NATIONAL CLINICAL TRAINING COURSE Basic Emergency ...

NATIONAL CLINICAL TRAINING COURSE Basic Emergency Obstetric and Newborn Care

Trainer’s Notebook Directorate of Reproductive Health Ministry of Public Health Islamic Republic of Afghanistan

2010

Prepared for the Ministry of Public Health (MoPH) of Islamic Republic of Afghanistan, as the national refresher training course in basic essential obstetric and newborn care (EmONC), for use by all those organizations implementing a basic Emergency Obstetric and Newborn Care refresher training course. The MoPH of Afghanistan duly acknowledges the financial support of UNCEF for developing and publishing the Basic Emergency obstetric and Newborn Care Course. Special mention goes to Jhpiego for the preparation of these documents. Initially, this publication was made possible through support provided by the Office of Health and Nutrition, Bureau for Global Health, U.S. Agency for International Development, under the terms of Contract No. EEE‐C‐ 00‐03‐00021‐00 in 2005. The opinions expressed herein are those of the contributors and do not necessarily reflect the views of the U.S. Agency for International Development. TRADEMARKS: All brand names and product names are trademarks or registered trademarks of their respective companies. Errors and omissions expected, the names of proprietary products are distinguished by initial capital letters. Printed in Afghanistan March 2010

FOREWORD: Dear Readers, Women’s and children’s health is one of the top priorities of the Ministry of Public Health (MoPH) in Afghanistan. As reflected in the National Reproductive Health Strategy for 2010–2015, the MoPH will increase access to and utilization of emergency obstetric and neonatal care (EmONC) through highquality training and performance improvement initiatives and retention strategies. The provision of basic Emergency Obstetric and Neonatal Care (BEmONC & CEmONC) is a globally recognized approach for improving safe motherhood and reducing maternal mortality. With a maternal mortality ratio, there is an urgent need to improve the quality and availability of BEmONC and CEmONC services to women in Afghanistan. These updated Learning Resource Packages (LRPs) provide updates needed to teach service providers the most current evidence-based care and best practices in BEmONC and CEmONC. These packages will enable clinicians to improve their communication with women, make appropriate clinical decisions, and develop competency in managing the most common complications of pregnancy and childbirth. Increasing the capacity of health care providers through training must be complemented by a fully functioning health system and efforts to ensure that providers are working within enabling environments and a system of supportive supervision. The MoPH jointly with its partners will ensure that all skilled providers involved in basic and comprehensive EmONC have the opportunity to receive these trainings and improve the quality of the training centers. The MoPH Government of Afghanistan acknowledges and appreciates the efforts of Reproductive Health Leadership and the organizations that supported the Reproductive Health Department, through the BEmONC and CEmONC working group of the Reproductive Health Taskforce, to update the BEmONC and CEmONC LRP. Technical and financial support was provided by UNICEF. JICA has kindly supported the Pashto language translation and printing of the LRP for the field level implementation. Professional staff from Jhpiego, Afghan Midwives Association (AMA) and the Afghan Society of Obstetrics and Gynecology (AFSOG) worked very hard to prepare these LRPs and are gratefully acknowledged. The MoPH recognizes these LRPs as official training materials for the BEmONC and CEmONC courses and requires all health organizations conducting BEmONC and CEmONC courses to use this LRP in their trainings.

Regards,

Dr. Surya Dalil Acting Minister of Public Health Kabul, Afghanistan

Basic EmONC Course

Foreword i

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Foreword ii

TABLE OF CONTENTS Trainer’s Notebook

SECTION 1: OVERVIEW AND INTRODUCTION Introduction ........................................................................................................................................ 1‐1 Training Considerations ...................................................................................................................... 1‐5 Foundation Topics............................................................................................................................. 1‐11 Instructions for Anatomic Models .................................................................................................... 1‐17 Being an Effective Trainer ................................................................................................................. 1‐25 Creating a Positive Learning Environment........................................................................................ 1‐27 Conducting Learning Activities.......................................................................................................... 1‐31 Using Checklists................................................................................................................................. 1‐41 Managing Clinical Practice ................................................................................................................ 1‐43 Basic EmONC Course Outline............................................................................................................ 1‐51 Precourse Knowledge Assessment Questionnaire Answer Key........................................................ 1‐87

SECTION 2: LEARNING TOOLS Role Play 1 Key: Communicating about a Woman’s Right to Safe Motherhood ................................ 2‐1 Exercise 1 Key: Who Has Hepatitis Or HIV? ........................................................................................ 2‐3 Session: Interpersonal Communication: Skills for Effective Communications with Communities ..... 2‐5 Case Study 1 Key: Vaginal Bleeding in Early Pregnancy .................................................................... 2‐15 Clinical Simulation 1: Management of Shock.................................................................................... 2‐19 Exercise 2 Key: Using the Partograph ............................................................................................... 2‐25 Case Study 2 Key: Supporting the Woman in Labor ......................................................................... 2‐31 Case Study 3 Key: Postpartum Assessment and Care (Breastfeeding Difficulty).............................. 2‐35 Role Play 2 Key: Communicating About Family Planning Choices .................................................... 2‐39 Case Study 4 Key: Pregnancy‐Induced Hypertension ....................................................................... 2‐41 Case Study 5 Key: Pregnancy‐Induced Hypertension ....................................................................... 2‐45 Case Study 6 Key: Fever After Childbirth .......................................................................................... 2‐49 Case Study 7 Key: Vaginal Bleeding After Childbirth......................................................................... 2‐53 Clinical Simulation 2: Management of Vaginal Bleeding After Childbirth ........................................ 2‐57 Clinical Simulation 3: Management of Newborn Asphyxia............................................................... 2‐61 Midcourse Knowledge Assessment Questionnaire: ......................................................................... 2‐65 Midcourse Knowledge Assessment Questionnaire Key:................................................................... 2‐73

SECTION 3: OPTIONAL CASE STUDIES Optional Case Study 1 Key: Vaginal Bleeding in Later Pregnancy....................................................... 3‐1 Optional Case Study 2 Key: Vaginal Bleeding in Later Pregnancy....................................................... 3‐5 Optional Case Study 3 Key: Malposition ............................................................................................. 3‐9 Optional Case Study 4 Key: Fever After Childbirth ........................................................................... 3‐13 Optional Case Study 5 Key: Fever After Childbirth ........................................................................... 3‐17 Optional Case Study 6 Key: Vaginal Bleeding After Childbirth.......................................................... 3‐21 Optional Case Study 7 Key: Shoulder Dystocia ................................................................................. 3‐25 Optional Case Study 8 Key: Vaginal Bleeding In Early Pregnancy ..................................................... 3‐27 Optional Case Study 9 Key: Prolapsed Cord...................................................................................... 3‐31

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SECTION 4: PRESENTATION HANDOUTS Improving Maternal and Newborn Health in Afghanistan.................................................................. 4‐1 Women‐Friendly Care: A Discussion ................................................................................................. 4‐11 Best Practices in Infection Prevention .............................................................................................. 4‐15 Best Practices in Focused Antenatal Care Rational, Components and Tools.................................... 4‐25 Best Practices in Management of Bleeding in Early Pregnancy........................................................ 4‐35 Best Practices in Post Abortion Care................................................................................................. 4‐43 Vaginal Bleeding in Late Pregnancy and Labor ................................................................................. 4‐51 Rapid Initial Assessment, Shock, Resuscitation and Emergency Management ................................ 4‐59 Best Practices in Care During Labor and Childbirth .......................................................................... 4‐67 Best Practices in Managing Labor Using the Partograph.................................................................. 4‐75 Best Practices in Inspection and Repair of Vaginal Sulcus, Periurethral and Cervical Tears ............ 4‐81 Best Practices in Postpartum Care of the Mother ............................................................................ 4‐85 Best Practices in Care for Assisted Breech Birth ............................................................................... 4‐97 Best Practices in Management of Headache, Convulsions, Loss of Consciousness or Elevated Blood Pressure .......................................................................................................................................... 4‐103 Best Practices in Managing Fever after Childbirth.......................................................................... 4‐111 Best Practices in the Management of Vaginal Bleeding After Childbirth ....................................... 4‐117 Prolapsed Cord................................................................................................................................ 4‐129 Best Practices in Immediate Care of the Newborn......................................................................... 4‐133 Best Practices in Vacuum Extractor‐Assisted Birth ......................................................................... 4‐143 Shoulder Dystocia ........................................................................................................................... 4‐157 Best Practices in Care of the Newborn with Problems ................................................................... 4‐161 Pain Management in Essential Obstetric Care................................................................................ 4‐171

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INTRODUCTION

RATIONALE FOR UPDATE Maternal and newborn morbidity and mortality in Afghanistan remains at an unacceptably tragic level. The country’s health indicators are appalling, including the second highest maternal mortality ratio (MMR) in the world estimated at 1,600 per 100,000 live births.1 Not surprisingly, the risk of death due to maternal causes increases among women living in remote regions. Bartlett (2005) reported 6,500 maternal deaths per 100,000 live births—the highest MMR ever reported—in the remote province of Badakshan. One Afghan woman dies every 30 minutes from pregnancy‐related causes, mainly hemorrhage, obstructed labor or sepsis, and 78% of such deaths are avoidable. The neonatal mortality ratio in Afghanistan is also among the world’s highest, at an estimated 60 per 1,000 live births.2 Most Afghan women deliver at home, and in 2003, less than 10% of births were attended by a skilled provider.3 Low rates of family planning (FP) use contribute to both maternal and newborn mortality; the contraceptive prevalence rate in 2006 was 15.4.4 Human resource shortages also constitute a major challenge for improving health outcomes. In Afghanistan, where these shortages are particularly acute, partners have been working with the Ministry of Public Health (MOPH) on a five‐year initiative to increase the number of midwives and other skilled professionals. This increase in midwives (over 2,000 to date) has led to increasing numbers of attended deliveries reported at 18.9% in 2006. International experts agree that the optimal strategy to reduce maternal and neonatal mortality is to ensure that all births are attended by skilled attendants and that all women with complications have access to emergency obstetric care (EmOC).5 It is recognized that availability of skilled care—the combination of an accredited health professional with midwifery skills working in a well‐equipped environment—is an important intervention necessary to promote safe pregnancy and birth for women and their newborns. High‐quality maternal and newborn care requires that each woman and newborn receives evidence‐ based care during normal (uncomplicated) pregnancy, labor and birth, and the postpartum period. Care of the “normal,” as well as early detection and management of complications with an effective referral system, are essential to reduce maternal and newborn mortality. The essential services that a midwife6 or other skilled birth attendant (SBA) should be capable to provide to the mother or newborn with problems include basic emergency obstetric and newborn care (BEmONC) as listed in the text box 1.

1

Bartlett, L., Mawji, S., Whitehead, S., et al., 2005. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002. The Lancet 365, 864–870. 2 Lawn, J.E., Cousens, S., Zupan, J., Neonatal Survival Series Steering Group, 2005. Four million neonatal deaths: When? Where? Why? The Lancet 365, 891–900. 3 MOPH, 2003a. Afghanistan multiple indicator cluster survey 2003: report to the Afghanistan MOPH, by the Johns Hopkins University Bloomberg School of Public Health & Indian Institute of Health Management Research. 4 Afghan Health Survey 2006. 5 International Journal of Gynecology & Obstetrics Amsterdam, Volume 107, Supplement 1, 2009. 6 International Confederation of Midwives Core Competencies for Midwifery Education and Practice. Basic EmONC Course

Trainer Overview and Introduction 1‐1

Text Box 1: BEmONC Services Services defined by Basic Emergency Obstetric and Newborn Care (BEmONC): • Administer parenteral antibiotics • Administer parenteral uterotonics • Administer parenteral anticonvulsants for pre‐eclampsia and eclampsia • Manually removal of the placenta • Remove retained products of conception (e.g., manual vacuum aspiration; dilatation and curettage) • Perform assisted vaginal delivery (e.g., vacuum extraction; forceps delivery) • Perform basic neonatal resuscitation (e.g., with bag and mask)

These BEmONC services are a vital component of essential maternal and newborn care as outlined in the MAMAN framework (Figure 1) for community‐ and facility‐based provision of essential maternal and newborn care. Figure 1: MAMAN, Minimum Activities for Mothers and Newborns

Minimum Activities for Mothers and Newborns (MAMAN) Essential Maternal and Newborn Care Minimum activities in the FACILITY ANC Emergency obstetric and newborn care Special care for low birth weight

ANC

•Birth preparedness •Tetanus toxoid

•Birth preparedness •Tetanus toxoid

Safe Birth with Skilled Attendance •Partograph •Infection prevention •Active mgt of 3rd stage of labor •Newborn resuscitation

Postpartum •Cord care •Thermal care •Immediate & excl breastfeeding •Infection treatment

Prophylactic eye care

Minimum activities in the COMMUNITY

Safe Birth •Clean delivery •Referral link for obstetric & newborn complications

Postpartum •Cord care •Thermal care •Immediate & excl breastfeeding •Infection recognition & referral or treatment

Other Essential Interventions

Adequate maternal nutrition

Iron and folate Family planning

Immunization

Context-Specific Interventions Intermittent presumptive treatment for malaria

Iodine

Syphilis detection and treatment

Prevention of mother-to-child transmission of HIV

USAID January, 2007

The midwife is often the care provider who is most accessible to pregnant and birthing woman and their newborns. And, the midwife is often the leader whom the health care community looks to for expertise in care of the woman and her newborn. As an SBA, her/his presence at a birth, during

Basic EmONC Course


pregnancy or postpartum is associated with a reduction in maternal and newborn mortality. Other providers of BEmONC include doctors and nurses with midwifery skills.7

Purpose and Use of This Learning Resource Package For years, much of basic emergency obstetric and newborn care was provided according to “tradition” and “routine” practice rather than according to evidence. Today, we know that to be effective, care should be evidence‐based. And yet, the “evidence” and current “best practices” in maternal and newborn care have failed to catch up with our teaching of students and in refresher training courses. This BEmONC Learning Resource Package helps provide updates on best practices needed to teach service providers the most current evidence‐based care. Use of this package assumes that basic skills, such as assisting normal birth or normal antenatal care (ANC) are already being provided by the participants. The learning resource package consists of the following components: • A Participant’s Handbook (Trainers must also have and read a copy of this.) • A Trainer’s Notebook, which includes answer keys for questionnaires, case studies and role plays, and detailed information for conducting the course • Reference manuals • Well‐designed teaching/learning aids such as presentation graphics, videos and anatomic models • Competency‐based performance evaluation

7

WHO, ICM, International Federation of Gynecology and Obstetrics (FIGO), 2004. Making pregnancy safer: the critical role of the skilled birth attendant. WHO, Geneva.

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TRAINING CONSIDERATIONS Before implementing a training program, consideration must be given to the learning process, the learning environment, the preparation of teachers and classrooms, the selection and preparation of clinical sites, the availability of learning resources, the preparation of a simulated practice environment, and scheduling considerations, as outlined below.

The Learning Process Midwives and doctors must have the knowledge and skills essential to the provision of safe and effective pregnancy, childbirth and newborn care. It is necessary, therefore, that they participate in a learning process that facilitates the development of: • Problem solving, critical thinking, and decision‐making skills, • Appropriate interpersonal communication skills, and • Competency in a range of essential clinical skills for basic maternal and newborn care and for the management of common complications in pregnancy and childbirth. In addition, the learning process must be supported by: • Training programs that provide appropriate managerial and technical support, • Skilled classroom and clinical teachers, and • Teaching materials that reflect the most recent evidence‐based information. Establishing a positive learning climate depends on understanding how adults learn. The teacher/trainer must have a clear understanding of what the learners need and expect. Adults who attend courses to acquire new knowledge, attitudes, and skills share the following characteristics: • Require learning be relevant. The teacher/trainer should offer learners learning experiences that relate directly to their future job responsibilities. At the beginning of the course, the objectives should be stated clearly and linked clearly to their future job performance. The teacher/trainer should take time to explain how each learning experience relates to the successful accomplishment of the course objectives. • Are highly motivated if they believe learning is relevant and will enable them to become effective health care providers. People bring high levels of motivation and interest to learning. Motivation can be increased and channeled by the clinical teacher/trainer who provides clear learning goals and objectives. • Need participation and active involvement in the learning process. Few individuals prefer just to sit back and listen. The effective teacher/trainer will design learning experiences that actively involve the learners in the training process. • Desire a variety of learning experiences. The teacher/trainer should use a variety of learning methods including: Audiovisual aids Illustrated lectures Demonstrations

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Brainstorming Small group activities Group discussions Role plays, case studies and clinical simulations •

•

Desire positive feedback. Learners need to know how they are doing, particularly in light of the objectives and expectations of the course. Is their progress in learning clinical skills meeting the teacher’s/trainer’s expectations? Is their level of clinical performance meeting the standards established for the procedure? Positive feedback provides this information. Learning experiences should be designed to move from the known to the unknown or from simple activities to more complex ones. This progression provides positive experiences and feedback for the learner. To maintain positive feedback, the teacher/trainer can: Give verbal praise either in front of other learners or in private Use positive responses during questioning Recognize appropriate skills while coaching in a clinical setting Let the learners know how they are progressing toward achieving learning objectives Have personal concerns; the teacher/trainer must be sensitive to and recognize that many learners fear failure and embarrassment in front of their colleagues. Need an atmosphere of safety. The teacher/trainer should open the course with an introductory activity that will help learners feel at ease. It should communicate an atmosphere of safety so that learners do not judge one another or themselves.

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Need to be treated as individuals, each of whom has a unique background, experience, and learning needs. To help ensure that learners feel like individuals, the teacher/trainer should:

Use learners’ names as often as possible Involve all learners as often as possible Treat learners with respect Allow learners to share information with others •

Must maintain their self‐esteem. Learners need to maintain high self‐esteem to deal with the demands of the course. It is essential that the teacher/trainer show respect for the learners, no matter what practices and beliefs they hold to be correct, and continually support and challenge them. This requires the teacher/trainer to:

Reinforce those practices and beliefs embodied in the course content Provide corrective feedback when needed, in a way that the learners can accept and use it with confidence and satisfaction Provide teaching/training that adds to, rather than subtracts from, their sense of competence and self‐esteem •

Have high expectations for themselves and the learners. People tend to set high expectations both for the teachers/trainers and for themselves. Strive for excellence always.

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•

Have personal needs that must be taken into consideration. All learners have personal needs. Taking timely breaks and providing the best possible ventilation, proper lighting, and an environment as free from distraction as possible can help to reduce tension and contribute to a positive learning atmosphere.

The Learning Environment The learning environment should: • Incorporate an educational philosophy that encourages the development of problem‐solving and critical thinking and emphasizes behaviors that respect and respond to a patient’s/client’s perceived needs. • Include relevant educational materials that reflect an adult learning approach. • Involve teachers who are adequately prepared to use competency‐based learning methods and clinically competent to teach and serve as role models for learners and who are able to use competency‐based assessment tools. • Facilitate comprehensive, supervised clinical learning experiences that will enable the development of essential skills for basic maternal and newborn care and for the management of common complications in pregnancy and childbirth. • Include evaluation methods that assess knowledge, skills, and attitudes.

Preparation of Teachers Trainers must be: • Current in their knowledge of care during pregnancy and childbirth, • Proficient in the skills they will teach, • Able to use competency‐based learning methods and methods of assessment, • Capable of serving as role models for learners and colleagues, and • Interested in being teachers.

Preparation of Classroom Facilities Classrooms should be available for interactive presentations (e.g., illustrated lectures) and group activities. Seating in classrooms should be comfortable and lighting and ventilation adequate. At a minimum, a writing surface should be provided for each learner, and a chalkboard and/or flip chart, chalk and/or felt pens, and an overhead projector should be available in each classroom. If possible, classrooms should be within easy access of the clinical sites used for the training course.

Basic EmONC Course


Selection of Clinical Sites Clinical sites should be assessed and selected based on the following criteria: • Patient/client mix and volume. Are there sufficient patients/clients in sufficient numbers for learners to gain the clinical experience needed? • Equipment, supplies, and drugs. Does the facility have the necessary equipment, supplies, and drugs, in sufficient quantities, to support the learning process? • Staff. Are staff members at the site willing to accept learners and participate in the learning process? Do they use up‐to‐date, evidence‐based practices for pregnancy, childbirth, and newborn care? Do they use correct infection prevention practices? • Transportation. Is the site within easy access for learners and teachers? Do special transportation arrangements need to be made? • Other training activities. Are there other training activities at the site that would make it difficult for learners to gain the clinical experience they need?

Availability of Learning Resources Learners need to have access to reference materials and other learning resources for the duration of the program. Ideally, these materials and resources should be made available at a single location, and should include reference manuals and other relevant printed materials; anatomic models (such as a childbirth simulator or newborn resuscitation models) and supplies and equipment for practicing with the models (such as gloves, drapes, etc.) should also be available.

Preparation of a Simulated Practice Environment A simulated practice environment provides students with a safe environment where they can work together in small groups, watch technical videos, and practice skills with anatomic models. If a room dedicated to simulated practice is not available, a classroom or a room at a clinical practice site should be set up for this purpose. The simulated practice environment must have the necessary supplies and equipment for the desired practice sessions. The room should be set up before learners arrive, and there should be enough space and enough light for them to practice with models or participate in other planned activities. The following resources should be available: • Anatomic models • Medical supplies such as a newborn resuscitation bag and mask, cloth sheets or drapes, cotton swabs, syringes and needles, and infection prevention supplies • Learning materials such as the reference manuals and checklists • Chairs, tables, and a place for hand washing or simulated hand washing, video cassette player and monitor, flip chart stand, paper and markers

Basic EmONC Course


Scheduling Considerations The number of participants in the course will need to be considered when scheduling classroom and clinical activities. For example, while it is possible to hold lectures for large groups of learners, clinical teaching in simulated situations and at clinical sites should be undertaken with small groups of learners. For these learning experiences, a ratio of one teacher to four to six learners is recommended. A course schedule of activities is available showing where and when classroom and clinical skills sessions will be held and when assessments will take place.

Student Teacher/Preceptor Ratio The ratio of students to teachers has a direct impact on the quality of learning and the ability of students to gain the knowledge and skills required. Ratios that have lead to success in other programs are:

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Classroom: one teacher for a maximum of 30 students

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Small group learning or discussion: one teacher for 15–18 students (a single teacher may oversee the work of two to three small groups that together have a maximum of 15–18 students)

•

Simulated practice: one teacher to 8–12 students who are working on models or in a simulated setting

•

Clinical practice: one teacher or clinical preceptor for four to six students who are providing patient care

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Basic EmONC Course


FOUNDATION TOPICS In this section, the three topics that are integral to the provision of high‐quality essential obstetric and newborn care are: • Clinical decision‐making, • Interpersonal communication, and • Infection prevention. It is important to note that these topics are incorporated throughout the materials in this learning resource package.

CLINICAL DECISION‐MAKING Clinical decision‐making is the systematic process by which skilled providers make judgments regarding a patient’s/client’s condition, diagnosis and treatment. Despite the importance of sound clinical decision‐making to the provision of high‐quality services, it is not usually well‐taught in either preservice or inservice training programs. Until recently, very little was known about how decisions are made. For many experienced providers, decision‐making is an intuitive process based on knowledge and experience. There is, however, a process for clinical decision‐making that can be broken down into a series of steps. Together, these steps provide a framework for the provider to gather the information needed to form accurate judgments, begin appropriate care and evaluate the effectiveness of that care. When teaching clinical decision‐making it is important to ensure that participants understand this step‐by‐step process (see below) and what occurs in each step. They also must understand that, although there is a sequence of steps for clinical decision‐making, movement through the steps is rarely linear or sequential. Rather, it is an ongoing, circular process, in which the provider moves back and forth between the steps as the clinical situation changes and different needs or problems emerge. Participants should be introduced to the steps in clinical decision‐making early in their training. After that, these steps should receive continual emphasis and be used in a variety of situations.

Terms Used in Clinical Decision‐Making There are various terms used to describe the process that a skilled provider goes through in reaching a final conclusion about a patient’s/client’s condition. These terms may differ somewhat from country to country and include: Differential Diagnosis. When a patient/client presents with a specific clinical sign and/or symptom, the provider usually considers a number of possible or differential diagnoses. For example, there may be a number of explanations why a woman has Basic EmONC Course


vaginal bleeding in early pregnancy. Possible explanations include complete, incomplete, or threatened abortion, or ectopic pregnancy. These possible diagnoses provide a starting point for understanding the exact pathology underlying the patient’s/client’s presenting clinical sign or symptom and serves as the basis for gathering information through history taking, physical examination or, sometimes, laboratory investigations. By creating a list of differential diagnoses, the provider helps to ensure that the many possible causes for the patient’s/client’s problem are considered. Hypothesis Testing. Typically, through a process known as hypothesis testing, a provider accepts or rejects as quickly as possible the various diagnoses that are on the list. The provider will consider other available information to give more or less priority to a particular diagnosis, and will “rule out” (find unlikely), or “rule in” (find more likely) a given diagnosis because of: • Other signs or symptoms; • Laboratory tests; • The probability of the diagnosis in this particular age group or ethnic group; or • Intuition or experience. Working diagnosis. After evaluating the possible diagnoses, using all available information from the history, physical examination, and laboratory tests (if performed), the provider reaches a working diagnosis. This diagnosis is also known as a provisional or initial diagnosis and, given what is known, is the single best explanation for the patient’s/client’s signs or symptoms. The provider may continue to gather information at this point or may begin to plan treatment. Final diagnosis. A final diagnosis is reached after more definitive information becomes available. Making a final diagnosis is useful in trying to understand or teach the process of clinical decision‐making, but it is not always possible or to make a rational treatment plan and take action. For example, in a life‐threatening situation or when the tests needed to confirm a working diagnosis are not available, the provider will need to move forward with treatment based on the working diagnosis alone.

Steps in Clinical Decision‐Making

1. Assessment (Gathering Information) Both the patient/client, through self‐assessment, and the provider complete this first step in clinical decision‐making. Usually it is the patient/client who first recognizes that there is a problem and goes to the provider for help. Often, the patient’s/client’s chief complaint leads to a more significant or underlying problem. To identify the problem correctly, the provider needs to collect information from and about the patient/client that will assist in accurately diagnosing and treating the problem. Providers obtain information through history taking, physical examination, and diagnostic tests, if available and necessary. It is important to collect only the

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information that is relevant to reaching a diagnosis and providing appropriate treatment or care. Participants and inexperienced providers usually use a standard format, or “external guide,” for history and physical examination, to assist them in gathering information about a patient/client in an orderly way. Experienced providers, however, have “internalized” this guide and gather information based on key diagnostic characteristics that help to direct their information gathering; they tend to ask fewer, more focused questions and perform a physical examination relevant to the patient’s/client’s chief complaint.

2. Diagnosis (Interpreting the Information) After gathering information, the provider begins to formulate a differential diagnosis. Working from this point, the provider uses her/his experience, fund of knowledge and clinical inference to guide the collection of additional information to accept or reject certain diagnoses and move toward a working diagnosis. Ultimately, through the process of hypothesis testing, the provider chooses a working diagnosis as a basis for planning treatment. Initial impressions are often formulated early in the interaction with the patient/client. Experienced providers may consider several possible diagnoses within the first five minutes with the patient/client, often based on very little information. New providers, who may not be as familiar with the possible diagnoses, may take longer.

3. Planning (Developing the Care Plan) After reaching a working diagnosis, the provider decides on a treatment or care plan, using the information collected in the previous steps. For example, a young mother who is reluctant to breastfeed because she has sore nipples, may be provided counseling and assistance for proper attachment and positioning during breastfeeding, and encouragement to continue exclusive breastfeeding on demand. There are a number of factors that influence the choice of a treatment option, including: • Provider’s experience • Research and clinical evidence • Provider’s values • Patient’s/client’s values • Bias due to missing or incomplete data

4. Intervention (Implementing the Care Plan) The next step in clinical decision‐making is implementing the treatment or care plan. Implementation requires certain clinical skills and attention to detail during the performance of these skills. Some actions will have to be carried out simultaneously and others in sequence. In either case, advance

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preparation of equipment, supplies and personnel will make the implementation of the treatment or care plan easier.

5. Evaluation (Evaluating the Care Plan) In this step of clinical decision‐making the treatment or care provided is evaluated for its effectiveness. For example, evaluation of care for a young mother with sore nipples may include further observation of breastfeeding technique that, in turn, may indicate the need for additional counseling and assistance to continue breastfeeding. Thus, planning, intervention, and evaluation follow a circular pattern in much the same way that assessment and diagnosis do. Sometimes the evaluation of treatment or care, especially if it has not been effective, will require the collection of additional information, and revision of the diagnosis, thus restarting the entire clinical decision‐making process. Evaluation of the treatment or care plan can also lead the provider to a final diagnosis—a working diagnosis that has been confirmed by more objective information. When the final diagnosis agrees with the working or provisional diagnosis, the provider will use the details of this case in her/his body of clinical experience.

TOOLS FOR TEACHING CLINICAL DECISION‐MAKING Tools for teaching clinical decision‐making are presented throughout this learning resource package. The case studies have been designed to facilitate the teaching of decision‐making by reinforcing the steps involved in the process described above. Clinical simulations have also been included in the package. Some clinical simulations are included in the formal course schedule or outline to help the trainer facilitate learning of clinical decision‐making and management of shock, eclampsia, and bleeding in early pregnancy. When using these tools, the trainer must take an active role in discussing, questioning, explaining, and challenging participants about how decisions are being made. This interaction must continue as the participants move into the clinical area and work with patients/clients. Clinical decision‐making is a difficult skill to teach. But by beginning early in a training program and continually providing practice opportunities and guidance— whether by using the tools included in this learning resource package or through experience with patients/clients—trainers will help participants more fully understand the decision‐making process and develop their decision‐making skills.

INTERPERSONAL COMMUNICATION Effective relationships between health care providers and patients/clients are made possible through interpersonal skills that enable the health care provider to understand and relate to the experiences of patients/clients. When a health care provider talks with a patient/client, the aim is to use interpersonal skills and/or communication techniques that help the development of Basic EmONC Course


an honest, caring, and trusting relationship. If the patient/client feels that the health care provider has her best interests at heart, she will be more likely to come back for ongoing care. The interpersonal skills needed for effective relationships with a patient/client include listening and understanding; these are the key skills that enable the health care provider to interact effectively with a patient/client and establish a meaningful relationship between the two. Listening. Through listening, health care providers learn about patients/clients as people who have unique experiences and needs related to health and illness. Listening enables patients/clients to be heard and accepted by health care providers. Listening is critical to effective interpersonal relationships because it: • Persuades patients/clients to share their experiences, • Acknowledges patients/clients as people with important things to say, • Encourages understanding between the health care provider and patient/client, and • Provides the health care provider with information on the basis of which to act. Attending, which means directing attention outward, is an important part of listening. The attending behavior of the health care provider communicates to the patient/client that she/he is available and ready to listen. Body posture and eye contact are the main attending behaviors. Observing, which involves paying attention to both what is being said and how it is being said, is also an important part of effective listening. Health care providers need to observe the nonverbal cues that patient/clients use. To convey feelings, patients/clients commonly use body posture, facial expression, eye contact, and other nonverbal behaviors. Understanding. While listening helps the health care provider form impressions of the patient’s/client's experiences, further interaction is needed to qualify these impressions. Taking the time to understand a patient’s/client's experience enables the health care provider to offer care that is based on the patient’s/client's reality. After listening to the patient/client and forming an initial impression, the health care provider responds verbally to move the interaction toward mutual understanding. Although it is important that responses be spontaneous and sincere, it is also important that they have the intention of moving the interaction between the health care provider and the patient/client toward greater understanding.

Tools for Teaching Interpersonal Skills Effective role modeling is essential to teaching interpersonal skills. When demonstrating a skill or coaching a participant who is developing a skill, whether in a simulated situation or in a clinical setting, the trainer must demonstrate effective interpersonal skills, as described above. These skills are woven throughout the components of this learning resource package. For example, checklists highlight good interpersonal skills, emphasizing understanding and respect for the Basic EmONC Course


patient’s/client’s needs. Case studies do the same, and also take into account the socio‐cultural environment of the woman and her family. And role plays provide unique opportunities for demonstration and development of these interpersonal skills.

INFECTION PREVENTION PRACTICES Infection prevention practices are essential in all health care settings to: • Decrease the transmission of blood‐borne pathogens such as HIV and HBV (hepatitis B virus), • Protect patients/clients, • Protect staff, and • Protect the community. The standard infection prevention practices are: • Handwashing; • Use of protective barriers such as gloves, gowns, plastic aprons, and goggles to prevent direct contact with blood and other body fluids; • Safe decontamination of instruments and other contaminated equipment; • Safe handling and disposal of sharps; and • Safe disposal of waste contaminated with blood and other body fluids. These infection prevention practices are integrated with all components of this learning resource package and included in the checklists. The trainer must model infection prevention practices, and be vigilant in demonstrating and coaching these throughout the learning experience. In addition, the trainer must emphasize that a skill will not be assessed as having been performed competently if infection prevention practices are not followed.

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INSTRUCTIONS FOR USING ANATOMIC MODELS The following anatomic models are suggested for use with this learning resource package for teaching clinical skills in simulated situations: • Childbirth simulator • Vinyl or cloth pelvic model • Foam block (for episiotomy and repair) • Fetal model • Placenta/cord/amnion model • Newborn resuscitation model

CHILDBIRTH SIMULATOR A Gaumard® S500 AOA Advanced Childbirth Simulator is a model of a full‐sized, pregnant adult female lower torso (abdomen and pelvis). It is a versatile training tool developed to assist in teaching the processes and skills needed to perform many childbirth techniques. The Childbirth Simulator is ideal for demonstrating and practicing the following procedures: • Palpation of the fetal backbone, knees, and elbow • Normal vaginal childbirth • Complete, frank, and footling childbirth • Vertex presentation • Intra‐uterine manipulation • Multiple births, including vertex/vertex, vertex/breech, breech/vertex, and breech/breech presentation • Prolapse of umbilical cord • Placenta previa: total, partial, and marginal • Vacuum extraction (with optional vacuum childbirth fetus) Contents of the Childbirth Simulator The Gaumard® S500 AOA Advanced Childbirth Simulator kit includes the following: Item Quantity Newborns (one male, one female)

2

Placentas

2

Detachable umbilical cords

6

Stomach covers

2

Vulval inserts

3

Umbilical cord clamps

1

Container of talcum powder

1

Soft nylon carrying bag

1

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The simulator may also be purchased with specialized modules to demonstrate Leopold maneuvers and cervical effacement. A 19‐piece articulating newborn for demonstration of many unusual birth presentations is also available. An optional module is available to simulate the conditions of the cervix and vagina before and during labor, and an optional vacuum childbirth fetus is also available for practicing that skill with the simulator. Instructions for Use The simulator is placed flat on its back to demonstrate one possible childbirth position. It can also be used to simulate other birthing positions such as sitting and squatting. The life‐size pelvic cavity has all major anatomic landmarks and a hand‐ painted outline of the bony pelvis. It is designed with both an open abdomen, which has a soft, detachable, replaceable vinyl cover that attaches with snaps to the outside of the abdominal wall, and an open diaphragm on the torso, which has an end plate that may be removed by unscrewing the three nuts that secure the end plate to the simulator. The birth canal is of average/normal dimensions and the vulval/perineal insert is manufactured in soft plastic and is replaceable. The simulator is provided with two newborns to allow the demonstration of multiple births. The newborns each measure approximately 48 cm (19 in). Relevant landmarks, such as the fontanelles (“soft spots” on the skull where unfused cranial bones meet), orbit, nose, mouth, ears, and vertebral column are palpable. A detachable umbilical cord is attached to each newborn so that the cord can be removed without cutting. The umbilical cord has a simulated umbilical blue vein and two red arteries. The hand‐painted placenta is detachable from the umbilical cord and is attached to the interior abdominal wall with velcro. This simulates the placement of the placenta on the uterine wall.

Procedures with the Childbirth Simulator

Normal Labor and Childbirth

Fetal Palpation The fetus may be palpated while in the abdominal cavity. To palpate the backbone, do the following: • Place the fetus face down in the abdominal cavity. • Snap the abdominal cover into place. • Gently press on the cover until the length of the backbone can be felt. To palpate the head and facial features, place the fetus face‐up in the abdominal cavity and repeat the above procedure. The fetus may be placed in the abdominal cavity so that the presenting part is either the head or the feet.

Fetal Descent To simulate fetal descent, do the following: Basic EmONC Course


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Apply talcum powder to the fetal head and shoulders and inside the vulval insert to simulate amniotic fluid. Remove the diaphragm end plate or the abdominal cover. Insert one hand in the abdominal cavity and gently grasp the fetal body above the shoulders to allow greater control. Move the newborn caudally (downward through the birth canal).

Internal/External Rotation Internal rotation of the head takes place as the fetal head meets the muscles of the pelvic floor. Thus, the fetus rotates so that it is face down or face up in the pelvis. Internal rotation may be simulated by manually turning the fetus as it enters the upper portion of the vaginal canal. External rotation can be demonstrated by manually rotating the newborn within the vaginal canal through the open diaphragm or abdomen after the head has been delivered.

Expulsion Expulsion can be demonstrated by allowing the provider who is delivering the newborn to gently pull down and then up on the fetus to deliver both shoulders. Once the shoulders have been delivered, the rest of the newborn should deliver easily. After expulsion, the newborn may be placed on the simulator’s stomach while the cord is detached.

Active Management of the Third Stage of Labor This stage may be simulated by first gently disengaging the placenta from the interior abdominal wall. The placenta may then be gently pulled through the vaginal opening using the umbilical cord. Manual exploration of the uterus may also be demonstrated by inserting a hand up through the vaginal opening.

Abnormal Labor and Childbirth

Prolapse of the Umbilical Cord This condition can be demonstrated by placing the umbilical cord in the front of the presenting part of the fetus before it is placed in the birth canal.

Placenta Previa To simulate this condition, place the placenta in the uterine cavity in the desired position to simulate total, partial or marginal placenta previa, with the maternal side against the uterine wall or cervical os. Then, place the fetus within the uterine cavity, with the presenting part closest to the placenta.

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CARE AND MAINTENANCE OF THE MODELS The following information applies to both the simulator and the newborns included in the kit: The models are constructed of material that approximates skin texture. Therefore, in handling them, use the same gentle techniques as you would in working with a patient. To avoid tearing the models’ “skin” when performing a procedure, use talcum powder to lubricate the newborn’s head or shoulders and inside the vulval insert. DO NOT use too much talcum powder within the abdominal cavity of the model because this will prevent the velcro from keeping the placenta in place. Clean the models after every training session using a mild detergent solution; rinse with clean water. Store the models in the carrying case and plastic bag provided with your kit. DO NOT wrap the models in other plastic bags, newspaper, plastic wrap, or any other kinds of material, as these may discolor their skin. DO NOT write on the models with any type of marker or pen, as these marks may not wash off. DO NOT use alcohol, acetone or Betadine® or any other antiseptic solution that contains iodine on the models. They will damage or stain the skin. DO NOT use excessive force to push the newborn out the vaginal opening or to remove the placenta during active management of the third stage of labor because this may damage the models. DO NOT cut the model’s skin to demonstrate any procedure such as episiotomy or cesarean section. These cuts cannot be repaired and will damage the model. DO NOT cut the umbilical cord. Instead, simulate cutting it so that it may be used repeatedly.

PELVIC MODEL, FETAL MODEL, OR PLACENTA/CORD/AMNION MODEL The cloth or vinyl pelvic model, fetal model, and placenta/cord/amnion model are designed to be used individually or together to assist in teaching the processes and skills needed to perform many childbirth techniques. These models are ideal for demonstrating and practicing the following: • Physiology of the placenta, cord, amnion, and chorion • Obstetric aspects of the fetal head • Pelvic station • Fetal lie and presentation • Fetal position, attitude, and rotation Basic EmONC Course


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Mechanism and maneuvers of normal labor and childbirth Cord clamping and cord difficulties

Instructions for Use

Physiology of the Placenta, Cord, Amnion, and Chorion Attach the umbilical cord to the fetal model and put them both inside the amniotic sac. Use this to show the fetal and maternal sides of the placenta. It also demonstrates how the amniotic sac attaches across the surface of the fetal side and envelopes the fetus.

Obstetric Aspects of the Fetal Head Identify the sutures and fontanelles on the head of the fetal model. Explain how they are used to identify fetal position during childbirth. Flex the chin of the fetal model to its chest to show how this movement helps to present the smallest surface of the head as it moves through the birth canal during childbirth.

Pelvic Station Pick up the fetal model by the shoulders. Place the fetal head just above the inlet of the pelvic model. While holding a pencil at the level of the ischial spines (zero station), lower the fetal head indicating the ‐4, ‐3, ‐2, and ‐1 locations until the widest transverse diameter of the fetal head (biparietal diameter) is just below the level of the pencil/spines (engagement). Show further descent to the pelvic floor while describing the +1, +2, +3, and +4 (on the perineum).

Fetal Lie and Presentation Fetal lie refers to the long axis of the fetus as it relates to the mother’s pelvis. To demonstrate fetal lie, fold the legs of the fetal model up to its chest and hold it perpendicular to the inlet of the pelvic model. The fetal model can also be held in the transverse and oblique positions. Presentation is determined by the part of the fetus that first enters the pelvic inlet, and can be demonstrated with the fetal and pelvic models. A breech presentation, for example, can be demonstrated by having the buttocks enter first.

Fetal Position, Attitude, and Rotation Position refers to the direction in which the fetus is facing in the birth canal. All of the vertex positions can be demonstrated using the pelvic and fetal models. Attitude is the angle of the fetal head as it approaches the pelvic inlet. Holding the head in normal alignment with the trunk shows synclitism. Tilting the head of the fetal model to the left or right while holding the fetal model in the pelvic model can show asynclitism, either anterior or posterior. During childbirth, the fetal head turns, or rotates, within the birth canal to help it move more easily through the canal. Usually the head rotates so that it is facing the Basic EmONC Course


mother’s back and then rotates so that it is facing upward once the head is out and the shoulders are being delivered. Rotation can be demonstrated by rotating the fetal model while moving it through the pelvic model. The posterior position and the more extensive rotation required for childbirth can also be demonstrated the same way. This demonstration is useful to show that a fetal head in the posterior position does not fit easily under the pelvic arch.

Mechanisms and Maneuvers of Normal Childbirth Move the fetal model while a participant holds the pelvic model.

Engagement Hold the fetal model by the shoulders and let the head enter the pelvic model inlet in a left occiput transverse position. Put the other hand just below the level of the ischial spines and lower the head to “zero station.”

Descent Move the fetal model further into the pelvis. Tip the pelvis forward to show that the head is well into the pelvis. Then turn the shoulder to align it with the side‐to‐side pelvic inlet axis. Slightly rotate the head to the occiput anterior position (facing the mother’s back).

