SBA Handbook

HANDBOOK
FOR
ANMs, LHVs AND STAFF NURSES TO

PROVIDE SKILLED ATTENDANCE AT
BIRTH
Maternal Health Division

Department of Family Welfare
Ministry of Health and Family Welfare
Government of India
2006
ACKNOWLEDGEMENTS
Government of India has taken the decision to empower the Auxiliary Nurse Midwives,
Lady Health Visitors and Staff Nurses to provide skilled attendance at birth. In this
endeavourer the above mentioned category of nursing personnel have been allowed to use
certain drugs and perform simple procedures in specific situations during pregnancy and
child birth to save the life of the mother and her newborn.
Government of India has developed and released the Guidelines for Antenatal Care and
Skilled Attendance at Birth by ANMs, LHVs and SNs. GoIs Skilled Attendance at Birth
initiative is now to be followed up by effective training and logistic inputs to empower
the knowledge and skills of ANMs, LHVs and SNs to become skilled birth attendants.
To operationalize the above guidelines, Government of India has developed a training
package consisting of two manuals:
1. Facilitators Guide for Operationalizing Guidelines for Antenatal Care and Skilled
Attendance at Birth by ANMs, LHVs and SNs and
2. Handbook for ANMs and LHVs to Provide Skilled Attendance at Birth.
This training package has been the result of technical expertise and guidance provided by
WHO, UNFPA, CEDPA India, White Ribbon Alliance of India (WRAI), National
Institute of Health and Family Welfare (NIHFW) and experts in the field of obstetrics and
Gynaecology. I am thankful to Dr. V.K. Manchanda, my predecessor for spear heading
this effort, Dr. Arvind Mathur, National Professional Officer, WHO-India and Dr. Dinesh
Agarwal, Team Manager Technical Support Group and Technical Advisor Reproductive
Health UNFPA, Dr. B. Sood, Country Director CEDPA and Co-Chairpreson, WRAI for
their active involvement and inputs.
A team of experts in the field of Obstetrics and Gynecology met several times to develop
this training package. My special thanks to Dr. Kamala Ganesh, Senior Consultant,
Obstetrics and Gynecology, Dr. Kalaivani, Director, NIHFW, Dr. V. Zutshi, Senior
Gynecologist-LNJPN Hospital, Dr. Leila C. Varkey, WRAI and Dr. Bindoo Sharma,
NIHFW, Dr. Himanshu Bhushan, and Dr. Manisha Malhotra, Assistant Commissioners,
Maternal Health, Ministry of Health and Family Welfare for their valuable inputs.
I appreciate the efforts of Dr. Rashmi Asif who handled the task of writing and editing
these manuals and Mr. Manoj Kohli for his contribution to scan the pictures in the
Handbook.
It is envisaged that this training package will facilitate the trainers while they conduct the
training of ANMs, LHVs and SNs to provide Skilled Attendance at Birth.
Dr. I.P. Kaur
Deputy Director General (MCH)
Ministry of Health and Family Welfare, Government of India
Contents
I.
Figures
Page numbers
1.1 Identification of pre-eclampsia
1.2 Assessment of Cervical effacement and dilatation
1.3 Pelvic assessment
1.4 Assessment of Engagement of foetal head
15
II. Partographs
2.1 Pre-prepared Sample Partographs
2.2 Sample of Completed Partographs
16
2.3 Exercises to Monitor Labour using Partograph
18
2.4 Explanations to Exercises
22
2.5 Interpreting newborn weight
29
Blank simplified partographs
31
III. References
IV. Self Assessment Checklists
CHECKLIST 1
CHECKLIST FOR PROCESSING INSTRUMENTS,
GLOVES AND EQUIPMENT; NEEDLES AND SYRINGES
(To be used by the Trainees during practice and by the Trainers during assessment of trainees)
Rate the performance of each step or task using the following rating scale:
1
Needs Improvement: Step or task not performed correctly or out of sequence (if necessary)
or is omitted
Competently Performed: Step or task efficiently and precisely performed in proper

sequence
All activities marked with an asterisk (*) are critical to be done according to standards
to pass the assessment.

GLOVES AND EQUIPMENT
STEP/TASK
OBSERVATIONS
NAME OF THE CLIENT/TRAINEE AND DATES OF

PRACTICE/ASSESSMENT
DECONTAMINATION
1. *Leave on surgical gloves after the clinical procedure or put on utility
gloves.
2. *Place all instruments in 0.5% chlorine solution for 10 minutes
immediately after completing the clinical procedure
3. *Dispose of waste material or put it in a leak proof container
4. Decontaminate exam table or OT table or other surfaces contaminated
during the procedure by wiping them with 0.5% chlorine solution
5.Remove instruments/gloves from 0.5% chlorine solution after 10
minutes and place them in water

STEP/TASK
OBSERVATIONS
6. Remove reusable gloves by inverting and soaking in 0.5% chlorine

solution for 10 minutes (if wearing utility gloves do not remove until
instrument cleaning is finished.)
CLEANING (instruments)
1. Place instruments in a basin with clean water and mild non-abrasive
detergent.
2. *Completely disassemble instruments and/or open jaws of joint items
3. *Wash all instrument surfaces with a brush or cloth until visibly clean
(hold instruments underwater while cleaning)
4. *Thoroughly clean serrated edges (e.g., jaws of clamps) of instruments
using a small brush.
5. *Wash surgical gloves in soapy water, cleaning inside and out.
6. *Towel dry instruments or allow them to air dry
7. *Hang surgical gloves up to allow them to air dry, and once first side is
dry, reverse them to dry completely
8. *After cleaning all items, remove utility gloves and allow to air dry.
PACKAGING
1. *Arrange instruments in tray or on cloth wrapping using appropriately
clean material.
2. *Wrap items using envelope or square wrap technique.
3. *Place packs in drums or tray for autoclaving.
AUTOCLAVING-STERILIZATION
1. *Arrange packs and loose items in autoclave chamber to allow free
circulation and penetration of steam to all surfaces.
2. *Sterilize for 30 minutes for wrapped items; 20 minutes for unwrapped
items (uses timer) at 121oc(250oF) and 106kPa(15 lbs/in2)

STEP/TASK
OBSERVATIONS
3. *Wait 20-30 minutes (or until pressure gauge reads zero) before
opening lid or door to allow steam to escape.
4. *Allow packs to dry completely before removing.
5. *Place sterilized drums or packs on a surface padded with paper or
fabric to prevent condensation.
6. *Allow drums or packs to reach room temperature before storing.
7. *Record sterilization conditions (time, temperature and pressure) in
logbook
HIGH LEVEL DISINFECTION
BOILING
1. *Completely submerge pre-cleaned items in water.
2. *Keep the instruments by opening them so that their teeth and joints are
open.
3. *Place lid over boiling pot and bring the water to a gentle, rolling boil.
4. *Start time when rolling boil begins.
5. *Keep a rolling boil for 20 minutes.
6. *Remove items with HLD cheattle forceps.
7. *Use immediately after air drying or place in covered, dry HLD
container.
CHEMICAL
1. *Prepare fresh solution of chemical high level disinfectant or check to
be sure solution is not out of date (0.5% chlorine solution in ordinary
clean water)
2. *Immerse clean, dried items in appropriate high level disinfectant.
3. *Keep the instruments by opening them so that their teeth and joints are
open.
4. *Cover container and soak for 20 minutes in 0.5% chlorine solution
5. *Remove items from chemical solution using HLD gloves or HLD
cheattle forceps.

STEP/TASK
OBSERVATIONS
6. *Rinse items thoroughly with HLD (boiled) water to remove all traces
of chemical disinfectant.
7. *Use items after air dry or place in a HLD covered container for storage
Score %
Score %: The denominator will be 3 X number of the tasks observed/performed. The

numerator will be the total points scored during the procedure or observation. This multiplied by
100 gives the score %. To be declared Performing to Standards (PTS), the trainee should score
at least 80% with all the critical steps performed to standards. It will be ideal if all the steps are
performed to standards.
CHECKLIST FOR PROCESSING NEEDLE AND SYRINGE

NAME OF CLIENT/TRAINEE AND DATE OF
PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
DECONTAMINATION (of reusable syringes and needles)

1. *Leave on gloves after surgical procedure.
2. *Leave needle attached to syringe.
3. *Fill syringe with 0.5% chlorine solution.
4. *Cover needle and syringe with chlorine and soak for 10 minutes. Use
one hand technique to cap the needle:
Place the cap on a flat surface, then remove your hand.
With one hand, hold the syringe and use the needle to scoop up the
cap.
When the cap covers the needle completely, use the other hand to
secure the cap on the needle hub.
CHECKLIST FOR PROCESSING NEEDLE AND SYRINGE

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
5. * To avoid needle stick accidents, do not disassemble single use

needles/syringes after use, and do not recap, bend or break before
disposal. For disposable syringes and needles put them in a puncture
proof container and dispose of the container when it is three-quarters
full.
CLEANING
1. *Put on utility gloves and expel 0.5% chlorine solution from syringe
and needle.
2. *Check to be sure needle is not blocked, then dissemble and clean with
soapy water.
3. *Reassemble and rinse syringe and needle by filling and expelling clean
water three times.
4. *Check to be sure that the needle and syringe are not damaged
5. *Detach needle from syringe.
*To check for the further processing of needles and syringes

follow the instructions given in the sterilization or HLD sections
of the checklist for processing instruments/gloves and
equipment.
Score %
Remember: Sharps should always be handled with extreme care.

Management of injuries from needles and other sharps:
If accidental exposure to blood or other body fluids occurs due to needle pricks or splatter of
blood or body fluids:
Wash needle sticks and cuts with soap and water.
Flush splashes to the nose, mouth or skin with water.
Splash eyes with water.
Post-exposure prophylaxis with drugs or other therapy can reduce the risk of transmission of
some blood-borne pathogens. Whether post-exposure prophylaxis is indicated following
exposure to blood or other body fluids depends on a number of factors. This includes the
infection status of the source client, the type of exposure (eg., a splash to the unbroken skin
or versus a deep puncture wound with a hypodermic needle), whether or not the exposed
person has been vaccinated against Hepatitis B, how much time has passed since the
exposure, and the availability of needed drugs or other therapy.
Note: Detailed protocols for the administration of post-procedure prophylaxis are beyond the
scope of this training. If you or a client has been exposed to blood or other body fluids, consult a
doctor at the PHC who is familiar with post-procedure prophylaxis.
CHECKLIST 10
CHECKLIST FOR MANAGEMENT OF
HYPERTENSION, PRE-ECLAMPSIA AND ECLAMPSIA
1
Needs Improvement: Step or task not performed correctly or out of sequence (if
necessary) or is omitted

sequence
All activities marked with an asterisk (*) are critical to be done according to standards to
pass the assessment.

