Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 19 - INFORMATION FOR MOTHERS AND MIDWIVES The Menstrual Period (Monthly Bleeding in Women) The Menopause (When Women Stop Having Periods) Pregnancy How to Stay Healthy during Pregnancy Minor Problems during Pregnancy Danger Signs in Pregnancy Check-ups during Pregnancy (Prenatal Care) Record of Prenatal Care Things a Mother Should Have Ready before Giving Birth Preparing for Birth Signs That Show Labor is Near The Stages of Labor Care of the Baby at Birth Care of the Cut Cord (Navel) The Delivery of the Placenta (Afterbirth) Hemorrhaging (Heavy Bleeding) The Correct Use of Oxytocics: Ergonovine, Oxytocin, Pitocin, etc. Difficult Births Tearing of the Birth Opening Care of the Newborn Baby Illnesses of the Newborn The Mother's Health after Childbirth Childbirth Fever (Infection after Giving Birth) Breast Feeding - And Care of the Breasts Lumps or Growths in the Lower Part of the Belly Miscarriage (Spontaneous Abortion) High Risk Mothers and Babies

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 19 - INFORMATION FOR MOTHERS AND MIDWIVES

The Menstrual Period (Monthly Bleeding in Women)

Most girls have their first 'period' or monthly bleeding between the ages of 11 and 16. This means that they are now old enough to become pregnant.

The normal period comes once every 28 days or so, and lasts 3 to 6 days. However, this varies a lot in different women.

Irregular or painful periods are common in adolescent (teenage) girls. This does not usually mean there is anything wrong.

If your menstrual period is painful:

There is no need for you to stay in bed. In fact, lying quietly can make the pain worse. Figure

It often helps to walk around and do light work or exercises... Figure

or to take hot drinks, or put your feet in hot water. Figure

If it is very painful, it may help to take aspirin or ibuprofen and to lie down and put warm compresses on the belly.

During the period - as at all times - a woman should take care to keep clean, get enough sleep, and eat a well-balanced diet. She can eat everything she normally eats and can continue to do her usual work. It is not harmful to have sex during the menstrual period. (However, if one of the partners has the AIDS virus, the risk of infecting the other partner may be higher.)

Signs of menstrual problems:

· Some irregularity in the length of time between periods is normal for certain women, but for others it may be a sign of chronic illness, anemia, malnutrition, or possibly an infection or tumor in the womb.

· If a period does not come when it should, this may be a sign of pregnancy. But for many girls who have recently begun to menstruate, and for women over 40, it is often normal to miss or have irregular periods. Worry or emotional upset may also cause a woman to miss her period.

· If the bleeding comes later than expected, is more severe, and lasts longer, it may be a miscarriage.

· If the menstrual period lasts more than 6 days, results in unusually heavy bleeding, or comes more than once a month, seek medical advice.

The Menopause (When Women Stop Having Periods)

Figure

The menopause or climacteric is the time in a woman's life when the menstrual periods stop coming. After menopause, she can no longer bear children. In general, this 'change of life' happens between the ages of 40 and 50. The periods often become irregular for several months before they stop completely.

There is no reason to stop having sex during or after the menopause. But a woman can still become pregnant during this time. If she does not want to have more children, she should continue to use birth control for 12 months after her periods stop.

When menopause begins, a woman may think she is pregnant. And when she bleeds again after 3 or 4 months, she may think she is having a miscarriage. If a woman of 40 or 50 starts bleeding again after some months without, explain to her that it may be menopause.

During menopause, it is normal to feel many discomforts - anxiety, distress, 'hot flashes' (suddenly feeling uncomfortably hot), pains that travel all over the body, sadness, etc. After menopause is over, most women feel better again.

Women who have severe bleeding or a lot of pain in the belly during menopause, or who begin to bleed again after the bleeding has stopped for months or years, should seek medical help. An examination is needed to make sure they do not have cancer or another serious problem.

After menopause, a woman's bones may become weaker and break more easily. To prevent this, it helps to eat foods with calcium.

Because she will not have any more children, a woman may be more free now to spend time with her grandchildren or to become more active in the community. Some become midwives or health workers at this time in their lives.

Pregnancy

Signs of pregnancy:

All these signs are normal:

· The woman misses her period (often the first sign).

· 'Morning sickness' (nausea or feeling you are going to vomit, especially in the morning). This is worse during the second and third months of pregnancy.

· She may have to urinate more often.

· The belly gets bigger.

· The breasts get bigger or feel tender.

· 'Mask of pregnancy' (dark areas on the face, breasts, and belly).

· Finally, during the fifth month or so, the child begins to move in the womb.

This is the normal position of the baby in the mother at 9 months.

How to Stay Healthy during Pregnancy

· Most important is to eat enough to gain weight regularly - especially if you are thin. It is also important to eat well. The body needs food rich in proteins, vitamins, and minerals, especially iron. (Read Chapter 11 in this book.)

· Use iodized salt to increase the chances that the child will be born alive and will not be retarded. (But to avoid swelling of the feet and other problems, do not use very much salt.)

· Keep clean. Bathe or wash regularly and brush your teeth every day.

· In the last month of pregnancy, it is best not to use a vaginal douche and to avoid sexual contact to keep from breaking the bag of water and causing an infection.

· Avoid taking medicines if at all possible. Some medicines can harm the developing baby. As a rule, only take medicines recommended by a health worker or doctor. (If a health worker is going to prescribe a medicine, and you think that you might be pregnant, tell her so.) You can take acetaminophen, or antacids once in a while if you need them. Vitamin and iron pills are often helpful and do no harm when taken in the right dosage.

· Do not smoke or drink during pregnancy. Smoking and drinking are bad for the mother and harm the developing baby.

· Stay far away from children with measles, especially German measles (see Rubella).

· Continue to work and get exercise, but try not to get too tired.

· Avoid poisons and chemicals. They can harm the developing baby. Do not work near pesticides, herbicides or factory chemicals - and do not store food in their containers. Try not to breathe fumes or powders from chemicals.

Minor Problems during Pregnancy

1. Nausea or vomiting: Normally, this is worse in the morning, during the second or third month of pregnancy. It helps to eat something dry, like crackers or dry bread, before you go to bed at night and before you get out of bed in the morning. Do not eat large meals but rather smaller amounts of food several times a day. Avoid greasy foods. Tea made from mint leaves also helps. In severe cases, take an antihistamine when you go to bed and when you get up in the morning.

2. Burning or pain in the pit of the stomach or chest (acid indigestion and heartburn): Eat only small amounts of food at one time and drink water often. Antacids can help, especially those with calcium carbonate. It may also help to suck hard candy. Try to sleep with the chest and head lifted up some with pillows or blankets.

3. Swelling of the feet: Rest at different times during the day with your feet up. Eat less salt and avoid salty foods. Tea made from maize silk (corn silk) may help. If the feet are very swollen, and the hands and face also swell, seek medical advice. Swelling of the feet usually comes from the pressure of the child in the womb during the last months. It is worse in women who are anemic or malnourished. So eat plenty of nutritious food.

4. Low back pain: This is common in pregnancy. It can be helped by exercise and taking care to stand and sit with the back straight.

