Tape measure and weight scale
11. Oral and rectal thermometer for the baby and mother
12. Syringe needles,
13. Commonly used medications Pethidine, Fortwin, Syntocin, Ergometrine Iron, Folic acid, and Paracetamol
14. Referral form
15. Urethral catheter
16. Antiseptic solution
17. Cord ties
18. Clamp forceps and scissors
19. Cotton gauze
20. Peripads or cloth
21. Sterile gloves
22. “Road to Health” baby card

Six cleans principles of delivery

• Clean hand before delivery
• Clean perineum
• Clean place for deliver
• Clean cord cutting instrument
• Clean cord care (clean cord tie and cutting surface)
• Nothing unclean introduced into the vagina

Birth Preparedness

 It involves a comprehensive strategy aimed at improving the use of skilled birth attendants and interventions to decrease maternal and newborn mortality. It focuses on reducing delays in seeking, reaching, and receiving care during pregnancy and childbirth.

• Plan for where to have delivery: Decide on a suitable and safe location for childbirth, whether at home, in a health facility, or a birthing center.
• Plan for a birth attendant: Choose and arrange for a skilled birth attendant, such as a midwife or healthcare professional, to assist during delivery.

Supplies needed for clean delivery (Clean Delivery Kit): Sufficiently prepared Clean Delivery Kit (CDK) containing:

• Clean sheet
• New blade or sterile scissors
• Clean thread
• Soap and water

Supplies needed for postpartum period for mother and baby: Ensure availability of necessary items for the postpartum period.

Complication readiness:

• Emergency fund
• Transportation
• Blood donors
• Name and location of nearest hospital

Postnatal care

Postnatal care refers to the care provided to the mother and newborn immediately after delivery and extends to the period of 42 days. This care is divided into two primary areas: the care of the mother, primarily the responsibility of the obstetrician, and the care of the newborn, a shared responsibility of the obstetrician and pediatrician. This collaborative field of responsibility is commonly known as perinatology.

Postnatal care involves a systematic examination of both the mother and the baby, along with providing appropriate advice to the mother during the postpartum period. The goal is to ensure the well-being of both the mother and the newborn, addressing any health concerns and providing guidance on postpartum recovery and infant care.

Objectives of postnatal care

1. To prevent infections and complications during the postnatal period.
2. To provide care for the rapid restoration of the mother to optimum health.
3. To check adequately for breastfeeding and prevent complications of the breast.
4. To offer emotional support to the mother.
5. To provide family planning services.
6. To offer basic health education to the mother and family, including self-care, baby care, immunization, follow-up visits, regular intake of iron and vitamin A supplements, and recognition of danger signs.

Postnatal advice/care to mother and baby 

Post-natal advice includes:

