Maternal Healthcare

Members:
2C Garcia, Jewelle 2D Mayugba, John Vince
2C Halasan, Kyle Lester 2D Medina, Aiko
2D Layda, Jan Michael Carl 2D Mendiola, Princess
2D Lequin, Remgia P. 2D Morales, Ladylysa Camille
2D Lescain, Janny Vave S. 2D Nitcha, King zeus
2D Likiyan, Chastine G. 2D Nolasco, Jerome Pierre
2D Lopez, Julyssa Jem
 OUTLINE:

I. INTRODUCTION
II. WHO MATERNAL HEALTH
A. MATERNAL AND PERINATAL HEALTH PROMOTION, PREVENTION AND PROTECTION
B. ANTENATAL CARE
C. PRE-ECLAMPSIA AND ECLAMPSIA PREVENTION
D. INTERVENTIONS TO IMPROVE PRETERM BIRTH OUTCOMES
E. PREVENTION OF MATERNAL PERIPARTUM INFECTIONS
F. LABOUR AND CHILD BIRTH AND PREVENTION OF OF POSTPARTUM HEMORRHAGE
G. POSTNATAL CARE AND HEALTH PROMOTION(MATERNAL AND NEWBORN)
H. MANAGEMENT OF MATERNAL CONDITION
III. Maternal Health Care Situation in the Country
IV. CONCLUSION
What´s the relevance of Maternal Health Care in
the Life Cycle Approach?

The relevant life-cycle is assumed to start before pregnancy and, in the context of the
reproductive and sexual health of women, to extend through pregnancy, birth and on to the
baby’s childhood and the health of its mother (WHO, 2012).
The stages of life cycle are interdependent. Reproductive health will impact on pregnancy,
and the health of a pregnant woman will impact on the health of the newborn child (WHO,
2021).
II. WHO Maternal Guidelines
 ANTENATAL CARE
FOR A
POSITIVE PREGNANCY
EXPERIENCE
 NUTRITION AND NUTRITIONAL SUPPLEMENTS
DIETARY INTERVENTION GOAL
RECOMMENDATIONS
(for pregnant women)
Counselling about healthy eating To prevent excessive weight gain
and keeping physically active during pregnancy
during pregnancy
Nutrition education on increasing To reduce risk of low-birth-weight
daily energy and protein intake (in neonates
undernourished populations)

Balanced energy and protein To reduce risks of stillbirths and

dietary supplementation (in small-for-age-gestational-age
undernourished populations) neonates
 NUTRITION AND NUTRITIONAL SUPPLEMENTS

RECOMMENDED NOT RECOMMENDED

✔ Iron and folic acid X Vitamin B6 (pyridoxine)
supplements supplements
✔Calcium supplements (in X Vitamin E and C supplements
population with low X Vitamin D supplements
dietary calcium intake) X Multiple micronutrient
✔Restrict caffeine intake

⮚ Vitamin A- only recommended for pregnant

women in areas where vitamin A deficiency is
a severe health problem

⮚ Zinc supplements-only recommended in

context of rigorous research
MATERNAL AND FETAL ASSESMENT
ANEMIA
• Full blood count testing
• *On-site hemoglobin testing

ASYMPTOMATIC BACTERIURIA (ASB)

• Midstream urine culture
• *On site midstream urine gram staining

GESTATIONAL DIABETES MELLITUS (GDM)

• Hyperglycemia first detected during
pregnancy should be classified as either
GDM or diabetes mellitus in pregnancy
MATERNAL AND FETAL ASSESSMENT
Human Immunodeficiency virus (HIV) and
syphillis
• High prevalence settings 🡪 Provider initiated
testing and counselling (PITC) for HIV as
routine component of package for pregnant
women
• Low prevalence settings🡪 PITC can be
considered

TUBERCULOSIS
• Systematic screening for active TB as part of
antenatal care - to be considered in settings
where TB prevalence is ≥100/100,000
MATERNAL AND FETAL ASSESSMENT
INTIMATE PARTNER VIOLENCE
• Clinical enquiry about possibility of IPV when
assessing conditions that may be caused or
complicated by IPV

TOBACCO USE
• Past and present tobacco use
• Exposure to second hand smoke

SUBSTANCE USE
• Alcohol use and other substances

DAILY FETAL MOVEMENT COUNTING

• Only recommended in the context of
rigorous research
MATERNAL AND FETAL ASSESSMENT
SYMPHYSIS-FUNDAL HEIGHT (SFH) MEASUREMENT
• Not recommended to replace abdominal
palpation for assessment of fetal growth

