Document text
A Book for Midwives
Care for pregnancy, birth,
and women's health
Susan Klein, Suellen Miller,
and Fiona Thomson
Hesperian
Berkeley, California, USA
The Hesperian Foundation and the contributors to A Book for Midwives do not assume
liability for the use of information contained in this book.
All health workers have a responsibility to be honest with themselves and the people they
care for about the limits of their skills. This means: only perform the procedures you are
trained to. Find help from other, more experienced health workers when a woman needs a
kind of care that you are not experienced with. Seek the advice of local health workers and
medical authorities about the safest ways to practice in your area. This manual can help
you learn new skills, but no book can take the place of hands-on training with a skilled and
experienced teacher. Keep watching, reading, listening, and learning more whenever you
have the chance.
Copyright © 2004, 2009, 201 0 by the Hesperian Foundation. All rights reserved.
First edition: December 2004, 2nd printing 2009, update 201 0
Printed in USA
ISBN: 978-0-942364-23-1
Library of Congress Cataloging-in-Publication Data
The Library of Congress has already cataloged the 1 0-digit ISBN as follows:
Klein, Susan, b. 1 948.
A book for midwives : care for pregnancy, birth, and women's health / by Susan Klein,
Suellen Miller, and Fiona Thomson.-- 1 st ed.
p. ; cm.
Includes index.
ISBN 0-942364-23-6 (pbk.)
1 . Midwifery. 2. Midwives. 3. Pregnancy. 4. Childbirth. 5. Women-Health and hygiene.
I. Miller, Suellen, 1 947- II. Thomson, Fiona, 1 974- III. Hesperian Foundation. IV. Title.
[DNLM: 1 . Midwifery. WQ 1 65 K635b 2004]
RG960.K56 2004
618.2— dc22
2004060651
The Hesperian Foundation encourages others to copy, reproduce, or adapt to meet local
needs any or all parts of this book, including the illustrations, provided that the parts
reproduced are distributed free or at cost — not for profit. Any organization or person who
wishes to copy, reproduce, or adapt any or all parts of this book for commercial purposes
must obtain permission from the Hesperian Foundation.
Before beginning any translation or adaptation of this book or its contents, please contact
the Hesperian Foundation for suggestions, updates on information here, and to avoid
duplication of efforts. Please send us a copy of any materials in which text or illustrations
from this book have been used.
Hesperian Foundation
1 91 9 Addison Street, #304
Berkeley, California 94704, USA
www.hesperian.org
nesperian
This book con be improved with your help. We
want to hear about your experiences, traditions
and practices. If you have any suggestions for
improving this book , or making it better meet
the needs of your community, please write to us.
Your comments will help make future editions
more useful. Thank you for your help.
Credits
Project coordination: Fiona Thomson
Design and production: Sarah Wallis
Cover design: Sarah Wallis
Additional writing and editing:
Darlena David, Todd Jailer,
Jane Maxwell, Susan McCallister,
Sarah Shannon, Kathleen Vickery,
Sarah Wallis
Art coordination: Fiona Thomson
and Sarah Wallis
Additional production: Lora Santiago
Artists: Namrata Bali, Jennifer Barrios,
Sara Boore, Heidi Broner,
May Florence Cadiente, Barbara Carter,
Gil Corral, Elizabeth Cox,
Regina Faul-Doyle, Christine Eber,
Inaki Fernandez de Retana,
Sandy Frank, Deborah Green,
Susie Gunn, Jesse Hamm, Haris Ichwan,
Anna Kallis, Delphine Kenze,
Susan Klein, Joyce Knezevich, Gina Lee,
June Mehra, Naoko Miyamoto,
Jeanne Muller, Mabel Negrete,
Gabriela Nunez, Kate Peatman,
Sara Reilly-Baldeschwieler,
Diana Reiss-Koncar, Petra Rohr-
Rouendaal, Leilani Roosman,
Lucy Sargeant, Mona Sfeir,
Akiko Aoyagi Shurtleff, Chengyu Song,
Fiona Thomson, Dovile Tomkute-
Veleckiene, Sarah Wallis, Lihua Wang,
David Werner, Christine Wong,
Allan Woong, Mary Ann Zapalac
Field-testing and networking: Starr Amrit
Copy editing: Rachel Markowitz
Indexing: Ty Koontz
Proofreading: Sunah Cherwin
Medical review: Ellen Israel, Lisa Keller,
Melissa Smith, Judith Standley
Editorial and production management:
Susan McCallister
Cover photographs:
1
2
1 . India by Starr Amrit
2. Nepal by Curt Carnemark/World Bank
3. Mexico by Rick Maiman/David and
Lucile Packard Foundation, courtesy of
Photoshare
4. Democratic Republic of Congo by
Gilberte Vansintejan
5. Tunisia by Curt Carnemark/World Bank
6. Burma (Myanmar) by Peter Williams/WCC
Back cover: Mexico by Rick Maiman/
David and Lucile Packard Foundation,
courtesy of Photoshare
The first edition of this book was imagined, written, and illustrated by Susan Klein.
Sadly, she died before it was published. This new revision is still carried largely by her
writing, her drawings, and we hope, her vision — that A Book For Midwives would be a
tool enabling all those who attend women in childbirth, regardless of their
educational background, to exercise independent judgment and to make the best
possible decisions at each birth.
Credits for the 2009 edition and 201 0 update: This updated, corrected printing relies
heavily on the generously offered, wise counsel of midwives Ellen Israel, Ellen Lapowsky,
Suellen Miller, Judith Standley, and Sarah Wallis; and Drs. Reuben Granich, Lisa Keller,
Scott Oesterling, Linda Spangler, Amy Stenson, and Lorna Thornton. Todd Jailer
coordinated the reprint with editorial and design assistance from Shu Ping Guan, Jane
Maxwell, Susan McCallister, Kathleen Tandy, Dorothy Tegeler and Fiona Thomson.
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Thanks
Only with the collaboration of hundreds of advisors, reviewers, writers, artists, and others
was it possible to create this book.
Every staff member, intern, and volunteer here at the Hesperian Foundation helped bring
this book into the world, including those who raise funds, manage finances, publicize our
books, and pack and ship them around the world. Outside our office, dozens of reviewers
helped decide what this book should cover and how to do it. Groups of midwives and
midwifery students in 1 0 countries critiqued early versions to make it as useful, appropriate,
and accurate as possible. Midwives, doctors, and other health workers, trainers, and
specialists volunteered their time to ensure the accuracy and clarity of the material here.
Along with our tireless medical editors, we called on a few reviewers over and over
again, and they deserve special mention here. Thank you Deborah Billings, Lisa de Avila,
Ruth Kennedy, and Karen Strange.
The following organizations contributed time, resources, and critical thinking: Averting
Maternal Death and Disability (AMDD) in the US; ASECSA in Guatemala; The Bangladesh
Women's Health Coalition; The Berkeley Midwives Study Group in the US; El Centro Para los
Adolescente de San Miguel de Allende (CASA) in Mexico; Centre For Rural Studies and
Development in India; El Centro de Atencion Integral de la Pareja in Mexico; The International
Confederation of Midwives; The Integrated Midwives Association of the Philippines;
Inuulitsivak Maternity Center in Canada; Ipas in the US, Ghana, and Kenya; Ixmucane and
Midwives for Midwives in Guatamala; Jamkhed Comprehensive Rural Health Program in India;
Kampot Hospital Maternity Center in Cambodia; the Maryknoll Sisters and the VEMA training
center of Tanzania; Pathfinder in Peru; and the Reproductive Health Research Unit at the
University of the Witwatersrand, Chris Hani Baragwanath Hospital in South Africa.
Thanks to the following publishers who gave us permission to use drawings: Family Care
International, from Healthy Women, Healthy Mothers; Freedom From Hunger; and Pesticide
Action Network Asia and the Pacific, from Breaking the Silence! Plantations and Pesticides.
Our deep gratitude goes to everyone who gave their time, thoughts, and knowledge
so generously, both to the original edition of A Book for Midwives and to this revision.
Your commitment to health for all is what brought this book into the world. Thank you:
Hilary Abell
Dee I Afroze
Arthur Ammann
Jana Anderson
Susan Anderson
Shoba Arole
Leonor Bahena Erazo
Alison Bastien
Naomi Baumslag
Denise Bergez
Erik Bergstrom
Alan Berkman
Ginger Bhakti
Deborah Bickel
Judith Bishop
Lisa Bohmer
Bill Bower
Jenny Bowers
Kate Bowland
Isabel Brabant
Barbara Briggs-
Letson
Sandy Buffington
Colin Bullough
Raquel Burgos
Medina
August Burns
Pauline Butcher
Sarah Buttrey
Ana Maria Camarillo
Kristen Cashmore
Teresa Cerezo
Gonzalez
Rebecca Chalker
Barbara Clifford
Davida Coady
Rani Coelho
Timothy Coen
Jeff Conant
Peggy Cook
Maureen Corbett
Antonia Cordova
Morales
Maricruz Coronado
Jennie Corr
Kyle Craven
Jane Crawley
Alice de la Gente
Maria de la Paz
Puebla Alvear
Barbara de Souza
David de Leeuw
Kim Dickson-Tetteh
Milka Dinev
France Donnay
Peg Donovan
Carol Downer-
Chatham
Jane Drake
A Book for Midwives (201 0)
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J.T. Dunn
Edith Eddy
Sylvia Estrada-
Claudio
Aryn Faur
Susan Fawcus
Juliet Fleischl
Nina Frankel
Carmen Frazier
Frances Ganges
Tracy Gary
Marlene Gerber-
Fried
Julie Gerk
Zafarullah Gill
Ruth Goehle
Fisa Gonzalves
Nadine Goodman
Suzan Goodman
Kristen Graser
James Green
Sadja Greenwood
Cindy Haag
Barb Hammes
Marcia Hansen
Roxanne Henderson
Griselda Hernandez
Kathy Herschderfer
Sarah Jane
Holcombe
Diana Hoover
Nap Hosang
Jennifer Houston
Mary Clare Hubert
Kathleen Huggins
Pamela Hunt
Robert Hurst
Peter Ivey
Nuriya Janss
Christine Johnson
Mary Johnson
Ralph Johnson
John Kadyk
Angela Kamara
Robert Keast
Christie Keith
Beverly Kerr
Mary Kroeger
Raven Fang
B.A. Faris
Brian Finde
Julie Fitwin
David Foeb
Roxane Fovell
Ronnie Fovich
Deborah Maine
Forraine Mann
Alan Margolis
Margaret Marshall
Alberto Martinez
Polis
Fuyanda Mavuya
Nicky May
Junice Melgar
Jose Fuis Mendoza
Elena Metcalf
Faura Miranda
Iris Moore
Syema Muzaffar
Papa Djibril Niang
Sandy Niemann
Besem Obenson
Deborah
Ottenheimer
Fauri Paolinetti
Bill Parer
Juana Payva
Nimal Perera
Fucille Pilling de
Fucena
Man Poon
Jennifer Potts
Paula Quigley
Sumana Reddy
Mary Ann Reiger
Marina Rodriguez
Palma
Judith Rogers
Forraine Rothman
Sabala and Kranti
Shelly Sala
Jason Sanders
Shira Saperstein
Merrie Schaller
Katherine Sear
John Sellors
Katharine Shapiro
Fonny Shavelson
Theresa Shaver
Mira Shiva
Christine
Sienkiewicz
Jael Silliman
Irene Sotelo
Alvarez
Jennifer Stonier
Susan Sykes
Michael Tan
Vijayalaxmi Taskar
Joe Taylor
Petra ten Hoope-
Bender
Carol Thuman
Finda Tietjen
Jan Tritten
Greg Troll
Mina Tulugak
Faura Turiano
Gilberte Vansintejan
Elmar Vinh-Thomas
Donna Vivio
Claire Von
Mollendorf
David Werner
Sharon Wilconson
Judith Winkler
Merrill Wolf
Juliana Yartley
Karen Zack
Fisa Ziebel
Additionally, the incredible patience and support of our families and friends during the
long process of producing this book allowed us to see the project through.
Finally, thank you so much to the individuals and foundations who financially
supported this project: Allan S. Gordon Foundation; Anna Falor Burdick Program of the
Falor Foundation, Inc.; Averting Maternal Death and Disability Program, Heilbrunn Center,
Mailman School of Public Health, Columbia University; Compton Foundation, Inc.;
Conservation, Food and Health Foundation, Inc.; David and Fucile Packard Foundation;
Dorothy and Jonathan Rintels Charitable Foundation; Erik E. and Edith H. Bergstrom
Foundation; Ford Foundation; International Confederation of Midwives; Jadetree
Foundation; Jeanne Kemp; Salt-Bush Fund of the Tides Foundation; Ruth Sherer; and the
United Nations Population Fund.
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A Book for Midwives (201 0)
How to use this book
Finding information
To find information, use the Contents, the Index, or the Tabs.
The Contents at the beginning of this book list the name of each chapter in the
order in which it appears. Contents of each chapter are also listed at the beginning
of that chapter.
The Index, or the yellow pages at the back of this book, lists all the topics
covered in this book in the order of the alphabet (a, b, c, d...).
Each page in this book has a number at the bottom. To find a chapter or topic
in this book, find it in the contents or index, and then turn to the page number
listed next to it.
Tabs on the right-hand pages separate most of the book into 5 sections.
You can quickly find the information on staying healthy, infection prevention,
pregnancy, labor and birth (including postpartum), and on other health skills,
by turning to the sections labeled with those tabs.
Warnings, medicines, and notes
Warnings, medicines, and notes are separate from the main text.
Warning boxes show very important information. When you see this kind of
box, you must take action to avoid danger.
WARNING! Do not insert an IUD for a woman who has
signs of infection. The infection can spread to the womb.
Medicine boxes show how to give medicines.
Read these boxes very carefully, and always look in
the green medicines pages starting on page 463
before giving a medicine.
These pictures show how
the medicines in the box
are given — in this case
as tablets. \
0
To lower a fever
• give 500 to 1 000 mg paracetamol by mouth, every
4 to 6 hours.
Notes show information that is useful, but not directly connected with the
information around it.
Note: Clean hands do not stay clean for long. If you touch anything
other than the mother's genitals, you must wash again.
A Book for Midwives (201 0)
nesperian. ore
Understanding pictures of the body
How we show the outside of the body
When we draw a person, we try to draw her whole body. If we do not have enough
room, we only show part of her body.
If it is important to see
the baby's head and the
vagina more clearly, we
will show only that part
of the body, so we can
make the picture bigger.
This picture
shows a mother
pushing her baby
out of her vagina.
How we show the inside of the body
Sometimes we need to show what is happening
inside a woman's body. So we include pictures that
show what a woman's body would look like if you
could see inside of her.
Usually, we use thick lines to show the outside
of a woman's body, and thin lines or dotted lines
to show what is happening on the inside.
the womb,
inside the
mother's body
the baby,
inside the
womb
A note on language
Medical and technical words Throughout this book, we try to use easily
understood words for parts of the body and things that the body does. We also
explain the medical words we use. If there is a medical or technical word you do
not understand, you can look it up in the index and see if it is explained in the
book. Or you can look in the glossary on page 503, which lists some medical and
technical words that are useful to know.
He and she When talking about babies, we did not want to say "he or she" each
time because it can be awkward. So sometimes we say "she," and sometimes we
say "he."
Getting help
The information in this book is not always enough to help you solve a health
problem. When this happens, get help! Depending on the problem, you should:
Get medical advice. A skilled health worker or doctor should be able to help you
decide what to do. This is not usually an emergency.
Get medical help. The woman or her baby need to see a skilled health worker or
doctor for tests or treatment as soon as possible.
Go to a medical center or hospital. There is an emergency. Take the woman or
her baby to a hospital right away for surgery or other immediate help.
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A Book for Midwives (201 0)
Contents
Introduction
Chapter 1: Words to mid wives
Learning is lifelong 1
Share what you know 3
Respectful and compassionate care .... 6
Chapter 2: Treating health problems
Finding the causes of health
problems 13
Finding the best treatment 16
Chapter 4: Helping women stay healthy.
Eating well 33
Caring for the body for good health . . 42
Chapter 5: Preventing infection
Preventing infection saves lives 49
Prevent infection by keeping
germs away 52
Clean your hands and wear
protective clothing 53
PREGNANCY
Introduction
1
Work to improve women's health 8
Work for the joy of it 11
12
Finding root causes of
health problems 21
Midwives can make change 25
,26
29
32
Things to avoid during
pregnancy and breastfeeding 45
48
Clean the space and bedding 57
Clean and sterilize tools 59
Get rid of wastes safely 67
70
Chapter 3: A woman's body in pregnancy
A woman's sexual and How women become pregnant
reproductive parts 27
Chapter 6: Common changes in pregnancy 72
Changes in eating and sleeping 73 Changing feelings and emotions .... 82
Body changes and discomforts 76
Chapter 7: Learning a pregnant woman's health history
Questions in a pregnancy
health history 86
Does she have signs of pregnancy? ... 86
How pregnant is she now?
When is the baby due? 88
Has she had any problems with past
pregnancies or births? 93
Malaria
HIV and AIDS
What else in her life might affect
her pregnancy and birth?
