Safe Pregnancy and Birth

• Staying Healthy
  During Pregnancy
• Danger Signs
  During Pregnancy
• Danger Signs
  During Birth
• Danger Signs
  After Birth
• How To...

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Baby is lying sideways (transverse)

If a baby is sideways near the end of the pregnancy, make a plan for the mother to give birth in a hospital. A baby lying sideways cannot be born without an operation.

If labor has already started and the baby is sideways, take the mother to a hospital to save her and her baby's life.

Bleeding after birth

It is normal for a woman to bleed a little after birth. But treat immediately for bleeding if she:

• Soaks 2 or more cloths or pads in an hour, OR
• Bleeds more than 2 cups

• Treat bleeding before the placenta

• Treat bleeding after the placenta

Even if you do not see a lot of blood, watch for these signs: feeling faint, pale skin, feeling like she lost too much blood.

Too much bleeding
after the placenta has come out

• Ask the mother to urinate. A full bladder prevents the womb from contracting.
• Keep the mother lying down and put the baby to her breast. If the baby will not suckle, try rolling the mother's nipples. This will make the womb contract and stop heavy bleeding.
• Firmly rub the top of her womb at the level of her navel until the womb becomes hard. Keep rubbing until heavy bleeding has stopped.
• Give medicine to stop the bleeding. Give 10 units of oxytocin by injection in the buttock or thigh.
• OR give 800 mcg of misoprostol, 1 time only. Dissolve inside the cheek or under the tongue for 30 minutes and then swallow what is left. If the woman cannot swallow, insert tablets in the rectum. Wear a glove.
• OR give 0.2 mg of ergometrine by mouth, or by injection in the thigh.

Too much bleeding
before the placenta comes out

• Ask the mother to squat and push the placenta out.
• Ask her to urinate. A full bladder prevents the womb from contracting.
• Put the baby to the mother's breast to start suckling. If the baby will not suckle, have the mother roll her nipples. This will help her womb contract and push the placenta out.
• Give 10 units of oxytocin by injection in the buttock or thigh, or give 800 mcg of misoprostol, 1 time only. Dissolve inside the cheek or under the tongue for 30 minutes and then swallow what is left. If the woman cannot swallow, insert tablets in the rectum. Wear a glove.

Bleeding during labor, before the baby is born

Some light, pink-colored fluid, or mucus and brown blood during labor is normal. But if the mother is bleeding bright red blood, it could mean that the placenta is separating from the womb wall or is covering the opening of the womb.

Bleeding During Pregnancy

Healthy signs:

• No bleeding.
• Very light bleeding or spotting for a few days during the first months, with no cramps.
• Pink or slightly bloody mucus 2 to 3 days before labor begins. This mucus is called show or the mucus plug, and is a sign that labor will start in a few days.

Warning signs: There is a lot of blood. Where is the woman in her pregnancy?

• In the first half of pregnancy?

• In the second half of pregnancy?

Bleeding during the first half of pregnancy: miscarriage

When a woman bleeds about the same as having her monthly bleeding, it is probably a miscarriage (losing the pregnancy). This is not normally dangerous to the physical health of the mother. But watch for danger signs like too much bleeding, or signs of infection such as fever, feeling faint, or a bad smell from the vagina.

Women who have had miscarriages or abortions may feel afraid, sad, or upset. This emotional pain is just as important as the pain women have in their bodies.

Bleeding during the second half of pregnancy

Bleeding during the second half of pregnancy could mean the placenta is in the wrong place or has detached from the womb. Both are serious problems.

Common complaints
during pregnancy

• Tiredness
• Increased vaginal discharge
• Nausea
• Cravings

Danger Signs
After Birth

• Bleeding
• Fever

Danger Signs
During Birth

• Too long labor
• Waters break
  but no labor
• Green or brown waters
• Seizures/Fits
• Fever
• Bleeding

Danger Signs
During Pregnancy

• Bleeding
• Severe pain in abdomen
• High blood pressure
• Seizures/Fits

Eating well

A woman who eats well is much more likely to have a healthy pregnancy and healthy baby.

