Basic Emergency Obstetric Care A Tra raii ne nerr ’s Gu Guii de
D epa epartment rtment of Health 2004
This manual is a publication of the Department of Health, and all rights are thus reserved by the DOH. This manual, however, may be freely reviewed, abstracted, reproduced and translated, in part or in its entirety, as long as it is not for sale or for use in conjunction with commercial purposes. Copyright © 2004 The Department of Health All Rights Reserved
Contents Foreword Acknowledgment Acronyms Introduction
1
Th e situation situation o f matern al and newbo rn care in in th e Philippines
1
Th e Saf Safee Mot herho od Po licy licy
2
The Pregnancy, Pregnancy, Ch ildbirth ildbirth , Postpartum and N ewborn C are (PCPNC ) Manual Manual
4
About the Trainer’s Guide
5
Par Part I
9
Pre Pre-Tr -Trainin ining g Activ tivitie itiess
Technical Technical p reparation
11
Organiz ati on of the trai ni ng team
11
Selec Selecti ti on of reso resou rce pers perso on s an d t rai n in g of of core core trai tr ain n ers
11
Identi fication fication of par par tn er in stit ut ions ions and facilities
12
Selec Selecti ti on of par ti cipant cipan t s an d t rai n in g needs needs ass assess essm ent
13
Sett Sett in g of of sche chedu le
13
De D evelopm velopment ent of cou cou rse rse sch schedule edule an a n d prepara preparati ti on of traini ng materials materials
13
Conduct of facilitators’ meeting for the training course
14
Par Part II
Condu Conducct of the the Tr Tra ainin ining g Cour Course
Didactic phase
15 17
Module Module 1 Overview Overview of of BEm OC an d t he PCPN C Manual
19
Module Modu le 2 Prin ciples ciples of Go G ood C are
21
Module 3 Qui ck Check Check an d R apid A ssessm en t an a n d Management
23
Module Module 4 A nt enat al Care
27
Module 5 Labor, Delivery and Immediate Postpartum
32
Module 6 Postpartum Care
39
Module 7 N ewborn wborn C are
42
Module 8 C oun selin g
48
Module Module 9 Mob Mobilizi ng C om m un ity Support
51
Practicum phase
53
Module 1 Orienta ti on on t he Practicum
55
Module 2 On-Site On -Site Te Team A cti vit ies for Cli n ical Skills in BEm OC
58
Monitoring, evaluation and action plan
61
R oles an d respo respon n sibili t ies of t he BEm OC t eam
63
Indicators for monitoring and evaluation
63
Moni torin g and an d evaluat evalu at ion proce processes
65
Mon itoring practicum practicum activ activities ities
69
D aily aily evaluation evaluation of training tr aining activities
72
Process and o ut put evaluation evaluation
74
A ction plan
Par Part III Post-Tr Post-Tra aining ining Activ Activiti ities es
76 79
O utcome indicators indicators
81
Con tinuing commun icati ication on
82
Mon itoring itoring and evalua evaluating ting t raining raining o utcomes
83
D ocum entat ion of experiences experiences
85
References
86
Glossary
87
Annexes
89
Trainer’s Trainer’s Not es
91
Guide to PowerPoint PowerPoint Presentations Presentations
177
Samp Sample le Training Training Sched ule
179
Foreword Th e past past d ecade was was marked marked b y a slow slow pro gress in th e field field of maternal and child health. O f the 1.6 to 2 million million babies born ann ually ually, over 3 to 4 %of them die during t he first first mon th , and nearly two-t hirds of death s occur occur in t he critical critical firs firstt week after after b irth – the perinatal period period . In like like manner, m aternal mor tality tality ratio cont inues to be a major public health health con cern at 17 2 per 10 0,0 00 live live birth s. Mo st of these death s are a result result of poor m aternal health health b roug ht ab out by poor nu trition al status coup coup led with with low qu ality ality care care before pregn ancy, ancy, du ring pregn ancy, ancy, childbirth and imm ediately after after b irth . Recent impro vement vement s in in m edical edical knowledge and advances in health t echnolog y have have caused caused a change in th e way servic services es to pregn ant wo men are provided. provided. Th e previous previous paradigm ut ilized ilized th e “risk approach” approach” where high-risk high-risk pregnancies were were first first identified identified and referred referred for closer attent ion d uring th e prenat al period. period. N ow, ow, in con trast, every pregnant woman is considered at risk risk and sho uld h ave ave access access to a skil skilled led att endant before, du ring and after after p regnancy. regnancy. For t he strategy to succeed, th e “t hree delays” delays” of deciding to seek seek care, care, reaching appropriate care, and receiv receiving care at appropriate h ealth ealth faci facili lities ties must be ad dressed. dressed. O ne critical critical pathway according according t o JIC A, WH O , U N IC EF and U N FPA is to improve the accessi accessibili bility ty,, ut ilization, ilization, and quality of servic services es for for t he treatm ent of complications complications during p regnancy and and childb childb irth . Th is is based based o n evidence evidence t hat at least least 1 5%o f all pregnant women will develop serious complications and require life-saving access to quality obstetric servic services es.. T hus, t he single most critical critical intervention is to ensure t he pr esence esence of a health worker with midwifery midwifery skil skills ls at every birth, and t ransportat ion t o a m ore com prehen siv sive level level of 24-ho ur q uality uality obstet ric care care in case of emergency. emergency. T he U N system system h as recom recom mend ed t he sett ing up of a facil facility ity with with capabili capability ty to pro vide compreh ensiv ensive obstet ric care (CEm O C) in an area with with at least least 5 00 ,00 0 po pulation and a facility with capability to provide basic emergency obstetric care (BEmOC) in an area with at least 125,000 population.
In response to t he glob al cal calll of effecting effecting substantial impro impro vement in mat ernal and child health, as defined defined in the Millennium Millennium D evelopment evelopment G oals, oals, the D epartm ent of H ealth ealth h as reaffirmed reaffirmed its comm itment to invest invest in women and children’s health health by adopting specif specific ic goals, goals, targets, strategies strategies and and inter vent ions to red uce matern al and and infant infant mor tality tality.. It is against against t his backgroun backgroun d t hat t his Trainer’ Trainer’ss Guide on Basic Basic Emergency O bstetric Care is developed. developed. T his wil willl serve serve as th e nation al stand stand ard for training d octo rs, nurses and midwives in in t he field of em ergency ergen cy obstet rics at primar pr imary y level level facili facilities. ties. Th is Trainer’s Trainer’s Guid e provides pr ovides a full full range of concepts and strategies th at enable master trainers to give give high q uality uality training to health workers on pr egnancy, egnancy, childbirt childbirt h, postpart um and newbor n care. It is ho ped th at this Guide becomes a useful useful too l for decision-makers, decision-makers, program m anagers and and health care providers in charting ou t ro admaps toward meeting t he health needs of women and children. children.
MANU EL M. DAY DAYRIT MD, MSc Secretary of H ealth ealth
Acknowledgment Th is Trainer’s Trainer’s Guide was prepared with th e help of many people and o rganizations. These include include th e Mod ule Writers Writers:: D r. Ma. Lou Andal, Dr. Juanita Basil Basilio, io, D r. Ma. Elizabeth Elizabeth Caluag, D r. Divina Divina Capuchino , Dr. Diego D anila, anila, Elizabeth Elizabeth D um aran, Dr. Josephine Josephine H ipolito ipolito , Dr. Jocely Jocelyn Ilagan, Dr. Carol Mirano and Dr. Aurora Musngi. Valuable aluable suppor t was provided provided by th e following following int ernation al dono r agencies: agencies: th e World World H ealth ealth O rganization, rganization, U nited N ations Children’s Children’s Fund, Fund, U nited N ations Population Population Fun d and Japan International Co operation Agency. Th e o ffici fficials als and staff staff memb ers of th e following following o rganizations provided t heir valuable valuable inpu ts and comm ent s to enh ance this training training gu ide, namely: namely: the Techn ical ical Working Working Gro up and Secretaria Secretariatt o f the Safe Safe Mot herhood Program - Maternal and Child H ealth ealth D ivis ivision ion of the D epartment o f H ealth, ealth, Ph ilippi ilippine ne O bstet rical and G ynecological Society, Society, the Ph ilippine ilippine Ped iatric Society, Society, th e Philippine Board of Midwifer Midwifer y, th e Philippine Philippine Board of N ursing, ursing, t he I nt egrated M idwive idwivess Ass Associa ociation tion of the P hilippines, hilippines, the League o f Go vernmen t M idwives, idwives, the Ph ilippine ilippine M edical Ass Association ociation , th e Philippine Academy of Family Family Phys Ph ysici icians, ans, Cent er for for H ealth ealth D evelopment evelopment - Nat ional Capital Capital Region, Region, D r. Jose Fabella Fabella Memorial H ospital, ospital, Bureau of In ternat ional H ealth ealth and C oop eration, Bureau of H ealth ealth Facilities Facilities and D evelopment evelopment , H ealth ealth Po licy licy Development Development and Planning Planning Bureau, H ealth ealth H uman Resource Development Development Bureau, O ffic fficee of the U ndersecretary of th e Depar tm ent o f H ealth ealth , and World World Bank. The commen ts of health workers who participated participated in t he pilot BEmO C t raining raining were also also crucial in the impro vement vement of this Training Training G uide. Finally Finally,, th e D epartm ent of H ealth ealth acknowledges acknowledges the t echnical echnical assi assistance stance provided provided by the C enter for Reproductive Reproductive H ealth ealth Leaders Leadership and D evel evelopment opment , In c. (CRH LD) in the finali inalization zation and prod uction of this guide.
Acronyms BEmOC — Bas Basiic Emergenc Emergency y O bstetri bstetricc Care Care
LR
— Lab o r R o o m
BP
— Blo o d P ressu re
M MR
— M aatt er er n al al M or or ttaalit y rat e
CD
— C o m p act D isc
NB
— N ewb o r n
C PR PR
— Co Co nt nt rraacep t iv ive Pr Prevalen ce ce Ra Rat e
O PD PD
— O ut u t -p at ien t De D ep lo ym en t
DR
— D eliver y Ro o m
OHP
— O ve verh ead P ro ject o r
ER
— E m erg en cy Ro o m
PCPNC
GP
— G ravid a P ara
— Pregna Pregnanc ncy y, Chil Childbirth, dbirth, Postpa Postpartum rtum and Newborn Care
IE
— I n t ern al E xam in at io n
POGS POGS
— Phi Philippi ppine Obste Obstetr triical and Gynecological Society
IM
— I n t ram u scu lar I n ject io n
PR
— P u lse R at e
IV
— I n t raven o u s I n ject io io n o r I n fu sio n
RAM
— Rapi Rapid d As Assess essment ment and Mana Manage geme ment nt
L BW
__ Lo w Bir t h Weig h t
RR
— Resp irat o r y Rat e
LC D
— Liq u id id C ry r yst al al D is isp lay
TNA
— T rain in in g N ee eed s Assessm een nt
LGU
— Lo cal G o vern m en t U ni n it
TOCT
— T ra rain in in g o f C o re re Tr Train er ers
Introduction A. The Situation of Maternal and Newborn Care in the Philippines The Philippines registered a Maternal Mortality Rate (MMR) of 172 per 100,000 in 1998 compared to 180 per 100,000 in 1995 (National Demo graphic graphic H ealth ealth Sur vey, ey, 19 98). Despite Despite t he decrease in MMR, the reduction of maternal deaths due to pregnancy related complication remains remains a chall challenge. enge. The 1998 N DH S indica indicated ted that postpartum hemorrhage is the leading cause of deaths followed by hypertensive complications, sepsis, obstructed labor and unsafe abortion. In the same survey, perinatal death was placed at 18 per 10 00 liv livebirth s. Com pared with M alay alaysi siaa and Singapore ingapore (9.1 per 1000 liv livebirths & 4.1 per 1000 liv livebirth s, respectiv respectively ely), ), th e I nfant M or tality tality Rate (IMR) in the coun tr y is is 36 per 100 0 livebirths. livebirths. In the latest latest 20 03N DH S, the percentage of LBW babies (<2500 gms) is high at 13 %, no t including th ose that were no t weighed. T his is is a reflec reflection tion of the intrauterine growth growth retardation retardation bro ught by matern al deprivation deprivation du ring pregnancy. pregnancy. Stillbirths Stillbirths or infant infant d eaths, on th e oth er hand, can be avoided avoided especially in the critical first week of life if essential care is available during pregnancy, childbirth and
the immediate immediate postpartum period. period. As explai explained ned in th e Th ree D elay elays Mod el, maternal death s occur occur d ue to delays delays in: in: (1) deciding to seek seek care for perceived obstetrical complications; (2) identifying identifying and reaching reaching th e appro priate facil facility ity;; and ( 3) receiving receiving appropriate and adequat e care in in t he facility facility.. The World World H ealth ealth O rganization rganization (2002 ) pointed out that although most pregnancies pregnancies and birth s are are un eventful, eventful, approximately 15 %o f all all pregnant women develop develop a pot ent iall ially y lif life-th e-th reatening complication that calls for skilled care and some will will require a major ob stetrical stetrical int int ervention to survive. If Emergency Obstetric Care is available, and women can access it in time, women’s lives can be saved. Th e establis establishm hm ent o r upgrading o f strategic strategic health facilities on Basic Emergency Obstetric Care (BEmOC) aims to avert death and disability among pregnant women and n ewborn babies. babies. BEmO C refers refers to th e functions functions that can be provided by a team of experienced and trained skilled birt h atten dant s compo sed sed of lic licensed ensed docto r, nurse
1
and m idwife idwife who act as a team at t he primar y lev level el in providing basic basic emergency care care to mo th ers and and babies babies to avert avert maternal and newborn morbidity and mo rtality rtality.. Th e WH O recomm recomm ends a ratio ratio of one BEm O C facil facility ity per one hun dred t wenty fiv fivee thousand (1:125,000) population. Th e following following are t he six (6) basic basic functions of a BEmOC facility: 1. adminis administer parenteral parenteral antibiotic antibioticss ( initia initiall loadloading dose) 2. adminis administer parenteral parenteral oxy oxytocic drug s (for (for activ active management of the 3rd stage of labor only) 3. adminis administer parenteral parenteral anticonv anticonvuls ulsants ants for for preeclampsia and eclampsia (initial loading dose) 4. perform perform manual removal removal of plac placenta enta 5. perform perform removal removal of retaine retained d products 6. perform perform assis assisted ted vagina vaginall deliv delivery ery
B. The Safe Motherhood Policy The Philippines is committed to pursuing the principles principles enunciated in t he C airo airo and Beijing Beijing Conferences on Population and Women respectively for the promotion of safe motherhood and women’s health, and to ensure healthy newborns. H ence, the enactment enactment o f the Departm ent of H ealth ealth ’s Administrative Administrative O rder No . 79s.2000 , otherwise known as the Safe Motherhood Policy on August 28, 2000. It is restating its commitment to the aspiration of a healthy nation through a more vibrant and vigorous Safe Safe Moth erhoo d I nitiatives. nitiatives. The following following principles principles form form th e basis basis for for pro gramming th e redu ction of matern al and perinatal mort ality ality and morbidity in in t he count ry: 2
Promotion of women’s rights and gender
sensitivity; Access to quality health and nutrition services; Focusing Focusing on h ealth ealth promot ion, education education and advocacy; Establishing linkages and developing collaboration to ensure sustainabili sustainability; ty; Mo bilizing bilizing families families and co mm unities to address famil family y planning planning and matern al and n ewborn care; care; Empowering commu nities nities to recognize recognize and correct gender discrimination and prevent violent and abusive abusive b ehavior ehavior t owards women and girls; and Reporting and reviewing all maternal deaths
Goal, Coverage and Scope The Safe Motherhood Policy embraces the goal of ensuring safe motherhood and healthy newborns, hence, its main ob jective jective is is to red uce matern al and and perinatal morbidity and mortality. Under this policy, all women of reprod uctive uctive age (15 -49) and newbor ns up t o 2 8 d ays ays of lif lifee are target o f int int ervention s and and ser vices. vices. Special Special att ent ion shall be given given t o indigenous women, women among highly highly marginalized groups (fisher folks, farmers, urban slums, lums, etc.) and teenage/ adoles adolescent grou ps. ps. Approaches or strategies shall shall be cultu re-based re-based and gender-sensitive.
Gui Gu i deli deli nes and an d Pr ocedur es 1. En suring Q uality uality Maternal and and N ewborn Care Go od q uality uality maternal and newbo rn h ealth ealth servic services es::
Are accessible and available as close as possible to where the women live, and at the lowest possible facility that can provide the services
safely and effect ively. Are acceptable acceptable to pot ent ial ial users and and responsive responsive to local cultural and social nor ms, such as preferen ces for for privacy privacy, con fiden fiden tiality and care by female female health workers. H ave ave on hand all all essential essential supplies supplies and and equipment. Provide comprehensive care and linkages to ot her r eprod uctive health health servic services es;; Provide for cont inuity of care and and follow-up; follow-up; Are staff staffed ed techn icall ically y competen t health care providers who rely on clear guidelines/ proto cols cols for for t reatment; Are staffed by workers who provide respectful and non-judgmental care that is responsive to women ’s needs; needs; In volve olve t he client in decision-making, decision-making, and see see th e client client as part part ners in health care and active active participants in protecting their own health; and Offer economic and social support to health care care providers providers that enable them to do the best best job th ey can; can; Encourage partner as well as family and commu nity involv involvement ement in pre-natal and post-nat al services.
N ata atal/ Delivery Delivery Car Care
All All deliveries deliveries sho sho uld b e att end ed b y a “skilled “skilled attendant” and is within two hours from first level referral referral or well-equipped well-equipped hospital that can h andle emergency obstetric cases cases and shou ld have the following services:
2. Elements of Quality Maternal and Newborn Care
Prenatal
Pregnant Women should have at least four (4) prenatal visits for:
H ealth ealth promot ion: advi advice ce on nut rition rition (e.g iodized salt salt u tilization) tilization) and h ealth ealth care, breastfeeding, newborn care as well as coun seli seling ng to alert alert women to danger signs signs and help plan for birth; Asses Assessment sment : histo r y taking, phys ph ysical ical examiexami-
nation and screening test like hemoglobin/ hemat ocrit d eterm ination, u rinaly rinalysis sis using using Baseed M other’s ther’s R ecord ( H BMR ) , th e H om e Bas dent al check-up check-up and p roph ylax ylaxis is.. (N ot e: The H BMR has been updated and replaced replaced by the Mother Mother and a nd Child Boo Book ) Prevention: Tetanus Toxoid immunization, Micronut Micronut rient rient supplementation (low dose Vitamin A, Multiple micronutrient supplement ation, ferrou s sulf sulfate) ate) and early early detection and management of complications. Treatmen t: M anagement of sexual sexually ly transmitted infections, anemia, toxemia, or other risk conditions.
Provide goo d q uality uality care that is hygienic, hygienic, safe safe and and sympat sympat hetic on an on -going basis; basis; Recognizes and m anage comp lications, lications, including instituting life-saving measures for mother and baby when called for; Monitor progress of labor using partograph; Refer promptly and safely when higher-level care is needed; and Ensure the support support / presence presence of husband/ partner.
Postpartum and Newborn Care
The postpartum m other to gether with with her newbo rn shou ld have at at least least 2 postpart um visits isits one mo nt h apart for the following following services services::
3
Newborn screening for 8 congenital metabolic disorder Apgar scoring, scoring, p roper co rd care Ident ific ification ation and management o f problems in moth ers and newborn in t he 1st 24 hours Immediate and safe referral cases needing higher level care Initiate exclusive breastfeeding Cou nseli nseling ng and health health promot ion on excl excluusive sive breastfeeding, breastfeeding, follow-up follow-up immu nization, family family planning, m icronut rient supplementation , personal hygiene hygiene and care of newborn. BCG immunization and compete assessment o f the newborn u sing Growth Mo nitoring Chart Chart (GM C)
C. The Pregnancy, Childbirth, Postpartum and Newborn Care (PCPN C) Manual Manual One of the strategies adopted to enable the service providers providers become become competent in the management of women and their newborns was the development of the Pregnancy, Childbirth, Postpartum and N ewborn wborn Ca re: A Guide Gu ide for Ess Essent ial Practice by the World World H ealth ealth O rganization. rganization. It aims aims to gu ide health care professi profession on als als in in t he m anagement of women and newborns in said periods as well as its application through an intensive skills training course.
4
The WH O -PCPNC Manual Manual was was adopted to the Philippine Philippine settings based on consultations with techn ical ical groups, academe, Philippine Philippine O bstetrical and Gynecological Gynecological Society Society (PO GS), M idwive idwivess Associ Association ation and on th e results results of the pilot t esting esting o f th anual in t he five five areas of local local government
units (LG U s) in in t he cou nt ry. ry. Th is local version ersion serves as the main reference book for the Skills Training in BEmO C. Th is will will guide service service providers in in th eir clinic clinical al decisi decision-m on-m aking aking th rou gh a systemat systemat ic collection , analysi analysis, s, classi classifi fication cation and use of relevant relevant inform inform ation by suggesting key questions, esse essent nt ial ial observations and/ or examinations examinations and recommend ing/ apply applying appropriate appropriate evievidenced-based interventions.
About the Trainer’s Guide Background of the Trainer’s Guide Pregnan cy, C hilbir hilbir th, The WH WH O do cument --- Pregnan Pos Postpart um an d N ewbo wborn Care: A Gui de for for Ess Essent ial Practic Practi ce ( PCPN C) was adopted as a reference reference manu al for for health care providers providers respon respon sible sible for the care of wom wom en d uring pregnancy and childbirth, and their newborns. To facil facilitate itate th e cond uct o f training, training, t his training training gu ide was developed developed in collaborat collaborat ion with variou ariou s partner organizations th at have a stake stake on red ucing matern al deaths in th e Philippines. Philippines.
A multi-sectoral multi-sectoral PC PN C Task Task Force was created, created, compo sed sed o f represent represent atives atives from from th e D r. Jose Jose Fabella Memo rial H ospital, Mid wives wives Ass Association ociation s, WH O, U NICEF, JICA JICA and and U NFPA NFPA with with D OH N CD PC as chair chair and co nvenor. Sev Several eral meetings were conducted with support support from U NI CEF and WH O to b rainstorm rainstorm on how best the training training can improve the health providers’ capability on managing em ergency complications complications of pregnan cy and childbirth. childbirth.
endo rsement rsement of the Guide from ot her partn ers like like the Philippine Pediatric Society, Philippine O bstetrics and and Gynecology Society Society,, and th ree groups from the midwives’ associations. The last three series of meetings to finalize the Trainer’s Gu ide and the pre-t esting was was funded b y th e U N FPA. FPA. A tot al of 23 h ealth ealth servic servicee providers from from lying-in lying-in o r birt hing facilities, facilities, Pro vincial vincial H ealth O ffices ffices from from six six UN U N FPA ass assis isted ted pro vinces, vinces, and from t he Cent er for for H ealth ealth D evel evelopment opment participated and gave a comprehensive assessment of the training. With suppor t from JI CA, a two-day con con sultative sultative workshop workshop was conducted by DO H to provide provide the different stakeholders with the opportunity to furth er review review the draft and recom mend ways ways to improve it. An additional off-shoo off-shoo t o f this workshop was an agreement to come up with a DO H Administrati dministrativ ve O rder entitled entitled “Im plementing plementing Gu idelines idelines for Basic Basic Emergen cy Ob stetric Care” th at will guide d ecisi ecision on makers and imp lementers of BEmO C in the count ry. ry.
A meeting hosted by the WH O was was condu condu cted to generate m ore t echnical echnical input s and and solic solicit it 5
H ow to U se the Tra Trainer’ iner’s Guide Th is Trainer’s Guid e shall pro vide vide facilitato facilitato rs and resou resou rce persons persons th e stand stand ard techn ical ical cont ent and design design of BEmO BEmO C t raining. raining. It promot es the t eam approach in th e delivery delivery of BEmO BEmO C. T he o verall erall objective objective of t he t raining raining is to en hance t he skill skillss of birt h att endant s (doctors, nu rses, rses, midwiv midwives) in in asse assess ssing ing and managing co ndition s related related t o pregnancy, childbirth, postpartum and newborn care. It is an an 11-d ay training training with 4 -day didactic sess sessions ions and 7 -day clinical clinical practice. T he objectives o bjectives of the th e didact ic phase are as follows: follows:
apply th e principles of goo d care; enhan ce clinic clinical al jud jud gmen t by identifying identifying and prioritizing patients through the application of Quick Check and RAM; discuss discuss the impact of do ing an imm ediate general asses assessment sment o f the wom an up on consultation at t he h ealth ealth facil facility ity;; perform an assessment and management of a woman during labo labo r, after after d eliv elivery and disdischarge from the health facility; recognize and respond to observed signs or volunt volunt eered problems of mo th ers; ers; show ho w to care care for for t he newborn; demo nstrate cou nseling nseling skill skillss on th e essential essential routine and emergency care of women and newborn during pregnancy, childbirth, postpartum and post-abortion; identify comm unity suppor t m echanisms echanisms for maternal and and newborn h ealth. ealth.
Th e didactic part part covers covers nine (9) m od ules, ules, namely: (1) O verview erview of BEmO C and th e PCPN C Manual; (2) P rinciples rinciples of Good Care; (3) Q uick Ch eck and 6
Rapid Ass Assess essment ment and M anagement ; (4) Anten atal Care; (5) Labo r, Deliv Delivery and Im mediate Postpartum; (6) PostPartum C are; (7) N ewborn Care; (8) Co unseling; unseling; and (9) Mobilization Mobilization of Com munity Support . Th e practicum ph ase ase covers two ( 2) p racticum racticum activities activities for clinical clinical skill skillss on BEmO BE mO C. It aims to enhance th e com peten cies cies of servic servicee pro viders in in applying basic emergency obstetric care to all women and t heir babies. Its sessi sessions ons include: (1) O rientation rientation for t he Practicum; Practicum; and (2) Practicum Practicum Activities Activities for Clinica C linicall Skil Skills ls in BEm O C. Th e practicum sessi session on shall take place in an accredit ed training training ho spital: pital: at at the outpatient department, emergency room, m aternity ward, ward, labor and delivery room and wherever trainees can practice their skills. Nearby lying-in clinics and birthing hom es, health centers and rural health health u nits may also also serve ser ve as practicum sites sites pro vided vided th ey are are accredited accredited as training training un its. Th e training team shall shall be composed of: (1) a training d irecto irecto r; (2) at least least fiv five core t rainers; rainers; and (3) a finance/ finance/ administrative administrative office officer. r. To ensure a common understanding on the T rainer’ rainer’ss Guide and PCP N C M anual, a two-day faci facili litato tato r’s meet ing before the training proper will be conducted for the team and o th er invi invited ted resource persons. Th e resource persons or facilitators for the training will be selected selected based on t heir experience/ experience/ expertise expertise in th e area of maternal and and n ewborn care, orientation on PC PNC , exposure exposure to conduct of training training activities activities and willi willingn ngn ess to be p art of th e t eam.
The Trainer’s Guide is organized in three parts: Part 1 provides provides checklis checklistt on pre-training preparation. It consists consists of the t echnical echnical and adm inistrative inistrative requirements requirements which which n eed to be prepared to ensure ensure smoot h implement ation of the training, such such as: as: (1) organization of the training team; (2) selection selection o f resource; resource; (3 ) persons and t raining-o raining-o f-trainers; f-trainers; (4) identification identification o f partn er institut ions and facil facilities ities;; (5 ) selection election of participants participants and t raining raining n eeds asses assessment; sment; ( 6) sett sett ing o f schedule; schedule; (7 ) d evelopevelopment of course schedule and preparation of training m aterials aterials;; (8 ) co ndu ct o f faci facili litato tato rs’ meeting; and (9) fulfil ulfillment lment of administrative administrative requ irements. Part 2 presents the nine modules of the didactic phase and two modules of the practicum phase. Each mo dule and sess session ion includes presentat presentat ion o f the objectives, topics, duration, methodology and materials needed. This part also provides practical tips on how to monitor and evaluate before, during and after the course, including the preparation of an action plan. Part 3 provides an overview of post-training activities which the trainers and participants can undertake collaboratively. This part includes discussion of outcome indicators for the training, the need for continuing commun icati ication, on, h ow to monitor and evalua evaluate te t raining raining ou tcomes and th e impor tance of do cument ing experiences experiences..
To facilitate facilitate th e use of th is bo ok, especially especially findin finding g information, information, t he th ree major major parts and t he Annex which includes includes th e Trainer’s Trainer’s No tes are color coded: P ar t 1 P re-T rain in g Act ivit ies Part 2 Conduct of the Traini Training ng Course Course A. D id act ic P h ase B. P ract icu m P h ase C . M o n it o rin g , E valu at io n and Action P lan lan P ar t 3 P o st -T rain in g Act ivit ies An n ex
Yello w Blu e P in k O ra ran g e G reen Vio let
A Glossary is also also included in page 8 7 t o aid th e trainers and readers in understanding the meanings of words/ words/ terms used used in the guide. guide. T he Annex Portion includes th e trainer’s no tes, guide to the powerpoint powerpoint presentation, presentation, and sample ample training schedu schedu le for for t he didactic phase. phase. Th e trainer’s no tes cont ain ain th e variou variou s reference reference and presentation materials. materials. Sample Sample forms and to ols are also included in this section. Together with this Trainer’s Guide are the instruction al materials materials such as th e Co mpact D isk isk of PowerPoint Presentations, a set of transparencies transparencies of selec selected ted p resent resent ation m aterials aterials and t he PC PN C Manu al as as main main resource b ook.
The introductory part walks the trainer or reader into the context of the guide which includes the situation of maternal and newborn care in the Philippines, Philippines, the Safe Safe Mo th erhoo d Po licy licy and t he cont ext of the PC PN C which serves serves as as the main reference reference bo ok of th e Trainer’s Trainer’s Guide. 7
PreTraining Preparation 9
Prior to conducting the skills training on BEmOC, certain preparations need to be don e to ensure ensure its smoot smoot h implementation. implementation.
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Technical Preparation
Organization of the Training Team A Training Team needs to be organized to lead the following r esponsi espon sibilities: bilities:
Management of the training which includes planning, planning, organizing organizing and runn ing the training training sessi session on s in an effective effective and collaborat ive ive manner; Mentoring by providing guidance and support to individual individual part icipants; icipants; Planning how the newly gained competencies can be applied by the p articipant articipant s in in t heir work place; Motivating participants by supporting them in meeting th eir learning learning o bjectives bjectives;; and Con ducting Training Training of Core Trainers Trainers (TOC T) amon g resou resou rce persons/ faci facili litato tato rs for th e different sessions in the didactic phase and area facilitators for the practicum phase.