5. Anemia and malnutrition: Many women in rural areas are anemic even before they are pregnant, and become more anemic during pregnancy. To make a healthy baby, a woman needs to eat well. If she is very pale and weak or has other signs of anemia and malnutrition, she needs to eat more protein and food with iron - foods like beans, groundnuts, chicken, milk, cheese, eggs, meat, fish, and dark green leafy vegetables. She should also take iron pills, especially if it is hard to get enough nutritious foods. This way she will strengthen her blood to resist dangerous bleeding after childbirth. If possible, iron pills should also contain some folic acid and vitamin C. (Vitamin C helps the body make better use of the iron.)

6. Swollen veins (varicose veins): These are common in pregnancy, due to the weight of the baby pressing on the veins that come from the legs. Put your feet up often, as high as you can. If the veins get very big or hurt, wrap them like this with an elastic bandage, or use elastic stockings. Take off the bandage or stockings at night.

Figure

7. Piles (hemorrhoids): These are varicose veins in the anus. They result from the weight of the baby in the womb.

To relieve the pain, kneel with the buttocks in the air like this:

Or sit in a warm bath.

8. Constipation: Drink plenty of water. Eat fruits and food with a lot of natural fiber, like cassava or bran. Get plenty of exercise. Do not take strong laxatives.

Danger Signs in Pregnancy

1. Bleeding: If a woman begins to bleed during pregnancy, even a little, this is a danger sign. She could be having a miscarriage (losing the baby) or the baby could be developing outside the womb (ectopic pregnancy). The woman should lie quietly and send for a health worker.

Bleeding late in pregnancy (after 6 months) may mean the placenta (afterbirth) is blocking the birth opening (placenta previa). Without expert help, the woman could quickly bleed to death. Do not do a vaginal exam or put anything inside her vagina. Try to get her to a hospital at once.

2. Severe anemia: The woman is weak, tired, and has pale or transparent skin (see The Signs of Anemia). If not treated, she might die from blood loss at childbirth. If anemia is severe, a good diet is not enough to correct the condition in time. See a health worker and get pills of iron salts. If possible, she should have her baby in a hospital, in case extra blood is needed.

3. Swelling of the feet, hands, and face, with headache, dizziness, and sometimes blurred vision, are signs of toxemia or poisoning of pregnancy. Sudden weight gain, high blood pressure, and a lot of protein in the urine are other important signs. So if you can do so, go to a midwife or health worker who can measure these things.

To treat TOXEMIA OF PREGNANCY a woman should:

· Stay quiet and in bed.
· Eat foods rich in protein, but with only a little salt. Avoid salty foods.
· If she does not get better quickly, has trouble seeing, swells more in the face, or has fits (convulsions), get medical help fast. Her life is in danger.

DURING THE LAST 3 MONTHS OF PREGNANCY:

To help prevent TOXEMIA OF PREGNANCY: eat nutritious food, making sure to get enough protein and use little salt (but do use a little).

Check-ups during Pregnancy (Prenatal Care)

Many health centers and midwives encourage pregnant women to come for regular prenatal (before birth) check-ups and to talk about their health needs. If you are pregnant and have the chance to go for these check-ups, you will learn many things to help you prevent problems and have a healthier baby.

If you are a midwife, you can provide an important service to mothers-to-be (and babies-to-be) by inviting them to come for prenatal check-ups - or by going to see them. It is a good idea to see them once a month for the first 6 months of pregnancy, twice a month during months 7 and 8, and once a week during the last month.

Here are some important things prenatal care should cover:

1. Sharing information

Ask the mother about her problems and needs. Find out how many pregnancies she has had, when she had her last baby, and any problems she may have had during pregnancy or childbirth. Talk with her about ways she can help herself and her baby be healthy, including:

· Eating right. Encourage her to eat enough energy foods, and also foods rich in protein, vitamins, iron, and calcium (see Chapter 11).

· Good hygiene (Chapter 12).

· The importance of taking few or no medicines.

· The importance of not smoking, not drinking alcoholic drinks, and not using drugs.

· Getting enough exercise and rest.

· Tetanus vaccination to prevent tetanus in the newborn. (Give at the 6th, 7th, and 8th month if first time. If she has been vaccinated against tetanus before, give one booster during the 7th month.)

2. Nutrition

Does the mother look well nourished? Is she anemic? If so, discuss ways of eating better. If possible, see that she gets iron pills - preferably with folic acid and vitamin C. Advise her about how to handle morning sickness and heartburn.

Is she gaining weight normally? If possible, weigh her each visit. Normally she should gain 8 to 10 kilograms during the nine months of pregnancy. If she stops gaining weight, this is a bad sign. Sudden weight gain in the last months is a danger sign. If you do not have scales, try to judge if she is gaining weight by how she looks.

Or make a simple scale:

3. Minor problems

Ask the mother if she has any of the common problems of pregnancy. Explain that they are not serious, and give what advice you can.

4. Signs of danger and special risk

Take the mother's pulse each visit. This will let you know what is normal for her in case she has problems later (for example, shock from toxemia or severe bleeding). If you have a blood pressure cuff, take her blood pressure. And weigh her. Watch out especially for the following danger signs:

· sudden weight gain · swelling of hands and face · marked increase in blood pressure · severe anemia · any bleeding

signs of toxemia of pregnancy

Some midwives may have paper 'dip sticks’ or other methods for measuring the protein and sugar in the urine. High protein may be a sign of toxemia. High sugar could be a sign of diabetes.

If any of the danger signs appear, see that the woman gets medical help as soon as possible. Also, check for signs of special risk. If any are present, it is safer if the mother gives birth in a hospital.

5. Growth and position of the baby in the womb

Feel the mother's womb each time she visits; or show her how to do it herself.

Figure

Each month write down how many finger widths the womb is above or below the navel. If the womb seems too big or grows too fast, it may mean the woman is having twins. Or the womb may have more water in it than normal. If so, you may find it more difficult to feel the baby inside. Too much water in the womb means greater risk of severe bleeding during childbirth and may mean the baby is deformed.

Try to feel the baby's position in the womb. If it appears to be lying sideways, the mother should go to a doctor before labor begins, because an operation may be needed. For checking the baby’s position near the time of birth. (1)

Figure

6. Baby's heartbeat (fetal heartbeat) and movement

After 5 months, listen for the baby's heartbeat and check for movement. You can try putting your ear against the belly, but it may be hard to hear. It will be easier if you get a fetoscope. (Or make one. Fired clay or hard wood works well.)

Fetoscope

If the baby's heartbeat is heard loudest below the navel in the last month, the baby is head down and will probably he horn head first.

If die heartbeat is heard loudest above the navel, his head is probably up. It may be a breech birth.

A baby's heart beats about twice as fast as an adult's. If you have a watch with a second hand, count the baby's heartbeats. From 120 to 160 per minute is normal. If less than 120, something is wrong. (Or perhaps you counted wrong or heard the mother's heartbeat. Check her pulse. The baby's heartbeat is often hard to hear. It takes practice.)

7. Preparing the mother for labor

As the birth approaches, see the mother more often. If she has other children, ask her how long labor lasted and if she had any problems. Perhaps suggest that she lie down to rest after eating, twice a day for an hour each time. Talk with her about ways to make the birth easier and less painful. You may want to have her practice deep, slow breathing, so that she can do this during the contractions of labor. Explain to her that relaxing during contractions, and resting between them, will help her save strength, reduce pain, and speed labor.

