Standard Treatment Guidelines for Antenatal, Intranatal, and Postnatal Care

Standard Treatment Guidelines for Antenatal, Intranatal, and Postnatal Care

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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 1 Standard Treatment Guidelines Antenatal, Intranatal & Postnatal Care Maternal & Newborn Health - A Professional Reference Aligned with Globally Accepted Guidelines Structured per WHO Antenatal Care, Intrapartum Care, Postnatal Care, and Essential Newborn Care recommendations, aligned with India's RCH/NHM, HBNC, and HBPNC programs: Definition → Timing/Schedule → Assessment & Investigations → Care → Pharmacological Management → Danger Signs → Referral Criteria → Family Education All clinical decisions, drug selection, and dosing must be confirmed, individualized, and administered by a licensed physician/skilled birth attendant per patient condition and current local/national protocol (RCH/NHM, WHO, FOGSI, etc.). Prepared by: Dr. J. L. Meena
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 2 Foreword The health of a mother and her newborn during pregnancy, childbirth, and the weeks that follow reflects the strength of the entire care system around them. Most of the deaths and complications we still see in this period are preventable with timely, well-organized, and respectful care at every contact - from the first antenatal visit to the final postnatal check. This reference has been compiled to bring together the essential elements of antenatal, intranatal, and postnatal care for both mother and newborn, structured around globally accepted frameworks - WHO's guidance on antenatal, intrapartum, postnatal, and essential newborn care - and aligned with India's RCH/NHM, Home-Based Newborn Care, and Home-Based Postnatal Care programs. It is intended as a quick, structured companion for healthcare providers, students, and field health workers, to reinforce - never replace - proper clinical training and judgment. I hope it supports safer pregnancies, safer deliveries, and healthier beginnings for every mother and child. Dr. J. L. Meena
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 3 Table of Contents Foreword .......................................................................................................................... 2 At-a-Glance: Danger Signs Across the Maternal & Newborn Continuum............................... 5 Section A: Antenatal Care (ANC) ........................................................................................ 6 Antenatal Care Visit Schedule & Content......................................................................................6 Routine Antenatal Supplementation & Immunization....................................................................6 Nutritional Assessment & Counseling in Pregnancy......................................................................7 Anemia in Pregnancy ...................................................................................................................7 Hypertensive Disorders of Pregnancy (Antenatal Monitoring) ........................................................8 Gestational Diabetes Mellitus (GDM)............................................................................................8 Danger Signs in Pregnancy (Antenatal Warning Signs) ...................................................................8 Section B: Intranatal Care (Labor & Delivery) .....................................................................10 Assessment on Admission in Labor............................................................................................10 First Stage of Labor - Monitoring (Partograph-Based Care)...........................................................10 Second Stage of Labor - Normal Vaginal Delivery ........................................................................11 Active Management of the Third Stage of Labor (AMTSL)..............................................................11 Essential Newborn Care at Birth (Immediate) .............................................................................11 Danger Signs in Labor Requiring Referral....................................................................................12 Section C: Postnatal Care (Mother) ...................................................................................13 Immediate Postpartum Care (First 24 Hours) ..............................................................................13 Postnatal Visit Schedule & Content............................................................................................13 Puerperal Sepsis .......................................................................................................................13 Postpartum Danger Signs (Maternal) ..........................................................................................14 Postpartum Family Planning Counseling ....................................................................................14 Lactation & Breastfeeding Support.............................................................................................15 Section D: Newborn Care (Postnatal) ................................................................................16 Newborn Examination & Classification at Birth...........................................................................16 Newborn Immunization at Birth..................................................................................................16 Home-Based Newborn Care (HBNC) Visit Schedule ....................................................................16 Newborn Danger Signs ..............................................................................................................17 Care of Low Birth Weight / Preterm Newborn ..............................................................................17 Neonatal Jaundice.....................................................................................................................18 Neonatal Sepsis (Recognition & Referral) ...................................................................................18 Essential Maternal & Newborn Drug List............................................................................19
