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AASHA Module 6
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Focus on Maternal and Newborn Health
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Contents
PART A: Being an ASHA
1.
Role of ASHA
7
2.
Activities of an ASHA's
8
3.
Measurable Outcomes of the ASHA Programme
9
4.
Essential Skills for an ASHA
10
5.
Qualities that Make an ASHA Effective
12
6.
Conducting a Home Visit
13
7.
Village Health and Nutrition Day (VHND)
15
8.
What Records do the ASHA Maintain
17
9.
ASHA Support and Supervision
18
PART B: Maternal Health
19
1.
Pregnancy Diagnosis
21
2.
Birth Preparedness for a Safe Delivery
26
3.
Management of Anaemia
28
4.
Identifying complications during Pregnancy and Delivery
30
5.
Care during Delivery
34
6.
Post-Parturn Care
38
PART C: Newborn Health
41
1.
Care of the Baby at the time of Delivery
43
2.
Schedule of Home Visits for the care of the Newborn
44
3.
Examining the Newborn at Birth
44
4.
Breastfeeding
50
5.
Keeping the Newborn Warm
57
6.
Management of fever in newborn
60
Annexes
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5
61
Contents 3.
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Being an
ASHA
Being an ASHA
Objectives of this Session
By the end of this session, the ASHA will learn about:
( • j The role of an ASHA and the activities expected of her.
The health outcomes that her work should result in.
fiy I The sets of skills that she needs to be effective in.
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•; • i The records that she has to maintain.
(" •“ 7%The arrangements for her support and supervision.
1. Role of ASHA
ASHA is considered to be a healthcare facilitator and provider of a limited
range of healthcare services. Health rights would be integral to her work
and would be focused in the areas of community mobilisation to improve
health status, access to services, and promote people's participation in health
programmes.
Didi, which day is the ANM
coming to our village? .
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This is the first day of diarrhoea. Do
Didi, they are charging me at the govt
I have go to the far away town or is
hospital and I don't have the money to
there something you can suggest?
pay - can you help me?
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Being an ASHA 7
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2. Activities of an ASHA's
ASHA's work consists mainly of five activities:
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2. Attending the Village Health and Nutrition Day
(VHND): On one day every month, when the Auxiliary
Nurse Midwife (ANM) comes to provide immunisation
and other services in the village, ASHA will promote
attendance by those who need the Anganwadi or ANM
services and helps with service delivery.
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1. Home Visits: For two to three hours every day, for at
least four or five days a week, the ASHA should visit the
families living in her allotted area. Home visits should
take place at least once in a month ifnot more. Home
visits are mainly for health promotion and preventive
care. Over time, families will come to her when there is
a problem and she would not have to go so often to their
houses. Meeting them anywhere in the community/
village is enough. However, where there is a child
below two years of age or any malnourished child or a
pregnant woman, she should visit the families at home
for counselling them. Also, if there is a newborn in the
house, a series of five visits or more becomes essential.
3. Visits to the health facility: This is usually
accompanying a pregnant woman or some other
neighbour who requests her services for escort. The visit
could also be to attend a training programme or review
meeting. In some months, there would be only one visit,
in others, there would be more.
4. Holding village level meeting of women's groups, and
the Village Health and Sanitation Committee (VHSC),
for increasing health awareness and to plan health
work.
5. Maintain records which would make her more
organised and make her work easier, and help her to
plan better for the health of the people.
The first three relate to facilitation or provision of healthcare
and the last two are supportive and mobilisational
activities.
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8 Simple Shills that Save Lives
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4. Essential Shills for an ASHA
The essential skills that an ASHA requires can be classified into six sets.
These are simple skills requiring only a few hours to learn, but they can save
thousands of lives. These six sets of skills are given below:
1. Maternal Care
a.
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b.
2. Newborn Care when visiting rhe
Counselling of pregnant
newborn at home:
women
a.
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Ensuring
complete antenatal
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care through home visits and
breastfeeding
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b.
Making the birth plan and
management of LBW (Low Birth
support for safe delivery
d.
Weight) and pre-term baby
Undertaking post-partum
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Keeping the baby warm
c. Identification and basic
enabling care at VHND
c.
Counselling and problem solving on
d.
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visits. Counselling for family
Examinations needed for
identification/first contract care for
sepsis and asphyxia
_____________________ ___________'
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3. Child Care
a.
Providing home care for diarrhoea. Acute
Respiratory Infections (ARI), fever and appropriate
referral, when required
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b.
Counselling for feeding during illness
c.
Temperature management
d.
De-worming and treatment of iron deficiency
anaemia, with referral where required
e. Counselling to prevent recurrent illness especially
diarrhoea.
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5. Qualities that Make an ASHA Effective
For an ASHA to be effective in improving people's access to health services
and their health status, an ASHA should:
•
Have the knowledge and skills to explain the basic maternal and child
health services, educate on preventive and promotive aspects of maternal
and child health, and provide some measure of immediate relief and
advice if there is any illness.
•
Have the knowledge and skills on other general health issues, especially
related to common infections, and be able to provide information on
access to services and preventive and promotive aspects of healthcare.
•
Be friendly and polite with people and known among community, and
establish rapport with the family during household visits.
•
Be a special friend to the needy, the marginalised, and the less powerful.
•
Possess the art of listening.
•
Have the skill of coordination with Panchayati Raj Institution (PRI), AWW
and ANM.
•
Be competent in conducting meetings in the community.
•
Be motivated and feel happy and rewarded to help community/serve
people.