Th e compo sition sition o f th e team includ includ es: es:
Training Director Core Trainers Administrat ive ive and Finance O fficer fficer
Selection of Resource Persons and Training of Core Trainers (TOCT) Th e selec selection tion o f resource persons/ persons/ facil facilitators itators should take into consideration appropriate matching of their qu alif alifica ication tion s with with t he t raining raining objectives and methodology, as well as the characteristic characteristicss of the part icipants. icipants. T he recru itmen t process sho sho uld b e gu ided b y selec selection tion criteria. criteria. The TO CT aims aims to level level-off -off understanding among th e Training Training Team, resource persons/ faci facili litato tato rs for th e didactic phase and area faci facili litato tato rs for for th e practicum ph ase ase abou t t he go als, als, objectives objectives and and mechanics of th e BEmO C skills skills training. T he discuss discussions/ ions/ meet ings will will focus focus on th e following: following:
Con text of IMPAC IMPAC o n Saf Safe Moth erhood Con text of the PC PN C as a Reference Reference Guide Mod ules for for t he BEm O C Skill killss Training Training O rientation rientation o n the Trainer’ Trainer’ss Guide, particularly: Didactic Phase - session objectives, group activities activities,, expected ou tpu ts and materials/ materials/ resources needed . 11
Practicum Phase objectives hospital hospital departm departm ents/ areas areas that will will be involved hospital hospital personnel/ personnel/ staff/ taff/ area fac facil ilitators itators who will will be in volved volved requirements of the practicum practicum and t he expected expected techn ical ical assi assistance stance from th e area facilitators determine schedule schedule of rotation t o approximate proximate completion of requirements (m ay use as basis basis result resultss of Training Needs Assessment (TNA) to address the gaps/ skil skills ls requ ired by th e participants participants on BEmOC BEmOC ) forms/ checklis checklists ts to be fill filled-up ed-up b y th e participants forms/ orms/ monitoring monitoring to ols to be accomaccomplished by the area facilitators to aid in facili facilitat tat ing application of skills skills cond uct of mid-practicum asses assessment sment how to effectively provide technical assi assistance stance and mo nito ring of th e part iciicipants including prop er feedbacking feedbacking of observations proper conduct and decorum during practicum Monitoring and Evaluation of the Training (during and after)
Criteria for th e Selection Selection of Resource Persons:
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Experie Experience/ nce/ expertis expertisee in t he area of maternal and newborn care O rientati rientation on on PCPNC Exposure to conduct of training activities Willingness to be part of the team
Identification of Partner Institutions and Facilities In stitution stitu tion s and facilities facilities th at will be involved in the delivery delivery of th e training cou rse shou shou ld be identified identified early early on. Th e ident ific ification ation process should consider consider the following criteria:
Training Institution for Practicum Accredited Accredited by Philippine Philippine O bstetrical and and Gynecological Society (POGS) or Department o f H ealth ealth for for teaching/ teaching/ training training Can be government government (as covered covered by DO H Administrative Order) or private institutions that will meet the criteria (covered by MOA with with Lo cal cal Government U nit) H ealth Facilities Facilities for for Practicum Pract icum With Business Business Plan Plan (according t o PhilH ealth ealth Accreditation Accreditation scheme) Accessibility of the facility Capability of the personnel to model cor rect service provision and assist participants during practice With adequate caseload for clinical procedure (BEmOC) Avail Availability ability of essent essent ial sup supplies plies and equ ipment Training Venue Venue for t he D idactic idactic Adequate space for the number of partici pants and activities activities th at will will be cond ucted, including including break-out break-out groups Availability of equipment and supplies Avail Availability ability of facilities facilities for co mm un ication Com fort able/ able/ wellwell-appointed appointed accommod accommod ation
In identifying identifying part ner institut ion and faci facili lities, ties, bear in mind that “the training scenario should be as close close as possible possible to t he work environm ent of the
participa participants” nts” (WH O , 199 7:40). I n t his way way, th ere is greater chance of put ting into p ractice ractice the new skill skillss learned learned in th eir own wo rk sites sites (M clnerney et al., al., 2001; JH JH PIEGO , 2001).
Selection of Participants and Training N eeds Assessment Assessment Th e success success of th e BEmO C skil skills ls training training course will also depend on a careful selection of participants. Criteria for for selecting selecting participants may include: LGU Participa Participant nt
LGU s/ provinces provinces with with h igh Maternal Mor tality tality Rate (MMR), n eonatal death and low Con traceptive ceptive Prevalence Prevalence Rate (C PR) Available BEmOC facilities of LGU Adequate support o f LGU in terms of upgrading facilities, availability of supplies and allocation of budget LGU with with Investment Investment Plan Plan and resource resource management capabili capability ty Available human resources for team composition Private Private institut ions will willing ing t o b e trained Level of competencies of participants
In dividual dividual Part icipant icipant
Team of d octo rs, nurses and m idwiv idwives who serve as skilled birth attendants at the birthing facilities that are capable of providing BEmOC At least least with experience in in h andling birt h deliveries Backgroun Backgroun d in b asic asic OB-GYN OB-GYN and Ped iatrics iatrics
Once the participants have been selected, a TNA
designed designed to determ ine th e skil skills ls which the par ticipants would like like to learn or improve during th e training, trainin g, as well as th eir level level of knowledg e and attitudes regarding BEmOC. The participants will be asked asked t o com plete a TN A form form which will will be used by the Training Team in improving the deliver delivery y of the th e course. cour se.
Setting of Schedule The schedules schedules for for T O CT among t he resource resource persons, dry-run for the course and actual training should be discussed and agreed upon early enough to prepare them accordingly. Inform them immediately as soon as the schedules are finalized.
Development of Course Schedule and Prepara Preparatio tio n o f Training Materials Materials A schedule of all the activities that will take place during the BEmOC skills training course should be d eveloped eveloped b y the Training Team. Th is includ includ es information about the objectives, methodology, time allotted to each activi activity ty and t he resources/ materials needed. It is both a planning tool and a guide for t he t rainers. rainers. The course schedule schedule aims to ensure th at t he flow of training training is logical logical,, th e participants are able to effectively acquire and apply new knowledge and skills and stay focused and interested. Together with the course schedule, training materials rials such as hand out s, com com put er-generated presentations (PowerPoint) (PowerPoint) u sing computer and LCD or o verhead verhead p rojectors, flipchart flipchart paper, pho to graphs and mo dels (e.g. d olls, olls, chicken chicken b reast, reast, etc.) have to be prepared. 13
List of T raining Mat M aterials aterials/ erials// Resources erials Training
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Metacards Pentel pens Masking tape Board LCD and computer Overhead projector PCPNC Manual Handouts on BEmOC Manila paper Transparencies of presentation materials CD of PowerPoint presentations Chalk Prizes for games 5 drill exercises Case study handouts Arm model IV butterfly/canula Chicken breast Drugs and supplies (magnesium sulphate, oxytocin, ergometrine, diazepam, IV/IM antibiotics, arthemeter or quinine IM) Quick Check and RAM chart Crayola Paste Assorted art papers Observation tool Partograph and Labor chart Examination chart for mothers (after discharge) Slide presentations Undressed doll Mannequin Self-inflating bag
Mask size 0 & 1 Suction tube/suction device 2 towels Clock Skills requirement handout Practicum forms Patients Hospital/birthing/lying-in facilities
Conduct Facilitators’ Meeting for the Trainers Course A two-day facil facilitator’s itator’s meeting sho uld b e con du cted with core trainers to ensure that all requirement s of training for th e didactic and and p racticum racticum phases have have been p repared. Th e result result o f the meeting should serve as basis basis for for d oing t he necessa necessary ry adjustm adjustm ent s or improvement in th e training cou rse. rse.
C o nduc ndu ct of o f the Training Course
Th is section section con sists sists the didactic phase, phase, practicum ph ase ase and m on itoring and evaluation evaluation of the actual ski skill llss training training o n BEm O C. T he o bjectives bjectives and and to pics of the t hree m ain ain part s, modu les and specific specific ses sessi sions ons are laid laid o ut to guide t he t rainers rainers and par ticipants ticipants during the conduct of the training course. An appropriate mix of training methods that were used in pre-testing th is trainers’ guide was adopt ed t o ensure t hat part icipants icipants realize the cou rse objectives. objectives.
Didactic Objectives By the end of the didactic phase, participants will be able to:
apply the principles of good care; enhance clinical judgment by identifying and prioritizing patients through the application of Quick Check and RAM; discuss the impact of doing an immediate general assessment of the woman upon consultation at the health facility; perform an assessment and management of a woman during labor, after delivery and discharge from the health facility; recognize and respond to observed signs or volunteered problems of mothers; show how to care for the newborn; demonstrate counseling skills on the essential routine and emergency care of women and newborn during pregnancy, childbirth, postpartum and postabortion; and identify community support mechanisms for maternal and newborn health.
Duration The didactic phase will be conducted in four (4) days.
Methodology Different methods and activities shall be employed to meet the objectives of the didactic phase, particularly participatory and hands-on methods. These include: lecture/ interactive-discussions, brainstorming/case studies, group work/ experiential sharing, demo-return demo, plenary sessions and clinical exposure. The participants will be provided with the opportunity to describe the skill, demonstrate the skill, practice the skill and verify whether the task is being performed proficiently.
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Module 1
Overview of BEmOC and the PCPNC Manual Objective
To enable participa participants nts to understand BEmO C and the use of the PC PNC Manual. Manual.
Topics
Overview of BemOC U se of the PCPNC Manual Manual
Duration 1 hour and 30 minutes
Session Session 1
Materials needed
BEmOC and the Use of PCPNC Manual Manual
Metacards, pentel pens, masking tape, board, LCD/ O H P, presentati presentation on m ateri aterial alss and and h andouts on BEmOC and PCPNC Manual. Manual.
Specific o bjective bjective At the end of the sess session, ion, t he part icipants icipants will will be able to understand BEmOC and the importance of PCPN C M anual and and its use. use.
Methodology War m -u -u p exercise Lect ur ure-d is iscu ss ssio n Rein fo r cem en t D rill
Procedure
1 0 m in in 3 0 m in in 1 0 m in 4 0 m in
Explain Explain t he o bjectives bjectives and m echanics of th e sess session ion t o t he p articipant articipant s; Provide each participant with 2 metacards, and ask ask all all of them to write their ideas abo abo ut BEmO C and post their cards cards in the bo ard; Summarize the contents of the metacards by identifying patterns of responses; After th e summ ary of part icipants’ icipants’ ideas, ideas, proceed with the lecture-discussion on BEmOC and rationale and design of the BEmOC skills training cou
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Proceed Proceed with the D rill rill on t he PCPN C Manual by explai explaining ning t he impor tance of knowing how to n avigate avigate the cont ents of th e manual, letting letting the participants go over the guide, and asking sample topics to identify pages and clarify contents; and Synthesize ynthesize t he con tent s of the session session and link link it with with M odule 2.
R efer to t o pages 91-98 of t he T rai n er’s er’s N otes
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Module 2
Principles of Good Care Objective To provide participant participant s with th e oppo rt unity to apply the principles principles of good care to all cont acts bet ween th e skil skilled led atten dant and all wom wom en and th eir babies. babies.
Topics
Communication Workplace and administrative procedures Universal precautions and cleanliness Organizing a visit
Duration 1 hour
Session 1
Materials needed
Principles Principles of Go od Care
4 pcs. pcs. m anila anila papers, pent el pens, masking masking tape, board, board, LCD/ OH P, PCPNC Guide, Guide, handouts handouts and and CD / transparenc transparencie iess of pres presentation m aterial aterialss on t he Principles Principles of Good Care.
Specific objective At t he end of the sessi session on , th e participant participant s shou shou ld be able to impro ve skil skills ls in applying th e principles of good care. care.
Methodology Lectur Lecturette ette 10 min Works orkshop 20 min P len ar y 3 0 m in
Principles of Good Care The principles of good care apply to all contacts between the skilled attendant and all women and their babies. These principles concern: Communication Workplace and administrative procedures Universal precautions and cleanliness Organizing a visit
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Procedure
Explain Explain th e ob jective jectivess and m echanics echanics of the sess session ion t o th e part icipants. icipants. D ivide ivide th e part icipants icipants into 4 g rou ps. Ask Ask each each group to list down the principles of good care to all contacts between all women and babies on 4 concerns: Communication; Workplace and administrative procedures; Universal precautions and cleanliness; and Organizing a visit; Instruct the grou ps to write write their inputs on the manila manila paper paper and and post them on th e wall wall// board for presentat presentat ion; Each group will be given 2 minutes to present th eir ou tpu ts. While While a grou p is presenting, ot her gro ups will will act act as observers and com mentators. Each Each grou p should come up with with a summary of their presentation; and Synthesize the workshop outputs and connect th em with th e next mod ule’s ule’s to pics. pics.
R efer efer to t o page 99 of the Tra in er’s er’s N otes
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Module 3
Quick Check and Rapid Assessment and Ma Mana nagement gement ( RAM) Objective To enh ance the clinic clinical al jud jud gmen t o f a health health worker by identifying identifying and prioritizing prioritizing patients thro ugh t he application application of Qu ick ick Check and and RAM.
Topics
Q uick check check RAM Referral system Emergency treatment for t he woman (repair of Laceration, Laceration, I V insertion,b insertion,b utt erfly erfly, IV cannu lation, lation, bleeding, eclampsia and pre-eclampsia and infection)
Duration
2 hours and 30 minutes
Session Session 1
Materials needed
Q uick uick Check
3 p cs manila manila papers with with th ree headings nam ely: ely: SIGN , C LASS LASSIFY and and TRE AT, m etacards with with descriptive descriptive words, words, LCD , chalk, chalk, bo ard and 1 prize.
Specific o bjective bjective At the end of the session, the participants should be able to identify and prioritize patients from the group.
Methodology Lect u r e-d iscu ssio n C on on t es est / rein fo rc rcem en en t
Procedure:
1 5 mi min 5 mi min / 2 0 m in in
Explain Explain t he o bjectives bjectives and m echanics of th e sess session ion t o t he p articipant articipant s; For t he C ont est est Activity Activity:: D ivide ivide th e participants into into 3 grou ps and and d istribute istribute to them pink, yellow yellow and green metacards with with descripdescriptive words of patients; Ask each group to post the cards on the corre-
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sponding h eading in the m anila anila paper. paper. Th e fastes fastestt grou p with th e correct answers answers wins wins a prize. Everybody part icipates icipates in in ch ecking ecking t he answers; For the Lecture-Discussion Activity: Discuss things that need to be considered considered during th e initial contact with the woman and child seeking care. Ask Ask th e part icipants icipants to share their own experiences experiences or what th ey want want clari clarifi fied ed in th e discussion; discussion; and End th e sessi session on by sy synt hesizing hesizing t he t opics covered and connect them with the next session.
Materials needed RAM chart, LCD, 5 drill exercises, manila papers, pent el pens, pens, masking masking tape, and bo ard.
Procedure
R efer efer to t o page 99 of the Tra in er’s er’s N otes
Session 2 Rapid Asses Assessment sment and Managemen t ( RAM)
Explain Explain th e ob jective jectivess and m echanics echanics of the session and link it to the previous session; For the Lecture-Discussion: Present the RAM chart by discussi discussing ng each item and clarif clarifyi ying ng qu estions/ queries queries from from the learners; learners; For th e Drill/ Drill/ Exercis Exercise: e: Check participants’ participants’ comprehen sion sion by posing posing situations, and ask them t o step by step solve a specific problem following the RAM RAM pro cedure; and and Ask Ask the par ticipants to summ arize what what t hey have have learned from the session; and then proceed to the next session.
R efer efer to t o page 99 of the Tra in er’s er’s N otes
Specific objective: To enable the learners to:
Perform RAM to all all women of childb childb earing, earing, labor and postpartum stages; Assess emergency and priority signs, and give appropriate appropriate treatment ; and Refer women to hospital.
Methodology Lect ur ur ee-d is iscu ss ssio n D ri rill o n R AM
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2 0 m in in 1 0 m in / d rill ( 5 d rills) / 3 0 min
Case Study 1 C ase Study Stu Stud dy y 1 Quick Check and RAM Case
Problem A young woman named Fatima, who is obviously pregnant, arrives at the health facility with an older woman. Fatima is complaining of severe abdominal pain. What action would you take? Additional Data Obtained During the RAM Fatima has the following abnormal signs: Cold moist skin Pulse >120/minute Severe abdominal pain What does this mean? Further assessment reveals that her blood pressure is 90/50 and the temperature is 40°C. How will you manage her?
Case Study Case S tudy 2
Quic uick k Chec Check k and RAM
Problem A woman named Umi arrives at the health facility with her mother-in-law. She is obviously in advanced pregnancy and appears distressed with intermittent abdominal pain, which she says occurs about every 5 minutes. What action would you take? Additional Data Obtained during RAM No emergency signs are detected and her vital signs are the following: BP 100/70, PR 85, RR 20, temperature 36.8°C. Umi is found to be in labor. What will you do next?
Session 3
After th e sharing, sharing, explai explain n th e correct process of referring referring patient s based based o n the th e referral referral system. system. Request a participant participant t o describe describe ho w she/ she/ he fill fillss up t he referral form. T he d iscuss iscussion ion shou ld lead to the correct way of fill filling ing up of form. form. H ighlight ighlight important points in in the referral referral system. Let participant ticipants’ s’ discuss discuss their m anagement system system b efore referring pat ients. Assi Assist st in the t he d iscuss iscussion ion b y providing viding add itional input s. Also, Also, ask ask participants to enu merat e sample sample cases cases need ing referral. Sum -up the t he discuss discussion ion by emphasizing emphasizing impor tant poin ts in th e referral system. system. G ive ive assi assign gnmen men t for the next session.
Session 4
Referral System System
Emergency Treatment for the Woman
Specific objective
Specific o bje bjective ctive
At the end of the session, the participants should be ab le to refer refer pat ients correctly. correctly.
Methodology Int eractiv eractivee discus discusssion 20 m in
Materials Materials n eeded Sho rt not es of own experiences, experiences, chalk, chalk, bo ard, LC D / O H P
Procedure
Recapitu late th e previous sess session ion and an d link it with the objectives and mechanics of Session 3. For this Interactive Discussion: Ask participants to share their own experiences in the field regarding referral referral of patient s;
To provide provide th e participa participants nts with with the o ppoprt unity to practice the details on emergency treatment identified during Quick Check and RAM.
Methodology L ect u r e-d iscu ssio n D em em on on st st ra rat io io n/ n/ R et et ur ur n D em em o
3 0 m in 1 hr hr/ 1 hr hr & 30 30 min
Materials Materials n eeded Arm M odel, IV Butt Butt erfly erfly// Cannula, Chicken Chicken Breast, Breast, d ru gs, and supplies
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With eclampsia and pre-eclampsia – instruct the participants to give give magn esium esium sulphate, diazepam (if MgSO 4 is not available), appropriate antihypertensi antihypertensiv ve drug, appropriate appropriate IV/ IM antibiot ics, ics, arth emeter or qu inine IM (for malaria, and glucose IV); During the Reinforcement Activity: Supported with actual samples, familiarize the participants with the different drugs. To check their comprehension, ask participants to identify active drugs; Let the participants do the Exercise on Correct Amputation and Regulation of Fluid; and Synthesize ynthesize t he con tent s of the sessi session. on.
R efer efer to t o pages pages 99-102 99-10 2 of the Tra in er’s er’s N otes
Procedure
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Start t he sess session ion by asking asking part icipants icipants t o share th eir experiences experiences in th e work place. Then link link th ese experiences experiences with with th e ob jectiv jectives es and m echanics of th e sessi session on ; For th e Lectu re-Discussi re-Discussion, on, discuss discuss the following: anatom y of female female genital tract including; degrees of laceration; and anatom y of the arm. In the Demonstration/ Demonstration/ Return Demonstrati Demonstration on Activ Activity ity:: With bleeding – instru ct t he participants to demo nstrate nstrate th e management of emergency treatm ent for th e woman (massage (massage uterus and expel clot clot s, apply apply bimanual uterine com pression, apply aortic compression, give oxyto cin, cin, g ive ive ergom etrine, remo ve placenta placenta and fragments fragmen ts manu ally ally, after after m anual anu al removal rem oval of the placent placent a, repair repair th e tear and empt y bladder).
Module 4
Antenatal Care Objective To enh ance the knowledge, att itudes and practices practices of ski skill lled ed h ealth ealth atten dants on quality antenat al care. care.
Topics
Process flow of antenatal care; Skill Skillss necessary necessary du ring an ten atal care; Im por tance o f General Ass Asses essment sment of a Pregnant Woman during a Visi Visitt
Duration 1 hour and 15 minutes
Session 1
Materials needed
General Asse Assess ssmen men t o f a Pregnant Woman D uring a Visit
Quick Check and RAM Chart, manila paper, pentel pen, masking tape, crayola, board, LCD and handouts.
At the end of the sessi session, on, t he part icipants icipants sho sho uld be able able to understand the impor tance of doing an immediate gen eral ass asses essment sment o f the pregn ant woman upo n con sultation sultation at t he facil facility ity..
Methodology D r awin g P len ar y Lect u ret t e
Procedure
1 5 m in 3 0 m in 3 0 m in
Recapitulate the previous session and link the cont ents to th e next to pic’s pic’s objectiv objective; e; Int rodu ce the Game Activity Activity:: Tell th e participants that th ey will will be grouped into 3 -5 members where each each gro up represents th eir areas areas or health facili facility ty.. Th e gro ups up s are are given man ila paper where they will make a symbolic drawing of the new lesson; lesson; 27
After 15 minutes, as ask them t o post th eir eir out puts on the board. A member of each group will explain explain their work in relation relation t o th e new les lesson son during the plenary; and For the lecturette: Give additional inputs that were not discussed during the plenary presentation s. Then synt synt hesize hesize t he sessi session on emph asizi asizing ng th e salient salient aspects of the t opic.
Procedure
R efer efer to t o pages pages 103-104 103-1 04 of the Tra in er’s er’s N otes
Session 2 Process Flow of Antenatal Care
Specific o bjective bjective At the end of the sessi session, on, t he part icipants icipants should be able to improve th eir ability ability in in explaining explaining t he pro cess flow of providing quality antenatal care.
Methodology Lect u ret t e-d iscu ssio n Rein fo rcem en t Ro le P lay Wo r ksh o p
2 0 m in 2 5 m in 2 0 m in 1 5 m in / 1 h r 2 0 m in
Materials needed 35 met acards acards (pink, yell yellow ow & green), p rinted hand out s, 25 pcs. manila manila papers, papers, pent el pen, maski masking ng tape/ paste, paste, b oard, ass assort ed art papers, papers, 2 scenari cenarios, os, observation observation tool, O H P/ LCD ,Q uick uick Ch eck and and RAM Ch art, case stu stu dies, dies,
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Recapitu Recapitu late late th e previou previou s ses sessi sion on with t he u se of metacards metacards to check check on the part icipa icipants’ nts’ comprecomprehension of Process Flow Flow ( e.g. em ergency signs signs encoun tered du ring visi visit; t; asses assessment sment of a pregnant woman, pregnancy status, birth and emergency plan; plan; screening screening the p regnant woman/ checki checking ng and proper management o f condition; condition; and response response to observed observed or volunteered prob lems). Ask Ask th em to comm ent on t he process of: a) elaborat elaborat ion, and b) clas classi sifi fication. cation. T he po sted met acards acards represent t he ph ases ases to be followed followed in th e discuss discussion ion o f the ant enatal care (e.g. B1 – Quick Check and RAM; B8 – Emergency Trea Treatme tment nt for the Woman; oman; and C0-C1 C0-C1 – Antenatal Care). After After everything h as been explained, explained, let a part icipant icipant m ake a brief sum sum mary of the activity; Proceed t o t he Reinforcement Activity ctivity for for Quick Check and RAM and Emergency Signs Encou nt er during Antenatal Care: Review Review first first the conditions relevant to antenatal care. Then divide divide th e part icipants icipants into 3 grou ps and assi assign gn each to work on a specif specific ic topic: Airway Airway and and breath ing (e.g. circulation/ circulation/ shock and convulsions/ convulsions/ un conscious; conscious; Vaginal bleeding (bleeding in early pregnancy, nancy, severe severe abdo minal pain, pain, not in labor); Dangerous fever (other danger signs). Provide the groups with the printed information on the metacards – emergency signs (white), measure measure (b lue), and treatment (pink). (pink). Let part icipants icipants work work for for 15 m inut es. es. Instru ct th em to arrange the information m aterials aterials accordingly (for example: Emergency sign – what signs, signs, what will will be don e to measure it, how t o manage it) it) and paste paste th e out puts in the m anila anila paper. The assigned leader of each group will
Case Study Case Stud y 3 Antenatal Care Ita is on her 6th month of pregnancy. She feels warm and unwell. Her sister-in-law accompanies her to the clinic. What would you do? Additional Data during Quick Check You elicit the information that Ita has burning urination and is febrile. Ita also looks very ill. What will you do next? During RAM Ita’s blood pressure is 110/70 and her temperature is 38.6°C. She is ambulatory. No other signs were noted. How will you manage her?
explain their output. Ask other groups to observe and and comment on the presentation. presentation. Congratulate the participants for their work. Th en summ arize the t opics disc discuss ussed ed b y highlight light ing t he salient salient features. Provide th e part iciicipants with reading assi assignm gnm ent s for for t he n ext topic. Introduce the Role Play Activity on the topic “Asses “Assessment sment of a Pregnan t Woman, Pr egnancy Status, Birth and Emergency Plan”. Tell the participant participant s that t hey will will be divided divided into 3 grou ps. The 2 grou ps will will work on a scenari scenario o while the third group acts as observers. The observers wil willl give give th eir commen ts on : goo d point s; what have been missed; missed; and areas for for improvement. Lead the discussion to the expected outputs of the presentations. After the presentation, ask a volunt eer to sum up th e activity activity.. Pro vide a synthesis of the topic discussed. Proceed to t he Works Workshop hop on Development Development of a Birth and Emergency Plan. Instruct the participants that same groups will work together to come up with a birth and emergency plan. Each group will present their outputs written in
a manila paper. paper. After After th e presentat ions, summarize the outpu ts and link link them with with t he next topic for discussion. Facil Facilitate itate th e next to pic, “Screening “Screening th e Pregnant Woman ”, a Lecturett e-D iscuss iscussion. ion. Ask Ask the participant participant s to share their own experiences, experiences, and th en answer/ answer/ clarif clarify y questions. Request a participant ticipant to summarize. Provide a synt synt hesis hesis of the discuss discussions ions and and t hen pro ceed to t he next t opic. Explain Explain t hat Lecture-D iscuss iscussion ion and ReinforceReinforcemen t Activities Activities will will be employed in t he t opic, “Response to O bserved bserved Signs Signs or Volunt Volunt eered Prob lems”. lems”. Begin Begin t he d iscuss iscussion ion b y using using th e
Case Study Case Study Stu dy 4 Antenatal Care Problem Effie finds the antenatal clinic for the first time on her seventh month of pregnancy. She looks thin and pale. Explain the care you would give. Additional Data during Quick Check No emergency or priority signs are revealed so Effie is asked to wait in line. Her blood pressure is 100/80 and her temperature is 36.7°C. What will you do next? Data Obtained during Antenatal Care Effie is 29 years old. She has 6 previous pregnancies, including one miscarriage and one stillbirth. One pregnancy was also complicated by postpartum hemorrhage and a manual removal of the placenta. Where will you recommend the delivery of the present pregnancy? On further check, Effie is noted to have conjunctival pallor and her hemoglobin is 70 g/l. How will you manage her? Tactful questioning on HIV status reveals that Effie has recently been tested positive for HIV, following a positive test result for her husband. What will you do next?
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Q uick Check and and RAM. After After this, instruct instruct t he participants to work in pairs in in d oing a case case study. study. Let th em write their out put s in the m anila anila paper and explain them during the plenary presentation. O th er participants wil willl observe and comment on t he presentation. presentation. End th e discussion discussion by pro viding viding a synt synt hesis. hesis. Proceed with th e last last t opic in th is sessi session on , “ Preventive Measures” by explaining the objectives and m echanics of the Lect ure-D iscuss iscussion ion and Reinforcement Activities. Discuss the topic focusing on how to: give preventive measures; advis advise and counsel on nut rition and self self-care; -care; advise advise on labor and danger signs; conduct routine and follow-up visits do newborn screening; and undergo home delivery without a skilled attendant. In th e Reinforcement Activi Activity ty,, divide divide par ticipants into 5 groups where each group will employ a met hod ology, ology, e.g. ro le-play le-play,, simulation, simulation, demo nstration, lecturette, etc. Instruct them to demonstrate their understanding of the topic with the use of a selected methodology. Each group will will be given given 1 0 m inut es for preparation and 1 5 minutes for presentation. presentation. Ask Ask oth er groups to observe and and com ment on t he presentation. presentation. Summarize the ou tput s. End th e sessi session on by synt synt hesizing hesizing m ajor ajor learnings learnings from t he d ifferent ifferent to pics discuss discussed, ed, g aps in in t he discussion and areas for improvement.
R efer efer to t o pages pages 103-104 103-1 04 of the Tra in er’s er’s N otes
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Case Study Case Stud y 5 Antenatal Care Care Problem Yani is 15 years old. She goes to the health facility for the first time with her mother on her 3rd month of pregnant complaining of fresh vaginal bleeding. What will you do next? Additional Data during Quick Check and RAM The only abnormality found is light vaginal bleeding with no clots. After 6 hours, the bleeding decreases and Yani’s vital signs are stable. How will you manage her?
Session 3 Skill Skillss Necessary Necessary du ring Ant enat al Care
Specific objective To enable learners to perform p erform the th e procedu res and skill skillss correct cor rectly ly and easi e asily ly..
Methodology Lect u re-d iscu ssio n D em em on on st st ra rat io n / Ret ur urn D em em o
1 0 m in 2 0 m in in / 3 0 m in in
Materials needed LCD LC D
Procedure
Recapitu Recapitu late late t he previous topic and link it with th e next t opic. After After explaining explaining t he o bjectives bjectives of th e sessi session on , proceed with th e Lecture-D iscusiscussion on “C omplete PE o f a Pregnant Pregnant Woman, Leopo ld’s Maneuver & Fetal H eart Beat; Sum marize the discuss discussion ion and pro ceed to t he
D emon stration/ Return Demo nstration nstration Activ Activity ity.. Let th e part icipants icipants work in pairs wherein wherein each skil skilll is is performed b y on e learner learner to h is/ is/ her partn er, and afterwards, exchange exchange r oles. oles. O nce th e skil skills ls have been performed , rando mly ask ask the participants about th eir experiences experiences while performing t he skill skillss and following following th e procedure. Th e sessi session on end s with with a synt synt hesis. hesis.