Making a transport plan
..84
. 98
. 99
104
106
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A Book for Midwives (201 0)
Chapter 8: Prenatal checkups
Talk with the mother 109
Check the mothers body 116
Check for signs of anemia 116
Weigh the mother 118
Check the mothers temperature .... 119
Check the mother's pulse 120
Check the mother's blood pressure . . 122
Check for signs of pre-eclampsia. ... 125
Signs of bladder or kidney infection. .128
LABOR AND BIRTH
Introduction
108
Check the baby 130
Measure the mother's womb 130
Find the position of the baby 135
Listening to the baby's heartbeat. ... 139
What to do if you find
warning signs 142
After the checkup 144
Record of prenatal care 145
146
Chapter 9: Getting ready for labor and birth 1 48
Signs that labor will start soon 149 What to bring to a birth 151
When to go to the birth 151 Sterilize your tools and wash up ... . 153
Chapter 1 0: Giving good care during labor and birth
What happens during labor Be ready for emergencies
and birth 155 Keep a record of what happens
Care for the mother during labor ... 157 during labor
Chapter 1 1 : Opening: stage 1 of labor
What happens during stage 1 167
When you first arrive 168
Helping the mother relax in stage 1 . 169
Signs for the midwife to check
in stage 1 170
The baby's position 170
The baby's heartbeat 172
The bag of waters 174
Chapter 1 2: Pushing: stage 2 of labor
Watch for signs that stage 2 is near
or starting 195
What happens during stage 2 197
Help the mother have a safe birth ... 199
Watch for warning signs 202
154
163
164
166
The mother's pulse 178
The mother's temperature 178
The mother's blood pressure 180
Bleeding during labor 183
Pain in the womb 183
Watch for signs of progress 185
Safe ways to encourage labor 191
194
Help the mother give birth 206
Baby is breech 215
Delivering twins 219
Baby is very small or more than
5 weeks early 221
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Chapter 1 3: The birth of the placenta: stage 3 of labor
.. 222
Check the mothers physical signs . .
. 223
Help her push out the placenta . . . .
. 227
Bleeding after birth
. 224
Watch for bleeding after the
Watch for signs the placenta
placenta is born
. 236
has separated
. 226
What to do for the baby
. 240
Chapter 1 4: The first few hours after the
birth
.. 246
What to do for the mother
. 247
Breathing, heartbeat, temperature . .
. 254
What to do for the baby
. 252
The baby's body
. 256
General appearance
. 253
Clean up and answer questions . . . .
. 267
Chapter 1 5: The first weeks after the birth
.. 268
What to do for the mother
. 269
Encourage the baby to breastfeed
Watch her womb and bleeding ....
. 270
and watch how she grows
. 274
Watch for signs of womb infection .
. 271
Care for the cord
. 277
Watch for signs of vaginal infection
. 272
Look for signs of infection
. 277
What to do for the baby
. 274
Watch the color of the baby's skin
and eyes
. 279
Chapter 16: Breastfeeding
Breast is best
. 281
Common difficulties while
.. 280
How to breastfeed
. 282
breastfeeding
. 286
When the mother works
Situations that affect breastfeeding .
. 291
outside the home
. 284
Alternatives to breastfeeding
. 294
HEALTH SKILLS
Introduction 296
Chapter 17: Family planning 298
Choosing a family planning method . 300 Making family planning work for
Chart: family planning methods .... 301 the communitY 318
Chapter 1 8: Sexually transmitted infections (STIs) 320
What are STIs?
. . 321
Teaching women how to
Discharge from the vagina
. . 323
prevent STIs
. 336
Sores on the genitals
STIs that affect the whole body . . .
. . 329
. . 334
How to help stop STIs in your
community
. 337
Chapter 1 9: Advanced skills for pregnancy and birth
.. 338
Vaginal exams during labor
. . 339
Episiotomy
. 354
Home methods for starting labor .
. . 341
Sewing a tear or an episiotomy . . . .
. 356
Injections
. . 345
Caring for a woman after female
How to give fluid through a vein .
. . 350
genital cutting (circumcision) ....
. 367
Catheters
. . 352
Turning a breech or sideways baby .
. 369
A Book for Midwives (201 0)
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Chapter 20: The pelvic exam: How to examine a woman's vagina and womb.,
When to do a pelvic exam 374 The speculum exam
Before the exam 375 Tests for infections and cancer
The visual exam 376 The bimanual exam (2-hand exam) .
Chapter 21: Howto insert an IUD
Help a woman decide if the IUD Inserting the IUD
is right for her 390 Afteryou insert tiiem|)
Before you insert the IUD 391 Removing the IUD
Chapter 22: Helping a woman after a pregnancy ends early
Problems from a pregnancy Bleeding
that ends early 401 shock
Emergency care for problems after
miscarriage or abortion 406
Infection 409
Work with the community to
prevent unsafe abortions . . .
Problems with the MVA ,
After the MVA
Working with medical centers
and doctors
Chapter 23: Manual vacuum aspiration .
Deciding when to do MVA 418
Getting ready for the MVA 419
Doing the MVA 422
Chapter 24: Getting medical help
What medical centers and hospitals
can provide 433
Getting to a medical center 438
Chapter 25: Homemade tools and teaching materials
Low-cost equipment 443 Teaching materials
Medicines (green pages): uses, dosage, and precautions
When to use medicines 463
How to take medicines safely 464
How to take medicines 467
Kinds of medicine 470
Problem index 472
Alphabetical list of medicines
Oral contraceptives
Medicines for HIV and AIDS .
To learn more.
Technical and medical words.
Index (yellow pages).
Due date calculator...
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372
377
379
385
388
392
398
399
400
412
414
415
416
428
430
432
438
442
447
463
473
490
492
499
503
505
527
A Book for Midwives (201 0)
Midwives and
community health
For thousands of years, since long before
there were doctors or hospitals, midwives
have been helping women stay healthy,
helping babies into the world, and helping
families grow. Ask a woman why she prefers
the care of a midwife and she will tell you
that midwives are knowledgeable, patient,
and respectful of her traditions.
Why are midwives such important and
valued health workers?
• Midwives trust in the safety of pregnancy and birth, and have
confidence that women can work together to protect their
own health.
• Midwives often live in the communities they serve, so the
families they help know and trust them.
• Many midwives spend more time with the women they care
for than a doctor or clinic worker would. This helps midwives
to better understand women's needs, and to see danger signs.
• Most midwives are women. Many women feel more
comfortable talking to a woman health worker.
• Midwives charge lower fees than most doctors or hospitals —
valuing service to the community over the pursuit of money
or power.
• In poor communities where there are few health services,
midwives are often the only health workers.
For all these reasons, in most of the world midwives are the first
and sometimes the only health workers women go to for help in
birth or for any health problem. But midwives face a number of
challenges in this important work.
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Challenges
Perhaps the biggest struggle for midwives (and for all health
workers) is fighting sickness and death in women and their babies.
Every year, hundreds of thousands of women die in pregnancy and
during labor. Millions more are injured or disabled. Most of these
deaths and injuries happen to women who are poor — who do not
have enough food, or safe homes, or adequate medical care.
Most of the midwives of the world live in poor communities,
and many are themselves not paid a livable wage. The people of
each community must
I work in a restaurant 6 days
a week , and then go home to care
for my family. I’m tired all the
time and my husband asks me to
stop attending births.
But I continue because
it is what I am good at,
what I love, what I am
called to do.
show midwives how
important their work is
by supporting them in
the ways that they can.
Local governments would
also be wise to invest in
midwives. These governments
rarely provide midwives with
adequate education or
supplies, yet they rely on
midwives to care for the many
women who have no access to
other medical care.
Along with being
underpaid, midwives may
struggle to receive the respect
they deserve for their work.
Doctors and others too often
dismiss the contributions of
midwives. When midwives
are not treated as valued
health workers — part of a
community of health care
providers who all share the
same goals — their ability to
care for women is hindered.
Midwives may actually be locked out
of the health system when a woman who has a health emergency is
not allowed to bring her midwife with her to the hospital.
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Traditional midwives (sometimes called TBAs) face particular
problems. Many professional health workers, including
professional midwives, see traditional midwives as incompetent or
old-fashioned. These traditional midwives may be very
knowledgeable about birth and skilled with plant medicines,
gentle massage techniques, or other safe, effective practices. As
more people leave their villages for cities, these midwives may be
some of the only people preserving the knowledge and customs of
their communities. Traditional midwives often work for little or no
pay, but instead because of a belief in the importance of their
work. Like other midwives, they do their work because they love
women and babies, because they want to contribute to their
communities, or because they are spiritually called to.
How A Book for Midwives can help
Midwives need accurate information to help them protect the
health and well-being of women, babies, and families. They need
strategies to fight poverty and the unequal treatment of women,
and for working together and with other health workers towards
health for all. We revised A Book for Midwives with these needs in
mind. In this edition of A Book for Midwives, you will find:
• information needed to care for women and their babies
during pregnancy, labor, birth, and in the weeks following
birth, because this is the primary work of most midwives.
• skills for protecting a woman's reproductive health
throughout her life, because a woman's health needs are
important whether or not she is having a baby, and because
a woman's health when she is
not pregnant affects how healthy
and safe her pregnancies
and births will be.
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A Book for Midwives (201 0)
safe, effective methods from both traditional midwifery and
modern, Western-based medicine, because good health care
in labor and birth uses
the best from both
My grandmother is a
midwife. She uses plant
medicines and massage
to help pregnant women.
Western medicine and
the traditions of midwifery
• discussion of the ways that
poverty and the denial of
women's needs affect
women's health, and
how midwives can
work to improve these
conditions, because
changing these
conditions can make
a lasting improvement
in health.
• suggestions for how
midwives can and must
work with each other,
with other health
workers, and with the
larger community,
because working
together strengthens
everyone's knowledge
and makes action to
improve women's health
more effective.
The basics of midwifery care
will never change. Women
and families will always need compassionate and respectful care
before, during, and after birth. And because midwives always
benefit from learning more, we hope that the expanded and
updated information in this book will help midwives everywhere
learn new and lifesaving skills, and apply those skills for the
good of the women, babies, and families they serve.
I went to school in the city
to become a midwife myself }
and I’ve been able to teach
my grandmother some new
ways to sterilize tools ,
watch for danger signs ,
and make birth safer.
7 C
But I’m still learning
the old ways from her.
So many of them still work
better than the new ways.
1 l it rfii $±kt\*r
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A Book for Midwives (201 0)
Chapter 1
Words to midwives
n this chapter:
Learning is lifelong
Share what you know
Share what you know with other
health workers and midwives 3
Respectful and compassionate care
Do not judge 6
Follow your own advice 6
Help people help themselves 7
Work to improve women's health
People who affect a woman's health ... 8
Men can care for women's health 9
Work for the joy of it
1
3
Share what you know with the
community 4
6
Listen more than you talk 7
Talk openly about difficult subjects .... 7
Keep things private (confidential) 7
8
Working together to save lives 10
11
i 1* 4li i if 4 «r
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Words to
midwives
To work for the health and well-being of women and babies — that is, to be
a midwife — you must be willing to learn, to treat people with respect and
compassion, and to work together with others to meet the health needs of
the community.
Learning is lifelong
The first step on the path to becoming a midwife — or any kind of health worker
— is learning from others. And even the most experienced midwives continue to
learn and gain new skills throughout their whole lives.
Midwives learn from experience and from books and classes. Each way of
learning is important. All midwives should find a balance between study and
practice.
Books and study help midwives
understand a broad range of
information.
But practice is the only way to learn
the skills needed to care for women
and babies.
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1
Chapter 1: Words to midwives
Experienced midwives continue to learn
There is always more to know about birth and about health. Every birth is
different, medical information changes, and there are new skills to be learned.
As long as you are a midwife you can:
• watch how other midwives,
health workers, and doctors do
things.
• ask the women and families you
work with what they like and do
not like about the care that you
give.
• read books or other written
materials. Keep helpful books
with you so you can look up
information you do not use
regularly or remember.
• learn new skills. If you can get
the training and tools to do new
procedures safely, do not be
afraid to learn a new skill. This
will allow you to help more
women in your community and
to become a better midwife.
Midwives learn from teachers, books, and other midwives and health workers.
Mostly they learn safe ways to practice. But as any midwife gains more experience,
she will discover that some of what she learned is not the safest or most effective
way to care for women.
Midwives must be willing to change their ideas when they learn new ways of
practicing so they are always practicing in the best ways they can. Midwives must
look honestly at the ways they practice to be sure they are working well —
whether they learned these practices from doctors, traditional healers, or
anyone else.
Asking "why?"
Asking "why" is important because it helps you do more than just remember what
you have been told or what you have read. When you know why, you can make
decisions even when there is no person or book to tell you exactly what to do. You
can also adapt a treatment or tool to be of use in a way that others may not use it.
Finally, asking "why" is important for understanding the causes of problems —
to treat problems effectively, and to prevent them from happening again.
A Book for Midwives (201 0)
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Share what you know
Share what you know
Along with learning from books and teachers, midwives learn much of what they
know from each other and from the families they care for. And midwives can
improve health by sharing what they know with the community.
Share what you know with other health workers
and midwives
Midwives can work together to help each other. If one midwife becomes sick or
cannot work, another midwife can help the women she was caring for. Midwives
can also learn from and teach each other. In some communities, midwives and
other health workers share information with each other, talking honestly about
their work. Some midwives come together to meet every few months, compare
information, and share resources. At midwife meetings you can:
• take turns telling stories about births you have attended.
Be sure to share the difficult
births and mistakes.
Admitting mistakes is
difficult, but it is a great gift
when there is an opportunity
to learn from them. Other
midwives can explain what
they would have done the
same or differently. To protect
the mother's privacy, do not
share her name.
Next time I’ll check a
woman’s temperature during
labor. Then I can find an
infection earlier.
• ask other health workers to come meet with your group. For example, an
herbalist could come talk about local plants that can fight infections. Or a
midwives group could talk with nurses from a local maternity center about
how midwives and nurses can work together.
• share educational books (including this one!)
with other midwives. If no one has much money,
perhaps a group of midwives can put their money
together to buy a book to share.
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A Book for Midwives (201 0)
3
Chapter 1: Words to midwives
• practice helping women with different problems by acting them out
(role play). For example, one
person can pretend to be a
pregnant woman who is not
eating enough healthy food.
Another person can pretend to be
her midwife — listening and
giving advice. Afterwards, each
actor can explain how she felt,
and the others in the group can
offer suggestions for what they
would do differently. Make sure everyone has a chance to play one of the roles.
• make use of different midwives' skills. If one midwife knows how to read,
she can read aloud from books to the other midwives. A midwife who knows
how to sterilize tools can teach the others in the group.
Share what you know with the community
As a midwife, you give advice, treat problems, even save lives. But the overall health
of those around you is not in your hands alone. In part, this is because people
decide for themselves how to eat, how to do their work, and what choices they
make. By teaching and sharing information, midwives can help people to make
their own choices more wisely. This is why your first job as a midwife is to teach.
Teaching can happen anywhere and anytime. During a checkup, when you
explain to a woman why you are asking each question, you are teaching her. When
you show a woman's husband why family planning is his responsibility too, you
are teaching him. Even at the market, at a community gathering, or anytime you
meet with others, you have the chance to teach.
Teaching classes
There are probably topics that many people in the community could benefit from
learning about. If possible, call meetings for pregnant women, families, or other
community members to teach about health and birth. You can teach about:
• how the body works.
• how to choose and use family planning.
• how to eat and care for yourself in pregnancy.
• how to have a safer birth.
• how to care for yourself after a birth and how to breastfeed.
Teaching is a skill, and it takes practice. A good place to start
is by listening. When you find out what people already know,
you can help them build on that knowledge. And when you
listen, you will learn from those you are teaching.
Your ears are
2 of your most
important
tools.
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A Book for Midwives (201 0)
Share what you know
For example, if a group of women wants to learn about sexually transmitted
infections (STIs), you can first ask each person to share what she knows about STIs.
Women may know about STIs from books or classes, from talking to other
women, or from having had infections themselves.
After people have shared their knowledge, find out what questions they have.
People in the group may be able to answer each others questions. You can
probably add some important medical information and point out when people
have incorrect beliefs too. By encouraging the group to talk, you find out what
they really need to know — and help them understand how much knowledge they
already have. A person who feels confident that she understands a problem is more
able to work to solve it.
Show respect for the people you teach, and be sure that what you say is
meaningful to their lives.
• Sit in a circle with everyone on the same level. This puts you in the same
place as everyone else, and shows that you are not the only one with
knowledge.
• Be prepared. Think about what you want to share before you start teaching.
• Use many methods to teach. People learn differently, and everyone learns
better when they learn the same thing in different ways. After you talk with
the group about STIs, the group could act out a play about them. Or make
posters about STIs to share with the community.
You all said you want to
learn about what to eat
during pregnancy and
after the baby comes.
What do you know about
healthy eating now?
I’ve heard you
should not eat
meat when you are
breastfeeding. It
will harm the baby.
That’s not true!
You need to eat
meat to make the
blood strong!
Asking questions will help you understand what people already
know, what they want to learn, and what obstacles they face.
Remember, some people are used to speaking up in groups. Others may be
afraid. Encourage women, those who have little schooling, or anyone who usually
keeps quiet to share his or her thoughts. For more ideas on how to teach so people
can truly learn, see Helping Health Workers Learn.
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5
Chapter 1: Words to midwives
Share your knowledge with the people you care for
With accurate information, each woman has the ability to understand her body
and to make wise decisions about her health. Each time you meet with a woman
during pregnancy or for other care, explain what you are doing and why. Answer
any questions the woman has about her body or her health.
Admit what you do not know
No one knows every answer. Some problems have no easy answer! Admit what
you do not know, and people will trust the knowledge you do have.
I worried about you
when you did not
come last month.
Was something
wrong?
Respectful and compassionate care
Everyone deserves to be treated with respect. As a
health worker, the way you treat a woman is
particularly important.
Midwives are often trusted
authorities. A kind or
encouraging word from you
can go a long way in giving a
woman confidence in her
ability to care for herself. An
unthinking or cruel remark can cause
hurt that lasts many years in a woman.
Do not judge
Some women are used to being treated
disrespectfully. When you begin to work with
a woman who is often treated with disrespect
because of her age, the work she does, her
ethnicity or religion, how much money she
has, having a disability, or for other reasons, she may expect you to treat her badly
as well. You can only overcome this fear by showing her that you are there to listen
and help her — not to judge or criticize.
