| A. MATERNAL CARE |
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| Maternal assessment |
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Physiological assessment of the woman
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| 1. All postpartum women should have regular assessment of vaginal bleeding, uterine tonus, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours, starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within 6 hours. Urine void should be documented within 6 hours.
At each subsequent postnatal contact beyond 24 hours after birth, enquiries should continue to be made about general well-being and assessments made regarding the following: micturition and urinary incontinence, bowel function, healing of any perineal wound, headache, fatigue, back pain, perineal pain and perineal hygiene, breast pain and uterine tenderness and lochia. | Recommended |
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HIV catch-up testing
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| 2a. In high HIV burden settings,a catch-up postpartum HIV testing is needed for women of HIV-negative or unknown status who missed early antenatal contact testing or retesting in late pregnancy at a third trimester visit. | Context-specific recommendation |
| 2b. In low HIV burden settings,b catch-up postpartum HIV testing can be considered for women of HIV-negative or unknown status who missed early antenatal contact testing or retesting in late pregnancy at a third trimester visit as part of the effort to eliminate mother-to-child transmission of HIV. Countries could consider this only for women who are in serodiscordant relationships, where the partner is not virally suppressed on ART, or who had other known ongoing HIV risks in late pregnancy at a third trimester visit. | Context-specific recommendation |
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Screening for tuberculosis disease
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| 3a. Systematic screening for tuberculosis (TB) disease may be conducted among the general population, including of women in the postpartum period, in areas with an estimated TB disease prevalence of 0.5% or higher. | Context-specific recommendation |
| 3b. In settings where the TB disease prevalence in the general population is 100/100 000 population or higher, systematic screening for TB disease may be conducted among women in the postpartum period. | Context-specific recommendation |
| 3c. Household contacts and other close contacts of individuals with TB disease, including women in the postpartum period and newborns, should be systematically screened for TB disease. | Recommended |
| Interventions for common physiological signs and symptoms |
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Local cooling for perineal pain relief
| 4. Local cooling, such as with ice packs or cold pads, can be offered to women in the immediate postpartum period for the relief of acute pain from perineal trauma sustained during childbirth, based on a woman’s preferences and available options. | Recommended |
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Oral analgesia for perineal pain relief
| 5. Oral paracetamol is recommended as first-line choice when oral analgesia is required for the relief of postpartum perineal pain. | Recommended |
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Pharmacological relief of pain due to uterine cramping/involution
| 6. Oral non-steroidal anti-inflammatory drugs (NSAIDs) can be used when analgesia is required for the relief of postpartum pain due to uterine cramping after childbirth, based on a woman’s preferences, the clinician’s experience with analgesics and availability. | Recommended |
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Postnatal pelvic floor muscle training for pelvic floor strengthening
| 7. For postpartum women, starting routine pelvic floor muscle training (PFMT) after childbirth for the prevention of postpartum urinary and faecal incontinence is not recommended. | Not recommended |
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Non-pharmacological interventions to treat postpartum breast engorgement
| 8. For treatment of breast engorgement in the postpartum period, women should be counselled and supported to practice responsive breastfeeding, good positioning and attachment of the baby to the breast, expression of breastmilk, and the use of warm or cold compresses, based on a woman’s preferences. | Recommended |
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Pharmacological interventions to treat postpartum breast engorgement
| 9. The use of pharmacological interventions such as subcutaneous oxytocin and proteolytic enzyme therapy for the treatment of breast engorgement in the postpartum period is not recommended. | Not recommended |
| Preventive measures |
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Non-pharmacological interventions to prevent postpartum mastitis
| 10. For the prevention of mastitis in the postpartum period, women should be counselled and supported to practice responsive breastfeeding, good positioning and attachment of the baby to the breast, hand expression of breastmilk, and the use of warm or cold compresses, based on a woman’s preferences. | Recommended |
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Pharmacological interventions to prevent postpartum mastitis
| 11. Routine oral or topical antibiotic prophylaxis for the prevention of mastitis in the postpartum period is not recommended. | Not recommended |
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Prevention of postpartum constipation
| 12. Dietary advice and information on factors associated with constipation should be offered to women for the prevention of postpartum constipation. | Recommended |