•
Have a positive attitude and be keen to learn new skills.
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suggestion is applicable and acceptable, and whether she would be able to
implement it. If necessary, ask the woman to repeat what has been suggested.
Discuss further and come to an understanding of what can be done
Then the third step, you should discuss and try to correct any
misconceptions or rumours.
Finally, you should also arrange for follow-up visit or referral.
Do NOT "prescribe" health advice: You need to "counsel." See the examples
below:
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To prevent diarrhoea, pay attention To prevent diarrhoea, please ensure that you
to cleanliness.
wash your hands with soap and water before
preparing food or feeding the child and after
cleaning up after defecation.
Are you able to find enough time to feed the
Take good care of the child.
child? To play with the child? Who looks after
the child when you are at work?
Your child is now one year old. You
must give it nutritious food.
Would it be possible for you to give your child
an egg daily (or milk, green vegetables etc)?
How would you manage it? Can you afford
it? Would other children in the family also
demand it, and would that create a problem?
Difficult Situations
If the woman is shy
•
Speak of general things to 'warm her up'.
•
Encourage the woman to speak.
•
Praise the woman more to make her confident.
•
Repeat the questions.
If the woman is non-cooperative or argumentative
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14 Simple Skills that Save Lives
•
Praise the women to make her feel secure.
•
Sympathise with her and be friendly; do not get angry.
•
Spend more time in listening to her.
•
Do not push if the woman is still not immediately receptive but just say that
you would like to come again.
If the woman is curious and asks many questions
•
Answer her questions in simple language.
•
Explain that you will be coming every month so they can talk again.
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Simple Skills that Save Lives
♦
Women who need to come for ANC for first time or for repeat visit.
♦
Infants who need their next dose of immunisation.
♦
Malnourished children.
♦
TB patients who are on anti-TB drugs.
♦
Those with fever who have not been able to see a doctor.
♦
Eligible couples who need contraceptive services or counselling.
♦
Any others who want to meet the ANM.
•
Specially identifying families who are new migrants, living in hamlets
or are vulnerable because of poverty or otherwise marginalised and
ensuring their attendance.
•
Coordinate with the AWW and the ANM to know in advance which day
the VEND is scheduled so as to inform those who need these services and
the community, especially the VESC members.
•
Undertake a part of the health communication work done at the VEND.
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9. ASHA Support and Supervision
For ASHA to be effective and for her skills to be
updated, she needs both on-the-job support and
refresher trainings.
•
Each ASHA will be supported in the field by an
ASHA facilitator.
•
The ASHA facilitator will interact with ASHA at
least twice if not thrice a month.
•
At least one of these interactions will be in the
form of a "mentoring" visit to the hamlet where
she provides her services. This would focus on
mentoring or on-the-job training.
•
Another one or two interactions would be in a local review meeting. This
could be held at Gram Panchayat (GP) level, or at the sector level or even
at the block level.
•
Each of the facilitators will have a clear protocol of activities to follow
for the mentoring visit to the ASHAs and for the review meetings. The
purpose of these interactions are:
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•
18 Simple Skills that Save Lives
•
a
Collecting health related information as observed by ASHA and
information on what work ASHA is doing.
b
For providing support to the ASHA to manage the health problems
they encounter.
c
For providing training and refresh or update their knowledge and
skills.
d
For helping ASHAs plan their work.
e
For building up mutual solidarity and motivation.
f
For troubleshooting problems, especially as regards payments and
addressing grievances.
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For refills to their drug kit
The Medical Officer In-charge of the block PHC/CHC should attend at
least one monthly meeting of all ASHAs in the Primary Health Centre
(PHC) area, to review work progress.
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Maternal Health
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Objectives of this session
By the end of the session the ASHA will learn about:
( • I Diagnosing pregnancy using Nisehay Kit
( • j Determining Last Menstrual Period (LMP) and Expected Date of Delivery (EDD).
( •
Key components of antenatal check-up1.
( • | Identification of problems and danger signs during the antenatal period and appropriate referral.
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• ■) Provide appropriate care for anaemia.
■j • J Developing plans for birth preparedness.
• ) Follow-up with pregnant women.
Knowledge of safe delivery.
Understand obstetric emergencies and enable appropriate referral for emergencies.
Updating Maternal Health Cards with support from the ANM.
1. Pregnancy Diagnosis
Diagnosis of pregnancy should be done as early as possible after the first missed
period.
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There are two ways to diagnose pregnancy early:
7
•
Missed Periods
•
Pregnancy testing: through use of the Nisehay home pregnancy test card
♦
The Nisehay test card can be used easily by you to test if a woman is pregnant.
❖
The test can be done immediately after the missed period.
❖
A positive test means that the woman is pregnant.
*
The benefit of early diagnosis of pregnancy is that the woman can be
registered early by the ANM and start getting antenatal care soon.
♦
A negative test means that the woman is not pregnant. In case she is not
pregnant and does not want to get pregnant, you should counsel her to
adopt a family planning method.
Instructions for the use of the Nishcay Kit are in Annexe 2.
1 All knowledge areas in this chapter have been covered in ASHA Module 2.
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Maternal Health 21
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Facts about Antenatal Check-up
How many antenatal chech-ups?