STEP/TASK
OBSERVATIONS

PRACTICE/ASSESSMENT
If the womans diastolic Blood Pressure (BP) is more than 90

mm Hg:
1. *Take a good personal and family history of:
Epilepsy: fits
Hypertension: dizziness, blurring of vision, pain in head,
Hypertension in previous pregnancies
Renal or heart disease
Cerebro-vascular accident (CVA)
2. *Take a good symptom history for danger signs. ASK the woman
if she has or had any:
Pain in the upper abdomen (heartburn)
Severe headache
Visual problems (double vision, blurring, transient blindness)
Sudden or severe swelling of the face, lower back and hands
Passing reduced amount of urine

STEP/TASK
OBSERVATIONS
3.*Check a mid-stream clean catch urine sample for protein. Make

sure the urine is not contaminated by vaginal secretion.
Make a differential diagnosis
Diastolic BP >90 but less than 110 without proteinuria, the woman has
HYPERTENSION
1. *If the diastolic BP is >90 but <110 and there is <1+ protein in the
urine, AND the woman has no symptoms of pre-eclampsia:
Ask the woman to lie on her left side for 20 minutes
2. *Check the BP again after 1 hour and then after 4 hours.
(Hypertension is diagnosed if BP is 140/90 mm Hg or more on 2
consecutive readings taken 4 hours apart).
3. *If the BP is now within normal limits (WNL): The woman can
be managed at home.
Counsel the woman to drink at least 8 glasses of water a day and
reduce her work load, rest and lie on her left side
Explain danger signs to the woman and tell her to seek care
immediately if she has any of these symptoms
Monitor her BP daily or on alternate days. Also check her urine
for proteinuria.
4. If the BP falls or remains the same, continue home management.
5. *If the BP is still elevated or is more than 160/110 mmHg without
proteinuria, refer her to MO at the PHC for care.
6. *If there is >1+ protein in the urine, verify that the sample was midstream/clean catch sample and check for UTI/STIs- refer to
hospital for treatment.
7.
*If the diastolic BP is > 90 mm Hg and protein in urine is >1+, the

woman has PRE-ECLAMPSIA. Refer her to an FRU for
admission and further management. Explain that high blood
pressure is dangerous for the woman and her baby as she may
develop premature pains, bleeding, fits and the baby may die.
8.
* if the woman has BP more than 160/110 with proteinuria or

any of the danger signs, she is suffering from IMMINENT
ECLAMPSIA and she may develop fits anytime. This is an
emergency. Refer the woman immediately to FRU

STEP/TASK
OBSERVATIONS
Make a plan of care

1. *Share your findings with the woman:
State of health and blood pressure
Discuss any complications / problems detected during the visit
Explain treatment and the importance for pregnancy, labour,
and delivery
2. *If the woman has to be referred, explain the need for referral and,
if possible, accompany her.
3. *Determine where the woman should deliver, and assist her in
developing a birth preparedness plan. If the woman has preeclampsia and is in late first stage or early second stage of
labour:
Carry out the delivery as usual
Monitor BP every hour
Refer the woman to an FRU after delivery for care.
4. Counsel the woman.
*Inform the woman about next steps either arrange for
hospitalisation, referral, or follow-up as an outpatient.
*Check the womans understanding of findings and next steps.
*Remind the woman to report any time she has
questions/concerns/danger signs and not to wait for the
scheduled visit
Give the woman her antenatal card and referral slip.
If the woman has fits during pregnancy, labour, delivery or
postpartum period, it is considered ECLAMPSIA

STEP/TASK
OBSERVATIONS
1. *Offer supportive care immediately:

Do not leave the woman alone.
Protect her from fall or injury
Ensure clear airway and breathing
If she is unconscious, keep her on the back with arms by
her side
Tilt her head backwards and lift her chin to open the airway
Remove any obstruction or foreign body from her mouth if
visible
After the convulsion is over, help her turn to the left side
Keep the mouth gag between the upper and lower jaw to
prevent tongue bite. Do not attempt this during a convulsion.
2. * Measure the BP and temperature of the woman and maintain a
record in her ANC card
3. * Give the first dose of Injection Magnesium Sulphate
Take a sterile10 cc syringe and 22 gauge needle.
Keep 10 ampoules of Injection Magnesium sulphate (2 ml
ampoules of 50% solution) ready.
Break 5 ampoules and fill the Magnesium sulphate solution one
by one from these 5 ampoules in the same 10 cc syringe. Take
care not to suck in air bubbles while filling the syringe.
Identify the upper outer quadrant of the hip
Identify the landmarks of iliac spine, hip joint (greater
trochanter), ischial tuberosity and the dimple on the back
(sacroiliac joint). This is the outer boundary of the buttock
Divide the buttock in four equal quadrants
Identify the area of the upper outer quadrant
Clean the upper outer quadrant with a spirit swab and let the
area dry
Give deep IM injection in the upper outer quadrant in one
buttock, slowly. (it is important to give deep in the muscle
otherwise there are chances that an abscess may develop at the
site of injection. Pierce the needle at right angles to the
buttock instead of a slanting position for deep penetration)
Tell the woman she will feel warm while the injection is being
given
Once the syringe is emptied in on buttock, fill it with the
solution of the other 5 ampoules and repeat the procedure in
the other buttock slowly.
Dispose the syringe in a puncture proof container (if disposable)
or decontaminate if reusable.

STEP/TASK
OBSERVATIONS
4. *Tell the woman that she may have flushing, feel thirsty have
headache, nausea or may vomit. In any such condition she should
inform you. DO NOT repeat the dose if the woman develops any
of these symptoms.
5. *Start an IV infusion and give IV fluids slowly at the rate of 30
drops per minute.
6. * Refer the woman immediately to an FRU. Ensure that the
woman reaches the referral centre within 2 hours of receiving the
first dose of magnesium sulphate
7. * If the woman is in labour, give her the first dose of magnesium
sulphate and refer to an FRU for delivery.
5. If the delievery is imminent, then
Give first dose of Injection Magnesium Sulphate
Try and deliver the baby in a domiciliary setting
Refer her to an FRU after delivery
Score%

numerator will be the total points scored during the procedure or observation. This
multiplied by 100 gives the score %. To be declared Performing to Standards (PTS), the
trainee should score at least 80% with all the critical steps performed to standards. It will
be ideal if all the steps are performed to standards.
CHECKLIST 11
CHECKLIST FOR PUERPERAL PYREXIA
1

sequence (
The tasks marked with an asterix (*) are critical and must be performed to standards to be
considered competent and Performing to Standards (PTS)

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
GETTING READY
1. *Prepare the necessary equipment
Stethescope
BP instrument
Watch
Surgical gloves
Cuscos speculum
Sterile/ disposable syringe and needle
0.5% chlorine solution and container
2. Greet the woman and her support person respectfully and with
kindness and introduce yourself.
3. Tell the woman and her support person what is going to be
done and encourage them to ask questions.
4. *Listen to what the woman and her support person have to say.
5. *Wash hands thoroughly with soap and water, dry with a clean,
dry cloth or air dry.

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
RAPID ASSESSMENT
1. *Make a rapid evaluation of the general condition of the
woman (pulse, blood pressure, respiration).
2. *If shock is suspected, begin treatment immediately.
TAKE A TARGETED HISTORY
1. Ask about any problems the woman may be experiencing
2. *Ask the woman if she has any records of delivery and
postpartum period, review them or ask the woman:
Date and place of delivery
When did the membranes rupture before delivery
Was the delivery normal or assisted by any procedure
Was there any problem during delivery of the placenta
Did you have excessive blood loss after delivery
Did you have fever during labour or after delivery
Was any local treatment given to you (herbs placed into the
vagina)
Since when have you had the present problem
3. *Ask about breast symptoms:
Do you feel engorgement or swelling in her breasts
Is there any throbbing pain in the breasts
Do you breast feed the baby frequently and regularly
4. *Ask about lochia:
How many pads do you soak in a day
What is the colour of the lochia
Is there any foul smell in the lochia

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
5. *Ask about respiratory symptoms:

Do you have pain in the chest, Cough (dry or productive),
Breathlessness or blood in sputum
6. *Ask about lower limbs:
Do you have pain and discomfort in the calf or thigh
Do you feel swelling in the lower limb
7. *Ask about urinary symptoms:
Do you have pain during urination
How frequently do you pass urine
Is there any pain in the loin or lower back
8. *Ask about an episiotomy or surgical wound, if applicable:
Do you have any discharge from the wound
Do you have any pain or discomfort in the perineum or
vagina
9. *Ask about symptoms of malaria (fever, headache, vomiting)
PERFORM A TARGETED PHYSICAL EXAMINATION
1. *Check vital signs
General appearance (energy level, hair, skin)
Temperature for fever
Respiratory rate
2. *Check for signs of anemia:
Conjunctiva, nailbeds, palms, tongue and gums
3. *Check breasts for pain, lump, fluctuant swelling, redness
4
Observe breastfeeding
*Check for thrombophlebitis:
Varicosities, calf pain and heat, edema

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
6.
*Check abdomen for distention, pain, lump
7.
*Check uterine involution and lochia:

Palpate abdomen for uterine size
Observe perineal pad and assess color, odor and amount of
lochia
8.
*Wash hands and put on gloves
9.
*Check genital health:

Look at the skin for ulcers or sores
Feel inguinal area for enlarged lymph glands or ulcers
Inspect vulva for episiotomies or lacerations; look for
discharge, pus, sores or ulcers
Perform speculum examination, if the woman complains of
lower abdominal pain or has foul smell to the discharge:
Inspect cervix for lacerations, discharge, and bleeding
Inspect vaginal mucosa for episiotomy and lacerations,
discharge noting odor, color and consistency
Perform a bimanual examination:
Feel cervix for pain on moving it
Palpate the uterus for position, enlargement, consistency and
pain
Palpate the ovaries for pain
10. *Check the placenta for completeness if she has just given
birth.
11. *Immerse gloves into a 0.5% chlorine solution and remove by
turning them inside out.
IDENTIFY PROBLEMS/NEEDS AND MANAGE
1. *Analyse the information gathered during the history and physical
examination, and make a diagnosis.

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
2. * If the woman has puerperal pyrexia, refer her to the MO at

the PHC
3
*Tell the family to put the complication plan into action :

agree that the woman needs to be referred,
get a means to transport the woman to the health facility,
get access to funds,
find the person who will accompany the woman and stay
behind with the family.
4. *If the general condition of the woman is fair, give first dose of
Capsule Ampicillin 1 gm orally,
tablet Metronidazole 400 mg orally and
injection Gentamicin 80 mg IM immediately, before referral.
5. *Clothe her appropriately to ensure that the fever can be reduced if
possible, continue to fan and sponge her during transport.
6. *Provide supportive care :
explain everything that is being done, include the woman and
appropriate family members in all decisions,
never leave the woman alone,
make sure the woman urinates frequently,
give the woman plenty of fluids to drink.
7. * If the general condition is poor that is there is temperature > 380C,
and any of the following:
Weakness
Profuse or foul smelling lochia
Severe abdominal pain
History of heavy vaginal bleeding
Burning during micturition with or without flank pain; then
Start IV fluids Ringer lactate or normal saline 30 drops

per minute
Give first dose of antibiotics and above
Refer to MO at the PHC.

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
8. *Remember to give the referral slip with the woman's record,

including all the actions you have taken so far, so that the doctor
will have as much information as possible about the woman.
9.
Help the woman and family understand what is happening so that

they will not be too afraid and nervous.
10. *Closely monitor the womans condition if you are accompanying

her to the referral facility.
Score %

CHECKLIST 2
CHECKLIST FOR ANTENATAL HISTORY,
PHYSICAL EXAMINATION AND BASIC CARE
1
2. Competently Performed: Step or task efficiently and precisely performed in proper

sequence
All activities marked with an asterisk (*) are critical to be done according to
standards to pass the assessment.

STEP/TASK
OBSERVATIONS
NAMES OF CLIENTS/TRAINEE OR DATES OF

PRACTICE/ASSESSMENT
GETTING READY
1. Prepare the necessary equipment.
2. Greet the woman respectfully and with kindness and introduce yourself.
3. Offer the woman a seat.
4. Tell the woman what is going to be done and encourage her to ask
questions.
5. * Listen to what the woman has to say.
HISTORY (ASK/LISTEN)

STEP/TASK
OBSERVATIONS
1. *Ask the woman how she is feeling and respond immediately to any
urgent problems. (Ask the woman about following danger signs(
Fever
Bleeding or watery discharge from vagina
Severe headache/blurring of vision
Difficulty in breathing, palpitations, easy fatiguability
Severe pain abdomen
Passing smaller amounts of urine
No fetal movement
Unusual swelling of legs, hands and face
Ask for symptoms indicating discomfort
Nausea
Heartburn
Constipation
Increased frequency of urine
2. Ask the woman her name, age, number of previous pregnancies, number
of children, menstrual history and contraceptive history and age of last
baby or duration from the last abortion.
3. *Calculate the EDD.
Ask the woman first day of her last menstrual period (LMP).
Add 9 months and 7 days to the LMP.