| 13. Routine use of laxatives for the prevention of postpartum constipation is not recommended. | Not recommended |
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Prevention of maternal peripartum infection after uncomplicated vaginal birth
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| 14. Routine antibiotic prophylaxis for women with uncomplicated vaginal birth is not recommended. | Not recommended |
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Preventive anthelminthic treatment
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| 15. Preventive chemotherapy (deworming), using annual or biannualc single-dose albendazole (400 mg) or mebendazole (500 mg), is recommended as a public health intervention for all non-pregnant adolescent girls and women of reproductive age, including postpartum and/or lactating women, living in areas where the baseline prevalence of any soil-transmitted helminth infection is 20% or more among adolescent girls and women of reproductive age, in order to reduce the worm burden of soil-transmitted helminths. | Context-specific recommendation |
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Preventive schistosomiasis treatment
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| 16a. In endemic communities with Schistosoma spp. prevalence of 10% or higher, WHO recommends annual preventive chemotherapy with praziquantel in a single dose for ≥ 75% up to 100% of pregnant women after the first trimester, and non-pregnant adolescent girls and women of reproductive age, including postpartum and/or lactating women, to control schistosomiasis morbidity and move towards eliminating the disease as a public health problem. | Context-specific recommendation |
| 16b. In endemic communities with Schistosoma spp. prevalence of less than 10%, WHO suggests one of two approaches based on the programmes’ objectives and resources: (i) where there has been a programme of regular preventive chemotherapy, continuing preventive chemotherapy at the same or a reduced frequency towards interruption of transmission; and (ii) where there has not been a programme of regular preventive chemotherapy, a clinical approach of test-and-treat, instead of preventive chemotherapy targeting a population. | Context-specific recommendation |
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Oral pre-exposure prophylaxis for HIV prevention
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| 17. Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) should be started or continued as an additional prevention choice for postpartum and/or lactating women at substantial riskd of HIV infection as part of combination HIV prevention approaches. | Context-specific recommendation |
| Mental health interventions |
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Screening for postpartum depression and anxiety
| 18. Screening for postpartum depression and anxiety using a validated instrument is recommended and should be accompanied by diagnostic and management services for women who screen positive. | Recommended |
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Prevention of postpartum depression and anxiety
| 19. Psychosocial and/or psychological interventions during the antenatal and postnatal period are recommended to prevent postpartum depression and anxiety. | Recommended |
| Nutritional interventions and physical activity |
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Postpartum oral iron and folate supplementation
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| 20. Oral iron supplementation, either alone or in combination with folic acid supplementation, may be provided to postpartum women for 6–12 weeks following childbirth for reducing the risk of anaemia in settings where gestational anaemia is of public health concern.e | Context-specific recommendation |
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Postpartum vitamin A supplementation
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| 21. Vitamin A supplementation in postpartum women for the prevention of maternal and infant morbidity and mortality is not recommended. | Not recommended |
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Physical activity and sedentary behaviour
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| 22. All postpartum women without contraindication should:
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undertake regular physical activity throughout the postpartum period; - ▪
do at least 150 minutes of physical activity throughout the week for substantial health benefits; and - ▪
incorporate a variety of physical and muscle-strengthening activities; adding gentle stretching may also be beneficial.
| Recommended |
| 23. Postpartum women should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. | Recommended |
| Contraception |
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Postpartum contraception
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| 24. Provision of comprehensive contraceptive information and services during postnatal care is recommended. | Recommended |
| B. NEWBORN CARE |
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| Newborn assessment |
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Assessment of the newborn for danger signs
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| 25. The following signs should be assessed during each postnatal care contact, and the newborn should be referred for further evaluation if any of the signs is present: not feeding well; history of convulsions; fast breathing (breathing rate > 60 per minute); severe chest in-drawing; no spontaneous movement; fever (temperature > 37.5 °C); low body temperature (temperature < 35.5 °C); any jaundice in first 24 hours after birth, or yellow palms and soles at any age.