Follow your own advice
People are more influenced by what you do than what you say. And because
midwives are respected by their communities, the things you do may encourage
others to care for themselves. If you breastfeed your children, other women in the
community may be more likely to breastfeed. If you do not smoke, other women
may follow your example and not smoke, or may stop smoking. Live your own life
as you would advise others to do.
A Book for Midwives (201 0)
www. nesperian.org
Respectful and compassionate care
Help people help themselves
Everyone has the right to decide
what happens to her own body.
And people can and should
take the lead in their
own care. In this way,
they can become —
actively responsible ~~ / / —
r i • iii WA'
tor their own health
and the health of
their communities.
Listen more than you talk
A woman often needs someone who will listen to her without judgment. And as
she talks, she may find that she has some of the answers to her problems.
Talk openly about difficult subjects
Some women feel shy, ashamed, confused, or private about their problems. This is
especially common with family problems and sex. A midwife who talks honestly
and openly about these subjects will discover that many women share the same
problems. By speaking directly and comfortably to women about their families,
sexuality, and sexual health, you will help women feel less alone, and you may
help them solve problems that have a large effect on their health.
Keep things private (confidential)
Never tell anyone about someone else's health or care — unless the person says it
is OK. And when you talk to women about their health, do it in a private place
where others cannot hear.
In particular, respect a woman's privacy about subjects that may be sensitive to
her, such as sexually transmitted infections, miscarriages and abortions, and
family problems. You should never share
this type of information without a
woman's permission.
There is only one time when it is OK
to share information about someone's
health: if another health worker is caring
for the woman during an emergency,
the health worker will need to know the
woman's health history in order to
provide safe and effective care.
A midwife must keep what she
knows about a woman private.
I will never tell ^
anyone what
youve shared
with me.
Thank you. It's
a relief to be
able to speak
freely.
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A Book for Midwives (201 0)
7
Chapter 1: Words to midwives
Work to improve women's health
Midwifery is not just about treating health problems as they arise. Health problems
have many causes. Some are physical, some are social, economic, or political.
By treating social, economic, and political causes, you can prevent many health
problems — and protect more women in the community.
Working to treat social causes and to improve women's health is not something
one midwife can do alone. She must work with the whole community.
Understanding causes and finding solutions is more possible when people work
together. See page 23 for ideas about working with others to make change.
People who affect a woman's health
A woman's health is affected by many people. To care for a woman, you must work
with those people too.
Some of the people that affect a woman's health are:
• her husband, children,
parents, and other family
members.
• the people she works with,
or works for.
• her neighbors and friends.
• community leaders —
including spiritual leaders,
government officials, and
village heads.
• other health workers —
like traditional healers, doctors,
and community health workers.
A woman's health can be
protected — or hurt —
by the whole community.
Anyone who influences the way a woman works, eats, has sex (or does not
have it), or cares for her daily needs has an effect on a woman's health. Sometimes
the effect is good — it protects or improves the woman's health. Sometimes it is
bad — the woman's health and well-being are endangered.
For example, it may not help to tell a pregnant woman to eat more if her
husband always eats first and there is not enough left for her. She herself may
believe her husband's and children's hunger is more important than her own.
Who else could you involve to try to improve a woman's nutrition, when she
does not have enough to eat?
• the woman's husband, who is eating first. Perhaps you could talk to him
about how much food a pregnant woman needs.
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A Book for Midwives (201 0)
Work to improve women's health
• the men of the community, who all expect to eat first. The woman's husband
may be more likely to change if other men do too. You could have a meeting
of men and women and discuss why pregnant women must eat more to be
healthy. If one man in the community agrees that women must have as much
or more healthy food as men, this opens the door for others.
• children, who will soon grow up to be mothers and fathers. Each time a man
eats first and most, and a woman eats last and least, their children see and
learn that a man's hunger is more important than a woman's. By talking to
groups of schoolchildren or by changing the way your own family eats, the
next generation may grow up to value men and women more equally.
Who could you involve to make sure there is enough food for everyone?
Men can care for women's health
Whenever you can, encourage men to be partners in improving women's
health. Husbands, fathers, sons, community leaders, spiritual leaders,
bosses, and other men all play a role in how healthy women will be. If
the men of the community feel responsible for the health of women, the
whole community will benefit. Midwives can help men be involved.
Build on the roles and skills that men already have. For example, in
many communities men are seen as protectors. Help
men learn how to protect the health of women.
Encourage men to share the responsibilities of
pregnancy and parenting. Men can care for children in
the same ways that women do: comforting, bathing,
feeding, teaching, and playing with them.
Invite women and men to community meetings,
and encourage women to speak up.
Work with men who are sympathetic to women's needs. They can talk
to other men who listen more closely to a man than to a woman.
Give practical suggestions. Men who care very much about the health
of women in their lives may not know where to start. For example:
• Tell men how they can get tested and treated for sexually
transmitted infections. If only a woman is treated, she will quickly
be infected again by her partner.
• Explain to a man that his pregnant wife needs help with her
daily work.
• During labor, show a man how and where to rub a woman's back
to relieve her pain.
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A Book for Midwives (201 0)
9
Chapter 1: Words to midwives
Working together to save lives
When midwives work with the whole community, they can find solutions to
help the women they care for — or to help everyone in the community. Here is
a true story:
A creative solution
In the small villages of West Africa, when a woman has a problem in labor,
it is very hard for her to get to a hospital. Few villagers have cars, and most
taxi drivers refuse to take women in labor. When a woman is in danger,
there is little her midwife can do.
Some midwives and
villagers talked about this
problem, and discovered a
creative solution. Even
though no villagers had
cars, they were near a large
road. All day and night,
trucks drove down the
road bringing products to
the city. Someone
suggested that if a woman
needed help in labor, she
could ride with a truck
driver to the hospital.
For this plan to work, the villagers needed to be sure that truck drivers
would agree to stop if they were needed. They talked to someone from the
union of truck drivers. The union members were happy to help, and now
they have a system that is simple and effective.
When a woman needs to go to the
hospital, the midwife puts a yellow flag
out near the road. When a passing truck
driver sees the flag, he stops and picks
up the woman and the midwife, and
takes them to the city hospital.
By working together with each other,
other villagers, the truck drivers, and
their union, these midwives helped
save lives.
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A Book for Midwives (201 0)
Work for the joy of it
Work for the joy of it
If you want other people to take part in improving their lives and caring for their
health, you must enjoy such activities yourself. If not, who will want to follow
your example?
Most midwives do their
work out of love and as a
service to the community.
Although their work has
great value, midwives are rarely
paid much (a sad truth for many
health workers and women workers in
general). Even so, a midwife who works
hard and puts the needs of her
community first will usually be
respected and appreciated by the
people she serves. ^ ^
You may or may not be paid for your work, but never refuse to care for
someone who is poor or cannot pay. Everyone deserves your full care and
attention.
The work of a midwife is often difficult. Midwives work long hours, lose sleep,
strain their bodies, and challenge their minds. Midwives feel an intense
responsibility that can cause stress or deep emotional pain. For most midwives,
these challenges are all worth facing, because the work of a midwife is also so
rewarding. Teaching women and families about their bodies and health, treating
serious health problems, and helping welcome new lives into the world are some
of the most important and rewarding tasks anyone can do in their lives. Our world
needs the valuable work of midwives because midwives make this world stronger,
healthier, and safer.
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11
A Book for Midwives (201 0)
Chapter 2
Treating health problems
In this chapter:
Finding the causes of health problems
Finding the best treatment
Benefits and risks 16 Know your limits,
Types of medicine 17
Finding root causes of health problems
Make change in your community to
prevent health problems 23
Midwives can make change
13
16
20
21
25
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12
Treating health
problems
Most of the daily work of a midwife is treating health problems. When a woman
you are caring for has a problem, like exhaustion, pain in the belly, or even
heavy bleeding, you will need to take these steps to solve it:
1. Find the immediate cause of the problem.
2. Choose the best treatment.
3. Look for the root (underlying) causes of the
problem — to fully address the problem or prevent
problems from happening again.
Finding the causes of health problems
In this section, we tell how Celeste, a midwife, solves a health problem. The details
of this story apply only to Celeste, but the way she thinks about the problem and
works to solve it can be used by any midwife for any health problem. We list
each step that Celeste uses so that you can use these steps too.
1. Start with a doubt. This means start by admitting what
you do not know.
2. Think of all the possible causes. Most ways of feeling
sick can be caused by many different problems.
3. Look for signs to find the likely cause. Health problems
have signs. You can see these signs in how someone
feels, how their body looks and acts, and by taking
medical tests.
4. Decide the most likely cause.
5. Make a plan for what to do. This could be a plan to change a person's
habits, change something in their home or environment, or give a medicine.
6. Look for results. Find out if your treatment is working. If it is not, start these
steps again.
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Chapter 2: Treating health problems
Celeste's steps for finding causes
1. Start with a doubt.
A young pregnant woman named Elena came to her midwife, Celeste,
for care. During the checkup, Elena said that she felt tired all the time.
First, Celeste acknowledged that she did not know what was making
Elena tired.
3. Look for signs to find the likely cause.
Celeste asked Elena questions to find out more about the tired feeling.
Are you
working more
than usual?
Are you
sleeping less?
Do you feel ill?
I work hard [
but no harder
than usual.
Vm sleeping
enough , and do
not feel ill.
Celeste also asked Elena what she usually ate. Elena said that she
mostly ate maize and beans every day. Actually, mostly just maize.
Elena complained of the high cost of buying meat.
Celeste checked Elena's physical signs. Elena had pale eyelids and
gums and a fast, weak pulse — all signs of anemia.
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A Book for Midwives (201 0)
Finding the causes of health problems
4. Decide the most likely cause.
Celeste could not do a blood test to be sure, because there was no
laboratory nearby, but all the other signs showed that Elena probably
had anemia.
5. Make a plan for what to do.
Celeste explained to Elena that anemia can cause tiredness and make it
hard for a woman to recover after a birth — especially if the woman
bleeds heavily. She told Elena that anemia means not enough iron in the
blood and that it can usually be cured by eating foods rich in iron and
protein or by taking iron pills.
6. Look for results.
When Elena came back for her next check up, Celeste checked for signs of
anemia. After improving her diet, Elena seemed be getting better. If Elena
had not gotten better, Celeste would have recommended that Elena take
iron and folate pills.
These 6 steps will help you solve most health problems.
Note: To "start with a doubt" is very difficult for most health workers.
Many health workers are afraid to admit when they do not know an
answer. But to accurately assess a problem, and to treat it
appropriately, we must admit what we do not know.
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A Book for Midwives (201 0)
15
Chapter 2: Treating health problems
Finding the best treatment
When you treat any health problem, from anemia to too-long labor
to heavy bleeding, you must find the treatment that 1
most benefits and the least risk of harm.
Benefits and risks
Any time you make a decision about a medical
treatment, you should consider the benefits and
risks.
A benefit is the good that an action or
treatment might bring. A risk is the harm that it
might cause. Each time you make a decision, try
to choose the action with the most benefit and
the least risk.
When the benefits "weigh'
more than the risks, an
action is worth doing.
Think again about Elena and Celeste:
What if Elena's anemia did not go away after eating
more iron-rich foods and taking iron pills? She and
Celeste would have to make a difficult decision.
Celeste knows that a woman with severe anemia is probably safer giving birth
in a well-equipped medical center than at home. This way, if severe bleeding
happens, a blood transfusion is immediately available. Without this care, Elena
might be very weak after the birth. This weakness will make her more likely to get
an infection. It will make it very hard for her to care for her family and herself. And
if a baby's mother is not able to care for him well, he may be in danger too.
On the other hand, most women in the village have anemia. And most of them
will not have serious problems after their births. The hospital is a day's journey
away and very expensive. Elena's family would have to spend most or all of their
money for her to give birth there.
Staying home and going to the hospital each have benefits and risks. What
would you do?
Medicines in particular have both benefits and risks. Even a medicine that is
very helpful for treating a health problem may have side effects or dangers. In this
book, there are procedures and medicines that have very serious risks. We include
them because when they are truly necessary, they can save lives. But before giving
any medicine or doing any invasive (inside the body) procedure, including
emergency procedures like removing the placenta by hand (page 230) or MVA
(page 416), you must decide if you can do it safely — with more benefit than risk.
16
A Book for Midwives (201 0)
WWW.
Finding the best treatment
I am going to have to
reach inside to get
the placenta out.
Yes , very! But the road is
washed out by the rain — and
there is no way to get help
before she bleeds to death.
Types of medicine
Around the world, people use many different ways of healing:
• Traditional medicine (also called folk medicine): These
ways of healing have been passed down from older healers
to younger ones for many generations. Traditional ways of healing use
massage, plant medicines, and communication with the spiritual world.
Traditional medicines, particularly home remedies, can be very effective.
They are often the safest, easiest, and least costly treatments for most health
problems. And when money runs out, or outside aid groups leave, the plants,
massage techniques, and other traditional ways of healing will still be here.
Many traditional medicines have been tested using science. Testing has shown
that some traditional medicines work well and others do not, or they only
work because people's belief in them is strong. Some traditional
medicines are harmful or dangerous.
• Western medicine: This system of healing relies on scientific testing, Q ©
manufactured medicines (drugs), and surgery to treat health problems.
• Non-Western systems like acupuncture, ayurveda, or homeopathy:
These systems of healing may have been used for thousands of years,
are taught in books and schools, and may have been tested using science.
Many of these systems also use plant medicines.
One person may use several of these ways of healing.
There is not enough space in this book to fully describe every system of healing.
What is important to remember is that each type of healing has benefits, and that
any kind of medicine must be used with care.
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Chapter 2: Treating health problems
Western medicine
Western medicine, when used correctly, can save lives. And Western medicine is
usually the best treatment for emergencies. For example, when a woman is
bleeding heavily after a birth, there may be plant medicines in your area that can
slow her bleeding. But Western medicines often work better and more quickly —
they are more sure to save a bleeding woman's life.
Use Western medicines correctly
Most Western medicines have been carefully tested by science. Western medicine is
usually very effective at treating problems. But Western remedies are often
expensive, some have side effects, and in many cases they are not necessary. Most
basic health problems could be treated just as well with traditional or home
remedies, or just by waiting.
Don't you
think he
needs an
injection? J
yW( m
M\\
Using any medicine when it is not necessary, or using too much, can cause
serious health problems. For example, some people believe that only an injection
will help them when
they are sick. These
people would usually
get better if they did
nothing, and in many
cases, unnecessary
injections have caused
abscesses or have passed
disease (like HIV) when
given with unsterilized
needles. So although
medicines can save lives,
they must be used Take time to explain why
correctly. medicines are not needed.
No. All he has is
a cold. Let him
rest , give him
good food and
lots to drink.
Strong medicine
won't help and
might even
harm him.
This book is mostly about Western medicine
This book mostly teaches how to use Western methods of healing. There is one
main reason for this: Western medicines are available in most parts of the world.
We do not know enough, nor do we have enough room to explain how to use the
millions of traditional plants and ways of healing that are used around the world.
Therefore, please use the back of this book to write down the traditional methods
that you use. And if you translate or adapt this book, be sure to include your local
ways of healing. It is very important to share these traditional ways of healing so
that they are not forgotten!
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A Book for Midwives (201 0)
Finding the best treatment
I make a tea from this
plant It always seems to
help when labor is slow.
Choosing a medicine that is safe and helpful
Before you give a medicine
(traditional or Western), you
should be confident that it is safe
and helpful. To know if this is true,
think about (and ask others)
these questions:
• What is it used for?
• What happens when you use it?
• How often does it help make a problem better?
• What side effects or other problems does it cause?
When you are trying a treatment for the first time,
use it alone, not mixed with other treatments. That way
you will know if it works, and if it causes problems.
See page 463 to learn more about using medicines safely.
Thanks!
But does it
cause any
problems?
Medicine and greed
Sadly, some healers and health workers are motivated by greed. In order to make
money, they may recommend a treatment that is not necessary, that does not work,
or even one that is dangerous. Some healers rely on the respect others have for
them to sell potions or medicines that do not really work.
Some companies that make and sell medicines use their reputations to mislead,
too. When drug companies act in this way, whole communities can be put in
danger. For example, a US drug company named Eli Lilly used to make a medicine
called diethylstilbestrol (DES).
DES was supposed to help
prevent miscarriages. In fact,
DES did not prevent
miscarriages. It caused birth
defects and cancer. Eli Lilly
knew that the drug might cause
these problems but kept selling
it anyway. And even after the
drug was made illegal in the
US, it was still sold in other
countries.
'f o
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Chapter 2: Treating health problems
Know your limits
Know when to do nothing
In this book, we talk mostly about how to solve health problems. This is
important. But in many cases, the best thing to do for a woman in labor is
nothing! A woman who is healthy is likely to have a healthy and happy birth.
Most births go well.
Doing unnecessary procedures can cause serious problems. Respect the process
of birth. When all is going well, simply watch and wait.
Know when to get help
No matter how skilled you are, there will be times when you need help. Knowing
when to get medical advice, when to enlist the support of another midwife, or
when to send a woman to a doctor or medical center, is a skill that every midwife
must try to master.
It can be hard to know when to get medical help.
Hospitals and medical centers are often expensive or far
away. Many women are afraid to go to them. A woman with
a small problem may want to stay home. She may not want
to go to a medical center unnecessarily. But if she stays at
home without help, the problem could get much worse.
If you know a woman is having a problem like
hemorrhage, infection, or pre-eclampsia, do not delay —
get medical help. The sooner you go, the better her chances
of recovery. Sometimes you may have to rush, sometimes
you may not. If labor is long, for example, and you live and
work very far from a medical center, you must start your
journey early, before the problem is serious. If the medical
center is only across the road, you have more time.