Flexion Using one hand, hold the fetal model at the hips. Place the other hand under the pelvic model so that the palm can represent the pelvic floor muscles. Allow the fetal head to touch this hand to show how the fetus will flex its chin to its chest.

Internal Rotation Turn the fetal head to complete its rotation to face the mother’s back.

Extension Reach into the pelvic inlet and put one hand under the trunk of the fetal model. Grasp the fetal head at the mouth or chin with the thumb and index finger. Apply pressure with the thumb to the chin to push it upward. This movement occurs during childbirth because the structure of the pelvic floor muscles combine with the mother pushing. As the fetal head extends upward, place the other hand over the head to represent the vaginal opening. Discuss episiotomies at this time, if appropriate. While pushing the head forward, open the other hand over the crown of the head (crowning). At this time, how to suction mucus or check for a cord around the newborn’s neck can be demonstrated.

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External Restitution (Rotation) Demonstrate how the shoulders, which are still in the birth canal, rotate to align vertically with the pelvic and vaginal outlets. Rotate the head to the side to realign it with the shoulders so that the head is facing the same direction that it was when it entered the pelvis.

Expulsion Remove the hand from the body of the fetal model and use both hands to “catch” the newborn. Support the head and pull gently downward to free the upper shoulder under the pubic bone. Pull upward to free the lower shoulder and let the whole newborn slide out of the pelvis. A full demonstration of vaginal breech childbirth can also be performed using the fetal and pelvic models.

Cord Difficulties By attaching the umbilical cord to the fetal model, it is possible to demonstrate how to unwrap the umbilical cord from around the newborn’s neck. Hold the placenta and sac under one arm and wrap the umbilical cord around the newborn’s neck. Then, deliver the newborn through the pelvic model. As the head reaches the pelvic outlet, show how to check for the cord and slip it over the head, if necessary. By allowing the cord to drop below the fetal head as it is delivered through the pelvic model, prolapsed cord can also be demonstrated.

NEWBORN RESUSCITATION MODEL This model is designed to assist in teaching the processes and skills needed to resuscitate a newborn using mouth‐to‐mouth resuscitation or a bag and a mask.

Contents of the Newborn Resuscitation Model The model includes the following: Item Quantity Newborn

1

Lungs (plastic bags)

3

Instructions for Use When the model is used for practicing mouth‐to‐mouth resuscitation, the plastic bag should be changed for each user. Replacement plastic bags are available in packages of 100.

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Airway Installation Fold the left side of the face shield end of the plastic bag toward the center of the bag (see figure below). Do the same for the right side. Insert the plastic bag through the mouth of the newborn. Tilt the head back and lay the plastic bag flat against the chest. Snap the chest overlay into place. Form the face shield to cover the newborn’s face from nose to chin.

A

B

A

B

B

Airway Removal First, unsnap the chest overlay from the shoulders and peel down. Then, pull the plastic bag through the face.

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BEING AN EFFECTIVE CLINICAL TRAINER Health professionals conducting clinical training courses are continually changing roles. They are trainers or instructors when presenting illustrated lectures and giving classroom demonstrations. They act as facilitators when conducting small group discussions and using role plays, case studies, and clinical simulations. Once they have demonstrated a clinical procedure, they then shift to the role of the coach as the participants begin practicing.

CHARACTERISTICS OF AN EFFECTIVE TRAINER AND COACH Coaching is a training technique in which the clinical trainer: • Describes the skills and client interactions that the participant is expected to learn. • Demonstrates (models) the skill in a clear and effective manner using learning aids such as visual aids, videotapes, and anatomic models. • Provides detailed, specific feedback to participants as they practice the skills and client interactions using the anatomic model and actual instruments in a simulated clinical setting and as they provide services to clients. An effective clinical trainer: • Is proficient in the skills to be taught. • Encourages participants in learning new skills. • Promotes two‐way communication. • Provides immediate feedback: - Informs participants whether they are meeting the objectives. - Does not allow a skill or activity to be performed incorrectly. - Gives positive feedback as often as possible. - Avoids negative feedback and instead offers specific suggestions for improvement. • Is able to receive feedback: - Asks for it. Find clinical trainers who will be direct with you. Ask them to be specific and descriptive. - Directs it. If you need information to answer a question or pursue a learning goal, ask for it. - Accepts it. Do not defend or justify your behavior. Listen to what people have to say and thank them. Use what is helpful; quietly discard the rest. • Recognizes that training can be stressful and knows how to regulate participant as well as trainer stress: - Uses appropriate humor. - Observes participants and watches for signs of stress. - Provides regular breaks. - Provides for changes in the training routine. - Focuses on participant success as opposed to failure. Basic EmONC Course


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The characteristics of an effective coach are the same as those of an effective clinical trainer. Additional characteristics especially important for the coach include: - Being patient and supportive. - Providing praise and positive reinforcement. - Correcting participant errors while maintaining participant self‐esteem. - Listening and observing.

SKILLS TRANSFER AND ASSESSMENT: THE COACHING PROCESS

The process of learning a clinical skill within the coaching process has three basic phases: demonstration, practice, and evaluation. These three phases can be broken down further into the following steps:

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First, during interactive classroom presentations, explaining the skill or activity to be learned.

•

Next, using a videotape (if available) showing the skill or activity to be learned. Following this, demonstrating the skill or activity using an anatomic model (if appropriate), role play (e.g., counseling demonstration), or clinical simulation. Then, allowing the participants to practice the demonstrated skill or activity with an anatomic model or in a simulated environment (e.g., role play, clinical simulation) as the trainer functions as a coach.

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•

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•

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After this, reviewing the practice session and giving constructive feedback. After adequate practice, assessing each participant’s performance of the skill or activity on models or in a simulated situation, using the competency‐ based checklist. After competence is gained with models or practice in a simulated situation, having participants begin to practice the skill or activity with clients under a clinical trainer’s guidance. Finally, evaluating the participant’s ability to perform the skill according to the standardized procedure as outlined in the competency‐based checklist. During initial skill acquisition, the trainer demonstrates the skill as the participant observes. As the participant practices the skill, the trainer functions as a coach and observes and assesses performance. When demonstrating skill competency, the participant is now the person performing the skill as the trainer evaluates performance.

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CREATING A POSITIVE LEARNING ENVIRONMENT A successful training course does not come about by accident, but rather through careful planning. This planning takes thought, time, preparation, and often some study on the part of the clinical trainer. The trainer is responsible for ensuring that the course is carried out essentially as it was designed. The trainer must make sure that the clinical practice sessions, which are an integral part of a clinical skills course, as well as the classroom sessions, are conducted appropriately. In addition to taking responsibility for the organization of the course in general, the trainer must also be able to give presentations and demonstrations and lead other course activities, all of which require prior planning. Well‐planned and executed classroom and clinical sessions will help to create a positive learning environment.

PREPARING FOR THE COURSE To prepare for the course, the following steps are recommended: Review the course syllabus, including the course description, goals, learning methods, training materials, methods of evaluation, course duration, and suggested course composition. Review the course schedule. Study the course outline. The course outline provides detailed suggestions regarding the teaching of each objective and the facilitation of each activity. Based on suggestions in the course outline and the trainer’s own ideas, the trainer will gather the necessary equipment, supplies, and materials. The trainer should also ensure that sufficient time has been allotted for all sessions and activities. Read and study the reference manual to ensure complete familiarity with the content to be presented during the course. Review the pre‐ and mid‐course questionnaires and make copies of the questionnaires, matrix, and answer sheets if needed. Check all audiovisual equipment (e.g., overhead projector, LCD, video player, flip chart stand). Check all anatomic models (e.g., are they clean and in good condition? are all parts in place?). Practice all clinical procedures using the anatomic model(s) and the checklists found in the participant’s handbook. Obtain information about the participants who will be attending the course. It is important for the clinical trainer to know basic information about participants such as: • The experience and educational background of the participants. The clinical Basic EmONC Course


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trainer should attempt to gather as much information about participants as possible before training (e.g., by reviewing their Confidential Clinical Experience Questionnaire). If this is not possible, the trainer should inquire about their backgrounds and expectations during the first day of the course. The types of clinical activities the participants will perform in their daily work after training. Knowing the exact nature of the work that participants will perform after training is critical for the clinical trainer. The trainer must use appropriate, job‐specific examples throughout the course so that participants can draw connections between what is being taught and what they will need to do. This is an excellent way to reinforce the importance of what is being learned.

Prepare the classroom and make sure that: • Tables are arranged in a U‐shape or other formation that will allow as many of the participants as possible to see one another and the trainer. • A table is in the front of the room where the trainers can place their course materials. • Space is available for audiovisual equipment (e.g., flip chart, screen, overhead projector, video player, monitor); the trainer should make sure that participants will be able to see the projection screen and other audiovisuals. • Space is available for participants to work in small groups (i.e., either arrange chairs in small circles or work around the tables), unless separate breakout rooms (see below) are available. • Space is available to set up simulated clinics (e.g., for activities with anatomic models or counseling practice). • Breakout rooms for small group work (e.g., case studies, role plays, clinical simulations, problem‐solving activities) are available if necessary, and are set up with tables, chairs and any materials that the participants will need. • The room is properly heated or cooled and ventilated. • The lighting is adequate, and the room can be darkened enough to show audiovisuals and still permit participants to take notes or follow along in their learning materials. • There will be adequate electric power throughout the course, and contingency plans have been made in case the power fails. • Furniture such as tables, chairs, and desks is available. The chairs are comfortable and tablecloths are available. • There is a writing board with chalk or marking pens, as well as an information board available for posting notes and messages for participants. Basic EmONC Course


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There is audiovisual equipment in working order, with spare parts such as bulbs readily available. The video monitor or screen is large enough so that all participants can see it well. There are sufficient electrical connections, and extension cords, electrical adaptors, and power strips (multi‐plugs) are available, if necessary. There are toilet facilities that are adequately maintained. The rooms are safe and secure.

USING EFFECTIVE PRESENTATION SKILLS It is also important to use effective presentation skills. Establishing and maintaining a positive learning climate during training depends on how the clinical trainer delivers information because the trainer sets the tone for the course. In any course, how something is said may be just as important as what is said. Some common techniques for effective presentations are listed below: Follow a plan and use trainer’s notes, which include the session objectives, introduction, body, activity, audiovisual reminders, summary, and evaluation. Communicate in a way that is easy to understand. Many participants will be unfamiliar with the terms, jargon, and acronyms of a new subject. The clinical trainer should use familiar words and expressions, explain new language, and attempt to relate to the participants during the presentation. Maintain eye contact with participants. Use eye contact to “read” faces. This is an excellent technique for establishing rapport and getting feedback on how well participants understand the content. Project your voice so that those in the back of the room can hear clearly. Vary volume, voice pitch, tone, and inflection to maintain participants’ attention. Avoid using a monotone voice, which is guaranteed to put participants to sleep! Avoid the use of slang or repetitive words, phrases, or gestures that may become distracting with extended use. Display enthusiasm about the topic and its importance. Smile, move with energy and interact with participants. The trainer’s enthusiasm and excitement are contagious and directly affect the morale of the participants. Move around the room. Moving around the room helps ensure that the trainer is close to each participant at some time during the session. Participants are encouraged to interact when the clinical trainer moves toward them and maintains eye contact. Use appropriate audiovisual aids during the presentation to reinforce key content or help simplify complex concepts. Basic EmONC Course


Be sure to ask both simple and more challenging questions. Provide positive feedback to participants during the presentation. Use participants’ names as often as possible. This will foster a positive learning climate and help keep the participants focused on the presenter. Display a positive use of humor related to the topic (e.g., humorous stories, cartoons on transparency or flip chart). Provide smooth transitions between topics. Within a given presentation, a number of separate yet related topics may be discussed. When shifts between topics are abrupt, participants may become confused and lose sight of how the different topics fit together in the bigger picture. Before moving on to the next topic, the clinical trainer can ensure that the transition from one topic to the next is smooth by: • Providing a brief summary, • Asking a series of questions, • Relating content to practice, or • Using an application exercise (case study, role play, etc.). Be an effective role model. The clinical trainer should be a positive role model in appearance (appropriate dress) and attitude (enthusiasm for the course), and by beginning and ending the session at the scheduled times.

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CONDUCTING LEARNING ACTIVITIES Every training session should begin with an introduction to capture participant interest and prepare the participant for learning. After the introduction, the clinical trainer may deliver content using an illustrated lecture, demonstration, small group activity or other learning activity. Throughout the presentation, questioning techniques can be used to encourage interaction and maintain participant interest. Finally, the clinical trainer should conclude the presentation with a summary of the key points or steps.

DELIVERING INTERACTIVE PRESENTATIONS

Introducing Presentations The first few minutes of any presentation are critical. Participants may be thinking about other matters, wondering what the session will be like, or have little interest in the topic. The introduction should: • Capture the interest of the entire group and prepare participants for the information to follow. • Make participants aware of the trainer’s expectations. • Help foster a positive learning climate. The clinical trainer can select from a number of techniques to provide variety and ensure that participants are not bored. Many introductory techniques are available, including: • Reviewing the session objectives. Introducing the topic by a simple restatement of the objectives keeps the participant aware of what is expected of her/him. • Asking a series of questions about the topic. The effective clinical trainer will recognize when participants have prior knowledge concerning the course content and encourage their contributions. The trainer can ask a few key questions, allow participants to respond, discuss answers and comments, and then move into the body of the presentation. • Relating the topic to previously covered content. When a number of sessions are required to cover one subject, relate each session to previously covered content. This ensures that participants understand the continuity of the sessions and how each relates to the overall topic. Where possible, link topics so that the concluding review or summary of one presentation can introduce the next topic. • Sharing a personal experience. There are times when the clinical trainer can share a personal experience to create interest, emphasize a point or make a topic more job‐related. Participants enjoy hearing these stories as long as they relate to the topic and are used only when appropriate. Basic EmONC Course


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Relating the topic to real‐life experiences. Many training topics can be related to situations most participants have experienced. This technique not only catches the participants’ attention, but also facilitates learning because people learn best by “anchoring” new information to known material.

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Using a case study, clinical simulation, or other problem‐solving activity. Problem‐solving activities focus attention on a specific situation related to the training topic. Working in small groups generally increases interest in the topic.

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Using a videotape or other audiovisual aid. Use of appropriate audiovisuals can be stimulating and generate interest in a topic.

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Giving a classroom demonstration. Most clinical training courses involve equipment, instruments, and techniques that lend themselves to demonstrations, which generally increase participant interest.

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Using a game, role play, or simulation. Games, role plays, and simulations generate tremendous interest through direct participant involvement and therefore are useful for introducing topics.

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Relating the topic to future work experiences. Participants’ interest in a topic will increase when they see a relationship between training and their work. The clinical trainer can capitalize on this by relating objectives, content, and activities of the course to real work situations.

Using Questioning Techniques Questions can be used at anytime to: • Introduce a topic • Increase the effectiveness of the illustrated lecture • Promote brainstorming • Supplement the discussion process Use a variety of questioning techniques to maintain interest and avoid a repetitive style: •

Ask a question of the entire group. The advantage of this technique is that those who wish to volunteer may do so; however, some participants may dominate while others may not participate.

•

Target the question to a specific participant by using her/his name prior to asking the question. The participant is aware that a question is coming, can concentrate on the question, and respond accordingly. The disadvantage is that once a specific participant is targeted, other participants may not concentrate on the question.

•

State the question, pause, and then direct the question to a specific participant. All participants must listen to the question in the event that

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they are asked to respond. The primary disadvantage is that the participant receiving the question may be caught off guard and have to ask the trainer to repeat the question. The key in asking questions is to avoid a pattern. The skilled clinical trainer uses all three of the above techniques to provide variety and maintain the participants’ attention. Other questioning techniques: • Use participants’ names during questioning. This is a powerful motivator and also helps ensure that all participants are involved. • Repeat a participant’s correct response. This provides positive reinforcement to the participant and ensures that the rest of the group heard the response. • Provide positive reinforcement for correct responses to keep the participant involved in the topic. Positive reinforcement may take the form of praise, displaying a participant’s work, using a participant as an assistant or using positive facial expressions, nods, or other nonverbal actions. • When a participant’s response is partially correct, the clinical trainer should reward the correct portion and then improve the incorrect portion or redirect a related question to that participant or to another participant. • When a participant’s response is incorrect, the clinical trainer should make a noncritical response and restate the question to lead the participant to the correct response. • When a participant makes no attempt to respond, the clinical trainer may wish to follow the above procedure or redirect the question to another participant. Come back to the first participant after receiving the desired response and involve her/him in the discussion. • When participants ask questions, the clinical trainer must determine an appropriate response by drawing upon personal experience and weighing the individual’s needs against those of the group. If the question addresses a topic that is relevant but has not been previously discussed, the clinical trainer can either: - Answer the question and move on, or - Respond with another question, thereby beginning a discussion about the topic.

Summarizing Presentations A summary is used to reinforce the content of a presentation and provide a review of its main points. The summary should: • Be brief Basic EmONC Course


• •

Draw together the main points Involve the participants

Many summary techniques are available to the clinical trainer: Asking the participants for questions gives participants an opportunity to clarify their understanding of the instructional content. This may result in a lively discussion focusing on those areas that seem to be the most troublesome. Asking the participants questions that focus on major points of the presentation. Administering a practice exercise or test gives participants an opportunity to demonstrate their understanding of the material. After the exercise or test, use the questions as the basis for a discussion by asking for correct answers and explaining why each answer is correct. Using a game to review main points provides some variety, when time permits. One popular game is to divide participants into two teams, give each team time to develop review questions, and then allow each team to ask questions of the other. The clinical trainer serves as moderator by judging the acceptability of questions, clarifying answers and keeping a record of team scores. This game can be highly motivational and serve as an excellent summary at the same time.

FACILITATING GROUP DISCUSSIONS The group discussion is a learning method in which most of the ideas, thoughts, questions, and answers are developed by the participants. The clinical trainer typically serves as the facilitator and guides the participants as the discussion develops. Group discussion is useful: • At the conclusion of a presentation • After viewing a videotape • Following a clinical demonstration or skills practice session • After reviewing a case study or clinical simulation • After a role play • Any other time when participants have prior knowledge or experience related to the topic The facilitator must consider a number of factors when selecting group discussion as the learning strategy: • Discussions involving more than 15 to 20 participants may be difficult to lead and may not give each participant an opportunity to participate. • Discussion requires more time than an illustrated lecture because of extensive interaction among the participants.

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•

A poorly directed discussion may move off target and never reach the objectives established by the facilitator.

•

If control is not maintained, a few participants may dominate the discussion while others lose interest.

•

In addition to a group discussion that focuses on the session objectives, there are two other types of discussions that may be used in a training situation:

•

General discussion that addresses participant questions about a learning event (e.g., why one type of episiotomy is preferred over another)

•

Panel discussion in which a moderator conducts a question and answer session between panel members and participants

Follow these key points to ensure successful group discussion: Arrange seating to encourage interaction (e.g., tables and chairs set up in a U‐shape or a square or circle so that participants face each other). State the topic as part of the introduction. Shift the conversation from the facilitator to the participants. Act as a referee and intercede only when necessary. Example: “It is obvious that Ismail and Friba are taking two sides in this discussion. Mirwais, let me see if I can clarify your position. You seem to feel that....” Summarize the key points of the discussion periodically. Example: “Let’s stop here for a minute and summarize the main points of our discussion.” Ensure that the discussion stays on the topic. Use the contributions of each participant and provide positive reinforcement. Example: “That is an excellent point, Homaira. Thank you for sharing that with the group.” Minimize arguments among participants. Encourage all participants to get involved. Ensure that no one participant dominates the discussion. Conclude the discussion with a summary of the main ideas. The facilitator must relate the summary to the objective presented during the introduction.

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FACILITATING A BRAINSTORMING SESSION Brainstorming is a learning strategy that stimulates thought and creativity and is often used in conjunction with group discussions. The primary purpose of brainstorming is to generate a list of ideas, thoughts, or alternative solutions that focus on a specific topic or problem. This list may be used as the introduction to a topic or form the basis of a group discussion. Brainstorming requires that participants have some background related to the topic. The following guidelines will facilitate the use of brainstorming: • Establish ground rules. Example: “During this brainstorming session we will be following two basic rules. All ideas will be accepted and Ismail will write them on the flip chart. Also, at no time will we discuss or criticize any idea. Later, after we have our list of suggestions, we will go back and discuss each one. Are there any questions? If not….” • Announce the topic or problem. Example: “During the next few minutes we will be brainstorming and will follow our usual rules. Our topic today is ‘Evidence‐based indications for episiotomy.’ I would like each of you to think of at least one indication. Friba will write these on the board so that we can discuss them later. Who would like to be first? Yes, Ajmal….” • Maintain a written record of the ideas and suggestions on a flip chart or writing board. This will prevent repetition and keep participants focused on the topic. In addition, this written record is useful when it is time to discuss each item. • Involve the participants and provide positive feedback to encourage more input. • Review written ideas and suggestions periodically to stimulate additional ideas. • Conclude brainstorming by reviewing all of the suggestions and clarifying those that are acceptable.

FACILITATING SMALL GROUP ACTIVITIES There are many times during training that the participants will be divided into several small groups, which usually consist of four to six participants. Examples of small group activities include: • Reacting to a case study, which may be presented in writing, orally, or introduced through videotape. Basic EmONC Course


•

Preparing a role play within the small group and presenting it to the entire group as a whole.

•

Dealing with a clinical situation/scenario, such as in a clinical simulation, that has been presented by the clinical trainer or another participant.

•

Practicing a skill that has been demonstrated by the clinical trainer using anatomic models.

Small group activities offer many advantages including: • Providing participants an opportunity to learn from each other. • Involving all participants; creating a sense of teamwork among members. • Providing for a variety of viewpoints: When small group activities are being conducted, it is important that participants are not in the same group every time. Different ways the clinical trainer can create small groups include: • Assigning participants to groups. • Asking participants to count off “1, 2, 3,” etc. and having all the “1s” meet together, all the “2s” meet together, etc. • Asking participants to form their own groups. • Asking participants to draw a group number (or group name). The room(s) used for small group activities should be large enough to allow different arrangements of tables, chairs, and teaching aids (models, equipment) so that individual groups can work without disturbing one another. The clinical trainer should be able to move easily about the room to visit each group. If available, consider using smaller rooms near the primary training room where small groups can go to work. Activities assigned to small groups should be challenging, interesting, and relevant; should require only a short time to complete; and should be appropriate for the background of the participants. Each small group may be working on the same activity or each group may be taking on a different problem, case study, clinical simulation, or role play. Regardless of the type of activity, there is usually a time limit. When this is the case, inform groups when there are five minutes left and when their time is up. Instructions to the groups may be presented: • In a handout • On a flip chart • On a transparency • Verbally by the clinical trainer Basic EmONC Course


Instructions for small group activities typically include: • Directions • Time limit • A situation or problem to discuss, resolve, or role play • Participant roles (if a role play) • Questions for a group discussion Once the groups have completed their activity, the clinical training facilitator will bring them together as a large group for a discussion of the activity. This discussion might involve: • Reports from each group • Responses to questions • Role plays developed in each group and presented by participants in the small groups • Recommendations from each group • Discussion of the experience (if a clinical simulation) It is important that the clinical trainer provide an effective summary discussion following small group activities. This provides closure and ensures that participants understand the point of the activity.

CONDUCTING AN EFFECTIVE CLINICAL DEMONSTRATION When introducing a new clinical skill, a variety of methods can be used to demonstrate the procedure. For example: • Show slides or a videotape in which the steps and their sequence are demonstrated in accordance with the accepted performance standards. • Use anatomic models such as the childbirth simulator to demonstrate the procedure and skills. • Perform role plays in which a participant or surrogate client simulates a client and responds much as a real client would. • Demonstrate the procedure with clients in the clinical setting (clinic or hospital). • Whatever methods are used to demonstrate the procedure, the clinical trainer should set up the activities using the “whole‐part‐whole” approach. • Demonstrate the whole procedure from beginning to end to give the participant a visual image of the entire procedure or activity. • Isolate or break down the procedure into activities (e.g., pre‐operative counseling, getting the client ready, pre‐operative tasks, performing the procedure, etc.) and allow practice of the individual activities of the procedure.

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•

Demonstrate the whole procedure again and then allow participants to practice the procedure from beginning to end.

When planning and giving a demonstration of a clinical procedure, either using anatomic models or with clients, if appropriate, the clinical trainer should use the following guidelines: • Before beginning, state the objectives of the demonstration and point out what the participants should do (e.g., interrupt with questions, observe carefully, etc.). • Make sure that everyone can see the steps involved. • Never demonstrate the skill or activity incorrectly; Demonstrate the procedure in as realistic a manner as possible • Include all steps of the procedure in the proper sequence according to the approved performance standards. • During the demonstration, explain to participants what is being done, especially any difficult or hard‐to‐observe steps. • Ask questions of participants to keep them involved. - Example: “What should I do next?” “What would happen if...?” •

Encourage questions and suggestions.

•

Take enough time so that each step can be observed and understood. Remember that the objective of the demonstration is learning the skills, not for the clinical trainer to show her/his dexterity and speed.

•

Use equipment and instruments properly and make sure participants clearly see how they are handled.

In addition, participants should use a clinical skills checklist developed specifically for the clinical procedure to observe the clinical trainer’s performance during the initial demonstration. Doing this: • Familiarizes the participant with the use of competency‐based checklists. • Reinforces the standard way of performing the procedure. • Communicates to participants that the clinical trainer, although very experienced, is not absolutely perfect and can accept constructive feedback on her/his performance. The clinical trainer must practice what s/he demonstrates (i.e., the approved standard method as detailed in the checklist). During the demonstration, the clinical

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trainer should provide supportive behavior and cordial, effective communication with the client and staff to reinforce the desired outcome.

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USING CHECKLISTS The checklists for obstetric and newborn care procedures are used by the clinical trainer to evaluate each participant’s performance in performing the procedures with women. These checklists are derived from the information provided in the reference manual(s) and focus on the key steps in the entire process. Criteria for satisfactory performance by the participant are based on the knowledge, attitudes, and skills set forth in the checklists. Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step or task not performed by participant during evaluation by trainer Evaluation of the counseling skills of each participant may be done with women. It may, however, also be accomplished through observation during role plays with volunteers or women in real situations at any time during the course. Evaluation of clinical skills usually will be done during the last days of the course (depending on class size and client caseload). In a participant’s first few cases, it is not mandatory (or even possible) for the trainer to observe the participant perform a procedure from beginning to end. What is important is that each participant demonstrates the steps or tasks at least once for feedback and coaching prior to the final evaluation. (If a step or task is not done correctly, the participant should repeat the entire skill or activity sequence, not just the incorrect step.) In addition, it is recommended that the clinical trainer not stop the participant at the incorrect step unless the safety of the woman is at stake. If it is not, the clinical trainer should allow her/him to finish the skill/activity before providing coaching and feedback on her/his overall performance. In determining whether the participant is qualified, the clinical trainer(s) will observe and rate the participant’s performance on each step of a skill or activity. The participant must be rated “Satisfactory” for each skill/activity group covered in the checklist in order to be evaluated as qualified. Finally, during the course, it is the clinical trainer’s responsibility to observe each participant’s overall performance in performing obstetric and newborn care procedures. Only by doing this can the clinical trainer assess the way the participant uses what s/he has learned (e.g., her/his attitude toward women). This provides a key opportunity to observe the impact of the participant’s attitude on women—a critical component of quality service delivery.

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Qualification The number of procedures each participant needs to observe, assist with, and perform will vary depending on her/his previous training and experience as well as how the current training is being conducted (e.g., are models being used for initial skill acquisition). The number of clinical cases needed must be assessed on an individual basis; there is no “magic number” of cases that automatically makes a person qualified to perform obstetric and newborn care procedures. When anatomic models are used for initial skill acquisition, nearly all participants will be judged to be competent after only two to four cases. Proficiency, however, invariably requires additional practice and each participant may need to perform obstetric and newborn care procedures on at least 2–5 women in order to “feel confident” about her/his skills. The goal of this training is to enable every participant to achieve competency (i.e., be qualified to perform essential obstetric care procedures). Therefore, if additional practice in, for example, manual vacuum aspiration is needed, sufficient extra cases should be allocated during the course to ensure that the participant is qualified. Finally on successful completion of the course each participant should have the opportunity to apply her/his new knowledge and skills as soon as possible. Failure to do so quickly leads to loss of provider confidence and ultimately loss of competence.

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MANAGING CLINICAL PRACTICE Getting the most out of clinical practice requires that the trainer be well‐acquainted with the clinical practice sites. Being familiar with the health care facility before training begins allows the trainer to develop a relationship with the staff, overcome any inadequacies in the situation, and prepare for the best possible learning experience for participants. Even the best planning, however, is not always enough to ensure a successful clinical practice experience. In the classroom, the trainer is able to control the schedule and activities to a large extent; whereas in the clinic, the trainer must always be alert to unplanned learning opportunities that may arise at any time, and be ready to modify the schedule accordingly.

PERFORMING CLINICAL PROCEDURES WITH CLIENTS The final stage of clinical skill development involves practicing procedures with clients. Anatomic models, no matter how realistic, cannot substitute entirely for the reality of performing the procedure with a living, breathing, feeling, and reacting human being. The disadvantages of using real clients during clinical skills training are obvious. Clients may be subjected to increased discomfort or even increased risk of complications when procedures are performed by unskilled clinicians. Therefore, when possible and appropriate, participants should be allowed to work with clients only after they have demonstrated skill competency on an anatomic model or in a simulated situation. The rights of clients should be considered at all times during a clinical training course. The following practices will help ensure that clients’ rights are routinely protected during clinical training: The confidentiality of any client information obtained during counseling, history taking, physical examinations or procedures must be strictly observed. Clients should be reassured of this confidentiality. When receiving counseling, undergoing a physical examination or receiving maternal and neonatal health services, the client should be informed about the role of each person involved (e.g., clinical trainers, individuals undergoing training, support staff, researchers). The client’s permission should be obtained before having a clinician‐in‐ training observe, assist with or perform any procedures. Understanding the right to refuse care from a clinician‐in‐training is important for every client. Furthermore, care should not be rescheduled or denied if the client does not permit a clinician‐in‐training to be present or provide services. In such cases, the clinical trainer or other staff member should perform the procedure. The clinical trainer should be present during any client contact in a training situation and the client should be made aware of the trainer’s role. Furthermore, the clinical trainer should be ready to intervene if the client’s safety is in jeopardy or if the client is experiencing severe discomfort.

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The trainer must be careful how coaching and feedback are given during practice with clients. Corrective feedback in the presence of a client should be limited to errors that could harm or cause discomfort to the client. Excessive negative feedback can create anxiety for both the client and the clinician‐in‐training. Clients should be chosen carefully to ensure that they are appropriate for clinical training purposes. For example, participants should not practice with “difficult” clients until they are proficient in performing the procedure.

CREATING OPPORTUNITIES FOR LEARNING

Planning for Learning The clinical trainer should develop a plan for each day spent in the health care facility. The plan will provide a daily focus that is consistent with the learning objectives and help to ensure that all required skills will be adequately addressed. When preparing the plan, the trainer should consider the following points: Clinical practice should progress from basic to more complex skills. This not only helps ensure the safety and quality of care provided by participants, but also allows them to gain self‐confidence as they demonstrate competency in the basic skills. There may be more participants than can be accommodated comfortably in one area of the health care facility at the same time. Generally, three or four participants are the most that a specific area of a facility can absorb without affecting service delivery. If there are more, the trainer should plan a rotation system that allows each participant to have equal time and opportunity in each clinical area. Some clinical experiences, such as obstetrical emergencies (e.g., eclampsia, postpartum hemorrhage, obstructed labor), cannot be planned or predicted. Before each day’s practice, the trainer should ask the staff to notify him/her of any clients that may be of particular interest, so that participants can be assigned to work with them. In addition to daily practice of specific clinical skills, the trainer’s plan should include other areas of focus such as infection prevention, facility logistics or client flow. Although these topics may not be directly assessed with a checklist or other competency‐based assessment tool, they play an important role in the provision of high‐quality maternal and neonatal health services. Inevitably there will be times when there are few or no clients in the facility. The trainer should have ready additional activities for the participants such as case studies and role plays.

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In the Health Care Facility As has been mentioned, planning alone is not sufficient to guarantee a successful clinical practice. There are several key strategies that a clinical trainer can use in the health care facility to increase the likelihood of success. The trainer must actively monitor the skills each participant is able to practice, and with what frequency, so that each participant has adequate opportunities to develop competency. A participant who demonstrates competency in performing a cesarean section operation or in administering spinal anesthesia should not be assigned additional patients requiring this operation or procedure until other participants have had an opportunity to develop such competency. It is essential that the trainer be flexible and constantly alert to learning opportunities as they arise. This requires knowing about the health care facility— how it is set up and functions, the client population, etc.—as well as having a good working relationship with the staff. The trainer will need to rely on staff cooperation in notifying her/him of unique or unusual clients and allowing participants to provide services to these clients. This relationship is most easily established beforehand, during site preparation and other visits made by the trainer. The participants also should be encouraged to watch for such learning opportunities. The trainer may then decide which, and how many, of the participants will be assigned to a particular client. The trainer and participants should remember that clinical experiences need to be shared equally. Therefore, the participant who identifies a case may not be assigned to it if this participant has had a similar case before. It is not appropriate to subject the client to a procedure multiple times simply so that all participants can practice a skill. To take advantage of opportunities as they occur, the trainer may modify the plan for that day and subsequent days, but with as little disruption as possible to the provision of services. Participants should be notified of any changes as soon as possible so that they can be well‐prepared for each clinical day. Rarely will all participants have the opportunity to work with all types of clients. The clinical trainer will need to supplement, with case studies and role plays, the work done with clients. The trainer should rapidly identify important but rare events or conditions, such as severe pre‐eclampsia, and prepare activities in advance. Actual cases seen in the health care facility may also serve as the basis for such activities.

CONDUCTING PRE‐ AND POST‐CLINICAL PRACTICE MEETINGS Although every health care facility will not have a meeting room, the clinical trainer must make every effort to find a space that: •

Allows free discussion, small group work, and practice on models.

•

Is away from the client care area if possible, so as to not interfere with efficient client care or other staff duties.

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Pre‐Clinical Practice Meetings The trainer and participants should meet at the beginning of each clinical practice session. The meeting should be brief. Items to be covered include: • The learning objectives for that day • Any scheduling changes that may be needed • Participants’ roles and responsibilities for that day, including the work assignments and rotation schedule if applicable • Special assignments to be completed that day • The topic for the post‐clinical practice meeting, so that the participants can take special note of anything happening during the day that would contribute to the discussion • Questions related to that day’s activities or from previous days if they can be answered concisely; if not, they should be deferred until the post‐clinical practice meeting

Post‐Clinical Practice Meetings The clinical trainer should end each clinical day with a meeting to review the day’s events and build on them as learning experiences. A minimum of one hour is recommended. These meetings are used to: • Review the day’s learning objectives and assess progress toward their completion • Present cases seen that day, particularly those that were interesting, unusual, or difficult • Respond to clinical questions concerning situations and clients in the health care facility or information in the reference manual • Plan for the next clinical session, making changes in the schedule as necessary • Conduct additional practice with models if needed • Review and discuss case studies, role plays, or assignments that have been prepared in advance by the participants. Topics for case studies, role plays, and assignments include: - Quality of care - Clinical services provided - Barriers to providing high‐quality services Basic EmONC Course


- Recommended follow‐up

THE TRAINER AS SUPERVISOR In the role of supervisor, the trainer must monitor participant activities in the health care facility so that: • Each participant receives appropriate and adequate opportunities for skill practice • Participants do not disrupt the efficient provision of services within the facility or interfere with staff and their duties • The care provided by each participant does not harm clients or place them in an unsafe situation The trainer must always be with participants when they are working with clients, especially when they are performing clinical procedures. Trainers may have more than one or two participants to supervise. Because the trainer cannot be with all of them at the same time, other methods of supervision must be used: • Participants must understand what they can do independently and what requires trainer supervision, so that they can keep busy when the trainer is involved with another participant. Participants should be made responsible for ensuring that they are supervised when necessary. The trainer, however, still holds the ultimate responsibility. • Additional activities that require no direct supervision will give participants the opportunity to be actively engaged in learning when they are not with clients. • Clinical staff also can act as supervisors if the trainer is confident of their clinical skills and ability to provide appropriate feedback. The possibility of having clinical staff supervise participants is another reason why the trainer should get to know the staff before the training begins. During clinical site preparation, the trainer can observe the skills of the staff members, and verify that they are competent, if not proficient, service providers. The trainer may also have the opportunity to assess their coaching skills. There may even be time to work with staff members to improve their skills so that they can serve as role models and support participant learning. • The more participants there are in the facility, the more the trainer relies upon the staff also to act as trainers. Nevertheless, the ultimate responsibility for each participant, including that of final assessment of skill competency, is the trainer’s. For this reason, if multiple clinical sites are used during a course, a trainer must be assigned to each site. • Because clinical staff usually are not involved in the classroom portion of a course, they do not have an opportunity to get to know the participants and their abilities before they arrive at the facility. Therefore, it is a good idea to Basic EmONC Course


share such information with the clinical staff whenever they will have to take over a large part of the participant supervision. Clinical staff should also be encouraged to do an initial assessment of participants’ skills before allowing them to work with clients so that they can feel confident that the participants are well‐prepared. Clinical staff should also be aware of the feedback the trainer would like to receive from them about participants. For example: • Will it be oral, written or both? • How frequently will feedback be provided? Daily? Weekly? Only at the end of training? When designing the feedback system, the trainer should keep in mind the time required to prepare and provide feedback. This will be extra work for the clinical staff who already have a very busy schedule. It is best to keep the system as simple and easy to use as possible.

THE TRAINER AS COACH DURING CLINICAL PRACTICE One of the most difficult tasks for the trainer, and one with which even experienced trainers struggle, is to be a good coach and provide feedback in the clinical setting. No matter how comfortable a trainer may be in giving feedback in the classroom or while working with models, the situation changes in the facility. The clients, staff, and other participants are nearby and the emergency services need to keep running smoothly and efficiently. The trainer often feels pressured to keep things moving because other clients need to be seen and the trainer needs to be available to all the participants. Spending “too much time” with any one client or participant has an impact on everyone.

Feedback Sessions The feedback sessions before and after practice are often skipped in an effort to save time. These sessions, however, are very important for the continued development of the participant’s psycho‐motor or decision‐making skills. Without adequate feedback and coaching, the participant may miss an important learning opportunity and take longer to achieve competency. Keep in mind that by this time the participant has already demonstrated competency on a model and may not need extensive feedback. To minimize disruption of services, the pre‐ and post‐ practice feedback sessions can take place in just a few minutes in a location away from the client care areas. The structure of the feedback session is essentially the same regardless of whether the session takes place before or after practice, and whether it is for a participant’s performance with models or with clients: • The participant should first identify personal strengths and the areas where improvement is needed. • Next, the trainer should provide specific, descriptive feedback that includes Basic EmONC Course


suggestions of not only what, but also how, to improve. •

Finally, the participant and the trainer should agree on what will be the focus of the practice session, including how they will interact while they are with the client. For example, they may agree that if the trainer places a hand on the participant’s shoulder, it is a signal to stop and wait for further instructions.

The feedback session before practice should be given before entering the room to work with the client. The feedback session after practice can be delayed until the client’s care has been completed or the client is in stable condition so that continuous care is no longer needed. The trainer should try not to delay feedback any longer than necessary. Feedback is always more effective when given as soon after care as possible. This will also allow the participant to use the feedback with the next client for whom services are provided, if appropriate.

Feedback during a Procedure Be sure the client knows that the participant, although already a service provider, is also a learner. Reassure the client that the participant has had extensive practice and mastered the skill on models. The client should expect to hear the trainer talk to the participant and understand that it does not mean that something is wrong. Finally, the client should clearly understand that the trainer is a proficient service provider and is there to ensure that the procedure is completed safely and without delay.

Positive Feedback Positive feedback is often easy to give and can be provided in the presence of the client. Trainers often think that hearing feedback, even positive feedback, will disturb the client. Many clients, however, find it comforting to hear the service provider being given positive feedback. Keep the feedback restrained and low‐key; overly exuberant praise can be as worrisome to the client as hearing negative comments. Too much praise may cause the client to wonder, “What is being hidden?” “Why is it so surprising that this person is doing a good job?” Positive feedback can be conveyed by facial expression and tone of voice rather than words, and still be highly effective. At the same time, the absence of feedback of any kind can be disturbing to the participant. By this phase of skill development the participant is expected to do a good job even with the first client, and is accustomed to hearing positive comments. Therefore, to maintain the participant’s confidence, it is still important to give positive feedback.

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Corrective Feedback Corrective feedback is difficult to give under any circumstances, but particularly when a client is present. It is important to keep such feedback low‐key and restrained. There are a number of techniques that will make it easier. Often a look or hand gesture (e.g., a touch on the shoulder) can be as effective as words and less worrisome to the client. Simple suggestions to facilitate the procedure can be made in a quiet, direct manner. Do not go into lengthy explanations of why you are making the suggestion or offering an observation—save that for the post‐practice feedback session. To help a participant avoid making a mistake, the trainer can calmly ask a simple, straightforward question about the procedure itself. If a step in a procedure is about to be missed, for example, asking the participant to name the next step before doing anything further could help avoid an error. This is not the time to ask hypothetical questions about potential side effects and complications, as this may distract the participant and alarm the client. Sometimes, even though they have had extensive practice on models, participants make mistakes that can potentially harm the client. In these instances, the trainer must be prepared to step in and take over the procedure at a moment’s notice. This should be done calmly and with complete control to avoid unnecessarily alarming the client.

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BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE COURSE OUTLINE Include a 15 minute break during the morning and afternoon each day.

DAY 1 OBJECTIVES: By the end of Day 1, the participant/student will be able to: 1. Identify co‐participants and trainers. 2. Outline the training program they will undertake, including training materials 3. Describe the current status of maternal and newborn health in Afghanistan 4. Explain the importance of human rights related to protecting, respecting, and fulfilling the woman’s right to safe motherhood. 5. Demonstrate women‐friendly care OBJECTIVES/ ACTIVITIES

TIME 15 Mins

TRAINING/LEARNING METHODS

Activity: Welcome the Welcome by representatives from the organization(s) sponsoring the training course. participants

RESOURCE MATERIALS Course Equipment: Overhead projector, screen, flip chart with markers, videotape player and monitor, anatomic models, instruments, and supplies (see Course Syllabus for details)

15 Mins

Activity: Facilitate introductions of the participants

First, ask participants to divide into pairs and interview each other. Then, participants should introduce each other by name, position, and any unique characteristics. The trainers should also be involved in this activity.