ANTENATAL CARDIOTOCOGRAPHY
• Not recommended routine antenatal
cardiotocography

ULTRASOUND SCAN
• One utrasound scan before 24 weeks is
recommended

DOPPLER ULTRASOUND OF FETAL BLOOD VESSELS

• Not recommended routine doppler ultrasound
Preventive measures
• Antibiotics for asymptomatic bacteriuria (ASB)
• Antibiotic prophylaxis to prevent recurrent urinary tract infections (RUTI)
• Antenatal anti-D immunoglobulin prophylaxis
• Preventive anthelminthic treatment
• Vaccination
• Malaria prevention
• Malaria prevention: intermittent preventive treatment in pregnancy (IPTp)
• Preventing relapse in P. vivax or P. ovale malaria
• Pre-exposure prophylaxis (PrEP) for HIV prevention
Antibiotics for asymptomatic bacteriuria (ASB)
• ASB - Defined as true bacteriuria in the absence of
specific symptoms of acute urinary tract infection.
• Common in pregnancy, with rates as high as 74%
• Benign for non-pregnant women.
• For pregnant women: Obstruction to the flow of
urine by the growing fetus and womb -> stasis in
the urinary tract -> acute pyelonephritis.
• Preterm birth
• E. coli (80%), Klebsiella, Proteus mirabilis, group B
Streptococcus
• Recommended: seven-day antibiotic regimen is
recommended for all pregnant women with
asymptomatic bacteriuria (ASB) to prevent
persistent bacteriuria, preterm birth and low birth
weight.
Antibiotic prophylaxis to prevent recurrent
urinary tract infections (RUTI)
• Evidence on maternal and neonatal outcomes: uncertain
• Antibiotic prophylaxis is only recommended to prevent
recurrent urinary tract infections in pregnant women in
the context of rigorous research.
• Additional considerations: Antibiotic prophylaxis to
prevent RUTI may lead to increased antimicrobial
resistance and there is a lack of evidence on this
potential consequence.
Antenatal anti-D immunoglobulin prophylaxis
• Antenatal prophylaxis with anti-D immunoglobulin in
non-sensitized Rh-negative pregnant women at 28
and 34 weeks of gestation to prevent RhD allo-
immunization is only recommended in the context of
rigorous research. Fetal and neonatal outcomes:
uncertain
• Only 60% of Rh-negative primigravidas will have an Rh-
positive newborn, therefore 40% of Rh-negative women
will receive anti-D unnecessarily with antenatal anti-D
prophylaxis.
Preventive anthelminthic treatment
• In endemic areas, a preventive anthelminthic
treatment is recommended for pregnant women after
the first trimester as part of worm infection reduction
programs.
• Single-dose albendazole (400 mg) or mebendazole
(500 mg).
• areas where:
(1) The baseline prevalence of hookworm and/or
T. trichiura infection is 20% or more and
(2) Where anaemia is a severe public health
problem, with prevalence of 40% or higher
among pregnant women, in order to reduce
the burden of hookworm and T. trichiura
infection
Vaccination
• Pregnant women with an inadequate or unknown
immunization history should always receive 2 doses of
tetanus toxoid-containing vaccine: the first dose as
early as possible during pregnancy and the second
dose at least 4 weeks later.
• Pregnant women should be vaccinated with trivalent
inactivated influenza vaccine at any stage of
pregnancy.
Malaria prevention
• In malaria endemic areas, mothers and babies should sleep under insecticide-impregnated bed nets.
Malaria prevention: intermittent preventive
treatment in pregnancy (IPTp)
• In malaria-endemic areas in Africa,
intermittent preventive treatment with
sulfadoxine-pyrimethamine (IPTp-SP) is
recommended for all pregnant women.
Dosing should start in the second trimester,
and doses should be given at least one
month apart, with the objective of ensuring
that at least three doses are received.
Preventing relapse in P. vivax or P. ovale malaria
• 14-day course of primaquine (0.25–0.5
mg/kg body weight daily)
• Except pregnant women, infants aged
<6 months, women breastfeeding
infants aged <6 months and people
with G6DP deficiency.
• 0.75 mg/kg body weight once a week for
8 weeks
• For people with G6PD deficiency
-> Monitor for potential primaquine-
induced haemolysis.
Pre-exposure prophylaxis (PrEP) for HIV
prevention
• Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) should be offered as
an additional prevention choice for pregnant women at substantial risk of HIV infection as part of
combination prevention approaches.
Interventions for common physiological
symptoms
• Nausea and Vomiting
• Chamomile, vitamin B6 and/or acupuncture are
recommended for the relief of nausea in early
pregnancy.
• Heartburn
• Lifestyle and diet, Antacid preparations.
• Leg cramps
• Magnesium and calcium + non-pharmacological
treatment options.
• Low back and pelvic pain
• Regular exercise
• Physiotherapy, support belts, acupuncture
• Constipation
• Dietary modification, Wheat bran or fiber supplements
• Varicose veins and edema
• Non-pharmacological options (Compression stockings,
leg elevation and water immersion)
 Health systems interventions to improve
the utilization and quality of antenatal care
• Woman-held case notes
• Pregnant woman to carry her own case notes
• Midwife-led continuity of care
• Issue support throughout the antenatal, intrapartum and
postnatal continuum
• Well-functioning midwifery programs
• Group antenatal care
• Qualified health-care professionals
• Infrastructures and resources
• Facilitated participatory learning and action (PLA)
cycles with women’s groups
• To improve maternal and newborn health, particularly in
rural settings with low access to health services.
• Opportunity for women to discuss their needs during
pregnancy, including barriers to reaching care, and to
increase support to pregnant women.
Health systems interventions to improve
the utilization and quality of antenatal care
• Community mobilization and antenatal home visits
• Household and community mobilization and antenatal
home visits
• Improve antenatal care utilization and perinatal health
outcomes.
• Task shifting components of antenatal care
delivery
• Promotion
• Distribution of nutritional supplements, IPTp
• Recruitment and retention of staffing rural and
remote areas.
• Educational, regulatory, financial and personal and
professional support to recruit and retain health
workers
• Antenatal care contact schedules
• Recommened: 8 contacts
PREVENTION OF PRE-ECLAMPSIA
AND ECLAMPSIA
Pre-eclampsia: Onset of a new episode of hypertension during pregnancy, characterized by: Persistent
hypertension (diastolic blood pressure ≥90 mm Hg) and substantial proteinuria (> 0.3 g/24 hours).
Eclampsia- Generalized seizures, generally in addition to pre-eclampsia criteria
In the Philippines, preeclampsia and eclampsia were the cause of up to 30% of maternal deaths according to
the Department of Health Philippine Health Statistics of 2017.
Prevention
▪ In populations with low dietary calcium intake, daily calcium supplementation (1.5–2.0 g oral elemental
calcium) is recommended for pregnant women to reduce the risk of preeclampsia.
▪ Low-dose acetylsalicylic acid (aspirin, 75 mg) is recommended for the prevention of preeclampsia in
women at high risk of developing the condition.
▪ Low-dose acetylsalicylic acid (aspirin, 75 mg) for the prevention of pre-eclampsia and its related
complications should be initiated before 20 weeks of pregnancy.
▪ Women with severe hypertension during pregnancy should receive treatment with antihypertensive
drugs.
Prevention
▪ Advice to rest at home is not recommended as an intervention for the primary
prevention of pre-eclampsia and hypertensive disorders of pregnancy in women
considered to be at risk of developing those conditions.
▪ Strict bed rest is not recommended for improving pregnancy outcomes in women with
hypertension (with or without proteinuria) in pregnancy.
▪ Restriction in dietary salt intake during pregnancy with the aim of preventing the
development of pre-eclampsia and its complications is not recommended.
▪ Diuretics, particularly thiazides, are not recommended for the prevention of pre-
eclampsia and its complications.
INTERVENTIONS TO IMPROVE
PRETERM BIRTH OUTCOMES
✔RECOMMENDED
Antenatal corticosteroid