If there is any reason to suspect the labor may result in problems you cannot handle, send the mother to a health center or hospital to have her baby. Be sure she is near the hospital by the time labor begins.

HOW A MOTHER CAN TELL THE DATE WHEN SHE IS LIKELY TO GIVE BIRTH: Start with the date the last menstrual period began, subtract 3 months, and add 7 days. For example, suppose your last period began May 10. May 10 minus 3 months is February 10, Plus 7 days is February 17. The baby is likely to be born around February 17.

8. Keeping records

To compare your findings from month to month and see how the mother is progressing, it helps to keep simple records. On the next page is a sample record sheet. Change it as you see fit. A larger sheet of paper would be better. Each mother can keep her own record sheet and bring it when she comes for her check-up.

Record of Prenatal Care

RECORD OF PRENATAL CARE

Things a Mother Should Have Ready before Giving Birth

Every pregnant woman should have the following things ready by the seventh month of pregnancy:

A lot of very clean cloths or rags.

A new razor blade. (Do not unwrap until you are ready to cut the umbilical cord.)

An antiseptic soap (or any soap).

If you do not have a new razor blade, have clean, rust-free scissors ready. Boil them just before cutting the cord.

A clean scrub brush for cleaning the hands and fingernails.

Sterile gauze or patches of thoroughly cleaned cloth for covering the navel.

Alcohol for rubbing hands after washing them.

Two ribbons or strips of clean cloth for tying the cord.

Clean cotton.

Both patches and ribbons should be wrapped and sealed in paper packets and then baked in an oven or ironed.

Additional Supplies for the Well-Prepared Midwife or Birth Attendant

Flashlight (torch).

Fetoscope - or fetal stethoscope - for listening to the baby's heartbeat through the mother's belly.

Suction bulb for sucking mucus out of the baby's nose and mouth.

Blunt-tipped scissors for cutting the cord before the baby is all the way born (extreme emergency only).

Sterile syringe and needles.

Two clamps (hemostats) for clamping the umbilical cord or clamping bleeding veins from tears of the birth opening.

Several injections of ergonovine or ergometrine.

Rubber or plastic gloves (that can be sterilized by boiling) to wear while examining the woman, while the baby is coming out, when sewing tears in the birth opening, and for catching and examining afterbirth.

Two bowls - 1 for washing hands and 1 for catching and examining the afterbirth.

Sterile needle and gut thread for sewing tears in the birth opening

1% silver nitrate drops, tetracycline eye ointment, or erythromycin eye ointment for the baby's eyes to prevent dangerous infection.

Preparing for Birth

Birth is a natural event. When the mother is healthy and everything goes well, the baby can be born without help from anyone. In a normal birth, the less the midwife or birth attendant does, the more likely everything will go well.

Difficulties in childbirth do occur, and sometimes the life of the mother or child may be in danger. If there is any reason to think that a birth may be difficult or dangerous, a skilled midwife or experienced doctor should be present.

CAUTION: If you have a fever, cough, sore throat, or sores or infections on your skin at the time of the birth, it would be better for someone else to deliver the baby.

Signs of Special Risk that Make It Important that a Doctor or Skilled Midwife Attend the Birth - if Possible in a Hospital:

· If regular labor pains begin more than 3 weeks before the baby is expected.

· If the woman begins to bleed before labor.

· If there are signs of toxemia of pregnancy.

· If the woman is suffering from a chronic or acute illness.

· If the woman is very anemic, or if her blood does not clot normally (when she cuts herself).

· If she is under 15, over 40, or over 35 at her first pregnancy.

· If she has had more than 5 or 6 babies.

· If she is especially short or has narrow hips.

· If she has had serious trouble or severe bleeding with other births.

· If she has diabetes or heart trouble.

· If she has a hernia.

· If it looks like she will have twins.

· If it seems the baby is not in a normal position in the womb.

· If the bag of waters breaks and labor does not begin within a few hours. (The danger is even greater if there is fever.)

· If the baby is still not born 2 weeks after 9 months of pregnancy.

THE BIRTHS WITH THE GREATEST CHANGE OF PROBLEMS ARE:

Checking if the Baby is in a Good Position

To make sure the baby is head down the normal position for birth, feel for his head, like this:

1. Have the mother breathe out all the way.

With the thumb and 2 finger, push in here, just above the pelvic bone. (1)

Figure

With the other hand, feel the top of the womb.

Figure

Figure

2. Push gently from side to side, first with one hand, then the other.

Figure

If the baby's head is down, his birth is likely to go well. If the head is up, the birth may be more difficult (a breech birth), and it is safer for the mother to give birth in or near a hospital. If the baby is sideways, the mother should have her baby in a hospital. She and the baby are in danger.

Signs That Show Labor is Near

· A few days before labor begins, usually the baby moves lower in the womb. This lets the mother breathe more easily, but she may need to urinate more often because of pressure: on the bladder. (In the first birth these signs can appear up to 4 weeks before delivery.)

· A short time before the labor begins, some thick mucus (jelly) may come, out. Or some mucus may come out for 2 or 3 days before labor begins. Sometimes it is tinted with blood. This is normal.

· The contractions (sudden tightening of the womb) or labor pains may start up to several days before childbirth; at first a long time usually passes between contractions - several minutes or even hours. When the contractions become stronger, regular, and more frequent, labor is beginning.

· Some women have a few practice contractions weeks before labor. This is normal. On rare occasions, a woman may have false labor. This happens when the contractions are coming strong and close together, but then stop for hours or days before childbirth actually begins. Sometimes walking, a warm bath, or resting will help calm the contractions if they are false, or bring on childbirth if they are real. Even if it is false labor, the contractions help to prepare the womb for labor.

Labor pains are caused by contractions or tightening of the womb. Between contractions the womb is relaxed like this: Figure During contractions, the womb tightens and lifts up like this: Figure The contractions push the baby down farther. This causes the cervix or ‘door of the womb’ to open - a little more each time.

· The bag of water that holds the baby in the womb usually breaks with a flood of liquid sometime after labor has begun. If the waters break before the contractions start, this usually means the beginning of labor. After the waters break, the mother should keep very clean. Walking back and forth may help bring on labor more quickly. To prevent infection, avoid sexual contact, do not sit in a bath of water, and do not douche. If labor does not start within 12 hours, seek medical help.

The Stages of Labor

Labor has 3 parts or stages:

· The first stage lasts from the beginning of the strong contractions until the baby drops into: the birth canal.

· The second stage lasts from the dropping of the baby into the birth canal until it is born.

· The third stage lasts from the birth of the baby until the placenta (afterbirth) comes out.

THE FIRST STAGE OF LABOR usually lasts 10 to 20 hours or more when it is the mother's first birth, and from 7 to 10 hours in later births. This varies a lot.

During the first stage of labor, the mother should not try to hurry the birth. It is natural for this stage to go slowly. The mother may not feel the progress and begin to worry. Try to reassure her. Tell her that most women have the same concern.

The mother should not try to push or bear down until the child is beginning to move down into the birth canal, and she feels she has to push.

The mother should keep her bowels and bladder empty.

If the bladder and the bowels are full, they get in the way when the baby is being born.