1. Greet the mother and inquire about the general well-being of both the mother and the baby.
2. Explain to the mother the procedures you are going to perform.
3. Record temperature, pulse, and blood pressure (TPR and BP) twice a day or as needed.
4. Conduct a head-to-toe examination of the mother.
5. Conduct laboratory investigations if needed, such as checking hemoglobin levels (Hb%).
6. Rest and sleep: Ensure adequate rest and sleep, and inquire about the mother’s ability to sleep. Some multiparous mothers may experience “after pain” in the first 2-3 days after delivery due to uterine contractions. If the mother is unable to sleep due to discomfort from after pain, consider relieving it with paracetamol.
7. Diet and nutrition: Encourage the mother to consume foods rich in iron, minerals, vitamins, and protein to support lactation and aid in the body’s readjustment. Additionally, ensure an ample intake of fluids and provide supplemental Vitamin A to the mother.
8. Ambulation: Promotes increased muscle tone and venous return in the legs and lower abdomen, aiding in the drainage of lochia and the voiding of urine. This, in turn, reduces the chance of stitch infection and promotes faster healing. Encourage ambulation as soon as possible; it should be initiated within 6-12 hours of delivery, while mothers who undergo Caesarean section (C/S) should begin ambulation after 24 hours.
9. Care of bladder: The mother should be encouraged to pass urine within 6-12 hours of delivery. If she is unable to do so during this time frame, the midwife must implement nursing measures such as ambulation, offering water to drink, opening the tap, and pouring hot and cold water over the vulva area to facilitate voiding. Under no circumstances should a hot water bottle be applied to the lower abdomen, as it may predispose (trigger) postpartum hemorrhage (PPH).
10. Care of bowel: Ensure daily bowel movements; postnatal mothers commonly complain of constipation, often associated with painful perineum. Encourage a diet rich in green leafy vegetables, roughage, and ensure an adequate intake of fluids to alleviate constipation.
11. Clothing and linen: Maintain cleanliness at all times, changing the bed sheets as needed. Clothing should be loose to provide comfort to the mother.
12. Emotional support: Giving birth is an emotional experience, marked by fear and the initiation of a new phase in family relationships. Mothers need to be encouraged and supported as they adjust to this significant life event.
13. Perineal care: This involves care during or after delivery, abortion, or any operation involving the birth canal or perineum.
14. Breast care: This includes care before and after feeding, emphasizing the importance of proper hygiene and support for optimal breastfeeding.
15. Post-natal exercise: Post-natal exercises are performed in the postnatal ward after delivery to prevent complications and improve blood circulation. The exercises include:

• Deep breathing exercises
• Limb exercises
• Abdominal exercises
• Perineal exercises

Note: No exercises should be done immediately after a meal, and caution should be taken with mothers who have undergone Caesarean section (C/S).

16. Administer Vitamin A 200,000 IU if not previously given.
17. Administer medication as prescribed, e.g., iron + folate tablets, until 6 weeks after the postpartum period.
18. Assist the mother with the care of the infant as needed.
19. If the mother is Rh-negative, check the Rh status of the baby. If the baby is Rh-negative, no further action is required. However, if the baby is Rh-positive, consider administering Rh immunoglobulin (RHOGAM) with one vial within 72 hours after delivery.

Immediate care of new born

The care of a newborn baby immediately after birth is crucial, particularly during the first hour, as it significantly influences the infant’s survival, future health and overall well-being. Health workers play a vital role during this time, providing critical care to prevent complications and ensure the newborn’s survival.

Objectives of immediate newborn care

1. To facilitate the establishment of respiration and prevent asphyxia.
2. To maintain a stable body temperature.
3. To prevent from injuries and infections.
4. To identify congenital abnormalities and provide necessary treatment.
5. To promote early initiation and exclusive breastfeeding.
6. To prevent hypoglycemic shock.
7. To promote overall neonatal health.

Immediate care includes;

1. Wipe the neonate’s eyes and mouth soon after delivery of the head.
2. Clean the airways: Immediately after delivery, suction the air passage to clear any fluids. Establishing and maintaining cardio-respiratory functions, such as breathing, is of utmost importance immediately after birth. To facilitate breathing, clear the airway of mucous and other secretions. Positioning the baby with its head lowered can aid in the drainage of secretions, and gentle suction may be applied to remove mucous and amniotic fluid.
3. APGAR Score (Activities, Pulse, Grimace, Appearance, Respiration): Assess the newborn’s condition using the APGAR score to evaluate various vital signs and overall well-being.
4. 2-3 minutes after delivery, the baby’s cord is clamped using two Kocher’s forceps. The first clamp is applied approximately 5 cm away from the umbilical base, followed by the second clamp positioned 2.5 cm away from the first one. Cut the cord between the two clamps using a new razor blade or sterile scissors. Do not apply any substances to the cord stump.
5. Note the time of birth and record the baby’s sex immediately after delivery.
6. Care of the skin involves drying the neonate promptly from head to toe using a warm cloth while simultaneously providing gentle stimulation. Subsequently, wrap the baby in a clean, dry, and warm cloth to prevent a drop in body temperature.
7. Breastfeeding: Place the baby on the mother’s chest for skin-to-skin warmth, then assist the mother in initiating breastfeeding within the first hours of birth.
8. Maintenance of body temperature: Assess the baby’s temperature using a rectal thermometer to ensure the patency of the rectum or anus. The normal body temperature of a newborn is between 36.5⁰-37.5⁰C.
9. Examine the newborn from head to toe, checking for any congenital abnormalities and injuries.
10. Weigh the baby before dressing.
11. Dress the baby in warm clothing such as a bhoto, daura, cholo, napkins, and cover the head with a cotton cap or topi. Wrap the baby in a warm cloth or blanket.
12. Following these procedures, ensure proper recording and reporting.