▪ in women at risk of preterm birth from 24 weeks to 34 weeks of gestation when the conditions are met
▪ when preterm birth is considered imminent within 7 days of starting treatment, including within the first 24 hours
In women at risk of preterm birth irrespective of whether a single or multiple birth is anticipated.
▪ In women with preterm pre-labour rupture of membranes and no clinical signs of infection.
▪ in women with hypertensive disorders in pregnancy who are at risk of imminent preterm birth
▪ in women at risk of imminent preterm birth of a growth restricted fetus.
▪ in women with pre-gestational and gestational diabetes who are at risk of imminent preterm birth, and this
should be accompanied by interventions to optimize maternal blood glucose control
▪ Either intramuscular (IM) dexamethasone or IM betamethasone (total 24 mg in divided doses)
▪ Antenatal corticosteroid if preterm birth does not occur within 7 days after the initial dose, and a subsequent
clinical assessment demonstrates that there is a high risk of preterm birth in the next 7 days. (moderate-quality
evidence for newborn outcomes and low-quality evidence for maternal outcomes).
✔RECOMMENDED

▪ The use of magnesium sulfate before 32 weeks of gestation for prevention of cerebral palsy in the infant and child
▪ Antibiotic administration for women with preterm pre-labour rupture of membranes.
▪ Erythromycin as the antibiotic of choice for prophylaxis in women with preterm pre-labour rupture of
membranes. (Conditional recommendation based on moderatequality evidence).
NOT RECOMMENDED
▪ Antenatal corticosteroid in women with chorioamnionitis who are likely to deliver preterm.
▪ Antenatal corticosteroid women undergoing planned caesarean section at late preterm gestations (34–36+6 weeks).
▪ Tocolytic treatments for women at risk of imminent preterm birth for the purpose of improving newborn outcomes.
▪ Routine antibiotic administration for women in preterm labour with intact amniotic membranes and no clinical signs
of infection.
▪ The use of a combination of amoxicillin and clavulanic acid (“co-amoxiclav”) for women with preterm pre-labour
rupture of membranes.
▪ Routine delivery by caesarean section for the purpose of improving preterm newborn outcomes, regardless of
cephalic or breech presentation.
PREVENTION OF MATERNAL PERINATAL
INFECTIONS
What is perinatal?
According to the WHO, perinatal is the period of gestation beginning
at 22 weeks (154 days) and ends seven days after birth.
Why is there a need to prevent maternal perinatal infections?
First reason, to prevent maternal mortality.
Second reason, to prevent early neonatal mortality.

How to prevent maternal and early neonatal mortality?