15 Mins

Activity: Identify participants’ expectations

Ask participants to share their expectations of the course and write their responses on a flip chart. Attach the flip chart page to the wall for reference throughout the course.

BEmONC Participant’s Handbook: Syllabus and Schedule

10 Mins

Activity: Identify course norms

Ask participants to propose and agree the norms of the training. Attach the flip chart page to the wall for reference throughout the course.

30 Mins

Activity: Provide an overview of the course

Review the course syllabus and schedule. Discuss the goals of the course and the participant learning objectives.

MCPC Manual, Infection Prevention Reference Manual, BMNC Reference Manual , BEmONC Participant’s Handbook and any supporting materials relevant to the course

30 Mins

Activity: Review course materials

Distribute, review, and discuss materials used in the course.

Basic BEmONC Course

Course Outline 1‐51

30 Mins

Activity: Assess participants’ pre‐ course knowledge

Ask participants to turn to the Pre‐course Knowledge Assessment Questionnaire in their handbook and BEmONC Participant’s Handbook: Pre‐course answer each of the questions. Knowledge Assessment Questionnaire

10 Mins

Activity: Review clinical experience

Ask participants to give the trainers the Confidential Clinical Experience Questionnaire they completed BEmONC Participant Introductory Packet and before beginning the course. Trainers will use this information to monitor progress in training. Participant’s Handbook: Confidential Clinical Experience Questionnaire

10 Mins

Activity: Review personal learning plan

Ask participants to review their personal learning plan. Explain to participants that they will use this information to monitor their progress in training.

40 Mins

Activity: Introduce participants to the topic of safe motherhood

Presentation Graphic: Improving maternal and Interactive Presentation: Use the presentation graphic to explain and discuss the factors that affect maternal mortality, how skilled attendance at every birth can reduce maternal mortality, and the need newborn health in Afghanistan to use evidence‐based interventions. Pause at appropriate intervals to emphasize particular points and encourage discussion.

20 Mins

Activity: Continue discussion of the topic of safe motherhood and the factors that affect maternal mortality

Videotape: Maternal Health in Afghanistan Presentation and Discussion: Show the videotape to illustrate the factors that affect maternal mortality in Afghanistan. Consider the concepts of safe motherhood and the factors affecting maternal (BBC/WHO) mortality in Afghanistan. Pause at appropriate intervals to emphasize particular points and encourage discussion.

20 Mins

Activity: Role play on Role Play: Use the discussion questions in the role play to discuss the concepts of woman's right to safe Role Play 1: Communicating about a Woman’s Right communicating about motherhood. Pause at appropriate intervals to emphasize particular points and encourage discussion. to Safe Motherhood a woman's right to safe motherhood

1 Hr

Activity: Discuss Interactive Presentation: Use the presentation graphic to explain and explore women‐friendly care. women‐friendly care Review the key recommendations and discuss how these can be implemented in facilities considering cultural and social norms.

BEmONC Participant Introductory Packet and Participant’s Handbook: Personal Learning Plan

LUNCH

Presentation Graphic: Women‐friendly care BEmONC Participant’s Handbook: Individual and Group Assessment Matrix BEmONC Trainer’s Notebook: Precourse Knowledge Assessment Answer Key

45 Mins (a 15 Activity: Identify min tea break to individual and group be included in learning needs afternoon)

Review the answers to the Pre‐course Knowledge Assessment Questionnaire. Using the Individual and Group Assessment Matrix, ask participants to help chart the number of correct answers for each of the questions. Examine the data in the matrix to determine the collective strengths and weaknesses of the group, and plan with the participants how to best use the course time to achieve the desired learning objectives.

10 Mins

Involve participants in review and discussion of the topics and activities covered during the day. Ask a participant to volunteer to write the agenda for the next day on a flip chart, in preparation for the opening session. The schedule in the BEmONC Participant’s Handbook should be used. Ask one or more of the other participants to plan an opening activity or warm‐up for the next day. Ensure participants are clear on the reading assignment for the next day.

Activity: Review of the day’s activities

Basic BEmONC Course


DAY 2 MORNING By the end of Day 2, the participant/student will be able to: 1. Describe the basic principles of infection prevention 2. Describe infection transmission in the health care setting 3. Explain the rationales for using personal protective equipment 4. Use recommended infection prevention practices for all aspects of BEmONC 5. Describe focused antenatal care and the components of birth preparedness and complication readiness 6. Use interpersonal communication techniques to strengthen communication with, and involvement of shuras in the design and implementation of EmONC services OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins

Activity: Agenda and Review the agenda with participants, as outlined on the flip chart. Ask the participant(s) who opening activity volunteered for the opening activity or warm‐up to lead the activity.

1 Hr

Activity: Describe the components of focused antenatal care

Interactive Presentation: Use the presentation graphic to explain and discuss the importance of early registration and return visits, birth preparedness and complication readiness, diet and rest, self‐care and other health practices, immunization and other preventive measures. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to compare the principles and practices presented with those currently used at their worksites.

Presentation Graphic: Focused Antenatal Care

45 Mins

Activity: Discuss the key components of birth preparedness and complication readiness

Group Discussion: Use the presentation graphic to explain and discuss the importance of birth preparedness and complication readiness and relate it with the working environment. Involve the participants to explain possible ways to meet the key steps of birth preparedness and complication readiness in their community.

Presentation Graphic: Focused Antenatal Care At end of presentation on FANC

5 Mins

Activity: Introduction Introduce the session with questions and answers. to interpersonal communication

30 Mins

Activity: Communicating with and involving shuras in provision of BEmOC services

Presentation Graphic: Interpersonal counseling and communication skills presentation

30 Mins

Activity: Develop Game: Interpersonal skills for interacting with communities. Keeping the message short, simple, and communication skills sensible for effective communication.

Basic BEmONC Course

Interactive Presentation: Use the presentation graphic on interpersonal counseling and communication skills mainly focusing on active listening, open‐ended questioning, observing the body language, praising and encouraging, acknowledging and reflecting feelings, summarizing, and asking for feedback while communicating with communities.

Game: Use a verbal game method and keep the message short, simple, and sensible (KISSS)


20 Mins

Activity: Use information, education, and communication materials to support behavior change communication

Game: Use information, education, and communication materials (printed and self drawings) while Drawing game activity communicating with the communities to improve understanding and behavior change communication.

5 Mins

Activity: Summary

Summarize main points.

20 Mins

Activity: Discuss infection transmission in health care setting

Exercise: Use the discussion questions in the exercise to discuss the concepts infection transmission and summarize the importance of infection prevention.

Exercise 1: Who has HIV/AIDS

30 Mins

Activity: Explain and discuss infection prevention principles and practices

Interactive Presentation: Use the presentation graphic to explain and discuss infection prevention principles and practices and their application, with particular emphasis on BEmONC. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to compare the principles and practices presented with those currently used at their worksites.

Presentation Graphic: Infection Prevention Infection Prevention Manual: Chapters 3, 7, 8, 10, Appendix E

30 Mins

Activity: Discuss infection prevention principles and practices

Presentation and Discussion: Show the videotape to illustrate the principles and practices of infection prevention.

Videotape: Infection Prevention

45 Mins

Activity: Apply infection prevention practices for care during pregnancy and childbirth

Demonstration: The demonstration should be carried out in the classroom using the appropriate equipment. Drawing a tap on a piece of flip chart paper can simulate running water. Demonstrate each of the following practices, provide an explanation of the steps involved and encourage participants to ask questions at any point during the demonstration: • Handwashing • Personal Protective Equipment • Decontamination – prepare solution if required • Sharps handling • Waste disposal • Instrument handling and preparation Ask for volunteers from group to do return demonstration

Flip chart paper and marker Soap/antiseptic hand cleanser Nail brush Gloves Plastic apron Goggles, boots or covered shoes Hat and mask Instruments Needles and syringes Plastic receptacles Chlorine solution

LUNCH

Basic BEmONC Course


30 Mins

Activity: Describe best practices for identifying and managing vaginal bleeding in early pregnancy

10 Mins


Involve participants in review and discussion of the topics and activities covered during the day. Ask a participant to volunteer to write the agenda for the next day on a flip chart, in preparation for the opening session. The schedule in the BEmONC Participant’s Handbook should be used. Ask one or more of the other participants to plan an opening activity or warm‐up for the next day. Ensure participants are clear on the reading assignment for the next day.

Basic BEmONC Course

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Vaginal Bleeding in Early Pregnancy MCPC Manual: Section 2, S‐7 to S‐23


Basic BEmONC Course


DAY 3 MORNING LEARNING OBJECTIVES By the end of Day 3 the participant/student will be able to: 1. Describe the process of quick check and rapid initial assessment for the woman of childbearing age who presents with a problem 2. Identify the presenting symptoms and signs and determine the probable diagnoses associated with vaginal bleeding in early pregnancy 3. Use initial management protocols for the specific diagnoses associated with bleeding in early pregnancy 4. Identify the presenting symptoms and signs of shock and provide appropriate management OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


30 Mins

Activity: Review and Interactive Presentation: Use the presentation graphic to: discuss management • Review and discuss the process of quick check and rapid assessment of shock • Review and discuss the recognition and management of shock • Explain the principles of adult resuscitation Pause at appropriate intervals to emphasize particular points and encourage discussion. Provide a brief summary at the end of each of the above topics.

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Rapid Initial Assessment and Management of Shock MCPC Manual: Section 1, C‐1 to C‐4, C‐23 to C‐29; Section 2, S‐1 to S‐5

1 hr

Activity: Practice adult resuscitation and management of shock

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant model and checklist, as described in Skills Practice Session: Adult Resuscitation and Management of Shock.

Skill Demonstration and Practice: Adult resuscitation and management of shock

40 Mins

Activity: Clinical simulation on management of shock

Guide participants through the clinical simulation on management of shock, following the guidelines provided in the Trainer’s Notebook.

BEmONC Trainer’s Handbook: Clinical Simulations Clinical Simulation: Management of Shock MCPC Manual: Section 2, S‐1 to S‐5

55 Mins

Activity: Review and • discuss vaginal bleeding in early pregnancy and post abortion care, especially family planning counseling

Basic BEmONC Course

Interactive Presentation: Use the presentation graphic to review and discuss bleeding in early pregnancy and PAC. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to cite the possible causes of bleeding in early pregnancy and describe the way in which they manage each of these. If there are differences between the recommended “best practices” for management and current practices at their worksites, discuss the reasons. Is there a need to change current practices? If so, how? Also discuss Postabortion family planning counseling and services

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Vaginal Bleeding in Early Pregnancy; BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Postabortion Care


LUNCH 30 Mins

Activity: Case studies Case Studies: Use case study 1 on vaginal bleeding in early pregnancy (ectopic pregnancy). Divide on vaginal bleeding in participants into groups of three or four. The groups can be given different case studies, or they can all early pregnancy work on the same one. Allow approximately 20 minutes for the group to work on each case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer keys to guide discussion.

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Study 1: Vaginal Bleeding in Early Pregnancy (Ectopic Pregnancy) and Answer Keys MCPC Manual: Section 2, S‐7 to S‐16

1 hr 15 Mins

Activity: Practice manual vacuum aspiration and postabortion family planning counseling.

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant model and checklists, as described in Skills Practice Session: Postabortion Care (Manual Vacuum Aspiration [MVA]) and Postabortion Family Planning Counseling. Before beginning the skill demonstration, explain to participants how checklists will be used for this skill and the other skills included in the course.

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklists for Postabortion Care (Manual Vacuum Aspiration [MVA]) and Postabortion Family Planning Counseling MCPC Manual: Section 3, P‐65 to P‐68

OPTIONAL Activity: Case studies on vaginal bleeding in later pregnancy

Case Studies: If time permits, use the two case studies on vaginal bleeding in later pregnancy (abruptio placentae and placenta previa). Divide participants into groups of three or four. The groups can be given different case studies or they can all work on the same one. Allow approximately 20 minutes for the groups to work on each case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer keys to guide discussion.

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Studies: Vaginal Bleeding in Later Pregnancy (Abruptio Placentae) and Vaginal Bleeding in Later Pregnancy (Placenta Previa) and Answer Keys MCPC Manual: Section 2, S‐17 to S‐23

10 Mins


Involve participants in review and discussion of the topics and activities covered during the day. Ask a participant to volunteer to write the agenda for the next day on a flip chart, in preparation for the opening session. The schedule in the BEmONC Participant’s Handbook should be used. Ask one or more of the other participants to plan an opening activity or warm‐up for the next day.

Basic BEmONC Course


DAY 4 MORNING LEARNING OBJECTIVES By the end of Day 4 the participant/student will be able to: 5. Explain the causes of vaginal bleeding in later pregnancy and labor. 6. Identify the presenting symptoms and signs and determine the probable diagnoses associated with vaginal bleeding in later pregnancy and labor. 7. Use initial management protocols for the specific diagnoses associated with bleeding in later pregnancy and labor. 8. Describe intrapartum care during first stage of labor, including supportive care and best practices. 9. Demonstrate use of the partograph to monitor progress in labor and identify deviations from normal. 10. Perform an initial assessment of the woman in labor, including abdominal and vaginal examinations to diagnose and confirm labor. 11. Provide ongoing assessment of mother and fetus and supportive care to mother during labor and following the birth. 12. Explain principles of managing a normal birth, including management of the third stage of labor, examination of the placenta, and inspection of the vagina and perineum for tears. OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


45 Mins

Activity: Describe best practices for identifying and managing vaginal bleeding in later pregnancy

Interactive Presentation: Use the presentation graphic to review and discuss bleeding in later pregnancy and labor. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to cite the possible causes of bleeding in later pregnancy and describe the way in which they manage each of these. If there are differences between the recommended “best practices” for management and current practices at their worksites, discuss the reasons. Is there a need to change current practices? If so, how?

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Vaginal Bleeding in later Pregnancy;

45 Mins

Activity: Review and discuss best practice during delivery

Interactive Presentation: Use the presentation graphic on normal labor and childbirth to review and discuss best practices for care during labor, with particular emphasis on supportive care. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants about the supportive care provided by them for women in labor. Is there a need for change? If so, why and how?

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Normal Labor and Childbirth MCPC Manual: Section 1, C‐57 to C‐59

20 Mins

Activity: Observe and Presentation and discussion: Show the video to illustrate updated delivery practice. Then have discuss best practice participants discuss how they can implement the suggested practices. during delivery

Video: Assisting a normal birth (JSI)

1 Hr 30 Mins

Activity: Practice assessment of the woman in labor

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Assessment of the Woman in Labor MCPC Manual: Section 1, C‐57 to C‐76

Basic BEmONC Course

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant models, and checklist, as described in Skills Practice Session: Assessment of the Woman in Labor.


LUNCH 30 Mins

Activity: Overview Interactive Presentation: Use the presentation graphic to review and discuss: using the partograph • The components of the partograph • How to plot progress in labor • How to identify normal labor • How to identify unsatisfactory progress in labor (prolonged active phase and obstructed labor) Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants if they use the partograph. How has its use affected care during labor? Have they experienced problems using it? How have the problems been resolved?

1 Hr 30 Mins

Activity: Practice Exercise: Follow the directions in the Exercise, Using the Partograph. Trainers should keep in mind that Exercise: Using the Partograph and Answer Key Partograph forms using the partograph some participants may be able to use the partograph more proficiently than others. Progress should Poster‐size laminated partograph and dry‐erase therefore be monitored closely to make sure that participants are able to complete the various steps involved in the exercise. Participants who experience difficulties should be provided additional help markers during the exercise.

10 Mins


Basic BEmONC Course

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Managing Labor Using the Partograph MCPC Manual: Section 1, C‐65 to C‐70; Section 2, S‐ 57 to S‐67 BMNC Manual: pages 2‐37 to 2‐79



DAY 5 MORNING LEARNING OBJECTIVES By the end of Day 5 the participant/student will be able to: 1. Explain the management of the third stage of labor. 2. Provide ongoing assessment of mother and fetus and supportive care to mother during labor and following the birth. 3. Manage a normal birth, including active management of the third stage of labor, examination of the placenta, and inspection of the vagina and perineum for tears. 4. Describe the special needs of women during labor and birth and the additional care required. 5. Demonstrate best practices for care during second stage of labor, active management of the third stage, and immediate postpartum care. OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


3 Hrs 45 Mins

Activity: Practice clean and safe childbirth

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant models and checklist, as described in Skills Practice Session: Assisting a Normal Birth.

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Assisting a Normal Birth MCPC Manual: Section 1, C‐57 to C‐76 BMNC Manual: pages 2‐83 to 2‐107

30 Mins

Activity: Case study on labour support

Case Study: Use the case study on Supporting the woman in labour. Divide participants into groups of Case Study: Supporting the woman in labor BMNC Manual: Ch 6 three or four. The groups can be given different case studies or they can all work on the same one. Allow approximately 20 minutes for the groups to work on the case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer key to guide discussion.

OPTIONAL Activity: Case study on malposition

Case Studies: If time permits, use the case study on malposition. Divide participants into groups of three or four. The groups can be given different case studies or they can all work on the same one. Allow approximately 20 minutes for the groups to work on the case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer key to guide discussion.

10 Mins



LUNCH

Basic BEmONC Course

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Studies: Malposition (Occiput Posterior) and Answer Key MCPC Manual: Section 2, S‐75 to S‐76, S‐83 to S‐85


Basic BEmONC Course


DAY 6 MORNING LEARNING OBJECTIVES By the end of Day 6, the participant/student will be able to: 1. Describe basic postpartum care, breastfeeding and breast care, complication readiness, support for mother‐baby‐family relationships, family planning, nutrition support, self‐care and other healthy behaviors, immunization and other preventive measures, and scheduling a return visit. 2. Provide counseling on postpartum family planning. 3. Support a woman and her baby to breastfeed successfully. 4. Demonstrate the technique of local anesthesia, repair of vaginal and perineal lacerations, and episiotomy 5. Describe malpresentations, including breech. 6. Perform a breech delivery. OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


45 Mins

Activity: Review and discuss postpartum care

Interactive Presentation: Use the presentation graphic to review and discuss the essential elements of BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Postpartum Care and best practices for postpartum care. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants if there are differences between the management described and current practices at their worksites. Is there a need to change current practices? If so, how?

30 Mins

Activity: Case study postpartum care

Case study: Postpartum assessment and Case study: Use the case study postpartum assessment and care (breastfeeding difficulty) and divide participants into groups of three or four. The groups can be given different case studies or they can all care(breastfeeding difficulty) work on the same one. Allow approximately 20 minutes for the groups to work on the case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer key to guide discussion.

20 Mins

Activity: Role play: Use the discussion questions in the role play to discuss. Pause at appropriate intervals to Communicating emphasize particular points and encourage discussion. about family planning choices postpartum

Role Play: Communicating about family planning choices

2 Hrs

Activity: Practice Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by episiotomy and repair participants in a simulated setting using the relevant learning aid and checklist, as described in Skills Practice Session: Episiotomy and Repair.

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Episiotomy and Repair MCPC Manual: Section 3, P‐71 to P‐75

Basic BEmONC Course


LUNCH 20 Mins presentation 10 Mins video

Activity: Observe Interactive Presentation: Use the presentation and then videotape on breech delivery to present and BEmONC Trainer’s Notebook: Illustrated Lectures Videotape: Vaginal Breech Delivery ‐ WHO presentation and discuss the diagnosis and management of breech presentation. Ask participants to share their video breech delivery experiences with respect to breech delivery. How did they manage? What was the outcome for mother MCPC Manual: Section 2, S‐74, S‐79 to S‐80 and newborn?

1 Hr 30 Mins

Activity: Practice breech delivery

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant model and checklist, as described in Skills Practice Session: Breech Delivery.

10 Mins



Basic BEmONC Course

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Breech Delivery MCPC Manual: Section 3, P‐37 to P‐42


DAY 7 MORNING By the end of Day 7, the participant/student will be able to: 1. Identify the presenting symptoms and signs and determine the probable diagnoses associated with pregnancy‐induced hypertension. 2. Use simplified management protocols for the specific diagnoses associated with pregnancy‐induced hypertension. 3. Define pre‐eclampsia and eclampsia. 4. Administer anticonvulsive drugs and antihypertensive drugs for the management of severe pre‐eclampsia and eclampsia. 5. Recognize and manage fever after childbirth. OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


1 hr

Activity: Practice vacuum extraction delivery and breech delivery

Skill Practice: The skill is to be practiced by participants in a simulated setting using the relevant model and checklist, as described in Skills Practice Session: Vacuum Extraction and Skills Practice Session: Assisting breech delivery

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Vacuum Extraction and Breech Delivery MCPC Manual: Section 3, P‐27 to P‐31

45 Mins

Activity: Review and discuss best practices in management pre‐ eclampsia and eclampsia

• • •

Interactive Presentation: Use the presentation graphic to review and discuss: Best practices for identifying and managing hypertension, pre‐eclampsia, and eclampsia Strategies for managing pregnancy induced Strategies for preventing and treating convulsions, with particular emphasis on the use of magnesium sulphate Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants if there are differences between the management described and current practices. Is there a need to change current practices? If so, how?

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Headache, Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood Pressure MCPC Manual: Section 1, S‐35 to S‐50

1 Hr

Activity: Case studies Case Studies: Use the two case studies on pregnancy‐induced hypertension (mild pre‐eclampsia and on pregnancy‐ severe pre‐eclampsia). Divide participants into groups of three or four. The groups can be given induced hypertension different case studies or they can all work on the same one. Allow approximately 20 minutes for the groups to work on the case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer key to guide discussion.

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Studies: Pregnancy‐Induced Hypertension (Mild Pre‐eclampsia) and Pregnancy‐Induced Hypertension (Severe Pre‐eclampsia) and Answer Key MCPC Manual: Section 2, S‐35 to S‐50

1 Hr

Activity: Practice management of severe pre‐ eclampsia/eclampsia

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Management of Severe Pre‐Eclampsia/Eclampsia

Basic BEmONC Course

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant model and checklist, as described in Skills Practice Session: Management of Severe Pre‐Eclampsia/Eclampsia.


MCPC Manual: Section 2, S‐35 to S‐50 LUNCH 1 Hr

Activity: Review and discuss fever after childbirth

Interactive Presentation: Use the presentation graphic to review and discuss the best practices for managing fever during pregnancy and after childbirth, strategies to prevent infection, and prophylactic and therapeutic use of antibiotics. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to cite the possible causes of fever after childbirth, and the obstetric, medical and health service factors affecting postpartum sepsis. What do they do to prevent postpartum sepsis? If there are differences between the recommended “best practices” for management and current practices at their worksites, discuss the reasons for this. Is there a need to change current practices? If so, how?

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Fever During Pregnancy and After Childbirth MCPC Manual: Section 2, S‐107 to S‐114

30 Mins

Activity: Case Study

Case Study: Use the case study on fever after childbirth (metritis). Divide participants into groups of three or four. Allow approximately 20 minutes for the groups to work on the case study, then allow 5– 10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer key to guide discussion.

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Study: Fever After Childbirth (Metritis) and Answer Key MCPC Manual: Section 2, S‐107 to S‐114

Optional Case Studies – if time allows

Case Studies: Use the case studies on fever after childbirth (perineal wound abscess and mastitis). Divide participants into groups of three or four. The groups can be given different case studies or they can all work on the same one. Allow approximately 20 minutes for the groups to work on the case study; then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer keys to guide discussion.

BEmONCTrainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Studies: Fever After Childbirth (Perineal Wound Abscess) and Fever After Childbirth (Mastitis) and Answer Keys MCPC Manual: Section 2, S‐107 to S‐114

10 Mins



Basic BEmONC Course


DAY 8 MORNING LEARNING OBJECTIVES By the end of Day 8, the participant/student will be able to: 1. Define postpartum hemorrhage. 2. Explain the causes of postpartum hemorrhage. 3. Identify the presenting symptoms and signs and determine the probable diagnoses associated with vaginal bleeding immediately after childbirth. 4. Use simplified management protocols for the specific diagnoses associated with vaginal bleeding immediately after childbirth. 5. Perform bimanual compression of the uterus. 6. Perform aortic compression. 7. Perform manual removal of the placenta. 8. Use simplified management protocols for prolapsed cord. OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


1 Hr

Activity: Describe best practices for managing vaginal bleeding after childbirth

Presentation Graphic: Vaginal Bleeding After Presentation and Discussion: Use the presentation graphic to review and discuss best practices for Childbirth managing vaginal bleeding after childbirth. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to cite the possible causes of vaginal bleeding after childbirth and describe the way in which they manage each of the causes. If there are differences between the recommended “best practices” for management and current practices at their worksites, discuss the reasons for this. Is there a need to change current practices? If so, how?

30 Mins

Activity: Case study on vaginal bleeding after childbirth

Case Studies: Use the case studies on vaginal bleeding after childbirth (genital trauma). Divide participants into groups of three or four. The groups can be given different case studies or they can all work on the same one. Allow approximately 20 minutes for the groups to work on the case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer keys to guide discussion.

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Studies: Vaginal Bleeding After Childbirth (Genital Trauma) and Answer Keys MCPC Manual: Section 2, S‐25 to S‐34

OPTIONAL Activity: Case study on vaginal bleeding after childbirth

Case Study: If time permits, use the case study on vaginal bleeding after childbirth (delayed postpartum hemorrhage). Divide participants into groups of three or four. Allow approximately 20 minutes for the groups to work on the case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer keys to guide discussion.

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Study: Vaginal Bleeding After Childbirth (Delayed PPH) and Answer Key MCPC Manual: Section 2, S‐25 to S‐34

Basic BEmONC Course


1hr 30 Mins

Activity: Practice bimanual compression of the uterus, abdominal aortic compression, and manual removal of placenta

Skill Demonstration and Practice: The skills are to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant models and checklists, as described in Skills Practice Session: Bimanual Compression of the Uterus, Skills Practice Session: Compression of the Abdominal Aorta and Skills Practice Session: Manual Removal of Placenta.

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skills Demonstration and Practice: Checklist for Bimanual Compression of the Uterus; Checklist for Compression of the Abdominal Aorta; Checklist for Manual Removal of Placenta MCPC Manual: Section 2, S‐25 to S‐34; Section 3, P‐ 77 to P‐79

LUNCH 50 Mins

Activity: Clinical Clinical Simulation: Guide participants through the clinical simulation on management of vaginal simulation on bleeding after childbirth, following the guidelines provided in the Trainer’s Notebook. management of vaginal bleeding after childbirth

15 Mins

Activity: Discuss and review management of cord prolapse

Presentation Graphic: Prolapsed Cord Presentation and Discussion: Use the presentation graphic to review and discuss best practices for managing cord prolapse. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to cite the possible reasons for cord prolapse and describe the way in which they manage each of these. If there are differences between the recommended “best practices” for management and current practices at their worksites, discuss the reasons for this. Is there a need to change current practices? If so, how?

1 Hr

Activity: Practice managing cord prolapse

Skill Demonstration and Practice: The skills are to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant models and checklists, as described in Skills Practice Session: Managing Cord Prolapse.

10 Mins



Basic BEmONC Course

BEmONC Trainer’s Handbook: Clinical Simulations Clinical Simulation: Management of Vaginal Bleeding after Childbirth MCPC Manual: Section 2, S‐141 to S‐146

BEmONC Trainers hand book Checklist: Managing prolapsed cord MCPC Manual: S‐97 to S‐98


DAY 9 MORNING LEARNING OBJECTIVES By the end of Day 9 the participant/student will be able to: 1. Provide essential newborn interventions, including those for warmth, cord care and eye care, recognition of danger signs, and promotion of early and exclusive breast‐feeding. 2. Define birth asphyxia. 3. Perform newborn resuscitation using a self‐inflating bag and mask. 4. Perform a vacuum extraction. OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


1 Hr

Activity: Review and Interactive Presentation: Use the presentation graphic to review and discuss prevention of infection, discuss best practices thermal protection, newborn resuscitation, breastfeeding, and best practices for promoting newborn in newborn care health. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to share their experiences with respect to newborn resuscitation. If there are differences between the recommended “best practices” for newborn resuscitation and current practices at their worksites, discuss the reasons for this. Is there a need to change current practices? If so, how?

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Normal Newborn Care MCPC Manual: Section 1, C‐75 to C‐80; Section 2, S‐ 141 to S‐150 BMNC Manual: pages 2‐109 to 2‐135

1 Hr 50 Mins

Activity: Practice newborn resuscitation

45 Mins

Activity: Clinical Clinical Simulation: Guide participants through the clinical simulation on management of an simulation on asphyxiated newborn, following the guidelines provided in the Trainer’s Notebook. management of an asphyxiated newborn

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by BEmONC Trainer’s Notebook: Humanistic Training participants in a simulated setting using the relevant model and checklist, as described in Skills Practice Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Session: Newborn Resuscitation. Newborn Resuscitation MCPC Manual: Section 2, S‐141 to S‐146 BEmONC Trainer’s Handbook: Clinical Simulations Clinical Simulation: Management of Asphyxiated Newborn MCPC Manual: Section 2, S‐141 to S‐146

LUNCH 25 Mins Presentation Then 15 Mins video

Activity: Observe presentation and video vacuum delivery

Basic BEmONC Course

Interactive Presentation: Use the presentation and then videotape on vacuum delivery to present and discuss the management of prolonged second stage and vacuum delivery. Ask participants to share their experiences with respect to vacuum delivery. How did they manage? What was the outcome for mother and newborn?

BEmONC Trainer’s Notebook: Illustrated Lectures Videotape: Vacuum Delivery: Reducing Risk (WHO) MCPC Manual: Section 3, P‐27 to P‐31


1 Hr 15 Mins

Activity: Practice vacuum extraction delivery

As time allows

Activity: Skills Trainers should provide guidance for participants to use the relevant models and checklists to practice practice with models the skills.

10 Mins


Basic BEmONC Course

Skill Demonstration and Practice: The skill is to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant model and checklist, as described in Skills Practice Session: Vacuum Extraction.

BEmONC Trainer’s Notebook: Humanistic Training Techniques; Checklists; Skills Practice Sessions Skill Demonstration and Practice: Checklist for Vacuum Extraction MCPC Manual: Section 3, P‐27 to P‐31 Various checklists as needed



DAY 10 MORNING LEARNING OBJECTIVES By the end of Day 10 the participant/student will be able to: 1. Identify and manage shoulder dystocia. 2. Recognize and describe the main complications of the newborn. OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


1 Hr

Activity: Practice managing shoulder dystocia

Skill Demonstration and Practice: The skills are to be demonstrated by trainers and practiced by participants in a simulated setting using the relevant models and checklists, as described in Skills Practice Session: Managing Shoulder Dystocia.

Presentation Graphic: Shoulder Dystocia

45 Mins

Activity: Review and discuss the main issues in newborn with problems

Interactive Presentation: Use the presentation graphic to review and discuss the management of newborn problems with focus on prematurity, infection, and asphyxia. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to share their experiences with respect to the provision of pain relief for women during labor and following obstetric surgery.

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Best Practices in Care of the Newborn with Problems

2 Hrs

Activity: Skill practice Trainers should evaluate the participants’ skills using the relevant models and checklists. Those and skill evaluations participants who need more time can be coached.

LUNCH 1 Hr 40 Mins

Activity: Skills evaluation with models

Trainers should evaluate the participants’ skills using the relevant models and checklists.

30 Mins

Activity: Review the results of the Midcourse Knowledge Assessment Questionnaire

The results of the Midcourse Knowledge Assessment Questionnaire should be reviewed with the class as a whole, emphasizing collective strengths and weaknesses. Trainers must allocate time to meet with participants who scored less than 85% and discuss missed items and/or incorrect responses. Participants should then spend time studying the relevant topics and complete the Midcourse Knowledge Assessment Questionnaire again to achieve a score of at least 85%.

5 Mins



Basic BEmONC Course


Basic BEmONC Course


Day 11 MORNING LEARNING OBJECTIVES By the end of Day 11 the participant/student will be able to: 1. Discuss the options for improving and managing pain related to emergency obstetric care (EOC). OBJECTIVES/ ACTIVITIES

TIME


RESOURCE MATERIALS

10 Mins


50 Mins

BEmONC Trainer’s Notebook: Midcourse Activity: Assess Make copies of the Midcourse Knowledge Assessment Questionnaire and distribute to participants. participants’ Review the instructions for completing the questionnaire with participants. Have participants complete Knowledge Assessment Questionnaire and Answer midcourse knowledge the questionnaire. Trainers should score the Midcourse Knowledge Assessment Questionnaires during Key the break and review the results with the entire group (time is allocated for this later in the session).

45 Mins

Activity

Interactive Presentation and Discussion with Group Work: Use the presentation graphic to review and discuss the general principles for and methods of obstetric analgesia and anesthesia applicable to EOC. Pause at appropriate intervals to emphasize particular points and encourage discussion. For example, ask participants to share their experiences with respect to the provision of pain relief for women during labor and following obstetric surgery.

30 Mins

Activity: Provide instructions for clinical practice

Trainers should explain to participants how the forthcoming days of clinical practice are structured and what is expected of them as individual practitioners and as team members. Each team consists of one doctor and one midwife from the same facility. Trainers should be identified for each of the teams so that participants are clear about who will provide guidance during clinical practice.

20 Mins

Activity: Review Clinical Experience Log Book

Trainers should review the Clinical Experience Log Book with participants and ensure that they Clinical Experience Log Book understand how it will be used during the guided clinical practice. Each participant should be asked to Case Studies record a case in a blank case record and present this to the class at the end of a clinical session or quiet time. It can be a normal or complicated case.

OPTIONAL Activity: Case study on shoulder dystocia

Case Study: If time permits, use the case study on shoulder dystocia. Divide participants into groups of three or four. The groups can be given different case studies or they can all work on the same one. Allow approximately 20 minutes for the groups to work on the case study, then allow 5–10 minutes for one participant from each group to report back to the class as a whole. Use the case study answer key to guide discussion.

BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making Case Study: Shoulder Dystocia and Answer Key MCPC Manual: Section 2, S‐75 to S‐76, S‐83 to S‐85

1 hr



Basic BEmONC Course

BEmONC Trainer’s Notebook: Illustrated Lectures Presentation Graphic: Analgesia and Anesthesia in EOC MCPC Manual: Section 1, C‐37 to C‐46


LUNCH 1 Hr 15 Mins



50 Mins

Activity: Tour of clinical facilities

All of the participants should visit both of the hospital facilities that will be used for clinical practice. Each trainer should take responsibility for one team of participants and guide them through the various wards and departments in which they are to practice. Hospital staff members should be introduced to participants and invited to provide information about their respective work areas.

10 Mins


Involve participants in review and discussion of the topics and activities covered during the day. Ask a participant to volunteer to write the agenda for next day on a flip chart, in preparation for the opening session. The schedule in the BEmONC Participant’s Handbook should be used. Ask one or more of the other participants to plan an opening activity or warm‐up for next day.

Basic BEmONC Course


DAY 12 Days 12–19 Outline for clinical care is the same as Day 12 Activity: Clinical experience

Clinical Experience with Clients/Patients Under Guidance of Trainers: Team 1 goes to the emergency reception area and high dependency area (if available) , where trainers demonstrate and participants practice rapid assessment and management of shock, management of early pregnancy bleeding and management of severe pre‐eclampsia and eclampsia . Team 2 goes to the admission/labor room. Trainers should first involve participants in admission of women in labor as well as ward rounds and discussion of client/patient needs. Participants should then be assigned, in pairs, to admit women in labor, assess labor using the partograph and provide care of women in labor. Where possible (i.e., depending on client/patient availability), participants should, under the guidance of a trainer, practice the skills learned earlier Team 3 goes to the labor ward. Trainers should first involve participants in ward rounds and discussion of client/patient needs. Participants should then be assigned, in pairs, to provide care during labor and childbirth and episiotomy and repair. Where possible (i.e., depending on client/patient availability), discussion of management of complicated delivery, postpartum hemorrhage, and newborn resuscitation should be undertaken. Participants should, under the guidance of a trainer, practice the skills learned earlier. The relevant checklists should be used to assess performance. Team 4 goes to the postnatal ward, where clinical trainers demonstrate postpartum care and newborn care. Participants then perform the activities in pairs and assess each other’s performance using the checklists for Postpartum Assessment and Basic Care and Family Planning.

Checklists for the skills learned during the first 11 days of the training program BEmONC Trainer’s Notebook: Case Studies Tips for Trainers: Teaching Clinical Decision‐Making


Involve participants in review and discussion of their clinical experience. If there was an especially interesting client/patient, ask the participants involved to share their experience. Also discuss factors that facilitated and barriers that hindered the provision of care.

Basic BEmONC Course


DAY 13 Activity: Clinical experience

Clinical Experience with Clients/Patients Under Guidance of Trainers: Team 2 goes to the emergency reception area and high dependency area (if available) , where trainers demonstrate and participants practice rapid assessment and management of shock, management of early pregnancy bleeding and management of severe pre‐eclampsia and eclampsia . Team 3 goes to the admission/labor room. Trainers should first involve participants in admission of women in labor as well as ward rounds and discussion of client/patient needs. Participants should then be assigned, in pairs, to admit women in labor, assess labor using the partograph and provide care of women in labor. Where possible (i.e., depending on client/patient availability), participants should, under the guidance of a trainer, practice the skills learned earlier Team 4 goes to the labor ward. Trainers should first involve participants in ward rounds and discussion of client/patient needs. Participants should then be assigned, in pairs, to provide care during labor and childbirth and episiotomy and repair. Where possible (i.e., depending on client/patient availability), discussion of management of complicated delivery, postpartum hemorrhage, and newborn resuscitation should be undertaken. Participants should, under the guidance of a trainer, practice the skills learned earlier. The relevant checklists should be used to assess performance. Team 1 goes to the postnatal ward, where clinical trainers demonstrate postpartum care and newborn care. Participants then perform the activities in pairs and assess each other’s performance using the Checklists for Postpartum Assessment and Basic Care and Family Planning.




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Basic BEmONC Course







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Basic BEmONC Course







Basic BEmONC Course


Basic BEmONC Course


DAY 19 – MORNING

Activity: Clinical Clinical Experience with Clients/Patients Under Guidance of Trainers: experience Team 1 goes to the emergency reception area and high dependency area (if available) , where trainers demonstrate and participants practice rapid assessment and management of shock, management of early pregnancy bleeding and management of severe pre‐eclampsia and eclampsia . Team 2 goes to the admission/labor room. Trainers should first involve participants in admission of women in labor as well as ward rounds and discussion of client/patient needs. Participants should then be assigned, in pairs, to admit women in labor, assess labor using the partograph and provide care of women in labor. Where possible (i.e., depending on client/patient availability), participants should, under the guidance of a trainer, practice the skills learned earlier Team 3 goes to the labor ward. Trainers should first involve participants in ward rounds and discussion of client/patient needs. Participants should then be assigned, in pairs, to provide care during labor and childbirth and episiotomy and repair. Where possible (i.e., depending on client/patient availability), discussion of management of complicated delivery, postpartum hemorrhage, and newborn resuscitation should be undertaken. Participants should, under the guidance of a trainer, practice the skills learned earlier. The relevant checklists should be used to assess performance. Team 4 goes to the postnatal ward, where clinical trainers demonstrate postpartum care and newborn care. Participants then perform the activities in pairs and assess each other’s performance using the Checklists for Postpartum Assessment and Basic Care and Family Planning.


LUNCH 1 Hr

Activity: Describe lessons learned during clinical practice

45 Mins

Activity: Presentation and Discussion: Use the presentation graphic to explain and discuss implementation of Discuss the Obstetric Register and emphasize the importance of reporting data on maternal and newborn implementation health. of the Obstetric Register

Basic BEmONC Course

Discussion: Use the following points to encourage participants to discuss the lessons learned during clinical practice: • Factors that facilitated clinical practice • Factors that made clinical practice difficult • Individual and team strengths with respect to clinical practice • Individual and team weaknesses with respect to clinical practice • Aspects of individual and team practice that need to improve • The most important thing learned by each participant during clinical practice

Presentation Graphic: Implementation of the Obstetric Register


15 Mins

Activity: Discussion: Trainers meet with participants individually to discuss and identify further learning needs. Identify further individual learning needs

10 Mins

Activity: Introduce group work for the development of action plans

Explain the purpose and content of the action plans that are to be developed by participants, working in teams. Each team is to begin discussing actions for change and indicators to measure success, in preparation for the development of their action plans during group work the next morning. Provide each team with copies of action plan worksheets and ensure that they understand how to complete them.

BEmONC Participant’s Handbook: Action Plan Worksheets

5 Mins


Involve participants in review and discussion of the topics and activities covered during the day. Ask a participant to volunteer to write the agenda for next day on a flip chart, in preparation for the opening session. The schedule in the BEmONC Participant’s Handbook should be used. Ask one or more of the other participants to plan an opening activity or warm‐up for next day.

Basic BEmONC Course


DAY 20

Activity: Review the agenda with participants, as outlined on the flip chart. Ask the participant(s) who Agenda and volunteered for the opening activity or warm‐up to lead the activity. opening activity

Activity: Clinical Conduct clinical check‐outs with clients for any remaining participants. check‐outs


Activity: Review personal learning plans and develop action plans

Group Work: Each team of participants is to prepare an action plan based on the guidelines provided during the introduction to group work.

BEmONC Participant’s Handbook: Action Plan Worksheets

Activity: Present action plans

Each team of participants is to present their action plan.

Activity: Identify next steps

Trainers should discuss with participants the following aspects of the log book and on‐the‐job training: Clinical Experience Log Book • Responsibilities of participants as individuals and team members • Use of Clinical Experience Log Book

Activity: Course Share form with all participants and encourage participants to complete clearly and honestly giving Evaluation examples where possible

Use end of course evaluation form and consolidate feedback

Activity: Course Provide a brief review of the topics and skills covered during the course. Emphasize that this is the summary conclusion of the first part of the course.

Activity: Closing ceremony

Basic BEmONC Course


Basic BEmONC Course


PRECOURSE KNOWLEDGE ASSESSMENT QUESTIONNAIRE MANAGEMENT OF SHOCK; RAPID INITIAL ASSESSMENT ANSWER KEY Questions

Answers

1. Quick check and rapid initial assessment should be carried out on all women of childbearing age who present with a problem.

TRUE

2. A woman who suffers shock as a result of an obstetric emergency may have a fast, weak pulse.

TRUE

3. The immediate management of ectopic pregnancy involves observing the woman for signs of improvement

FALSE

BLEEDING DURING PREGNANCY AND LABOR 4. Manual vacuum aspiration (MVA) is an effective method for treatment of incomplete abortion if the uterine size is not greater than 8 weeks.

FALSE

5. A client cannot become pregnant until the first menses after an abortion

FALSE

6. If bleeding is heavy in the case of abruptio placentae and the cervix is fully dilated, delivery should be assisted by vacuum extraction.

TRUE

LABOR AND CHILDBIRTH 7. Cervical dilation plotted to the right of the alert line on the partograph indicates unsatisfactory progress of labor.