The parents and family should be encouraged to seek health care early if they identify any of the above danger signs between postnatal care visits. | Recommended |
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Universal screening for abnormalities of the eye
| 26. Universal newborn screening for abnormalities of the eye is recommended and should be accompanied by diagnostic and management services for children identified with an abnormality. | Recommended |
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Universal screening for hearing impairment
| 27. Universal newborn hearing screening (UNHS) with otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) is recommended for early identification of permanent bilateral hearing loss (PBHL). UNHS should be accompanied by diagnostic and management services for children identified with hearing loss. | Recommended |
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Universal screening for neonatal hyperbilirubinaemia
| 28. Universal screening for neonatal hyperbilirubinaemia by transcutaneous bilirubinometer (TcB) is recommended at health facility discharge. | Recommended |
| 29. There is insufficient evidence to recommend for or against universal screening by total serum bilirubin (TSB) at health facility discharge. | No recommendation issued |
| Preventive measures |
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Timing of first bath to prevent hypothermia and its sequelae
| 30. The first bath of a term, healthy newborn should be delayed for at least 24 hours after birth. | Recommended |
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Use of emollients for the prevention of skin conditions
| 31. Routine application of topical emollients in term, healthy newborns for the prevention of skin conditions is not recommended. | Not recommended |
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Application of chlorhexidine to the umbilical cord stump for the prevention of neonatal infection
| 32a. Clean, dry umbilical cord care is recommended. | Recommended |
| 32b. Daily application of 4% chlorhexidine (7.1% chlorhexidine digluconate aqueous solution or gel, delivering 4% chlorhexidine) to the umbilical cord stump in the first week after birth is recommended only in settings where harmful traditional substances (e.g. animal dung) are commonly used on the umbilical cord. | Context-specific recommendation |
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Sleeping position for the prevention of sudden infant death syndrome
| 33. Putting the baby to sleep in the supine position during the first year is recommended to prevent sudden infant death syndrome (SIDS) and sudden unexpected death in infancy (SUDI). | Recommended |
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Immunization for the prevention of infections
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| 34. Newborn immunization should be promoted as per the latest existing WHO recommendations for routine immunization. | Recommended |
| Nutrition interventions |
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Neonatal vitamin A supplementation
| 35a. Routine neonatal vitamin A supplementation is not recommended to reduce neonatal and infant mortality. | Not recommended |
| 35b. In settings with recent (within the last five years) and reliable data that indicate a high infant mortality rate (greater than 50 per 1000 live births)f and a high prevalence of maternal vitamin A deficiency (≥ 10% of pregnant women with serum retinol concentrations < 0.70 µmol/L), providing newborns with a single oral dose of 50 000 IU of vitamin A within the first three days after birth may be considered to reduce infant mortality. | Context-specific recommendation |
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Vitamin D supplementation for breastfed, term infants
| 36. Vitamin D supplementation in breastfed, term infants is recommended for improving infant health outcomes only in the context of rigorous research. | Context-specific recommendation |
| Infant growth and development |
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Whole-body massage
| 37. Gentle whole-body massage may be considered for term, healthy newborns for its possible benefits to growth and development. | Recommended |
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Early childhood development
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| 38. All infants and children should receive responsive care between 0 and 3 years of age; parents and other caregivers should be supported to provide responsive care. | Recommended |
| 39. All infants and children should have early learning activities with their parents and other caregivers between 0 and 3 years of age; parents and other caregivers should be supported to engage in early learning with their infants and children. | Recommended |
| 40. Support for responsive care and early learning should be included as part of interventions for optimal nutrition of newborns, infants and young children. | Recommended |
| 41. Psychosocial interventions to support maternal mental health should be integrated into early childhood health and development services. | Recommended |
| Breastfeeding |
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Exclusive breastfeeding
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| 42. All babies should be exclusively breastfed from birth until 6 months of age. Mothers should be counselled and provided with support for exclusive breastfeeding at each postnatal contact. | Recommended |
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Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services
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| 43a. Facilities providing maternity and newborn services should have a clearly written breastfeeding policy that is routinely communicated to staff and parents. | Recommended |
| 43b. Health-facility staff who provide infant feeding services, including breastfeeding support, should have sufficient knowledge, competence and skills to support women to breastfeed. | Recommended |
| C. HEALTH SYSTEMS AND HEALTH PROMOTION INTERVENTIONS |
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Schedules for postnatal care contacts
| 44. A minimum of four postnatal care contacts is recommended.