Know when to take action at home
Midwives who work very far from medical care must also sometimes give
treatments that are better done in a medical center or hospital — because the
woman needs the treatment right away. For example, if a woman in an isolated
village has a seizure from eclampsia, her midwife should give her magnesium
sulfate, a drug that is not usually
safe to give at home. Then the
midwife should take the woman
to a medical center right away,
because both the seizure and the
magnesium sulfate are very
dangerous.
Deciding when to get
help can be difficult.
When in doubt —
get medical help.
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Finding root causes of health problems
WARNING ! In this book, we explain how to do some procedures
that can be dangerous if they are not done correctly, such as: how
to do a pelvic exam, how to insert an IUD, or how to sew a tear.
It is not enough to read about these procedures. Before you do
many of the procedures in this book, first watch other
experienced health workers doing them. Then practice while
someone with experience and training watches and helps you.
Only after you have practiced many times in this way is it safe for
you to do these procedures on your own.
Finding root causes of health problems
As a midwife, you must find and treat the immediate causes of health problems. For
example, think again about the story of Celeste and Elena. The immediate cause of
Elena being tired was her anemia. If she eats more iron-rich foods or perhaps takes
iron pills, her anemia will probably get better. By looking at the immediate causes,
we can help people feel better or save their lives, especially in emergencies.
Treating the immediate cause is very important. But if we only treat the
immediate cause, the problem may not truly be solved. It may come back, or it may
affect others in the community. Sickness usually results from a combination of
causes — direct causes, like germs or lack of iron, and less direct root causes that
may be social, economic, or political. By finding these root causes, you can prevent
problems from happening again.
In the case of Elena, there are many root causes of her problem. Celeste could
probably figure out some of those causes herself. Better yet, she and Elena could
meet with a group of people from the community to help think about the problem,
because anemia is not just Elena's problem, it is a community problem.
Why was Elena tired?
But why did she have anemia?
But why didn't she eat
enough iron-rich foods?
But why else?
But why couldn't she afford
meat?
But why do farmers make
so little money?
Because she had anemia.
Because she did not eat enough foods with iron.
She did not know which foods had iron.
She could not afford meat.
Because she is poor. She and her husband
work on a farm and make little money.
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21
Chapter 2: Treating health problems
After you have asked everyone "why" in this way for some time, you will find
that there are many reasons why Elena had anemia. This exercise also shows why
anemia is not just a problem for Elena but for most of the women in the village.
Indeed, it is a problem for most women in most villages and poor communities
around the world.
Look deeply to prevent more problems
Finding the many root causes of health problems means
looking hard at the different parts of people's lives that
contribute to the problem.
For example: A fistula is a terrible complication of
some births. When a labor goes on much too long, the
tissue inside a woman's vagina can become crushed and
break open, leaving a hole to her bladder. This cai
serious health problems and constant leaking of
urine. To prevent a fistula, simply prevent a long
labor. If a woman is in labor for more than a day,
bring her to a medical center or hospital.
But by looking more deeply at the many
causes of a long labor, we can do more to
prevent fistula and other related problems.
• Young girls who do not eat well often grow up to have small bones
(including small pelvises). An abnormally small pelvis can cause a
long labor. Some young girls do not eat enough because their
families cannot afford food. Some are not fed enough because they
are not considered as important as boys.
• Some girls have children too young. Young girls have long,
complicated labors because their bodies have not fully grown. Girls
might marry and have children early because it is the custom of their
communities or because their parents are poor and cannot care for
them. Or both.
• Women in bad health are more likely to have long, complicated
labors. Anyone can have health problems, but those who do not
have access to basic health care are in the greatest danger.
• Rural and poor women cannot easily get medical help in an
emergency.
To prevent fistulas, must we simply get women to hospitals faster,
or can we also work to change the conditions that cause long labors,
like poor nutrition of young girls and too-early marriage and childbirth?
How can we work to stop the root causes of these problems — poverty
and unfair treatment of women and girls?
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Finding root causes of health problems
Make change in your community to
prevent health problems
Most deaths and injuries from pregnancy and childbirth can be prevented by
looking at and treating root causes. But to do so, a community must look beyond
the experiences of individual women. Look at the common dangers that affect all
women in pregnancy and birth. And use the skills of every community member to
protect women's health.
Midwives, who are most experienced with birth, can tell others in the
community why women are dying and being injured during birth. Families,
midwives, and other health workers and community members can work together
to make changes, small and large, to improve health for all. When everyone in the
community becomes involved with health, we can do much more than one
midwife alone.
How to start
Lack of healthy food, dirty drinking water, lack of transportation in emergencies,
and alcohol abuse are a few of the problems that contribute to serious health
problems for women. These can all be addressed when they are not considered
individual problems and when the whole community works together for change.
But it can be difficult to know where to start. A good first step is to meet with
community members to talk. If you teach birth classes to pregnant women, meet
with other midwives, or are a member of a social or church group, you can use that
group to solve problems.
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23
Chapter 2: Treating health problems
First, name the problems you are facing.
You have all read how to stay
healthy in pregnancy. But not
everyone can do these things. Why?
How can we
eat well when
there is no
money for
food?
We always have
to wait hours to
be seen at the
clinic.
After you have named some of the problems in the community, choose what
to work on first. It might be the problem that is the most common, the problem
that causes the most serious harm, or the problem that can be most easily solved.
List every idea the group can think of to work on this problem. Then focus on
solutions that someone in the group can make happen.
We agree that the whole \
community can help \
pregnant women eat \
better. But how? J
I could plant'
some green
vegetables in
the coffee field.
We should talk to t/re\
storekeeper. He should \
sell more beans and \
rice and less liquor! J
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A Book for Midwives (201 0)
1*Ahn*ly?L
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Finding root causes of health problems
Make a plan. You will need
to decide who will do each task,
what they will need to do it, and
when they will do it.
I can pay for the seeds ,
but we all must work
together to plant and
care for them.
Be sure to meet again to talk about how the plan is going.
^ The seedlings are coming\
up well. And everyone 1
has been taking turns 1
watering them J
I I talked to the storekeeper ,
/ and he said he will not sell
I beans — they don’t make
y^^enough money for him.
goi
storekeeper together.
If we tell him we’ll stop
buying anything from
him , he may listen to
our demands!
Midwives can make change
Midwives and the women they serve may face any kind of health problem, from
simple ones like nausea to serious ones like a bad hemorrhage. But when
midwives work carefully to discover causes, and use wise judgment and support
from the community, they can solve nearly any problem, even many of the most
difficult ones.
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25
Chapter 3
A woman's body in pregnancy
In this chapter:
A woman's sexual and reproductive parts
How women become pregnant
How the baby grows 30 Menopause
Infertility 30
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A woman's body
in pregnancy
In this chapter, we describe the parts of a woman's body that are most affected by sex,
pregnancy, and birth. We call these parts sexual or reproductive parts. We also explain
how pregnancy happens, and how a woman's body changes during pregnancy.
A woman's sexual and reproductive parts
A woman's genitals (vulva)
outer lips
inner lips
opening of
the vagina
oy clitoris
a very sensitive spot
that can give sexual
pleasure when touched
urethra
~ the opening that
urine comes out of
anus
the opening of
the rectum and
intestine, where
stool comes out
The pelvis
The bones below the belly
are called the pelvis.
pelvis
$ | , .
I t pubic
bone
The pelvis is shaped like a bowl
with a hole in the bottom.
through the hole to get out.
27
Chapter 3: A woman's body in pregnancy
The womb, tubes, and ovaries
The womb (uterus) is a hollow muscle. It sits
inside the pelvis. Monthly bleeding comes
from the womb, and the womb is where the
baby grows during pregnancy.
intestines
kidney
The womb is
in the woman's
belly along with
her other organs.
bladder
If you could see the womb inside a woman's belly, it would look like this:
womb
tube
The tubes connect
the womb to the
cervix
The cervix is the opening
of the womb into the
vagina. It is usually closed
and plugged with mucus.
ovary
The ovaries hold tiny
eggs. Some people
call eggs, "the seeds
of the woman."
vagina
The vagina is the opening in
the outside of the woman's
body that leads to the cervix
and womb.
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A Book for Midwives (201 0)
How women become pregnant
How women become pregnant
About once a month, a woman's Men make tiny cells called sperm inside
ovary releases a tiny egg. The of their testicles. When a man ejaculates
egg moves down the tube and (comes), a fluid called semen comes
into the womb. out of his penis. Millions of sperm cells
come out in that fluid.
The semen and
sperm travel through
this tube and out of
the penis.
testicle
The sperm is made
in the testicles.
If a man ejaculates inside a woman's vagina during sexual intercourse, his
sperm cells can travel through her vagina, through her womb, and into her tubes.
If the woman and man have sexual intercourse near the time of the month that
the woman's egg is moving down her tube, one of the man's sperm cells may meet
her egg. The egg may then plant itself in the lining of the womb. If this happens,
the woman becomes pregnant.
Every month that the woman does not become pregnant, the bloody lining of
her womb comes out about 2 weeks after she releases the egg. We call this
monthly bleeding, or menstruation.
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A Book for Midwives (201 0)
staying well
Chapter 3: A woman's body in pregnancy
How the baby grows
After a sperm and egg join inside a woman's womb, they combine to become one
group of cells that multiply and grow into a baby.
The mother's blood contains oxygen from the air she breathes and nutrition
from the food she eats. Her blood then passes air and food to the baby through the
cord and placenta.
During the first 3 months of pregnancy, it is hard to see much happening from
the outside. But inside the womb, the baby is forming organs, bones, and other
body parts. During these early months, it is especially important that a pregnant
woman avoid noisonous
When a person has difficulty having a child, he or she
is infertile. For a couple that wants to have children,
infertility can bring sadness, anger, or shame.
Often the woman is blamed when she does not
become pregnant. Even if the couple gets medical help,
many doctors will check only the woman for fertility problems.
But often the man is the one who is infertile. Neither men nor women should be
blamed for infertility. And both need support during this difficult time.
This is what
you would
see if you
could look
inside a
pregnant
woman's
womb.
The baby is connected to the
placenta (afterbirth) by a cord,
Inside the womb, the baby
floats in a bag of fluid called
inside of the mother's womb.
amniotic fluid (the bag of waters).
and the placenta is attached to the
Infertility
30
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A Book for Midwives (201 0)
WWW.
How women become pregnant
Infertility has many causes. Some cannot be prevented. But
many causes of infertility are preventable.
• Sexually transmitted infections can leave scars
inside a man's or woman's reproductive parts
that prevent pregnancy.
• Illnesses such as diabetes, tuberculosis,
malaria, and mumps can cause infertility.
• Dangerous chemicals from
pesticides, cleaning products, or
factories can get into the air, water,
or food. These chemicals can make it Even washing clothes that have dangerous
difficult for a woman to get pregnant, chemicals on them can harm fertility,
or can harm the growing baby.
• Smoking, chewing tobacco, drinking a lot of alcohol or using drugs can all
harm fertility.
There are other causes of infertility that are not preventable. To learn more, look
at a general health book like Where Women Have No Doctor.
Menopause
When women grow older, they stop bleeding each month (menopause). They also
stop producing eggs and lose the ability to become pregnant.
This may happen suddenly, or slowly over 1 or 2 years. For
most women, menopause happens when they are between
45 and 55 years old.
During menopause, many women have some of these signs:
• changes in monthly bleeding before it stops completely
• suddenly feeling very hot and sweaty (hot flashes)
• vagina becomes smaller and more dry
• sudden changes in feelings
Many women are relieved when they do not have to worry
about pregnancy anymore. As elders, women can share the
wisdom of their years of life experience.
Men make sperm through most of their lives, even when
they are very old.
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A Book for Midwives (201 0)
staying well
Chapter 4
Helping women stay healthy
n this chapter:
Eating well
Talking to women about food 34
Eat more food 34
Eat a variety of foods 34
Eat these 5 important vitamins
and minerals every day 36
Ideas about food affect
women's health
Eating well with little money
33
39
41
Caring for the body for good health
Keep clean 42
Care for the teeth and mouth 43
Exercise 43
,42
Sleep, rest, and relax 44
Enjoy the pregnancy 44
Things to avoid during pregnancy and breastfeeding 45
Stay away from people with rubella Stay away from chemicals
and other sicknesses
45
and fumes
47
Avoid taking medicines
45
Avoid smoking, alcohol,
and other drugs
46
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32
Helping women
stay healthy
A woman who eats well and takes good care of her body is much more likely to
have a healthy pregnancy and healthy baby. In fact, the ways to stay healthy listed
in this chapter can be used by women and their families to stay well throughout
their whole lives.
Eating well
Eating well means eating enough food and eating
a variety of healthy foods.
Eating well:
• helps a woman resist illness and stay healthy.
• keeps a woman's teeth and bones strong.
• gives a woman strength to work.
• helps the baby grow well in the mother's womb.
• helps prevent heavy bleeding after birth.
• helps a mother recover her strength quickly
after birth.
Eating well helps a
woman and her baby stay
healthy and strong.
Problems from poor nutrition (not eating well)
Poor nutrition can cause tiredness, weakness, difficulty
fighting infections, and other serious health problems.
Poor nutrition during pregnancy is especially
dangerous. It can cause miscarriage or cause a baby to be
born very small or with birth defects. It also increases the
chances of a baby or a mother dying during or after birth.
1 Or
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33
Chapter 4: Helping women stay healthy
Talking to women about food
Talk to women about the food they eat. The earlier women start eating healthier
foods, the better chance they have to stay healthy, to have normal births, and to
have healthy babies. ^
To find out whether a woman is
eating well, ask her what she
usually eats, and how much. For
example: "What did you eat
yesterday?" Be sure to tell her what
is healthy about what she eats.
Then make a suggestion for how
she could eat better.
I eat cassava
every day, and I
usually have
some fish — or
beans cooked
with onions and
tomatoes, and I
drink soda pop.
That sounds good.
Cassava gives energy.
Beans and fish give
strength. If you drink
fruit juice instead of
soda pop, and you also
eat some green
vegetables, you will
get more vitamins.
Even if a woman knows the best
foods for health, she may not eat them. Many
families cannot afford to buy enough food or a
wide variety of foods. Other women simply may
not like the taste of some foods. To help a
woman eat better, suggest healthy foods that she can and will choose to eat.
Eat more food
Pregnant women and women who are breastfeeding need to eat more than usual.
The extra food gives them enough energy and strength, and helps their babies grow.
Some pregnant women feel nauseated and do not want to eat. But pregnant
women need to eat enough — even when they do not feel well. Simple foods like
chapatis, tortillas, or rice can be easier for these women to eat.
Eat a variety of foods
It is important for pregnant
women (like everyone else)
to eat different kinds of
food: main foods
(carbohydrates),
grow foods (proteins),
glow foods (vitamins
and minerals), and
go foods (fats, oils,
and sugar), along with
plenty of fluids.
For a healthier body,
eat many kinds of foods.
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Eating well
Main foods (carbohydrates)
In most parts of the world, people eat one main food at each meal. This main food
may be rice, maize, wheat, millet, cassava, taro, plantain, breadfruit, or another
low-cost starchy food. These foods give the body energy. But to grow and stay
healthy, the body needs other types of food too.
Grow foods (proteins)
Grow foods contain protein, which is needed for the growth of muscles, bones,
and strong blood. Everyone needs protein to be healthy and to grow.
Some grow foods high in proteins:
• meat, fish, and insects
Note: Meat, fish, and cheese are nutritious foods but they can carry
parasites or disease when they are eaten raw. Pregnant women should
only eat fish, meat, or cheese that is well cooked or pasteurized.
Fish, especially fatty fish, can also contain mercury and other poisons
because water is often contaminated. Pregnant women
should avoid fatty fish, to be safe.
Fruits and vegetables are high in vitamins and minerals. It is
important for women to eat as many different fruits and vegetables as they can.
Go foods (sugars and fats)
Go foods contain sugars and fats, which give the body energy. Everyone needs
these foods to be healthy.
These days, many people eat more sugars and fats than they need. That is
because more people drink sugary soda pop, or eat foods that come from packages
instead of foods made at home. These packaged, sugary foods are expensive and
not as healthy. They also damage the teeth. It is better to eat go foods that are
natural, not packaged.
and lentils)
• nuts and seeds
• legumes (beans, peas,
• eggs
• cheese, milk,
and yogurt
Glow foods (vitamins and minerals)
Glow foods contain vitamins and minerals, which help
the body fight infection and keep the eyes, skin, and
bones healthy and strong.
Some healthy go foods
high in sugars:
• fruit
• honey
• molasses
Some go foods
high in fats:
nuts and seeds
avocados
vegetable oil,
butter, ghee, and lard
fatty meat
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A Book for Midwives (201 0)
Chapter 4: Helping women stay healthy
Eat these 5 important vitamins and minerals every day
Pregnant and breastfeeding women need more of five vitamins and minerals —
iron, folic acid, calcium, iodine, and vitamin A — than other people do. Pregnant
women should try to get these vitamins and minerals every day because the baby
needs them to grow and be healthy. Every pregnant woman needs enough for the
baby and for herself.
Iron
Iron helps make blood healthy and prevents anemia (weak blood, see page 116).
A pregnant woman needs a lot of iron to have enough energy, to prevent too
much bleeding at the birth, and to make sure that the growing baby can form
healthy blood and store iron for the first few months after birth.
These foods contain a lot of iron:
• beans, peas, and lentils
• sunflower, pumpkin, and squash seeds
• dark green leafy vegetables
• breadfruit
• yams
• hard squash
molasses
meat (especially liver, kidney, and
other organ meats)
poultry (birds)
grasshoppers, crickets, and termites
fish, clams, and oysters
Other ways to get more iron:
• Eat iron foods with citrus fruits or tomatoes. The vitamin C in these foods
helps a woman absorb iron into her system.