STEP/TASK
OBSERVATIONS
4. *Ask the woman about past pregnancy problems.
Any abortion (spontaneous or induced)?
Any Dilatation and Curettage performed following abortion?
Any complication during antenatal period (like pre-eclampsia,

haemorrhage, abnormal presentation-breech, transverse lie,
twins etc.)?
Assisted delivery (like forceps, caesarean section)?
Any complication during intra-natal period (prolonged labour,

obstructed labour, retained placenta)?
Any problem after delivery (like hemorrhage, retained

placenta, fever, breastfeeding problem etc.)?
Condition of the baby after birth (live or still birth)?
What was the gestational age of the baby at birth?
Any surgery on the reproductive tract uterine surgery,

perforation during MTP)?
Did she receive any costly injection within 72 hours of her

previous delivery?
5. *Ask the woman about any systemic illness:

High BP
Diabetes
Breathlessness on exertion, palpitation (Heart diseasse)
Chronic cough, blood in the sputum, prolonged fever
(tuberculosis)
Renal disease
Convulsions (Epilepsy)
Atacks of breathlessness or dama (asthma)
Rashes
Jaundice
6. Ask the woman about her Family History:
High BP
Diabetes
Tuberculosis
Thalessaemia (anybody in the family has received blood
transfusions repeatedly)
Delivery of twins or delivery of an infant with congenital
abnormalities
History of consanguineous marriages

STEP/TASK
OBSERVATIONS
7 *Ask the woman about medications, any allergies to drugs, any drugs or
treatment for infertility.
8. *Ask the woman about alcohol use, tobacco chewing and smoking.
7. *Ask the woman about HIV status
8. *Ask the woman about tetanus immunization.
9. Ask the woman about social support.
10. Ask the woman about other problems or concerns related to her
pregnancy. Specifically fetal movements and kick counts
11. Record all pertinent information on the womans record/antenatal card.
PHYSICAL EXAMINATION (LOOK/FEEL)
1. *Ask the woman if she needs to empty her bladder. Save and test
urine, if necessary. It is important that physical examination during
pregnancy should be done with empty bladder.
2. *Observe the womans general appearance.
3. *Explain each step of the physical examination to the woman and
check: (Refer to the Checklist 3 for Physical Assessment and Vital
Signs for details)
Gait
Any obvious deformity/abnormality (like paralysis, difficulty in
breathing)
Weight
Anemia
Pallor in conjunctiva
Pallor on palm/gums/tongue/nails
Oedema (in legs, hands, face and abdomen)
4. *Help the woman on to the examination table and place a pillow under
her head and upper shoulders.
5.
*Take the womans blood pressure (BP) and respiration rate. Refer to
the figures and in the Handbook to take BP and Checklist for Physical
Assessment and Vital signs.

STEP/TASK
6.
OBSERVATIONS
*Examine the breasts. Examine each breast upto the axilla separately
with the pulp of your fingers for any lumps. Look at the skin for any
infection, sores, cracks or flat and inverted nipples.
7. *Examine abdomen and measure the fundal height in centimeters and

note it in the ante natal card. Refer to the guidelines Annexure A III.
8. *Determine lie and presentation (second and third trimesters). Refer
to guidelines Annexure IV
Fundal grip
Lateral grip
Superficial pelvic grip
Deep pelvic grip
9. *Listen to the fetal heart (second and third trimesters) with a
foetoscope. Refer to Guidelines Annexure V.
10. *Wash hands thoroughly with soap and water and dry them.
11. *Put high-level disinfected gloves on both hands.
12. *Check external genitalia for sores and swelling.
13. *Check the vaginal orifice for bleeding and abnormal discharge.
14 *Immerse both gloved hands in 0.5% chlorine solution:
Remove gloves by turning them inside out.
If disposing of gloves, place in leakproof container or plastic bag.
If reusing surgical gloves, submerge in 0.5% chlorine solution for
10 minutes to decontaminate.
15. *Wash hands thoroughly with soap and water and dry.
16. Record all relevant findings from the physical examination on the
antenatal card.
LABORATORY INVESTIGATIONS
1.
*Put high-level disinfected gloves on both hands.
2.
*Draw blood and do hemoglobin test, collect sample of urine and

estimate sugar and albumin, interpreting results accurately (see
Annexure B I of Guidelines for hemoglobin estimation, see Annexure
B II and B III of Guidelines for estimating albumin and sugar in urine
by uristix).

STEP/TASK
OBSERVATIONS
3.
*Empty and soak the test tubes in a 0.5% chlorine for at least 10
minutes.
4.
*If reusing needle or syringe, fill syringe (with needle attached) with
0.5% chlorine solution and submerge in solution for 10 minutes for
decontamination.
5.
*If disposing of needle and syringe, place in puncture proof container.
6. *Immerse both gloved hands in 0.5% chlorine solution:

If disposing of gloves, place in leakproof container or plastic bag.
If reusing surgical gloves, submerge in 0.5% chlorine solution for
10 minutes to decontaminate.
7.
*Wash hands thoroughly with soap and water and dry.
8.
Record the results on the antenatal card and discuss them with the
woman.
IDENTIFY PROBLEMS/NEEDS
1.
*Identify the womans individual problems/needs, based on the

findings of the antenatal history, physical examination and screening
procedures.
PROVIDE CARE/TAKE ACTION

1.
*Refer the woman to the PHC for blood group test and VDRL test.
2.
*Develop or review individualized birth plan with the woman.
3.
*Give Iron-folic acid (IFA) tablets for iron supplementation:

To prevent Anaemia: All pregnant women need one tablet of IFA
every day orally for 100 days from the second trimester (14-16
weeks) onwards (100 tablets IFA in three months).
In Anaemic Women (Hb <11 g/dl or who have pallor): Give two
IFA tablets per day for 100 days (200 tablets IFA in three monthsTherapeutic dose).
In Severe Anaemia (Hb <7 g/dl or breathlessness and tachycardia):
Start two tablets IFA daily and refer to the MO at PHC for care

STEP/TASK
OBSERVATIONS
4. *Provide tetanus immunization

First dose just after the first trimester or as soon as the woman
registers. DO NOT give TT in the first trimester.
The second dose is to be given one month after the first dose
preferably in the second trimester. (Ensure that the second dose is
given at least one month or earlier from the EDD as it takes at least
3-4 weeks for the vaccine to be effective).

STEP/TASK
OBSERVATIONS
5. *Provide counseling about necessary topics:

If she is taking treatment for Malaria and Tuberculosis, advise her
to continue treatment
In Malaria endemic area follow NAMP guidelines for prophylaxis.
Birth preparedness and complication readiness:
Encourage women for institutional delivery and its benefits
Identification of skilled provider for birth
Disposable delivery kit (clean plastic sheet, soap, clean water,
new razor blade, at least 3 clean pieces of thread, clean pieces
of cotton cloths or gauze)
Other items required during and after delivery (Home-based
ANC card, clean towels/cloth for washing, drying, wrapping
the baby, clean clothes for mother and baby, pads/cloths for
mother
Food and water for the woman and support person
Identify support people for care I n hospital, arrange transport,
accompany her in an emergency
Finances for emergency fund, transport
Early identification of signs of labour
o Identification of danger signs-go to an FRU if she has:
Any bleeding P/V during pregnancy
Heavy (>500 ml) vaginal bleeding during and
following delivery
Severe headache with blurred vision
Convulsions and loss of consciousness
Labour lasting for more than 12 hours
Failure of placenta to deliver within 30 mins of
delivery
Preterm labour (labour starting before 8 gestational
months)
Premature or pre labour rupture of membranes
Continuous severe abdomianal pain
All cases giving history of medical illness
associated with pregnancy (diabetes, Heart disease,
asthma)
o Identifications of danger signs to go to a 24 hour PHC:
High fever with or without abdominal pain, feels
too weak to get out of bed
Fast or difficult breathing
Decreased or absent foetal movements
Excessive vomiting when she is not able to
anything orally and decreased urinary output
Locaion of nearest PHC/FRU
Identification of transportation facilities
Preparedness for blood donation (at least 2-3 donors ready)

STEP/TASK
OBSERVATIONS
6. Counsel the woman regarding diet and rest (refer to guidelines Module
1 for details).
7.
Counsel the woman regarding infant and young child feeding:

Importance of initiating breast feeding including colostrums within
half an hour of normal delivery or within 2 hours after Caesarean
delivery or as soon as mother gains consciousness)
Methods and benefits of exclusive breast feeding
Demand feeding
Benefits of rooming in
Complementary feeding at 6 months
8.
Counsel her regarding sex during pregnancy, process of labor and use
of a contraceptive method after delivery.
9.
Record the relevant details of care on the antenatal card.
10.
11.
Ask the woman if she has any further questions or concerns.

Thank the woman for coming and tell her when she should come for
her next antenatal visit.
Score %

CHECKLIST 3
CHECKLIST FOR PHYSICAL ASSESSMENT AND VITAL SIGNS
1
or is omitted

sequence

STEP/TASK
OBSERVATIONS

PRACTICE/ASSESSMENT
PREPARATION
1. *Make sure equipment and examination room are prepared and
clean.
2. *Greet the client, introduce yourself, make client comfortable.
3. Assist the client into the position needed for the exam.
MEASURING THE TEMPERATURE
1. *Wash your hands.
2. *Shake the thermometer until it reads below 35 o
3. *Place the thermometer under the patients tongue or in the armpit
under the arm.
4. *Leave the thermometer in place under the tongue for 3 full
minutes or in the armpit for full 5 minutes.

STEP/TASK
OBSERVATIONS
5. *Take out the thermometer and read the temperature.

6. *Wash the thermometer in warm water and soap or disinfectant;
dry and store.
7. *Record the temperature.
MEASURING THE PULSE AND BREATHING
1. *Position yourself so that your watch or clock is viewed easily.
2. *Turn the clients hand so that the palm is facing towards the body.
3. *Place your index and middle fingers on the thumb side of the
wrist and press down until you feel the pulse.
4. *Count the number of beats for a full minute; note whether the
rhythm is regular or not.
5. *Remove your fingers from the wrist after checking the pulse.
6. *Observe the upward movement of the chest and measure the
breathing for one full minute.
7. *Record the pulse and respiration rate.
MEASURING THE BLOOD PRESSURE
1. *Position the client sitting down or lying on one side with the arm
supported at the level of the chest. If the woman has come walking,
let her rest for 5-10 minutes before measuring her BP. The woman
should be tilted to her left side using a cusion placed behind her
back.
2. *Place the sphygmomanometer (BP Instrument) on a flat surface,
level with the womans heart. Ensure that the pointer on the dial or
scale is at zero. If not adjust it by rotating the knob attached to the
dial. The dial/manometer is placed at the same level as your eye.
3. *Remove all clothing from the upper arm. Wrap the inflatable cuff
around the upper arm and secure it, with the balloon/bladder of the
cuff directly over the brachial artery. The lower border of the cuff
should not be more than 2.5 cms from the cubital fossa (inner part
of elbow).
PALPATORY METHOD

STEP/TASK
OBSERVATIONS
3. *Feel for the brachial pulse over the cubital fossa just medial to the
biceps tendon. Or alternatively feel for the pulse at the wrist of the
arm to which the cuff is tied with your left hand.
4. *With the other hand, tighten and close the screw of the rubber
bulb and repeatedly squeeze the bulb with your right hand to
inflate the cuff until the pulse is not felt.
5. *Note the manometer reading. Increase the pressure by and 10 mm
Hg further.
6. *Deflate the cuff gradually till you feel the pulse again.
7. *Note the reading on the manometer. This is the systolic BP.
8. *Deflate the cuff by loosening the screw of the rubber bulb and
remove the cuff from the womans arm or you can proceed for the
auscultatory method to measure the BP.
AUSCULTATORY METHOD
9. *Follow steps 1-8 and note down the womans systolic BP. Raise
the pressure of the cuff to 30 mm Hg above the level at which the
brachial/radial pulse was no longer felt.
10. *Put the stethoscope in your ears with ear pieces facing forwards;
place the flat part (diaphragm) of the stethoscope over the brachial
pulse and hold it in place. You should not be able to hear any
sound.
11. *Slowly release the valve to lower the pressure in the cuff, 2mm
Hg at a time and listen for the pulse sounds.
12. *Remember the numbers on the instrument where you hear the
first thumping sound (the systolic pressure) and then when the
sound dissappears (the diastolic pressure).
13. *Release the valve and quickly allow all the air to go out of the
cuff; remove the cuff.
14. *Record the blood pressure as systolic/diastolic reading
mmHG.
MEASURING WEIGHT
1. *Balance the scale. Adjust the pointer to zero by moving the screw
on the front of the scale
2. *Have the client remove shoes and heavy clothing, place a

paper on the scale platform.

