Safe pregnancy and birth: antenatal and postnatal contacts
Most deaths of mothers and newborns can be prevented with good care before, during and after birth, and much of that care can be given in primary care by nurses, midwives and clinical officers. This course takes you through the WHO antenatal (2016) and postnatal (2022) recommendations, then the three emergencies that kill most often around the birth: bleeding, infection and a baby who does not breathe. Each lesson starts from what to do, which medicines to give and who needs referral now.
- Plan and deliver the WHO eight-contact antenatal model and the four postnatal contacts.
- Give the antenatal preventive package with correct doses: iron and folic acid, calcium, IPTp, tetanus vaccination and deworming.
- Recognise hypertension, pre-eclampsia and eclampsia, give magnesium sulfate and refer safely.
- Diagnose and treat anaemia in pregnancy using WHO haemoglobin cut-offs.
- Recognise danger signs in mothers and newborns after birth, and offer contraception and nutrition advice after birth.
- Detect postpartum haemorrhage early and start the WHO first-response bundle.
- Recognise maternal sepsis, give first treatment and refer.
- Give essential newborn care at birth and start bag-and-mask ventilation within the first minute when a baby does not breathe.
The WHO antenatal model: eight contacts
- Describe the 2016 WHO antenatal contact schedule and why it replaced four visits.
- List what to ask, examine and test at the first contact.
For many years, WHO advised four "focused" antenatal visits. In 2016 WHO published 49 recommendations on routine antenatal care and replaced the four-visit model with a minimum of eight contacts. The evidence suggested that more contacts lead to fewer perinatal deaths and a better experience for women.
| Trimester | Contacts (weeks of pregnancy) |
|---|---|
| First | Contact 1: up to 12 weeks |
| Second | Contact 2: 20 weeks; contact 3: 26 weeks |
| Third | Contacts 4 to 8: 30, 34, 36, 38 and 40 weeks |
WHO uses the word contact rather than visit because it means a real connection with a health worker. Contacts can be adapted to local services, including outreach and community health workers. Anything missed at one contact should be done at the next.
The first contact
- History: last menstrual period, previous pregnancies and births, illnesses, medicines, tobacco, alcohol and other substances.
- Examination: blood pressure, weight, pallor, fundal height or uterine size, fetal heart when audible.
- Tests: haemoglobin, HIV and syphilis, urine for asymptomatic bacteriuria (culture, or Gram stain if no culture; not dipstick).
- One ultrasound scan before 24 weeks, where available, to date the pregnancy and detect twins and anomalies. It can be done at contact 1 or contact 2.
- Ask about intimate partner violence when assessing conditions it may cause, if you are trained, can see her in private and have somewhere to refer.
Every contact
Ask how she is feeling and about danger signs; measure blood pressure; look for anaemia; check fetal growth and the fetal heart; give and check supplements; give one or two key messages; and update her birth and emergency plan. WHO recommends that each woman carries her own case notes, which improves continuity when she is seen by different workers.
Worked case 2: Late booking at 28 weeks
Ms F, 31, has her first contact at 28 weeks because the clinic was closed during the rainy season. She has had no tests. BP 118/72, no danger signs.
- What should she have today?
- Answer: Everything from the first contact: history, BP, Hb, HIV and syphilis tests, urine for bacteriuria where culture or Gram stain is available, and the preventive package (lesson 2). It is now too late for the dating scan before 24 weeks, so do not delay care for it.
- When are her next contacts?
- Answer: At 30, 34, 36, 38 and 40 weeks, with a return at 41 weeks if she has not given birth. Missed contacts are not repeated: you simply carry on with the schedule from where she is.
Ms A, 19, comes because her period is late. A pregnancy test is positive and she is about 10 weeks pregnant. The clinic has a haemoglobinometer, rapid HIV and syphilis tests and no ultrasound. The nearest scan is at the district hospital.
When should her next contacts be?
At 20, 26, 30, 34, 36, 38 and 40 weeks: eight contacts in all including today. She should come back at 41 weeks if she has not given birth, and at once with any danger sign.
What tests should she have today, and what about a scan?
Haemoglobin, HIV and syphilis today, and a urine test for bacteriuria if culture or Gram stain is available. Arrange one ultrasound before 24 weeks, ideally by contact 2 at 20 weeks, at the district hospital.