• Cook food in iron pots or add a clean piece of iron — like an iron nail —
to the cooking pot. Only use a nail that you know is made of pure iron,
not a mix of metals.
• Put a clean piece of pure iron, like an iron nail, in a
little lemon juice for a few hours. Drink the juice
mixed with clean water.
It can be difficult for a pregnant woman to get enough
iron, even if she eats iron-rich foods every day. If possible,
she should also take iron pills or iron syrup. These
medicines may be called ferrous sulfate, ferrous gluconate,
ferrous fumerate, or other names.
In many places health centers will give iron pills to
pregnant women. Sometimes iron pills are combined with folic acid. The iron pills
may make it hard for the woman to pass stool (constipation), and her stool may
turn black. These problems should get better in a few days. (See page 76.)
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A Book for Midwives (201 0)
Eating well
Hookworm and malaria can cause anemia
Women with hookworm are likely to have anemia. Hookworm can
easily be treated with mebendazole or albendazole, though these drugs
should not be taken in the first 3 months of pregnancy. These drugs
have not been tested enough to be sure that they are safe for women who
are in the later months of pregnancy or who are breastfeeding. However,
most doctors believe that the benefit of treating hookworm is greater
than the possible harm of these medicines.
If hookworm is common in your community, ask your local health
authority what treatment is recommended for pregnant women.
Malaria can also cause anemia and other serious problems in
pregnancy. See page 98 for how to prevent or treat malaria.
Folic acid (folate)
Lack of folic acid can cause anemia in the mother and severe birth defects in the
baby. To prevent these problems, it is most important for a woman to get enough
folic acid before she gets pregnant and in the first few months of pregnancy.
These foods contain a lot of folic acid:
dark green leafy vegetables
meat (especially liver, kidney,
and other organ meats)
peas and beans
sunflower, pumpkin, and
squash seeds
whole grains (brown rice,
whole wheat)
fish
eggs
mushrooms
Some women also take folic acid pills.
Folic acid pills
• take 0.5 to 0.8 mg (500 to 800 meg) folic acid
by mouth, 1 time each day
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Calcium
A growing baby needs a lot of calcium to
make new bones, especially in the last few
months of pregnancy. Women need
calcium for strong bones and teeth.
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Chapter 4: Helping women stay healthy
These foods contain a lot of calcium:
• milk, curd, yogurt, and cheese
• ground sesame (tahini)
• almonds
• green leafy vegetables
• yellow vegetables (hard squash, yams)
• shellfish
• lime (carbon ash)
• bone meal and eggshells
Women can also get more calcium in these ways:
• Soak bones or eggshells in vinegar or lemon juice for a few
hours. Then use the liquid to make soup or eat with other foods.
• Add lemon juice, vinegar, or tomatoes when cooking bones.
• Grind eggshells into a fine powder and mix into food.
• Soak maize in lime (carbon ash) before cooking it.
Iodine
Iodine prevents goiter (swelling of the throat) and other problems in adults. Lack
of iodine in a pregnant woman can cause her child to have hypothyroidism
(cretinism), a disability that affects thinking and brain development.
The easiest way to get enough iodine is to use
iodized salt instead of regular salt.
These foods contain a lot of iodine:
• shellfish (like shrimp)
• fish
• seaweed
• egg yolks
• liver
If hypothyroidism or goiter are common in your
area, find out if the local health ministry will give
iodized oil by mouth or iodine by injection. If not,
women can make iodine solution at home with polyvidone iodine.
To make an iodine solution to drink
Add 1 drop of Lugol's iodine to 1 glass of clean drinking water or milk.
p In places where goiter or cretinism are common, everyone except
breastfeeding babies should drink 1 glass of this iodine solution
0 every month of his or her life. This is especially important for children
and pregnant women. Do not take more iodine than this. Too much
. ■
is dangerous.
Store iodine at room temperature, and in dark containers to protect
it from light.
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Eating well
Vitamin A
Vitamin A prevents night blindness and helps fight
infections. Lack of vitamin A also causes blindness in
children. A woman needs to eat plenty of vitamin A
during pregnancy and while breastfeeding.
Dark yellow and green leafy vegetables and yellow fruits have vitamin A.
Along with eating healthy foods, women should drink plenty
of clean water and other fluids every day. Fruit juices, coconut
water, animal milks, and many herbal teas are all healthy fluids
to drink.
Ideas about food affect women's health
Some beliefs about foods are harmful — especially when people believe that
women should not eat as much as men do, or should not eat a variety of foods.
It is not safe for girls to be fed less than boys
Girls need as much food as boys — to grow and learn and work. If a girl does not
get enough food, her bones may not grow well. This can cause serious problems
during labor when the girl becomes a woman and has babies of her own.
When a woman must feed her family first,
she may not get enough to eat
A woman may be taught to feed her family before
herself. She eats only what is left and often does
not get as much as others in the family. This is
never healthy. And when a woman is pregnant,
or has just had a baby, it can be very dangerous.
If the family will not help the woman eat
enough, she may need to hide food, eat while
she is cooking, or eat while her husband is
out of the house.
Packaged and processed foods are rarely as good as homemade
People are eating more and more packaged and processed foods. Some people like
the taste, and some people think that packaged foods are healthier.
Packaged foods may be advertised as the healthiest choice, but this is rarely the
truth! Advertisers will say anything just to sell products. Some packaged foods are
fortified with vitamins and minerals, but our bodies cannot use these added-on
vitamins as well as our bodies use the vitamins that we get from eating whole,
fresh foods. Most packaged foods contain more sugar, salt, and fat than we need.
Many are full of chemicals to keep the food looking and tasting fresh, and some of
these chemicals have not been carefully tested to be sure of their safety.
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Chapter 4: Helping women stay healthy
Avoiding foods can be dangerous
In many places, pregnant women are told not to eat certain foods. In these
communities, people believe that these foods will harm the baby. At the same
time, a doctor or a midwife may tell a woman it is important to eat those same
foods. This can be confusing for the woman.
Avoiding foods can be
dangerous. For a woman to
be healthy during and after
pregnancy, she must eat a
wide variety of foods — main
foods, grow foods, glow
foods, and go foods. Eating
only one kind of food is not
enough.
If a woman does choose to
avoid certain foods, make sure
she is getting enough of each
kind of food, and enough
vitamins and minerals from her food.
Everyone needs to eat a wide variety of foods.
Finding creative answers
Beliefs about food can be hard to change. But you may find ways to help
women eat better without working against their beliefs. This example is
based on a true story:
Maria is a midwife in Guatemala. She and her
people believe that some foods are "hot" foods, and
some foods are "cold" foods. They believe that
pregnant women should not eat cold foods.
To Maria and her people, beans and eggs are cold
foods (even when they are cooked). But Maria knows
that beans and eggs are good, low-cost ways for
pregnant women to get the protein and iron they need.
Maria wants pregnant women to eat well, but they
will not eat cold foods. And Maria too thinks that cold
foods may not be good for pregnant women to eat. Her solution is simple
and smart. She tells pregnant women to eat beans and eggs with a little hot
pepper or another hot food. This way, the foods will not be cold anymore.
Maria has found a creative answer to a problem. She has found a way for
pregnant women to eat better and has shown respect for the beliefs of her
community.
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Eating well
Eating well with little money
The biggest cause of poor nutrition
is poverty. Rich people in wealthy
countries can buy any foods they
want, while those in poor
communities cannot. And
within each community, some
can afford to eat better than
others. A few people own most
of the land or businesses, and
make money off of the work of
others. Even within each
family, a father may eat better
than his wife or children.
To learn more about the
root causes of poverty and
ways to work for change,
see the books Where There Is
No Doctor and Helping
Health Workers Learn.
The problems of hunger and poor nutrition will not be
solved until we all share with each other fairly.
Even a very poor family can eat better by
spending money wisely. A father who buys alcohol
and tobacco could instead buy nutritious food or
he could buy a hen to lay eggs. A mother who buys
her children sweets or soda pop could instead buy
eggs, beans, or other low-cost healthful foods.
Here are some ideas that families can use to eat
better with little money:
Breast milk
Breast milk costs nothing, and has all the nutrition a baby needs. Young children
do not need fortified milks — especially if they are still breastfeeding and eating
other foods.
Beans , peas , and lentils
Beans and other legumes have a lot of
protein and vitamins, and they usually
do not cost much. They have even
more vitamins if they are sprouted
before being eaten.
Grow beans this year. Next year, maize.
Planting legumes makes soil richer.
Other crops will grow better in a field where legumes once grew.
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41
Chapter 4: Helping women stay healthy
Less expensive meats and animal products A.
Blood and organ meats like liver, heart, and kidney have a
lot of iron and may cost less than other meats. Fish and
chicken are as healthy as other meats, and usually cost less — JjL _
especially for a family that fishes or raises their own chickens. ^ C 5o
Eggs have a lot of protein, iron, and vitamin A. Eggs give more protein for less
money than almost any other food.
Whole grains
Grains, like wheat, rice, and corn, are more nutritious when they have not been
refined (processed to take out the color). Taking out the color takes out healthy
things too. White bread and white rice have less vitamins, minerals, and proteins
than brown bread or brown rice.
Vegetables and fruits
When vegetables are boiled or steamed, some
of the vitamins from the foods go into the
cooking water. Use this water to make soups.
Use only a little water
to cook vegetables.
The outside leaves of plants are usually thrown away,
but sometimes they can be eaten. The leaves of the cassava
plant have more vitamins and protein than the root.
Many wild fruits and berries are rich in vitamins and
natural sugars that give energy.
Avoid buying vitamins
Most of the time people can get enough vitamins and minerals by eating a variety
of foods. Buying vitamins is usually a waste of money.
But pregnancy and breastfeeding are times that women may need to take extra
vitamins — more than what they can get from food. Vitamin pills work as well as
vitamin injections, and cost less.
Caring for the body for good health
For a woman to stay healthy in pregnancy — or anytime — it is wise for her to
keep clean, exercise, and get plenty of rest.
Keep clean
Keeping the body clean helps prevent infections. If possible, the mother should
regularly wash her body, including her genitals, with clean water.
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Caring for the body for good health
Care for the teeth and mouth
Healthy teeth help a person's whole body be healthy, and care for the teeth
is especially important in pregnancy because unhealthy teeth can lead to
gum infections. This can cause a baby to be born too early.
In some places there is a saying, "Have a baby, lose a tooth." But this does not
have to be true! A woman can protect her teeth in these ways:
• Eat calcium-rich foods.
• Avoid sweets, candy, and soda pop.
• Clean the teeth after every meal with a soft brush,
tooth stick, or rough cloth. Toothpaste, salt,
or plain water on the brush are helpful but
not necessary.
To make a tooth-cleaning stick:
Clean the surfaces of all the
teeth, between the teeth,
and the gums every day.
Sharpen this end to clean Chew on this end and Or tie a piece of rough cloth
between the teeth. use the fibers as a brush. on the end of a stick.
If possible, everyone should see a dentist or dental worker regularly.
Exercise
Exercise makes a woman's body
stronger. During pregnancy, exercise
helps her body get ready for labor
and birth. Exercise can also help a
woman have energy and feel happy.
Many women get all the exercise
they need by hauling water, working
in the fields, milling grain, chasing
after children, and walking up and
down hills.
Women who work sitting or
standing (in offices, stores, or
factories, for example) or who do not
move around much during the day
usually need more exercise. They can
take long walks, dance, do physical
work, or find another way to move.
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Chapter 4: Helping women stay healthy
Squeezing exercise (Kegels)
The squeezing exercise strengthens
muscles in the pelvis and vagina.
Doing the squeezing exercise can help
to:
• prevent leaking urine.
• prevent the vagina from tearing
during birth.
• speed healing after birth.
• increase sexual pleasure.
A woman can learn this exercise
while she is urinating. As the urine
comes out, she should squeeze the muscles in her vagina until the urine stops.
Once she learns how to squeeze these muscles, she should only do it when she is
not urinating.
The squeezing exercise is helpful at all times, not just during pregnancy.
If possible, women should practice at least 4 times a day, doing at least
10 squeezes each time.
Sleep, rest, and relax
Sleep and rest help women stay strong and resist sickness. Getting enough rest also
helps prevent high blood pressure, sick babies, and other problems.
Many women must work all day in fields, factories,
or stores. Then they must also haul water, find fuel,
mill grain, cook, clean, and care for their families.
This can be very hard at any time. It can be especially
hard for pregnant women who need more rest than
usual.
Explain to pregnant women that it is important for
them to rest for a few minutes every 1 or 2 hours.
Help the woman's family understand why it is
important for her to rest and sleep.
Enjoy the pregnancy
If women have enough food, rest, and care, pregnancy
can be a wonderful time.
Many communities have rituals and practices that honor
pregnant woman. People help her with her work, bring her
special foods, or give her massages or gifts. Customs like
these help a woman get the food and rest she needs, and
help her feel good about herself and her pregnancy.
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Things to avoid during pregnancy and breastfeeding
Things to avoid during pregnancy
and breastfeeding
Sicknesses, drugs, and poisonous chemicals are not healthy for anyone. They are
particularly dangerous in pregnancy and while breastfeeding. The following things
are the most dangerous in the first 3 months of pregnancy, but they can be
dangerous at all times.
Stay away from people with rubella and other sicknesses
Pregnant women
should stay away
from people with
sicknesses or rashes.
It is best for pregnant women to stay away from people who
are sick. This will help protect them from becoming sick
themselves.
Some sicknesses are particularly dangerous to pregnant
women or their babies. Rubella (German measles) is one
sickness that can cause serious birth defects or disabilities in
the baby, including deafness and heart problems, and can
even cause death.
Avoid taking medicines
When a woman takes medicines, they pass through her
blood to her baby. Medicines that are safe for a grown
woman or even a child can be dangerous to the tiny
baby inside the womb.
Cough syrups, pain relievers, some modern
medicines, and some plant medicines can all be
dangerous. Some of them can cause birth defects or
disabilities in the baby, including disabilities that
affect thinking or the brain.
If possible, pregnant women and women who are
breastfeeding should not take medicines. If a woman is
sick and needs medicine, find out if this medicine is
safe in pregnancy or while breastfeeding. Look in the green medicine pages at the
end of this book (see page 463) or ask a doctor if the medicine is safe. If plant
medicines are used in your community, try to learn which ones are safe during
pregnancy and breastfeeding.
Most of the medicines we recommend in this book are safe to take during
pregnancy or breastfeeding. (If they are not safe, we will include a warning about
when they can be dangerous.) But even drugs that are safe should only be taken
when they are truly needed. Rest, water, and healthful foods are often enough to
cure sicknesses and other problems.
Pregnant women should
only take medicines that
are safe in pregnancy and
that are truly needed.
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Chapter 4: Helping women stay healthy
Avoid smoking, alcohol, and other drugs
Cigarette smoke, alcohol, and other drugs are all harmful to
the mother. When a woman smokes, drinks, or takes drugs,
they also pass through her blood to her baby.
Smoking is dangerous for anyone. It can lead to serious
problems including cancer. When a pregnant woman
smokes, or even when she breathes the smoke from someone
near her, her blood vessels get smaller and do not carry as
much air or food to her baby. Because of this, babies of
women who smoke are more likely to be small or sick.
Drinking a lot of alcohol can be dangerous for anyone.
Heavy drinking can lead to many illnesses including serious
problems of the liver. When a pregnant woman drinks, even
just 1 or 2 drinks a day, her baby can have birth defects or
disabilities that affect the brain.
Some drugs, particularly opium, heroin, cocaine, and
barbiturates, are very addictive and dangerous. When a
pregnant woman takes these drugs, her baby can be born
with a drug addiction or with other serious health problems.
If you work with a woman who may be addicted to
alcohol or other drugs, try to find help for her. She may be
able to stop if she understands the risks to her and her baby.
Advise her to stay away from people who are smoking, drinking, or taking drugs.
You may be able to help her find others in your community who have
stopped using alcohol or drugs and who meet to support each other. The book
Where Women Have No Doctor has more ideas about how to help someone stop
abusing alcohol and drugs.
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A Book for Midwives (201 0)
Whatever a mother
puts into her body
passes to her baby.
Things to avoid during pregnancy and breastfeeding
Stay away from chemicals and fumes
Strong chemicals used for cleaning, and poisons used to kill pests in the fields or
at home, are dangerous for everyone. They are especially dangerous to women
who are pregnant or breastfeeding. These chemicals can cause miscarriage,
infertility, birth defects, cancer, and other
illnesses.
Any chemical with a strong smell is
probably not safe. Many dangerous
chemicals have no smell at all.
If possible, everyone should avoid
these dangerous chemicals. But a
pregnant woman should have no contact
with them. She should not use them
herself or breathe chemical fumes or dust.
Her family should not store food in
containers that once had chemicals inside.
Tiny amounts of the chemicals may be left
in the container even after it is washed —
enough to harm a person's health!
Families should try not to use
chemicals at all. But many people who
work with chemicals have no choice. It is
part of their job at a factory, on a farm,
cleaning, or somewhere else. People who use chemicals at work may be able to
talk to the other workers about the problem. Maybe all the workers together can
talk to the owner about using fewer chemicals or using safer ones.
Poisonous chemicals include:
• pesticides (chemicals that
kill bugs or weeds) used in
farming.
• pesticides used at home to
kill bugs or rodents.
• strong cleaners and solvents.
• some kinds of glue and paint.
• gasoline, oil, and other fuels.
If someone in the family must work with chemicals, he or she should:
• use as few chemicals, and as little of each one, as possible.
• keep chemicals away from places where food is stored.
• keep chemicals away from children.