STEP/TASK
OBSERVATIONS
3. *Assist the client onto the scale.

4. *Read the display with the client standing as still as possible.
5. *If using a balance scale:
Slide the lower balance to the groove representing the largest

increment below the clients weight.
Slide the upper balance until the beam balances
Add the upper and lower figures to determine the weight
GENERAL PHYSICAL ASSESSMENT

1. *During the interview or while measuring vital signs:
observe the clients appearance, and color.

observe the clients behaviour and speech.
listen to the clients breathing.
2. *During the measuring of weight:
observe the clients ability to move around or walk.
3. *Tell the client you are going to look at and touch parts of her body
and gain permission to proceed.
4. *Look at the skin color of face, hands, palms.
5. *Feel the skin to note temperature, moisture, and turgor.
6. *Look at exposed skin for any lesions.
7. *Look at the eyes,
ask the woman to look up
gently pull down the lower eyelid to look at the color of the
conjunctiva. (It should be pink or red. If it is pale pink or
white, the woman has pallor.
8. *Ask the client to open her/his mouth, look at the gums, tongue and
mucus membrane. If it is white and smooth, the woman has pallor.
Also look for yellowness in eyes to rule out jaundice.

STEP/TASK
OBSERVATIONS
9. *Examine the nails. If they look white, the woman has pallor. If
the nails are thin, brittle or concave (spoon shaped), the woman has
severe and long standing iron deficiency anaemia.
10. *Look at the clients legs for:
swelling/edema
swollen veins
11. *Wash your hands.

12. *Tell the client your findings, discuss the findings.
13. *Record all findings.
Score %
CHECKLIST 4
CHECKLIST FOR ASSESSMENT IN LABOR
1
or is omitted

sequence
All activities marked with an asterix (*) are critical to be done according to standards to

(HISTORY)
PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
GETTING READY
1. * Prepare the necessary equipment.
Examination bed
Chair
Equipment for conducting a normal delivery
Clients records and partograph
2. Greet the woman and her family members respectfully and
with kindness and introduce yourself.
Help the woman to feel at ease and reduce stress and
build an atmosphere of trust and mutual respect.

(HISTORY)
PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
3. Give the woman a seat or a bed to lie on, depending on her

condition, and tell those accompanying her where they can wait.
Ask the woman if she would like someone to accompany
her.
Welcome the womans support person.
4. Help the woman onto the examination table and make her
comfortable.
5. Tell the woman and her support person what is going to be done
and encourage them to ask questions.
Explain to her that you need to ask her some questions
about her labour to evaluate her condition and the
condition of her baby.
6. Listen to what the woman and her support person have to say.
7. *Make an immediate assessment of whether delivery is imminent
(pushing, grunting, bulging thin perineum, or vagina gaping and
head visible):
If so, prepare for birth.
If not, continue as follows.
TAKE A TARGETED HISTORY
1. *Start the labor record by writing the womans name and time of
arrival. Keep noting her answers on the record. Ask the woman
how she is feeling and whether she has any problems. Respond
immediately to life-threatening complaints of:
Vaginal bleeding
Fever
Severe headache or blurred vision
Difficulty breathing
Severe abdominal pain

(HISTORY)
PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
2. Ask the woman for the following information and record her
responses:
When labour pains started
*Whether she has noticed a trickle or gush of fluid (if so,
when, how much and colour)
Frequency of labor pains
Strength of labor pains
Presence of vaginal bleeding or bloody mucus (show)
*Presence of foetal movement and whether it is normal or
changed
When was the last time she passed urine and stools
When did she last eat
*If she took any medicine or treatment to speed up or slow
down labour and whether they worked
If she was being cared for by a traditional birth attendant prior
to coming in to the facility. (If possible, meet and welcome
the TBA and get any additional history from her in a
domiciliary setting)
3. Check the womans antenatal record for the following information.
If she has had no antenatal checks or records are not available,
ask for the following information and record responses:
How old is she
How many months pregnant is she
Is this her first pregnancy? If not, number of previous
pregnancies/deliveries
*Previous cesarean births, forceps deliveries or vacuum
extractions
Other problems with previous pregnancies/deliveries
Any problems during this pregnancy
*TT vaccinations during pregnancy
Investigations carried out and results, including treatment
Any noted recommendations for delivery
General medical problems such as high blood pressure,
asthma, diabetes, heart disease, tuberculosis
Medications being taken (if yes, then what, why and prescribed
by who)
HIV status (if known)

(HISTORY)
PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
4. *Calculate the expected date of delivery and gestational age.
CHECKLIST FOR GENERAL EXAMINATION IN LABOR

STEP/TASK
OBSERVATIONS
PERFORM A TARGETED PHYSICAL EXAMINATION

Clients records
Blood pressure instrument
Stethoscope
Thermometer
Bottle with 0.5% chlorine solution for
thermometer
Watch with seconds hand
2. Wash hands thoroughly with soap and water and air dry them.
3. Explain each step of the physical examination to the woman and
the reasons for it. The woman should be made comfortable.
GENERAL EXAMINATION
1.*Take the womans blood pressure, pulse and temperature.
Check her height and general appearance (whether she
is looking ill, exhausted or malnourished)
Record your findings.
CHECKLIST FOR GENERAL EXAMINATION IN LABOR

STEP/TASK
OBSERVATIONS
2. Check the womans conjunctiva, tongue and palms for pallor and
hydration.
3. Observe the womans emotional response:
Fear
Anxiety
4. Count the respiratory rate and note the kind of breathing
(normal,shallow, deep,gasping) between and during contractions
5. Count the heart rate
6. *Look for enlarged neck veins and shortness of breath which may
mean serious sickness
7. Look and feel the breasts for problems that might interfere with
breast feeding
8.* Look and feel the arms and legs for swelling
9. *Look for deformities of legs, back and pelvis that may make
vaginal delivery difficult or impossible
CHECKLIST FOR ABDOMINAL EXAMINATION IN LABOR

STEP/TASK
OBSERVATIONS
GETTING READY
1. *Prepare the necessary things
Examination bed
Foetoscope
Clients records
Pillow

STEP/TASK
OBSERVATIONS
ABDOMINAL EXAMINATION
1. Ask the woman if she needs to empty her bladder. (Save urine for
testing, if necessary.)
2. Help the woman on to the examination table and place a pillow
under her head and upper shoulders. Help her relax with some
deep breathing.
3. Wash hands thoroughly with soap and water and dry with clean,
4. Explain each step of the abdominal examination as you proceed
and encourage the woman to ask questions.
5. Ask the woman to place her arms by her sides or across her chest
and bend her knees slightly.
6. *Observe shape and size of the abdomen and presence of scars.
Look for the way the baby is lying and its movements,
contractions, unusual shapes or bumps.
Estimating Fundal Height
1. Make sure your hands are warm and dry and place the ulnar
border of one hand just below the xiphisternum.
2. *Press gently and move hand down the abdomen until the curved
upper border of the fundus is felt. Use landmarks of the umbilicus
and sternum to help confirm fundal height.
Determining Lie and Presentation
1. Face the womans head. Stand on the right side

STEP/TASK
OBSERVATIONS
2. *Place your hands on the sides of the fundus and curve fingers
around top of fundus.
Feel for contraction.
Hold hands in the same position for the entire contraction
of the uterus
Feel the strength of the contraction.
Time the duration of the contraction.
3. *Between contractions, palpate shape, size, consistency and
mobility:
The foetal breech will feel irregular, larger or bulkier than
a head; the breech cannot be well outlined or readily
moved or balloted.
The foetal head feels round and hard and can be balloted
between your hands or between the thumb and a finger of
one hand.
If there is a transverse lie, the fundus (supra pubic region)

will feel empty.
4. *Now place one hand on either side of the uterus about halfway
between the symphysis pubis and the fundus:
The foetal back will feel like a firm, curved, continuously
smooth mass extending from the breech to the neck. If
you cannot feel the back on either side, then the back is
towards the back of the woman, a posterior position. In a
transverse lie the babys body is felt across the abdomen.
5. *Apply pressure to one side of the uterus, pushing the fetus to the
other side of the abdomen against your other hand (your
examining hand).
6. *Maintain this pressure while your examining hand palpates the
other side of the uterus, from the abdominal midline to the lateral
side and from the symphysis pubis to the fundus:
The foetal hands, feet, knees and elbows will feel small,
knobby and irregular and will move when pressed on.
7. Reverse the procedure to examine the other side of the uterus,
using the other hand as the examining hand and pressing with the
hand used for examination on the other side.
8. *Now use the thumb and four fingers to grasp the portion of the
lower abdomen immediately above the symphysis pubis.

STEP/TASK
OBSERVATIONS
9. *Press gently but firmly into the abdomen to feel the presenting
part below and between your thumb and four fingers.
10. *Palpate for shape, size, consistency and mobility to determine the
head or the breech:
If the presenting part is the head, try to move it from side
to side. If the head cannot be moved it is engaged.
If neither the head nor the buttocks are felt, the baby is
lying sideways, a transverse presentation. This is
abnormal and you need to refer the woman to an
FRU/CHC for expert care.
11. Now turn and face the woman's feet.

12. Make sure that the woman still has her knees bent.
13. *Place one hand on either side of the uterus with the palms just
below the level of the umbilicus and fingers directed toward the
symphysis pubis.
14. *Press deeply with fingertips into the lower abdomen and move
them toward the pelvic inlet:
A vertex presentation is indicated if one hand feels the
sinciput (hard round mass) on the same side of the
abdomen that the foetal small parts were felt, while at the
same time the other hand continues down toward the
pelvis.
A breech presentation is indicated if both hands continue
to move toward the pelvic inlet and experience a feeling
of "give" along with the trunk of the fetus.
In transverse lie, no pole is felt
Feel to assess if there is more than one baby
Assessing Descent of the Foetal Head

STEP/TASK
OBSERVATIONS
1. Feel the presenting part with your right hand. Place the fingers of
the other hand horizontally above the symphysis pubis and see how
much of the head can be felt above it:
5 finger breadths = 5/5 (five-fifths) above the brim
4 finger breadths = 4/5 (four-fifths) above the brim
3 finger breadths = 3/5 (three-fifths) above the brim
2 finger breadths = 2/5 (two-fifths) above the brim (the
head is generally accepted to be engaged when the portion
above the pelvic brim is represented by two fingers)
2. Verify findings on vaginal exam.

Checking uterine contractions
1. Ask the woman to lie on her left side.
2. *Place your hand on the womans abdomen to feel the
contractions.
3. *Palpate the number of contractions in a 10-minute period, time
their duration in seconds and assess the strength.
4. *Record your findings.
Asking about Foetal Movement
1. Ask if the baby is moving regularly and observe for foetal
movement during the examination.
* Listening to the Foetal Heart
1. *Place the foetoscope on the woman's abdomen at right angles to
it immediately following a contraction.
2. *Place the ear in close, firm contact with the foetoscope.
3. *Move the foetoscope around to where the foetal heart is heard
most clearly.
4. *For vertex and breech presentations listen through the back of the
fetus.