If birth is in a health facility, healthy women and newborns should receive postnatal care in the facility for at least 24 hours after birth. If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth. At least three additional postnatal contacts are recommended for healthy women and newborns, between 48 and 72 hours, between 7 and 14 days, and during week six after birth. | Recommended |
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Length of stay in health facilities after birth
| 45. Care for healthy women and newborns in the health facility is recommended for at least 24 hours after vaginal birth. | Recommended |
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Criteria to be assessed prior to discharge from the health facility after birth
| 46. Prior to discharging women and newborns after birth from the health facility to the home, health workers should assess the following criteria to improve maternal and newborn outcomes:
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the woman’s and baby’s physical well-being and the woman’s emotional well-being; - ▪
the skills and confidence of the woman to care for herself and the skills and confidence of the parents and caregivers to care for the newborn; and - ▪
the home environment and other factors that may influence the ability to provide care for the woman and the newborn in the home, and care-seeking behaviour.
| Recommended |
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Approaches to strengthen preparation for discharge from the health facility to home after birth
| 47. Information provision, educational interventions and counselling are recommended to prepare women, parents and caregivers for discharge from the health facility after birth to improve maternal and newborn health outcomes, and to facilitate the transition to the home. Educational materials, such as written/digital education booklets, pictorials for semi-literate populations and job aids should be available. | Recommended |
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Home visits for postnatal care contacts
| 48. Home visits during the first week after birth by skilled health personnel or a trained community health worker are recommended for the postnatal care of healthy women and newborns. Where home visits are not feasible or not preferred, outpatient postnatal care contacts are recommended. | Recommended |
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Midwifery continuity of care
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| 49. Midwife-led continuity-of-care (MLCC) models, in which a known midwife or small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum, are recommended for women in settings with well-functioning midwifery programmes. | Context-specific recommendation |
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Task sharing components of postnatal care delivery
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| 50a. Task sharing the promotion of health-related behaviours for maternal and newborn healthg to a broad range of cadres, including lay health workers, auxiliary nurses, nurses, midwives and doctors, is recommended. | Recommended |
| 50b. Task sharing the provision of recommended postpartum contraception methodsh to a broad range of cadres, including auxiliary nurses, nurses, midwives and doctors, is recommended. | Recommended |
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Recruitment and retention of staff in rural and remote areas
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| 51. Policy-makers should consider a bundle of interventions covering education, regulation, incentives and personal and professional support to improve health workforce development, attraction, recruitment and retention in rural and remote areas. | Recommended |
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Involvement of men in postnatal care and maternal and newborn health
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| 52. Interventions to promote the involvement of men during pregnancy, childbirth and after birth are recommended to facilitate and support improved self-care of women, home care practices for women and newborns, and use of skilled care for women and newborns during pregnancy, childbirth and the postnatal period, and to increase the timely use of facility care for obstetric and newborn complications.
These interventions are recommended, provided they are implemented in a way that respects, promotes and facilitates women’s choices and their autonomy in decision-making, and that supports women in taking care of themselves and their newborns. | Recommended with targeted monitoring and evaluation |
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Home-based records
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| 53. The use of home-based records, as a complement to facility-based records, is recommended for the care of pregnant and postpartum women, newborns and children, to improve care-seeking behaviour, men’s involvement and support in the household, maternal and child home care practices, infant and child feeding, and communication between health workers and women, parents and caregivers. | Recommended |
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Digital targeted client communication
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| 54. WHO recommends digital targeted client communication for behaviour change regarding sexual, reproductive, maternal, newborn and child health, under the condition that concerns about sensitive content and data privacy are adequately addressed. | Context-specific recommendation |
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Digital birth notifications
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| 55. WHO recommends the use of digital birth notifications under these conditions:
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in settings where the notifications provide individual-level data to the health system and/or a civil registration and vital statistics (CRVS) system; - ▪
the health system and/or CRVS system has the capacity to respond to the notifications.
| Context-specific recommendation |