During labor, the mother should urinate often. If she has not moved her bowels in several hours, an enema may make labor easier. During labor the mother should drink water or other liquids often. Too little liquid in the body can slow down or stop labor. If labor is long, she should eat lightly, as well. If she is vomiting, she should sip a little Rehydration Drink, herbal tea, or fruit juices between each contraction.

During labor the mother should change positions often or get up and walk about from time to time. She should not lie flat on her back for a long time.

During the first stage of labor, the midwife or birth attendant should:

· Wash the mother's belly, genitals, buttocks, and legs well with soap and warm water. The bed should be in a clean place with enough light to see clearly.

· Spread clean sheets, towels, or newspapers on the bed and change them whenever they get wet or dirty.

· Have a new, unopened razor blade ready for cutting the cord, or boil a pair of scissors for 15 minutes. Keep the scissors in the boiled water in a covered pan until they are needed.

The midwife should not massage or push on the belly. She should not ask the mother to push or bear down at this time.

If the mother is frightened or in great pain, have her take deep, slow, regular breaths during each contraction, and breathe normally between them. This will help control the pain and calm her. Reassure the mother that the strong pains are normal and that they help to push her baby out.

THE SECOND STAGE OF LABOR, in which the child is born: Sometimes this begins when the bag of water breaks. It is often easier than the first stage and usually does not take longer than 2 hours. During the contractions the mother bears down (pushes) with all her strength. Between contractions, she may seem very tired and half asleep. This is normal.

To bear down, the mother should take a deep breath and push hard with her stomach muscles, as if she were having a bowel movement. If the child comes slowly after the bag of waters breaks, the mother can double her knees like this, while

squatting

sitting propped up

kneeling

or lying down.

When the birth opening of the mother stretches, and the baby's head begins to show, the midwife or helper should have everything ready for the birth of the baby. At this time the mother should try not to push hard, so that the head comes out more slowly. This helps prevent tearing of the opening.

In a normal birth, the midwife NEVER needs to put her hand or finger inside the mother. This is the most common cause of dangerous infections of the mother after the birth.

When the head comes out, the midwife may support it, but must never pull on it.

If possible, wear gloves to attend the birth - to protect the health of the mother, baby, and midwife. Today this is more important than ever.

Normally the baby is born head first like this:

1. Now push hard.

2. Now try not to push hard. Take many short, fast breaths. This helps prevent tearing the opening.

The head usually comes out face down. If the baby has feces (shit) in her mouth and nose, clean it out immediately.

Then the baby's body turns to one side so the shoulders can come out.

If the shoulders get stuck after the head comes out:

1. The midwife can take the baby's head in her hands and lower it very carefully, so the shoulder can come out.

2. Then she can raise the head a little so that the other shoulder comes out.

All the force must come from the mother. The midwife should never pull on the head, or twist or bend the baby's neck, because this can harm the baby.

THE THIRD STAGE OF LABOR begins when the baby has been born and lasts until the placenta (afterbirth) comes out. Usually, the placenta comes out by itself 5 minutes to an hour after the baby. In the meantime, care for the baby. If there is a lot of bleeding or if the placenta does not come out within 1 hour, seek medical help.

Care of the Baby at Birth

Figure

Immediately after the baby comes out:

· Put the baby's head down so that the mucus comes out of his mouth and throat. Keep it this way until he begins to breathe.

· Keep the baby below the level of the mother until the cord is tied. (This way, the baby gets more blood and will be stronger.)

· If the baby does not begin to breathe right away, rub his back with a towel or a cloth.

· If he still does not breathe, clean the mucus out of his nose and mouth with a suction bulb or a clean cloth wrapped around your finger.

· If the baby has not begun to breathe within one minute after birth, start MOUTH-TO-MOUTH BREATHING at once.

· Wrap the baby in a clean cloth. It is very important not to let him get cold, especially if he is premature (born too early).

How to Cut the Cord

When the child is born, the cord pulses and is fat and blue. WAIT.

Figure

After a while, the cord becomes thin and white. It stops pulsing. Now tie it in 2 places with very clean, dry strips of cloth, string, or ribbon. These should have been recently ironed or heated in an oven. Cut between the ties, like this:

Figure

IMPORTANT: Cut the cord with a clean, unused razor blade. Before unwrapping it, wash your hands very well. Or wear clean rubber or plastic gloves. If you do not have a new razor blade, use freshly boiled scissors. Always cut the cord close to the body of the newborn baby. Leave only about 2 centimeters attached to the baby. These precautions help prevent tetanus.

Care of the Cut Cord (Navel)

The most-important way to protect the freshly cut cord from infection is to keep it dry. To help it dry out the air must get to it. If the home is very clean and there are no flies, leave the cut cord uncovered and open to the air. If there are dust and flies, cover the cord lightly. It is best to use sterile gauze. Cut it with boiled scissors. Put it on like this:

Figure

Figure

Figure

thin and loose

If you do not have sterile gauze, you can cover the navel with a very clean and freshly ironed cloth. It is better not to use a belly band, but if you want to use one, use a thin, light cloth, like cheesecloth, and be sure it is loose enough to let air under it, to keep the navel dry. Do not make it tight.

Be sure the baby's nappy (diapers) does not cover the navel, so that the cord does not get wet with urine.

Cleaning the Newborn Baby

With a warm, soft, damp cloth, gently clean away any blood or fluid.

It is better not to bathe the baby until after the cord drops off (usually 5 to 8 days). Then bathe him daily in warm water, using a mild soap.

Put the Newborn Baby to the Breast at Once

Place the baby at its mother's breast as soon as the baby is born. If the baby nurses, this will help to make the afterbirth come out sooner and to prevent or control heavy bleeding.

The Delivery of the Placenta (Afterbirth)

Normally, the placenta comes out 5 minutes to an hour after the baby is born, but sometimes it is delayed for many hours (see below).

Checking the afterbirth:

When the afterbirth comes out, pick it up and examine it to see if it is complete. If it is torn and there seem to be pieces missing, get medical help. A piece of placenta left inside the womb can cause continued bleeding or infection.

Use gloves or plastic bags on your hands to handle the placenta. Wash your hands well afterwards.

When the placenta is delayed in coming:

If the mother is not losing much blood, do nothing. Do not pull on the cord. This could cause dangerous hemorrhage (heavy bleeding). Sometimes the placenta will come out if the woman squats and pushes a little.

If the mother is losing blood, feel the womb (uterus) through the belly. If it is soft, do the following:

Massage the womb carefully, until it gets hard. This should make it contract and push out the placenta.

Figure

If the placenta still does not come out, and the heavy bleeding continues, try to control the bleeding as follows and seek medical help fast.

Hemorrhaging (Heavy Bleeding)

When the placenta comes out, there is always a brief flow of blood. It normally lasts only a few minutes and not more than a quarter of a liter (1 cup) of blood is lost, (A little bleeding may continue for several days and is usually not serious.)

WARNING: Sometimes a woman may be bleeding severely inside without much blood coming out. Feel her belly from time to time. If it seems to be getting bigger, it may be filling with blood. Check her pulse often and watch for signs of shock.

To help prevent or control heavy bleeding, let the baby suck the mother's breast. If the baby will not suck, have the husband (if possible) gently pull and massage the mother's nipples. This will cause her to produce a hormone (pituitrin) that helps control bleeding.