Case Study 6 Antenatal care Teresa is 23 years old, G 2 P1 on her 8 month age of gestation, with companion. She had an adequate prenatal check up (all normal). Had a traumatic experience during her last delivery, doesn’t want to deliver in a hospital. However, she is new in the area, doesn’t know any skilled attendant, wants a home delivery or a birthing home. What is your advise?
Case Study 7 Antenatal Care Martha is 38 years old G8 P7, went to visit the facility because of dizziness and severe anemia. All her deliveries according to her, were all normal and at home. Upon examination: BP 160/90, with blurring of vision, with her condition she is still insisting to have a home delivery (all her deliveries were handled by a Hilot). What is your advise for a birth or emergency plan?
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Module 5
Labor, Delivery and Immediate PostPartum Objective To improve participants’ skills in assessing and managing a woman in labor, during and after delivery, and until her discharge from the health facility.
Topics
Stages of labor First stage of labor Second stage of labo labo r Th ird stage of labor labor
Duration 5 hou rs and 20 minutes
Session 1 Stages of Labor
Specific objective At the en d of th e sess session, ion, t he part icipants icipants shou shou ld be able to:
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recognize and assess the woman’s and fetal statu s at at t he time o f admiss admission; ion; and decide stage o f labo labo r after after co mplete mp lete rapid assessassessment on adm issi ission. on.
Methodology Lect u re-D iscu ssio n
3 0 mi min
Materials needed LCD/ O H P, CD/ transpa transparenc rencie iess of presenta presentation tion materials, materials, white b oard marker, board , slides slides presentation tation and PCPN C Gu ide
Procedure
Present the objectives of the session and link it with with M odule 4. Proceed with the Lecture-Discussion on the to pics “E xamine xamine th e Wom Wom an in Labor o r with Ruptu red Membranes and and D ecide ecide th e Stage Stage of Labo r”. r” . Th is is an interact ive ive discuss discussion ion where participants are enjoined enjoined to ask ask questions or clarify clarify gray areas, while rand om ly aski asking ng part iciicipants with with q uestions to check th eir com com prehension. The session ends with a summary of the discussions.
R efer efer to t o pages pages 105-107 105-1 07 of the Tra in er’s er’s N otes
Session 2 First First Stage o f Labor
Specific o bjective bjective At the end of the sessi session, on, t he part icipants icipants should be able to:
identif ident ify y abn abnorm orm al findings findings in a wom an while asses assessi sing ng pregnancy pregn ancy and fetal status statu s on admission; admission; manage iden tified tified abn orm al findings findings in a woman du ring labor; labor;
provide suppo suppo rt ive ive care for for a wom an in labor; and review and develop skills needed while attending to a woman in labor.
Methodology P re-Test / G am e Lect u re C ase St u d y Sm al all G ro ro up up D is iscu ss ssio n P len ar y 55 min
1 5 m in 3 0 m in 3 0 m in 3 0 m in in 1 0 m in / 1 h r &
Materials needed Q C and RAM RAM C hart, 4 big cards cards with with letters A-D, A-D, prize, prize, OH P/ LCD, N4-N5 of PCPNC, 2 cas case studies, Part ograph and Labo r, record record acetate (4 sets), sets), m anila anila paper, pent el pens, masking masking t ape and board
Procedure
Int roduce the n ew topic with with t he use of Q uick uick Check and RAM RAM C hart. In t he Pre-Tes Pre-Test/ Game Acti Activ vity on t he topic “First Stage Stage of Labor – Respon Respon d to O bstetrical Care and Provide Suppo Suppo rt ive ive Care, t ell part part iciicipants th at th ey will will be divided divided into 4 gro ups. Each grou p is giv given 4 big letter cards A-D A-D . O nce the grou ps have have been provided their cards, cards, give give a situation situation and m ention 4 cho ices ices (A-D) wherein o ne of th ese ese is th e best course of action to take. The grou ps will will raise raise th e corresponding lett er th ey th ink is is the correct answer. answer. Th e fastes fastestt gro up with t he correct answer wins wins a point, point, and th e group with with t he most numb er of point s wins wins th e game. 33
Q6.During active labor a. monitor the woman every 30 minutes b. do not do vaginal exam more frequently than every 4 hours unless indicated c. both a and b* d. none of the above
Pre-Test Game Topics from: 1st Stage of Labor Respond to OB problems IE, Partograph and Labor Records Q1.Classification of > 4 cm cervical dilatation late active phase a. early active phase* b. early labor c. not yet in labor Q2. If a woman is not in active labor, discharge her and advise her to return if, EXCEPT: a. vaginal bleeding b. discomfort* c. membranes rupture d. uterine contraction Q3. Signs of obstructive labor, EXCEPT: a. horizontal ridge across lower abdomen b. continuous contraction c. moderate abdominal pain* d. labor > 24 hours Q4.Considered as obstetrical complication, EXCEPT: a. abdominal pain* b. FHT = 100x2 determinations c. Pulsation felt during IE d. 2 fetal heart tones Q5.All are correct regarding supportive care throughout labor, EXCEPT: a. tell the woman what position to take to relieve discomfort or pain during labor* b. a birth companion should be around to watch the woman in labor* c. encourage the woman to eat and drink as she wishes throughout the labor e. explain all procedures to be done to the woman
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Proceed with with the t opics opics on “IE , Partograph and Labo r Record” employing employing lecture-d iscusiscussion, small group discussion and plenary present ation s. In t he Lectu re-D iscuss iscussion ion Activity Activity,, introd uce the pro cedures and and forms. While While explaining the procedure on Leopold’s Maneuver, demon strate it it to on e of th e participarticipants. Questions and clarification are elicited during the demonstration, afterwards, proceed to the discussion of a Partograph and Labor Record. For t he Small Grou p D iscuss iscussion, ion, d ivide ivide part iciicipants into into 4 gro ups, where where 2 gro ups work separately separately on o ne case case and th e oth er 2 grou ps work on th e oth er cas case. Instruct th e groups to analyze analyze the cases cases relating relating t hem with t he t opics being d iscuss iscussed ed in 3 0 m inutes. In the Plenary, the leader of each group will present present t he ou tput s, while while oth er groups observe and give comments on the presentation. Ask on e of the learners learners to summarize the discussion. End the session by providing additional inputs and synt synt hesizing hesizing t he d ifferent ifferent to pics covered. covered.
Lect ur ure-D em em on on st st rraat io io n
3 0 m in in / 5 0 m in in
Materials needed OH P/ LCD, LCD, AV AVP
Procedure
R efer to t o pages pages 108-109 108-1 09 of the Tra in er’s er’s N ot es
Session 3 Second Second Stage of Labo Labo r
Specific objective At the en d of th e sess session ion th e participant participant s should b e able to:
describe the course and conduct of normal delivery; and review review and and describe describe steps in in t he m anagement of breech d eliver elivery y, stuck sho sho ulder, m ultiple fetuses and cord prolapse. prolapse.
Explain th e ob jectives jectives of the session session an d link it with with th e previous previous to pic by recapitu recapitu lating the cont ents of th e discuss discussion; ion; For th e Lecture-D iscuss iscussion ion on “ D eliv elivery of the Baby”, discuss the topic using illustrations from audio-visual audio-visual product ion. Th is is is an int eractive eractive discuss discussion ion where q uestions and sharing sharing of own experiences experiences are encouraged from par ticipants. ticipants. Sum marize th e d iscuss iscussion ion an d explai explain n th at Im mediate C are of Newbo rn will be d iscuss iscussed ed in Module 7. Proceed with with t he Lecture-Demon stration on normal vaginal delivery, breech delivery, stuck shoulder, dysto dysto cia, cia, multiple birt hs and cord prolapse by first introducing the important skills needed. Explain the principles while demonstrating the procedure. This is an interactive activity where sharing of own experiences and questions are encouraged from the participants. The session ends with synthesis and explanation t hat skill skill enhancemen t will will be don e during th e clinical clinical period .
R efer to t o pages pages 110-115 110-1 15 of the Tra in er’s N ot es
Session 4 Th ird Stage Stage of Labor
Methodology L ect u re-D iscu ssio n
2 0 mi min
Specific objective
35
At the end of the sessi session, on, t he part icipants icipants sho sho uld be able to:
describe steps in the d eliver elivery y of placenta; determ ine activ activee management of the 3rd stage of labor; asse assess ss and m anage the m ot her du ring and after th e 1st hou r of com com plete delivery delivery of the placenta placenta un til discharge discharge from t he health healt h facility; facility; identify and m anage problems encoun tered in th e moth er imm imm ediately ediately postpartu m; and provide preventive measures to the mother after delivery.
Methodology Lect u re-D iscu ssio n Lect ur ure-D em em on on st st rraat io io n C ase St u d y P len ar y Didacti Didacticc with with Ill Illustra ustrati tions ons
3 0 mi m in 3 0 m in in 3 0 m in 2 0 m in 15 min/ min/ 2 hrs & 5 min min
Materials needed: AVP, VP, LCD/ LC D/ O H P, 2 case case studies, studies, manila papers papers,, pentel pent el pens, masking masking tape and bo ard
Procedure:
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Recapitulate the previous session, explain the ob jectives jectives of the n ew sessi session on and link it with past past to pics; pics; For th e Lectu Lectu re-D iscuss iscussion ion on th e “D eliv elivery of the Placenta”, d iscuss iscuss th e to pic with with t he use of visuals. Tell participants to share their own experiences experiences and and ask ask questions to enrich th e discuss discussion. ion. Ask Ask one of the participants to summarize the discussion; Proceed to t he next to pics pics: Care of the mother and newborn within first
hou r o f placenta placenta d elive elivery; ry; Care of the mo th er 1 hou r after after delivery delivery of placenta; and Asses Assessment sment of the th e mo th er after after d eliver eliver y and before discharge discharge thro ugh Lecture-D iscusiscussion. D iscuss iscuss th e t opic with t he aid o f illustraillustrations, and sharing sharing of experiences experiences from from th e participants. Ask Ask one o f the part icipants icipants to summarize the discussion; Con tinue with with t he next topic, “Respond “Respond to Problems Immediately Immediately Postpartum Postpartum .” U sing the case case study met hod , th e part icipants icipants are divided divided into 4 groups where 2 groups work separately on 1 case study, and the other 2 groups work separately separately on an ot her case. case. Let t he gro ups work for for 30 minutes and ask ask them t o put their out put s in the manila paper; During the Plenary, tell the first 2 groups with the same case to present their outputs. Ask the other groups to observe observe and give give comment s. After the presentations, ask the next 2 groups to present present t heir cas casee stud stud y output s. Th e oth er groups observe and give comments. Summarize rize the ou tput s of the 4 groups; Proceed with the last activity, Didactic Illustrations on: managemen t of abnorm al stage of labor; and active active managemen t o f 3rd stage of labor. Th e discuss discussion ion o f the t opic starts with an explanation explanation o f the impor tant skil skills ls needed by th e part icipants. icipants. E xplain xplain t he principles principles while while demo nstrating th e procedure. T his is an interactive active activity activity where sharin g of o f own experien ces and qu estions estions are encouraged from participants.
Case Study 88 (Groups 2 and 4)
D uring th e sum sum mary, mary, ment ion th at skil skilll enenhancement will will be don e during t he clinical clinical period and t he abno rmal 3rd stage of labor labor will be dis d iscuss cussed ed in em ergen cy measures. The session ends with the synthesis of all the to pics covered.
R efer efer to t o pages pages 116-119 116-1 19 of the Tra in er’s er’s N ot es
Christine M. 18 years old G2 P1 came in because of lumbo-sacral and abdominal pain which started 1 hour ago. No other associated signs and symptoms. During ASK, CHECK RECORD, it was found out that Christine is single, no prenatal check-up done because she claimed her baby is moving throughout the pregnancy. She expects to deliver anytime this week. You now perform the physical examination. Vital signs are normal including fetal heart rate. The abdomen is term size, uterine contraction is mild, 1-2x/ 10 min. You now perform vaginal examination which revealed: cervix 1 cm dilated, not effaced, no vaginal bleeding nor watery discharge. So you sent her home since she is living 5 minutes away. However, 8 hours later, she returned to your clinic with bloody-mucoid vaginal discharge, mild to moderate uterine contractions 2x/10 min., IE – cervix 4 cm dilated, cephalic, station -2, (+) BOW. You monitored her every hour. 4 hours later, IE – cx 7-8 cm, BOW spontaneously ruptured, thinly-meconiumsatained AF. She voided urine = 120 cc, uterine contraction 2-3x/ 10 mins. modstrong. 2 hours later, IE – 9 cm, st +1, vital signs still normal. 30 minutes later, you noticed that the vulva was gaping, you did an IE – fully dilated, station +2 to +3.
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Case Study Study 99 (Groups 1 and 3) Cheska O. 32y/o G3 P2 came to the health facility at 3:00 AM, few minutes apart, she told you that uterine contractions contractions occurred 2x in 10 minutes, 40-60 sec. Duration, moderate strong. On PE, vital signs were all normal, she claimed that she has not voided urine for 6 hours now, no urge to void till now. IE -4 cm cervical dilatation, cephalic, BOW (-) with clear amniotic fluid admixed with scantly bloodymucoid material. Still unable to void, you did bladder catheterization obtaining 200 cc. At 7:00 AM, IE – cervix was 8-9 cm dilate, station 0, clear AF, FHR – 156 / min. BP – 140/100, uterine contraction now strong, 3x in 10 min. Patient voluntarily voided amounting to 130 cc, vital signs remains within normal limits, BP now = 130/80. At 8:00 AM, patient complained that something was about to come of her vagina. IE revealed that full cervical dilatation, fully effaced, cephalic, station +2, clear AF. Materials to use 1) Labor Record 2) Partograph.
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Module 6
Postpa Po stpartum rtum Ca Carre
Objective To enh ance participant participant s’ capabili capability ty in recognizing and responding to observed signs signs or volunt eered pro blems of mot hers so so t hey can can p rovide rovide preventive measures measures and additional treatment .
Topics
Postpart um examination of the m ot her up t o six six weeks; weeks; Respond t o observ ob served ed signs signs or volunt volunt eered pro blems; and Preventive Preventive measure measure and additional treatmen t
Duration 1 hour and 10 m inutes
Session 1 PostPartum Examination Examination of the Mo ther U p to Six Six Weeks
Specific objective At the end of the sessi session on , th e participants participants should be able to:
assess and examine the mother after discharge from t he facility; facility; and cond uct complete histo histo ry and physica physicall examinaexamination of a mot her after d ischarge ischarge from a facil facility ity..
Methodology Lect u re-D iscu ssio n
1 5 mi min
Materials needed Examination Ch art for mo th ers after after d ischarge ischarge and powerpoint powerpoint presentation/ presentation/ transpare transparenci ncies es
Procedure
Recapitu Recapitu late late th e previou previou s sess session, ion, link it t o th e next t opic by explai explaining ning th e ob jective jectivess of the new sessi session on ; D uring t he Lecture-D iscuss iscussion, ion, present t he first first side side of th e chart ( Ask, sk, Ch eck Record Record , Loo k, Listen, Listen, Feel) to be u sed sed for examining examining t he 39
mother after discharge from a facility or after a ho me delivery. delivery. T his is an an interactive inte ractive discussi discussion on where participants share actual experiences and relate these with the session’s topic; and End the session by providing synthesis of the topic discussed.
Procedure
R efer efer to t o pages pages 120-121 120-1 21 of the Tra in er’s N otes
Session 2 Respond to Observed Signs or Volunteered Problems
Specific objective At the end o f the sesss sesssion, ion, t he part icipants icipants shou shou ld be able to:
different different iate abnor mal from from nor mal signs signs and manage appro priately and accord accord ingly; ingly; and recognize volunt volunt eered prob lems of a wom wom an after discharge from a facility and to properly manage t hem accord ingly. ingly.
Methodology L ect u re-D iscu ssio n Wo rksh o p / P yram id in g C rit iq u in g / Pl P len ar y
1 0 m in 3 0 m in 3 0 m in
Materials needed H andouts/ ndouts/ PCPNC Manua Manuall, OH P/ LCD, Chart, Chart, paper, pencil, pencil, man ila ila paper, pentel pen and masking masking tape
Recapitu late th e previous sess session, ion, link it with the new topic by discussing the session’s objectives; During the Lecture-Discussion on Observed Signs or Volunt Volunt eered Pr ob lems, lems, explain explain th e Ask, Check Record/ Record/ Look, Listen, Listen, Feel part part of the chart. Encourage participants to ask question s or clarify clarify gray areas areas in th e dis d iscuss cussion; ion; In the Workshop Activity, divide participants into 4 and let the gro ups analy analyze the prob lems, and and based on t heir experiences experiences answer answer t he following: following: what problematic signs will they observe on postpartum mot hers; hers; ho w do th ey clas classi sify fy th e pro blematic signs observed; what treatment do they giv give and the possible possible advise advise regarding t he prob lematic signs. Provide participants participants with t he format in preparing their responses (Ch art). After After 30 m inut es, es, let each group present outputs, while other groups provide comments or additional inputs; Ensure th at th e discuss discussion ion results to th e expected ou tpu t from th e manual for for faster faster Teaching-Learning process. Ask participants abou t t heir reasons reasons for th e responses given, given, and after after th e discuss discussion ion summ arize arize th e impor tant point s covered covered in th e sessi session on ; For t he po stpartu m sessi sessions, ons, synt synt hesize hesize pregnancy from antenat al to po stpartu m care th roug h simulation or ro le play play by the part iciicipants.
R efer to page 121 of the Tra in er’s N ot es 40
Observed Signs or Volunteered Problems
If Elevated Diastolic Blood Pressure If Pallor (Check for Anaemia) If Signs Suggesting HIV If Heavy Vaginal Bleeding If Fever or Foul-Smelling Lochia If Dribbling Urine If Pus or Perineal Pain If Feeling Unhappy or Crying Easily If Vaginal Discharge 4 Weeks After Delivery If Breast Problem If Cough or Breathing Problem If Taking Anti-TB Drug
Procedure
Recapitu la Recapitu late te th e previous previous sessi session on , link it with th e new t opic by b y discuss discussing ing t he session’s session’s objectiv ob jectives; es; D uring t he Lecture-D is iscuss cussion, ion, explain explain the prevent preve nt iv ivee measures th at need to be con si sidered dered for the women. This is an interactive discussion encouraging shari sharing ng of own experi experiences ences and clarif cla rific ication ation of import ant point s. At the en d o f the discuss discussion, ion, ask on e of the participants to summarize th e discuss discussion. ion. End th e sessi session on with a synt synt hesi hesiss of the t opic covered in the discussion.
R efer efer to t o pages pages 121-122 121-1 22 of the Tra in er’s er’s N otes
Session 3 Preventive Preventive Measures Measures and Additional Treatment s
Specific objective To en able participants participants t o p rovide rovide p revent revent ive ive measures and and add itional treatment s to a woman after discharge discharge from a facil facility ity including including immu nization, vitam vitam in K, folic folic acid, acid, eben dazo le, antim alarial alarial treat ment, etc.
Methodology Lect u re-D iscu ssio n
1 5 mi min
Materials needed OH P/ LCD, handouts handouts and PCPNC Manual Manual
41
Module 7
N ewbo ewborrn Car Care Objective To enable health workers care for for t he n ewborn baby by developdeveloping th e appropriate skill skillss and and needed knowledge.
Topics
Care of the newborn at th e time of birth birth ; Newborn resuscitation; Examination of the newbo rn baby; and and Care of th e no rmal and small babies until discharge discharge from t he health facility.
Duration 6 hou rs and 40 minutes
Session 1
Materials needed
Care of the Newborn at t he Time of Birth Birth
board and chalk chalk// white white board and pen, LCD and computer/ computer/ O H P, undress undressed doll, doll, and bed
Specific objective At the en d of th e sess session, ion, t he part icipants icipants sho sho uld be able to describe describe and carr y out routine rou tine care of the th e newborn at th e time of birth.
Procedure:
Methodology I n t eract ive D iscu ssio n D em o n st rat io n
42
5 0 m in 1 0 m in / 1 h o u r
Recapitu Recapitu late late t he p revious revious sess session, ion, link it with th e new t opic op ic by discussi discussing ng th e sessi session on ’s ob jectives; jectives; Lead an interactive interactive discuss discussion ion on th e following following topics: basic basic needs of the n ewborn preparing to m eet th e baby’s baby’s needs universal precautions initial initial care care of th e baby at b irth keeping keeping t he b aby warm warm cord care
Session 2 N ewborn Resuscitation Resuscitation
Specific objective At the en d of th e sess session, ion, t he paticipant paticipant s sho sho uld be able able to :
assess and identify newborns needing resuscitation; perform resuscitation resuscitation of th e newborn using using standard g uidelines; uidelines; and provi pro vide de after care if a baby requ ires help with breathing.
Methodology eye care Vitamin K injection keeping keeping the m oth er and baby together after delivery baby’ bab y’ss first first breast br east feed. With With th e und resse ressed d do ll on t he table, ask ask participants ticipants abou t t he basic basic needs of th e newborn at th e time o f birth. Accept Accept all the responses and show the appropriate card on the table as each each o f the 4 main main po ints are are mentioned. Then ask ask participants participants what th ey should do to prepare for and what to do during the delivery of the baby and why. why. T he r esponses of th e part icipants icipants are written written on the b oard, after after which, which, t he trainer comp ares their respon respon ses ses with with th e recomm endation s in the manual. Th e sessi session on end s with with a synt synt hesis hesis..
L ect u re-D iscu ssio n Lect ur ure-D em em on on st st rraat io io n
1 hour 1 h ou ou r/ r/ 2 ho ho ur ur s
R efer efer to t o pages pages 123-135 123-1 35 of the Tra in er’s er’s N ot es
Materials needed O H P/ LCD and computer computer,, PCPNC Manual Manual/ / H ando ut , Maniqu in, self-i self-infla nflating ting b ag, mask size size 0 & 1 , suction suction tub e/ suction devic device, e, 2 towels and clock
Procedure
Recapitu la Recapitu late te th e previou previou s ses sessi sion, on, li link nk it with t he new t op opic ic by discussi discussing ng th e sessi session on ’s ob jectiv jectives; es; During the Lecture-Discussion on “Preparing for Birt Birt h and Ess Essent ent ia iall It ems for Resuscitation Resuscitation of the Newborn”, discuss things to be considered in preparing for for birt h and explain explain th e necessi neces sity ty of th e items need ed in res resusci uscitation tation of newbor n. Ask part part ic icipants ipants relevant relevant qu es estions tions t o check th eir com com prehen si sion on o f th e top ic and summarize t he dis discuss cussion ion once fi finished; nished;
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Session 3 Examinati Examination on of the N ewborn Baby
Specific objective At the end of the sessi session on,, the th e participants sho should uld be able to:
For the Lec Lecture-D ture-D emonstrati emonstration on on “Steps in Resusci Res uscitation tation and Care After After Resus Resusci citation tation ”, demo nstrate t he steps and ask lea learners rners whether they comprehen d th e discuss discussion. ion. Summarize the to pic and link it it with th e next activity activity.. Proceed with the Workshop Activity: Tell participants tici pants th at th ey wil willl be divided divided into 4 gro ups. Each gro up wil willl be given th e same scenario scenario to enhance decis decision-making ion-making skills skills on when to start, cont inue or sto sto p resusci resuscitation tation . Instru ct participa partic ipants nts to demon strate th e proper t echniques in resusci resuscitation tation using th e appropriate equipmen t t o b e assi assisted sted by faci facili litato tato rs. During group pres presentation, entation, t he ot her groups observe, observe, givee comm ents and pro vi giv vide de add itional inpu inpu ts to the presentation presentation . The session ends by asking participants if they havee q uestions, and provi hav provide de sy synt nt hesi hesiss to all the to pics discussed. discussed.
R efer efer to t o pages pages 135-155 135-1 55 of the Tra in er’s N otes 44
describe and carry out an examination of the baby soon after birth, before discharge from the hospital, during du ring the t he first first week of life life at rout ro utine, ine, followfollowup and sick sick newborn visi visit; t; and assess, classify and treat a newborn using the Examine Examine the N ewborn chart.
Methodology Lect u re-D iscu ssio n Wo r ksh o p P len ar y
3 0 mi min 1 5 m in 1 5 m in / 1 h r
Materials needed LCD and com put er, 3 case case stu stu dies, dies, manila paper, paper, pent el pens and m aski asking ng t ape and powerpo int presentation/ presentation/ transpare transparenci ncies es
Procedure
Recapitulate th e previou previouss sess session, ion, link it with th thee new topic by discussing the session’s objectives; In the Lec Lecture-D ture-D is iscus cusssion on “Exami “Examination nation o f th e N ewborn ”, d is iscuss cuss th e chart, give ideas ideas on what questions to ask the mother regarding her baby and explain explain how t o examine the b aby and and what things should should b e observed observed on the b aby un til discharge. discharge. Ask Ask part ic icipants ipants qu es estion tion s during the discussion to determine comprehension, si on, sum marize the t opic and link link it with th e
ne xt activi next act ivitt y. For th e Workshop Workshop Ac Activ tivity ity,, gr oup part ic icipants ipants into 3 where each gro up is given given a case case to work on. U si sing ng th e chart, th e gro ups will will clas classi sify fy th e baby’ss con baby’ con dition an d give the approp riate treatm ent and advise. advise. After After 1 5 m inutes, ask ask the groups to post their out puts on the bo ard. D uring t he Plenar y, ask ask th e leader of each each group t o present present t heir output s whil whilee oth er grou ps act act as observers and give commen ts or additional input s on th e present present ation. Ask Ask for for a volunt eer to summarize th e discuss discussions. ions. Th e sess session ion end s with with a short input and synthesis sis of th e dis d iscuss cussion. ion.
R efer to page 156 of the Tra in er’s N ot es
Case Study 10 Rosie is a preterm baby who was delivered an hour ago at about 35-week gestation weighing 1800g. At birth she started breathing spontaneously. She has not suckled at the breast, although her mother tried to feed her about half an hour ago. The health worker assesses Rosie at one hour of life. She checks the maternal record to determine if Rosie needs any special treatment and finds that the mother did not have any problems or illnesses during pregnancy. Her membranes ruptured 1 hour before delivery. She also asks the mother if she has any concerns. She learns that the mother is anxious because Rosie does not want to suck. On examination, she finds that Rosie’s temperature is 36°C. No abnormal findings noted. Q: Based on these findings, how do you classify Rosie and how will you proceed? After 1 hour Rosie’s temperature is 36.8° C. Her mother
was able to feed Rosie breast milk which was dripped into her mouth as she only made a feeble attempt to suckle the breast. After short periods of suckling at the breast, breast milk is expressed into Rosie’s mouth to ensure that she has an adequate intake of milk. Although Rosie’s mother is healthy and could go home, she arranges with her family to take care of the other children so that she can stay with Rosie in the hospital. Breastfeeding gradually improves during the next 2 to 3 days and special support is given. The mother is encouraged to breastfeed exclusively. Rosie is fed two times hourly and by the 3rd day of life, she no longer requires additional breast milk expressed into her mouth. Rosie is weighed daily and loses 10% of her birthweight (180 g) in the 1st thre e days of her life. On the 4th day her weight is static and thereafter she starts to gain weight daily. Q: How do you know if the baby is gaining weight? Q: When should Rosie receive vaccinations? What vaccinations should be given? Rosie is ready for discharge on the 7th day after birth. She is now breastfeeding exclusively and has gained weight and now weighs 1700 g. Health worker carries out pre-discharge examination again. Rosie is examined for local infection and jaundice. There is no jaundice nor other complications. Q: How will you classify Rosie at this point? What will be the criteria for discharge? Q: How would you follow up this baby after discharge?
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Case Study 11 Joe was born 6 hours ago by vacuum extraction for fetal distress. His weight is 2500 g. He required resuscitation at birth but started to breathe spontaneously after 4 minutes. At 1 hour of life he made feeble attempt to suckle at the breast but has had breast milk expressed into his mouth on two occasions. Now the mother is calling the health worker urgently because Joe is having convulsion. The health worker goes to the mother immediately but by the time she gets there Joe has stopped convulsing but looks very pale. On examination, it was found that Joe is not able to feed; he is cyanosed around his mouth, looks very pale and feels stiff.
Hygiene is poor and Daisy has erythematous papular rashes on her buttocks. Q: What are the medical problems can you identify using the flow chart? What should be done?
Session 4 Care of th e N orm al and and Small Small Babies Babies Un til Discharge from from t he H ealth ealth Facil Facility ity
Specific objective At the end of the sessi session, on, t he part icipants icipants sho sho uld be able to d escribe escribe and carry out th e everyday everyday care of th e baby. baby.
Case Study 12 Daisy is brought to the health facility by her mother and grandmother when she was 4 days old because she will not feed and is very fretful. She had a normal birth at term, breathed immediately and weighed 2700g. On discharge from the health facility 12 hours after birth she was a well baby and breastfeeding well. The mother has had 2 previous live children, but her second baby was about 4 weeks preterm and died at home at the age of 3 weeks. The only record for cause of death is failure to thrive. The health worker checks the records and finds it unremarkable. Upon query, it was found out that Daisy has been fretful and not feeding well for the last 2 days. Daisy was breastfeeding breastfeeding 6 times a day and to try to settle her, she has been given mashed banana and pacifier when she cries. She has lost 300g since discharge from the health facility 3 days ago. The umbilicus and surrounding skin are red. The mother denies having put any substances on the umbilicus. umbilicus.
46
Methodology I n t eract ive D iscu ssio n Lect u re-D em o n st rat io n
2 0 m in 4 0 m in / 1 h o u r
Materials needed board, chalk, chalk, whiteboard whiteboard pen, PCPN C M anual, anual, LCD and comput er, er, and powerpoint presentation presentation
Procedure
Recapitu late th e previou previou s ses sessi sion on , link it it with the new topic by discussing the session’s objectives; D uring the t he Interactive In teractive D is iscuss cussion, ion, tell t ell part partici icipants pants to wriite import ant po ints in the bo ard based on t he wr following foll owing qu es estions: tions: how long d o m ot hers and and b abies stay in the health healt h facility; facility; what reasons may delay a baby from being
discharged from the health facility; and when is the best time to t eac each h th e mot her ho w to take care of her baby. baby. Enu merate t he responses, responses, provide provide addition al input s, sum sum up t he d is iscuss cussion ion and li link nk it with th e next activity; activity; and For the Lec Lecture-demonstrati ture-demonstration, on, introd uce the activity by asking participants what they need to teach th e mot her ho w to t ake care of her baby. baby. Proceed t o discuss discuss and dem onstrate cord care care,, hygiene, hygie ne, eye care, care, and keepi keeping ng th e baby warm. End the session with a synthesis of all the topics covered.
R efer efer to t o pages pages 156-159 156-1 59 of the Tra in er’s er’s N ot es
47
Module 8
Counseling
Objective To en able health wo rkers to d evelop evelop cou nseling nseling skill skillss to comm unicate effectiv effectively ely with wom en, th eir partners and families families on th e essential essential rou tine and emergency care care of women and n ewborn during pregnancy, pregnancy, childbirth, childbirth, postpartum and po st-abortion periods. periods.