Four antenatal visits must be ensured, including registration within the first
three month period. The suggested schedule is as below:
1st visit: Within 12 weeks preferably as soon as pregnancy is suspected
for registration of pregnancy and first antenatal check-up
2nd visit: Be tween 14 and 26 weeks
3rd visit: Between 28 and 34
weeks
4th visit: After 36 weeks
It is advisable for the pregnant
woman to visit the Medical Officer
(MO) at the PHC for the third
antenatal visit, as well as availing
of the required investigations at
the PHC.
Essential components2 of antenatal care
•
Early registration
•
Regular weight check
•
Blood test for anaemia
•
Urine test for protein and sugar
•
Measure blood pressure
•
One tablet of IFA every day
for three months to prevent
anaemia
•
Treatment for anaemia
•
Two doses of Tetanus Toxoid
(TT) vaccine
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Nutrition counselling
•
Preparing for birth.
2 The components of ANC have already been covered in Module 2.
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Maternal Health 23
Integrated Child Development Services
National Rural Health Mission
•
•
Emphasise the importance of a balanced and nutritious diet during
pregnancy. The diet of the pregnant woman should contain a mix of
cereals, pulses (including beans and nuts), vegetables including greens,
milk, eggs, meat and fish. If possible, the family should be encouraged to
add oils, jaggery and fruits to the diet. Meat and nuts are especially good
for anaemic women. You should explain to the mother and family that no
foods should be forbidden during pregnancy.
See when ANC is due for each check-up and remind them appropriately.
Mother
and
Child
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Photograph of Mother & Child
Family Identification
Mother's Name-
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Father’s Name_
Address______
Mother's Education: tBHeraWpnmary/mlddWhigti schooVgraduate
Pregnancy Record
Mothers ID No.______________________________
Date ot the last menstrual period
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Expected date ot (Joinery
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No. ot pregnancies/ previous live births
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Last delivery conducted at
Institution |
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Home [
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Cuirenl detivory
institution |
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Home |
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JSY Registration No._____
JSY payment
Amount (“
| Date |
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Birth Record
Child’s Name
•
•
Escort pregnant woman to VHND where they are hesitant or need such
support.
Ensure that all components of ANC are delivered.
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Birth Roglwahon No: |
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Institutional Identification
AWW____________
.AWC/Bloc*_________________
ASHA
ANM
SHC/Clinic_______
PHC/Town
Contacl Nos. ANM __
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Transport Arrangema
•
Ensure that the Maternal Card is updated.
Planning for Save Delivery
You should
•
Know how to calculate the EDD and communicate this to the pregnant woman.
•
Know which institutions in the area provide different levels of care and establish linkages with
providers there.
•
At least once before delivery, take the pregnant woman to this centre and introduce her to the
providers.
•
Know what transport is available - whether funded by the state or other private means - that is easily
accessible and affordable and how to call on it when the need arises.
•
Assist all pregnant women and families to prepare plans for birth: including identifying funding
sources should money be required at short notice. Sometimes Self-Help Groups (SHGs) may advance
money in emergency even if the woman is not a member. This is most important for women in remote
hamlets, or in communities which are currently not availing of institutional delivery or those at high
risk for complications.
•
Know what records (BPL card) need to be carried to the institution.
•
Share birth plans with ANM and PHC MO at the VHND or monthly meeting.
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•
Identify mothers with complications, or a high likelihood of developing complications with support
from the ANM. Inform them of the institutions that it is most advisable for them to go to and motivate
the mother and the family to go there and escort them if required.
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Maternal Health 25
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Decisions People Make
if I go to the PHC which is open 24 hours, I will be
cared for and can rest for two days. Also, if there
is any surgery needed, they can rush me to the big
hospital quickly.
Where should I go
for a safe delivery?
if danger signs or complications develop before
the delivery, I will need to go to the big hospital
straight away, but I hope that does not happen.
I will a Iso need to ensure that I have an escort,
maybe the ASHA, to accompany me, and that
someone is taking care of the children and
things at home.
if she has any danger signs or complications, I will ask
her to go to the CHC or DH when her delivery is due. p
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the transport is readu and available at that time.
if she has no complications, I will counsel her to go
to the 24X7 PHC, and for this too, I must ensure that
transport arrangements are made in time.
I help every family with a pregnant
woman to make a birth plan. /
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But if she and her family do not want to go that far
and the 24X7 PHC is crowded, I will advise her to go to
the nearby sub-centre where two ANMs are trained to
conduct deliveries and one of them is always there.
For some women, family circumstances and beliefs
make even going to the sub-centre difficult. I will then
get the ANM to come to her house, and will assist in the
preparations needed, after counselling that a safe delivery
in this situation may not always be possible.
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•
The dosage regimen of two IFA tablets per
day should be repeated for three months
post-partum also.
A
Counselling pregnant women on anaemia:
•
Encourage women to take iron-rich foods
such as green leafy vegetables, whole
pulses, ragi, jaggery, meat and liver. This
advice should be discussed with family and
finalised based on the family situation.
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•
Encourage the woman, where possible,
to take plenty of fruits and vegetables
containing vitamin C (such as mango, guava, orange and sweet lime) as
these enhance the absorption of iron.
•
Counsel the women on the necessity of taking IFA, the dangers associated
with anaemia, and inform the women that these
side-effects are common and not serious, and will reduce over time.
•
IFA tablets must be taken regularly, preferably early in the morning on an
empty stomach. If the woman has nausea and pain in abdomen, she may
take the tablets after meals or at night. This will avoid nausea.
•
Dispel the myths and misconceptions related to IFA and convince the
woman about the importance of taking it. An example of a common myth
is that the consumption of IFA may affect baby's complexion.