- At least eight antenatal contacts: up to 12 weeks, then 20, 26, 30, 34, 36, 38 and 40 weeks.
- First contact: history, BP, Hb, HIV and syphilis, urine for bacteriuria, plan one scan before 24 weeks.
- Woman-held notes and a birth and emergency plan at every contact.
The preventive package
- Give iron and folic acid, calcium, IPTp, tetanus vaccination and deworming at the right dose and time.
- Explain which supplements WHO does not recommend for all women.
Iron and folic acid
WHO recommends daily oral iron 30 to 60 mg (elemental) with folic acid 400 micrograms (0.4 mg) for every pregnant woman, to prevent maternal anaemia, puerperal sepsis, low birth weight and preterm birth. Where 40% or more of pregnant women are anaemic, 60 mg is preferred. Folic acid should start as early as possible, ideally before conception, to prevent neural tube defects.
If daily iron is not tolerated because of side effects, and where fewer than 20% of pregnant women are anaemic, weekly iron 120 mg with folic acid 2.8 mg is an option. This is prevention, not treatment.
Calcium
Where diets are low in calcium, give 1.5 to 2.0 g elemental calcium a day to reduce the risk of pre-eclampsia. WHO suggests splitting it into three doses with meals and taking it several hours apart from iron, because the two interfere with each other.
Malaria in pregnancy
In malaria-endemic areas of Africa, give intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) to all pregnant women, starting as early as possible in the second trimester (from 13 weeks), at scheduled contacts at least one month apart, aiming for at least three doses. Together with an insecticide-treated bed net. Use folic acid 0.4 mg, not 5 mg: high doses may stop SP from working.
Tetanus
- Never vaccinated, or not known: two doses of a tetanus toxoid-containing vaccine one month apart, the second at least two weeks before birth. A third dose six months later, and two more in later years or pregnancies.
- One to four doses in the past: one dose in this pregnancy, up to a total of five.
Deworming
Where more than 20% of people have soil-transmitted worm infection, give preventive anthelminthic treatment after the first trimester, as part of the national programme.
Not routinely recommended
WHO does not recommend routine vitamin B6, vitamin C and E, or vitamin D supplements, multiple micronutrients, or high-protein supplements for all pregnant women. Vitamin A is only for areas where deficiency is a severe public health problem. Women with high caffeine intake (over 300 mg a day) should cut down.
Mrs B lives in an area with high malaria transmission and lots of hookworm. She is 16 weeks pregnant, Hb 112 g/L. She had two tetanus doses in her last pregnancy three years ago. The pharmacy has stocked folic acid 5 mg tablets instead of combined iron and folic acid.
What should she receive today?
Daily iron 30 to 60 mg with folic acid 0.4 mg; her first dose of IPTp-SP (she is past 13 weeks); one dose of tetanus toxoid-containing vaccine; deworming (she is past the first trimester, in an endemic area); calcium if diets are low in calcium; a bed net.
What is the problem with the 5 mg folic acid?
High-dose folic acid (5 mg or more) may reduce how well SP works. Folic acid for antenatal use should be 0.4 mg daily. Raise it with the pharmacy and district.
- Daily iron 30 to 60 mg plus folic acid 0.4 mg for every pregnant woman.
- Calcium 1.5 to 2.0 g a day where intake is low, several hours apart from iron.
- IPTp-SP from 13 weeks, at least a month apart, at least three doses, in endemic Africa.
- Tetanus vaccination according to previous doses; deworming after the first trimester where worms are common.
Hypertension, pre-eclampsia and eclampsia
- Classify hypertension in pregnancy and recognise severe pre-eclampsia.
- Give the magnesium sulfate loading dose and lower severe BP before referral.
Hypertensive disorders affect about one in ten pregnant women. In Africa and Asia, nearly one in ten maternal deaths is associated with them. Most of these deaths can be avoided with timely care.
Classify
| Findings | Classification |
|---|---|
| BP 140/90 or more before 20 weeks | Chronic hypertension |
| BP 140 to 159 / 90 to 109 twice, 4 hours apart, after 20 weeks; no proteinuria | Gestational hypertension |
| As above with proteinuria 2+ on dipstick | Pre-eclampsia |
| BP 160/110 or more with proteinuria, or any severe feature: severe headache, blurred vision, upper abdominal pain, breathlessness, little urine, clonus | Severe pre-eclampsia |
| Convulsions with raised BP | Eclampsia |
Pre-eclampsia may have no symptoms, and swelling of the feet is not a reliable sign. That is why blood pressure is measured at every contact. Eclamptic fits can happen with only modestly raised BP and in about a quarter of cases they happen after the birth.