Topics
Basic facts about counseling; and Applying Applying th e cou nseling skills skills..
Duration 2 hou rs and 30 minutes
Session 1
Materials needed
Basi Basicc Facts about Co unseling unseling
O H P/ LCD and computer, computer, metacar metacards ds,, pentel pens pens,, masking tape, board, powerpoint presentation/ transparencies
Specific objective At t he end of the sessi session on , th e participant participant s shou shou ld be able to:
D efine efine coun seli seling ng and interpersonal commu nication; nication; and Discuss principles of counseling and interpersonal communication.
Methodology teractive Discuss Discussion ion 40 m in 4 8 In teractive
Procedure
Recapitu la Recapitu late te th e previous previous sessi session on , link it with th e new t opic by b y discuss discussing ing t he session’s session’s objectiv ob jectives; es; D urin uring g th e Interact In teractiv ivee Dis D iscuss cussion ion Activity Activity,, provide participants with with met aca acards rds and as ask k them to write all the things they know about counseling based on the guide questions. Participants will be made to work on their responses for 10 minut es es,, after which t hey will will paste their cards on the board.
Aft er all the p articipant Aft articipant s have have pasted t heir cards, th e trainer categorizes th e responses according according to: what th ey know; why there is a need for co unseling; unseling; how t o coun sel mothers, partners and and families; and characteris characteristics tics of goo d coun seling. seling. End th e sessi session on by providing providing add itional inpu inpu ts, synthesizing the discussion and linking it with the n ext ext t opic. opic.
Materials needed LCD and comput er, er, slides slides,, PCPN C Manual, Manual, observation tool, board and chalk
Procedure
R efer to page 160 of the Tra in er’s N ot es
Session 2 Applying the Counseling Skills
Specific objective At t he end of the sessi session on , th e participant participant s shou shou ld be able to:
Demonstrate effective communication skills; and Demonstrate appropriate counseling techniques in th e different different matern al health health situ situ ations.
Methodology Lect u re-D iscu ssio n Ro le P lay O bs bser vat io n / P len ar y G r o u p Wo rk
1 h r an d 1 5 m in 4 0 m in 3 0 m in 1 0 m in / 2 h rs & 3 5 min
Recapitu late th e previous sess session ion,, link link it with the new topic by discussing the session’s objectives; During the Lecture-Discussion, provide inputs on the following issues: HIV; family family planning ; post-abortion; adolescent adolescent pregnancy; and violence violence against against wome n/ VAW. Participant Participant s will will be encouraged to ask ask questions or share own experiences with regards to th e issues being discussed. Sum up the discussion and pro ceed to th e next activity activity;; Ask for for a volunt eer from t he part icipants icipants who will will act act as the mo th er or relative relative of the mot her. D emo nstrat e critical skil skills ls.. For th e Role Play Play, instruct par tici ticipants pants to grou p th emsel emselve vess int int o 4 where each each gro up po rt ray rayss a scenario or a counseling session on the following: HIV; woman with special needs; family famil y plann plann ing; and post abortion. Participant Participa nt s will will be asked asked t o p repare for t heir presentation in 15 minut es and after which which present a 10 minut e play; play; and D uring t he Plenary, Plenary, select select 4 part ic icipants ipants to serve se rve as observers observers// cri critique. tique. Th ey wil willl look look int o th e stro stro ng po ints and areas areas for impro impro vement of the counseling session. After all the groups have presented, t he 4 observers wil willl present present th eir
49
comm ents for for 10 m inutes while while you you write th e important po ints on the board, and pro vide additional input s for for clarifi clarification cation d uring t he discussion. A participant will be asked to summarize mari ze the o utput s. End the sess session ion b y synth synth esizing esizing th e discussions. discussions.
R efer efer to t o pages pages 161-162 161-1 62 of the Tra in er’s er’s N otes
50
Case study 14 Post Abortion and Family Planning A 35 year old woman had recent completion curettage (cc) on her fifth pregnancy. She had an incomplete abortion 5th month of gestation. She felt guilty because her fetus happens to be a boy, for she had a daughter. However, her recent cc happens to be an emergency one. She had a blood transfusion and was advised not to get pregnant in 3 years time. Her husband is very quiet. What will be your appropriate counseling?
Case study 13
Case Study 1 5 HIV 15
Client: “I am worried what my husband will say when he finds out I have lost the baby, and whether he will blame me or think I did something.” Counselor: What is the worst thing that your husband can do to you?”
A 28-year old G2 P1, 12 weeks AOG, went to your facility for the first time with her husband, an overseas worker who just arrived from Saudi Arabia. Feeling guilty, the husband admitted to his wife that he has been diagnosed to be HIV+3 years ago while abroad.They are now very worried about the baby being infected and are thinking of terminating the pregnancy? What will be your appropriate counseling?
Image from Midwives’ Manual on Maternal Ca re, Department of Health, 2000
Module 9
Mobilizing Community Support Objective To en able participants participants establish establish comm un ity suppo suppo rt mechanisms for for maternal and and newborn h ealth. ealth.
Topic Establishing Links
Duration 40 m inutes inutes
Session 1
Methodology
Establishing Links
I n t eract ive D iscu ssio n Lect u ret t e
Specific objective At the en d o f the sessi session, on, th e participants shou shou ld be able to:
Id ent ify ify partn ers and mem bers of th e com com mu nity who who can can become part of the support group; and D evelop evelop strategies/ strategies/ mechanisms mechanisms to encourage active active commu nity participation participation in suppor ting maternal and and newborn h ealth. ealth.
3 0 m in 1 0 m in
Materials needed LCD and comput er, er, powerpoint powerpoint presentation, presentation, chalk and b oard
Procedure
Recapitu la Recapitu late te th e previou previou s ses sessi sion, on, li link nk it with t he new t op opic ic by discussi discussing ng th e sessi session on ’s ob jectiv jectives. es.
51
Th e In teractive teractive D iscuss iscussion ion start s by aski asking ng part icipants icipants with th e following following questions: what groups/ organizations organizations they hav have in th eir own areas; areas; and what kind o f ser servi vices ces or assis assistt ance these groups provide to the com mun ities. ities. Write the responses on t he bo ard, and after all respon ses have been no ted, categorize and sum sum marize th ese for the learners. learners. Proceed t o provide additional inputs to expound on th e dis d iscuss cussion ion and clarify clarify issues. issues. In the lecturette lecturette on “Comm unity Partici Participati pation/ on/ Support”, begin begin with with the discussion by asking participants “whet her it is necessa necessary ry for the com mu nity to be involved involved in m aternal and newbo rn h ealth ealth ”. Respon ses ses wil willl be written written on t he board, and after after which you you summ arize arize th e out puts and provide provide additional input input s on th e topic. End th e sessi session on with a synt synt hesis hesis of the discussion.
R efer efer to t o pages pages 163-164 163-1 64 of the Tra in er’s er’s N otes
Image from Midwives’ Manual on Maternal Care, Department of Health, 2000
52
Practicum Objective To enhance the competencies of participants in applying basic emergency obstetric care to all women and their babies.
Duration The practicum activities will be conducted in seven (7) days. This period includes on-site orientation, clinical work in the areas of assignment and mid-practicum assessment.
Methodology A mix of methods such as observation, hands-on/experiential learning and coaching will be employed during the practicum phase.
53
54
Module 1
Orientation on the Practicum Objective To familiarize participants with the overall objectives and m echanics of the practicum practicum phase.
Topics
O bjectives bjectives and m echanics of th e practicum Expected Expected out puts from th e participants participants Areas for exposure
Duration 2 hours
Session Session 1
Materials needed
Pre-Practic Pre-Practicum um O rientation rientation
Form s, Skil Skills ls requiremen ts hando ut s, board and chal chalk/ whiteboar whiteboard d pen
Specific objective At th e end of the sess session, ion, t he part icipants icipants will will be able to un derstand th e objectives objectives of the practicum, practicum, met hod ology, ology, schedule of activities activities and kn ow t he hospital heads, area facilitators and preceptors.
Methodology Lect u ret t e I n t eract ive D iscu ssio n
3 0 m in 1 h r & 3 0 m in
Procedure
Explain the objectives of the session and link it with with th e didactic phase; phase; D ivide ivide th e part icipants icipants int int o t eams of 4 (physi(physician, cian, nurse, midwif midwife and M CH Coo rdinator rdinator as monitoring officer). Explain to the teams the objectives, methodology, schedule of activities and t he personn el they will will be working with at th e hospital/ health facil facility ity (e.g. ho spital spital heads, area facilitators and preceptors); Discuss the areas for exposure exposure (e.g. O PD , ER, LR, DR , 55
Ward and P ost-discharge) ost-discharge) and th e expected expected out puts from t he participants. participants. Explai Explain n that they have to g o on dut y to see and experience experience the real situ situation ation , especially especially in han dling a pat ient from the emergency emergency room; Provide Provide t hem with t he forms containing containing th e skills requirement and explain the process of filling-up and submission. Allow time for comments and questions. questions. Encourage the parparticipants to voice out their apprehensions or fears if there are any; Instruct t he participants participants to refer refer to t he PCPNC manual when necessary; and End th e sessi session on by sy synt hesizing hesizing t he t opics covered.
Practicum Requirements
Scrub suit Smock gown Cap and masks Slippers Colored ID picture (2x2) Completion of requirements Evaluation test “Full attention and cooperation”
Example of Team Schedule for Area Assignments during Practicum Phase Area
ER LR DR Ward OPD Postdischarge (2nd F/OPD
Mon (Aug 2)
Tue (Aug 3)
Wed (Aug 4)
Thu (Aug 5)
AM
PM
AM
PM
AM
PM
AM
1 2 3 4 5 6
2 3 4 5 6 1
3 4 5 6 1 2
4 5 6 1 2 3
5 6 1 2 3 4
6 1 2 3 4 5
PM
Note: Sample schedule was used during the pre-test of this BEmOC Skills Training Guide on July 26-August 6, 2004.
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Skills Requirements per Category of Service Provider per Facility No. of Requirements per Category of Service Provider Per Team
Skills Requirements ER 1. IV Insertion 2. Skin testing 3. Intravenous (IV push) to include antibiotics 4. IM injection of Mag sulfate loading with monitoring of vital sign 5. Internal exam DR 6. Normal spontaneous delivery 7. Perineal repair 8. Manual extraction of placenta 9. Recognition of case for assisted delivery 10.Removal of retained placenta 11.Intramuscular injection 12. Vitamin K injection OPD 13. TT Immunization 14. Catherer insertion 15. Uterine abdominal compression 16. Partograph 17. Complete physical examination to include: Leopold’s FHT, BP, etc. PP 18. Eye care 19. Cord care 20. Breastfeeding latching OPD/ER/DR/LR 21. Recognition of danger signs
MD
PH N
R HM
3 2 2
3 2 2
3 2 3
1
2
1
3
5
5
1
3
1
2 3
3
3
1
1
1
1
1
1
3 1 1
1 1
1 1
3 (new); 2 (old) 3
3 (new); 2 (old) 3
3 (new); 2 (old) 3
3 3 3
3 3 3
3 3 3
3
3
3
1 2
Legend Orange box = Participant Participants s are already competent Green Green box box = Not Not provi provided ded by law
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Module 2
On-Site Team Activities for Clinical Skills in BEmOC Objective To practice BEmO C skills skills learned learned during th e didactic phase
Topics
Q uick Check and Rapid Asses Assessment sment and Managemen t (RAM) Routine Care to Moth ers and Newborns Managemen t of Emergency during Ant Ant enatal, Labor, Labor, D eliv elivery and and Po stPartu m Accomplishment of Records and forms on PCPNC
Duration 7 days
Session 1
Materials needed
O n-site n-site Practicum Practicum O rientation
Forms, gu idelines idelines for practitioners (from th e facil facility ity where practicum practicum will will be held), ro tation schedu schedu le
Specific objective At t he end of the sess session, ion, t he part icipants icipants will will be able to execute t heir practicum practicum assi assignm gnm ents.
Methodology 58
I n t eract ive D iscu ssio n Tour of the hospi hospita tall/ facilitie ties
1 hour 1 hour hour
Procedure
Tell the teams that they will proceed to the ho spital/ spital/ faci facili lity ty and pay a cour tesy call call to t he head of the institution/ institution/ agency agency;
Th e head of the h ospital/ ospital/ facil facility ity or any staff staff assi assigned gned to orient th e part icipants icipants will will brief brief them on relev relevant ant m atters concerning concerning the practicum site or facil facility ity and t he p ersonn ersonn el. After After t he b riefing, riefing, t he p articipants articipants will will und ergo a to ur o f hospital departm ent s and facil facilities ities;; The area facilitator assigned for each group will supervise supervise th e part icipants icipants during t he practice of skills learned. Each team will be assigned a person who will mo nito r and o bserve the practicum activities activities in in the areas of assignment, as well as look into the administrative administrative needs of th e team; Tell the teams that with the briefing given they can can no w proceed proceed to their area area rotation/ ass assignments.
Session Session 2 Performance Performance of Area Area Rotation/ Assignments
Specific o bjective bjective At th e end of the sess session, ion, t he part icipants icipants will will be able to apply to:
Procedure
The participants will perform the skills required on rotation to the areas of assignment; Instruct the participants to fill up the forms for the skill requirements that they need to accomplish during the practicum and submit these at the end of the period; Ask them to document their personal observations, experiences and lessons learned in their practicum journal; Facilitators will fill in the monitoring sheet/ to ol for each each t eam assi assigned gned in th eir areas. areas. They will also report during the mid-practicum assessment; The team observer/ observer/ monitoring person person will will provide daily feedback to the facilitators and Training Training Team during t he entire duration of the practicum period; and A mid-practicum assessment meeting will be conducted condu cted for completion of requirements, identification of issues and problems encountered, and possible solutions or adjustments that could still still be done do ne during d uring th e practicum practicum period.
R efer to t o pages pages 165-166 165-1 66 of the Tra in er’s N ot es
Apply quick check and RAM Perform Perform ro utine care to mot hers and newborns Manage emergency during antenatal, labor, delivery and postpartum periods Accomplish records and forms on PCPNC
Methodology H ands-on application application of skil skills ls
Materia Materials/ ls/ resources esources Patients, equipmen t, supplies and forms 59
Checklist for Facilitators during Mid-Practicum Assessment 1. a. b. c. 2. a. b. c. 3.
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Feedb eedbac ack k on on: dail daily y acco accomp mpli lish shme ment nt indi indivi vidu dual al ski skillls area areas s for for imp mpro rove veme ment nt Prob Proble lems ms ident identif ifie ied: d: area area of assi assign gnme ment nt provisi provision on of technica technicall assistan assistance ce indi indivi vidu dual al trai traine nee e Reco Recomm mmen enda dati tion ons s
Monitoring, Evaluation and Action Plan
Mo nitoring and evaluating evaluating ( M & E) t raining raining is necessa necessary ry to determ ine th e effectiv effectiveness eness of the course. By mo nito ring and eval evaluating uating th e didactic and p racticum racticum activities activities of th e part icipants, icipants, trainers can can measure wheth er t hey are able to describe describe t he skill skill,, d emon strate th e skill skills, s, practice practice th e skills skills or verify verify whet her t he skills skills are being completed com pleted correctly cor rectly.. Evaluation can also also gau ge the t he satisf satisfaction action of the par ticipants ticipants and pro vide inform inform ation on how t o impro ve th e BEmO C skill skillss training course. Besides Besides M & E, t he preparation o f an action plan is also also an impo impo rt ant com pon ent o f a training course. Training can only be considered successful if the participants are able to apply their newly acquired skills and knowledge in their own work place, and eventually transfer the learnings to ot her health workers. Th is section section provides provides practical practical tips on ho w to m onito r and evaluate evaluate b efore, efore, d uring and after after t he course, including including t he preparation of an action action plan. To cont extualize extualize th e discuss discussion, ion, t he roles and responsibilities responsibilities of the BEmO C Team and t he indicators for for mo nitoring an d evaluation evaluation are described.
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Ro les and Roles and Resp Respo o nsibili nsibilities ties of the BEmOC Team
Th e BEmO C Team is compo sed of a physic physicia ian, n, nurse and midwife. Their specific duties and responsibilities are as follows:
Physician Team leader Perform all six (6) BEmOC functions Super visor isor y function Networking and referral Nurse Assistant team leader D oes IV administration administration of 1-3 signal signal fun fun ctions Administrative function H ealth ealth education Networking & referral for community & institutional support Midwife Can do 1-3 signal functions Assist in 4-6 signal functions H ealth ealth education Prenatal & postnatal care Networking & referral for community support
Indicators for M & E Th e indicators for th e part icipant’s icipant’s lev level el of competency will will be measured in t erms of: servicee pro viders viders (part icipants/ icipants/ %o f targeted servic trainees) trainees) who performed appropriately 6 signal functions
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Average score is pre and post-tests in terms of KAS KAS (T N A/ compet ency and capability) capability) which which will be administered through the following: K – written exam (case study) A – self assessment; observer checklist S – ob server checklist checklist
What Can Evaluation Measure? Evaluation can provide trainers with information about: Learner satisfaction: Were learners’ expectations and needs met? Were learners satisfied with the performance of the trainers, the materials and the training process in general? The training process: Were the training activities conducted effectively effectively and as planned? The results of the train ing: By the end of the training course, did learners experience the expected changes in their attitudes, knowledge and skills? To what extent did learners meet the training objectives? Transfer of the training: Are learners implementing their new attitudes, knowledge and skills after the training? What are some of the barriers that learners encounter when they try to use their new knowledge and skills? Do learners experience problems with the retention of new knowledge and skills over time? Wegs, Cristina, et.al, (2003:73)
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Monitoring and Evaluation Processes
Pre and Post-Tests Before Before t he cou rse, rse, th e trainers shou shou ld administer a pre-test to asse assess ss the par ticipants’ ticipants’ knowledge, attitudes and skill skillss/ competency in in BEmO C. After the training, trainers should do a post-test to deter mine what KAS KAS th e participant participant s have acquired or learned du ring th e training. A sample sample of the pre and po st-tests questionnaire which which h as been u sed sed during th e pre-testing o f this trainers’ guide is shown below.
65
Skills Training On BEmOC Pre-Test and and Po st-Test st-Test Q uestionnaire I. Tr ue or False False Write letter T if the statement is tr ue and F if the statem ent is false. false. Write Write your an swers on th e space provided. ______ _______ _ 1. In tern al examination examination can be don e on a patient with vaginal vaginal bleeding late in pr egnancy. egnancy. ______ _______ _ 2. O ral Rehydration Rehydration solut solut ion is given given t o a patient patient who se blood press pressure is <90/ 60. ______ _______ _ 3. Pr egnant patient is imminent delivery delivery with with a blood pressure pressure of 150/ 100 cannot cannot deliv deliver in a p rimar y health facili facility ty.. ______ _______ _ 4. Tetanu s Toxoid Toxoid shou ld not be given given t o a pregnant woman if she has already received 3 do ses ses during h er last last pregnancy 1 year ago. ago. _______ 5. Oxytocin should be given after placent al delivery. delivery. _______ _______ 6. As a health worker, you sho uld g ive ive antibiot ics ics when th e memb ranes has been ru ptured for >8 h ours. _______ _______ 7. Blurred visi vision on , epigastric pain an d severe severe h eadache are signs of pre-eclamp sia. sia. ______ _______ _ 8. G oo d cou nseling nseling requ ires an interactive process which allows for two-way exchange of information. _______ 9. Counseling is the same as giving advice. _______ 10. Violence against women by their intimate partn er affects affects her p hysiv hysival, al, ment al, including reprod uctive uctive health status. ______ _______ _ 11. It is part icularl icularly y impo impo rt ant to give give adolescents adolescents whether m arried arried or u nm arried, arried, information on b irth planning planning prevention prevention of STI STI , H IV / AID S and FP. FP. ______ _______ _ 12. Bathing t he newbo rn b aby is is the 66
most import ant task to do within within t he firs firstt 2 hours of life. ______ _______ _ 13. A bod y tem perature o f 37 C is not a danger sign in a new bor n b aby. aby. ______ _______ _ 14. A newbo rn b aby does not req uire resuscitation if the baby is gasping. _______ _______ 15. Small baby bab y is is synon synonymou ymou s with with preterm baby. baby. II . Multiple Ch oice Please Please encircle encircle t he lett er of t he cor rect answer. answer. 1. O ne of the foll followi owing ng is NO T a major major caus causee of maternal mort ality ality a. Ab or or ttiio n b. H e mo mo rr rrh ag ag e c. H yperte pertens nsiion d. Teen Teenaage Preg Pregna nanc ncy y 2. This ski skill llss traini training ng is intended for a health health facility based providers. One of the following is not considered as a skilled attendant a. D oc oct o r b. H il ilo t c. M id id wi wife d. N ur urse 3. The followi following ng are criteria criteria of a good comm unication, except: a. U se si simple and cle clear ar langua language. ge. b. Encoura Encourage ge her her to ask ask ques questions tions c. Ask and and provi provide informati information on related related to her needs d. Make Make the woman woman fee feell wel welcome
4. Which Which of the followi following ng is NO T a cri criteria teria of confi con fiden den tiality and and privacy privacy a. Ensure a private private plac placee for for the exami examination nation and counseling b. Make sure you you have the woman’s consent consent before discuss discussing ing with with her part ner/ family family c. Ensure, Ensure, when when discus discusssing/ transmitti transmitting ng neces necessary messages messages,, th at you cannot be o verhead. d. N ever ever dis discuss cuss confidentia confidentiall informati information on about clients clients with with ot her pro viders, viders, or ou tside the h ealth ealth facility 5. The followi following ng are emergency emergency signs seen in in a pregnant patient requ iring iring imm ediate referral referral,, except: a. fever b. vagina ginall blee bleedi ding ng c. headac headache he and vis visual ual disturbanc disturbancee d. sever everee pal palllor 6. Which Which of the foll followi owing ng is NO T an emergency emergency sign sign in a b aby requiring requiring imm ediate newbo rn care a. ju st st b or or n b. convul onvulssions c. any materna maternall conce concern rn d. eye eye dis discharge charge 7. A woman woman in the immedia immediate te postpartum postpartum period. period. Th e uteru s few minut es ago was not soft. soft. O n her examination, examination, her u ter us is no w hard. You You ob served served th at she has consumed 1 pad fully fully soaked. soaked. 4-5 minut es after, after, you you fou nd o ut t hat t he ut erus is is soft soft again. again. What is you you r next step? a. o bs bser v vee b. reques requestt for hemogl hemoglobi obin n status status c. ref refer to hospi hospita tall
d. consi onsider der it it normal normal 8. The counsel counseliing envi environment should should be: a. wel welcomi coming ng and and comforta comfortabl blee b. a plac placee with with few destructions destructions and and where privac privacy y can be m aintained aintained c. conduci onducive to a couns counsel elor or d . b ot ot h a an d b 9. a. b. c. d.
A good couns counsel elor or is is: non-j non-judg udgme menta ntall t ru ru st st wo wo rt rt hy hy b o th th a an d b none of the above bove
10. Th e characteris characteristic tic of a good cou nselor nselor is: a. both the counsel counselor or and and the clie client nt expl explore ore options together b. facil acilita itate te decis decision-making ion-making c. b o th th a an d b d. none of the above bove 11. In cou nseling nseling a pregnant adolescent, adolescent, it is important for the servic servicee provider to observe th e followfollowing points: a. strict trict privac privacy y and confidentia confidentiali lity ty b. use of simple imple and and clear clear language language c. not t o discus discusss topics topics relate related d to RH and sex sexual ualiity d. non-j non-judg udgme menta ntall 12. Th e key role of health health worker includes includes the linking linking o f the health services services with with th e following. following. a. community community group, women’ women’ss group and and leade leaders rs b. peer peer support upport group group c. TBA and other health health serv serviice prov provide iderr
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13. When giving giving emot ional support support to adoles adolescent girls girls and wom en living living with violence, violence, it is impor tant to rem ember which of the following: following: a. crea create te a comfortabl comfortablee envir environment onment b. overc overcome ome your own dis discomfort comfort with with her situa situa-tion c. make sure you you have have time and and space space to t alk alk priprivately d. be patie patient nt and pay attention attention only to things that is relevant relevant to present situation 14. Which of th e followi following ng statemen ts is is true: a. breastfe breastfeeding eding should should be rou tinely tinely as assess essed as part o f the newborn exami examination nation b. the moth er’s er’s breas breastt should should be examine examined d if the mo th er complains of nipple or breast breast pain c. a mothe motherr wi with H IV / AIDS who who choos chooses es to breastfeed breastfeed her baby should no t b e allowed allowed to do so and mu st be encouraged t o give give milk formula d. a an d b on on ly ly 15. A ver very y small baby: bab y: a. is a baby with with birth wei weight ght <1500g and and / or is is a pre-term less less than 2 2 weeks b. ref refers ers to twin twin babies babies c. requires requires urgent referr referral al to a hospital hospital d. a an d b on on ly ly
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Monitoring Practicum Activities D uring the practicum practicum period, the Training Training Team should carefully monitor the performance of the participants in t heir areas of assi assignm gnm ent s. It is important important t o ass assign ign a permanent permanent m onitor/ observer per team throughout the practicum activities to en sure cont inuity of observations, provisi provision on of administrative/ administrative/ techn ical ical ass assis istance tance and immediate feedbacking feedbacking on th e pro gress of each individual individual participant and the team as a whole. Tools for the practicum activities include the Monitoring Checklis list for Im plementation plementation o f PCPNC Instructions to Mon itor and O bserva bservation tion Tool. R efer to t o pages pages 167-176 167-1 76 of the Tra in er’s N ot es
69
70
71
Daily Evaluation of Training Activities At the en d of the th e day, day, trainers sho should uld condu con duct ct evaluaevaluation of training activities activities to identify iden tify prob lems and and gaps in the th e knowledge and an d skill skillss of the part icipant icipants. s. By By doing do ing this t his on a daily basis, basis, imm immediate ediate feedback on areas requiring requ iring improvement can be elicited, elicited, part icularly larly on the design design and implement implementation ation of th e training. training. Specifically, feedback should be solicited on participants’ pant s’ satisf satisfaction action with the th e sessi session on activities activities,, m ethod eth odss use, resource persons, flow flow and pace of the t raining. An evaluation evaluation t ool oo l for for resource resour ce persons is is sho shown wn on the right.
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Process and Output Evaluation Th is is do ne after the t raining raining t o evaluate evaluate th e implementation of the course and determine whether the objectives objectives were were achieved. achieved. I n t he pre-t esting esting of this trainers’ trainers’ guide on BEm O C, a cou rse eval evaluation uation to ol was used by th e trainers to solici solicitt feedback feedback from t he p articipant articipant s about th eir overall overall satis satisfa faction ction and recommen dation s for improvement s. Th is to ol is sho sho wn b elow. elow.
Sample Evaluation Process of BEmOC Skills Training Participants were given metacards to write their difficulties, helps and insights during the two-week training period. After 15 minutes, they were asked to post their responses on the manila paper. Their responses were processed by asking them further explanation or citing their reasons. The Training Team gave their comments based on the responses. Afterwards, the participants were divided into 4 and tasked to compose a song whose lyrics are the following: 1) most unforgettable experience in the two-week activity, 2) what lessons must be included in the course that were not included at present, or if they feel all important lessons were already included, which must be allotted more time, 3) the most important lessons they learned, and 4) descriptions of the facilitators and resource speakers. After 30 minutes, each each group gave their best performance.
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Action Plan Trainers sho sho uld aid t he p articipant articipant s in applying applying their new knowledge and skills by assisting them in developing developing an action plan which th ey could could implement upon return t o th eir eir work plac place. e. Two examexamples of matrix for an action plan are shown b elow which the participants could use in planning their future activities.
Effective Action Plans
76
Divide activities into discrete steps that are realistic and measurable Identify roles and responsibilities for learners, as well as their community partners, co-workers and supervisors Identify the resources needed to successfully complete all steps Include a specific timeline for completing each step
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PostTraining Activities 79
The Training Team should conduct post-training activities such as monitoring and out come evaluation evaluation based on identified identified ind icato icato rs to asse assess ss th e application application o f new knowledge and skil skills ls in BEmO C b y the part icipants icipants in in t heir work place. place. Th ese activities activities will will be facil facilitated itated t hro ugh sustained sustained com mu nication with th e part icipants icipants and d ocumentation of experi experiences ences in BEmO C.
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Outcome Indicators
After three (3) months, the following outcomes of the training may be measured according to the following indicators:
Competency
%of deliveries in BEmOC facilities (normal and complicated) %o f complicated complicated d eliv eliveries managed properly (done in BEmOC facility & referred to CEmOC from BEmOC) BEmOC) Attend ance of BEmO BEmO C team du ring deliv delivery (met hod ology – exit exit inter view; view; postpartu m counseling, counseling, ob servation servation checklist) checklist) Patient satisfaction (exit interview; provider client interaction, e.g. respect of privacy, observation checklist) Total cost of deliveries deliveries from h ome to BEmO C faci facili lities ties
Records keeping
Completeness of record
Budget
Amoun t of bud get ut ilize ilized d for BEmO C services Sou rce of fun fun ds SO Ps within within BEmO C MO A signed igned w/ CEmO C in LGUs cov cov-ered Mechanisms in place (transportation, communication)
Facilities
%of facilities experiencing stock-out supplies within the last 3 months %o f equipment in BEmO C facili facilities ties which which are functional/ functional/ complete 81
Continuing Communication
Trainers should continue their communication with the participants to follow-up their progress in applying their new knowledge and skills in BEmO C. T he content and process process of commun icaication can be both informative and motivational. These can be done through email exchanges, telephone conversations, site visits and text messages. It is also important to provide the participants with user-friendly reference materials and job aids which they can use after the course as guide in completing BEmOC procedures or tasks.
How to Build Buil d Skil Skillful lful Communic ommunication ation
82
Encode messages in terms that are easily understood by the receiver; Use specific examples rather than vague generalizations; Use simple and clear language; Think about and construct the message before sending it; Check understanding with the receiver; When listening, concentrate and make mental summaries; Avoid evaluating the message until it has been completed; Occasionally summarize what is being said to check for accuracy (paraphrase); and Ask clarifying questions to check understanding (Felix, 1998:108-109)
Mo nito ring and Ev Eva alua luating ting Training Outcomes
After t hree month mo nths, s, the Training Training Team m ay conduct condu ct visits to the work place of the participants to monitor and evaluate evaluate the implement implementation ation of BEmO C services. During monitoring visits, a competency-based skil skills ls asses assessment sment of the th e team and m embers emb ers can can b e conducted to determine whether changes hav have occurred in the delivery of BEmOC services in the health facility. Also, the capability of the health facility in terms of its equipments, record keeping and budget allocation for BEmOC should be assessed. The outcomes of the training can be gauged through client exit interview, observation checklist, site visits, interviews with participants, community partners, supervis upervisors and oth er colleagues colleagues// co-workers co-workers..