•
Many women do not take IFA tablets regularly due to some common
side-effects such as nausea, constipation and black stools. Tell women not
to worry about passing black stool while consuming IFA. It is normal.
•
In case of constipation, the woman should drink more water and add
roughage (plenty of green leafy vegetables) to her diet.
•
IFA tablets should not be consumed with tea, coffee, milk or calcium tablet
as it reduces the absorption of iron.
•
IFA tablets may make the woman feel less tired than before. However,
despite feeling better, she should not stop taking the tablets and must
complete the course as advised by the healthcare provider.
•
Ask the woman to return to you if she has problem taking IFA tablets.
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How do you get the IFA?
The IFA tablets are part of your drug kit. Try to ensure that you always have
enough stock. Either your facilitator or a person appointed by the MO of the
PHC is given the responsibility of refills for the drug kit. IFA tablets are also
made available at VHND or in any health facility.
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Maternal Health 29
1
Swollen Face/hands
Pitting oedema over bach palm
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Convulsions/fits
a.
Eyes roll, face and limbs
twitch, body gets stiff and
shakes, fists clinched
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Non-Emergencyref
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How to recognise
Action to be
taken
Severe anaemia
Tongue very
pale, weakness,
general swelling
in body
Refer to PHC/
Dist./Tertiary
Hospital
Night Blindness
Pregnant women
Find it difficult to
Refer to ANM
or PHC
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Maternal Health 31 p |
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Multiple pregnancies
Suspicion/Knowledge:
usually suspected by
ANM or by doctor after
abdominal examination.
Refer to CHC/DH.
Ultrasound examination
would confirm this.
Malpresentation
Suspicion/Knowledge:
Diagnosed by ANM or
doctor after abdominal
examination.
Refer to CHC/DH.
Ultrasound examination
would confirm this.
Danger signs in labour and delivery
These danger signs can occur at any time:
•
Bleeding (Fresh blood)
•
Swollen Face and hands
•
Baby lying sideways
•
Water breaks but labour does not start within 24 hours or less
•
Colour oFwater-green or brown
•
Prolonged labour - woman pushing for more than 12 hours (eight hours in the
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case of women who have already had children) with the baby not coming out
•
Fever
Fits
•
Retained placenta
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Maternal Health 33
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Before Delivery
The delivery room should be
cleaned before the delivery.
If the delivery is happening at
home, you should facilitate a
clean delivery space.
Immediately after birth, if the
baby remains naked, it may
become cold. Hence, baby
clothes should be kept ready
before delivery.
Safe Delivery
Three Stages of Labour
1st Stage of labour
Starts from the beginning of pain until the mouth of the womb is fully open. This
happens inside and cannot be seen. The bag of water also breaks at the end of
this stage. The fluid is usually clear but may be yellow or green or red.
This first stage of labour usually lasts about 8 to 12 hours in the first pregnancy.
May take much less time in subsequent pregnancies.
(a)
(b)
S'
Illustration (a) - drawing of side view of a pregnant woman.
In illustration (b) - the mouth of the womb is almost closed, and thick.
In illustration (c) - the mouth is thinner and is opening little.
In (d) - the mouth of the womb is fully open. When the womb is completely
open, it is the end of the first stage of labour. At this time, the water bag usually
breaks. This first stage of labour usually lasts about 8 to 12 hours. It takes longer
if the woman is having her first baby.
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Maternal Health 35
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The very top of the head comes first, then the eyes, nose and mouth (d). While
in most babies, the eyes are facing the floor; sometimes they are bom looking
towards the ceiling. When the baby's head is out, it turns to one side (e) and the
shoulders and rest of the body are delivered (f). Once out, the baby will cry.
Delivery of Placenta
The cord will be connected to the placenta which is still inside the womb.
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The placenta usually comes out after 15-20 minutes.
Points for you to pay attention to if you are also present at the time of delivery in
the institution:
•
It is not necessary to shave the area, or give an enema to the mother at the
time of delivery.
•
All deliveries do not require an episiotomy (cut at the perineal site).
•
Fundal pressure (pushing on the abdomen) should not be applied.
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You should be alert if injections are being given to hasten the delivery
process. Such injections can cause a baby who is still born, birth of a
baby who is unable to breathe, or even cause the death of the newborn.
However, the same injections are advisable after the baby has been born
in order to control bleeding after delivery. Only the ANM or doctor should
give the injection.
•
When the mother and baby stay in the hospital and if you are staying with
them as a birth companion, she should ensure that the mother and baby
are seen by the MO and nurse at least twice a day and whenever required
if there are problems.
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Maternal Health ■:
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Encourage and support for exclusive breastfeeding (Please see section
on Breastfeeding-Part C, Section 3)
♦
Discuss with the mother the need for contraceptive services.
Caution her on the risk of unprotected sex and the high
chances of conceiving again. You should counsel her on the
importance of spacing the next child birth for her own
health and that of the baby. You should help her in making
the choice of the method of family planning, whether spacing or
limiting.
Complications during the post-partum period
Some women can develop complications after
the childbirth. The symptoms of these major
complications are:
1. Excessive bleeding: Ask the mother if the
bleeding is heavy. Often this is quite obvious,
but sometimes it may be difficult to judge.
If the woman is using more than five pads
a day or more than one thick cloth in a day,
she is having heavy bleeding. You should
immediately refer her to an institution which
manages complications. You should also ask
the mother to begin breastfeeding immediately, that should help reduce
the bleeding. Referral is most urgent. Even the delay of a few minutes can
make a difference.