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 4 Antenatal..................................................................................................................................19 Intranatal..................................................................................................................................20 Postnatal (Mother).....................................................................................................................20 Newborn...................................................................................................................................21 References ......................................................................................................................22 Abbreviations ..................................................................................................................23 Important Notes...............................................................................................................24
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 5 At-a-Glance: Danger Signs Across the Maternal & Newborn Continuum For rapid orientation - see full entries for complete management Stage Key Danger Signs Immediate Action Antenatal Bleeding, severe headache/visual changes, convulsions, high fever, severe abdominal pain, reduced fetal movements, facial/hand swelling, watery discharge Immediate facility evaluation - do not wait for next ANC visit Intranatal (Labor) Abnormal fetal heart rate, thick meconium, partograph action line crossed, hemorrhage, high fever, hypertension with symptoms, cord prolapse, malpresentation Stabilize, arrange emergency transport to CEmONC facility Postnatal (Mother) Heavy bleeding, foul discharge, fever, severe headache/convulsions, breast engorgement with fever, calf swelling, breathing difficulty, thoughts of self-harm Prompt evaluation; emergency referral for severe signs Newborn Poor/no feeding, lethargy, fast breathing/chest indrawing, fever or low temperature, convulsions, early/spreading jaundice, umbilical redness/discharge, bleeding, abdominal distension Keep warm, continue feeding if able, urgent transport to newborn care facility
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 6 Section A: Antenatal Care (ANC) Antenatal Care Visit Schedule & Content Definition/Purpose Structured contacts between a pregnant woman and a health provider to monitor maternal/fetal wellbeing, detect complications early, and provide preventive care and education Timing/Schedule Per WHO's 8-contact ANC model and India's RCH guidelines: first contact by 12 weeks (booking visit), then contacts around 20, 26, 30, 34, 36, 38 and 40 weeks; at least one visit by a physician/specialist; PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan) offers a free specialist ANC check-up on the 9th of every month at designated government facilities in India Assessment & Investigations • History (LMP, EDD calculation, obstetric/medical history), general exam (BP, weight, pallor, edema) • Abdominal exam - fundal height, lie/presentation, fetal heart sound (from ~28 weeks) • Urine for protein/sugar • Blood group and Rh typing, hemoglobin, blood sugar (GDM screening) • HIV, syphilis, and Hepatitis B screening • Ultrasound for dating and anomaly screening per schedule Care / Non-Pharmacological Management • Birth preparedness and complication readiness planning • Nutrition counseling and rest advice • Danger sign education for the woman and family • Breastfeeding counseling • Mental health/wellbeing screening Pharmacological Management • Iron-folic acid supplementation, calcium supplementation • Tetanus toxoid/Td immunization • Deworming (albendazole) after the first trimester • Malaria chemoprophylaxis (IPTp) in endemic areas per national protocol Danger Signs / Red Flags Bleeding, severe headache/visual disturbance, reduced fetal movements, severe abdominal pain, high fever, reduced urine output, facial/hand swelling, watery vaginal discharge Referral Criteria Any high-risk feature identified (severe anemia, hypertension, malpresentation near term, multiple pregnancy, prior cesarean, medical comorbidities) - refer to a facility with specialist/emergency obstetric care Patient & Family Education Importance of completing all visits, recognizing danger signs, birth planning (place of delivery, transport, blood donor identification), nutrition, and postpartum family planning options Routine Antenatal Supplementation & Immunization Definition/Purpose Preventive interventions during pregnancy proven to reduce maternal and neonatal morbidity/mortality Timing/Schedule Initiated as early as possible after pregnancy confirmation, continued through pregnancy and into the postpartum period per protocol Pharmacological Management • Iron-folic acid (IFA): daily oral supplementation throughout pregnancy per national program, continued for 6 months postpartum
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 7 • Calcium carbonate: daily supplementation from the second trimester, particularly where dietary calcium intake is low, to reduce pre-eclampsia risk • Tetanus toxoid/Td vaccine: 2 doses (or 1 booster if previously immunized), spaced 4 weeks apart, completed at least 2 weeks before expected delivery • Albendazole (deworming): single dose after the first trimester • Malaria chemoprophylaxis (IPTp) in endemic areas per NVBDCP protocol Danger Signs / Red Flags Signs of severe anemia despite supplementation, allergic reaction to vaccine Referral Criteria Non-response to iron supplementation (persistent severe anemia), suspected malabsorption Patient & Family Education Adherence importance, taking iron with food to reduce GI side effects, avoiding tea/coffee close to the iron dose (reduces absorption), completing the full vaccination schedule Nutritional Assessment & Counseling in Pregnancy Definition/Purpose Ensuring adequate maternal nutrition to support fetal growth and maternal health Assessment & Investigations Weight gain monitoring against expected trajectory, dietary history, screening for undernutrition (e.g., MUAC) or excessive weight gain Care / Non-Pharmacological Management Counseling on a balanced diet with adequate calories/protein, iron-rich and calcium-rich foods, small frequent meals for nausea, adequate hydration, avoiding alcohol/tobacco Pharmacological Management As per routine supplementation (iron-folic acid, calcium) - see above Danger Signs / Red Flags Severe nausea/vomiting preventing oral intake (hyperemesis gravidarum), inadequate weight gain, signs of severe malnutrition Referral Criteria Hyperemesis gravidarum with dehydration/ketosis, severe undernutrition Patient & Family Education Practical, locally appropriate dietary advice; continued