Sample Survey for BEmOC Team Member’s Application of the Principles of Quality Care Health Worker • • •
Please do not write your name on this survey. Please complete this survey after you have seen the health worker. Your health team would appreciate honest feedback
Please rate each of the following areas by circling ONE number on each line: Poor Fair Good Very Good 1. My overall satisfaction with this visit to the health facility is… 2. The reception/greeting afforded to me by the health worker was… 3. On this visit I would rate the health worker ability to explain to me my condition as… 4. The health worker’s patience in providing information related to my needs… 5. The extent to which I felt my privac y during examination and counseling was observed by the health worker… 6. The extent to which I felt reassured by the health worker that all the information I gave to them will be treated with utmost confidentiality… 7. The opportunity the health worker gave me to express my fears or concerns and ask questions… 8. My confidence in the ability of the health worker to respond to our health care needs (mother and new born baby)… 9. The amount of time given by the health worker in explaining to me what the treatment is and why it should be given… 10. The health worker’s ability to make me understand the procedure for examination and treatment… 11. The health worker’s concern for me as a person in this visit was… 12. The recommendation I would give to my friends about the health worker would be…
Excell ent
How can this health worker improve his/her service?
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Sample Competency-Based Skills Assessment Checklist
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Documentation of Experiences
It is important that the participants are able Sample BEmOC Experience (s) Documentation Form to document their experiences in handling Trainee/Participant __________________________________ _______________________________________ _____ BEmO C cases cases,, part icularl icularly y the application application of Trainee/Participant Frame____________________________________ ___________________ _____ knowledge and skil skills ls acquired from t he t rainrain- Date/Time Frame______________________ ing and mobilization of institutional and Subject/Topic ______________________________ ___________________________________________ _____________ commun ity support support for m aternal and newborn care. By documenting their experiences, Documentation objective: th e part icipants icipants and t he t rainers rainers will will be able to identify areas for impro vement which can Activity/Case Date(s) Actions/ Outputs be inputted in redesigning the training course Activity/Case Steps Taken or gu ide in det ermining follow-up activities activities for th e part icipants. icipants. Below is a sample sample do cumentation form which can help the participants in systematizing their experiences with BEmOC in their work place.
Lessons Learned
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References Cunningham, Gary F., et.al. Williams Obstetrics, 21st Ed. T he McGraw-H McGraw-H ill ill Companies, Companies, Inc., 20 01. Midwives’ Manu al on on Mat ern al Ca re , D epartment Department of H ealth, ealth, Midwives’ epartment o f Health, Health, 200 0. t he Peo People: ple: A H an dboo dbook on C om m un it y-Base -Based L eadership adership . H oly Spirit Felix, Maria Leny. Leadin g wit h the Spirit Cen ter of Tarlac, Tarlac, 19 98. Works:: A Policy Policy an d Program Program Guide Gu ide to t o the Evidence on Fam ily Plann in g, Safe MotherMotherGay, Jill, et.al. W hat Works hoo hood, an d STI / H IV / A ID S In tervent tervent ions ions - Module 1 Safe Mothe Motherho rhoo od . January 2003 .
Lauver, Philip and and D avid avid R. H arvey. arvey. T he Practi cal C ou n selor: rooks/ Cole Cole elor: Elem Elem ents ent s of Ef fect fect ive H elpin elpin g. Brooks Publishing Company, 1997. N ati onal Demograph Demographic ic H ealth Sur vey vey, 1998. produ cti ve H ealth: alt h: Course Course Design Design a n d D elivery, 2003 . Wegs, Christina, et. al. Eff ecti ve Tra in in g in R eprodu
World H ealth ealth O rganization, Geneva. Pregnan Pregnan cy, Childbir th an d N ewborn wborn Ca re A Guide Gu ide for for Ess Essen ti al Practice. World H ealth ealth O rganization, rganization, 2002 . _____. Int egrated egrated M anagement anagement of Pregnancy Pregnancy and and Childbirth. Managing Conplications in Pregnancy and Childbirt Child birt h: A Guide Gu ide for for Midwi M idwi ves ves an d D octors. tors. World H ealth ealth O rganization, rganization, 2000 . _____. _____. Pregnan Pregnan cy, Childbirt C hildbirt h, Pos Postpar tu m an d N ewborn wborn Ca re : A Guide Gu ide for Ess Essen ti al Practice. Practice. World H ealth ealth O rganizati rganization, on, 2003 . 86
Glossary Anaemia — low hemoglobin in the blood and is seen as pallor of the conjunctiva, mouth, tongue and nail beds
Lochia — sloughing of decidual tissue results in a vaginal discharge of variable quantity early in the puerperium
Antenatal care — a care care for for t he wom an and fetus during pregnancy
Partograph — a tool that h elps the m anagement anagement of labor
Cervix Cervix — the part of the uteru s that is in the vagina
Placenta Placenta — t issue issue with with in a wom an’s ut erus (womb) that is created during pregnancy to feed the gro wing wing fetus
Co rd pro lapse lapse — when u mb ilica ilicall cord presents itself ou tside of th e ut erus while th e fetus is still inside Dystocia — literally means difficult labor and it is chracterized by abnormally slow progress of labor
Pre-eclampsia — hypertensive disease of pregnancy associated with pitting edema but without convulsions
Eclampsia — hypertensive disease of pregnancy resulting in convulsions
Shock — a gen ral body disturbance caused by hemorrhage, trauma, dehydration and sepsis characterized by a fall in blood pressure, rapid pulse, cold, clammy skin, vomiting and restlessness
Glucose — a major nut rient of fetal fetal growth an d energy
Uterus — an organ within a woman’s body that support the growth of a fetus fetus
Labor — the last few hours of human pregnancy characterized characterized b y uterine cont ractions that effect effect dilation of the cervix and force the fetus through the birth canal.
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Annexes
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90
Tra Tr ainer’ iner’ss N o tes Didactic Phase
10 women d ie every every 24 h ours from causes related related t o pregnancy and childbirth. or 36 50 matern al deaths/ year, year, most are in in th e rural areas. areas.
Module 1 : Overview Overview of BEmOC and PCPN C Manual Manual Session 1a: Overview of BEmOC Infant and and under Five Five Mortality Mortality (19 90 -19 98 )
1.6
86
57
1.7
77
55
74
72
65
67 1.3
54
52
56
43
48
1.2 1.1
35
1.0
1.0 MMR
0.8
0.8 0.7
0.7 1990
1991
1992
1993
1994
1995
0.6
1998 0.5
Source: Source: UN IC EF, EF, PPA PPA C R epo eport 1997 & State of the World’s World’s Children Children 1997;N 1997;N SO, 1998 ND H S
1.3
0.4
0.6
0.5
0.4 0.3 0.2
Maternal Mortality Rate in the Philippines: 172/ 100,000 209
0.0 NCR NCR CAR
I
II
III
IV
V
VI
V II II
V II II I I X
X
X1
XI I CARAGA ARMM
REGION 203
197 191
186
180
172
Sour So ur ce ce:: FHSI S, 2000
1990 1991 1992 1993 1994 1995
So
N DH S 1998, Philippines
1998
91
More than 90 percent of the total births received prenatal care care from a t rained rained b irth attendant (nurses and midwives 50%; 50%; doct ors 45 .5%; .5%; and tr ained h ilots 4.4 %)
Deliveries by Place 70% of births were delivered in the home
Traditional birth attendants 4%
Hospital 27%
Doctors 46%
Others 3% Nurse/Midwives 50 %
Home 70%
Source Source : MC H S-PNSO, Philippines Philippines 2002
Only 6 0 percent percent o f births were attended by a health care care nurse/ midwife midwife)) professional (doctor or trained nurse/
Iron Supplementation and Pre-natal Visits
Nurse 1%
82.2 81
80.6
Doctor 33%
PERCENT OF
Midwife 26%
WOMEN 74.6
97
98
99 YEARS
Traditional Birth Attendant 39%
IRON SUPPLEMENTA SUPPLEMENTATION TION PRENATAL VISITS (3 OR MORE)
Source: Source: MCH S-PNSO Philippin Philippin es 2002
92
78.3
77
74.1
Others 1%
78.6
78.1
80.9
00
02
Maternall Mo rtality by Main Cause Materna
NUMBER OF
RATE
%
603
0.4
38.19
425
0.3
26.92
3. Postpartum Hemorrhage (ICD 072)
286
0.2
18.11
4. Pregnancy with abortive outcome (ICD O000-O08)
144
0.1
9.12
5. Hemorrhage related to pregnancy (ICD o20;045;047)
121
0.1
7.66
CAUSE CASES
AO 79 series 200 0: Safe Safe Mot herhoo d Po licy licy Reproductive Reproductive H ealth ealth Program Framework AO 34 -A series series 20 00 : Ado Ado lescent lescent an d You You th P olicy AO 45-B series series 2000: Prevention and Managemen t of Abortion and I ts Com plicati plications ons
1. Complications related to pregnancy occuring in the course of labor, delivery and puerperium (ICD 021-099)
2. Hypertension (complicating pregnancy, childbirth and puerperium; ICD 010-016)
Constraints/ Constraints/ Problems in Improving Improving Safe Motherhood and Perinatal Perinatal H ealth Decreasing health budget H igh cost o f facil facility-based ity-based health ser vices vices H uman resou rce and faci facili lities ties concen trated in high ly urbanized cities cities// areas areas and and limited resources resources in in rural areas. H ealth ealth is not main concern of Local Government U nit Insufficient Insufficient obstet ric equipmen t and supp lies lies Advocacy of Safe Safe Mo th erho od policy do es not reach implementors U navailability navailability of skilled skilled professi pr ofession on al Policy D irection irection s-Maternal s-Maternal Care in matern ity benefits for women RA 7322 - Increase in workers leave RA 8187 - Grant of Paternity leave RA 7600 - Room ing-in ing-in and breastfee breastfeeding ding DO H Circular Circular 69 -A - Auth Auth ority for for t rained rained ‘hilots’ ‘hilots’ to atten d to n ormal deliveries deliveries DO H Circular Circular 187 -A - Proto col for for ho me deliveries deliveries
On Family Planning AO 50 series series 2001 : National FP Po licy licy AO 125 series series 2002: N ational Natural FP Strategic Strategic Plan AO 153 series series 2000 : Nation al Strategy Strategy for VS and Imp lementing Gu idelines idelines for for Itinerant Teams S T D / H I V/ V/ AI DS DS Nat ional STD Strategy/ Nat ional Policy Policy Guidelines for the Prevention Prevention and M anagement of STD STD s AO No . series series of 57-A, 198 9: Po licie liciess In Abating Abating Spread Spread of H IV/ IV/ AIDS AO 5 7-A, Expansi Expansion on t o Nation al AIDS-STD AIDS-STD Prevention Prevention and Co ntrol Program (NASPCP) (NASPCP) EO No . 39: Framework for for the O perations of PN AC
Policy Directions-Child Care Policies on EPI, CDD and CARI AO 3-A series series 2000: G uidelines uidelines on Vitamin Vitamin A and Iron Supplementation IMCI ECCD Law Law CHILD 21
Support Policies Food Fortification Fortification Law EO 51 - Milk Milk Code HSRA Sentrong Sigla Sigla C ertifica ertification tion PH IC C ircular ircular #6 - Maternity Package Package for for no rmal spont aneou s vaginal vaginal d elivery elivery in n on -hospital facili facilities ties
93
Standards Standards// Protocol D evelopment evelopment - Maternal Maternal Care Care DOH DO H Guidelines for for birth ing hom es (draft) (draft) MC H S quality quality standards embo died in SS Cert ifica ification tion Protocols on H ome D elive eliverie riess Midwive’s Manual on Maternal Care (Partograph) WHO Manu al on E ssential Care Pract ice Gu idelines for for Pr egnan cy, cy, Childbirth Childbirth and N ewborn (IMPAC) Managing Complications in Pregnancy and Child Birth (IMPAC) UNICEF Matern al Death Review Review Guide UNFPA RH Service Pro to cols By By Level Level of Health Facility Facility WHSMP Com prehensive prehensive Emergency OB M anual (CEO BM) focusing focusing on effectiv effectivee managemen t o f emergency OB cases cases up t o ho spital level level Referral framework for emergency OB cases and protocols for transporting patients Revision Revision of DO H guid elines on pap -smear cervical cervical screening Strategy Development-Pregnancy Tracking and Birthing Plan Protocol POPCOM Pre-Marriage Counseling Manual Standards Standards// Protocol D evelopment evelopment - Child Care Care DOH DO H AO 3 -A serie seriess 200 0: Gu idelines idelines on Vitamin Vitamin A and Iron Supplementation Assess Assessmen men t C hecklist hecklist for Essential Child H ealth Services Essential Child H ealth Visits Visits Integrated Management o f Childhood Illness Illnesses es Chart Booklet Expanded Expanded Pro gram on Imm unization unization M anual Manu al on EPI D isease isease Sur Sur veilla veillance nce
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Both Child and Mother DOH Up ang H igit igit Pang Makapagli Makapaglingkod ngkod Manual for for Pu blic blic H ealth ealth Midwives UHNP Integrated M aternal and Ch ild ild H ealth ealth Manual for for H ealth ealth Workers Capability Capability Building/ Training Training - Maternal Care Care UNFPA Int egrated Approach in C oun seling seling and Basic Basic RH Servic Services es (RH Training Training Co urse) Peer Educators Training Training o n C oun seling seling UNICEF Maternal D eath Review; Review; Midwife’s Midwife’s Manu JICA Reprod uctive H ealth Training Training Supplement ary Kit Kit Male Family Family Planning/ Reprodu ctive ctive Health Mot ivator ivator Program WHSMP Training Training in Partography Cyto-Screening Cyto-Screening Training Training o f PGH MedTechs Pap Smear Preparation Preparation T raining raining o f PH C staff Training on Syndromic Case Management o f STD STD DOH O rientation o n use of Midwives Midwives Manual Partograph Training at regional and and local lev level el Regular post-graduate course on Suturing of Perineal Laceration and In travenou s Fluid Fluid In sertion for Midwives Midwives Orientation on Integrated M anagement of Pregnancy and Childbirth Childbirth (IMPAC) (IMPAC) – MCPC and PCPN C Training o f BH BH Ws on L ife ife Cycle Appro Appro ach Capability Capability Building/ Training-Child Training-Child Care Care UNFPA Integrated Approach in in Co unseling unseling (RH Training Training Co urse) U N ICEF and WHO IMCI
H KI IM CI ; Training o n Advocacy Skills Skills DOH IMCI Training Training WHSMP Training Training in Partography Cyto-Screening Cyto-Screening Training Training o f PGH MedTechs Pap Smear Preparation Preparation T raining raining o f PH C staff ECCD Commu nity IMCI Training Training IMC I T raining raining of health workers Basic Basic EPI Skills Skills Training Training and Co ld Ch ain Management Training IEC/ Advoca Advocacy cy UHNP Developmen Developmen t of an IMCH Manual for for H ealth ealth Workers Workers DOH Guidebo ok on Adolescent Adolescent Health Teen-agers Gu ide to a H ealthy Life Life Style Style JICA MCH Record Record Book Series of video dramas (TV 99 Program- Adolescent VTR) ARH P romotion Program sa K alusugan n g In a at San ggol” ggol” A Booklet “Pangan galaga sa Cou nseling nseling Guide for H ealth ealth Workers and and Information for Mothers Teatro Teatro 9 9 Program Pu ppet Show UNFPA Video Video o n ARH ; commu nity and facil facility-based ity-based IEC interventions H KI Int egrated MC H Basic Basic Learning Learning Package Package Vitamin Vitamin A Supp Supp lementation IEC Materials 20-m inute do cument ary – Vit. Vit. A, A, A Cause for Action Action IMCI Behavior Behavior Change C ommu nication nication Plan National Nat ional Advocacy AdvocacyPlan for Food Fortif Fort ifica ication tion and an d Supplementation Supplemen tation Comprehensive Comprehensive I ron Comm unication unication P lan lan
Nutrition Bulletin ECCD Mot her and Child Book (draft) (draft) USAID Flip Flip Charts on “ Int egrated Cou nseling nseling Cards for MCH CBMIS to identify mot hers’ unm et needs on FP and TT and children’s un met n eeds for for immu nization and Vitamin A supplementation Service Delivery UNICEF Birthing ro om s for for aseptic deliveries deliveries by skill skilled ed b irth att end ants JICA Established Established U nder Five Clinic Clinic Program in Region 3 (up grading o f health health facilities facilities and p rovision rovision of equ ipment in Region 3) Reproduction of mother and child book IMaCH Package Package Tosang-Making Project Botika Binhi ECCD EPI - distribution of cold chain equipment IMC I - reproduction of modu les, les, manuals, manuals, IMC I patient record record and EC CD cards cards WHSMP ECP G being pilot-tested in NC R and Eastern Samar Samar Renovation/ Renovation/ construction construction o f deliv delivery ery rooms Distribution of disposable disposable O B kits (colposcopes, (colposcopes, pap smear supplies, LEEP machines procurement, etc.) Social hygiene clinics Partn ership ership amon g LGU , commu nity, nity, NG O s for for referral referral and services UNICEF Child-Friendly Child-Friendly Integrated Ch ildhoo ildhoo d C are and D evelopment evelopment UNFPA Teen Cent C enters ers in in pilot areas; RH service service provi pro visi sion on in 9 project pro ject sites sites H KI Rou tine distribut ion o f Vitamin Vitamin A capsules capsules
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MIS/ Monito ring ring and Resear Research ch WHSMP KAP KAP Survey Survey on RTI/ STD H KI Evaluati Evaluation on of IMC I approach (baseline (baseline and end-line survey) survey) Developed Developed mon itoring system system for LGU s on Vitamin Vitamin A availa availability bility and coverage FH I Con ducted enh anced STI STI Co ntro l in Angeles Angeles City and a prevalence prevalence sur sur vey vey of RTI/ STD in the Ph ilippines ilippines MSH Community-Based Management Information System WHSMP II Technical Technical stud stud ies to be condu cted o n FP, adolescents, adolescents, maternal mortality mortality and and STI contro l and H IV prevention prevention UNFPA Quality Care Survey (pipeline) Financing/ Financing/ Priva Private te Sector PhilHealth Developed matern ity package package by which th e first first two d eliveries eliveries are paid by PH IC provided th ese occur in accredited accredited facil facilitie itiess or are att end ed b y accredited accredited m idwives. idwives. On ly midwives attached t o an accredited institution are eligible eligible for accreditation. JSI Establishments of Well Midwife Clinics primarily for FP services; services; now beg inning t o expand t o providing child health services FCFI Establishmen Establishmen t o f clinics clinics providing matern al and child health services, services, with focus on Family Planning
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Issues and Co ncerns ncerns (Ch allenges) Policy and Structure Service Proto cols and and G uidelines Service Service Delivery Recording/ ng/ Monitori Monitoring Recordi
Issues and Co ncerns
Policy and Management Structure Policies and frameworks exist but on individual programs (e.g. Safe Motherhood, Child’s Health, RH Framework, FP Policies, etc.) Overarching framework on family health where maternal and child health belongs not yet in place Office structure at national level still on a programspecific specific assignm assignm ent s Life-cycl Life-cyclee Approach - I nt erface between m atern al care, care, family family planning, and RTI/ STD no t yet clea clearr Finalization Finalization of the T BA policy Allowing midwives to do intravenous injection
Issues and Concerns Standards and Service Protocols Service Service proto cols on m aternal and child health developed and packaged by program Core maternal and child health services to be made available per level of facility not that clear yet (e.g. what midwives midwives or th e BH Ss shou shou ld pro vide vide Several Several reference reference m aterials abou nd - consistency of standards across references references in dou bt Service Delivery Service Service provision provision is seldom seldom client-o riented , but rather programm atic; child consultation consultation m ost prob ably includ includ e mot her’s concern; but mot her’s consultation does not necessarily necessarily includ includ e child’s concerns, resulting to missed oppo rtunities for the client client and oth er members of the family Lack of a single single package of guid elines for for h ealth workers to use as reference at t he facility facility level level Manpower MIS/ MIS/ Monitor Monitoring ing Proliferation Proliferation o f diffe different rent recording forms (e.g. ITRs, FP Form 1, ECCD/ GMC, HBMR, etc. etc.))
H ome-Based ome-Based Maternal Record Record (H BMR) is not utilized utilized to the fulles fullestt and remains to record only prenatal care. care. Often times, the care provided is not recorded or the card is not updated. In most hospitals, HBMR is not hon ored as a record of care already already provided. provided. ECCD card/ card/ UFC is often times times used used to record immunization only
H ealth Sector Sector Reforms While While private-pub private-pub lic lic partnership (thro ugh market segmentat ion) is importan t in the operation alization alization of ILH Zs), the DO H has not been able to exert exert strong strong influence influence on the private private sector and the practitioners practitioners outside DO H Referral Referral sys system tem – commu nity componen t n ot yet yet designed Some LGUs not convinced nor motivated to participate in the ILH Z Investment for pub lic lic health very low
Integrated Management o f Pregnancy and and Childb irth (IMPAC) Components: Standardization Standardization o f care care by setting no rms and standards Imp roving health system system response Imp roving family family and co mmu nity participation, participation, p ractices and response Integrated M anagement of Pregnancy and and Childbirth Childbirth
Module 1:Overview of BEmOC and PCPNC Manual Session 1b: Overview of Pregnancy, Childbirth, Postpartum and Newborn Care (PCPNC) Pregnancy, Pregnancy, Childb irth, Po stpartum stpartum and N ewborn Care: (A g uide fo r essential practice practice)) WHO recommendations for for t he skill skilled ed attend ant providing providing rout ine and emergency care care for for women and newborn d uring pregnancy, pregnancy, delivery delivery,, postpartu m and post abor tion at primary health care. PCPNC… manual formulated formulated by WH O H eadquarters in in Geneva A manual and introdu ced by the World World H ealth ealth OrganizationOrganizationWestern Pacific Pacific Regional O ffice ffice in M anila End orsed by the following following organization World World H ealth Organization Organization (WHO ) U nited Nations International International Children’s Children’s Educational Educational Fund (UN ICEF), U nited Nations Popu lation lation Fun d (U NFPA) and and t he World World Bank Bank It was review reviewed ed and endo rsed by the Federation International in Gynecology Gynecology and O bstetrics bstetrics (FIGO) Technical and ed itorial assi assistance stance was provided by th e John H opkins Program Program for International Education Education in Gynecology Gynecology and and O bstetrics bstetrics (JH (JH PIEGO ) W h at at i s P C P N C Guides clinical decision-making. Promot es the early detection detection o f complicati complications ons and the initiation initiation o f early early and appro priate treatmen t, including timely referral. H elps reduce reduce h igh maternal and perinatal perinatal mortality mortality and morbidity U sed as a training training and advocacy advocacy tool Adaptable to local local circumstances circumstances and settings (needs, resources, local beliefs systems) systems)
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Content Q uick check, check, emergency management an d referral referral Post abortion care care Antenat al care care Labour and delivery Postpartum care Newbo rn care care Structure and Presentation Con tent is presented presented in a framework framework of colored flow flow charts support support ed by information information and treatment charts based on syndro syndro mic approach Framework is based Severity is marked in color: - red for emergencies - yellow for less urgent conditions - green for normal care
MCPC For m idwive idwivess and d octors at the district district ho spital spital who are respon sible for the care of wom wom en with com plication plication s of pregnancy and and childbirth childbirth or th e immediate postpartum period, period, including including immediate immediate p roblems of a newborn. The interventions described described in these manual are based on the latest available scientific evidence.
Format of PCPNC Information boxes, illustrati illustrations ons D isease isease mo del for assessment, assessment, classif classification ication an d management of complications With With overview overview for for each chapter o r compon ent
Integration Integration Approach Approach of PCPN C and MCPC Pregnan cy, cy, childb childb irth, postpart um Pregnan cy related complications complications and end emic cond cond itions / disease diseasess and preventive preventive measures Care at the facil facility ity,, comm unity and hom e care Mo th er, newbor n, part ner, family family, comm un ity and and facility facility Routine and emergency Primary and referral care Different vertical pro grams
Format of PCPNC (5 area columns) What to ask ask What to loo k for for What to expect to see H ow to classi classify fy What What to do/ treat treat
Next Steps Advertis Advertisee the manu als and encou rage governments, international agencies agencies and NG O s to use it. Provide financial financial and tech nical suppo rt to go vernment t o translate translate and adapt the m anual Provide Provide t echnical echnical support support on adaptation adaptation and t raining raining
Basic EmOC: 6 functions (PCPNC) Injectable ant ibiotics ibiotics Injectable oxytocics Injectable anticonvulsants anticonvulsants Manual removal of placenta Assisted Assisted vagin al delivery Removal of retained products
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Comprehensive EmOC (MCP C) the same same as above plus the following: Caesarean Section Safe Safe Blood Transfusion
Module 2: Principles of Good Care
Principles of Good Care Communication Workplace and Administrative Procedures Universal Precautions and Cleanliness Organizing a Visit Communication Make the woman (and her companion) feel welcome Uses simple and clear language her to ask questions Encourage Ask and provide information information related related t o h er needs erstanding her options and Support the woman in und erstanding making decision decision s Seek permission permission from t he patient when examining Summarize Summarize th e most important information, information, including including t he information information on routine laboratory tests and and treatments. Organizing a Visit Emer gency care visit visit Care of woman or baby referred for special care to secondar secon dar y level level facility facility Routine visi visitt for for the woman and/ or the baby Workplace and Admin istrative Proced ures Set-up and preparation preparation of th e Workplac Workplacee Daily and occasional adm inistrative activities activities Record keeping Int ernational conventions conventions
U niversal niversal Precautions Precautions and Cleanliness Wash hand s Wear gloves Protect yourself from from blood and o ther b ody fluids fluids during deliveries Practice safe sharps disposal Practice safe waste d isposal
Deal with with con taminated Ensure clean clean laundr y Clean and steralize contaminated equipment Clean and disinfect disinfect gloves Sterilize Sterilize gloves
Mo dule 3 : Quick Check and and Rapid Assessment and Management Session 1 : Quick Check Please Please refer refer to Sec. Sec. B2 o f PCPN C.
Mo dule 3 : Quick Check and and Rapid Assessment and Management Session 2 : Rapid Rapid Assessment and Management Please Please refer to Sec. B3-B7of PCPN C.
Mo dule 3 : Quick Check and and Rapid Assessment and Management Session 3 : Emergency Emergency Treatment Treatment for the Woman H ow to prepare prepare a syr syringe inge fo r an an injection Wash you you r hand s Take the syringe syringe and n eedle out of the package syringe nge at the end of the plunger and and ho ld the H old the syri needle at the b ase syringe and needle Attach t he syringe If using a vial vial of ready to u se medicine eg. Ge nt amicin, clean the vial and t hen carefully carefully break the to p off Put the n eedle into into the vial. vial. Draw up a little little more o f the medicine than required H old th e syringe syringe upright with needle facing facing up To remove bu bbles from from the m edicine, edicine, tap the syringe syringe lightly lightly on th e side. side. Pu sh the plung er unt il the air comes out and t he medicine begins to spill spill from from t he tip of th e needle.
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Push th e plunger un til you you h ave ave the correct do se in in th e syringe.