TRUE

8. If the active phase of labor is prolonged, delivery should be by cesarean section.

FALSE

9. An episiotomy should be routinely performed in primigravida

FALSE

10. Continuous supportive care from a caring health provider or a relative improves birth outcomes

TRUE

11. All instruments used in a delivery should be decontaminated with 0.5% chlorine for 30 minutes

FALSE

12. Conditions for vacuum extraction are fetal head at least at 0 station or not more than 2/5 above the symphysis pubis and a fully dilated cervix.

TRUE

13. A head that is felt in the flank on abdominal examination indicates a shoulder presentation or transverse lie.

TRUE

14. If labor is prolonged in the case of a breech presentation, a cesarean section should be performed.

TRUE

15. Absent fetal movements and fetal heart sounds, together with intra‐ abdominal and/or vaginal bleeding and severe abdominal pain, suggest ruptured uterus.

TRUE

MANAGEMENT OF THIRD STAGE OF LABOR 16. Active management of the third stage of labor should be practiced only on women who have a history of postpartum hemorrhage.

Basic EmONC Course

FALSE

Precourse Knowledge Assessment Questionnaire Key 1‐87

Questions

Answers

17. The utertonic of choice for active management of the third stage of labor is Ergometrine 0.5mg

FALSE

VAGINAL BLEEDING AFTER BIRTH 18. Vaginal bleeding in excess of 500ml after birth is defined as post partum hemorrhage

TRUE

19. Immediate postpartum haemorrhage is always due to uterine atony

FALSE

20. Delayed postpartum bleeding is always characterized by light, irregular vaginal bleeding

FALSE

HEADACHES, BLURRED VISION, CONVULSIONS, LOSS OF CONSCIOUSNESS OR ELEVATED BLOOD PRESSURE 21. Hypertension in pregnancy can be associated with protein in the urine.

TRUE

22. The presenting signs and symptoms of eclampsia include convulsions, diastolic blood pressure of 90 mm Hg or more after 20 weeks gestation and proteinuria of 2+ or more.

TRUE

23. A pregnant woman who is convulsing should be protected from injury by moving objects away from her.

TRUE

24. The management of mild pre‐eclampsia should include sedatives and tranquilizers.

FALSE

25. The drug of choice for preventing and treating convulsions in severe pre‐ eclampsia and eclampsia is diazepam.

FALSE

FEVER DURING AND AFTER CHILDBIRTH 26. Breast pain and tenderness 3 to 5 days after childbirth is usually due to mastitis

FALSE

27. Lower abdominal pain and uterine tenderness, together with foul‐smelling lochia, are characteristic of metritis.

TRUE

NEWBORN 28. The three main causes of newborn mortality globally are birth asphyxia, prematurity and infection

TRUE

29. Room air rather than oxygen is sufficient for resuscitation on most cases

TRUE

30. When using a bag and mask to resuscitate a newborn, the newborn’s neck must be slightly extended to open the airway.

TRUE

Basic EmONC Course

Precourse Knowledge Assessment Questionnaire Key 1‐88

LEARNING TOOLS

ROLE PLAY 1: COMMUNICATING ABOUT A WOMAN’S RIGHT TO SAFE MOTHERHOOD ANSWER KEY DISCUSSION QUESTIONS 1. How did the midwife approach Kamila and her mother? 2. Did the midwife give Kamila and her mother enough information about the role of the midwife? About the health center? About safe motherhood? 3. How did Kamila and her mother respond to the midwife? 4. What did the midwife do to demonstrate emotional support and reassurance during her interaction with Kamila and her mother? Were the midwife’s explanations and reassurances effective? ANSWERS The following answers should be used by the teacher to guide the class discussion after the role play. Although these are “likely” answers, other answers provided by the learners during the discussion may be equally acceptable. 1. The midwife should introduce herself and address Kamila and her mother by name. She should speak in a calm and reassuring manner, using words that the women will easily understand. 2. Sufficient information should be provided about the role of the midwife and other skilled birth attendants, including: prenatal and postnatal care, care during labor and birth, care of the newborn, family planning, prevention of complications, and early recognition of complications and referral to the appropriate facility. The midwife should describe safe motherhood, emphasizing Kamila’s right to receive the care that she needs to be safe and healthy throughout pregnancy and childbirth. She should reassure Kamila and her mother that most complications during pregnancy and childbirth can be detected early and responded to appropriately. 3. Kamila and her mother should ask questions and express concerns until the midwife has provided them with enough information so that they understand the role of the midwife and the care available at the health center. 4. The midwife should listen to the questions and concerns that Kamila and her mother express. She should address each of their questions with respect, ensuring that the women fully understand the care that is available. Nonverbal behaviors, such as touching or squeezing Kamila’s hand or a look of concern, may be enormously helpful in providing emotional support and reassurance for Kamila.

Basic EmONC Course

Role Play 1 Key: Communicating about a Woman’s Rights to Save Motherhood 2‐1

Basic EmONC Course

Role Play 1 Key: Communicating about a Woman’s Rights to Save Motherhood 2‐2

EXERCISE 1: WHO HAS HEPATITIS OR HIV? OBJECTIVES The participant will be aware that: 1) any person may have HIV/HBV or HCV without showing signs or symptoms of the disease (AIDS, hepatitis B or C); 2) anyone can be infected if they don’t protect themselves regardless of the status of the person that they are in contact with; and 3) HIV/HBV/HCV infection is a problem everywhere, not just in “other countries.” TIME: APPROXIMATELY 30 MINUTES (ACCORDING TO THE TIME THAT YOU HAVE) INSTRUCTIONS TO THE TRAINER: • Ask group to stand in a circle. • Explain that a few people in the group (e.g., 15%) will have their hand tickled by the trainer. • Then ask all of the group should shake hands with each other quickly and those who were tickled should tickle the person’s hand when they shake. • After this, regroup; ask the original people who were tickled to raise their hands; then ask all people who were not tickled to raise their hands. • Tell participants that those who were tickled have now been “exposed” to HIV, HBV or HCV. Those who were not tickled have not been infected. DISCUSSION QUESTIONS 1. The group is then asked to share its ideas on this activity—what was being demonstrated? 2. How did you feel once you knew you had been exposed to HIV, HBV or HCV? 3. Why is it difficult to NOT participate in the hand shaking? What would you do differently? 4. How is this anonymous contact similar to the work you do in your health care setting every day? SUMMARIZE THE MAIN POINTS • The person who was tickled didn’t know he or she was infected until they were told. • When you don’t know the risks, you don’t protect yourself. • Everyone is at risk for exposure to HIV, HBV or HCV and you will not always know when people are infected. The best way to protect us as health care providers is to consider every person potentially infected and protect ourselves always (use standards precautions with each and every client/patient).

Basic EmONC Course

Exercise 1: Who Has Hepatitis Or HIV? 2‐3

Basic EmONC Course

Exercise 1: Who Has Hepatitis Or HIV? 2‐4

Session: Interpersonal Communication (IPC) Skills for Effective Communications with Communities Duration: 75 minutes SESSION OBJECTIVES At the end of the session participants will be able to: • Define interpersonal communication (IPC) • Explain the IPC pyramid • Describe why active listening is important for effective communication • List five non‐verbal skills required for active listening • List three verbal skills required for active listening • Describe the importance of short, simple, and sensible messages for effective communication • Explain the importance of using different visual aids for effective communication OVERVIEW OF SESSION PLAN No. Content Time Method Materials 1 Introduction 5 min Q&A Computer, LCD projector, and PowerPoint presentation 2 Interpersonal communication and 10 min Interactive Computer, LCD projector, its characteristics Lecture and PowerPoint presentation Computer, LCD projector, 3 Active listening 20 min Interactive and PowerPoint presentation Lecture Q & A Hard copy of message 4 Keeping the message short, simple, 15 min Verbal Flip chart and marker game and sensible for effective Q & A communication 5 Keeping the message short, simple, 5 min Interactive Computer, LCD projector, and sensible for effective Lecture and PowerPoint presentation communication Hard copy of the instruction 6 Use of visual aids for effective 15 min Drawing of drawing communication Activity Q & A Lecture 7 Summary and evaluation 5 min Lecture Q & A

Basic EmONC Course

Session: Interpersonal Communication (IPC) 2‐5

PROCESS AND METHODOLOGY Step 1: Introduction • Explain to the participants that effective communication leads to an increase in affinity and a decrease in uncertainty while communicating with the communities regarding BEmONC services that will result in greater involvement of the communities in the planning, implementation, utilization, monitoring and evaluation of BEmONC services. • Explain that a number of skills are required to become effective communicators, and in this session we will discuss the skills required for effective communication. • Introduce the session objectives to the participants. • Explain to the participants, at the end of the session, that questions regarding each session objective will be asked to clarify if session objectives were achieved. Step 2: Interpersonal communication and its characteristics (PowerPoint Presentation) • Present the definition of the interpersonal communication and its characteristics. • Emphasize that interpersonal communication is not merely the exchange of knowledge • Present the IPC pyramid—reinforce that image with the image of a pyramid in Egypt by showing the Egyptian pyramids in the presentation so that participants can memorize it. Step3: Active listening (PowerPoint Presentation) • Ask the participations how many ears and tongues we have? • Why are we gifted with two ears and one tongue? • Present the active listening from the PowerPoint presentation. Step 4: Keeping the message short, simple, and sensible for effective communication (Verbal game) • Tell the participants that just active listening only won’t be enough for effective communication. • Select four volunteers (who are very good in reading and listening to others!). • Send the four volunteers outside of the training hall. • Select a fifth volunteer from the remaining participants and give her/him the message to read. • Ask one of the four volunteers to come in and listen to the message carefully as she/he should pass this message to the next volunteer coming after her/him. • S/he can listen just once and the reader has cannot repeat it again. • After the reader reads the message, he/she should take his/her seat. • The first volunteer will be asking the second volunteer to come in and listen to the message. • Then second volunteer should pass the message to the next volunteer, this will go on and the third volunteer will pass the message to the fourth one. Basic EmONC Course


• • • •

• •

Finally, the fourth volunteer will pass the message loudly to the plenary. Ask the second or the third volunteer to repeat the message loudly to the plenary. Ask the first volunteer to repeat the message loudly to the plenary. Ask the plenary to note that the message passing from one volunteer to the other has lost some of its parts: the final message read to the plenary by the fourth volunteer may be short. At the end, read the message again from the paper to the plenary to compare it with the messages they heard. Participants will notice a lot of changes in the message (may be words change, whole idea changes, parts missing, etc.)

•

Ask the four volunteers the following questions and write their responses on a flip chart: – Why were they unable to pass or receive the message correctly? – What would have prevented distortion of the original message? Step 5: Keeping the message short, simple, and sensible for effective communication (PowerPoint Presentation) • Present the slide of KISSS to the participants. • Emphasize that they should keep their messages short, simple, and sensible while communicating with communities regarding BEmONC services. • Tell the participants that long and complicated messages create confusion, so they should avoid long, complicated messages while communicating with communities. • Tell the participants they should remember to KISSS their messages before sending them toward the communities for effective communication. • Tell the participants even if they have interacted with the communities using short, simple, and sensible messages, they should always ask for a feedback at the end of each communication—whether communities have correctly understood the message or not. • Tell the participants that they should keep an eye on the non‐verbal gestures while communicating with the communities, so as to get continuous and true feedback while interacting with communities. • Non‐verbal gestures are important; through them we can understand if communities have decoded our messages correctly and then shape our messages accordingly. Step 6: Use of visual aids for effective communication (Drawing activity) • Ask the participants to draw an animal according to your verbal instructions. • Read the written instructions for the activity. (See below.)

Basic EmONC Course


•

Allow the participants to draw according to what they think, observe, and how they interpret the instructions given to them, according to their own perception.

•

Collect the slips from the participants and show each drawing one by one (this is fun) to the rest of the participants.

•

At the end, ask the participants why they drew different drawings in spite of having the same instructions. – Possible answers: 1. Different drawing skills 2. Different perspectives from instruction 3. Others

•

Explain that they are educated and likely have more knowledge than people in their communities. The verbal instructions were interpreted in different ways, applied to different drawing skills, and different drawings were produced. In the same way, when you are communicating with communities and provide verbal messages clearly in local language, different people will get different perspectives and they will take different pictures of the messages to their homes; and sometimes these wrong pictures can complicate the situation. Ask the participants: What will help us improve communication with the communities?

• •

Possible Answer: – IEC materials and visual aids, if these materials are used properly it will prevent misconceptions and misunderstandings and will help clarify messages; this will also give the communities the opportunity to ask more questions.

–

IEC materials are not only the materials produced by the MoPH and its partners. Health providers’ drawings and health products (FP materials, like the oral contraceptive pills packet, or showing a woman an IUCD, etc.) could be used as visual aids.

Step 7: Summary and Evaluation • Summarize the session by revising the verbal and non‐verbal skills required for active listening and re‐explaining the IPC skills pyramid. • Ask the participants if they have any question. • Ask the participants questions regarding each objective of the session to determine whether the session objectives were achieved or not. FACILITATOR’S NOTES: • Interpersonal Communication (IPC): person‐to‐person communication, verbal and non‐ verbal exchange that involves sharing information and feelings between individuals or in a small group. It is face‐to‐face, and all parties involved are senders and receivers of information at the same time (two‐way communication process) on a particular topic for establishing trusting relationships. Basic EmONC Course


CHARACTERISTICS OF INTERPERSONAL COMMUNICATION Interpersonal communication is a skill we use every day; at work, with our families, with our friends and most importantly with our clients. We often think of it in terms of knowledge exchange, but there is much more happening than pure information sharing. Interpersonal communication is not merely exchange of information as most people think of it. Interpersonal communication has some basic elements which can be divided into three main areas forming a pyramid. Until and unless those elements that are present at the foundation of the pyramid are satisfied we cannot make progress in the process of interpersonal communication any further. When the elements at the foundation are satisfied then we can proceed to the next (upper) area of interacting with each other and only after satisfying the elements of interaction then only can information, ideas, emotions be exchanged with each other. Therefore we should not merely take interpersonal communication as exchange of ideas, information, and emotions. Foundational elements (Respect, values, non‐verbal behaviors, being nonjudgmental) For any interaction between two persons to be meaningful, there has to respect amongst the two and the interaction is generally guided by the values of the two persons. The non‐verbal behavior that is shared helps to guide the course of the interaction. For e.g., if two people do not have any respect for each other, then the interaction between the two will not be meaningful. If the two people have different sets of values, then it may be difficult for them to come to an understanding. If a person approaches another to have a conversation, and if the other person is in an angry mood, and displays utter displeasure at the person approaching, it is unlikely that the person will start a conversation. Unless a person is satisfied that non‐verbal behavior of another person is conducive, the person may not start an interaction Interaction (verbal reassurances, two‐way communication and feedback) It is only after this foundation is laid that the interaction between people will begin. During an interaction, the elements of importance are the verbal reassurance between the people interacting. For e.g., imagine you are talking to someone on the telephone. If the person at the other end does not respond to you in any way, you will not be reassured that the person is listening to or understanding what you are saying. At this juncture, you are likely to keep on saying, “Hello… Hello… Are you hearing me?” Thus two‐way listening, involvement and feedback are the essential components of a successful interaction. Knowledge (ideas, emotions, information, experience) Only after a successful interaction has been established will knowledge become of importance in IPC. Sharing of ideas, experiences and information only happens after the foundation has been laid and interaction established. If we think of ourselves as well educated and literate people, consider the communities members illiterate and thus pay no respect to them then all the knowledge that we share with them will fall on their deaf ears and will have no net effect. For example, people taking child with jaundice to Mullah is a common practice in Afghanistan. Compare Mullah’s knowledge about Jaundice and Doctor’s knowledge about all types of Hepatitis(A,B,C,D,E) but refer to pyramid what elements does Mullah have more or respect more as compared to a doctor. From the above discussion of the characteristics of interpersonal communication we can say that if a person is exhibiting no pleasure in his/her face and unacceptable behavior physically and also he has lack of verbal interaction skills but at the other hand he is so expert in his professional life he is very weak from IPC perspective as he has the knowledge but not the skills to transfer the knowledge to the others, meanwhile if another person is an expert as well as very good in interaction but has poor non‐verbal communication skills, he will be able to transfer knowledge

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but cannot get the acceptance and confidence from the others, thus he/she does nothing in making people change their behaviors

ACTIVE LISTENING During interactions we should be good listeners. Listening is as important as sharing information. During health shura meetings, we are used to providing people with information; it may be difficult to remember that it is important to listen. Through listening to community members you can find out information you need to assist them with problems, and help them to make decisions. When listening to someone, listen actively. Active listening is equal to respect given to someone. We cannot measure respect but from communication perspective if we listening to someone then we are respecting him/her and if are not listening to someone while interacting then we not respect her/him. Relate active listening to IPC pyramid and the respect (element) present in the foundation of the pyramid. Active listening: Active listening is sensing the verbal component of the message and paying attention to the non‐verbal component by pay attention to the sender and interpreting it and giving meaningful feedback. Or in short, we can say “Active listening is hearing with ears and eye” and hearing is just sensing the sounds with ears. Hearing: Hearing is a passive process of just sensing the verbal component of a message and sending it to the auditory center of the brain. Non‐verbal skills required for active listening: The fallowing five non‐verbal skills are required for active listening; so while interacting with others we should pay attention if we have got these skills and using them while interacting with them. (ROLES in short form) 1. Relax 2. Open up 3. Lean forward 4. Eye contact 5. Smile/head nodding Verbal skills required for active listening: The following verbal skills are required for active listening; so while interacting with others we should pay attention if we have got these skills and using them while interacting with them. 1. Acknowledge and reflect feelings 2. Paraphrasing/Summarizing 3. Asking questions Acknowledge and reflect feelings: Acknowledge both the verbal and non‐verbal feelings of the people with whom we are interacting and then reflecting it toward them. Reflecting relays back emotions and key feelings that you have observed. When you reflect feelings, you can add to the paraphrase those affective or emotional words that tune into the person’s emotional experience. Reflecting focuses on acknowledging how a person feels and showing that you understand his/her needs and concerns. When a person says something, repeat using her/his own words what s/he just said and stop there. It is said that a good communicators should be like a mirror. What ever the feelings of the people are, they should acknowledge them and reflect them back to them for getting the trust of the people.

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•

This can enable you to know how other people are feeling and also make that person attentive toward his/her feelings so that he/she can be able to give a better description of his/her condition.

•

During the community interactions when you are explaining something to the communities and the community member’s non‐verbal expressions says that he/she has become confused so by acknowledging and reflect feelings you can ask relevant questions and explain the matter in more simple and understandable way.

Reflection helps the provider check whether the emotions observed are correct. This helps to show that do you have empathy and respect for them and their feelings PARAPHRASING: Repeating back what you heard someone say, in a short form. To make sure you understood him/her, to show him/her you are listening and to help him/her clarify his/her feelings. This is most needed when trying to get information from the community members. Misunderstanding can happen very easily when two people discuss something. A community member may tell you something that you understand in quite a different way from the way he/she meant it. To prevent misunderstanding when listening to a community problem or when sharing information with a community member, it is useful to summarize or paraphrase what has been said. Paraphrasing Involves: 1. A sentence stem such as: you appear to be saying... or what I hear you saying is... 2. Key descriptors and concepts used to describe the situation or person. Use the community member’s own words for the most important things. 3. The essence of what the community member has said in summarized form. 4. A check for accuracy. Am I hearing you correctly? Example: Community member: I don’t know what the matter is. A lot of children are dying in our village. Provider: You’re concerned about large number of child deaths and you’re not sure why, is that right? Paraphrasing is concerned with interpreting back to other person the essence of what has been said.

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SUMMARIZING Summarizing is similar to paraphrasing except that a longer time period and more information are involved. Summarizing may be used to begin or end an interview, to transition to a new topic, or to provide clarity in lengthy and complex issues or statements. It recaps what has been said. Example of summarizing at the beginning: “At our last meeting we decided that you will discuss with other community members regarding, the use of BEmONC services as a life‐saving services once complications have occured and today you here again so what was the result of you discussion” Example of summarizing at the end: Client: “I am terribly concerned over my wife. She has this feeling she has to get out of the house and see the world and get a job. I am the breadwinner, and I imagine I have a good income. The children view Amina as a perfect mother and I do too. But last night, we really saw the problem differently and had a terrible argument.” Provider: “Let me see if I can visualize the situation. You are concerned over your wife who wants to work even though you have a good income, and it resulted in a terrible argument. Is that how you see it?” TYPES OF QUESTIONS AND THEIR USAGE The following are the two types of questions: 1. Open‐ended: It helps the provider get more information about the client. These are known as “W” and “H” i.e., the questions which starts with what, why, when, who, where, and how. These questions allow the community members to describe and reveal information. The community members can take the lead by choosing how and where the answer will go. 2. Closed‐ended: Close‐ended questions do not invite elaboration but a specific response. They result in yes, no, or one to two word answers. They are useful in gathering factual information but not creating a comfortable environment in which true communication and decision making can occur. By using a series of closed questions, you can control the interview. The community members will only reveal information on the specific question asked. Importance of Using Open‐Ended Questions • Open‐ended questions allow others to express her thoughts and feelings with their OWN words, not merely in response to your closed‐ended questions. • They encourage others to make positive decisions about their problem and their solutions. • Using open‐ended questions to enhance good interpersonal communication is not as easy as it sounds. It takes practice to communicate effectively with others.

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ADVANTAGES Makes the health worker’s job easier because: • • •

They will understand the community needs more clearly and can provide information that is appropriate to that community unique situation. The community members will not repeatedly seek attention from the health worker if they get appropriate answers to their questions. By giving the community members the information they need, the community members will gain some control over their situation and be able to make decisions.

Knowledge

Interaction

Foundation

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Ideas and experience sharing

Verbal reassurance two‐way listening, involvement and feedback

Non‐verbal Non‐judgmental Respect Values


READ A MESSAGE I am going to give you a message and you will share this information with another volunteer. I am going to say this only once, so you should listen carefully. Zarif Khan who was living in Konar had a son named Zareen Khan, who he encouraged to finish school and get admission to Kabul University. Zareen Khan met with one of his classmates Zareena, the daughter of Zameen Gul, in Kabul; they married after graduation and decided to visit Band Ameer in Bamayan during their honeymoon after they heard about the beauty of Bamayan in summer from their friend Zameer. Notes: We should always KISSS our messages before sending them toward others in community interactions. KISSS stands for Keep It (your messages) Short, Simple, and Sensible. Short means that message should not be lengthy and should to the point. Simple means that the message should be delivered in local terminologies and avoid medical jargons. Sensible means that the values, interest and awareness level of the clients should be kept in mind and then frame the message accordingly. It is important to note that if the message sent toward a person is personalized, well timed and repeated it will become a part of his/her memory and the chances of acting accordingly increases. Instruction for drawing a picture: We are not going to tell you about the name of the animal. Please think about it and draw a picture of animal accordingly. Please draw an animal with following characteristics: • Four legs and short neck • A triangular face, the base of the triangle is upward • It has a chin but it’s very short • The ears of the animal are not so small, not so long, and are erected in a semi‐horizontal way • It has tail with twisted end

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CASE STUDY 1: VAGINAL BLEEDING IN EARLY PREGNANCY ANSWER KEY CASE STUDY Basri is 20 years old. She came to the health center 2 days ago with irregular vaginal bleeding and abdominal and pelvic pain. Symptoms of early pregnancy were detected and confirmed with a pregnancy test. Basri was advised to avoid strenuous activity and sexual intercourse and return immediately if her symptoms persisted. Basri returns to the health center today and reports that irregular vaginal bleeding has continued and she now has acute abdominal pain that started 2 hours ago. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Basri, and why? • Basri should be greeted respectfully and with kindness. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to check for the following signs to determine if she is in shock and in need of emergency treatment/resuscitation: rapid, weak pulse; systolic blood pressure less than 90 mm Hg; pallor; sweatiness or cold, clammy skin; rapid breathing; confusion. She should also be assessed to determine whether vaginal bleeding has increased or products of conception have been passed. 2. What particular aspects of Basri’s physical examination will help you make a diagnosis, and why? • An abdominal examination should be done to check for distension and rebound tenderness, which may indicate ectopic pregnancy; and to determine whether the uterus is softer or larger than normal for dates, which may indicate molar pregnancy. • A gentle bimanual examination should be performed to check for cervical motion tenderness and tender adenexal mass, which may indicate ectopic pregnancy; and to check for products of conception in the cervical os, which may indicate incomplete abortion. 3. What screening procedures will you include (if available) in your assessment of Basri, and why? • An ultrasound scan may help to distinguish a threatened abortion or twisted ovarian cyst from an ectopic pregnancy.

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Case Study 1 Key: Vaginal Bleeding in Early Pregnancy Answer Key 2‐15

DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Basri and your main findings include the following: - Basri’s pulse rate is 130 beats/minute and weak, her blood pressure is 85/60 mm Hg, her respiration rate is 20 breaths/minute and her temperature is 36.8º C. - Her skin is pale and sweaty. - Basri has acute abdominal and pelvic pain, her abdomen is tense and she has rebound tenderness. - She has light vaginal bleeding and the cervix is closed. 4. Based on these findings, what is Basri’s diagnosis, and why? • Basri’s symptoms and signs (e.g., signs of shock, acute abdominal and pelvic pain, rebound tenderness, light vaginal bleeding, closed cervix) are consistent with ruptured ectopic pregnancy. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Basri, and why? • Basri should be treated for shock immediately: - Position her on her side. - Ensure that her airway is open. - Give her oxygen at 6–8 L/minute by mask or cannula. - Keep her warm. - Elevate her legs. - Monitor her pulse, blood pressure, respiration, and temperature. - Start an IV using a large bore needle for rapid infusion of fluids (1 L of normal saline or Ringer’s lactate in 15–20 minutes). - Monitor her intake and output (an indwelling catheter should be inserted to monitor urinary output). • Blood should be drawn for hemoglobin and cross‐matching, and blood for transfusion should be made available as soon as possible. • Arrangements should be made for immediate transfer to the district hospital for an emergency laparotomy. Surgery should not be delayed while waiting for blood to be made available for transfusion. • Provide emotional support and reassurance to Basri and her family (or support person), explaining the situation and what to expect, and answering questions and concerns. EVALUATION - Basri has recovered well from surgery. - She is now ready to be discharged; however, her hemoglobin is 9 g/dL. - She has indicated that she would like to become pregnant again, but not for at least a year.

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6. Based on these findings, what is your continuing plan of care for Basri, and why? • Basri’s anemia should be treated with ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic acid 400 µg by mouth once daily for 6 months. • Counseling and advice should be provided on prognosis for fertility and the increased risk of a future ectopic pregnancy. • Family planning counseling should be provided, and her family planning method of choice provided to Basri before discharge. • A follow‐up visit should be arranged for Basri in 4 weeks, and she should be encouraged to return before then if she has any questions or concerns. REFERENCES Managing Complications in Pregnancy and Childbirth: C‐1 to C‐2; S‐1; S‐8; S‐13 to S‐15; S‐26

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CLINICAL SIMULATION 1: MANAGEMENT OF SHOCK (HYPOVOLEMIC OR SEPTIC SHOCK) Purpose: The purpose of this activity is to provide a simulated experience for learners to practice problem‐solving and decision‐making skills in the management of hypovolemic or septic shock, with emphasis on thinking quickly and reacting (intervening) rapidly. Instructions: The activity should be carried out in the most realistic setting possible, such as the labor and delivery area of a health center, clinic or maternity center, where equipment and supplies are available for emergency interventions. • One learner should play the role of patient and a second learner the role of skilled provider. Other learners may be called on to assist the provider. • The teacher will give the learner playing the role of provider information about the patient’s condition and ask pertinent questions, as indicated in the left‐hand column of the chart next page. • The learner will be expected to think quickly and react (intervene) rapidly when the teacher provides information and asks questions. Key reactions/responses expected from the learner are provided in the right‐hand column of the chart on the next page. • Procedures such as starting an IV and giving oxygen should be role played, using the appropriate equipment. • Initially, the teacher and learner will discuss what is happening during the simulation in order to develop problem‐solving and decision‐making skills. The italicized questions in the simulation are for this purpose. Further discussion may take place after the simulation is completed. • As the learner’s skills become stronger, the focus of the simulation should shift to providing appropriate care for the life‐threatening emergency situation in a quick, efficient and effective manner. All discussion and questioning should take place after the simulation is over. Resources: sphygmomanometer, stethoscope, equipment for starting an IV infusion, syringes and vials, oxygen cylinder, mask and tubing, bladder catheterization equipment, new examination or high‐level disinfected surgical gloves.

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Clinical Simulation 1: Management of Shock 2‐19

SCENARIO 1 (Information provided and questions asked by the teacher)

KEY REACTIONS/RESPONSES (Expected from learner) •

1. Alisha is a 36‐year‐old multigravida who has five children. Her husband, who tells you that she gave birth at home with the help of a family member, has carried her into the health center. The family member told him that the placenta delivered easily and completely immediately after birth, but Alisha has been bleeding “too much” since then. The family tried numerous things to help Alisha before bringing her to the health center, but she continues to bleed “too much.” z What do you do?

Shout for help to urgently mobilize all available personnel • Evaluate Alisha immediately for shock, including vital signs (temperature, pulse, blood pressure and respiration rate), level of consciousness, color and skin temperature • Tell Alisha (and her husband) what is going to be done, listen to her and respond attentively to their questions and concerns. • Turns Alisha on her side, if unconscious or semi‐conscious, and keeps the airway open

2. On examination, you find that Alisha’s blood pressure is 84/50 mm Hg, pulse 120 beats/ minute, respiration rate 34 breaths/minute, temperature 37º C. Her skin is cold and clammy. z What do you think is wrong with Alisha? z What will you do now?

• •

•

• • •

• •

State that Alisha is in shock Ask one of the staff that responded to your shout for help to start an IV infusion, using a large‐bore cannula and normal saline or Ringer’s lactate at a rate of 1 L in 15–20 minutes While starting the IV, collect blood for appropriate tests (hemoglobin, blood typing and cross matching, and bedside clotting test for coagulopathy) Start oxygen at 6–8 L/minute Catheterize bladder Look for the cause of shock (hypovolemic or septic) by palpating the uterus for firmness and tenderness, assessing the amount of blood loss Cover Alisha to keep her warm Elevate legs

Discussion Question 1: How do you know when a Expected Responses: Pulse greater than 110 woman is in shock? beats/ minute; systolic blood pressure less than 90 mm Hg; cold, clammy skin; pallor; respiration rate greater than 30 breaths/minute; anxious and confused or unconscious Discussion Question 2: If a peripheral vein cannot be cannulated, what should be done?

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Expected Response: A venous cut‐down should be performed.


SCENARIO 1 (Information provided and questions asked by the teacher) 3. On further examination, you find that Alisha’s uterus is soft and not contracted, but not tender. Her clothing from the waist down is blood‐ soaked. z What are Alisha’s main problems? z What are the causes of her shock and bleeding? z What will you do next?

KEY REACTIONS/RESPONSES (Expected from learner) • • • • •

State that Alisha reportedly lost “too much” blood after childbirth and considerable blood loss is evident on her clothes State that Alisha’s uterus is soft and not contracted, but not tender; she has no fever Determine that Alisha’s shock is due to postpartum hemorrhage, atonic uterus Massage Alisha’s uterus to stimulate a contraction Start a second IV infusion and gives 20 units oxytocin in 1 L of fluid at 60 drops/minute

4. After 15 minutes, the uterus is firm, bleeding has stopped, but Alisha’s blood pressure is still 88/ 60 mm Hg, pulse116 beats/minute, respiration rate 32 breaths/minute. z What will you do now?

z

5. After another 15 minutes, the uterus is still firm, there is no further bleeding, Alisha’s blood pressure is 100/60 mm Hg, pulse 90 beats/ minute, respiration rate 24 breaths/minute. z What will you do now?

z

6. Alisha’s conditions has stabilized. Twenty‐ four hours later, her hemoglobin is 6.5 g/dL. z What will you do now?

z

z z

z

z

z

z

Give another liter of fluid to ensure 2 L are infused within an hour of starting treatment Continue to give oxygen at 6–8 L/minute Continue to check that uterus remains contracted Continue to monitor blood pressure and pulse Adjusts rate of IV infusion to 1 L in 6 hours Continue to check to ensure that uterus remains contracted Continue to monitor blood pressure and pulse Check that urine output is 30 mL/hour or more Begin ferrous fumerate 120 mg by mouth PLUS folic acid 400 μg by mouth daily, and advise Alisha that she will need to take this for 3 months

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KEY REACTIONS/RESPONSES (Expected from learner)

1. Toorpekay is 26 years old and gave birth at home to her second child, with the help of her neighbor. The family reports that Toorpekay has had a fever since yesterday, was very restless during the night and is very drowsy this morning. She was carried into the health center by her husband and neighbor. z What do you do?

z

2. On examination, you find that Toorpekay’s blood pressure is 80/50 mm Hg, pulse 136 beats/ minute; respiration rate 34 breaths/minute; temperature 39.4º C. She is confused and drowsy. z What do you think is wrong with Toorpekay? z What will you do now?

z

z

z

z

z

z

z z z

z

z

3. On further examination, you find that Toorpekay’s uterus is tender and that she has foul‐smelling lochia. Upon questioning, the neighbor admits that herbs were inserted into Toorpekay’s vagina during labor. z What are Toorpekay’s main problems? z What are the causes of her shock and why? z What will you do next?

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z

z

z

Shout for help Evaluate Toorpekay immediately for shock, including vital signs (temperature, blood pressure, pulse and respiration rate), level of consciousness, color and skin temperature Tell Toorpekay (and her husband and neighbor) what is going to be done, listen to them and respond attentively to their questions and concerns Turn Toorpekay on her side, if unconscious or semi‐conscious, and keep the airway open State that Toorpekay is in shock Ask one of the staff that responded to your shout for help to start an IV infusion, using a large‐bore cannula and normal saline or Ringer’s lactate at a rate of 1 L in 15–20 minutes Collect blood for appropriate tests (hemoglobin, blood typing and cross match, and tests for coagulopathy), while starting the IV Start oxygen at 6–8 L/minute Catheterizes bladder Look for the cause of the shock (hypovolemic or septic) by palpating the uterus for firmness and tenderness Cover Toorpekay with blanket to keep her warm Elevate legs State that Toorpekay has a fever, a tender uterus and foul‐smelling lochia Determine that Toorpekay’s shock is due to infection resulting from unclean labor and childbirth practices Gives penicillin G 2 million units OR ampicillin 2 g IV (and repeats every 6 hours) PLUS gentamicin 5 mg/kg body weight IV (and repeats every 24 hours) PLUS metronidazole 500 mg IV (and repeats every 8 hours)


4. After 6 hours, Toorpekay’s blood pressure is 100/60 mm Hg, pulse 100 beats/minute, respiration rate 24 breaths/minute, temperature 38º C. She is easily roused and is oriented. z What will you do now?

z z

z

z

Adjust rate of IV infusion to 1 L in 6 hours Continue to monitor blood pressure, pulse and temperature Check that urine output is 30 mL/hour or more Continue to administer antibiotics

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EXERCISE 2: USING THE PARTOGRAPH ANSWER KEY

CASE 1

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Exercise 2 Key: Using the Partograph 2‐25

z

Step 1—see partograph

z

z

Step 2—see partograph - Steps: Inform Mrs. A. and her family of the findings and what to expect; encourage her to ask questions; provide her comfort measures, hydration, and nutrition - Advice: Assume position of choice; drink plenty of fluids and eat as desired - Expect at 13.00: Progress to at least 9 cm dilation Step 3—see partograph - Steps: Prepare for birth - Advice: Push only when urge to push - Expect: Spontaneous vaginal birth

z

Step 4 - 1st stage of active labor: 5 hours (4 hrs plotted [09.00 to 13.00] plus estimated 1 hour for dilation from 4–5 cm) - 2nd stage of active labor: 20 minutes

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CASE 2

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z

Step 1—see partograph - Diagnosis: Active labor - Action: Inform Mrs. B. and her family about findings and what to expect; give continual opportunity to ask questions; encourage Mrs. B. to walk around and to drink and eat as desired

z

Step 2—see partograph - Diagnosis: Prolonged active phase; less than 3 contractions per 10 minutes, each lasting less than 40 seconds; good fetal and maternal condition - Action: The facilitator should take the opportunity to open a discussion about using oxytocin for augmenting labor based on the clinical setting. For instance, is the woman being cared for at a health post that is 4 hours away from a district hospital where an oxytocin drip can be started? Or if she is being cared for in a district hospital, can other measures be used (such as hydration, ambulation) before oxytocin is started?

z

Step 3 - Diagnosis: Prolonged active phase; less than 3 contractions per 10 minutes, each lasting less than 40 seconds; good maternal and fetal condition - Action: Augment labor with oxytocin and artificial rupture of membranes; inform Mrs. B. and her family of the findings and what to expect; reassure; answer questions; encourage drinks; encourage Mrs. B. to assume position of choice

z

Step 4 - Steps: Continue to augment labor (maintain oxytocin infusion rate at 50 dpm), provide comfort (psychological and physical); encourage drinks and nutrition

z


z


z

Step 7 - 1st stage of labor: 9 hours - 2nd stage of labor: 1 hour 10 minutes - Why augment: Less than 3 contractions in 10 minutes, each lasting less than 40 seconds (lack of progress)

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CASE 3

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z


z


z


z

Step 4—see partograph - Final diagnosis: Obstructed labor with fetal head 3/5 palpable above the symphysis pubis - Cesarean section because Mrs. C. is already in secondary arrest of dilatation and descent despite at least 3 contractions in 10 minutes, each lasting more than 40 seconds - 15.00 action: Continue emotional and physical support, including hydration (because Mrs. C. and her family may become discouraged with lack of progress and emotionally and physically exhausted); continue attentive monitoring of maternal and fetal condition; have crossed alert line; blood‐stained amniotic fluid - Decision to perform caesarean section: Correct because fetal condition deteriorating, failure to progress despite at least 3 contractions in 10 minutes, each lasting more than 40 seconds, acetone in urine, rising maternal pulse - Problems expected in newborn: asphyxia, meconium aspiration

Q: Q: Q: Q:

What is the final diagnosis? What action was indicated at 14.00, and why? What action was indicated at 15.00, and why? At 17.00, a decision was taken to do a cesarean section, and this was rapidly done. Was this a correct action? Q: What problems may be expected in the newborn?

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CASE STUDY 2: SUPPORTING THE WOMAN IN LABOR ANSWER KEY CASE STUDY Rona is 30 years old. She attended antenatal clinic two weeks ago and has now come to the health center with her mother‐in‐law because labor pains started three hours ago. The pains start in her back and move forward, last 20 seconds and occur about every 8 minutes. ASSESSMENT (history, physical examination, screening procedures/laboratory tests) 1. What will you include in your assessment of Rona and why? • Rona should be greeted respectfully and with kindness. • A quick check should be performed to rule out danger signs and to determine whether labor is advanced (i.e. observation of pushing, grunting, bulging thin perineum, or gaping vagina and visible head). • If danger signs are present, a rapid initial assessment should be performed and the appropriate care provided • If labor is advanced, in the absence of danger signs, preparations should be made for the birth. • If labor is not advanced, an initial assessment should be performed, including history (personal information, EDC/menstrual history, present pregnancy, present labor/birth, obstetric history, medical history) and physical examination (assessment of well‐being, vital signs, inspection of breast, abdominal examination, and external and internal vaginal examinations). 2. What particular aspects of Rona’s physical examination will help you make a diagnosis or identify her problems/needs and why? • Assessment of general well‐being should include gait and movements, behavior and vocalizations, breathing, skin, and conjunctive to determine any deviations from normal. • Rona’s blood pressure, temperature and pulse should be taken. • Her breast should be inspected to detect any deviations from normal. • Abdominal examination should include noting the presence of scares, the uterine shape, fundal height, fetal lie and presentation, descent of the presenting part, fetal heart rate, and the strength, frequency and duration of contraction. • External vaginal examination should include the vaginal opening, skin, labia, and vaginal secretions. • Internal vaginal examination should include assessment of dilatation of the cervix, and assessment of the membranes and amniotic fluid, presentation and position, and molding. 3. What screening procedures/laboratory tests will you include in your assessment of Rona and why? • No screening procedures/laboratory tests are necessary at present.

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Case Study 2 Key: Supporting the Woman in Labor 2‐31

DIAGNOSIS (identification of problems/needs) You have completed your assessment of Rona and your main findings include the following: - Rona is 39 weeks pregnant. - This is her second pregnancy. - Her first pregnancy and birth were uncomplicated, although she reports that labor was more painful than she had expected. - She has no abnormal physical findings, but is very anxious and becomes agitated during contractions. - Rona’s cervix is 3 cm dilated. - The presentation is vertex and the fetal head is at four‐fifths above the pelvic brim. 4. Based on these findings, what is Rona’s diagnosis (problem/need) and why? • Rona is in the latent phase of the first stage of labor. • She is anxious and agitated during contractions, possibly because she remembers her first labor and delivery as being more painful than she had anticipated. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis (problem/need identification), what is your plan of care for Rona and why? • A supportive, encouraging atmosphere, respectful of Rona’s wishes, should be provided. • She should be attended as needed, at least every 4 hours. • Her mother‐in‐law should be encouraged to stay with her. • Rona should be allowed to remain active, as she desires; rest and sleep should also be encouraged as she desires so that she will be well rested when active labor begins. • She should be given a back rub or massage and be taught to breath our more slowly than usual during contractions and relax with each breath – this should, in particular, help to relieve her anxiety. • Food should be encouraged as tolerated and no restrictions should be placed on intake as long as Rona has no nausea and/or vomiting. She should be provided with nutritious drinks to maintain hydration (2 liters of oral fluids/24 hours as a minimum amount). • Rona should be encouraged to empty her bladder every 2 hours and empty her bowels as needed (she should not be given an enema). • To maintain cleanliness, Rona should be encouraged to bathe before active labor begins; the genital area should be cleansed before each examination. EVALUATION - Rona continues to have regular contractions; two hours after admission she is having 2 contractions in 10 minutes, each lasting 20‐40 seconds. - Maternal pulse and fetal heart rate are within normal range. - Rona’s level of anxiety remains high and she continues to become agitated during contractions 6. Based on these findings, what is your continuing plan of care for Rona and why? • Care should continue as outlined above. • Breathing technique should be explained again to Rona, emphasizing the importance of breathing out more slowly than usual and relaxing with each expiration. Basic EmONC Course


• •

Praise, reassurance and encouragement should be given to Rona Information on the process of labor and her progress should be provided to Rona

REFERENCES Basic Maternal and Newborn Care, Chapter 6

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CASE STUDY 3: POSTPARTUM ASSESSMENT AND CARE (BREASTFEEDING DIFFICULTY) ANSWER KEY CLIENT PROFILE Hanifa is 18 years of age and gave birth to her first baby at home 10 days ago. Her pregnancy, labor, and birth were uncomplicated. The midwife who attended the birth checked Hanifa and her baby the day after the birth. She has not seen a healthcare provider since then. This is her first postpartum clinic visit. Hanifa has come to the clinic because she has sore, red nipples. Her baby is with her. PRE‐ASSESSMENT 1. Before beginning your assessment, what should you do for and ask Hanifa? • Hanifa should be greeted respectfully and with kindness and offered a seat to help her feel comfortable and welcome, establish rapport, and build trust. Her baby should also be warmly acknowledged. A good relationship helps to ensure that the client will adhere to the care plan and return for continued care. • Ascertain, from other staff or from records, whether or not Hanifa and her baby have had a Quick Check. If not, you should conduct a Quick Check now. The Quick Check detects signs/symptoms of life‐threatening complications so that a woman or newborn receives the urgent care required before receiving routine assessment/care. ASSSESSMENT (Information gathering through history, physical examination, and testing) 2. What history will you include in your assessment of Hanifa and why? • Because this is Hanifa's first postpartum visit, you should take a complete history (i.e., personal information, daily habits and lifestyle, history of present pregnancy and labor childbirth, present postpartum, period, obstetric history, contraceptive history/plans, medical history) to guide further assessment and help individualize care provision. Some responses may help determine whether point toward reasons for her sore, red nipples, and/or indicate a special need/condition that requires additional care or a life‐threatening complication that requires immediate attention. • Special emphasis should be given to obtaining information about how the baby is doing and how breastfeeding is going, because she is complaining of breast problems. 3. What physical examination will you include in your assessment of Hanifa and why? • Because this is Hanifa's first postpartum visit, you should perform a complete physical examination (i.e., general well‐being, vital signs, breast inspection and palpation, abdomen [uterus/involution, bladder], leg examination, and genital examination [lochia, perineum]) to guide further assessment and help individualize care provision. Some findings may help determine whether point toward reasons for her sore, red nipples, and/or indicate a special need/condition that requires additional care or a life‐threatening complication that requires immediate attention. Basic EmONC Course

Case Study 3 Key: Postpartum Assessment and Care (Breastfeeding Difficulties) 2‐35

• •

Special attention should be given to the examination of Hanifa’s breasts to determine possible causes of her discomfort. Hanifa should be observed breastfeeding her baby to check positioning, attachment and suckling, and her comfort during breastfeeding.