• avoid breathing chemicals. Wear a mask or at least cover the mouth
and nose, and try to work where there is a good air flow.
• avoid getting chemicals on the skin. Wear gloves, long sleeves, and
closed shoes.
• after working with chemicals, change clothes before coming in
the house. Pregnant women should not wash these clothes.
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A Book for Midwives (201 0)
Chapter 5
Preventing infection
In this chapter:
Preventing infection saves lives 49
Infection is caused by germs 49 How germs get into the body 50
Prevent infection by keeping germs away 52
Clean your hands and wear protective clothing 53
Wash your hands often 53 Protect yourself from infection 56
Wear gloves 54
Clean the space and bedding 57
Clean the space 57 Clean or sterilize the bedding 58
Clean and sterilize tools
Soak your tools 59
Clean your tools 59
Sterilize your tools 59
Baking 61
Pressure steaming 61
Get rid of wastes safely
Burying wastes 68
59
Boiling 62
Steaming 62
Using chemicals 63
Some equipment needs special care . . 65
,67
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48
Preventing
infection
Preventing infection saves lives
Infection makes people sick and can even kill them. It is one of the most common
causes of death after childbirth. Procedures that involve putting medical tools
inside a woman's womb, like inserting an intrauterine device (IUD) or doing
manual vacuum aspiration (MVA), can also cause infection. Much of the work of a
midwife, and any procedure inside the womb (invasive procedure), can only be
safe if you are able to follow the steps we outline in this chapter to prevent
infection.
This chapter explains how to avoid infection by killing or
controlling harmful germs. Germs are organisms that carry
sickness. Germs are everywhere, but
they are so small that they can only be
seen with a microscope. The dangerous
germs in blood, stool, body fluids
(like semen and amniotic waters), and dirt
can cause serious sickness when they get Germs live in
into someone's body. body fluids,
like blood.
Infection is caused by germs
Some sicknesses, like arthritis, diabetes, asthma, and epilepsy, are not caused by
germs. They cannot be passed from one person to another.
Other sicknesses, like measles, hepatitis, tetanus, womb infection, HIV, and the
flu, are called infections and are caused by germs. People get sick when the germs
that cause these infections get inside their bodies.
Germs can live on
tools, even tools
that look clean.
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Chapter 5: Preventing infection
How germs get into the body
Germs can get inside the body in different ways.
Some germs pass through semen or vaginal mucus
(body fluids) when people have sex. HIV and other
sexually transmitted infections like chlamydia and
gonorrhea can spread this way.
Some germs pass through blood when the blood or body
fluid of an infected person get into a cut or through the
skin — like with a needle that has been used for piercing
or injections. HIV, hepatitis B, and hepatitis C can spread
this way.
Some germs live in dirty water and pass when people
drink it. Cholera and diarrheal diseases spread this way.
Some germs live in dirt, on skin, or in the air, and are not
dangerous unless they get into a person's blood. These germs
can get into the blood when an instrument that has germs
on it is used inside a woman's womb, or to cut the skin or a
baby's cord. Tetanus and womb infection can spread this way.
Some germs pass through the air when a sick person
coughs or sneezes. Colds, flu, and tuberculosis can
spread this way.
Keep sick people away from births
One simple thing midwives can do to prevent
infection is to keep sick people away from women
who are pregnant or giving birth. Keep
anyone who has a sore throat, cough, fever, or
other illness that passes through germs away
from births. And do not let anyone with a sore
on his or her hands or face touch a new baby.
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Preventing infection saves lives
If you are sick but you must go
to a birth, you can cover your mouth
and nose with a scarf, a folded cloth
or a mask. Wash your hands often
and cover your mouth when you
sneeze or cough. Be sure to wash
your hands after each time you
sneeze or cough. Try not to touch
the new baby too much.
Anyone may carry germs that cause sickness
People do not always know that they have an infection. And there is no way to tell
for sure what germs a person has just by looking at her. Some people have germs
in their blood or other body fluids but do not seem sick.
To be safe, and to stop the spread of dangerous
infections like hepatitis and HIV, health workers
must treat everyone as if they might have dangerous
germs in their body fluids. Health workers can
prevent germs from spreading:
• by wearing gloves and
other protective clothing,
to prevent blood and
other body fluids that
contain germs from
getting on themselves or
others.
• by cleaning and sterilizing the
tools they use during births and
other procedures.
Note: Good general health can help avoid infection. Healthy eating,
enough rest, and emotional and spiritual well-being are all important
for staying healthy. Sometimes they are enough to help people fight
germs that get inside the body so the person does not get sick.
But during birth and invasive medical procedures, a woman's body is
more open and vulnerable to infection, and good general health is
usually not enough. Germs that are usually kept out of the body can
get into the womb. Any cut in the skin also makes a person more
vulnerable to infection because the skin usually helps keep germs out
of the body. Even an injection can cause an infection if the syringe has
harmful germs on it.
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preventing
infection
Chapter 5: Preventing infection
Prevent infection by keeping germs away
Here are the basic rules to prevent infection.
Clean your hands and wear protective clothing.
Wash your hands often and wear protective clothing to
prevent spreading germs from one person to another and
to keep germs away from yourself (see page 53).
Clean the space and bedding.
Clean the area where births and exams happen, to
keep germs away (see page 57).
Clean and sterilize tools.
Wash and sterilize tools to kill any germs on them
(see page 59).
Get rid of wastes safely.
Throw away waste products carefully to prevent people in
the community from getting sick from the germs left on
them (see page 67).
Remember: Infection can spread most easily when a health worker is
caring for many people. For example, if her hands are not clean or her
tools are not sterile, she will pass germs from one woman to another
to another. For this reason, a woman giving birth at a hospital or
maternity center with many other women has more risk of infection
than a woman giving birth at home.
Adapt this book to work for you
This chapter contains many detailed instructions for
preventing infection. They are all important, but they
may not all be possible. You will have to decide
which you are able to do, or if there are ways you
can adapt the instructions to work for you.
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Prevent infection by keeping germs away
Clean your hands and
wear protective clothing
Wash your hands often
Washing your hands is one of the most important things you
can do to prevent infection. It prevents you from spreading
germs to another person, and it helps protect you from germs,
too. If you can do nothing else to prevent infection, you must wash your hands.
Wash your hands with soap and clean water. If you do not have soap, you can
use ash (but not dirt!). Be sure to rinse all the soap or ash off. When you wash your
hands, and especially when you rinse them, use clean water that is flowing, not
water sitting in a bowl. When you wash your hands in a bowl, the germs that come
off into the water will get back onto your hands again.
Wash your hands each time before you touch a woman's body. Wash after you
touch her body, or after you touch anything that has her blood or fluid on it (like
the placenta). Wash before you put on gloves and after you take gloves off. If you
are helping more than one woman at once, like at a hospital, it is very important to
wash between helping each person.
Normal hand washing removes most germs. But sometimes to remove more germs,
you should wash your hands for a full 3 minutes, and scrub under your fingernails.
How to do a 3-minute hand wash
Before you start, take off rings, bracelets, and other jewelry.
1
Wash your hands and
arms with soap and
clean water — all the
way up to your elbows.
Make sure to scrub in
between your fingers.
Keep scrubbing, brushing,
and washing your hands
and arms for 3 minutes!
Spend most of this time
on your hands.
Rinse
with clean,
running water.
If you have a clean brush,
scrub your fingernails.
Dry your hands in the air
instead of using a towel.
Do not touch anything
until your hands are dry.
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53
preventing
infection
Chapter 5: Preventing infection
Always do a 3-minute hand wr^u
before you:
• touch the mothers vagina
• do a pelvic exam i
• deliver the baby
• sew up a tear
after you:
• clean up after the birth
• touch any blood or
other body fluids
• urinate or pass stool
• insert an IUD (see Chapter 21)
• do an MVA (see Chapter 23)
Alcohol and glycerine hand cleaner
You can make a simple hand cleaner to use if you do not have water to wash your
hands. When used correctly, this cleaner will kill most of the germs on your hands.
Mix 2 milliliters glycerine with 100 milliliters of ethyl or isopropyl alcohol
60% to 90%.
To clean your hands, rub about 5 milliliters (1 teaspoon) of the hand cleaner
into your skin. Be sure to clean between your fingers and under your nails. Keep
rubbing until your hands are dry. Do not rinse your hands or wipe them with a
cloth.
Clean water
Throughout this book we talk about how important it is to wash
your hands and wash your tools. But the water you use must be
clean to be of any use. If the water in your community may
carry germs, be sure that water is boiled before using it to ^
wash your hands or to wash tools before a birth.
Wear gloves
Latex and other plastic gloves protect
B women from any germs that
may be hiding under your
fingernails or on your skin.
They also protect you from
Plastic bag gloves
If you do not have a a
getting infections. Wear clean gloves
whenever you touch the mothers
genitals, or any blood or body fluid.
or if you are touching any tools that
have been sterilized, you must wear
sterile gloves.
If you are doing invasive procedures,
gloves, use plastic bags Li/JLIa
that have been washed
in disinfectant soap instead. Bags
are harder to use than gloves, but
they are better than nothing.
In the rest of this book, we will
only mention gloves. But be sure
to use plastic bags if you do not
have gloves.
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Prevent infection by keeping germs away
How to put on sterile gloves
1
2
Open the package without Carefully wash your
touching the gloves. Do hands. Let them dry
not touch the outside of a in the air.
sterile glove with your
hand or it will not be
sterile anymore.
The gloves should be
folded out at the cuff.
Pick up one glove under
the cuff on the inside of
the glove and slip your
hand into it. Do not touch
the outside of the glove.
Wiggle your hand in
while you pull with
your finger tucked
inside the glove.
Pick up the second glove
by slipping your gloved
fingers into the fold of
the cuff. Slide your hand
into the glove.
Once the gloves are on,
do not touch anything
that is not sterile — or
the gloves will not be
sterile anymore either!
Practice with the same pair of gloves over and over again until it feels easy.
Remember:
If you carefully wash and put on and then scratch your glove is not
your hands... sterile gloves .. . your head... sterile anymore!
Of course, when you touch a woman you will get germs on your gloves, but do
not move germs from one part of her body to another. For example, if you touch a
woman's anus where there are many germs, do not put your fingers inside the
vagina with the same gloves. Germs from the anus can make a woman sick if they
get into the vagina or womb.
After you use a pair of gloves one time, throw them away, or sterilize them
before you use them again (see page 66).
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Chapter 5: Preventing infection
Protect yourself from infection
Midwives must protect themselves from germs and infection. You will not be able to
help women if you are sick. And if you are infected with dangerous germs, you can
easily spread them to the women you are trying to help.
Some germs that cause serious illnesses, like AIDS and hepatitis B, only live in
blood, urine, stool, the bag of waters, and other body fluids. That means you do not
get these illnesses just by touching someone's skin. But the germs that cause AIDS
and hepatitis B can infect you if an infected person's blood gets into a cut or opening
in your skin — even a cut so small that you cannot see it (see page 99 for all the ways
HIV can spread). Keep blood and other body fluids off your clothing and skin, and
if they do get onto you, wash them off right away with soap and water.
Wear protective clothing
You do not need expensive equipment to keep body
fluids off your skin, out of cuts, and out of your
mouth and eyes. You can wear an apron or an extra
shirt to keep fluid off your body. Protect your eyes
with eyeglasses or plastic goggles. Cover your feet
so that you do not step into blood or other fluids.
Wash all your clothing after any blood, waters, or other
body fluids gets on it. If you get body fluids in your eyes
or mouth, rinse them for several minutes with clean water
or saline (water with a little salt added).
If you do not have
clothing made to protect
you from blood and fluids,
you can make it from
what you already have.
56
Be careful with needles
If a syringe is used to give an injection, or a needle was used for sewing a vaginal tear,
the needle has blood on it. If you accidentally stick yourself with that used needle, you
will be exposed to germs. Carry needles carefully with the point away from your body.
Do not leave needles lying around.
Use each needle only once and then throw it away in a box like the one on page 68.
You may be able to get needles that can only be used once and do not need a cap. If you
must reuse a needle, put the cap on very carefully and then put the needle in a bucket
filled with bleach solution (see page 57) until you are ready to clean and sterilize it.
How to avoid puncturing
Do not use your hand to
put the cap on the needle.
your skin with a needle
Instead, use the needle
to pick up the cap.
Note: If you do get stuck by a needle, immediately wash the area with
soap and water or alcohol and dispose of the needle properly (see
pages 67 and 68). Do not use it on another person.
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Clean the space and bedding
Clean the space and bedding
Clean the space
At home
One reason that birth or medical procedures
can happen as safely in a woman's home as
in a medical center is that there are not as
many germs in a clean house as in a hospital.
But the home should still be cleaned carefully —
especially the area where the baby will be born or where procedures such as a pelvic
exam or IUD insertion will be done.
Sweep these areas free of dust and dirt, and wash surfaces with soap and water.
Put your tools or birth kit on a clean surface.
Move animals out of the house and do not do any medical procedures in places
where animals sleep or pass stool, or where people urinate or pass stool. If the floor
in the house is made of animal waste (dung), do not let the woman's body or any
of your tools touch the floor. Dung has many germs in it that can easily spread to
pregnant women. You can cover the floor with clean straw, cloth, or plastic.
In a hospital , maternity center ; or clinic
Be extra careful. Germs can easily be passed from one person to another.
After each birth, wash floors and surfaces. If possible, use a bleach
(sodium hypochlorite) solution to wash the floor.
How to make a disinfecting solution of 5% bleach
If your bleach says:
5% available chlorine 10% available chlorine 15% available chlorine
use undiluted,
straight bleach
use 1 part and 1 part
bleach water
use 1 part and 2 parts
bleach water
Mix just enough solution for 1 day. Do not use it again the next day.
It will not be strong enough to kill germs anymore.
If you do not have bleach, you can wash the floor with:
• ethanol (medical alcohol) 70%
• isopropyl alcohol 70%
• hydrogen peroxide 6%
• soapy water
• ammonia
(But do not ever mix
bleach with ammonia
— when mixed they
make a poison.)
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Clean or sterilize the bedding
At home
Wash cloth for covering the bed (bedding) in
soap and water, and dry it thoroughly by
hanging it in the sun or ironing it. Do not dry
bedding on the ground; it will pick up germs.
In a hospital , maternity center ; or clinic
Bedding must be sterilized after each birth. Use one of these methods to kill
the germs:
• Wash the bedding with soap or
and water. Then boil for 30
minutes. Dry thoroughly in a
• Wash bedding with soap
and water. Then use a hot
iron to dry it.
If neither of these methods is possible, wash the bedding in soap and water and
hang it in the sun until it is fully dried. Turn the bedding so the sun shines on
both sides, and take care to keep it clean.
Store bedding to keep germs away
If you are not going to use the bedding right away, keep it clean and dry until you
are ready to use it. Put it in a clean bag or wrap it in clean paper and store it in a
clean, dry place.
Note: Do not store bedding that is damp or wet. Germs will come back!
Other kinds of underpadding
Sometimes there is no bed or bedding. The birth or procedure happens on the
floor. In these cases, it is useful to have some kind of underpadding. This protects
the baby and the mother from the germs and dirt that
are on the floor. Find a way to clean the
underpadding before it is used. For example,
banana leaves can be washed with a
disinfectant solution, and then smoked or
dried in the sun. Cloth rags or sacks can be
boiled and then dried.
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Clean and disinfect tools
Clean and sterilize tools
All the tools used at a birth, exam, or procedure must be cleaned and sterilized.
Cleaning and sterilizing the tools gets rid of germs. This protects women from
getting sick.
1. Soak your tools
Tools that have been used must be soaked for at least 20 minutes in bleach
solution (see page 57).
2. Clean your tools
All tools and equipment you use at a birth or a procedure
must be clean. Wash them well after each birth, using a
brush to remove any blood or dirt in the hinges or rough
edges of your tools. Clean off any rust, and get rid of tools
that are dull or damaged. To protect yourself, wear heavy
gloves when you clean your tools.
After everything is washed, any tools that you use inside
a woman's body must also be sterilized to kill germs.
3. Sterilize your tools
To sterilize means to kill all the germs on something. If your tools are sterilized,
they will not spread germs to women when you use them. This will protect women
from getting infections.
Carefully wash
all the dirt off
What do we mean when we say "sterile"?
Sterilize means kill all the germs that cause infections. To sterilize a tool
you must use baking or pressure steaming.
Disinfect means to kill most of the germs that cause infections. Some soaps
and cleaning products are called "disinfectant." But to disinfect medical tools
or instruments you cannot simply clean something with a disinfectant soap
— you must boil, steam, or soak the tool in disinfectant chemicals. This kind
of disinfection is called High Level Disinfection (HLD).
All the procedures in this book can be done safely with tools that are
either sterile or HLD. To be simple, we only use the word "sterilize" or
"sterile" throughout the book. But any time we say that a tool should be
sterile, we really mean it can be sterile or HLD.
1 i
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Chapter 5: Preventing infection
Sterilize everything that will go inside a woman's body, will cut her skin, or will
be used to cut the cord at birth.
Sterilize these items:
• syringes and needles
• scissors or razor blade for cutting the cord
• materials for sewing tears
• clamps or hemostats
• gloves
• gauze
• compress cloths
• bulb syringe or mucus trap
• MVA cannula
(see page 420)
• speculums, in some cases
Note: You do not need to sterilize tools that are used only on the
outside of the body. Stethoscopes, measuring tape, and blood pressure
cuffs must be clean but do not need to be sterile.
When you sterilize a tool, the germs on it are killed
and it is safe to use. But if that tool touches anything
(including the bed, a table, or you!) it is no longer sterile.
Germs from whatever it touched are on it, and those
germs can cause an infection when the tool is used.