nutrition guidance through lactation Anemia in Pregnancy Definition/Purpose Hemoglobin below 11 g/dL in pregnancy (WHO threshold); common in India, predominantly due to dietary iron deficiency Assessment & Investigations Hemoglobin estimation at booking and again in the third trimester at minimum; peripheral smear if severe or non-responsive to treatment Care / Non-Pharmacological Management Dietary counseling (iron-rich foods, vitamin C to enhance absorption), treat underlying contributing causes (deworming, malaria treatment if present) Pharmacological Management • Oral iron-folic acid at treatment dose (higher than prophylactic dose), per severity • Parenteral iron for moderate anemia or oral intolerance, physician-directed • Blood transfusion for severe anemia, especially near term, per physician/facility protocol Danger Signs / Red Flags Hemoglobin <7 g/dL, breathlessness at rest, palpitations, signs of cardiac decompensation Referral Criteria Severe anemia, anemia not responding to oral iron, anemia near term requiring correction before delivery Patient & Family Education Adherence to iron therapy, dietary modification, recognizing symptoms of worsening anemia
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 8 Hypertensive Disorders of Pregnancy (Antenatal Monitoring) Definition/Purpose New-onset hypertension (≥140/90 mmHg) after 20 weeks' gestation, with or without proteinuria/other organ involvement (pre-eclampsia) Assessment & Investigations Blood pressure measured at every ANC visit; urine protein testing; blood tests (liver/renal function, platelet count) if pre-eclampsia is suspected; fetal growth monitoring Care / Non-Pharmacological Management Increased frequency of monitoring once hypertension identified; rest; monitoring of fetal wellbeing Pharmacological Management • Antihypertensive therapy for sustained significant hypertension, individualized and physician-directed • Low-dose aspirin for pre-eclampsia prevention in high-risk pregnancies, started early in pregnancy, physician-directed Danger Signs / Red Flags Severe headache, visual disturbance, epigastric pain, rapidly worsening swelling, reduced fetal movements - see Eclampsia/Severe Pre-eclampsia in the Emergencies guideline for acute seizure management Referral Criteria Any new-onset hypertension after 20 weeks, any proteinuria, or symptoms of severe pre- eclampsia - refer immediately Patient & Family Education Recognizing warning symptoms, importance of attending increased-frequency visits once hypertension is identified Gestational Diabetes Mellitus (GDM) Definition/Purpose Glucose intolerance first recognized during pregnancy Assessment & Investigations Universal screening with an oral glucose tolerance test per national protocol (typically 24-28 weeks, earlier if high-risk); fasting/random blood glucose at booking Care / Non-Pharmacological Management Medical nutrition therapy, physical activity as advised, self-monitoring of blood glucose Pharmacological Management Insulin therapy if glycemic targets are not met with lifestyle measures, physician-directed and individualized; oral hypoglycemic agents only per specific local/national protocol where used Danger Signs / Red Flags Poor glycemic control, suspected fetal macrosomia, polyhydramnios Referral Criteria Need for insulin initiation/titration, poor glycemic control, suspected fetal macrosomia Patient & Family Education Diet and exercise counseling, self-monitoring technique, importance of postpartum glucose re-testing (future type 2 diabetes risk) Danger Signs in Pregnancy (Antenatal Warning Signs) Definition/Purpose Clinical signs during pregnancy indicating potential serious complications requiring urgent evaluation, regardless of the scheduled visit calendar Danger Signs / Red Flags • Vaginal bleeding • Severe headache with visual disturbance • Convulsions • High fever
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 9 • Severe abdominal pain • Reduced or absent fetal movements • Swelling of face and hands • Watery vaginal discharge before term (possible ruptured membranes) • Severe/persistent vomiting Immediate Action Any of these signs warrants immediate facility evaluation - the woman should not wait for the next scheduled ANC visit Referral Criteria All danger signs above require urgent referral to a facility with emergency obstetric care capability Patient & Family Education All pregnant women and family members should be taught to recognize these signs and know the nearest facility with emergency obstetric care, as part of birth preparedness and complication readiness planning
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 10 Section B: Intranatal Care (Labor & Delivery) Assessment on Admission in Labor Definition/Purpose Initial clinical evaluation of a woman presenting in labor, to confirm labor, assess maternal/fetal wellbeing, and plan care Assessment & Investigations • Confirm true labor (regular painful contractions with cervical change) • Review obstetric history and ANC record/danger signs • General exam (vital signs) • Abdominal exam - fundal height, lie, presentation, fetal heart rate • Vaginal examination - cervical dilatation, effacement, station, membrane status • Urine for protein Care / Non-Pharmacological Management Explain findings and the care plan to the woman and her companion; ensure a birth companion is allowed; provide privacy and emotional support; encourage mobility if low-risk Pharmacological Management Not routinely required at admission unless clinically indicated (e.g., antibiotic prophylaxis for prolonged rupture of membranes, per protocol) Danger Signs / Red Flags Fetal heart rate abnormality, meconium-stained liquor, malpresentation, antepartum hemorrhage, hypertension, signs of infection Referral Criteria Any high-risk feature identified on admission that exceeds the facility's capability - refer promptly while maternal/fetal condition is stable Patient & Family Education Explain the process of labor, pain relief options, and what to expect First Stage of Labor - Monitoring (Partograph-Based Care) Definition/Purpose The period from onset of true labor to full cervical dilatation, monitored using a partograph to detect abnormal progress early Assessment & Investigations • Fetal heart rate every 30 minutes • Contraction frequency/duration every 30 minutes • Cervical dilatation every 4 hours (more frequently if concern), plotted on partograph • Maternal pulse/BP/temperature per protocol, urine output Care / Non-Pharmacological Management • Encourage mobility and upright positions as tolerated • Adequate hydration/light nutrition as appropriate • Continuous emotional support/birth companion • Non-pharmacological comfort measures (breathing techniques, position change, massage) Pharmacological Management • Analgesia per facility capability and physician (e.g., parenteral opioid or epidural) • Oxytocin augmentation only if indicated for slow progress per partograph action line, physician-directed Danger Signs / Red Flags Partograph crossing the action line, fetal heart rate abnormality, maternal fever, hypertension, heavy bleeding Referral Criteria Prolonged/obstructed labor (partograph action line crossed) at a facility without cesarean section capability - urgent referral Patient & Family Education Explain labor progress, pain relief options, and provide reassurance throughout