STEP/TASK
OBSERVATIONS
5. *Count the heart rate for one full minute (while listening to the
foetal heart, the hand should not touch the foetoscope). If the fetal
heart rate is below 120 or above 160 beats per minute, the fetus
may be having problems. Refer such a case to the
PHC/CHC/FRU as soon as possible for expert care.
POST EXAMINATION TASKS
1. Inform the woman of your findings.
2. Record all findings from the abdominal examination.
CHECKLIST FOR VAGINAL EXAMINATION IN LABOR

STEP/TASK
OBSERVATIONS
GETTING READY
Sterile/HLD surgical gloves
Plastic/Rubber apron
Swab and antiseptic solution
0.5% chlorine solution for decontamination
3. *Listen to what the woman and her support person have to say.
VAGINAL EXAMINATION
Examining the Vulva
1. *Put on a clean plastic or rubber apron.
2. *Wash hands thoroughly with soap and water and dry with clean,
dry cloth (or air dry).
3. *Put new/sterile/HLD examination gloves on both hands.
10

STEP/TASK
OBSERVATIONS
4. *Ask the woman to flex her knees and separate her legs. Ensure
that the bladder is empty and the woman does not have a desire to
pass urine.
5. *Observe the vulva for the presence of:
Blood-DO NOT do a vaginal examination if there is
bleeding anytime after 5 months (20 weeks) of pregnancy.
Refer her to CHC/FRU
Mucus
Amniotic fluid (if so, colour and smell) If greenish or
yellowish fluid, it indicates foetal distress, refer her to
PHC/CHC/FRU
Other discharge
Warts or keloid tissue that may interfere with delivery
6. *Cleanse the vulva from above downwards with one gloved hand
(not the examining hand), using a swab dipped in an antiseptic
solution.
Examining the Vagina

1. Use the thumb and forefinger of the non-examining hand to part
the labia majora so that the vaginal opening is clearly visualized.
2. *Gently insert the index and middle fingers of the examining hand
downwards and backwards into the vagina. Once your fingers are
inserted do not take them out till the examination is complete.
3. *Direct the fingers along the anterior wall of the vagina and note:
Vaginal temperature and moisture (should be warm and
moist)
Vaginal texture (should be soft and distensible)
Feel for hard scarring and stool in the rectum
Examining the Cervix

1. Keep the other hand (abdominal hand) on the clients abdomen in
the suprapubic region. When the examining fingers reach the end
of vagina, turn the pads of the fingers upwards to come in contact
with the cervix. You will be able to feel and examine the cervix.
11

STEP/TASK
OBSERVATIONS
2. Palpate around the fornices and sense the proximity of the

presenting part of the fetus to the examining fingers.
3. Gently sweep the fingers from side to side to locate the cervical
os: This will be felt as an opening in the cervix.
The os is normally situated centrally but sometimes in
early labour it will be very posterior (backwards).
4. Note the length of the cervix:
A long, tightly closed cervix indicates that labour has not
yet started.
Check for degree of effacement of the cervix (refer to the

figures in the Handbook).
5. Feel the consistency of the cervix:

It should be soft and elastic and applied closely to the
presenting part.
Note any hard scarring on the cervix which may affect

cervical dilatation.
6. * Measure dilatation of the cervical os by estimating the distance

in centimetres between the two examining fingers: practice
estimating cervical dilatation with cut-out rings during your free
time).
0 cm equates to a closed external cervical os
10 cm equates to a full dilatation
7. *Feel the application of the cervix to the presenting part:
When the presenting part is not well applied to the cervix,
dilatation may not occur as efficiently as if the presenting
part is well applied.
When the presenting part is not well applied to the cervix,
it may mean that there is cephalopelvic disproportion.
8. *Feel the membranes and forewaters:
Intact membranes can be felt through the dilating os.
If the membranes have ruptured, ensure that the colour of
the amniotic fluid is clear and cord has not prolapsed.
12

STEP/TASK
OBSERVATIONS
9. *Identify the presentation:

In vertex presentations (96% of cases), the hard bones of
the vault of the skull will be felt. Feel for caput and
moulding and how far the head has progressed in the
cervix
A breech presentation means the buttocks or legs are at

the cervix
A transverse presentation will present as an arm or

shoulder at the cervix
10. *Assess pelvis: (refer to Figures and instructions for pelvic

assessment in the Handbook)
Try to feel the sacral promontory if head is not engaged.

If felt, pelvis is contracted. Refer this woman to the
CHC/FRU for expert care
Trace down and feel for sacral hollow
Spread your two fingers to feel for ischial spines. If both

ischial spines can be felt, cavity is contracted. Refer her
to a PHC/CHC/FRU for further care
11 Immerse both gloved hands in 0.5% chlorine solution

12 *Remove gloves by turning them inside out.
If disposing off gloves, place in a leak-proof container or
plastic bag.
If reusing surgical gloves, submerge in 0.5% chlorine solution
for 10 minutes to decontaminate. Then wear utility gloves,
turn the surgical gloves inside out and wash them well with
soap and water and dry them.
13 *Wash hands thoroughly with soap and water and dry with clean,
dry cloth (or air dry).
14 Inform the woman of findings and provide reassurance.
15 Record all findings from the vaginal examination.
If the woman is in active labour (cervical dilatation 4 cms or more
and the uterine contractions are at least 2/10 mins of 20-40 secs
duration) start noting your findings on the partograph. If she is
not in active labour, note your findings in the clients record file.
13

STEP/TASK
OBSERVATIONS
16. Monitor labour and record your findings on the partograph

Score %

14
CHECKLIST 5
CHECKLIST FOR ASSISTING A BIRTH
(To be used by the Trainees during practice and by the Trainers for skill assessment of trainees)
1
or is omitted
Competently Performed: task efficiently and precisely performed in proper sequence

CHECKLIST FOR ASSISTING A BIRTH: BIRTH OF A BABY

STEP/TASK
OBSERVATIONS

PRACTICE/ASSESSMENT
GETTING READY
Plastic apron
Sterile/HLD surgical gloves
Two artery forceps 6
Plain scissors 6
New blade
Cord ligatures
Swabs/ Gauze pieces
Antiseptic solution
Disposable delivery kit
Stethoscope
Baby tray 24x12
Pads
Delivery kit
Clean dry towel for baby
Mucus extractor
Clean warm cloth for the baby Light source
Kidney basin
I/V stand
Sterile disposable/reusable syringe and needle
Tab. Misoprostol 200 mcg. (6 tablets)
IV set, Normal saline/Ringer lactaqte 1 bottle
Watch/clock
* Note: Keep sterile and HLD items seperate

STEP/TASK
OBSERVATIONS
2. Allow the woman to adopt the position of choice

Semi-sitting
Squatting
Lying on her back with legs raised
4. Listen to what the woman and her support person have to say and
support the presence of the womans birthing companion
5. Provide emotional support and reassurance.
CONDUCTING THE DELIVERY
1. *Put on a clean plastic apron.
2. *Wash hands thoroughly with soap and water and dry with a
clean, dry cloth (or air dry).
3. *Put high-level disinfected surgical gloves on both hands.
4. *Place one clean plastic sheet from the delivery kit under the
womans buttocks
Delivery of the Head
1. *Use one hand to cover the perineum with a warm, moist pad for
support to facilitate flexion and prevent perineal tears.
2. Place fingers of the other hand on the advancing head as the head
is crowning.
3. *Maintain light downward pressure on the head to encourage
flexion.
4. *After crowning (the head does not go up in the vagina after a
contraction), allow the head to gradually extend under your hand.

STEP/TASK
OBSERVATIONS
6. *Gently feel around the babys neck for the cord:

If found, slacken the cord to form a loop through which
the shoulders can pass.
If the cord is tightly wound around the neck, clamp the
cord with two artery forceps, placed 3 cm apart, and cut
the cord between the two clamps.
7. Allow restitution and external rotation of the head to occur.
8. *Clean the mouth and nose with sterile/HLD swabs/gauze pieces.
Delivery of the Shoulders
1. Place one hand on either side of the baby's head, over the ears and
ask the woman to push gently.
2. *Apply gentle downward traction to allow the anterior shoulder
to slip beneath the symphysis pubis.
3. *When the axillary crease is seen, guide the head and trunk in an
upward curve to allow the posterior shoulder to escape over the
perineum.
4. Grasp the baby around the chest to aid the birth of the trunk and
lift the baby toward the woman's abdomen.
5. Note the time of delivery.
Immediate Care of the Baby
1. *Dry the baby quickly and thoroughly with a clean, dry
towel/cloth immediately after birth.
2. *Wipe the babys eyes from inner to outer side with two separate
clean pieces of cloth/gauze piece.
3. *Observe the babys breathing while completing steps 1 and 2:
If the baby is not breathing, clear the airway with the mucous
extractor. If still the baby does not breathe begin resuscitation
measures with bag and mask (as in the Revised Guidelines
Module 1 Essential Newborn Care section).
If the baby is breathing normally, continue with the following
care.

STEP/TASK
OBSERVATIONS
4. *Clamping and Cutting the Cord

*Put the sterile ties tightly on the cord 2 cms. and 5 cms. from
the babys abdomen.
*Cut the cord after 2-3 minutes of the birth, using a new blade.
*Cut off the excess cord. Do not apply anything on the cut
surface or the stump.
*Palpate the womans abdomen to exclude second baby.
5. *Leave the baby in skin to skin contact on the mothers abdomen
or chest, covered by a clean, dry towel/cloth
5.
*Note the Apgar Score of the baby. Refer to Guidelines Module

1 Table 2.
6. *Proceed for separation of the placenta (Active management) refer

checklist below
7. *Weigh the baby
8. *Clean the perineum.
CHECKLIST FOR ASSISTING A BIRTH: ACTIVE MANAGEMENT OF THE THIRD

STAGE OF LABOUR
STEP/TASK
OBSERVATIONS
WATCH FOR SIGNS THAT THE PLACENTA HAS SEPARATED

1
Ask the woman what position she would like to be in.
2. *Palpate the abdomen to rule out a second baby.

3. *Give Tablet Misoprostol 3 tablets sublingually or orally
immediately after delivery
4.
*Perform controlled cord traction and countertraction (refer to

guidelines Annexure C IV.

STAGE OF LABOUR
STEP/TASK
5.
OBSERVATIONS
*Place one hand on the symphysis pubis and verify that the
placenta has separated by pushing the uterus up from below :
- find the lower part of the uterus
- put your hand just above the symphysis pubis, and push the
uterus up from below
- look to see if the cord moves up with the uterus
- if the cord does not move up, the placenta is probably
separated
- if the cord moves up with the uterus, the placenta is probably
still attached, wait and try again later
6. *If the cord does not move up when pushing the uterus up, the
placenta is probably separated - deliver the placenta
DELIVERY OF THE PLACENTA
1. Assure the woman that delivering the placenta will not hurt,
because it is much smaller and softer than the baby. She should
also feel more comfortable once the placenta is out.
2. *Make sure you have sterile or HLD gloves on. If you have
removed your gloves, then wash your hands with soap and water,
dry them with a clean, dry towel (or air dry them), and put on
sterile or HLD gloves.
3. *When the placenta is visible at the vaginal opening, cup it in
both hands.
4. *Use a gentle upward and downward movement or twisting
action to deliver the membranes.
5. Place the placenta in the receptacle (e.g., kidney basin) provided.
6. *Gently massage the uterus and make sure that the uterus is well
contracted.
DELAY IN DELIVERY OF THE PLACENTA
1. *If the placenta does not come out in 10 to 15 minutes after
giving tab. Misoprostol and the woman is not bleeding, try and
remove the placenta again by CCT.
2. Encourage the woman urinate. A full bladder can slow the birth
of the placenta. Encourage her to breast feed her baby.