•

Hanifa’s baby should also be examined (e.g., overall appearance/well‐being; head, face and mouth, eyes; chest, abdomen, cord stump, external genitalia, and anus; back and limbs; breastfeeding; and mother‐baby bonding) to assess for potential problems.

4. What laboratory tests will you include in your assessment of Hanifa and why? You should conduct an HIV test if available and as needed (if status is unknown and she does not “opt out”), to guide further assessment and help individualize care provision. A positive result would indicate a special need/condition that requires additional care. DIAGNOSIS You have completed your assessment of Hanifa and your main findings include the following: HISTORY: • Hanifa is feeling well but has sore, red nipples. • She reports that the baby breastfeeds approximately every 2 hours. • All other aspects of her history are normal or without significance. PHYSICAL EXAMINATION: • Hanifa generally appears well. • Vital signs are as follows: BP is 110/72, Pulse is 76 beats per minute; Temperature is 37.6°C. • There is no redness, tenderness, streaking, or masses palpable in the breast tissue; however, during observation of breastfeeding, it was found that the baby was not attaching well to the breast. • All findings on examination of the baby are within normal range and without significance. • All other aspects of her physical examination are within normal range and without significance. TESTING: HIV test is negative. 5. Based on these findings, what is Hanifa's diagnosis (problem/need) and why? • Hanifa has sore, red nipples related to difficulty attaching the baby to the breast. This is her first baby and her first experience with breastfeeding.

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CARE PROVISION 6. Based on your diagnosis (problem/need identification), what is your plan of care for Hanifa and why? • Hanifa should receive basic care provision (i.e., breastfeeding and breast care, complication readiness plan, nutritional support, support for mother‐baby‐family relationships, self‐care and other healthy practices, HIV counseling, immunizations and other preventive measures as well as about newborn care), which will help support and maintain a healthy postpartum/newborn period. The following emphases should be included: - Hanifa should be encouraged and reassured about practicing exclusive breastfeeding on demand. - Additional counseling and support should be provided on attachment and positioning for breastfeeding. Hanifa should be able to help her baby attach to the breast correctly before leaving the clinic. - Hanifa should be asked to return to the clinic in 2 days so that attachment and positioning for breastfeeding can be checked again, and additional support and encouragement provided. EVALUATION • Hanifa returns to the clinic in 2 days. • You find that her nipples are less sore and red, and attachment has improved, although the problem has not fully resolved. • Hanifa is very eager to continue breastfeeding 7. Based on these findings, what is your continuing plan of care for Hanifa and why? • Hanifa should again be encouraged and reassured about continuing exclusive breastfeeding on demand to prevent discouragement or discontinuation of breastfeeding. • Breastfeeding should be observed and Hanifa should be counseled again about attachment and positioning at the breast to ensure continued success at breastfeeding. • The baby should be weighed to ensure adequate intake. • Hanifa should be asked to return to the clinic every 2 days until the problem has fully resolved. • Once the problem is resolved, she should be asked to return for follow‐up 6 weeks postpartum, or before then if she has questions or concerns.

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ROLE PLAY 2: COMMUNICATING ABOUT FAMILY PLANNING CHOICES ANSWER KEY DISCUSSION QUESTIONS 1. How did the midwife approach Feroza? 2. Did the midwife give Feroza all of the information that she needed to make the best decision for herself? 3. What did the midwife do to demonstrate emotional support and reassurance during her interaction with Feroza? Were the midwife’s explanations and reassurance effective? 4. What could the midwife do to improve her interaction with a client? ANSWERS The following answers should be used by the trainer/teacher to guide the class discussion after the role play. Although these are “likely” answers, other answers provided by the participant/students during the discussion may be equally acceptable. 1. The midwife should introduce him/herself and address Feroza by name. She should speak in a calm and reassuring manner, using terminology that Feroza will easily understand. 2. Sufficient information should be provided about each of the family planning methods available (IUD, Depo‐Provera, condoms, and the Pill); the risks and benefits of each of these methods should be explained. 3. The midwife should listen and express understanding and acceptance of Feroza’s feelings about family planning. She should address each of Feroza’s questions with respect, ensuring that Feroza fully understands the family planning methods available to her. 4. Nonverbal behaviors, such touching or squeezing Feroza’s hand or a look of concern, may be enormously helpful in providing emotional support and reassurance for Feroza. Using visual aids, such as posters, flipcharts, drawings, samples of methods and anatomic models as well improves the interaction with Feroza.

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Role Play 2 Key: Communication about Family Planning Choices 2‐39

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Role Play 2 Key: Communication about Family Planning Choices 2‐40

CASE STUDY 4: PREGNANCY‐INDUCED HYPERTENSION ANSWER KEY CASE STUDY Samia is 16 years old. She is 30 weeks pregnant and has attended the antenatal clinic three times. All findings were within normal limits until her last antenatal visit 1 week ago. At that visit it was found that her blood pressure was 130/90 mm Hg. Her urine was negative for protein. The fetal heart sounds were normal, the fetus was active and uterine size was consistent with dates. She has come to the clinic today, as requested, for followup. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Samia, and why? • Samia should be greeted respectfully and with kindness. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • Samia should be asked how she is feeling and whether she has had headache, blurred vision or upper abdominal pain since her last clinic visit. • She should be asked whether fetal activity has changed since her last visit. • Her blood pressure should be checked and her urine tested for protein (the presence of proteinuria, together with a diastolic blood pressure greater than 90 mm Hg, is indicative of pre‐ eclampsia). 2. What particular aspects of Samia’s physical examination will help you make a diagnosis, and why? • Blood pressure should be measured. • An abdominal examination should be done to check fetal growth and to listen for fetal heart sounds (in cases of pre‐eclampsia/eclampsia reduced placental function may lead to low birth weight; there is an increased risk of hypoxia in both the antenatal and intranatal periods, and an increased risk of abruptio placentae). 3. What screening procedures/laboratory tests will you include (if available) in your assessment of Samia, and why? • As mentioned above, urine should be checked for protein.

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Case Study 4 Key: Pregnancy Induced Hypertension 2‐41

DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Samia and your main findings include the following: • Samia’s blood pressure is 130/90 mm Hg, and she has proteinuria 1+. • She has no symptoms suggesting severe pre‐eclampsia (headache, visual disturbance, upper abdominal pain, convulsions or loss of consciousness). • The fetus is active and fetal heart sounds are normal. Uterine size is consistent with dates. 4. Based on these findings, what is Samia’s diagnosis, and why? • Samia’s signs and symptoms (e.g., diastolic blood pressure 90–110 mm Hg after 20 weeks gestation and proteinuria up to 2+) are consistent with mild pre‐eclampsia. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Samia, and why? • Samia should be provided reassurance and counseled about the danger signs related to severe pre‐eclampsia and eclampsia (severe headache, blurred vision, upper abdominal pain, and convulsions or loss of consciousness) and the need to seek help immediately if any of these occur. She should be advised of the possible consequences of pregnancy‐induced hypertension. • She should be encouraged to take additional periods of rest and to eat a normal diet (salt restriction should be discouraged as this does not prevent pregnancy‐induced hypertension). • Samia should be asked to return to the clinic twice weekly to have her blood pressure, urine and fetal condition monitored. • Samia’s management should not include the use of anticonvulsives, antihypertensives, sedatives or tranquilizers (these should not be given unless the blood pressure or urinary protein level increases). • Basic antenatal care (early detection and treatment of problems, prophylactic interventions, birth plan development/revision, plan for newborn feeding) should be provided, as needed. • She should be advised to plan for childbirth in the hospital. EVALUATION • Samia attends antenatal clinic on a twice‐weekly basis, as requested. • Her blood pressure remains the same, she continues to have proteinuria 1+, and the fetal growth is normal. • Four weeks later, however, her blood pressure is 130/110 mm Hg and she has proteinuria 2+. • Samia has not suffered headache, blurred vision, upper abdominal pain, convulsions or loss of consciousness and says that she feels well. • However, she finds it very tiring to have to travel to the clinic by bus twice weekly for followup and wants to come only once a week. Basic EmONC Course


6. Based on these findings, what is your continuing plan of care for Samia, and why? • Samia needs to be monitored on a twice‐weekly basis, especially since her diastolic blood pressure and proteinuria have increased. Since this will be difficult on an outpatient basis because travel to the clinic twice weekly is making Samia very tired, she should be admitted to the district hospital. • The need for close followup should be explained to Samia In relation to this, she should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance. • Her care in hospital should be as follows: - Normal diet - Blood pressure monitored twice daily - Urine tested for protein daily - Fetal condition monitored twice daily - No anticonvulsants, antihypertensives, sedatives or tranquilizers • If Samia’s blood pressure returns to normal or her condition is stable, she could be discharged, providing arrangements can be made for twice‐weekly followup (e.g., it may be possible for her to attend antenatal clinic once a week and be monitored at home once a week by a community midwife). • If her condition remains unchanged, she should remain in the hospital and be monitored as described above. • Basic antenatal care should continue to be provided, as needed. • If Samia develops signs of fetal growth restriction, early childbirth should be considered. • If fetal and maternal conditions are stable, she should be allowed to go into spontaneous labor and may deliver vaginally without the need for vacuum extraction or forceps. REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐35 to S‐43

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CASE STUDY 5: PREGNANCY‐INDUCED HYPERTENSION ANSWER KEY CASE STUDY Shakila is 23 years old. She is 37 weeks pregnant and has attended the antenatal clinic four times. No abnormal findings were detected during antenatal visits, the last of which was 1 week ago. Shakila has been counseled about danger signs in pregnancy and what to do about them. Her mother has brought her to the health center because she developed a severe headache and blurred vision this morning. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Shakila, and why? • Shakila and her mother should be greeted respectfully and with kindness. • They should be told what is going to be done and listened to carefully. In addition, their questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to check level of consciousness and blood pressure. Temperature and respiration rate should also be checked. Shakila should be asked how she is feeling, when headache and blurred vision began, whether she has had upper abdominal pain and whether there has been a decrease in urinary output during the past 24 hours. • Shakila’s urine should be tested for protein. 2. What particular aspects of Shakila’s physical examination will help you make a diagnosis or identify her problems/needs, and why? • Shakila should be checked for elevated blood pressure and protein in her urine (the presence of proteinuria, together with a diastolic blood pressure greater than 90 mm Hg, is indicative of pre‐ eclampsia). • An abdominal examination should be done to check fetal condition and to listen for fetal heart sounds (in cases of pre‐eclampsia/eclampsia reduced placental function may lead to low birth weight; there is an increased risk of hypoxia in both the antenatal and intranatal periods, and an increased risk of abruptio placentae). • Note that a diagnosis should be made rapidly, within a few minutes. 3. What screening procedures/laboratory tests will you include (if available) in your assessment of Shakila, and why? • As mentioned above, urine should be checked for protein.

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DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Shakila and your main findings include the following: • Shakila’s blood pressure is 160/110 mm Hg, and she has proteinuria 3+. • She has a severe headache that started 3 hours ago. • Her vision became blurred 2 hours after the onset of headache. • She has no upper abdominal pain and has not suffered convulsions or loss of consciousness. • Her reflexes are normal. • The fetus is active and fetal heart sounds are normal. • Uterine size is consistent with dates. 4. Based on these findings, what is Shakila’s diagnosis, and why? • Shakila’s symptoms and signs (e.g., diastolic blood pressure 110 mm Hg or more after 20 weeks gestation and proteinuria up to 3+) are consistent with severe pre‐eclampsia. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Shakila, and why? • An antihypertensive drug should be given to lower the diastolic blood pressure and keep it between 90 mm Hg and 100 mm Hg to prevent cerebral hemorrhage. Hydralazine is the drug of choice; however, if this is not available, labetolol can be used. • Anticonvulsive therapy should be started. Magnesium sulfate is the drug of choice for preventing and treating convulsions in severe pre‐eclampsia and eclampsia; however, if it is not available, diazepam may be used. • Equipment to respond to a convulsion (airway, suction, mask and bag, oxygen) should be available at her bedside. • Shakila should not be left alone if she has a convulsion. • An IV of normal saline or Ringer’s lactate should be started to administer IV drugs. • An indwelling catheter should be inserted to monitor urine output and proteinuria (magnesium sulfate should be withheld if the urine output falls below 30 mL/hour over 4 hours). • A strict record of intake and output should be kept to ensure that there is no fluid overload. • Vital signs (blood pressure and respiration rate, in particular), reflexes and fetal heart rate should be monitored hourly (magnesium sulfate should be withheld if the respiration rate falls below 16 breaths/minute or if patellar reflexes are absent). • Auscultate the lung bases hourly for rales indicating pulmonary edema. • The steps taken to manage the complication should be explained to Shakila and her mother. In addition, they should be encouraged to express their concerns, listened to carefully, and provided emotional support and reassurance. Basic EmONC Course


EVALUATION • Two hours following the initiation of treatment, Shakila’s diastolic blood pressure is 100 mm Hg. • She has not had a convulsion, but still has a headache. • She does not have coagulopathy. • During the past 2 hours, however, Shakila’s urinary output has dropped to 20 mL/hour. • The fetal heart rate has ranged between 120 and 140 beats/minute. 6. Based on these findings, what is your continuing plan of care for Shakila, and why? • Do not repeat the dose of magnesium sulfate until the urine output is greater than 30 mL/hour. • Plans should be made to deliver Mrs. D.: - If the cervix is favorable (soft, thin, partly dilated), membranes should be ruptured and labor should be induced using oxytocin or prostaglandins. - If vaginal delivery is not anticipated within 24 hours, if there are fetal heart abnormalities (less than 100 or more than 180 beats/minute), or if the cervix is unfavorable, Shakila should be delivered by cesarean section. • The steps taken for continuing management of the complication should be explained to Shakila and her mother. In addition, they should be encouraged to express their concerns, listened to carefully, and provided continuing emotional support and reassurance. • After childbirth: - Anticonvulsive therapy should be continued for 24 hours. - Antihypertensive drugs should be continued if Shakila’s diastolic blood pressure is 110 mm Hg or more, and her urinary output should continue to be monitored. REFERENCES Managing Complications in Pregnancy and Childbirth: pages C‐21; S‐43 to S‐48

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CASE STUDY 6: FEVER AFTER CHILDBIRTH ANSWER KEY CASE STUDY Lailuma is a 35‐year‐old para three. She gave birth at home 48 hours ago. Her pregnancy was term and her birth was attended by a trained birth attendant (TBA). Labor lasted 2 days and the TBA inserted herbs into Lailuma’s vagina to help speed up the birth. The baby breathed spontaneously and appears healthy. Lailuma’s mother‐in‐law has brought her to the health center today because she has had fever and chills for the past 24 hours. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Lailuma, and why? • Lailuma and her mother‐in‐law should be greeted respectfully and with kindness. • They should be told what is going to be done and listened to carefully. In addition, their questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to determine the degree of illness: Lailuma’s temperature, pulse, respiration rate and blood pressure should be taken and she should be asked whether she has felt weak and lethargic or whether she has had frequent, painful urination, abdominal pain or foul‐smelling vaginal discharge. Determine whether she is from a malarial area. • The following information should also be obtained about the birth: when the membranes ruptured, problems delivering the placenta, whether it was complete and whether there was excessive bleeding following the birth. • Because herbs were inserted into Lailuma’s vagina during labor, tetanus vaccination status should be checked. 2. What particular aspects of Lailuma’s physical examination will help you make a diagnosis or identify her problems/needs, and why? • Lailuma’s abdomen should be checked for tenderness and her vulva should be checked for purulent discharge (lower abdominal pain, tender uterus, and purulent, foul‐smelling lochia are symptoms and signs of metritis). Her legs should be checked for calf muscle tenderness, which may indicate deep vein thrombosis. • Lailuma’s perineum, vagina and cervix should be examined carefully for tears, particularly since labor was prolonged and because foreign substances were inserted into the vagina.

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Case Study 6 Key: Fever After Childbirth 2‐49

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Lailuma, and why? • None at this point. DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Lailuma and your main findings include the following: • Lailuma’s temperature is 39.8º C, her pulse rate is 136 beats/minute, her blood pressure is 100/70 mm Hg and her respiration rate is 24 breaths/minute. • She is pale and lethargic and slightly confused. • She has lower abdominal pain, her uterus is soft and tender, and she has foul‐smelling vaginal discharge. • It is not known whether the placenta was complete. • Lailuma is fully immunized against tetanus. 4. Based on these findings, what is Lailuma’s diagnosis, and why? • Lailuma’s symptoms and signs (e.g., fever, together with signs of shock [rapid pulse, confusion], and lower abdominal pain, uterine tenderness, and foul‐smelling vaginal discharge) are consistent with metritis. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Lailuma, and why? • Lailuma should be treated for shock immediately: Position her on her side. Ensure that her airway is open. Give her oxygen at 6–8 L/minute by mask or cannula. Keep her warm. Elevate her legs. Monitor her pulse, blood pressure, respiration and temperature. Start an IV using a large bore needle for rapid infusion of fluids (1 L of normal saline or Ringer’s lactate in 15–20 minutes). Monitor her intake and output (an indwelling catheter should be inserted to monitor urinary output). • Blood should be drawn for hemoglobin and cross‐matching and blood for transfusion should be made available, if necessary. • The following combination of antibiotics should be given: ampicillin 2 g IV every 6 hours; plus gentamicin 5 mg/kg of body weight IV every 24 hours; plus metronidazole 500 mg IV every 8 hours. • If retained placental fragments are suspected, a digital exploration of the uterus should be performed to remove clots and large pieces of tissue. If necessary, ovum forceps or a large curette should be used. Basic EmONC Course


• • •

Uterine involution and lochia should be monitored for improvement. Because Lailuma’s childbirth was unhygienic, a booster of tetanus toxoid 0.5 mL IM should be given. The steps taken to manage the complication should be explained to Lailuma, she should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance.

EVALUATION Thirty‐six hours after initiation of treatment, you find the following: • Lailuma’s temperature is 38º C, her pulse rate is 96 beats/minute, her blood pressure is 110/70 mm Hg and her respiration rate is 20 breaths/minute. • She is less pale and no longer confused. 6. Based on these findings, what is your continuing plan of care for Lailuma, and why? • IV antibiotics should be continued until Lailuma has been fever‐free for 48 hours. Oral antibiotics should not be necessary after stopping the IV antibiotics. • Her vital signs, intake and output, and uterine involution should continue to be monitored. • IV fluids should be continued to maintain hydration until Lailuma is well enough to take adequate fluid and nourishment by mouth. • The steps taken for continuing management of the complication should be explained to Lailuma and her mother‐in‐law, they should be encouraged to express their concerns, listened to carefully, and provided continuing emotional support and reassurance. • Arrangements should be made to talk with the TBA who attended the birth and provide community education about clean birth practices. REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐1 to S‐2; S‐107 to S‐110; S‐51

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CASE STUDY 7: VAGINAL BLEEDING AFTER CHILDBIRTH ANSWER KEY CASE STUDY Alisha is a 30‐year‐old para four. She gave birth at the health center to a full‐term healthy baby weighing 4.2 kg. She received active management of the third stage and the placenta was delivered 5 minutes later, without complication. Half an hour after delivery, however, Alisha reports that she has heavy vaginal bleeding. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Alisha, and why? • Alisha should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • At the same time, a rapid assessment should be done to check for signs of shock (rapid, weak pulse, systolic blood pressure less than 90 mm Hg, pallor and sweatiness, rapid breathing, confusion). • The placenta should be checked thoroughly for completeness. 2. What particular aspects of Alisha’s physical examination will help you make a diagnosis immediately or identify her problems/needs, and why? • Alisha’s uterus should be checked immediately to see whether it is contracted. If the uterus is contracted and firm, the most likely cause of bleeding is genital trauma. If the uterus is not contracted and the placenta is complete, the most likely cause of bleeding is an atonic uterus. The most important causes of bleeding can be suspected by palpating the uterus. • Her perineum, vagina and cervix should be examined carefully for tears. 3. What screening procedures/laboratory tests will you include (if available) in your assessment of Alisha, and why? • None at this stage. DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Alisha and your main findings include the following: • Alisha’s pulse rate is 88 beats/minute, her blood pressure is 110/80 mm Hg, her respiration rate is 18 breaths/minute and her temperature is 37º C. • Her uterus is firm and well contracted. The placenta is complete. • She has no perineal trauma.

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Case Study 7 Key: Vaginal Bleeding After Childbirth 2‐53

•

Examination of the vagina and cervix is difficult because she continues to have heavy vaginal bleeding; therefore, tears of the cervix and vagina have not yet been ruled out.

4. Based on these findings, what is Alisha’s diagnosis, and why? • Alisha’s symptoms and signs (e.g., immediate postpartum hemorrhage, placenta complete, uterus well contracted) are consistent with genital trauma. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Alisha, and why? • An IV should be started using a large bore needle to replace fluid loss, using Ringer’s lactate or normal saline. • A careful speculum examination of the vagina and cervix should be conducted, without delay, as tears of either the cervix and/or the vagina are the most likely cause of Alisha’s bleeding. • Any tears should be repaired immediately. • Alisha’s vital signs and fluid intake and output should be monitored. • Her uterus should also be checked to make sure that it remains firm and well‐contracted. • Blood should be drawn for hemoglobin and cross‐matching, and blood for transfusion should be made available as soon as possible, in the event that it is needed. • The steps taken to manage the complication should be explained to Alisha She should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance. EVALUATION • One hour after childbirth, Alisha has a cervical tear repaired. 6. Based on these findings, what is your continuing plan of care for Alisha, and why? • Alisha’s vital signs and blood loss should continue to be monitored, every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 4 hours for 24 hours. Her uterus should be checked to make sure that it remains firm and well contracted. In addition, she should be encouraged to breastfeed her newborn. • Twenty‐four hours after the bleeding has stopped, a hemoglobin and hematocrit should be done to check for anemia. • If Alisha’s hemoglobin is below 7 g/dL, or her hematocrit is below 20% (indicating severe anemia), she should be given ferrous sulfate or ferrous fumarate 120 mg by mouth plus folic acid 400 µg by mouth once daily for 3 months. After 3 months, she should continue with ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic acid 400 µg by mouth once daily for 6 Basic EmONC Course


months. A blood transfusion is not needed if her vital signs are stable and no further bleeding occurs. •

If Alisha’s hemoglobin is between 7–11 g/dL, she should be given ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic acid 400 µg by mouth once daily for 6 months.

•

The steps taken for continuing management of the complication should be explained to Alisha She should be encouraged to express her concerns, listened to carefully, and provided continuing emotional support and reassurance.

•

Alisha should remain at the health center for an additional 24 hours, and before discharge counseling should be provided about danger signs in the postpartum period (bleeding, fever, headache, blurred vision) and about compliance with iron/folic acid treatment and the inclusion in her diet of locally available foods rich in iron. In addition, counseling about breastfeeding and newborn care should be provided.

REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐25 to S‐31

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CLINICAL SIMULATION 2: MANAGEMENT OF VAGINAL BLEEDING AFTER CHILDBIRTH Purpose: The purpose of this activity is to provide a simulated experience for learners to practice problem‐solving and decision‐making skills in the management of vaginal bleeding after childbirth, with emphasis on thinking quickly and reacting (intervening) rapidly. Instructions: The activity should be carried out in the most realistic setting possible, such as the labor and delivery area of a health center, clinic or maternity center, where equipment and supplies are available for emergency interventions. • One learner should play the role of patient and a second learner the role of skilled provider. Other learners may be called on to assist the provider. • The teacher will give the learner playing the role of provider information about the patient’s condition and ask pertinent questions, as indicated in the left‐hand column of the chart on the next page. • The learner will be expected to think quickly and react (intervene) rapidly when the teacher provides information and asks questions. Key reactions/responses expected from the learner are provided in the right‐hand column of the chart on the next page. • Procedures such as starting an IV and bimanual examination should be role played, using the appropriate equipment. • Initially, the teacher and learner will discuss what is happening during the simulation in order to develop problem‐solving and decision‐making skills. The italicized questions in the simulation are for this purpose. Further discussion may take place after the simulation is completed. • As the learner’s skills become stronger, the focus of the simulation should shift to providing appropriate care for the life‐threatening emergency situation in a quick, efficient and effective manner. All discussion and questioning should take place after the simulation is over. Resources: sphygmomanometer, stethoscope, equipment for starting an IV infusion, oxygen cylinder, mask and tubing, syringes and vials, new exam or high‐level disinfected or sterile surgical gloves.

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Clinical Simulation 2: Management of Vaginal Bleeding After Childbirth 2‐57


KEY REACTIONS/RESPONSES (Expected from learners)

1. Fauzia is 24 years old and has just given birth to a healthy baby girl after 7 hours of labor. Active management of the third stage was performed, and the placenta and membranes were complete. The midwife who attended the birth left the health center at the end of her shift. Approximately 30 minutes later, a nurse rushes to tell you that Fauzia is bleeding profusely. z What will you do?

z

2. On examination, you find the Fauzia’s blood pressure is 86/60 mm Hg and pulse 120 beats/ minute and weak. Her skin is not cold and clammy. z What is Fauzia’s problem? z What will you do now?

z

z

z

z z

z

Shout for help to urgently mobilize all available personnel. Make a rapid evaluation of Fauzia’s general condition, including vital signs (temperature, pulse, blood pressure and respiration rate), level of consciousness, color and temperature of skin Explain to Fauzia what is going to be done, listen to her and respond attentively to her questions and concerns

State that Fauzia is in shock from postpartum bleeding Palpate the uterus for firmness Ask one of the staff that responded to your shout for help to start an IV infusion, using a large‐bore cannula and normal saline or Ringer’s lactate at a rate of 1 L in 15–20 minutes with 20 units oxytocin While starting the IV, collect blood for appropriate tests (hemoglobin, blood typing and cross matching, and bedside clotting test for coagulopathy)

Discussion Question 1: How do you know when a woman is in shock?

Expected Responses: Pulse greater than 110 beats/minute; systolic blood pressure less than 90 mm Hg; cold, clammy skin; pallor; respiration rate greater than 30 breaths/ minute; anxious and confused or unconscious

3. You find that Fauzia’s uterus is soft and not contracted. On further examination of the placenta, you find that it is complete. z What will you do now?

z

z z z z z

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Massage the uterus to expel blood and blood clots and stimulate a contraction Start oxygen at 6–8 L/minute Catheterize bladder Cover Fauzia with blanket to keep her warm Elevate legs Continue to monitor (or has assistant monitor) blood pressure, pulse and blood loss


SCENARIO 1 (continuation)

KEY REACTIONS/RESPONSES (continuation)

Discussion Question 2: What would you have Expected Responses: done if examination of the placenta had • Explain the problem to Fauzia and provide shown a missing piece (placenta incomplete)? reassurance. • Give pethidine and diazepam IV slowly or use ketamine. • Give a single dose of prophylactic antibiotics (ampicillin 2 g IV plus metronidazole 500 mg IV OR cefazolin 1 g IV plus metronidazole 500 mg IV). z Use sterile or high‐level disinfected gloves to feel inside the uterus for placental fragments and remove with hand, ovum forceps or large curette.

3. Forty‐five minutes have passed since treatment for Fauzia was started. Her blood pressure is now 96/60 mm Hg, pulse 100 beats/minute and respiration rate 24 breaths/minute. She is resting quietly. z

z z z z z

Adjust rate of IV infusion to 1 L in 6 hours Continue to check for vaginal blood loss Continue to monitor blood pressure and pulse Check that urine output is 30 mL/hour or more Continue with routine postpartum care, including breastfeeding of newborn

What will you do now?

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Basic EmONC Course


CLINICAL SIMULATION 3: MANAGEMENT OF NEWBORN ASPHYXIA Purpose: The purpose of this activity is to provide a simulated experience for participants to practice problem‐solving and decision‐making skills in the management of an asphyxiated newborn, with emphasis on thinking quickly and reacting (intervening) rapidly. Instructions: The activity should be carried out in the most realistic setting possible, such as the labor and delivery area of a hospital, clinic or maternity center, where equipment and supplies are available for emergency interventions. • One participant should play the role of skilled provider. Other participants may be called on to assist the provider. • The trainer will give the participant playing the role of provider information about the patient’s condition and ask pertinent questions, as indicated in the left‐hand column of the chart below. • The participant will be expected to think quickly and react (intervene) rapidly when the trainer provides information and asks questions. Key reactions/responses expected from the participant are provided in the right‐hand column of the chart below. • Procedures such as newborn resuscitation should be performed with a model and other appropriate equipment. • Initially, the trainer and participant will discuss what is happening during the simulation in order to develop problem‐solving and decision‐making skills. The italicized questions in the simulation are for this purpose. Further discussion may take place after the simulation is completed. • As the participant’s skills become stronger, the focus of the simulation should shift to providing appropriate care for the life‐threatening emergency situation in a quick, efficient and effective manner. All discussion and questioning should take place after the simulation is over. Resources: newborn resuscitation model, newborn self‐inflating bag and mask, suction equipment, blanket, towels

Basic EmONC Course

Clinical Simulation 2: Management of Newborn Asphyxia 2‐61

SCENARIO 1 (Information provided and questions asked by the trainer) 1. Fatima has given birth to a 2,800 g baby boy after a prolonged second stage of labor. This was her second pregnancy. Her first baby is alive. At birth, the newborn is blue and limp and does not breathe. z What do you do?

KEY REACTIONS/RESPONSES (Expected from participant) z

z

z

z z

z

z z

z

z

z

Does not suction deeply, because this may cause the newborn to stop breathing or may cause his heart to stop

2. You have started ventilating, but the newborn’s chest does not rise. z What will you do now?

z

Rechecks and corrects, if necessary, the position of the newborn Repositions the mask on the newborn’s face to improve the seal between mask and face Squeezes the bag harder to increase ventilation pressure

3. After repositioning the mask, the newborn’s chest rises when ventilated. z What will you do now?

z

Discussion Question 1: From which newborns would you withhold naloxone?

Expected Response: Newborns whose mother is suspected of having recently abused narcotic drugs

4. After 2 more minutes of ventilating, the newborn starts to cry.

z

z

What precautions about suctioning do you observe, and why?

Dries the newborn rapidly, wraps him in a dry cloth/towel and moves him to a warm, flat surface Places the newborn on his back with his head slightly extended to open the airway Keeps the newborn wrapped or covered, except for the face and upper chest Suctions the mouth and then the nose Reassesses the newborn and if still not breathing starts ventilating with bag and mask Places the mask on the newborn’s face, covering the chin, mouth and nose Forms a seal between the mask and the face Squeezes the bag and checks seal by ventilating twice and observing if the chest rises Simultaneously tells the mother what is happening and provides reassurance If the newborn’s chest is rising, ventilates at 40 breaths/minute for 20 minutes or until the newborn starts to breathe

Basic EmONC Course

z

z

Ventilates for 1 minute and then stops to quickly assess if the newborn is breathing

Stops ventilating and observes for 5 minutes after crying stops


SCENARIO 1 (Information provided and questions asked by the trainer)

KEY REACTIONS/RESPONSES (Expected from participant) z

z

What will you do now?

Determines that breathing is normal (30–60 breaths/ minute) and that there is no indrawing of the chest and no grunting

Discussion Question 2: What would you do if the newborn is breathing but has severe indrawing of the chest?

Expected Response: Give oxygen by nasal catheter or prongs, if possible, and arrange transfer to a facility with special care for sick newborns.

6. The newborn is now breathing normally. z What ongoing care does the newborn need?

z

z

z

z

z

Prevents heat loss by placing in skin‐to‐skin contact with mother or putting under radiant heater Examines the newborn and counts the number of breaths/minute Measures the newborn’s axillary temperature Encourages the mother to breastfeed and provides reassurance (a newborn that requires resuscitation is at higher risk of developing hypoglycemia) Monitors closely for 24 hours

Basic EmONC Course


Basic EmONC Course


MIDCOURSE KNOWLEDGE ASSESSMENT QUESTIONNAIRE: INFECTION PREVENTION PRACTICES 1. HIV/HBV/HCV can be transmitted from clients to health care workers through: a) Contaminated needles or other sharp instruments that pricked the health worker’s skin b) Splashes of contaminated blood or body fluids to health workers clothes c) Skin contact with clients d) Touching HIV/HBV/HCV clients clothes

2. The single‐most practical procedure for preventing the spread of infection is a) Wearing gloves b) Wearing a mask c) Hand washing d) Cleaning skin with alcohol before injections

ANTENATAL CARE 3. A history of past pregnancies should be obtained at: a) The first antenatal visit b) The second antenatal visit c) The third antenatal visit d) Every antenatal visit

4. Focused antenatal care should ideally a) Be provided by physicians b) Be individualized and woman‐centered c) Be provided monthly after the fourth month and twice per week during the last 2 months d) Be provided by traditional birth attendants

VAGINAL BLEEDING IN EARLY PREGNANCY 5. The immediate management of ectopic pregnancy involves a) Cross‐matching blood and arranging for immediate laparotomy b) Making sure that blood is available for transfusion before surgery is performed c) Observing the woman for signs of improvement

d) Surgery performed only when patient’s condition deteriorated

Basic EmONC Course

Midcourse Knowledge Assessment Questionnaire 2‐65

6. The MVA procedure is complete when a) the wall of the uterus feels smooth b) the vacuum in the syringe decreases c) red or pink foam and no more tissue is visible in the canula d) the uterus relaxes

RAPID INITIAL ASSESMENT AND MANAGEMENT OF SHOCK 7. Rapid initial assessment should be carried out a) Only on women who present with abdominal pain and vaginal bleeding b) Only on women who present with abdominal pain c) Only on women who present with vaginal bleeding d) On all women of childbearing age who present with a problem 8. A woman who suffers shock as a result of an obstetric emergency may have a) A weak, fast pulse b) High blood pressure c) Normal breathing d) A good urine output

CHILDBIRTH CARE 9. The Partograph is a record of a) Labor for women who experience problems b) Observations during labor with the main element being the plotting of cervical dilatation c) Maternal well‐being d) Fetal well‐being 10. Plotting on the partograph should begin a) In the active phase of the first stage of labor b) In the latent phase c) When the cervix reaches full dilatation d) When the woman is admitted to the labor ward 11. During the active phase of labor the woman should: a) Be encouraged to take light meals/food as tolerated b) Be given fluids only c) Not be given food or fluids d) Be started on IV normal saline 12. Before applying controlled cord traction during active management of the third stage of labor a) Oxytocin is administered intramuscularly and the attendant waits for the uterus to contract b) The mother is asked to push c) Pressure is applied to the fundus d) The bladder is cathetherized Basic EmONC Course


13. Active management of the third stage of labor is believed to a) Reduce maternal effort b) Shorten the third stage of labor and reduce blood loss c) Minimize the risk of infection during labor d) Help rapid recovery of mother 14. For repair of vaginal and perineal tears, local anaesthetic should be infiltrated a) Only beneath the vaginal mucosa b) Only beneath the skin of the perineum c) Only deeply into the perineal muscle d) Beneath the vaginal mucosa, skin of the perineum and deep into the perineal muscle

UNSATISFACTORY PROGRESS OF LABOR 15. Cervical dilatation plotted to the right of the alert line on the partograph indicates a) Satisfactory progress of labor b) Unsatisfactory progress of labor c) The end of the latent phase d) The end of the active phase 16. Condition for vacuum extraction include: a) A preterm fetus b) A fully dilated cervix c) Fetal head is 3/5 or more above the symphysis pubis d) A brow presentation 17. Signs of impending uterine rupture include a) Normal maternal pulse b) Persistent abdominal pain and suprapubic tenderness with signs of fetal distress c) Fetal heart rate increase at every contraction d) Blood pressure increase

MALPOSITIONS AND MALPRESENTATIONS 18. When assessing fetal presentation in labor a) the examination should be done during a contraction b) vaginal examinations should not be performed c) examination should be performed every 30 minutes during the active phase d) the woman should be resting in a supine position and the examination should be done between contractions

Basic EmONC Course


19. External rotation of the fetal head indicates that the shoulders are: a) in the anterior diameter of the pelvic outlet b) in the posterior diameter of the pelvic outlet c) in the antero‐posterior diameter of the pelvic outlet d) stuck behind the symphysis pubis

20. In performing a breech delivery a) when the buttocks are seen, traction should be applied b) meconium is a sign of fetal distress c) suprapubic pressure should be avoided during delivery of the head d) the newborn should be held by the hips, not by the flank or abdomen

HEADACHE, BLURRED VISION, CONVULSIONS OR LOSS OF CONCIOUSNESS, ELEVATED BLOOD PRESSURE 21. Diastolic blood pressure 90 mmHg or more before 20 weeks of gestation is symptomatic of a) Mild Pre‐Eclampsia b) Chronic Hypertension c) Superimposed mild pre‐eclampsia d) Pregnancy‐induced hypertension 22. Elevated blood pressure and proteinuria in pregnancy define a) Pre‐Eclampsia b) Chronic hypertension c) Pyelonephritis d) None of the above Eclampsia

23. Eclamptic fits may occur in the a) antepartum period only b) intrapartum period only c) postpartum period only d) antepartum, intrapartum or postpartum periods 24. Pulmonary edema in a woman who has Pre‐Eclampsia should be considered a sign of a) Tuberculosis b) Mild Pre‐eclampsia c) Severe Pre‐Eclampsia d) Pneumonia 25. The loading dose of Magnesium sulfate is given by a) IV over 5 minutes, followed by deep IM injection into each buttock b) IV over 5 minutes, followed by deep IM injection into one buttock c) Simultaneously IV and IM injections d) IV bolus, followed by deep IM injection into each buttock Basic EmONC Course


26. An antihypertensive drug should be given for hypertension in severe Pre‐Eclampsia or Eclampsia if diastolic blood pressure is a) Between 100 and 110 mmHg b) 110 mmHg or more c) 115 mmHg or more d) 120 mmHg or more

VAGINAL BLEEDING AFTER CHILDBIRTH 27. Postpartum hemorrhage is defined as a) vaginal bleeding of any amount after childbirth b) sudden bleeding after childbirth c) vaginal bleeding in excess of 300 mL after childbirth d) vaginal bleeding in excess of 500 mL after childbirth 28. Immediate postpartum hemorrhage is most commonly due to a) Contracted uterus b) Aortic compression c) Atonic uterus d) Coagulation defect 29. Tears of the cervix, vagina or perineum should be suspected when there is immediate postpartum hemorrhage with a) A complete placenta and contracted uterus b) An incomplete placenta and a contracted uterus c) A complete placenta and an atonic uterus d) An incomplete placenta and an atonic uterus 30. If a retained placenta is undelivered after 30 minutes of oxytocin administration and controlled cord traction and the uterus is contracted a) More aggressive controlled cord traction should be attempted b) Controlled cord traction and fundal pressure should be attempted c) Manual Removal should be attempted d) Ergometrine should be given 31. If manual removal of the placenta is performed a) Give ergometrine prior to the procedure b) Give antibiotics 24 hours after the procedure c) Place one hand in the uterus and use the other hand to apply traction on the cord d) Place one hand in the uterus and one hand on the abdomen to provide counter traction on the uterine fundus

Basic EmONC Course


32. If there is continued heavy bleeding after manual removal of the placenta a) Ergometrine 0.2 mg should be given by mouth b) Ergometrine 0.2 mg should be given IM c) Oxytocin 10 units should be given as an IV bolus d) Prostaglandin 2.5 mg should be given IM

FEVER 33. Factors that may predispose to postpartum infection a) Prolonged labor and prolonged rupture of membranes b) Frequent passing urine c) No hand washing before palpating the abdomen d) Giving plenty of drinks during labor 34. A reddened, wedge‐shaped area on the breast is a typical sign of a) Breast abscess b) Mastitis c) Breast engorgement d) Post partum breast

NEWBORN 35. The newborn loses heat a) If the surface of the body is wet b) If the skin of the baby comes in contact with mother’s skin c) If the newborn is in a baby’s box d) If the baby is bottle fed 36. To help prevent heat loss, the newborn should be a) Dried thoroughly immediately after birth b) Dried thoroughly after the cord has been cut c) Dried thoroughly and covered with a clean cloth immediately after birth d) Covered with a clean, dry cloth after the cord has been cut 37. Newborn cord care involves a) Applying a dry dressing to the cord stump b) Swabbing the cord stump with alcohol and applying a dry dressing c) Keep the cord stump dry without putting any substance on it d) Covered with antiseptic soaked wet gauze 38. Clearing the airway before beginning resuscitation of the newborn involves a) Suctioning the mouth only b) Suctioning the nose only c) Suctioning the mouth then the nose d) Suctioning the nose and then the mouth Basic EmONC Course