The key is to have access to quality health care before pregnancy,

during and after pregnancy (childbirth) because most of the causes are
avoidable.
WHO 2017 unrecommend
- 1. Routine perineal/pubic shaving prior to giving vaginal birth
REASON:
-Discomfort
-Cultural and religious setting
-Individual preferences
- Autonomy and dignity
NOT RECOMMENDED
2. Routine vaginal cleansing with chlorhexidine during labour for the
purpose of preventing infectious morbidities
REASON:
-Discomfort
-Not cost-effective and no added benefits for the mother and
baby
NOT RECOMMENDED
3.Routine vaginal cleansing with chlorhexidine during labour in women
with group B Streptococcus (GBS) colonization is not recommended for
prevention of early neonatal GBS infection
REASON:
-Discomfort (stinging and irritation)
-Possible emergence of antimicrobial insensitivity
-Not cost-effective
NOT RECOMMENDED
4.Routine antibiotic prophylaxis during the second or third trimester
for all women with the aim of reducing infectious morbidity
REASON:
- Lack of data and possible emergence of antibiotic resistance
-Cost cutting
-Prevention of bigger problem
NOT RECOMMENDED
5.Routine antibiotic administration is not recommended for women in
preterm labour with intact amniotic membranes
REASON:
-Neonatal deaths and cerebral palsy
-Cost cutting
NOT RECOMMENDED
6.Routine antibiotic administration is not recommended for women
with prelabour rupture of membranes at (or near) term
REASON:
-Prevention of antibiotic resistance
-Cost-cutting
NOT RECOMMENDED
7. Routine antibiotic administration is not recommended for women
with meconium-stained amniotic fluid
REASON:
-Prevention of possible antibiotic resistance
-Lack of data regarding its effectiveness
-Cost cutting
NOT RECOMMENDED
8. Routine antibiotic prophylaxis is not recommended for women
undergoing operative vaginal birth
REASON:
-Prevention of possible antibiotic resistance
-Cost cutting
NOT RECOMMENDED
9. Routine antibiotic prophylaxis is not recommended for women with
episiotomy
REASON:
-Low-rate of infection
-Prevention of the emergence of antibiotic resistance
-Prevention of side-effects
-Cost cutting
NOT RECOMMENDED
10. Routine antibiotic prophylaxis is not recommended for women with
uncomplicated vaginal birth
REASON:
-Prevention of antibiotic resistance
-Cost cutting
-Prevention of bigger problem
-Prevention of unwanted side-effects
THE RECOMMENDATIONS:
11. Digital vaginal examination at intervals of four hours is
recommended for routine assessment of active first stage of labour in
low-risk women
REASON:
-To reduce risk infection for both mother and baby
12.Intrapartum antibiotic administration to women with group B
Streptococcus (GBS) colonization is recommended for prevention of
early neonatal GBS infection.
REASON:
-Reduction of early onset GBS infection incidence
-To prevent potential adverse outcomes
13. Antibiotic administration is recommended for women with preterm
prelabour rupture of membranes
REASON:
-Reduce the possibility of chorioamnionitis
-Reduced neonatal pneumonia
-Reduced the need for exogenous surfactant or oxygen therapy
-Reduced risk of cerebral abnormalities
-Shorter NICU stay
14.Routine antibiotic prophylaxis is recommended for women
undergoing manual removal of the placenta
REASON:
-Reduced incidence of puerperal fever and endometritis
-Cost saving for possible adverse outcomes
15. Routine antibiotic prophylaxis is recommended for women with a
third- or fourth-degree perineal tear
REASON:
-Lesser chance of wound infection at 2-weeks after delivery
-To reduce infection due to anatomical considerations.
-Prevention of complications and consequences
-Cost saving for possible adverse outcomes
16. Vaginal cleansing with povidone-iodine immediately before
caesarean section is recommended
REASON:
-Reduced risk of post-CS endometritis
-No important clinical consequences in neonates
-Cost-effective
17.Routine antibiotic prophylaxis is recommended for women
undergoing elective or emergency caesarean section
REASON:
-Reduced incidence of serious infectious complications
-cost-effective
WHO SUGGESTIONS
18.The choice of an antiseptic agent and its method of application for
skin preparation prior to caesarean section should be based primarily
on the clinician’s experience with that particular antiseptic agent and
method of application, its cost and local availability
REASON:
-Patient’s welfare
19. For caesarean section, prophylactic antibiotics should be given
prior to skin incision, rather than intraoperatively after umbilical cord
clamping
REASON:
-Reduced hospital stay
-Reduced incidence of endomyometritis
-More effective
20. For antibiotic prophylaxis for caesarean section, a single dose of
first-generation cephalosporin or penicillin should be used in
preference to other classes of antibiotics
REASON:
- Effective in reducing the risk for cases of endometritis in non-
elective CS
LABOR AND CHILD BIRTH
INDUCTION OF LABOR
RECOMMENDED:
✔Prelabour ROM at term
✔Reached 41 wks AOG

NOT RECOMMENDED:
o Uncomplicated pregnancy, AOG <41
wks
o Gestational DM is the only
abnormality
o Suspected fetal macrosomia
METHODS OF INDUCTION OF LABOR
STRONG RECOMMENDATIONS
✔Oral Misoprostol 25mcg q2h
✔Low- dose vaginal misoprostol 25mcg q6h
✔Misoprostol C/I in previous CS
✔Low dose vaginal prostaglandin
✔Balloon catheter
✔Oral or vaginal misoprostol for dead or
anomalous fetus in the 3rd trimester
✔Sweeping membranes
METHODS OF INDUCTION OF LABOR
WEAK RECOMMENDATIONS
✔IV oxytocin alone should be used, if
prostaglandins are not available.
Amniotomy alone is not
recommended for induction of labor.
✔Balloon catheter and oxytocin as
alternative method when
prostaglandins and misoprostol are
not available or are C/I.
MANAGEMENT OF ADVERSE EVENTS
RELATED TO INDUCTION OF LABOR
✔Betamimetics for
uterine
hyperstimulation during
labor induction. (WR;
LQE)
SETTING FOR LABOR INDUCTION
✔Outpatient labor
induction not
recommended for
improving birth outcomes.
(WR; LQE)
DIAGNOSIS OF DELAY IN THE 1st STAGE OF
LABOR
✔Active Phase Partograph
with a four-hour action line is
recommended for monitoring
labor progress. (SR; LQE)

✔Digital Vaginal Examination

at intervals of 4hrs for routine
assessment and identification
of delay in active labor. (WR;
VLQE)
PREVENTION OF DELAY IN THE FIRST STAGE
OF LABOR
NOT RECOMMENDED
oPackage of care for active labor management. (WR, LQE)
oEarly amniotomy with early oxytocin augmentation. (WR, VLQE)
oOxytocin for prevention of delay in labor in women receiving epidural
analgesia. (WR, LQE)
oUse of amniotomy alone for prevention of labor delay. (WR, VLQE)
oAntispasmodic agents. (WR, VLQE)
oPain relief. (WR, VLQE)
oIV Fluids for shortening duration of labor. (WR, VLQE)
oAdministration of enema for reducing the use of labor augmentation. (SR,
VLQE)
PREVENTION OF DELAY IN THE FIRST STAGE
OF LABOR
RECOMMENDED
✔Oral fluid and food intake in low-risk
women during labor. (WR, VLQE)
✔Encouraging mobility and upright
position in low-risk women during
labor. (SR, VLQE)
✔Continuous companionship during
labor. (SR, MQE)
 TREATMENT OF DELAY IN FIRST STAGE OF
LABOUR WITH AUGMENTATION
• NOT RECOMMENDED
• Augmentation with IV oxytocin PRIOR TO
CONFIRMATION of delay in labour (WR, VLQE)