Pregnant women need to eat more than usual. The extra food gives them enough energy and strength, and helps their babies grow.

Pregnant women should eat a variety of foods, some foods from each of these 3 groups every day:

Carbohydrates: such as rice, maize, wheat, millet, cassava, taro, or plantains.

Proteins: such as beans, peas, lentils, eggs, nuts and seeds, cheese, milk, yogurt, meat, fish, or insects.

Fruits and vegetables: such as leafy greens, carrots, cabbage, peppers, oranges, melons, pineapples, ripe papayas, or mangoes.

If a woman is not getting enough to eat, encourage her family, neighbors, and friends to share with her. Perhaps they can help tend her garden, bring her eggs from their chickens, or cook a bit extra to bring to her.

Iron and folic acid: A pregnant woman also needs to get enough iron to prevent anemia, and folic acid to prevent birth defects in her baby. She should take supplements of these to make sure she gets enough. Each day she should take 400 to 500 mcg folic acid, and
300 mg ferrous sulfate (60 mg iron), until the baby is born.

Fever after birth

If the mother has a fever during the first weeks after the birth, she may have an infection of the womb. Other signs of womb infection are:

• Chills
• Pain and tenderness in the belly
• Bad-smelling fluid from the vagina

Fever during labor

It can be normal for a woman to get warm in labor. This may be because she is dehydrated. Give rehydration drink.

A fever above 38°C (100.4°F) is usually a sign of infection. Give antibiotics on the way to the hospital.

• Antibiotics to treat infection

Fever during pregnancy

If a woman has a fever during pregnancy, it could be caused by malaria, a sickness like flu, a kidney infection, or dehydration. Find the cause of the fever and treat it.

Along with the fever does she also:

• Have shivering, body aches and severe headache? She might have malaria.
• Have a cough, stuffy nose, body aches, feel weak and perhaps vomiting? She might have the flu.
• Have pain in the sides or in the middle of the back, and feel the need to urinate more often or have burning with urination? She might have a kidney infection.
• Feel thirsty, have little or no urine, have dry mouth, or feel dizzy when standing up? She may be dehydrated. Give rehydration drink.

Along with treating the cause, a high fever needs to be lowered right away.

Foods with iron

Pregnant women are especially at risk for anemia (weak blood). Eating more foods with iron will help prevent and treat anemia. Foods with a lot of iron include:

• Meat (especially liver, kidney, and other organ meats)
• Beans, peas, and lentils
• Fish
• Eggs
• Dark green leafy vegetables

Green or brown waters

Green or brown waters mean that the baby has passed stool inside the womb. He may be in trouble. The stool can get in the baby's mouth and nose, and it can be hard for him to get enough air.

What to do if the waters are green or brown

If the mother is already pushing and the birth is coming soon, be ready to clean the baby's mouth at birth. As soon as the baby's head is born, wipe his mouth and nose with a clean cloth or use a suction bulb to suck the mucus out. Keep the baby's head lower than his body to help the mucus come out. If the baby has difficulty breathing, or his skin stays blue after a few minutes, take him to a hospital.

How to change the baby's position

During the last month of pregnancy, it may be possible for a pregnant woman to change the baby's position by lying in this position for 10 minutes, 2 times a day:

Lie on the floor with pillows under the hips. Try to get the hips higher than the head. Do this every day with an empty stomach, until the baby changes to a head-down position. Then stop.

How to give medicine
to stop bleeding

Oxytocin
Inject 10 units of oxytocin in the side of the thigh muscle.

Misoprostol
Dissolve 800 mcg inside the mouth, against the cheek or under the tongue, for about 30 minutes. Then swallow what is left. If she feels nauseous, you can insert tablets into the woman's rectum instead. Wear a glove.

Ergometrine (only give after the placenta has come out)
Inject 0.2 mg ergometrine in the side of the thigh muscle.
OR, give 0.2 mg of ergometrine pills by mouth. You can give ergometrine every 2 to 4 hours for severe bleeding, or every 6 to 12 hours for less severe bleeding. But continue to give the medicine until bleeding has stopped and the womb is hard, usually about 48 hours. Pills do not work as quickly as injections. Do not give ergometrine to a woman with high blood pressure.