39. The correct rate for ventilating a newborn is: a) 20 breaths per minute b) 30 breaths per minute c) 40 breaths per minute d) 60 breaths per minute 40. A baby should be a) Exclusively breastfed for 6 month and then given a varied diet with no breastfeeding b) Exclusively breastfed for 6 months and then should be introduced to complimentary foods in addition to breast milk c) Exclusively breastfed for 3 months and then should begin receiving complimentary foods in addition to breast milk d) Introduced to complimentary foods at 12 months

Basic EmONC Course


Basic EmONC Course


MIDCOURSE KNOWLEDGE ASSESSMENT QUESTIONNAIRE: ANSWER KEY INFECTION PREVENTION PRACTICES 1. HIV/HBV/HCV can be transmitted from clients to health care workers through: a) Contaminated needles or other sharp instruments that pricked the health worker’s skin b) Splashes of contaminated blood or body fluids to health workers clothes c) Skin contact with clients d) Touching HIV/HBV/HCV clients clothes

2. The single‐most practical procedure for preventing the spread of infection is a) Wearing gloves b) Wearing a mask c) Hand washing d) Cleaning skin with alcohol before injections

ANTENATAL CARE 3. A history of past pregnancies should be obtained at: a) The first antenatal visit b) The second antenatal visit c) The third antenatal visit d) Every antenatal visit

4. Focused antenatal care should ideally a) Be provided by physicians b) Be individualized and woman‐centered c) Be provided monthly after the fourth month and twice per week during the last 2 months d) Be provided by traditional birth attendants

VAGINAL BLEEDING IN EARLY PREGNANCY 5. The immediate management of ectopic pregnancy involves a) Cross‐matching blood and arranging for immediate laparotomy b) Making sure that blood is available for transfusion before surgery is performed c) Observing the woman for signs of improvement

d) Surgery performed only when patient’s condition deteriorated

Basic EmONC Course

Midcourse Knowledge Assessment Questionnaire ‐ Key 2‐73

6. The MVA procedure is complete when a) the wall of the uterus feels smooth b) the vacuum in the syringe decreases c) red or pink foam and no more tissue is visible in the canula d) the uterus relaxes

RAPID INITIAL ASSESMENT AND MANAGEMENT OF SHOCK 7. Rapid initial assessment should be carried out a) Only on women who present with abdominal pain and vaginal bleeding b) Only on women who present with abdominal pain c) Only on women who present with vaginal bleeding d) On all women of childbearing age who present with a problem 8. A woman who suffers shock as a result of an obstetric emergency may have a) A weak, fast pulse b) High blood pressure c) Normal breathing d) A good urine output

CHILDBIRTH CARE 9. The Partograph is a record of a) Labor for women who experience problems b) Observations during labor with the main element being the plotting of cervical dilatation c) Maternal well‐being d) Fetal well‐being 10. Plotting on the partograph should begin a) In the active phase of the first stage of labor b) In the latent phase c) When the cervix reaches full dilatation d) When the woman is admitted to the labor ward 11. During the active phase of labor the woman should: a) Be encouraged to take light meals/food as tolerated b) Be given fluids only c) Not be given food or fluids d) Be started on IV normal saline 12. Before applying controlled cord traction during active management of the third stage of labor a) Oxytocin is administered intramuscularly and the attendant waits for the uterus to contract b) The mother is asked to push c) Pressure is applied to the fundus d) The bladder is cathetherized Basic EmONC Course


13. Active management of the third stage of labor is believed to a) Reduce maternal effort b) Shorten the third stage of labor and reduce blood loss c) Minimize the risk of infection during labor d) Help rapid recovery of mother 14. For repair of vaginal and perineal tears, local anaesthetic should be infiltrated a) Only beneath the vaginal mucosa b) Only beneath the skin of the perineum c) Only deeply into the perineal muscle d) Beneath the vaginal mucosa, skin of the perineum and deep into the perineal muscle

UNSATISFACTORY PROGRESS OF LABOR 15. Cervical dilatation plotted to the right of the alert line on the partograph indicates a) Satisfactory progress of labor b) Unsatisfactory progress of labor c) The end of the latent phase d) The end of the active phase 16. Condition for vacuum extraction include: a) A preterm fetus b) A fully dilated cervix c) Fetal head is 3/5 or more above the symphysis pubis d) A brow presentation 17. Signs of impending uterine rupture include a) Normal maternal pulse b) Persistent abdominal pain and suprapubic tenderness with signs of fetal distress c) Fetal heart rate increase at every contraction d) Blood pressure increase

MALPOSITIONS AND MALPRESENTATIONS 18. When assessing fetal presentation in labor a) the examination should be done during a contraction b) vaginal examinations should not be performed c) examination should be performed every 30 minutes during the active phase d) the woman should be resting in a supine position and the examination should be done between contractions

Basic EmONC Course


19. External rotation of the fetal head indicates that the shoulders are: a) in the anterior diameter of the pelvic outlet b) in the posterior diameter of the pelvic outlet c) in the antero‐posterior diameter of the pelvic outlet d) stuck behind the symphysis pubis

20. In performing a breech delivery a) when the buttocks are seen, traction should be applied b) meconium is a sign of fetal distress c) suprapubic pressure should be avoided during delivery of the head d) the newborn should be held by the hips, not by the flank or abdomen

HEADACHE, BLURRED VISION, CONVULSIONS OR LOSS OF CONCIOUSNESS, ELEVATED BLOOD PRESSURE 21. Diastolic blood pressure 90 mmHg or more before 20 weeks of gestation is symptomatic of a) Mild Pre‐Eclampsia b) Chronic Hypertension c) Superimposed mild pre‐eclampsia d) Pregnancy‐induced hypertension 22. Elevated blood pressure and proteinuria in pregnancy define a) Pre‐Eclampsia b) Chronic hypertension c) Pyelonephritis d) None of the above Eclampsia

23. Eclamptic fits may occur in the a) antepartum period only b) intrapartum period only c) postpartum period only d) antepartum, intrapartum or postpartum periods 24. Pulmonary edema in a woman who has Pre‐Eclampsia should be considered a sign of a) Tuberculosis b) Mild Pre‐eclampsia c) Severe Pre‐Eclampsia d) Pneumonia 25. The loading dose of Magnesium sulfate is given by a) IV over 5 minutes, followed by deep IM injection into each buttock b) IV over 5 minutes, followed by deep IM injection into one buttock c) Simultaneously IV and IM injections d) IV bolus, followed by deep IM injection into each buttock Basic EmONC Course


26. An antihypertensive drug should be given for hypertension in severe Pre‐Eclampsia or Eclampsia if diastolic blood pressure is a) Between 100 and 110 mmHg b) 110 mmHg or more c) 115 mmHg or more d) 120 mmHg or more

VAGINAL BLEEDING AFTER CHILDBIRTH 27. Postpartum hemorrhage is defined as a) vaginal bleeding of any amount after childbirth b) sudden bleeding after childbirth c) vaginal bleeding in excess of 300 mL after childbirth d) vaginal bleeding in excess of 500 mL after childbirth 28. Immediate postpartum hemorrhage is most commonly due to a) Contracted uterus b) Aortic compression c) Atonic uterus d) Coagulation defect 29. Tears of the cervix, vagina or perineum should be suspected when there is immediate postpartum hemorrhage with a) A complete placenta and contracted uterus b) An incomplete placenta and a contracted uterus c) A complete placenta and an atonic uterus d) An incomplete placenta and an atonic uterus 30. If a retained placenta is undelivered after 30 minutes of oxytocin administration and controlled cord traction and the uterus is contracted a) More aggressive controlled cord traction should be attempted b) Controlled cord traction and fundal pressure should be attempted c) Manual Removal should be attempted d) Ergometrine should be given 31. If manual removal of the placenta is performed a) Give ergometrine prior to the procedure b) Give antibiotics 24 hours after the procedure c) Place one hand in the uterus and use the other hand to apply traction on the cord d) Place one hand in the uterus and one hand on the abdomen to provide counter traction on the uterine fundus

Basic EmONC Course


32. If there is continued heavy bleeding after manual removal of the placenta a) Ergometrine 0.2 mg should be given by mouth b) Ergometrine 0.2 mg should be given IM c) Oxytocin 10 units should be given as an IV bolus d) Prostaglandin 2.5 mg should be given IM

FEVER 33. Factors that may predispose to postpartum infection a) Prolonged labor and prolonged rupture of membranes b) Frequent passing urine c) No hand washing before palpating the abdomen d) Giving plenty of drinks during labor 34. A reddened, wedge‐shaped area on the breast is a typical sign of a) Breast abscess b) Mastitis c) Breast engorgement d) Post partum breast

NEWBORN 35. The newborn loses heat a) If the surface of the body is wet b) If the skin of the baby comes in contact with mother’s skin c) If the newborn is in a baby’s box d) If the baby is bottle fed 36. To help prevent heat loss, the newborn should be a) Dried thoroughly immediately after birth b) Dried thoroughly after the cord has been cut c) Dried thoroughly and covered with a clean cloth immediately after birth d) Covered with a clean, dry cloth after the cord has been cut 37. Newborn cord care involves a) Applying a dry dressing to the cord stump b) Swabbing the cord stump with alcohol and applying a dry dressing c) Keep the cord stump dry without putting any substance on it d) Covered with antiseptic soaked wet gauze 38. Clearing the airway before beginning resuscitation of the newborn involves a) Suctioning the mouth only b) Suctioning the nose only c) Suctioning the mouth then the nose d) Suctioning the nose and then the mouth Basic EmONC Course


39. The correct rate for ventilating a newborn is: a) 20 breaths per minute b) 30 breaths per minute c) 40 breaths per minute d) 60 breaths per minute 40. A baby should be a) Exclusively breastfed for 6 month and then given a varied diet with no breastfeeding b) Exclusively breastfed for 6 months and then should be introduced to complimentary foods in addition to breast milk c) Exclusively breastfed for 3 months and then should begin receiving complimentary foods in addition to breast milk d) Introduced to complimentary foods at 12 months

Basic EmONC Course


Basic EmONC Course


OPTIONAL CASE STUDIES

OPTIONAL CASE STUDY 1: VAGINAL BLEEDING IN LATER PREGNANCY ANSWER KEY CASE STUDY Fatima, who is 32 weeks pregnant, gravida three, has two healthy children. She has attended antenatal clinic regularly and all findings were within normal limits until her clinic visit 10 days ago. At that visit her blood pressure was noted to be 120/96 mm Hg; there were no other signs or symptoms of pregnancy‐induced hypertension. Fatima was counseled about danger signs and what to do if they occur and asked to return to the clinic in 2 weeks. She presents at the health center 2 days before her next clinic visit, accompanied by her mother‐in‐law, with vaginal bleeding, abdominal pain and a bad headache. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Fatima, and why? • Fatima and her mother‐in‐law should be greeted respectfully and with kindness. • They should be told what is going to be done and listened to carefully. In addition, their questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to check for the following signs to determine if she is in shock and in need of emergency treatment/resuscitation: rapid, weak pulse; systolic blood pressure less than 90 mm Hg; pallor; sweatiness or cold, clammy skin; rapid breathing; confusion. She should also be assessed to determine when vaginal bleeding started, the amount of blood lost, and whether the blood is bright and contains clots. • It will also be important to determine: when abdominal pain started (e.g., at the same time as vaginal bleeding) and the nature of the pain whether fetal movement has been felt since the onset of bleeding and pain when headache started and whether there has been/is any visual disturbance (abruptio placentae can be associated with pregnancy‐induced hypertension) 2. What particular aspects of Fatima’s physical examination will help you make a diagnosis and identify her problems/needs, and why? • An abdominal examination should be done to establish the location and nature of pain, to feel the consistency of the uterus and check for guarding, and to detect fetal movement (a tense/tender uterus and decreased fetal movements are signs of abruptio placentae). Palpation should be kept to a minimum, however, to avoid exacerbating the symptoms. • An attempt should be made to detect fetal heart sounds, which may be absent with an abruption. Basic EmONC Course

Optional Case Study 1 Key: Vaginal Bleeding in Later Pregnancy 3‐1

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Fatima, and why? • No laboratory tests are required to make a diagnosis. However, an ultrasound scan may be performed if possible to locate placenta if placenta previa is suspected. DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Fatima and your main findings include the following: • Fatima’s pulse rate is 120 beats/minute and weak, blood pressure is 110/60 mm Hg, respiration rate is 20 breaths/minute and her temperature is 37º C. • Her skin is pale and sweaty. • Fatima has constant abdominal pain, her uterus is tender on palpation, and the fetal heartbeat could not be heard. • She has heavy vaginal bleeding containing some old clotted blood. • Coagulopathy was not detected. 4. Based on these findings, what is Fatima’s diagnosis, and why? • Fatima’s signs and symptoms (e.g., signs of shock, constant abdominal pain, uterine tenderness, vaginal bleeding, and absent fetal heart sounds) are consistent with abruptio placentae. 5. What laboratory tests would be appropriate at this time? • A bedside clotting test should be performed to detect or rule out coagulopathy (coagulopathy can be triggered by abruptio placentae). CARE PROVISION (Planning and Intervention) 6. Based on your diagnosis, what is your plan of care for Fatima, and why? • Fatima should be treated for shock immediately: Position her on her side. Ensure that her airway is open. Give her oxygen at 6–8 L/minute by mask or cannula. Keep her warm. Elevate her legs. Monitor her pulse, blood pressure, respiration and temperature. Start an IV using a large bore needle for rapid infusion of fluids (1 L of normal saline or Ringer’s lactate in 15–20 minutes). Monitor her intake and output (an indwelling catheter should be inserted to monitor urinary output). • Blood should be drawn for hemoglobin and cross‐matching and blood for transfusion should be made available as soon as possible. • Arrangements should be made for childbirth as soon as possible. Basic EmONC Course


•

The steps taken to manage the complication should be explained to Fatima and her mother‐ in‐law. Provide emotional support and reassurance, and answer any questions and concerns.

EVALUATION • Half an hour after admission, Fatima’s condition has been stabilized, although she continues to bleed vaginally. • Her cervix is found to be 3 cm dilated. • Fetal heart sounds cannot be detected. • Her blood clotting test is normal. 7. Based on these findings, what is your continuing plan of care for Fatima, and why? • Since vaginal delivery is not imminent, arrangements should be made to deliver Fatima by emergency cesarean section. • Blood loss should be replaced with blood transfusion, although the availability of blood for transfusion should not delay surgery. • The nature of the procedure and the risks involved should be explained to Fatima and her mother‐in‐law and continuing emotional support and reassurance should be provided. In particular, they should be prepared for the inevitability of a stillbirth. • Vigilant observation of Fatima’s condition (vital signs, uterine involution, lochia) should be provided after childbirth, since there is a high risk of postpartum hemorrhage in women with abruptio placentae. • In addition, Fatima should be encouraged to see and hold her baby to facilitate grieving, and she and her family should be allowed to prepare the baby for its funeral, if they wish. • Before discharge from health center, possible preventive measures for the future should be discussed with Fatima and her partner or, if she wishes, another family member. REFERENCES Managing Complications in Pregnancy and Childbirth: pages C‐1; C‐10 to C‐11; S‐1 to S‐2; S‐18 to S‐ 20

Basic EmONC Course


Basic EmONC Course


OPTIONAL CASE STUDY 2: VAGINAL BLEEDING IN LATER PREGNANCY ANSWER KEY CASE STUDY Sabera is a healthy 20‐year‐old primigravida. Her pregnancy has been uncomplicated. At 38 weeks gestation, Sabera walks into the emergency department at the health center, accompanied by her husband. She reports that she has painless, bright red vaginal bleeding that started 2 hours ago. Sabera has visited the antenatal clinic three times during her pregnancy. At her last antenatal clinic visit, which was 2 weeks ago, there were no abnormal findings. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Sabera, and why? • Sabera and her husband should be greeted respectfully and with kindness. • They should be told what is going to be done and listened to carefully. In addition, their questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to check for the following signs to determine if she is in shock and in need of emergency treatment/resuscitation: rapid, weak pulse; systolic blood pressure less than 90 mm Hg; pallor; sweatiness or cold, clammy skin; rapid breathing; confusion. She should also be assessed to determine the amount of blood lost since vaginal bleeding started. • A vaginal examination should not be carried out as part of the initial assessment; however, a careful speculum examination should be done to rule out incidental causes of bleeding (e.g., cervicitis, trauma, cervical polyps). 2. What particular aspects of Sabera’s physical examination will help you make a diagnosis and identify her problems/needs, and why? • An abdominal examination should be done to establish the lie and presentation of the fetus (abnormal lie and malpresentation can be associated with placenta previa, as can a high fetal head in a primigravida with placenta previa). The consistency of the uterus should be checked and the presence of pain determined to differentiate between symptoms and signs for abruptio placentae. (Abruptio placentae is usually accompanied by a tense, tender uterus.) • Fetal condition should be assessed by listening to the fetal heart sounds (the fetal condition should be normal if Sabera has placenta previa, whereas for an abruption, there may be fetal distress or absent fetal heart sounds). 3. What screening procedures/laboratory tests will you include (if available) in your assessment of Sabera, and why? Basic EmONC Course


An ultrasound scan should be performed, if possible, to localize the placenta. • DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Sabera and your main findings include the following: • Sabera’s pulse rate is 88 beats/minute, her blood pressure is 110/80 mm Hg, her respiration rate is 16 breaths/minute and her temperature is 37º C. • Vaginal bleeding is found to be light to moderate and bright red, and Sabera reports soaking 12 pads before coming to the health center. • Uterine consistency is normal and there is no abdominal pain. The lie is longitudinal, the presentation is vertex, and the head is well above the pelvic brim. The fetus is active and the fetal heart rate is 120 beats/minute. • It has not been possible to do an ultrasound scan. 4. Based on these findings, what is Sabera’s diagnosis, and why? • Sabera’s symptoms and signs (e.g., painless vaginal bleeding, high fetal head in a primigravida, normal fetal condition) are consistent with placenta previa. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Sabera, and why? • An intravenous infusion should be started, using normal saline or Ringer’s lactate, to replace blood loss. • Blood should be drawn for hemoglobin and cross‐matching and blood for transfusion should be made available, if required. • Sabera should be kept in the health center and closely monitored. • An ultrasound scan should be done as soon as possible to localize the placenta. • Give ferrous sulfate or ferrous fumarate 60 mg daily. • The steps taken to manage the complication should be explained to Sabera and her husband. In addition, they should be encouraged to express their concerns, listened to carefully, and given emotional support and reassurance. EVALUATION • Sabera has had light vaginal bleeding for 2 days since admission to the health center. • Her condition has been stable, the fetus has remained active, and the fetal heart rate has ranged from 120 to 140 beats/minute. • On the morning of the third day in the health center, the bleeding increases from light to moderate and is bright red. • It has still not been possible to do an ultrasound scan.

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6. Based on these findings, what is your continuing plan of care for Sabera, and why? • Since an ultrasound scan has not been possible, and since Sabera is more than 38 weeks pregnant, arrangements should be made immediately to do a vaginal examination, using a high‐level disinfected vaginal speculum to view the cervix. The vaginal examination should be done in the operating room, in preparation for a cesarean section, should it be necessary. • The nature of the procedure and the risks involved should be explained to Sabera and her husband, and continuing emotional support and reassurance should be provided. • Before the vaginal examination is carried out, an intravenous line must be established and cross‐matched blood should be available. • Placenta previa should be confirmed, if on vaginal examination: the cervix is dilated and placental tissue is visible the cervix is not dilated but spongy tissue is felt at the vaginal fornices • If placenta previa is confirmed, there is low implantation of the placenta and bleeding is light, vaginal delivery could be considered; otherwise, delivery should be undertaken by cesarean section. • Vigilant observation of Sabera’s condition (vital signs, uterine involution, lochia) should be provided after childbirth, since there is a high risk of postpartum hemorrhage in women with placenta previa. • After childbirth, counseling and support should be provided for breastfeeding and care of the newborn, nutrition, rest and hygiene for Sabera, and the early recognition of danger signs and what to do about them, for both Sabera and her newborn. • A follow‐up appointment for postpartum care should be arranged before Sabera leaves the health center. • Sabera should be discharged with iron tablets and instructions for daily use. REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐6; S‐21 to S‐23

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Basic EmONC Course


OPTIONAL CASE STUDY 3: MALPOSITION ANSWER KEY CASE STUDY Mariam is a 26‐year‐old gravida three, para two. She was brought to the health center in active labor at 2:00 pm; membranes ruptured 30 minutes before her arrival; the fetal head was palpable at 3/5 above the symphysis pubis; the cervix was 5 cm dilated; contractions were two in 10 minutes, each lasting 20–40 seconds. Amniotic fluid is clear. There were no abnormal findings on admission. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your ongoing assessment (monitoring progress in labor) of Mariam, and why? • Mariam’s progress in labor should be monitored using a partograph. Ongoing observations should include: maternal pulse, fetal heart rate, and contractions half hourly, blood pressure and temperature every 4 hours, urine for protein and acetone every 2–4 hours, vaginal examination every 4 hours (cervical dilation, descent of presenting part, amniotic fluid and molding), preceded by abdominal examination (descent of presenting part). • Mariam’s emotional response to labor should also be assessed to determine her level of anxiety and tolerance of pain. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. DIAGNOSIS (Identification of Problems/Needs) Ongoing assessment of Mariam’s progress in labor reveals the following: • On abdominal examination at 6:00 pm, the lower part of the abdomen is flattened and fetal limbs are palpable anteriorly. • Contractions are three in 10 minutes, each lasting 20–40 seconds. • Mariam complains of continuous and severe backache, worsening with contractions. • On vaginal examination, the posterior fontanelle is felt towards the sacrum. • The cervix is 8 cm dilated. Amniotic fluid is clear. 2. Based on these findings, what is Mariam’s diagnosis, and why? • Mariam’s symptoms and signs (e.g., the occiput lies in the posterior rather than the anterior part of the pelvis) are consistent with occiput posterior position.

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Optional Case Study 3 Key: Malposition 3‐9

CARE PROVISION (Planning and Intervention) 3. Based on your diagnosis, what is your plan of care for Mariam, and why? • Continue to monitor Mariam every 30 minutes using the partograph. In particular, it will be important to watch for signs of obstruction (secondary arrest of cervical dilation and descent of presenting part with large caput, third degree molding, cervix poorly applied to the presenting part, edematous cervix, ballooning of lower uterine segment, formation of retraction band, maternal and fetal distress). • An IV infusion of dextrose or normal saline should be started and oxytocin 2.5 units in 500 mL of dextrose or normal saline should be infused at 10 drops/minute. • The rate of infusion should be increased by 10 drops/minute every 30 minutes (up to a maximum of 60 drops/minute) until there are three contractions in 10 minutes, each lasting more than 40 seconds. This rate should be maintained until the birth is completed. • Mariam should not be left alone during augmentation of labor. She should be made as comfortable as possible, and a supportive, encouraging atmosphere, respectful of her wishes, should be provided. In particular, massage and other comfort measures such as changes in position and posture may help to relieve discomfort. • All procedures should be explained to Mariam, and all findings should be discussed with her. EVALUATION • At 8:00 pm Mariam is having three contractions in 10 minutes, each lasting more than 40 seconds. • Her partograph recordings show that her vital signs are normal, the fetal heart rate is within normal range, the cervix is fully dilated, the anterior fontanelle can be felt just behind the symphysis pubis, and the head is at +1 station. 4. Based on these findings, what is your continuing plan of care for Mariam, and why? • Mariam should be encouraged to adopt her position of choice for childbirth when she reaches late (expulsive) second stage. • When the head is visible, she should be encouraged to follow her own tendency to push; the intensity of her contractions should regulate her efforts to push. She should be given praise, encouragement and reassurance regarding her progress. • If the expulsive phase is prolonged, vacuum extraction or forceps should be used to deliver the baby. • Active management of the third stage should be carried out to reduce postpartum blood loss. • Immediate postpartum care should be provided for Mariam, including continuing emotional support and reassurance. • If her newborn requires special care, this should be provided. Otherwise, routine newborn care should be provided, including leaving the newborn in skin‐to‐skin contact with Mariam Basic EmONC Course


and encouraging her to breastfeed, as soon as she feels able to, when the newborn shows interest. REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐69 to S‐72; S‐75 to S‐76

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Basic EmONC Course


OPTIONAL CASE STUDY 4: FEVER AFTER CHILDBIRTH ANSWER KEY CASE STUDY Shahgul is 22 years old. She gave birth to a full‐term baby 3 days ago at the hospital. The baby weighed 4 kg and Shahgul suffered a perineal laceration that required suturing. She was counseled about danger signs before leaving the hospital, including the need to seek care early if any danger signs occur. Shahgul has come to the health center today complaining that her perineal wound has become increasingly tender during the past 12 hours. She also says that she feels hot and unwell. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Shahgul, and why? • Shahgul should be greeted respectfully and with kindness. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to determine the degree of illness: Shahgul’s temperature, pulse, respiration rate and blood pressure should be taken and she should also be asked if she has had other symptoms, such as: abdominal pain and/or tenderness or foul‐ smelling lochia. 2. What particular aspects of Shahgul’s physical examination will help you make a diagnosis or identify her problems/needs, and why? • Shahgul’s perineal wound should be examined for pain and tenderness, discharge, abscess formation and cellulitis (wound tenderness, bloody or serous discharge, and slight erythema beyond the edge of the incision may be present with a wound abscess, wound seroma or wound hematoma; whereas, pain and tenderness, erythema or edema beyond the edge of the incision, purulent discharge, and a reddened area around the wound are signs of wound cellulitis). If purulent discharge is seen, determine whether it is coming from the wound or from above the wound (vagina, uterus). • An abdominal examination should also be done and lochia checked to detect other signs characteristic of postpartum fever (abdominal pain and tenderness, and purulent foul‐ smelling lochia). 3. What screening procedures/laboratory tests will you include (if available) in your assessment of Shahgul, and why? • None at this stage.

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DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Shahgul and your main findings include the following: • Shahgul’s temperature is 38º C, her pulse rate is 88 beats/minute, her blood pressure is 120/80 mm Hg and her respiration rate is 20 breaths/minute. • Her perineal wound is tender, with pus draining from the center. • The wound is not edematous but there is slight erythema present extending beyond the edge of the incision. • She has no abdominal pain or tenderness. • Her lochia is red, normal in amount, and does not have an offensive odor. 4. Based on these findings, what is Shahgul’s diagnosis, and why? • Shahgul’s symptoms and signs (e.g., wound tenderness, pus discharge, erythema, fever) are consistent with wound abscess. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Shahgul, and why? • Because there is pus draining from the wound, it should be opened and drained. The infected skin and subcutaneous sutures should be removed and the wound debrided and a damp dressing placed in it. Antibiotics are not required because there is no wound cellulitis. • The steps taken to manage the complication should be explained to Shahgul, she should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance. • Shahgul should be counseled about the need for good hygiene, to change her perineal pad/cloth at least three times a day, and to wear clean clothes. • She should also be encouraged to rest at home and to drink as much fluid as possible. • Shahgul should be asked to return the next day for followup and to have the perineal dressing changed. EVALUATION • Shahgul returns to the health center the next day. • Her temperature is 37.6º C. • Her perineal wound is slightly less tender and there is less discharge. 6. Based on these findings, what is your continuing plan of care for Shahgul, and why? • The wound should be dressed again with a damp dressing. • The steps taken for continuing management of the complication should be explained to Shahgul, she should be encouraged to express her concerns, listened to carefully, and provided continuing emotional support and reassurance. Basic EmONC Course


Shahgul should be followed up on a daily basis until the wound has healed satisfactorily. • REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐107 to S‐108; S‐113 to S‐114

Basic EmONC Course


Basic EmONC Course


OPTIONAL CASE STUDY 5: FEVER AFTER CHILDBIRTH ANSWER KEY CASE STUDY Meena is 17 years old. She gave birth to her first baby 3 weeks ago at the hospital. Her birth was uncomplicated and the baby was healthy and of normal birth weight. You last saw Meena 2 days after the birth, when she and her newborn were found to be doing well. She has come to the health center today because she has breast pain and tenderness and feels unwell. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your assessment of Meena, and why? • Meena should be greeted respectfully and with kindness. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to determine the degree of illness; Meena’s temperature, pulse, respiration rate and blood pressure should be checked. In addition, she should be asked how breastfeeding is going, whether she has had any problems, how many times in a 24‐hour period the newborn is feeding, whether she has fed the newborn anything other than breast milk, and whether she has cracked or sore nipples. 2. What particular aspects of Meena’s physical examination will help you make a diagnosis or identify her problems/needs, and why? • Meena’s breasts should be checked for pain and tenderness, swelling and inflammation, and cracked nipples. 3. What screening procedures/laboratory tests will you include (if available) in your assessment of Meena, and why? • None at this stage. DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Meena and your main findings include the following: • Her temperature is 38º C, her pulse rate is 120 beats/minute, her blood pressure is 120/80 mm Hg and her respiration rate is 20 breaths/minute. • She has pain and tenderness in her left breast, and there is a wedge‐shaped area of redness in one segment of the breast. • Meena reports that for the first week or so after birth, her newborn seemed to have difficulty taking the nipple into his mouth, but more recently she thinks that he has been doing better. Basic EmONC Course

Optional Case Study 5 Key: Fever After Childbirth 3‐17

• •

He feeds about six times in a 24‐hour period and is given water between feedings. Meena had breastfed the newborn less than an hour before you examined her.

4. Based on these findings, what is Meena’s diagnosis, and why? • Meena’s symptoms and signs (e.g., fever, breast pain and tenderness, and a reddened, wedge‐shaped area on one breast) are consistent with mastitis. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Meena, and why? • Meena should be treated with one of the following antibiotics: cloxacillin 500 mg by mouth four times/day for 10 days; or erythromycin 250 mg by mouth three times/day for 10 days. • Her breastfeeding technique should be observed for correct positioning (i.e., newborn’s head and body straight, well supported, and held close to mother’s body, newborn facing breast with nose opposite nipple) and attachment (i.e., more areola visible above than below the mouth, mouth open wide, lower lip turned outward, chin touching breast). • Meena should be provided reassurance and encouragement to continue breastfeeding, at least eight times in a 24‐hour period. She should also be encouraged to stop giving her newborn water and counseled about exclusive breastfeeding. • A breast binder or brassiere should be worn to support her breasts and cold compresses should be applied between feedings to reduce swelling and pain. • Paracetamol 500 mg by mouth should be given, as needed. • Meena should be asked to return for followup in 3 days.

EVALUATION • Three days later Meena reports that she is feeling better and has stopped taking her medication. • Her temperature is 37.6º C, her pulse is 90 beats/minute, her blood pressure is 120/80 mm Hg and her respiration rate is 20 breaths/minute. • There is less pain and swelling in her breast. • She reports that she has stopped giving her newborn water and he has been feeding more than six times in 24 hours. • She also reports that the newborn seems to be attaching better to the breast. 6. Based on these findings, what is your continuing plan of care for Meena, and why? • Meena should be counseled about the importance of completing the full 10‐day course of antibiotics (3 days of antibiotic therapy is insufficient to resolve infection). • Breastfeeding technique should be observed again to check positioning and attachment, and further reassurance and encouragement should be provided to Meena to continue breastfeeding at least eight times in 24 hours. Basic EmONC Course


•

Meena should be followed up every 2–3 days to ensure that she complies with antibiotic therapy, that her symptoms and signs resolve, and to provide continuing reassurance and encouragement for breastfeeding.

REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐107 to S‐108; S‐112

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Basic EmONC Course


OPTIONAL CASE STUDY 6: VAGINAL BLEEDING AFTER CHILDBIRTH ANSWER KEY CASE STUDY Karima is 20 years old. She gave birth at the health center 6 days ago to a healthy baby, with no apparent complications. She has come back to the health center today complaining that she feels weak, light‐headed and generally unwell. She says that she has vaginal bleeding equal to a heavy period. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Karima, and why? • Karima should be greeted respectfully and with kindness. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to determine the degree of illness: her temperature, pulse, respiration rate and blood pressure should be taken check for signs of shock, and she should be asked about changes in the color, amount and odor of lochia since birth. • Karima’s record should be checked for information about amount of blood loss immediately after childbirth, completeness of the placenta, and genital trauma. 2. What particular aspects of Karima’s physical examination will help you make a diagnosis or identify her problems/needs, and why? • Karima’s uterus should be checked immediately to see whether it is contracted (a uterus that is not contracted would suggest atonic uterus, whereas if the uterus is well contracted, genital trauma may be the cause of bleeding). • Her perineum, vagina and cervix should be examined carefully to detect tears. • The amount, color and odor of Karima’s lochia should be checked. • Conjunctival and palmar pallor should be checked for signs of anemia. 3. What screening procedures/laboratory tests will you include (if available) in your assessment of Karima, and why? • A hemoglobin test should be done, as Karima has vaginal bleeding that is heavier than it should be, as well as signs that suggest anemia (weak and light‐headed).

Basic EmONC Course

Optional Case Study 6 Key: Vaginal Bleeding After Childbirth 3‐21

DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Karima and your main findings include the following: • Karima’s pulse rate is 90 beats/minute, her blood pressure is 120/80 mm Hg, her respiration rate is 20 breaths/minute and her temperature is 37º C. • Her uterus is soft and almost to the level of her umbilicus. • She has no signs of cervical, vaginal or perineal trauma. • However, vaginal bleeding has become progressively heavier and Karima’s lochia now has a slightly offensive odor. • She also has mild conjunctival and palmar pallor, and her hemoglobin is 9 g/dL. • Karima’s record does not indicate blood loss after childbirth or whether the placenta was complete. 4. Based on these findings, what is Karima’s diagnosis, and why? • Karima’s signs and symptoms (e.g., a uterus that is not well contracted, vaginal bleeding that is heavier than it should be at 6 days postpartum and anemia) are consistent with delayed postpartum hemorrhage. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Karima, and why? • Karima’s uterus should be massaged, after she has emptied her bladder, to cause it to contract and expel retained blood clots. • Oxytocin 10 units IM should be given. • If Karima’s cervix is dilated, manual exploration of the uterus should be carried out to remove large clots and placental fragments. • If the cervix is not dilated, Karima’s uterus should be evacuated using manual vacuum aspiration. • If bleeding continues, clotting status should be assessed using a bedside clotting test and, if necessary, coagulopathy should be treated. • Karima’s vital signs should be monitored, and her uterus should be checked to make sure that it remains firm and well contracted. • Anemia should be treated with ferrous sulfate or ferrous fumarate 60 mg by mouth plus folic acid 400 µg by mouth once daily for 6 months. • The steps taken to manage the complication should be explained to Karima, she should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance.

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EVALUATION • Two hours later Karima is resting after having had placental remnants removed from her uterus. • Her uterus is now well contracted and she has light vaginal bleeding. • Her pulse is 82 beats/minute, her blood pressure is 120/80 mm Hg, her respiration rate is 20 breaths/minute and her temperature 37.2º C. 6. Based on these findings, what is your continuing plan of care for Karima, and why? • Karima should remain at the health center for 24 hours to have her vital signs and vaginal bleeding monitored. Her uterus should be checked to make sure that it remains firm and well contracted. In addition, she should be encouraged to breastfeed her newborn. • Before leaving the health center, counseling should be provided about danger signs in the postpartum period (bleeding, abdominal pain, fever, headache, and blurred vision), compliance with iron/folic acid treatment and the inclusion in her diet of locally available foods rich in iron, and breastfeeding and newborn care. In addition, Karima should be provided emotional support and reassurance. • Arrangements should be made for her to have postpartum followup care in 1 week. REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐25 to S‐34

Basic EmONC Course


Basic EmONC Course


OPTIONAL CASE STUDY 7: SHOULDER DYSTOCIA ANSWER KEY CASE STUDY Amina is a 35‐year‐old gravida seven, para six. She was brought to the health center in active labor at 10:00 pm. Labor has progressed well, as indicated on her partograph. It is now 4:00 am and the fetal head has just delivered and remains tightly applied to the vulva. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your immediate assessment of Amina, and why? • Rapidly determine whether the chin retracts and depresses the perineum. Apply traction to the baby’s head to deliver the shoulder (if shoulder dystocia is present, the shoulder will be caught behind the symphysis pubis and cannot be delivered by traction on the baby’s head). • While managing this problem, quickly tell Amina what is happening and what is going to be done (shoulder dystocia is a frightening experience for the woman and for the provider, so it is important to remain calm and explain as much as possible to the woman as you proceed with care).

DIAGNOSIS (Identification of Problems/Needs) Immediate assessment of the situation reveals the following: • The chin retracts and depresses the perineum. • Traction on the head fails to deliver the shoulder, which is caught behind the symphysis pubis. 2. Based on these findings, what is Amina’s diagnosis, and why? • The findings are consistent with shoulder dystocia. CARE PROVISION (Planning and Intervention) 3. Based on your diagnosis, what is your plan of care for Amina, and why? • An adequate episiotomy should be made immediately to reduce soft tissue obstruction and to allow space for manipulation. • With Amina lying on her back, help her to flex both knees. Two assistants should be asked to push her flexed knees firmly up onto her chest (this should help to rotate the angle of the symphysis pubis superiorly). • Firm, continuous downward traction should be applied to the fetal head to move the shoulder that is anterior under the symphysis pubis. At the same time, an assistant should be asked to apply suprapubic pressure downward to assist delivery of the shoulders. Basic EmONC Course

Optional Case Study 7 Key: Shoulder Dystocia 3‐25

•

Continuing encouragement and reassurance should be provided for Amina

EVALUATION • Five minutes have lapsed since the head delivered. No further progress has been made. 4. Based on these findings, what is your continuing plan of care for Amina, and why? • Amina should remain in the same position (i.e., on her back with her knees well flexed). • A gloved hand should be inserted into the vagina and pressure should be applied to the shoulder that is anterior in the direction of the baby’s sternum (this should rotate the shoulder and decrease the shoulder diameter). If necessary, pressure can also be applied to the shoulder that is posterior in the direction of the sternum. • If the shoulder is still not delivered, insert a hand into the vagina and grasp the humerus of the arm that is posterior. The arm should be well flexed at the elbow and should be swept across the chest (this should provide room for the shoulder that is anterior to move under the symphysis pubis). • Throughout these maneuvers, Amina should be provided continuing encouragement and reassurance. • Active management of the third stage should follow (blood loss may be excessive due to injury associated with the childbirth). • Immediate postpartum care should be provided for Amina, including continuing emotional support and reassurance. • If her newborn requires special care, this should be provided (newborn asphyxia may occur following shoulder dystocia, and brachial plexus injury may result in an Erb’s palsy). Otherwise, routine newborn care should be provided, including leaving the newborn in skin‐ to‐skin contact with Amina and encouraging her to breastfeed her newborn as soon as she feels able to, when the newborn shows interest. REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐83 to S‐85

Basic EmONC Course

Optional Case Study 7 Key: Shoulder Dystocia 3‐26

OPTIONAL CASE STUDY 8: VAGINAL BLEEDING IN EARLY PREGNANCY ANSWER KEY CASE STUDY Adela is 28 years old. She is 12 weeks pregnant when she presents at the health center complaining of light vaginal bleeding. This is Adela’s first pregnancy. It is a planned pregnancy, and she has been well until now. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Adela, and why? • Adela should be greeted respectfully and with kindness. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • A rapid assessment should be done to check for the following signs to determine if she is in shock and in need of emergency treatment/resuscitation: rapid, weak pulse; systolic blood pressure less than 90 mm Hg; pallor; sweatiness or cold, clammy skin; rapid breathing; confusion. 2. What particular aspects of Adela’s physical examination will help you make a diagnosis or identify her problems/needs, and why? • An abdominal examination should be done to check for tenderness and to determine the size, consistency and position of the uterus. A pelvic examination should be done to check for tenderness and to determine whether the cervix is closed, whether there is any tissue protruding from the cervix and the amount of bleeding. 3. What causes of bleeding do you need to rule out? • Abortion (threatened, inevitable, complete, incomplete) • Ectopic pregnancy • Molar pregnancy DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Adela, and your main findings include the following: • Adela’s temperature is 36.8º C, her pulse rate is 82 beats/minute and her blood pressure is 110/70 mm Hg. • She has no skin pallor or sweating. • She has slight lower abdominal cramping/pain and light vaginal bleeding. Basic EmONC Course

Optional Case Study 8 Key: Vaginal Bleeding during Early Pregnancy 3‐27

•

Her uterine size is equal to dates, she has no uterine tenderness and no cervical motion tenderness, and the cervix is closed.

4. Based on these findings, what is Adela’s diagnosis, and why? •

Adela’s symptoms and signs (e.g., light bleeding, closed cervix, uterus corresponds to dates) are consistent with threatened abortion.

CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Adela, and why? • No medical treatment is necessary at this point. • Adela should be advised to avoid strenuous activity and sexual intercourse. • She should be given emotional support and reassurance. Counseling about rest, nutrition and danger signs in pregnancy should be provided, with particular emphasis on vaginal bleeding. • If bleeding stops, Adela should be followed up at the antenatal clinic. • If bleeding continues, she should be advised to return for further assessment. EVALUATION • Adela returns to the health center in 3 days. • She reports that the bleeding became heavier last night, and that since then she has been having cramping and lower abdominal pain. • She has not passed any products of conception, her uterus corresponds to dates and her cervix is now dilated. • She has no signs or symptoms of shock. • Adela is very upset about the possibility of miscarrying. 6. Based on these findings, what is your continuing plan of care for Adela, and why? • Adela’s signs and symptoms are now consistent with those of inevitable abortion. • She should be counseled about the potential outcome for her pregnancy and given emotional support and reassurance. • Because she is less than 16 weeks pregnant, arrangements should be made for evacuation of the uterus, using manual vacuum aspiration. • If evacuation is not immediately possible, ergometrine 0.2 mg IM should be given and, if necessary, repeated after 15 minutes; OR misoprostol 400 µg should be given by mouth and, if necessary, repeated once after 4 hours. • Arrangements should then be made for evacuation of the uterus as soon as possible. Basic EmONC Course


• •

Provide emotional support and reassurance to Adela, explain what to expect, listen to her carefully and respond to any fears or concerns she may have. After the evacuation procedure, Adela should be reassured about the chances of a subsequent successful pregnancy and encouraged to delay the next pregnancy until she has completely recovered.

• •

Counseling about suitable family planning methods should be provided. Adela should be advised to return for immediate attention if she has: Prolonged cramping (more than a few days) Prolonged bleeding (more than 2 weeks) Severe or increased pain Fever, chills or malaise Fainting

•

Identify any other reproductive health services (e.g., tetanus prophylaxis or tetanus booster, treatment of STIs, cervical cancer screening) that Adela may need.