The next few pages explain 5 different ways to sterilize your tools:
baking, pressure steaming, boiling, steaming, and soaking in chemicals.
Baking and pressure steaming are best — they kill the most germs. If you cannot
use either of those methods, boiling, steaming, or using disinfectant chemicals
is fine. Use the ways that work best for you.
WARNING! If you cannot sterilize your tools, then do not
use them. Unsterilized tools will do more harm than good.
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Clean and disinfect tools
Baking
Use baking to sterilize metal tools, and
string for tying the cord. Do not bake
rubber or plastic. It will melt.
Wash and rinse all the tools well, then put them into 4 layers of
clean cloth or heavy paper. Wrap the cloth up around the
instruments and tie it shut.
Put the packet of tools or string into a container or on a pan.
Bake on a medium-high heat (1 70°C or 340°F) for 1 hour.
This is a little longer than it takes to bake a big potato or yam. If you cannot
make your oven hot enough, bake items longer.
Let the packet cool, then store it in a clean, dry place.
Pressure steaming
Use pressure steaming to sterilize metal tools or rubber
or plastic equipment.
Some clinics and hospitals have a machine for
sterilizing called an autoclave. Autoclaves sterilize
instruments using pressure and steam. If you have a
pressure cooking pot, you can sterilize your tools in the
same way that an autoclave does.
Put a steamer basket and water in the pressure cooking pot. Put your tools
into the steamer, close the lid on the pot, and put the pot on a flame to boil
After it comes to a boil, cook at 1 5 or 20 pounds of pressure for 20 minutes.
After sterilizing tools, let them dry. Do not touch them, or they will not be
sterile anymore!
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Use sterilized tongs, chopsticks, or spoons to pick the tools out of the pot. Move
them directly to a sterilized container. Remember, if the tool touches anything,
including your hands, it is no longer sterile.
Let the tools dry in the sterilized container. Cover the container
/l; m with a sterilized cloth or paper to keep dust out.
When the tools are all dry, put the lid on the container
and seal it with tape or some other material to keep the
germs out.
Boiling
Use boiling to sterilize metal tools, rubber or
plastic equipment (like mucus bulbs), and cloth
After you wash and rinse your tools, cover with
water and boil for 20 minutes.
Start counting the 20 minutes when the water
starts boiling.
Use sterilized tongs, chopsticks, or spoons to pick the tools out of the pot. Move
them directly to a sterilized container. Remember, anything you touch is no longer
sterile.
Steaming
Use steaming to sterilize metal tools,
gloves, plastic equipment, and other tools.
A steaming pot has 3 parts that
fit together tightly: one pot on the bottom
to boil water in, one pot in the middle that
has holes in its bottom, and a lid.
Boil a little water in the bottom pot. Put the tools into
the steamer pot with the holes. Cover with the lid.
Steam over boiling water for at least 20 minutes.
Start counting the 20 minutes when the water
starts boiling.
mm>)
steaming pot method
a lid
one pot
with holes
in the
bottom
one pot on
the bottom
to boil water
in
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Clean and disinfect tools
Wait for the tools to dry, and then use sterilized tongs to
move the tools from the steamer into a sterilized container,
and seal the container.
Steaming uses less water than boiling, and tools that are
steamed do not get dull or broken as quickly as tools that
are boiled.
A method from the Philippines
The Medical Mission Sisters in the Philippines have
developed a method to sterilize tools with steam:
1. Put your clean tools into a metal tray.
Place the tray in a cooking pan.
Fill the pan with
water until it
reaches halfway up the tray.
water level
Cover the pan with 8 layers of clean
green banana leaves. Bind the leaves tightly
in place with strips of banana leaf or bark.
Be careful not to spill water into the tray
when you do this.
Put the pan on a low fire and boil for
about 1 hour.
6. Throw away the top layer of the leaves.
You can use one of the inner layers to
put your instruments on.
Using chemicals
Some people use chemicals to sterilize metal,
rubber, or plastic tools and equipment. We do
not recommend using chemicals to sterilize.
Most chemicals used to sterilize are poisonous.
They poison the ground and the water when they
are thrown away. They are poisonous to the
people who work in factories making them, and
they are poisonous to the people who use them to clean tools.
But some tools can only be sterilized with chemicals.
Thermometers and some kinds of gloves cannot be baked, boiled, or steamed.
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If you do need to use chemicals:
• mix up the bleach solution on page 57.
or If you do not have bleach, use one of the following chemicals:
• ethanol (medical alcohol) 70%
• isopropyl alcohol 70%
• hydrogen peroxide 6%
or If you cannot get any of these chemicals, you can use:
• strong drinking alcohol like gin, or a strong local brew.
Be sure that all of your tools are very clean before sterilizing them with chemicals.
Even a little blood or body fluid left on the tool can stop the chemicals from
working. Do not use chemicals to sterilize tools that will go inside the womb.
Soak in bleach or disinfecting chemicals for at least 20 minutes.
or
Soak in strong drinking alcohol for a whole day.
After soaking, pour the chemicals off and let the tools dry.
WARNING! Glutaraldehydes and formaldehyde are chemicals
that we think are too dangerous to ever use. Many clinics and
hospitals use these to sterilize, but they are very toxic.
Formaldehyde, for example, causes cancer. Try to find a
different way to sterilize.
If you use chemicals, keep them off your skin, and wear gloves when you use
them. Get rid of chemicals carefully. You may have to dump bleach or other
chemicals into a latrine to be sure animals and children do not drink it.
Storing tools and supplies
At some births there will be plenty of time to sterilize
your tools and equipment at the mother's house. But at
other births, you may not have time. For this reason, try
to sterilize your tools and equipment at home and keep
them in a sterilized container in your kit. A metal
box or pot with a tight-fitting lid is best.
Use any of the above methods to sterilize a
container and tools to move equipment.
Do not touch the inside of the container.
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Clean and disinfect tools
If you cannot get such a container, wrap the tools and equipment in 4 layers of
cloth or heavy paper before sterilizing them. Then keep the sterilized tools
wrapped up until you are ready to use them. (You can only use cloth or heavy
paper to wrap your tools if you are sterilizing by baking.)
Remember that germs grow in moisture, and they will come back if the
instruments are put away while they are wet. But if you are going to use the tools
right away, it is OK to use them when they are wet. Germs need time to grow.
Some equipment needs special care
Sterile packets
Gauze, compresses, gloves, and other
equipment sometimes come in sterile
packets. Because the inside of the
packet is sterile too, you can use this
equipment directly out of the packet.
But remember: once you take
something out of its sterile packet Thls glove IS stenle-
and use it, or if the packet gets wet or
gets holes in it, the equipment is not sterile anymore.
tear in package
Things in sterile packets are often meant to be used only once and then thrown
away (disposable). But some of these things can be used again if they are carefully
cleaned and sterilized before each use. Gloves can be boiled or steamed. Gauze and
compresses can be washed and then boiled or baked.
Thermometers
Wash the thermometer in soap and rinse with cool, ^ r~ ,, tL ^
clean water before and after you use it. Do not use
hot water because the thermometer may break.
After washing, it is best to soak the thermometer in alcohol for 20 minutes. You
can use ethyl, isopropyl, or medical alcohol (ethanol). Do not reuse the alcohol.
Rinse the thermometer in clean water before you use it again.
Razor blades
Razor blades for cutting cords often come inside of a sterile packet. To keep the
packet sterile, wrap it in clean paper or cloth, or keep it in a clean dry box. If the
packet gets wet or dirty, it is not safe to use the razor blade
unless you sterilize it again.
Try not to reuse razor blades — but if you do, they must be
sterilized first. Razor blades can be sterilized by any method.
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Gloves
Most plastic gloves can be boiled or steamed, but some will fall apart in the water.
Get strong gloves that can be boiled and reused a few times.
Before boiling or steaming gloves, turn the cuff inside
out. After sterilizing a glove, touch only the inside part of
it. If you touch the outside, it will not be sterile anymore.
If the gloves you have cannot be boiled, wash them
carefully and soak them in bleach or medical alcohol. Then
Only touch the rinse them in clean water before using them again.
inside of the glove.
Mucus bulb (bulb syringe) \
When you wash out a mucus bulb, make sure to fill it with soapy water
and then squeeze the water out. Do this several times. Then rinse it out well.
If you sterilize the mucus bulb by boiling, make sure to let water into the
inside of the bulb before boiling and then squeeze out all the water afterward.
Needles
Many people get sick with serious illnesses like hepatitis or HIV from using
unsterilized needles.
Reusable syringes and disposable syringes
Reusable syringes can be used again and again. Reusable syringes make less waste
and can save money, but they must be washed very carefully and sterilized after
every use.
Disposable syringes are
made to be thrown out
after one use. Some
disposable syringes can be
taken apart, boiled or
steamed, and reused several
times. But we do not
recommend this, because
needles that are not
completely sterilized can
spread disease.
Never reuse a needle
or syringe without
cleaning and
sterilizing it first!
How to wash and sterilize a syringe
and needle for reuse:
1. Put on a pair of
heavy gloves to
protect your hands
from germs.
2. Draw 5% bleach solution
(see page 57) up through the
needle into the syringe barrel.
3. Squirt out the bleach solution.
4. Repeat several times. Rinse
everything several times with clean water.
5. Take the syringe and needle apart and
boil or steam them. (See page 62.)
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Get rid of wastes safely
Remember:
If you take a sterile syringe and put it in it is not sterile anymore,
out of boiling water . . . your pocket . . . Instead, it is dangerous!
Get rid of wastes safely
There are three different kinds of waste after a birth or procedure:
body wastes sharp wastes other wastes
"A
like blood,
like needles for
like used
stool, or placenta
sewing or syringes
plastic gloves
These wastes carry germs and can spread infections to you and to people in the
family and community. Wear gloves when you touch wastes, and get rid of them
carefully.
Body wastes
The simplest way to dispose of body wastes is to put them in a latrine or to
bury them deep in the ground.
In many communities, families bury the placenta, sometimes with other special
objects. Burying the placenta is an important ritual for many people, and is also a
way to protect the community from germs that may grow in the placenta.
Sharp wastes
Sharp wastes must be put into a container so they will not
injure anyone who finds them. A container made of metal or
heavy plastic, with a lid or tape to close it, works well.
When the container is half full, add bleach if possible, then
seal it closed and bury it deep in the ground (see page 68).
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Make a box to dispose of needles safely
Find a metal or hard plastic box. Make a long
hole in the lid of the box that is wide on one
side and gets narrower on the other side.
When you have finished using a
disposable syringe, put the needle
into the box and slide it down to
the narrowest point.
Then pull up on the syringe
and the needle will fall off into
the box. The plastic syringe can
When the box is half full, pour 5% bleach solution into the box, seal it
closed, and then bury it deep in the ground.
Other wastes
Other wastes, like plastic gloves, syringe barrels, or cloth soaked in blood, should
be sterilized and then buried deep in the ground. You can sterilize them by
soaking them in bleach for 20 minutes.
WARNING! Do not burn plastic gloves, syringes, or any
other plastics. Burning plastic wastes is dangerous — when
plastic burns, it makes smoke and ash that is very poisonous.
Burying wastes
Find a place away from where people get their
drinking water and away from where children
play. Dig a safe waste pit to bury wastes.
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Get rid of wastes safely
A safe waste pit
1. Dig a pit 1 to 2 meters wide and 2 to 5 meters deep. The bottom of the pit
should be at least 1 meters above the water table.
2. Line the inside of the pit with a layer of
clay or rocks at least 10 centimeters thick.
3. Build up a ridge of earth around the
top of the pit to prevent surface water
from running in.
4. Build a fence around the area where the
pit is located to keep animals out.
Each time waste is put in the pit, cover the waste with 10 centimeters of soil, or
a mix of soil and lime. Lime helps
disinfect the waste, and will also keep animals away while the pit is in use.
When the waste rises to V2 meter from the surface, cover it with V2 meter of soil
and seal it with a layer of concrete at least 90 centimeters thick. If the pit is used
only for medical waste and not for regular garbage, it will not fill up too quickly.
Garbage dumps
When wastes are sent to a garbage dump, they can spread infections there.
In many places, people pick through garbage to find things to sell, like used
syringes. This is dangerous for the people picking through the garbage, and
for the people who buy the syringes to use them again.
When a syringe is not usable anymore, dispose of it safely. If you must
send needles to the garbage dump, sterilize them first, and seal them in a
box or tin.
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Pregnancy
INTRODUCTION
All women need care and attention during
pregnancy. This care is usually called
prenatal or antenatal care. Prenatal care
helps pregnant women be healthier
and have fewer problems in birth.
Prenatal care should come from the
woman herself, from her family and
the community, and from a midwife
or someone else who is experienced
in helping pregnant women.
In some places, midwives only care for women when they are in
labor or giving birth, not during pregnancy. This may be because
most of the time, people only go to a healer or doctor when they are
sick or if something is wrong. Pregnancy is usually normal and
healthy, so people may not think that prenatal care is important. But
most midwives know that women who have good care during
pregnancy are more likely to have safer births and healthier babies.
Care in pregnancy has 2 purposes:
1. Observing and listening to the pregnant woman
by checking her body for healthy signs and warning
signs and by asking her about problems or listening
to her questions.
2. Teaching a woman how to have a healthier
pregnancy (for example, how to eat a healthy diet
and how to avoid harmful things).
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Midwives should start prenatal care as soon as a woman knows
she is pregnant, and should examine the woman regularly during
the pregnancy. We call these meetings "checkups." If possible,
every woman should have at least 4 checkups.
Doing more checkups will give you more chances to share
important information and to prevent health problems. And any
woman who has warning signs should have checkups more often.
This section is divided into 3 different chapters:
• Chapter 6 explains the changes a woman may go through
in pregnancy.
• Chapter 7 explains how to learn about a woman's health history
during the first checkup.
• Chapter 8 explains how to check a woman for healthy signs
and warning signs at each checkup.
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Chapter 6
Common changes in pregnancy
In this chapter:
Changes in eating and sleeping
Upset stomach (nausea) and
dislike of some foods
Food cravings
Burning or pain in the stomach or
between the breasts (heartburn) . . .
Body changes and discomforts
Swollen breasts
Swollen feet
Swollen veins (varicose veins)
Constipation
(difficulty passing stool)
Hemorrhoids (piles)
Needing to urinate often
Discharge
(wetness from the vagina)
Difficulty getting up and down
Shortness of breath
Feeling hot or sweating a lot
Sleepiness
73
Difficulty sleeping
74
74
76 The mask of pregnancy
76 Purple spots on the skin ....
76 Aches and pains in the joints
Sudden pain in the side of
76 the lower belly
77 Cramps in early pregnancy. .
77 Baby's kicks hurt the mother
Back pain
77
' / Leg cramps
Headaches
70
Other pains
78
73
75
75
76
79
79
79
79
79
80
80
80
81
81
Changing feelings and emotions
Sudden changes in feelings 82
Worry and fear 82
Strange dreams and nightmares 82
82
Forgetfulness 83
Feelings about sex 83
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Common changes
in pregnancy
During pregnancy a woman's body changes. These changes can sometimes be
uncomfortable, but most of the time they are normal. In this chapter, we describe
some of these changes, and discuss ways to help women feel better. We also
explain how to tell when a woman's discomfort may be a sign that something
dangerous is happening with her pregnancy.
There are many ideas about how to treat the discomforts of pregnancy. We
cannot explain all of these ideas here. If you know remedies or treatments for these
problems which we do not explain, use the remedies that work for you. We do not
have all the answers. But use the ideas on page 19 to help you decide if remedies
are helpful or if they may be harmful. Not all remedies work.
Changes in eating and sleeping
Upset stomach (nausea) and dislike of some foods
Many women have nausea in the first months of pregnancy. Sometimes it is
called morning sickness. No one knows for sure what causes morning sickness, but
for many women, the way they eat affects it. If the nausea is mild, encourage the
woman to try any of these remedies:
• Eat a food that has protein before bed or
in the night. Some good foods with
protein are beans, nuts, and cheese.
• Eat a few crackers, dry bread, dry
tortillas, dry chapatis, or other grain
food when she first wakes up in the
morning.
• Eat many small meals instead of 2 or 3 larger ones, and take small sips
of liquid often.
• Take 50 milligrams vitamin B-6, 2 times each day. (Do not take more.)
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pregnancy
Chapter 6: Common body changes in pregnancy
• Use acupressure to relieve nausea. Find the spot
3 fingers above the wrist between the 2 tendons on
the inside of the woman's arm. Press on this spot, —
moving your finger in small circles. Press firmly but
not hard enough to hurt. If acupressure is going to
help, the woman should start to feel better within 5 minutes.
• Drink a cup of ginger, mint, or cinnamon tea
2 or 3 times a day, before meals. To make mint or
cinnamon tea, put a teaspoon of mint leaves or a stick of
cinnamon in a cup of boiled water. Let the tea sit for a few
minutes before drinking it. To make ginger tea, boil
crushed or sliced ginger root in water for at least 15
minutes.
A pregnant woman may suddenly dislike a food that she usually likes. It is OK
not to eat that food, and she will probably begin to like it again after the birth. She
should be careful that the rest of her diet contains a lot of nutritious food.
Food cravings
A food craving is a strong desire to eat a
not food at all, like dirt, chalk, or clay.
If a woman gets a craving for
nutritious foods (like beans, eggs,
fruits, and vegetables), it is OK for her
to eat as much as she wants. But if she
wants a lot of "junk food" (like candy,
soda, or packaged snacks) she should
eat nutritious food first.
A woman who craves things that are
not food, like dirt or clay, should not
eat them. They may poison her and her
baby. They may also give her parasites,
like worms, that can make her sick.
Encourage her to eat iron-rich foods
(see page 36) and calcium-rich foods
(see page 38) instead.
certain food, or even something that is
I just want \
to eat clay.