How to help a woman while getting her to the hospital

If a woman is bleeding heavily, send 2 family members with her to the hospital to give blood if needed.

If she is in shock, treat her for shock while transporting her to the hospital. If you know how, start an intravenous drip (IV). Or give rectal fluids.

How to lower a fever

Lowering a fever will help a woman feel better, but it will not treat the cause of the fever, such as infection or malaria.

Lower a fever by giving 500 to 1,000 mg paracetamol by mouth every 4 to 6 hours (but do not give more than 4000 mg paracetamol in one day). Do not give ibuprofen to a pregnant woman in the last 3 months of pregnancy. It is not safe.

Give a sponge bath with cool (not cold) water, or use cool cloths to help bring the fever down.

Help the woman drink rehydration drink or 1 cup of water every hour. If she is too sick to drink, start an intravenous drip (IV) if you know how, or give rectal fluids.

How to make bleach solution

If possible, use a 0.5% solution of bleach (chlorine) for disinfecting tools. If you do not have 0.5% bleach solution, you can make your own by mixing bleach and water:

Soaking your tools in bleach solution for 20 minutes before you clean them will help protect you from infection.

How to prevent malaria

Malaria is spread by mosquitoes. To prevent malaria, avoid mosquito bites.

• Get rid of standing water and stay away from places where mosquitoes breed.
• Use local remedies to keep mosquitoes away. Some people use citronella oil on their skin.
• Wear long sleeves and long skirts or pants, or use mosquito repellant when mosquitoes are biting.
• Sleep under treated bed nets or hang treated curtains in doors and windows.

How to roll nipples

Rolling, squeezing, and massaging the nipples can help a woman have stronger contractions and start labor. Keep squeezing and massaging until her contractions get strong. If her contractions do not get stronger within half an hour, rolling the nipples probably will not help.

Rolling the nipples can also help the womb contract and stop bleeding.

How to rub the womb

Put your hand on top of the womb and squeeze while you move the same hand in a circle. Rub the womb until it feels like a hard round ball. The womb should be in the center of the belly, not off to the left or right. If it is not in the center, have the woman urinate. Check the womb every 1 or 2 minutes for a while. If it gets soft again, rub it until it contracts again.

Rubbing the womb will be painful for the mother. You must keep rubbing to stop the bleeding, even if she is in pain.

How to treat infection during labor or after birth

For mild fever during labor, ampicillin plus gentamicin will usually work. For high fever in labor, or for signs of infection after birth, use metronidazole as well to fight all the possible bacteria that can cause the infection. It is best to inject at least the first dose of ampicillin, but if you have only pills give those instead.

Ampicillin: inject 2 grams. Wait 6 hours, then inject or give by mouth 1 gram every 6 hours. AND

Gentamicin: inject 5 mg per kg, once a day. If you cannot weigh the woman, inject 80 mg, 3 times a day. AND

Metronidazole: give 500 mg by mouth, 3 times a day.

Give all 3 medicines until 2 days after signs of infection have stopped.

In case of allergy to penicillins, give 500 mg erythromycin 4 times a day instead of ampicillin. Other combinations of antibiotics can be given if they are all you have. Choose a combination that fights a wide-range of bacteria.

How to treat malaria

If a pregnant woman is sick with malaria, she should be treated right away.

Malaria should usually be treated with an Artemesinin-based Combination Therapy (ACT). Check with your local health authority to find out which ACT works best in your area.

If you do not know which works best, give artemether plus lumefantrine. This usually comes as a combined pill. Give 4 pills by mouth 2 times a day for 3 days. The woman should take the medicine right away after opening the package because it can lose strength once outside the package.

If the woman is in the first 3 months of pregnancy, she should take quinine plus clindamycin instead, if possible. Give 600 mg quinine 3 times a day for 7 days, AND 300 mg clindamycin 4 times a day for 7 days.