H ow to prepare prepare a syringe syringe fo r an an injection (For m edicine edicine th at needs t o b e mixed with with sterile sterile water, water, e.g. Ampicillin) Clean the vial vial containing containing t he sterile sterile water and b reak the top o ff Fill Fill the syringe syringe with t he amo unt of water you you require according according to the instructions Remove the b ubb les if any edicine vial vial with with alcohol alcohol Clean the rubber top of the m edicine swab sterile water into into the b ottle with the p owdered Inject the sterile medicine. Shake the bo tt le until the m edicine is well mixed with with t he water H olding the vial vial upside upside do wn, put the n eedle insi inside de and fill fill th e syringe syringe with a little more th an th e med icine icine required Remove the bubb les and push th e medicine medicine out until the correct dose is obtained. Cover the needle unt il you are ready to give give the injection injection
Mo dule 3 : Quick Check and and Rapid Assessment and Management Session 4 :Emergency :Emergency Treatment Treatment for th e WomanWomanAnatomy o f the Female Reproductive Tract Classification External Organ -copulation Internal Organ -ovulation -site of fertilization -blastocyst -blastocyst transpo rt -implantation -development -development and birth of fetus Internal Generative Organs (visible (visible externally externally from th e pub is to t he perinium )
Mons Pubis/ Pubis/ Veneris eneris Fat-filled Fat-filled cushion at th e anterior surface of the symphasis pubis Escutcheon Female - triangular shape Male - diamond -like -like Labia Majora adipose tissues covered with with skin skin two ro un ded folds of adipose extending downward and b ackwar ackward d from th e mon s pubis homologue-scrotum vary vary in appearance (fat cont ent): nullipara -close apposition -moist inner surface surface (mucus m embrane) multipara -gape widely -skin -skin like like inn er surface
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Labia Minora two flat reddish folds of tissues tissues beneat h th e labia majora hom ologue-penile urethra and p art of skin skin of penis nu llipara-no llipara-no t visible visible multipara-project beyond the labia majora two lamellae -fren u lu m -lo wer pa pair -p rep u ce -u p p e r p air Clitoris short cylind cylind rical erectile organ located n ear the superior extremity of th e vulva vulva projects between th e prepuse and prenulum parts: -glans -body/ -body/ corpus corpus -crura -principal erogenous organ Vestibule almond shaped area enclosed b y labia labia minora laterally laterally exten exten ding from from the clitoris clitoris to t he fourchette function ally ally matu re female female structu re of the uro genital sinu sinu s of the embryo perforated b y six six opening s: -urethra -vagina -duct s of bartho lin lin gland -ducts o f paraurethral gland gland Bartho Bartho lin Gland major vestibular vestibular gland located ben eath t he fascia fascia at at 4 and 8 o’clock position homologue homologue -cowper -cowperss gland gland ducts open on the sides of the vestibule vestibule just just o utside the lateral margin o f the vagina orifice orifice
U rethr rethral al Opening/ Opening/ Meatus Meatus membrano us conduit for urine urine from the urinary bladder to t he vestibule vestibule Skene/ Paraur Parauretheral etheral branched tu bular gland gland adjacent adjacent to distal distal urethra ducts open on t he vestibule vestibule on either side of the urethra homologue homologue -prostate -prostate gland gland Vestibu lar Tubes veins almond sahp ed aggregat ions of veins homol homologue ogue -bulb -bulb of peni peniss liable to injury and ru pture liable vulv vulvar hemotom a/ hemmorhage Hymen thin porpo rated membrane at the entrance of the vagina, vagina, hidd en b y labia mino ra new newbor born -vascula ular/ redunda dundant nt pre pregna gnant -thi thick epi epith thel eliium -rich in glycogen menopause menopause -thin -thin epithel epitheliium -with focal cornification hymenal opening -cresenti -cresentic/ c/ circul circular ar -cribriform -septate/ -septate/ fimbriated fimbriated imperforate hymen myrtiform myrtiform caruncle -cicatri -cicatrized zed no dules/ tissue tissue remnants of the hymen Vagina tubu lar, lar, m usculomembranous usculomembranous strcuture extending extending from from the vulva vulva to the u terus, interposed anteriorly and po steriorly steriorly between the b ladder ladder and rectum functions-excretory canal of the uterus -organ of copulation
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-part of the b irh canal -upp -upper er mull mulleri erian suc sucts ts -lower urogen ital sinus sinus nullipar para -with nume numero rous us ruga rugaee null multi multipa para ra -smooth mooth wall cyst vaginal inclusion cyst -remnants of mucosal tags buried during repair of vaginal laceration after childbirth
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por portion tionss
Mod ule 4 : Antenatal Antenatal Care Care Session 1&2: Process Flow of Antenatal Care
QUICK CHECK, RAM
DURING 1ST ANTENATAL ANTENATAL VISIT PREPARE A BIRTH AND EMERGENCY PLAN
CHECK FOR PRE-ECLAMPSIA ASK, CHECK, RECORD
CHECK FOR ANEMIA
LOOK, LISTEN, FEEL
CHECK FOR SYPHILIS IDENTIFY SIGNS
CLASSIFY TREAT TREA T AND RECORD
If yes, proceed to Sec. G1G8, H1-H4 of PCPNC
CHECK FOR HIV HI V STATUS STATUS
RESPOND TO OBSERVED SIGN OR VOLUNTEERED PROBLEMS*
GIVE PREVENTIVE MEASURES
ADVISE AND COUNSEL ON NUTRITION AND SELF-CARE
ADVISE ON ROUTINE FOLLOW-UP VISITS
HOME DELIVERY WITHOUT SKILLED ATTENDANT
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Antenatal Care Always Always begin with RAM (If the wom an has no emergency or priority signs signs ). U se the Pregnancy Status and and Birth Plan Chart. C2 ;C14 Ch eck all women for pre-eclampsia, anemia, syphilis syphilis and H IV status status C3-C6 U se chart chart on ‘Respon ‘Respon d to O bserved Signs Signs or Volun teered Prob lems’ to class classif ify y the con dition an d identify appropriate treatm ents Respond to Observed Signs or Volunteered Problems No fetal fetal movement movement C 7 Ruptured membranes C7 With fever ever or bu rning on urination urination C8 With With vaginal discharge discharge C 9 With With signs signs suggestive of HI V infection infection C 10 Smoking, Smoking, on alcoho alcoho l or drug abu se or with with h istor istor y of violence violence C1 0 With With cou gh o r breathing d iffi ifficulty culty C11 On anti-tuberculosi anti-tuberculosiss treatment C1 1 Give preventive measures due C1 2 Develop a birth and emergen cy plan C14-C 15 Advise Advise on nu trition , family family planning , labor signs, danger signs, signs, rou tine and follow-up visi visits ts C13 using In formation and Co unselling unselling Sheets Record: po sitive sitive findings, findings, birth plans, treatmen t given, next sched uled visit visit If H IV positive, positive, adolescent, adolescent, or h as specia speciall needs G1-G 8; H1-H4
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Module 5: Labor, Delivery, Immediate Postpartum Period Session 1 : Stages Stages of Labor-O verview Labor sequence of uterine contractions cervical dilatatio dilatation n bearing down delivery delivery of the b aby Delivery expulsion expulsion o f the baby Immediate Postpartum Period Equ ally ally impo impo rtan t as labor labor and delivery delivery Most com plications plications occur
Role of physician, nurse & midwife To ant icipate icipate To assess assess or ident ify ify prob lems To treat or manage pro blems of the woman
Respond to problems during labour and delivery pp. D14 – D18 Ob serve serve mother and baby in in th e labor labor room one ho ur after after delivery delivery.. U se charts on Care of th e Mth er and Newborn Within Within th e First First H our o f Delivery Delivery of the Placenta Sec. D19 of PCPNC For immediate postpart um man agement u ntil delivery delivery,, use Care of the Mo ther After After th e First First H our Fo llowing llowing Delivery Delivery of the Placenta Sec. Sec. D20 of PCPN C advise on d anger signs, signs, when t o seek routine and To advise emerge ncy care, and and family family plann plann ing, u se Preventive Treatment and Advise dvise on Postpartum C are pp. D26 – D28 Examination o f the mo ther for discharge discharge Examination Do not dischar discharge ge the mot her before before 12 h ours. If mot her is H IV Positive Positive or Adolescent Adolescent o r has Special Special Needs If attend ing a d elivery elivery at the woman’s home, see Sec. D29 of PCPNC.
Module 5: Labor, Delivery, Immediate Postpartum Period Session 1 : Stages of Labor-Rapid Assessment Assessment and Management
Rapid Assessment and Management B3-B7 Examine Examine Woman Woman in Labo r or With Rupt ured M embranes D2 – D3. T hen decide the stage of labor. labor. If and abn ormal sign sign is identified, identified, u se the charts on Respond to O bserved Signs Signs or Volunteered Volunteered Pr oblems D4-D 5 For suppor tive tive care throu gho ut labou r and d elive elivery ry,, use Supportive Care chart chart D 6 Record findings findings conitnually on Labor record and partograph
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Look, listen and feel: Response Response to contractions contractions Check abdomen Feel abdomen Listen to the FHB Measure VS Loo k for for pallor, dehydration Decide the Stage of Labor Ask, check record: Explain to th e woman t hat you will give her a vaginal vaginal examinatio n Ask for her consent Look, listen & feel: Ob serve serve th e vulva vulva Perform vaginal vaginal examination DO NO T perform vaginal vaginal examination examination if currently bleeding bleeding o r at any time after 7 months of pregnancy Module 5: Labor, Delivery, Immediate Postpartum Period Session 1: Stages of Labor Contents: Examine Examine the wom an in labor labor o r with with ru ptured membranes Decide stage of labor Examine the wom an in labor or with ruptured membranes Ask, check record: H istor istor y of this labor labor Check record, or if no record If prior p regnancies Current pregnancy
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Signs — Classify — Manage Imminent Delivery Late active labor Early active active labo r No t yet in active active labo labo r
Review First d o RAM (B3 – B7) First Assess ssess the status of the wom an and her fetus status (D2 ) labor (D 3) Decide stage of labor
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Module 5: Labor, Delivery, Immediate Postpartum Period Session Session 2 : First Stage of Labor Contents: First stage of labor -not in active active labor -in active labor Respond to obstetrical problems ive care Support ive Skil Skills ls:: IE, Parto graph, Labo r record
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Supportive Care throughout Labor To provide a supportive, encouraging atmosphere for birth , be respectful of the woman ’s wishes. wishes. Communication Cleanliness Mobility Urination Eating, drinking Breathing technique discomfort relief relief Pain and discomfort Birth companion If woman is distressed or anxious, investigate the cause (D2 – D3) If pain is constant constant (persisting (persisting between con tractions) and very severe or sudden onset (D4)
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Module 5: Labor, Delivery, Immediate Postpartum Period Session 3: Second Stage of Labor
Second Stage of Labor Cervix dilated 10 cm Bulging thin perineum H ead visible visible Contents: Delivery Delivery of the baby Skills: -Normal vaginal delivery -Breech delivery -Stuck shoulder
-Multiple birth -Cord prolapse Second Stage of Labor Monitor every every 5 minutes: For em ergency signs signs u sing sing RAM (B3– B7) Frequency, intensity and duration of contractions F e t a l H e a rt rt R a t e ( D 1 4 ) Perineum thinning or bulging Visible descent of fetal head or during contraction Mood and behavior: distressed, anxious (D6) Record findings regularly in Labor Record and Partograph (N4 – N6) Never leave leave th e woman alone
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All All delivery delivery equ ipment and supplies, supplies, including newborn (NB) resuscitati resuscitation on equipment are avai availa lable, ble, and place place o f delivery delivery is clean clean and warm (25º C) (L3 ); Empty bladder (B12); Assist to choose a comfortable position, upright as possible; Stay with mother and offer emotional and physical support (D10-D11) Allow her to push as she wishes with c o n t r a ct ct i o n s. s. D o n o t u r g e h e r t o p u sh sh . Wait unt il head visi visible ble and p erineum d istend istend ing Refer urgently to hospital if 2 nd stage lasts for for 2 hrs or mo re with with ou t visi visible ble steady descent of the head .(B17 ) Do not perform episiotom episiotom y routinely. routinely. Wash ash hand s w/ w/ clean clean water and soap. Put on gloves just before delivery. See un iversal iversal precaut ions during labor and delivery A4. Ensure controlled delivery of the head Feel gently aroun aroun d b aby’s aby’s neck for for t he cord . Await Await spontan eous rot ation of shoulders and delivery delivery within within 1-2 minut es (D1 7- managing STU STU CK SHOULDERS).
Exclude 2 nd baby. Palpate mother’s abdomen. Give Give 10 I U oxytocin oxytocin IM to the mot her. her. Watch for vaginal bleeding. Chang e gloves or wash wash g loved loved h ands. Clamp Clamp and cut the cord. Encou rage initiation initiation of breastfeeding. breastfeeding. K2
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Module 5: Labor, Delivery, Immediate Postpartum Period Session 3: Second Stage of LaborPerineal Repair Episiotomy Or perineotomy Is an incision into the perineum to enlarge the space at the outlet, thereby facilitating the birth of the child. Maternal benefits: A straight straight incision incision is simpler simpler t o repair and heals bett er than a jagged, uncontrolled laceration; Strength of the pelvic pelvic floor floor can be preserved and t he incidence of uterine pro lapse, lapse, cyctoco cyctoco ele and and rect ocoele reduced; Structures in in front and rear are are protected ; Less stretching stretching of and less damage to the anterior vaginal vaginal wall, wall, blader, u reth ra and p ericlitoral ericlitoral tissues; tissues; Tears into th e rectum can be avoided; Second Second stage of labor labor is shortened. Fetal benefits: Lessens Lessens pound ing of the head on t he perineum so helps prevent prevent brain damage; Makes birth easier. Indications: pelvic floor; floor; Pro phylactic: To preser ve the integ rity of th e pelvic Arrest of progress by resistant perineum (thick and heavily heavily muscled t issue, issue, ope rative scars, scars, and previous wellrepaired episioto episioto my); To obviate uncont rolled tears, including extension extension into the rectum; Fetal reasons reasons (p remature b abies, abies, large babies, abnormal position s, and fetal distress).
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Timing of Episiotomy: If made t oo late, procedure fails fails to prevent lacerations; lacerations; If made t oo early, early, th e incision incision leads to loss of blood ; Is made when the perineum is bulging, when 3 to 4 cm diamete r of the fetal scalp scalp is visi visible ble du ring con traction ; Lacerations of the Perineum Maternal causes: Precipitate, uncontrolled or unattended delivery (most commo n cause); cause); inability to sto p bearing do wn; Th e patient’s inability H astening t he d elivery elivery by excessiv excessivee fundal pressure; friability of the perineu m; Edem a and friability Vulvar varicosities weakening the tissue; Narrow pub ic arch arch with with outlet con traction, traction, forcing the head p osteriorly; osteriorly; Extension of episiotomy. Fetal causes: Large baby; Abnormal positions of the head ( OP, face); face); Breech deliveries; Difficult Difficult forceps extractions; Shoulder dystocia; dystocia; Co ngen ital anomalies (hydroceph alus). alus). Classification Classification o f Lacera Laceration tion s of t he Perineum involves the fourchet te, p erineal skin skin First degree laceratio laceratio n involves and vaginal vaginal mucosa membrane BUT N O T th e underlying underlying fascia fascia and mu scle. scle.
issue and Repair aims reapproximation o f the divided issue hem ostasis. ostasis. A simple simple interru pted su tu re is eno ugh . If bleeding is profuse, figure-8 sutures may be used. involves, in in add ition t o th e skin skin Second degree laceration laceration involves, and mu scous membrane, th e muscles muscles of the perineal bod y BUT N O T the rectal sphincter. sphincter.
Repair: Interrupted, continuous or lock stitches are used to approximate the edges. The deep muscles of the perineal body are sutured together with interrupted sutures. A running subcuticular suture or interrupted sutures, loosely tied, bring together the skin edges. Third degree laceration extends through th e ski skin, n, mucou s membrane, perineal bod y AND IN VOLVE the anal sphincter. Repair - Similar Similar to repair of fou fou rth d egree laceration except that t he reapproximation reapproximation starts with with t he to rn ends of the anal sphincter. Fourth degree laceration – extends through the rectal mucosa to expose the lumen of the rectum.
layers) Repair: (repaired in layers) The anterior wall wall of the rectum is repair repaired ed with fine 000 or 00 00 chro mic catgut catgut o n a fused fused needle. Starting Starting at the apex, interrupted sutures are placed placed submuco sall sally y so th at the serosa, serosa, muscularis muscularis and sub mucosa of th e rectum are apposed. Oth ers approxi approximate mate edges with with continuou s sutu re going th rou gh all layers. layers. The line line o f repair repair is overse oversewn wn by bringing t ogeth er the perirectal fasci fasciaa and t he fascia fascia of the r ectovaginal septu m. Int errupted or cont inuous sutures are are used. used. sphincter are identified, identified, The torn ends of the rectal sphincter grasped with allis forceps and app roximated with interrupted sutu res or two figure-8 figure-8 sutu res. res. Th e vaginal vaginal muco sa is is then repaired as a midline midline episiotom episiotom y with continuo us or interru interru pted sutu res. The perineal perineal muscles muscles are sewn sewn to gether with with interrupted sutures. The skin edges are are sewn sewn to gether with a continu ous subcuticular suture loosely tied interrupted sutures.
Disruption of Episiotomy or Laceration Repair: Poor healing powers (nutritional deficiencies, anemia, exhaustion after a long and difficult labor). Failure Failure of t echnique (careless (careless approximation approximation of th e wound, incomplete hemostasis leading to hematoma formation, failure failure to obliterate dead space). space). Devitalization of tissue (use of crashing instruments, strangulation of tissue by tying sutures too tightly, employment o f heavy heavy catgut catgut ). Infection
Aftercare Maintain cleanliness cleanliness Use o f antiseptic antiseptic after after each urination or b owel movement No alcoho alcoho l Perilight Perilight may be used Daily shower and washing using soap and water U se of stool softener softener for those who had t hird or fourth degree laceration laceration s Well balanced d iet Other locations of lacerations Tissue Tissue on either u rethra Labia mino mino ra Lateral walls walls of th e vagina Area of the clitoris Cervix Urethra Bladder
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Repair of median episiotomy. A. Chromic 2-0 or 3-0 suture is used as a cont inuo us suture to close th e vaginal vaginal musoca and submu cosa cosa.. B. After closing th e vaginal incisi incision on and reapproximating reapproxi mating th e cut margins of the hymenal ring, the suture is tied tied and cut. Next, three or four interrupted sutures of 2-0 o r 3-0 chromic are placed in t he fascia fascia and muscle of the incised perineum. C. A continuo continuo us suture is carri carried ed do wnward to u nite th e sup erficia erficiall fascia. fascia. D . Co mpletion of repair. repair. The cont inuou s sutu sutu re is carri carried ed upward as a subcut icular stitch. stitch. (An alternative alternative method of closure of skin skin and subcu taneous fascia is illustrated in E.) pletion on of repair repair of E. Com pleti med ian episioto my my.. A few interrupt ed sutures of 3-0 chromic are are placed placed throu gh th e skin ski n and subcut aneou s fasc fascia ia and loo sel sely y tied. Th is closure closure avoids avoi ds bu rying two lay layers ers of suture in t he mo re superficia superficiall layers lay ers of the perineu m.
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Module 5: Labor, Delivery, Immediate Postpartum Period Session 3: Second Stage of LaborThird Stage of Labor Contents: Delivery of the placenta st Care of the Mother and NB WITH IN 1 hour of placental delivery Care of the Mother 1hour AFTER delivery of the placenta Assessment of the Mother after delivery and Before Discharge Respond to Problems Immediately Postpartum Skills -Management of abnormal 3 rd stage -Antepartum -Antepartum H emorrhage -Active management of 3 rd stage Delivery of the Placenta Monitor Mother every 5 mins: For emergency signs using RAM (B3-B7) Feel if uterus is well-contracted Mood and behavior (distressed or anxious) (D6) rd Time since 3 stage begun (time since birth)
Record findings, findings, treatment and pro cedures in in Labor R ecord ecord and Partograph (N4-N5) D eliver the Placenta Placenta - Treat & Advise If Required Ensure 10 IU oxytocin oxytocin IM is given given Await strong contraction (2-3mins) and deliver by controlled cord traction. 30mins u ndelivered ndelivered -empty b ladder, ladder, encourage breastfeeding, repeat controlled cord traction 1hr un delive delivered red - manual delive delivery ry (doctor), IM/ IV antibiotic
Another 1hr undelivered — refer to hospital DO NOT exert excessive traction on the cord. deliverr the DO NO T squeeze or push the uterus to delive placenta. Check the placenta and membranes if complete. If incomplete — remo ve fragments fragments manu ally ally (doctor), IM/ IV antibi antibiotic otic B11, B11, B15 Check uterus if well contracted and no bleeding. Repeat check every 5 mins. If heavy bleeding Massage uterus to expel clots if any, until it is hard B10 10 IU Oxytocin IM Call for help IV line line B9, B9, add 20 IU oxytocin oxytocin x 60 drops/ min Empty bladder If bleeding persists and uterus soft — Continue massage Bimanual Bimanual or aortic compression compression B10 Continue IVF with with 20 IU oxytoci oxytocin n x 30 d rops/ rops/ min Refer urgent ly to h ospital B17 B17 Examine perineu m, lower vagina vagina and vulva vulva for for tears. If 3 rd degree refer to ho spital spital Collect, Collect, estimate estimate and record bloo d loss throu ghou t th e 3 rd stage and imm ediately afterwards. afterwards.
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Care Care of t he Mother and N B within 1 st hour of delivery of the Placenta Monitor mot her every every 15 mins Monitor baby every 15 mins Care of the Mother and NB Assess amount of bleeding. Less than 5mins soaked or constant trickle of blood — B10 -if bleeding from a perineal tear, repair if required — B10 or Refer to hospital B17 B17 Ask the companion to stay with the mother Encourage the woman to pass urine Care Care of the Mo ther 1H R after D elivery of th e Placenta Placenta Use chart for continuous care of the mother until discharge. Monitor mother at 2, 3 and 4 hrs, then every 4 hrs: For emergency signs using RAM Feel uterus if hard and round Record findings, treatments and ecord an d procedures in Labor R ecord Partograph N 4 - N 5 Never leave leave the woman and b aby alone alone DO NO T discharge discharge before before 12 h rs. rs.
Care of the Mother –— Interventions if Required Postpartu m Care and H ygiene, giene, N utrit ion ion D 26 Advise Advise o n Pos Advise when to seek care D28 Cou nsel on Birth Spacing Spacing and oth er Family Family Planning Planning Methods D27 Repeat examination examination of th e mot her before discharge discharge using Asses Asses the mot her after after delivery delivery D2 1. For baby J2-8.
Assess the Mot her after after Delivery Use chart to examine the m oth er the first first time after delivery delivery (at 1 hr after delivery or later) and for discharge.
Ask, Check record: Bleeding >250 ml Completeness of placenta and membranes Complications during delivery and postpartum Needs tubal ligation or IUD Others Look, Listen and Feel: Temperature Feel the ut erus Vaginal bleeding Perineum: tear, swelling, pus Pallor Sig ns – Classify – Treat & Advise Give Preventive Measures D25 Ensure that all are given before discharge.
Assess, Check records – Treat & Advise D25 RPR status. If none — do RPR test L5 If (+) administer Benzat Benzat hine Penicilli Penicillin n (F6) Tetanus toxoid status -give -give if if due (F2) Give Give 500m g of Mebendazole to every woman woman on ce in in 6 months (F3) Check woman’s supply supply of iron/ iron/ folate, folate, vitamin vitamin A Give Give 3 m ont hs supply of iron iron and cou nsel on compliance compliance (F3) , give vitamin vitamin A if du e (F2) Ask wheth wheth er mot her and baby are sleepi sleeping ng u nder insectici insecticide de bed net. F4 Record all all treatment treatment given given using Postpartum Record (N6)
Advise on Po stpartum stpartum Care D 26 st Companion for the 1 24hrs Not to insert anything in the vagina Rest and sleep washing Imp ortan ce of washing Avoid Avoid sexual intercou rse unt il perineal perineal woun d is healed
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Counsel on Nutrition Greater amount of variety of nutritious and healthy foods Ensure she can eat any normal foods More nutrition counseling on thin mothers and adolescents No to myths and fallacies about foods Seek help help from family family members about proper nut rition of the mother Counsel on Birth Spacing and Family Planning D 27 Impo rtance o f Family Family Planning Include partner of family member to be included in the counseling Explain Explain non -breastfeeding -breastfeeding can m ake her pregnant again again Ask desired family size 2-3 years gap is healthy to the mother and child Give info info on wh en to st art a meth od after delivery will will vary vary on wheth er the woman is breastfeeding breastfeeding or n ot Make arrangemen arrangemen t on when to see a FP counselor, or coun sel directly directly Advis Advisee correct and consistent consistent use of condo ms for dual protection against STIs STIs or H IV and pregnancy. pregnancy. Promo te their use (G2) For H IV (+) women see G4 for FP considerations considerations Ask Ask cho ice for for Vasecto Vasecto my of part ner
Progestero ne- on ly injectable injectable Implant Spermicide Female steril sterilizati ization on (w/ in 7 d ays ays or delay 6 weeks) weeks) IU D (w/ in 48 hrs of dela delay y 4 weeks weeks))
Delay 3 weeks: Combined OCPs Combined injectables Diaphragm Fertility awareness
method
Lactation Amenorrhea Method (LAM) A breastfeeding woman is protected from pregnancy only if: Not > 6 months postpartum Breastfeeding Breastfeeding exclusiv exclusively ely (8 or more times/ day) Can also choose additional FP method Method Options fo r the N on-breastfeedi on-breastfeeding ng Woman Woman Can be used immediately postpartum: Condoms Progesteron e-only pills pills
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Delay 6 Weeks: OCPs Progesterone-only Progesteron e-only injectables injectables Implants Diaphragm Delay 6 mo nths: Combined OCPs, injectables Fertility awareness method Advise Advise on When to Return D2 8 Use chart for advising on postpartum care Encourage woman to bring her partner or family member to at least 1 visit Routine Postpartum Care Visits D28 1 st visit visit (D1 9) within st 1 week, preferably within 2-3 days nd 2 visit (E2) 4-6 weeks Follow-up Visits for Problems: I f p r o b lem was: R et u rn in : F eve r 2 d ays L o wer U T I 2 d ays P er erin ea eal in fe fe ct ct io io n or or pa pain 2 d ay ays 1 we e k H yp ert en t io n U rin ar y in co n t in en ce 1 we week
I f p ro b le m was: Se ve re an e m ia P o st p art u m b lu es H I V ( +) M o d erat e an em ia If treated in ho spital fo r co m p licat io n
R et u r n in : 2 weeks 2 weeks 2 weeks 4 weeks
Advise dvise the women to bring h er H BMR to th e H C, even for an em ergen cy visi visit. t.
n o t lat er than 2 weeks
Advise on danger signs Go to hospital or H C immedaitely immedaitely, anytime, urgently if: if: Bleeding 2 -3 pad s soaked soaked in 20 -30 m ins after after Vaginal Bleeding delivery, delivery, increases after d elivery elivery Convulsion Fast or difficult breathing Fever and too weak to get out of bed Severe abdominal pain Go to H ealth ealth Center ASAP ASAP for the following signs: Fever Abdominal pain Feels ill Breast swollen, red, tender, sore nipple Urine dribbling or pain on micturition Pain in perineum perineum or draining pus Foul-smelling lochia H ow t o prepare prepare for an Emergency Emergency in postpartum Always have someone near at least 24hrs after delivery Discuss Discuss with with partner o r family family member abou t em ergency issues: - where to go - how to reach the ho spital spital - costs involved - family family and com mun ity suppo rt Advis Advisee th e woman to ask ask for help from th e comm unity if needed I 1-3.
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Module 6: Postpartum Care Session Session 1 : Post Partum examina examination tion o f the Mother U p to Six Weeks Alway Alwayss begin with RAM pp E2-E 7 For examination examination of th e woman on postpartum follow-up follow-up or after hom e delivery delivery,, use Po stpartum Examination Examination of the Mother (P2) U se ‘Respond ‘Respond to Ob served served Signs of Volunteered Volunteered Pro blems’ chart if an abn orm al sign is ident ified ified (E3 E10) Record all find find ings and and t reatmen t given then schedule next visit. visit. For t he first first and second second postpartum visi visits, ts, during the fisrt fisrt week after after delivery, delivery, use the Po stpartu m Examination chart chart (E2 ) For furt her advise, use Advis Advisee and C ou nselling nselling Section D26 D2 6 If the wom an is H IV Positive, Ado Ado lescent lescent o r with Special Special Needs G2-G8, H1-H 4 Overview Time bet ween delivery delivery of the baby – 6 weeks Complications may usually occur Morbidity & mortality attributed to inadequate knowledge of proper asses assessment sment and management while while the mot her is in the health facil facility ity Important role of health providers: prevent such problems to occur Postpartum Care Sessions: Postpartum Examination Examination of the Mot her U p to Six Six Weeks, eeks, Postpart um Care Respond to Observed Signs and Volunteered Problems Preventive Preventive M easures easures and Additional Additional Treatmen ts
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Session Session 1 : Postpartum Postpartum Examination Examination of t he Mother U p to Six Weeks (E2) Use this chart for examining the mother after discharge from a facility
If she de livers livers less less than 1 week ago witho ut a skilled skilled attendant, use the chart Assess the Mother After Delivery (D21)
Ask, Check Record When, where delivered H ow are you feeling? feeling? Pain, fever, bleeding since delivery? H ard to void urine? urine? Family Planning? Other concern? complications, tx during delivery? delivery? Check recor ds: complications, H IV Status Status Look, Listen & Feel BP, Temp Feel uterus. Is it hard, round? Look at vulva & perineum for: tear, swelling, pus Look at pad for bleeding bleeding and lochia: lochia: -does it smell? -is it profuse? Look for pallor Treat and Advise What to watch for hygiene, counsel on nutrition (D26) Coun sel sel on birth spacing spacing and FP (D2 7) Iron supply for 3months, compliance (F3) Treatment or prophylaxis due: TTd (F2) Impragnated bed for mother and babyRecord babyRecord o n th e mother’s HBMR Advise Advise to retu rn within 4-6 weeks
ASSESS AND EXAMINE THE MOTHER’S COMPLETE COMPLET E HISTORYAND PE
SIGNS
CLASSIFY
TREAT AND ADVISE
Module 6: Postpartum Care Session 2: Respond to Observed Signs & Volunteered Problems Observed signs & Volunteered problems: Elevated diastolic BP Pallor HIV status H eavy eavy bleeding Fever or foul-smelling lochia Dribbling urine Pus or perineal pain Feeling unhappy or crying easily Vaginal discharge 4 weeks after delivery Breast Breast problem Cough or breathing difficulty Taking anti-tuberculosis drugs Signs Signs suggesting H IV infection infection
Summary Recognize problem Respond to volunteered problem or observed signs Manage properly the problem
Module 6: Postpartum Care Session 3 : Preventive Preventive Measures & Addition al Treatments Treatments Contents: Tetanus Tetanus toxoid (TTd ) Vitamin Vitamin A postpartu m Iron and Folic Acid Compliance Compliance on Iron treatment Antimalarial ntimalarial treatment and Paracetamol Paracetamol antibiotics O ral antibiotics Signs of allergy Tetanus Tetanus to xoid All women, 0.5 ml IM Check TT d status: when last given, given, which do se -if unkno wn -give -give TTd 1 -give -give TT d 2 in 4 weeks Explasin its safe in pregnancy, ADR Advise when is next dose Record on mother’s card Tetanus toxoid schedule: At 1 st contact w/ woman of childbeari childbearing ng age or at 1 st antenatal care visist, ASAP - TTd1 At least least 4 weeks after after TTd 1 — TTd 2 At least least 6 mont hs after after TTd 2 — TTd 3 At least 1 year after TTd3 — TTd4 At least 1 year after TT4 — TTd5
Vitamin A 200 ,000 IU capsule capsule after after delivery delivery or w/ in 6 weeks of delivery H elps recovery recovery,, goo d t o t he baby also also Nausea and headache tempo rary only Do no t givecapsules givecapsules with with high d ose of vitamin vitamin A du ring pregnancy
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Iron & Folic acid All All pregnant, postpartum and po stabortion women Give Give 3 mont hs supply 1 t ablet = 60mg iron, 40 0ug folic folic aci acid d Mottivate cmpliance
Summary Complete management of a mother by: Giving Giving t hese preventive measures Treating infectious infectious cond itions Recogn ize and initially initially manage allergy after after giving giving medications
Antimalarial treatment Give preventive preventive intermitten t treatm ent for falciparum malaria Sulfodo Sulfodo xine-pyri xine-pyrimethamine methamine at t he beginning of 2 nd and 3 rd trimester to all women accord ing to n at’l policy Check when last dose is given: -if no dose in last last mo nth , give give 3 t ablets in in clinic Advise Advise when next d ose is du e Mo nito r baby for jaundic eif given just before d elivery elivery Record in hom e-based e-based record Sulfadoxine-pyrimethamine 1 tablet= 500 mg sulfadoxi sulfadoxine ne + 25 mg pyrimethamine Second Second trimester = 3 tablets Third trimester = 3 tablets O ral anti-malaria anti-malariall treatmen t
Module 6: Postpartum Care Session 3: Preventive Measures Additional Treatments-RAM
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&
Pregnanct women
Good communication/rights of women Organizing a visit Workplace and administrative procedures Universal precautions
QUICK CHECK AND RAM
Emergency signs
Paracetamol For severe pain 500 mg 1-2 t abs every every 4-6 hrs Insecticide-treated Insecticide-treated b ednet Dip in insectici insecticide de every 6 mon ths Provide Provide information information t o help her d o th is Mebendazole Give Give 500 mg to every every woman once in 6 months Do not give give in the first first trimester
Mebendazole 100mg tablet tablet = 5 tablets
A-Airway B- Breathing C- Circulation D- Drugs
Priority signs
Labor pains Classify stage of labor
Emergency treatment
Routine care
Labour and delivery
Vaginal bleeding Convulsions Severe abdominal pain Dangerous fever Labour
Non-emergency signs
Partograph and labor record
Postpartum
Newborn
Antenatal care
Term pregnancy
Module 7 : Newborn Care Care Session 1:Care of the Newborn Baby at the Time of Birth Birth D 11 - Im mediate mediate N ewborn Care Care Basic Basic Needs of the N ewborn at Birth Birth
To breathe normally
To be warm
To be fed
To be prot ected
Preparing Preparing to Meet the Baby’s Needs
“Go od care of the newborn begins with with good preparation” H ave ave clean clean warm towels/ towels/ cloth cloth s ready ready for for th e newborn (warmth) H ave ave a sterile sterile kit kit to t ie and and cu t th e cord (prot ection) Keep the d elivery elivery room clean and warm (warmth, protection) Keep the mot her and b aby in in skin-to skin-to -skin -skin contact from birth t o encourage breastfeeding breastfeeding (warmth, feeding) H ave resuscitation resuscitation eq uipmen ts near the delivery delivery bed (breathing)
U niversal niversal Precautions Precautions A4 Alway Alwayss remember th e impor tance of obser ving ving precautions to help protect the mo ther and b aby and ou rselves rselves from from infection infection s with b acteria, viruses viruses including H IV Chan ge th e gloves. gloves. If not possible, possible, wash wash gloved hand s. Give Immediate N ewbo rn Care Care J10 J10 Place Place baby on th e mother’s abdom en or arms; No te th e time of delive delivery; ry; Dr y the b aby . Wipe Wipe eyes. eyes. D iscard iscard wet cloth; Asses Assesss baby’s breath ing wh ile ile d rying; Most babies cry at birth and breathe normally.