Magnesium sulfate
Magnesium sulfate is the best drug to prevent and treat eclamptic fits, and WHO recommends it in preference to other anticonvulsants. WHO says it should be available in all health facilities. The full regimen is a loading dose and 24 hours of maintenance. Where the full regimen cannot be given, give the loading dose and transfer immediately.
- Loading dose (IM regimen): 4 g of 20% solution IV over 5 minutes, then 10 g of 50% deep IM, 5 g in each buttock, with 1 mL of 2% lidocaine in the syringe.
- Before each maintenance dose: breathing at least 16 per minute, knee reflexes present, urine at least 30 mL per hour.
- Antidote: calcium gluconate 1 g (10 mL of 10%) IV slowly.
Blood pressure
Treat BP of 160/110 or more. WHO says the choice of drug should depend on the clinician's experience, cost and availability; hydralazine, methyldopa, labetalol and nifedipine have all been widely used. For non-severe hypertension (140 to 159 / 90 to 109), WHO 2020 says to offer treatment where there is good follow-up, with methyldopa or a beta-blocker. Never use ACE inhibitors or ARBs in pregnancy, and do not give ergometrine to women with high BP.
Prevention
- Low-dose aspirin 75 mg daily for women at high risk (previous pre-eclampsia, diabetes, chronic hypertension, kidney or autoimmune disease, twins), started before 20 weeks.
- Calcium where intake is low (lesson 2).
- Bed rest, salt restriction, vitamins C, D and E, and diuretics do not prevent pre-eclampsia.
Worked case 2: Fits two days after birth
A community health worker brings Mrs G to the health centre on day 2 after a normal birth at home. She had a fit an hour ago. BP 158/104, proteinuria 2+. She is drowsy but breathing normally.
- What is the diagnosis?
- Answer: Postpartum eclampsia. About a quarter of eclamptic fits happen after birth, and the BP need not be very high.
- What do you do?
- Answer: ABCDE and recovery position; the magnesium sulfate loading dose; check breathing rate, knee reflexes and urine before any further dose; lower BP if it reaches 160/110; transfer with a health worker and calcium gluconate. Keep the baby with her and breastfeeding if possible.
Mrs C comes to a health centre with a headache that paracetamol has not helped and blurred vision. BP is 164/112 and 162/110 fifteen minutes later. Urine protein 3+. The district hospital is 2 hours away. The health centre has magnesium sulfate, nifedipine and calcium gluconate.
What is the classification?
Severe pre-eclampsia: BP 160/110 or more with proteinuria and severe symptoms after 20 weeks.
What do you do before she leaves?
Give the magnesium sulfate loading dose (4 g IV over 5 minutes plus 10 g deep IM, 5 g in each buttock), give oral nifedipine to bring BP below 160/110 (repeat after 30 minutes if needed, per protocol), start an IV line, and transfer urgently with a health worker, calcium gluconate and a note of the doses. Never leave her alone.
- Measure BP at every contact; 140/90 or more after 20 weeks needs a urine protein check.
- Severe pre-eclampsia or eclampsia: magnesium sulfate loading dose, lower BP of 160/110 or more, urgent transfer.
- Aspirin 75 mg from before 20 weeks for high-risk women; calcium where diets are low in calcium.
Anaemia in pregnancy
- Diagnose and grade anaemia in pregnancy using WHO cut-offs and clinical signs.
- Treat anaemia and know when to refer.
Anaemia makes women tired and breathless and lowers their reserve if they bleed at birth. Common causes in low-resource settings include iron deficiency, malaria, hookworm, schistosomiasis, HIV, TB and sickle cell disease.
Diagnose
Measure haemoglobin at the first contact. WHO recommends a full blood count, or an on-site haemoglobinometer where there is no laboratory, rather than the haemoglobin colour scale. At later contacts look for pallor of the palms and conjunctiva, and ask about tiredness and breathlessness.
| Trimester | Anaemia if Hb is below | Severe if Hb is below |
|---|---|---|
| First and third | 110 g/L | 70 g/L |
| Second | 105 g/L | 70 g/L |
Treat
- Increase elemental iron to 120 mg a day with folic acid 400 micrograms until Hb is 110 g/L or more, then go back to the preventive dose (WHO ANC 2016). PCPNC gives this as one 60 mg tablet twice a day for 3 months.