Eight steps for new born care

Step 1- Dry stimulate and wrap the baby

• Dry head and entire body with a clean warm cloth.Rub up and down baby back. Discard wet clothes. Wrap the baby in a clean dry warm cloth

Step 2- Assess breathing and colour

• Check baby breathing (normal, trouble not breathing)
• Assess baby’s colour (pink, grey, blue, pale)

Step 3- Decide if baby needs resuscitation

• Check if breathing less than 30 breaths in one min, gasping or not breathing. If baby need resuscitation, do it

Step 4- Tie and cut the cord, take birth weight, note APGAR score, record sex and time of birth

Step 5- Place the baby in skin to skin contact

• Put the baby in skin to skin contact with mother’s chest
• Cover both mother and baby together with a warm cloth or blanket
• Cover baby’s head

Step 6- Have the woman start breastfeeding within first hour of birth

• Help mother with baby’s position
• Check for good attachment
• Check for good baby’s sucking
• Do not limit time of sucking

Step 7- Give eye care within one hour of birth

• Give eye care if necessary with normal saline or cold boil water within one hour after birth.

Step 8- Explain findings to the mother and both normal and abnormal findings

Examination of Newborn Baby

This is the process of examination of newborn from head to toe.

Purpose

• To assist baby’s condition and provide immediate care based on the baby’s needs.
• To detect congenital abnormalities, present from birth
• To detect illness and birth injury for prompt treatment.
• To measure and record body temperature

Equipment

• Thermometer set
• Weighing scale
• Tape measure
• Baby’s chart or card
• Torch light
• Babies clothes
• Pen

Procedure for Newborn Examination

Explanation to the mother:

• Clearly communicate the examination procedure and its purpose to the mother.
• Emphasize that the examination aims to assess the baby’s overall health and detect any potential issues early on.

Equipment preparation:

• Ensure all necessary equipment is prepared and readily available for the examination.
• This may include a thermometer, stethoscope, measuring tape, and any other tools required for a thorough assessment.

Room preparation:

• Set up a clean and warm examination room.
• Ensure the environment is comfortable for both the baby and the mother.

Hand hygiene:

• Wash hands thoroughly with soap and water.
• Dry hands using a clean towel or disposable hand towels.

Positioning of neonate:

• Place the neonate in a supine position on the examination table under a warmer.
• Choose a clean, warm surface where the mother can observe the examination process.

Observation of baby:

• Conduct a careful observation of the baby from head to toe.
• Begin by assessing the color of the skin, noting whether it appears pink or if there are signs of cyanosis.

Assessment of movements:

• Observe the movement of the baby’s limbs.
• Ensure a full range of motion and assess for any abnormalities.

Evaluation of crying:

• Pay attention to the baby’s cry, noting whether it is normal or feeble.
• Consider the baby’s vocalizations as an indicator of their well-being.

Vital signs assessment: check the neonate’s vital signs, aiming for normal values:

• Temperature: 97.9°F – 98°F
• Pulse: 120-160 beats per minute
• Respiratory rate: 36-60 breaths per minute

Weight assessment:

• Evaluate the newborn’s weight, with the normal range being 2.5-3 kg.

