Information for Mothers and Midwives. Lesson from Book "Where there is no doctor"

COMMUNITY HEALTH CELL
37/7, (First Floor) St. Marke BR

M-1 6 Ranaatora - 560.001 3
| INFORMATION FOR MOTHERS
19 AND MIDWIVES

This is a reprint from

RR There Is-No Docher

(Indian adaptation)

published by the

Voluntary Health Association of India
C-14 Community Centre
Safdarjung Development Area
New Delhi 110016

COMM Ute tase PELL

—— 291

CHAPTER

INFORMATION FOR MOTHERS
7 ) AND MIDWIVES.

THE MENSTRUAL PERIOD
(MONTHLY BLEEDING IN WOMEN)

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

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

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

If your menstrual period is painful:

There is no need for you to It often helps to walk around | or to take hot drinks, or put
stay in bed. In fact, lying and do light work or your feet in hot water.
quietly can make the pain exercises...

worse.

Also, it may help to take baralgan (p.416) or to put hot compresses on the belly.

During the period—as at all times—a woman should take care to keep clean, get
enough sleep, and eat a well-balanced diet. She can eat everything she normally
eats and can continue to do her usual work. It is not harmful to have sex during
the menstrual period.

She should change her pads everyday. If she uses a cloth, she should wash
and change everyday.

292 LIM } 7.0 8 ait =e diate cg SS

1S:
Signs of menstrual er
- some irregularity in the length of time between periods is normal for certain
women, but for others it may be a sign of chronic illness, anemia, malnutrition, OF
possibly an infection or tumor in the womb.

e |f a period does not come when it should, this may be a sign of pregnancy. But
for many girls who have recently begun to menstruate, and for women over 40,

‘t is often normal to miss or have irregular periods. Worry or emotional upset may
also cause a woman to miss her period.

e If bleeding starts during pregnancy, this almost always is the beginning of a
miscarriage (death of the developing baby, see O32 7%:

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

THE MENOPAUSE
(WHEN WOMEN STOP HAVING PERIODS)

The menopause or climacteric 1s the time ina
woman’s life when the menstrual periods stop coming.
After menopause, she can no longer bear children. In
general, this ‘change of life’ happens between the ages
of 40 and 50. The periods often become irregular for
several months before they stop completely.

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

Women who have severe bleeding or a lot of pain in
the belly during menopause, or who begin to bleed
again after the bleeding has stopped for months or
years, should seek medical help. An examination is
needed to make sure they do not have cancer or
another serious problem (see p.326):.

293

PREGNANCY
Signs of pregnancy:

All these signs are normal:

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

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

e She may have to urinate more
often.

e The belly gets-bigger.

e The breasts get bigger.

e ‘Mask of pregnancy’ (dark areas
on the face, breasts, and belly).

Ny
Hf]

e Finally, during the fifth month or This is the normal position of the baby in
so, the child begins to move in the womb. the mother at 9 months.

How to Stay Healthy during Pregnancy:

¢ It is very important to eat well. The body needs food rich in proteins,
vitamins, and minerals, especially iron. (Read Chapter 1 1 in this book.)

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

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

® In the last month of pregnancy, it is perhaps best to avoid sexual contact to
keep from breaking the bag of waters and causing an infection.

¢ Avoid taking medicines if at al! possible. Some medicines can harm the
developing baby. Asa rule, only take medicines recommended by a health worker
or doctor. (If a health worker is going to prescribe a medicine, and you think that

you might be pregnant, tell him so.) You can take aspirin or antacids once in a
while if you need them. Vitamin and iron pills are often helpful and do no harm

when taken in the right dosage.

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

¢ Stay far away from children with measles, especially German measles (see
Rubella, p. 359).
¢ Continue to work and get exercise, but try not to get too tired.

294

Minor Problems during Pregnancy:

Nausea or vomiting: Normally, this is worse in the morning, during the
Sec ond or third month of pregnancy. It helps to eat something dry, like crackers
or dry bread, before you get out of bed in the morning. Do not eat large meals,
but rather smaller amounts of food several times a day. In severe cases, take an
antihistamine (see p.419) when you go to bed and when you get up in the
morning. Avoid greasy foods.

2. Burning or pain in the pit of the stomach or chest (acid indiers ae and heart
burn—see p. 149): Eat only small amounts of food at one time. |f possible, drink
milk. Avoid taking antacids. It helps to suck hard candy. Try to sleep with the
chest and head lifted up some with pillows or blankets.

3. Swelling of the feet: Rest at different times during the day with your feet up
(see p.215). Eat less salt and avoid salty foods. Tea made from corn silk may help
(see p. 21). If the feet are very swollen, and the hands and face also swell, seek
medical advice. Swelling of the feet usually comes from the pressure of the child
in the womb during the last months. It is worse in women who are anemic, ©
malnourished, or who eat a lot of salt. So eat nutritious food with little or no salt.

4. Low back pain: This is common in pregnancy. It can be hetped by exercise -
and taking care to stand and sit with the back straight (p.212).

5. Anemia and malnutrition: Many women in rural areas are anemic even’
before they are pregnant, and become more anemic during pregnancy. To make a
healthy baby, a woman needs foods rich in protein and iron. If she is very pale
and weak or has other signs of anemia and malnutrition (see p.125' and146), she
needs to eat more protein. She can get this by eating beans, groundnuts, chicken,
milk, cheese, eggs, meat, fish, and dark green leafy vegetables. She should also
take iron pills (9.424), especially if it is hard to get enough nutritious foods. This
way she will strengthen her blood to resist dangerous bleeding after childbirth. lf
possible, iron pills should also contain some folic acid and vitamin C.

6. Swollen veins (varicose veins): These are common
iN pregnancy, due to the weight of the baby pressing on
the veins that come from the legs. Put your feet up
often, as high as you can (see p.213). If the veins get
very big or hurt, wrap them like this with an elastic
bandage. Take off the bandages at night.

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

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

Also see p.213.

8. Constipation: Drink plenty of water. Eat fruits and food with a lot of

natural fiber, like fruits, tapiocaor bran. Get plenty of exercise. Do not take
strong laxatives.

295
Danger Signs in Pregnancy:

1. Bleeding: |f a woman begins to bleed during pregnancy, even a little, this is
a danger sign. She is probably having a miscarriage (losing the baby). The woman
should lie quietly and send for a health worker. Bleeding late in pregnancy (after
6 months) may mean the placenta (afterbirth) is blocking the birth opening
(placenta previa). Without expert help, the woman could hleéd to death. Try to
get her to a hospital at once. Bae

2. Severe anemia: The woman is weak, tired, and has pale or transparent skin
(see The Signs of Anemia, p. 146). If not treated, she might die from blood loss
at childbirth. If anemia is severe, a good diet is not enough to correct the
condition in time. See a health worker and get pills or injections of iron salts (see
p.424). If possible, she should have her baby in a hospital, in case extra blood is
needed.

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

To treat TOXEMIA OF PREGNANCY a woman should:

¢ Stay quiet and in bed at least for a few hours in the afternoon.

¢ Avoid salt. (Use no salt; eat no foods that contain salt.)