• High starting and increment dosage regimen

of Oxytocin (WR, VLQE)

• Use of oral Misoprostol (SR, VLQE)

• Use of amniotomy ALONE (WR, VLQE)

 TREATMENT OF DELAY IN FIRST STAGE OF
LABOUR WITH AUGMENTATION

• RECOMMENDED
✔ Use of oxytocin in delayed labour
(WR, VLQE)

✔ Amniotomy and Oxytocin use for

confirmed delayed labour (WR, VLQE)
 PREVENTION OF POSTPARTUM HEMORRHAGE
• NOT RECOMMENDED
• Doing Controlled cord traction in
the absence of a skilled birth
attendants (SR, MQE)

• Early cord clamping (<1 minute

after birth). Unless the neonate is
asphyxiated. (SR, MQE)

• Sustained uterine massage in

women who have received
prophylactic Oxytocin. (WR, LQE)
 PREVENTION OF POSTPARTUM HEMORRHAGE
• Recommended
✔Use of uterotonics (oxytocin 10 IU, IV/M) during the third stage of
labour (SR, MQE)
✔Administration of misoprostol (600 μg PO) by community health care
and lay care workers if skilled birth attendants are not present and
oxytocin is unavailable (SR, MQE)
✔Controlled cord traction is recommended in the presence of skilled
birth attendants for vaginal births if the care provider and the
parturient woman regard a small reduction in blood loss and a small
res=duction in the duration of the third stage of labour as important
(WR, HQE)
✔Late cord clamping while initiating simultaneous essential newborn
care. (SR, MQE)
✔Postpartum abdominal uterine tonus assessment for uterine atony.
(SR, VLQE)
✔Controlled Cord Traction for Caesarian section(SR, MQE)
 POSTNATAL CARE AND
HEALTH PROMOTION FOR
MATERNAL AND NEWBORN
HEALTH
POSTNATAL CARE
• Time of Discharge from the health facility
• Uncomplicated vaginal birth IN FACILITY – strong recommendation to
receive care at least after 24 hours
• Timing and number of postnatal contacts
• Birth AT HOME – strong recommendation for first postnatal contact within
24 hours
• 3 additional postnatal contacts:
• Day 3 (48-72 hours)
• Days 7-14
• 6 weeks
POSTNATAL CARE
• Home visits for postnatal care
• Assessment of the Mother
• First 24 hours after birth
• Assess for vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely
• BP: shortly after birth
• Urine void: within 6 hours
• Strong recommendation
• Beyond 24 hours after birth
• Assess micturition and urinary incontinence, bowel function, healing of any perineal wound, headache,
fatigue, back pain, perineal pain and perineal hygiene, breast pain, uterine tenderness, and lochia
• Breastfeeding: each postnatal contact
• Emotional well-being and social support
• “Maternal blues”: mild, transitory postpartum depression (at 10-14 days after birth)
• Domestic abuse
• Resumption of sexual intercourse, dyspareunia (2-6 weeks after birth)
• GDG consensus
POSTNATAL CARE
• Counselling
• Signs and symptoms of:
• PPH – sudden and profuse blood loss/
persistent increased blood loss,
faintness, dizziness, palpitations,
tachycardia
• Pre-eclampsia/eclampsia – headaches
+ (one or more of) visual disturbances,
nausea, vomiting, epigastric or
hypochondrial pain, faintness,
convulsions
• Infection – fever, shivering, abdominal
pain and/or offensive vaginal loss
• Thromboembolism – unilateral calf
pain, redness or swelling of calves,
shortness of breath/ chest pain
POSTNATAL CARE
• Nutrition counselling and supplementation
• Iron supplementation in postpartum women
• Vitamin A supplementation in postpartum
women
• Psychosocial support
• Prevention of postpartum depression
• Insufficient evidence to recommend routine
formal debriefing
• Counselling on Infection prevention
• Counselling about hygiene, especially
handwashing
• Mobilization, rest and exercise
• Women are encouraged to mobilize (gentle
exercise) and to rest as soon as appropriate
following the birth.
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH

• Birth Preparedness and Complication Readiness

-strongly recommended to increase the use of skilled care at birth and to
increase the timely use of facility care for obstetric and newborn
complications.
• Male involvement interventions for MNH
-promoting the involvement of men during pregnancy, childbiorth and after
birth
-strongly recommended to facilitate and support improved self-care of the
woman,improved home care practices for the woman and newborn, and
improved use of skilled care during pregnancy, childbirth and the postnatal
period for women and newborns.
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Maternity waiting homes (MWHs)
-Conditionally recommended to be established close to a health
facility, to increase access to essential childbirth care and/or care for
obstetric and newborn complications and skilled care for populations
living in remote areas or with limited access to services.
• Community-organized transport schemes