- Test and treat malaria in endemic areas; make sure IPTp and a bed net are in place.
- Deworm after the first trimester where worms are common.
- Reassess at the next contact (4 to 6 weeks); if anaemia persists, check adherence and refer.
After birth, iron (with or without folic acid) for 6 to 12 weeks reduces anaemia where it is common in pregnancy.
Worked case 2: Breathless at 36 weeks
Mrs H, 36 weeks, Hb 64 g/L, is breathless at rest with breathing 34 per minute and very pale palms. Malaria is common in the area.
- How do you classify her?
- Answer: Severe anaemia: Hb below 70 g/L with breathlessness at rest.
- What is the plan?
- Answer: Urgent referral to a facility that can transfuse and manage birth; test and treat for malaria; she should give birth where blood is available because she has little reserve if she bleeds (lesson 6).
Mrs D is 24 weeks pregnant with her fourth child. She says she is tired all the time. Her palms are pale but she is not breathless at rest; breathing rate 22 per minute. Hb on the haemoglobinometer is 88 g/L. She stopped her iron because it upset her stomach.
How do you classify her anaemia?
Second trimester, Hb 88 g/L: moderate anaemia (70 to 94 g/L). No severe signs, so not severe anaemia.
What is your plan?
Explain why iron matters and discuss side effects; restart iron at 120 mg elemental iron a day (for example 60 mg twice daily) with folic acid 0.4 mg; malaria test and IPTp in an endemic area; deworm if indicated; recheck in 4 to 6 weeks and refer if not improving.
- Anaemia: Hb below 110 g/L (below 105 in the second trimester); severe below 70 g/L.
- Treat with 120 mg elemental iron daily plus folic acid until Hb is normal.
- Treat malaria and worms; refer severe anaemia and plan birth where blood is available.
Postnatal care of mother and baby, contraception and nutrition
- Schedule the four WHO postnatal contacts.
- Recognise maternal and newborn danger signs and give routine postnatal care.
- Offer contraception after birth that is safe with breastfeeding, and give nutrition advice.
The days after birth are the most dangerous time for mothers and newborns, but postnatal care is often the most neglected part of maternity care. WHO's 2022 recommendations call for a minimum of four postnatal contacts.
| Contact | When |
|---|---|
| 1 | In the facility for at least 24 hours after a vaginal birth; after a home birth, as early as possible within 24 hours |
| 2 | Day 3 (48 to 72 hours) |
| 3 | Between days 7 and 14 |
| 4 | During week 6 |
The mother
- First 24 hours: bleeding, uterine tone, fundal height, temperature and pulse from the first hour; BP soon after birth and again within 6 hours; passed urine within 6 hours.
- Later: well-being, bleeding, urine and bowels, perineum, breasts, headache, tiredness, BP, and mood.
- Screen for depression and anxiety with a validated tool, with care available for women who screen positive.
- Offer full contraceptive information and services.
- Iron for 6 to 12 weeks where anaemia in pregnancy is common.
The baby
- Exclusive breastfeeding until 6 months, with support at every contact.
- Delay the first bath for at least 24 hours.
- Clean, dry cord care. Chlorhexidine only where harmful substances are commonly put on the cord.
- Sleep on the back. Immunise according to the national schedule.
Contraception after birth
WHO recommends offering full contraceptive information and services at postnatal contacts. A pregnancy soon after birth carries more risk for mother and baby: WHO advises waiting at least 24 months after a live birth before trying to become pregnant again. Ovulation can return before the first period, especially if the woman is not fully breastfeeding.
| Method | Breastfeeding, under 6 weeks after birth | Notes |
|---|---|---|
| Copper IUD | Insert within 48 hours of birth, or wait until 4 weeks or more | Not between 48 hours and 4 weeks |
| Progestogen-only pill, implant | Usually safe to start (MEC category 2) | Category 1 from 6 weeks |
| Progestogen-only injectable (DMPA) | Not usually recommended before 6 weeks (category 3) | Category 1 from 6 weeks |
| Combined pill, patch or ring | Do not use (category 4) | Breastfeeding: wait until 6 months; not breastfeeding: from 3 to 6 weeks depending on clot risk |
| Lactational amenorrhoea method (LAM) | Works only if all three: no periods, fully or nearly fully breastfeeding, baby under 6 months | Start another method when any one stops |
| Condoms | Any time | Also protect against STIs and HIV |
Nutrition after birth
- Encourage a varied diet and enough to drink. Breastfeeding needs extra food; do not let the mother eat less to save food for others.