¢ |f she does not get better quickly, has trouble seeing, swells more in the face,
or has fits (convulsions), get medical help fast. Her life is in danger.

ae If you have a headache or trouble
seeing, |

DURING THE LAST 3 MONTHS - -
OF PREGNANCY:

and

if your face and hands begin to
swell, you may be suffering from
.—— TOXEMIA OF PREGNANCY.

GET MEDICAL HELP !

If only your feet swell, it
probably is not serious. But watch
out for other signs of toxemia.

Use little or no salt. a

-~*

To help prevent TOXEMIA OF PREGNANCY: eat nutritious food, making sure
to get enough protein (p. 128) and use very little salt.

296

CHECK-UPS DURING PREGNANCY (PRENATAL CARE)

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

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

Here are some important things prenatal care should cover:
1. Sharing information

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

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

¢ Good hygiene (Chapter 12).

¢ The importance of taking few or no medicines (p. 66).

¢ The importance of not smoking (p. 178) and not drinking alcoholic drinks
(p47 7).

¢ Getting enough exercise and rest.

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

2. Nutrition

Does the mother look well nourished? Is she anemic? If so, discuss ways of
eating better. If possible, see that she gets iron pills—preferably with folic acid and
vitamin C. Advise her about how to handle morning sickness (p. 294) and heart-
burn (p. 149). |

Is she gaining weight normally? If possible, weigh her each visit. Normally she
should gain 8 to 10 kilograms during the nine months of pregnancy. If she stops
gaining weight, this is a bad sign. Sudden weight gain in the last months is a

danger sign. If you do not have scales, try to judge if she is gaining weight by how
she looks.

Or make
a simple
scales.

bricks or ————————>
other objects

of known

weight

297

3. Minor problems

Ask the mother if she has any of the common problems of pregnancy. Explain
that they are not serious, and give what advice vou can (see p. 294).

4. Signs of danger

. Check for each of the danger signs on page 295. Take the mother’s pulse each
visit. This will let you know what is normal for her in case she has problems later
(for example shock from toxemia or severe bleeding). If you have a blood pressure
cuff (see p. 147), take her blood pressure. And weigh her. Watch out especially
for the following danger signs:

sudden weight gain signs of
swelling of hands and face toxemia of
marked increase in blood pressure pregnancy (p. 295)
severe anemia (p. 146)

any. bleeding (p. 295)

Some midwives may Have paper ‘dip sticks’ or other methods for measuring the
protein and sugar-in the urine. High protein may be a sign of toxemia. High sugar
is a sign of diabetes (p. 149).

If any of the danger signs appear, see that the woman gets medical help as
soon as possible.

5. Growth and position of the baby in the womb
Feel the mother’s womb each time she visits; or show her how to do it herself.

_% , ty
2 —

7 — oa. A . Normally the womb will be 2
7 ones wr Apes fingers higher each month.
6 months (12 cme a
Ae oy oe ae At 4% months it is usually
3 onthe at the level of the navel.

eer

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

Try to feel the baby’s position in the womb. Ait BP.
appears to be lying sideways, the mother should go to \

a doctor before labor begins, because an operation may be
needed. For checking the baby’s position near the time of

birth, see page 303.

298

| Fet

6. Baby’s heartbeat (feta! heartbeat) etoscope
After 5 months, listen for the baby’s heartbeat and check

for movement. You can try putting your ear against the belly,

but it may be hard to hear. It will be easier if you get a

fetoscope. (Or make one. Fired clay or hard wood works well.)
If the baby’s heartbeat is heard loudest: If the heartbeat is heard loudest above
below the navel in the last month, the the navel, his head is bg up. It may

baby is head down and will pres be... be a breech birth.
_born head first.

\f you have a watch with a second hand, count the baby’s heartbeats. From
120 to 160 per minute is normal. If less than 120, something is wrong. (Or
perhaps you counted wrong or heard the mother’s heartbeat. Check her Sia The
baby’s heartbeat is often hard to hear. It takes practice.)

7. Preparing the mother for labor

As the birth approaches, see the mother more often. |f she has other children,
ask her how long labor lasted and if she had any problems. Talk with her about
ways to make the birth easier and less painful (see the next pages). You may want
to have her practice deep, slow breathing, so that she can do this during the
contractions of labor. Explain the importance of relaxing between contractions.

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

HOW A MOTHER CAN TELL THE DATE
WHEN SHE IS LIKELY TO GIVE BIRTH:

Start with the date the last menstrual period began, subtract 3 months,
and add 7 days.

For example, suppose your last period began May 10.

May 10 minus 3 months is February 10,
plus 7 days is February 17.
The baby is likely to be born around February 17.

8. Keeping records

PO compare your findings from month to month and see how the mother is
progressing, it helps to keep simple records. On the next page is a sample record
sheet. Change it as you see fit. A larger sheet of paper would be better. Each

mother can keep her own record sheet and bring it when she comes for her
check-up.

299

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300

THINGS A MOTHER SHOULD HAVE READY
BEFORE GIVING BIRTH

Every pregnant woman should have the following things ready by the seventh
month of pregnancy:
A lot of very clean cloths or rags. A new razor blade. (Do not unwrap

until you are ready to cut the
umbilical cord.)

RAZOR

/ BLADES \

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

A clean scrub brush for cleaning the
hands and fingernails.
a oa i if {4 z
ae . a s Sterile gauze or patches of
thoroughly cleaned cloth for

ee Ki \ ey covering the navel.

Alcohol Cc)

for rubbing Ps

hands A

after $ Two ribbons or strips of clean cloth
washing : for tying the cord.

them. e a ee

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

Clean cotton.

¢

301

Additional Supplies
for the Well-Prepared Midwife or Birth Attendant

Flashlight (torch). Fetoscope—or fetal
stethoscope—for listening

to the baby’s heartbeat ”
through the mother’s
belly.

Suction bulb for sucking

mucus out of the baby’s nose Blunt-tipped scissors for cutting the
and mouth. cord before the baby is all the way
born (extreme emergency only).

=
~~ ae

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

Several ise of ergonovine
(or ergometrine).

: ‘ j : Sterile needle and gut thread for

sewing tears in the birth opening.

Two bowls—1 for washing hands and 1 forcatching
and examining the afterbirth.

Silver nitrate drops for the
baby’s eyes.

eu

302

PREPARING FOR BIRTH

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

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

Danger Signs that Make It Important that a Doctor
or Skilled Midwife Attend the Birth:

e |f the woman begins to bleed before labor.
e |f there are signs of toxemia of pregnancy (see p. 295).
e |f the woman is suffering from a chronic or acute illness.

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

e \f she has had serious trouble or severe bleeding with other births.
e |f she has a hernia. |

e If it looks like she will have twins (see p.315).

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

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

THE BIRTHS WITH THE GREATEST CHANCE OF PROBLEMS ARE:

the first birth and the last births after having |
many children

——-

303

Checking if the Baby Is in a Good Position

To make sure the baby is head down, in the normal position for birth, feel for
his head, like this: |
1. Have the mother breathe out all the way.

With the thumb and 2 fingers, push in here,
just above the pelvic bone.

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

The baby’s butt is Butt up
larger and wider. feels larger a
high up.

Butt down
feels larger
low down.

His head is hard and-
round.

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

If the baby still is high in
the womb, you can move
the head a little. But if it
has already engaged
(dropped lower) getting
ready for birth, you can-
not move it. =
A ‘voman’s first baby
sometimes engages 2
weeks before labor begins.
Later babies may not
engage until labor starts.