H owever, a baby may behave in a num ber o f ways ways after it is born, th us we should b e alway alwayss be prepared for t he baby who will will need help with with its breath ing. (N ewborn Resuscitation Resuscitation – B11) Clamp Clamp and cut the cord -put t ies tightly aroun aroun d th e cord at 2 cm and 5 cm from baby’s abdomen; -cut bet ween ties with with sterile instrum instrum ent. -observe for for oo zing blood. Leave baby on the mot her’s chest chest in skin-to-skin skin-to-skin con tact; Leave Place identification label; breastfeeding (K2); Enco urage initiation of breastfeeding If H IV-positive IV-positive mot her-G7 ,G8
Care Care of the N ewborn within the first first hours of life J19 J19 Permanent surveillance Never leav leavee the wom an and n ewborn alone; Keep the moth er and baby in the delivery delivery room; Record findings, findings, treatment s and procedu res in in t he labor record; Monitor every 15 minutes: Baby Breathing warmth Care of the mother and newborn Wipe the eyes within 1 ho ur o f birth Apply an eye antimicrobial within - 1%silver 1%silver nitrate drops or - 2.5%po vidon vidon e iodine drops or - 1%tetracycl 1%tetracycline ine ointmen ointmen t. Administer Vitami Vitamin n K 0.5 -1 mg IM If blood or meconium, wipe off with wet cloth and dry. DO NO T remove vernix vernix or bathe th e baby. baby. Keep Keep th e baby warm and in skin-to-skin skin-to-skin con tact with th e mot her – K9
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Keep the baby warm K9 At birth and within the first hour(s) Warm d elivery elivery room Dry the baby: place the baby on the mother’s abdomen or on a warm, clean and dry surface. Dry the whole body and hair thoroughly, with a dry cloth. Skin-to-ski Skin-to-skin n con tact: Leave Leave the baby on the m oth er’s er’s abdom en (before cord cut) o r chest (after (after cord cut) after birth for at least least 2 hou rs. Cover the baby with with a soft dry cloth.
If unab le to initiate breastfeeding, plan for alternative feeding feeding met hod K5-K8 K5-K8 If moth er H IV+ and chooses replacement replacement feeding, feeding, feed accordingly (G8 ) If the baby does not feed in 1 hou r, examine examine the baby (J2-J9). I f healthy healthy,, leave leave the b aby with with the m oth er to tr y later. Asses Assesss in 3 h ou rs, or earlier if the b aby is small small (J4). If the mo ther is ill ill and u nable to b reastfeed, reastfeed, help her to express express breast milk and and feed feed the baby by cup (J4). reastfeed at all, all, use one of the If moth er cannot b reastfeed following following opt ions: - hom e-made or com mercial mercial formu formu la - don ated heat-treated b reast reast milk.
In the first two hours after birth, it is not necessary to: Weigh or measure th e baby Bathe the baby Dress the baby Give Give the b aby any any other food oth er than b reast reast milk Give Give the baby to anyone apart from from th e moth er
H elp the mother to initiate breastfeeding breastfeeding within 1 hour, when b aby is ready ready (K2 box 2) Sign Sign s of readiness to b reastfeed are: baby loo loo king around/ moving, moving, mouth open, searc searching. hing. Ch eck position and attachment at the first first feed. feed. O ffer ffer to help the mo ther at any time time (K3). Let th e baby releas releasee the b reast reast by her/ himself; himself; then offer offer the second breast. 124
Review Make sure that the delivery delivery area area is ready for for th e mot her and baby; Observe universal precautions at all times (protection); Keep Keep th e delivery delivery room warm (warmth, protection); H ave resuscitation resuscitation eq uipmen t near the delivery bed (breathing); H ave ave clean clean warm warm towels/ towels/ cloth cloth s ready for the baby (warmth); H ave ave a sterile sterile kit kit to tie/ clamp clamp and cut the cord; Apply antimicrob ial to t he eyes(protectio n); Keeping Keeping th e mo ther and baby in skin-to-skin skin-to-skin contact encou rages early early breastfeeding (warmth , feeding).
Module 7 : Newborn Care Care Session 1: Care of the Newborn Baby at the Time of Birth D 11 -Keeping the Baby War Warm m – K9
What is hypot hypot hermia?
The “Warm “Warm Chain” Warm delivery room Immediate drying Skin-to-skin contact Breastfeeding Bathing and weighing postponed Appropriate clothing and bedding Mother and baby together Warm transpor tation Warm resuscitation Training and awareness E n s u r e W ar ar m t h f o r t h e N e w b o r n Keep the baby warm Keep a small small baby warm Rewarm the baby skin-to-skin
B ab ab y
K9
Rewarm the baby skin-to-skin Before Before rewarming, rem ove the baby’s baby’s cold clothing. the newborn skin-to-skin on the Place mother’s chest dressed in a pre-warmed shirt shirt o pen at t he front,a diaper, hat and socks. socks.
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Cover the infant infant o n th e moth er’s er’s chest chest with with h er cloth cloth es and an additional (pre-warmed) blanket. Check the temperature every hour until normal. Keep the baby with the mother until the baby’s body temperature is in normal range.
Re-warming a cold baby If the baby is LBW or preterm, encourage the mother to keep the baby in skin-to-skin contact for as long as possible, day and night. Be sure the temperature of the room where the rewarming takes place is at least 25°C. If the baby’s baby’s temperature is not 36.5 º C or mo re after after 2 hou rs of rewarming, rewarming, reasses reassesss the baby (J2-J7) . If referral referral needed, keep t he b aby in skin-to skin-to -skin -skin position/ contact with the mo ther or o ther person accompanying accompanying the baby.
Taking a baby’s temperature If you have a thermometer: Make sure it is clean. Shake it down so that it reads < 35ºC Place Place the silv silver/ er/ red bulb end of the thermometer under the baby’s arm, in the middle of the armpit Gently hold the baby’s arm against his body Keep the thermometer in place for 3-5 minutes Remove Remove the t hermometer and read the t emperature emperature Record the temperature in the baby’s notes If you do not have a thermometer: Feel the baby’s feet. If they are cold to touch, the baby is cold and needs to be warmed If the baby’ baby’s temperature temperature is is < 36º C or >37.5º C, the baby will need to be observed.
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D oes a newborn baby’s baby’s temperature temperature need to be taken routinely by a thermometer? An accurate accurate tem perature is needed if the b aby is: is: Preterm or low birthweight or sick Admitted to the hospital Suspected of being either hypothermic or hyperthermic Being rewarmed during the management of hypothermia Being cooled down during the management of hyperthermia
Module 7 : Newborn Care Care Session 1: Care of the Newborn Baby at the Time of Birth-Breastfeeding Birth-Breastfeeding the N ewborn Baby What to teach the mother about breastfeeding: Correct attachment and p ositioning ositioning (K3box 2) Imp ort ance of exclusi exclusive ve breastfeeding breastfeeding (K2 b ox 1) H ow to express express her milk (K5) (K5) H ow to prevent prevent or t reat reat common problems help When to seek help
Anatomy o f the Breast
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Physiology of breastfeeding
Problems th at may arise arise if the baby is not well attached to the breast The baby: May cry a lot and be unhappy May be slow to gain weight, or may even lose weight The mother: May get sore/ cracked cracked nipples nipples May get very full full breasts which feel feel hard, som etimes th ey may feel hot and may look red Key points to good positioning- p.K3 The baby’s baby’s head and bod y are in in a straight line The baby’s face is opposite the nipple and breast The baby’s upper lip or nose is opposite the mother’s nipple The baby is held as close to the mother’s body as possible The baby’s whole body is supported if the mother is in a sitting sitting position. position. The baby’s first breastfeed H elp the mot her to initiate initiate breastfee breastfeeding ding within within 1 hour, when th e bab y is ready. ready.
Key points to goo d attachment: attachment: Th e baby’s mou th is widely widely open The t ong ue is far far for for ward in in th e mout h, and m ay be seen over over the bottom gum The lower lip is turned outwards The chin is touching the breast More areola is visible above the baby’s mouth than below it K3 box 2 For the mother to attach her baby, she should: Tou ch her b aby’s lips lips with her n ipple y’s mout h is opened widely Wait unt il her bab y’s Move her baby quickly onto the breast, aiming the infant’s lower lip well below the nipple 128
Other breastfeeding con cerns cerns K8 Give Give special special suppo suppo rt to the m oth er who is not breastfeeding breastfeeding ( Mot her or baby ill) ill) If the baby does not have a mot her Advise the mother who is not breastfeeding at all on how to relieve engorgement ( baby died or stillborn or mother chose replacement feeding
Module 7 : Newborn Care Care Session 1: Care of the Newborn Baby at the Time of Birth-Alternative Methods o f Feeding a Baby Baby
Why a baby baby may not be able to breastfeed breastfeed Preterm Low birth weight The baby or the mother is ill The baby or mother is referred to another hospital Alternative feeding feeding metho ds Alternative Direct expression of breastmilk Cup feeding Gastric tube Spoon Syringe Breastfeedi Breastfeeding ng supplementer Bottle What What are the advantages of direct expression o f breastmilk? The mot her can can do it She can do it anytime and anywhere It does not require the baby to use a lot of energy It encourages skin-to-skin contact between the mother and baby It encourages the baby to use its instinctiv instinctivee responses It can be d one b efore efore th e baby is is able able to coord inate its swall swallowing, owing, sucking and breath ing. Di rect rect expression expression o f breastmilk breastmilk into the baby’s mou th H old the b aby in in skin-to skin-to -skin -skin contact, the mo uth close close to the nipple. Express the breast un til some some drop s of breast milk appear on the nipple. Wait ait u ntil the b aby is is alert alert and opens mo uth and eyes, or stimulate stimulate the baby lightly lightly to awaken awaken her/ him. smell and lick lick the nipple, and attempt to Let th e baby smell suck.
Let some breast milk fal falll into the baby’s baby’s mou th. Wait un til the baby swallows swallows before expressing expressing mor e drops of breast milk. After some time, when the baby has had enough, she/ he will will close close her/ his mou th and t ake no mo re breast breast milk. Ask the mother to repeat this process every 1-2 hours if the baby is very small (or every 2-3 hours if the baby is not very small). Be flexible at each feed, but make sure the intake is adequate by checking daily weight gain.
Why cup feeding? A cup is a simple piece of equipment A cup is easy to clean Simple method of feeding The baby can take what he needs in his own time H ow to Cup Feed Feed Ask the mother to: Measure the quantity of milk in the cup Hold the baby sitting semi-upright on her lap H old th e cup of milk to the b aby’s aby’s lips lips:: - rest cup light ly on lower lip lip - tou ch edge of cup to o uter part of upper lip - tip cup so that milk just reaches the baby’s lips - do not po ur the m ilk ilk into into the baby’s baby’s mouth. When th e baby smells smells the m ilk, ilk, the baby becomes alert, opens mo uth and eyes, eyes, and starts to feed. The baby will will sip sip or suck th e milk into into his mout h Preterm / Small Small babies babies take milk milk into into their mout h with their ton gue using a lapping lapping movement. Preterm babies do not d ribble as much as older babies. Baby finishes finishes feeding when m ou th closes or when no t interested in taking taking m ore.
Cup Feeding If the baby does not take the calcula calculated ted amo unt : Feed for a longer time or feed mo re often
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Teach Teach t he mo ther t o measure th e baby’s baby’s intake intake over 24 hou rs, not just at each feed. feed. Feed th e baby by cup if the m oth er is not avail available able to do so. Baby is cup feeding well if required amount of milk is swallowed, spilling little and weight gain is maintained.
H ow to hand hand express express breastmilk breastmilk Prepare a clean clean containers to collect collect and store th e milk. milk. A wide necked jug, jar, bowl or cup can be used. Once expressed, the milk should be stored with a wellfitting lid or cover. Teach Teach t he m oth er to express express her milk by herself herself.. D O N OT do it for her. H ow to hand express express breastmilk breastmilk Teach the mother how to: – Wash her hands thoroughly. – Sit or stand comfortably and hold a clean container underneath her breast. – Put her first first finger finger and t hum b o n either side of the areola, behind th e nipple nipple ( about 4 cm from the tip of the nipple). – Com press and and release release the b reast reast b etween her finger finger and thumb. – Compress in the same way all the way around the breast keeping her fingers the same distance from the nipple H ow to hand hand express express breastmilk breastmilk Express one breast until the milk just drips, then express express the oth er side side u ntil the milk milk just drips. Continue alternating sides for at least 20-30 minutes. If milk does not flow well: Apply warm compresses to the breast Gently massage the breast
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H ave ave someon e massage massage her back and n eck before before expressing.
H ow to hand express express breastmilk breastmilk Feed the baby by cup immediately. If not, store expressed milk in a cool, clean and safe place. If necessary, repeat the procedure to express breast milk at least 8 times in 24 hours. Express as much as the b aby would take or m ore, every 3 hours.
Module 7 : Newborn Care Care Session Session 1: N ewborn Resuscitation-Neo Resuscitation-Neo natal natal Resuscitation Why learn learn neonatal resuscitation? Birth asphyxia accoun accoun ts for 1 9%of 9%of appro x. 5 m illion illion neonatal deaths that occur each year year worldwide worldwide (WHO , 1995) O utcom es of more than 1 milli million on newborns per year might b e impro impro ved by resuscitation resuscitation t echniqu es Which babies require resuscitation? At least least 90 percent n ewly ewly born babies are vigorous vigorous Ten percent require some kind of assis assistance tance O ne p ercent n eed resuscitativ resuscitativee measures to survive survive Overview and and Principles of Resuscitation chang es at birth Physiologic chang Resuscitation flow diagram Resuscitation risk factors Equipment and personnel personnel needed Lungs and Circulation In the fetus In u tero, th e fetus fetus is depend ent on the placenta as the organ of gas exchange exchange Air sacs are filled with fetal lung fluid Arterioles are are con stricted Pulmon ary blood flow flow is diminished diminished Blood flow is diverted across ductus arteriosus After delivery Lun gs expand with air Fetal Fet al lung fluid leaves alveoli alveoli Pulmo nary arterioles dilate dilate Pulmo nary blood flow flow increases Blood oxygen levels rise rise Du ctus arteriosus constricts constricts Blood Blood flows flows through the lung s to pick up oxygen
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Cardiac Cardiac function and co mpensatory mechanisms in asphyxia Initial response –Constriction of vascular beds in lungs, intestines, kidneys, muscle, and skin to redistribute blood flow to heart and brain Late effects –Myocardial –Myocardial function function may be impaired, cardiac outpu t decreases, decreases, and organ damage may occur What Can Go Wrong During Transition Insufficient ventilation, airway blockage, or both Excessive blood loss or poor cardiac contractility Sustained con striction striction o f pulmonar y arterioles arterioles Sustained
N ormal Transition Transition These major changes changes t ake place place within seconds after birth: Fluid in the alveoli is absorbed Umbilical arteries and vein constrict Blood vessels in lung tissue relax Fetal lung fluid clearance Impro ved ved with labor labor before delivery delivery Facilitated with effective initial breaths Impaired by –Apnea at birth with no lung expansion –Shallow –Shallow ineffective ineffective re spirations
Pulmonary blood flow Decreases with hypoxemia and acidosis due to vasoconstriction Increases with with ventilation, ventilation, oxygenation, oxygenation, and correction of acidosis
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Signs of a Compromised Newborn Cyanosis Bradycardia Low blood pressure Depressed respiratory effort Poor muscle tone Interruption in Normal Transition: Apnea Primary apnea Rapid attempts to breathe Respirations cease H eart rate decreases decreases Blood pressure is usually maintained Responds to stimulation stimulation Secondary Apnea Respirations cease H eart rate decreases decreases Blood pressure decreases No response response to stimulation stimulation
Provider Responses: Resuscitation Resuscitation Flow D iagram iagram Initial Steps (Block A) Evaluation After After th ese initial initial steps, steps, furth er actions are based on e valuatio valuatio n of: Respiration eart Rate H eart Color
Breathing Breathing (Block B) If Apnea Apnea or HR <10 0 bpm: Assi Assist st n ewborn by pro viding viding positive-press positive-pressure ure ventilation ventilation with with a b ag and m ask for 30 second s. Th en, evaluate again
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Important Points in the N eonatal eonatal Resuscitation Resuscitation Flow Diagram H e ar ar t rat e < 60 60 ad di dit io io na nal st ep ep s n ee eed ed ed Heart Heart rate rate > 60 ches hest comp compre resssions can be be stoppe topped d H eart eart rate rate > 100 posi positiv tive-pre e-presssure ventil entilation ation can can be stopped Asteris Asterisk k (*) endo tracheal intu intu bation may be con sidered sidered at several steps Timeline Timeline – 3 0 seconds if no improvement, th en proceed to n ext step step
Circulation Circulation ( Block C) If H R <60 bpm despite adequate adequate ventila ventilation: tion: Suppo rt circulation by starting chest com pression pression s while while continuing ventilation. Then , evaluate evaluate again. again. If heart rate rate <60, proceed to D .
Drug (Block D) If H R <60 bpm despite adequate adequate ventilations and chest chest compressions: Administer Administer epinep hrine as ventilation ventilation and ch est compressions compressi ons cont inue 134
Evaluation, Decision and Action Cycle Prepara Preparatio tio n for Resuscitation P ersonnel and Equipment Trained perso n to initiate resuscitation at every delivery delivery Recruit add itional personnel, if needed for com plex delivery delivery Prepare n ecessary ecessary equipment Turn o n radiant warmer warmer Check resuscitation equipment
Module 7 : Newborn Care Care Session Session 2: N ewborn Resuscitation-Initial Resuscitation-Initial Steps
Prepara Preparatio tio n fo r Resuscitation Risk Facto Facto rs Antepartu m factors Intrapartum factors
Evaluating Evaluating the N ewborn Immediately after birth, the following questions must be asked:
Why are are Premature Premature N ewborns at H igher Risk?
Initial Steps Provide Warmth Position ; clear airway (as necessary) necessary) Dr y, stimulate, reposition Give O2 (as necessary)
Possible surfactant deficiency Increased Increased heat loss, poor temparature contro l Possible infection Susceptible to intracranial hemorrhage
D ecide if resuscitation resuscitation is needed Op en the airway airway Manag e if mecon ium is present Provide free-flow oxygen
Prevent heat loss by Placing newborn under radiant warmer Drying thoroughly Removing wet towel
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Preventing Preventing H eat Loss Loss Premature newborns Special Special prob lems
-Thin skin -Decreased Decreased subcutaneou s tissue tissue -Large surface area
Additional steps
–Raise Raise environment environment temperature –Co ver with with clear plastic plastic sheet sheet ing Open t he airway by Positioning on back or side side Positioning Slightly extending neck “Sniffing” position Aligning Aligning po sterior phar ynx, larynx larynx and trachea Opening the Airway Meconium Present Present and N ewborn Vigorous If : Respiratory effort is stron stron g, an d Respiratory Muscle ton e is good , an d rate is greater than 100 b pm H eart rate
Then: U se bulb syringe syringe or large-bore suction catheter t o clear mouth and no se Meconium Present Present and and N ewborn No t Vigorous Tracheal suction Administer oxygen Insert laryngoscope, use 12F or 14 F suction catheter to clear clear mout h Insert endot racheal racheal tube Attach end otracheal tube to suction source Apply suction as tub e is with with drawn Repeat as necessary
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Suctioning Meconium
Tactile Stimulation
Stimulate to Breathe, Reposition
Potentially H azardous azardous Forms of Stimulation Stimulation Slapping Slapping t he back Squeezing Squeezing the rib cage Forcing Forcing t highs into into abdomen Dilating anal sphincter H ot or cold compresses compresses or baths Shaking Free-flow Free-flow O xygen
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Module 7: Newborn Care Session 2: Newborn ResuscitationResuscitation Bag and Mask U se of r es es u s c i t a t i o n bag and When to ventilate Types of resuscitation bags Operation of each type of bag Face-mask placement Troubleshooting resuscitation bags Evaluating ventilation Types of Resuscitation Bags
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mask
General General Characteris Characteristics tics o f N eonatal Resuscitation Bags and Masks Size of bag (200 t o 75 0 mL) O xygen xygen capab ility ility 90%-10 90%-10 0% Capable of avoiding excessive pressures Appropriate-sized mask (cushioned, anatomically shaped masks preferred)
Withou t reservoir: Delivers only 40%oxygen to t he patient Self-inflating Bag
Self-inflating Bag: Basic Parts Parts
Con trol of Oxygen Oxygen With reservoir: 90%-100 90%-100 %oxygen delivered delivered t o p atient Self-inflating Bag Control of Oxygen
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SelfSelf-inf infla latin ting g Bag: Bag: Types ypes of
Oxygen Oxygen Rese Reserv rvoir oirss
Self-inflating Bag: Pressure Amoun t of pressure pressure delivered delivered dep ends on t he following following three factors: factors: H ow hard the bag is squeezed squeezed Any leak between mask and newborn’s face Set point of pressure-release valve
Resuscitation Bags: Safety Features Every bag should have at least 1 safety feature to prevent excessiv excessivee pr essure. Pressure manometer and flow-control valve Pressure-release valve
Self-inflating Bags With Pressure-release Valve Bag and Mask: Equipment Masks Rims
-Cushioned -Non-cushioned Shape
-R o u n d - Anatomic
shape
Size
-Small -Large Mask should Tip o f chin Mouth Nose
cover
Preparation for Resuscitation Assemble equipment Test equipmen equipmen t
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Testing a Self-inflating Bag Pressure against your hand? Pressure manometer working? Pressure-release valve opens?
with
side
or
head
of
Positioning Bag and Mask on Face Do not jam the mask down on the face Do not allow your fingers or parts of the hands to rest on the newborn’s eyes Do not put pressure on the throat (trachea)
Checklist Before assisting ventilation Select appro priate-sized mask Select
Clear airway Position newborn’s head Position yourself at the the baby
bag,
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Face-mask Seal Airtigh Airtigh t seal is essent essent ial to achieve po sitive sitive pressure. Tight seal requ ired for flow-infl flow-inflating ating b ag to inflate inflate Tight seal seal required to infla inflate te lungs when bag squeezed H ow H ard ard to Squeeze the Bag Bag Noticeable rise and fall of chest Bilatera Bilaterall breath sound s Improvement of color and heart rate Overinflation of Lungs If the baby appears to be taking a very deep breath, Too much pressure is being used Danger of producing a pneumothorax
Causes of and Solutions for Inadequate Chest Expansion
C o n d it io n 1. I n ad eq u at e
2.
B lo c k e d
se a l
a ir w a y
Frequency of Ventilation:40 to 60 breaths per minute
Chest N ot Expanding Expanding Adequately Po ssible ssible causes Seal inadequat e Seal Airway blocked Not enough pressure given
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Act io n s R e a p p ly m a sk face.
to
R e p o si t io n the head. Check for secretions; Suction if present. Ventilate with newborn’s mouth slightly open.
3. Not enough pressur pressuree Increa Increasse press pressure un til ther e is an easy rise and fall of the chest.Con chest.Con sider sider end otracheal intubation. 4. Mal Malfunc unctioni tioning ng equi quipme pment
Chec Check or replace bag.
Signs of Improvement Improvement Increasing Increasing heart rate Improving color Spontaneous breathing
Continued Bag-and-Mask Ventilation Orogastric tube should be inserted relieve gastric distention. Gastric distention may elevate diaphragm, preventing full lung expansion Possible regu rgitation and aspiration aspiration Possible
Insertion of Orogastric Tube: Technique Insert through mouth, rather than through nose (resume ventilation) syringe and aspirate aspirate gently Attach 2 0-mL syringe Remove syringe and leave tube end open to air Tape tube to newborn’s cheek
Insertion of Orogastric Tube Equipment
8F feeding feeding tub e 20-m L syringe syringe
Measuring correct length
to
N ewborn ewborn N ot Improving Improving Check o xygen, xygen, b ag, seal, seal, and pressure pressure Is chest movement adequate? Is 100%oxygen being administered?
Then
- Consider endotracheal - Check breath sounds;
intubation pneumothorax
is
possible Newborn
Not
Improving
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Module 7 : Newborn Care Care Session 2: Newborn Resuscitation-Chest Compressions Chest Compressions In dications for for chest compressions Performance o f chest compressions compressions Coo rdination of chest compressions compressions with positivepositivepressure ventilation Stopping chest compressions
Chest Com pressions: pressions: Com press heart against against spine spine Increase intratho racic racic p ressure ressure Circulate blood to vital organs
Chest Compressions Temporarily increase circulation Must be accompanied b y ventila ventilation tion Chest Compressions: Indications H R less less than 6 0 d espite espite 3 0 seconds of effectiv effectivee positive-pressure ventilation
Chest Com pressions: pressions: 2 People Needed One person compresses chest One person continues ventilation
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Comparison of Chest Compression Techniques Thumb Technique Technique (Preferred)
–Less tiring –Better control of compression depth Two-Finger Technique
–More convenient with only one rescuer –Better for small hands –Pro vides vides access to u mb ilicus ilicus for for med ications
Chest Com pressions: pressions: Thumb Technique Technique Chest Compressions Thumb t echnique echnique Pressure must remain on sternum Chest Compressions: Two-finger Two-finger Technique -Tips of middle finger and index or ring finger of one hand compress sternum-Other hand supports back
Chest Compressions: Compressions: Positioning o f Thumb or Fingers Fingers Apply Apply pressure pressure t o lower third o f sternum Avoid xyphoid process
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Potential Co mplications mplications Laceration of liver Broken ribs Coordination With Ventilation A fou fou r event cycle sho sho uld t ake approximately 2 second s Approximately 120 “events” per minute (30 b reaths reaths and 90 compressions)
Chest Co mpressions: mpressions: Com pression pression Pressure Pressure and D epth -Depress sternum sternum one t hird of the anterior-posterior diameter of chest -Duration of downward stroke shorter than duration of release
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Stopping Compressions Compressions After 30 seconds of compressions and ventilation, ventilation, stop and check the heart rate for 6 seconds N ewborn N ot Improving Improving If heart rate less less than 6 0 b pm d espite espite adequ ate ventilation ventilation and chest compressions for 30 seconds, administer epinephrine.