If heavy bleeding continues, or if the mother is losing a great deal of blood through a slow trickle, do the following:

· Get medical help fast. If the bleeding does not stop quickly, the mother may need to be given serum blood in a vein (a transfusion).

· If you have ergonovine or oxytocin, use it, following the instructions on the next page. (Use oxytocin instead of ergonovine if the placenta is still inside.)

· The mother should drink a lot of liquid (water, fruit juices, tea, soup, or Rehydration Drink). If she grows faint or has a fast, weak pulse or shows other signs of shock, put her legs up and her head down.

· If the mother is losing a lot of blood, and is in danger of bleeding to death, try to stop the bleeding like this:

Massage the belly until you can feel the womb get hard.

Figure

If the bleeding stops, check every 5 minutes to make sure the womb stays hard. If it does not, massage it again.

As soon as the womb gets hard and bleeding stops, stop massaging. Check it every minute or so. If it gets soft, massage it again.

· If the bleeding continues in spite of massaging the womb, do the following:

Using all of your weight, press down with both hands, one over the other, on the belly just below the navel. You should continue pressing down a long time after the bleeding stops.

Figure

· If the bleeding is still not under control:

Press both hands into the belly above the womb. Scoop it up and fold it forward so the womb is pressed hard against the pubic bone. Press as hard as you can, using your weight if your muscles are not strong enough. Keep pressing for several minutes after the bleeding has stopped, or until you can get medical help.

Figure

Note: Although some doctors use it, vitamin K does not help stop bleeding related to childbirth, miscarriage, or abortion. Do not use it.

The Correct Use of Oxytocics: Ergonovine, Oxytocin, Pitocin, etc.

Oxytocics are medicines that contain ergonovine, ergometrine, or oxytocin. They cause contractions of the uterus and its blood vessels. They are important but dangerous drugs. Used the wrong way, they can cause the death of the mother or the child in her womb. Used correctly, sometimes they can save lives. These are their correct uses:

1. To control bleeding after childbirth. This is the most important use of these medicines. In a case of heavy bleeding after the placenta has come out, inject one 0.2 mg. ampule (or give two 0.2 mg. tablets) of ergonovine or ergometrine maleate (Ergotrate, etc.) once every hour for 3 hours or until the bleeding is under control. After the bleeding is controlled, continue giving 1 ampule (or 1 pill) every 4 hours for 24 hours. If there is no ergonovine or if heavy bleeding starts before the placenta comes out, inject oxytocin (Pitocin) instead.

IMPORTANT: Each expectant mother, and the midwife, should have ready enough ampules of oxytocin and ergonovine to combat heavy bleeding if it occurs. But these medicines should be used only in serious cases.

2. To help prevent heavy bleeding after birth. A woman who has suffered from heavy bleeding after previous births can be given 1 ampule (or 2 pills) of ergonovine immediately after the placenta comes out, and every 4 hours for the next 24 hours.

3. To control the bleeding of a miscarriage. The use of oxytocics can be dangerous, and only a skilled health worker should use them. But, if the woman is rapidly losing blood and medical help is far away, use an oxytocic as suggested above. Oxytocin (Pitocin) is probably best.

WARNING: The use of Ergotrate, Pitocin, or Pituitrin to hasten childbirth or 'give strength' to the mother in labor is very dangerous for both her and the child. The times when oxytocics are needed before the baby is born are very rare, and it is better that only a trained birth attendant use them then. Never use oxytocics before the child is born!

THE USE OF OXYTOCICS DURING CHILDBIRTH TO ‘GIVE STRENGTH’ TO THE MOTHER...

CAN KILL THE MOTHER, THE BABY, OR BOTH.

There is no safe medicine for giving strength to the mother or for making the birth quicker or easier.

If you want the woman to have enough strength for childbirth, have her eat plenty of nutritious foods during the 9 months of pregnancy. Also encourage her to space her children. Suggest that she not get pregnant again until enough time has passed for her to regain her full strength (see Family Planning).

Difficult Births

It is important to get medical help as quickly as possible when there is any serious problem during labor. Many problems or complications may come up, some more, serious than others. Here are a few of the more common ones:

1. LABOR STOPS OR SLOWS DOWN, or lasts a very long time after being stronger after the waters break. This has several possible causes:

· The woman may be frightened or upset. This can slow down or even stop contractions. Talk to her. Help her to relax. Try to reassure her. Explain that the birth is slow, but there are no serious problems. Encourage her to change her position often and to drink, eat, and urinate. Stimulation (massage or milking motion) of the nipples can help speed labor.

Figure

· The baby may be in an unusual position. Feel the belly between contractions to see if the baby is sideways. Sometimes the midwife can turn the baby through gentle handling of the woman's belly. Try to work the baby around little by little between contractions, until the head is down. But do not use force as this could tear the womb or placenta, or pinch the cord. If the baby cannot be turned, try to get the mother to the hospital.

· If the baby is facing forward rather than backward, you may feel the lumpy arms and legs rather than the rounded back. This is usually no big problem, but labor may be longer and cause the woman more back pain. She should change positions often, as this may help turn the baby. Have her try on her hands and knees.

Figure

· The baby's head may be too large to fit through the woman's hip bones (pelvis). This is more likely in a woman with very narrow hips or a woman who is very much shorter than her husband. (It is very unlikely in a woman who has given normal birth before.) You may feel that the baby does not move down. If you suspect this problem, try to get the mother to a hospital as she may need an operation (Cesarean). Women who have very narrow hips or are especially short should have at least their first child in or near a hospital.

· If the mother has been vomiting or has not been drinking liquids, she may be dehydrated. This can slow down or stop contractions. Have her sip Rehydration Drink or other liquids after each contraction.

2. BREECH DELIVERY (the buttocks come out first). Sometimes the midwife can tell if the baby is in the breech position by feeling the mother's belly and listening to the baby's heartbeat.

A breech birth may be easier in this position:

If the baby's legs come out, but not the arms, wash your hands very well, rub them with alcohol (or wear sterile gloves), and then...

slip your fingers inside and push the baby's shoulders toward the back, like this:

or

press his arms against his body, like this:

If the baby gets stuck, have the mother lie face up. Put your finger in the baby's mouth and push his head towards his chest. At the same time have someone push the baby's head down by pressing on the mother's belly like this

Figure

Have the mother push hard. But never pull on the body of the baby.

3. PRESENTATION OF AN ARM (hand first). If the baby's hand comes out first, get medical help right away. An operation may be needed to get the baby out.

Figure

4. Sometimes the CORD IS WRAPPED AROUND THE BABY'S NECK so tightly he cannot come out all the way. Try to slip the loop of cord from around the baby's neck. It you cannot do this, you may have to clamp or tie and cut the cord. Use boiled blunt-tipped scissors.

5. FECES IN THE BABY'S MOUTH AND NOSE. When the waters break, if you see they contain a dark green (almost black) liquid, this is probably the baby's first stools (meconium). The baby may be in danger. If he breathes any of the feces into his lungs, he may die. As soon as his head is out, tell the mother not to push, but to take short, rapid breaths. Before the baby starts breathing, take time to suck the feces out of his nose and mouth with a suction bulb. Even if he starts breathing right away, keep sucking until you get all the feces out.

6. TWINS. Giving birth to twins is often more difficult and dangerous - both for the mother and babies - than giving birth to a single baby.

Figure

To be safe, the mother should give birth to twins in a hospital.