If the baby’s butt
is pushed gently
sideways, the
baby’s whole body
will move too.

But if the head is
pushed gently side-
ways, it will bend

at the neck and the
back will not move.

If the baby’s head is down, his birth is likely to go well. oy
If the head is up, the birth may be more difficult (a breech birth), and it is

safer for the mother to give birth in or near a hospital.

If the baby is sideways, the mother should have her baby in a hospital. She
and the baby are in danger (see p. 313).

304

SIGNS THAT SHOW LABOR IS NEAR

e A few days before labol begins, the baby moves lower in the womb. This lets
the mother breathe more easily, but she may need to urinate more often because
of pressure on the bladder. (In the first birth these signs can appear up to 2 weeks
before delivery.)

® Ashort time before the labor begins, a small plug of mucus (jelly) may come
out. Or some mucus may come out for 2 or 3 days before labor begins. Some-
times it is tinted with blood. This is normal.

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

® Some women have a few practice contractions weeks before labor. This is
normal. On rare occasions, a woman may have false labor. This happens when the ©
contractions are coming strong and close together, but then stop for hours or
days before childbirth actually begins. Sometimes walking or an enema will help -
calm the contractions if they are false or bring on childbirth if they are real.

Labor pains are caused by contractions or tightening of the womb.

Between contractions the womb is relaxed like this:

™— | | ee \

The contractions cause the cervix or ‘door of the womb’ to open—a little
more each time.

a The bag of waters that holds the baby in the womb usually breaks with a
flood of liquid sometime after labor has begun. If the waters break before the
contractions start, this usually means the beginning of labor. After the waters

break, the mother should keep very clean. Walking back m :
and
on labor more quickly. : nd forth may ee bring

305

THE STAGES OF LABOR

Labor has 3 parts or stages:

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

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

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

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

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

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

The mother should keep her bowels and bladder empty.

lf the bladder and the

bowels are full, they get in
the way when the baby is
‘being born.

BLADDER FULL

OF URINE FECES

(STOOLS)

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

contraction.

During labor the mother should change positions often or even get up and walk
about from time to time.

306
During the first stage of labor, the midwife or birth attendant should:

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

e Spread clean sheets, towels, or newspapers On the bed and change them
whenever they get wet Or dirty. a ere |

*¢ Have a new, unopened razor blade ready for cutting the cord, or boil a pair
of scissors for 15 minutes. Keep the scissors in the boiled water in a covered pan

until they are needed.

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

if the mother is frightened or in great pain, have her take deep, slow, regular
breaths during each contraction, and breathe normally between them. This will |
help control the pain and calm her. 7 e

THE SECOND STAGE QF LABOR, in which the child is born: Sometimes this —
begins when the bag of waters breaks. It is usually easier thansthe first stage and
takes less time. During the contractions the mother bears down (pushes) with all
her strength. Between contractions, she may seem exhausted and half asleep. This
is normal.

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

squatting, “i sitting propped up, or lying down.

When the birth opening of the mother stretches, and the baby’s head begins to
show, the midwife or helper should have everything ready for the birth of the
baby. At this time the mother should try not to push, so that the head comes ou
more sighs @ This helps prevent tearing of the opening (see p. 315 for more —
details).

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

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

aa a

Sa

307

<

Now try not to push hard. Take
many short, fast breaths. This
helps prevent tearing the opening
(see p. 269).

Then the baby’s body turns to
one side so the shoulders can

come out.

The head usually comes out face
down.

if the shoulders get stuck after the head comes out:

Then she can raise the head a
little so that the other shoulder

comes out.

The midwife can take the baby’s
head in her hands and lower it
very carefully, so the shoulder

can come out.

All the force must come from the mother. The midwife should never pull on

the head, because pulling harms the baby.

308

THE THIRD STAGE OF LABOR begins when the baby has been born and lasts
until the placenta (afterbirth) comes out. Usually, the placenta comes out by
itself 5 mintues to an hour after the baby. In the meantime, care for the baby.

CARE OF THE BABY AT BIRTH

Immediately after the baby comes out:

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

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

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

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

¢ if the baby has not begun to breathe within one minute after birth, start
MOUTH-TO-MOUTH BREATHING at once (see p. 92,93)

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

How to Cut the Cord:

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

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

IMPORTANT: Cut the cord with a clean, unused razor blade. Before unwrapping
it, wash your hands very well. If you do not have a new razor blade, use freshly
boiled scissors. Always cut the cord close to the body of the newborn baby. Leave

only about 2 centimeters attached to the baby. These precautions help prevent
tetanus (see p.225). |

ee oa

309

Care of the Cut Cord:

The most important way to protect the freshly cut cord from infection is to
ceep it dry. To help it dry out, the air must get to it. |f the home is very clean and
chere are no flies, leave the cut cord uncovered and open to the air.

If there are dust and flies, cover the cord lightly. It is best to use sterile gauze.
Cut it with boiled scissors. Put it on like this:

Cut the gauze here!

4. Des

If you do not have sterile gauze, you can cover the navel with a very clean and

freshly ironed cloth. It is better not to use a belly band, but if you want to use
one, use a thin, light cloth, like cheesecloth, and be sure it is loose enough to let

-air in under it, to keep the navel dry. Do not make it tight.

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

Cleaning the Newborn Baby:
| The baby is covered with a white waxy substance called Vermix. This is.
antiseptic. Do not remove it. It will fall "away by itself in 2 or 3 days.”
With a warm, soft, damp cloth, gently clean away any blood or fluid.

| after the cord drops off (usually 5 to 8

It is better not to bathe the baby unti . |
ter, using a mild soap.

days). Then bathe him daily in warm wa

Put the Newborri Baby to the Breast at Once:

ther’s breast as soon as the cord is cut. If the baby

Place the baby at its mo
ke the afterbirth come out sooner and to prevent or

nurses, this will help to ma
control heavy bleeding.

310
TRE DELIVERY OF THE PLACENTA (AFTERBIRTH)

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

Checking the afterbirth:

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

When the placenta is delayed in coming:

If the mother is not losing much blood, do nothing. Never pull on the cord.
This could cause dangerous hemorrhage (heavy bleeding).

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

Massage the womb carefully, until it ge’ If the placenta does not come out soon,

hard. This should make it contract and and bleeding continues, push downward

push out the placenta. on the top of the womb very carefully,
while
supporting
the bottom

i" Vee e of the womb

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

HEMORRHAGING (HEAVY BLEEDING)

When the placenta comes out, there is always a brief flow of blood. It normally
lasts only a few minutes and not more than a quarter of a liter (1 cup) of blood is
lost. (A little bleeding may continue for several days and is usually not serious.)
Bleeding can often be slowed down by putting the baby to the breast. If he will
not suck, perhaps someone can stroke or stimulate the mother’s nipples.

WARNING: Sometimes a woman may be bleeding severely inside without much
blood coming out. Feel her belly from time to time. If it seems to be getting

_ bigger, it may be filling with blood. Check her pulse often and watch for signs of
shock (p.89).