How to treat yeast infections

Yeast infections are common during pregnancy. They are not dangerous, but should be treated before birth.

• Very itchy inside or outside the vagina
• White, lumpy discharge, like milk curd or yogurt
• Bright red skin outside and inside the vagina that may bleed
• A burning feeling when urinating
• A smell like mold or baking bread

• Mix 3 tablespoons of vinegar with 1 liter boiled and cooled water. Soak a piece of clean cotton in the mixture and insert it into the vagina every night for 3 nights. Remove the cotton each morning. OR
• Soak a clean piece of cotton in gentian violet 0.5%. Insert the cotton into the vagina, every night for 3 nights. Remove the cotton each morning. OR
• Insert 200 mg miconazole high in the vagina each night for 3 nights. OR
• Insert 100,000 units nystatin high in the vagina each night for 14 nights.

How To...

• How to take blood pressure
• How to take temperature
• How to lower a fever
• How to treat malaria
• How to prevent malaria
• How to check urine for protein
• How to treat bladder and kidney infections
• How to treat yeast infections
• How to check the baby's position
• How to change the baby's position
• How to strengthen labor
• How to roll nipples
• How to give castor oil
• How to make bleach solution
• How to treat someone in shock
• How to make rehydration drink
• How to give rectal fluids
• How to rub the womb
• How to treat infection during labor or after birth
• How to help her get to the hospital
• How to give medicine to stop bleeding
• How to give an injection
• How to give magnesium sulfate
• How to suction a baby's mouth

How to treat bladder and
kidney infections

If the woman has a bladder infection, she should drink 1 glass of liquid every hour while she is awake to help wash the infection out of her body. Cranberry juice, cornsilk tea, or other home remedies often work.

If she does not start to improve quickly, or if she has any signs of a kidney infection, give antibiotics.

Antibiotics for bladder and kidney infection:
Give 500 mg amoxicillin by mouth 3 times a day for 7 days. If she is allergic to amoxicillin or penicillin give 960 mg cotrimoxazole by mouth 2 times a day for 7 days. But do not give cotrimoxazole in the last 3 months of pregnancy.

Prevention:
Wipe from front to back after urinating or passing stool to keep germs away from the pee hole. Remind women's partners to clean their hands and genitals before sex. Women should also urinate right after having sex.

Safe Pregnancy and Birth
Version 2.0.2

This app is a collaboration between Hesperian and UnaMesa.

Hesperian Health Guides is a non-profit publisher of books, newsletters and online resources for community-based health care.

Visit Hesperian for more great resources.

The UnaMesa Association is a public charity dedicated to improving healthcare, education, and social services through innovations in technology and tools for sharing knowledge.

Learn more at www.unamesa.org

Copyrights and Credits

• Zena Herman
• Tawnia Litwin
• Divya Ramachandran
• And many other Hesperian staff members

Pre-eclampsia
(danger of seizures)

Pre-eclampsia is when a woman has:

• High blood pressure (140/90 or greater), AND
• Protein in her urine

Pre-eclampsia can cause premature birth, bleeding, seizures, or even death for the mother.

If she only has high blood pressure, check it once a week to see if it goes up, and watch for signs of severe pre-eclampsia.

• Signs of severe pre-eclampsia

Seizures or fits

When a woman has a seizure, she may have some or all of these signs:

• Rolling eyes
• Twitching hands and face
• Stiff, rigid, or shaking body
• Blue skin
• Loud, bubbly sound while breathing
• Unconsciousness

A seizure may last anywhere from a few seconds to many minutes.

What to do if she has a seizure

1. Stay calm.
2. Do not put anything in the mother's mouth. She must be allowed to breathe freely.
3. Put the mother on her side, so she does not breathe in her spit or vomit.
4. Remove hairpins or other sharp objects that could harm the mother.
5. Give her oxygen, if you have it.
6. Give magnesium sulfate if you know how.

Get medical help as soon as possible when the seizure is over.

Severe abdominal pain in pregnancy

Severe pain in the belly with or without bleeding may mean that the placenta has become separated from the wall of the womb.