-strongly recommended in settings where other sources of transport

are less sustainable and not reliable, but measures should be taken to
ensure the sustainability, efficacy and reliability of these schemes while
seeking long term solutions to transport
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Partnership with Traditional Birth Attendants (TBAs)
-dialogue with TBAs, women, families, communities and service
providers in order to define and agree on alternative roles for TBAs,
recognizing the important role they can play in supporting the health of
women and newborns.
-Strongly recommended to places where TBAs remain the main
providers of care at birth.
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Providing culturally appropriate skilled maternity care
-Ongoing dialogue with communities and ensuring that women’s voices
are meaningfully included in these dialogues
-strongly recommended as an essential component in defining the
characteristics of culturally appropriate, quality maternity care services
that address the needs of women and newborns and incorporate their
cultural preferences.
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Companion of choice during labour and childbirth for improved
quality of care
-Continuous companionship during labour and birth is recommended
for improving labour outcomes; and improving women’s satisfaction
with services
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Community mobilization through facilitated participatory learning
and action cycles with women’s group
-strongly recommended to implement community mobilization
through facilitated participatory learning and action cycles with
women’s groups to improve maternal and newborn health
-particularly implemented in rural settings with low access to health
services.
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Community participation in quality improvement processes
-strongly recommended for maternity care services to improve quality
of care from women’s, communities’ and health care providers’
perspectives
-recommended also that communities should be involved in jointly
defining and assessing quality and ensuring that women’s voices are
meaningfully included
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Community participation in program planning and implementation
-strongly recommended to improve use of skilled care during
pregnancy, childbirth and the postnatal period for women and
newborns, increase the timely use of facility care for obstetric and
newborn complications and improve maternal and newborn health.
-Mechanisms that ensure women’s voices are meaningfully included
are also recommended.
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Community participation in Maternal Death Surveillance and
Response (MDSR)
-Because of the paucity of evidence available, additional research is
recommended. The sharing information on pregnancy related deaths
with communities including discussion of the different factors causing
these deaths and affecting access to skilled care is of great importance
as affirmed by GDG
HEALTH PROMOTION FOR MATERNAL AND
NEWBORN HEALTH
• Interventions to promote awareness of human, sexual and
reproductive rights and the right to access quality skilled care
-Because of the paucity of evidence available, additional research is
recommended. The
• GDG affirms the importance for MNH programmes to inform
women about their right to health and to access quality skilled care
and to continue to empower them to access such care.
 MANAGEMENT OF
MATERNAL CONDITIONS
A. TREATMENT OF POSTPARTUM
HEMORRHAGE
Intravenous oxytocin alone is the recommended as uterotonic drug Strongrecommendation,
moderate QE

Intravenous ergometrine , oxytocin-ergometrine fixed dose, or a Strongrecommendation,

prostaglandin drug(if oxytocin is unavailable or unresponsive to oxytocin) low QE

Isotonic crystalloids for the initial intravenous fluid resuscitation Strongrecommendation,

low QE

Uterine massage Strongrecommendation,

very low QE

Tranexamic acid (if oxytocin or others fail or if bleeding may be partly due to Weak recommendation,
trauma) moderate QE
A. TREATMENT OF POSTPARTUM
HEMORRHAGE
Intrauterine balloon tamponade for uterine atony (if does not respond to Weak recommendation,
uterotonics/unavailable) very low QE

Uterine artery embolization for uterine atony (If other measures have Weak recommendation,
failed) very low QE

surgical interventions (if uterotonics and other interventions are Strong recommendation,
unsuccessful) very low QE

Bimanual uterine compression for uterine atony (temporizing measure until Weak recommendation,
appropriate care is available) very low QE

External aortic compression for uterine atony (temporizing measure ) Weak recommendation,
very low QE
 Uterine artery embolization
Intrauterine balloon tamponade

Surgical intervention: B lyncH SUTURE

Bimanual uterine compression External aortic compression
A. TREATMENT OF POSTPARTUM
HEMORRHAGE
Non-pneumatic anti-shock garments (temporizing measure) Weak recommendation,
low QE

Uterine packing is not recommended for uterine atony Weak recommendation,

very low QE

IV/IM oxytocin (10 IU) + controlled cord traction(If the placenta is not Weak recommendation,
expelled spontaneously) very-low-QE

Ergometrine for the management of retained placenta (delay the Weak recommendation,
expulsion of the placenta) very low QE

Prostaglandin E2 alpha (dinoprostone or sulprostone-for retained Weak recommendation,

placenta) very low QE

Single dose of antibiotics- ampicillin (manual removal of placenta) Weak recommendation,

very low QE
NON-PNEUMATIC ANTISHOCK GARMENT

OXYTOCIN + CONTROLLED CORD TRACTION

B. INTERVENTIONS FOR TREATMENT OF
PRE-ECLAMPSIA AND ECLAMPSIA
Choice and ROA of an antihypertensive drug should be based primarily on the Weak recommendation,
prescribing clinician’s experience with that drug very low QE

Magnesium sulfate for PREVENTION OF severe pre-eclampsia (in preference to Strong recommendation,
other anticonvulsants) high QE

Magnesium sulfate full IV/IM (Treatment of women with eclampsia) Strong recommendation,
moderate QE

Magnesium sulfate loading dose followed by immediate transfer to a higher level Weak recommendation,
health-care facility (If not possible to administer the full magnesium sulfate regimen) very low QE

Induction of labour (if fetus not viable) Strong recommendation,

very low QE
B. INTERVENTIONS FOR TREATMENT OF PRE-
ECLAMPSIA AND ECLAMPSIA
In severe pre-eclampsia, a viable fetus ,before 36 weeks of gestation, a POLICY OF Weak recommendation,
EXPECTANT MANAGEMENT is recommended, provided that uncontrolled maternal very low QE
hypertension, increasing maternal organ dysfunction or fetal distress are absent and
can be monitored.