- Give iron, with or without folic acid, for 6 to 12 weeks after birth where anaemia in pregnancy is common (WHO 2022).
- If she had severe anaemia or a large blood loss, check Hb and treat (lesson 4).
- Keep breastfeeding support at every contact: good attachment, feeding on demand, nothing else to drink for the baby.
You can breastfeed and still use a family planning method that is safe for your baby. Let us choose one today, before your periods come back.
Worked case 2: Contraception at the week-6 contact
Mrs J, 24, is fully breastfeeding her 6-week-old baby and has had no period. She wants to wait at least two years before another pregnancy and does not want an IUD.
- What can she use now?
- Answer: A progestogen-only method: implant, progestogen-only pill or DMPA are all category 1 from 6 weeks while breastfeeding. LAM also works now, but only while all three conditions hold.
- What should she not be given?
- Answer: Combined oral contraceptives: not until 6 months after birth while breastfeeding, because they can reduce milk supply.
A community health worker visits Mrs E on day 3 after a home birth. Mrs E feels tired but well, her bleeding is less than on day 1, BP is 132/84. The baby has been sleepy and feeding poorly since this morning and feels hot; the temperature is 38.0 °C.
Who needs urgent referral?
The baby: not feeding well and a temperature above 37.5 °C are both newborn danger signs. Refer urgently to the health facility, with the mother continuing to breastfeed if the baby can.
What should still be done for Mrs E?
Reassure, check for her own danger signs, ask about mood, support breastfeeding, and plan her next contacts (days 7 to 14 and week 6). Remind her of her own danger signs, and discuss contraception.
- Four postnatal contacts: first 24 hours, day 3, days 7 to 14, week 6.
- Check BP after birth and at every contact; BP can peak at the end of the first week.
- Newborn danger signs: poor feeding, convulsions, fast breathing, chest indrawing, no movement, fever or low temperature, early jaundice.
- Exclusive breastfeeding, delayed bathing, clean dry cord, depression screening and contraception.
- Offer contraception at every postnatal contact: copper IUD within 48 hours or from 4 weeks; progestogen-only methods while breastfeeding; no combined pill before 6 months if breastfeeding.
- Advise at least 24 months before the next pregnancy; iron for 6 to 12 weeks where anaemia is common.
Postpartum haemorrhage: prevent, detect early, act at once
- Prevent postpartum haemorrhage with a uterotonic for every woman.
- Detect PPH early by measuring blood loss and watching vital signs.
- Start the WHO first-response bundle (MOTIVE) and know when to escalate.
Postpartum haemorrhage (PPH) is the leading direct cause of maternal death worldwide. Most deaths happen within hours of birth, and many happen because bleeding is recognised late: looking at blood loss usually underestimates it. WHO now recommends measuring blood loss objectively, for example with a calibrated drape, and acting early.
Prevent: every woman, every birth
- Give a uterotonic immediately after the baby is born. Oxytocin 10 IU IM or IV is the first choice. Heat-stable carbetocin is an alternative where oxytocin quality cannot be assured.
- Where no injectable uterotonic can be given safely (for example a home birth with a community health worker), oral misoprostol (400 or 600 micrograms) is an option per national programme.
- Delay cord clamping for at least 1 minute unless the baby needs resuscitation.
- After the placenta: check the uterus is firm by feeling the abdomen, and check again regularly over the first hours.
- Do not give ergometrine to women with high BP or pre-eclampsia (lesson 3).
Detect: measure, do not guess
Place a calibrated drape (or another collection device) under the woman straight after birth and read it at intervals during the first hour. Record pulse and BP at the same time. Signs of shock: fast weak pulse, low BP, pallor, sweating, fast breathing, confusion, little urine.