You may need more calcium '
and iron. Try eating green
vegetables , nuts , seeds , or
beans instead. Dirt and clay
can give you parasites ana
make you sick. ,
Burning or pain in the stomach or between the breasts
(heartburn)
A burning feeling or pain in the stomach or between the breasts is called
indigestion or heartburn. Heartburn happens because the growing baby crowds
the mother's stomach and pushes it higher than usual. The acids in the mother's
stomach that help digest food are pushed up into her chest, where they cause a
burning feeling. This is not dangerous and usually goes away after the birth.
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Changes in eating and sleeping
Here are some things a woman can try to make herself more comfortable:
Keep her stomach less full by eating smaller
meals more often and by eating foods and
drinking liquids separately.
Avoid eating spicy or greasy foods, drinking
coffee, or smoking cigarettes — all of which can
irritate the stomach.
Regularly eat papaya or pineapple, which have
enzymes that help the stomach digest food.
Keep her head higher than her stomach when
lying down or sleeping. This will keep her
stomach acids in her belly and out of her chest.
As the baby
grows, he
pushes the
woman's
stomach up.
• Calm the acids in the stomach by drinking milk or taking a low-salt antacid
that contains no aspirin. (Antacids are not dangerous but they cost money
and they make it harder for the body to use nutrients from food. Try other
methods before using antacids.)
Sleepiness
Some pregnant women feel sleepy much of the day. This is most
common during the first 3 months.
It is normal for pregnant women to feel sleepy. Their bodies
are telling them to slow down and rest. But if a woman also feels
weak, she may have other problems, like a sickness, depression
(see page 274), or anemia (see page 116).
Difficulty sleeping
If a woman cannot sleep because she is uncomfortable or restless, it may help if:
• she lies on her side with something
comfortable between her knees and at
her lower back. She can use a pillow, a
rolled-up blanket, banana leaves, or
some other padding.
• someone gives her a massage.
• she drinks herbal teas that help her sleep.
Fighting, worry, and unhappiness in a woman's house or family can make it
difficult for her to sleep. If possible, a family should avoid arguing before going
to sleep.
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Chapter 6: Common body changes in pregnancy
Body changes and discomforts
Swollen breasts
A woman's breasts get bigger during
pregnancy because they are getting ready
to make milk for the baby. Sometimes the
breasts are also itchy or sore.
During the last months of pregnancy, a watery, yellowish
fluid may leak out of the nipples. This is normal. The fluid is
colostrum — the first milk for the baby.
Swollen feet
Swelling of the feet is very common, especially in the afternoon or in hot weather.
Swelling of the feet is usually not dangerous, but severe swelling when the mother
wakes up in the morning, or swelling of the hands and face anytime, can be signs
of pre-eclampsia (see page 125).
Swelling in the feet may improve if the woman puts her feet up for a few
minutes at least 2 or 3 times a day, eats fewer packaged foods that are
very salty, and drinks more water or fruit juices.
Swollen veins (varicose veins)
Swollen blue veins that appear in the legs or on the woman's
genitals are called varicose veins. Sometimes these veins
hurt. If the swollen veins are in the legs, they may feel
better if the mother puts her feet up often. Strong
stockings or elastic bandages may also help.
If the swollen veins are around the genitals,
they can cause bleeding problems if they tear
during birth. Putting a cool cabbage leaf on the
genitals may help.
Constipation (difficulty passing stool)
Some pregnant women have difficulty passing stool. This is called constipation.
To prevent or treat constipation, a woman should:
• eat more vegetables and fruits.
• eat whole grains (brown rice and whole wheat
instead of white rice or white flour).
• drink at least 8 cups of clean water a day.
• walk, move, and exercise every day.
Home or plant remedies that soften the stool or make it slippery (like remedies
made from psillium seed or certain fruits or fiber plants) may also help.
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Body changes and discomforts
WARNING ! Pregnant women should not take medicines called
laxatives or purgatives for constipation. These work by making
the bowels tighten or contract — and they may cause labor to
start too soon. Some can harm the baby.
Also, pregnant women should not wash out the bowels with
water (enema). This could also start labor too soon.
Hemorrhoids (piles)
Hemorrhoids are swollen veins around the anus. They may burn, hurt, or itch.
Sometimes they bleed when the woman passes stool, especially if she is constipated.
The woman should try to avoid getting constipated by eating a lot of fruit and
vegetables and drinking plenty of fluids.
Sitting or standing a lot can make hemorrhoids worse. But
sitting in a cool bath or lying down can help. Some women say
it helps to soak a clove of garlic in vegetable oil and then
insert it into the anus.
If you have heard of other remedies, ask an experienced
health worker whether they are safe. Some remedies are
dangerous for pregnant women and may hurt the baby.
Pregnant women
need to urinate
much more often.
Needing to urinate often
Needing to urinate (pee) often is normal, especially in the first
and last months of pregnancy. This happens because the
growing womb presses against the bladder (the place where the
body stores urine). It is so common that some midwives joke:
"A man who cannot find his pregnant wife should wait near the
place where she urinates. If she is not there, she will be soon! "
If urinating hurts, itches, or burns, the woman may have
a bladder infection (see page 128) or a vaginal infection
(see Chapter 18). Be sure to treat these infections right away —
they can cause early labor and other problems.
Discharge (wetness from the vagina)
Discharge is the wetness all women have from the vagina. A woman's body uses
this discharge to clean itself from the inside. For most women the discharge
changes during their monthly cycle. Pregnant women often have a lot of
discharge, especially near the end of pregnancy. It may be clear or yellowish.
This is normal.
Changes in the discharge can be a sign of an infection if the discharge is gray,
green, lumpy, or has a bad smell, or if the vagina itches or burns (see Chapter 18).
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Chapter 6: Common body changes in pregnancy
Difficulty getting up and down
It is better if a pregnant woman does not lie flat on her back. When a woman is on
her back, the weight of the womb presses on the big blood vessels that bring food
and oxygen to the baby. If the mother wants to be on her back, she should put
something behind her so she is not lying completely flat.
A pregnant woman should also be careful how she gets up. She should not
sit up like this:
Getting up like this can harm the
muscles of the belly.
NO!
Shortness of breath
Many women get short of breath (cannot breathe as deeply as usual) when they are
pregnant. This is because the growing baby crowds the mother's lungs and she has
less room to breathe. Reassure her that this is normal.
But if a woman is also weak and tired, or if she is short of breath all of the time,
she should be checked for signs of sickness, heart problems, anemia (see page 116),
or poor diet (see page 117). Get medical advice if you think she may have any of
these problems.
Feeling hot or sweating a lot
Feeling hot is very common, and as long as
there are no other warning signs (such as signs
of bladder infection, see page 128), the woman
should not worry. She can dress in cool clothes,
bathe frequently, and drink plenty of water
and other fluids.
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Body changes and discomforts
The mask of pregnancy
The mask of pregnancy is a name for dark-colored
areas that may appear on the face, breasts, and belly
of some pregnant women. This mask is not harmful.
Usually most of the color goes away after the birth.
A woman may be able to avoid dark areas on her
face by wearing a hat when she goes out in the sun.
Purple spots on the skin
Purple spots come from small groups of veins under the
skin. They sometimes happen when blood vessels swell.
They are not harmful and usually go away after the birth.
dark-
colored
areas
Aches and pains in the joints
A pregnant woman's body gets soft and loose so the baby can get bigger, and so
she can give birth. Sometimes her joints also get loose and uncomfortable,
especially the hips. This is not dangerous, but she can more easily sprain her ankles
or other joints. So she should move more carefully. Her joints will feel better after
the birth.
Sudden pain in the side of the lower belly
The womb is held in place by ligaments on each
side. Ligaments are like ropes that attach the
womb to the mother's bones.
A sudden movement will sometimes cause a
sharp pain in these ligaments. This is not
dangerous. The pain will stop in a few minutes.
It may help to stroke the belly gently, or to put
a warm cloth on it.
the womb
Cramps in early pregnancy
It is normal to have mild cramps (like mild monthly bleeding cramps)
at times during the first 3 months of pregnancy. These cramps happen
because the womb is growing.
Cramps that are regular (come and go in a pattern) or constant
(always there), are very strong or painful, or come with spotting or
bleeding are warning signs. The woman may have a tubal pregnancy
(see page 113) or maybe having a miscarriage (see page 91). She
should get medical help immediately.
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Chapter 6: Common body changes in pregnancy
Baby's kicks hurt the mother
Most of the baby's movements feel good. But sometimes babies kick very hard or
always in the same place. And sometimes the baby's head bounces against the
mother's back or bladder during the last weeks of pregnancy. These movements
may make the mother sore or uncomfortable, but they are not harmful.
WARNING! The mother usually feels regular kicks every day by
the 6th or 7th month. If the baby stops kicking for a few hours,
it is OK. But if the mother feels no movement for more than
a day and a night, there may be a problem. The mother
should meet with her midwife or get medical help.
Back pain
Many women get back pain. The weight of the baby, the womb, and the waters
puts a strain on the woman's bones and muscles. Too much standing in one place
or leaning forward can cause back pain. Hard work can also cause back pain.
Most kinds of back pain are normal. But it can be caused by a kidney infection
(see page 128).
Encourage husbands, children, other family members, or friends to massage the
woman's back. A warm cloth or hot water bottle on her back may also feel good.
Her family can also help by doing some of the heavy work (carrying small
children, washing clothes, farming, and milling grain) for her.
A woman can also do an exercise — called the angry cat exercise — to reduce
lower back pain. She should do this exercise several times in a row, 2 times a day,
and whenever her back hurts her.
Start on hands and knees Push the lower back up.
with the back flat.
Return to flat back.
Repeat.
80
Point the
toe up,
then stroke Do
the leg. the
Leg cramps
Many women get foot or leg cramps —
sharp sudden pain and tightening of a
muscle. These cramps especially come
at night, or when women stretch and
point their toes. To stop the cramp: flex
the foot (point it upward) and then
gently stroke the leg to help it relax (do not
stroke hard). See page 273 to learn when leg pain can be dangerous.
not point
toe down.
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Body changes and discomforts
To prevent more cramps, a woman should not point
her toes (even when stretching), and she should eat
more foods high in calcium and
potassium. The woman can also try
taking calcium, magnesium,
and potassium pills.
Foods rich in calcium and potassium
can help prevent leg cramps.
Headaches
Headaches are common in pregnancy but are usually harmless. Headaches may
stop if the mother rests and relaxes more, drinks more juice or water, or gently
massages her temples. It is OK for a pregnant woman to take 2 paracetamol tablets
with water once in a while.
Some women have migraine headaches. These are strong
headaches, often on the side of the head. The woman may see spots
and feel nauseated. Bright light or sunshine can make them worse.
Migraines may get worse in pregnancy.
Unfortunately, migraine medicine is very dangerous in pregnancy. It can cause
labor to start too soon, and it may also harm the baby. It is better for a pregnant
woman with migraines to take 500 to 1000 milligrams paracetamol, and rest in a
dark room. Although coffee and black tea are usually not healthy in pregnancy,
they are OK occasionally and they may help cure a migraine.
Headaches late in pregnancy are a warning sign of pre-eclampsia, especially
if there is also high blood pressure or swelling of the face or hands. See
page 125.
Other pains
It is common to have other small aches and pains during pregnancy.
Get medical advice for pain that is not normal in pregnancy, such as:
• red, swollen joints.
• severe pain.
• signs of anemia with joint pain (see page 1 16 on anemia).
WARNING! If there is pain in one leg that will not go away, it
may be a blood clot. See page 273 and get medical help.
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Chapter 6: Common body changes in pregnancy
Changing feelings and emotions
Pregnancy is an important time in a woman's life. Her baby
is growing inside her, her body is changing, and she needs
more food and more rest. As a woman's body changes,
her relationships, her sexuality, and her work life
can change too.
It s normal, Alfredo,
she's pregnant!
She just needs you
to listen and stay
close to her.
Maria!
What's wrong i
Can I help?
( No . (sob) I'm fine.
I I don't even know
I why I'm crying.
Sudden changes in feelings
Pregnancy can make women very emotional
Some women laugh or cry for no
clear reason. Some feel depressed,
angry, or irritable.
Odd laughing or crying and
other sudden mood changes or strong
feelings are normal. They usually pass quickly.
But do not ignore a woman's feelings simply
because she is pregnant. Her feelings are real.
Worry and fear
Many women worry when they are
pregnant, especially about the baby's health
and about giving birth. A woman's worries about other problems in her life
may also become stronger when she is pregnant.
Such worries are normal. They do not mean that something bad will happen.
Women with these feelings need emotional support, like someone to listen to their
worries and encourage them to feel hopeful. They may also need help to solve the
problems they are having in their lives, like problems with their partners, money,
drugs or alcohol, or other issues.
Strange dreams and nightmares
Pregnant women may have strong, vivid dreams.
They can be beautiful, strange, or frightening.
For many people, dreams are an important way of
understanding themselves and the world. Some people
believe that dreams can tell us about the future or give
us messages from spirits.
But usually, when something happens in a dream,
that does not mean that it will happen to us in life. The events in the dream may
be telling us what we are afraid of or what we desire. Or they may simply be stories
our minds make up while we sleep. Women who are having frightening dreams
may need someone to talk to about their hopes, fears, and feelings.
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Changing feelings and emotions
Forgetfulness
Some women forget things when they are pregnant. For most
women, this is not a big problem. But some may worry if they
do not know it is normal. No one knows why women become
more forgetful when they are pregnant, but it is common.
Feelings about sex
Some women do not want much sex when
they are pregnant. Others want sex more
than usual. Both feelings are normal.
Having sex and not having sex are both OK
for the woman and her baby. Sex is not
dangerous for the baby.
Sometimes sex is uncomfortable in
pregnancy. A woman and her partner can try different positions for making love. It
may feel better with the woman on top, or in a sitting or standing position, or
with the woman lying on her side.
There are other ways, besides sexual intercourse, for couples to be close and please
each other. Some couples touch and massage each others bodies. Some talk about
hopes and fears together.
Safer sex
When a pregnant woman has sex, it is important
to avoid infection by making sure that anything
put inside her body is clean. This includes the
penis and hands.
A man who is having sex with more than
one woman must always use condoms —
including with his pregnant partner.
Condoms are a good way to prevent infections,
HIV, and other illnesses. See Chapter 18 to
learn more about HIV and other sexually
transmitted infections.
Sex and early labor
A woman who has gone
into early labor in other
pregnancies might
choose to avoid sex after
the 6th month. This may
help prevent going into
labor too early.
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Chapter 7
Learning a pregnant woman's health history
n this chapter:
Questions in a pregnancy health history
Does she have signs of pregnancy? ... 86
How pregnant is she now?
When is the baby due? 88
How old is she? 90
How many children has she had? .... 90
Has she had any miscarriages or
abortions? 91
Has she had any problems with past
pregnancies or births? 93
Is she healthy? 97
Malaria 98
HIV and AIDS 99
Has she been vaccinated against
tetanus? If yes, when? 101
Is she taking any medicines now? ... 103
86
Has any medicine ever given her
problems? 103
What else in her life might affect her
pregnancy and birth? 104
Money 104
Living conditions 104
Distance from care 104
Work 105
Family 105
Making a transport plan 106
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Learning a pregnant
woman's health history
To give good care to a pregnant woman, you should find out about her general
health, her past health, and her past pregnancies and births. You also need to know
what this pregnancy has been like so far. This is called a health history.
Learning a woman's health history will help you give advice to make this
pregnancy and birth as safe as possible.
The best way to learn about a woman's history is to ask her. At first, she may not
be comfortable talking with you. If she feels shy about her body or about sex, it may
be difficult for her to tell you things that you need to know about her health. Try to
help her feel comfortable by listening carefully, answering her questions, keeping
what she tells you private, and treating her with respect.
This chapter suggests questions to ask each woman so you can learn more
about her. You probably have some questions of your own that you want to ask
but that we do not include here. For example, if there is hepatitis B in your
community, you may want to ask the woman if she has hepatitis B or tell her how
to prevent it. Think about the information
you need to know in order to give f
good care. What questions do you
usually ask a pregnant woman?
If you can, write down what you
learn about each pregnant woman.
This information may be needed
later in the pregnancy, or during
labor or birth.
After learning a woman's health
history, and every time you meet
with a pregnant woman, you
should do a regular pregnancy
checkup. The next chapter of this
book, Chapter 8, explains how to
do the regular pregnancy checkup.
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Chapter 7: Learning a pregnant woman's health history
Questions in a pregnancy health history
Does she have signs of pregnancy?
Some signs of pregnancy are sure signs — they mean the woman is definitely
pregnant. Some signs are probable signs, meaning the woman is probably
pregnant, but the sign could be caused by something else.
Probable signs of pregnancy
The woman's monthly bleeding stops. This is often the first sign of pregnancy.
Other possible causes of this sign are poor nutrition, emotional troubles, or
menopause (change of life).
The woman has nausea or wants to vomit. Many pregnant
women have nausea in the morning (which is why this feeling
is often called "morning sickness"), but some women may feel
this way all day. Nausea is common during the first 3 months
of pregnancy. Other possible causes of this sign are illness or
parasites.
The woman feels tired and sleepy
during the day. This is common in the
first 3 or 4 months of pregnancy. Other
possible causes of this sign are anemia
(see page 116), poor nutrition,
emotional troubles, or too much work.
The woman needs to urinate often. This is most common
during the first 3 months and the last 1 or 2 months of
pregnancy. Other possible causes of this sign are stress,
bladder infection (see page 128), or diabetes
(blood sugar disease — see page 115).
The woman's belly grows. After 3 or 4 months,
the pregnancy is usually big enough to be seen from
the outside. Other possible causes of this sign are that the
woman has a cancer or another growth in her belly
or that she is just getting
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