311

If heavy bleeding continues, or if the mother is losing «
; a great deal of
- through a steady trickle, do the following: see Bal of blood

: ¢ Get medical help fast. |f the bleeding does not stop quickly, the mother may
need to be given serum blood ina vein (a transfusion). |

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

¢ The mother should drink a lot of liquid (water, fruit juices, tea, soup, Or
: Rehydration Drink—p. 182}. If she grows faint or has a fast, weak pulse or shows
3 other signs of shock, put her legs up and her head down (see p. 89).

e |f the mother is losing a lot of blood, and is in danger of bleeding to death,
try to stop the bleeding like this: .

and with the other hand massage
the bottom of the womb.

the womb get hard. Then lift the

Massage the belly until you can feel
womb with one hand, |

=
)

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

e |f the bleeding continues in spite of massaging the womb, do the following:

Using all of your weight, press down with Lome nr
both hands, one over the other, on the
belly just below the navel. You should ee: dy

continue pressing down a long time after
the bleeding stops. Zw

- a

e |f the bleeding is still not under control:

Grasp the womb between your hands and squeeze hard.
Keep squeezing it firmly until the bleeding has stopped

for several minutes or until. i
you get medical help. |

312

THE CORRECT USE OF OXYTOCINS: _
ERGONOVINE, OXYTOCIN, P/TOCIN, ETC.

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

1. To control bleeding after-childbirth. This is the most important use of these
‘medicines. Ina case of heavy bleeding after the placenta has come out, inject one
0.5mg.ampule of ergonovine or ergometrine maleate (Methergin, etc.p. 423) —
in the muscle. If she continues to bleed for half an hour, inject “2 amoule more and

take her to the health center. After bleeding is controlled, continue giving 1 tablet.
every 4 hours for 24:hours. If no ergonovine is available, or if heavy bleeding Start.
before the placenta.comes Out, inject oxytocin (Pitocin. p.423) instead.

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

2. To help prevent heavy bleeding after birth. A woman who has suffered from
heavy bleeding after previous births can be given 1 ampule (or 2 pills) of
ergonovine immediately after the placenta comes out, If she continues to bleed
after half an hour, give'another dose and take her to the héalth center.

3. To contro! the bleeding of a miscarriage (p.327). The use of Oxytocics can
be dangerous, and only a skilled health worker should use them. But, if the
woman is rapidly losing blood and medical help is far away, use an Oxytocic as
Suggested above. Oxytocin (Pitocin) is probably best.

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

THE USE OF OxXYTOCICS | CAN KILL THE
DURING CHILDBIRTH TO MOTHER, THE

‘GIVE STRENGTH' TO BABY, OR BOTH.
THE MOTHER... | |

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

lf yOu want the woman to Have enough strength for childbirth, have her eat
body-building and Protective foods during the full 9 months of pregnancy. Also
encourage her to have children less often. Suggest that she not get pregnant again

until enough time:has passéd for her to regain her full strength (see Family
Planning, p.329). 3 | |

313
DIFFICULT BIRTHS

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

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

8 The woman may be frightened or upset. This can slow down or even stop _
contractions. Talk to her. Try to reassure her. Explain that the birth is slow, but
there are no serious problems. Encourage her to change her position often, and to

- drink, eat, and urinate.

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

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

" 'e head may be too large to fit through the woman’s hip bones
Be «more ae in a woman with very narrow hips (and very unlikely
in a woman who has given normal birth before). You may feel that the baby does
not move down. If you suspect this problem, try to get the mother to a aly
as she may need an operation (cesarian). Women with very narrow hips should

have at least their first child in or near a hospital.

as been vomiting or has not been drinking, she may be

« If the mother h tractions. Have her sip Rehydration

dehydrated. This can slow down or stop con
Drink or other liquids between contractions.

314

2. BREECH DELIVERY (the buttocks
come out first). Sometimes the midwife can
tell if the baby is in the breech position by
feeling the mother’s belly (p.303) and ~
listening to the baby’s heartbeat (p. 298).

A breech birth may be easier in this position:

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

slip your fingers inside and push the or press his arms against his body,
baby’s shoulders toward the back, like this: like this:. Ae

Yass

J H ‘

( {

\ pony ay s ts ~ 6
a o3s sen! , ie . =;
eth Bs }

‘ « e 4 .7
‘
a d }
’

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

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

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

4. Sometimes the CORD IS WRAPPED
AROUND THE BABY’'S NECK so tightly he
Cannot come out all the way. Try to slip the
loop of cord from around the baby's neck.
If you cannot do this, you may have to clamp or tie and cut the cord. Use boiled
blunt-tipped scissors. 3

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

et ~f “a

315

ia

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

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

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

_ Signs that a woman is likely to have twins:

.* The belly grows faster and the womb is larger than usual, especially in the
~ last months (see p. 297).
~ . e lf the woman gains weight faster than normal, or the common problems of
| pregnancy (morning sickness, backache, varicose veins, piles, swelling, and ;

. difficult breathing) are worse than usual, be sure to check for twins.
~ @ =f you can feel 3 or more large objects (heads and buttocks) ina womb that
seems extra large, twins are likely.

e Sometimes you can hear 2 different heartbeats (other than the mother’s)—

but this is difficult.

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

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

TEARING OF THE BIRTH OPENING

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

Tearing can usually be prevented if care is taken: |

When the birth opening is It may also help to put hot

The mother should try to = hgiceie p

stop pushing when the baby’s _ stretching, the midwife can compresses against the skin

~ head is coming out. This gives support it with one hand and _ below the birth opening.
her birth opening time to with the other hand gently » Start when it begins to
stretch. In order not to push, keep the head from coming stretch.

she should pant (take many too fast, like this:

short rapid Sree V
/f

y Se -

If a tear does happen someone who knows how should carefully sew it shut
after the placenta comes out (see P- 99 and415).

ee

316:

CARE OF THE NEWBORN BABY
The Cord:

é i . . 7 . kept
To prevent the freshly cut cord from becoming infected, it should be
clean ane dry. The drier it is, the sooner it will fall off and the navel will heal. For

this reason, it is better not to use a belly band, or if one is used, to keep it very
loose (see p. 225 and 309).

The Eyes:

To protect a newborn baby’s eyes from dangerous
conjunctivitis, put a drop of 1% silver nitrate, or a
little tetracycline eye Ointment, in each eye as soon as
he is born (p. 226}. This is especially important if |
either parent has ever had signs of gonorrhea (p. 280).

Keeping the Baby Warm—But Not Too Warm:

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

IN COLD WEATHER

BUT IN HOT WEATHER
BABY HAS A FEVER)

oN
=
rege

(OR WHEN THE

WRAP THE BABY WELL.

LEAVE HIM NAKED.

To keep a baby just warm enough, keep him close to his mother’s body.

Cleanliness:

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

¢ Change the baby’s diapers (nappy) or bedding each time he wets or dirties
them. If the Skin gets red, change the diaper more often—or better, leave it
off! (See p. 256:) |

¢ After the cord drops off, bathe the baby daily with mild SOap and warm
water, 3

¢ If there are flies or mosquitos, cover the baby’s crib with Mosquito netting
Or a thin cloth.

,¢ Persons with open sores, colds, sore throat, tuberculosis, or other infectious
, illnesses should not touch or go near the baby.

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

317

| (Also see “The Best Diet for Small Children,” p. 141.)