Because with twins labor often begins early, the mother should be within easy reach of a hospital after the seventh month of pregnancy.

Signs that a woman is likely to have twins:

· The belly grows faster and the womb is larger than usual, especially in the last months.

· If the woman gains weight faster than normal, or the common problems of pregnancy (morning sickness, backache, varicose veins, piles, swelling, and difficult breathing) are worse than usual, be sure to check for twins.

· If you can feel 3 or more large objects (heads and buttocks) in a womb that seems extra large, twins are likely.

· Sometimes you can hear 2 different heartbeats (other than the mother's) - but this is difficult.

During the last months, if the woman rests a lot and is careful to avoid hard work, twins are less likely to be born too early.

Twins are often born small and need special care. However, there is no truth in beliefs that twins have strange or magic powers.

Tearing of the Birth Opening

The birth opening must stretch a lot for the baby to come out. Sometimes it tears. Tearing is more likely if it is the mother's first baby.

Tearing can usually be prevented if care is taken:

The mother should try to stop pushing when the baby's head is coming out. This gives her birth opening time to stretch. In order not to push, she should pant (take many short rapid breaths).

Figure

When the birth opening is stretching, the midwife can support it with one hand and with the other hand gently keep the head from coming too fast, like this:

Figure

It may also help to put warm compresses against the skin below the birth opening. Start when it begins to stretch. You can also massage the stretched skin with oil.

Figure

If a tear does happen, someone who knows how should carefully sew it shut after the placenta comes out.

Care of the Newborn Baby

The Cord

To prevent the freshly cut cord from becoming infected, it should be kept clean and dry. The drier it is, the sooner it will fall off and the navel will heal. For this reason, it is better not to use a belly band, or if one is used, to keep it very loose.

The Eyes

To protect a newborn baby's eyes from dangerous conjunctivitis, put a drop of 1% silver nitrate, or a little tetracycline or erythromycin eye ointment, in each eye as soon as he is born. This is especially important if either parent has ever had signs of gonorrhea or chlamydia.

Figure

Keeping the Baby Warm - But Not Too Warm

Protect the baby from cold, but also from too much heat. Dress him as warmly as you feel like dressing yourself.

IN COLD WEATHER Figure WRAP THE BABY WELL.

BUT IN HOT WEATHER (OR WHEN THE BABY HAS A FEVER) Figure LEAVE HIM NAKED.

To keep a baby just warm enough, keep him close to his mother's body. This is especially important for a baby that is born early or very small. See 'Special Care for Small, Early, and Underweight Babies'.

Cleanliness

It is important to follow the Guidelines of Cleanliness as discussed in Chapter 12. Take special care with the following:

· Change the baby's diapers (nappy) or bedding each time he wets or dirties them. If the skin gets red, change the diaper more often - or better, leave it off!

· After the cord drops off, bathe the baby daily with mild soap and warm water.

· If there are flies or mosquitos, cover the baby's crib with mosquito netting or a thin cloth.

· Persons with open sores, colds, sore throat, tuberculosis, or other infectious illnesses should not touch or go near the newborn baby or the woman while she is giving birth.

· Keep the baby in a clean place away from smoke and dust.

Feeding

(Also see “The Best Diet for Small Children.”)

Breast milk is by far the best food for a baby. Babies who nurse on breast milk are healthier, grow stronger, and are less likely to die. This is why:

· Breast milk has a better balance of what the baby needs than does any other milk, whether fresh, canned, or powdered.

· Breast milk is clean. When other foods are given, especially by bottle feeding, it is very hard to keep things clean enough to prevent the baby from getting diarrhea and other sicknesses.

· The temperature of breast milk is always right.

· Breast milk has things in it (antibodies) that help protect the baby against certain illnesses, such as diarrhea, measles, and polio.

The mother should give her breast to the baby as soon as he is born. For the first few days the mother's breasts usually produce very little milk. This is normal. She should continue to nurse her baby often - at least every two hours. The baby's sucking will help her produce more milk.

If the baby seems healthy, gains weight, and wets her diaper (nappy) regularly, the mother is producing enough milk.

It is best for the baby if the mother gives him only breast milk for the first 4 to 6 months. After that, she should continue to breast feed her baby, but should begin to give him other nourishing foods also.

HOW A MOTHER CAN PRODUCE MORE BREAST MILK:

She should...

· drink plenty of liquids,
· eat as well as possible, especially milk, milk products, and body-building foods,
· get plenty of sleep and avoid getting very tired or upset,
· nurse her baby more often - at least every 2 hours.

BOTTLE-FED BABIES ARE MORE LIKELY TO GET SICK AND DIE.

BREAST-FED BABIES ARE HEALTHIER.

Care in Giving Medicines to the Newborn

Many medicines are dangerous for the newborn. Use only medicines you are sure are recommended for the newborn and use them only when they are absolutely necessary. Be sure you know the right dose and do not give too much. Chloramphenicol is especially dangerous to the newborn... and even more dangerous if the baby is premature or underweight (less than 2 kilograms).

Illnesses of the Newborn

It is very important to notice any problem or illness a baby may have - and to act quickly.

Diseases that take days or weeks to kill adults can kill a baby in a matter of hours.

Problems the Baby is Born with

These may result from something that went wrong with the development of the baby in the womb or from damage to the baby while he was being born. Examine the baby carefully immediately after birth. If he shows any of the following signs, something is probably seriously wrong with him:

· If he does not breathe as soon as he is born.
· If his pulse cannot be felt or heard, or is less than 100 per minute.
· If his face and body are white, blue, or yellow after he has begun breathing.
· If his arms and legs are floppy - he does not move them by himself or when you pinch them.
· If he grunts or has difficulty breathing after the first 15 minutes.

Some of these problems may be caused by brain damage at birth. They are almost never caused by infection (unless the water broke more than 24 hours before birth). Common medicines probably will not help. Keep the baby warm, but not too warm. Try to get medical help.

If the newborn baby vomits or shits blood, or develops many bruises, she may need vitamin K.

If the baby does not urinate or have a bowel movement in the first 2 days, also seek medical help.

Problems that Result after the Baby is Born (in the first days or weeks)

1. Pus or a bad smell from the navel (cord) is a dangerous sign. Watch for early signs of tetanus or bacterial infection of the blood. Soak the cord in alcohol and leave it open to the air. If the skin around the cord becomes hot and red, treat with ampicillin or with penicillin and streptomycin.

2. Either low temperature (below 35°) or high fever can be a-sign of infection. High fever (above 39°) is dangerous for the newborn. Take off all clothing and sponge the baby with cool (not cold) water. Also look for signs of dehydration. If you find these signs, give the baby breast, milk and also Rehydration Drink made with water, sugar, and salt only. Alternate this with equal amounts of cooled boiled water.

3. Fits (convulsions). If the baby also has fever, treat it as just described. Be sure to check for dehydration. Fits that begin the day of birth could be caused by brain damage at birth. If fits begin several days later, look carefully for signs of tetanus or meningitis.

4. The baby does not gain weight. During the first days of life, most babies lose a little weight. This is normal. After the first week, a healthy baby should gain about 200 gm. a week. By two weeks the healthy baby should weigh as much as he did at birth. If he does not gain weight, or loses weight, something is wrong. Did the baby seem healthy at birth? Does he feed well? Examine the baby carefully for signs of infection or other problems. If you cannot find out the cause of the problem and correct it, get medical help.