2. Puerperal Sepsis (Infections): Ask if the discharge is foul smelling. If the
answer is yes, then suspect infection. Fever, chills and pain in abdomen
along with the foul smell make infections even more likely. You should
measure temperature to confirm fever. Referral is required since the
mother needs antibiotics. Referral on the same day is advisable.
I
3. Convulsions with or without swelling of face and hands, severe
headache, and blurred vision: Such patients need immediate referral. If
ANM is available within 15 minutes, she can stabilise the patient before
referral.'
4. Anaemia: You should check if the mother is pale and enable the mother to
get her blood Hb status checked (for management of anaemia in the post
partum period, please see Section 3).
5. Breast engorgement and Infection: (Part C: Newborn Health)
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Maternal Health 3^?
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Newborn
Health
Newborn Health
Objectives of the session
By the end of this session, the ASHA will learn about:
• ) Observe and assist during the immediate newborn period in case she is
present at the time of delivery.
• } Observe the baby during the first hour, during the first two days and
during the first month to take care of the newborn, support and help
the mother to breastfeed, and to keep the baby warm.
• J Know what her specific role is during the home visits, and learn how to
care for the newborn.
1. Care of the Baby at the time of Delivery
Many babies die immediately after birth due to
asphyxia. In case of home delivery, when mild labour
pains start, you can manage asphyxiated babies by
removing mucus and can initiate respiration with the
help of the instruments you have.
'SB
You should encourage the mother to
start breastfeeding immediately after
the delivery, as this will help in quick
delivery of placenta and minimises
bleeding. Starting to breastfeed
immediately after the birth makes
the baby stronger.
Chances of the baby's death and
getting sick are higher among the
babies born before time (pre-term)
and in LBW babies, (Weight less
than 2500 gm increases the risk
and below 1800 gm, the risk is
considered very high.)
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Newborn Health 4^
Stillbirth Decision Tree Examination at 30 seconds
Brewing
Cr
Limb Movement
no
Cry
no
Examination at 5 minutes
Limb Movement
Breathing
no
no
no
no
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Still Birth
■■
■
Examination at 30 seconds
Limb Movement
Brea
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yes
Examination at 5 minutes
Limb Movement
Cry
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------------------------
OB :
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sw?
Breathing
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Birth
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Newborn Health 4B' R9?'
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•
How the baby is suckling at the breast.
•
Whether the baby has loose limbs.
•
Listen to the cry of the baby.
•
Provide care of eyes. If there is pus/purulent discharge from
eyes and no doctor or nurse available, apply tetracycline
ointment. Even for normal eyes, tetracycline is used as a
preventive, so even in doubt as to whether it is pus, it could
be given.
•
Keep umbilical cord dry and clean.
b. General precautions the family must take
The newborn is delicate and can easily fall sick if the family
and mother are not careful. You should explain some general
precautions that the family should take.
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•
Bathing the baby: Although it is recommended that the baby should not
be bathed until the first seven days, many families would like to bathe
the baby on the first or second day. You should explain that bathing the
baby and leaving it wet or exposed may cause it to get cold and fall sick.
Thus, it is better to wipe the baby with a warm wet cloth and dry the baby
immediately, at least for the first five to seven days.
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•
Keep the baby away from people who are sick.
•
People who are sick with cold, cough, fever, skin infection, diarrhoea, etc.
should not hold the baby or come in close contact with the baby.
•
The newborn baby should not be taken to places where there are other
sick children.
•
j.
The newborn baby should also not be taken to places where there are
large gatherings of people.
c. What are you expected to do during the newborn visits?
•
Enquire and fill the mother's information on home visit form. (Annexe 6)
•
Enquire and fill newborn information on home visit form. These forms
help you to think about all the steps you need to take. (Annexe 7)
•
Take out the necessary equipment from the bag and keep on a clean cloth.
•
Wash your hands well as taught.
•
Then examine the baby - a. measure temperature, b. weigh the baby, and
c. perform other activities in the sequence provided in the newborn home
visit form. (Annexe 8 & 9)
•
Provide the care of eyes, skin and cord.
•
Check that the home visit form is filled in completely.
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Newborn Health 47
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Remember:
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The usual bathroom scales cannot reliably record small
differences in weights. That is why bathroom scales cannot
accurately record newborn weight and it is not advisable to
use these for weighing newborns.
All babies below 1.8 kg must be taken to a 24x7 facility or other facility known
to provide referral care for sick newborn and examined by a doctor or nurse.
h. Umbilical cord care
•
Cord should be kept clamped for at least 24 hrs after the birth. The clamp
can be removed when the cord is dried and occluded
•
No application of any medicine is required if there is no bleeding or
discharge.
•
The umbilical cord should be kept clean and dry at all times.
i. Eye care
7x i'XavX
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Skill checklist for applying eye ointment
/
If a newborn has pus discharging from its eyes you can put antibiotic
ointment in the baby's eyes or a capsule which is available in the market.
How to put antibiotic ointment:
•
Gently pull the baby's lower eyelid down.
•
Squeeze a thin line of ointment moving from the inside corner to the
outside of the eye.
•
Do not touch the baby's eye with the tip of the tube. If the tube touches the
babies eyes, it shouldn't be used again.
•
If the eyes are swollen with pus, then put the ointment two times a day for
5 days.