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

f

t

| s Breast milk has a better balance of what the baby needs than does any other

. milk, whether fresh, canned, or powdered.

a

| 8 Breast milk is clean. When other foods are given, especially by bottle feeding,
it is very hard to keep things clean enough to prevent the baby from getting

diarrhea and other sicknesses.
= The temperature of breast milk is always right.

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

The mother should give her breast to the baby as soon as he is born. For the
first few days the mother’s breasts usually produce very little milk. This is normal.
She should not start bottle feeding her baby, but should nurse her baby often.
The baby’s sucking will help her produce more milk.

A mother whose breasts make enough milk should give her baby only breast »
milk for the first 4 to 6 months. After that, she should continue to breast feed her
bahy, but should begin to give him other nourishing foods also (see p. 142).

HOW A MOTHER CAN PRODUCE MORE MILK:

She should...

@ drink plenty of liquids,

pecially milk, milk products, and body-building
s beans, dals, green leafy vegetables and fruits |
amount of milk

-@ eat as well as possible, es
foods (see p. 128), ‘such a
like papaya, dry fish and garlic increase the

¢ get plenty of sleep and avoid getting very tired or upset,

¢ nurse her baby more often.

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

ELY BREAST-FED BABIES ARE HEALTHIER.

318

Care in Giving Medicines to the Newborn:

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

ILLNESSES OF THE NEWBORN

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

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

Problems the Baby is Born with: (Also see p. 363)

These may result from something that went wrong with the development of the —

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

e If he does not breathe as soon as he is born.

e If his pulse cannot be felt or heard, or is less than 100 per minute.

e If his face and body are white, blue, or yellow after he has begun breathing.

e If his arms and legs are floppy—he does not move them by himself or when
you pinch them.

e |f he grunts or has difficulty breathing after the first 15 minutes.

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

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

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

_ 1. Pus or a bad smell from the navel (cord) is a dangerous sign. Watch for early
signs of tetanus (p.223) ora bacterial infection of the blood (p. 321). Soak the
cord in hydrogen peroxide, paint it with gentian violet (0.409), and leave it open
to the air. If the skin around the cord becomes hot and red, treat with ampicillin
(p. 399) or with penicillin and streptomycin (p. 4.00) .

2 Either low temperature (below 35°) or high fever can be a sign of infection.
High fever (above 3S) /s dangerous for the newborn. Take off all clothing and

319

3. Fits (convulsions, see p. 217). If the bab l
i )e y also has fever, treat it as just
described. Be sure to check for dehydration. Fits that begin the day of ak are
probably caused by brain damage at birth. If fits begin several days later, look
carefully for signs of tetanus (p. 223) or meningitis (p.2:25).

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

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

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

A baby who vomits violently, or so much and so BURP YOUR BABY
often that he begins to lose weight or become AFTER FEEDING
dehydrated, is ill. If the baby also has diarrhea, he
probably has a gut infection (p. 188). Bacterial infection of the blood (see the
next pages), meningitis (p. 2.25), and other infections may also cause vomiting.

If the vomit is yellow or green, there may be a gut obstruction (p. 1 07)
especially if the belly is very swollen or the baby has not been having bowel

movements. Take the baby to a health center at once.

than 4 hours pass and the baby still will

tops sucking well. |f more
ee ee : f the baby seems very sleepy or ill, or if

not nurse, this is a danger sign—especially |
he cries or moves differently from normal. Many illnesses can cause these signs,

but the most common and dangerous causes in the first 2 weeks of life are a
bacterial infection of the blood (see next 2 pages) and tetanus (p.223).

rsing during the second to fifth day of life

ho stops nu
fees bacterial infection of the blood.

may have a
o fifteenth day

) i i fifth t
ho stops nursing during the
phsnsis may have tetanus.

320

If a Baby Stops Sucking Well or Seems III:

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

» Notice if the baby has difficulty breathing. If the nose is stuffed up, suck it
out as shown on page 201. Fast breathing (50 or more breaths a minute), blue
color, grunting, and sucking in of the skin between the ribs with each breath are
signs of pneumonia (p.209). Small babies with pneumonia often do not cough;
sometimes none of the common signs are present. If you suspect pneumonia,
treat as for a bacterial infection of the blood (see the next page).

» Look at the baby’s skin color.

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

if the face and whites of the eyes begin to get yellow (jaundiced) in the first .
day of life or after the fifth day, this is serious. Get medical help. Some yellow
color between the second and fifth day of life is usually not serious. Give the
baby plenty of liquid—Rehydration Drink is best, in addition to breast milk
(p. 182). Take off all his clothes and put him in bright light near a window (but
not direct sunlight).

# Feel the soft spot on top of the head (fontanel). See p. 6.

If the soft spot is ; If the soft spot is

SUNKEN, : SWOLLEN,

DEHYDRATED. MENINGITIS.

IMPORTANT: \f a baby has meningitis and dehydration at the same time, the

soft spot may feel normal. Be sure to check for other signs of both dehydration
(see p. 181) and meningitis (see p.225).

® Watch the baby’s movements and expression on his face.

Stiffness of the body and/or strange movements
may be signs of tetanus, meningitis, or brain
damage from birth or fever. If, when the baby is
touched or moved, the muscles of his face and
body suddenly tighten, this could be tetanus.
See.if his jaw will open arid check his knee
reflexes (p.224). ~, atk

321

If the baby’s eyes roll back or flutter when he makes sudden or violent
movements, he probably does not have tetanus. Such fits may be caused by

# Look for signs of a bacteria] infection in the blood.

Bacterial Infection in the Blood (Septicemia):

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

Signs:

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

e does not suck well e swollen belly

yellow skin (jaundice)

e seems very sleepy
fits (convulsions)

e very pale (anemic)
¢ vomiting or diarrhea e times when the baby turns blue
e fever or low temperature (below 35°)

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

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

Treatment when you suspect septicemia in the newborn:
¢ Inject ampicillin (p. 399)
¢ Or inject penicillin

* Be sure the baby has enough liquids. Spoon feed breast milk and
Rehydration Drink, if necessary (see p. 182).

¢ Try to get medical help.

Infections in newborn babies are weiipni 267 io Saad
i ible, get medical heip. ;

Often there is no fever. If possible, edical

with ampicillin as described above. Ampicillin is one of the safest

and most useful antibiotics for babies.
LAS -_~ G be

gr f $) ; See | * .

322

THE MOTHER’S HEALTH AFTER CHI LDBIRTH

Diet and Cleanliness:

As was explained in Chapter 11, after she gives birth to a ons yeah
and should eat every kind of nutritious food she can get. es oes er ed
avoid any kind of food. Foods that are especially good for her at m pe. : i
chicken, eggs, meat, fish, fruits, vegetables, grains, beans, grounanuts, : Bee: a
she has is chapatties. rice and dal , she should eat them together at eac ;
and other dairy products help the mother make plenty of milk tor her baby.

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

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

eat nutritious foods and bathe regularly.

Ag

Childbirth Fever (Infection after Giving Birth):

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

Tie signs of childbirth fever are: chills or fever, headache or low back pain,

sometimes pain in the belly, and a foul-smelling or bloody discharge from the
vagina.

Treatment:

Vaginal wash with warm water and vinegar or potassium permanganate
will help (p 286) She should do it three times a day till she is better. Penicillin
Other antibiotics (ampicillin or sulfadiazine) may be used instead.