Module 7 : Newborn Care Care Session 2: Newborn Resuscitation-Endotracheal Intubation Indications Equipment preparation Laryngoscope Laryngoscope use Determination of tube placement Suctioning meconium from trachea Positive-pressure ventilation via endotracheal tube Meconium present and baby is not vigorous positive-press pressure ure ventilati ventilation on required Prolong ed positive Bag-and-mask ventilation ineffective compressions necessary necessary Chest compressions Epinephrine administration administration necessary necessary Special indications: prematurity, surfactant administration, administration, diaphragmatic hernia Endotracheal Intubation: Equipment and Supplies Equipment should be clean, protected from contamination Sterile Sterile disposable disposable end otracheal tub es with with uniform diameters preferred
Characteristics Characteristics of Endo tracheal tracheal Tube Sterile, disposable Uniform diameter Centimeter marks and vocal cord guides helpful Uncuffed Endot rachea racheall Tube:
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Appropriate Size Select Select tu be size based on weight weight and gestational age age Consider shortening tube to 13-15 cm Stylet Stylet op tional
Preparation of Laryngoscope: Supplies Select blade size -No 0 for preterm newborns -No 1 for term newborns Check laryngoscope light Connect suction source to 100 mm Hg Use large suction catheter (greater than or equal to 10F) for secretions Small suction catheter for ET tube
Preparation for Intubation Prepare resuscitation bag and mask Turn on oxygen Get stethoscope Cut tape or prepare endotracheal tube stabilizer
Endotracheal Landmarks
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Intubation:
Anatomic
Endot rachea racheall Intubatio n: H olding olding t he Laryngoscope Laryngoscope
Endotracheal Intubation Step 1: Preparation for In sertion sertion Step 2: Insert Laryngoscope Step 3: Lift Blade Step 4: Visualize Visualize Land marks Step 5: Inserting Tube Step 6: Remove Laryngoscope
Endotracheal Intubation: Checking Tube Position Signs of correct tube position Chest rise with with each breath Breath Breath sounds over bot h lung fields fields No gastric gastric distention with ventilation ventilation Vapor condensing on inside of tube during exhalation
Suctioning Meconium Via Endotracheal Tube
Con nect endot racheal racheal tube to mecon ium aspira aspirator tor and suction source Occlude suction port to apply apply suction suction Gradually withdraw endot racheal tub e Repeat intub ation and suction suction as necessa necessary ry Suction Suction for only 3 to 5 seconds as tub e is withdrawn withdrawn If no meconium is recover recovered, ed, pro ceed to resusci resuscitation tation If meconium is recovere recovered, d, check heart rate H eart rate OK: Reintubate, suction again again if indicated indicated H eart rate decreased: Administer positive-pressure positive-pressure ventilation
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Carbon dioxide dioxide det ector will will change color (or reads more than 2%-3%during exhalation) exhalation)
Tip-to- lip m easurement easurement
Endotracheal Intubation: Checking Tube Position The tube is likely not in trachea if No chest rise rise No breath sounds over over lungs No ises ises over the stomach No mist in endotracheal tube Abdomen becomes distended Carbon dioxide detector does not indicate exhaled Carbon dioxide Newborn remains cyanotic or bradycardic
Tube Locatio n in Trachea
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Endot rachea racheall Int ubation: Radiographic Confirmation
Module 7: Newborn Care Session 2: Newborn ResuscitationMedications Indications Epinephrine administration administration via via Endotracheal tube -U mb ilical ilical vein -Volume expansion Sodium bicarbonate administration
Heart rate less than 60 after 30 seconds of assisted ventilation and 30 seconds of compressions and assisted ventilation Total 60 seconds Note: Epinephrine n ot indicated before adequate ventilation established Epinephrine: Rout es of Administration Administration Endotracheal tube U mb ilical ilical vein Epinephrine: Administration Via Endot racheal racheal Tube Give directly into endotracheal tube May use 5F feeding tube Dilution vs flush After instillation, give positive-pressure ventilation Epinephrine: Administration Via Um bilical Vein Vein Placing catheter in umbilical vein -Preferred route -3.5F or 5 F end-hole catheter catheter -Sterile -Sterile techn ique Insert 2 to 4 cm Free flow of blood when aspirated Less depth in preterm newborns In sertion in liver may cause damage
Epinephrine: Effects Repeated Repeated D osing Increase strengt strengt h and rate of cardiac cardiac contractions Peripheral vasoconstriction vasoconstriction May repeat dose every 3 to 5 minutes Consider repeat dose via umbilical vein if first dose given given via via endo tracheal tube Epinephrine: Epinephrine: Poor Response (H eart eart Rate <60 bpm) Recheck effectiveness of Ventilation Chest compressions Endotracheal intubation Epinephrine delivery delivery Consider possibility of H y p o v o le le m i a Severe m etabo lic lic acidosis Severe
Poo r Response Response to Epinephrine: Epinephrine: Hypovolemia Signs of Hypovolemia Pallor after after oxygenation Pallor Weak pulses (high or low heart rate) Poor response to resuscitation Low blood pressure/ pressure/ poor perfusion perfusion Blood Volume Expansion: Acceptable Solutions No rmal Saline Saline Ringer’s lactate O-negative blood Medication: Volume Expanders Expanders Expected signs of volume expansion: Blood p ressure increases increases Pulses stron stron ger Pallor lessens Follow up if hypovolemia persists Repeat volume expanders Give sodium b icarbonat e for for presum ed acidosis
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Prolonged Resuscitation: Physiologic Consequences Lactic acid buildup Poo r cardiac cont ractili ractility ty Decreased pulmonary blood flow Metabolic acidosis suspected Sodium b icarbon icarbon ate administration is contro versial versial after adeq uate ventilation ventilation is established established U se only after
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Medication Medication Given: No Improvement Improvement Recheck effectiveness effectiveness of Ventilation Chest compressions Endotracheal intubation Epinephrine delivery delivery If heart rate is less than 60 or absent: Consider possibility of -H ypovolemia ypovolemia -Severe metabolic acidosis Consider conditions such as -Pneumothorax -Diaphragmatic hernia -Congenital Heart Disease Consider discontinuing resuscitation
Special Special Co nsideratio nsideratio ns Special problems that complicate resuscitation Management after after resuscitati resuscitation on Ethical consideration Resuscitation beyond newborn period or outside hospital delivery room N o Improvement After Resuscitation Resuscitation : Categories Failure to begin spontaneous respirations ventilation with with positive-press positive-pressure ure Inadeq uate ventilation ventilation Baby remains cyanotic or bradycardic despite good ventilation Failure to Initiate Spontaneous Respirations Brain injury (hypoxic ischemic encephalopathy) Sedation secondary to maternal drugs
Posit ive-pressure ive-pressure Ventilation Ventilation Fails to Produ ce Adequate Ventilation Mechanical Mechanical blo ckage ckage o f airway Meconium or mucous plug Cho anal atresia atresia Airway malformation Oth er rare conditions conditions
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Posit ive-pressure ive-pressure Ventilation Ventilation Fails to Prod uce Adequate Ventilation Impaired lung function Pneumothorax
Mechanical Mechanical Blo ckage ckage o f Airway: Choanal Atresia
Mechanical Mechanical Blo ckage ckage o f Airway: Pharyngeal Airway Malformation Robin syndrome
Pleur al effusion Pleural effusion Congenital diaphragmatic hernia Pulmon ary h ypopla ypoplasi siaa Extreme prematurity Congenital pneumonia
Impaired Lung Function: Pneumothorax Impaired Lung Function: Cong enital Diaphragmatic Diaphragmatic H ernia ernia
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Baby Remains Cyanotic or Bradycardic Ensure ch est is moving moving with ventilation ventilation Co nfirm 100 %oxygen is being given Con sider sider con genital heart b lock or cyanotic heart d iseas iseasee (rare)
H ypoglycemia Necrotizing ent erocolitis erocolitis Oxygen injury
E th th ic ical P ri ri nc nci pl pl es es: St St ar art in in g an an d S to to pp pp in in g Resuscitation No different than older child or adult No advantage to delayed, graded, or partial support Support can be withdrawn after initiation initiation Base decision on data (may not be available in delivery room) icate with family family prior to resuscitati resuscitation on if Com mun icate possible Ethical Ethical D ecisions: ecisions: N on-initiation o f Resuscitation Resuscitation Confirmed gestation < 23 weeks or birthweight < 400 grams Anencephaly Confirmed trisomy 13 or 18
Post-resuscitation Care Baby requires Close monitoring Anticipatory care Laboratory studies
Ethical Decision: Stopping Resuscitation Ensure adequate resuscitation efforts May stop after 15 minutes of asystole Ongoing evaluation, discussion with parents and team, if prognosis uncertain
Post-resuscitation Problems Pulmonary hypertension Pneumonia, aspiration, or infection Hypotension Fluid management Seizure, Seizure, apnea H ypoglycemia Feeding problems management Temperature
Post- resuscitation resuscitation Problem s: Premature Premature Infants Temperature management Immature lungs Intracranial hemorrhage
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Module 7: Newborn Care Session 3: Examination of Baby J2-J8
the
Newborn
When should a newborn baby be examined? Examine routinely all babies: within an hour of birth for discharge at rou tine and follow-up follow-up postn atal vis visits its in in the 1 st week of life, life, and when the mother or provider observes danger signs. Examination Format Ask, Check Record Look, Listen and Feel SIGNS CLASSIFY TREAT AND ADVISE Newborn
Care
Guidelines
CASE CASE STU DY Ask, Check Record Look, Listen and Feel SIGNS CLASSIFY TREAT AND ADVISE
Module 7: Newborn Care Session 4: Care of the Newborn Until D i s c h a rg rg e from H ealth F ac ac i l i t i e s Parent Education Keeping the baby warm Breastfeeding the newborn baby Giving cord care Ensuring hygiene Watching her baby and reporting her concerns Sleeping Sleeping with her baby and positioning her baby Attaching the breast J1 0
at
Keeping the baby warm In cold climate climate keep at least an area of the roo m warm. Newborns need mo re clothing clothing th an other childre children n or adults If cold, put hat on the baby’s head. During cold nights cover the baby with an extra blanket. At night, let the baby sleep with the mother or within easy reach to facilitate breastfeeding. DO NOT put the baby on the cold surface DO NO T swaddle swaddle the baby (wrap too tight ly) ly) because because swaddling makes them cold DO NOT leave the baby in direct sun because it may become too hot and dehydrated Giving cord care Wash hands before and after cord care Put nothing on the stump Fold diaper below the stump Keep stum p loo loo sely covered with with clean cloth es If the stump is wet, wash with clean water a n d so so a p , d r y w it it h cl cl e an an cl cl o t h .
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If umbilicus is red or draining pus or blood, see the health worker. DO NOT bandage the stump or abdomen DO NOT apply substances or medicines to stump Avoid touching the stump unnecessarily
Washing the baby Wash the face, neck and underarms daily Wash the buttocks when soiled. Dry thoroughly Bathe when necessary: -Ensure the room is warm -Use warm water for bathing Thoroughly dry the baby, dress and cover after bath Monito ring the Baby Baby Cold feet Breathing Breathing diffic difficulties ulties (”gru nting” , fast fast or slow slow breathing, chest in-drawing) Any bleeding Give prescribed prescribed treatment treatment s according according to the schedule treatm ents for infections infections Immunizations
K12 & K13 : “Treat and immunize the baby“ Discharge examination Examine every baby before planning discharge the mother and baby Tell the mother when to return for -routine postnatal visit -if danger signs
to
Routine Visits Postnat Po stnat al visit visit -Within th e 1st week preferably within 2-3 days Immunization visit (if BCG, BCG, O PV-0 and H B-1 given given in t he 1 st week of lif life) e) -at age 6 Follow-up Visits I f t h e p r o b lem was Feed in g d ifficu lt y R ed u m b ilicu s Skin in fect io n E ye in fect io n Follow-up Visits I f t h e p r o b lem was T h ru sh Mot her has either breast en g o rg em en t o r m ast it is Low birth birth weight weight and either first fi rst week of life life or n ot gaining weig h t ad eq u at ely Follow-up Visits I f t h e p r o b lem was O r p h an b ab y I N H p ro p h ylaxis T reat ed fo r p o ssib le congenital con genital syphilis syphilis M o t h er H I V p o sit ive
R et u rn in 2 d ays 2 d ays 2 d ays 2 d ays
R et u rn in 2 d ays 2 d ays
7 d ays
R et u rn in 7 d ays 1 4 d ays 1 4 d ays 1 4 d ays
Advise the mo ther to seek care care for the baby Return or go to the h ospital immediately immediately if if the baby has:
Advise when to return with the baby K14
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D iffi ifficulty culty breath ing convulsions Fever or feels Bleeding H as diarrhea not feeding at all
cold
Go to the health center as quickly as possible if the babyhas: Difficulty feeding Pus from eyes Skin pustules Yellow skin A cord stump which is red and draining pus Feed less than 5 times in 24 hours Other concern
Module 7 : Newborn Care Care Session 4: The Small Baby What do we mean by a “small baby”? Small baby - born b etween etween 32-36 weeks weeks gestati gestation, on, or o ne to two month s early early, and/ or - with with a birth weight weight b etween etween 1500 g and 25 00g. Very small baby: - A very preterm baby born less than 32 weeks gestation or more than 2 months early, or -A baby with birth weight less than 1500 g Refer baby urgently to hospital (B14) Ensure extra extra warmth warmth d uring referra referral/ l/ transport Special needs of a small baby To breathe normally To be kept warm To be fed To be pro tected
Newbo rn examination examination as in N2 -N9 Care of the small baby Care of the Newborn Newborn p.N10 Additional care of a small baby (or twin) p.N11
Additional care of a Small Baby (or Twin) Plan to keep the small baby longer before discharging. Allow visits to the mother and baby.
Additional care of a Small Baby (or Twin) Give special support for breastfeeding the small baby (or twins) ( B 4 ) Encourage the mother to breastfeed every 2-3 hours. Assess breastfeeding daily: attachment, suckling, duration and frequ ency of feeds, feeds, and baby satisfaction satisfaction with t he feed (K3)
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alternative feeding feeding m eth od is used, assess assess the to tal daily amou nt o f milk milk given. given. Weigh daily and assess weight gain (K7) . -Weigh and assess weight gain B7 Weigh the small baby Every day until 3 consecutive times gaining w ei ei g h t ( a t l ea ea st st 1 5 g / d a y) y) . Weekly until 4-6 weeks of age (reached term). Weigh and assess weight gain B7 If weighing daily using a precise and accurate scale Response to abnormal finding the small baby is not suckling If effectively and does not have other danger signs, consider alternative feeding methods Teach the mother how to hand express breast milk directly into the baby’s mouth Teach the mother to express breast milk and cup feed the baby Determine appropriate amount for daily feeds by age If feeding difficulty persists for 3 days, or weight loss greater than 10 % of birth weight and no other problems, refer for breastfeeding counselling and management. Additional care of a Small Baby (or Twin) Ensure additional warmth for the small baby E n s u r e t h e r o o m i s ve r y w ar ar m ( 2 5 º - 2 8 º C ) . Teach the mother how to keep the small baby warm in skin-to-skin contact Provide extra blankets for for m oth er and baby. baby. Ensure h ygiene ygiene D O N O T bath the small baby. Wash as needed.
Additio nal care care of a Small Baby (or Twin) Assess the small baby daily Measure temperature Assess breathing (baby must be quiet, not crying): listen for grunting; count breaths per minute, repeat the count if >60 or <30; look for chest indrawing Look for jaundice (first 10 days of life): first 24 hours on the abdomen, then on palms and soles. If difficult to keep body temperature within t h e n o r m al al ra r a n g e (3 (3 6 . 5 º C t o 3 7 . 5 º C ) : Keep the baby in skin-to-skin contact with the mother as much as possible – If bod y temperature below 36.5º p e r s is is t s for 2 hours despite skin-to-skin contact with mother, assess the baby If breathing difficulty, assess the baby If jaundice, refer the baby for phototherapy. If any maternal concern, assess the baby and respond to the mot her. her. Discharging the small baby Plan to discharge when: Breastfeeding well Gaining weight adequately on 3 consecutive days Body temperature temperature between 36 .5 and 37.5 on 3 consecutive consecutive days Mother able and confident in caring for the baby No maternal concerns. Assess the baby for discharge.
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Module 8 : Counseling Counseling Session 1: Basic Facts About Counseling Overview H ealth ealth workers are expected expected to be coun selors selors inmaternal and newbo rn care, where where the patient h as to m ake choices choices based on accurate accurate information and in a climate climate where his/ her reprodu ctive ctive rights are are respected. respected. It is a service which which t he h ealth facility facility sho sho uld pr ovide. Effective comm un ication ication en sures that th e client client can Effective comprehen d and act on improving his/ his/ her, as well well as as his/ her family’ family’ss state of health. Purpose of Cou nseling In maternal and neo natal health health counseling counseling serves 3 main purposes: Co nt ributes to t he satisfac satisfaction tion o f women women , their families families and com mun ities ities from from the services services she/ she/ they receive; receive; helps to ensure th at peo ple use services services appropriately; appropriately; and, return to use them and recommend them to o thers H elps to develop skill skillss to enab le women and th eir famili families es to take better care of themselves themselves and t heir babies Most import antly, antly, it helps to empo wer women and teach them new skil skills ls to help them take action action o n th e decisions decisions th ey have to m ake in all aspects aspects o f their lives lives Principles in Counseling Total Honesty Confidentiality Non-judgemental Counseling Skills 1. Interpersonal communication 2. Em phatic listening listening 3. Q uestioning uestioning 4. N egotiating egotiating 5. Planning 6. Evaluating
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Knowledge on: Maternal and newborn care Basic Basic Information, transmissi transmission on and m anagement of H IV(H uman Imm un odeficiency odeficiency Virus) Virus) Family Family Planning Planning and Mod ern Metho d Ch oices oices Infant Feeding Ch oice oice Adolescent Adolescent Pregn ancy Violence Against Against Wom Wom en and Ch ildren ildren Institut ions, Health programs and projects that may be resources to th e client client National polici policies es and and laws related related to t he opt ions/ metho ds Qualities of an Effective Counselor Personal Qualities and and Attitu des A desire to work with peo ple Respect Respect for th e right & ability ability of people to make their own decisions decisions Com fort with with issues issues related related to hum an sexuali sexuality ty & t he expression of feelings Self-aw Self-awareness areness (of on e’s own biases, expectation s, capabilities & limitatio ns) Unbiased attitudes toward various population groups Tolerance for values values th at differ from from on e’s own Emp athy for for client client s Supportive attitude t oward clients clients Ability Ability to maint ain cofidentiality Unb iase iased d attitudes/ attitudes/ non-judgmental non-judgmental Com fort with with issues issues related related to hum an sexuali sexuality ty & t he expression of feelings. Self-aw Self-awareness areness (of on e’s own biases, expectation s, capabilities & limitation s.) Six Counselor Task of Counseling Process Model 1. I nitiate counseling counseling relationship relationship 2. Un derstand cou nselee nselee concerns emphatically emphatically 3. N egotiate coun seling seling objectives objectives 4. Id entify entify plan plan to meet ob jectiv jectives/ es/ achiev achievee out comes 5. Support t he plan 6. E valuate valuate co nseling nseling
Module 8 : Counseling Counseling Session 2: Applying Counseling Skills H I V / AI D S deficie iency ncy Virus Caused b y a viru viruss called called th e H um an I mm un odefic This virus is spread from person to person through body fluids such as semen, vaginal fluid or blood during unprotected sexual intercourse; H IV-infected IV-infected blood t ransfusions ransfusions or contaminated n eedles for drug abuse or tattoos. From an infected infected mot her to h er child child during: -pregnancy -labour and d elivery elivery -postpartum -postpartum through breastfee breastfeeding ding H IV cannot cannot be transmitted transmitted through hugging or mosquito bites A special blood test is done to find out if the person is infected infected with with H IV Asymptom atic Carrier Carrier 1 mo nth after after picking picking u p H IV, IV, flu-lik flu-likee sympto sympto ms develop develop tem por arily arily such such as: Fever Sore throat Malaise Muscle aches Rash Large lymph nodes Symptomatic H IV (8-10 years later) Oral and vulvovaginal candidiasis Diarrhea Bacterial infections (skin, (skin, u pper & lower respiratory tract) Tuberculosis H erpes zoster/ simplex simplex Skin infections (Fu ngal infections) Skin O pport un istic istic malignancies: malignancies: Kaposi’s sarcoma Lymphoma
H IV status in Pregnancy, Pregnancy, WH Y? Get m edical care care to prevent associated illnesses illnesses Prot ect sexual partn er from infection infection Make a choice abou abou t future pregnancies Counseling Why is HIV/ AIDS counseling necessa necessary? ry? P r e ve ve n t s p r ea ea d o f H I V / A I D S Provide emotional support survival Maximize survival Assist beareavement process Coordinate support resources Who should should rece receive ive H IV/ AIDS counseling? counseling? People seeking seeking H IV test People proven H IV positive positive People diagnosed with AIDS Significant others (family, friends, etc.) Worried well people at high risk for H IV Where Where can can H IV/ AIDS counseling be held? any setting/ setting/ venues which which is comfortable for for client client to discuss discuss th ings over in privacy Who Who should provide provide HIV/ AIDS counseli counseling? ng? any person person can be enco uraged and t hose willi willing ng to be trained to provide provide counseling counseling N eed to know about counselling: counselling: Essentials of counseling Counseling skills Types of counseling Ethical principles Referral system & network for counselling Types of coun coun seli seli ng seling Primary prevention coun seling People at risk risk for for H IV but n ot kno wn to b e infected infected
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-Stress that infected persons should NOT donate blood or syringes syringes or piercing piercing equ ipment s -Address perinatal t ransmission ransmission -Discourage -Discourage interruption of pregnancy -Encourage prevention of future pregnancy
PERSON
COUNSELING COMPETENCE
COUNSELING SKILLS
KNOWLEDGE on maternal and neonatal care, HIV HIV,, VAWC, VAWC, adolescent adoles cent pregnancy, family planning, infant feeding choices
H ighlight an d discuss risk risk beh avior avior of o f H IV and review ways ways of managing ind ividual ividual change
Types of coun counsseli ng Cou nseling nseling of H IV testing testing a. Pretest counseling, counseling, aims: -informed -informed consent t o procedure -necessary preparation for (+) result -provide necessary risk reduction information in acquiring passing the infection b. Post test counseling - depends on the outcome of test test Secondary prevention counseling -Person/ -Person/ known considered considered w/ w/ H IV & way wayss to avoid avoid transmission -Focus on the need of infected persons to recognize their responsibili responsibility ty for the health & welfa welfare re of th eir lover/ lover/ spouses -Discuss -Discuss the need of current/ previous previous partn er of possibil possibility ity of infection
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Psychosocial Psychosocial suppo suppo rt coun seling seling -H IV infec infected ted & persons persons liv living w/ them n eed emotional support support -Suppo rtive cou cou nseling to h elp the person react positively positively with with the problems -H elp live live a full full & pro ductive life life enabling enabling them to resume/ assum assum e auth ority over th eir lives lives & d ecision-m ecision-m aking aking
Referral Referral system system & N etwo rk for Coun seling H ow to tal talk about about H IV/ IV/ AIDS Learni Learning ng to liv live w/ w/ H IV/ IV/ AIDS Self Self H elp group H elping care-givers Care-giv Care-givers ers// loved loved on es should should be taught t o handle the pressures pressures of taking taking care of H IV/ AIDS persons persons Dealing w/ w/ feelings feelings of loneliness, depre ssion ssion and and powerlessness. Reducing stress and avoiding conflicts. Managing the implications of adopting & maintain safer sex behaviors and practices STD Prevention Prevention Abstinence Safe sex practices Stick to o ne faith faith ful partn er Male and female latex Condom correctly STD check up every every 6 mont hs if if you you or your partner have more than o ne sex partner If STD diagnosed, have complete treatment including partner before resuming sex not share needles for tattoo ing, bod y pierci piercing ng o r injecting injecting drugs If pregnant, seek prenatal care for early detection and treatment of STD STD to pr event event t ransmiss ransmission ion to the b aby
Module 9 : Mobilizing Community Support Session 1 : Establishing Establishing Links
Community Support Support
Ways to work together…. A good team work involves: A common task or purpose Understanding of different roles Different Different expertise for for different6 different6 functions/ tasks Skil Skills ls and personalities personalities complement one anoth er achieving ing functions/ functions/ tasks tasks Commitment to achiev A leader leader to take responsibili responsibility ty & coord inate
Overview Co mmu nity support is also also vital in addressing matern al and infant infant mo rbidities & mo rtalities. rtalities. Everyone in the commu nity should b e informed and involv involved ed in the process of improving improving the health of th eir locality locality.. Involving the community in Quality of services Developing a comprehensive plan (to include community involvement) in support to Maternal & newborn health care Community Linkages Advantages of working working toget her Collaboration is a difficult challenge but brings many benefits: It increases the knowledge and understanding of what different groups provide It helps to classify roles and avoid duplication of effort and work It helps to clarify roles and avoid duplication of effort and work It leads to a more effective use of resources
Advantages…..
Some groups who would not normally see themselves as having having a role in m aternal and n ewborn health can see how they might contribute Health problems can be addressed more comprehensively A more comprehensive picture of local needs is drawn up It helps to m inimize inimize gaps in provision provision and provide provide b etter target ing of services services
The same same m essages essages and advise advise are given given o ut rather th an conflicting conflicting informat ion
To help you establish linkages with other health care providers & com com m u ni ty grou grou ps & to es establis ta blish h ways of worki workin n g with them Make a list of providers & groups that work in your community Org anize a meeting/ s where where representatives representatives from from each of these providers or groups can attend Find Find o ut what each each of these groups / providers providers currently do with respect to the care of the woman & newborn during pregnancy, delivery & the postnatal period. Collate this information information into a document to be used as a futu futu re resource Work out a way to coordinate & unify messages related to th e care care of the woman & newborn during pregnancy, pregnancy, delive delivery ry & the postnatal period. period. Think about how you might be able to do this in advance: a. You cou ld con con sider gen erating th e key key messages together b. You cou ld provide a list list in advance that you discuss at the meeting To help help you you esta establis blish h lin kages with other healt h care providers & com com mu ni ty groups & to establis ta blish h ways of workin g with wit h them Try to keep it simple simple & focused focused on t he most impor tant messages & informat ion relevant for women in your community
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Ident ify ify the most commo n h ealth ealth p roblems rela related ted to pregnancy & childbirth childbirth in your commun ity & t ry to find solutions solutions tog ether. Use local morbidity & mor tality tality data to h elp you. you. Prepare an action plan defining responsibilities & circulate it to all participants Prepare an action plan defining responsibilities & circulate it to all participants Decide upon a person or group who will be responsible for monitoring how the implementation of the action is occuring
Links with traditional birth attendants and traditional healers: Include them in your referral system Get them to refer women to you Providing them with feedback on anybody they have referred to you Clarify Clarify toget her what constitutes h armful, armful, h armless armless or helpful practices Examine Examine what resources you you could share Links with TBAs… Share with them your knowledge and expertise Work with them to explain the key message of the PCPNC Invite them to participate during meetings that you have for community groiupos and providers Ask Ask for for t heir help in iden tifying tifying wom en who may be at risk Encourage them to encourage all women to deliver with a skilled birth attendant Encourage them to act as labour companions for women Tap them as a valuable source of feedback about the services you provide
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Practicum Phase
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Legend: Yellow Yellow box: N ot required
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Monitoring, Evaluation and Action Plan
Skills Training Training on BEmO C Monito ring Checklis Checklistt for Implementation of PCPN C Instructions for Monitor Part Part 1 : Demo graphic graphic Information: This part of the monitoring checklist is self-explanatory and should be completed at the beginning of the monitoring visit. Part Part 2: U se of the PCPNC: (Allow approximately approximately 1 hour to complete Part Part 2 ) The person condu cting the mon itoring itoring visit visit (the mo nitor) should sit with the health care worker who has been trained to u se the PCPN C and ask ask the relevant relevant qu estions estions in this part of the monitoring checklist. For each “NO” response, the monitor should discuss and record the reasons in the “NOTES” column. It will not be necessary to ask all of the questions in this part of the monitoring tool of all health care workers workers using using t he PC PN C. Fo r example, example, a health care worker who pro vides vides on ly anten anten atal care care shou ld on ly be asked the questions pertaining to the provision of antenatal care. H owever, owever, questions 3, 3.1, 3.2, 3.3, 4, 5, 5.1, 5.2, 6, 6.1, 6.2, 6.3, 6.4, 6.5 should be asked of all health care workers who are using using th e PCPN C.
It is import import ant to sit in a quiet room / area while while aski asking ng th e questions, to ensure th at the h ealth ealth care worker being being interviewed interviewed can concentrate on the q uestions being asked. asked. It
is als also o import ant to make sure that t he h ealth ealth care worker worker und erstands erstands that you are not testing her/ his ability ability to use the PCPN C bu t, instead, instead, that you are interested interested in knowing how useful it it is as a guide for pro viding viding p regn ancy, ancy, childbirt h and newborn care. care. Part 3: Observations of Clinical Care: (Allow approximately half a day to complete Part 3) After After completing Part 2, th e monitor shou ld observe the health care worker while while she/ he pro vides vides clinical clinical care. During these observations, observations, the mo nitor should comp are the care being provided by the health care worker worker with with the corresponding section(s) of the PCP NC . For example, if if she she is observing care in an antenatal clinic, she should follow the sections on quick check and RAM and antenatal care, as well as the linkages to other relevant sections. Following these observations, further discussion should be held with the h ealth ealth care worker, worker, focusing focusing on any issues issues and/ and/ or problems encountered with respect to using the information information in the PCPNC .
If there is more than one h ealth ealth care worker worker using the PCPN C p er faci facili lity ty,, mo re time will will be need ed t o o bserve th em ind ividually ividually. H owever, if if they are working working t oget her o n the labou labou r and delivery delivery ward, it may be p ossible ossible to observe several workers at the same time. In addition, you may wish to h old a group d iscussi iscussion on following you you r observation s, rath rath er than individual discussions.
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Part 4: H ealth System System Implications: (Allow approximately approximately 30 minutes to complete Part Part 4 ) Part 5: Summary of Discussion: (Allow approximately 15 minutes to complete Part 5) The key points points from t he individual individual and group discuss discussions ions should be recorded in t his part part of the mo nitoring too l before before leaving leaving t he h ealth facili facility ty where th e mo nitoring activity activity has taken place.
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Guide to PowerPoint Presentations
Below Below are the title of each Modu le and and Sessi Session on and th e correspon correspon ding PowerPo int Presentation t hat can be found inside the compact disk disk (CD ).
M o d u le an d Sessio n T it le
P o w erP o in t P resen t at io n
Di dacti c Phas Phasee M od od ul ule 1 , Sessio n 1 : BE m O C an d t he he U se se o f t he he P C PN PN C Ma Man ua ual
M od od ul ule1 A, M od od ul ule1 B
M o d u le 2 , Sessio n 1 : P rin cip les o f G o o d C are
M o d u le2
M o d u le 3 , Sessio n 1 : Q u ick C h eck
M o d u le3 A
M o d u le 3 , Sessio n 2 : Rap id Assessm en t an d M an ag em en t
M o d u le3 B
M o d u le 3 , Sessio n 4 : E m erg en cy T reat m en t fo r t h e Wo m an
M o d u le3 C , M o d u le3 D
M o d u le 4 , Sessio n 1 an d 2 : P ro cess Flo w o f An t en at al C are
M o d u le4 A
M o d u le 5 , Sessio n 1 : St ag es o f Lab o r
M o d u le5 A, M o d u le5 B, Module5C
M o d u le 5 , Sessio n 2 : First St ag e o f Lab o r
M o d u le5 D
M o d u le 5 , Sessio n 3 : Seco n d St ag e o f L ab o r
M o d u le5 E
M o d u le 5 , Sessio n 4 : T h ird St ag e o f Lab o r
M o d u le5 F, M o d u le5 G
Modu le 6, Ses Sesssion 1: PostPartum Examinati Examination on of the M other u p to Six Weeks eeks Modu le6A le6A Modu le 6, Ses Sesssion 2: Res Respond pond to O bserved bserved Signs Signs and Volunteered Volunteered Problems Problems Modu le6B le6B Modul Modulee 6, Se Session 3: Pre Prev venti entiv ve Mea Measure ures and Addi Additi tiona onall Tre Treaatments tments
Modul Modulee6C, Mod Modul ulee6D
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M o d u le 7 , Sessio n 1 : N ew ewb o rn C are-C are o f t h e N ew ew Bo rn at t h e T im e o f Bir t h
M o d u le7 A, M o d u le7 B, M o d u le 7 C , M o d u le7 D
M o d u le 7 , Sessio n 2: 2: N ew ewb o rn Ca Care-N ew ewb o rn Re Resu scit at io n
M o d u le7 E , M o d u le7 F, Module7G, Module7H, Module7I, Modu le7J le7J
Module Module 7, Ses Sesssion 3: New Newborn born CareCare-Ex Exaamina minati tion on of the New Newborn born Ba Baby
Modul Module7K
Mo dule 7, Sessi Session on 4 : Care of the N ewborn-Small Babies Babies U nt il D isch arg e fro m t h e H ealt h Facilit y
M o d u le7 L, M o d u le7 M
M o d u le 8 , Sessio n 1 : Basic Fact s Ab o u t C o u n selin g
M o d u le8 A
M o d u le 8 , Sessio n 2 : Ap p lyin g t h e C o u n selin g Skills
M o d u le8 B
M o d u le 9 , Sessio n 1 : E st ab lish in g Lin ks
M o d u le9 A
Mo Moni toring, Evaluati on and A cti on Plan M o d u le 1 , Sessio n 1: 1: M o n it o rin g , E valu at io n an d Ac Act io n P lan
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M o d u leM E PA, ModuleMEPB
Sample Training Schedule
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