■ -
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Newborn Health 49
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d Breastfeeding observation tips
-------------------- - - Signs of breastfeeding going welU
Mother's body relaxed, comfortable, confident, eye
Mother tense, leans over baby. Not much eye contact
contact with baby, touching
or touching
Baby's mouth well attached, covering most of the
Mouth not opened wide, not covering areola
areola, opened wide, lower lip turned outwards
I.
Lips around nipple
Rapid sucks, cheeks tense or sucked in Smacking or
i Suckling well, deep sucks, bursts with pauses
clicking sounds
Cheeks round, swallowing heard or seen
! Baby calm and alert at breast, stays attached. Mother
Baby restless or crying, slips off breast; Mother not
may feel uterus cramping, some milk may be leaking
feeling cramping, no milk is leaking (showing that
(showing that milk is flowing)
milk is not flowing)
_______
After feed, breast full or enlarged, nipples may be red,
After feed, breast soft, nipples protruding
cracked, flat or inverted
e. Correct position For breastfeeding
To obtain maximum benefit of breastfeeding, the baby should be held in the
correct position and be put correctly to the breast. The baby is in the correct
position when:
•
While holding the baby, the mother also supports the baby's bottom, and
not just the head or shoulders.
•
Mother holds the baby close to her body.
•
The baby's face is facing the breast, with nose opposite the nipple
Breastfeeding Positions
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Cradle Position
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Side-lying Position
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Underarm Position
Alternate Underarm Position
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Newborn Health -51
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Managing Common Breastfeeding Problems
Sore nipples
Causes: poor latch-on or positioning at breast
1
Management
• Improve attachment and/or position.
• Continue breastfeeding (reduce engorgement if present).
•
•
.
•
.
Build mother's confidence.
. .breast-------Advise her to wash
oncej a day; not to use soap for this.
Put a little breast milk on nipples after feeding is finished (to lubricate the nipple) and air-dry.
Wear loose clothing.
If nipples are very red, shiny, flaky, itchy, and their condition does not get better with above treatment, it
may be fungus infection. Apply gentian violet paint to nipples after each breastfeed for five days. If the
condition does not improve, refer to a doctor.
Inverted nipples
Sometimes the nipple will retract in to the breast, and can be checked even during pregnancy.
The best treatment is to encourage the mother to gently pull out the nipple and roll it, several times in a day.
Not enough milk
Causes: Delayed initiation of breastfeeding; infrequent
H
‘
feeding; giving fluids other than breast milk; mother's
anxiety, exhaustion, insecurity; inadequate family support.
Management
•
Decide whether there is enough milk or not:
♦
Does the baby pass urine six times or more each day?
♦
Has the baby gained sufficient weight? (During the 1st week there is
usually a small weight loss, after that a newborn should gain 150200 gm per week.)
♦
•
Is the baby satisfied after feeds?
Re-assure mother.
•
If there is not enough milk, have the baby feed more often.
•
Check breastfeed to observe mother attachment and positioning of the
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mother and baby.•
Encourage rest. Emphasise the mother to drink and eat more.
•
Praise her and return for follow-up.
W.
Newborn Health 53
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Expressing milk
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Feeding baby with
traditional spoon lihe
utensil used for milh
feeding
9. Repeat with the other breast.
Signs that the baby is not getting enough milh
•
•
•
Poor weight gain
♦
Weight gain of less than 500 gm in a month
♦
Less than birth weight after two weeks
Passing small amounts of concentrated urine
♦
Less than six times a day
♦
Yellow and strong smelling
Other signs are:
♦
Baby not satisfied after breastfeed and often cries
♦
Very frequent breastfeeds
♦
Very long breastfeeds
♦
Baby refuses to breastfeed
♦
Baby has hard, dry or green stools
♦
No milh comes when mother tries to express
♦
Breast did not enlarge
Milh did not come in.
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Newborn Health
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5. Keeping the Newborn Warm
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Objectives of the session
By the end of this session, the ASHA will learn about:
f'7) identify the newborn whose body temperature is less than
normal and whose body temperature is more than normal.
Teach mothers how to keep the newborns warm.
f.
( • ! Teach mothers how to re-warm cold babies.
(1) Teach mothers how to control newborn temperature in hot
weather.
V • ) Learn to take the temperature.
Keeping newborn warm and the problem of hypothermia
Why is it important to keep baby warm after delivery?
Babies have difficulty maintaining their temperature at
birth and in the first day of life.They come out wet, and
lose heat quickly. If they get cold, they use up energy,
and can become sick. LBW and pre-term babies are at
greater risk of getting cold.
When and why do most newborns get cold?
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_ __ -
Most newborns lose heat in first minute after delivery.
They are born wet. If they are left wet and naked, they lose a lot of heat to the
air. A newborn baby's skin is very thin and its head is big in size compared
to its body. It loses heat very quickly from its head. Babies do not have the
capacity to keep themselves warm. If the newborn baby is not properly dried,
wrapped, and its head is not kept covered, it can lose 2 to 4 degree Celsius
within 10-20 minutes.
Example: If the baby's temperature was 97.7 degree Fahrenheit (36.5 degree
Celsius) (normal temperature) at the time of birth and if there was a loss of
2.7 degree Fahrenheit because the baby was not properly dried and covered,
the body temperature will become 95 degree Fahrenheit (35.0 degree Celsius),
which is below normal.
^0
What is the term for a situation when a baby's temperature falls below
normal?
When a baby has a temperature below normal, it suffers from hypothermia.
What happens to a baby with hypothermia?