Early delivery in severe pre-eclampsia at term Strong

recommendation, low QE

Induction of labour in mild pre-eclampsia or mild gestational hypertension at term Weak recommendation,
moderate QE

Antihypertensive drugs antenatally and continued antihypertensive Strong recommendation,

treatment postpartum / if with severe postpartum hypertension very low QE

corticosteroids for the specific purpose of treating women with HELLP syndrome Weak recommendation,
very low QE
C. TREATMENT OF MATERNAL
PERIPARTUM INFECTIONS
Ampicillin and once-daily gentamicin as first line antibiotics for Conditional
chorioamnionitis. recommendation based
on very low-QE

Clindamycin and gentamicin as first-line antibiotics for Conditional

of postpartum endometritis recommendation based
on very low QE
D. HIV INFECTION DURING
PREGNANCY
HIV diagnosis
Couples and partners in antenatal care settings should be offered voluntary Strong
HIV testing and counselling with support for mutual disclosure. recommendation, low
quality evidence
Generalized epidemics
Provider-initiated testing and counselling is recommended for women No strength, no quality
of evidence
Re-testing is recommended in the third trimester, or during labour or shortly No strength, no quality
after delivery of evidence
Low-level and concentrated epidemics
Provider-initiated testing and counselling should be considered for pregnant No strength, no quality
women. of evidence
D. HIV INFECTION DURING
PREGNANCY
When to start antiretroviral therapy (ART) in pregnant and breastfeeding women
All pregnant and breastfeeding women infected with HIV should initiate triple ARVs Strong
(ART) recommendation,
moderate quality
evidence
For programmatic and operational reasons, particularly in generalized epidemics, all Conditional
pregnant and breastfeeding women infected with HIV should initiate ART as lifelong recommendation, low
treatment. quality evidence
In some countries, for women who are not eligible for ART for their own health, Conditional
consideration can be given to stopping the ARV regimen after the period of mother- recommendation, low
to-child transmission risk has ceased. quality evidence
D. HIV INFECTION DURING
PREGNANCY
Special considerations for the care and management of pregnant women
living with HIV
General guidance
Pregnant women with HIV should receive at least the minimum package of (No strength, no quality
recommended antenatal visits and pregnancy care, and additional interventions of evidence).

There is a high risk of HIV transmission during labour and delivery. This risk can be No strength, no quality
minimized by following several key principles and practices of evidence).
D. HIV INFECTION DURING
PREGNANCY
Additional measures to reduce HIV transmission include:
The early identification of mothers with HIV and providing ARV drugs to both the (No strength, no quality
mother and the newborn baby are essential. of evidence).
For mothers presenting at labour with unknown HIV status, rapid HIV testing should (No strength, no quality
be done during labour or immediately postpartum. of evidence).
For women testing positive, ARV drugs should be provided to both the mother and No strength, no quality
child in accordance with current treatment recommendations and with of evidence).
consideration of extended prophylaxis to the infant.
Health care workers should follow universal precautions for all deliveries, including No strength, no quality
those involving mothers with HIV. of evidence).
D. HIV INFECTION DURING
PREGNANCY
Special efforts should be made to ensure that delivery care is provided in a No strength, no quality
nonstigmatizing and supportive manner. of evidence
Although caesarean section has been shown to protect against HIV transmission, No strength, no quality
especially in the absence of ARV drugs or in the case of high viral load* of evidence
Women with HIV and women of unknown HIV status who deliver outside health No strength, no quality
facilities should be encouraged to be medical assessed at a maternal and child of evidence
health facility as soon as possible after delivery and to begin or continue
appropriate HIV interventions
Providing follow-up, linkages to care and treatment and postpartum care are No strength, no quality
especially important for women with HIV and their HIV-exposed infants. of evidence
Initial care of the child is usually scheduled at the first immunization visit at four to
six weeks, including reinforcement of safe feeding practices, review of ARV
coverage and early infant diagnosis testing.
D. HIV INFECTION DURING
PREGNANCY
First-line ART for pregnant and breastfeeding women and ARV drugs for their
infants
A once-daily fixed-dose combination of TDF + 3TC (or FTC) + EFV is recommended Strong recommendation,
as first-line ART in pregnant and breastfeeding women low to moderate quality
evidence
Infants of mothers who are receiving ART and are breastfeeding should receive six Strong recommendation,
weeks of infant prophylaxis with daily NVP. moderate quality
If infants are receiving replacement feeding, they should be given four to six weeks evidence for
of infant prophylaxis with daily NVP (or twice-daily AZT). Infant prophylaxis should breastfeeding infants;
begin at birth or when HIV exposure is recognized postpartum. strong recommendation,
low quality evidence for
infants receiving only
replacement feeding.
Mothers known to be HIV-infected should be provided with lifelong ART or ARV Strong recommendation,
prophylaxis interventions to reduce HIV transmission through breastfeeding high quality of evidence
according to WHO recommendations
D. HIV INFECTION DURING
PREGNANCY
Vitamin A supplementation in pregnancy for reducing the risk of mother-to-child
transmission of HIV
Vitamin A supplementation in HIV-positive pregnant women is not recommended Strong recommendation,
as a public health intervention for reducing the risk of mother-to-child transmission very low to moderate
of HIV. quality evidence
E. MALARIA DURING PREGNANCY
Treating uncomplicated P. falciparum malaria in special risk groups
First trimester of pregnancy
Treat pregnant women with uncomplicated P. falciparum malaria during the first Strong recommendation
trimester with 7 days of quinine + clindamycin.
Pregnant and breastfeeding women
In women who are pregnant or breastfeeding, consider weekly chemoprophylaxis Conditional
with chloroquine until delivery and breastfeeding are completed, then, on the basis recommendation,
of G6PD status, treat with primaquine to prevent future relapse. moderate-quality
evidence
F. TUBERCULOSIS DURING
PREGNANCY
Nutritional Care and support for patients with tuberculosis
Pregnant women with active TB and moderate undernutrition, or with inadequate Strong recommendation,
weight gain, should be provided with locally available nutrient rich or fortified very low quality of
supplementary foods evidence
Patients with active multidrug-resistant TB and moderate undernutrition should be Strong recommendation,
provided with locally available nutrient-rich or fortified supplementary foods, as very low quality of
necessary to restore normal nutritional status. evidence
F. TUBERCULOSIS DURING
PREGNANCY
Micronutrient supplementation:
A daily multiple micronutrient supplement at 1×recommended nutrient intake Conditional
should be provided in situations where fortified or supplementary foods should recommendation, very
have been provided low quality of evidence
All pregnant women with active TB should receive multiple micronutrient Conditional
supplements that contain iron and folic acid and other vitamins and minerals, recommendation, very
low quality of evidence
F. TUBERCULOSIS DURING
PREGNANCY
For pregnant women with active TB in settings where calcium intake is low, calcium Strong recommendation,
supplementation as part of antenatal care is recommended for the prevention of very low quality of
pre-eclampsia, particularly among those pregnant women at higher risk of evidence
developing hypertension
All lactating women with active TB should be provided with iron and folic acid and (Conditional
other vitamins and minerals recommendation, very
low quality of evidence).
III. Maternal Health Care
Situation in the Country
Maternal mortality ratio
• MMR in the country remains
high and decreased very
slowly.
• Majority of maternal deaths
directly result from pregnancy
complications occurring
during labor, delivery and the
post-partum period.
• Maternal deaths account for
14% of deaths among women
of reproductive age.
Pregnancy complications
• hypertension
• post-partum hemorrhage
• severe infections
• medical problems arising from
poor birth spacing,
• maternal malnutrition,
• unsafe abortions and
• infections like TB, malaria and STI
• Diabetes
Under-five Mortality Rate 1990- Infant Mortality Rate 1990-2015
2015
Factors Contributing to Maternal and
Neonatal Deaths
• These direct causes of maternal
and neonatal deaths require
care by skilled health
professionals in well-equipped
facilities.