5. Vomiting. When healthy babies burp (or bring up air they have swallowed while feeding), sometimes a little milk comes up too. This is normal. Help the baby bring up air after feeding by holding him against your shoulder and patting his back gently, like this.

BURP YOUR BABY AFTER FEEDING.

If a baby vomits when you lay him down after nursing, try sitting him upright for a while after each feeding.

A baby who vomits violently, or so much and so often that he begins to lose weight or become dehydrated, is ill. If the baby also has diarrhea, he probably has a gut infection. Bacterial infection of me blood (see the next pages), meningitis, and other infections may also cause vomiting.

If the vomit is yellow or green, there may be a gut obstruction, especially if the belly is very swollen or the baby has not been having bowel movements. Take the baby to a health center at once.

6. The baby stops sucking well. If more than 4 hours pass and the baby still will not nurse, this is a danger sign - especially if the baby seems very sleepy or ill, or if he cries or moves differently from normal. Many illnesses can cause these signs, but the most common and dangerous causes in the first 2 weeks of life are a bacterial infection of the blood (see next 2 pages) and tetanus.

A baby who stops nursing during the second to fifth day of life may have a bacterial infection of the blood. A baby who stops nursing during the fifth to fifteenth day may have tetanus.

If a Baby Stops Sucking Well or Seems Ill

Examine him carefully and completely as described in Chapter 3. Be sure to check the following:

· Notice if the baby has difficulty breathing. If the nose is stuffed up, suck it out. Fast breathing (50 or more breaths a minute), blue color, grunting, and sucking in of the skin between the ribs with each breath are signs of pneumonia. Small babies with pneumonia often do not cough; sometimes none of the common signs are present. If you suspect pneumonia, treat as for a bacterial infection of the blood.

· Look at the baby's skin color.

If the lips and face are blue, consider pneumonia (or a heart defect or other problem the baby was born with).

If the face and whites of the eyes begin to get yellow (jaundiced) in the first day of life or after the fifth day, this is serious. Get medical help. Some yellow color between the second and fifth day of life is usually not serious. Give plenty of breast milk - by spoon if necessary. Take off all the baby's clothes and put him in bright light hear a window (but not direct sunlight).

· Feel the soft spot on top of the head (fontanel).

Figure

Figure

IMPORTANT: If a baby has meningitis and dehydration at the same time, the soft spot may feel normal. Be sure to check for other signs of both dehydration and meningitis.

· Watch the baby's movements and expression on his face.

Figure

Stiffness of the body and/or strange movements may be signs of tetanus, meningitis, or brain damage from birth or fever. If, when the baby is touched or moved, the muscles of his face and body suddenly tighten, this could be tetanus. See if his jaw will open and check his knee reflexes.

If the baby's eyes roll back or flutter when he makes sudden or violent movements, he probably does not have tetanus. Such fits may be caused by meningitis, but dehydration and high fever are more common causes. Can you put the baby's head between his knees? If the baby is too stiff for this or cries out in pain, it is probably meningitis.

· Look for signs of a bacterial infection in the blood.

Bacterial Infection in the Blood (Septicemia)

Newborn babies cannot fight infections well. Therefore, bacteria that enter the baby's skin or cord at the time of birth often get into the blood and spread through his whole body. Since this takes a day or two, septicemia is most common after the second day of life.

Signs:

Signs of infection in newborn babies are different from those in older children. In the baby, almost any sign could be caused by, a serious infection in the blood. Possible signs are:

· does hot suck well
· seems very sleepy
· very pale (anemic)
· vomiting or diarrhea
· fever or low temperature (below 35°)
· swollen belly
· yellow skin (jaundice)
· fits (convulsions)
· times when the baby turns blue

Each of these signs may be caused by something other than septicemia, but if the baby has several of these signs at once, septicemia is likely.

Newborn babies do not always have a fever when they have a serious infection. The temperature may be high, low, or normal.

Treatment when you suspect septicemia in the newborn:

· Inject 125 mg. of ampicillin 3 times a day. Or inject 150 mg. (250,000 units) of crystalline penicillin 3 times a day.

· If possible, also inject kanamycin or streptomycin: Give 25 mg. of kanamycin 2 times a day; or give 20 mg. of streptomycin for each kilogram the baby weighs (60 mg. for a 3 kilogram baby) once a day. Be careful not to give too much of either of these medicines!

· Be sure the baby has enough liquids. Spoon feed breast milk. Also give Rehydration Drink, if necessary, made with water, sugar, and salt only. Alternate this with equal amounts of cooled boiled water.

· Try to get medical help.

Infections in newborn babies are sometimes hard to recognize. Often there is no fever. If possible, get medical help. If not, treat with ampicillin as described above. Ampicillin is one of the safest and most useful antibiotics for babies. Figure

The Mother's Health after Childbirth

Diet and Cleanliness

As was explained in Chapter 11, after she gives birth to a baby, the mother can and should eat every kind of nutritious food she can get. She does not need to avoid any kind of food. Foods that are especially good, for her are milk, cheese, chicken, eggs, meat, fish, fruits, vegetables, grains, beans, groundnuts, etc. If all she has is corn and beans, she should eat them both together at each meal. Milk and other dairy products help the mother make plenty of milk for her baby.

The mother can and should bathe in the first few days after giving birth. In the first week, it is better if she bathes with a wet towel and does not go into the water Bathing is not harmful following childbirth. In fact, women who let many days go by without bathing may get infections that will make their skin unhealthy and their babies sick.

During the days and weeks following childbirth, the mother should:

eat nutritious foods

and

bathe regularly

Childbirth Fever (Infection after Giving Birth)

Sometimes a mother develops fever and infection after childbirth, often because the midwife was not careful enough to keep everything very clean or because she put her hand inside the mother.

The signs of childbirth fever are: Chills or fever, headache or low back pain, sometimes pain in the belly, and a foul-smelling or bloody discharge from the vagina.

Treatment:

Give penicillin: injections of 500,000 units of procaine penicillin twice a day, or 2 pills of 400,000 units 4 times a day for a week. Ampicillin, co-trimoxazole, or tetracycline may be used instead.

Childbirth fever can be very dangerous. If the mother does not get well soon, get medical help. Very severe infections may need treatment with a stronger antibiotic (chloramphenicol, gentamicin, kanamycin, or a cephalosporin) in addition to high doses of penicillin or ampicillin.

Breast Feeding - And Care of the Breasts

Taking good care of the breasts is important for the health of both the mother and her baby. Breast feeding should be started the same day the baby is born. At first the baby may not suck much, but this lets the mother's body get used to his sucking, and helps prevent sore nipples. The very first milk the breast makes (called colostrum) also protects the baby against infection and is rich in protein. Although it looks watery, this first milk is very good for the baby. So...

BEGIN BREAST FEEDING THE SAME DAY THE BABY IS BORN.

Normally, the breasts make as much milk as the baby needs. If the baby empties them, they begin to make more. If the baby does not empty them, soon they make less. But when a baby gets sick and stops sucking, after a few days the mother's breasts stop making milk. So when the baby is able to suck again, and needs a full amount of milk, there may not be enough. For this reason,

When a baby is sick and unable to take much milk, it is important that the mother keep producing lots of milk by milking her breasts with her hands.