Act: the MOTIVE first-response bundle
| Step | What to do |
|---|---|
| M: Massage | Rub the uterus through the abdomen until it is firm; expel clots |
| O: Oxytocic | IV oxytocin infusion per protocol; other uterotonics (misoprostol, ergometrine if BP is normal) if bleeding continues |
| T: Tranexamic acid | 1 g IV over 10 minutes, as soon as possible and within 3 hours of birth; a second 1 g if bleeding continues after 30 minutes or restarts within 24 hours |
| I: IV fluids | Large-bore IV line; crystalloid (normal saline or Ringer's lactate); take blood for Hb and cross-match if possible |
| V: Vaginal examination | Look for tears and bleeding from the cervix and vagina; check the placenta is complete; empty the bladder |
| E: Escalate | Still bleeding after the bundle: call senior help, bimanual uterine compression, transfer to a facility that can transfuse and operate |
Think of the causes
A soft uterus (atony) is the commonest cause. Others are tears of the cervix, vagina or perineum, a retained placenta or pieces of it, a ruptured or inverted uterus, and a clotting problem. A firm uterus with ongoing bleeding means look for a tear.
Source: WHO recommendations for the prevention and treatment of postpartum haemorrhage (2012); WHO, FIGO and ICM consolidated PPH guideline (2025).
Worked case 2: Bleeding at a health post
Mrs L gave birth at a health post 20 minutes ago. She had oxytocin 10 IU IM. The drape now reads 350 mL. Her pulse has risen from 84 to 112 and BP is 96/60. The uterus feels soft.
- Is this PPH?
- Answer: Yes. 300 mL or more with abnormal vital signs (fast pulse, falling BP) meets the 2025 criteria. Do not wait for 500 mL.
- What do you do in the next 15 minutes?
- Answer: Call for help and start everything at once: uterine massage, IV oxytocin, TXA 1 g IV over 10 minutes, IV crystalloid, examine for tears and check the placenta, empty the bladder. If bleeding continues: bimanual compression and urgent transfer.
Mrs K, 29, has given birth to her fourth baby at a health centre. Oxytocin 10 IU was given. Thirty minutes later the placenta has not delivered and she is bleeding steadily. The drape reads 550 mL. Pulse 108, BP 100/64. The nearest hospital is 90 minutes away.
Does she have PPH, and what is the likely cause?
Yes: measured loss over 500 mL. The likely cause is the retained placenta, which stops the uterus contracting.
What do you do now?
Call for help. Start the bundle: massage, IV oxytocin infusion, TXA 1 g IV over 10 minutes, IV fluids, examine for tears, empty the bladder. Try controlled cord traction once if trained. If the placenta does not deliver or bleeding continues, transfer urgently with a health worker, IV fluids running and a written record. Manual removal of the placenta needs a skilled provider, pain relief and a prophylactic antibiotic (lesson 7).
- Oxytocin 10 IU IM or IV for every woman straight after the birth.
- Measure blood loss; act at 500 mL, or at 300 mL with abnormal vital signs.
- MOTIVE bundle together: massage, oxytocic, tranexamic acid, IV fluids, vaginal examination, escalate.
- TXA 1 g IV within 3 hours of birth; repeat after 30 minutes if still bleeding.
- Still bleeding: bimanual compression and urgent transfer.
Maternal sepsis
- Define maternal sepsis and recognise it early.
- Give first treatment and refer.
- Use the WHO measures that prevent infection around birth.
WHO defines maternal sepsis as a life-threatening condition in which infection causes organ dysfunction during pregnancy, childbirth, after an abortion, or after birth (WHO statement on maternal sepsis, 2017). It is one of the leading direct causes of maternal death, and many deaths follow a delay in noticing that a woman with an infection is getting worse.
Where the infection comes from
- The uterus: infection of the membranes in labour (chorioamnionitis) or of the lining after birth (endometritis), often after prolonged rupture of membranes, long labour, many vaginal examinations, retained products or a caesarean.
- After an unsafe or incomplete abortion.
- Wound, breast (mastitis or abscess), urinary tract or pneumonia.
- Malaria, HIV-related infections and TB can also cause sepsis in pregnancy.
Recognise it
| Look for infection | Look for organ dysfunction (sepsis) |
|---|---|
| Fever 38 °C or more (or a low temperature), chills | Fast breathing or low oxygen |
| Foul-smelling vaginal discharge or lochia | Fast pulse, low BP, cold hands, slow capillary refill |
| Tender uterus, lower abdominal pain | Confusion, drowsiness |
| Red, painful wound or breast; burning urine; cough | Little or no urine; jaundice |
Act
- ABCDE (see the Basic emergency care course): oxygen if breathing is fast or oxygen is low; IV line and fluid if signs of shock.