Childbirth fever can be very dangerous.
if the mother does not get well soon, get medical help.

Bie 3. ate

323

CARE OF THE BREASTS

Taking good care of the breasts is j
mportant for the health of both th
a, rela Wipe should be started the same day the baby is eee
not suck much, but this lets the mother’ ae
sucking, and helps prevent sore nipples. So... other's body get used to his

BEGIN BREAST FEEDING THE SAME DAY THE BABY IS BORN.

The milk that the breast makes for the first two days is called co/ostrum. This is thin
and watery . Often mothers believe that this milk has gone bad. So they do not feed
the baby with this milk. This is not truel Colostrum contains a lot of antibodies in it
which protect the baby against infections. It also has a lot of proteins: If the baby
starts sucking on the first day, the breasts will also produce more milk.

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

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

TO MILK YOUR BREASTS:

Take hold of the breast
way back, like this,

!

then move your hands
forward, squeezing,

eee and finally, squeeze the
milk out of the nipple.

ortant to milk the breasts when the baby stops sucking
m getting too full. When they are too full, they
fully full is more likely to develop an abscess.
king them even if he wants to.

Another reason it is imp
is that this keeps the breasts fro
are painful.-A breast that is pain
Also, the baby may have trouble suc

When your baby is too weak to suck, squeeze milk out of your breasts by hand

and give it to the baby by spoon or dropper.

324
Always keep your breasts clean. Before breast feeding your baby, wipe your

nipples with a clean, moist cloth. Do not use soap each time you clean your
nipples, as this may lead to cracking of the skin, sore nipples, and infection.

Sore Nipples:

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

NIPPLE

Prevention:

If a woman with short nipples
squeezes her nipples like this several
times a day during pregnancy, this
will make it easier for her child to
suck, and she will be less likely to
get sore nipples.

Treatment:

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

Breast Abscess (Infection Inside the Breast, Mastitis):

A breast abscess may result from an infection that
enters through a sore or cracked nipple. This is most
common during the first weeks or months of breast
feeding.

BRN AZ
TN a aha
: (pie

Signs:

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

Prevention:

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

¢ Also put a little vegetable oi! or baby oil on the nipples after each feeding.

Treatment:

¢ Let the baby continue to feed fr

‘ om the absce bike al
whichever is less painful. ssed breast, or milk it by hand,

¢ Use hot compresses to ease the pain. Also take aspirin

¢ Take an antibiotic as for childbirth fever (see p.322).

Different kinds of breast lumps:

A painful, hot lump in the breast of a nursing mother
__ ts probably‘a breast abscess (infection).
A painless breast lump may be cancer.

Breast Cancer:

Cancer of the breast is fairly common in women, and is always dangerous.
Successful treatment depends on spotting the first sign of possible cancer and

getting medical care soon. Surgery is usually necessary .
Qe
AX ieee
ge ee = ce

Signs of breast cancer:

e The woman may notice a lump, often in
this part of the breast.

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

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

e The lump grows slowly.

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

SELF-EXAMINATION OF THE BREASTS:

Every woman should learn how to
examine her own breasts for possible
signs of cancer. Once a month:

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

¢ While lying with a pillow or
folded blanket under your back, feel
your breasts with the flat of your

325

326

fingers. Press your breast and roll it
beneath your finger tips. Start near
the nipple and go around the breast
Sie. nae up into the armpit.

2h ¢ Then squeeze your nipples and
check whether blood or a discharge
; comes out.

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

LUMPS OR GROWTHS IN THE LOWER PART OF THE BELLY

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

= acyst or watery swelling in one of the ovaries

-® by a baby that has accidentally begun to
deveiop outside of the womb (ectopic
pregnancy), or |

® cancer

All 3 of these conditions are usually painless or
mildly uncomfortable at first, and become painful later. All require medical

attention—usually surgery. If you find any unusual, gradually growing lump, seek
medical advice.

Cancer of the Womb:

Cancer of the uterus (womb), cervix (neck of the womb), or ovaries is most
common in women over 40. The first sign may be anemia or unexplained bleeding.

Later, an uncomfortable or painful lump in the belly may be noticed.

At the first suspicion of cancer, seek medical help.

Home remedies are not likely to help.

ere

327

Out-of-Place or Ectopic Pregnancy:

ata Sometimes a baby begins to form
where a baby Outside the womb, in one of the

: tubes that comes from t i

is normally : he ovaries.
made ,

There may be abnormal
menstrual bleeding together with
to ovary signs of pregnancy—also cramps low
in the belly and a tender lump
ovary— outside the womb. -
where the
eggs are

_A baby that begins to form out

of place usually cannot live.

Ectopic pregnancy requires surgery
. In a hospital. If you suspect this

vulva— problem, seek medical advice soon,
or lips of as dangerous bleeding could start
vagina any time.

MISCARRIAGE (SPONTANEOUS ABORTION)

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

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

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

30 days

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

A miscarriage is like a birth in that the embryo
(the beginning of the baby) and the placenta (after-
birth) must both come out. Bleeding often
continues until both are completely out.

Treatment:
nerally there is no problem. The woman should

ing, ge
If there is no heavy bleeding, 9 hould be treated with the same care and

stay in bed, and the miscarriage s
precautions as a birth.

328

If there is heavy bleeding, or bleeding continues for many days:

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

¢ Stay in bed until the heavy bleeding stops and for 2 or 3 days after the
miscarriage.

¢ If the bleeding is extreme, follow the instructions on page 313.

¢ |f fever or other signs of infection develop, treat as for Childbirth Fever (see
p: 322). .

If you have
bleeding and

remain lying down until
everything comes out,

suspect a and the bleeding stops.

miscarriage,

HIGH RISK MOTHERS AND BABIES

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

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

The book Where There I s No Doctor is available
at Rs 29/- plus postage. Multiple copies of reprints
of various chapters are also available,

Please write to:

Publications Officer

Voluntary Health Association of India
C-14 Community Centre

Safdarjung Development A rea

New Delhi 110016
Rs. 2.50

Summary: COMMUNITY HEALTH CELL  37/7, (First Floor) St. Marke BR    M-1 6 Ranaatora - 560.001 3  | INFORMATION FOR MOTHERS  19 AND MIDWIVES    This is a reprint from    RR There Is-No Docher    (Indian adaptation)    published by the    Voluntary Health Association of India  C-14 Community Centre  Safdarjung Development Area  New Delhi 110016    COMM Ute tase PELL    —— 291    CHAPTER    INFORMATION FOR MOTHERS  7 ) AND MIDWIVES.    THE MENSTRUAL PERIOD  (MONTHLY BLEEDING IN WOMEN)    Most girls have…


Instructions and Precautions for Injections. Lesson from Book "Where there is no doctor"

COMMUNITY SZ ALTH CTL

47/1, (First Fleor) St. Marks Road

Md-28 Bandatore - 580 091,
INSTRUCTIONS AND PRECAUTIONS
9) FOR INJECTIONS

This is a reprint from

Where There Is No Doctor

(Indian adaptation)

published by the

Voluntary Health Association of India
C-14 Community Centre
Safdarjung Development Area
New Delhi 110016

COMMUSt ry WEA TH CELL | 77

CHAPTER

INSTRUCTIONS AND PRECAUTIONS
FOR INJECTIONS

WHEN TO INJECT AND WHEN NOT TO.