• 55 percent of births are

delivered at home, of which 36
percent are attended to by
hilots.
Delays that lead to maternal and neonatal
deaths
• delay in identification of complications,
• delay in referral, and
• delay in the management of complications.
What program focuses on
Maternal Health Care?
 National Safe
Motherhood Program
(NSFP)
 NATIONAL SAFE MOTHERHOOD PROGRAM
Local Delivery of the Maternal– National Capacity to Sustain Paradigm Shift
Newborn Service Package Maternal-Newborn Services

BemONc-CEMonc
Service Delivery Team Family Planning
network

Reliable Sustainable
Network of Training Improved Family
Support Systems:
Providers planning
Initiatives

Screenings into the

antenatal care protoclos
I. Local Delivery of the Maternal–Newborn
Service Package

Service Delivery Team

a. Barangay Health Workers

b. BEmONC Teams:
Doctors, Nurses and Midwives
Initiatives
• Establishment of Safe Blood Supply Network with support from the National
Voluntary Blood Program

• Behavior Change Interventions in

collaboration with the Health
Promotion and Communication Service
• Sustainable financing of maternal - newborn services and commodities
through locally initiated revenue generation and retention activities
including PhilHealth accreditation and enrolment.
II. National Capacity to Sustain
Maternal-Newborn Services

• Operational and Regulatory Guidelines

– Identification and profiling of current FP users
and identification of potential FP clients and
those with unmet need for FP (permanent or
temporary methods)
– Mainstreaming FP in the regions with high unmet
need for FP
– Development and dissemination of Information,
Education Communication materials
– Advocacy and social mobilization for FP
• Training Centers that provide BEmONC Skills Training

– Monitoring, Evaluation, Research, and Dissemination with support from the

Epidemiology Bureau and Health Policy Development and Planning Bureau f. Monitoring
and Supervision of Private Midwife Clinics in cooperation with PRC Board of Midwifery
and Professional Midwifery Organizations

– Maternal Death Reporting and Review System in collaboration with Provincial and City
Review Teams

– Annual Program Implementation Reviews with Provincial Health Officers and Regional
Coordinators
Paradigm shift

(1) Risk approach

 Women deciding to give birth in facilities with
capability to provide BEmONC, assisted by skilled
health care professionals via:
- birthing centers with BEmONC nearest homes
- Designated referral hospitals for women needing CEmONC
(Public and private secondary and tertiary hospitals and
Health specialists)
- Safe blood
- Efficient emergency transport service during referral
- Atleast 4 Antenatal Care visits and atleast 2 post-natal care
check-ups
 Paradigm Shift
(2) improved quality of FP
counseling and expanded service
availability of post-partum family
planning in hospitals and primary
birthing centers

(3) the integration of cervical

cancer, syphilis, hepatitis B and HIV
screening among others into the
antenatal care protocols.
IV. Conclusion
In the Philippine Setting….
● The department of health imposed multiple projects that would
help lessen pregnancy and childhood mortality.
● 211 deaths were reported on 2011 showing the need of
importance of a better maternal health care.
● The inhabitants of the philippines faces unique challenges (income
distribution, etc.) that contributes to the misalignment of its
health care system (WHO, 2012)
● Due to the implementation of the Maternity program created,
issues regarding maternity and childbirth are easily addressed.
That was able to lessen the the mortality rate.
Results of NSMP in lessing MMR

Table shows the target

and accomplishments by the
program from 2013 - 2017.
 Information Dissemination
● Started on 2016, DOH its promotion for the
program (2019).
● As statistics shows improvement toward
lessening its target (MMR).
● It is held by local officials,addressed to
pregnant women about having monthly
check-ups to detect any risks.
● Ensuring that Filipino women will have full
access to quality maternal health care
services so they will have a safer pregnancy
and delivery of their child.