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 11 Second Stage of Labor - Normal Vaginal Delivery Definition/Purpose The period from full cervical dilatation to delivery of the baby Assessment & Investigations Continuous or frequent fetal heart rate monitoring; assessment of descent and maternal urge to push; monitor for signs of obstruction Care / Non-Pharmacological Management Support the woman's preferred position; encourage effective pushing with contractions; perineal support to reduce trauma; avoid routine episiotomy (perform only if clinically indicated) Pharmacological Management Not routinely required unless complications arise; local anesthesia if episiotomy/perineal repair is needed Danger Signs / Red Flags Prolonged second stage, fetal heart rate abnormality, shoulder dystocia, failure to progress despite adequate pushing Referral Criteria Delay or complications in the second stage beyond facility capability - escalate to instrumental/operative delivery per skilled provider availability Patient & Family Education Continuous encouragement and clear communication throughout delivery Active Management of the Third Stage of Labor (AMTSL) Definition/Purpose Evidence-based package of care after birth of the baby to reduce the risk of postpartum hemorrhage - a globally recommended standard practice Care / Non-Pharmacological Management • Immediate assessment for a second baby before uterotonic administration • Controlled cord traction with counter-traction once signs of placental separation are present • Uterine massage after placental delivery • Examination of placenta and membranes for completeness • Inspection of the genital tract for tears Pharmacological Management Oxytocin 10 IU IM within one minute of birth (after ruling out a second baby) - the core, globally recommended component of AMTSL Danger Signs / Red Flags Excessive bleeding, retained placenta beyond 30 minutes, uterine inversion Referral Criteria Retained placenta, uncontrolled bleeding, or suspected uterine inversion - refer/escalate immediately (see Postpartum Hemorrhage in the Common Medical Emergencies guideline) Patient & Family Education Briefly explain the process to the mother; reassure regarding expected normal blood loss Essential Newborn Care at Birth (Immediate) Definition/Purpose Standardized package of care for every newborn immediately after delivery, regardless of setting Care / Non-Pharmacological Management • Immediate and thorough drying • Skin-to-skin contact with the mother • Delayed cord clamping (per current WHO recommendation, typically 1-3 minutes after birth unless resuscitation is needed)
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 12 • Keep the baby warm • Initiate breastfeeding within the first hour • Avoid unnecessary separation from the mother Pharmacological Management • Vitamin K injection (prophylaxis against hemorrhagic disease of the newborn) per protocol • Eye care (antimicrobial eye ointment) per protocol • First dose of Hepatitis B vaccine, BCG, and OPV-zero dose before discharge, per national immunization schedule Danger Signs / Red Flags Not breathing/crying at birth (see Neonatal Resuscitation), low birth weight, visible congenital anomaly, signs of birth asphyxia Referral Criteria Any newborn requiring resuscitation beyond initial steps, birth weight <2000 g, gestational age <34 weeks, or any danger sign - refer to a facility with newborn care capability Patient & Family Education Importance of immediate and exclusive breastfeeding, keeping the baby warm, delayed bathing (at least 24 hours), and clean cord care Danger Signs in Labor Requiring Referral Definition/Purpose Clinical findings during labor indicating the need for escalation of care Danger Signs / Red Flags • Fetal heart rate persistently abnormal • Thick meconium-stained liquor • Prolonged labor / partograph action line crossed • Antepartum or intrapartum hemorrhage • High fever • Hypertension with symptoms • Cord prolapse • Malpresentation • Retained placenta Immediate Action Stabilize (positioning, IV access, oxygen if indicated), arrange emergency transport with a skilled attendant, and communicate ahead to the receiving facility Referral Criteria All listed danger signs warrant referral to a facility with Comprehensive Emergency Obstetric and Newborn Care (CEmONC) capability Patient & Family Education Birth preparedness planning during the antenatal period should identify the referral facility and transport plan in advance
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 13 Section C: Postnatal Care (Mother) Immediate Postpartum Care (First 24 Hours) Definition/Purpose Close monitoring period immediately after delivery, when most severe maternal complications (especially hemorrhage) occur Assessment & Investigations Vital signs and vaginal bleeding assessed frequently (e.g., every 15 minutes for the first 1-2 hours, then hourly); uterine tone/fundal height; bladder emptying; perineal/wound check Care / Non-Pharmacological Management Encourage early breastfeeding initiation and rooming-in; keep the mother warm; ensure adequate nutrition and hydration; provide pain relief as needed; offer emotional support Pharmacological Management Continue iron-folic acid; analgesia as needed; uterotonic if not already given (per AMTSL); antibiotics only if indicated (e.g., prolonged rupture of membranes, instrumental delivery, per protocol) Danger Signs / Red Flags Heavy bleeding, fever, severe headache/visual disturbance, calf pain/swelling, difficulty breathing, severe abdominal pain Referral Criteria Any danger sign above requires immediate escalation Patient & Family Education Recognizing warning signs