STAGE OF LABOUR
STEP/TASK
OBSERVATIONS
3. If the placenta is still not delivered after 30 minutes and the

woman is not bleeding excessively, ask the woman to lie on her
back. Explain that you will put your hand in her vagina to feel if
the placenta has separated but is sitting in the vagina or cervix.
4. *Wash your hands and put on a new pair of sterile or HLD
gloves.
5. Your non-examining hand should be placed at the uterine
fundus, to support the uterus. Grasp the cord with your
examining hand and gently follow it up until just past the vagina
to find out if the placenta is in the vagina and can be easily
removed.
6. *Deliver the placenta and membranes
- hold the placenta in your examining hand and gently pull it
out of the vagina
- deliver the placenta slowly, holding and supporting it with
both hands
- to deliver the membranes, hold the placenta in both hands,
turn it slowly and gently, until the membranes are twisted.
Then slowly and gently pull the membranes out.
7. Place the placenta in the receptacle (e.g., kidney basin) provided.
8. *Gently massage the uterus and make sure that the uterus is well
contracted.
9. *If the placenta has not separated after 30 minutes of tab.
Misoprostol and CCT, refer to checklist for identification and
management of immediate and delayed postpartum
haemorrhage and manage accordingly.
UTERINE MASSAGE
1. *Immediately after delivery of the placenta, massage the fundus
of the uterus through the womans abdomen until the uterus is
contracted.
2. *Repeat uterine massage every 15 minutes for the first hour.
3. *Ensure that the uterus does not become relaxed (soft) after you
stop uterine massage

STAGE OF LABOUR
STEP/TASK
OBSERVATIONS
4. *Teach the woman how to massage her own uterus, and how to
tell when the uterus is not contracting adequately.
5. Help the woman to breast-feed. The oxytocin produced with
breast-feeding will help keep the uterus contracted. If the woman
cannot breast-feed, encourage manual nipple stimulation.
6. *Check the uterus and vaginal bleeding at least every 15 minutes
for the first hour, massaging as necessary to keep it hard. Make
sure the uterus does not become soft (relaxed) after you stop
rubbing.
7. *Examine the perineum and vagina for tears and lacerations.
CHECKLIST FOR ASSISTING A BIRTH: EXAMINING THE BIRTH CANAL

STEP/TASK
OBSERVATIONS
GETTING READY
3. Provide emotional support and reassurance.
Examining the Birth Canal
1. Ensure good light onto the perineum.
2. * With gloved hands, gently separate the labia and inspect the
vulva and lower vagina for lacerations/tears.
3. *Inspect the perineum and vagina for lacerations/tears. If present
refer to Checklist for identification and management of
immediate and delayed postpartum haemorrhage
4. *Wash the vulva and perineum gently with warm water or an
antiseptic solution and dry with a clean, soft cloth.
CHECKLIST FOR ASSISTING A BIRTH: EXAMINING THE BIRTH CANAL

STEP/TASK
OBSERVATIONS
5. *Place a clean cloth or pad on the woman's perineum.

6. Remove soiled bedding and make the woman comfortable.
7. *Before removing gloves, place soiled linen in 0.5% chlorine
solution for 10 minutes for decontamination.
8. *Place instruments in 0.5% chlorine solution for 10 minutes for
decontamination.
9. *Decontaminate or dispose of syringe and needle:
If reusing needle or syringe, fill syringe (with needle attached)
with 0.5% chlorine solution and submerge in solution for 10
minutes for decontamination.
If disposing of needle and syringe, flush needle and syringe
with 0.5% chlorine solution three times, then place in a
puncture proof container.
If disposing of gloves, place in leak-proof container or plastic
bag.
for 10 minutes to decontaminate.
12. Examine the placenta.
CHECKLIST FOR ASSISTING A BIRTH: EXAMINATION OF PLACENTA

STEP/TASK
OBSERVATIONS
1. *Put clean gloves on both hands.

EXAMINATION OF PLACENTA
1. Hold the placenta on the back of the hand or a fist, with maternal
side facing upwards to exclude any missing cotyledons.
CHECKLIST FOR ASSISTING A BIRTH: EXAMINATION OF PLACENTA

STEP/TASK
OBSERVATIONS
2. *Check whether all of the lobules are present and fit together
See if there is a hole where a piece seems to be missing, it may
still be inside the woman.
3. Keep the placenta in a bowl and insert one hand inside the
membranes, with fingers spread out.
4. *Inspect the membranes for completeness.
5. Turn the placenta around and note the position of insertion of the
cord.
1. *Inspect the cut end of the cord for the presence of two arteries
and one vein.
If only 2 holes are present, the baby should be checked by a
doctor soon.
Refer such babies immediately to a doctor
6. *If the placenta is not complete, refer to Checklist for
identification and management of immediate and delayed
postpartum haemorrhage.
7. *Dispose off the placenta by placing it in 0.5% chlorine solution

in a leakproof container for burial
If disposing off gloves, place in leakproof container or plastic
bag.
for 10 minutes to decontaminate.
10. Record all findings on the woman's record.
Score %

10
CHECKLIST 6
CHECKLIST FOR CARE IN THE IMMEDIATE POSTPARTUM PERIOD
1
or is omitted
Competently Performed: or task efficiently and precisely performed in proper sequence


PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
IMMEDIATE CARE AFTER DELIVERY

1. *Check the bladder, and assist the woman to void urine if full
2. *Remove all soiled clothing and make the woman warm
3. *Monitor vaginal bleeding, uterine fundus, vital signs,
temperature, pulse and blood pressure:
(After delivery of placenta check vaginal bleeding) every

5 minutes until uterus is well-contracted round and hard.
Check all factors in # 3:
Every 10 minutes for the first 30 minutes after delivery
Then every 30 mins for the next three (3) hours
Then at least every 6 - 8 hours (3 - 4 times a day)
4. *Analyse the information gathered and make a decision about care

provision and/or need for referral

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
5. If a decision is made to refer, explain why, where and how to the

woman and any accompanying family members
6. *Keep the mother and the newborn together. Encourage and
facilitate breastfeeding after 1 hour of birth, adequate fluid intake,
good hygiene, frequent voiding of urine and rest.
7. Do complete examination of the baby and provide immediate care
for the newborn
8. Write the delivery notes
VISIT WITHIN FIRST 24 HOURS OF BIRTH
HISTORY AND PHYSICAL EXAMINATION
1. Review labour and birth record
2. *Check:
Vital Signs (temperature, pulse, BP, and respirations)

uterine fundus and contraction
vaginal bleeding
perineum
3. Check conjunctiva, tongue, and palms for pallor

4. *Examine the breasts and observe breast-feeding.
5. Assist the woman to fix the baby on the breast, if necessary.
Identify Problems/Needs
1. *Make a decision to manage and/or refer to higher level of care for
management of complications.
2. If the woman needs to be referred, provide a careful explanation to
the woman and anyone accompanying her

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
3. Explain findings and conclusions from the examination and

discuss management plan (including preventive prescriptions)
Provide Care/Take Action
1. *Give woman-centred counselling on postpartum care:
Rest
Nutrition
Resumption of sexual activity and safer sex
Hygiene
Breast-feeding
2. *Provide counseling about family planning and provide
contraception, if appropriate
3. Provide iron and folic acid tablets.
4. *Examine the newborn for breathing, bleeding from the umbilicus
and breast feeding. Advise the mother to keep the baby warm and
keep the nappy area clean and dry.
5.*Discuss danger signals as written below and help the woman and
her family develop a complication readiness plan for the newborn and
the woman
Bleeding more than a heavy period or passing clots
Soft uterus that wont get hard with massaging
Abdominal pain
Fever
Urinary incontinence
Inability to void
Follow-up
1. Discharge the woman (not before 24 hours postpartum)
2. Schedule a postnatal visit within the first week on day 3 of
delivery.
3. Allow time for woman to ask questions and talk.
4. Record all information obtained.
Score %

CHECKLIST 7
CHECKLIST FOR CARE OF THE MOTHER 3 AND 7 DAYS AFTER DELIVERY
1
or is omitted

sequence
All activities marked with an asterisk (*) are critical to be done according to standards to

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
HISTORY- ASK/LISTEN (to mother and family)

1. Review record if available if you were not present at the time
of delivery. Ask the woman:
Where did the delivery take place and who conducted the
delivery?
Was there heavy bleeding at the time of birth or within 24
hours of birth? (Refer to the Guidelines Module 1 Postpartum
Care section for details of bleeding). Soaking more than one
pad in 5 mins is heavy bleeding.
Did she have any convulsions or loss of consciousness after
the delivery?
2. General condition
a. How are you feeling today?
b. Do you have any problems or concerns?
3. Rest and sleep

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
a. Have you been able to rest and sleep?

b. If not, why?
4. Diet and fluids
a What have you eaten today (or yesterday if this visit is in the
morning)?
b. Are you drinking fluids every time you breast feed?
5. * Fever do you feel chills or very hot?
6. * Bowel and bladder action
a. When was the last time you urinated?
b. Do you feel like you have to urinate often?
c. Do you feel pain or burning when you urinate?
d. When did you pass stool?
e. Are your bowel movements normal?
7. * Uterine discomfort Have you felt any pain in your uterus/lower
abdomen?
8. * Lochia/discharge
a How often do you need to change your pad or cloth?
b. What color is the discharge?
c. Does the discharge smell bad?
9. * Any perineal pain
a. Where is the pain (location)?

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
b. Can you describe the pain ( strong, constant, only happens

when you urinate)?
10. * Breast feeding
a. Is the baby attaching well?
b. Is the baby sucking well?
c. Are your breasts tender?
d. Are your nipples sore?
e. Do your breasts feel very full (engorged)?
11. Feelings about the baby
a. How do you feel about caring for the baby?
b. Do you have any problems or questions about what you need to
do to care for the baby?
c. Are you happy you have your baby, or is your baby a bother?
12. Assess if the woman understands new born care
a. Do you feel comfortable holding and bathing the baby, and
changing its diaper, cleaning the eyes and keeping the baby
warm?
b. Do you put anything on the cord? The cord should be cleaned
with clean water and left dry.
13. Signs of depression Do you feel sad or worried about anything?
14. Taking medication
a. Are you taking iron folic acid tablets?
b. Remind her to take the iron folic acid tablets for 60 days.

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
PHYSICAL EXAMINATION LOOK/FEEL

1. * Wash hands and use gloves
2. Observe mothers relationship with her baby
a Does she appear to enjoy physical contact with her baby?
b. Does she use her full hand when she touches her baby (not just
finger tips)?
c. When feeding or holding her baby, are they turned toward each
other?
d. Does she make eye contact with her baby?
3. * Vital signs (explain to mother the results )
a. Temperature
b. Pulse
c. Blood pressure
4. * Breasts
a. Check for engorgement. The breasts will feel tight and the
woman may complain of pain on touch.
b. Check the nipples for cracks and soreness
c. Watch the baby feed and show the mother how to breast feed?
d Remind the mother the more the baby sucks, the better her milk
supply will be. As the baby sucks every 2-3 hours,
discomfort from engorgement will decrease, and how much
her breasts produce will adjust to the babys needs.
5. * Check the Uterus

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
a. Check whether it is firm or soft. Normally the uterus should be

firm.
b. Check for its position and size. Normally after birth of the
placentait is at the the level of the umbilicus. It should
reduce at the rate of 1 cm per day from the level of the
umbilicus after delivery.
c. Check for any pain in the uterus by putting your hand and
looking at the womans face. If she will have pain in the
uterus, she may wince or say so.
d. Ask the mother if she has felt her uterus since your last visit
and what she did she find? Explain that the uterus will keep
getting smaller during the next 2 weeks until it is almost as
small as before her pregnancy.
6. * Check for Lochia
a. its amount
b. color
c. odor
d. Explain that her discharge should start to change color,
becoming lighter red, then pink, then yellow and white. It
should not have a bad smell. If her discharge remains red, or
if it smells bad, she must inform you. If the discharge
increases, then too she should inform you.
7. * Check the perineal area
a. is it clean
b. is there any swelling
c. is there any discomfort on touching the perineum

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
d. Remind her to wash each time she passes urine or stool with
soap and water (from front to back). She should wash her
hands before and after this. She must change her pad/cloth as
soon as it gets soaked. When possible, she should lie with her
legs a little apart, so air can get to the area to help it heal.
8. * Remove gloves and wash hands
9. Explain findings from the exam to the mother and family
IDENTIFY PROBLEMS/NEEDS
TAKE APPROPRIATE ACTION
1. *Make a plan of care with the mother and family on the problems /
needs identified. Refer if necessary.
a. If she has excessive bleeding, refer to the Checklist 9
Identification and Management of Immediate and Delayed
Postpartum Haemorrhage and manage accordingly.
b. If she has pain during urination or in the lower abdomen with foul
smelling lochia, Refer to the Checklist 11 Management of
Puerperal Sepsis and manage accordingly.
2. Provide counseling (general)
a * Hygiene Remind her to keep her clothing, bedding, genital
area and pd/cloth clean
b. *Importance of rest getting enough rest will prevent
problems with little breast milk, bleeding too much, and
depression. She should sleep at night and also take at least
one nap during the day. If possible she should return to
normal household duties slowly. Other family members must
help with this until she is stronger.
c. Importance of giving not only good physical care to the baby,
but also to show the baby love. The mother can teach the
baby to love and trust by communicating her love.