A baby who is cold, and has a low temperature (hypothermia) suffers from:
•
Decreased ability to suckle at the breast, leading to poor feeding and
weakness.
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Newborn Health 57
How to re-warm a baby getting cold?
<97 degree Fahrenheit (36.1 degree Celsius) or too cold <95 degree Fahrenheit
(35.0 degree Celsius)
•
Increase the room temperature.
•
Remove any wet or cold blankets and clothes.
•
Hold the baby with its skin next to its mother's skin (skin-to-skin contact) and place a warmed cloth
(not too hot to avoid burns) on its back or chest. As this cloth cools down, replace it with another
warmed one, and repeat until the baby is warmer. Continue until the baby's temperature reaches the
normal range.
•
Put on its clothes and its cap, put it in warm bag, and make it lie close to its mother.
•
Continue to breastfeed the baby to provide calories and fluids to prevent a drop in the blood glucose level.
♦
A common problem in hypothermic babies.
If a baby is too cold <95 degree Fahrenheit (35.0 degree Celsius), follow the above advice, and
•
Place skin-to-skin, and once the baby is a little warmer, then clothe baby and place.in a bed pre
warmed with warm clothes, or a hot stone or hot water bottle. (Remove these articles before putting
baby on the bed.)
•
In an institutional delivery, there should be a newborn corner available with a radiant
warmer, or some other suitable heating arrangement where the newborn baby
can be kept.
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Newborn Health 59
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Annexes
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Annexe 1: ASHA Drug Kit Stock Card
-
S.No.
Name of
Drug
Symbol*
Balance I
Refill
given
Balance
w-____
—---------_
Refill
given
IBalance
1
2
<
Renn
given
. * * ____
iBalance Refill
given
3
4^
5
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Balance: This is what was left in kit at the time of refill - after recovering
explained drugs/supplies.
Refill: This is what was put into the kit.
^Symbol is a pictorial symbol that could be used to denote a drug, since often.
the drugs comes labelled only in English.
Card is to be updated by person providing the refill.
_ .jm.
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Annexe 3: Format for Individual Plans
(Birth Preparedness)
Name:
Age:
Husband's name:
HH income
LMP
EDO
Past pregnancy history (Include abortion, if any):
Order of
pregnancy
,ft 4#,'
Place of
delivery:
Home, SC,
I PHC, CHC,
DH,
Private
Nursing
Date of
delivery
(Month and
Year)
Type of
delivery:
Natural,
Forceps,
C-Section
Birth
Outcome:
Live Birth,
Stillborn,
j Home
,Age and
Any other
Status of
complications:
child currently Fever, Bleeding
■■
First
Second
Third
•
Any risk factors:
•
Nearest SBA: Phone:
Nearest 24X7 PHC: Distance: Time: Cost
Nearest Sub-Centre with a Skilled Birth Attendant
•
Nearest CHC with facilities to manage complications: Distance:
Time: Cost
•
Distance to District Hospital:
•
How much is transport going to cost?
•
Is the vehicle fixed: Owner:
•
Will we need extra money for the treatment ? How to organise it?
®
Who will take care of the children when mother goes to the facility?
•
Who will accompany her to the facility?
•
Where will they stay?
•
How will they finance their stay?
•
Have they organised clothes and blankets for the baby?
Annexes 65
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Dry the baby
: Yes/No
Cover the baby
: Yes/No
For Supervisors#
Yes/No/NA
9a) Observe the baby at birth:
Yes/No/NA
At 30 seconds
At 5 minutes
a) Cry______________
No/Weah/Forceful
No/Weah/Forceful
b) Breathing
No/Gasping/Forceful
No/Gasping/Forceful
c) Movement of limbs
No/Weah/Forceful
No/Weah/Forceful
— Was ASHA present when
_ the baby came out?
_ Yes/No/NA
Correct/lncorrect
9b) Diagnosis - Normal/Stillbirth
9c) If still birth - Fresh/Macerated
Correct/lncorrect
Correct/lncorrect
10) Sex of the child: Male/Female
11) Number of baby/babies born: 1/2/3
Yes/No/NA
12) Actions:
Correct/lncorrect
Give the mother something to drink immediately after the delivery:
13) Time at which placenta came out fully? Hrs.
Yes/No
Yes/No/NA
Min.
Immediate breastfeeding reduces mother's bleeding and helps to quicken delivery
of placenta
14) Actions:
Yes/No/NA
Yes/No/NA
Other Information
#; Mark 'Yes' if
necessary and possible
Cover the baby:
Keep close to mother:
Early and exclusive breastfeeding:
Yes/No
Yes/No
Yes/No
15) Special features/Comments/Observations, if any
action has been taken
without any mistake
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Weight: Kg.
5)
Record
Gm.
Colour on scale: Red/Yellow/Green
For Supervisor
Weighing matches
X
with the colour?
Yes/No
1. All limbs limp
2. Feeding less/stop
Correct/lncorrect
3. Cry weah/stopped
Action taken?
Routine Newborn Care
Yes/No/NA
Whether the task was performed
Yes/No/NA
1) Dry the baby
Yes/No
Yes/No/NA
Yes/No
Yes/No
2) Keep warm, don't bathe.
wrap in the cloth, keep
closer to mother
3) Initiate exclusive breastfeeding
Yes/No
Yes/No
Yes/No
6) Anything unusual in baby? Curved limbs/Cleft lip/Other.
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For Supervisor
Form checked by: Name.
Date.
Corrections:.
Unusual or different observation:
Whether the form has been completed?