before discharge, breastfeeding support, hygiene Postnatal Visit Schedule & Content Definition/Purpose Structured follow-up contacts after delivery to monitor maternal and newborn recovery, per WHO and India's Home-Based Postnatal Care (HBPNC) guidance Timing/Schedule Recommended contacts at 24 hours, 48-72 hours (day 3), day 7, and 6 weeks postpartum; India: ASHA home visits on days 1, 3, and 7 for institutional delivery (additional visits for home delivery), plus a facility visit at 6 weeks Assessment & Investigations Maternal vital signs, uterine involution, lochia, perineal/wound healing, breast/breastfeeding assessment, mood/mental health screening, and newborn assessment (see Section D) at each visit Care / Non-Pharmacological Management Continued breastfeeding support, nutrition counseling, hygiene advice, rest advice, family planning counseling Pharmacological Management Continue iron-folic acid for 6 months postpartum; complete any pending immunizations Danger Signs / Red Flags As in Immediate Postpartum Care, plus signs of postpartum depression/psychosis and mastitis symptoms Referral Criteria Any danger sign identified at a postnatal visit Patient & Family Education Family planning options, exclusive breastfeeding for 6 months, newborn care and immunization schedule, recognizing when to seek care Puerperal Sepsis Definition/Purpose Infection of the genital tract occurring between rupture of membranes/labor and 42 days postpartum
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 14 Clinical Features Fever, foul-smelling lochia, lower abdominal pain, uterine tenderness, sub-involuted uterus; may progress to sepsis/septic shock if untreated Assessment & Investigations Clinical diagnosis; blood counts and cultures (blood, high vaginal swab) where available, ideally before starting antibiotics if this does not delay treatment Care / Non-Pharmacological Management Supportive care, adequate hydration, source control (e.g., evacuation of retained products if present, per physician) Pharmacological Management Empirical broad-spectrum antibiotics started promptly per physician/facility protocol, adjusted once culture results are available Referral Criteria Signs of severe sepsis/septic shock, retained products of conception requiring evacuation, or non-response to initial antibiotics - refer immediately Patient & Family Education Postpartum hygiene practices, recognizing fever/foul discharge as warning signs requiring prompt evaluation Postpartum Danger Signs (Maternal) Definition/Purpose Clinical signs after delivery indicating potential serious maternal complications Danger Signs / Red Flags • Heavy or persistent vaginal bleeding • Foul-smelling vaginal discharge • Fever • Severe headache, visual disturbance, or convulsions • Breast engorgement with fever (possible mastitis/abscess) • Calf pain and swelling (possible thromboembolism) • Breathing difficulty • Severe abdominal pain • Thoughts of self-harm or harming the baby (possible postpartum depression/psychosis) Immediate Action Any of these signs requires prompt evaluation - if thoughts of self-harm are present, treat as a mental health emergency requiring immediate, compassionate support and referral Referral Criteria All listed danger signs require facility evaluation; several require emergency referral Patient & Family Education The mother and family should be counseled on these signs before discharge from the facility Postpartum Family Planning Counseling Definition/Purpose Counseling and provision of contraceptive options in the postpartum period to support healthy birth spacing Timing/Schedule Ideally initiated antenatally and reinforced at every postnatal contact Care / Non-Pharmacological Management Counseling on the Lactational Amenorrhea Method (LAM) and its criteria/limitations; options including postpartum intrauterine device (PPIUCD), barrier methods, progestin-only methods (compatible with breastfeeding), and permanent methods if desired; addressing myths and concerns Pharmacological Management Method-specific, per patient choice and medical eligibility, provided per national program protocol
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 15 Referral Criteria Complex medical eligibility situations requiring specialist input Patient & Family Education Importance of birth spacing (at least 24 months) for maternal and child health; method-specific counseling and follow-up Lactation & Breastfeeding Support Definition/Purpose Support to help establish and maintain effective breastfeeding Care / Non-Pharmacological Management Early initiation within the first hour; correct positioning and attachment assessment; exclusive breastfeeding counseling for the first 6 months; addressing common problems (engorgement, sore nipples, perceived low supply); support for working mothers (expressing and storing milk) Danger Signs / Red Flags Signs of mastitis (painful, red, warm area of the breast with fever); suspected breast abscess Referral Criteria Mastitis not responding to conservative measures/antibiotics; suspected abscess (may require drainage) Patient & Family Education Benefits of exclusive breastfeeding, correct technique, and expressing/storing milk if separated from the baby
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 16 Section D: Newborn Care (Postnatal) Newborn Examination & Classification at Birth Definition/Purpose Systematic assessment of every newborn shortly after birth to identify immediate problems and classify risk Assessment & Investigations APGAR scoring at 1 and 5 minutes; birth weight; gestational age assessment; head-to-toe examination for congenital anomalies/birth injury; temperature Care / Non-Pharmacological Management Keep the baby with the mother (skin-to-skin) during assessment where possible; ensure a warm environment for examination Danger Signs / Red Flags APGAR <7 at 5 minutes; birth weight <2500 g (low birth weight) or <1500 g (very low birth weight); visible anomaly; signs of birth trauma Referral Criteria Any risk classification (low birth weight, prematurity, birth asphyxia, congenital anomaly) - refer per facility capability Patient & Family Education Explain findings to parents and address their concerns clearly and compassionately Newborn Immunization at Birth Definition/Purpose Vaccines recommended at birth per the national immunization schedule to provide early protection Timing/Schedule Before discharge or within the first few days of life Pharmacological Management BCG (single dose), Hepatitis B birth