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
d. Postpartum exercises to help her return to her healthy non

pregnant condition.
e. *Nutrition she needs to have a diet high in body building
(protein) and energy (fats, grain, tubers) foods, and to drink
every time she breast feeds. Check for any food taboos and
remove the myths about them. Encourage her to take a
balanced diet having dal, wheat/rice, seasonal green/other
vegetables, milk and seasonal fruits (if she can afford).
f. Sexual activity Talk with both woman and her partner to
make sure that safe sex is practiced.
g. * Family Planning
h. HIV refer for voluntary HIV counseling and testing as
appropriate. Counsel HIV positive women who choose to
breast feed and HIV positive women who choose to
replacement feed appropriately.
i.* Complication readiness plan explain the danger signs for her
and her baby and to make plan for decision making in
emergency in the absence of decision maker, establish a
savings plan/scheme, transport, arrange blood donor in case
of need.
j. * The mother should inform you immediately if any danger
signs occur:
Too much bleeding
Fever
Abdominal pain or foul smelling lochia
k. * Ensure the woman that you will see her whenever she has
some problems and the family can call you if she needs help.
4. *Diagnosis and management of minor ailments
a. After pain (pain the uterus and lower abdomen after delivery)

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
Diagnosis - infrequent low abdominal colicky pain after

delivery. It is often felt during breast feeding
Management
- Reassure the mother
- Lie face down with a pillow under her abdomen
- Walk around or change positions if sitting or lying
down
- Urinate regularly to prevent bladder becoming too full
- Gently massage abdomen
b. Backache
Explain th at the mother may feel some backache. She

should lie on a hard bed and stand with back straight.
Management
- Have a warm water bath
- Calcium tablet, 1000 mg 1 tablet daily
- Analgesics 2 paracetamol tablets when needed
c. Constipation
Explain that it is common in postpartum period. It will

return to regular bowel habit by day 3.
Management
- Have regular food with vegetables, fruits, whole grains
and plenty of fluids

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
- Defecate when urge is felt. Avoid laxatives.

5. * Breastfeeding problems
a. Sore or cracked nipples
If the mother has sore nipples, sit with the mother and
watch the baby attach and feed. Watch if the mother is
holding the baby well or the attachment is poor.
Management
- Good breast feeding position and good attachment to
the breast
- Use other positions
- Keep nipples clean and dry
- Start feed with breast that is not sore or is least sore
- Mother should not stop breast feeding. Only in extreme
cases, rest the problem nipple for 24 hours
- Give 1 tablet paracetamol for pain
- Tell the mother to inform you if the nipples are not
healing
b. Engorged breasts
Breasts are full, shiny and painful
Management
- Place hot wet cloth on the breast for 5 mins before
feeding or massage the breasts from outside towards
the nipple

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
- Express some breast milk by hand so the nipples are

softer before feeding
- Put cool cloth on breasts after breast feeding
- Breast feed often, on demand of the baby or at least
every 2 3 hours
- Ask mother to sit in a quiet comfortable place, with
good support for her arms and back
c. Not enough breast milk
Ask if the mother is exhausted, not drinking or eating

enough. Ask if baby is allowed to sleep more than 3-4
hours at a time, if other feeds are given or if the breasts
are not emptied well at each feed.
Management
- Encourage mother to rest more, eat well and increase
fluids
-Watch the mother breast feed her baby and correct any
attachment or positioning problems
- Feed baby every 2 hours night and day while trying to
increase milk supply
- Wake a sleepy baby when it is time to feed
- Make sure baby is well attached, listen for active
swallowing
- Feed baby in a quiet, comfortable place
- Sleep with baby next to you in bed
10

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
- Give only breast milk, not other feeds

6. Possible complications during early postpartum period
a. * Secondary postpartum hemorrhage
Assess if there is excessive bleeding from vagina (500ml

or more) or excessive lochia after 24 hours up to 42 days
following delivery.
Management
- Inject Oxytocin 10 units i.m immediately. Refer to
Checklist 9 and manage accordingly. Refer the
woman to FRU/CHC along with family members
who can donate blood
Retained bits of placenta and membranes refer to
Checklist 9 for management and refer to PHC/CHC/FRU
for manual removal of placental bits and membranes
Tears of cervix, vagina and perineum - refer to
Checklist 9 and manage accordingly
b. * Puerperal sepsis
Diagnosis- fever, lower abdominal pain, tender uterus,

fundal height not decreasing by 1 cm/day, foul smelling
lochia, sometimes signs of shock and increased vaginal
bleeding, pain during urination
Management- refer to Checklist 11 Management of

Puerperal sepsis and manage accordingly.
d. Deep vein thrombosis
11

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
Diagnosis- Difficult to diagnose clinically in early stages.

Seen usually between 7-10th postpartum period. May
present with pain in calf and sole, swelling of the leg with
increasing temperature, rapid pulse, calf tenderness on
deep pressure and pain in the calf with dorsiflexion of the
foot (Homans sign).
Management
-Refer to PHC/CHC/FRU for management
e. Postpartum blues and depression
Diagnosis of postpartum blues Transient, usually lasts

3-5 days and characterized by tearfulness, anxiety, mild
depression and irritability.
Management of postpartum blues

- Explain to family and mobilize strong family support to
overcome the problem
Diagnosis of postpartum depression Mother is

depressed, not interested in the baby, unable to cope with
her new life
Management of postpartum depression

- Refer to DWH/CHC for appropriate treatment
CARE OF THE NEWBORN

HISTORY-ASK/LISTEN ( to mother and family)
1. Ask the mother how is her newborn?
12

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
2. Ask whether the baby had any of the following problems after
birth till date. If yes, refer the baby to the PHC/CHC/FRU for expert
care.
Convulsions. If yes refer the baby to the FRU immediately.
Fever or became cold to touch
Is not sucking well
Has difficulty in breathing (fast breathing or chest indrawing)
Lethargic or unconscious
Blood in stool.
EXAMINATION AND MANAGEMENT OF THE BABY

1. *Convulsions, lethargic or unconscious: If the baby has jerky
movements or appears lethargic and unconscious, refer her/him to an
FRU for expert care. This baby is very sick.
2. *Fever: Take the temperature of the baby.
Ensure that the mercury of the thermometer is in the bulb and
not in the tube.
Place the bulb end of the thermometer in the axilla of the baby
for 5 mins.
Take out the thermometer and note the reading. Normal
temperature of the baby is 36.50C to 370C. If the baby has
fever, give syrup paracetamol and refer the baby to PHC.
3. *Too cold: If the baby is cold to touch, advise the mother to:
Wrap the baby in warm cloth and keep the baby close to her
body.
Discourage her from giving bath to the baby. She can clean
the baby quickly in a warm room with warm water.
13

PRACTICE/ASSESSMENT
STEP/TASK
OBSERVATIONS
4. *Check breathing: Note:
whether the baby is crying well and breathing normally (more

than 30 breaths /min but less than 60 breaths/min). If yes, this is
a normal baby.
If there is difficult breathing: The baby is not breathing or

gasping, has fast breathing (60 or more breaths/min) or has
severe chest indrawing at the level of the junction of the chest
with the abdomen in the left or right upper part of the abbys
abdomen. This baby is in danger. Start Resuscitation
immediately. Refer to Revised Guidelines Module 1, Newborn
Resuscitation section in Essential Newborn Care.
5. * Check the babys skin, eyes and umbilicus for cleanliness or

any infection. If there are pustules on the skin or dirty discharge
from the eyes or umbilicus, refer the baby to the PHC for skilled
care. The umbilicus should be dry. Tell the mother not to apply
anything on the umbilicus.
*COUNSELLING FOR NEWBORN CARE
1. *Counsel the mother how to keep the baby clean.
2. *Encourage her to continue breast feeding and give exclusive
breast feeding with proper attachment of the baby to the breast.
Explain that colostrums is beneficial for the health and growth of the
baby.
3. *Counsel her to take the baby to the PHC if the following danger
signs appear: Looks ill, fast or difficult breathing, develops fever or
cold to touch, blood in stool.
4. *Counsel the mother to take the baby to the sub-centre for
immunization after one and a half months.
Score %

14
15
CHECKLIST 8
CHECKLIST FOR IDENTIFICATION AND MANAGEMENT OF SHOCK AND
BLEEDING DURING PREGNANCY
1

sequence
3
CHECKLIST FOR IDENTIFICATION AND MANAGEMENT OF SHOCK AND
BLEEDING DURING PREGNANCY

PRACTICE/ASSESSMENT
SN
Step/Task
1. Greet the woman and the persons accompanying her.
2. Ask the woman or her companion what made her
come to the health centre or if you are called, ask
them the reason for calling you.
3. If the woman appears conscious and complains of
bleeding, ask when was her last menstrual period to
ascertain whether she is pregnant and whether she is
in early pregnancy (less then 20 weeks) or late
pregnancy (more than 20 weeks)?
4. * In both the conditions make a rapid assessment of
the general condition of the woman including vital
signs (pulse, blood pressure, respiration) and check
her bleeding.
5. * Examine her general condition, pulse, temperature
blood pressure and respiration. If shock is suspected
(pulse more than 110/min, BP less than 90/60
mmHg, respiration 30/min or more, general condition
confused, anxious, unconscious)
or the woman is bleeding heavily (soaking 1 pad in
<5 mins or bleeding continuously, with or without
clots)
1
Observations
begin treatment immediately. It is an emergency.

6. * Establish an I/V line and start I/V infusion rapidly
(ringer lactate or normal saline @ 60 drops/min).
7. * Explain to the woman/companion of the woman
that her condition is serious and may be dangerous
for her life. Therefore, she has to be referred to the
PHC for further care immediately.
8. * Take help of the relatives of the woman or a village
person to help arrange a transport quickly or call for
the transport which you have already arranged for
emergencies.
9. * Transport the woman to a 24 hour PHC. During
transport- keep the woman warm
- slow the rate of infusion to 30 drops/min
carry another bottle of fluid with you
- if possible, accompany the woman to the
PHC and inform the MO of the womans
condition.
Bleeding In Early Pregnancy- if shock is not
present, keep shock in mind as you evaluate the
woman further because her status may worsen
rapidly. If shock develops, it is important to begin
treatment immediately.
10. *If the woman is not in shock and not bleeding
heavily, perform a vaginal examination using
infection prevention practices to assess the size of the
uterus and the condition of the cervical os.
11. Feel for any products of conception (POC)
protruding through the cervical os if it is open.
12. * Perform a digital removal of the POC if they can
be felt in the vagina through the os with your index
and middle fingers.
Ensure aseptic precautions wearing HLD gloves
in both hands do not touch any thing or surface
which is not HLD.
Tell the woman what is to be done and she may
feel some discomfort
Encourage her to ask questions or tell you if it
hurts
Put your left hand on the suprapubic region and
press downwards gently
Look at the face of the woman for any signs of
pain
Hold the POC between your two fingers which
are already in the vagina at the level of the
cervical os and gently pull the POC downwards
2
by a rotating movement of the fingers