Other signs that the placenta is separting from the womb are:

• Starting contractions early
• Back or abdominal pain that continues between contractions
• Frequent contractions

Watch the woman for signs of shock and start IV fluids if you know how.

Severe pre-eclampsia

Signs of severe pre-eclampsia are:

• 160/110 blood pressure
• Strong headaches
• Vision changes such as spots, blurriness, or double vision
• Steady, severe pain in the top of the belly or the right side just under the ribs
• Swollen face, or swelling all over when she wakes up
• Seizures

Shock

Shock is a life-threatening condition that can result from heavy bleeding. Bleeding inside the body can also cause shock.

Signs:

• Very fast heart rate, more than 110 beats a minute
• Pale, cold, damp, skin
• Pale inner eyelids, mouth, and palms
• Fast breathing, more than 30 breaths a minute
• Confusion or unconsciousness (fainting)

How to treat a woman in shock

• Treat the bleeding or other cause of shock.
• Lay her down with her head to one side so she does not choke on vomit.
• Put something under her legs to raise them. Cover her with a blanket or clothes. Help her stay calm.
• If she can drink, give her sips of water or rehydration drink. If she cannot drink, start rectal fluids. Or if you know how, start a fast intravenous drip (IV) with a wide needle.

If she is unconscious, do not give her anything by mouth - no medicines, drink, or food until she has been awake for one hour.

Signs of malaria

High fever, especially along with shivering, body aches, and severe headache, can be caused by malaria. Malaria is especially dangerous for pregnant women and their babies. The typical malaria attack has 3 stages:

1. It begins with chills and often headache. She shivers or shakes for 15 minutes to an hour.
2. Chills are followed by fever, often 40°C (104°F) or more. She is weak, flushed (red skin), and at times delirious (not in her right mind). The fever lasts several hours or days.
3. Finally she begins to sweat, and her temperature goes down. After an attack, she feels weak, but may feel more or less OK.

Malaria attacks usually happen every 2 or 3 days, but they can also happen every day or only once in a while.

Staying Healthy
During Pregnancy

• Eating Well
• Things to Avoid
• Common Complaints
• Things to Check

Things to avoid
during pregnancy

• Sick people
• Smoking and alcohol
• Unnecessary medicines
• Chemicals and fumes
• Malaria

Things to check
during pregnancy

• Temperature
• Blood pressure
• The position of the baby
• Signs of anemia
• Signs of bladder or kidney infection

Too long labor

A very long labor can lead to lasting health problems for the mother, or may be a sign that the baby cannot come out without medical help. Labor is too long when:

• The mother has been in strong, active labor for more than 12 hours, OR
• She has been pushing for more than 2 hours without any signs that the baby will be born soon

If her contractions are not coming every 2 to 3 minutes, or if she can still talk through them, she is not in active labor yet. Encourage her to sleep. If she cannot sleep, have her walk, dance, climb stairs or hills. Help her to drink and eat light foods.

Once contractions are coming regularly and are strong, be mindful of the time. Also think about how far from help you are, in case it is needed. You may need to try to strengthen her labor at home or get medical help.

• How to strengthen labor

The water breaks, but labor does not start

Most women will give birth within 24 hours after their waters break. If labor has not started within 12 hours, the woman and her baby could get a serious infection.

What to do if the water breaks but labor does not start

The mother must not put anything in her vagina. This could cause an infection.

Try to strenghten labor. If labor does not start after a few more hours, she should go to a health center or hospital.

If she has a fever or there is a bad smell in the vagina, an infection is starting. Give antibiotics on the way to the hospital.

• Antibiotics to treat infection

How to strengthen labor

First, check the baby's position to make sure he is not sideways.

• Have the woman urinate.
• Roll her nipples. Or have a baby nurse.
• Mix about ¼ cup castor oil with some juice and have the mother drink it. This usually causes painful diarrhea and cramps, but it may also strengthen contractions.
• If she has been pushing for a long time, have her change positions. She can try squatting, getting on her hands and knees, or sitting against a pillow with her knees up.