TO MILK YOUR BREASTS

Take hold of the breast way back, like this,

then move your hands forward, squeezing,

and finally, squeeze the milk out of the nipple.

Another reason it is important to milk the breasts when the baby stops sucking is that this keeps the breasts from getting too full. When they are too full, they are painful. A breast that is painfully full is more likely to develop an abscess. Also, the baby may have trouble sucking them even if he wants to.

When your baby is too weak to suck, squeeze milk out of your breast by hand and give it to the baby by spoon or dropper.

Always keep your breasts clean. Before breast feeding your baby, wipe your nipples with a clean, moist cloth. Do not use soap each time you clean your nipples, as this may lead to cracking of the skin, sore nipples, and infection.

Sore Nipples

Sore nipples may develop when the baby bites on the nipple instead of taking the whole thing into his mouth. This is most likely to happen in women who have short nipples.

Figure

Prevention:

Be sure the whole nipple, not just the tip, is in the baby's mouth.

For a woman with short nipples, or nipples that sink into the breast, it helps to squeeze the nipples like this several times a day during pregnancy. This will make it easier for her child to suck, and she will be less likely to get sore nipples.

Figure

Treatment:

It is important to keep breast feeding the baby, even though this hurts. First let him suck the side that is least sore. Only stop breast feeding if the nipple oozes a lot of blood or pus. In this case, milk the breast by hand until the nipple heals. When the baby feeds again on the breast, be sure the whole nipple enters his mouth.

Breast Infection (Mastitis) and Abscess

A breast infection may result from a sore or cracked nipple. This is most common during the first weeks or months of breast feeding. Sometimes the infection leads to an abscess, or pocket of pus.

Figure

Signs:

Part of the breast becomes hot, red, swollen, and very painful. Lymph nodes in the armpit are often sore and swollen. A severe abscess sometimes bursts and drains pus. The woman may have a fever.

Prevention:

· Keep the breast clean. If a sore nipple or painful cracks develop, breast feed the baby for shorter periods, but more often.

· Also put a little vegetable oil or baby oil on the nipples after each feeding.

Treatment:

· Let the baby continue to feed from the abscessed breast, or milk it by hand, whichever is less painful.

· Use cold (or hot) compresses to ease the pain. Also take aspirin.

· Take an antibiotic as for childbirth fever.

Different kinds of breast lumps:

A painful, hot lump in the breast of a nursing mother is probably a breast abscess (infection). A painless breast lump may be cancer, or a cyst.

Breast Cancer

Cancer of the breast is fairly common in women, and is always dangerous. Successful treatment depends on spotting the first sign of possible cancer and getting medical care soon. Surgery is usually necessary.

Signs of breast cancer:

· The woman may notice a lump, often in this (1) part of the breast.

Figure

· Or the breast may have an abnormal dent or dimple - or many tiny pits like the skin of an orange.

· Often there are large but painless lymph nodes in the armpit.

· The lump grows slowly.

At first it usually does not hurt or get hot. Later it may hurt.

SELF-EXAMINATION OF THE BREASTS

Every woman should learn how to examine her own breasts for possible signs of cancer. She should do it once a month, preferably on the 10th day after her menstrual period started.

· Look at your breasts carefully for any new difference between the two in size or shape. Try to notice any of the above signs.

· While lying with a pillow or folded blanket under your back, feel your breasts with the flat of your fingers, Press your breast and roll it beneath your finger tips. Start near the nipple and go around the breast and up into the armpit. (2)

Figure

· Then squeeze your nipples and check whether blood or a discharge comes out. (3)

Figure

If you find a lump or any other abnormal sign, get medical advice. Many lumps are not cancer, but it is important to find out early.

Lumps or Growths in the Lower Part of the Belly

Figure

The most common lump is, of course, caused by the normal development of a baby. Abnormal lumps or masses may be caused by:

· a cyst or watery swelling in one of the ovaries
· by a baby that has accidentally begun to develop outside of the womb (ectopic pregnancy), or
· cancer

All 3 of these conditions are usually painless or mildly uncomfortable at first, and become very painful later. All require medical attention-usually surgery. If you find any unusual, gradually growing lump, seek medical advice.

Cancer of the Womb

Cancer of the uterus (womb), cervix (neck of the womb), or ovaries/is most common in women over 40. The first sign may be anemia or unexplained bleeding. Later, an uncomfortable or painful lump in the belly may be noticed.

There is a special test called a Pap smear (Papanicolaou) to find cancer of the cervix when it is just beginning. Where it is available, all women over 20 should try to get one of these tests once a year.

At the first suspicion of cancer, seek medical help.

Home remedies are not likely to help.

Out-of-place or Ectopic Pregnancy

Figure

Sometimes a baby begins to form outside the womb, in one of the tubes that comes from the ovaries. (1)

There may be abnormal menstrual bleeding together with signs of pregnancy - also severe cramps low in the belly and a painful lump outside the womb.

A baby that begins to form out of place usually cannot live. Ectopic pregnancy requires surgery in a hospital. If you suspect this problem, seek medical advice soon, as dangerous bleeding could start any time.

Miscarriage (Spontaneous Abortion)

A miscarriage is the loss of the unborn baby. Miscarriages are most frequent in the first 3 months of pregnancy. Usually the baby is imperfectly formed, and this is nature's way of taking care of the problem.

Most women have one or more miscarriages in their lifetime. Many times they do not realize that they are having a miscarriage. They may think their period was missed or delayed, and then came back in a strange way, with big blood clots. A woman should learn to know when she is having a miscarriage, because it could be dangerous.

A woman who has heavy bleeding after she has missed one or more periods probably is having a miscarriage.

A miscarriage is like a birth in that the embryo (the beginning of the baby) and the placenta (afterbirth) must both come out. Heavy bleeding with big blood clots and painful cramps often continues until both are completely out.

The embryo of a miscarriage may be no longer than 1 or 2 centimeters.

Treatment:

The woman should rest and take aspirin, ibuprofen, or codeine for pain.

If heavy bleeding continues for many days:

· Get medical help. A simple operation may be needed to clean out the womb (dilatation and curettage, or D and C, or suction).

· Stay in bed until the heavy bleeding stops.

· If the bleeding is extreme, follow the instructions from “The Correct Use of Oxytocics: Ergonovine, Oxytocin, Pitocin, etc.”.

· If fever or other signs of infection develop, treat as for Childbirth Fever.

· A woman may continue to bleed a little for several days after the miscarriage. It will be similar to her menstrual flow (period).

· She should not douche or have sex for at least 2 weeks after the miscarriage, or until the bleeding stops.

· If she is using an IUD and has a miscarriage, serious infection may occur. Seek medical help fast, have the IUD removed, and give antibiotics.

High Risk Mothers and Babies

A note to midwives or health workers or anyone who cares:

Some women are more likely to have difficult births and problems following birth, and their babies are more likely to be underweight and sick. Often these are mothers who are single, homeless, poorly nourished, very young, mentally slow, or who already have malnourished or sickly children.

Often if a midwife, health worker, or someone else takes special interest in these mothers, and helps them find ways to get the food, care, and companionship they need, it can make a great difference in the well-being of both the mothers and their babies.

Do not wait for those in need to come to you. Go to them.

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