Put the removed products in a kidney basin
Reinsert your fingers to remove any remaining
products and blood clots from high up in the
vagina and cervical opening
Check for bleeding.
Check for the POC removed.
Put the wastes including the POC in the waste
bucket
Put all instruments in 0.5 % chlorine solution for
10 mins for decontamination
Immerse your gloved hands for a few moments in
the chlorine solution and remove them in the
solution by turning them inside out for 10 mins.
If the bleeding reduces and or the POC appear to
be removed completely, clean the woman, give
her a clean pad and observe her for general
condition and bleeding for at least 4-6 hours.
If the bleeding continues and no POC are felt in
the vagina and the os is still open, refer her to
MO of the 24 hour PHC.
If the bleeding stops, check for general condition
and vital signs of the woman, if they are better,
reassure her and send her home
Advise her to come for follow up (see below)
13. If there are no products in the vagina, the os is closed
and the bleeding is mild, observe the woman for 4-6
hours. If the bleeding or pain in lower abdomen do
not increase,
check vital signs and if normal/stable,
advise-complete bed rest for a few days, reassure
her and send her home
14. Advise the woman for
follow-up if she has any of the followingIncreased bleeding, continued bleeding for two days,
foul smelling vaginal discharge, abdominal pain,
fever, feels unwell, weakness, dizziness fainting,
does not have menses 4-6 weeks after the abortion
Self care-rest, use clean pads every 4-6 hours,
clean perineum while bathing with soap and
water, avoid sexual intercourse until bleeding
stops or use a condom
Family planning (FP)-Explain the she may
conceive soon if she resumes sexual intercourse
without any contraceptive use. Counsel her for an
appropriate FP method.
Bleeding during Late Pregnancy (APH)

1.
2.
3.
4.
5.
6.
If the woman is not in shock and is bleeding (light or

heavy) It is an Emergency.
* Start an I/V line and give IV fluids slowly @30
drops per minute if the woman is not in shock.
* Do not do a pelvic examination
* Explain to the woman/companion of the woman
that her condition is serious and may be dangerous
for her life. Therefore, she has to be referred to the
FRU for further care immediately.
Take help of the relatives of the woman or a village
person to help arrange a transport quickly or call for
the transport which you have already arranged for
emergencies.
* Transport the woman to an FRU with blood
transfusion facilities.
During transport- keep the woman warm
- keep the rate of infusion to 30 drops/min
carry another bottle of fluid with you
- if possible, accompany the woman to the
FRU and inform the MO of the womans
condition.
Score %

CHECKLIST 9
CHECKLIST FOR IDENTIFICATION AND MANAGEMENT OF IMMEDIATE AND
DELAYED POSTPARTUM HAEMORRHAGE
1

sequence
CHECKLIST FOR IDENTIFICATION AND MANAGEMENT OF IMMEDIATE AND

DELAYED POSTPARTUM HAEMORRHAGE

PRACTICE/ASSESSMENT
SN
Step/Task
1. Greet the woman and the persons accompanying her.
2. Ask the woman or her companion what made her
come to the health centre or if you are called, ask
them the reason for calling you.
3. *If the woman appears conscious and complains of
heavy bleeding after delivery of the baby, ask her or
if she is unconscious, ask her companion when did
she deliver the baby?
Identify immediate PPH if heavy bleeding started
within 24 hours of delivery of baby.
Identify delayed PPH if the heavy bleeding
started after 24 hours of delivery of the baby or
bleeding is lasting for more than 24 hours after
delivery.
Identify heavy bleeding if the woman is bleeding:
o continuously for more than10 minutes after
delivery or
o is soaking 1 pad in less than 5 minutes or
o if there is a constant trickling of blood or
o the woman is in shock
1
Observation
4.
5.
6.
7.
8.
* Make a rapid evaluation of the general condition of

the woman including vital signs (general condition,
pulse, BP, respiration) and check for bleeding
* If shock is suspected (pulse more than 110/min, BP
less than 90/60, respiration more than 30/minute and
general condition of the woman is anxious, confused
or unconscious), and/or
If the woman is bleeding heavily
begin treatment immediately.
Try to ascertain the cause of PPH using the
flowchart.
Even if signs of shock are not present, keep shock in
mind as you evaluate the woman further because her
status may worsen rapidly. If shock develops, it is
important to begin treatment immediately
* Give Inj. Oxytocin 10 units IM stat.
* Massage the uterus to expel placenta (if
undelivered), blood and blood clots:
Help the woman to lie down on the examination
table
If she is conscious, place a kidney basin or a
bowl near her perineum and encourage her to
pass urine, remove the kidney basin after she is
able to do so.
Place a container or a clean plastic sheet close to
the vulva to estimate the amount of blood lost
Place your cupped hand on the uterine fundus and
feel for the contraction
Massage the uterine fundus in a circular motion
with the cupped hand until the uterus is well
contracted
If placenta is not delivered, try CCT to deliver the
placenta.
If placenta is delivered and the uterus has become
well contracted, place your fingers behind the
fundus and push down in one swift action to
expel clots.
Ensure that blood gets collected in the container
or the clean plastic sheet placed close to the vulva
Estimate and record the amount of blood lost.
* Check the vagina to see if the lower end of a
partially separated placenta is seen protruding
through the os in the upper vagina. If it is visible,
assist in removing the partially separated
placenta
o insert a gloved hand in the vagina in the form
2
9.
of a cone bringing the fingers and thumb

together along the side of the cord
o Reach up to the upper part of vagina
o Put your other hand on the lower abdomen
o Hold the placenta in the hand firmly but
gently
o Remove the placenta and the membranes
gently by pushing the uterus up with the hand
on the abdomen and pulling the placenta
down by slow rotatory or zig-zag movement
of the hand in the vagina
o Keep holding the placenta firmly as it slowly
comes out of the cervix, continue the rotatory
or zig-zag movement of the hand to let the
membranes come out completely
o Check for completeness of the placenta and
membranes
If the placenta is not delivered completely and
there is a breach in the placenta or the
membranes, refer the woman immediately to a 24
hour PHC
* Look for presence of any vaginal and perineal
tears
Clean the perineum of the woman with a clean
pad or cloth so that you can see clearly
Ensure that there is enough light to see the
perineal area
With your left gloved hand separate the labia to
see the area of the perineum and lower vagina
If the tear is only in the skin and mucous
membrane, it is superficial/I degree tear
o Clean the area and cover with a clean pad.
Suturing it is not required. Advise the woman
to maintain perineal hygiene and it will heal
spontaneously
o If it is bleeding, apply pressure on it for a few
minutes, the bleeding will get controlled
If the tear is involving the muscles and deeper
structures, it is second or third degree tear
o if the deep tear is bleeding profusely, also
apply pressure on the area for some time
o cover the tear with a clean pad
o put the legs of the woman together but DO
NOT cross the ankles
o Refer the woman to the MO at 24 hour PHC
after stabilizing with IV infusion if she is
10.
11.
12.
13.
14.
15.
16.
17.
18.
bleeding heavily
If the woman is bleeding heavily because of tears
and you are unable to decide the nature of the tear
o put a clean vaginal pad in the vaginal cavity
o refer the woman to the MO at the 24 hour
PHC after starting an IV infusion
* Start an I/V infusion and give IV fluids (Normal
Saline or Ringers Lactate). Add 10 units of
Injection Oxytocin to every bottle (500 ml) of fluid
that is infused.
If the woman is in shock or bleeding heavily, give
fluids rapidly @ 60 drops/min
If the IV line can not be arranged and the woman is
conscious, give her enough fluids to drink. DO NOT
give anything orally if the woman is unconscious.
*Raise the legs of the woman by keeping a pillow
under her ankles so that her head is lower than the
body. Remove the pillow from under her head.
*Keep the woman warm and covered with a blanket.
Monitor the pulse and BP every 15 mins.
* If the woman is conscious, encourage her to pass
urine. If she cannot do so and the bladder is full,
refer the woman to the PHC, CHC, FRU and call
the MO to catheterize the bladder
* Inform the relatives that the condition of the
woman is serious and there may be danger to her life
hence she has to be referred to the FRU for care.
Tell them to arrange for 2-3 people to accompany the
woman to donate blood if required
* Rapidly arrange for transport and refer the woman
to a FRU with blood transfusion facilities.
During transport continue IV fluids @30 drops/min.
Estimate the blood loss (by counting the number of
soaked pads)
Accompany the woman to the FRU and inform the
MO.
* Check for possibility of infection in a woman with
delayed PPH (Temperature more than 380 C and
presence of foul smelling vaginal discharge) give
first dose of antibiotics (Caps Ampicillin 1 g orally,
Tab Metronidazole 400 mg orally and Injection
Gentamycin 80 mg IM stat) before referral.
* Look for pallor and signs of Anaemia.
Estimate Hb level.
If the woman has severe anaemia, refer her to FRU as
she may need a blood transfusion.
Score %
References
1. Kirti Ayengar, Sharad Ayengar; Matra-Navjat Shishu Swasthya Hetu Kushal
Dekhbhal. Guidelines for Nurse Midwives, Arth, Udaipur;2005.
2. Training Modules on Midwifery Practice for Safe Motherhood. Module 2-Intranatal
care, UNICEF.
3. Reproductive Health Practical MMEL-102; Checklist manual-2, Indira Gandhi
National Open University (IGNOU), School of Health Sciences, New Delhi, 2003.
4. Manuals for Training Community Midwives in UP; USAID, State Innovations in
Family Planning Services Agency (SIFPSA), Directorate Health Services,
Government of UP, Lucknow, 2003.

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HANDBOOK

ANMs, LHVs AND STAFF NURSES TO

Maternal Health Division

1.1 Identification of pre-eclampsia

1.2 Assessment of Cervical effacement and dilatation

1.3 Pelvic assessment

1.4 Assessment of Engagement of foetal head

2.2 Sample of Completed Partographs

2.3 Exercises to Monitor Labour using Partograph

2.4 Explanations to Exercises

2.5 Interpreting newborn weight

Blank simplified partographs

Competently Performed: Step or task efficiently and precisely performed in proper

CHECKLIST FOR PROCESSING INSTRUMENTS,

NAME OF THE CLIENT/TRAINEE AND DATES OF

CHECKLIST FOR PROCESSING INSTRUMENTS,

6. Remove reusable gloves by inverting and soaking in 0.5% chlorine

CHECKLIST FOR PROCESSING INSTRUMENTS,

CHECKLIST FOR PROCESSING INSTRUMENTS,

Score %: The denominator will be 3 X number of the tasks observed/performed. The

CHECKLIST FOR PROCESSING NEEDLE AND SYRINGE

DECONTAMINATION (of reusable syringes and needles)

Place the cap on a flat surface, then remove your hand.

CHECKLIST FOR PROCESSING NEEDLE AND SYRINGE

5. * To avoid needle stick accidents, do not disassemble single use

*To check for the further processing of needles and syringes

Remember: Sharps should always be handled with extreme care.

Wash needle sticks and cuts with soap and water.

Flush splashes to the nose, mouth or skin with water.

Splash eyes with water.

Competently Performed: Step or task efficiently and precisely performed in proper

CHECKLIST FOR MANAGEMENT OF

NAME OF CLIENT/TRAINEE AND DATE OF

If the womans diastolic Blood Pressure (BP) is more than 90

Sudden or severe swelling of the face, lower back and hands

Passing reduced amount of urine

CHECKLIST FOR MANAGEMENT OF

3.*Check a mid-stream clean catch urine sample for protein. Make

*If the diastolic BP is > 90 mm Hg and protein in urine is >1+, the

* if the woman has BP more than 160/110 with proteinuria or

CHECKLIST FOR MANAGEMENT OF

Make a plan of care

CHECKLIST FOR MANAGEMENT OF

1. *Offer supportive care immediately:

CHECKLIST FOR MANAGEMENT OF

Score %: The denominator will be 3 X number of the tasks observed/performed. The

Competently Performed: Step or task efficiently and precisely performed in proper

CHECKLIST FOR PUERPERAL PYREXIA

NAME OF THE CLIENT/TRAINEE AND DATES OF

CHECKLIST FOR PUERPERAL PYREXIA

NAME OF THE CLIENT/TRAINEE AND DATES OF

CHECKLIST FOR PUERPERAL PYREXIA

NAME OF THE CLIENT/TRAINEE AND DATES OF

5. *Ask about respiratory symptoms:

*Check for thrombophlebitis:

Varicosities, calf pain and heat, edema

CHECKLIST FOR PUERPERAL PYREXIA

NAME OF THE CLIENT/TRAINEE AND DATES OF

*Check abdomen for distention, pain, lump

*Check uterine involution and lochia:

*Wash hands and put on gloves

*Check genital health:

Palpate the ovaries for pain

CHECKLIST FOR PUERPERAL PYREXIA