dose (within 24 hours), and Oral Polio Vaccine (OPV) zero dose - all per the national Universal Immunization Programme schedule Care / Non-Pharmacological Management Explain the immunization schedule and provide/update the immunization card Referral Criteria Contraindications (e.g., a very sick/unstable newborn) - defer vaccination until stable per physician advice; do not omit Patient & Family Education Importance of completing the full immunization schedule as per the national program Home-Based Newborn Care (HBNC) Visit Schedule Definition/Purpose Structured home visits by trained health workers (e.g., ASHA in India) to monitor newborn health and support the family, per national HBNC guidelines Timing/Schedule For institutional deliveries: visits on days 3, 7, and 42; for home deliveries: additional visits on days 1 and 6 (total of 6 visits within the first 42 days per Indian HBNC guidelines) Assessment & Investigations Feeding assessment, weight check, temperature, umbilical cord stump check, jaundice screening, danger sign screening, and maternal wellbeing check at each visit Care / Non-Pharmacological Management Reinforce exclusive breastfeeding, warmth (Kangaroo Mother Care counseling if low birth weight), hygiene, and clean cord care Danger Signs / Red Flags See Newborn Danger Signs entry below
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 17 Referral Criteria Any danger sign identified during a home visit - immediate referral to a facility Patient & Family Education Danger sign recognition for the family, birth registration, and immunization schedule adherence Newborn Danger Signs Definition/Purpose Clinical signs in a newborn indicating potential serious illness requiring urgent care Danger Signs / Red Flags • Poor or no feeding • Lethargy / reduced activity • Fast breathing (≥60 breaths/min) or difficulty breathing / chest indrawing • Fever or low body temperature • Convulsions • Yellow discoloration of skin, especially if appearing within the first 24 hours or spreading to palms/soles • Umbilical redness, discharge, or foul smell • Multiple pustules / skin infection • Bleeding • Abdominal distension Immediate Action Keep the baby warm, continue breastfeeding if able, and arrange immediate transport to a facility with newborn care capability Referral Criteria Any danger sign above requires urgent facility referral Patient & Family Education All caregivers should be taught to recognize these signs before discharge, as part of essential newborn care counseling Care of Low Birth Weight / Preterm Newborn Definition/Purpose A newborn with birth weight <2500 g and/or born before 37 completed weeks of gestation, at higher risk of complications Assessment & Investigations Careful weight and gestational age assessment; temperature monitoring; feeding ability assessment Care / Non-Pharmacological Management • Kangaroo Mother Care (continuous skin-to-skin contact) - strongly recommended, especially for stable low birth weight/preterm babies • Extra warmth measures and delayed bathing • Support for feeding (breastfeeding or expressed breast milk; cup feeding if unable to suckle effectively) • Extra vigilance for danger signs Pharmacological Management Routine newborn care as above (Vitamin K, immunizations per protocol, timing adjusted if unstable); facility-based interventions such as phototherapy for jaundice or antibiotics for suspected infection, physician-directed Referral Criteria Very low birth weight (<1500 g), gestational age <32 weeks, feeding difficulty, temperature instability, or any danger sign - refer to a facility with Special Newborn Care Unit (SNCU) capability
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 18 Patient & Family Education Kangaroo Mother Care technique, importance of frequent feeding and warmth, and adherence to follow-up visits Neonatal Jaundice Definition/Purpose Yellow discoloration of skin/sclera due to elevated bilirubin, common in the first week of life; most is physiological, but some requires treatment Clinical Features Physiological jaundice typically appears after 24 hours of age and progresses head-to-toe; assess extent and any associated danger signs Assessment & Investigations Visual/clinical assessment in good light (blanch the skin to assess); serum bilirubin measurement if jaundice is early-onset (<24h), extensive, or in a high-risk baby, per facility capability Care / Non-Pharmacological Management Ensure adequate breastfeeding frequency (supports bilirubin excretion); sunlight exposure is not a substitute for clinical phototherapy and should not be relied upon alone Pharmacological Management Phototherapy per bilirubin level and risk nomogram (facility-based); exchange transfusion for severe/rapidly rising bilirubin, physician-directed Referral Criteria Jaundice within the first 24 hours of life, jaundice extending to palms/soles, jaundice persisting beyond 2 weeks, or any jaundice with poor feeding/lethargy - refer urgently Patient & Family Education Explain the difference between physiological and concerning jaundice; stress the importance of follow-up visits in the first week of life Neonatal Sepsis (Recognition & Referral) Definition/Purpose Systemic infection during the newborn period, a leading cause of neonatal mortality, which can progress rapidly Clinical Features Often non-specific - poor feeding, lethargy, temperature instability (fever or hypothermia), fast/labored breathing, abdominal distension, seizures, poor perfusion Assessment & Investigations Facility-based - blood counts, cultures, CRP where available; clinical diagnosis is often needed to initiate urgent treatment without delay given the rapid progression risk Care / Non-Pharmacological Management Supportive care - warmth, maintain hydration/feeding as tolerated, oxygen if hypoxic Pharmacological Management Empirical broad-spectrum antibiotics started urgently per physician/facility/national protocol once sepsis is suspected, without waiting for culture results Referral Criteria Any suspected neonatal sepsis is a medical emergency - immediate referral to a facility with newborn care/NICU capability Patient & Family Education Family education on danger sign recognition (see above) is the most important preventive measure, given how quickly neonatal sepsis can progress