Yes/No
Signature
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Annexes <^9
... ..
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-Day7~T >ay15
Day28^ Day 42
I Action by the ASHA
i .....
......
I.':. ~
C, Examination of Baby
Are the eyes swollen or with pus
Weight (on day 7,15, 28 and 42)
___ ________
___
c
>orv
Check
Action Take
Y/N
Y/N
Temperature: Measure and Record
Skin:
Pus filled pustuIes
Cracks or redness on the skin fold
(thigh/Axilla/Buttock)
Yellowness in eyes or skin:
Jaundice
|
D. Check now for the following signs
of sepsis: IF sign is present mention - Yes, if it is absent, mention - No
Record jhej)bservations on Daynromthe first examination of newborn Form
Ask/Examine
Day 1
Day 2
Day 3
Day 7
Day 15
Day 28
Day 42
Action by the
ASHA
i------ - ------------------------- --------------
L________ __________
All limbs limp
—
Action Taken
Y/N
Y/N
Feeding less/Stopped
Cry weak/Stopped
------------------------ ---Distended abdomen or mother says 'baby
vomits often'
Mother says 'baby is cold to touch' or baby's
temperature >99 degree F (37.2 degree C)
—L
Chest indrawing
Pus on umbilicus
1
• - - ----------------------------------- - ------------- L_______
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Supervisor's note: Incomplete work/incorrect work/incorrect record/incorrect record
Name of ASHA:
1
t
_______
.Date:
Name of Trainer/Facilitator:.
--
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Annexe 8: Skills Checklist:
Measuring Temperature
Picture/lllustration
Skills Checklist
...........
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For Peer Record
'
1
2
3
5
1) Take thermometer out of its storage case, hold at
broad end, and clean the shinning tip with cotton ball
soaked in spirit.
2) Press the pink button once to turn the
thermometer on. You will see "188.8" flash in the
centre of the display window, then a dash (-), then
the last temperature taken and then three dashes
(- - -) and a flashing "F" in the upper right corner.
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3) Hold the thermometer upward and place the
shinning tip in the centre of the armpit. Place arm
against it. Do not change the position.
4) You will hear a beep sound every 4 seconds while
the thermometer is recording the temperature. When
rm?
you hear 3 short beeps, look at the display. When
"F" stops flashing and the number stop changing,
remove the thermometer.
5) Read the number in the display window.
6) Record the temperature reading on the Form.
7) Turn the thermometer off by pushing the pink
button one time.
8) Clean the shinning tip of the thermometer with a
cotton ball soaked in spirit.
9) Place thermometer back in its storage.
Annexes 73
IHMI
*
Acronyms
ANM
Auxiliary Nurse Midwife
ASHA
Accredited Social Health Activist
AWC
Anganwadi Centre
AWW
Anganwadi Worker
ARI
Acute Respiratory Infection
ANC
Antenatal Care
AIDS.
Acquired Immuno-deficiency Syndrome
ART
Anti-Retroviral Therapy
BEmoC
Basic Emergency Obstetric Care
BCG
Bacillus Calmette-Guerin
BPNI
Breastfeeding Promotion Network of India
CEmoC
Comprehensive Emergency Obstetric Care
CHC
Community Health Centre
DPT
Diphtheria, Tetanus and Pertussis
EDD
Expected Date of Delivery
FRU
First Referral Unit
GP
Gram Panchayat
GV paint
Gentian Violet paint
HBNC
Home-Based Newborn Care
IFA
Iron Folic Acid
IMNCI
Integrated Management of Neonatal Childhood Illnesses
LBW
Low Birth Weight
LMP
Last Menstrual Period
MO
Medical Officer
ORS
Oral Rehydration Solution
PHC
Primary Health Centre
PRI
Panchayati Raj Institution
SBA
Skilled Birth Attendant
TB
Tuberculosis
TT
Tetanus Toxoid
UNICEF
United Nations Children's Fund
VHND
Village Health and Nutrition Day
VHSC
Village Health and Sanitation Committee
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Acronyms ;7S
APPENDIX 3: Participant Consent Form
Title:
"A Study on the Barriers affecting the functioning of ASHA Workers in
Mariyamanahalli and Nagenahalli village of Hospet taluk"
sroS)
steLooic
Consent Form
Of So*
La
aodo
sscraOod
aS?
cofioivs
sSroaex, sb* * adaob*.
d?
rbo&cS© z^^F^eo
£dQobg aeoiws 5S^
rbdo^crorb^Ou sjocb ^^erohdodd. d? doddFddi) ^o^raerf^saddo
Sciri
d^Oddzds^ eroddsdci^ aofstoo±>*dfe3. dcdri xia^saad^ sisbobdsddii ds ?3o!ddF?dd€> ^crbo
'S^cdood ^aridSoJbddfd. ds tfodJac^csa
shaSododd^ ddrt dddssah WsieroAcbdd.
•
Participation in the in-depth interview:
Yes
No
•
Audio-recording of the in-depth interview:
Yes
No
•
Publishing of words/sentences spoken in interview verbatim: Yes
No
I
Name of the Researcher
Name of the Research Participant
r
...........................................................
Signature of the Researcher
Signature of the Research Participant
I k (to (
Date
Date
REVOCATION OF CONSENT
I hereby wish to WITHDRAW my consent to participate in the study described above and
understand that such withdrawal WILL NOT jeopardise my relationship with the Institute of
Public Health:
Signature of participant
Date
r
Name
Position: 2659 (2 views)