Measurement of height and circumferences:

• Head height: 48-50 cm
• Head circumference: 32-34 cm
• Chest circumference: 30-32 cm

Head to toe examination:

1. Head:

• Shape and size: assess for symmetry and normal proportions.
• Fontanelle: check for the soft spots’ normal size and tension.
• Suture: ensure the skull sutures are aligned.
• Moulding: assess for any molding due to the birthing process.
• Swelling: check for any abnormal swelling on the head.
• Skull fracture: inspect for any signs of fracture.
• Hydro or microcephalic: assess for abnormal head size, indicating hydrocephaly or microcephaly.

2. Eye:

• Examine colour: observe the colour of the eyes for normalcy.
• Jaundice: check for any signs of jaundice in the eye.
• Discharge: assess for abnormal eye discharge.
• Edema and hemorrhage: look for any swelling or bleeding in the eye region.

3. Ear:

• Structure: examine the ears for normal structure.
• Discharge: check for any abnormal ear discharge.

4. Mouth:

• Cleft palate/hare lip: inspect for any congenital abnormalities in the mouth.
• Deciduous teeth/thrush: look for the presence of baby teeth or signs of thrush (white patches on the mouth).
• Tongue tie: assess for any restriction of tongue movement.

5. Nose: structure and septum: examine the nose for normal structure and septum.

6. Neck: congenital goiter: assess for swelling or abnormalities in the neck.

7. Chest:

• Respiratory rate and rhythm: monitor the rate and rhythm of respiration.
• Lung sounds: auscultate for normal lung sounds.
• Heart sounds: listen for normal heart sounds.
• Chest movement during respiration: observe chest movement during breathing.
• Breast enlargement: check for any signs of breast enlargement.

8. Abdomen:

• Size and shape: assess for normal size and shape.
• Distention: check for any abnormal swelling or distention.
• Respiration: observe the movement of the abdomen during respiration.
• Condition of cord: inspect the umbilical cord for any signs of infection or abnormality.
• Auscultation for bowel sounds: listen for normal bowel sounds using a stethoscope.

9. Extremities:

Arm movement: assess for normal arm movement and range of motion.

• Dislocation and fracture: check for any signs of dislocation or fracture.
• Paralysis: look for any indications of paralysis.
• Range of motion: assess the range of motion in the arms.

Legs:

• Dislocation of hip movement: check for hip movement and signs of dislocation.
• Extra fingers: examine for the presence of extra fingers.
• Talipes (clubfoot): assess for any deformities like clubfoot.

10. External genitalia:

Male baby:

• Congenital hydrocele: check for swelling in the scrotum.
• Phimosis: examine for any tightness of the foreskin.
• Absence of testes: ensure the presence of both testes.

Female baby:

• Labia majora and minora: examine the labia majora covering the labia minora.
• Discharge: check for any abnormal discharge.

11. Rectum:

• Patency: examine for the patency of the rectum.
• Passing of meconium: confirm the passage of meconium.
• Imperforate anus or fistula: check for any signs of imperforate anus or fistula.

12. Back:

• Observation for spina bifida: check for any visible signs of spina bifida.
• Vertebral dislocation or fracture: examine for any dislocation or fracture in the vertebral region.
• Neurological response:

• Moro reflex: assess the moro reflex by observing the baby’s response to a sudden startle or loud noise.
• Rooting reflex: test the rooting reflex by gently stroking the baby’s cheek and observing the turning of the head toward the stimulus.
• Grasp reflex: check the grasp reflex by placing a finger in the baby’s palm and observing the grip response.
• Stepping reflex: observe the stepping reflex by allowing the baby’s feet to touch a surface and noting any stepping movements.
• Sucking reflex: check the sucking reflex by offering a clean finger or pacifier and observing the baby’s sucking response.
• Tonic neck reflex: assess the tonic neck reflex by turning the baby’s head to one side and observing the extended arm and flexed opposite arm.
• Pupillary reflex: examine the pupillary reflex by shining a light into the baby’s eyes and observing pupil constriction.