REFERENCES Managing Complications in Pregnancy and Childbirth: pages C‐1 to C‐2; S‐7 to S‐8; S‐10 to S‐13

Basic EmONC Course


Basic EmONC Course


OPTIONAL CASE STUDY 9: PROLAPSED CORD ANSWER KEY CASE STUDY Basri is a 35‐year‐old gravida seven, para six. You have provided antenatal care at two antenatal visits, during which Basri’s pregnancy was found to be progressing well. Her last antenatal visit was 1 week ago. She is now 37 weeks pregnant and has come to the health center to report that labor pains started 2 hours ago. ASSESSMENT (History, Physical Examination, Screening Procedures/Laboratory Tests) 1. What will you include in your initial assessment of Basri, and why? • Basri should be greeted respectfully and with kindness. • She should be told what is going to be done and listened to carefully. In addition, her questions should be answered in a calm and reassuring manner. • An immediate assessment (e.g., observation of pushing, grunting, bulging thin perineum, or vagina gaping and head visible) should be done to determine whether childbirth is imminent. • If childbirth is imminent, preparations should be made for this. • If childbirth is not imminent, a targeted history should be taken; Basri should first be asked how she is feeling and whether she has any of the following signs or symptoms: severe headache, blurred vision, epigastric pain, breathlessness, fever, vaginal bleeding, leakage of fluid from the vagina. Determine the color of amniotic fluid if membranes are ruptured. She should also be asked about fetal movement, the time labor began and the strength and duration of contractions, as well as about complications during previous pregnancies. • In addition to noting the time labor began and the strength and duration of contractions, information should be obtained about membranes (ruptured or not), the color of amniotic fluid, presence of vaginal bleeding, and presence of fetal movement. • Basri’s blood pressure, temperature and pulse should be taken, and her emotional response to labor should be observed. 2. What particular aspects of Basri’s physical examination will help you make a diagnosis or identify her problems/needs, and why? • An abdominal examination should be done to check whether uterine size is consistent with gestation estimated by dates; to assess the frequency and duration of contractions; to assess the lie and presentation of the fetus; to assess the descent of the presenting part; and to listen to the fetal heart. • The vulva should be examined to note the presence of blood, mucus, amniotic fluid, Community Midwife Program

Optional Case Study 9 Key: Prolapsed Cord 3‐31

discharge or other symptoms of sexually transmitted infections, and warts or keloid tissue that may interfere with childbirth. •

A vaginal examination should follow to determine dilation of the cervix, identify presentation and measure the level of the presenting part.

3. What screening procedures/laboratory tests will you include (if available) in your assessment of Basri, and why? • A urine specimen should be tested for protein and ketones. DIAGNOSIS (Identification of Problems/Needs) You have completed your assessment of Basri and your main findings include the following: • Basri is having two contractions in 10 minutes, each lasting 20–40 seconds. • Her cervix is 4 cm dilated. • The presentation is vertex and the head is not engaged. The fetal heart rate is 130 beats/minute. • Basri’s vital signs are normal. 4. Based on these findings, what is Basri’s diagnosis, and why? • Basri is in the active phase of the first stage of labor. Fetal descent should begin and cervical dilation should continue at a rate of 1 cm/hour. CARE PROVISION (Planning and Intervention) 5. Based on your diagnosis, what is your plan of care for Basri, and why? • A supportive, encouraging atmosphere, respectful of Basri’s wishes, should be provided. • All procedures should be explained to Basri and findings discussed with her. • She should be made comfortable and encouraged to move around freely. • A partograph should be started, using the information obtained during the initial examination. • Ongoing observations should include: maternal pulse, fetal heart rate, and contractions half hourly, blood pressure and temperature every 4 hours, urine for protein and acetone every 2–4 hours, vaginal examination every 4 hours (cervical dilation, descent of presenting part, amniotic fluid and molding), preceded by abdominal examination (descent of presenting part). • It will be important to keep in mind that Basri’s multiparity, and the fact that the presenting part is high, increases the possibility for the cord to slip down in front of the presenting part.

Community Midwife Program


EVALUATION • Two hours after admission, Basri’s membranes rupture. • On vaginal examination, the cord is felt below the head, which is at 0 station. • The cervix is 6 cm dilated. • The fetal heart rate is 160 beats/minute. 6. Based on these findings, what is your continuing plan of care for Basri, and why? • All available personnel should be mobilized to assist with emergency care. • Oxygen should be given at 4–6 L/minute by mask or nasal cannula. • Because Basri is in the first stage of labor, the following steps should be taken, while at the same time someone makes arrangements for immediate transfer to the district hospital: Wearing high‐level disinfected surgical gloves, one hand should be inserted into the vagina to push the presenting part upward to decrease pressure on the cord. The other hand should be placed on the abdomen in the suprapubic region to keep the presenting part out of the pelvis. Once the presenting part is firmly held above the pelvic brim, the hand should be removed from the vagina. The hand on the abdomen should be kept there during transfer of Basri to the operating room, where cesarean section should be performed without delay. If available, salbutamol 0.5 mg IV should be given slowly over 2 minutes to reduce contractions. • The steps taken to manage the complication should be explained to Basri, she should be encouraged to express her concerns, listened to carefully, and provided emotional support and reassurance. • Postoperatively, a clear airway and adequate ventilation should be ensured. Basri’s vital signs (blood pressure, pulse, respiration rate) and temperature should be taken every 15 minutes for the first hour, then every 30 minutes for the next hour. If a general anesthetic has been used, level of consciousness should be assessed every 30 minutes until she is alert. • The fundus should be checked to make sure that the uterus is well contracted. • Appropriate analgesic drugs should be given. • Basri should be provided continuing emotional support and reassurance. • If her newborn requires special care, this should be provided. Otherwise, routine newborn care should be provided, including leaving the newborn in skin‐to‐skin contact with Basri and encouraging her to breastfeed as soon as she feels able to, when the newborn shows interest. REFERENCES Managing Complications in Pregnancy and Childbirth: pages S‐97 to S‐98 Community Midwife Program


Community Midwife Program


HANDOUTS

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Improving Maternal and Newborn Health in Afghanistan

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Objectives

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Summary of global situation of maternal mortality Review maternal and newborn health status in Afghanistan Review maternal and newborn health services in Afghanistan The way forward in maternal newborn health in Afghanistan

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What is Safe Motherhood?

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A woman’s ability to have a SAFE and healthy pregnancy and childbirth

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Basic EmONC Course

Handouts 4‐1

Maternal Mortality: A Global Tragedy

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Annually, approximately 600,000 women die of pregnancy related complications

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99% in developing

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world ~ 1% in developed countries

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Maternal Death Watch Every Minute...

Of every day...

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380 women become pregnant 190 women face unplanned or unwanted pregnancy 110 women experience a pregnancy related complication 40 women have an unsafe abortion 1 woman dies from a pregnancy-related complication

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Maternal Mortality

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MATERNAL DEATH:

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The death of a woman while pregnant or within 42 days after

termination of pregnancy, irrespective of the site and duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Is the TIP OF THE ICEBERG – For every maternal death 16 – 100 mothers suffer from morbidity due to the consequences of pregnancy and child birth. ICD –10 Late maternal death: the death of a woman from direct or indirect obstetric causes more than 42days but less than one year after termination of pregnancy

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Basic EmONC Course

Handouts 4‐2

Maternal Mortality Ratio in Afghanistan

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MMR 1600 per 100 000 live births About? deaths every year About? maternal deaths every day Direct Causes Prolonged and obstructed labour/Ruptured Uterus Sepsis Haemorrhage Pre-eclampsia and Eclampsia Complications of abortion Indirect causes:

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Malaria and Anaemia

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Picture copied with permission from the Friends of Malawi web page. 7

Status of Maternal Health Services Afghanistan (AHS 2006)

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Skilled Antenatal Care (at least 1 visit, excluding TT)

32.3%

Pregnant Women Receiving at least 2 Doses of Tetanus Toxoid

23.8%

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Skilled Birth Attendance

18.9%

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Exclusive Breastfeeding (%)

83%

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MDG 5 - Improve Maternal health

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Target:

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1. Reduce by three quarters, by 2015, the maternal

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mortality ratio 2. To achieve universal access to reproductive health by 2015

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NEED Increase the proportion of births that are attended by skilled health personnel to 40% by 2013, SBA based on NRVA 2008 was 23.9%

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Basic EmONC Course

Handouts 4‐3

20 years after Safe Motherhood introduced

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Maternal deaths are not predictable Major obstetric complications are not predictable A substantial proportion of maternal deaths take place in hospital Most maternal deaths occur during labour, delivery or the first 24H postpartum 80% of maternal deaths are preventable by appropriate treatment

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The three delays….

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Neonatal Health - Scope Of Problem

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Every year: 4 million neonatal deaths (first month of life) Of those who die in the 1st month of 2/3 die in the first week. Of those who die in the first week, 2/3 die in the first 24 hours. Eight neonatal deaths every minute 4 million still births

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Basic EmONC Course

Handouts 4‐4

Neonatal Health status - Afghanistan

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Newborn death rate 60 per 1000 live births

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Causes:

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Asphyxia

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Infection Preterm

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The Lancet 2005.

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What are the key interventions to reduce maternal and neonatal mortality?

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Skilled attendants during pregnancy and childbirth Availability and use of emergency obstetric care services Fully functioning health services 24/7 Increased utilization of Family Planning Essential newborn care Effective referral system

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Evidence based care

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For years, much of basic and emergency obstetric and newborn care was provided according to “tradition” and “routine” practice rather than according to evidence. Today, we know that to be effective, care should be evidence-based. And yet the “evidence” and current “best practices” in maternal and newborn care has failed to catch up with our teaching of students and in refresher trainings.

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Basic EmONC Course

Handouts 4‐5

The evidence

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Recent global evidence shows that availability and use of Emergency Obstetric Care (EmOC) and skilled attendants at birth are key to the reduction of maternal mortality Access to skilled care during pregnancy and childbirth is a woman’s basic human right.

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The evidence base for Maternal and Newborn Care (MNC) interventions

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Recognition that most deaths occur in the postpartum period and that programs needed to be adjusted accordingly Better understanding of emergency obstetric care (EmOC) and ‘best practices’ in labour and delivery Enhanced appreciation of the role that community mobilization, birth preparedness, and a continuum of care make

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Proven Interventions for Maternal Survival

Magnesium Sulfate Calcium

Partogram Cesarean Section Clean Delivery Antibiotics Tetanus Toxoid

Hypertensive disorder 9% Obstructed Labor 4%

Family Planning Postabortion Care

Anemia 4%

Nutrition Counseling Iron Folate IPTp, Malaria Control

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Hemorrhage 34%

Sepsis 16%

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Unsafe Abortion 4%

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Other Causes 30%

Active Management of the Third Stage of Labor Misoprostol

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Source: WHO Analysis of causes of maternal deaths: A systematic review.” The Lancet, Vol 367, April 1, 2006.

18

Basic EmONC Course

Handouts 4‐6

Emergency Obstetric Care

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In guidelines jointly issued in 1997 by WHO, UNICEF, and UNFPA, it is recommended that for every 500,000 people there should be FOUR facilities offering basic and one facility offering comprehensive essential obstetric care.

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EmONC Signal Functions (2008) Basic EmONC

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Comprehensive EmONC

1) Administer parenteral antibiotics

Perform EmOC Signal functions 1-7, plus:

2) Administer uterotonic drugs (e.g. parenteral oxytocin, misoprostol)

8) Perform surgery (e.g. cesarean delivery)

3) Administer parenteral anticonvulsants (e.g. magnesium sulfate)

9) Perform blood transfusion

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4) Perform manual removal of placenta 5) Perform removal of retained products (e.g. MVA)

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6) Perform assisted vaginal delivery (e.g. vacuum extraction)

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7) Perform neonatal resuscitation (e.g. w/ bag and mask)

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Why the signal functions work well

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Focus on emergencies and life-threatening complications Demonstrate facility functioning Stimulate review of policies Identify interventions needed

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Clinical training

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Supportive supervision Standardized protocols

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Distribution of equipment and maintenance Logistics for drugs and supplies

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Community mobilization

21

Basic EmONC Course

Handouts 4‐7

What do women want?

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Respectful provider attitude and availability of drugs and medical equipment Culturally appropriate services Women friendly care – kindness, respect, information

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EmONC Building Blocks Framework

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Utilization

Service Delivery Stage Preparation Stage

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On-site QI Process On-going Readiness Training Renovation & Maintenance

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External Supervision

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24/7 EmOC Team Building

Staffing Supplies & Equipment

Facility Setup

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Data Collection

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EmONC Needs Assessment

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The right to Safe Motherhood Maternal death is the biggest challenge in strengthening health systems….If we can get maternal health services to perform, then we are very nearly perfecting the entire health system." (Omaswa 2007)

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The MOPH in Afghanistan is committed to increasing accessibility of mothers and women of child bearing age to quality reproductive health services

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Basic EmONC Course

Handouts 4‐8

Our goal- for BEmONC training!

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Do the right things, and do things right

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Afghanistan health system services Health system priorities

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Health Service BPHS (Basic Package of Health Service) EPHS( Essential Package of Hospital Service) Establish and expand of preventive programs

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Afghanistan Health System Services Definition of BPHS: BPHS is the infrastructure of Afghanistan`s health

system which includes all primary health activities and primary health care elements.

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Basic EmONC Course

Handouts 4‐9

EPHS objectives: Specification of standard health system package at all hospitals level Preparation of guide to organize the hospital staff , instrument , materials and drugs for MOPH, private sectors, NGOs and donors Develop high quality referral system and coordination among BPHS and hopitals

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EPHS and BPHS levels BPHS

EPHS

Health post

DH

Sub center

PH

Mobile teams

RH (including

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specialized hospital)

BHC

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CHC

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CHC plus

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DH

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BPHS Framework Coverage population

Minimum number of personal

1000-1500

2 CHWs ( male, female )

Health post

3500-5000

Nurse, midwife and male nurse

Health sub center

15000-30000

Doctor or male nurse, midwife ,auxiliary midwife, 2 vaccinators

BHC

30000-60000

2 doctors (male, female) midwife ,2 nurses (male, female) lab tech , pharmacist , 2 vaccinators , admin

CHC

30000-60000

General surgeon ,Gyn Obs surgeon ,2 general medicine doctors (male, female) , anesthesia tech, dental tech,2 midwifes, 4 nurses (male),X-ray tech, lab tech , pharmacy tech,2 vaccinators , community supervisor(CHS) and admin

CHC plus

100000-300000

General surgeon ,4 general medicine doctors (male, female) , anesthetist, pediatricians, dental doctor, 4 midwifes ,5 male nurses ,5 female nurses ,X-ray tech, lab tech, pharmacists, 2 vaccinators , CHS and admin

DH

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Type of health facility

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Basic EmONC Course

Handouts 4‐10

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Women-Friendly Care: A Discussion

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Best Practices in Maternal and Newborn Care

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Divide into Groups of 3–5 Participants

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Discuss the following questions:

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How would you define “women-friendly care”?

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Why is women-friendly care important? Give some examples of care you have seen that is

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not women-friendly. Give some examples of care that is women-friendly. How can you help ensure that your students will value and learn to provide women-friendly care?

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After Small Group Discussion . . .

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. . . Reconvene as a large group to share your thoughts, conclusions and recommendations . . .

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Basic EmONC Course

Handouts 4‐11

Discussion Guide for Facilitator

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The next slides will have some points you will want to bring out during the discussion.

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Be sure to allow, and build on, participant contributions as much as possible in summarizing the discussions.

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How would you define “women-friendly care”?

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Provides services that are acceptable to the woman:

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Respects beliefs, traditions, and culture Includes family, partner, or other support person in care Provides relevant and feasible advice

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Empowers woman and her family to become active participants in care Considers the rights of the woman:

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Right to information about her health Right to be informed about what to expect during visit Obtains permission/consent prior to exams and procedures

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Ensures that all health care staff use good interpersonal skills Considers the emotional, psychological and social well-being of the woman

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Why is women-friendly care important?

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Women-friendly care is life-saving, as studies have shown that women may refuse to seek care from a provider who “abuses” them or does not treat them well, even if the provider is skilled in preventing and managing of complications.

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Basic EmONC Course

Handouts 4‐12

Give some examples of care that is not women-friendly

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Does not respect woman or her culture or background Rude, offensive, demeaning language by health personnel Physically restrains, pushes or hits the woman Insists on routine procedures that are convenient for the health care provider but may be shameful or disgusting to the woman, e.g., lithotomy position only, routine episiotomy, frequent vaginal exams, assembly-line fashion of care Excludes partner or companion from care Separates mother and baby

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Give some examples of care that is womenfriendly

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Individualizes care to woman’s needs Recognizes the richness and spiritual significance of community and culture:

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Is aware of traditional beliefs regarding pregnancy and childbirth Cooperates and liaises with traditional health care system when possible Provides culturally sensitive care

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Respects and supports the mother-baby dyad:

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Encourages bonding Keeps baby with mother Places baby on mother’s abdomen (at breast) immediately after birth

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Give some examples of care that is womenfriendly (cont...)

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Speaks to the woman in her own language Observes rules and norms of her culture as appropriate Is aware of who makes decisions in her life and involves that person in discussions and decisions Works with traditional birth attendants when possible Learns about traditional practices:

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Promotes/builds on positive traditional practices Offers alternatives to those that are harmful

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Basic EmONC Course

Handouts 4‐13

How can you help ensure that your students will value and learn to provide women-friendly care?

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Consistent role modeling of women-friendly care Use of women-friendly approaches in simulated settings, e.g., with anatomic models Emphasis of women-friendly care during teaching of all procedures and types of care

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Basic EmONC Course

Handouts 4‐14

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Best Practices in Infection Prevention

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Session Objectives

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By the end of session, participants will be able to:

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Describe disease treatment cycle

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Outline key IP principles Discuss appropriate hand washing and antisepsis Discuss appropriate gloving and personal protective equipment

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Outline safe handling of sharps Discuss proper instrument processing and waste disposals

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The six Components of the Disease Transimi9ssion Cycle 1. Agent: Disease-producing microorganisms 2. Reservoir: Place where agents lives, such as in or on humans, animals, plants, or water 3. Place of exit: Where agent leaves host 4. Mode of transmission: How agent travels from place to place (or person to person) 5. Place of entry: Where agent enters next host 6. Susceptible host: Person who can become infected

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Basic EmONC Course

Handouts 4‐15

Question? How can we prevent the spread of infection?

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How we can prevent the spread of infection? Break disease-treatment agent (applying antiseptic to skin prior to surgery) Inhibit or kill infectious agent (applying antiseptic to skin prior to surgery) Block agent’s means of getting from infected person to susceptible person (hand washing or using alcohol-based rub) Ensuring that people, especially healthcare workers, are immune or vaccinated

How we can prevent the spread of infection? (Cont…) Providing health care workers with proper protective equipment to prevent contact with infectious agents. Give some example of ways to break transmission cycle (see notes)

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Basic EmONC Course

Handouts 4‐16

Why is infection prevention important? Protects patients/clients—helps provide quality care that is also safe Lowers health care costs—prevention less expensive than treatment Prevents infection among health care staff and community Limits number and spread of infectious agents that can become antibiotic-resistant

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Question? What is the most important infection prevention practice?

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Hand washing The single most practical procedures for preventing infection: Hand washing When to wash hands: Before and after examining client After contact with blood, body fluids or soiled

instrument, even if gloves are worn Before and after removing gloves Upon arriving at and before leaving workplace

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Basic EmONC Course

Handouts 4‐17

Hand washing: How to wash hands Steps: Use a plain or antiseptic

soap Vigorously rub lathered

hands together for 10 – 15 seconds Rinse with clean running water from a tap or bucket Dry hands with a clean towel or air dry them Source: Larsen 1995

Alcohol-Based Hand rub More effective than hand washing unless hands are visibly soiled 2 mL emollient (e.g., glycerin) + 100 mL ethyl or isopropyl alcohol 60-90% Use 3 to 5 ml for each application and continue rubbing the solution over the hands until dry

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Antisepsis Antisepsis for mucous membranes: Ask about allergic reaction Use water-based product (e.g., ionosphere or

chlorhexidine), as alcohols may burn or irritate mucous membranes

Skin preparation for injections: If skin clean, antisepsis is not necessary If skin appears dry, wash with soap and water

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Before giving injection, dry with the towel

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Basic EmONC Course

Handouts 4‐18

When to glove When there is reasonable chances of contact with broken skin, mucous membranes, blood or other body fluids When performing invasive procedure When Handling:

Soiled instruments Medical, or contaminated surfaces When touching contaminated surface

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Guideline for Gloving Wear separate pair of gloves for each woman/newborn to prevent spreading infection from client to client What kind of gloves do you wear for:

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Procedures involving contact with broken skin or tissue under

skin? Starting IV, drawing blood, or handling blood or body fluid? Cleaning instruments, handling waste and cleaning up blood and

body fluid? Never wear gloves that are cracked, peeling or have holes

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Personal Protective Equipment Gloves: utility, examination, HLD/sterile Eyewear: face shields, goggles, glasses Aprons Should be fluid-resistant Should be decontaminated after use

Protective footwear

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Basic EmONC Course

Handouts 4‐19

What’s wrong with this picture?

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Global Statistics on Occupational Exposure 3 million health care workers (HCWs) per year report needlestick injuries per year 2.5% HIV infections among HCWs are transmitted by needlestick injuries 40% of Hepatitis C and Hepatitis B infections among HCWs are transmitted by needlstick injuries ( WHO,2002)

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Safe Handling of Sharps Never pass sharp instruments from one hand directly to another person’s hand After use, decontaminated syringes and needles flushing three times with chlorine solution Immediately dispose of sharps in puncture-proof container Which is greatest, the risk of acquiring Hepatitis B or HIV from a needlestick injuries?

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Basic EmONC Course

Handouts 4‐20

Safe Handling of Sharps (Con.) Do not recap, bend, break, or disassemble needles before disposals Always use needle holder when suturing Never hold or guide needle with finger

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Instrument Processing Decontamination: Should be done immediately after use Makes objects safer to handle How do you make a 0.5% chlorine solution for

decontamination

Cleaning: Most effective way to reduce number of organisms Removes visible dirt and debris

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Instrument Processing (Con.) Sterilization:

Destroys all microorganisms Includes autoclave, dry heat, chemicals

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High-level disinfection (HLD)

Destroys all microorganisms except bacterial endosperms Includes boiling, steaming, soaking

Storage:

After processing, must remain dry and clean

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Basic EmONC Course

Handouts 4‐21

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What is wrong with this picture?

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Housekeeping

Each site should follow housekeeping schedule Always wear utility gloves when cleaning Clean from top to bottom Ensure that fresh bucket of disinfectant solution is available at all times

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Basic EmONC Course

Handouts 4‐22

Housekeeping (Cont...) Immediately clean up spills of blood or body fluids After each use, wipe off beds, tables and procedures trolleys using disinfectant solution Decontaminate cleaning equipment with chlorine solution

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Waste Disposal Contaminated waste includes blood and other body fluids, and items that come into contact with them such as dressing

Separate contaminates waste from non contaminated waste Use puncture-proof container for sharps and destroy when two-thirds full

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Waste Disposal (Cont…) Follow these steps to destroy contaminated waste and sharps: Add small amount of kerosene to burn Burn contaminated waste in open area downwind

from care site Dispose of waste at least 50 meters away from water sources

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Basic EmONC Course

Handouts 4‐23

Summary Everyone (staff and patients) is at risk for infection This risk can be reduced through rigorous adherence to IP practices:

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Hand washing or using alcohol-based hand rub Antisepsis Personal protective equipment, including gloving Safe handling of sharps and needles Instrument processing Housekeeping and waste disposal

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Basic EmONC Course

Handouts 4‐24

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BEST PRACTICES IN FOCUSED ANTENATAL CARE RATIONAL, COMPONENTS AND TOOLS

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Session Objectives

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Describe focused antenatal care (FANC) Describe basic elements of FANC assessment and care Define the elements of effective counseling Describe the elements of Birth Preparedness and Complication Readiness Demonstrate the provision of focused antenatal care

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Objective of ANC

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A healthy pregnancy A healthy outcome for mother and newborn Promotion of physical, mental, and social health

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Basic EmONC Course

Handouts 4‐25

Benefits of FANC

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ANC visits are a unique opportunity for early diagnosis and treatment of problems:

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Maternal problems: anemia, vaginal bleeding, Pre-eclampsia/eclampsia, infection, abnormal fetal

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position after 36 weeks Fetal/newborn problems: abnormal fetal growth or movement, syphilis, malaria, malnutrition

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ANC - Is There a Problem?

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ANC coverage is high

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Average number of visits: 2.5

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32.3% pregnant women in Afghanistan have at least

1 ANC visit

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MMR REMAINS HIGH Significant maternal and neonatal mortality preventable through FANC

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ANC - Why Is There a Problem?

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Quality of care is poor

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We gather information but do not use it to manage patient eg. Anemia Poor clinical management of problems – eclampsia, bleeding in pregnancy Failure to record relevant information

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Not woman friendly –

Inhumane ‘factory assembly line’ ANC system Women treated poorly so do not return

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Poor communication

Poor counseling skills Information and education is not relevant to the woman

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Basic EmONC Course

Handouts 4‐26

A Midwife says:

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“What I dislike about the assembly line system was that I alone had to palpate about 150 pregnant women a day. There was no privacy during history taking and the women did not give us correct information . . It was tedious work….” A care provider

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What Focused ANC Means?

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An approach to ANC that emphasizes Individualized care Client centered Fewer but comprehensive visits Disease detection not risk Categorisation Care by a skilled provider

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Four Goals of Focused ANC

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Early detection and treatment of problems and complications Prevention of complications and disease Birth preparedness and complication readiness Health promotion

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 9

Basic EmONC Course

Handouts 4‐27

The Focused ANC System

___________________________________ ___________________________________

Privacy/ confidentiality are assured Continuous care provided by same provider Promotes partner/ support person involvement Adheres to national protocols Referral facilitated ANC, PNC and family planning services are linked and housed within the same location if possible

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 10

“High risk” women and “low risk” women

___________________________________

What are the benefits of assigning women to “risk” categories?

___________________________________

What are the problems with assigning women to “risk” categories?

___________________________________

___________________________________

___________________________________ ___________________________________ ___________________________________ 11

Why Risk Approach Is Not Effective?

___________________________________

Complications cannot be predicted: all pregnant women are at risk. Risk factors are not usually the direct cause of complications Many low risk women develop complications Most high risk women give birth without complications

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐28

Focused ANC Visit Schedule For The Healthy Client

___________________________________

FOUR VISITS FIRST SECOND THIRD FOURTH

___________________________________ ___________________________________

180 beats/min):

– Perform rapid vaginal delivery – If vaginal delivery not possible, deliver by immediate C/Section

___________________________________ ___________________________________ 11

Question?

___________________________________

What is placenta previa?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐54

Bleeding in Late Pregnancy: Placenta Previa

___________________________________

Placenta previa: implantation of placenta at or near cervix Three types:

___________________________________ ___________________________________

Low placental implantation

___________________________________

Partial placenta previa

___________________________________

Complete placenta previa

___________________________________ ___________________________________ 13

Placenta Previa

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 14

Bleeding in Late Pregnancy: Diagnosis of Placenta Previa Bleeding after 22-28 weeks gestation

___________________________________

Symptoms sometimes present: Shock Bleeding may be precipitated by intercourse Relaxed uterus Fetal presentation not in pelvis/lower uterine pole feels empty Normal fetal condition

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐55

Bleeding in Late Pregnancy: Confirming Placenta Previa

___________________________________

Localize placenta with ultrasound, if available If placenta previa is confirmed:

___________________________________ ___________________________________

Plan delivery if fetus is mature Manage expectantly if fetus is less than 37 weeks and

___________________________________

bleeding is not life threatening.

If diagnosis is uncertain:

___________________________________

Manage expectantly as placenta previa until 37

___________________________________

weeks gestation If pregnancy is 37 weeks or more, examine under

___________________________________

double-set up 16

Bleeding in Late Pregnancy: Expectant Management of Placenta Previa

___________________________________

Assess amount of bleeding:

___________________________________

Do not perform a vaginal examination

___________________________________

If bleeding is heavy and continuous, deliver by

cesarean section regardless of gestation

___________________________________

Consider expectant management if: Bleeding is light or has stopped

___________________________________

Fetus is alive but less than 37 weeks gestation

___________________________________ ___________________________________ 17

Bleeding in Late Pregnancy: Expectant Management

___________________________________ ___________________________________

Keep woman in hospital until delivery. Correct anemia with oral iron Ensure blood is available for transfusion If bleeding recurs, weigh benefits and risks for woman and fetus of further expectant management versus delivery

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 18

Basic EmONC Course

Handouts 4‐56

Bleeding in Late Pregnancy: Delivery for Placenta Previa

___________________________________

Plan delivery by cesarean section if:

___________________________________

Hemorrhage is severe enough to cause risk to mother

___________________________________

Fetus is at least 37 weeks gestation Fetus is dead or cannot survive Major praevia

___________________________________

Vaginal delivery may be possible with low placental implantation Women with placenta previa are at high risk for postpartum hemorrhage and placenta accreta

___________________________________ ___________________________________ ___________________________________ 19

Summary

___________________________________

Vaginal bleeding in late pregnancy and labor can be catastrophic:

___________________________________ ___________________________________

Evaluate rapidly Resuscitate if patient in shock

___________________________________

Differentiate abruptio placenta and placenta previa

because of difference in mode of delivery

___________________________________ ___________________________________ ___________________________________ 20

Basic EmONC Course

Handouts 4‐57

Basic EmONC Course

Handouts 4‐58

___________________________________ Rapid Initial Assessment, Shock, Resuscitation and Emergency Management

___________________________________


___________________________________

___________________________________

___________________________________ ___________________________________ ___________________________________

Session Objectives

___________________________________

To discuss best practices for the initial assessment of obstetrical patients To discuss best practices in the management of shock To discuss adult resuscitation To describe an emergency tray/trolley To discuss the management of emergencies and emergency drills

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 2

A quick check and rapid initial assessment

___________________________________

A quick check of a woman’s condition when she presents with a problem to rapidly determine her degree of illness is good practice.

___________________________________

What would you include in a rapid initial assessment?

___________________________________

___________________________________

___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐59

Assess Condition

___________________________________ ___________________________________

Airway and breathing Circulation (sign of shock) Vaginal bleeding (early or late pregnancy or after childbirth) Unconscious or convulsing Dangerous fever Severe abdominal pain

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 4

ABC of Adult Resuscitation: What To Do!

___________________________________ ___________________________________

Airway: check airway: if not breathing: Clear airway, position to prevent tongue falling back, insert an airway

___________________________________

Breathing: no breaths or chest movements Help client breath by ventilating (mouth to mouth, mouth to mask, Ambu bag) with/or without oxygen

___________________________________

Circulation - no pulse or heart beat:

___________________________________

Begin cardiac massage and check response (5:1 heart compressions: respiration effort)

___________________________________ ___________________________________ 5

Assess Circulation

___________________________________

Examine:

___________________________________

Skin: Cool and moist

___________________________________

Pulse: Fast (110 beats/min. or more) and weak Blood Pressure: Low (systolic less than 90 mm Hg)

___________________________________

Consider shock even if blood pressure is normal

___________________________________ ___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐60

Definition of Shock

___________________________________

Failure of circulatory system to maintain adequate perfusion of vital organs LIFE-THREATENING REQUIRES IMMEDIATE AND INTENSIVE TREATMENT

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 7

Question?

___________________________________ ___________________________________

When would you anticipate shock?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 8

When to Expect or Anticipate Shock

___________________________________

Bleeding:

___________________________________

Early pregnancy (e.g. abortion, ectopic pregnancy, molar

pregnancy)

___________________________________

Late pregnancy or labor (e.g., placenta previa, abruption

placement, ruptured uterus) After childbirth (e.g., ruptured uterus, uterine atony)

___________________________________

Infection (e.g., unsafe or septic abortion, metritis) Trauma (e.g., injury to uterus or bowel during abortion, ruptured uterus)

___________________________________ ___________________________________ ___________________________________ 9

Basic EmONC Course

Handouts 4‐61

Question?

___________________________________ ___________________________________

What are the signs and symptoms of shock?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 10

Symptoms and signs of Shock

___________________________________ ___________________________________

Fast, weak pulse (110 beats/min. or more) Low blood pressure (systolic less than 90) Pallor (inner eyelids, palms, around mouth) Sweatiness or cold clammy skin Rapid breathing (30 breathing/min. or more) Anxiousness, confusion, unconsciousness Low urine output (less than 30 mL/hour)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11

Immediate Management of Shock

___________________________________ ___________________________________

Shout for help—mobilize personnel Monitor vital signs Position woman onto her side Keep woman on her side Elevate her legs Collect blood for testing

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐62

Specific Management

___________________________________

Start IV infusion (two if possible)

___________________________________

Infuse fluids at a rate of 1 L in 15-20 min., then give at least 2L of

fluids in first hour

___________________________________

If shock results from bleeding, more rapid infusion is necessary

Monitor vital signs Catheterize bladder Give oxygen at 6-8 L/min Blood work: Hemoglobin, cross-match Manage specific cause

___________________________________ ___________________________________ ___________________________________ ___________________________________ 13

Shock: Further Management

___________________________________

Continue IV infusion at 1L in 6 hours and oxygen at 6-8 L/min Monitor closely Perform lab tests for hematocrit, blood grouping, Rh typing and cross-match If facilities available, check serum electrolytes, serum creatinine and blood pH

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 14

Question?

___________________________________ ___________________________________

What could you do to help your staff be ready for an emergency?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐63

The Emergency Team

___________________________________

Remember: Everybody can resuscitate when necessary Have a recognized team who are trained and ready for emergencies The roles: Change Person Runner Supplier Assistant

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 16

ResponsibilitiesPerson One: Charge Person

___________________________________

Receive patients Does quick assessment/rapid appraisal and decide on management steps Stabilizes patients (massage uterus, gives oxygen, initiates immediate resuscitation, gives directions to other) Stays with patients until specialized care arrives for referral Documents findings and actions taken

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 17

Person Two: Runner

___________________________________

Sounds alarm, telephones or runs to inform doctors when alarm is raised Brings emergency tray or trolley to site Assists as needed (e.g., gathers equipments, starts, administers emergency drugs, ventilation, cardiac massage, etc.) Monitors vital signs Records vital signs and treatment given

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 18

Basic EmONC Course

Handouts 4‐64

Person Three: Supplier

___________________________________

Checks emergency tray at the beginning of each shift Brings emergency tray to site of emergency Brings protective wear to site when alarm is raised Brings trolley/drips stands. Etc., as needed Takes sample to labs Calls lab technicians if beside lab work necessary

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 19

Person Four: Assistant

___________________________________

Care for newborn if well Reassure relatives/friends—escort family members away from bed; keeps family informed of situation Assist with crowed control as needed Assist in clean up of patient

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 20

Emergency Tray/ Trolley Items List: Ambu bag +face mask Airway Sphygmomanometer Stethoscope Cotton dressings Gauze dressing Plaster Scissors

Tourniquet Gloves Syringe and needles Emergency packs:

Iv fluids Drugs Oxygen source + tube Foley catheter

___________________________________ ___________________________________ ___________________________________ ___________________________________

e.g. PPH, eclampsia

___________________________________ ___________________________________ ___________________________________ 21

Basic EmONC Course

Handouts 4‐65

O/G Emergency Packs Surgical/for shock IV Fluids 1I(N/S or rI) IV Cannula (X2) Blood-giving set Specimen cont (G/xm) Foley catheter Pair of gloves Drugs

___________________________________ ___________________________________

Medical/e. g., eclampsia IV fluid 1I(D/S or rI) Iv cannula (X2) Administration set Specimen container Pair of gloves Foley catheter Drugs

___________________________________ ___________________________________ ___________________________________

Oxytocin 20 u (x2) Ergot 0.2 mg (X2)

Mag SO4 NIFEDIPINE 20mg HYDRALAZINE 20mg Calcium gluconate

___________________________________ ___________________________________ 22

Implementing a Rapid Assessment Scheme

___________________________________

Train all staff to act in coordinated way when woman arrives at facility Practice clinical or emergency drills with staff Ensure that access is not blocked, equipment is in working order and staff are properly trained Clearly identify women in waiting room who needs prompt or immediate attention Agree on schemes by which woman with emergencies can be exempted from payment

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 23

Team Work

___________________________________

Roles and responsibilities are defined on each shift PROMPT RESPONSE to emergency call - Emergency tray must always be in ready

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 24

Basic EmONC Course

Handouts 4‐66

Using the Partograph (Cont…)

___________________________________ Molding:

___________________________________

1: sutures apposed 2: sutures overlapped but reducible

___________________________________

3: sutures overlapped and not reducible

Cervical dilatation: Assess at every vaginal examination, mark with cross (X) Alert line: Line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1cm per hour Action line: Parallel and 4 hours to the right of the alert line

___________________________________ ___________________________________ ___________________________________ ___________________________________ 8

Using the Partograph (Descent)

___________________________________

Descent assessed by abdominal palpation: Part of head (divided into 5 parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the level of the symphsis pubis.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 9

Using the Partograph (Timing)

___________________________________

Hours: Time elapsed since onset of active phase of labor (observed or extrapolated) Time: Record actual time Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds

___________________________________ ___________________________________ ___________________________________ ___________________________________

Less than 20 seconds:

___________________________________

Between 20 and 40 seconds: More than 40 seconds:

___________________________________ 10

Basic EmONC Course

Handouts 4‐67

Basic Postpartum Care Provision (Cont...)

___________________________________

During every visit:

___________________________________

Assessment of condition of mother and baby

___________________________________

Provide all elements of basic care package If abnormal signs or symptoms provide additional care Integrate maternal and newborn care visits when possible

___________________________________

During return visit:

___________________________________

Make necessary changes to care plan (based on assessment) Review and update mother’s and newborn’s complication

readiness plan

___________________________________

Reinforce key messages Replenish supply of supplements and drugs/medications

___________________________________ 7

Using the Partograph (Vital Signs and Urine)

___________________________________

Temperature: Record every 2 hours Pulse: Record every 30 minutes and mark with a dot (•) Blood pressure: record every 4 hours and mark with arrows Protein, acetone and volume: Record every time urine is passed

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

___________________________________ The Modified WHO Partoghraph

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 13

Basic EmONC Course

Handouts 4‐68

___________________________________ Sample Partograph for Normal Labor

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 14

___________________________________ Partograph Showing Obstructed labor

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

___________________________________ Partograph Showing Inadequate Uterine Contractions Corrected with Oxytocin (Oxytocin should have been started 2 hours earlier – hour 2)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 16

Basic EmONC Course

Handouts 4‐69

Restricted Use of Episiotomy

___________________________________

Implications for practice: Clear evidence to restrict use of episiotomy in normal labor Further trials needed to assess use of episiotomy at:

___________________________________ ___________________________________

Assisted delivery (forceps or vacuum)

___________________________________

Preterm delivery Breech delivery

___________________________________

Predicted macrosomia Presumed imminent tears (threatened 3rd degree tear or history

of 3rd degree tear with previous delivery)

___________________________________ ___________________________________

Carroli and Belizan 2000. WHO 1999. 10

Clean Delivery

___________________________________

Infection accounts for 11% of all maternal deaths Infection/pneumonia accounts for 26% of newborn deaths Tetanus accounts for 7% of newborn deaths These deaths can be largely avoided with infection prevention practices

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11

Infection Prevention Practices

___________________________________

Wear protective clothing (shoes, apron, glasses) Wash hands Wear gloves during vaginal examination, during birth of newborn and when handling placenta Use disposable materials once and decontaminate reusable materials throughout labor and childbirth Wash perineum with soap & water and keep it clean Ensure that surface on which newborn is delivered is kept clean Sterile or high-level disinfect instruments, gauze and ties for cutting cord

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐70

Neglected Area of Care

___________________________________

Few women receive postpartum care. An estimated 70% of women in developing countries, do NOT receive postpartum care. In a study by Forte et. al. of 29 countries, those women who received PPC receive it within 2 days, but for the other nine countries, the peak of PPC occurs 7-41 days after birth. (Forte A et al. 2006. Postpartum Care Levels and Determinants in Developing Countries. )

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Best Practices: Third Stage of Labor

___________________________________

Offer active management of third stage for ALL women:

___________________________________

Oxytocin administration

___________________________________

Controlled cord traction Uterine massage after delivery of the placenta to keep the uterus

contracted

___________________________________

Routine examination of the placenta and membranes Routine examination of vagina and perineum for lacerations and injury

___________________________________ ___________________________________ ___________________________________

WHO 1999

14

Question?

___________________________________

How effective is active management of the third stage of labor at preventing postpartum hemorrhage?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐71

ICM/FIGO Joint Statement on Active Management of the Third Stage of Labor (AMTSL)

___________________________________

AMSTL has been proven to reduce the incidence of postpartum hemorrhage, reduce the quantity of blood loss and reduce the use of transfusion AMSTL should be offered to all women who are giving birth Every attendant at birth needs to have the knowledge, skills, and critical judgement needed to carry out AMSTL

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 16

Best Practices: Labor and Childbirth

___________________________________

Use non-invasive, non-pharmacological methods of pain relief during labor (massage, relaxation techniques, etc.): Offer oral fluids throughout labor and childbirth

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Neilson 1998.

17

Position in Labor and Childbirth

___________________________________

Allow freedom in position and movement throughout labor and childbirth Encourage any non-supine position:

___________________________________ ___________________________________

Side lying

___________________________________

Squatting Hands and knees

___________________________________

Semi-sitting

___________________________________

Sitting

___________________________________ 18

Basic EmONC Course

Handouts 4‐72

Position in Labor and Childbirth (continued)

___________________________________

Use of upright or lateral position compared with supine or lithotomy position is associated with:

___________________________________ ___________________________________

Shorter second stage of labor Fewer assisted deliveries

___________________________________

Fewer episiotomies Fewer reports of severe pain

___________________________________

Less abnormal heart rate patterns for fetus

___________________________________

More perineal tears Blood loss > 500 mL

___________________________________

Gupta and Nikodem 2000. 19

4 Million Newborn Deaths - When?

___________________________________

Up to 50% of neonatal deaths are in the first 24 hours

___________________________________ ___________________________________

75% of neonatal deaths are in the first week – 3 million deaths

___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)

Presence of Female Relative During Labor:

___________________________________

Support from female relative improves labor outcomes including:

___________________________________ ___________________________________

Shorter labours Improved newborn outcomes

___________________________________

Reduced incidence post partum depression And many others

___________________________________ ___________________________________ ___________________________________ 21

Basic EmONC Course

Handouts 4‐73

Basic EmONC Course

Handouts 4‐74

___________________________________ ___________________________________

Best Practices in Managing Labor Using the Partograph

___________________________________ ___________________________________

Best Practices in Maternal and New born Care

___________________________________ ___________________________________ ___________________________________

Question?