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 19 Essential Maternal & Newborn Drug List Commonly required drugs across antenatal, intranatal, and postnatal/newborn care - to be stocked and administered per facility protocol by trained personnel Antenatal Drug Primary Indication Route Standard Dose Key Precaution Iron-Folic Acid (IFA) Prevention/treatment of anemia in pregnancy PO Daily, per national program; higher treatment dose per severity Take with food; avoid tea/coffee close to dose Folic Acid (standalone) Periconceptional supplementation, neural tube defect prevention PO Daily, ideally from before conception through early pregnancy Most effective when started before conception Calcium carbonate Reduce pre-eclampsia risk, bone health PO Daily from 2nd trimester, per national program Separate timing from iron dose for better absorption Tetanus Toxoid / Td vaccine Prevent maternal and neonatal tetanus IM 2 doses (or 1 booster), 4 weeks apart, completed ≥2 weeks before delivery Check prior immunization history Albendazole Deworming in pregnancy PO Single dose after 1st trimester Avoid in 1st trimester Low-dose Aspirin Pre-eclampsia prevention in high-risk pregnancy PO Started early pregnancy, physician-directed Physician-directed; individualized to risk Antimalarial (IPTp, e.g., sulfadoxine-pyrimethamine class) Malaria chemoprophylaxis in endemic areas PO Per NVBDCP protocol Only in malaria- endemic areas per national guidance Antihypertensives (e.g., labetalol, nifedipine, methyldopa) Chronic/gestational hypertension control in pregnancy PO Individualized, physician- directed and titrated Choice/dose depends on severity and gestation; avoid ACE inhibitors/ARBs in pregnancy Insulin Glycemic control in GDM/pre-existing diabetes not controlled by diet SC Individualized, physician- titrated to glucose targets Preferred over oral agents in many protocols; requires monitoring Antenatal Corticosteroids (Dexamethasone/Betamethasone) Fetal lung maturation when preterm birth anticipated (24-34 weeks) IM Course per standard regimen, physician- directed Timing-sensitive - given when preterm birth is likely within 7 days Anti-D Immunoglobulin Prevent Rh alloimmunization in Rh- negative women IM Per protocol - routinely at 28 weeks and after any sensitizing event/delivery of Rh-positive baby Only for Rh-negative women; timing is important Antiemetic (e.g., doxylamine- pyridoxine, or per physician) Nausea/vomiting of pregnancy, hyperemesis gravidarum PO/IV Physician-directed Rule out dehydration/ketosis in severe cases; IV
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 20 Drug Primary Indication Route Standard Dose Key Precaution fluids may be needed first Intranatal Drug Primary Indication Route Standard Dose Key Precaution Oxytocin Active management of third stage of labor / PPH prevention IM/IV 10 IU IM within 1 minute of birth First-line uterotonic (WHO recommended) Misoprostol AMTSL/PPH where oxytocin unavailable PO/Sublingual/Rectal Per facility protocol Causes shivering/fever - counsel the woman Ergometrine / Methylergometrine Additional uterotonic for PPH (adjunct/second-line) IM/IV Per physician/facility protocol Avoid in hypertension/pre- eclampsia Magnesium sulfate Severe pre- eclampsia/eclampsia seizure prevention and treatment IV/IM Loading + maintenance per standard regimen Monitor reflexes, respiratory rate, urine output; keep calcium gluconate available Tranexamic Acid Adjunct in PPH management IV Within 3 hours of onset, per protocol Give early - reduced benefit if delayed Antibiotic prophylaxis (per protocol) Prolonged rupture of membranes / instrumental delivery / cesarean section IV/PO Per physician/facility protocol Use only per specific indication, not routinely Local anesthetic (e.g., lignocaine) Perineal infiltration for episiotomy/repair Local infiltration Per physician/facility protocol Check for allergy before use Postnatal (Mother) Drug Primary Indication Route Standard Dose Key Precaution Iron-Folic Acid Continue anemia prevention/treatment postpartum PO Daily for 6 months postpartum Adherence support important Analgesics (e.g., paracetamol) Postpartum/perineal pain PO Per standard dosing, physician/pharmacist-guided Avoid NSAIDs if contraindicated Broad-spectrum antibiotics Puerperal sepsis IV/PO Per physician/facility protocol Start promptly on clinical suspicion Oxytocin/Uterotonics (continued) Ongoing uterine atony management if bleeding persists IM/IV Per physician/facility protocol Reassess cause of bleeding if persistent Postpartum contraceptive (method-specific) Birth spacing Varies by method Per method and patient eligibility Confirm compatibility with breastfeeding
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 21 Drug Primary Indication Route Standard Dose Key Precaution Antidepressant (physician-directed) Postpartum depression, if diagnosed by a qualified provider PO Individualized, physician- prescribed only Requires proper clinical assessment; compatibility with breastfeeding to be reviewed by physician Newborn Drug Primary Indication Route Standard Dose Key Precaution Vitamin K1 Prevention of hemorrhagic disease of the newborn IM Single dose at birth, per protocol Given once, soon after birth Tetracycline / Erythromycin eye ointment Prevention of neonatal conjunctivitis Topical (eye) Single application at birth, per protocol Applied to both eyes shortly after birth BCG vaccine Tuberculosis prevention Intradermal Single dose at birth, per UIP schedule Per national immunization schedule Hepatitis B (birth dose) Hepatitis B prevention IM Within 24 hours of birth, per UIP schedule Time-critical for effectiveness OPV - zero dose Poliomyelitis prevention Oral At birth, per UIP schedule Per national immunization schedule Chlorhexidine (7.1%) Cord care in home/community settings per national program Topical (cord stump) Per national program protocol Used where recommended by national program; keep cord dry and clean otherwise Empirical antibiotics Suspected neonatal sepsis IV/IM Per physician/facility/national protocol Start urgently on clinical suspicion; facility-based Surfactant (facility-based) Respiratory distress syndrome in preterm newborns Endotracheal/IT Facility-based, physician/NICU- directed Administered only in a facility with newborn ventilatory support capability Caffeine citrate (facility-based) Apnea of prematurity IV/PO Facility-based, physician- directed Used in NICU/SNCU settings for preterm infants This list covers commonly required maternal and newborn drugs for orientation purposes and is not exhaustive. Exact doses, dilutions, and administration must always follow current facility protocol, patient-specific factors, and be administered only by trained, authorized personnel.