- Give the first dose of IV or IM antibiotics before transfer, following your national protocol. WHO suggests ampicillin plus gentamicin for chorioamnionitis, and clindamycin plus gentamicin for endometritis after birth (WHO 2015).
- Test for malaria where it occurs and treat if positive.
- Refer urgently. Retained products, an abscess or a uterus that needs surgery cannot be treated with antibiotics alone.
- The baby of a mother with infection around birth is at risk of sepsis too: check the baby for danger signs (lesson 5).
Prevent it
- Hand hygiene and clean birth practices at every birth.
- Vaginal examinations only when needed: in active labour, WHO suggests every 4 hours.
- Prophylactic antibiotics for caesarean section (before the skin incision), manual removal of the placenta, and third- or fourth-degree perineal tears.
- WHO does not recommend routine antibiotics after an uncomplicated vaginal birth or an episiotomy, or routine perineal shaving.
Source: WHO recommendations for prevention and treatment of maternal peripartum infections (2015); WHO statement on maternal sepsis (2017).
Worked case 2: Sick after an abortion
Ms N, 20, comes with lower abdominal pain and fever 4 days after an abortion done outside a health facility. Temperature 38.8 °C, pulse 124, BP 88/56, breathing 28 per minute. The vaginal discharge smells bad.
- What is happening?
- Answer: Sepsis after an unsafe abortion, with signs of shock. She may have retained products or an injury to the uterus.
- What do you do?
- Answer: ABCDE, oxygen, IV fluids for shock, first doses of IV antibiotics per protocol, and urgent transfer to a facility that can evacuate the uterus and operate. Treat her without judgement: fear of blame delays care.
Mrs P gave birth at home 4 days ago after a 2-day labour; her waters broke a day before the birth. She has fever and lower abdominal pain. Temperature 38.6 °C, pulse 118, BP 104/68, breathing 24 per minute, alert. The uterus is tender and the lochia smells bad.
What is the likely diagnosis, and is it sepsis?
Endometritis (infection of the uterus) after prolonged rupture of membranes and a long labour. Her fast pulse and breathing are warning signs: treat as possible sepsis and do not wait for her BP to fall.
What do you do before she leaves?
IV line and fluids, first dose of antibiotics per national protocol (clindamycin plus gentamicin is a WHO-suggested regimen for endometritis), malaria test where relevant, and urgent referral. Check the baby for danger signs and keep breastfeeding if she can.
- Maternal sepsis is infection plus organ dysfunction in pregnancy, birth, after abortion or after birth.
- Check pulse, BP, breathing, temperature and consciousness in every woman with fever or who feels very unwell.
- First dose of antibiotics and IV fluids before transfer; refer urgently.
- Prevent: clean birth, fewer vaginal examinations, prophylactic antibiotics for caesarean, manual removal and severe tears.
The newborn at birth: essential care and the golden minute
- Give essential newborn care in the first hour.
- Help a baby who does not breathe: dry, stimulate, and start bag-and-mask ventilation within one minute.
- Know when to stop resuscitation and when to refer.
Around one in ten babies needs some help to start breathing, and a small number need ventilation with a bag and mask. Most can be saved by a prepared health worker with simple equipment. Every birth attendant should be ready for this at every birth.
Prepare before every birth
- A warm room, free of draughts; two clean dry cloths; a cap.
- A self-inflating bag with newborn masks (sizes for term and preterm babies), checked to work.
- A suction device; cord ties or clamps and clean scissors.
- A helper who knows what to do, and a plan for referral.
Essential newborn care in the first hour
- Dry the baby thoroughly at once, wiping the face and body, and remove the wet cloth. Look at breathing while you dry.
- Breathing well or crying: place the baby skin-to-skin on the mother's chest and cover both.
- Delay cord clamping for at least 1 minute (unless the baby needs ventilation).
- Help the mother start breastfeeding within the first hour.
- After the first feed: eye care per national protocol, vitamin K 1 mg IM, weigh, examine, and birth-dose vaccines on the national schedule. Delay the first bath for at least 24 hours.