Injections are not needed fied. Most sicknesses that require medical treatment
can be treated as well or better with medicines taken by pent. As a general rule:

It is more dangerous to inject
medicine than to take it by mouth.

Injections should be used only when absolutely necessary, Except in
emergencies, they should be given only by health workers or persons trained in
their use. |

The only times medicines should be injected are:

1. When the recommended medicine does not come in a form that can be taken
by mouth.

2. When the person vomits often, cannot swallow, or is unconscious.

3. In certain unusual emergencies and special cases (see the next page).

WHAT TO DO WHEN THE DOCTOR PRESCRIBES INJECTIONS

Doctors and other health workers sometimes prescribe injections when they are
not needed. After all, they can charge more money for injections. They forget
the problems and dangers of giving them in rural areas.

1, If a health worker or healer wants to give you an injection, be sure the
medicine is appropriate and that he takes all the necessary precautions,

2. |\f a doctor prescribes injections, explain that you live where no one is well
trained to give injections and ask if it would be possible to prescribe a medicine to
take by mouth.

3. If a doctor wants to prescribe injections of vitamins, liver extract, or vitamin
B72, but has not had your blood tested, tell him you would prefer to see another
doctor.

78
EMERGENCIES WHEN IT IS IMPORTANT TO GIVE INJECTIONS

In case of the following sicknesses, get medical help as fast as you can. If there
will be any delay in getting help or in taking the sick person to a health center,
inject the appropriate medicine as soon as possible. For details of the doses,
consult the pages listed below. Before injecting, know the possible side effects and
take the needed precautions.

For these sicknesses | Inject these medicines

Severe pneumonia (p 208)
Infections after childbirth (p. 322) penicillin in high doses (p. 398'+99
Gangrene (p. 254)
Tetanus (p. 222) penicillin (p. 397=98)
and tetanus antitoxin (p.421 )
and phenobarbital (p.422)
or diazepam (p.423)

Appendicitis (p.108) penicillin or ampicillin

Peritonitis (p,108) and bullet wound in strong doses (p. 399)
or other puncture wound in the

belly

Poisonous snakebite (p.121) snake antivenin (p. 421)

Scorpion sting (p.123) scorpion antivenin (p. 421)

Meningitis (p. 225) penicillin (p. 398) in very high doses
when you do not suspect or ampicillin (p.399 400)

tuberculosis

Meningitis (p.226) ampicillin or penicillin together
when you suspect tuberculosis with streptomycin (p.399~ 400)”
} and other ‘anti- tuberculosis

drugs (p. 403)

Vomiting (p.192) when it antihistamines, for example,
cannot be controlled promethazine (p.419,420)

Severe allergic reaction

allergic shock, (p. 83) Adrenalin (p. 419)
and severe asthma, (p. 204)

The following chronic illnesses generally require injections. but they are
rarely emergencies. It is best to consult a health worker for treatment.

Tuberculosis (9.219 220) streptomycin (p.403.404) together

with INH tablets and PAS tablets
(p. 404)

syphilis (p.281) procaine penicillin in very high
Gonorrhea (p.280) doses (p. 399)

79

WHEN NOT TO INJECT:

Never give injections if you can get medical help quickly.
Never give an injection for a sickness that is not serious.
Never give injections for a cold or the flu.

Never inject a medicine that is not recommended for the illness you
want to treat.

Never inject a medicine unless you know and take all the recommended
precautions.

Avoid giving injections especially to smail children when
there is an epidemic of polio in your village.

MEDICINES NOT TO INJECT

In general, it is better never to inject the following:

1. Vitamins. Rarely are injected vitamins any better than vitamins taken by
mouth. Injections.are more expensive and more dangerous. Use vitamin pills
or syrups rather than iniections. Better still, eat foods rich in vitamins (see
0.130).

2. Liver extract and vitamin B12. Do not inject them! Ferrous sulfate pills will

do more good for almost all cases of anemia (see p. 424)

3. Calcium. Injected into a vein calcium is extremely dangerous, if not given
very slowly. An injection in the buttock may Cause a large abscess. Untrained
people should never inject calcium.

4. Penicillin, Nearly all infections that require penicillin can be effectively
treated with penicillin taken by mouth. Penicillin is more dangerous when
injected. Use injectable penicillin only for dangerous infections.

5. Penicillin with streptomycin. Avoid this combined medicine. Never use it

for colds or the flu (p.200).

6. Chloramphenicol or tetracycline. These medicines do as much or more good

when taken by mouth. Use capsules or syrups rather than injections (p.401).

7. Intravenous (1.V.) solutions. These should be used only for severe

dehydration and given only by someone who is well trained. When not given
correctly they can cause dangerous infections or death (p. 64).

8. Intravenous medicines. There is so much danger in injecting any medicine in

the vein that only well-trained health workers should do it. However, never
inject into a muscle (the buttock) medicine that says ‘for intravenous use
only’. Also, never inject in the vein medicine that says for intramuscular use
only’.

sO

RISKS AND PRECAUTIONS

The risks of injecting any medicines are (1) infection caused by germs entering
with the needle and (2) allergic or poisonous reactions caused by the medicine.

1. To lower the chance of infection
when injecting, take great care that
everything is completely clean. It is
very important to boil the needle and
syringe before injecting. After boiling,
do not touch the tip of the needle with your
fingers or with anything else.

Always boil the needle before each injection,
especially if you are using the same needle
for many persons. Carefully follow all of

the instructions for injections (see following
pages) cs

|

An abscess like this one comes from
injecting with a needle that has not
been well boiled and is not sterile
(completely clean and germ-free).

2. This child was injected with a needle
that was not sterile.

The dirty needle caused an infection that

produced a large painful abscess (pocket
of pus)and ‘gave the child a fever.

Finally, the abscess burst as shown in
the picture below.

The child was injected for a cold. It
would have been far better to give him no?
medicine at all. Rather than doing him .

good, the injection caused the child
suffering and harm.

81

3. To avoid problems like this:

Inject only when absolutely necessary.

* Boil the syringe and needle just before
giving the injection and be very careful
to keep them completely clean.

* Use only the medicine recommended for
the disease and be sure that it is still

in good condition and not spoiled:

* Inject in the correct place. (Notice

that this child was injected too low on the
‘buttock, where it is possible to damage
the nerve.

4. It is very important to know what

reactions medicine can produce and to
take the recommended precautions before |
injecting. -

DANGEROUS REACTIONS FROM INJECTING
CERTAIN MEDICINES

Certain drugs like penicillin, ampicillin, and antitoxins are likely
to give severe allergic reactions. Before injecting the full dose of
any of these medicines, ALWAYS DO A SENSITIVITY TEST * to find
Out. if the person is sensitive to the medicine.

Always keep adrenalinready before and after doing a sensitivity
test.