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 22 References • World Health Organization (WHO) - Recommendations on Antenatal Care for a Positive Pregnancy Experience • World Health Organization (WHO) - Intrapartum Care for a Positive Childbirth Experience • World Health Organization (WHO) - Recommendations on Maternal and Newborn Care for a Positive Postnatal Experience • World Health Organization (WHO) - Essential Newborn Care / Early Essential Newborn Care guidance • World Health Organization (WHO) - Recommendations for Prevention and Treatment of Postpartum Haemorrhage; Management of Hypertensive Disorders of Pregnancy • Ministry of Health and Family Welfare, Government of India - Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) / RCH Programme Guidelines • Ministry of Health and Family Welfare, Government of India - Home Based Newborn Care (HBNC) Operational Guidelines • Ministry of Health and Family Welfare, Government of India - Home Based Postnatal Care (HBPNC) Guidelines • National Health Mission (NHM) - Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) and Janani Suraksha Yojana (JSY) programme documents • Federation of Obstetric and Gynaecological Societies of India (FOGSI) - Good Clinical Practice Recommendations • Universal Immunization Programme (UIP), Government of India - National Immunization Schedule • Indian Academy of Pediatrics (IAP) - Newborn care and immunization guidelines
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 23 Abbreviations Abbreviation Full Form STG Standard Treatment Guidelines ANC Antenatal Care AMTSL Active Management of the Third Stage of Labor APGAR Appearance, Pulse, Grimace, Activity, Respiration (newborn scoring system) ASHA Accredited Social Health Activist BCG Bacillus Calmette-Guérin (TB vaccine) CEmONC Comprehensive Emergency Obstetric and Newborn Care EDD Expected Date of Delivery FOGSI Federation of Obstetric and Gynaecological Societies of India GDM Gestational Diabetes Mellitus HBNC Home-Based Newborn Care HBPNC Home-Based Postnatal Care Hb Hemoglobin IFA Iron-Folic Acid IPTp Intermittent Preventive Treatment of malaria in pregnancy IU International Unit IUCD / PPIUCD Intrauterine Contraceptive Device / Postpartum IUCD KMC Kangaroo Mother Care LAM Lactational Amenorrhea Method LMP Last Menstrual Period NHM National Health Mission NICU / SNCU Neonatal Intensive Care Unit / Special Newborn Care Unit OPV Oral Polio Vaccine PMSMA Pradhan Mantri Surakshit Matritva Abhiyan PPH Postpartum Hemorrhage RCH Reproductive and Child Health Td / TT Tetanus-diphtheria vaccine / Tetanus Toxoid UIP Universal Immunization Programme WHO World Health Organization
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 24 Important Notes • This document follows the structure and general principles of globally accepted maternal and newborn care frameworks - WHO's Antenatal, Intrapartum, Postnatal, and Essential Newborn Care recommendations - aligned with India's RCH/NHM, HBNC, and HBPNC programs. • It is intended for orientation and educational reference only, and does NOT replace certified clinical training in skilled birth attendance, emergency obstetric care, or newborn resuscitation. • Drug doses referenced (e.g., oxytocin in AMTSL, magnesium sulfate in eclampsia, Vitamin K in newborns) reflect standard, globally published figures, but must still be confirmed against current local protocol and the individual patient by a trained/licensed provider. • For acute obstetric and newborn emergencies (postpartum hemorrhage, eclampsia, neonatal resuscitation), refer to the companion Standard Treatment Guidelines - Common Medical Emergencies document for detailed emergency management. • Birth preparedness and complication readiness - identifying the place of delivery, a skilled birth attendant, transport plan, and blood donor in advance - remains one of the most effective preventive measures against maternal and newborn mortality. • Emergency number in India: 108 (ambulance, most states) or 112 (national emergency number). ॐ जय माता द( ॐ
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  Standard Treatment GuidelinesAntenatal Intranatal Postnatal Care – Dr J L Meena pg. 25