13. Record and report:

• Documentation: record all findings from the examination accurately, including vital signs, measurements, and neurological responses.
• Reporting: share the results with the relevant healthcare professionals, ensuring proper communication of any abnormalities or concerns.
• Parental communication: discuss the examination findings with the parents, providing them with a clear understanding of their baby’s health status.
• Follow-up recommendations: provide any necessary follow-up recommendations, such as scheduled vaccinations or further diagnostic tests.

Postnatal visit

Postnatal care (PNC) is crucial for monitoring the health and well-being of both the mother and the newborn after delivery. The World Health Organization (WHO) recommends a series of postnatal visits for proper care and assessment.

Three post-natal care(PNC) visits (within 24 hour of delivery, on 3rd and 7th day of delivery) was recommended in Nepal. (NDHS, 2018). In addition to the three recommended visits, there is an extra post-natal care visit scheduled within six weeks of delivery.

• 1st visit: within 24 hours of delivery.
• 2nd visit: 3^rd following the delivery
• 3rd visit: 7-14 days of delivery.
• 4th visit:  6 weeks after delivery (42 days)

Overall, 70% of women received a postnatal check during the first 2 days after delivery, with 54% receiving a check-up within 4 hours of delivery. Twenty-eight percent of women did not receive any postnatal check during the first 2 days after the delivery of their most recent live birth or stillbirth in the 2 years preceding the survey (NDHS, 2022).

First visit for mother

• History-taking
  • Place of delivery
  • Person who conducted the delivery
  • History of any complications during the delivery / bleeding per vagina / convulsions or loss of consciousness
  • Pain in the legs / abdominal pain / fever / dribbling or retention of urine / any breast tenderness, etc.
  • Initiation of breastfeeding the baby
  • Has she started her regular diet?
  • Are there any other complaints?
• Examination
  • Pulse, blood pressure, temperature and respiratory rate.
  • Presence of pallor.
  • Abdominal examination.
  • Examine vulva and perineum for the presence of any tear, swelling or discharge of pus.
  • 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
  • Examine the breasts for any lumps or tenderness, check the condition of the nipples and observe breastfeeding.
• Management / Counseling
  • Post-partum care and hygiene
  • Nutrition
  • Contraception
  • Registration of birth
  • Iron and vitamin A supplementation
  • Breastfeeding

First visit for baby

• History-taking
  • When did the child pass urine and meconium?
  • Has the mother started breastfeeding the baby and are there any difficulties in breastfeeding?
  • Fever
  • Not suckling well
  • Difficulty in breathing
  • Movements of the newborn are less than normal
• Examination
  • Count the respiratory rate for one minute.
  • Look for severe chest indrawing
  • Check the baby’s color for pallor / jaundice / central cyanosis (blue tongue and lips)
  • Check the baby’s body temperature.
  • Examine the umbilicus for any bleeding, redness or pus.
  • Examine for skin infection
  • Examine the newborn for cry and activity
  • Examine the eyes for discharge
  • Examine for congenital malformations and any birth injury
• Management / Counseling
  • Maintain hygiene while handling the baby
  • Delay the baby’s first bath to beyond 24 hours after birth.
  • Maintain body temperature.
  • Should not apply anything on the cord, and must keep the umbilicus and cord dry.
  • Should observe the baby while breastfeeding and try to ensure proper/good attachment.