___________________________________

What basic care should be included in care of the postpartum mother?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 8

Usefulness of the Partograph

___________________________________

Assessment of fetal well-being Assessment of maternal well-being Assessment of progress of labor

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐75

Measuring Fetal Well-Being during Labor

___________________________________

Fetal heart rates and pattern Degree of molding, caput Color of amniotic fluid

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 4

Measuring Maternal Well-Being during Labor

___________________________________

Pulse, temperature, blood pressure, repiration Urine output, ketones, protein

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Measuring Progress of Labor

___________________________________

Cervical dilatation Descent of presenting part Contractions

___________________________________ ___________________________________

Duration

___________________________________

Frequency

___________________________________

Alert and action lines

___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐76

Using the Partograph

___________________________________

Patient information: Name, gravida, para, hospital number, date and time of admission and time of ruptured membranes Fetal heart rate: Record every half hour Amniotic fluid: Record the color at every vaginal examination:

___________________________________ ___________________________________ ___________________________________ ___________________________________

I: membranes intact C: membranes ruptured, clear fluid

___________________________________

M: meconium-stained fluid B: blood-stained fluid

___________________________________ 7

Using the Partograph (Cont…)

___________________________________

Molding:

___________________________________

1: sutures apposed

___________________________________

2: sutures overlapped but reducible 3: sutures overlapped and not reducible

Cervical dilatation: Assess at every vaginal examination, mark with cross (X) Alert line: Line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1cm per hour Action line: Parallel and 4 hours to the right of the alert line

___________________________________ ___________________________________ ___________________________________ ___________________________________ 8

Using the Partograph (Descent)

___________________________________

Descent assessed by abdominal palpation: Part of head (divided into 5 parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the level of the symphsis pubis.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 9

Basic EmONC Course

Handouts 4‐77

Using the Partograph (Timing)

___________________________________

Hours: Time elapsed since onset of active phase of labor (observed or extrapolated) Time: Record actual time Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds

___________________________________ ___________________________________ ___________________________________ ___________________________________

Less than 20 seconds:

___________________________________

Between 20 and 40 seconds: More than 40 seconds:

___________________________________ 10


___________________________________

During every visit:

___________________________________


___________________________________


___________________________________

During return visit: Make necessary changes to care plan (based on assessment)

___________________________________

Review and update mother’s and newborn’s complication

readiness plan

___________________________________

Reinforce key messages Replenish supply of supplements and drugs/medications

___________________________________ 7

Using the Partograph (Vital Signs and Urine)

___________________________________

Temperature: Record every 2 hours Pulse: Record every 30 minutes and mark with a dot (•) Blood pressure: record every 4 hours and mark with arrows Protein, acetone and volume: Record every time urine is passed

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐78

___________________________________ The Modified WHO Partoghraph

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 13

___________________________________ Sample Partograph for Normal Labor

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 14

___________________________________ Partograph Showing Obstructed labor

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐79

___________________________________ Partograph Showing Inadequate Uterine Contractions Corrected with Oxytocin (Oxytocin should have been started 2 hours earlier – hour 2)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 16

Basic EmONC Course

Handouts 4‐80

___________________________________ Best Practices in Inspection and Repair of Vaginal Sulcus, Periurethral and Cervical Tears

___________________________________

Best Practice in Maternal and Newborn Care

___________________________________

___________________________________

___________________________________ ___________________________________ ___________________________________

Breastfeeding and Breast Care

___________________________________

Early and exclusive breastfeeding Breast care Breastfeeding information and support – provide as needed

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 10

Objectives of Repair of Vaginal Sulcus, Periurethral and Cervical Tears

___________________________________

Prevent blood loss Facilitate return of genital tract to sexual and reproductive health

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐81

Question?

___________________________________

What is the difference between a vaginal sulcus, periurethral and cervical tear?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 4

Definitions

___________________________________

Vaginal Sulcus Tear(s): One or more lacerations/tears of one or both sides of the vagina Periurethral Tear(s): One or more lacerations/tears near the urethra Cervical Tear(s): One or more lacerations/tears of the cervix

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Question?

___________________________________

What anesthesia is generally used for repair of a vaginal sulcus or periurethral tear?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐82

Anesthesia for Repair of Vaginal Sulcus or Periurethral Tear

___________________________________

Anesthesia of choice – 0.5% lignocaine. Use approximately 10mL of lignocaine. If more that 40mL is needed, add adrenaline to the solution. Do not use more that 50mL. Aspirate to be sure that no vessel is penetrated. Anesthetize at least 2 minutes prior to suturing, and test that anesthesia has been effective.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 7

Question?

___________________________________ ___________________________________

What anesthesia is generally used for repair of a cervical tear?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 8

Anesthesia for Cervical Tear

___________________________________

Anesthesia is not required for most cervical tears:

___________________________________ ___________________________________

Emotional support and encouragement is needed.

Relief of anxiety is important in reducing discomfort

___________________________________

If tears are high and extensive, give pethidine and diazepam IV slowly (do not mix in same syringe) or use ketamine.

___________________________________ ___________________________________ ___________________________________ 9

Basic EmONC Course

Handouts 4‐83

Suture

___________________________________

For vaginal sulcus tear, use 2-0 chromic or vicryl suture For periurethral tears, use 3-0 or 4-0 chromic or vicryl suture For cervical tears, use 0 chromic suture

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 10

Tips

___________________________________

Start suture 1cm above apex of vaginal or cervical tears to catch any vessels that may have retracted Insert a catheter before beginning repair of periurethral tears to prevent damage to urethra Always use forceps, NEVER your fingers, to handle/maneuver needle

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11

Post-Procedure Counseling

___________________________________

___________________________________

Change pad/cloths frequently to keep wound dry Do sitz/warm soapy baths 3-4 times per day Do not insert anything in the vagina Get rest and good nutrition Delay intercourse to avoid breaking sutures Do not return for suture removal as they are absorbable Return within a week for check-up

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐84

___________________________________ ___________________________________

Best Practices in Postpartum Care of the Mother

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Session Objective

___________________________________

By end of session, participants will be able to:

___________________________________

Describe the significance of postpartum care Describe client assessment during the postpartum

___________________________________

period Describe the elements of care provision of the postpartum mother

___________________________________ ___________________________________ ___________________________________ ___________________________________ 2

Basic Postpartum Care Provision

___________________________________

Mother and baby should be seen at 6 hours after birth, and again before discharge if in a facility; or approximately 6 hours after birth if delivered at home Every mother and baby should be visited again by a provider or trained community health worker by 72 hours after birth

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐85

When is the mother most vulnerable? (evidence from Matlab, Bangladesh)

___________________________________ ___________________________________

160

Deaths per 1000 person year

140

___________________________________

120 100 80

___________________________________

60 40

___________________________________

20

ar 2 Ye

18 0

-3 65

91 -

18 1 ay

ay D

D

2

43 -9 0 ay D

D

ay

84

37

2

ay D

1 ay

ay D

D

___________________________________

D

ur in

g

pr e

gn

an cy

0

___________________________________ 4

4 Million Newborn Deaths - When?

___________________________________

Up to 50% of neonatal deaths are in the first 24 hours

___________________________________ ___________________________________

75% of neonatal deaths are in the first week – 3 million deaths

___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)

Neglected Area of Care

___________________________________

Few women receive postpartum care. An estimated 70% of women in developing countries, do NOT receive postpartum care. In a study by Forte et. al. of 29 countries, those women who received PPC receive it within 2 days, but for the other nine countries, the peak of PPC occurs 7-41 days after birth. (Forte A et al. 2006. Postpartum Care Levels and Determinants in Developing Countries. )

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐86


___________________________________

During every visit:

___________________________________


___________________________________


___________________________________

During return visit: Make necessary changes to care plan (based on assessment)

___________________________________

Review and update mother’s and newborn’s complication

readiness plan Reinforce key messages Replenish supply of supplements and drugs/medications

___________________________________ ___________________________________ 7

Question?

___________________________________

What basic care should be included in care of the postpartum mother?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 8


___________________________________

Ongoing supportive care up to discharge Basic care package:

___________________________________ ___________________________________

Breastfeeding and breast care Complication readiness plan

___________________________________

Support for mother-baby-family relationships

___________________________________

Family planning Nutritional support

___________________________________

Self-care and other healthy practice Immunizations and other preventive measures

___________________________________ 9

Basic EmONC Course

Handouts 4‐87

Breastfeeding and Breast Care

___________________________________

Early and exclusive breastfeeding Breast care Breastfeeding information and support – provide as needed

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 10

Question?

___________________________________

For how many months is it recommended that a woman should continue breastfeeding?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11

Breastfeeding and Breast Care (Cont...)

___________________________________

Feeding guidelines:

___________________________________

Initiation of breast feeding especially colostrum within

___________________________________

an hour of birth Breastfeed exclusively for first 6 months – no other

___________________________________

food or fluids Breastfeed on demand day and night – every 2-3 hours during first weeks

___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐88


___________________________________

Additional advice:

___________________________________

Choose position that is comfortable and effective

___________________________________

Use both breasts at each feed; do not limit time at

either Ensure adequate sleep/rest – take nap when baby sleeps Ensure adequate food/fluid intake

___________________________________ ___________________________________ ___________________________________ ___________________________________ 13


___________________________________

Breast care:

___________________________________

To prevent engorgement, breastfeed every 2-3 hours

___________________________________

Wear supportive (but not tight) bra or binder Keep nipples clean and dry

___________________________________

Wash nipples with water only once per day – no soap

___________________________________ ___________________________________ ___________________________________ 14

Complication Readiness Plan

At first visit after birth:

___________________________________

Introduce concept and each element Assist in developing plan

___________________________________

Return visits:

___________________________________

Check arrangements made Note changes and problems

___________________________________

Components:

Appropriate healthcare facility for emergency care Emergency transportation Emergency funds Decision-maker/decision-making process Support person/companion Blood donor Danger signs for mother and newborn

___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐89

Complication Readiness Plan (Cont...)

___________________________________

Danger signs: ensure that woman and family know danger signs for her and her newborn, which indicate need to enact complication readiness plan

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 16

Question?

___________________________________

What are the primary indications for use of the vacuum extractor?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 7

Complication Readiness Plan (Cont...) Maternal danger signs: Vaginal bleeding (heavy or

sudden increase) Breathing difficulty Fever Severe abdominal pain Severe headache/

___________________________________

Foul-smelling discharge

___________________________________

from vagina or tears/incisions Pain in calf, with our without swelling Verbalization/behavior indicating she may hurt self or baby; hallucinations

___________________________________ ___________________________________ ___________________________________

blurred vision Convulsions/loss of

___________________________________

consciousness

___________________________________ 18

Basic EmONC Course

Handouts 4‐90

Support for Mother-Baby-Family Relationships (Cont...)

___________________________________

Bonding

___________________________________

Encourage touching, holding, exploring

___________________________________

Encourage the baby to sleep with the mother

Challenges

___________________________________

Discuss woman’s increased need for rest and (if

breastfeeding) intake of food/fluids with family

___________________________________ ___________________________________ ___________________________________ 19

Support for Mother-Baby-Family Relationships (Cont...)

___________________________________

Support

___________________________________

Encourage sharing in care of newborn

___________________________________

Assist in devising strategies for overcoming challenges

Information

___________________________________

Discuss key aspects of postpartum and newborn care Encourage questions

Encouragement and praise

___________________________________

Help build confidence

___________________________________

Provide reassurance that woman is capable of caring for

newborn

___________________________________ 20

Family Planning

___________________________________

Discuss:

___________________________________

Birth spacing – healthy timing and spacing – Intervals of 2 - 5 years beneficial to women and babies

___________________________________

Woman’s previous experience, beliefs, preferences

___________________________________

regarding contraception Safe methods for postpartum women – benefits and limitations of each Available methods and how to access them

___________________________________ ___________________________________ ___________________________________ 21

Basic EmONC Course

Handouts 4‐91

Family Planning (Cont...)

___________________________________

Discuss (cont.):

___________________________________

Return of fertility after birth: – Not predictable – Can occur before menstruation resumes – On average, women who:

___________________________________ ___________________________________

• Do not breastfeed, ovulate by 11 weeks • Breastfeed exclusively for 3 months, ovulate by 4-5 months • Breastfeed exclusively for 6 months, ovulate by 7 months (due to lactational amenorrhea) • Ovulation can occur as early as 4-6 weeks after birth

___________________________________ ___________________________________ ___________________________________ 22

Family Planning (Cont...)

___________________________________

Discuss (Cont...):

___________________________________

Limitations of LAM, for women who choose this

___________________________________

method Dual protection with condoms Assist the woman in choosing a method that best meets her needs and fertility goals

___________________________________ ___________________________________

Ensure that she receives an appropriate method or has access to the service

___________________________________ ___________________________________ 23

Nutritional Support

___________________________________

General guidelines:

___________________________________

Eat balanced diet including variety of foods each day

___________________________________

Have at least one extra serving of staple food per day Try smaller, more frequent meals if necessary

___________________________________

Take micronutrient supplements as directed – Folic acid, vitamin A, zinc, calcium, iron and other nutrients if micronutrient requirements cannot be met through food sources

___________________________________ ___________________________________ ___________________________________ 24

Basic EmONC Course

Handouts 4‐92

Flexion

___________________________________

When flexion is complete, the shortest anteroposterior diameter, the suboccipitobregmatic (dotted line), is passing through the pelvic inlet. The solid dark line indicates the mentoccipital diameter.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Self Care and Other Healthy Practices

___________________________________

Tips:

___________________________________

Individualize messages based on woman’s history

___________________________________

and other relevant findings Encourage woman’s family to be present during these discussions

___________________________________ ___________________________________ ___________________________________ ___________________________________ 26

Self Care and Other Healthy Practices (Cont...)

___________________________________

Prevention of infection/hygiene:

___________________________________

Good general hygiene (handwashing, safe food and

___________________________________

water preparation/handling, bathing and general cleanliness) Good genital hygiene – especially important for postpartum women because more susceptible to infection

___________________________________ ___________________________________ ___________________________________ ___________________________________ 27

Basic EmONC Course

Handouts 4‐93


___________________________________

Good genital hygiene (cont.):

___________________________________

Keep vulvar/vaginal area clean and dry

___________________________________

Wash hands before and after touching Wash genitals after using toilet

___________________________________

Change pads/cloths 6 times/day in first week; then 3

times/day

___________________________________ ___________________________________ ___________________________________ 28


___________________________________

Rest and activity:

___________________________________

Increase rest time – All postpartum need additional rest to speed recovery – Breastfeeding women need even more rest

___________________________________

Wait at least 4 to 5 weeks to resume normal activity;

___________________________________

start back gradually

___________________________________ ___________________________________ ___________________________________ 29


___________________________________

Sexual relations and safer sex:

___________________________________

Avoid sex for at least 2 weeks and until it is

___________________________________

comfortable Increased susceptibility to STIs during postpartum

___________________________________

period Consistent use of condoms

___________________________________ ___________________________________ ___________________________________ 30

Basic EmONC Course

Handouts 4‐94

Immunization and Other Preventive Measures

___________________________________

Tetanus toxoid immunization Iron/folate supplementation Region/population-specific preventive measures, e.g., malaria prevention

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 31

Immunization and Other Preventive Measures (Cont...)

___________________________________

Tetanus Toxoid Immunization Schedule

___________________________________

TT Injection

Due

TT 1

At first contact with woman of child bearing age or as early as possible in pregnancy (at 1st ANC visit)

___________________________________

TT 2

At least 4 weeks after TT 1

___________________________________

TT 3

At least 6 months after TT 2

TT 4

At least 1 year after TT 3

TT 5

At least 1 year after TT 4

___________________________________ ___________________________________ ___________________________________

2-34 32

Engagement

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Engagement is defined as the point when the widest diameter of the presenting part (in a cephalic occipital presentation, the biparietal diameter) has passed through the pelvic inlet. In most circumstances, when the head is engaged, the lowermost part of the presenting part is at the level of ischial spines, or 0 station.

___________________________________ 5

Basic EmONC Course

Handouts 4‐95

Immunization and Other Preventive Measures (Cont...)

___________________________________

In areas of endemic disease/deficiency:

___________________________________

Insecticide-treated nets (ITNs) for malaria – both

___________________________________

mother and baby should sleep under one Presumptive treatment for hookworm infection

___________________________________

Vitamin A supplements Iodine supplements

___________________________________ ___________________________________ ___________________________________ 34

Scheduling a Return Visit

___________________________________

Advise her to bring her relative with her if possible Ensure that she understands that she should not wait for next appointment if she or newborn is having problems or develops any danger sign Review maternal and newborn danger signs and complication readiness plan

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 35

Summary

___________________________________

Postpartum care provision includes:

___________________________________

Ongoing supportive care up to discharge Basic care provision for mother and newborn – – – – – – – –

___________________________________

Breastfeeding and breast care Complication readiness plan Support for mother-baby-family relationships Newborn care Family planning Nutritional support Self-care and other healthy practices Immunizations and other preventive measures

___________________________________ ___________________________________ ___________________________________

Care is individualized according to woman’s and newborn’s needs, history, and other findings

___________________________________ 36

Basic EmONC Course

Handouts 4‐96

___________________________________ ___________________________________

Best Practices in Care for Assisted Breech Birth

___________________________________ ___________________________________


___________________________________ ___________________________________ ___________________________________

Session Objectives

___________________________________

To identify best practices for managing breech birth:

___________________________________ ___________________________________

Procedures to assist in delivery Post-procedure tasks

___________________________________ ___________________________________ ___________________________________ ___________________________________ 2

Indications for Vaginal Breech Birth

___________________________________

Frank or complete breech presentation Cervix completely dilated No evidence of cephalopelvic disproportion

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐97

Breech Presentations

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 4

Overall Tasks

___________________________________ ___________________________________

Plot all parameters on partograph during labor Start an IV infusion Provide emotional support and encouragement Perform all maneuvers gently and without force

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Procedure: Delivery of Buttocks and Legs

___________________________________

Once buttocks are in vagina, tell woman she may push Perform episiotomy if perineum is tight. Allow buttocks to deliver until shoulder blades are seen. Gently hold buttocks in one hand, but do not pull. Do not hold by flanks or abdomen as this may cause kidney or liver damage.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐98

Holding the Baby at the Hips

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 7

Procedure: If Legs Do Not Deliver Spontaneously

___________________________________ ___________________________________

Deliver one leg at a time Push behind the knee to bend the leg Grasp the ankle and deliver the foot and leg Repeat for other leg DO NOT PULL THE BABY WHILE THE LEGS ARE BEING DELIVERED

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 8

Procedure: Normal Delivery of the Arms

___________________________________

If the arms are felt on the chest:

___________________________________

Allow arms to disengage spontaneously

___________________________________

After delivery of first arm, lift buttocks toward mother’s

abdomen If arm does not delivery spontaneously, place one or two fingers in elbow and bend arm, bringing down over baby’s face.

___________________________________ ___________________________________ ___________________________________ ___________________________________ 9

Basic EmONC Course

Handouts 4‐99

PROCEDURE

___________________________________

Lovset’s Maneuver

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Procedure: If the Baby’s Body Cannot Be Turned to Deliver Anterior Arm first

___________________________________

Lift baby up by ankles Move baby’s chest towards woman’s inner leg. The shoulder that is posterior should deliver. Deliver the arm and hand Lay the baby back down by ankles so that anterior shoulder now delivers with arm and hand.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11

PROCEDURE – Delivery of head Mauriceau Smellie Veit Maneuver

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Basic EmONC Course

Handouts 4‐100

Procedure: If Head is Entrapped

___________________________________

Catheterize bladder Have and assistant hold the baby while you apply piper forceps Wrap baby in cloth or towel and hold baby up Use forceps to flex and deliver that baby’s head Apply firm pressure above the woman’s pubic bone to flex baby’s head

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 13

PROCEDURE

___________________________________

Complete steps as normal delivery after delivering the baby, including active management of third stage of labor

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Post-Procedure Tasks

___________________________________

Keep baby warm and dry Examine the woman carefully for tears of the vagina, perineum and cervix, and repair episiotomy Complete records

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐101

Basic EmONC Course

Handouts 4‐102

___________________________________ Best Practices in Management of Headache, Convulsions, Loss of Consciousness or Elevated Blood Pressure

___________________________________

Best Practices in Pregnancy and Childbirth

___________________________________

___________________________________

___________________________________ ___________________________________ ___________________________________

Session Objectives

___________________________________

Discuss best practices for diagnosing and managing hypertension, pre-eclampsia and eclampsia Describe strategies for controlling hypertension Describe strategies for preventing and treating convulsions in eclampsia

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 2

What is the problem?

___________________________________

Pregnant or recently postpartum woman who:

___________________________________

Has elevated blood pressure

___________________________________

Complains of headache or blurred vision Is found unconscious or convulsing

___________________________________ ___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐103

Elevated Blood Pressure

___________________________________

Classifications:

___________________________________

Chronic hypertension

___________________________________

Pregnancy-induced hypertension – Pregnancy-induced hypertension without proteinuria – Mild pre-eclampsia – Severe pre-eclampsia – Eclampsia

___________________________________ ___________________________________ ___________________________________ ___________________________________ 4

Questions?

___________________________________

What is pre-eclampsia? When can it occur?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Pre-Eclampsia

___________________________________

Woman over 20 weeks gestation with:

___________________________________

Diastolic blood pressure > 90 mm Hg AND

___________________________________

Proteinuria

Predisposes woman to develop eclampsia

___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐104

Mild Pre-eclampsia

___________________________________

Two readings of diastolic blood pressure 90-110 mm Hg 4 hours apart after 20 weeks gestation Proteinuria up to 2+ No other signs/symptoms of severe preeclampsia

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 7

Severe Pre-eclampsia Diastolic blood pressure > 110 mm Hg Proteinuria > 3+

___________________________________

Other signs and symptoms sometimes present:

___________________________________ ___________________________________

Epigastric tenderness

___________________________________

Headache Visual changes

___________________________________

Hyperreflexia

___________________________________

Pulmonary edema Oliguria

___________________________________ 8

Predicting Pre-eclampsia : What do the Studies* Tell Us?

___________________________________

Those women who developed gestational hypertension at an earlier gestational age were more likely to progress to pre-eclampsia. Approximately 15–25% of women initially diagnosed with gestational hypertension will develop pre-eclampsia It is difficult to predict who will develop preeclampsia

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

*Saudan et al 1998; Moutquin et al 1985

9

Basic EmONC Course

Handouts 4‐105

Eclampsia: Typical signs

___________________________________

Convulsions occurring after 20 weeks gestation in a woman without a previously known seizure disorder. (Can also occur in first few days postpartum.) Proteinuria 2+ or more Blood pressure 90 mm Hg or more

___________________________________ ___________________________________ ___________________________________ ___________________________________

A small proportion of women with eclampsia have

___________________________________

normal blood pressure

___________________________________ 10

Strategies for Preventing Eclampsia Antenatal care and recognition of hypertension Identification and treatment of preeclampsia by skilled attendant Timely delivery

___________________________________

3.4% of women with severe pre-eclampsia will have convulsion Eclampsia is the number one cause of in-hospital maternal death in Nepal Eclampsia is abrupt in onset, without warning signs in about 20% of women

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11

Question?

___________________________________

What should be your initial response when you find a woman in late pregnancy who is convulsing?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐106

Initial Assessment and Management of Eclampsia

___________________________________ ___________________________________

Shout for help - mobilize personnel Rapidly evaluate breathing and state of consciousness Check airway, blood pressure and pulse Position on left side Protect from injury but do not restrain Start IV infusion with large bore needle (16-gauge) Give oxygen at 4 L/minute

___________________________________ ___________________________________ ___________________________________ ___________________________________

DO NOT LEAVE THE WOMAN UNATTENDED

___________________________________

13

Antihypertensive Drugs

Drugs Hydralazine Labetolol Nifedipine

___________________________________

Principles:

___________________________________

Initiate

___________________________________

antihypertensives if diastolic blood pressure > 110 mm Hg Maintain diastolic blood pressure 90-100 mm Hg to prevent cerebral hemorrhage

___________________________________ ___________________________________ ___________________________________ ___________________________________ 14

Emergency!!!

___________________________________

Question:

___________________________________

What do you do if a woman is suddenly convulsing?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐107

Management During a Convulsion

___________________________________ ___________________________________

Give magnesium sulfate IM Gather emergency equipment (O2, mask, etc.) Position on left side Protect from injury but do not restrain

___________________________________ ___________________________________ ___________________________________ ___________________________________

DO NOT LEAVE THE WOMAN UNATTENDED

___________________________________

16

Anticonvulsive Drugs

___________________________________

Magnesium sulfate – the best drug! Diazepam Phenytoin

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 17

Post-convulsion Management

___________________________________

Prevent further convulsions Control blood pressure Prepare for delivery (if undelivered)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 18

Basic EmONC Course

Handouts 4‐108

Magnesium Sulfate

___________________________________

Use magnesium sulfate in

___________________________________

Women with eclampsia

___________________________________

Women with severe pre-eclampsia necessitating

delivery

___________________________________

Start magnesium sulfate when decision for delivery is made Continue therapy until 24 hours after delivery or the last convulsion, whichever occurs last

___________________________________ ___________________________________ ___________________________________ 19

Magnesium Sulfate vs. Placebo in Women With Pre-Eclampsia: Results

___________________________________

In women with severe pre-eclampsia, eclampsia occurred 11 times less often in women receiving magnesium sulfate than in women receiving placebo

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Coetzee, Domisse and Anthony 1998.

20

Monitoring Hourly Assess

Normal Finding

Level of consciousness

Sleepy but arousable

Diastolic blood pressure

Should be maintained between 80100mmHg

Respiratory rate

16 breaths/minute or more

Deep tendon reflexes

Minimal but present

Fetal heart sounds (if undelivered)

Decrease in variability

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 21

Basic EmONC Course

Handouts 4‐109

Monitoring Hourly Assess

Abnormal Finding

Management

Lungs

Pulmonary edema

Discontinue magnesium sulfate

Urine output

Falls below 30 mL/hour or 120 mL/4 hours

Discontinue magnesium sulfate

Uterus (after delivery)

Atonic uterus (postpartum bleeding)

Consider oxytocin for 24 hours after delivery

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 22

Principles of Management

___________________________________

Timing and route of delivery: condition of mother vs. maturity of fetus. In eclampsia delivery should occur within 12 hours of onset convulsions Assessment of fetus: evidence of fetal compromise Control of convulsions Control of hypertension Referral due to other organ complications: pulmonary, renal, central nervous system

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 23

Summary

___________________________________

There are many manifestations of increased blood pressure in pregnancy It is not possible to predict which patients are at risk for severe preeclampsia or eclampsia Vigilant care is needed to make the diagnosis Once the diagnosis is made, timely, appropriate treatment can reduce morbidity and mortality Anticonvulsants should be used, with magnesium sulfate being the first line Antihypertensives should be employed as needed Close monitoring is needed for side effects Ensure woman and family are fully informed

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 24

Basic EmONC Course

Handouts 4‐110

___________________________________ ___________________________________

BEST PRACTICES IN MANAGING FEVER AFTER CHILDBIRTH

___________________________________ ___________________________________


___________________________________ ___________________________________ ___________________________________

Objectives

___________________________________

By the end of the session the learner will be able to Discuss the Prevalence of Post Partum Infection Describe Risk Factors for and Diagnosis of Post Partum Infection Discuss Strategies for Preventing Postpartum Infection Describe Clinical Treatment Approaches Programmatic Approaches for Prevention and Treatment

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 2

Questions?

___________________________________

Would you consider the use of the partograph an important intervention for reducing post partum infection?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐111

Distribution of Maternal Deaths Khan, et al; WHO Analysis of Causes of Maternal Deaths; Lancet April 2006

___________________________________

Asia Specific Distribution

Unclassified 6%

___________________________________

Other Indirect 12%

Haemorrhage Haemorrhage 31%

Other Direct 2%

Hypertensive

___________________________________

Sepsis

E mbolism 0%

Abortion

E ctopic Preg 0%

Anaemia

Obstructed Labor

___________________________________

Ectopic Preg Embolism

Anaemia 13%

___________________________________

Other Direct Other Indirect Hypertensive 9%

Unclassified

___________________________________

Obstructed Labor 9%

Abortio n 6%

Sepsis 12%

___________________________________ 4

Question?

___________________________________

What are some natural barriers to maternal infection?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Natural Barriers to Maternal Infection

___________________________________

Amniotic fluid is a wonderful culture medium! Placental membranes form a barrier at the uterine level Mucus plug in the cervix Lochia (post partum discharge) is a natural effluent which keeps pathogens flowing outward Increased pelvic blood flow at the systemic level

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐112

Risk Factors for Postpartum Infections Frequent vaginal examinations Prolonged and obstructed labor – Length of Labor Prelabour rupture of membranes – Length of ROM Cesarean section

___________________________________

Maternal anemia Micronutrient deficiencies Sexually transmitted infections

___________________________________ ___________________________________ ___________________________________ ___________________________________

Preterm birth Episiotomies, vacuum extractions, forceps delivery, catheterization Poor maternal hygiene

___________________________________ ___________________________________ 7

Question?

___________________________________

What are some causes of fever after childbirth?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 8

Vaginal Bleeding after Childbirth (Cont…): Management

___________________________________

If signs of uterine atony:

___________________________________

Massage uterus

___________________________________

Start IV infusion (plus oxytocin 20 units/liter IV fluids)

or ORS Give oxytocin 10 units IM* Ensure bladder empty (catheterize if needed)

___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐113

Postpartum Infections and Subsequent Maternal Morbidity

___________________________________ ___________________________________

Pelvic inflammatory disease Chronic pelvic pain Dysmenorrhoea Menorrhagia Infertility

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 10

Prevention Strategies At the Time of Childbirth

___________________________________

Reduce the length of labor

___________________________________

Partograph

___________________________________

Ambulation Labor support Appropriate controlled augmentation of labor

___________________________________

Reduce the time of rupture of membranes Delay artificial rupture of membranes

___________________________________

Shorten labor

Reduce the number of vaginal exams

___________________________________

Partograph helps to schedule vaginal examination

___________________________________ 11

Prevention Strategies At the Time of Childbirth Infection prevention practices for every delivery:

___________________________________

5 Cleans:

___________________________________

Clean hands and nails

___________________________________

Clean surface

Hand washing

Clean blade

Minimum manipulation

Clean tie

High-level disinfected or

Clean perineum

___________________________________

sterile gloves for examination Avoid unnecessary procedures (e.g., episiotomy)

___________________________________ ___________________________________ ___________________________________ 12

Basic EmONC Course

Handouts 4‐114

Providing Prophylactic Antibiotics for Cesarean Section: Cochrane Review

___________________________________

Objective: To determine which antibiotic regimen is most effective in reducing infectious morbidity in women undergoing cesarean section Methods: 51 randomized controlled trials Outcomes: Fever, wound infection, urinary tract infection, other serious infections, adverse reactions, cost, newborn outcomes

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Hopkins and Smaill 2000.

13

Providing Prophylactic Antibiotics for Cesarean Section: Cochrane Review

___________________________________

Results:

___________________________________

Ampicillin and 1st generation cephalosporin have

___________________________________

similar efficacy in reducing postoperative endometritis – No need for more broad spectrum agents – Single dose is same as multiple doses – Need randomized controlled trial to test optimal timing (preoperative vs. at cord clamp)

___________________________________ ___________________________________ ___________________________________ ___________________________________

Hopkins and Smaill 2000.

14

Managing Metritis: Cochrane Review

___________________________________

Results:

___________________________________

Combination antibiotics are necessary for metritis

___________________________________

Should include a penicillin (ampicillin), an

aminoglycoside (gentamicin) and clindamycin/metronidazole Single daily dosing of gentamicin is effective Continued oral antibiotics after clinical improvement is not necessary in cases of uncomplicated endometritis

___________________________________ ___________________________________ ___________________________________ ___________________________________

French and Smaill 2000. 15

Basic EmONC Course

Handouts 4‐115

Antibiotics for Metritis

___________________________________

IV antibiotics:

___________________________________

Ampicillin every 6 hours Gentamicin every 24 hours Metronidazole every 8 hours

___________________________________

Continue until fever-free for 48 hours No oral antibiotics after treatment:

___________________________________ ___________________________________

Not proven to add any benefit Only add to expense

___________________________________ ___________________________________ 16

Post Partum Infections: Summary

___________________________________

Post Partum Infection/Sepsis remains an important cause of maternal morbidity and mortality 3 biggest risk factors are:

___________________________________ ___________________________________ ___________________________________

Prolonged labor, prolonged ROM and multiple exams

(Ahhh, the partograph!)

___________________________________

Most common diagnosis of post partum fever is Metritis Antibiotics: Less is more!

___________________________________ ___________________________________ 17

Basic EmONC Course

Handouts 4‐116

___________________________________ ___________________________________

Best Practices in the Management of Vaginal Bleeding After Childbirth

___________________________________ ___________________________________


___________________________________ ___________________________________ ___________________________________

Session Objectives

___________________________________

By end of session, participants will be able to:

___________________________________

Describe the significance of postpartum hemorrhage

___________________________________

Discuss the causes of postpartum hemorrhage Discuss the prevention of postpartum hemorrhage

___________________________________

Describe the management of postpartum hemorrhage

___________________________________ ___________________________________ ___________________________________ 2

Vaginal Bleeding after Childbirth

___________________________________

WARNING: Rapid action in response to PPH is critical! More than half of all maternal deaths occur within 24 hours of childbirth, mostly due to excessive bleeding. Uterine atony is the major factor of postpartum hemorrhage (PPH) which causes more than one-quarter of all maternal deaths worldwide.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 3

Basic EmONC Course

Handouts 4‐117

Definition

___________________________________

Vaginal bleeding in excess of 500ml or any amount sufficient enough to cause cardiovascular compromise. Primary and secondary PPH FACT Estimated amounts of blood loss are notoriously low, often half the actual loss. The lower the Hb level the poorer is the woman’s tolerance of blood volume loss.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 4

The Causes

___________________________________ ___________________________________

Atonic uterus Retained placenta or fragments Tears of uterus, cervix, vagina, perineum Coagulation defects Inversion of uterus Infection (delayed PPH)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 5

Management

___________________________________

This is a life threatening complication which must be managed promptly and effectively. Get all the help you can. Prevention is the best management.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 6

Basic EmONC Course

Handouts 4‐118

Question?

___________________________________

What measures can we take to prevent postpartum hemorrhage?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 7

Prevention

___________________________________

CLIENT CARE

___________________________________

Prevent Prolonged Labor Active Management of the

___________________________________

Third Stage of Labor Avoid perineal/vaginal

___________________________________

trauma Monitor closely

___________________________________

EMERGENCY PREPAREDNESS

___________________________________

Have emergency PPH

pack ready

___________________________________ 8

ICM/FIGO Joint Statement on Active Management of the Third Stage of Labor (AMTSL)

___________________________________

AMSTL has been proven to reduce the incidence of postpartum hemorrhage, reduce the quantity of blood loss and reduce the use of transfusion AMSTL should be offered to all women who are giving birth Every attendant at birth needs to have the knowledge, skills, and critical judgement needed to carry out AMSTL

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 9

Basic EmONC Course

Handouts 4‐119

Prevention: Be prepared

___________________________________

ALL women are at risk of PPH! Women who are predisposed to fatal consequences of PPH include women with:

___________________________________ ___________________________________

Over distended uterus (Twins, big baby, Polyhydraminios)

___________________________________

Prolonged labour Severe Pre-eclampsia/Eclampsia Prolonged Intrauterine Death

___________________________________

APH (weakens) Anemia (weakens)

___________________________________ ___________________________________ 10

Question?

___________________________________

What are the first things you should do when you encounter a woman with bleeding after third stage (postpartum hemorrhage)?

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 11

General Management Steps

___________________________________

Call for help Perform Rapid Evaluation (Vital Signs - BP, pulse, Respiratory Rate, Pallor & Cause ) Massage Uterus If shock is present start Immediate Resuscitation

___________________________________ ___________________________________ ___________________________________ ___________________________________

Start IV Infusion 1 litre/15 min Take Blood for Grouping and Cross-matching

___________________________________

Give Oxygen Elevate feet and keep woman warm.

___________________________________ 12

Basic EmONC Course

Handouts 4‐120

Iv Fluid Replacement: In Shock

___________________________________

Start resuscitation with intravenous fluids (Normal saline or Ringers lactate) Use large bore cannula (16 or bigger) Volume to give

___________________________________ ___________________________________

First 1000 ml ( 500 ml x 2) rapidly in 15-20 mins GIVE AT LEAST 2000 ml ( 500 X 4 ) IN FIRST HOUR Aim to replace 2-3x the volume of estimated blood loss. If condition stabilizes then adjust rate to 1000 mls / 6 hrly

___________________________________

___________________________________

Monitor BP, Pulse every 15 mins and Urine output hourly (> 30 ml /hr) Avoid Dextrans they interfere with grouping and x matching as well as with coagulation of blood

___________________________________ ___________________________________ 13

Management: Rapid Assessment

___________________________________

Assess for signs of following conditions and perform appropriate action before proceeding with additional care:

___________________________________ ___________________________________

Uterine atony (uterus soft/not contracted)

___________________________________

Tears of perineum, vagina, cervix Retained placenta or placental fragments

___________________________________

Ruptured or inverted uterus

___________________________________

Delayed postpartum hemorrhage (PPH)

___________________________________ 14

Vaginal Bleeding after Childbirth (Cont…): Management

___________________________________

If signs of uterine atony:

___________________________________

Massage uterus

___________________________________

Start IV infusion (plus oxytocin 20 units/liter IV fluids)

or ORS Give oxytocin 10 units IM* Ensure bladder empty (catheterize if needed)

___________________________________ ___________________________________ ___________________________________ ___________________________________ 15

Basic EmONC Course

Handouts 4‐121

Vaginal Bleeding after Childbirth: Management (Cont…)

___________________________________

If bleeding continues:

___________________________________

Perform bimanual compression of uterus OR

___________________________________

compression of abdominal aorta (per next two slides) Give additional oxytocics e.g. Misoprostol, Ergometrine, Prostaglandins if available. If bleeding continues, facilitate urgent referral/transfer

___________________________________ ___________________________________

If bleeding stops, proceed with additional care plus measure woman’s hemoglobin in 2 or 3 hours

___________________________________ ___________________________________ 16

Bimanual Compression of the Uterus

___________________________________

Wearing HLD gloves, insert hand into vagina; form fist. Place fist into anterior fornix and apply pressure against anterior wall of uterus. With other hand, press deeply into abdomen behind uterus, applying pressure against posterior wall of uterus. Maintain compression until bleeding is controlled and uterus contracts.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 17

Compression of Abdominal Aorta

___________________________________

Apply downward pressure with closed fist over abdominal aorta through abdominal wall (just above umbilicus slightly to patient’s left) With other hand, palpate femoral pulse to check adequacy of compression

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Pulse palpable = inadequate Pulse not palpable = adequate

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Maintain compression until bleeding is controlled

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Basic EmONC Course

Handouts 4‐122

Atonic Uterus! First Action Is Massage Uterus DRUG OXYTOCIN

ERGOMETRINE

CONTRAINDICATION

___________________________________

Not > 40 U infused at rate of 0.02-0.04 U/min.

No IV admin., not even slow IV push unless IV fluids are running

___________________________________

Five doses (Total 1.0 mg)

High BP

___________________________________

DOSE &

CONT.

MAX

ROUTE

DOSE

DOSE

IM 10 U OR

IV 20 u in 1000ml at 40 drps /min

IV 20 U in 1000 ml NS at >60 drp/min OR 5-10 U slow IV push IM OR IV Slowly 0.2mg

Repeat 0.2mg after 15 mins if required every four hours

___________________________________

___________________________________

Heart Disease

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Atonic Uterus! First Action Is Massage Uterus DRUG

DOSE &

CONT.

MAX

ROUTE

DOSE

DOSE

200mg

2000mg

MISOPROSTO ORAL/SL L INTRAVAG (CYTOTEC) RECTAL

Every 4 hours

___________________________________ CAUTIONS & CI

___________________________________

Asthma

___________________________________

Heart Dis*

___________________________________

200-800mcg (600mcg) PROSTAGLAN IM only DIN 0.25mg F2a

0.25mg

Total 8

Asthma

Every 15

Doses=2 mg

Heart Dis*

___________________________________

Minutes

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Question?

___________________________________

If a woman with postpartum hemorrhage has no signs of atonic uterus, what should you do?

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Basic EmONC Course

Handouts 4‐123

Management of Atonic Uterus (Cont…)

___________________________________

If no signs of uterine atony:

___________________________________

Examine vagina, perineum, cervix for tears

___________________________________

Start IV infusion or oral rehydration solution (ORS) – if

woman is conscious

___________________________________

Keep woman warm; elevate legs Ensure bladder empty (catheterize if needed)

___________________________________

Proceed with assessment

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Additional Management (Cont…)

___________________________________

If signs of tears:

___________________________________

If extensive tears (3rd or 4th degree), facilitate urgent

___________________________________

referral/transfer If 1st or 2nd degree tears, perform repairs

___________________________________

If signs of retained placenta, perform appropriate management to deliver placenta If signs of retained placental fragments, perform appropriate management to remove fragments

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Anaesthesia and Analgesia: Local anaesthesia

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Lidocaine Only use in concentration of 0.5%. ( Drug is usually available in 1% & 2% preparations) If more than 40 ml is required add adrenaline to delay dispersion MAX safe dose is 4mg/kg BW for plain and 7mg/kg BW with adrenaline. Anaesthetic effect can last for 2hrs Dose can be repeated after 2hr as needed Avoid injecting into vessel

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Basic EmONC Course

Handouts 4‐124

Retained Placenta

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If you can see the placenta, ask the woman to push it out – kneeling on bed may help If you can feel the placenta in the vagina, remove it If the placenta is still not delivered:

___________________________________ ___________________________________

Give oxytocin 10 units IM (if not already given for AMTSL) and

___________________________________

attempt CCT with the next contraction Catheterize the bladder using aseptic technique if not already done If CCT unsuccessful, attempt manual removal of the placenta

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Managing Retained Placenta

___________________________________ ___________________________________

Ensure Bladder is Empty Apply Controlled Cord Traction: If fails Repeat Oxytocin 10u IV: If no success of CCT in 30 minutes Attempt Manual Removal of Placenta

___________________________________

Give Diazepam 10mg IM/IV Give antibiotics: (Ampicillin 2g + Metronidazole 500mg) Perform procedure and examine placenta for completeness Give Oxytocin 10IU IM If heavy bleeding give Oxytocin 20IU /1000 mls NS or RL at 60 dpm Monitor BP, Pulse, Pad and Urine output closely Add Ergot or Prostaglandin if bleeding continues Transfuse PRN and treat for anaemia

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Anaesthesia and Anaelgesia for short procedures