How to do a sensitivity test.
¢ Prepare the syringe for injection as shown in page 85

¢ Use avery small needle

e Clean the skin of the inner side of the forearm with soap and water
or alcohol

* Be sure the skin is dry before injecting

LL TT RT ISN RE Ae SO ETP A RN TEI

- * 7 e.¢ ‘ * { ) Af 4 “\f Tt \V rc | -
David Werner has not included the ‘sensitivity test’ in his original book, as he tee thay subi Atesl dbas Ty iB
not prove that a person is not sensitive to the medicine G//1, (First Floor) St. Marke 5. 4
——_ tr - “s m4 ¥ af nN S Noa -_

82

® Hold the syringe flat against the skin

@ Inject Q)1 ml. of the medicine just into the skin so that a raised area, J
the size of a pea, is formed,. Do not injoct under the skin.

@ Remove the needle and wait for 30 minutes. ; a 4

4

PZ
Watch for the following signs: Sf-————

site of the injection becomes red, painful, or swells up

hives or a rash with itching
swelling anywhere

difficult breathing

signs of shock (see p. 83)

dizzy spells with nausea
(wanting to vomit)

problems with vision
ringing in the ears or deafness
severe back pain

difficulty urinating

lf any of the signs appear, DO NOT INJECT THE REST OF THE
MEDICINE. DO NOT EVER GIVE THE MEDICINE TO THE SAME
PERSON AGAIN.Inject 2 mi. of adrenalin for adults and % ml. for
children.

lf none of these signs appear within 30 minutes, then inject the
rest of the medicine in the muscle of the buttocks as shown in
page. 86

Sometimes a person who shows no signs of allergic reaction after a sensitivity test

may show the signs after a full dose. Always keep adrenalin ready even after doing
a sensitivity test.

lf a person complains of hives or rash a few days after getting a full dose of the

injection, he is probably allergic to the medicine. Do not give him the same medicine
again.

Sometimes, hives or arash with itching can appear a few hours or several days after
getting an injection.

83

The following groups of medicines sometimes produce a dangerous reaction
called ALLERGIC SHOCK a short time after injection:

® penicillins (including ampicillin)

snake antivenin

scorpion antivenin
s antitoxins that are made from horse serum

tetanus antitoxin

The risk of Allergic snock is greater in a person who has previously oN
injected with one of these medicines or with another medicine of the same group.
This risk is especially great if the medicine caused an allergic reaction (hives,
itching, swelling, or trouble breathing) a few hours or days after the injection was
given.

Rarely, ALLERGIC SHOCK may
result from the sting of a wasp or bee or
from medicine taken by mouth. ie

q

To prevent a serious reaction from an injection:

1. Use injections only when absolutely necessary.

2. Before injecting one of the medicines listed above, always have ready Z
ampules of Adrenalin (p. 419) and an ampule of an antihistamine like
promethazine (Phenergan, p.419) or diphenhydramine (Benadryl, p.420).

3. Before injecting, always ask if at any other time a similar injection caused
itching or other reactions. if the person says yes, do not use this medicine or any
other medicine of the same group, either injected or taken by mouth.

If he says no, do a sensitivity test before injecting the full dose of the medicine

4. In very serious cases, like tetanus or snakebite, if there is a good chance that
the antitoxin might produce an allergic reaction (if the person suffers from
allergies or asthma or has had horse serum before), inject promethazine or
diphenhydramine 15 minutes before giving the antitoxin: adults, 3 ml.; children
1 or 2 ml. depending on their size.

5. After injecting any medicine, always stay with the person for 30 minutes to
watch for any of the following signs of ALLERGIC SHOCK:

e cool, moist, pale, gray skin (cold sweat)

@ weak, rapid pulse or heartbeat

e difficulty breathing

e loss of consciousness
These signs can appear even if the sensitivity test was normal.

6. If these signs appear, immediately inject Adrenalin: adults, % ml.; children,
% mt. Treat the person for SHOCK (see p..89). Follow by giving an antihistamine
in double the normal dose.

84

How to Avoid Serious Reactions
to a Penicillin Injection &

1. For mild to moderate infections: 2. Before injecting ask the person:

give penicillin pills ao “Have you ever had
hives, itching, swelling, or

trouble breathing after
getting an injection of
penicillin?”

instead of injections.

If the answer is yes, do not use penicillin o
ampicillin. Use another antibiotic like
erythromycin (p. 400) or a sulfonamide (p.402).
If the answer is no, do a sensitivity test.

OSS etree

3. Before injecting penicillin: 4, After injecting:

always have ampules of
ADRENALIN ready.

i
ADRENALIN

\s
ADRENALIN

stay with the person for at least 30
minutes.

5. If the person becomes very pale, his heart beats very fast, he
has difficulty breathing, or he starts to faint, immediately inject
into a muscle half an ampule of ADRENALIN (a quarter of an
ampule in small children) and repeat in 10 minutes if necessary.

—

85

HOW TO PREPARE A SYRINGE FOR INJECTION

: ps
1. Take the syringe apart » gee
and boil it and the

5 aa ~)at
needle for 15 minutes. as

aa

prem di eg

catty)
3. Put the needle and the syringe
together, touching only the base of
the needle and the button of the
plunger. ee

—_—=

5. Fill the syringe. = 6. Rub the rubber of the 7. Inject the t \
(Be careful that / , bottle with clean cloth distilled water. ,
the needle does 7 f wet with alcohol into the bottle

not touch f- or boiled ~~“). with the

the outside water. ., Leonor’ f powdered

of the Zee medicine.

ampule.)

8. Shake until the

medicine dissolves. again.

9. Fill the syringe

2. Pour out the boiled
water without touching
the syringe or the needle.

4. Clean the ampule of distilled
water well, then break off the top.

10. Remove all air.
from the eee
syringe.

Be very careful not to touch the tip of the needle with anything not even the cotton
with alcohol. If by chance the tip of the needle touches your finger or something

else, boll it again.

86 .

WHERE TO GIVE AN INJECTION

It is preferable to inject in the muscle of the buttocks, always in the upper outer
quarter.

: Never inject children under 2 years of
ues age in the buttock. Inject them in the
ee upper outer part of the thigh.

HOW TO INJECT

1. Clean the skin with soap and water 2. Put the needle straight in, all the
(or alcohol—but to prevent severe pain, way. (If it is done with one quick
be sure the alcohol is dry before movement, it hurts less.)

injecting).

3. Before injecting, pull back 4. |f no blood enter
on the plunger. (If blood enters inject the medicine
the syringe, take the needle slowly.

out and put it in somewhere

else.)

5. Remove the needle
and clean the skin
again.

6. After injecting, rinse the syringe and needle at i
f once. Squirt water through the
peace and then take the syringe apart and wash it. Boil before using again.

The book Where There Ts No Doctor is available
F plus postage. Multiple copies of reprints
s chapters are also available, . 73a

Publications Officer . | : oo
/ Voluntary Health Association of India
_C-14 Community Centre

Safdarjung Development A rea
New Delhi 110016 cae.

Summary: COMMUNITY SZ ALTH CTL    47/1, (First Fleor) St. Marks Road    Md-28 Bandatore - 580 091,  INSTRUCTIONS AND PRECAUTIONS  9) FOR INJECTIONS    This is a reprint from    Where There Is No Doctor    (Indian adaptation)    published by the    Voluntary Health Association of India  C-14 Community Centre  Safdarjung Development Area  New Delhi 110016    COMMUSt ry WEA TH CELL | 77    CHAPTER    INSTRUCTIONS AND PRECAUTIONS  FOR INJECTIONS    WHEN TO INJECT AND WHEN NOT TO.    Injections are not…