Second and third visits for mother

• History-taking
  • Apart from the questions asked during the first visit, also ask about the following:
    1. Continued bleeding P/V – occurring 24 hours or more after delivery
    2. Foul-smelling vaginal discharge
    3. Fever
    4. Swelling (engorgement) and/or tenderness of the breast
    5. Any pain or problem while passing urine (dribbling or leaking)
    6. Fatigue / not feeling well
    7. Unhappiness / Cry easily – post-partum depression
• Examination
  • Pulse, blood pressure and temperature.
  • Check for Pallor.
  • Conduct an abdominal examination to see if the uterus is well contracted
  • Examine the vulva and perineum for the presence of any swelling or pus.
  • Examine the pad for bleeding and lochia.
  • Examine the breasts for the presence of lumps or tenderness.
  • Check the condition of the nipples.
• Management / Counseling
  • Diet and rest
  • Contraception

Second and third visits for baby

• History-taking – same questions as during the first post- partum visit
• Examination – observe the baby for 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 diarrhea with blood in the stool
  • If there are convulsions or arching of the baby’s body.
• Management / Counseling – In addition to what was provided during the first visit counsel
  • Exclusively breastfeed the baby for six months.
  • Should feed the baby on demand or every 2 hours
  • Supplementary foods should be introduced at 6 months of age, while breastfeeding can continue simultaneously.
  • Baby’s weight loss
  • Hygiene of the baby
  • When and where to seek help in case of signs of illness
  • Immunization

Fourth visit for mother

• 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
• 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.
• Management / Counseling
  • Diet and rest
  • As in the second and third visits, emphasize the importance of Nutrition / Contraception.

Fourth visit for baby

• 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?
• Examination
  • Check the weight of the baby
  • Check if the baby is active/lethargic.
• Management / Counseling
  • Emphasize the importance of exclusive breastfeeding.
  • Tell the mother that if the baby is having any of the following problems, he/she should immediately consult the health professional. The baby is not accepting breastfeeds / The baby 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 diarrhea.
  • Counsel the mother on where and when to take the baby for further immunization.

Maternity care to the mother and baby in community level

Home level -Family/community

• Recognize pregnancy, provide nutritious food, supplement and adequate rest
• Encourage utilization of antenatal care services
• Identify a SBA for care during delivery
• Birth preparedness and complication readiness including arrangement of emergency funds and transport
• Encourage utilization of postnatal care
• Support breastfeeding
• Encourage registration of birth and maternal and neonatal deaths

Community Health Workers

• Support skilled birth attendants in the community
• Create awareness about the SBAs offer
• Mobilize the community to support referral and transportation (emergency fund and transport)
• Identify potential blood donors for emergency
• Support local health institution providing Maternal and Neonatal Health (MNH) services
• Help the poor and underprivileged to utilize MNH services
• IEC (Information Education and Communication)/counseling for dangers signs during pregnancy, delivery, postpartum for mother and newborn
• Birth preparedness and complication readiness with families (delivery by SBA, preparation of money, transport)
• Health promotion (information on uterus prolapse, smoking)
• Breast feeding promotion/counseling
• Detection of complication in mother and newborn and facilitation of referral to nearest health facilities
• Postnatal visit for mother and newborn (within 72 hrs. of birth and check weight of baby)
• Counseling on unwanted pregnancy and safe abortion services
• Encourage registration maternal & neonatal birth & deaths.

Health post level

Antenatal care

• Four focused antenatal visit
• Monitor Blood Pressure, weight, Fetal Hearth Rate
• IEC/counseling for danger signs of pregnancy, delivery and postpartum periods for mother and newborn.
• Birth preparedness (delivery by SBA/complication readiness with family)
• Detection and management of co-existing conditions and obstetric firs aid complication
• Iron folate supplementation
• Treatment of night blindness
• Tetanus diphtheria immunization
• Treatment for worms
• Syndrome detection, treatment and referral of RTIs/STIs
• Anti-malarial treatment in endemic areas
• Health promotion (include information on uterus prolapse, smoking)
• Facilitated referral to higher levels of care as necessary

Delivery and immediate newborn care

• Clean and safe delivery by SBA
• Monitor BP and FHR
• Detection of complication, obstetric first aid and referral if necessary
• Immediate and excessive breastfeeding
• Resuscitation and stabilization of newborn with asphyxia using bag and mask hypothermia and sepsis
• Identify stabilize and manage premature/LBW newborn with KMC and refer if necessary
• Suture vaginal tears
• Facilities referral for complications
• Encourage registration of birth and maternal and neonatal deaths.