The golden minute: a baby who does not breathe
| If | Then |
|---|---|
| Not breathing or gasping after drying | Keep warm; clear the airway only if mouth or nose is blocked by secretions; rub the back two or three times |
| Still not breathing well | Clamp and cut the cord, move to a warm flat surface and start bag-and-mask ventilation within 1 minute of birth, with room air |
| Ventilating | Head slightly extended; firm mask seal over chin, mouth and nose; watch the chest rise with each breath. About 40 breaths a minute |
| Chest not rising | Reposition the head, reapply the mask, clear the airway, squeeze harder |
| After about 1 minute of ventilation | Check heart rate and breathing. Breathing well: stop, skin-to-skin, watch closely. Not breathing: continue and call for help |
When to stop
WHO advises stopping resuscitation if there is no detectable heart rate after 10 minutes of effective ventilation, and if the heart rate stays below 60 per minute with no breathing after 20 minutes. Support the family and record what happened.
After resuscitation
Any baby who needed ventilation is at risk: keep skin-to-skin, check breathing, temperature and feeding often, and refer to a facility that can care for sick newborns. Small babies (under 2.0 kg) need kangaroo mother care, starting as soon as possible after birth, and closer follow-up (see the sick young infant protocol).
Source: WHO Guidelines on basic newborn resuscitation (2012); WHO Essential newborn care course; WHO recommendations on maternal and newborn care for a positive postnatal experience (2022); WHO recommendations for care of the preterm or low-birth-weight infant (2022).
Worked case 2: A small baby born early
Mrs S gives birth at 34 weeks at a health centre. The baby cries after drying and weighs 1.8 kg. The room is cool.
- What does this baby need first?
- Answer: Skin-to-skin contact on the mother's chest (kangaroo position), a cap and a cover, and breastfeeding support. Delay cord clamping, give vitamin K and delay the bath.
- Does the baby need referral?
- Answer: Yes: a baby under 2.0 kg needs care at a facility able to support small babies, with kangaroo mother care continued during transfer and feeding checked often.
You attend a birth at a health centre. The baby is born after a long second stage, is floppy and is not breathing. You dry the baby and rub the back. After 30 seconds the baby is still not breathing. You have a bag and mask.
What do you do now?
Clamp and cut the cord, place the baby on a warm flat surface, position the head slightly extended and start bag-and-mask ventilation with room air so that it begins within 1 minute of birth. Watch for the chest to rise; about 40 breaths a minute.
After 1 minute of ventilation the baby has a heart rate but is gasping. What next?
Continue ventilation, call for help, and check again. When the baby breathes well, stop ventilation, place skin-to-skin and monitor closely. Refer the baby for observation and care after resuscitation.
- Prepare for every birth: warm room, dry cloths, working bag and mask, a helper.
- Dry at once, skin-to-skin, delayed cord clamping, breastfeeding in the first hour, vitamin K.
- Not breathing after drying and rubbing: bag-and-mask ventilation within 1 minute, with room air.
- Stop if no heart rate after 10 minutes of effective ventilation.
- Refer babies who needed ventilation or weigh under 2.0 kg; kangaroo mother care.
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Sources
- World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016 (ISBN 9789241549912).
- World Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. 2022 (ISBN 9789240045989).
- World Health Organization. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. 2011 (ISBN 9789241548335).
- World Health Organization. WHO recommendations on drug treatment for non-severe hypertension in pregnancy. 2020.
- World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd edition. 2017.
- World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. 2024.
- World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015.
- World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012 (ISBN 9789241548502).
- World Health Organization. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. 2017 (ISBN 9789241550154).
- World Health Organization. WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage. 2023 (ISBN 9789240085398).
- World Health Organization, International Federation of Gynecology and Obstetrics and International Confederation of Midwives. Consolidated guideline on the prevention, diagnosis and treatment of postpartum haemorrhage. 2025. Launched October 2025; diagnostic threshold taken from the launch summary.
- World Health Organization. WHO recommendations for prevention and treatment of maternal peripartum infections. 2015 (ISBN 9789241549363).
- World Health Organization. Statement on maternal sepsis. 2017 (WHO/RHR/17.02).
- World Health Organization. Guidelines on basic newborn resuscitation. 2012 (ISBN 9789241503693).
- World Health Organization. WHO recommendations for care of the preterm or low-birth-weight infant. 2022.
- World Health Organization. Medical eligibility criteria for contraceptive use, 5th edition. 2015 (ISBN 9789241549158).
- World Health Organization. Report of a WHO technical consultation on birth spacing. 2005.