Postnatal newborn care (includes essential newborn care)

• Three postnatal visit
• Detection of complications of mother and newborn, obstetric first aid and referral if necessary
• Identification of puerperal sepsis and obstetric first aid with referral if necessary
• Blood pressure detection of hypertension, obstetric first aid and referral for postpartum eclampsia
•  Detection and treatment for mastitis
• Detection and management of heavy PPH with oxytocin and referral if needed
• IEC/counseling for postpartum danger signs for mother and newborn
• Exclusive breastfeeding
• Vitamin A for mother
• Treatment of minor infections and referral after stabilization for major infections
• Health promotion
• Family planning
• Syndromic detection, treatment and referral of RTIs/STIs.
• Encourage registration of births and maternal and neonatal deaths

Comprehensive abortion care

• Diagnosis of early pregnancy
• Counseling
• Referral to nearest safe abortion services if required
• Detection, management (obstetric first aid) of spontaneous and induced abortion complication
• Post abortion FP counseling and services

Maternity care/newborn at the PHCC level

Antenatal care

• Four focused antenatal visit
• Monitor BP, weight, FHR
• IEC/counseling for danger sign pregnancy, delivery and postpartum periods for mother and newborn
• Birth preparedness (delivery by SBA/complication readiness with family)
• Detection and management of co-existing conditions and BEOC service for complications with facilitated referral if necessary.
• Iron folate supplementation
• Treatment of night blindness
• Tetanus toxic immunization
• Universal treatment for worms
• Diagnosis treatment and referral of RTIs/STIs
• Anti-malarial treatment in endemic areas
• Health promotion (including information on uterus prolapse, smoking)
• Hemoglobin estimation
• Blood group typing (including Rhesus)
• VDRL
• Cerebral spinal fluid examination
• Urine analysis (protein, sugar and bacteria)

Delivery and immediate newborn care at PHCC

• Clean and safe delivery by SBA
• Monitor BP and FHR
• Detection and management of complication, (BEOC service) with facilitated referral if necessary
• Management of shock and referral if necessary
• Immediate and exclusive breast feeding
• Resuscitation and stabilization of newborn with asphyxia using bag and mask hypothermia and sepsis
• Vacuum delivery
• Identify stabilize and mange premature/LBW newborn with kangaroo mother care and refer if necessary
• Suture vaginal and rectal tears
• Facilities referral for complications
• Encourage registration of birth and maternal and neonatal deaths

Postnatal newborn care (includes essential newborn care)

• Three postnatal visit
• Detection of complications of mother and newborn, BEOC services and referral if necessary
• Detection and treatment for mastitis
• Detection and management BEOC services for heavy postpartum bleeding/hemorrhage with referral if necessary
• Identify, stabilize and manage premature/LBW newborn with referral if necessary
• IEC/counseling for postpartum danger signs for mother and newborn
• Exclusive breastfeeding
• Vitamin A for mother
• Treatment of minor infections, referral after stabilization for major infections in newborn
• Health promotion
• Family planning
• Diagnosis, treatment referral of RTIs/STIs for immunization
• BCG vaccination and counseling
• Encourage registration of births and maternal and neonatal deaths.

Comprehensive abortion care

• Diagnosis of early pregnancy
• Counseling
• Manual Vacuum Aspiration (MVA) (safe abortion procedure) if required.
• Detection, management of spontaneous and induced abortion complication with antibiotics, oxytocin and MVA/, D & C (Dilatation and Curettage) if necessary
• Post-abortion Family Planning counseling and services.